Patient handout

Placenta Previa & Placenta Accreta Spectrum

PRODUCTION

1. Your condition

This handout is for placenta previa & placenta accreta spectrum. Your care team identified this based on: painless bright-red vaginal bleeding in pregnancy ≥ 20 wk — gateway feature of placenta previa; distinguishes from the painful, tender, hypertonic uterus of placental abruption (oyelese smulian 2006; cross-anchor oyelese ananth 2006 pmid 17012465).

Other reasons your team may use this plan: self-limited painless herald (sentinel) bleed in a pregnancy ≥ 20 wk — frequently precedes a larger hemorrhage (rcog gtg 27a 2018/2024); placenta overlying or within 2 cm of the internal cervical os on tvus at ≥ 20 wk (complete previa) or placental edge < 2 cm from os not covering (low-lying placenta) (rcog gtg 27a 2018/2024); sonographic pas markers — multiple placental lacunae, loss of the clear retroplacental hypoechoic zone, myometrial thinning < 1 mm, bridging vessels, bladder-wall interruption, uterovesical hypervascularity on color doppler (figo 2024; acog/smfm occ 7 2018/2024).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
tranexamic acid	1 g IV over 10 min within 3 h of birth	IV	single dose; may repeat 1 g IV × 1 after 30 min if continued bleeding	WOMAN trial 2017 — TXA within 3 h reduces death due to bleeding (~ 19% relative reduction); PMID 28456509
norepinephrine	0.05 mcg/kg/min, titrate to MAP ≥ 65	IV (central preferred)	continuous	SSC 2026 first-line vasopressor for refractory shock; bridge to definitive surgical/transfusion control
hydrocortisone	200 mg/day divided q6h OR continuous infusion	IV	q6h or continuous	SSC 2026 conditional for refractory shock

Plan: Placenta previa & PAS — hemorrhage resuscitation + expectant-vs-delivery + PAS surgical planning + limited tocolysis + RhoGAM (ACOG/SMFM OCC 7 2018/2024 + RCOG GTG 27a 2018/2024 + FIGO 2024 + Pacheco LD AJOG 2016)

3. When to call your provider

Contact your care team if any of the following happen:

Any antepartum bleeding in an outpatient previa patient → immediate ED / L&D (no digital exam)
Postpartum bleeding / persistent uterine tenderness / foul lochia → endometritis or retained-products workup (ED visit)
New mental health crisis (PHQ-9 ≥ 15 or suicidal ideation) → urgent mental health referral
Newborn high-risk features → urgent peds visit

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Placenta previa / PAS + massive antepartum or intrapartum hemorrhage with maternal hemorrhagic-shock features (SBP < 90 OR MAP < 65 OR HR > 120 OR lactate > 2 OR rapid Hgb decline) — life-threatening; emergent cesarean (± hysterectomy) regardless of GA + massive transfusion protocol (1:1:1 PRBC:FFP:platelets) + TXA + cryoprecipitate + ICU; do NOT delay for further imaging; do NOT perform digital cervical exam(life-threatening)
Placenta previa / PAS + Category III FHR (late decelerations, prolonged decelerations, bradycardia, sinusoidal, minimal variability) + viable GA + alive fetus — life-threatening fetal compromise; emergent cesarean with surgical team + neonatology stand-by + simultaneous maternal resuscitation(life-threatening)
Placenta percreta with bladder and/or parametrial invasion (FIGO clinical grade 3 / percreta) — life-threatening surgical complexity; accreta center of excellence + full multidisciplinary team (MFM, gyn-onc/pelvic surgeon, urology, IR, anesthesia, critical care, blood bank, NICU); cesarean hysterectomy with placenta left in situ; consider staged/delayed surgery; do NOT attempt placental removal(life-threatening)
Suspected PAS — prior cesarean delivery (especially ≥ 2) + anterior placenta previa overlying the hysterotomy scar + sonographic markers (lacunae, loss of clear zone, myometrial thinning, bridging vessels, bladder-wall interruption) — severe; refer accreta center of excellence; targeted US ± MRI; planned cesarean hysterectomy 34+0-35+6 wk; preoperative ureteral stents; IR balloon; pretest probability gradient per Silver 2006 (with previa: 2 CS ~ 11%, 3 ~ 40%, 4 ~ 61%, ≥ 5 ~ 67%)
Complete placenta previa with recurrent or heavy antepartum bleeding — severe; inpatient management; type & screen + crossmatch; antenatal corticosteroids if 24-34 wk; deliver if recurrent/heavy bleeding compromises mother or fetus rather than waiting for the scheduled 36-37+6 wk window
Self-limited painless sentinel (herald) bleed with stable maternal-fetal status + preterm previa — severe (sentinel bleeds frequently precede a larger hemorrhage); inpatient observation; type & screen; antenatal corticosteroids if 24-34 wk; limited tocolysis only to gain a 48 h steroid window in the absence of ongoing bleeding/fetal compromise
Scheduled late-preterm delivery timing decision — stable complete previa (no PAS) → scheduled cesarean 36+0-37+6 wk; suspected/confirmed PAS → scheduled cesarean hysterectomy 34+0-35+6 wk at an accreta center after a betamethasone course, before labor/bleeding — severe (timing balances prematurity vs catastrophic unscheduled hemorrhage)
Rh-negative mother with placenta previa / PAS and an antepartum bleed — severe; Kleihauer-Betke to quantify fetomaternal hemorrhage; RhoGAM 300 mcg IM within 72 h, dose-adjusted per KB (300 mcg per 30 mL fetal whole blood); MCA-PSV doppler + MFM if large FMH
Conservative (placenta-left-in-situ, uterine-preserving) PAS management in a highly selected fertility-desiring patient — severe; intensive surveillance for delayed secondary hemorrhage, infection/endometritis/sepsis, and need for interval or emergency hysterectomy; not routine; informed consent required; routes to id.sepsis.core.v1 if infection features emerge

5. Follow-up

6-wk postpartum visit + previa/PAS-specific anticipatory guidance: previa recurrence ~ 4-8% in a subsequent pregnancy; PAS history → high recurrence risk + accreta-center planning for any future pregnancy; iron repletion for postpartum/hemorrhage anemia; contraception counseling + ≥ 18 mo interpregnancy interval discussion (cesarean-scar PAS risk rises with each repeat CS); mental-health screen (EPDS for PPD; PCL-5 for peripartum PTSD given peripartum hysterectomy / massive hemorrhage); pelvic-floor and surgical-recovery follow-up; immunization audit (Tdap, influenza, COVID per ACIP); newborn outpatient 24-48 h post-discharge peds visit + developmental tracking for the first year if preterm. Counsel that hysterectomy ends fertility where performed; fertility-sparing conservative PAS management carries delayed-hemorrhage/infection surveillance.

6. Sources

Guideline: ACOG/SMFM Obstetric Care Consensus 7 — Placenta Accreta Spectrum (Obstet Gynecol 2018; 132(6): e259-e275; reaffirmed 2024) + RCOG Green-top Guideline 27a — Placenta Praevia and Placenta Praevia Accreta (2018, reaffirmed 2024) + RCOG Green-top 27b — Vasa Praevia (2018, reaffirmed 2024) + FIGO consensus guidelines on placenta accreta spectrum disorders (2024 update) + Silver RM et al — Maternal morbidity associated with multiple repeat cesarean deliveries (NICHD MFMU; Obstet Gynecol 2006; 107(6): 1226-1232; PMID 16738145) + Oyelese Y, Smulian JC — Placenta previa, placenta accreta, and vasa previa (Obstet Gynecol 2006; 107(4): 927-941) + Pacheco LD et al — An update on the use of massive transfusion protocols in obstetrics (Am J Obstet Gynecol 2016; PMID 26348379) + WOMAN trial Shakur 2017 (Lancet; PMID 28456509) + ACOG PB 181 2017 Anti-D Immunoprophylaxis + ACOG CO 713 2017 / ALPS NEJM 2016 antenatal corticosteroids + ACOG PB 222 2020 Gestational HTN and Pre-eclampsia