A score to predict the risk of emergency caesarean delivery in women with antepartum bleeding and placenta praevia

doi:10.1016/j.ejogrb.2015.10.015

European Journal of Obstetrics & Gynecology and Reproductive Biology

Volume 195, December 2015, Pages 173-176

https://doi.org/10.1016/j.ejogrb.2015.10.015 Get rights and content

Abstract

Objective

To identify antenatal events associated with emergency caesarean sections in women presenting with antepartum bleeding and placenta praevia and to establish a score to predict the risk of emergency caesarean after a first bleeding episode has resolved.

Study design

This retrospective multicentre study included 250 women presenting with antepartum bleeding and placenta praevia from 20 weeks of gestation until term in three maternity units. The score was constructed from data from 163 women after identification of antenatal risk factors associated with emergency caesareans for profuse bleeding due to placenta praevia. It was validated on a second independent cohort of 87 women.

Results

Three variables were significantly associated with emergency caesareans: major or complete praevia, defined as complete or partial praevia (OR = 33.15 (95% CI 4.3–257); p = 0.001), occurrence of 3 or more episodes of antepartum of uterine bleeding (OR = 2.53 (95% CI 1.1–5.86); p = 0.03), and a first (sentinel) bleeding episode before 29 weeks of gestation (OR = 2.64 (95% CI 1.17–5.98); p = 0.02). A fourth variable, moderate or severe antepartum uterine bleeding, was significantly associated with emergency caesareans in the univariate but not the multivariate analysis (p = 0.006). These four variables were incorporated into a weighted scoring system that included major praevia (4 points), three or more episodes of antepartum bleeding (3), first bleeding episode before 29 weeks of gestation (3), and bleeding episode estimated as moderate or severe (1). A score ≥6/11 had a sensitivity of 83% and a specificity of 65% for predicting an emergency caesarean in the score development group and 95% and 62% in the validation group.

Conclusion

A scoring system for placenta praevia with previous bleeding events, based on intensity, gestational age at sentinel bleed (before 29 weeks), number of bleeding episodes (≥3) and type of praevia (major) might be helpful to guide obstetric management and especially to determine the need for admission.

Introduction

Placenta praevia (PP) with antepartum bleeding has a reported incidence rate of 0.3–0.5% and is associated with high rates of maternal and fetal morbidity [1]. As the main risk factors for PP – maternal age above 40 years and previous caesarean deliveries [2], [3] – continue to rise, the rates of PP and its complications will increase with them. Maternal risks include antepartum bleeding, intrapartum and postpartum haemorrhage, and need for hysterectomy and blood transfusion [1], [4], [5], [6]. Outcomes of pregnancies complicated by PP are highly variable, and it is difficult to predict antenatal events of heavy and sudden uterine haemorrhaging that requires emergency caesarean delivery. Guidelines (most recently republished in 2011) by the Royal College of Obstetricians and Gynaecologists [7] recommend that women with major praevia (complete and partial PP) with previous bleeding events should be admitted at or after 34 weeks’ gestation, and that outpatient care should be considered for those with minor praevia (marginal and low-lying PP) or those without previous antepartum bleeding episodes. Nonetheless, a randomized controlled trial comparing hospital vs home care published in 1996 [8] showed a significant reduction in length of hospital stay without severe maternal and neonatal complications. The current literature has otherwise failed to identify antenatal events associated with a high risk of maternal or fetal morbidity. This study sought to identify antenatal events associated with emergency caesarean sections for profuse haemorrhage in women presenting with antepartum bleeding and PP after a first episode of such bleeding. Our objective was to establish a predictive score for emergency caesareans after the resolution of a first (sentinel) bleeding episode to help guide the obstetric management of these women.

Section snippets

Material and methods

This retrospective multicentre study examined records of women with PP from 1998 to 2013 in three maternity departments: two in Marseille, Hôpital Nord and Hôpital de la Conception, and the Hôpital d’Aix en Provence. Using the hospital's standard codes, we searched for all pregnant women during the study period who were admitted with intact membranes for antepartum bleeding and PP from 20 weeks of gestation until term and gave birth at the same hospital to a live newborn after 24 weeks. Women

Results

This study included 250 patients: 163 for the score development, and 87 for its validation. Of the 163 patients in the score development group, 46 had emergency caesareans for profuse antepartum bleeding for PP and 117 gave birth by other modes: either other caesareans (n = 81) or vaginal delivery (n = 36). An earlier gestational age at delivery (34.8 vs 37.6 weeks’ gestation; p < 0.001), lower birth weight (2128 g vs 2809 g, p < 0.001), and more postpartum haemorrhages (30.4% vs 8.5%, p < 0.001) were all

Discussion

The RCOG guidelines, last republished in 2011, recommend that women with major PP with a previous bleeding episode should be admitted to hospital and managed as inpatients from 34 weeks’ gestation [7]. Underlying these guidelines is the strong concern that sudden heavy bleeding could lead to maternal death. In the absence of identified risk factors, management has traditionally been cautious and has led to admissions that last for weeks to prevent or minimize serious maternal or fetal

Conclusion

An antepartum PP score including intensity, precocity of first bleeding, number of bleeding episodes and type of PP might be helpful in determining whether women with PP should be managed as in- or out-patients.

Conflict of interest

Claude d’Ercole consults for LFB and Ferring. Other authors report no conflict of interest.

References (14)

T. Rosenberg et al.
Critical analysis of risk factors and outcome of placenta previa
Arch Gynecol Obstet
(2011)
E. Sheiner et al.
Placenta previa: obstetric risk factors and pregnancy outcome
J Matern Fetal Med
(2001)
Y. Oyelese et al.
Placenta previa, placenta accreta, and vasa previa
Obstet Gynecol
(2006)
M.G. Zlatnik et al.
Placenta previa and the risk of preterm delivery
J Matern Fetal Neonatal Med
(2007)
S.S. Osmundson et al.
Second-trimester placental location and postpartum hemorrhage
J Ultrasound Med
(2013)
C.M. Lam et al.
Risk factors for preterm delivery in women with placenta praevia and antepartum hemorrhage: retrospective study
Hong Kong Med J
(2002)
Royal College of Obstetricians and Gynaecologists (RCOG)
Placenta praevia, placenta praevia accreta and vasa praevia: diagnosis and management
(2011, January)

There are more references available in the full text version of this article.

Cited by (35)

Placenta accreta spectrum care infrastructure: an evidence-based review of needed resources supporting placenta accreta spectrum care
2024, American Journal of Obstetrics and Gynecology MFM
The incidence of placenta accreta spectrum, the deeply adherent placenta with associated increased risk of maternal morbidity and mortality, has seen a significant rise in recent years. Therefore, there has been a rise in clinical and research focus on this complex diagnosis. There is international consensus that a multidisciplinary coordinated approach optimizes outcomes. The composition of the team will vary from center to center; however, central themes of complex surgical experts, specialists in prenatal diagnosis, critical care specialists, neonatology specialists, obstetrics anesthesiology specialists, blood bank specialists, and dedicated mental health experts are universal throughout. Regionalization of care is a growing trend for complex medical needs, but the location of care alone is just a starting point. The goal of this article is to provide an evidence-based framework for the crucial infrastructure needed to address the unique antepartum, delivery, and postpartum needs of the patient with placenta accreta spectrum. Rather than a clinical checklist, we describe the personnel, clinical unit characteristics, and breadth of contributing clinical roles that make up a team. Screening protocols, diagnostic imaging, surgical and potential need for critical care, and trauma-informed interaction are the basis for comprehensive care. The vision from the author group is that this publication provides a semblance of infrastructure standardization as a means to ensure proper preparation and readiness.
Gestation of delivery in people with antepartum hemorrhage and placenta previa
2023, American Journal of Obstetrics and Gynecology MFM
Emergent prelabor cesarean delivery in solid organ transplant recipients: associated risk factors and outcomes
2023, American Journal of Obstetrics and Gynecology MFM
Citation Excerpt :
This study focused on anesthesia management and neither further defines or characterizes the emergent cesarean deliveries nor discusses why there was a higher rate of emergent cesarean delivery in transplant recipients. Certain other obstetrical populations have been identified to be at an increased risk of prelabor emergent cesarean delivery owing to deterioration of maternal or fetal status, including patients with advanced maternal age,22 type I diabetes mellitus,23 and placenta previa.24 Our group recently studied the indications for cesarean delivery in solid organ transplant recipients and associated outcomes over 5 decades of clinical practice.25
Pregnancies after solid organ transplant are at a higher risk of antepartum admission and pregnancy complications including cesarean delivery. Emergent prelabor cesarean delivery is associated with increased maternal and neonatal morbidity in other high-risk populations, but its incidence and impact in transplant recipients is not well-understood.
This study aimed to characterize the risk factors and outcomes of emergency prelabor cesarean delivery in kidney and liver transplant recipients.
This was a retrospective cohort study of all kidney and liver transplant recipients at >20 weeks gestation enrolled in the Transplant Pregnancy Registry International between 1976 and 2019. Participants admitted antepartum who required emergency prelabor cesarean delivery were compared with those admitted antepartum who underwent nonemergent birth. The primary outcomes were severe maternal morbidity and neonatal composite morbidity. Multivariable logistic regression was conducted for neonatal composite morbidity.
Of 1979 births, 181 pregnancies (188 neonates) with antepartum admission were included. 51 pregnancies (53 neonates, 28%) were delivered by emergent prelabor cesarean delivery compared with 130 pregnancies (135 neonates, 72%) admitted antepartum who subsequently did not require emergent delivery. The most common indication for emergent delivery was nonreassuring fetal heart tracing (44 pregnancies /51 emergent deliveries = 86%). Pregnant people who underwent emergent prelabor cesarean delivery were less likely to deliver at a transplant center (37.3% vs 41.5%; P=.04) and had increased rates of chronic hypertension (33.3% vs 16.2%; P=.02). There was no significant difference in severe maternal morbidity (3.9% vs 4.6%; P=.84), though there was an increase in surgical site infection in the emergent prelabor cesarean delivery cohort (3.9% vs 0%; P=.02). Among those with emergent prelabor cesarean delivery, there was a significant increase in neonatal composite morbidity (43.4% vs 19.3%; P<.001) with earlier gestational age at delivery (33.4 vs 34.7 weeks; P=.02), lower birthweight (1899 g vs 2321 g; P<.001), lower birthweight percentile (30.3% vs 40.6%; P=.03), increased neonatal intensive care unit admission (52.8% vs 35.6%; P=.03), and increased neonatal mortality (11.3% vs 1.5%; P=.002). After adjusting for year of conception, race, hypertensive disorders, and fetal malformations, there was a persistent increased risk of neonatal morbidity (adjusted odds ratio, 3.01; 95% confidence interval, 1.50–6.08; P=.002) associated with emergent prelabor cesarean delivery after transplant.
Almost one-third of kidney and liver transplant recipients admitted antepartum had an emergency prelabor cesarean delivery, and 63% of this cohort delivered outside of a transplant center. Pregnancies after transplantation should involve multidisciplinary transplant-obstetrics collaboration to ensure optimal antepartum disease management, especially for preexisting hypertension, to prevent and mitigate obstetrical and neonatal morbidity in the setting of emergent cesarean delivery.
Guideline No. 402: Diagnosis and Management of Placenta Previa
2020, Journal of Obstetrics and Gynaecology Canada
Citation Excerpt :
In the absence of risk factors (Box 1), outpatient management of women with placenta previa has been shown to be safe.13,41,45 The risk of urgent/preterm cesarean delivery is increased in women with a history of antepartum hemorrhage, particularly the first episode (sentinel bleed) <29 weeks gestation or recurrent episodes (≥3), or with a thick placental edge covering (or close to) the cervical os, short cervical length (<3 cm with placenta previa, <2 cm with low-lying placenta), or a previous cesarean delivery the risk of urgent/preterm cesarean delivery is increased.7,16,17,26,36,37,39,40,46–48 In these patients, in-hospital management should be considered.
To summarize the current evidence and to make recommendations for diagnosis and classification of placenta previa and for managing the care of women with this diagnosis.
To manage in hospital or as an outpatient and to perform a cesarean delivery preterm or at term or to allow a trial of labour when a diagnosis of placenta previa or a low-lying placenta is suspected or confirmed.
Prolonged hospitalization, preterm birth, rate of cesarean delivery, maternal morbidity and mortality, and postnatal morbidity and mortality.
Family physicians, obstetricians, midwives, and other maternal care providers.
Pregnant women with placenta previa or low-lying placenta.
Medline, PubMed, Embase, and the Cochrane Library were searched from inception to October 2018. Medical Subject Heading (MeSH) terms and key words related to pregnancy, placenta previa, low-lying placenta, antepartum hemorrhage, short cervical length, preterm labour, and cesarean. This document represents an abstraction of the evidence rather than a methodological review.
This guideline has been reviewed by the Maternal–Fetal Medicine and Diagnostic Imaging committees of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and approved by the SOGC Board of Directors.
Women with placenta previa or low-lying placenta are at increased risk of maternal, fetal and postnatal adverse outcomes that include a potentially incorrect diagnosis and possibly unnecessary hospitalization, restriction of activities, early delivery, or cesarean delivery. Optimization of diagnosis and management protocols has potential to improve maternal, fetal and postnatal outcomes.
- 1
  All women with placenta previa or low-lying placenta have an increased risk of a morbidly adherent placenta, particularly those who have had a prior cesarean delivery (strong/moderate).
- 2
  In women with placenta previa or a low-lying placenta, presence of a marginal/velamentous cord insertion close to the cervical os or a succenturiate placental lobe increases the risk of vasa previa (strong/moderate).
- 3
  History of antepartum hemorrhage (first episode <29 weeks or recurrent episodes [≥3]), a thick placental edge covering (or close to) the cervical os, short cervical length (<3 cm with placenta previa, <2 cm with low-lying placenta), and a previous cesarean delivery are risk factors with an associated increased risk of urgent/preterm cesarean delivery (strong/moderate).
- 4
  In the absence of risk factors, outpatient management of women with placenta previa is safe (strong/moderate).
- 5
  Bed rest or reduced activity is not beneficial in women with placenta previa and can be potentially harmful. However, sexual intercourse/insertion of foreign bodies in vagina or rectum should be avoided (conditional [weak]/low).
- 6
  Preoperative bedside ultrasound assessment of placental location can be useful for planning of surgical technique and may reduce risk of intraoperative transection of placenta (conditional [weak]/low).
- 7
  Regional anaesthesia is safe and adequate as a first-line anaesthetic approach for the peripartum management of patients with placenta previa or low-lying placenta (conditional [weak]/low).
- 8
  When deciding the location of delivery, consider ultrasound assessment of placental location, any risk factors, the patient's history, and logistical factors, including available resources at the delivery unit (conditional [weak]/low).
- 1
  Classify placental location as placenta previa (placenta covering the cervical os), low-lying placenta (edge located ≤20 mm from cervical os), or normally located placenta (edge located >20 mm from cervical os) (strong/moderate).
- 2
  Diagnosis of placenta previa or low-lying placenta should not be made <18 to 20 weeks gestation, and the provisional diagnosis must be confirmed after >32 weeks gestation, or earlier if the clinical situation warrants. In women with a low-lying placenta, a recent ultrasound (within 7 to 14 days) should be used to confirm placental location prior to a cesarean delivery (strong/moderate).
- 3
  Assessment by transvaginal ultrasound is recommended in all cases where placenta previa or a low-lying placenta is present or suspected by transabdominal sonography, with attempt to clearly define placental location (including laterality), characteristics of placental edge (including thickness, presence of a marginal sinus), and associated findings (succenturiate lobe, cord insertion close to the cervix) (strong/moderate).
- 4
  In women with placenta previa or low-lying placenta and in the presence of risk factors or limited access to urgent obstetrical care, consider in-hospital management (strong/moderate).
- 5
  A cervical cerclage can be considered in women with a short cervical length, particularly in association with antepartum hemorrhage, but not as a prophylactic measure for all women with placenta previa (conditional [weak]/low).
- 6
  Administer antenatal corticosteroids for potential preterm delivery only if the risk of delivery within 7 days is very high and not solely because admission to the hospital is deemed necessary (strong/moderate).
- 7
  Tocolysis can be considered in women with antepartum hemorrhage associated with uterine contractions in order to allow administration of corticosteroids or transfer of care, but not for prolongation of pregnancy (conditional [weak]/low).
- 8
  Cesarean delivery is recommended in women with placenta previa at 36⁰ to 36⁶ weeks gestation in the presence of risk factors and at 37⁰ to 37⁶ weeks gestation in the absence of risk factors (strong/moderate).
- 9
  Cesarean delivery is recommended in women with a low-lying placenta with the placental edge ≤10 mm from the cervical os at 37⁰ to 37⁶ weeks gestation in the presence of risk factors and at 38⁰ to 38⁶ weeks gestation in the absence of risk factors (strong/moderate).
- 10
  A trial of labour is recommended in women with a low-lying placenta where the placental edge is 11 to 20 mm from the cervical os and can be considered in carefully selected women where the placental edge is ≤10 mm from the cervical os (strong/moderate).
Directive clinique n<sup>o</sup> 402: Placenta prævia: Diagnostic et prise en charge
2020, Journal of Obstetrics and Gynaecology Canada
Résumer les données probantes actuelles et formuler des recommandations pour le diagnostic et la classification du placenta prævia et pour la prise en charge des femmes ayant reçu ce diagnostic.
En cas de diagnostic soupçonné ou confirmé de placenta prævia ou de placenta bas inséré, prendre en charge la patiente en milieu hospitalier ou en consultation externe puis pratiquer une césarienne avant ou à terme ou effectuer une épreuve d'accouchement.
Hospitalisation prolongée, accouchement prématuré, taux de césariennes, morbidité et mortalité maternelles, et morbidité et mortalité postnatales.
Médecins de famille, obstétriciens, sages-femmes, et autres fournisseurs de soins de maternité.
Femmes enceintes présentant un placenta prævia ou un placenta bas inséré.
Une recherche a été effectuée dans les bases de données Medline, PubMed et Embase ainsi que dans Cochrane Library, de leur création jusqu’à octobre 2018, au moyen de termes MeSH (Medical Subject Heading) et de mots-clés liés aux termes suivants : grossesse, placenta prævia, placenta bas inséré, hémorragie ante partum, col court, travail avant terme et césarienne. Le présent document est un résumé des données probantes et non pas une revue méthodologique.
La présente directive clinique a été revue par le comité de médecine fœto-maternelle et le comité d'imagerie diagnostique de la Société des obstétriciens et gynécologues du Canada (SOGC) puis approuvée par le conseil d'administration de la SOGC.
Les femmes ayant un placenta prævia ou un placenta bas inséré présentent un risque accru d'issues maternelles, fœtales et postnatales défavorables, ce qui comprend un diagnostic potentiellement erroné et une hospitalisation possiblement injustifiée, une restriction des activités, un accouchement précoce ou une césarienne. L'optimisation des protocoles de diagnostic et de prise en charge peut améliorer les issues maternelles, fœtales et postnatales.
- 1
  Toutes les femmes ayant un placenta prævia ou un placenta bas inséré présentent un risque accru d'adhérence morbide du placenta, en particulier celles qui ont déjà subi une césarienne (forte, moyenne).
- 2
  Chez les femmes ayant un placenta prævia ou un placenta bas inséré, la présence d'une insertion marginale ou vélamenteuse du cordon ombilical près de l'orifice interne du col ou d'un lobe placentaire accessoire augmente le risque de vasa prævia (forte, moyenne).
- 3
  Les facteurs associés à une augmentation du risque de césarienne d'urgence ou avant terme sont les antécédents d'hémorragie ante partum (premier épisode < 29 semaines d'aménorrhée ou épisodes répétés [≥ 3]), le bord placentaire épais recouvrant (ou près de) l'orifice interne du col, le col court (< 3 cm pour le placenta prævia, < 2 cm pour le placenta bas inséré) et la présence d'une cicatrice césarienne (forte, moyenne).
- 4
  En l'absence de facteur de risque, la prise en charge en consultation externe des femmes ayant un placenta prævia est sécuritaire (forte, moyenne).
- 5
  L'alitement et la réduction des activités ne sont pas bénéfiques pour les femmes ayant un placenta prævia et sont potentiellement nuisibles. Toutefois, il y a lieu de déconseiller les rapports sexuels et l'insertion de tout corps étranger dans le vagin ou le rectum (conditionnelle [faible], basse).
- 6
  L’évaluation échographique préopératoire faite au lit de la patiente pour déterminer la localisation placentaire peut s'avérer utile pour planifier la technique chirurgicale et réduire le risque de section transversale peropératoire du placenta (conditionnelle [faible], basse).
- 7
  L'anesthésie régionale est sécuritaire et constitue un mode d'anesthésie de première ligne adéquat pour la prise en charge périnatale des patientes ayant un placenta prævia ou un placenta bas inséré (conditionnelle [faible], basse).
- 8
  Pour déterminer le lieu de l'accouchement, il y a lieu de prendre en compte l’évaluation échographique de la localisation placentaire, la présence de facteurs de risque, les antécédents de la patiente et les facteurs logistiques, y compris les ressources disponibles à l'unité des naissances (conditionnelle [faible], basse).
- 1
  La localisation placentaire doit être classée comme un placenta prævia (placenta recouvrant l'orifice interne du col), un placenta bas inséré (bord à ≤ 20 mm de l'orifice interne du col) ou un placenta normalement localisé (bord à > 20 mm de l'orifice interne du col) (forte, moyenne).
- 2
  Le diagnostic du placenta prævia ou de placenta bas inséré ne doit pas être fait avant 18 à 20 semaines d'aménorrhée; ce diagnostic provisoire nécessite une confirmation, laquelle peut être obtenue à compter de 32 semaines d'aménorrhée ou plus tôt si la situation clinique le justifie. Chez les femmes ayant un placenta bas inséré, il y a lieu d'utiliser une évaluation échographique récente (dans les 7 à 14 jours) pour confirmer la localisation placentaire avant la césarienne (forte, moyenne).
- 3
  L’évaluation par échographie endovaginale est recommandée pour tous les cas soupçonnés ou confirmés de placenta prævia ou de placenta bas inséré d'après l’échographie obstétricale afin de tenter de déterminer clairement la localisation placentaire (y compris la latéralisation), les caractéristiques du bord placentaire (y compris l’épaisseur, la présence d'un sinus marginal) et les observations associées (lobe placentaire accessoire, insertion du cordon près du col) (forte, moyenne).
- 4
  Chez les femmes ayant un placenta prævia ou un placenta bas inséré, il y a lieu d'envisager la prise en charge en milieu hospitalier en présence de facteurs de risque ou en cas d'accès limité à des soins obstétricaux d'urgence (forte, moyenne).
- 5
  Il est possible d'envisager le cerclage du col chez les femmes présentant un col court, en particulier en association avec une hémorragie ante partum, mais il ne s'agit pas d'une mesure préventive pour toutes les femmes ayant un placenta prævia (conditionnelle [faible], basse).
- 6
  Il convient d'administrer une corticothérapie prénatale pour l'accouchement prématuré potentiel uniquement si le risque d'accouchement dans les 7 jours est très élevé et non pas seulement parce que l'hospitalisation est jugée nécessaire (forte, moyenne).
- 7
  La tocolyse peut être envisagée chez les femmes qui présentent une hémorragie ante partum associée à des contractions utérines pour gagner du temps afin d'administrer une corticothérapie ou d'effectuer un transfert de soin et non pas pour prolonger la grossesse (conditionnelle [faible], basse).
- 8
  En cas de césarienne indiquée pour un placenta prævia, il est recommandé de la pratiquer entre 36 SA + 0 j et 36 SA + 6 j en présence de facteurs de risque et entre 37 SA + 0 j et 37 SA + 6 j en l'absence de facteur de risque (forte, moyenne).
- 9
  En cas de césarienne indiquée pour un placenta bas inséré avec un bord placentaire à ≤ 10 mm de l'orifice interne du col, il est recommandé de la pratiquer entre 37 SA + 0 j et 37 SA + 6 j en présence de facteurs de risque et entre 38 SA + 0 j et 38 SA + 6 j en l'absence de facteur de risque (forte, moyenne).
- 10
  L’épreuve de travail est recommandée chez les femmes ayant un placenta bas inséré dont le bord se situe de 11 à 20 mm de l'orifice interne du col; l’épreuve peut aussi être envisagée dans les cas soigneusement sélectionnés de bord placentaire à ≤ 10 mm de l'orifice interne du col (forte, moyenne).
Major or minor placenta previa: Does it make a difference?
2019, Placenta
Citation Excerpt :
Pivano et al. established a score to predict the risk of emergency CS after the first bleeding episode [25]. Major PP seemed to be a major contributor [25]. In our study, women with minor PP had a higher rate of emergency CS than women with major PP.
Placenta previa is a severe pregnancy complication with considerable maternal and neonatal morbidity. Placenta previa can be defined as major or minor by location. Major placenta previa is associated with higher complication rates. Management of women with minor placenta previa has not been well defined. The primary goal of the study was to evaluate the accuracy of our existing screening protocol for placenta previa. Secondly, we wanted to compare pregnancy and delivery outcomes by the type of placenta previa.
The study was conducted at the Helsinki University Hospital between June 2010 and September 2014. The study population consisted of all women with the antenatal ultrasound diagnosis of placenta previa during delivery. Data were retrospectively collected and analysed.
Altogether 176 women had placenta previa at delivery (major 129, minor 47). Placenta previa remained undiagnosed at second trimester screening ultrasound in 32 women (18.2%). Twenty (62.5%) of these cases had minor placenta previa and 12 (37.5%) had major placenta previa. Five (15.6%) of the undiagnosed cases developed life-threatening hemorrhage (≥2500 ml) during the delivery and two had abnormally invasive placenta followed by hysterectomy. Women with major placenta previa had significantly more blood loss and delivered earlier than women with minor placenta previa. The groups were otherwise similar, including the rate of abnormally invasive placenta.
The existing protocol for placenta previa missed almost one fifth of cases. Both major and minor placenta previa are risk factors for abnormally invasive placenta and should be treated as severe conditions.

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A score to predict the risk of emergency caesarean delivery in women with antepartum bleeding and placenta praevia

Abstract

Objective

Study design

Results

Conclusion

Introduction

Section snippets

Material and methods

Results

Discussion

Conclusion

Conflict of interest

Critical analysis of risk factors and outcome of placenta previa

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Placenta previa: obstetric risk factors and pregnancy outcome

J Matern Fetal Med

Placenta previa, placenta accreta, and vasa previa

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Placenta previa and the risk of preterm delivery

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Second-trimester placental location and postpartum hemorrhage

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Risk factors for preterm delivery in women with placenta praevia and antepartum hemorrhage: retrospective study

Hong Kong Med J

Placenta praevia, placenta praevia accreta and vasa praevia: diagnosis and management