Placenta Previa (322)

The facts

The placenta is a bed of cells formed inside the uterus (womb) during pregnancy. The purpose of the placenta is to carry nourishment and oxygen from the parent to the fetus and to carry waste products and carbon dioxide from the fetus to the parent through the umbilical cord.

The placenta is usually formed along the upper part of the uterus, allowing enough space for the fetus to grow. In placenta previa, the placenta starts forming very low in the uterus or even over the cervix (the opening of the uterus that leads to the vagina). This obstruction impairs normal vaginal delivery of the baby at birth.

There are 3 types of placenta previa:

• complete placenta previa: The internal cervical opening is completely covered by the placenta.
• partial placenta previa: The internal cervical opening is partially covered by the placenta.
• marginal placenta previa: The placenta is at the edge of the internal cervical opening.

A "low-lying" placenta does not cover or touch the cervix, but is within 2 centimetres of the opening. Placenta previa is estimated to occur in 1 in 250 pregnancies.

Causes

The causes and risk factors for placenta previa are:

• The fertilized egg implanted very low in the uterus, causing the placenta to form close to or over the cervical opening.
• The lining of the uterus (endometrium) has abnormalities such as fibroids or scarring (from previous previa, incisions, caesarean sections or abortions).
• The placenta formed abnormally.
• The pregnancy is multiple (i.e., twins or triplets). The chances of developing placenta previa are doubled for these pregnancies.
• The birth parent may have had several previous pregnancies. The chances of developing placenta previa are increased to 1 in 20 for people who have had 6 or more pregnancies.
• The birth parent smokes or uses cocaine. Smoking and cocaine use can increase the risk of this condition.
• The birth parent is older. The risk of developing placenta previa is 3 times as high in people over 30 years of age as in people under 20 years of age.
• The pregnancy has been conceived with the help of assisted reproductive technology, such as in-vitro fertilization.

Symptoms and Complications

Slight and occasional bleeding may occur during the first and second trimester of pregnancy. The colour of the blood may be bright red and it may start and stop, then restart after several days or weeks.

Sudden and excessive bleeding may occur in the third trimester of pregnancy.
Bleeding is usually not accompanied by pain, although uterine cramping may occur at the time of bleeding in some people. In up to one third of people, there may be no bleeding at all.

The bleeding occurs because as the pregnancy progresses, the placenta gets detached from the uterine walls. In the third trimester the uterine walls become thinner and spread to accommodate the growing fetus. If placenta previa is present, the placenta is attached very low on the uterine wall. This thinning makes the placenta stretch and tear away from the uterine wall, leading to bleeding.

The following are the possible complications of placenta previa:

• slow fetal growth due to insufficient blood supply
• fetal anemia
• fetal distress due to low oxygen supply
• shock and death of the birth parent if the bleeding is excessive
• infection and formation of blood clots
• blood loss requiring transfusion

If you are diagnosed with complete placenta previa, birth by caesarean section is usually advised.

Making the Diagnosis

The condition may be diagnosed by an ultrasound showing the position of the placenta. If it is detected late in the first or early in the second trimester, often the placenta's location will shift as the uterus enlarges. This can be followed by serial ultrasound. Some people may even remain undiagnosed until delivery, especially in cases of marginal placenta previa. Painless bleeding from the vagina during the third trimester of pregnancy may also indicate the condition.

In many cases, a diagnosis of placenta previa in the early weeks (usually before Week 20) may correct itself as the pregnancy progresses. In other cases, placenta previa may be missed if the placenta is located behind the baby's head.

If you have been diagnosed with placenta previa, your doctor will avoid digital (which means using the fingers) examination of the vagina and the cervix, as this could cause the placenta to tear and lead to heavy bleeding.
In addition to painless vaginal bleeding, other signs that your doctor may look for to confirm a diagnosis of placenta previa include:

• abdominal ultrasound during the second trimester showing the low placement of the placenta
• low-lying placenta revealed by transvaginal or transperineal ultrasound

Treatment and Prevention

Placenta previa is a condition that cannot be prevented. However, if you are at high risk, talk about this with your health care provider to avoid complications.

The treatment for placenta previa is usually aimed at minimizing symptoms and ensuring the pregnancy completes 36 weeks. The goal of this treatment is safe delivery of the fetus as close to term as possible by caesarean section. The treatment will therefore depend on answers to the following questions:

• What is the extent or amount of abnormal bleeding?
• How much of the placenta is covering the cervix?
• What is the position of the fetus in the uterus?
• Is the fetus developed enough to survive outside the uterus?
• How many births has the parent previously had?
• Has labour commenced?

Once placenta previa has been diagnosed, further bleeding and complications may be avoided by ensuring the parent has complete bed rest, sometimes in the hospital. Also, pelvic examinations or any sexual activity that may lead to irritation of the cervix or the uterine walls should be avoided.

Once the pregnancy comes to term, or if the bleeding is excessive, the baby will be delivered by caesarean section, especially in cases of complete placenta previa. Vaginal delivery for people with placenta previa might result in placental tear and hemorrhage, putting the parent and the baby at risk. Vaginal delivery may be possible for a person with a low-lying placenta.

With early and more accurate diagnosis of placenta previa, this condition is no longer as big a threat to the parent and the baby as it historically was. The biggest danger remains premature delivery of the baby because of the heavy bleeding. Corticosteroids may be given to help the baby’s lung development if premature delivery cannot be avoided.

[references]

• Mayo Clinic. Placenta previa. http://www.mayoclinic.com/health/placenta-previa/DS00588/METHOD=print.
• Joy S. Obstetrical Complications: Placenta Previa. http://emedicine.medscape.com/article/262063-overview.
• Journal Watch. 2005;4(11), Infertility Treatments Associated with Adverse Pregnancy Outcomes http://www.medscape.com/viewarticle/518668 (Accessed May 15/10)
• Merck Manual for Healthcare Professionals. Placenta Previa. http://www.merck.com/mmpe/sec18/ch263/ch263i.html.
• Oppenheimer, L. Diagnosis and Management of Placenta Previa. J Obsteet Gynaecol Can 2007;29(3):261-266. Available at: http://www.sogc.org/guidelines/documents/189e-cpg-march2007.pdf.
• Patient Education: Placenta previa (The Basics). UpToDate. Accessed Mar 11, 2020.
• Lockwood CJ, Russo-Stieglitz K. Placenta previa: Epidemiology, clinical features, diagnosis, morbidity and mortality. Last updated July 01, 2019. Accessed Mar 11, 2020.
• March of Dimes. Placenta previa. Available at : https://www.marchofdimes.org/find-support/topics/pregnancy/placenta-previa./ Last reviewed January 2022. Accessed December 7, 2023.