Placenta previa (PP) is a condition where the placenta is fully or partially located in the lower segment of the uterus. The typical characteristics of bleeding associated with placenta previa include abrupt onset, absence of pain, no identifiable cause, and a tendency to recur [1]. Although the precise aetiology of placenta previa (PP) remains elusive, extensive literature has established strong links to several predisposing factors, including older maternal age, high parity, history of prior spontaneous abortions, prior caesarean deliveries or other uterine procedures, and tobacco use [2,3]. Worldwide, PP affects approximately 5.2 out of every 1,000 pregnancies, with considerable geographic disparities; notably, the highest rates are reported in research from Asian populations [4]. With the escalating trends in caesarean sections and delayed childbearing, we can anticipate a surge in PP incidences along with its associated sequelae, such as placenta accreta (PA). This disorder carries substantial risks for maternal health, including hemorrhagic shock, heightened need for surgical procedures, and infectious complications like sepsis, as well as adverse fetal and neonatal outcomes such as premature birth and its sequelae, including reduced birth weight, hypoxic events at delivery, and infections in newborns [5]. In contemporary obstetrics, the primary reason for urgent peripartum hysterectomy has shifted from uterine atony to pathological placental implantation, largely attributable to the growing cohort of pregnancies following caesarean scars [6]. Our present investigation aims to examine these risk elements and analyse the maternal-fetal consequences across different PP subtypes. Aim: To evaluate the fetomaternal morbidity and mortality associated with placenta previa in patients managed at a tertiary care hospital, Kurnool. Objectives: 1. To determine the incidence of placenta previa among obstetric admissions. 2. To classify the cases based on type and grade of placenta previa. 3. To assess maternal complications and outcomes associated with placenta previa. 4. To evaluate perinatal outcomes, including neonatal morbidity and mortality. 5. To analyse the relationship between type/grade of placenta previa and fetomaternal outcome.

This prospective observational study was conducted in the Department of Obstetrics and Gynaecology, Kurnool Medical College and Government General Hospital, Kurnool, from January 2024 to February 2025. A total of 40 women with placenta previa diagnosed after 28 weeks of gestation were included. Inclusion criteria: (i) Antepartum haemorrhage confirmed by ultrasonography (USG) after 28 weeks, (ii) placenta previa detected intraoperatively during caesarean section for other indications, and (iii) asymptomatic cases with clinical and radiological evidence of placenta previa. Exclusion criteria: (i) Low-lying placenta diagnosed before 28 weeks, and (ii) antepartum haemorrhage due to other causes. Diagnostic definition: Placenta partially or completely covering the internal os, or lying within 2 cm of the os on USG after 28 weeks. Gestational age was determined using at least two of the following: last menstrual period, USG dating, or early pregnancy USG findings.[7] Data were recorded in a predesigned proforma after written informed consent. At admission, a detailed history, clinical examination, and USG evaluation were performed. Maternal outcomes included transfusion requirement, severity of antepartum and postpartum haemorrhage, surgical/operative interventions (placental bed packing or under-running sutures, uterine artery ligation, internal iliac artery ligation, uterine artery/internal iliac artery embolisation, caesarean hysterectomy), ICU admission, morbidity, mortality, and hospital stay. Fetal outcomes included birth weight, gestational age at delivery, Apgar scores, NICU admission, morbidity, and perinatal mortality. All live births were followed until maternal and/or neonatal discharge. Data analysis: Sample size was based on feasibility during the study period. Data were entered in Microsoft Excel and analysed using SPSS version 20.0. Categorical variables were compared using the chi-square test or Fisher’s exact test, and continuous variables using Student’s t-test or Mann–Whitney U test, as appropriate. A p-value ≤0.05 was considered statistically significant.

During the study period, a total of 10,800 deliveries were conducted, of which 40 cases (0.37%) were complicated by placenta previa. Maternal Demographics The age distribution of the study population is summarised in Table 1. The majority of patients were aged 20–25 years (n = 28; 70%), followed by 26–30 years (n = 11; 27.5%), and >30 years (n = 1; 2.5%). Gravidity distribution showed 5 primigravida (12.5%), 14 second gravida (35%), 12 third gravida (30%), 5 fourth gravida (12.5%), and 4 grand multipara (10%). This indicates a higher prevalence among multiparous women. Table 1: Age distribution. Age (years) Number (N=40) Percentage (%) <20 0 0% 20-25 28 70% 26-30 11 27.5% >30 1 2.5% Type of Placenta Previa Placental location was determined using antenatal ultrasonography or confirmed intraoperatively (Table 2). Placenta accreta was observed in 4 cases (10%) and placenta percreta in 1 case (2.5%). No cases of placenta increta were noted. Table 2: Type of placenta previa (by USG and intraoperative findings) Types (by ACOG, NIH) Number (N=40) Percentage (%) Type I 07 17.5% Type IIa (anterior) 08 20% Type IIb (posterior) 03 7.5% Type III 06 15% Type IV 16 40% Clinical Presentation Most patients (n = 25; 62.5%) presented with antepartum bleeding per vaginum. Other presentations included abdominal pain (n = 9; 22.5%), leaking per vaginum (n = 1; 2.5%), intrauterine fetal death (IUFD) at admission (n = 1; 2.5%), and asymptomatic cases detected incidentally (n = 4; 10%) (Figure 1). FIGURE 1: Clinical Presentation Obstetric History Previous obstetric interventions included one prior caesarean section in 16 cases (40%), two prior caesarean sections in 9 cases (22.5%), and a history of abortion with dilatation and curettage in 8 cases (20%). Ten cases (25%) occurred in unscarred uteri, highlighting that placenta previa can also occur in women without prior uterine surgery (Figure 2). FIGURE 2: Causes/ Risk factors Gestational Age and Mode of Delivery: Of the 40 cases, 11 (27.5%) were term and 29 (72.5%) were preterm. All patients were delivered via caesarean section due to the increased risk of maternal and fetal complications associated with placenta previa. Maternal Outcomes Postpartum haemorrhage occurred in 20 patients (50%). Conservative management with uterotonics and haemostatic techniques was initially attempted. Internal iliac artery ligation was performed in 15 patients (37.5%) to control bleeding. Bladder injury occurred in 4 cases (10%), all of which were repaired intraoperatively. Emergency caesarean hysterectomy was required in 8 patients (20%) when bleeding could not be controlled by conservative measures. All patients received blood transfusions, with 12 (30%) requiring massive transfusions of blood and blood products. Intensive care unit (ICU) admission was necessary in 5 patients (12.5%), and there was one maternal death (2.5%) due to severe postpartum haemorrhage. Neonatal Outcomes Neonatal outcomes are summarised in Table 3. Preterm delivery occurred in 29 neonates (72.5%). NICU admission was required in 2 cases (5%), and 2 neonatal deaths (5%) were recorded. Malpresentation was observed in 2 cases (5%), both transverse lie. No congenital anomalies were detected. Table 3: Neonatal outcome Factors Number ( N=40) Percentage (%) Preterm birth 29 72.5% NICU admission 2 5% Neonatal death 2 5% Malpresentation 2 5%

Placenta previa continues to pose a significant risk to both maternal and neonatal health, particularly in settings with high rates of early childbearing and prior uterine surgery. In this study, the incidence of placenta previa was 0.37%, consistent with global estimates ranging from 0.3% to 0.5% [8,9]. Maternal Age and Parity Our cohort predominantly included women aged 20–30 years, a lower age distribution likely attributable to early marriage and early childbearing in India, consistent with the findings of Tai Ho Fung et al. and Rabin et al. [10,11]. Multiparity was a major risk factor, with 95% of cases occurring in multiparous women, reflecting cumulative uterine trauma from previous pregnancies, as reported by Nyango DD, Srivannajain et al., and Ojha et al. [12-14]. Obstetric History and Scarred Uterus A history of caesarean section or dilatation and curettage was present in 75% of patients, reaffirming that a scarred uterus is a significant independent risk factor for placenta previa [14,16]. True placenta previa, as classified by NIH and ACOG criteria, was present in approximately 75% of cases, and 12.5% of patients had adherent placenta, highlighting the potential for severe haemorrhagic complications [17]. Gestational Age and Delivery Preterm delivery was common, affecting 72.5% of patients, a higher rate than previously reported by Osha et al. and Shivananjain et al. [14,15]. Only 27.5% of patients reached term, emphasising the frequent need for early intervention. All patients underwent caesarean delivery, slightly higher than rates reported in Rangaswamy et al. (95.2%) and Daskalakis et al. (93.9%) [16,17]. These findings underscore the necessity of surgical management to minimise maternal and fetal morbidity. Maternal Morbidity and Mortality Postpartum haemorrhage (PPH) occurred in 50% of patients, exceeding the 35% incidence reported by Osha et al. [14]. All patients required blood transfusion, in line with Rangaswamy et al. [17], and 12 patients (30%) required massive transfusion. Emergency caesarean hysterectomy was necessary in 20% of cases, comparable to the 17.3% reported by Neelam Meena et al. [18]. The high rate of hysterectomy was primarily due to atonic PPH unresponsive to devascularization techniques or complications from adherent placenta. Maternal mortality was 2.5%, approximately double that reported by Sharma and Bhatt et al., with death resulting from PPH and shock [19,20]. These findings highlight the critical importance of early recognition and prompt, multidisciplinary management of haemorrhagic complications. Neonatal Outcomes Preterm birth was the most common adverse neonatal outcome (72.5%), significantly higher than previously reported by Ojha et al. [14]. Preterm neonates were at increased risk for morbidity, with NICU admissions in 5% and neonatal deaths in 5% of cases. Malpresentation occurred in 5%, and no congenital anomalies were observed. These outcomes emphasise the need for neonatal preparedness in cases of placenta previa, especially in high-risk preterm deliveries. Clinical Implications Our findings underscore the importance of antenatal identification of high-risk women, particularly those with prior caesarean sections or uterine interventions. Meticulous planning for delivery, including readiness for blood transfusion, surgical interventions, and intensive neonatal care, is essential to reduce maternal and perinatal morbidity and mortality. Limitations The study is limited by its single-centre design and modest sample size. Larger, multicentred studies are warranted to further validate these findings and refine management protocols.

Placenta previa in multiparous women with prior uterine surgery remains a significant contributor to preterm delivery, postpartum haemorrhage, and caesarean hysterectomy. Early detection, careful surgical planning, and multidisciplinary management are essential to optimise maternal and neonatal outcomes, particularly in resource-limited settings.

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