Vasa Previa: The Impact of Prenatal Diagnosis on

Outcomes
Yinka Oyelese, MD, Val Catanzarite, MD, PhD, Federico Prefumo, MD, Susan Lashley, MD,
Morey Schachter, MD, Yosi Tovbin, MD, Victoria Goldstein, MBA, and John C. Smulian, MD, MPH

OBJECTIVE: To evaluate outcomes and predictors of neona- 35 weeks of gestation or earlier should rupture of mem-
tal survival in pregnancies complicated by vasa previa and branes, labor, or significant bleeding occur. (Obstet Gy-
to compare outcomes in prenatally diagnosed cases of vasa necol 2004;103:937– 42. © 2004 by The American College
previa with those not diagnosed prenatally. of Obstetricians and Gynecologists.)
METHODS: We performed a multicenter study of 155 preg- LEVEL OF EVIDENCE: II-3
nancies complicated by vasa previa. Cases were obtained
from the Vasa Previa Foundation and 6 large hospitals. Vasa previa is said to occur when fetal vessels, unsup-
Comparisons were made between groups based on prena- ported by placenta or umbilical cord, traverse the mem-
tal diagnosis status and neonatal survival.
branes over the cervix, below the presenting part. There
RESULTS: The overall perinatal mortality was 36% (55 of are 2 variants; type 1 results from velamentous cord
155). In 61 cases (39%), vasa previa was diagnosed prena- insertion and type 2 from vessels running between lobes
tally; 59 of 61 (97%) infants from these pregnancies sur-
of a bilobed or succenturiate lobed placenta.1 Spontane-
vived compared with 41 of 94 (44%) in cases not diagnosed
ous or artificial rupture of membranes frequently leads to
prenatally (P < .001). Median 1- and 5-minute Apgar
scores in cases diagnosed prenatally were 8 and 9, respec- rapid fetal exsanguination.2 As a consequence, the con-
tively, compared with 1 and 4 among survivors in cases not dition is associated with a high perinatal mortality.2– 6
diagnosed prenatally (P < .001). More than half (24 of 41) Because vasa previa is relatively rare, with a reported
of surviving neonates born to women without prenatal incidence of approximately 1 in 2,500 pregnancies,2
diagnosis required blood transfusions compared with 2 of most reports in the literature have consisted of 3 or fewer
59 diagnosed prenatally (P < .001). Multivariable logistic cases. In 1987, Gianopoulos et al7 first described the
regression analysis showed that the only significant predic- ultrasonographic diagnosis of vasa previa. Before this,
tors of neonatal survival were prenatal diagnosis (P < .001) most reports had focused on the universally dismal
and gestational age at delivery (P ⴝ .01). outcomes with pregnancies complicated by vasa pre-
CONCLUSIONS: Good outcomes with vasa previa depend via.3,4 Since that initial report, several small case series
primarily on prenatal diagnosis and cesarean delivery at have demonstrated the ability of ultrasonography and
color Doppler to diagnose vasa previa prenatally and
From the Division of Maternal-Fetal Medicine, Department of Obstetrics, Gyne-
have suggested improved outcomes associated with pre-
cology, and Reproductive Sciences, UMDNJ-Robert Wood Johnson Medical
School/Robert Wood Johnson University Hospital, New Brunswick, New Jersey; natal diagnosis of the condition.1,6,8 –10
Department of Obstetrics and Gynecology, Georgetown University Hospital, Wash- It is intuitive that prevention of perinatal mortality
ington, DC; Maternal Fetal Medicine, Sharp Perinatal Center and Sharp Mary would depend on prenatal diagnosis of the condition and
Birch Hospital, San Diego, California; Fetal Medicine Unit, Department of cesarean delivery before rupture of membranes occurs.
Obstetrics and Gynaecology, St. George’s Hospital Medical School, London,
United Kingdom; Department of Obstetrics and Gynecology, Assaf Harofeh However, because vasa previa is relatively uncommon,
Medical Center, Zerifin, Tel Aviv University, Israel; and Vasa Previa Founda- no single institution would be able to put together a large
tion, Moline, Illinois. collection of cases.
The authors are indebted to the members of the Vasa Previa Foundation, who The primary objectives of this study were to describe
obtained their records from their physicians, mailed and faxed them to us, and pregnancy outcomes in a large series of cases of vasa
allowed us to review them. We are also grateful to the physicians and nurses who previa and to assess the differences in outcomes between
assisted in writing institutional Review Board applications and gathering the data cases diagnosed prenatally and those not diagnosed pre-
for this study. In particular, we recognize the contribution of Bruce Meyer, MD, and
Marian Lake, MPH. Finally, the authors thank Anthony Vintzileos, MD, Cande
natally. It was also our objective to determine predictors
Ananth, PhD, MPH, and Anthony Scialli, MD, for reviewing the manuscript and of neonatal survival in pregnancies complicated by vasa
offering invaluable editorial and statistical advice. previa.

VOL. 103, NO. 5, PART 1, MAY 2004

© 2004 by The American College of Obstetricians and Gynecologists. 0029-7844/04/$30.00 937
Published by Lippincott Williams & Wilkins. doi:10.1097/01.AOG.0000123245.48645.98
MATERIALS AND METHODS was associated with a vasa previa. Also, in all the twin
This was a chart review of cases of vasa previa. Cases cases, the outcomes of the second twin were similar to
were ascertained from 2 sources, women registering with that of the first. Twenty-five of the cases in this study
the Vasa Previa Foundation web site, or through dis- have been described in previous publications.1,6,11
charge diagnoses from 5 large hospital obstetric services: Statistical analyses were performed with SPSS (SPSS,
Georgetown University Hospital, Washington, DC (n ⫽ Inc, Chicago, IL) and Statview for Windows (SAS Insti-
14); Robert Wood Johnson University Hospital, New tute, Inc, Cary, NC). Comparisons were made between
Brunswick, New Jersey (n ⫽ 3); Saint Peter’s University groups based on prenatal diagnosis status and neonatal
Hospital, New Brunswick, New Jersey (n ⫽ 18); Assaf survival. Because of the potential for bias between the
Harofeh Medical Center, Zerifin, Israel (n ⫽ 12); and St cases ascertained from the Vasa Previa Foundation and
George’s Hospital, London, UK (n ⫽ 7). At the San those from the participating hospitals, comparisons were
Diego Perinatal Center/Sharp Mary Birch Hospital for also made between these 2 groups based on prenatal
Women, San Diego, California, cases were ascertained diagnosis and neonatal survival. For intergroup compar-
from the perinatal ultrasound database system (n ⫽ 14). isons, one-way analysis of variance, Student t test, the ␹2
Appropriate institutional review board approvals were test, Fisher exact test and Mann–Whitney U test were
obtained. used as appropriate. Statistical significance was defined
The Vasa Previa Foundation (www.vasaprevia.org), as a P value of less than .05. Multivariable logistic
established in 2001, consists of women and families who regression was performed to determine which variables
have been affected by pregnancies with vasa previa. Its were predictive of neonatal survival. Variables signifi-
mission is to raise awareness about vasa previa, to dis- cant in the univariable analysis at a level of P ⬍ .2 were
seminate information on the condition, and to facilitate considered for inclusion in the regression model. Vari-
research aimed at further understanding of vasa previa ables were retained in the model if they remained signif-
with the aim of minimizing the perinatal mortality from icant at P ⬍ .05.
the condition. The Vasa Previa Foundation provided an
invaluable resource for data on pregnancies complicated
by vasa previa. Women who registered with the Vasa RESULTS
Previa Foundation web site were invited to participate in One hundred fifty-five women with confirmed vasa pre-
the study if they had a pregnancy complicated by vasa via formed the study population. Eighty-seven cases
previa. After informed consent, their medical records came from the Vasa Previa Foundation and 68 from the
were obtained from their physicians as well as the hos- participating hospitals. The cases occurred between 1991
pitals where they delivered. and 2003. There were 7 twin pregnancies. In 61 cases
Data were extracted from the charts, including demo- (39%), the diagnosis of vasa previa was made prenatally
graphic information, information about the affected by ultrasonography/color Doppler. Patient demograph-
pregnancy and previous pregnancies, as well as neonatal ics compared between those with and without prenatal
outcomes. Only cases in which the clinical diagnosis of diagnosis and between neonatal survivors and nonsurvi-
vasa previa was verified by pathology reports, photo- vors are given in Table 1.
graphic documentation of the velamentous vessels, or an Antepartum and intrapartum obstetric factors based
entry in the chart by the physician documenting the on prenatal diagnosis status and neonatal survival status
presence of vasa previa at delivery were included. For are presented in Table 2. Fifty (32.3%) of the women had
cases ascertained from the collaborating hospitals, a sim- bilobed or succenturiate lobed placentas. Ninety-five
ilar process of verification of vasa previa was applied. (61%) had second-trimester low-lying placentas; in only
Data were incomplete for some cases regarding loca- 31 (20%) of these did the placenta remain low-lying at the
tion of the placenta in the second trimester (n ⫽ 2) and at time of delivery. Fifty-six patients (36.1%) had third-
delivery (n ⫽ 2), presence or absence of a bilobed trimester vaginal bleeding. In only 3 cases of third-
placenta (n ⫽ 3), antepartum hemorrhage (n ⫽ 4), trimester bleeding, a test was performed to determine
steroid administration (n ⫽ 1), intrapartum hemorrhage whether the blood was of maternal or fetal origin. Of the
(n ⫽ 60), mode of delivery (n ⫽ 1), and need for 108 pregnancies that did not have an elective cesarean
transfusion of the newborn (n ⫽ 1). Percentages were delivery, data regarding intrapartum bleeding were
therefore calculated as proportions of the nonmissing available in 91 cases. Of the 87 who did not have
data. In twin pregnancies, only the perinatal data for the prenatal diagnosis, intrapartum bleeding occurred in 82
first twin was included in our analysis. In all the twin (94.3%). The mean gestational age at delivery was
cases studied, the first twin was the fetus whose placenta 34.9 ⫾ 2.1 weeks for cases diagnosed prenatally com-

938 Oyelese et al Vasa Previa Outcomes OBSTETRICS & GYNECOLOGY

Table 1. Demographic Details of Study Population
Prenatal No prenatal
All cases diagnosis diagnosis Did not survive Survived
(N ⫽ 155) (n ⫽ 61) (n ⫽ 94) P (n ⫽ 55) (n ⫽ 100) P
Maternal age (y) 31.6 ⫾ 4.9 32.2 ⫾ 4.7 31.2 ⫾ 5.0 .19 30.6 ⫾ 5.0 32.1 ⫾ 4.8 .08
Previous cesarean 12/154 (7.8) 4/61 (6.6) 8/93 (8.7) .89 4/54 (7.4) 8/100 (8) .90
delivery
Previous vaginal 60/155 (38.7) 29/61 (47.5) 31/94 (33.0) .07 17/55 (30.9) 43/100 (43) .14
delivery
Previous spontaneous 41/155 (26.5) 18/61 (29.5) 23/94 (24.5) .49 12/55 (21.8) 29/100 (29) .33
or therapeutic
abortion
Smoking 12/155 (7.7) 3/61 (4.9) 9/94 (9.6) .37 8/47 (14.5) 4/99 (4) .02
In vitro fertilization 15/155 (9.7) 6/61 (9.8) 9/94 (9.6) .96 4/55 (7.3) 11/100 (11) .58
Values are presented as mean ⫾ standard deviation or proportion (%).

pared with 38.1 ⫾ 2.5 weeks in cases not diagnosed In cases from the Vasa Previa Foundation, perinatal
prenatally. mortality occurred in 40 (45.9%) of 87 cases, compared
Perinatal outcomes are reported in Table 3. The over- with 15 (22%) of 68 in cases obtained from the hospitals
all perinatal mortality was 36%. In 59 (97%) of the (P ⫽ .002). Twenty-five (28.7%) of 87 cases from the
pregnancies with prenatal diagnosis, the infants sur- Vasa Previa Foundation were diagnosed prenatally com-
vived, compared with 41 (44%) of 94 when the diagnosis pared with 36 (52.9%) of 68 of the cases from the
was not made prenatally. Thus the perinatal mortality hospitals (P ⫽ .02). Of those diagnosed prenatally, the
was 56% when the diagnosis was not made prenatally. neonatal survival in cases from the Vasa Previa Founda-
Median 1- and 5-minute Apgar scores were 8 and 9, tion was 24 (96%) of 25 compared with 35 (97.2%) of 36
respectively, in cases in which the prenatal diagnosis had cases from the hospitals (P ⫽ .99).
been made. However, in the survivors in cases not On multivariable logistic regression analysis, the vari-
diagnosed prenatally, the median 1- and 5- minute Apgar ables considered for the model included prenatal diagno-
scores were 1 and 4, respectively. Twenty-four (58.5%) sis, prior cesarean delivery, maternal age, administration
of the 41 surviving neonates born to mothers whose vasa of steroids for lung maturation, presence of bilobed
previa was not diagnosed prenatally required blood placentas, in vitro fertilization, the presence of a second-
transfusions, compared with 2 of the 59 (3.4%) surviving trimester low-lying placenta, a low-lying placenta at the
neonates in pregnancies where vasa previa was diag- time of delivery, smoking, and gestational age at deliv-
nosed prenatally (P ⬍ .001). ery. Because the source of the data (cases obtained from

Table 2. Relationship of Prenatal Diagnosis of Vasa Previa to Associated Risk Factors and Management
Prenatal No prenatal
All cases diagnosis diagnosis Did not survive Survived
(N ⫽ 155) (n ⫽ 61) (n ⫽ 94) P (n ⫽ 55) (n ⫽ 100) P
Twin pregnancy 7/155 (4.5) 3/61 (4.9) 4/94 (4.3) .99 2/55 (3.6) 5/100 (5) .99
Second-trimester low- 95/153 (62.1) 57/61 (93.4) 38/92 (41.3) ⬍ .001 26/44 (48.1) 69/98 (70.4) ⬍ .001
lying placenta
Low-lying placenta at 31/153 (20.3) 27/61 (44.3) 4/92 (4.3) ⬍ .001 2/55 (3.6) 29/98 (29.6) ⬍ .001
delivery
Bilobed placenta 50/152 (32.9) 32/60 (53.3) 18/92 (19.6) ⬍ .001 11/54 (20.4) 39/98 (39.8) .01
Antepartum 74/151 (49.0) 40/61 (65.6) 34/90 (37.8) .001 17/52 (32.7) 39/98 (39.8) .39
hemorrhage
Steroids 52/154 (33.8) 49/61 (80.3) 3/93 (3.2) ⬍ .001 2/55 (3.6%) 50/99 (50.5) ⬍ .001
Gestational age at 36.9 ⫾ 2.8 34.9 ⫾ 2.5 38.2 ⫾ 2.1 ⬍ .001 37.6 ⫾ 3 36.5 ⫾ 2.6 .02
delivery (wk)
Mode of delivery
Elective cesarean 46/154 (29.9) 42/61 (68.9) 4/93 (4.3) ⬍ .001 — 45/100 (45) ⬍ .001
Vaginal 28/154 (18.2) 2/61 (3.3) 26/93 (28.0) 20/54 (37) 8/100 (8)
Emergency 80/154 (51.9) 17/61 (27.9) 63/93 (67.7) 34/54 (63) 47/100 (47)
cesarean
Values are presented as mean ⫾ standard deviation of proportion (%).

VOL. 103, NO. 5, PART 1, MAY 2004 Oyelese et al Vasa Previa Outcomes 939
Table 3. Relationship of Prenatal Diagnosis of Vasa Previa to Selected Perinatal Outcomes
All cases Prenatal diagnosis No prenatal diagnosis
(N ⫽ 155) (n ⫽ 61) (n ⫽ 94) P
Survivor 100/155 (64.5) 59/61 (96.7) 41/94 (43.6) ⬍ .001
Stillbirth 30/155(19.4) 1/61 (1.6) 29/94 (30.1) ⬍ .001
Apgar score at 1 minute* 8 (0–10) 8 (7–10) 1 (0–10) ⬍ .001
Apgar score at 5 minutes* 9 (0–10) 9 (7–10) 4 (0–10) ⬍ .001
Neonatal death† 25/125 (20) 1/60 (1.67) 24/65 (36.9) ⬍ .001
Transfusion* 26/100 (26) 2/59 (3.4) 24/41 (58.5) ⬍ .001
Values are presented as proportion (%) or median (range).
* Based on survivors: all cases n ⫽ 100; prenatal diagnosis n ⫽ 59; no prenatal diagnosis n ⫽ 41.
†
Based on live births: all cases n ⫽ 125; prenatal diagnosis n ⫽ 60; no prenatal diagnosis n ⫽ 65.

the Vasa Previa Foundation versus cases obtained from authors observed that routinely identifying placental
the participating hospitals) may have been a confounder, cord insertion added no significant time to the obstetric
we adjusted for the data source in our regression model. sonographic examination. It should be emphasized,
After removing variables that were not significant (de- however, that not all cases of vasa previa necessarily
fined as P ⬍ .05), the only variables that were significant would be recognized by sonography. Such factors as
predictors of survival were prenatal diagnosis (odds ratio abdominal wall scarring, maternal obesity, or an incom-
102.9; 95% confidence interval 16.2, 638.3; P ⬍ .001) pletely filled maternal bladder may prevent visualization
and gestational age at delivery (odds ratio 0.77; 95% of the cord entry into the placenta and/or visualization of
confidence interval 0.64, 0.93; P ⫽ .01). fetal vessels over the cervix. Furthermore, vessels that
course over the cervix in a transverse rather than an
DISCUSSION anteroposterior direction may be missed by transabdom-
inal color Doppler ultrasonography.1
Our findings indicate that the best outcomes with vasa
Previous studies have suggested that a second-trimes-
previa are achieved when the condition is diagnosed
ter low-lying placenta or placenta previa is associated
prenatally and the fetus is delivered by cesarean, ideally
with vasa previa, regardless of whether the placenta
before the membranes rupture. The most striking find-
remains low-lying at the time of delivery.5,6,10,14,15 More
ing was that, when the diagnosis was made prenatally,
than 60% of the cases of vasa previa in our study were
more than 96% of infants survived, whereas more than
half of all fetuses/infants died when there was no prenatal associated with a second-trimester placenta previa or
diagnosis. Among survivors when the diagnosis had not low-lying placenta, whereas two thirds of these had
been made prenatally, 1- and 5-minute Apgar scores resolved by the time of delivery. Other investigators
were very low (median 1 and 4, respectively). In addi- have reported that succenturiate and bilobed placentas
tion, more than half of surviving neonates required appear to be associated with the development of vasa
blood transfusions when the diagnosis was not made previa.1,16 These placental abnormalities were present in
prenatally. 32.9% of our cases, considerably higher than the esti-
Previous studies have demonstrated that prenatal di- mated prevalence in the general population of
agnosis of vasa previa is feasible. Nomiyama and col- 4 –5%.16,17 Approximately 10% of the women in our
leagues,12 using ultrasonography, attempted to routinely study had undergone in vitro fertilization (IVF). It is not
locate the insertion of the umbilical cord into the placenta clear why IVF appears to be associated with vasa pre-
in 667 women. They were able to do this in all cases via.11,14,18 A study of 100 placentas from IVF pregnan-
except 1 and diagnosed 3 cases of vasa previa. These cies revealed 14 cases of velamentous insertion among
investigators found that it took a mean time of less than them.18 This prevalence was higher than the prevalence
20 seconds to identify the placental cord insertion ultra- of velamentous cord insertion in the general population,
sonographically and that in 95% of cases it took less than even after correcting for the higher prevalence of vela-
a minute. Lee and colleagues10 and Catanzarite et al,1 mentous insertion in multiple pregnancies.18 Similarly,
using ultrasonography and color Doppler, routinely in a recent study, Schachter and colleagues11 found an
screened large populations of pregnant women for vasa incidence of vasa previa at their institution of 1 in 293
previa and diagnosed 15 and 10 cases, respectively. IVF deliveries compared with a vasa previa rate of 1 in
More recently, Sepulveda et al13 performed routine 6,068 total deliveries. In our study, women with second-
sonography to locate the placental cord insertion in 832 trimester low-lying placentas, those with bilobed placen-
women and were successful in 825 cases (99.2%). These tas, and those who experienced third-trimester vaginal

940 Oyelese et al Vasa Previa Outcomes OBSTETRICS & GYNECOLOGY

bleeding were more likely to have prenatal diagnosis of perinatal survival based on whether cases came from the
their vasa previa (Table 2), possibly because the presence Vasa Previa Foundation or the hospitals, suggesting that
of these findings prompted sonographic evaluation of the the source of case ascertainment does not appreciably
region overlying the cervix. However, in neither multi- diminish the positive impact of prenatal diagnosis on
ple pregnancies nor those resulting from IVF was vasa survival.
previa more likely to be diagnosed prenatally. This study demonstrates that the mortality from vasa
What should the plan of management be once vasa previa can be minimized; a good outcome depends al-
previa has been diagnosed? Although our study design most entirely on prenatal diagnosis followed by cesarean
did not allow us to evaluate the effect of prenatal hospi- delivery before rupture of membranes. In very few con-
talization on outcomes, admission to hospital early in the ditions does prenatal diagnosis lead to such a dramatic
third trimester may be reasonable. Hospitalization al- improvement in outcome. It is our opinion therefore that
lows proximity to facilities for emergent delivery should standard obstetrical ultrasound protocols should be
the membranes rupture. However, we did not evaluate modified to include screening for vasa previa. An at-
the cost-effectiveness of this approach. An alternative tempt to identify placental umbilical cord insertion
approach is to follow the pregnancies with serial trans- should be a routine part of the second-trimester obstetric
vaginal cervical length determinations, along with hospi- ultrasound examination. In women at increased risk
talization should the patient experience contractions or (those with second-trimester low-lying placentas, preg-
spotting, with a plan for elective delivery at about 35 nancies resulting from IVF, and those with accessory
weeks of gestation. Because of the potential for emer- placental lobes), we would recommend consideration of
gency preterm delivery, consideration should be given to routine transvaginal color Doppler sonography of the
administering steroids to promote fetal lung maturation. region over the cervix if vasa previa cannot be excluded
The mean gestational age for delivery in prenatally by transabdominal sonography. Based on the findings of
diagnosed cases was 34.9 ⫾ 2.5 weeks, with 27.9% this study, it is our opinion that sonographic prenatal
requiring emergency cesarean delivery because of bleed- diagnosis and careful perinatal management have the
ing, labor, or rupture of membranes, although in the potential to prevent the overwhelming majority of fatal
majority of cases elective delivery had been planned for outcomes associated with vasa previa.
later gestational ages. Based on our findings, we recom-
mend that women with prenatally diagnosed vasa previa
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942 Oyelese et al Vasa Previa Outcomes OBSTETRICS & GYNECOLOGY