Pregnancy and childbirth are universally celebrated as an event. It can also be one of the experiences of misery and suffering when complications and adverse events complicate pregnancy causing morbidity and even mortality .1 Placenta is an organ that attaches the developing fetus by umbilical cord to uterine layers to permit nutrient uptake, thermoregulation, waste removal and gas exchange and to fight against internal infection and to produce hormones that pre- serve pregnancy.2

In placenta there are two circulation-maternal and fetal. Hence, abnormalities in placental location may affect the blood supply of fetus leading to adverse maternal and fetal outcomes such as gestational hypertension, preeclampsia, gestational diabetes, malpresentation, malposition, preterm birth, IUGR, low birth weight, still birth etc.3,4 Placental location classified as central (anterior and posterior), lateral, fundal and low lying.3

Despite the universal documentation of USG at the time of 2nd-trimester USG evaluation of fetal anomaly, a detailed appraisal of placental location with exception of placenta previa and its predictability of adverse maternal and neonatal outcome has not been undertaken.5,6 Present study was aimed to find the association of placental location and maternal-neonatal outcomes

Present study was prospective, observational study, conducted in department of Obstetrics & Gynaecology, Government Medical College, Ch. Sambhajinagar, India. Study duration was of 2 years (September 2022 to August 2024). Study was approved by institutional ethical committee.

Inclusion criteria

• Pregnant women more than 28 weeks of gestation, delivered at our institute, willing to participate in the study

Exclusion criteria

• Not willing to participate in study
• Those cases with past or present medical obstetrics disorder at the time of study not willing for follow-up E.g.: Diabetes mellitus\ , Hypertension ,Asthma.
• Those cases with existing congenital anomalies as well as subjects with placental abnormality.
• Those cases less than 28weeks of GA.
• Those cases with multiple pregnancy e.g.: twins, triplets.

 Study was explained to participants in local language & written informed consent was taken. A detailed history of the patient was taken regarding name, age, socio economic status, address, occupation, duration of amenorrhea, history of trauma, any history suggestive of Pregnancy Induced Hypertension, previous medical disorders, personal history. Thorough general, systemic and obstetric examination was conducted.

Women’s RECENT USG scan was noted down for placental location and follow up till delivery was kept. Data was documented in case proforma and data collection sheets were prepared. Decision of termination and mode of delivery was taken by senior obstetrician. Maternal outcomes regarding development of any co morbidity like preeclampsia, GDM, IUGR, any malpresentations, prelabor rupture of membranes, mode of delivery, any intrapartum, postpartum complications were studied. Perinatal outcomes in terms of NICU admissions, birth weight, Apgar score of new born at 5 min and any perinatal complications were noted.

The data was compiled in master chart i.e. in MS Excel sheet and for analysis of this data SPSS (Statistical package for social sciences) Version 20th was used. Frequencies and percentages were calculated to show the distribution.

Total 400 patients with ultrasound diagnosed case of early pregnancy were enrolled in study. Mean age of patient was 23.98 ± 3.32 years with range was from 18-34 years. 208 (52%) of patients belonged to age group of 20-24 years followed by 133 (33.3%) in the age group of 25-29 years & 32 (8%) aged less than 20 years. Only 27 (6.8%) patients aged ≥30 years. 92.5% of women were Booked and 7.5% women were Unbooked. In present study, 29% cases were Primigravida, 39% cases were Gravida 2 , 22% cases were Gravida 3 , 10% cases were Gravida 4 and above Maximum number of cases were second Gravida .

Table 1: General characteristics

In present study, majority of placenta were situated anteriorly (35%), followed by placenta situated posteriorly (33%), low lying (13%), at fundus (11%) & laterally (8 %).

Table 2: Placental location

Common obstetric high risk factors noted were PROM (27.7%), preeclampsia (24.7%), malpresentations (11.5%), placenta previa in bleeding phase (10 %), DM (5.3%), IUGR (5.2%), abruptio placenta (3.7%) & eclampsia (2 %),

Table 3: Maternal outcome according to different locations of placenta

In present study, majority women undergone vaginal delivery (75.7 %) as compared to women undergone caesarean delivery (24.2 %).

Table 4: Mode of delivery

Out of 400 cases ,36 cases (9%) had Postpartum Hemorrhage & 6 (1.5%) cases underwent obstetric hysterectomy, maximum were due to placenta accreta spectrum disorders. 2.2% of cases i.e. 9 cases required ICU admission of which 7 cases required ventilatory support and 0.2% cases had mortality.

Table 5: Maternal postoperative complications according to placental location

Out of 400 cases, 10 cases were still birth, of which maximum cases (40%) were seen in cases having posterior placentation.

Table 6: Placental location and neonatal outcome (live birth still birth)

The birth weight of baby (p value - 0.016) & the APGAR score of baby at 5 minutes (p value - 0.049) was significantly associated with the placental location. The risk of NICU admission was not associated with the placental location (p value >0.05).

Table 7: Association of neonatal outcome with placental location

Maximum number of babies are admitted in NICU in view of preterm and low birth weight. Most common reason of NICU admission among neonates was pre-term baby (40%) followed by Asphyxia (30.76%) & LBW (18.46%). About 4.61% baby admitted to NICU due to delayed cry. About 2% neonates had hypoglycemia.

Table 8: Indication of NICU admission

The birth of a healthy baby depends upon a coordinated series of events in the development of placenta and the fetus. Detailed analysis of gross placental structure provide biologically relevant regarding placental growth, development and their potential consequences.

Over the years, USG has evolved as a safe noninvasive imaging technique for evaluation of fetal placental unit to detect and predict abnormalities and it is being used for fetal wellbeing by many researchers.

In the present study, it was observed that mean maternal age in anterior placentation was 23.98±3.2 years, posterior placenta was 23.93±3.4 Years, fundal placenta was 23.52±4.4 years, lateral placenta was 24.51±3.3 years, low lying placenta was 23.47±2.6 years.

In the study done of Dhingra S et al.,3 they found that the mean maternal age in years in anterior placenta was 22.2±1.2 years, posterior placenta was 23.1±1.4 years ,fundal placenta was 23.2±1.6 years, lateral placenta was 22.4 ±1.5 years, low-lying placenta was 22.2 ±1.4 years which is similar to our findings.

In the present study we found that 35% cases had anterior placentation, 33 % had posterior placenta, 11 % had fundal placenta, 8% had lateral placenta and 13% had low-lying placenta. 

In the study of Dhingra S et al.,3 30% cases had anterior placenta , 8% cases had posterior placenta ,42% cases had fundal placenta ,18% cases had lateral placenta and 2% cases had low-lying placenta, which is similar to our findings.

For endometrial growth, embryonic growth and placentation, blood flow at the implantation site and angiogenesis are necessary. The fundoanterior part has the highest endometrial tissue blood flow and may therefore be the favourable site of implantation. Hence, our study shows maximum cases with anterior placental location.7

In the present study, the mean gravidity in cases with anterior placenta is 2.04±1.7, posterior placenta is 2.4 ±1.5, fundal placenta is 2.8±1.4, lateral placenta is 2.2±1.0 and low-lying placenta is 2.8 ±1.5.

In the study done by Shumaila Zia.,8 the mean gravidity was 5.4±2.2 for fundal placenta ,5.03±1.7 for anterior placenta and 5.5±2.6 for posterior placenta respectively. The mean gravidity in this study is more than that in our study which can be at- tributed to low sociodemographic conditions in the area where the study was conducted.

Out of 400 cases, 27.7% cases of PROM, 24.7% cases of preeclampsia, 5.7% cases of gestational DM, 11.5% cases of malpresentations, 3.7% cases of abruptio placenta, 9.2% cases of preterm labor and 5.2% cases of IUGR were found.

In the study of Shumaila Zia., 8 they showed a significant association between posterior placenta and preterm labour i.e. 100% cases of preterm labor had posterior placenta, also 50% cases of abruptio placenta had posterior placenta. It also showed a statistically significant association of anterior placenta with an increased incidence of PIH, GDM, BOH, placental abruption, IUGR and IUFD. Of all the cases of 35.7% cases of preeclampsia, 50% cases of Gestational DM, 100% cases of IUGR had anterior placenta.

In theory, a placenta which is primarily implanted near the uterine and/or ovarian arteries might receive more blood than one implanted centrally, whether anterior or posterior, and this could account for poor pregnancy outcome with anterior placenta, as seen in our study.8 In our study fundal placenta is associated with preterm de- livery probably because placenta located on the fundal region may be somehow less efficient due to the anatomy of that wall. As a result of uneven uterine blood supply and somewhat thicker. Each of these factors may affect uterine blood supply, especially as the uterus expands to accommodate the pregnancy.

In the present study, the cesarean section rate in anterior placenta was 11%, posterior placenta was 16.4%, fundal placenta was 11.3%, lateral placenta was 6.7% and low-lying placenta was 100% in the study

In the study of Ban Amer Mousa,2 the C-section rate in those with anterior placenta is 27%, those with posterior placenta is 85% and those with fundal placenta is 59% which is inconsistent with our findings. The overall decreased caesarean section in our study is attributed to use of Respectful maternal care practiced in our institute. The practice of use of different Birth position, Birth companion and supportive care can be attributed to decreased c section rate in our study.           

In the present study , the mean birth weight in anterior placenta is 2626.4±365.4 gms ,posterior placenta is 2628.0±380 gms, fundal placenta is 2678.2±350.9 gms , lateral placenta is 2688.1±940.3 gms , low-lying placenta is 2363.5±490.75 gms. In the study by Shumaila Zia,8 the mean birth weight was 2857±493.4 gms in anterior placenta , 2808±658.3 gms in posterior placenta and 2842±503 gms in fundal placenta which is similar to our findings. In the present study,

In the study of Neetu Singh et al., 1, the still birth were 1.0% which was consistent with our findings. Also, the babies with APGAR score of >=7 were 91.1 % and the NICU admission rate was 16.2 % which is similar to our findings. In the study of Dhingra S et al.,3 the APGAR score at 5 minutes of >=7 was seen in 95% of cases and the NICU Admission rate was 10% which is almost similar to our findings. In the study of Shumaila Zia,8 the still birth was 1.0% and the APGAR score of >=7 was seen in all the babies (100%) which is almost similar to our findings .

Maximum number of NICU admissions were seen in babies of mother with anterior placenta. This is may be due more complications associated with anterior placentation. Also, placenta accreta spectrum disorders has placenta low-lying and anterior which asks for preterm caesarean hysterectomy which leads to NICU admissions due to preterm births(40%) followed by asphyxia. Also, maximum cases had NICU Stay duration of ≤2 days which can be attributed to good resuscitation and NICU care in our institute.

Routinely obstetric ultrasound is done in the pregnant women in third trimester to look for fetal growth, amniotic fluid volume and placental location.9,10 Ultrasound in pregnant women >28 weeks of gestation can be used as easy, non-invasive

Women with Anterior placenta has high risks of Severe preeclampsia, Gestational diabetes mellitus, IUGR, NICU admissions due to perinatal asphyxia Whereas, Women with Low-lying or placenta previa has high risks of Antepartum hemorrhage, Emergency caesarean section, Preterm birth, Low birth weight.

Women with Posterior placenta has high risks of Abruptio placenta, PROM and stillbirths. In contrast, women with a fundal and lateral location placenta had better out- comes, with lower risks of complications. These findings support the importance of routine placental location assessment during pregnancy to identify high-risk cases and guide management decisions. Early detection and appropriate intervention can improve maternal and neonatal outcome.

1. Neetu Singh*, Renu Gupta, Kiran Pandey, Neena Gupta, Ani Chandanan, Priya Singh (2016) : To study second trimester placental location as a pre- dictor of adverse pregnancy outcome
2. Ban Amer Mousa. . Placental location in the uterus and its roles in fetal, maternal outcome and mode of delivery. 2021. https://doi.org/10.5281/zenodo.5449660
3. Dhingra S, Premapriya G, Bhuvaneshwari K, Gayathri N , Vimala D. (2019) : Correlation between placental location and maternal fetal out- come
4. Nair VV, Nair SS, Radhamany K. Study of placental location and pregnancy outcome. Int J Reprod Contracept Obstet Gynecol 2019
5. Magann EF, Doherty DA, Turner K, Lanneau GS, Jr, Morrison JC, Newnham JP. Second trimester placental location as a predictor of an adverse preg- nancy outcome. J Perinatol. 2007
6. Singh N, Gupta R, Pandey K, Gupta N, Chandanan A, Singh P. To study second trimester placental location as a predictor of adverse pregnancy out- come. Int J ReproductContracep, Obstet Gynecol. 2016
7. Reyes L, Wolfe B, Golos T: Hofbauer ce ls: placental macrophages of fetal origin. Results Probl Ce l Differ 62:45, 2017
8. Zia S. Placental location and pregnancy outcome. J Turk Ger Gynecol Assoc. 2013 Dec 1;14(4):190-3.
9. Jauniaux E, Ramsay B, Campbell S. Ultrasonographic investigation of pla- cental morphologic characteristics and size during the second trimester of pregnancy. Am J Obstet Gynecol 1994
10. Elchalal U, Ezra Y, Levi Y, Bar-Oz B, Yanai N, Intrator O, et al. Sonograph- ically thick placenta: A marker for increased perinatal risk--a prospective cross sectional study. Placenta 2000.