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Placenta previa is a condition where the placenta implants very low in the uterus and often covers, either partially or entirely, the cervix or the opening from the uterus to the outside.

Placenta previa can be a serious condition. It's important to let the patient know that they have a previa so that they're aware of things that they want to avoid. In particular, you put them on pelvic rest, limit the amount of physical activity. We don't want to put anybody on bedrest 'cause that can increase the risk for blood clot but just to be smart in terms of their activity and maybe modify the type of physical activities that they do to kind of decrease any stress in the cervical region or where that placenta is. The majority of placenta previas will resolve by the end of third trimester so it may make somebody a little anxious at the beginning to know that and when we're talking about restrictions, they get little uncomfortable thinking that there's a problem when in many cases, it turns out not to be a problem. But the biggest concern with this condition is the amount of bleeding that somebody could present with if that placenta starts to separate from the cervix.

There are multiple risk factors for placenta previa. There's a whole list of them, probably at least 10, but the most common ones are the more pregnancies you have, each subsequent pregnancy, you're at greater risk for placenta previa. If you've had prior uterine surgery, so women who've had a prior C-section, anybody who's had prior surgery to remove a fibroid, anything that interrupts or disrupts the endometrial lining. Women who've had recurrent miscarriages, even spontaneous losses, they're at increased risk for placenta previa. In today's day and age, with technology and advanced reproductive, or assisted reproductive technologies such as IVF, we are seeing increased risk of placenta previa in those pregnancies as well. Smoking is a huge risk factor for placenta previa, as well as cocaine use. I think those are probably the major risk factors or the major conditions we see associated with a risk for placenta previa.

Symptoms of placenta previa are typically bleeding, usually in the second and third trimester. Most women won't know they have a previa. It's found incidentally when they have their second trimester ultrasound. Typically, women will have a routine anatomy scan around 18 to 20 weeks, average is about 20 weeks. Often time, the placenta previa's diagnosed at that time. They notice the placenta's implanting lower by the cervix or covering the cervix. But the good news, the majority of those will become, or move out-of-the-way by late in the third trimester. So just because it's diagnosed incidentally on the ultrasound doesn't mean it's going to be there at the time of delivery. But most women will present, in terms of symptoms, will present second or third trimester with bleeding. Usually it's painless bleeding but bleeding itself from a previa will cause contractions, and so some women may present with contraction pain and possibly signs of preterm labor when in fact, it's actually a previa.

The three most common types of pelvic pain ... when you talk about chronic pelvic pain, it's ubiquitous in regards to there's many, many etiologies or causes of pain in general. And typically, chronic pain, you look at, it's usually been present for over six months. It's usually sub-umbilical, and there's usually some reason for treatment, or it affects their [inaudible 00:00:58] day living.

So when you look at the three most common of the chronic pelvic pain issues, I would say endometriosis is probably number one. I think we see a lot of what's called pelvic inflammatory disease. And I would also say that dysmenorrhea, or painful periods, would be another one as well.

Of those three, endometriosis can definitely affect fertility or subfertility, depending on the extent of it affects the pelvis. But dysmenorrhea will probably not affect fertility. That's more of a painful period situation. And the pelvic inflammatory disease could also affect fertility in regards to adhesion formation and affect the tubal function within the pelvis.

Pelvic pain in general, probably the most common thing that you'll see from the patient's perspective is they'll come in with pain, either all month long, or pain associated strictly with their menstrual cycle. But pain is probably the most common thing that we see, and it's usually been going on for a long time in these patients. And they may have seen multitudes of doctors in the past, and they're getting somewhat frustrated in regards to ... they're telling them it's either in their head, it's the GI system, it's their bladder. But pelvic pain can be associated ... it can be made worse by your menstrual cycle, or it can be there all month long, as well.

I think when you look at the treatment options as far as pelvic pain goes, you look at the fact that you want to treat it kind of as fluidity in regards to the woman's reproductive life. And it depends where they are in that reproductive life, as far as what you're going to do. But for endometriosis, it could be treated medically. And initially, you could try to treat it medically from that perspective. If that's not efficient, or controls her pain from that perspective, then you can look at surgical options.

For the painful periods or dysmenorrhea, you would treat that with medications. You can try over-the-counter, non-steroidal medications like Motrin and Advil or Aleve. And then if that doesn't work, you can try other prescriptive medications from that perspective.

And then when you look at pelvic inflammatory disease, you're really trying to treat the infection. And by treating the infection, you're trying to prevent the adhesion formation inside the pelvis. Because once the patient forms adhesions, there's nothing to really treat that, short of surgical intervention.

I would say that from a cause perspective, as far as pelvic pain, if you look at pelvic inflammatory disease, it's related really to sexual activity. Number of sexual partners, onset of sexual activity, because usually that's related to one of three potential vaginal infections.

If you look at painful periods, or dysmenorrhea, a lot of times you see that in our younger patients. And you can have primary dysmenorrhea, which is usually less than 20 years of age. And there's usually no etiology for that. There's not really a cause for that. And then over the 20-year age category, you can see secondary dysmenorrhea, which usually has a cause. And that could be related to, like, cervical stenosis, endometriosis, adenomyosis, pelvic congestion syndrome. Those all can be related to secondary dysmenorrhea.

The endometriosis in general, that is related to the implantation of either the endometrial stroma or glands outside of the endometrium. And that can happen anywhere in the body.

I'm not so sure that pelvic pain in general has a negative impact on pregnancy, because actually, some of the conditions are actually improved when the patient does become pregnant. So I would not say that any of the pelvic pain symptoms that we have would have a negative impact on a pregnancy.