What is the order of management for placental previa?

Management Order for Placenta Previa

The management of placenta previa should follow a structured approach with early diagnosis, appropriate referral to a level III or IV maternal care center, and planned delivery at 34-36 weeks of gestation via cesarean section with a multidisciplinary team. 1

Diagnostic Phase

• Perform ultrasound examination at 18-20,28-30, and 32-34 weeks of gestation in at-risk patients 2
• Transvaginal ultrasonography is the diagnostic modality of choice for placenta previa 3
• Assess for risk factors:
  • Previous cesarean delivery
  • Prior uterine surgeries or curettage
  • Advanced maternal age
  • Multiparity
  • Smoking
  • Multifetal gestation 1
• Evaluate for signs of placenta accreta spectrum (PAS), especially with prior cesarean deliveries 1

Antenatal Management

1. Referral to appropriate facility

   • Transfer care to a level III or IV maternal care center with experience in managing placenta previa 1
   • Arrange co-management between local physicians and referral center to minimize travel 2

2. Multidisciplinary team assembly

   • Maternal-fetal medicine specialist
   • Experienced pelvic surgeon
   • Anesthesiologist
   • Blood bank personnel
   • Interventional radiologist (if needed)
   • Urologist (if bladder involvement suspected) 1

3. Expectant management for premature cases

   • Hospitalization for significant bleeding
   • Consider tocolytics for preterm contractions
   • Blood transfusion as needed 4
   • Antenatal corticosteroids if delivery anticipated before 37 weeks 1

Delivery Planning

1. Timing of delivery

   • Schedule cesarean delivery at 34-36 weeks of gestation 1
   • Earlier delivery may be required for:
     • Persistent bleeding
     • Preeclampsia
     • Labor
     • Rupture of membranes
     • Fetal compromise
     • Developing maternal comorbidities 1

2. Pre-operative preparation

   • Maximize preoperative hemoglobin values
   • Verify timing and location of delivery
   • Ensure necessary consultations have occurred 2
   • Prepare blood products (consider 1:1:1 to 1:2:4 ratio of packed red cells:fresh frozen plasma:platelets) 1
   • Consider cell salvage if available 1

Surgical Approach

1. For uncomplicated placenta previa

   • Cesarean delivery with transverse lower uterine segment incision away from placenta
   • Regional anesthesia is safe 3

2. For placenta previa with suspected accreta

   • Position patient in dorsal lithotomy
   • Consider vertical skin incision or wide transverse incision
   • Make uterine incision away from placenta when possible
   • Do not attempt to remove adherent placenta 1
   • Cesarean hysterectomy with placenta left in situ is standard approach 1
   • Consider ureteric stent placement if bladder involvement suspected 1

Management of Complications

1. Hemorrhage management

   • Activate massive transfusion protocol
   • Administer 1g IV tranexamic acid within 3 hours of delivery
   • Monitor and maintain fibrinogen levels >200 mg/dL 1
   • Consider interventional radiology techniques in select cases 1

2. Sepsis management

   • Broad-spectrum antibiotics (carbapenem or extended-range penicillin/β-lactamase inhibitor plus aminoglycoside)
   • Add vancomycin or linezolid if MRSA risk 1
   • Serial lactate measurements to assess response 1

Postoperative Care

• Intensive hemodynamic monitoring in ICU setting
• Vigilance for ongoing bleeding
• Monitor for complications (renal failure, liver failure, infection) 1
• Daily blood cultures until clearance if infection present 1

Special Considerations

• Conservative management (removing placenta without hysterectomy) should only be considered in carefully selected cases with focal placental adherence 2, 1
• Expectant management (leaving placenta in situ) has high failure rates, especially with placenta percreta (44%) 1
• Methotrexate is not recommended for hastening placental resorption due to unproven benefit and possible harm 2

The key to successful management of placenta previa is early diagnosis, appropriate referral, multidisciplinary planning, and delivery at an optimal time in a facility with adequate resources to handle potential complications.