Interventions for suspected placenta praevia
The limited available data suggest that both home care and cerclage are associated with reduced length of stay in hospital during the antenatal period, but there is little evidence of any clear advantage or disadvantage of the policy of home versus hospital care. Hence, no change is recommend in existing polices for dealing with placenta praevia.
RHL Commentary by Osman NB
1. EVIDENCE SUMMARY
This Cochrane review (1) was updated in 2003. Three trials were included in this review, involving a total of 114 women.
Two interventions were tested in women with suspected placenta praevia: home versus hospitalization and cervical cerclage versus no cerclage.
The review found that both interventions (home care and cerclage) were associated with reduced length of stay in hospital during the antenatal period. There was little evidence of any clear advantage or disadvantage of the policy of home versus hospital care. One woman in the home-care group had a haemorrhage severe enough to require immediate blood transfusion and induction of delivery.
Cervical cerclage was found to reduce the risk of delivery before 34 weeks of gestation and delivering a baby weighing less than two kilograms. Also, there was a trend towards reduction of risk of delivering a neonate with a low five-minute Apgar score. In general, these possible benefits were more evident in one of three included trials that was adjudged by the reviewers to be of lower methodological quality.
The methods used to search the literature for relevant trials were adequate. Unpublished data in languages other than English were included, and the review authors contacted the concerned researchers for clarifications where needed. Maternal and fetal outcomes as well as medical interventions were adequately covered.
The weakness of this systematic review is that only three trials with 114 women met the inclusion criteria. These small numbers do not give sufficient power to the review to reach reliable conclusions. The authors therefore concluded that available data were insufficient to recommend any change in clinical practice.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
Placenta praevia is a life-threatening complication of pregnancy and an important public health problem worldwide. Its impact in under-resourced settings is much greater than its impact in developed countries. In under-resourced setting there is often a lack of awareness of the danger signs placenta praevia, which can lead to delays in seeking medical care. In addition, poor transport facilities and the need to travel long distances to reach a health unit (which may have only limited resources to deal with the problem) increase the risk of haemorrhage, which is the leading causes of maternal death in Africa and Asia (2).
2.2. Applicability of the results
All three studies included in this systematic review were conducted in North America, where accesses to health care and socioeconomic status of women are very different from under-resourced countries in Asia and Africa. Although the physiopathology of placenta praevia is similar worldwide, it is likely that an intervention to deal with the problem might yield different results in developed and developing countries. In any case, owing to lack of data, this review could not arrive at a clear conclusion about the tested interventions.
2.3. Implementation of the intervention
At the present time data are not enough to recommend a change in existing polices for dealing with placenta praevia.
There is a need for further research, particularly large methodologically sound randomized controlled trials, in different settings (developed and developing countries) to address the safety of more conservative policies for the care of women with suspected placenta praevia, and the possible effectiveness of cervical cerclage.
- Neilson JP. Interventions for suspected placenta praevia. Cochrane Database of Systematic Reviews 2003; Issue 2, Art. No.: CD001998 DOI: 10.1002/14651858.CD001998.
- Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet 2006;367:1066-74 Medline.
This document should be cited as: Osman NB. Interventions for suspected placenta praevia: RHL commentary (last revised: 28 August 2007. The WHO Reproductive Health Library; Geneva: World Health Organization.