para>Do not perform digital cervical exam in any woman with a complaint of bleeding until placental position has been verified.
Careful sterile speculum exam can be performed to evaluate for vaginal/cervical source of bleeding.
Evaluate for rupture of membranes as cause for bleeding.
‚
DIFFERENTIAL DIAGNOSIS
- Abruptio placentae
- Vasa previa
- Labor
- Vaginal infections
DIAGNOSTIC TESTS & INTERPRETATION
- Transvaginal ultrasound is gold standard to identify placental position accurately (1)[A].
- Transabdominal US may be associated with incorrect diagnosis in 25% of cases (1).
- MRI if placenta accreta or percreta is suspected
- Fetal heart monitoring
Initial Tests (lab, imaging)
- Maternal blood type and antibody screen
- CBC
- Cross-match for 2 to 4 units if heavy bleeding
- Coagulation labs including fibrinogen, prothrombin time (PT), and partial thromboplastin time (PTT) if massive blood loss or abruption is suspected.
- Kleihauer-Betke test: Positive test indicates fetal " “maternal transfusion may be present and can determine Rho(D) immunoglobulin dosing in Rh-negative patients.
Follow-Up Tests & Special Considerations
- Repeat US to look for resolution.
- Assess CBC in cases of large blood loss.
TREATMENT
GENERAL MEASURES
- Avoid vaginal intercourse and strenuous exercise after 20 weeks.
- Avoid vaginal exams, sexual intercourse, douching, or other vaginal manipulation.
- Rh-negative women should receive 300 Ž Ľg Rho(D) immunoglobulin (RhoGAM).
- Supportive therapy
- Bed rest is not necessary.
MEDICATION
- Antenatal corticosteroids for symptomatic women 23 to 34 weeks to enhance fetal pulmonary maturity
- Magnesium sulfate for neuroprotection in preterm patients 24 to 32 weeks
- Oxygen supplementation if needed
- Adequate IV access via large-bore catheters
- Aggressive IV fluids/blood products as needed: fresh frozen plasma, platelets, and packed RBCs
- Use of tocolytics is controversial (1).
ISSUES FOR REFERRAL
- Maternal " “fetal medicine consult for delivery decisions regarding stable patients
- Neonatal ICU team should be alerted for high-risk delivery and consulted for preterm delivery.
- Appropriate interdisciplinary planning with blood bank, anesthesia, nursing staff in anticipation of placenta previa delivery
- Hospitals with obstetric units should consider massive transfusion protocols and staff training.
ADDITIONAL THERAPIES
Recombinant factor VII is an alternative blood product for DIC when fresh frozen plasma and cryoprecipitate fail. ‚
SURGERY/OTHER PROCEDURES
- Timing of delivery
- Delivery recommended between 36 0/7 and 37 6/7 weeks without documentation of fetal lung maturity by amniocentesis (2)[C]
- If accreta, increta, or percreta is suspected, may delivery between 34 0/7 and 35 6/7 weeks (2)[C].
- Emergent delivery should occur if (i) vaginal bleeding for nonreassuring fetal heart tracing, (ii) life-threatening maternal hemorrhage, or (iii) active labor.
- Route of delivery
- Cesarean delivery always indicated in scenario of complete previa and a viable fetus
- Reasonable for vaginal delivery if the placenta is > 20 mm from the internal os in the case of low-lying placenta.
- Emergent delivery should occur if (i) vaginal bleeding for nonreassuring fetal heart tracing, (ii) life-threatening maternal hemorrhage, or (iii) active labor.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- First episode of vaginal bleeding warrants prolonged inpatient monitoring.
- Symptomatic women often remain hospitalized from their initial or second significant bleed to the time of delivery.
- Should remain hospitalized until at least 48 hours without bleeding (1)
- Multiple large bleeds may necessitate admission until scheduled delivery between 34 and 36 weeks, depending on institutional guidelines.
- May consider transfer to high-risk perinatology service based on patient condition, local services, and concern for accreta
- Bed rest and NPO until delivery decision made
- Two large-bore IV sites and IV fluids as needed for resuscitation
- Continuous fetal heart and contraction monitoring
Nursing
- Continuous fetal heart tracing and tocometry
- Monitor vital signs and pad counts.
Discharge Criteria
- Demonstration of fetal well-being by fetal heart tracing/biophysical profile
- Demonstration of maternal hemodynamic stability
- No active bleeding for >48 hours
- Proximity of patient to health care facility and patient reliability
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Repeat US of placenta location if last US was done at <37 weeks ' gestational age.
- Placentae should be sent for pathologic evaluation.
DIET
No restrictions once stable; NPO if delivery possible ‚
PATIENT EDUCATION
www.nlm.nih.gov/medlineplus/ency/article/000900.htm ‚
PROGNOSIS
- Low maternal mortality
- Greatest fetal risk is preterm delivery and associated sequelae.
COMPLICATIONS
- Peripartum hysterectomy
- Especially with associated accreta/increta/percreta
- Blood transfusion
- DIC risk is low unless massive bleeding is present.
REFERENCES
11 Rao ‚ KP, Belogolovkin ‚ V, Yankowitz ‚ J, et al. Abnormal placentation: evidence-based diagnosis and management of placenta previa, placenta accreta, and vasa previa. Obstet Gynecol Surv. 2012;67(8):503 " “519.22 American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 560: medically indicated late-preterm and early-term deliveries. Obstet Gynecol. 2013;121(4):908 " “910.
ADDITIONAL READING
- Belfort ‚ MA. Placenta accreta. Am J Obstet Gynecol. 2010;203(5):430 " “439.
- Bhide ‚ A, Prefumo ‚ F, Moore ‚ J, et al. Placental edge to internal os distance in the late third trimester and mode of delivery in placenta praevia. BJOG. 2003;110(9):860 " “864.
- Briggs ‚ GG, Wan ‚ SR. Drug therapy during labor and delivery, part 2. Am J Health Syst Pharm. 2006;63(12):1131 " “1139.
- Committee on Obstetric Practice. Committee Opinion No. 529: placenta accreta. Obstet Gynecol. 2012;120(1):207 " “211.
- Downes ‚ KL, Hinkle ‚ SN, Sjaarda ‚ LA, et al. Previous prelabor or intrapartum cesarean delivery and risk of placenta previa. Am J Obstet Gynecol. 2015;212(5):669.e1 " “669.e6.
- Neilson ‚ JP. Interventions for suspected placenta praevia. Cochrane Database Syst Rev. 2003;(2):CD001998.
- Oyelese ‚ Y, Smulian ‚ JC. Placenta previa, placenta accreta, and vasa previa. Obstet Gynecol. 2006;107(4):927 " “941.
- Oyelese ‚ Y. Evaluation and management of low-lying placenta or placenta previa on second-trimester ultrasound. Contemp Ob Gyn. 2010;55(12):30 " “33.
- Predanic ‚ M, Perni ‚ SC, Baergen ‚ RN, et al. A sonographic assessment of different patterns of placenta previa "migration " ť in the third trimester of pregnancy. J Ultrasound Med. 2005;24(6):773 " “780.
- Rac ‚ MW, Dashe ‚ JS, Wells ‚ CE, et al. Ultrasound predictors of placental invasion: the placenta accreta index. Am J Obstet Gynecol. 2015;212(3):343.e1 " “343.e7.
- Robinson ‚ BK, Grobman ‚ WA. Effectiveness of timing strategies for delivery of individuals with placenta previa and accreta. Obstet Gynecol. 2010;116(4):835 " “842.
- Silver ‚ RM, Landon ‚ MB, Rouse ‚ DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006;107(6):1226 " “1232.
- Simon ‚ EG, Fouche ‚ CJ, Perrotin ‚ F. Three-dimensional transvaginal sonography in third-trimester evaluation of placenta previa. Ultrasound Obstet Gynecol. 2013;41(4):465 " “468.
- Stafford ‚ IA, Dashe ‚ JS, Shivvers ‚ SA, et al. Ultrasonographic cervical length and risk of hemorrhage in pregnancies with placenta previa. Obstet Gynecol. 2010;116(3):595 " “600.
CODES
ICD10
- O44.10 Placenta previa with hemorrhage, unspecified trimester
- O44.11 Placenta previa with hemorrhage, first trimester
- O44.12 Placenta previa with hemorrhage, second trimester
- O44.00 Placenta previa specified as w/o hemorrhage, unsp trimester
- O44.03 Placenta previa specified as w/o hemorrhage, third trimester
- O44.01 Placenta previa specified as w/o hemorrhage, first trimester
- O44.13 Placenta previa with hemorrhage, third trimester
- O44.02 Placenta previa specified as w/o hemor, second trimester
ICD9
- 641.10 Hemorrhage from placenta previa, unspecified as to episode of care or not applicable
- 641.13 Hemorrhage from placenta previa, antepartum condition or complication
- 641.11 Hemorrhage from placenta previa, delivered, with or without mention of antepartum condition
- 641.00 Placenta previa without hemorrhage, unspecified as to episode of care or not applicable
- 641.01 Placenta previa without hemorrhage, delivered, with or without mention of antepartum condition
- 641.03 Placenta previa without hemorrhage, antepartum condition or complication
SNOMED
- Placenta previa (disorder)
- Placenta previa with hemorrhage - not delivered
- Placenta previa with hemorrhage
- Placenta previa without hemorrhage
- Placenta previa with hemorrhage - delivered
CLINICAL PEARLS
- Placenta previa is a major cause of vaginal bleeding in the 2nd and 3rd trimesters.
- Many pregnancies diagnosed with placenta previa will have resolution by term.
- Do not perform digital cervical exam if placenta previa is being considered, only careful speculum exam.
- Delivery is almost exclusively by cesarean section.