Placenta Previa

If you have placenta previa, it means that your placenta is lying unusually low in your uterus, next to or covering your cervix. The placenta is the pancake-shaped organ normally located near the top of the uterus that supplies your baby with nutrients through the umbilical cord. If you're found to have placenta previa early in pregnancy, it's not usually considered a problem. But if the placenta is still close to the cervix later in pregnancy, it can cause bleeding, which can lead to other complications and may mean that you'll need to deliver early. If you have placenta previa when it's time to deliver your baby, you'll need to have a cesarean section. If the placenta covers the cervix completely, it's called a complete or total previa. If it's right on the border of the cervix, it's called a marginal previa. (You may also hear the term "partial previa," which refers to a placenta that covers part of the cervical opening once the cervix starts to dilate.) If the edge of the placenta is within two centimeters of the cervix but not bordering it, it's called a low-lying placenta. The location of your placenta will be checked during your mid-pregnancy ultrasound exam (usually done between 16 to 20 weeks) and again later if necessary.

What happens if I'm diagnosed with placenta previa?

It depends on how far along you are in pregnancy. Don't panic if your mid-pregnancy ultrasound shows that you have placenta previa. As your pregnancy progresses, your placenta is likely to "migrate" farther from your cervix and no longer be a problem.

(Since the placenta is implanted in the uterus, it doesn't actually move, but it can end up farther from your cervix as your uterus expands. Also, as the placenta itself grows, it's likely to grow toward the richer blood supply in the upper part of the uterus.) If placenta previa is seen on your second-trimester ultrasound, you'll have a follow-up ultrasound early in your third trimester to recheck the location of your placenta. If you have any vaginal bleeding in the meantime, you'll have an ultrasound to find out what's going on. Only a small percentage of women who have a low-lying placenta or previa detected on an ultrasound before 20 weeks still have it when they deliver their baby. A placenta that completely covers the cervix is more likely to stay that way than one that's bordering it (marginal) or nearby (low-lying). Overall, placenta previa is present in up to 1 in 200 deliveries.

What will happen if my previa persists?

If the follow-up ultrasound reveals that your placenta is still covering or too close to your cervix, you'll be put on "pelvic rest," which means no intercourse or vaginal exams for the rest of your pregnancy. And you'll be advised to take it easy and avoid activities that might provoke vaginal bleeding, such as strenuous housework or heavy lifting. When it's time to deliver, you'll need a c-section. With a complete previa, the placenta blocks the baby's way out. And even if the placenta is only bordering the cervix, you'll still need to deliver by c-section in most cases because the placenta can bleed profusely as the cervix dilates. You're likely to have some painless vaginal bleeding in the third trimester. If you do start bleeding (or if you have contractions), you'll have to be hospitalized. The bleeding happens when your cervix begins to thin out or open up (even a little), which disrupts the blood vessels in that area. What happens next will depend on how far along you are in your pregnancy, how heavy the bleeding is, and how you and your baby are doing. (By the way, if you have bleeding and you're Rh-negative, you'll need a shot of Rh immune globulin, unless the baby's father is Rh-negative, too.) If you're near full-term, your baby will be delivered by c-section right away. If your baby is still premature, he'll be delivered immediately if his condition warrants it or if you have heavy bleeding that doesn't stop. Otherwise, you'll be watched in the hospital until the bleeding stops. If you're less than 34 weeks, you may be given corticosteroids to speed up your baby's lung development and to prevent other complications in case he ends up being delivered prematurely. If the bleeding stops and you continue to remain free of bleeding for at least a couple of days and if both you and your baby are in good condition and you have quick access to a hospital should the bleeding start up again you may be sent home. But it's likely for the bleeding to start again at some point and, if this happens, you'll need to return to the hospital immediately.

If you and your baby continue to do well and you don't need to deliver right away, you'll have a scheduled c-section at around 37 weeks, unless there's a reason to intervene earlier. When making the decision, your medical team will weigh the benefit of giving your baby extra time to mature against the risk of waiting, with the possibility of facing an episode of heavy bleeding and the need for an emergency c-section.

What other complications can placenta previa cause?

Having placenta previa makes it more likely that you'll have heavy bleeding and need a blood transfusion. This is the case not only during pregnancy but also during and after delivery. Here's why: After a baby is delivered by c-section, the obstetrician delivers the placenta and the mother is given Pitocin (and possibly other medications). Pitocin causes the uterus to contract, which helps stop the bleeding from the area where the placenta was implanted. But when you have placenta previa, the placenta is implanted in the lower part of the uterus, which doesn't contract as well as the upper part so the contractions aren't as effective at stopping the bleeding. Women who have placenta previa are also more likely to have a placenta that's implanted too deeply and that doesn't separate easily at delivery. This is called placenta accreta. Placenta accreta can cause massive bleeding and the need for multiple blood transfusions at delivery. It can be life threatening and require a hysterectomy to control the bleeding. The incidence of placenta accreta has been on the rise, hand in hand with the rising c-section rate. That's because having a prior c-section makes it more likely that a woman with placenta previa will also have placenta accreta. In fact, the risk goes up dramatically as the number of prior c-sections goes up. Finally, if you need to deliver before term, your baby will be at risk for complications from premature birth such as breathing problems and low birth weight.

Who's most at risk for placenta previa?

Most women who develop placenta previa have no apparent risk factors. But if any of the following apply to you, you're more likely to have this complication:

You had placenta previa in a previous pregnancy. You've had c-sections before. (The more c-sections you've had, the higher the risk.) You've had some other uterine surgery (such as a D&C or fibroid removal). You're pregnant with twins or more. You're a cigarette smoker. You use cocaine.

Also, the more babies you've had and the older you are, the higher your risk.

Placenta previa
Placenta previa is a complication of pregnancy in which the placenta grows in the lowest part of the womb (uterus) and covers all or part of the opening to the cervix. The placenta grows during pregnancy and feeds the developing baby. The cervix is the opening to the birth canal.

Causes, incidence, and risk factors

During pregnancy, the placenta moves as the womb stretches and grows. It is very common for the placenta to be low in the womb in early pregnancy. But as the pregnancy continues, the placenta moves to the top of the womb. By the third trimester, the placenta should be near the top of the womb, so the cervix is open for delivery. Sometimes, the placenta partly or completely covers the cervix. This is called a previa. There are different forms of placenta previa:

Marginal: The placenta is next to cervix but does not cover the opening. Partial: The placenta covers part of the cervical opening. Complete: The placenta covers all of the cervical opening.

Placenta previa occurs in 1 out of 200 pregnancies. It is more common in women who have:

Abnormally developed uterus Large or abnormal placenta Many previous pregnancies Multiple pregnancy (twins, triplets, etc.) Scarring on the lining of the uterus, due to surgery, c-section, previous pregnancy, or abortion

Women who smoke or have their children at an older age may also have an increased risk.

Symptoms
The main symptom of placenta previa is sudden bleeding from the vagina. Some women have cramps, too. The bleeding often starts near the end of the second trimester or beginning of the third trimester. Bleeding may be severe. It may stop on its own but can start again days or weeks later. Labor sometimes starts within several days of heavy bleeding. Sometimes, bleeding may not occur until after labor starts.

Signs and tests

Your health care provider can diagnose this condition with a pregnancy ultrasound.

Treatment
Treatment depends on:

The amount of bleeding Whether the baby is developed enough to survive if delivered How much of the cervix is covered The baby's position The number of previous births you have had Whether you are in labor

If the placenta is near or covering a part of the cervix, your doctor may recommend:

Reducing your activities Bed rest Pelvic rest, which means no sex, no tampons, and no douching

Nothing should be placed in the vagina. You may need to stay in the hospital so your health care team can closely monitor you and your baby. If you have lost a lot of blood, you may receive:

Blood transfusions Medicines to prevent early labor Medicines to help pregnancy continue to at least 36 weeks Shot of special medicine called Rhogam if your blood type is Rh-negative Steroid shots to help the baby's lungs mature

Your health care providers will carefully consider the risk of bleeding against early delivery of your baby. After 36 weeks, delivery of the baby may be the best treatment. An emergency c-section may be done if the bleeding is heavy and cannot be controlled. Nearly all women with placenta previa need a c-section. If the placenta covers all or part of the cervix, a vaginal delivery can cause severe bleeding. This can be deadly to the mother and baby.

Expectations (prognosis)
Women with placenta previa need to be carefully monitored by a health care provider. Careful monitoring and delivery by c-section help prevent most complications. The biggest risk is severe bleeding that can be life threatening to the mother and baby. If you have severe bleeding, you baby may need to be delivered early, before major organs, such as the lungs, have developed.

Complications
Risks to the mother include:

Major bleeding (hemorrhage) Shock Death

Other risks include:

Blood clots Infection Need for blood transfusions

Risks to the baby include:

Blood loss in the baby Death

Most infant deaths due to placenta previa occur when the baby is delivered before 36 weeks of pregnancy.

Calling your health care provider

Call your health care provider if you have vaginal bleeding during pregnancy. Placenta previa can be dangerous to both you and your baby.

References
1. Francois KE, Foley MR. Antepartum and postpartum hemorrhage. In: Gabbe SG, Niebyl JR, Simpson JL, eds. Obstetrics - Normal and Problem Pregnancies. 5th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2007:chap 18. 2. Houry DE, Salhi BA. Acute complications of pregnancy. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosens Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, Pa: Mosby Elsevier; 2009:chap 176.

Placenta previa
Placenta previa is an obstetric complication that occurs in the second and third trimesters of pregnancy. It may cause serious morbidity and mortality to both the fetus and the mother. It is one of the leading causes of vaginal bleeding in the second and third trimesters.

Placenta previa. Placenta previa is generally defined as the implantation of the placenta over or near the internal os of the cervix.

Total placenta previa occurs when the internal cervical os is completely covered by the placenta. Partial placenta previa occurs when the internal os is partially covered by the placenta. Marginal placenta previa occurs when the placenta is at the margin of the internal os. Low-lying placenta previa occurs when the placenta is implanted in the lower uterine segment. In this variation, the edge of the placenta is near the internal os but does not reach it. A recent study concluded that more than two thirds of women with a distance of more than 10 mm from the placental edge to cervical os have vaginal delivery without an increased risk of hemorrhage.[1]

What is placenta previa? If you've heard the word, you have probably figured out just from the word alone that it has something to do with the placenta. You are exactly right. Placenta previa occurs when the placenta attaches in the lower portion of the uterus instead of in the normal position in the upper more muscular portion of the uterus. Placenta previa is a frequent cause of bleeding during the second and third trimester of pregnancy

What are the different types of placenta previa?

Complete previa - The placenta completely covers the cervix. Partial previa - The placenta covers a portion of the cervix, but does not completely cover the cervix. Marginal previa - The placenta extends to the edge of the cervix but does not cover it. This can also be called low placental implantation.

What is the cause of placenta previa?

The cause of placenta previa is unknown.

Am I at risk for placenta previa?

Placenta previa occurs in about 1 in 200 births. Risk factors include:

previous history of placenta previa multiple births having given birth before (second or greater pregnancy) smoking over the age of 35 surgery of the uterus prior delivery of a baby via cesarean section history of uterine abnormalities

Symptoms of placenta previa

Vaginal bleeding after 20 weeks of pregnancy is the primary symptom of placenta previa. Bleeding during pregnancy may have another cause, however, it is important to call your doctor if you experience bleeding. The placenta normally attaches to the upper portion of the uterus which is more muscular and stronger to support the placenta. However, in placenta previa the placenta attaches to the lower portion of the uterus which is weaker, thinner, and more vascular. As you enter your second and third trimester, the cervix begins to thin and stretch in preparation for labor. As this area stretches it can cause the villi (blood vessels) to break therefore causing bleeding. Placenta previa can lead

to complications for both mother and baby. Complications that may arise include placenta abruption, hemorrhaging, preterm labor, anemia for either mother or baby.

Treatment of placenta previa

Placenta previa will often correct itself during pregnancy. In more than 90 percent of women diagnosed with placenta previa in the second trimester, the placenta will correct itself by the end of the pregnancy. The placenta itself doesn't actually move, but as the uterus stretches it is not as close to the cervix as it was earlier in pregnancy. Think of it this way, imagine taking a balloon and drawing a circle on it at the lower end of the balloon. Then blow up your balloon. The circle doesn't actually move, but it may not still be at the lower end once it has completed stretching. So for the majority of women, placenta previa will correct itself. If placenta previa, however, does not correct itself there are several things that can be done to manage it. Placenta previa will usually require bedrest and frequent visits to your doctor or hospital. Vaginal exams are not recommended for the pregnant woman with placenta previa. You may be given steroid shots to mature your baby's lungs because you at risk for delivering early. Treatment will vary depending on how far along you are in your pregnancy and whether you have complete, partial, or marginal placenta previa. If you start bleeding or having contractions, you will be hospitalized. Your doctor will want to monitor you baby's heart rate and monitor your vital signs as well. If bleeding stops, your doctor may send you home on bedrest. If bleeding cannot be controlled an immediate cesarean section is given regardless of length of gestation. If bleeding is controlled your doctor will discuss scheduling a cesarean section with you. In most cases of placenta previa that does not correct itself, a cesarean section is necessary due to the location of the placenta. Complications after delivery Because the risk of hemorrhaging is higher for women with placenta previa, mothers will be monitored for signs of hemorrhaging. She may be given medications to control bleeding such as pitocin and a transfusion may sometimes be necessary. Anemia may occur in mother or baby therefore hemoglobin levels will be monitored and iron supplements may be given.