The Journal of Maternal-Fetal & Neonatal Medicine

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Diagnosis and management of placenta previa and

low placental implantation

Souhail Alouini, Pascal Megier, Arnaud Fauconnier, Cyrille Huchon, Adele

Fievet, Anna Ramos, Charles Megier & Antoine Valéry

To cite this article: Souhail Alouini, Pascal Megier, Arnaud Fauconnier, Cyrille Huchon, Adele
Fievet, Anna Ramos, Charles Megier & Antoine Valéry (2019): Diagnosis and management of
placenta previa and low placental implantation, The Journal of Maternal-Fetal & Neonatal Medicine,
DOI: 10.1080/14767058.2019.1570118

To link to this article: https://doi.org/10.1080/14767058.2019.1570118

Published online: 27 Jan 2019.

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THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE
https://doi.org/10.1080/14767058.2019.1570118

ORIGINAL ARTICLE

Diagnosis and management of placenta previa and low placental

implantation
Souhail Alouinia, Pascal Megiera, Arnaud Fauconnierb, Cyrille Huchonb, Adele Fieveta, Anna Ramosa,
Charles Megiera and Antoine Val
eryc
a
Department of Gynaecology and Obstetrics, Centre Hospitalier R
egional d’Orl
eans, Orleans, France; bDepartment of Gynecology and
Obstetrics, University of Versailles Saint-Quentin in Yvelines, Versailles, France; cDepartment of Medical Informatics and Statistics,
Centre Hospitalier R
egional d’Orl
eans, Orleans, France

ABSTRACT ARTICLE HISTORY

Objective: To evaluate the migration of low-placental implantation (LPI) during the third trimes- Received 17 July 2018
ter of pregnancy and its effect on delivery and post-partum hemorrhage. Accepted 12 December 2018
Methods: We conducted a retrospective study at a level 3 maternity center including all cases
KEYWORDS
of placenta previa (PP) and LPI between 1998 and 2014. The distance (d) between cervical
Caesarean section; low-lying
internal os (CIO) and placental edge (PE) were measured by vaginal ultrasonography in the third placenta; placenta previa;
trimester of pregnancy at 32 and 3 weeks after. We analyzed CIO-PE distance, volume of post- placental edge; placental
partum hemorrhage, delivery decision, and mode of delivery using Kruskall–Wallis test. migration; post-
Results: In total, 319 patients presented with PP or LPI. All complete PP (121) and 90.6% (58 of partum hemorrhage
64) of the placentas less than 1 cm from the CIO did not migrate. Among the 138 placentas
with an initial CIO-PE d greater than 1 cm, only 17 (12.3%) did not migrate above 2 cm. The
patients for whom the decision to perform a cesarean section (C-section) was retained and real-
ized had a CIO-PE d significantly lower than those who delivered vaginally (p < .001). The
patients who delivered by C-section had a lower CIO-PE d when an emergency C-section was
performed, specifically for hemorrhage (p < .001). The mean volume of hemorrhage was signifi-
cantly higher for patients with a CIO-PE d less than 2 cm.
Conclusion: Complete PP and the majority of the placentas less than 1 cm from the CIO did not
migrate. Above 1 cm, the majority of the placentas migrated three to four weeks later. For the
placentas less than 1 cm from the CIO, a significant risk of hemorrhage at delivery was observed.
Thus, prophylactic cesarean section is required for CIO-PE distances <1 cm. For distances
between 1 and 2 cm, the volume of blood loss tends to be more important than for distances
>3 cm without statistical significance. A vaginal delivery could be tried after information
of patients.

Introduction characterize the relation between the placenta and

Placenta previa (PP) and low-placental implantation
(LPI) are obstetrical situations that pose a high risk of
antepartum and post-partum hemorrhage as well as
perinatal mortality [1–5]. Therefore, ultrasound (US)
screening of the placental implantation is essential.
Advances in ultrasonography performance support the
precise measurement of the distance between the pla-
cental edge (PE) and the cervical internal os (CIO). This
measurement was previously performed abdominally
and the classifications of PP were based on abdominal
measures [5,6]. Abdominal measures can still be used
for screening purposes [7].
The developments in vaginal probes make vaginal
measurements more precise and seem to better
the cervix [8]. According to Bhide et al. [9], the dis-
tance to be measured is between the CIO and the PE.
Cases in which the placenta completely covers the cer-
vical os are defined as complete PP. The placenta is
considered low lying at a distance of up to 3–4 cm
from the CIO [10]. Some authors characterized the pla-
centa as low lying when the distance between the
CIO and the PE is less than 2 cm [11]; according to
others, this distance could be extended to 3 or 3.5 cm.
Some authors reported the possible migration of LLP
above 1 or 2 cm [12]. The relation between CIO-PE
distance (d), mode of delivery and the occurrence
of post-partum hemorrhage (PPH) is inad-
equately determined.

CONTACT Souhail Alouini alouini.s@orange.fr Department of Gynecology and Obstetrics, Centre Hospitalier R
egional d’Orl
eans, 14 avenue de
l’H^opital, CS 86709, Orleans CEDEX 2, France
ß 2019 Informa UK Limited, trading as Taylor & Francis Group
2 S. ALOUINI ET AL.
Table 1. General characteristics of the patients with placental
edge to cervical internal os distance less than or equal to
4 cm (n ¼ 319).
% Standard deviation
N patients 319
Mean age (years) 33 6 meters. We defined five categories of CIO-PE distances:
Previous 84 26
C-section
(n patients)
Previous curettage (n patients) 87 27
Mean term of delivery (WG) 37.41 2.53
Birth weight of newborn (g) 2942 583
Mean volume of post-partum 694 873
hemorrhage (ml)
According to some authors, vaginal delivery should
be attempted when the CIO-PE d is greater than 1 cm
[13]; others propose vaginal delivery when the CIO-PE
d is greater than 2 cm [9].
The present study evaluated the evolution of the
CIO-PE d during the third trimester in patients who
presented with PP or LPI and assessed its effect on
mode of delivery and PPH.
Methods
We conducted a retrospective study in the maternity
department of the Regional Hospital Center of Orleans
between 1998 and 2014 including all cases of PP or
LLP. All patients were managed in the protocol frame-
work of the department. According to the framework,
in case of a suspected diagnosis of a PP or LPI in the
third trimester of pregnancy (31–32 weeks) by abdom-
inal US exam or of bleeding, another ultrasound exam
would be performed by an endovaginal probe to
measure the CIO-PE distance. All US examinations
were performed by a senior specialist in obstetrics
ultrasonography. The measure was realized when the
image of the whole length of the cervix and the lower
PE was obtained. A complete previa was diagnosed if
the placenta covered the internal cervical os. When
the placenta did not cross the CIO, we measured the
smallest distance between the PE and the CIO.
In France, three US examinations are routinely per-
formed to screen fetal or placental abnormalities at
12, 22, and 32 weeks of gestation according to the
French guidelines on obstetrics and gynecology. These
exams are usually performed through the abdom-
inal way.
A second US examination was performed at 35 or
3 weeks after the first one to evaluate the potential
migration of the placenta and to plan a delivery route.
All patients with a CIO-PE d less than or equal to 4 cm
were included in the subsequent analysis. Calipers
were placed at the CIO and the lower extremity of the
placenta. The echographs used were Voluson 730
(RIC5-9H transvaginal probe), followed by Voluson E8
(GE Ric 5–9D vaginal transducer probe).
The measures were reported by intervals in centi-
0, 0–1, 1–2, 2–3, and >3 cm. Complete previa was
defined as 0 cm between the CIO and the PE.
Cases of CIO-PE d greater than 4 cm were excluded
in the first US measure. Cases of placenta accreta or
percreta diagnosed by histopathologic exams were
excluded from the study.
The volume of blood loss and mode of delivery
were recorded. PPH was quantified during delivery
using a graduated bag placed under the patient’s but-
tocks. In case of a C-section, blood loss was quantified
by collecting the blood sucked into a graduated jar
and weighing the compresses soaked in blood.
According to the French guidelines of the College of
Obstetricians and Gynecologists, a planned C-section
should be proposed for patients presenting with com-
plete PP. A trial of vaginal delivery could be proposed
for CIO-PE distance >2 cm or less than 2 cm if blood
loss is not important and controlled [14].
Data were acquired from medical charts and each
case was anonymized by numbering. The study was
approved by the French committee (Commission of
Informatics and Liberty, number 2017–005).
Statistical analysis
Following a descriptive analysis (mean, 95% confi-
dence interval, standard deviation, and percentage),
the means were compared using the Student’s t-test
or the Wilcoxon, test for not normal distributions. For
multiple means comparison, we used the
Kruskal–Wallis test. When the results were statistically
significant, comparison by pairs was performed to cal-
culate the p values, which were adjusted using
Holm’s method.
For binary variables, the proportions were com-
pared using the chi-squared test of independence or
Fisher’s exact test (if a number was at least theoretic-
ally less than five). Nominal requirements were used
for more than two classes: Pearson’s chi-squared or
Fisher’s exact test. In case of significance, Holm’s
method was used for a two-to-two post hoc compari-
son. The software application used was R version 3.1.2.
Results
In total, 319 patients presented with PP or LPI in the
third trimester of pregnancy. The mean age of

TABLE 2. Evolution of the placental edge to cervical internal
os distance (n ¼ 319).
[0] [0–1] [1–2] [2–3] >3
N initial measure of CIO–PE d 123 62 60 43 31
% 38.56 19.43 18.8 13.48 9.72
N final measure of CIO–PE d 123 58 17 26 95
% 38.56 18.18 5.33 8.15 29.78
patients was 33 years ± 6. Among the patients, 84
(26%) previously had one or more C-sections and 87
(27%) previously had one or more curettages. The
mean term of delivery was 37 weeks and the mean
newborn birth weight was 2941 g. The mean volume
of hemorrhage was 693 ml ± 872. The patients’ gen-
eral characteristics are summarized in Table 1.
Migration of the placenta
Among the 123 cases of complete PP, none had
moved at the time of the second US and remained
complete. Among the patients in group 0–1, the pla-
centa did not move significantly. The most notable
migration of the placenta occurred in cases of a CIO-
PE d between 1 and 4 cm (Table 2). In the majority of
the cases, placentas less than 1 cm from the CIO at
32 weeks did not migrate.
Mode of delivery and PPH (Table 3)
In the complete PP group, 123 patients (100%) had a
C-section and the mean volume of hemorrhage was
918 ml ± 1034. In the group [0–1] (n ¼ 58), only one
patient delivered vaginally (700 ml of blood loss) and
57 of 58 (98%) had a C-section. The mean volume of
hemorrhage was 680 ml ± 471.
In the group [1–2] (n ¼ 17), 9 patients (52.9%)
underwent a C-section (793 ml ± 482 of blood loss)
and 8 delivered vaginally with a mean blood loss of
522 ml ± 433. In these three groups, 189 of the 198
patients (89.5%) underwent a C-section and 9 deliv-
ered vaginally.
The volume of blood loss tends to be more import-
ant in vaginal delivery (VD) when the CIO-PE d is less
than 2 cm (Figure 1), however, the number of patients
is insufficient to show statistically significant difference
(p ¼ .11, Kruskal–Wallis test).
In total, 219 of the 319 patients (69%) had a C-sec-
tion and 100 patients underwent vaginal delivery.
Only one vaginal delivery occurred below 1 cm
between the CIO and the PE. Only one tentative vagi-
nal delivery was successful but the patient lost 700 ml
of blood.
THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 3
For cesarean section, the volume of blood loss was
significantly higher when the CIO-PE d was <1 cm
Total than when it was >3 cm (adjusted p ¼ .0267).
319 When the CIO-PE d was between 1 and 2 cm, there
100
319 was a tendency to more important bleeding but it
100 was not statistically significant.
In 62% of the cases, the decided mode of delivery
was prophylactic C-section, but the effective rate of C-
sections was significantly higher at 69%. Delivery deci-
sion seemed more closely correlated with the final US
measure, which is nearer the delivery. Most of the dis-
crepancies between the delivery decision and the
effective mode of delivery were related to the per-
formance of a C-section. Patients for whom the deci-
sion to perform a C-section was retained and realized
had a significantly lower PE-CIO d than those who
delivered vaginally (p < .001) (Table 4 and Figure 2).
PPH and CIO-PE d
The mean volume of PPH in cases of vaginal delivery
was 321 ml ± 389 and that in cases of C-section was
852 ml ± 969 (p < .001). The mean volume of hemor-
rhage was significantly higher for C-section. Thirty per-
cent of the patients had an emergency C-section,
including 24% for hemorrhage. For patients who deliv-
ered by C-section, the PE-CIO d was lower for emer-
gency C-sections, especially for those involving
hemorrhage (p < .001). The mean volume of hemor-
rhage differed significantly according to the PE-CIO d
(Kruskal–Wallis test, p < .001).
As shown in Figure 3, the mean volume of hemor-
rhage was significantly higher for patients with a
CIO–PE d less than 2 cm (p < .001). In total, the mean
volume of blood loss during delivery was higher for
patients who had a CIO–PE d less than 2 cm and for
women who underwent a C-section (Figure 4). The
threshold of 2 cm distinguishes deliveries with a high
volume of blood loss from those with a low volume of
blood loss.
Discussion
The initial mean of the CIO-PE d at 32 weeks corre-
lated with the placenta migratory prognosis. Indeed,
the CIO-PE d at 32 weeks did not change for measures
between 0 and 1 cm; the distances only increased sig-
nificantly above 1 cm. According to Haino et al. [12],
51% of the patients (23 cases) with LLP normalized
their placental position between 30 and 33 weeks and
34–38 WG. Oppenheimer et al. [15] reported that
migration of LLP occurred in all cases (n ¼ 29) at a
4 S. ALOUINI ET AL.

TABLE 3. Volume of blood loss according to CIO-PE distances and mode of delivery.
Cesarean section Caesarean section Vaginal delivery Vaginal delivery
CIO-PE d (cm) N Mean ± Sd blood loss (ml) N Mean ± Sd blood loss (ml)
[0] 123 1022.13 ± 1186.04 0 0
[0;1] 57 679.09 ± 471.28 1 700 ± 0
[1;2] 9 793.75 ± 482.88 8 522.5 ± 433.65
[2;3] 12 495 ± 409.91 14 381.82 ± 454.57
[3;n] 18 452.78 ± 509.46 77 283.8 ± 371.37
Total 219 852.11 ± 9 69.11 100 321.21 ± 389.36
Sd: standard deviation.

The repetition of measurements 3–4 weeks later (at

Figure 1. Volume of blood loss in vaginal delivery according
to CIO-PE distance.
TABLE 4. Blood loss and mode of delivery according to the
CIO–PE d.
Placental edge to
cervical internal os
distance (cm) Rate of C-section
<2 95.79%
2 28.13%
p<.001
CIO-PE d greater than 20 mm. The US exam was
repeated after 4 weeks (third trimester).
The initial US measurement of the CIO-PE d should
be repeated at 35–36 weeks before the delivery
because of the possible migration of the placenta
from the CIO and to plan the delivery route. The pre-
sent study found no migration of the placenta cover-
ing the internal orifice of the cervix or that up to 1 cm
from the cervical os in the first ultrasound. Significant
migrations were observed only for initial distances
greater than 1 cm.
Haino et al. [12] revealed that US measurement at
30–33 weeks should be repeated 3 weeks later, as the
diagnosis of placental position changed for 49.5% of
the patients. Durst et al. [16] reported the migration
of the majority of CIO-PE d greater than 1 cm.
34–35 weeks) is essential either to confirm the first
measurement in the case of the placenta covering the
OI and up to 1 cm or to observe placental migration
away from the CIO when the initial measure is greater
than 1 cm. The latest US measure correlated with the
mode of delivery. The patients for whom the C-section
decision was chosen and performed had a lower CIO-
PE d than those who delivered vaginally. Similarly, the
patients who underwent emergency C-section for
bleeding had a lower CIO-PE d than those who deliv-
ered vaginally. Both PP and LLP were high-risk situa-
tions for bleeding and must be controlled upstream.
According to Ohira et al. [17], the weak migration
of LLP was associated with a high C-section rate
because of antepartum vaginal bleeding. In our study,
the mean volume of PPH was significantly higher for
patients with a CIO-PE d less than 2 cm. The threshold
value of 2 cm facilitated the identification of signifi-
cantly more hemorrhagic deliveries, below 2 cm, deliv-
ery was significantly more hemorrhagic than above
Mean volume of
hemorrhage 2 cm. In this situation, delivery must be controlled and
898.57 ± 1005 the patient should be informed of the increased hem-
355.65 ± 415 orrhagic risks.
p < .001
A planned C-section at 36–37 weeks is imperative in
cases of a CIO-PE d less than 1 cm. According to
Dashe [18], a C-section was performed for bleeding in
one-third of the cases in which the placenta was
within 2 cm of the os. Vergani et al. [13] reported a C-
section rate of 75% for a distance of 1–10 mm (24
patients) and 31% for a distance of 11–20 mm (29
patients). Bhide et al. [9] reported a C-section rate of
90% for a CIO-PE d less than 2 cm (64 patients). A trial
of vaginal delivery was considered appropriate when
the CIO-PE d was greater than 2 cm.
Patients should be managed in a maternity center
with a blood bank and informed preoperatively [19].
The intervention should be performed during the day
by operators who are familiar with vascular ligations,
hemostatic sutures, and other hemostatic techniques
[20]. In case of placental migration above 2 cm in the
last US examination, the risk of hemorrhage remains
greater than that of placental fundal insertion but

Figure 2. Mode of delivery by CIO–PE distance.
Figure 3. Hemorrhagic volume according to final measure of
PE-CIO d (n ¼ 319)
vaginal delivery may be proposed and discussed with
the patient.
In our study, hemorrhage volume was greater dur-
ing a C-section than during a vaginal delivery. Even in
cases of normally positioned placentas, a C-section is
usually more hemorrhagic than a vaginal delivery (9).
A quarter of the patients had a previous C-section,
which was identified as a risk factor of PPH.
Approximately, a quarter of the C-sections was per-
formed for emergency antepartum vaginal bleeding.
Moreover, repeated antepartum hemorrhage remains
THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 5
Figure 4. Volume of blood loss in cesarean section according
to CIO-PE distance.
unquantified, especially in cases of vaginal delivery
[21]. Only hemorrhage during delivery was quantified
using a graduated bag placed under the patient’s but-
tocks. Our statistical analysis showed that the CIO-PE d
was the major factor in bleeding. In a study on 73
patients, Matsubara et al. [11] reported that total
blood loss was greater in women with a CIO-PE d less
than or equal to 4 cm and especially those with a CIO-
PE d less than 2 cm. According to Taga et al. [22], the
LLP group bled more in a planned C-section (seven
patients) than in a vaginal delivery (11 patients)
(Figure 4).
Limitations of the study
As this work was a retrospective study, some biases
were likely to occur. Nevertheless, the large sample of
patients with PP and LPI (319) means that the results
have significant implications for decision making in
high-risk obstetrical situations, such as post-par-
tum hemorrhage.
Conclusion
In our study, the vaginal US measure of the distance
between CIO and PE in the third trimester of preg-
nancy at around 32 weeks enabled the precise diagno-
sis and prognosis of PP or LPI. When the CIO-PE d in
the first US examination was less than 1 cm, the pla-
centas did not migrate 3 weeks after. For distances
greater than 1 cm, the majority of the placentas
migrated within three to four weeks and a repetition
of the US examination was necessary in deciding the
mode of delivery.
6 S. ALOUINI ET AL.
The threshold CIO-PE d of 2 cm enabled the differ-
entiation of high-risk hemorrhagic deliveries from
those at moderate risk. Below 1 cm, the delivery is at a
significantly high risk of post-partum hemorrhage and
a planned C-section under optimal conditions is indi-
cated. For a CIO-PE d greater than 2 cm, a trial of vagi-
nal delivery could be proposed to patients. For
distances between 1 and 2 cm, the volume of blood
loss tends to be more important than for distances
superior to 3 cm; however, the tendency is not statis-
tically significant. A vaginal delivery could be tried
after information of patients concerning its risks
and benefits.
Disclosure statement
No potential conflict of interest was reported by the authors.
References
[1] Kramer MS, Berg C, Abenhaim H, et al. Incidence, risk
factors, and temporal trends in severe postpartum
hemorrhage. Am J Obstet Gynecol. 2013;209:
449.e1–449.e7.
[2] Kollmann M, Gaulhofer J, Lang U, et al. Placenta prae-
via: incidence, risk factors and outcome. J Matern
Fetal Neonatal Med. 2016;29:1395–1398.
[3] Wortman AC, Twickler DM, McIntire DD, et al.
Bleeding complications in pregnancies with low-lying
placenta. J Matern Fetal Neonatal Med. 2016;29:
1367–1371.
[4] Vahanian SA, Lavery JA, Ananth CV, et al. Placental
implantation abnormalities and risk of preterm deliv-
ery: a systematic review and meta-analysis. Am J
Obstet Gynecol. 2015;213:S78–S90.
[5] Fan D, Xia Q, Liu L, et al. The incidence of postpartum
hemorrhage in pregnant women with placenta previa:
a systematic review and meta-analysis. Plos One.
2017;12:e0170194.
[6] Heer IM, M€ uller-Egloff S, Strauss A. Placenta praevia –
comparison of four sonographic modalities.
Ultraschall Med. 2005;27:355–359.
[7] Quant HS, Friedman AM, Wang E, et al.
Transabdominal ultrasonography as a screening test
for second-trimester placenta previa. Obstet Gynecol.
2014;123:628–633.
[8] Vintzileos AM, Ananth CV, Smulian JC. Using ultra-
sound in the clinical management of placental
implantation abnormalities. Am J Obstet Gynecol.
2015;213:S70–S77.
[9] Bhide A, Prefumo F, Moore J, et al. Placental edge to
internal os distance in the late third trimester and
mode of delivery in placenta praevia. BJOG. 2003;110:
860–864.
[10] D’Antonio F, Bhide A. Ultrasound in placental disor-
ders. Best Pract Res Clin Obstet Gynaecol. 2014;28:
429–442.
[11] Matsubara S, Ohkuchi A, Kikkawa M, et al. Blood loss
in low-lying placenta: placental edge to cervical
internal os distance of less vs. more than 2 cm.
J Perinat Med. 2008;36:507–512.
[12] Haino K, Ishii K, Kanda M, et al. Variations of placental
migration in patients with early third trimester malpo-
sition. J Med Ultrason. 2018;45:99–102.
[13] Vergani P, Ornaghi S, Pozzi I, et al. Placenta previa:
distance to internal os and mode of delivery. Am J
Obstet Gynecol. 2009; 201:266.e1–266.e5.
[14] Sentilhes L, Vayssiere C, Deneux-Tharaux C, et al.
Postpartum hemorrhage: guidelines for clinical prac-
tice from the French College of Gynaecologists and
Obstetricians (CNGOF): in collaboration with the
French Society of Anesthesiology and Intensive Care
(SFAR). Eur J Obstet Gynecol Reprod Biol. 2016;198:
12–21.
[15] Oppenheimer L, Holmes P, Simpson N, et al.
Diagnosis of low-lying placenta: can migration in the
third trimester predict outcome? Ultrasound Obstet
Gynecol. 2001;18:100–102.
[16] Durst JK, Tuuli MG, Temming LA, et al. Resolution of
a low-lying placenta and placenta previa diagnosed
at the midtrimester anatomy scan. J Ultrasound Med.
2018;37:2011–2019.
[17] Ohira S, Kikuchi N, Kobara H, et al. Predicting the
route of delivery in women with low-lying placenta
using transvaginal ultrasonography: significance of
placental migration and marginal sinus. Gynecol
Obstet Invest. 2012;73:217–222.
[18] Dashe JS. Toward consistent terminology of placental
location. Semin Perinatol. 2013;37:375–379.
[19] Pande B, Shetty A. An audit to review the characteris-
tics and management of placenta praevia at
Aberdeen Maternity Hospital, 2009–2011. J Obstet
Gynaecol. 2014;34:403–406.
[20] Huchon C, Dumont A, Traor
e M, et al. A prediction
score for maternal mortality in Senegal and Mali.
Obstet Gynecol. 2013;121:1049–1056.
[21] Chama CM, Wanonyi IK, Usman JD. From low-lying
implantation to placenta praevia: a longitudinal
ultrasonic assessment. J Obstet Gynaecol. 2004;24:
516–518.
[22] Taga A, Sato Y, Sakae C, et al. Planned vaginal deliv-
ery versus planned cesarean delivery in cases of low-
lying placenta. J Matern Fetal Neonatal Med. 2017;30:
618–622.