CASE REPORT

A case of vasa previa diagnosed prenatally, and review

of the literature
Atsushi Komatsu

Shiro Kozuma

Shiro Yoshida

Hironobu Hyodo

Takahiro Yamashita

Yoshimasa Kamei

Tomoyuki Fujii

Yuji Taketani
Received: 9 June 2010 / Accepted: 17 August 2010 / Published online: 30 October 2010
The Japan Society of Ultrasonics in Medicine 2010
Abstract The perinatal mortality rate of vasa previa is
high if it is not prenatally diagnosed. In this report, a case of
vasa previa diagnosed prenatally is presented. Antepartum
hemorrhage at 24 weeks of gestation prompted a close
investigation of the uterine cervix, internal os, and placenta.
We detected a low-lying bilobed placenta with umbilical
cord insertion in the lower uterine segment. Furthermore,
one of the connecting vessels of the bilobed placenta passed
directly above the internal os. Vasa previa was suspected
and conrmed with color Doppler and MRI. The fetus was
delivered uneventfully by planned Cesarean section at
38 weeks of gestation. It should be considered that placenta
previa (including low-lying placenta), bilobed placenta, and
umbilical cord insertion in the lower uterine segment are
associated with high risk of vasa previa. Ultrasound
screening for cord insertion and placenta around the internal
os enables efcient and certain detection of vasa previa.
Keywords Vasa previa Lobed placenta
Transvaginal ultrasound
Introduction
Vasa previa refers to vessels that traverse the membranes
located in the lower uterine segment in advance of the fetal
presenting part. The prevalence of vasa previa is approxi-
mately 1 in 2500 deliveries [1]. Patients at increased risk of
vasa previa include:
those with a second-trimester low-lying placenta or
placenta previa even if it has resolved;
pregnancies conceived after use of assisted reproduc-
tive technologies; and
patients with bilobed and succenturiate lobe placentas
in the lower uterine segment [25].
Vasa previa is an important obstetrics complication; the
associated perinatal mortality rate has been reported to be as
high as 5266% [68]. This high fetal loss rate is probably
because of the several factors. Fetal vessels, which are
normally protected by Whartons jelly within the umbilical
cord, are unsupported in vasa previa. These vessels are
rmly adherent to overlying chorionic membranes, which at
the time of either spontaneous or articial rupture may lead
to tearing of the underlying vessels. Furthermore, hemor-
rhage because of vasa previa is rapidly fatal because the
bleeding is from the fetus, which has only a small circula-
tion volume. To prevent this cascade of complications, one
must have a high index of suspicion when managing women
with antepartum hemorrhage so that affected pregnancies
can be delivered early. Alternatively, a good fetal outcome
can be expected if this condition is diagnosed and the fetus
delivered before the onset of bleeding.
We herein present a case of vasa previa in which routine
transvaginal ultrasound revealed a low-lying placenta but
vasa previa was not detected until ultrasound examination of
the uterine cervix and uterine lower segment was repeated.
Case
A 42-year-old woman, gravida 3, para 1, achieved spon-
taneous pregnancy, and the pregnancy course until early
second trimester was favorable. Routine transvaginal
A. Komatsu (&) S. Kozuma S. Yoshida H. Hyodo
T. Yamashita Y. Kamei T. Fujii Y. Taketani
Department of Obstetrics and Gynecology, Faculty of Medicine,
The University of Tokyo, 7-3-1 Hongo, Bunkyo,
Tokyo 113-8655, Japan
e-mail: atsukoma@yahoo.co.jp
1 3
J Med Ultrasonics (2011) 38:4145
DOI 10.1007/s10396-010-0287-2
ultrasound revealed a low-lying placenta at 22 weeks of
gestation. Further investigation was advised several weeks
later. She had a small hemorrhage vaginally at 24 weeks
of gestation. An ultrasound that included a transvaginal
examination showed no abnormality other than the low-
lying placenta. A repeat transvaginal ultrasound scan
showed the umbilical cord inserted in the lower uterine
segment and vessels running across the internal os.
Furthermore, one of the connecting vessels of the low-
lying bilobed placenta passed directly above the internal
os. Vasa previa was suspected and conrmed with color
Doppler (Figs. 1, 2). MRI examination showed a bilobed
placenta and vessels running around the internal os
(Figs. 3, 4). Because massive bleeding was expected,
autologous blood was collected and stored before surgery.
The fetus was delivered by planned Cesarean section at
38 weeks of gestation. Intraoperative total blood loss was
870 ml (including amniotic uid volume). The patient
received an autologous blood transfusion. The baby boy
weighed 3174 g, with an Apgar score of 9 and 9 at 1 and
5 min, respectively. The baby required no resuscitation
and there were no neonatal complications. Examination
showed a lobed placenta and blood vessels connecting one
lobe of the placenta to another. This connecting bridge
vessel with attached fetal membrane lay on the internal os
(Fig. 5).
Fig. 1 Visualization using
color Doppler of vessels
overlying the internal os
Fig. 2 Bilobed placenta and
vessels connecting the lobes.
The arrows points to the
internal os
42 J Med Ultrasonics (2011) 38:4145
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Discussion
Vasa previa is a condition in which the umbilical vessels,
unsupported by either the umbilical cord or placental tis-
sue, traverse the fetal membranes of the lower segment
above the cervix [5]. The reported incidence varies from 1
in 1275 to 1 in 5000 [9, 10]. Vasa previa usually occurs in
association with velamentous insertion of the umbilical
cord, bipartite placenta, or succenturiate lobe. In the pres-
ence of a velamentous insertion of the cord with the pla-
centa in the lower uterine segment, the incidence of vasa
previa has been reported to be 1 in 50 [10].
There are three theories postulated with respect to vel-
amentous insertion of the cord and vasa previa [11]:
1. Initially, there is satisfactory implantation of the
umbilical cord vessels on the decidua basalis, but it
becomes inadequate with growth and expansion of the
fetus and the placenta. The chorion frondosum
surrounding the insertion regresses to become the
chorion leave, resulting in velamentous insertion.
2. In velamentous insertion, the richest vascularization
shifts to the decidua basalis, site of the future placenta,
resulting in the vessels extending to the margin of the
placenta.
3. Restricted intrauterine space or limitation of fetal
mobility is responsible for the abnormal morphology
in both fetus and placenta.
Velamentous insertion of the cord is a prerequisite for
vasa previa [12].
The incidence of vasa previa has been reported to be as
high as 1 in 202 after IVF compared with 1 in 2200 in non-
IVF pregnancies, with a likelihood ratio of 7.75 [3, 5, 13].
Other signicant risk factors for vasa previa include second
trimester placenta previa, with an odds ratio of 22.86, and
bilobed and succenturiate-lobed placentas, with an odds
ratio of 22.11 [5]. It has been reported that the risk of vasa
previa may be associated with fetal anomalies including
renal tract anomalies, spina bida, single umbilical artery,
exomphalos, and, to a lesser extent, prematurity, antepar-
tum hemorrhage, and fetal growth restriction [5]. But this
review discovered only nine cases of vasa previa and was
not a casecontrol study, so there is no relevant evidence
for an association between vasa previa and fetal anomalies.
Before widespread use of transvaginal ultrasound, the
classical modes of presentation included vessel rupture at
Fig. 5 Bilobed placenta and connecting vessel between the lobes
(arrow)
Fig. 3 Bilobed placenta
Fig. 4 Vessel running around uterine lower segment (arrow)
J Med Ultrasonics (2011) 38:4145 43
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amniotomy, vessel rupture before rupture of the membranes,
vessel rupture after rupture of the membranes [14], vessel
compression, and vessels palpable on vaginal examination.
Ideally, in this day and age, vasa previa should be detected
antenatally by vaginal ultrasound and color Doppler before
there is fetal bleeding. Unfortunately, the most frequent
presentation is still vaginal bleeding occurring at the time the
membranes rupture, the bleeding being most often attributed
to placenta previa, placental abruption, or heavy show.
Bleeding of even 100 ml is sufcient to cause fetal shock
and death [15]. Variable-type fetal heart rate deceleration
could also occur with extrinsic cord compression secondary
to velamentous insertion, and, if prolonged, could lead to
fetal asphyxia and death [16]. A sinusoidal fetal heart rate
may be a terminal event during fetal hemorrhage [17, 18].
Antenatal diagnosis of vasa previa can be made by
ultrasound, MRI, amnioscopy, palpation of the vessels by
digital vaginal examination, and identication of fetal blood
in vaginal blood intrapartum. Velamentous cord insertion
near the cervix can be diagnosed antenatally by transvaginal
sonography. In women at high risk, transvaginal ultrasound
with color Doppler can be used during routine second-tri-
mester ultrasound to screen for vasa previa. Placental cord
insertion can be identied in up to 99% of ultrasound
examinations performed at 1820 weeks [19, 20]. Diag-
nostic criteria for vasa previa using transvaginal ultrasound
include the presence of a linear sonolucent area over the
internal os of the cervix with the absence of Whartons jelly
[21]. When using color Doppler or power color Doppler,
blood ow can be demonstrated through these umbilical
vessels, and the Doppler waveforms are typical of umbilical
cord Doppler ow waveforms. Because a normal loop of
cord may be mistaken for vasa previa, it is important to
ascertain that the vessel is not displaced with maternal
movement. Visualization of vasa previa may be difcult
with transvaginal sonography alone. Fetal vessels may run
at an unfavorable insonation angle of 90 to the relatively
xed transducer. If transvaginal visualization by color
coded Doppler is not possible, the transabdominal route
may allow for a more favorable insonation angle (inson-
ation: exposure of a tissue and/or organ to ultrasound
waves) and better visualization of blood ow. Furthermore,
only the combined use of transabdominal and transvaginal
ultrasound allows the diagnosis of placental type, placental
situation, and cord insertion [22]. The presence of an
amniotic sheet carrying fetal vessels may be observed only
when using the combined approach. Furthermore, preg-
nancy-associated varicosities of the uterine vessels may be
mistaken for aberrant placental vessels [23]. In this case,
exact localization by a combined approach may prevent
erroneous diagnosis of vasa previa.
In a prospective trial, a sensitivity of 100%, a specicity
of 99.8%, a positive predictive value of 83%, and a negative
predictive value of 100% have been reported using this
approach to diagnose velamentous insertion of the cord [19].
In a series of 12069 pregnancies screened, Baulies et al. [5]
were able to diagnose up to 78% of occurrences of vasa
previa in asymptomatic pregnant women antenatally, which
is the ideal time to reduce the risk of fetal bleeding and death
[1]. Although vasa previa can be diagnosed antenatally,
missing the diagnosis is possible even when ultrasound is
performed under the best circumstances in tertiary centers.
It is important to note that in 89% of cases of vasa
previa, one of the following risk factors is present: placenta
previa, low-lying placenta, and bilobate or succenturiate
placenta [24]. In all cases diagnosed antenatally, elective
Cesarean section performed before the onset of labor
should result in live healthy newborns [25].
In one of the most important studies by Oyelese et al.
[26], 155 cases of vasa previa were considered [2]. A
comparison of women who were diagnosed antenatally and
those who were not showed respective neonatal survival
rates of 97 and 44%, and the rates of neonatal blood
transfusion were 3.4 and 58.5%, respectively. The authors
concluded that given the vital importance of antenatal
diagnosis of vasa previa, every second trimester ultrasound
examination should evaluate placental cord insertion; also,
transvaginal ultrasound should be systematically performed
for all women who are pregnant after IVF, because they are
a group at particularly high risk of vasa previa. Other
groups at risk include those with low or velamentous
insertion of the placenta cord, bilobate or succenturiate
placenta, and those having third trimester vaginal bleeding.
If vasa previa is suspected, color Doppler should be used to
facilitate the diagnosis. Although it is not possible to detect
every case of vasa previa, antenatal ultrasonography can be
used to identify some asymptomatic women before deliv-
ery. When technically feasible, evaluation of the internal os
should be done for women at risk of vasa previa. The
differential diagnosis includes chorioamniotic separation,
normal cord loop, marginal placental vascular sinus, vari-
cosities of the uterine veins, and amniotic band [27, 28].
In this case, routine transvaginal ultrasound revealed the
low-lying placenta but could not detect the vasa previa. We
can check for vasa previa by repeated investigation of the
uterine cervix and uterine lower segment. It is important to
perform repeated examinations when one encounters a
low-lying, bilobed placenta and umbilical cord insertion to
the lower uterine segment.
MRI is an accurate tool with which antenatal diagnosis
of vasa previa can be made [29, 30]; however, it is
expensive and not widely available, and thus, at present, is
not a method that can be used in most obstetric practices to
diagnose vasa previa.
Diagnosis of vasa previa should be considered in the
event of vaginal bleeding that occurs upon rupture of the
44 J Med Ultrasonics (2011) 38:4145
1 3
membranes. The concomitant nding of fetal heart rate
abnormalities, particularly a sinusoidal pattern, is highly
suggestive of vasa previa. Conrmation should be sought
by assessing the origin of the vaginal bleeding via Apt,
KleihauerBetke tests, or other tests (Ogita, Londersloot).
However, there usually is no time to wait for test results
before performing an emergency Cesarean delivery.
Conclusion
Although vasa previa is a rare condition, it may have cat-
astrophic consequences. In this regard, the antenatal diag-
nosis of vasa previa by means of ultrasound has had a
benecial effect on prognosis. If the placenta is found to be
low lying at the routine second trimester ultrasound
examination, further evaluation for placental cord insertion
should be performed. Transvaginal ultrasound may be
considered for all women at high risk of vasa previa,
including those with low or velamentous insertion of the
cord, bilobate or succenturiate placenta, or vaginal bleed-
ing, in order to evaluate the internal cervical os. If vasa
previa is suspected, transvaginal color Doppler ultrasound
may be used to facilitate the diagnosis. When vasa previa is
diagnosed antenatally, an elective Cesarean section should
be offered before the onset of labor.
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