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Journal of Pharmaceutical Research International
27(5): 1-8, 2019; Article no.JPRI.48851
ISSN: 2456-9119
(Past name: British Journal of Pharmaceutical Research, Past ISSN: 2231-2919,
NLM ID: 101631759)
The Association between Placental Location in the
First Trimester and Fetal Sex
Fariba Mirbolouk
1
, Maryam Mohammadi
1*
, Ehsan Kazemnejad Leili
2
,
and Seyedeh Fatemeh Dalil Heirati
1
1
Reproductive Health Research Center, Department of Obstetrics and Gynecology, Alzahra Hospital,
School of Medicine, Guilan University of Medical Sciences, Rasht, Iran.
2
Faculty of Midwifery and Nursing, Guilan University of Medical Sciences, Rasht, Iran.
Authors’ contributions
This work was carried out in collaboration among all authors. Author FM designed the study and wrote
the protocol. Author MM performed the statistical analysis. Author EKL wrote the protocol, wrote the
first draft of the manuscript and managed the analyses of the study. Author SFDH managed the
literature searches and wrote the manuscript. All authors read and approved the final manuscript.
Article Information
DOI: 10.9734/JPRI/2019/v27i530183
Editor(s):
(1)
Dr. Jinyong Pen, Professor, College of Pharmacy, Dalian Medical University, Dalian, China.
Reviewers:
(1) M. V. Seeman, University of Toronto, Canada.
(2)
Shigeki Matsubara, Jichi Medical University, Japan.
(3)
Sreelatha S. Ramesh, International Medical University, Malaysia.
Complete Peer review History:
http://www.sdiarticle3.com/review-history/48851
Received 26 February 2019
Accepted 05 May 2019
Published 23 May 2019
ABSTRACT
Background:
Because advance knowledge of fetal sex can satisfy parental curiosity and allay
anxiety, attempts at its determination prior to birth have a long history. There may also be reason to
determine fetal sex when sex-specific genetic disorders are suspected. The aim of this study was to
investigate the association between gestational sac (GS) location and fetal sex.
Materials and Methods: This cross-sectional study was conducted on 751 pregnant women.
Transvaginal ultrasound was performed during 7-8 weeks of gestation for prenatal care and
assessment of pregnancy sac and GS location. Age, parity, gravidity and GS location were
recorded. Abdominal ultrasound was performed at 16-20 weeks of gestation to determine fetal
health and sex and finally data was analyzed and compared to sex of the fetus after birth using
SPSS software version 21.
Results: There was a significant relationship between GS location and fetal sex (P<0.0001).
Original Research Article
Mirbolouk et al.; JPRI, 27(5): 1-8, 2019; Article no.JPRI.48851
2
However, pregnancy outcomes (male or female) and GS location (anterior or posterior) were not
significant correlated (P= 0.290). There was, on the other hand, a significant relationship between
outcomes and GS location (right or left) (P<0.0001).
Conclusion: Maybe GS location could be considered as a helpful method for earlier fetal sex
determination.
Keywords: Sex; gestational sac location; placental location; ultrasound; fetus.
1. INTRODUCTION
The determination of fetal sex is carried out for a
variety of reasons, including medical reasons
(diagnosis of diseases), convenience reasons
(knowing what clothes and colours to purchas in
advance) [1,2]. Furthermore, early detection of
fetal sex is important for researchers and
parents. Some fetal diseases are sex dependent
and if one of the parents or both had specific
diseases, early detection can help families
receive on time genetic consultations. They can
consequently decide on whether or not to
continue the pregnancy [3]. Fetal sex
determination can also be requested by parents
for unethical reasons e.g. to determine whether
fetuses, if they are female, are worth keeping.
This unlawful practice is carried out in many
regions of the world, fetal sex can be determined
by different methods, including Chorionic villus
sampling (at 10-11 weeks of gestation) and
amniocentesis (at 15-16 weeks of gestation).
These methods are invasive and sometimes fail
[4-6]. Commonly, clinicians determine fetal sex
by ultrasound, which is a noninvasive and cost
effective method compared to other methods
[4,7]. Ultrasound has been the key technology for
assessing fetal disease during the late 3 decades
[8,9]. Recently, clinicians use ultrasound as an
alternative screening method to determine fetal
abnormalities, fetal growth disorders, GS location
and gestational age; it is widely applied during
pregnancy [10-12].
Fetal sex determination can reveal important
information regarding fetal health. It can be
helpful for deciding on the necessity for invasive
methods in patients with family history of sex
dependent abnormalities, including hemophilia
and Duchenne’s muscular dystrophy. Ultrasound
can facilitate the diagnosis of fetal anomalies,
including posterior urethral valve in male fetuses
and Turner syndrome in female fetuses,
dichorionic twin pregnancies and
hermaphroditism [12].
Furthermore, it has been reported that fetal sex
determination could help identify the high risk
pregnancies as preeclampsia occurs at higher
rates in male fetus pregnancies [13,14]. Fetal sex
determination can also help reduce the risk of
female masculinization in 21 hydroxylase
deficient fetuses by early sex detection and
prompt corticosteroid therapy [6].
Previous investigations assessed the effect of
placental location on fetal sex and reported
inconsistent results. Ismail et al. reported a
significant relationship between placental
location and fetal sex. They mentioned that male
fetuses had right chorionic villi/placenta location
[15], However, The et al. observed a weak
relationship between placental location and fetal
sex [16] and Erdolu et al. [11] noted only a
probable effect of fetal sex on placental location.
Fetal sex can be determined with
ultrasonography at eleven or twelve weeks of
gestation. Otherwise, sex detection is not reliable
by ultrasound in earlier gestational ages. Though
fetal sex determination is made possible before
14 weeks gestation by 3D ultrasound, the use of
three or four-dimensional ultrasounds costs more
and may be associated with complications [3,17].
Therefore, there is a need for a low cost and
non-invasive diagnostic tool for the determination
of embryonic sex in early gestational weeks. It is
hypothesized that GS location can help as a
predictor of fetal sex by the sixth week of
pregnancy. However, this is not actual used in
clinically and just we suggest it. As there is no
consensus on the effect of GS location on fetal
sex and due to the importance of early fetal sex
determination in some cases, we aimed to
assess the association between GS location
(gestational sac) and fetal sex in pregnant
women.
2. METHODS
2.1 Study Population
This analytic cross-sectional study was
conducted on pregnant women, who referred to
Al-Zahra hospital and Private offices in Rasht,
Mirbolouk et al.; JPRI, 27(5): 1-8, 2019; Article no.JPRI.48851
3
Iran. Sample size was calculated based on the
findings of a study by Erdolu et al. [11] using the
following equation. The calculated sample size
was 800 women.
(z
1- α /2
+ z
1- β
)
2
[P
1
(1- P
1
) + P
2
(1- P
2
) ]
(P
1
- P
2
)
2
Z
1
-∝2
= 1.96
z
1-β
=Z
80
= 0.84
P
1
= 0.62
P
2
=0.481
2.2 Inclusion and Exclusion Criteria
The inclusion criteria were age between 20 and
31 years old, no previous history of diseases
including chronic hypertension, diabetes mellitus,
chronic renal disease, cigarette smoking or
alcohol consumption, as well as no history of
diseases known to affect fetal growth, including
early miscarriage and assisted conception, and
determined normal uterus. Exclusion criteria
were twin pregnancy, ectopic pregnancy, fetal
death, abortion, polyhydramnios or
oligohydramnios, as well as existence of
congenital anomalies.
2.3 Data Collection
Pregnant women at their 8
th
week of gestation
underwent transvaginal ultrasound by a single
radiologist in a single radiology center.
Transvaginal ultrasound was performed as a
component of prenatal care with the aim of
observing the location of the gestational sac and
the placental location (anterior- posterior, right-
left).
Data (age graviity, parity) were gathered through
interviews At 16-20 weeks of gestation, routine
transabdominal ultrasound was performed to
assess fetal health and sex determination. After
birth, the investigators confirmed the neonatal
sex through phone call and matched the actual
sex with the transabdominal ultrasound result. A
single radiologist performed the ultrasound -
coronal and sagittal planes. (Medison V 20 and
3- 7 MHz).
2.4 Statistical Analysis
Data were collected and analyzed by SPSS v.21.
The chi square test was used to assess the
relationship between the frequency distribution of
sex and placental location. The relation between
sex and placental location based on age,
gravidity and parity were assessed by logistic
regression. P<0.05 was considered as statistical
significance and 95% confidence interval was
used.
3. RESULTS
A total of 800 pregnant women enrolled in this
study. Forty-nine women were excluded (8 twin
pregnancy, 26 abortion, 5 fetal death and 10
unwilling to participate) resulting in the final 751
pregnant women. The mean age of pregnant
women was 28.56±5.51 years. The mean
gravidity and parity were 1.6±0.79 and 0.56±0.42
respectively. The pregnancies resulted in 380
boys (50.6%) and 371 girls (49.4%).
Assessing the pregnancy outcomes regarding
placental location revealed a significant
difference between sexes (p = 0.0001). However,
no significant difference was noted between
pregnancy outcomes regarding anterior or
posterior placental location (p = 0.290) (Table 1).
There was a significantly relationship between
maternal age groups (26-35 years old) and
placental location (p<0.05) (Table 2). The
relationship between frequency distribution of
pregnancy outcomes in primigravida mothers
and gravida are shown in Table 3. Relation
between frequency distribution of pregnancy
outcomes and right and left placental location in
nuliparus and primiparus mothers are shown in
Table 4.
Multivariate analysis assessed the relation
between placental location and the probability of
male and female birth using backward
conditional regression logistic (LR). After
controlling for maternal age, parity and gravidity,
no significant difference was observed between
left anterior and left posterior (reference group)
placental location and fetal sex (P=0.291). After
controlling for maternal age, parity and gravidity,
it was found that the chance of female birth was
significantly related to left posterior placental
location (p<0.0001) and the prevalence of left
anterior placenta (p=0.002) were significantly
higher than right anterior placenta (reference
group).
Whereas, the chance of female birth in left
posterior placenta was 2.4 fold higher than right
anterior placenta. (OR = 2.42, 95% CI: 1.54-
3.79). Furthermore, the chance of female birth in
left posterior placenta was 1.88 fold higher than
Mirbolouk et al.; JPRI, 27(5): 1-8, 2019; Article no.JPRI.48851
4
right posterior (reference group) placenta (OR =
1.88, 95% CI: 1.23-2.87). There was no
significant difference between right posterior
and right anterior (reference group) placental
location regarding the chance of female birth
(P=0.205).
4. DISCUSSION
The results of this study showed that the most
frequent pregnancy outcomes in right anterior
placenta were male and in left posterior placenta
were female. There was no significant difference
between sexes regarding anterior and posterior
placental location as well as right and left
placental position, whereas most of the fetuses in
right and left placental location were male and
female respectively.
To the best of our knowledge, the relationship
between fetal sex and anterior-posterior, right
left placental location has not been assessed
before.
A study on 5376 pregnant women revealed that
location of placenta in the first trimester of
pregnancy could predict of 97.97% of female
cases and 97.92% of male cases. They
concluded that there is a more tendency toward
right placement of placenta in male pregnancies
while the tendency is toward left placement in
female pregnancies [18]. In the current study, in
most female cases, the placenta was located
anteriorly, the placental position was located
posteriorly in male pregnancies.
Erdolu et al. [11] found that 62% of female
fetuses had an anterior placenta and 51.9% of
male fetuses had posterior placenta which was
similar to the results of our study. Similarly, the
results of a study by Jafari et al. [19] were also
in line with the findings of our study.
Hwida et al. reported opposite results compared
to the findings of our study. They found that most
placental positions among female and male
fetuses were anterior and posterior respectively
[20] But, in this study, results demonstrated no
significant difference between anterior- posterior
placenta between fetal sexes. This difference
between study findings might be due to
heterogeneous samples and the effect of
demographic factors.
Assessing the relation between right- left position
of placenta and fetal sexes:
Ismail et al. noted that the placental position was
on the right side among most male fetuses [15],
which was similar to the findings of our study.
The et al., however, assessed 227 pregnant
women and reported that 51% of male fetuses
had a right placenta while 57% of female fetuses
had a left placenta which was not significantly
different. They indicated that genital tubercle
ultrasound was a more effective tool for fetal sex
prediction [16]. The difference between the
findings of our study and The et al. might be due
to our sample size beingtoo small.
It seems that the association between fetal sex
and placental location could result from different
blood supplies in different sections of the uterus,
which depends on the distance between each
section and uterine artery. Increased distance
might decrease the blood supply, therefore;
blood supply in the central section of uterine
might be more appropriate than peripheral
section. It has been estimated that the lateral
placental location in fetuses with intrauterine
growth retardation were four fold higher than
anterior or posterior locations [21].
In addition, Kavraiskaya et al. noted that blood
supply to the right side of uterus was higher than
left side [22]. It seems that the difference in blood
supply might affect sex determination and each
sex might prefer different type of blood supply. A
previous study showed that endometrial
movement and electrical activity could affect
sperm transfer. The polarity of uterine wall
and sperm could be indicated as probable
causes for different implantation by different
sexes [21].
Although, no definite hypothesis for this
occurrence has yet been established, it is
thought that implantation in the right upper part of
uterine commonly occurs 4 days before
implantation in left upper quadrant, which could
be due to hormonal and temperature differences.
The imbalance in sexual hormones has been
confirmed previously, excessive estrogen may
affect male fetuses and can affect sexual
chromosomes. On the other hand, excessive
androgen can affect female fetuses. It can be
hypothesized that the right side of uterine may
allow male hormones to transfer more than the
left side. The right side may have a positive
polarity in comparison with the negative left
uterine side [15].
In this study, variables including maternal age,
gravidity and parity were assessed which were
not previously evaluated. The results of this
Mirbolouk et al.; JPRI, 27(5): 1-8, 2019; Article no.JPRI.48851
5
study showed that maternal age between 26 and
35 years old, first and second gravidity and first
parity were associated with the placental location
and fetal sexes. After adjustment for these
factors, the only predictive factor was the
placental location.
The limitations to this study include relatively a
small sample size. It is recommended that future
studies be performed on a larger population in a
multicenter study. Furthermore, this study was
the first study to assess three variables including
maternal age, number of pregnancies (gravidity)
and parity. It is recommended that future studies
should be conducted to assess the role of each
of these variables on fetal sex. This study did
not investigate abnormalities of uterus.
Considering the fact that different blood
transfusion exists in different uterine parts, it is
recommended that various hypotheses be
assessed in future studies. Additional placental
locations (lateral, fundal, etc.) could offer more
explanations. Geneticists use the X, Y
chromosome isolation technique for sex
determination that are costly and invasive while
past studies along with our study provide a low
cost and non-invasive method to help determine
the sex.
Table 1. The frequency distribution of pregnancy outcomes regarding the placental location
p-value Girls
N (%)
Boys
N (%)
Placental
location
0.0001 73(39.5) 112(60.5) Right Anterior Placental location
104(55.3) 84(44.7) Left anterior
109(45.6) 130(54.4) Right posterior
85(61.2) 54(38.8) Left posterior
0.290 178(47.5) 197(52.5) Anterior Placental location
193(51.3) 183(48.7) Posterior
0.0001 185(43.5) 240(56.5) Right Placental location
186(57.1) 140(42.9) Left
Table 2. The frequency distribution of pregnancy outcomes regarding the placental location in
maternal age groups
>36 years old
(n=69)
26-35 years old
(n=456)
21-25 years old
(n=189)
<20 years old )
(N=37)
Female
N(%)
Male
N(%)
Female
N(%)
Male
N(%)
Female
N(%)
Male
N(%)
Female
N(%)
Male
N(%)
8(22.2) 7(21.2) 40(17.7) 75(32.6) 22(24.2) 26(26.5) 3(16.7) 4(21.1) Right
anterior
13(36.1)
8(24.2) 60(26.5) 48(20.9) 23(25.3) 25(25.5) 8(44.4) 3(15.8) Left
anterior
9(25.0) 12(36.4)
71(31.4) 80(34.8) 25(27.5) 31(31.6) 4(22.2) 7(36.8) Right
posterior
6(16.7) 6(18.2) 55(24.3) 27(11.7) 21(23.1) 16(16.3) 3(16.7) 5(26.3) Left
posterior
0.669 0.0001 0.687 0.295 P -value
21(58.3)
15(45.5)
101(44.7)
124(53.9)
45(49.5) 51(52.0) 11(61.1)
7(36.8) Anterior
15(41.7)
18(54.5)
125(55.3)
106(46.1)
46(50.5) 47(48.0) 7(38.9) 12(63.2)
Posterior
0.285 0.049 0.722 0.140 P -value
17(47.2)
19(57.6)
113(50.0)
153(66.5)
48(52.7) 57(58.2) 7(38.9) 11(57.9)
Right
19(52.8)
14(42.4)
113(50.0)
77(33.5) 43(47.3) 41(41.8) 11(61.1)
8(42.1) Left
0.390 0.0001 0.454 0.248 P -value
Mirbolouk et al.; JPRI, 27(5): 1-8, 2019; Article no.JPRI.48851
6
Table 3. The frequency distribution of pregnancy outcomes regarding the placental location
and gravidity
≥3 gravida
(n=82)
Gravida 2
(n-266)
Primigravida
(n=403)
Female
N (%)
Male
N (%)
Female
N (%)
Male
N (%)
Female
N (%)
Male
N (%)
6(17.1) 12(25.5) 32(23.9) 40(30.3) 35(17.3) 60(29.9) Right
anterior
11(31.4) 9(19.1) 34(25.4) 30(22.7) 59(29.2) 45(22.4) Left
anterior
13(37.1) 17(36.2) 34(25.4) 48(36.4) 62(30.7) 65(32.3) Right
posterior
5(14.3) 9(19.1) 34(25.4) 14(10.6) 46(22.8) 31(15.4) Left
posterior
0.539 0.008 0.010 P -value
17(48.6) 21(44.7) 66(49.3) 70(53.0) 95(47.0) 106(52.7) anterior
18(51.4) 26(55.3) 68(50.7) 62(47.0) 107(53.0) 95(47.3) posterior
0.727 0.538 0.252 P -value
19(54.3) 27(57.4) 67(50.0) 88(66.7) 99(49.0) 125(62.2) Right
16(45.7) 20(42.6) 67(50.0) 44(33.3) 103(51.0) 76(37.8) Left
0.775 0.006 0.008 P -value
Table 4. The frequency distribution of pregnancy outcomes regarding the placental location
and parity
≤2 parity
(n=28)
Primipara
(n=256)
Nuliparity
(n=467)
Female
N (%)
Male
N (%)
Female
N (%)
Male
N (%)
Female
N (%)
Male
N (%)
2(16.7) 6(37.5) 29(23.2) 41(31.3) 42(17.9) 65(27.9) Right anterior
3(25.0) 4(25.0) 37(29.6) 28(21.4) 64(27.4) 52(22.3) Left anterior
5(41.7) 3(18.8) 31(24.8) 46(35.1) 73(31.2) 81(34.8) Right
posterior
2(16.7) 3(18.8) 28(22.4) 16(12.2) 55(23.5) 35(15.0) Left posterior
0.509 0.025 0.001 P -value
5(41.7) 10(62.5) 66(52.8) 69(52.7) 107(45.7) 118(50.6) anterior
7(58.3) 6(37.5) 59(47.2) 62(47.3) 127(54.3) 115(49.4) posterior
0.274 0.984 0.288 P -value
7(58.3) 9(56.3) 61(48.8) 85(64.9) 117(50.0) 146(62.7) Right
5(41.7) 7(43.8) 64(51.2) 46(35.1) 117(50.0) 87(37.3) Left
0.912 0.009 0.006 P -value
5. CONCLUSIONS
We here demonstrated that male and female
fetuses are more likely to have right anterior and
left posterior placentas, respectively. Although
this study was based on a small population, this
may provide a fundamental data for the future
study to associate fetal gender and the placental
location.
CONSENT
A written consent was obtained from each
participant.
ETHICAL APPROVAL
Ethical approval was obtained from the Ethics
Committee of the Guilan University of
Mirbolouk et al.; JPRI, 27(5): 1-8, 2019; Article no.JPRI.48851
7
Medical Sciences (Registration Number:
1393014414).
FUNDING / SUPPORT
Financial support was done with Vice-
chancellorships Research of Guilan University of
Medical Sciences.
ACKNOWLEDGEMENTS
The authors acknowledge with grateful
appreciation the support provided by the Vice-
chancellorships Research of Guilan University of
Medical Sciences. Also, this investigation was
based on a thesis submitted by Dr Mohammadi
(Guilan University of Medical Sciences in Iran).
COMPETING INTERESTS
Authors have declared that no competing
interests exist.
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