www.AJOG.
org
A new classification of placenta previa:
Measuring progress in obstetrics
Lawrence W. Oppenheimer, MD, FRCOG, FRCSC; Dan Farine, MD, FRCSC
O ld obstetric dogmas can take a long time to debunk. Wit-
ness castor oil, enemas, and lying-in hospitals, to name
but a few. So it is with the traditional classification of placenta
previa. The original description of placenta previa is credited to
Portal in 1683, although Schacher in 1709 was the first to dem-
onstrate postmortem the exact relationship of the placenta to
the uterus.1 The classification of placenta previa into complete,
partial, and marginal probably had its origins in the 19th cen-
tury. The description was meant to refer to the extent to which
the placenta could be palpated through the cervix.1 Complete
previa referred to an implantation over the internal os where
the margin of the placenta could not be felt; partial previa re-
ferred to the placenta covering a closed internal os, but not
completely covering a dilated os; and marginal previa meant an
implantation in which the margin could be easily felt. Lateral
(or low-lying) previa is the variety in which the margin of the
placenta can only be felt with difficulty. In the United King-
dom, the description of placenta previa into grades I-IV or
major and minor has been used commonly.
The distinction between placental abruption and previa was
based on the ability to palpate the placenta through the cervical
os; the difference was important because the treatment of pre-
via involved rupture of the membranes, internal podalic ver-
sion, and use of the fetus as a tamponade! The realization that
digital palpation might not be such a good idea, and the intro-
duction of conservative management with blood transfusion
by MacAfee2 in 1945, lead to the need for a more accurate
diagnosis. Imaging modalities to investigate placental location
were introduced after the advent of radiology. In the 1930s
amniography and cystography were explored. Gottesfeld et al3
introduced the use of ultrasound for placental location in 1966,
and the first description of vaginal sonography, attributed to
Kratochwil, followed in 1969.4 Transvaginal sonography
(TVS) for the diagnosis of placenta previa has become the gold
standard.5 Transabdominal ultrasound is inaccurate in the di-
agnosis of previa and should be used only as a screening tool.6
TVS is safe, even in the presence of active bleeding.7,8 The ac-
curate localization of the placental edge in relation to the dis-
From the Division of Maternal Fetal Medicine (Dr Oppenheimer),
University of Ottawa, Ottawa Hospital General Campus, Ottawa,
Ontario, Canada; and the Division of Maternal Fetal Medicine (Dr
Farine), University of Toronto, Mount Sinai Hospital, Toronto,
Ontario, Canada.
0002-9378/free
© 2009 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2009.06.010
See related article, page 266
Editorials
crete point of the internal os by TVS makes the use of the terms
marginal, partial, and low-lying outmoded (Figure). What the
clinician really wants to know to guide treatment is the likeli-
hood of antepartum hemorrhage and need for cesarean section
delivery, based on the exact distance from the cervix. There is
now a growing literature on this relationship.9-13 A placental
edge lying ⬍2 cm away from the internal os on TVS has become
generally accepted as the threshold for the performance of ce-
sarean section delivery for previa at term. An inherent problem
in all the published studies to date is the likelihood that knowl-
edge of the distance itself may have lead to the decision to
perform the cesarean section delivery, rather than the clinical
features of the case. In this respect, the contribution by Vergani
et al14 in this edition of the Journal is valuable. Although also a
retrospective study, the authors describe a policy of expectant
management in the largest series to date of 53 women with a
cephalic presentation and a placental edge–to– os distance on
TVS between 1-20 mm. Cases were divided into 2 groups: 1-10
mm from the os (n ⫽ 24 cases) and 11-20 mm (n ⫽ 29 cases).
They found a cesarean section delivery rate of 75% and 31%,
respectively, and an incidence of antepartum hemorrhage of
29% vs 3%, respectively. The scans were all performed within
28 days of delivery at a mean gestational age of 36.4 weeks, and
delivery occurred on average 10 days later. None of the 11-20
mm group required cesarean section delivery for antepartum
hemorrhage, and none required cesarean section delivery in
labor. They conclude that women with a placenta that is situ-
ated 11-20 mm away can be offered a trial of labor. The data of
Vergani corroborates well with the 2 other publications that
have reported the same distance groups.10,11 Pooling the 3 data
sets gives a cesarean section delivery rate of 78% (17/50 cases)
for a distance of 0-10 mm and 34% (39/50 cases) for 11-20 mm.
Vergani et al propose that the time-honored classification of
placenta previa should be abandoned. We agree with them and
others who have published the same sentiments.15,16 Admit-
tedly, the data is imperfect. The numbers of cases that have
been reported is still small and are based only on retrospective
studies, although it might be difficult to mount a trial in which
the obstetrician is blinded to the exact location of the placenta.
We need more information on the likelihood of antepartum
hemorrhage based on placental edge distance and the safety of
out-patient treatment.17 Treatment decisions should be based
on the measured distance of the placental edge to the internal
cervical os by transvaginal ultrasound whenever possible. The
routine reporting of this distance will enable us to confirm the
current assumptions rapidly. Recognizing that measurements
of ⬍1 cm may be subject to error and operator variability, it
probably makes sense to group the distance to the nearest
centimeter.
SEPTEMBER 2009 American Journal of Obstetrics & Gynecology 227
Editorials
FIGURE
Transvaginal sonogram
The tip of the probe is located at the top of the picture. The cervical canal is seen in the upper half of the image, and a posterior placenta is seen in
the lower half of the image, with the placental edge lying 7 mm away from the internal cervical os. Part of the fetal head is seen on the left side.
Oppenheimer. A new classification of placenta previa. Am J Obstet Gynecol 2009.
A new classification could describe the distance on TVS that
is performed within 28 days of term in the following way: (1)
⬎20 mm away from the internal os; cesarean section delivery
for previa not indicated; (2) 11-20 mm; lower likelihood of
bleeding and need for cesarean section delivery; (3) 0-10 mm;
higher likelihood of bleeding and need for cesarean section
delivery; and (4) overlap of the internal os by any distance:
cesarean section delivery indicated.
The distance alone should not be a replacement for clinical
judgment in regard to factors such as unstable lie or significant
antepartum hemorrhage. As more data accumulates, we can
add better estimates of the risk of bleeding before and during
labor and the likelihood of successful vaginal delivery. We still
have 4 groups, but the description makes a lot more sense. The
education exercise really has to start not just in the obstetric
domain but with the sonographers and physicians who per-
form and report obstetric ultrasound.
Approximately 3% of the obstetric population in the second
trimester will have a placental edge low enough to justify follow
up with transvaginal ultrasound.18 The study by Vergani et al
also allows an estimate of the incidence of a placenta lying
within 2 cm of the os at 36 weeks of gestation at approximately
0.6%, one-half of whom will have a placental edge overlapping
the internal os and a similar number will have a placental edge
of 1-20 mm away that will warrant a decision regarding treat-
ment. The benefits of accurate diagnosis by TVS include risk
assessment for outpatient treatment, selection for trial of labor,
and screening for placenta accreta.19 In addition, exclusion of
228 American Journal of Obstetrics & Gynecology SEPTEMBER 2009
www.AJOG.org
vasa previa, which is associated strongly with a placenta that is
initially located in the lower segment,20 can also be achieved
with color Doppler sonography. Investigation of antepartum
hemorrhage by TVS should be routine whenever there is doubt
about the exact placental location.
The capability to measure accurately placental location has
been around for ⬎20 years. All it will take to consign the old
classification of placenta previa to the history books is a shift in
our thinking by a couple of centimeters. f
REFERENCES
1. Chassar Moir J, Myersough PR, eds. Munro Kerr’s operative obstet-
rics, 8th ed. London: Balliere, Tindall & Cassell; 1971:771-804.
2. MacAfee CHG. Placenta previa: a study of 174 cases. J Obstet Gy-
necol Br Commonwealth 1945;52:313-7.
3. Gottesfeld KR, Thompson JH, Taylor ES. Ultrasound placentography:
a new method for placental localization. Am J Obstet Gynecol
1966;96:538-47.
4. Merz E. Ultrasound in obstetrics and gynecology, 2nd ed. New York,
NY: Thieme; 2007.
5. Farine D, Fox HE, Jakobson S, Timor-Tritsch IE. Vaginal ultrasound
for diagnosis of placenta previa. Am J Obstet Gynecol 1988;159:
566-9.
6. Smith RS, Lauria MR, Comstock CH, et al. Transvaginal ultrasonogra-
phy for all placentas that appear to be low-lying or over the internal
cervical os. Ultrasound Obstet Gynecol 1997;9:22-4.
7. Timor-Tritsch IE, Yunis RA. Confirming the safety of transvaginal
sonography in patients suspected of placenta previa. Obstet Gynecol
1993;81:742-4.
www.AJOG.org
8. Leerentveld RA, Gilberts ECAM, Arnold KJCW, Wladimiroff JW. Accu-
racy and safety of transvaginal sonographic placental localization. Obstet
Gynecol 1990;76:759-62.
9. Oppenheimer L, Farine D, Ritchie K, Lovinsky RM, Telford J, Fairbanks LA.
What is a low-lying placenta? Am J Obstet Gynecol 1991;165:1036-8.
10. Dawson WB, Dumas MD, Romano WM, Gagnon R, Gratton RJ,
Mowbray D. Translabial ultrasonography and placenta previa: Does mea-
surement of the os-placental distance predict outcome? J Ultrasound
Med 1996;15:441-6.
11. Sallout B, Oppenheimer LW. The classification of placenta previa
based on os-placental edge distance at transvaginal sonography. Am J
Obstet Gynecol 2002;187(suppl):S94.
12. Bhide A, Prefumo F, Moore J, Hollis B, Thilaganathan B. Placental
edge to internal os distance in the late third trimester and mode of delivery
in placenta previa. BJOG 2003;110:860-4.
13. Predanic M, Perni SC, Baergen RN, Jean-Pierre C, Chasen ST, Cher-
venak FA. A sonographic assessment of different patterns of placenta
previa “migration” in the third trimester of pregnancy. J Ultrasound Med
2005;24:773-80.
Editorials
14. Vergani P, Ornaghi S, Pozzi I, et al. Placenta previa: distance to internal
os and mode of delivery. Am J Obstet Gynecol 2009;201:266-8.
15. Oppenheimer LW, Farine D, Ritchie JWK. The classification of pla-
centa praevia-time for a change? Fetal Matern Med Rev 1992;4:73-8.
16. Oyelese Y. Placenta previa and vasa previa: time to leave the Dark
Ages. Ultrasound Obstet Gynecol 2001;18:96-9.
17. Wing DA, Paul RH, Millar LK. Management of the symptomatic pla-
centa praevia: a randomized, controlled trial of inpatient versus outpatient
expectant management. Am J Obstet Gynecol 1996;175:806-11.
18. Mustafa SA, Brizot ML, Carvalho MHB, Watanabe L, Kahhale S,
Zugaib Z. Transvaginal ultrasonography in predicting placenta previa
at delivery: a longitudinal study. Ultrasound Obstet Gynecol 2002:20:
356-9.
19. Yang JI, Lim YK, Kim HS, Chang KH, Lee JP, Ryu HS. Sonographic
findings of placental lacunae and the prediction of adherent placenta in
women with placenta previa totalis and prior cesarean section. Ultra-
sound Obstet Gynecol 2006;28:178-82.
20. Oyelese Y, Catanzarite V, Prefumo F, et al. Vasa previa: the impact of
prenatal diagnosis on outcomes. Obstet Gynecol 2004;103:937-42.
SEPTEMBER 2009 American Journal of Obstetrics & Gynecology 229