eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Placenta Previa: Treatment & Medication

Author: Patrick Ko, MD, Clinical Assistant Professor, Department of Emergency Medicine, New York University Medical School; Assistant Program Director, Department of Emergency Medicine, North Shore University Hospital
Coauthor(s): Young Yoon, MD, Associate Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai Medical Center
Contributor Information and Disclosures

Updated: Aug 10, 2009

Treatment

Prehospital Care

  • The key to prehospital care of placenta previa is to ensure hemodynamic stability of the patient and transfer to an appropriate facility.

Emergency Department Care

  • Because of the potential morbidity and mortality secondary to profuse bleeding, obtain immediate gynecologic consultation, if available. Before gynecologic consultation or transfer, the hemodynamic stability of the patient should be addressed. This includes the establishment of 2 large-bore intravenous access lines with intravenous crystalloids or blood products, as necessary.
  • Obtain continuous fetal monitoring, if available.
  • If the fetus is preterm and immediate delivery is unnecessary (eg, fetus <37 weeks' gestation and hemorrhage not present), the patient may be treated expectantly on an outpatient basis.
  • If the fetus is reasonably mature (ie, >37 weeks' gestation) and the patient is in labor or if severe hemorrhage is present, therapy is directed at the delivery of the fetus. The patient should receive crystalloids and/or blood, and the patient should be transferred to the operating room with double set-up conditions.
  • A trial of labor may be considered for anterior marginal previa, including oxytocin (Pitocin) augmentation.
  • Guidelines for the diagnosis and management of placenta previa have been established.3,4

Consultations

  • Consult an obstetrician.

Medication

The goal of ED treatment in patients with placenta previa should be directed at the hemodynamic stability of the patient. The primary therapeutic agents should be intravenous crystalloids and/or transfusions.

Recent studies are now using prothrombin complex and recombinant factor VII to control hemorrhage associated with obstetric complications and placenta previa.

Corticosteroids

Steroids may be administered after consultation with a gynecologist, if vaginal bleeding is mild and intermittent, if the patient is not in labor, and if gestation is less than 37 weeks.


Betamethasone (Celestone)

Helps promote fetal lung maturity.

Adult

Assess dosing after consulting with obstetrician

Pediatric

Not established

Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; decreases effect of salicylates and vaccines used for immunization

Documented hypersensitivity; systemic fungal infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use

Tocolytics

Some specialists advocate tocolytics to promote the time for expectant management of symptomatic placenta previa. They should only be used after consultation with an obstetrician. A recent study seems to suggest that the use of tocolytics increases the duration of pregnancy and increases the baby's birth weight without causing adverse effects on the mother and the fetus.


Magnesium sulfate

Nutritional supplement in hyperalimentation. Cofactor in enzyme systems involved in neurochemical transmission and muscular excitability. In adults, 60-180 mEq of potassium, 10-30 mEq of magnesium, and 10-40 mmol/L of phosphate per day may be necessary for optimum metabolic response. Discontinue treatment as soon as desired effect is obtained. Repeat doses are dependent on continuing presence of patellar reflex and adequate respiratory function.

Adult

Assess dosing after consulting with obstetrician

Pediatric

Not established

Concurrent use with nifedipine may cause hypotension and neuromuscular blockade; may increase neuromuscular blockade observed with aminoglycosides and potentiate neuromuscular blockade produced by tubocurarine, vecuronium, and succinylcholine; may increase CNS effects and toxicity of CNS depressants and betamethasone; may increase cardiotoxicity of ritodrine

Documented hypersensitivity; heart block; Addison disease; myocardial damage; severe hepatitis

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

Precautions

Magnesium may alter cardiac conduction, leading to heart block in digitalized patients; respiratory rate, deep tendon reflex, and renal function should be monitored when electrolyte is administered parenterally; caution when administering magnesium dose because magnesium may produce significant hypertension or asystole; in overdose, calcium gluconate, 10-20 mL IV of 10% solution, can be administered as antidote for clinically significant hypermagnesemia


Terbutaline (Brethine)

Acts directly on beta2-receptors to relax uterine contractions.

Adult

Assess dosing after consulting with obstetrician

Pediatric

Not established

Concomitant use with beta-blockers may inhibit bronchodilating, cardiac, and vasodilating effects of beta agonists; concomitant administration of MAOIs with beta sympathomimetics may result in a hypertensive crisis; concurrent administration of oxytocic drugs such as ergonovine with terbutaline may result in severe hypotension

Documented hypersensitivity; tachycardia resulting from cardiac arrhythmias

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Maternal death has occurred through intracellular shunting; terbutaline may decrease serum potassium levels, which can produce adverse cardiovascular effects, decrease is usually transient and may not require supplementation

More on Placenta Previa

Overview: Placenta Previa
Differential Diagnoses & Workup: Placenta Previa
Treatment & Medication: Placenta Previa
Follow-up: Placenta Previa
Multimedia: Placenta Previa
References

References

  1. Vergani P, Ornaghi S, Pozzi I, Beretta P, Russo FM, Follesa I, et al. Placenta previa: distance to internal os and mode of delivery. Am J Obstet Gynecol. Jul 23 2009;[Medline].

  2. Milosevic J, Lilic V, Tasic M, Radovic-Janosevic D, Stefanovic M, Antic V. [Placental complications after a previous cesarean section]. Med Pregl. May-Jun 2009;62(5-6):212-6. [Medline].

  3. [Guideline] Royal College of Obstetricians and Gynaecologists (RCOG). Placenta praevia and placenta praevia accreta: diagnosis and management. Oct 2005;[Full Text].

  4. [Guideline] Oppenheimer L. Diagnosis and management of placenta previa. J Obstet Gynaecol Can. Mar 2007;29(3):261-73. [Medline][Full Text].

  5. Ananth CV, Smulian JC, Vintzileos AM. The effect of placenta previa on neonatal mortality: a population-based study in the United States, 1989 through 1997. Am J Obstet Gynecol. May 2003;188(5):1299-304. [Medline].

  6. Besinger RE, Moniak CW, Paskiewicz LS, Fisher SG, Tomich PG. The effect of tocolytic use in the management of symptomatic placenta previa. Am J Obstet Gynecol. Jun 1995;172(6):1770-5; discussion 1775-8. [Medline].

  7. Crane S, Chun B, Acker D. Treatment of obstetrical hemorrhagic emergencies. Curr Opin Obstet Gynecol. Oct 1993;5(5):675-82. [Medline].

  8. Dola CP, Garite TJ, Dowling DD, Friend D, Ahdoot D, Asrat T. Placenta previa: does its type affect pregnancy outcome?. Am J Perinatol. Oct 2003;20(7):353-60. [Medline].

  9. Gidiri M, Noble W, Rafique Z, Patil K, Lindow SW. Caesarean section for placenta praevia complicated by postpartum haemorrhage managed successfully with recombinant activated human coagulation Factor VIIa. J Obstet Gynaecol. Nov 2004;24(8):925-6. [Medline].

  10. Glynn JC, Plaat F. Prothrombin complex for massive obstetric haemorrhage. Anaesthesia. Feb 2007;62(2):202-3. [Medline].

  11. Iyasu S, Saftlas AK, Rowley DL, Koonin LM, Lawson HW, Atrash HK. The epidemiology of placenta previa in the United States, 1979 through 1987. Am J Obstet Gynecol. May 1993;168(5):1424-9. [Medline].

  12. Otsubo Y, Shinagawa T, Chihara H, Araki T. Conservative management of a case of placenta praevia percreta. Aust N Z J Obstet Gynaecol. Nov 1999;39(4):518-9. [Medline].

  13. Rani PR, Haritha PH, Gowri R. Comparative study of transperineal and transabdominal sonography in the diagnosis of placenta previa. J Obstet Gynaecol Res. Apr 2007;33(2):134-7. [Medline].

  14. Rathore SS, McMahon MJ. Racial variation in the frequency of intrapartum hemorrhage. Obstet Gynecol. Feb 2001;97(2):178-83. [Medline].

  15. Sharma A, Suri V, Gupta I. Tocolytic therapy in conservative management of symptomatic placenta previa. Int J Gynaecol Obstet. Feb 2004;84(2):109-13. [Medline].

  16. Smith RS, Lauria MR, Comstock CH, Treadwell MC, Kirk JS, Lee W, et al. Transvaginal ultrasonography for all placentas that appear to be low-lying or over the internal cervical os. Ultrasound Obstet Gynecol. Jan 1997;9(1):22-4. [Medline].

  17. Taber. Manual of Gynecologic and Obstetric Emergencies. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1984:313-318.

  18. Taylor VM, Peacock S, Kramer MD, Vaughan TL. Increased risk of placenta previa among women of Asian origin. Obstet Gynecol. Nov 1995;86(5):805-8. [Medline].

  19. Timor-Tritsch IE, Monteagudo A. Diagnosis of placenta previa by transvaginal sonography. Ann Med. Jun 1993;25(3):279-83. [Medline].

  20. Williams, Cunningham, Macdonald. Williams' Obstetrics. 19th ed. Norwalk, Conn: Appleton & Lange; 1993:836-841.

  21. Zhang J, Savitz DA. Maternal age and placenta previa: a population-based, case-control study. Am J Obstet Gynecol. Feb 1993;168(2):641-5. [Medline].

Further Reading

Keywords

placenta previa, disseminated intravascular coagulopathy, vaginal bleeding, pregnancy complications, obstetric complications, total placenta previa, partial placenta previa, marginal placenta previa, low-lying placenta previa, internal cervical os, abnormal placental implantation, uterine bleeding, treatment, diagnosis

Contributor Information and Disclosures

Author

Patrick Ko, MD, Clinical Assistant Professor, Department of Emergency Medicine, New York University Medical School; Assistant Program Director, Department of Emergency Medicine, North Shore University Hospital
Patrick Ko, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Young Yoon, MD, Associate Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai Medical Center
Young Yoon, MD is a member of the following medical societies: Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Joseph J Sachter, MD, FACEP, Consulting Staff, Department of Emergency Medicine, Muhlenberg Regional Medical Center
Joseph J Sachter, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
Disclosure: Medicines Company Consulting fee Consulting; Pfizer Salary Employment

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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