Ultrasound Obstet Gynecol 1998;12:430–433
Poor perinatal outcome associated with vasa
previa: is it preventable? A report of three cases
and review of the literature
T. Y. Fung and T. K. Lau
Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin,
Hong Kong
Key words: VASA PREVIA, PREGNANCY OUTCOME, ULTRASOUND
ABSTRACT
We describe three cases of vasa previa and review the
English-language literature for all cases reported since
1980. Antenatal diagnosis was significantly associated with
decreased fetal mortality (p = 0.033). A low- lying placenta
is a risk factor for vasa previa, as it occurred in 81% of
patients.
INTRODUCTION
Vasa previa is a condition in which the umbilical vessels,
unsupported by either the umbilical cord or placental
tissue, traverse the fetal membranes of the lower segment in
front of the presenting part1. The true incidence is still
unknown, but varies from 1 in 1275 to 1 in 50002–5. Vasa
previa generally occurs only in association with velamen-
tous insertion of the umbilical cord, bipartite placenta, or
succenturiate lobe.
Vasa previa is an important obstetric complication; the
associated perinatal mortality rate has been reported to be
as high as 52–66%1,6,7. This high fetal loss rate is probably
due to the following factors. Fetal vessels, which are
normally protected by Wharton’s jelly within the umbilical
cord, are unsupported in vasa previa. These vessels are
firmly adherent to overlying chorionic membranes, which
at the time of either spontaneous or artificial rupture may
lead to tearing of the underlying vessels. Furthermore,
hemorrhage due to vasa previa is rapidly fatal, because the
bleeding is from the fetus which has only a small circula-
tory 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.
Correspondence: Dr T.Y. Fung, Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong,
Shatin, Hong Kong
CA SE REPO RT
We describe here the perinatal management of three
cases of vasa previa, and review the literature.
CASE 1
A 29-year-old woman, gravida 3, para 1, had an ante-
partum hemorrhage at 29 weeks of gestation. An ultra-
sound scan revealed an anterior placenta which extended
over the internal os. A repeat ultrasound scan at 32 weeks
showed the placenta not to be low lying. The woman was
admitted again because of vaginal bleeding at 35 weeks of
gestation, and vasa previa was suspected on trans-
abdominal sonography and confirmed with color Doppler
(Figures 1 and 2). An elective lower segment Cesarean
section was performed at 36 weeks, and a bilobed placenta
was found with vessels running across the internal os. A
2500-g female was delivered with Apgar scores of 7 and 9
at 1 and 5 min, respectively. The baby required no resusci-
tation and there were no neonatal complications.
CASE 2
A 20-year-old woman, gravida 3, para 0, was admitted for
‘heavy show’ at 39 weeks of gestation. The antenatal
course was uncomplicated and no antenatal ultrasound
examination was performed. Labor was induced with arti-
ficial rupture of membranes, which revealed clear amniotic
fluid. There were recurrent delay decelerations soon after
the rupture of membranes. The fetus was therefore deliv-
ered by emergency Cesarean section, at which the diagnosis
of vasa previa was made. The baby boy weighed 3200 g,
with an Apgar score of 3 at 1 min and 5 at 5 min. The baby
required immediate resuscitation, including intubation,
mechanical ventilation and blood transfusion; he sub-
sequently developed convulsions. Examination of the
430 Received 20–11–97
Revised 7–5–98
Accepted 11–5–98
AMA: First Proof 97/199
 Vasa previa
Colour
Figure 1 Longitudinal section through the internal cervical os
with color Doppler showing the vasa previa
Colour
Figure 2 Slightly oblique view across the cervical os, demonstrat-
ing by color Doppler the running of the vessels that pass above
the os
placenta confirmed velamentous insertion of the cord and
that the velamentous portion of the vessels had ruptured.
CASE 3
A 34-year-old woman, gravida 4, para 3, had an ultra-
sound scan performed at 23 weeks of gestation because of
a previous intrauterine death. The fetus was normal but
observations of the placental site were not recorded. The
woman was admitted at 37 weeks for proteinuria and
impaired renal function. An ultrasound scan was repeated
and the placenta was shown to be situated in the upper
posterior uterine wall. Induction of labor was performed
by artificial rupture of membranes, which revealed blood-
stained amniotic fluid and was followed by recurrent late
decelerations. An emergency Cesarean section was per-
formed and vasa previa was confirmed. A female baby was
delivered with birth weight of 2500 g and Apgar scores of
8 and 10 at 1 and 5 mins, respectively. Examination of the
placenta showed velamentous insertion of the cord, and
97/199 AMA: First Proof
Fung and Lau
that the vessels close to the site of amniotomy had rup-
tured. There was no evidence of direct injury to the vessels
by the instruments used.
DISCUSSION
With the advances in ultrasound technology in recent
years, vasa previa has been successfully visualized and diag-
nosed antenatally by means of transabdominal sonography,
transvaginal sonography and spectral and color Doppler.
From the three cases reported here, we found that antenatal
diagnosis of vasa previa was associated with the better
outcome. To confirm this observation, and to identify
possible risk factors, we identified all cases of vasa previa
reported in the English-language literature by CD-Plus
Medline using the key word ‘vasa previa’. The latest review
on vasa previa was reported in the 1980s, when examina-
tion by ultrasound, especially Doppler ultrasound, was still
not widespread6. We therefore limited our review to the
period between 1980 and 1997. The original papers were
retrieved and reviewed and references were checked. We
recorded all those fetuses with Apgar scores of less than 7
at 5 min (excluding stillbirths and neonatal deaths) and all
those fetuses who suffered from anemia or required blood
transfusion after delivery.
Including our three cases, there were 48 cases of vasa
previa reported in 34 papers between 1980 and 19978–41.
There were five sets of twins and 43 singleton pregnancies.
The fetal outcomes according to the time of diagnosis of
vasa previa are shown in Table 1. Overall, there were six
stillbirths and one neonatal death, giving a perinatal mor-
tality rate of 13.2% (seven of 53 babies). In the remaining
46 who were live born, ten (21.7%) had a 5-min Apgar
score of less than 7 (overall 18.9%) and 14 fetuses (30.4%)
suffered from anemia or required blood transfusion (over-
all 26.4%). Among these 14 patients, 12 fetuses required
neonatal blood transfusion22,29,31,35–37,39–41 and two fetuses
had suffered from anemia27,34. The fetal loss rate
(p = 0.033; Fisher’s exact test), the incidence of 5-min
Apgar scores less than 7 (p = 0.033; Fisher’s exact test) and
the incidence of fetal anemia or neonatal blood transfusion
(p = 0.002; Fisher’s exact test) were significantly less if the
diagnosis was made in the antenatal period (Table 1).
When antenatal diagnosis was not made before the on-
set of labor, all the five fetuses (including one pair of twins)
complicated with antepartum hemorrhage had very poor
outcomes (Table 1). The fetal mortality was significantly
higher than in those who had vaginal bleeding during
labor, irrespective of whether it was spontaneous
(p = 0.010; Fisher’s exact test) or after obstetric manipula-
tion (p = 0.032; Fisher’s exact test). The difference in neo-
natal outcome was most probably because of early
detection and intervention for fetal distress by intrapartum
fetal monitoring when bleeding occurred during labor.
Since more fetal losses occurred among those with a
history of antepartum hemorrhage when vasa previa was
not diagnosed antenatally, it remains to be proved that
prenatal diagnosis of vasa previa reduces mortality com-
pared to active management of intrapartum bleeding or
Ultrasound in Obstetrics and Gynecology 431
Vasa previa Fung and Lau

Table 1 Fetal outcome according to the time of diagnosis of vasa previa

Number of
Number of fetuses suffering Number of
Number fetuses with from anemia or Number of fetuses with
Time of diagnosis of Apgar score of requiring blood stillbirths and unknown
of vasa previa References fetuses < 7 at 5 min transfusion neonatal deaths outcome
Antenatal 8–22, case 1 22 1 (4.5%) 1 (4.5%) 0 (0.0%) 0
No history of vaginal bleeding 8–17, 20 16 0 0 0 0
History of antepartum 18–22, case 1 6 1 1 0 0
hemorrhage
Intrapartum or after delivery 23–41, cases 2,3 31 9 (29%)* 13 (41.9%)** 7 (22.5%)*** 1
No intrapartum bleeding
no history of vaginal bleeding 23–27, 39 6 0 0 1 1
history of antepartum 20, 28–30 5 1 1 4 0
hemorrhage (vasa previa
not diagnosed antenatally)
Intrapartum bleeding
spontaneous 26, 27, 30–37 12 4 8 1 0
after manipulation (digital 26, 38–41, 8 4 4 1 0
examination, artificial cases 2,3
rupture of membranes or
insertion of scalp electrode)
Total 53 10 (18.9%) 14 (26.4%) 7 (13.2%) 1
The asterisks represent significant differences between the ‘Antenatal’ and ‘Intrapartum or after delivery’ groups. *p = 0.033 (Fisher’s
exact test); **p = 0.002 (Fisher’s exact test); ***p = 0.033 (Fisher’s exact test)

distress with expeditious fetal delivery. However, it should
be noted that fetal morbidity, e.g. with fetal anemia, or
with neonatal blood transfusion or low 5-min Apgar score,
was significantly increased when intrapartum bleeding
occurred (p < 0.002 and p = 0.02, respectively; Fisher’s
exact test). With the current information, however, it is
unclear whether the low Apgar score was a direct result of
fetal bleeding or was secondary to compression of unpro-
tected vessels by the presenting part.
The results of our review show that the major risk of
vasa previa to fetal mortality and morbidity is potentially
preventable if the correct diagnosis is made before the onset
of labor. Various methods have been used to diagnose vasa
previa. Among the 20 cases (including two sets of twins) in
which diagnosis was made antenatally, 16 were by ultra-
sound, three by direct visualization either by endoscopy or
by amnioscopy17 and one by the Apt test22. Among all
diagnostic methods, ultrasound appears to be the most
non-invasive, and one that potentially could be used in all
cases. However, it is important to determine which patients
should have an ultrasound examination to exclude vasa
previa.
Vasa previa is usually associated with velamentous
insertion of the umbilical cord or a bilobed placenta. If
either of these two conditions is detected on ultra-
sound examination, vasa previa must be excluded. The
visualization of fetal vessels over the lower segment may be
facilitated by the use of spectral and color Doppler
ultrasound9–16,18–20.
Among the 48 cases reviewed, 21 had a documented
ultrasound scan performed before 30 weeks’ gestation
(14–30 weeks of gestation). The placental site was des-
cribed as low lying in 17 cases8–15,18–20,26,32,34,40,Case 1 (81%),
as bilobed in one17, not low in one17 and was not com-
mented upon in two21,Case 3. The incidence of low-lying
placenta in this group of patients (81%) was significantly
(p < 0.001) higher than that in the general population
which has been estimated to be 53/100042. In fact, the
diagnosis of vasa previa or bilobed placenta was estab-
lished with color Doppler in 12 cases during subsequent
scans. The diagnosis was missed in the remaining five cases
and in none of these cases was Doppler ultrasound
reported to have been used. On the basis of these findings,
we suggest that low-lying placenta before 30 weeks of
gestation is an important risk factor for vasa previa.
The observed association between low-lying placenta
and vasa previa is in agreement with the theory of tropho-
tropism first proposed in 1902 by Strassmann, who des-
cribed the pathogenesis of velamentous insertion of
the umbilical cord from a low-lying placenta in early
gestation43.
On the basis of our findings, we suggest that the placen-
tal site and extraplacental lobe should be recorded in all
routine second-trimester ultrasound scans. If an extra-
placental lobe is detected in the second trimester, vasa
previa should be excluded or confirmed by transvaginal
B-mode or Doppler ultrasound with or without color-
coding. If the placenta is found to be low lying in the
second trimester, the cord insertion needs to be determined.
A repeat ultrasound examination must be performed in the
third trimester to exclude placenta previa, which occurs in
10% of these patients42. If placenta previa is not present in
the subsequent examination, particular attention should be
paid to exclude the presence of vasa previa, by transvaginal
B-mode or Doppler ultrasound.
In summary, vasa previa is strongly associated with ab-
normal placentation before 30 weeks of gestation. Both
vasa previa and abnormal placentation in the second tri-
mester can be accurately diagnosed by modern ultrasound
technology. Most of the adverse fetal outcomes associated

432 Ultrasound in Obstetrics and Gynecology

AMA: First Proof 97/199

Vasa previa
with vasa previa should be preventable if the correct diag-
nosis is made antenatally.
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Ultrasound in Obstetrics and Gynecology 433