What is the management plan for a patient diagnosed with placenta previa?

Management of Placenta Previa

Patients with placenta previa should be hospitalized if they have experienced any bleeding episode, as they are at high risk for subsequent bleeding that can lead to significant maternal and fetal morbidity and mortality. 1

Diagnosis and Initial Assessment

• Ultrasound Evaluation:

  • Transabdominal ultrasound is the mainstay for diagnosis 2
  • Transvaginal ultrasound provides more detailed evaluation of placental-myometrial interface 2
  • Doppler imaging is essential to assess placental vascularity and identify potential placenta accreta spectrum disorder 2

• Risk Assessment:

  • Evaluate for risk factors: prior cesarean delivery, multiparity, advanced maternal age, prior uterine surgery, smoking 3
  • Screen for placenta accreta spectrum disorder, especially with prior cesarean deliveries 1
  • MRI may be indicated if ultrasound findings are equivocal or to better define extent of invasion in suspected placenta accreta 2, 4

Management Protocol

For Stable Patients with No Active Bleeding:

1. Hospitalization Decision:

   • Hospitalize all patients who have had any bleeding episode, even if currently stable 1
   • Consider outpatient management only for carefully selected patients without bleeding history 5
   • Distance from hospital and logistical considerations should influence hospitalization decisions 1

2. Activity Restrictions:

   • Decreased activity is recommended for all patients 1
   • Avoid moderate-to-vigorous physical activity 1
   • Low-intensity activity (walking) may be maintained based on individual assessment 1

3. Antenatal Monitoring:

   • Regular ultrasound evaluations at 28-32 weeks to assess:
     • Placental location
     • Evidence of placenta accreta
     • Fetal growth
     • Cervical length 1

4. Anemia Management:

   • Evaluate and treat anemia
   • Consider iron supplementation (oral or IV) to optimize hemoglobin 1
   • Establish IV access with two large-bore catheters if bleeding occurs 1
   • Collaborate with blood bank to ensure availability of blood products 1

5. Corticosteroid Administration:

   • Complete a full course of antenatal corticosteroids (betamethasone or dexamethasone) for fetal lung maturation 1

For Patients with Active Bleeding:

1. Immediate Interventions:

   • Continuous monitoring of maternal vital signs and fetal heart rate 1
   • Establish IV access with two large-bore catheters 1
   • Send blood samples for complete blood count, coagulation profile, and type and cross-match 1
   • Prepare for potential emergency delivery if bleeding is heavy or maternal/fetal condition deteriorates 1

2. Transfusion Protocol:

   • Initiate massive transfusion protocol if necessary 6
   • Monitor for coagulopathy and replace blood products as needed 6

Delivery Planning

1. Timing of Delivery:

   • For stable patients with complete placenta previa: plan delivery at 34-35 weeks gestation 1
   • Earlier delivery may be required if:
     • Bleeding becomes heavy
     • Maternal condition deteriorates
     • Fetal compromise develops 1
   • Waiting beyond 36 weeks is not advised due to high risk of emergency delivery for hemorrhage 1

2. Mode of Delivery:

   • Cesarean delivery is the standard of care for complete placenta previa 1, 3
   • For low-lying placenta (1-2 cm from internal os), vaginal delivery may be considered based on individual assessment 7

3. Multidisciplinary Team Approach:

   • Coordinate with:
     • Maternal-fetal medicine
     • Anesthesiology
     • Neonatology
     • Blood bank
     • Interventional radiology and gynecologic oncology if placenta accreta is suspected 1

Special Considerations for Placenta Accreta Spectrum

• If placenta accreta is suspected, refer to a center with expertise in managing this condition 2
• Planned delivery at an experienced center is recommended whenever possible 2
• Preoperative coordination with anesthesiology, maternal-fetal medicine, neonatology, and expert pelvic surgeons 2
• Consider preoperative ureteric stent placement if bladder involvement is noted 2

Pitfalls and Caveats

• Do not discharge patients prematurely after a bleeding episode, as recurrent bleeding is common 1
• Digital pelvic examination should be avoided until placenta previa has been excluded 2
• Do not attempt forced placental removal during cesarean delivery as it can result in profuse hemorrhage 2
• Do not delay corticosteroid administration, as delivery before 37 weeks is likely 1
• Avoid routine use of preoperative placement of catheters or balloons into pelvic arteries, as serious complications may occur 2