Risk factors and outcome of placenta previa: accrete in a tertiary health care center of Punjab, India
Keywords:Caesarian hysterectomy, Placenta accrete (PA), Placenta previa (PP), Risk factors
Background: The aim of this study was to identify and evaluate risk factors associated with placenta accrete (PA) and its clinical outcome.
Methods: A descriptive, case control study was conducted in department of obstetrics and gynecology, GMC Amritsar in which authors retrospectively reviewed data of 180 patients of placenta previa (PP) over 5 years, categorized as PA (cases; n=23) or no PA (control; n=157). Furthermore, these groups were compared as to maternal demographics, intrapartum and postpartum complications and neonatal outcomes. Stepwise logistic regression analysis was done to evaluate the extent to which exposure variable contributed to the incidence of PA including advanced maternal age (AMA), parity, location of placenta and previous caesarian section (CS). Primary aim was to identify and quantify the various risk factors of PA and secondary aim measured incidences of PP, PA and fetomaternal outcome.
Results: The cumulative incidence of PA over 5 years was 2.98 per 1000 deliveries. Accrete rate increased with number of CSs at 4.76% in patients with no previous CS versus 45.94% in ≥1 CS (p < 0.003). Anterior PP (AOR 10.128 CI 2.406 -42.632; p <0.001) and number of previous CSs (AOR 36.405, 95% CI 2.743 -483.24, p =0.006) were significant risk factors for PA. AMA (OR >30 years: 4.326 95% CI 0.724 -25.856; p =0.108), parity (AOR 1 vs 0: 2.526 95% CI 0.242-26.41; p=0.439), prior uterine curettage (AOR ≥1 vs 0: 11.143 95% CI 0.522-9.726; p=0.278) although had association with PA but was not statistical significant. Caesarian hysterectomy was done in 95.65% patients of PA while only 1 patient of PP required hysterectomy (p<0.001). Neonatal outcome was similar in both groups.
Conclusions: Prior caesarian and anterior PP emerged out as significant predictors of PA. Other risk factors like AMA, multiparous, history of prior uterine curettage, central PP have incremental risk of having PA and such patients should be managed diligently to lower feto-maternal morbidities and mortalities.
Oyelese Y, Smulian JC. Placenta previa, placenta accrete, and vasa previa. Obstet Gynecol. 2006;107:927-41.
Gielchinsky Y, Rojansky N, Fasouliotis SJ, Ezra Y. Placenta accrete-summary of 10 years: a survey of 310 cases. Placenta. 2002;23:210-4.
Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol. 2005; 192:1458-61.
Hung TH, Shau WY, Hsieh CC, Chiu TH, Hsu JJ, Hsieh TT. Risk factors for placenta accrete. Obstet Gynecol. 1999; 93:545.
Benirschke KKP, Kaufmann P. Pathology of the human placenta, 4th ed. New York: Springer, 2000.
Wax JR, Seiler A, Horowitz S, Ingardia CJ. Interpregnancy interval as a risk factor for placenta accrete. Conn Med. 2000;64:659-1.
Gielchinsky Y, Mankuta D, Rojansky N, Laufer N, Gielchinsky I, Ezra Y. Perinatal outcome of pregnancies complicated by placenta accrete. Obstet Gynecol. 2004;104:527-30.
O’Brien JM, Barton JR, Donaldson ES. The management of placenta percreta: conservative and operative strategies. Am J Obstet Gynecol. 1996;175:1632-8.
Bahar A, Abusham A, Eskandar M,Sobande A, Alsunaidi M. Risk factors and pregnancy outcome in different types of placenta previa. J Obstet Gynaecol Can. 2009;31:126-31.
Clark SL, Koonings PP, Phelan JP. Placenta previa/accrete and prior cesarean section. Obstet Gynecol. 1985;66:89-2.
Kayem G, Davy C, Goffinet F, Thomas C, Clément D, Cabrol D. Conservative versus extirpative management in cases of placenta accrete. Obstet Gynecol. 2004;104(3):531-6.
Bennett MJ, Sen RC. ‘Conservative’ management of placenta praeviapercreta: report of two cases and discussion of current management options. Aust N Z J Obstet Gynaecol.2003;43:249-51.
Mussalli GM, Shah J, Berck DJ, Elimian A, Tejani N, Manning FA. Placenta accrete and methotrexate therapy: three case reports. J Perinatol. 2000;20:331-4.
Jagielska I, Kazdepka-Ziemińska A, Tyloch M, Żołnieżewicz K, Grabiec M, Szymański W, et al. Clinical study of perinatal hysterectomy between 2000-2011 in the clinic of obstetrics, gynecological diseases and oncological gynecology in Bydgoszcz. Ginekol Pol.2014;85(3).
Roethlisberger M, Womastek I, Posch M, Husslein P, Pateisky N, Lehner R. Early postpartum hysterectomy: incidence and risk factors. Acta Obs Gynecol Scand. 2010;89(8):1040-4.
Cheng KK, Lee MM. Rising incidence of morbidly adherent placenta and its association with previous caesarean section: A 15-year analysis in a tertiary hospital in Hong Kong. Hong Kong Med J. 2015; 21:511-7.
Aggarwal R, Suneja A, Vaid N B, Yadav P, Sharma A, Mishra K. Morbidly adherent placenta: a critical review. J Obstet Gynecol. 2012; 62(1):57-61.
Chaudhari HK, Shah PK, D'Souza N. Morbidly adherent placenta: Its management and maternal and perinatal outcome. J Obstet Gynaecol India. 2017;67(1):42-7.
Usta IM, Hobeika EM, Musa AA, Gabriel GE, Nassar AH. Placenta previa-accrete: risk factors and complications. Am J Obstet Gynecol. 2005;193:1045-9.
Kennare R, Tucker G, Heard A, Chan A. Risks of adverse outcomes in the next birth after a first cesarean delivery. Obstet Gynecol. 2007;109(1):270-6.
Fitzpatrick KE, Sellers S, Spark P, Kurinczuk JJ, Brocklehurst P, Knight M. Placenta accrete/increta/percreta: incidence, risk factors, management and outcomes. Arch Dis Child Fetal Neonatal Ed. 2012; 97(1):A4-5.
Zaki ZM, Bahar AM, Ali ME, Albar HA, Gerais MA. Risk factors and morbidity in patients with placenta previa accrete compared to placenta previa non-accrete. Acta Obstet Gynecol Scand. 1998;77(4):391-4.
Farquhar CM, Li Z, Lensen S, McLintock C, Pollock W, Peek MJ, et al. Incidence, risk factors and perinatal outcomes for placenta accreta in Australia and New Zealand: a case-control study. BMJ open. 2017;7(10):e017713.
Jang DG, We JS, Shin JU, Choi YJ, Ko HS, Park IY et al. Maternal outcomes according to placental position in placental previa. Int J Med Sci. 2011;8(5):439-44.
Bowman ZS, Eller AG, Bardsley TR, Greene T, Varner MW, Silver RM. Risk factors for placenta accrete: a large prospective cohort. Am J Perinatol. 2014;31(9):799-804.
Zhang D, Yang S, Hou Y, Su Y, Shi H, GuW. Risk factors, outcome and management survey of placenta accrete in 153 cases: a five-year experience from a hospital of Shanghai, China. Int J Clin Exp Med. 2017;10(8):12509-16.
Balayla J, Bondarenko HD. Placenta accrete and the risk of adverse maternal and neonatal outcomes. J Perinat Med. 2013;41(2):141-9.