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Placenta previa

Key sources
The following summarized guidelines for the evaluation and management of placenta previa are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2020) and the Royal College of Obstetricians and Gynaecologists (RCOG 2019).
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Guidelines

1.Screening and diagnosis

Indications for screening: determine placental location during mid-pregnancy routine fetal ultrasound to identify women at risk of persisting placenta previa or a low-lying placenta.
B
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  • Diagnosis

2.Classification and risk stratification

Risk factors
Recognize that Cesarean delivery is associated with an increased risk of placenta previa in subsequent pregnancies and this risk rises as the number of prior C-sections increases.
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Recognize that ART and maternal smoking increase the risk of placenta previa.
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  • Terminology

  • Risk stratification

3.Diagnostic investigations

Ultrasound: as per SOGC 2020 guidelines, obtain ultrasound to confirm placental location in patients with a low-lying placenta within 7-14 days before Cesarean delivery.
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4.Medical management

Setting of care
As per SOGC 2020 guidelines:
Offer outpatient management in patients with placenta previa in the absence of risk factors.
B
Consider offering in-hospital management in patients with placenta previa or low-lying placenta in the presence of risk factors or limited access to urgent obstetrical care.
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  • Antenatal corticosteroids

  • Tocolytics

  • Management of anemia

5.Nonpharmacologic interventions

Bed rest: advise patients with placenta previa to avoid bed rest or reduced activity.
B

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  • Pelvic rest

6.Therapeutic procedures

Cervical cerclage: as per SOGC 2020 guidelines, consider performing cervical cerclage in patients with a short cervical length, particularly in association with antepartum hemorrhage, but not as a prophylactic measure in all patients with placenta previa.
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  • Setting of delivery

  • Timing of delivery

  • Mode of delivery

  • Trial of labor

7.Perioperative care

Regional anesthesia: as per SOGC 2020 guidelines, administer regional anesthesia as first-line anesthetic approach for the peripartum management of patients with placenta previa or low-lying placenta.
B

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  • Intrapartum fluid resuscitation

  • Peripartum blood transfusion

8.Surgical interventions

Cesarean section, indications
Offer Cesarean delivery in patients with placenta previa at 36⁰ to 36⁶ weeks of gestation in the presence of risk factors and at 37⁰ to 37⁶ weeks of gestation in the absence of risk factors.
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Offer Cesarean delivery in patients with a low-lying placenta with the placental edge ≤ 10 mm from the cervical os at 37⁰ to 37⁶ weeks of gestation in the presence of risk factors and at 38⁰ to 38⁶ weeks of gestation in the absence of risk factors.
B

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  • C-section (surgical team)

  • C-section (technical considerations for surgery)

9.Patient education

General counseling: counsel patients with asymptomatic placenta previa or a low-lying placenta in the third trimester regarding the risks of preterm delivery and obstetric hemorrhage and tailor care to individual needs.
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  • Counseling before delivery