Case Discussion

Placenta previa
Definition
The Latin previa means going beforethe placenta goes before the fetus into the
birth canal. In obstetrics, placenta previa describes a placenta that is implanted somewhere
in the lower uterine segment, either over or very near the internal cervical os.
Placental migration
With the frequent use of sonography in obstetrics, the term placental migration was
used to describe the apparent movement of the placenta away from the internal os. The
placenta does not move but the mechanism of apparent movement is considered. The term
migration is clearly a misnomer, because decidual invasion by chorionic villi on either side of
the cervical os persists.
The mechanism of which is presented in Williams Obstetrics 24 th edition and are the
following:
a. apparent movement of the low-lying placenta relative to the internal os is related
to the imprecision of two-dimensional sonography in defining this relationship.
b. there is differential growth of the lower and upper uterine segments as pregnancy
progresses. With greater upper uterine blood flow, placental growth more likely
will be toward the fundus trophotropism
c. low-lying placenta is less likely to migrate within a uterus with a prior cesarean
hysterotomy scar. Of interest, at the time of delivery there are an equal number
of anterior and posterior placentas.
Classification
1. Placenta previathe internal os is covered partially or completely by placenta. In the
past, these were further classified as either total or partial previa.
2. Low-lying placentaimplantation in the lower uterine segment is such that the
placental edge does not reach the internal os and remains outside a 2-cm wide
perimeter around the os. A previously used term, marginal previa, described a
placenta that was at the edge of the internal os but did not overlie it.
Incidence and Associated Factors
Reported incidences for placenta previa average 0.3 percent or 1 case per 300 to 400
deliveries. Several associated factors have been observed to increase risk for placenta
previa.
a. Multifetal gestation
One of which is multifetal gestation most probably because of the larger
placental area
b. Maternal age
The frequency of placenta previa increases with maternal age.
c. Multiparity
The risk for previa increases with parity. It is postulated that endometrial
damage as an etiologic factor.

d. Prior caesarean delivery

The cumulative risks for placenta previa that accrue with the increasing
number of cesarean deliveries are extraordinary.
e. Cigarette Smoking
The relative risk of placenta previa is increased at least twofold in women who
smoke. It has been postulated that carbon monoxide hypoxemia causes
compensatory placental hypertrophy and more surface area. Smoking may also
be related to decidual vasculopathy that has been implicated in the genesis of
previa.
f.

Elevated Maternal Serum Alpha-Fetoprotein (MSAFP) levels

Women who have otherwise unexplained abnormally elevated prenatal screening
levels of maternal serum alpha-fetoprotein (MSAFP) are at increased risk for
previa and a host of other abnormalities

Clinical Features
Painless bleeding (sentinel bleed) is the most characteristic event with placenta
previa. Bleeding usually does not appear until near the end of the second trimester or later,
but it can begin even before midpregnancy. And undoubtedly, some late abortions are
caused by an abnormally located placenta.
A specific series of events leads to bleeding in cases in which the placenta is located
over the internal os. First, the uterine body remodels to form the lower uterine segment.
With this, the internal os dilates, and some of the implanted placenta inevitably separates.
Bleeding that ensues is augmented by the inherent inability of myometrial fibers in the lower
uterine segment to contract and thereby constrict avulsed vessels. Similarly, bleeding from
the lower segment implantation site also frequently continues after placental delivery. Last,
there may be lacerations in the friable cervix and lower segment. This may be especially
problematic following manual removal of a somewhat adhered placenta.
Diagnosis
Whenever there is uterine bleeding after midpregnancy, placenta previa or abruption
should always be considered. Diagnosis by clinical examination is done using the double setup technique because it requires that a finger be passed through the cervix and the placenta
palpated. A digital examination should not be performed unless delivery is planned. A
cervical digital examination is done with the woman in an operating room and with
preparations for immediate cesarean delivery. Even the gentlest examination can cause
torrential hemorrhage.
Quick and accurate localization can be accomplished using standard sonographic
Techniques. In many cases, transabdominal sonography is confirmatory. xplanations
proposed to account for the false-positive error rate, summarized by Langlois and
colleagues, include placental conversion, overdistention of the urinary bladder, low-lying
myometrial contraction, or leiomyomas and extraembryonic blood clots.
1. Placental conversion is the main source of the false-positive results of the first and
second trimester diagnosis of placenta previa. Various studies have indicated that the
incidence of placenta previa in mid-gestation is more frequent than at term.The
explanation of placental conversion, supported by most authors, is based on the
theory that the uterus grows at a faster rate than the placenta as pregnancy
progresses. This differential growth rate results in a decrease in the proportion of the
inner uterine surface that is covered by placenta. Thus, with time, an initially

diagnosed low-lying placenta appears to be carried away from the os toward the
fundus.
2. Overdistention of the maternal urinary bladder is sometimes cited as a cause of falsepositive diagnosis of placenta previa. Apposition of the anterior and posterior walls of
the lower uterine segment may decrease the length of this segment and falsely
suggest a placenta previa. Although some authors recommend the routine use of
post-voiding scans, other doubt their usefulness, citing the difficulties of visualizing
the placenta and its relationship to the os without a full bladder.
3. Focal low-lying myometrial contractions may also distort the lower uterine segment
and contribute to a previa misdiagnosis. Myometrial contractions can either simulate
placental tissue or shorten the distance between the placental edge and the internal
os. Townsend and co-workers documented myometrial contractions in 16% of the
false-positive diagnoses and recommended repeat scanning after 30 minutes if the
myometrial thickness exceeds 1.5 cm.
4. Low-lying leiomyomas and extraembryonic blood clots can be easily confused with
low-lying placenta and cause false-positive results. Moreover, accurate localization of
placenta via the transabdominal route can be difficult in the presence of obesity and
posterior or lateral placentation. The acoustic shadow of the fetal head in a vertex
presentation may prevent an accurate localization of a low placenta.
.

Transvaginal sonographic placental localization appears to be a simple, reliable, and

safe technique, and it is recommended as a second-line diagnosis in patients who are
diagnosed to have minor placenta previa by transabdominal sonography. Transperineal
sonography is another technique for imaging the cervix during the third trimester of
pregnancy, allowing cervical visualization in most patients in whom transabdominal
sonography of this area is unsuccessful. Although transvaginal ultrasound is more commonly
used to complement transabdominal studies, a transperineal approach provides a more
convenient means of imaging the cervix and lower uterus without requiring specialized
equipment, vaginal penetration, or external fetal manipulation.
Despite the encouraging research results, MRI diagnosis of placenta previa is still an
experimental technique and is not widely used in a clinical setting. Disadvantages
associated with MRI for diagnosis of placenta previa include: (1) safety concerns regarding
moving a patient from labor and delivery to a radiology suite; (2) the relatively lengthy
examination (typically 3060 minutes); (3) long-term safety in pregnancy has yet to be
established; and (4) MRI scans are more costly than ultrasound examination. Although there
is some evidence for using MRI as a complementary technique to ultrasound, these barriers
effectively preclude its use in most patients.
Delivery
Practically all women with placenta previa undergo caesarean delivery. Many
surgeons recommend a vertical skin incision. Cesarean delivery is emergently performed in
more than half because of hemorrhage, for which about a fourth require blood transfusion.
Although a low transverse hysterotomy is usually possible, this may cause fetal bleeding if
there is an anterior placenta and the placenta is cut through. In such cases, fetal delivery
should be expeditious. Thus, a vertical uterine incision may be preferable in some instances.
That said, even when the incision extends through the placenta, maternal or fetal outcomes
are rarely compromised.
Following placental removal, there may be uncontrollable hemorrhage because of
poorly contracted smooth muscle of the lower uterine segment. Management can be as
follows:

Suturing implantation site

combined use of a Bakri balloon and compression sutures.
Packing of LUS
Hysterectomy
Others
o bilateral uterine or internal iliac artery ligation pelvic
o artery embolization
If these more conservative methods fail and bleeding is brisk, then hysterectomy is
necessary.

Maternal and perinatal Outcomes

Marked reduction in maternal mortality rates from placenta previa was achieved
during the last half of the 20th century. Optimal outcomes with vasa previa depend on
accurate antenatal diagnosis and cesarean delivery prior to membrane rupture.