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OBSTETRICS
Effect of placenta previa on fetal growth
Lorie M. Harper, MD; Anthony O. Odibo, MD, MSCE; George A. Macones, MD, MSCE;
James P. Crane, MD; Alison G. Cahill, MD, MSCI

OBJECTIVE: To estimate the association between placenta previa and RESULTS: Of 59,149 women, 724 (1.2%) were diagnosed with a com-
abnormal fetal growth. plete or partial previa. After adjusting for significant confounding factors
(black race, gestational diabetes, preeclampsia, and single umbilical
STUDY DESIGN: Retrospective cohort study of consecutive women artery), the risk of intrauterine growth restriction remained similar (ad-
undergoing ultrasound between 15 and 22 weeks. Groups were de- justed odds ratio, 1.1; 95% confidence interval, 0.9 –1.5). The pres-
fined by the presence or absence of complete or partial placenta ence of bleeding did not impact the risk of growth restriction.
previa. The primary outcome was intrauterine growth restriction
CONCLUSION: Placenta previa is not associated with fetal growth re-
(IUGR), defined as a birthweight ⬍10th percentile by the Alexander
striction. Serial growth ultrasounds are not indicated in patients with
growth standard. Univariable, stratified, and multivariable analyses
placenta previa.
were used to estimate the effect of placenta previa on fetal growth
restriction. Key words: intrauterine growth restriction, placenta previa

Cite this article as: Harper LM, Odibo AO, Macones GA, et al. Effect of placenta previa on fetal growth. Am J Obstet Gynecol 2010;203:330.e1-5.

P lacenta previa, defined as a placenta

that implants at or over the cervical
os,1 occurs in approximately 0.3-0.5% of
oxygenation and growth. Prior studies
assessing the association between pla-
centa previa and fetal growth restriction
tively collected over an 18-year period
(1990-2008) by dedicated research
nurses. Each patient seen in our center
pregnancies at delivery. Because of the have yielded conflicting results.8,9 was given a standardized form request-
possibility of maternal hemorrhage, it is Although the majority of placenta pre- ing information regarding the pregnancy
a significant contributor to maternal via diagnosed at routine midtrimester outcome, to be returned after delivery. If
morbidity, as well as prematurity and anatomy ultrasound will resolve, predic- a form was not returned within 4 weeks
perinatal mortality.2-4 In addition, this tion of previa resolution or persistence is of the expected delivery date, the coordi-
inherently abnormal placentation cre- impossible at this time. It is only a late- nator called the patient. If the patient
ates concern for fetal well-being and fetal gestation ultrasound that can defini- could not be contacted, the coordinator
growth. Several features of placenta pre- tively establish persistence or resolution contacted the referring physician to ob-
via suggest that this patient population is of placenta previa, which does little to
tain outcome data. The follow-up form
at higher risk of intrauterine growth re- assist the clinical management of fetal
contains details regarding pregnancy
striction (IUGR), a significant risk factor surveillance if a relationship between
complications, delivery complications,
for perinatal mortality.5,6 First, the blood placenta previa and restricted fetal
and neonatal outcomes.
supply to the lower uterine segment is growth exists. In the many interim
weeks, concern for poor fetal growth po- Patients were included in this study if
less than at the fundus,4,7 presumably re- they had a confirmed singleton gestation
tential would necessitate additional ul-
sulting in less perfusion for a placenta delivered after 20 weeks’ gestation. They
trasounds for fetal growth assessments,
previa. Also, repeated bleeding episodes were excluded if they had a fetal demise
as opposed to a single scan in the late
from placental previa may impact fetal at the time of presentation for anatomic
third trimester to assess placental loca-
tion to determine mode of delivery. survey or if they carried a higher-order
We therefore sought to estimate the re- fetal gestation. Because women with
From the Department of Obstetrics and
Gynecology, Washington University in St. lationship between placenta previa and fe- known major fetal anomalies have an in-
Louis School of Medicine, St. Louis, MO. tal growth restriction in an effort to assist creased risk for growth restriction, they
Presented as a poster at the 30th Annual physicians with clinical management. were excluded from this analysis. Gesta-
Meeting of the Society for Maternal-Fetal tional age was determined by either last
Medicine, Chicago, IL, Feb. 1-6, 2010. M ATERIALS AND M ETHODS menstrual period if known and concor-
Received Jan. 6, 2010; revised Feb. 26, 2010; We performed a retrospective cohort dant with ultrasound (within 7 days of
accepted May 5, 2010. first-trimester ultrasound or 14 days of
study of all consecutive patients under-
Reprints not available from the authors. second-trimester ultrasound) or by the
going routine second-trimester (15-22
0002-9378/$36.00 earliest ultrasound available when the
weeks) ultrasound at a single tertiary
© 2010 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2010.05.014 center. Institutional review board ap- last menstrual period was unknown or
proval was obtained. Data were prospec- discordant with ultrasound.

330.e1 American Journal of Obstetrics & Gynecology OCTOBER 2010

www.AJOG.org Obstetrics Research

across groups. The statistical analysis was

TABLE 1 performed using STATA, version 10
Demographic data Special Edition (StataCorp, College Sta-
No previa Previa tion, TX).
Demographic (n ⴝ 57,015) (n ⴝ 724) P
Age, y 30.2 ⫾ 6.3 32.5 ⫾ 5.8 ⬍ .01
..............................................................................................................................................................................................................................................
Gravidity 2.7 ⫾ 1.6 3.1 ⫾ 1.7 ⬍ .01 R ESULTS
..............................................................................................................................................................................................................................................
Of 72,373 women who underwent rou-
Parity 1.1 ⫾ 1.2 1.2 ⫾ 1.2 ⬍ .01
.............................................................................................................................................................................................................................................. tine second-trimester ultrasound at our
Race facility, complete outcome data were
.....................................................................................................................................................................................................................................
White 36,337 (63.7%) 479 (66.2%) .18 available for 65,414 (90.4%). Within the
.....................................................................................................................................................................................................................................
Black 11,716 (20.5%) 124 (17.1%) .02 cohort of 65,414 women for whom com-
..............................................................................................................................................................................................................................................
plete outcomes data were available,
Tobacco use 6308 (11.1%) 94 (13.0%) .11
.............................................................................................................................................................................................................................................. 57,739 remained after exclusions for
Diabetes 2998 (5.4%) 38 (5.3%) .95 presence of any fetal anomaly. Of these
..............................................................................................................................................................................................................................................
Preeclampsia 4244 (7.6%) 38 (5.3%) .02 women, 1665 received a diagnosis of any
..............................................................................................................................................................................................................................................
Preterm premature rupture 1311 (2.3%) 27 (3.8%) .01 type of previa on routine second-trimes-
of membranes ter ultrasound: 392 complete, 332 par-
..............................................................................................................................................................................................................................................
Single umbilical artery 260 (0.5%) 2 (0.3%) .47 tial, and 941 marginal. The 724 patients
..............................................................................................................................................................................................................................................
who received a diagnosis of either com-
Intrauterine fetal demise 415 (0.7%) 13 (1.8%) ⬍ .01
.............................................................................................................................................................................................................................................. plete or partial previa were included in
Bleeding (any time) 3286 (5.8%) 123 (17.0%) ⬍ .01 the primary analysis. Patients with and
..............................................................................................................................................................................................................................................
without placenta previa differed slightly
Harper. Previa and fetal growth. Am J Obstet Gynecol 2010.
(Table 1). Patients with placenta previa
tended to be slightly older, had more
At our institution, second-trimester The incidence of placenta previa by pregnancies, had less preeclampsia, and
ultrasounds routinely involve assess- previa type was described, and their as- had higher rates of preterm premature
ment of placenta location.10,11 Suspected sociation with IUGR was estimated. Pa- rupture of membranes, bleeding during
placenta previa by transabdominal scan- tients with and without placenta previa pregnancy, and intrauterine fetal de-
ning is confirmed with transvaginal ul- were compared with descriptive and bi- mise. The 2 groups were similar with re-
trasound. Placenta previas diagnosed by variate statistics using unpaired Student spect to tobacco use, diabetes, and single
transvaginal ultrasound were coded as t tests for continuous variables and ␹2 umbilical artery.
complete (placenta covering the entire tests for categorical variables. Potentially Of the 724 women with placenta pre-
cervical os), partial (placenta covering confounding variables of the exposure- via on second-trimester ultrasound, 51
part of the internal cervical os), or mar- outcome association were identified in (7.2%) had an infant with a birthweight
ginal (placenta within 2 cm of the inter- the stratified analyses. Multivariable lo- less than the 10th percentile, compared
nal cervical os). Comparisons were made gistic regression models for IUGR less with 4026 (7.2%) in patients without
between women with no placenta previa than the 10th and fifth percentiles were placenta previa (risk ratio [RR], 1.0; 95%
and those diagnosed with either a com- then developed to better estimate the ef- confidence interval [CI], 0.77–1.3) (Ta-
plete or partial previa. As the majority of fect of placenta previa on fetal growth ble 2). After adjusting for black race, di-
marginal previas are known to resolve, while adjusting for potentially con- abetes, preeclampsia, and single umbili-
they were not included in the primary founding effects. Clinically relevant co- cal artery, the rate of IUGR remained the
analysis.4 variates for initial inclusion in multiva- same between those with and without
The primary outcome was IUGR, de- riable statistical models were selected previa (AOR, 1.1; 95% CI, 0.9 –1.5). The
fined as a birthweight less than the 10th using results of the stratified analyses, presence of bleeding did not impact the
percentile using the Alexander growth and factors were removed in a backward rate of IUGR. The rate of IUGR less than
standard for gestational week at deliv- stepwise fashion, based on significant the fifth percentile was similar between
ery.12 The secondary outcome examined changes in the exposure adjusted odds the 2 groups (3.0% vs 3.1%; AOR, 1.1;
was birthweight less than the fifth per- ratio (AOR) or significant differences 95% CI, 0.8 –1.7).
centile using the Alexander growth stan- between hierarchical models using like- In a secondary analysis, the association
dard. Secondary analyses included as- lihood ratio test. In patients with a repeat between IUGR and type of placenta pre-
sessing the impact of previa type on fetal ultrasound, the rate of previa at the first via was examined (Table 3). In patients
growth, as well as examining the effect of and the last ultrasound were described. with any type of previa, 103 out of 1665
previa persistence on fetal growth in the McNemar ␹2 analysis was used to com- were diagnosed with IUGR (6.5%).
subset of patients who underwent at least pare the rate of resolution between types Compared with patients with no previa,
1 repeat ultrasound. of previa, and Pearson ␹2 test for trend patients with any previa had similar odds

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TABLE 2
Risk of IUGR in placenta previa
Complete or
No previa Partial previa RR AORa
Variable (n ⴝ 57,015) (n ⴝ 724) (95% CI) (95% CI) P
Birthweight ⬍10th percentile 4026 (7.2%) 51 (7.2%) 1.0 (0.8–1.3) 1.1 (0.9–1.5) .70
................................................................................................................................................................................................................................................................................................................................................................................
Birthweight ⬍5th percentile 1705 (3.1%) 21 (3.0%) 0.98 (0.6–1.5) 1.1 (0.8–1.7) .93
................................................................................................................................................................................................................................................................................................................................................................................
AOR, adjusted odds ratio; CI, confidence interval; IUGR, intrauterine growth restriction; RR, relative risk.
a
Adjusted for black race, diabetes, preeclampsia, and single umbilical artery.
Harper. Previa and fetal growth. Am J Obstet Gynecol 2010.

of IUGR (AOR, 1.0; 95% CI, 0.8 –1.2). Of (Table 3). In the 94 patients in whom 11.3%; P ⬍ .01), but they were less likely
392 patients with a complete previa, 32 complete previa did not resolve, 20.2% to have a single umbilical artery (0.3% vs
(8.7%) were diagnosed with IUGR were affected by IUGR, compared with 0.6%; P ⫽ .01). They were statistically
(AOR, 1.4; 95% CI, 0.9 –2.0). Nineteen 13.5% of patients whose complete previa similar on all other measured covariates
(5.9%) of 332 patients with partial previa did resolve. The AOR for IUGR was 1.6 and baseline characteristics.
experienced IUGR (AOR, 0.9; 95% CI, (95% CI, 0.7–3.5) after controlling for
0.6 –1.4) and 52 (5.8%) of 941 patients the presence of a single umbilical artery.
with a marginal previa were affected Patients with persistent partial previa C OMMENT
(AOR, 0.8; 95% CI, 0.6 –1.1). had no cases of IUGR. The rate of IUGR We found no association between pla-
The rate of previa resolution and the in patients who had a resolved marginal centa previa diagnosed at routine sec-
risk of IUGR in persistent previa was also previa vs those who had a persistent pre- ond-trimester ultrasound and a birth-
examined (Table 3). A second ultra- via was similar (4.3% vs 10.2%; AOR, weight less than the 10th percentile, or
sound was available in 1002 patients. Of 0.5; 95% CI, 0.1– 4.2). 5th percentile, on the Alexander growth
these women, 185 (16.9%) had a pla- Finally, in a sensitivity analysis com- standard. In addition, we found that the
centa previa (complete, partial, or mar- paring those women with complete fol- risk of IUGR is not increased in patients
ginal) on third-trimester ultrasound, low-up information to those without, with persistent placenta previa through
indicating that 83.1% of all previas diag- the rate and types of placenta previa were the third trimester.
nosed in the second trimester resolve. A similar between the 2 groups (2.8% vs In an era when the majority of patients
marginal previa was the most likely to 2.7%; P ⫽ .58). Compared with patients will undergo a second-trimester ultra-
resolve (94.5%), followed by partial pre- for whom complete data were available, sound,11 clinicians must be capable of
via (80.1%), then complete previa patients who had incomplete outcome counseling patients on the implications
(58.5%; P ⬍ .01). data differed only slightly in that they of the findings of that ultrasound. Prior
The risk of IUGR was examined in pa- were more likely to be black (40.6% vs large studies examining the relationship
tients with a persistent placenta previa 20.7%; P ⬍ .01) and to smoke (16.0% vs between placenta previa and neonatal

TABLE 3
Risk of IUGR by previa type and resolution
IUGR in
Resolved Persistent persistent
IUGR, AORa previa, previa, previa, AORb
Variable n (%) (95% CI) P n (%) n (%) n (%) (95% CI) P
Any previa (n ⫽ 1665) (second 103 (6.5) 1.0 (0.8–1.2) .33 837 (83.5) 165 (16.5) 21 (13.9) c
1.4 (0.8–2.3) .23
scan available 1002)
................................................................................................................................................................................................................................................................................................................................................................................
Complete previa (n ⫽ 392) 32 (8.7) 1.4 (0.9–2.0) .23 135 (59.0) 94 (41.0) 15 (20.2) c
1.6 (0.7–3.5) .23
(second scan available 229)
................................................................................................................................................................................................................................................................................................................................................................................
Partial previa (n ⫽ 332) 19 (5.9) 0.9 (0.6–1.4) .43 168 (80.8) 40 (19.2) 0 — .23
(second scan available 208)
................................................................................................................................................................................................................................................................................................................................................................................
Marginal previa (n ⫽ 941) 52 (5.8) 0.8 (0.6–1.1) .11 534 (94.5) 31 (5.5) 1 (4.3) d
0.5 (0.1–4.2) .56
(second scan available 565)
................................................................................................................................................................................................................................................................................................................................................................................
AOR, adjusted odds ratio; CI, confidence interval; IUGR, intrauterine growth restriction.
a
Reference group: patients with no previa, n ⫽ 57,015, rate of IUGR, 7.2% (Table 2). Adjusted for black race, diabetes, preeclampsia, and single umbilical artery; b Reference group: patients with
resolved previa; c Adjusted for single umbilical artery; d Adjusted for preeclampsia.
Harper. Previa and fetal growth. Am J Obstet Gynecol 2010.

330.e3 American Journal of Obstetrics & Gynecology OCTOBER 2010

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outcomes have limited analyses to pla- for gestational age. However, the authors could not be included in the subanalysis
centa previa confirmed at delivery, did not comment on the comparative of the impact of previa resolution on
which many argue is the most accurate difference in the frequency of growth re- fetal growth restriction, thereby intro-
and precise method of defining placenta striction in patients with and without ducing a potential bias into the study
previa.13,14 Unfortunately, when a pa- previa. population. As this is a tertiary facility,
tient receives a diagnosis of placenta pre- Ogueh et al performed a study similar patients who continue their care at our
via in the second trimester, one cannot to ours in which they examined 703 facility tend to be higher-risk patients
predict whether her previa will persist pregnancies diagnosed with “low-lying” compared with those who are followed
until delivery and must counsel and de- placenta at second-trimester ultrasound at nearby community facilities; conse-
vise a clinical plan based on the informa- compared with 6938 women with nor- quently, any bias introduced would
tion available at the time. The inclusion mally situated placentas.15 However, de- likely influence results away from the
of placenta previa diagnosed at second- fining the exposure as “low-lying” makes null. However, in the subgroup of pa-
trimester ultrasound makes this study this study difficult to interpret. A pla- tients with previa and a repeat scan that
clinically applicable; based on our find- centa may be located in the lower uterine was statistically representative of the
ings, a patient diagnosed with placenta segment but more than 2 cm from the larger sample with previa, we did not
previa at second-trimester ultrasound internal os; furthermore, no comment find an association between previa and
can be managed with a follow-up ultra- was made on the use of transvaginal ul- IUGR. The attrition of patients because
sound in the third trimester to document trasound to confirm placental location of lack of follow-up and previa resolu-
placental location but does not need se- in suspected placenta previa. Conse- tion also decreased our sample size in the
rial ultrasounds for growth. Further- quently, it was likely that many patients follow-up groups, potentially limiting
more, the finding that placenta previa is without the true risk factor (placenta our ability to detect a difference in the
not associated with growth restriction covering or partially covering the cervi- rate of IUGR between those with a per-
suggests that placenta previa is not syn- cal os) were included in this study, po- sistent previa and those with a resolved
onymous with placental insufficiency. In tentially biasing the study results toward previa (type II error). However, in the
the absence of evidence of uteroplacental the null. subgroup of patients with a persistent
insufficiency or presence of factors asso- One strength of our study was the large complete previa, a post hoc power anal-
ciated with stillbirth, antepartum test- sample size, allowing us to test a hypoth- ysis assuming an alpha error of .05, dem-
ing, a tool reserved for fetuses at risk for esis regarding a fairly rare exposure (pla- onstrated that our study had 80% power
stillbirth, may not be warranted in this centa previa). Furthermore, the prospec- to detect a 2.1-fold increase in the rate of
population. tively collected nature of the information IUGR, which we would offer is a reason-
Two large population-based studies provided a uniquely robust dataset with able threshold of clinical significance.
have addressed the impact of placenta lo- complete follow-up in more than 90% of Last, the diagnosis of placenta previa was
cation on fetal growth. Ananth et al per- patients who underwent routine second- not confirmed at the time of delivery, al-
formed a retrospective cohort study us- trimester ultrasound at our facility. The lowing for the possibility of resolution
ing ICD-9 codes to identify patients with comprehensive clinical data available in between the time of the latest ultrasound
placenta previa and linked birth certifi- this cohort allowed us to assess impor- and delivery. However, as discussed pre-
cate data to obtain infant birthweights; tant confounding factors for IUGR, such viously, this approach estimates the rela-
this large study of more than 500,000 pa- as preeclampsia, single umbilical artery, tionship between the antepartum clini-
tients found a small increase in the rate of and diabetes. cal diagnosis of previa and the risk of
IUGR in patients with placenta previa One important consideration when IUGR, improving generalizability to
that they thought was predominantly ex- interpreting the results from this study is clinical management. In light of this, we
plained by the increased rate of prema- the potential for selection bias with re- believe clinically useful conclusions can
turity.13 However, the use of ICD-9 gard to those patients in whom outcome be drawn from this study.
codes to identify cases of placenta previa data were incomplete. However, these Despite the fact that placenta previa
may have resulted in a nondifferential patients comprise less than 10% of the represents an abnormal placentation, it
misclassification bias, which would di- total study population and were statisti- does not appear to be independently as-
lute the effect of placenta previa on fetal cally similar to those in the study sample sociated with an increased risk for IUGR,
growth, and bias the results toward not (data not presented; available on re- regardless of whether the placenta previa
finding a difference in birthweights be- quest). Most importantly, they had the is complete, partial, or marginal. Al-
tween patients with and without previa. same rate and type of placenta previa, though patients with such a diagnosis
Crane et al also performed a retrospec- making this potential source for bias un- should undergo at least 1 additional ul-
tive cohort study that used a perinatal likely to have impacted the findings. trasound to evaluate for the resolution of
database based on a coding system simi- A second concern is that only a subset placenta previa, serial ultrasounds for
lar to ICD-9 codes.14 In this study, a dif- of patients underwent a repeat ultra- the purpose of fetal growth assessment
ference in birthweight was found that sound at our facility, and patients who based on previa alone do not seem
was not significant after being adjusted had repeat ultrasounds at other facilities warranted. f

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330.e5 American Journal of Obstetrics & Gynecology OCTOBER 2010