What is the management plan for placenta previa totalis?

Management of Placenta Previa Totalis

For placenta previa totalis, planned cesarean delivery at 34 0/7 to 35 6/7 weeks of gestation at a tertiary care facility with multidisciplinary team coordination is the standard of care, with mandatory evaluation for placenta accreta spectrum disorder in all women with prior cesarean deliveries. 1, 2

Diagnostic Confirmation

• Transvaginal ultrasound is the gold standard for confirming placenta previa totalis, with 90.7% sensitivity and 96.9% specificity 2, 3
• Transabdominal ultrasound should be performed first, followed by transvaginal ultrasound for definitive assessment 2
• Digital pelvic examination must be absolutely avoided until placenta previa has been excluded, as it can trigger life-threatening hemorrhage 1, 3
• Doppler ultrasound should be used to identify vasa previa and assess placental blood flow patterns 2

Critical Risk Stratification for Placenta Accreta Spectrum

All women with placenta previa totalis and any prior cesarean delivery must be evaluated for placenta accreta spectrum disorder, as this dramatically increases morbidity and mortality 1, 2, 3

• Risk increases exponentially: 7-fold after one prior cesarean to 56-fold after three cesarean deliveries 1, 2
• Additional risk factors include advanced maternal age, high parity, prior uterine surgery, prior postpartum hemorrhage, Asherman syndrome, uterine anomalies, smoking, hypertension, and in vitro fertilization 1, 2
• MRI may be helpful when ultrasound findings are concerning for placenta accreta, particularly for posterior placenta previa or suspected placenta percreta 1, 2
• Failure to diagnose placenta accreta spectrum can lead to catastrophic hemorrhage 3

Antepartum Management and Activity Restrictions

• Women with asymptomatic placenta previa totalis can continue moderate-to-vigorous physical activity before 28 weeks 1, 2, 3
• After 28 weeks, moderate-to-vigorous physical activity must be avoided, but activities of daily living and low-intensity activity such as walking can be maintained 1, 2, 3
• Hospitalization is mandatory for any active bleeding 1, 2
• Ultrasound examinations should be scheduled at approximately 18-20 weeks, 28-30 weeks, and 32-34 weeks to assess placental location and possible bladder invasion 2

Anemia Optimization

• Hemoglobin values must be maximized during pregnancy by treating anemia with oral or intravenous iron as needed to prepare for potential massive hemorrhage at delivery 1, 2
• Baseline laboratory assessment should include platelet count, prothrombin time, partial thromboplastin time, and fibrinogen levels 1

Delivery Timing

Planned cesarean delivery at 34 0/7 to 35 6/7 weeks of gestation is recommended for uncomplicated placenta previa totalis, balancing neonatal complications against increased maternal bleeding risk after 36 weeks 1, 2, 3

• Delivery should not be delayed beyond 36 0/7 weeks, as approximately 50% of women with placenta accreta spectrum beyond 36 weeks require emergent delivery for hemorrhage 1, 2
• Earlier delivery is required for persistent bleeding, preeclampsia, labor, rupture of membranes, or fetal compromise 2, 3
• Antenatal corticosteroids should be administered when delivery is anticipated before 37 0/7 weeks 2
• Consider corticosteroid administration at 28 to 32 weeks if premature delivery is anticipated 1

Delivery Location and Multidisciplinary Team Assembly

Delivery must occur at a level III or IV maternal care facility with the following capabilities 1, 2:

• Maternal-fetal medicine subspecialists
• Expert pelvic surgeons (gynecologic oncologists or urogynecologists)
• Urologists for potential bladder involvement
• Interventional radiologists
• Obstetric anesthesiologists
• Neonatologists
• Blood bank capable of employing massive transfusion protocols
• Strong nursing leadership experienced in managing high-level postpartum hemorrhage

Preoperative Planning

• Preoperative coordination with anesthesiology, maternal-fetal medicine, neonatology, and expert pelvic surgeons is essential 1, 2
• The blood bank must be notified in advance due to the frequent need for large-volume blood transfusion 1, 2
• For suspected bladder involvement, consider ureteric stent placement and collaboration with urologic surgeons 1, 2
• A contingency plan for emergent delivery should be in place, as patients are at increased risk of prepartum hemorrhage as gestational age increases 1

Intraoperative Management

• Consider dorsal lithotomy positioning to allow access to vagina and optimal surgical visualization 1
• Inspect the uterus after peritoneal entry to determine placental location and optimize uterine incision approach 1
• The uterine incision should be made away from the placenta when possible 1, 2, 3
• After delivery of the fetus, leave the placenta in situ if there is evidence of abnormal placental attachment 1
• Forced placental removal must never be attempted, as this causes profuse hemorrhage 1, 3
• Regional anesthesia for cesarean delivery is safe in women with placenta previa 4

Hemorrhage Management Protocol

Massive transfusion protocol should be activated early rather than late 2, 3

• Transfuse packed red blood cells, fresh frozen plasma, and platelets in a 1:1:1 to 1:2:4 ratio for acute hemorrhage 1, 2
• Keep patients warm (>36°C) during surgery, as many clotting factors function poorly at lower temperatures 1
• Re-dose prophylactic antibiotics if blood loss ≥1,500 ml 1
• Tranexamic acid should be considered to reduce blood loss 2, 3

Management of Placenta Accreta Spectrum

For placenta accreta spectrum, cesarean hysterectomy with placenta left in situ is the most accepted approach, as attempts at placental removal are associated with significant hemorrhagic morbidity 1, 2, 5

Postoperative Care

• Intensive hemodynamic monitoring in the early postoperative period is recommended, often best provided in an intensive care unit setting 1, 2, 3
• Close monitoring of volume status, urine output, blood loss, and hemodynamics is critical 1, 2
• Maintain a low threshold for reoperation if ongoing bleeding is suspected 1, 2, 3
• Ensure adequate iron supplementation and follow-up of hemoglobin levels if significant blood loss occurred 1, 2

Common Pitfalls to Avoid

• Delayed activation of massive transfusion protocol worsens outcomes; activation should occur early 3
• Digital examination without excluding placenta previa can trigger life-threatening bleeding 3
• Attempting forced placental removal in cases of placenta accreta spectrum results in catastrophic hemorrhage 1, 3
• Delivering at a facility without adequate blood banking and multidisciplinary expertise increases maternal morbidity and mortality 1, 2