American Journal of Obstetrics and Gynecology (2005) 193, 10459

www.ajog.org

Placenta previa-accreta: Risk factors and complications

Ihab M. Usta, MD, Elie M. Hobeika, MD, Antoine A. Abu Musa, MD, Gaby E. Gabriel, MD, Anwar H. Nassar, MD
Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
Received for publication March 1, 2005; revised May 18, 2005; accepted June 7, 2005

KEY WORDS
Placenta Previa Accreta Complications Risks

Objective: The purpose of this study was to identify risk factors and complications of placenta previa-accreta (PA). Study design: Patients with placenta previa (n = 347) delivered over 20 years were reviewed, divided into PA (cases, n = 22) and no accreta (controls, n = 325), and compared. Results: Cases were older with a higher incidence of smoking and previous cesarean delivery (CS). Grandmultiparity, recurrent abortions, anterior/central placentae, and low socioeconomic status were similar. PA incidence increased with the number of previous CS: 1.9%, 15.6%, 23.5%, 29.4%, 33.3%, and 50.0% after 0, 1, 2, 3, 4, and 5 previous CS, respectively. Hypertensive disorders (odds ratio [OR] 13.9, 95%CI 2.1-91.2], P = .006), smoking (OR 3.4, 95%CI 1.1-10.2, P = .031) and previous CS (OR 7.9, 95%CI 1.7-37.4, P = .009) were selected by the stepwise logistic regression analysis as predictors of PA. Cases had a longer hospital stay, a higher estimated blood loss, and need for transfusion. Cesarean hysterectomy and hypogastric artery ligation were only performed in PA cases. The 2 groups had a similar delivery gestational age and neonatal outcome. Conclusion: Hypertensive disorders, smoking, and previous cesarean are risk factors for accreta in placenta previa patients. Placenta previa-accreta is associated with higher maternal morbidity, but similar neonatal outcome compared with patients with an isolated placenta previa. 2005 Mosby, Inc. All rights reserved.

The incidence of placenta previa which requires abdominal delivery is 0.33% of all deliveries.1 Risk factors for placenta previa include previous uterine scar, smoking, maternal age over 35 years, grandmultiparity, recurrent abortions, low socioeconomic status, infertility treatment, and male gender. In addition to hemorrhagic complications, placenta previa is associated with abruptio placentae, congenital malformations, abnormal presentations, and preterm delivery.2-5
Presented at the Twenty-Fifth Annual Meeting of the Society for Maternal Fetal Medicine, February 7-12, 2005, Reno, Nev. Reprints not available from the authors. 0002-9378/$ - see front matter 2005 Mosby, Inc. All rights reserved. doi:10.1016/j.ajog.2005.06.037

Placenta accreta occurs when there is a defect of the decidua basalis, resulting in abnormally invasive implantation of the placenta.6 Risk factors for accreta include placenta previa, maternal age over 35 years, grandmultiparity, previous curettage, previous myomectomy, previous uterine surgery, submucous myoma, Ashermans syndrome,6-8 a short caesarean-to-conception interval,9 and a female fetus.10 Placenta accreta is associated with 7% mortality rate, as well as intraoperative and postoperative morbidity caused by massive blood transfusions, infection, and adjacent organ damage.6 The rate of placenta accreta in previa cases varies between 1.18% and 9.3%.3,11 On the other hand, 10%

1046 of accreta cases have anterior previa.8 Some risk factors and complications in patients with placenta accreta might be attributed to the coexistence of the 2 entities. We conducted our study to identify risk factors and complications of placenta accreta in the presence of placenta previa.

Usta et al 3.8% 3 times, and .3% 4 times for bleeding, ruptured membranes, or preterm labor. The mean predelivery stay was 4.93 G 5.16 days (range 1-32) and the delivery stay was 5.90 G 7.2 days (range 1-92). The previa was complete in 24.0%, partial in 12.1%, marginal in 7.5%, and low-lying in 15.4%. In 41.0%, the exact location of the previa in relation to the cervix was not specied. Risk factors including smoking, AMA, grandmultiparity, recurrent abortions, and low socioeconomic status were absent in 23.3% of patients. After excluding 12 patients delivered in an outside hospital and 12 delivered at !24 weeks of gestation, 347 patients were analyzed for their delivery admission. The placenta was PA in 22 (cases) and non-accreta in 325 (controls), with a rate of placenta accreta in previa patients of 6.3%. Table I describes the demographic characteristics of cases and controls. The incidence of PA was 12.2% in smokers compared with 4.8% in nonsmokers (P = .041) and 1.9% in those with no previous CS versus 21.0% in the 81 patients with a previously scarred uterus (P ! .001). It increased with the number of previous CS at a rate of 1.9%, 15.6%, 23.5%, 29.4%, 33.3%, and 50.0% after 0, 1, 2, 3, 4, and 5 previous CS, respectively. The incidence of PA was signicantly higher in patients with AMA compared with those !35 years (13.6% vs 4.1%, P = .005). Accreta rate was 3.3% in those !25 years, 3.4% in those 25 to 29 years, 5.5% in those 30 to 34 years, and 13.6% in those with AMA. Although the incidence of PA was higher in grandmultiparas (11.1% vs 5.5%, P = .117), in patients with recurrent abortions (13.0% vs 5.9%, P = .171), in those with low socioeconomic status (5.2% vs 7.4%, P = .401), and in those with anterior or central placental location (8.9% vs 5.1%, P = .258), the dierences did not reach statistical signicance. AMA was not found to be a signicant risk factor for PA when patients were subgrouped according to the presence (30.3% vs 14.6%, P = .153) or absence (2.1% vs 1.8%, P = 1.000) of a previous scar. Anterior or central placental location was found to be a signicant risk factor in the presence of a previous scar (28.6% vs 1.9%, P ! .001), but not in its absence (2.4% vs 6.0%, P = .239). The variables selected using the stepwise logistic regression analysis as predictors of PA were hypertensive disorders (OR 13.9, 95%CI 2.1-91.2, P = .006), smoking (OR 3.4, 95%CI 1.1-10.2, P = .031), and previous CS (OR 7.9, 95%CI 1.7-37.4, P = .009); more than 1 CS further increased the risk (OR 30.5, 95%CI 8.2-113.6, P ! .001). Table II describes antepartum and peripartum complications in cases and controls. The placenta was removed piecemeal in 5 (22.7%), suturing of placental bed was required in 4 (18.2%), hypogastric artery ligation in 1 (4.5%), and hysterectomy in 2 (9.1%). Placenta

Material and methods

Our computer database was used to retrieve all cases admitted with the diagnosis of placenta previa over 20 years (1983-2003). Charts were reviewed for maternal demographics, including age, parity, gestational age, previous cesarean delivery (CS), placental location, social status, and history of smoking. Data on mode of delivery, estimated blood loss, presence of placenta accreta, placental pathology, bleeding complications, procedures needed to control bleeding, and transfusions were documented. Neonatal charts were reviewed for birth weights, Apgar scores at 1 and 5 minutes, intensive care nursery admission, respiratory distress, need for mechanical ventilation, intraventricular hemorrhage, necrotizing enterocolitis, suspected or conrmed sepsis, periventricular leukomalacia, nursery stay, and perinatal mortality. Patients were divided into those with placenta previaaccreta (PA) (cases) and those without placenta accreta (controls). The 2 groups were compared for maternal demographics, intrapartum and postpartum complications, and neonatal outcome. Placenta accreta was dened according to clinical or histologic criteria as follows: 1) manual removal of the placenta partially or totally impossible, and no cleavage plane between part or all of the placenta and the uterus; 2) heavy bleeding from the implantation site after forced placental removal or piecemeal removal of the placenta; or 3) histologic conrmation of placenta accreta.12 Advanced maternal age (AMA) was dened as age R35 years and grandmultiparity as parity R5. Discrete variables were compared with the use of the chi-square test or 2-tailed Fisher exact test if the expected cell frequencies were small. Continuous variables were compared by the Student t test. A P value ! .05 was considered statistically signicant. Stepwise logistic regression analysis was used to identify risk factors for previa-accreta. Independent variables included in the model were: AMA, grandmultiparity, recurrent abortions, smoking, anterior or central placental location, hypertensive disorders, and previous cesarean delivery (0, 1, or R2).

Results
A total of 371 patients admitted with the diagnosis of placenta previa were reviewed. Apart from the delivery admission, 27.0% were admitted once, 20.8% twice,

Usta et al
Table I Demographic characteristics Cases (n = 22) Controls (n = 325) P value .040 .005 .199 .207 .041 .536 ! .001 .171 .258 Table II Antepartum and peripartum events Cases (n = 22) 45.5 31.8 4.5 13.6 0 0 12.8 G 9.0 Controls (n = 325) 52.9 34.5 1.5 3.1 24.3 7.7 5.5 G 5.3

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Characteristics Age (y)*y R35 (%)* Parityy Grandmultiparity (%) Smoking (%)* Low socioeconomic status (%) Previous cesarean (%)* Recurrent abortions R3 (%) Anterior or central placenta (%)

Characteristic Needed antepartum admission (%) Bleeding as indication for delivery (%) Diabetes (%) Hypertensive disorders (%)* Vaginal delivery (%)* Abruptio (%) Maternal hospital stay (days)*y Estimated blood loss (ml)*y Transfusion (%)* Excessive bleeding (%)*

P value .210 .984 .327 .042 .006 .387 ! .001

32.6 G 4.80 30.0 G 5.77 50.0 21.5 3.25 G 2.43 2.54 G 2.51 27.3 14.8 40.9 20.0 40.9 50.2 77.3 13.6 45.5 19.7 6.2 31.4

2262 G 1261 847 G 420 ! .001 95.5 100.0 25.2 27.1 ! .001 ! .001

* Statistically signicant. y Data presented as mean G standard deviation.

accreta was conrmed in both hysterectomy specimens. Blood loss was estimated at R3000 mL in 22.7% cases compared with only .3% controls (P ! .0001) and transfusion with R5 units was needed in 9.1% cases versus 3.1% controls (P = .172). We had no cases of bladder or bowel invasion and no maternal mortalities. Table III describes the neonatal outcome in cases and controls. The outcome was similar in all respects, including respiratory distress (9.1% and 11.1%), need for mechanical ventilation (4.5% and 13.2%), intraventricular hemorrhage (0% and 3.7%), necrotizing enterocolitis (0% and 1.5%), suspected sepsis (13.6% and 14.2%), conrmed sepsis (0% and 2.2%), patent ductus (4.5% and 1.5%), periventricular leukomalacia (0% and .6%), and retinopathy of prematurity (4.5% and .3%) in cases and controls, respectively.

* Statistically signicant. y Data presented as mean G standard deviation; excessive bleeding = postpartum hematocrit !25%, or blood loss O1200 mL, or drop in hematocrit R10 units or needed transfusion.

Table III

Neonatal outcome Cases (n = 22) Controls (n = 325) P value .808 .207 1.000 1.000 .295 .973 .471 .278 .491

Characteristic Gestational age (wk)* Birth weight (g)* Preterm delivery !28 weeks (%) !32 weeks (%) !37 weeks (%) Apgar score at 1 min* Apgar score at 5 min* ICN admission (%) Perinatal mortality (per thousand)

35.90 G 2.76 36.14 G 3.70 2948 G 642 2753 G 800 4.5 9.1 45.5 6.52 G 2.36 8.52 G 2.04 22.7 45 4.3 12.6 37.2 6.50 G 2.64 8.13 G 2.42 36.6 110

Comment
The rate of placenta accreta in the literature varies between 0.001% and 0.9% of deliveries, a rate that depends on the denition adopted for accreta (clinical or histopathologic diagnosis) and the population studied.8 There has been an almost 10-fold increase in the incidence of accreta in recent years compared with that reported in the 1950s, probably resulting from the increased cesarean section rate.6,11 The rate of accreta in our previa cases was 6.3%. One of the factors highly associated with PA was previous CS, where the rate of PA increased with the number of previous CS. The risk for PA in patients with one CS was w8-fold higher compared with those with an unscarred uterus and further increased w4-fold with 2 or more CS. The same was observed in a recently published abstract from the Maternal Fetal Medicine Unit Cesarean Section Registry, although the rate of

ICN, Intensive care nursery. * Data presented as mean G standard deviation.

increase in the incidence of PA with 1 and 2 CS was lower than previously reported (3.3% and 11.0%, respectively).13 Miller et al11 studied 590 cases of placenta previa and found a rate of PA of 4%, 14%, 23%, 35%, 50% after 0, 1, 2, 3, and 4 CS, respectively. The incidence of accreta was higher in other reports reaching 4% to 5%, 24%, 60%, and 67% after 0, 1, R3, and R4 CS7,14 and even higher, reaching 34.8%, 56%, 75%, and 100% after 0, 1, 2, and R2 CS.15 The American College of Obstetrics and Gynecology (ACOG) warns of a rate of accreta of 40% in patients with more than 2 CS and anterior or central placenta previa.6

1048 Our study shows an almost stable rate of accreta until maternal age exceeds 35 when the incidence of accreta rises dramatically. Advanced age and previous uterine scar seem to act synergistically to increase the risk of PA. AMA was also an important risk factor for PA in a study by Lachman et al.16 Miller et al11 reported an increase in accreta incidence with age, but the increase was progressive with a rate of PA of 3.2%, 6.2%, 10.2%, and 14.6% for those !25, 25 to 29, 30 to 34, and R35 years, respectively. The incidence of PA was not signicantly higher in grandmultiparous women. Zaki et al14 reached similar conclusions where the eect of age and parity was less dramatic than previous scar. Unlike previous reports,8,11 we did not nd a higher incidence of accreta with an anterior or central placenta; however, the location of the placenta had an impact only in those with a previously scarred uterus. Recurrent abortions were not associated with a higher incidence of accreta, although previous curettage was previously reported as an important risk factor for PA, in which the incidence of accreta was 36%, 58%, and 70% in those with 0, 2, and 3 previous curettages, respectively.15 Although peripartum complications were higher in PA cases, the rate of antepartum complications, however, was similar, except for hypertensive disorders. It is plausible that hypertensive disorders might be a risk factor for accreta because of the possible vascular endothelial damage in hypertension. On the other hand, placenta accreta might increase the risk for preeclampsia caused by abnormal trophoblastic invasion. Further studies are needed to test this hypothesis and conrm this association. The possible overlap between previous CS, maternal age, parity, and hypertensive disorders was accounted for using stepwise logistic regression analysis. CS and hypertensive disorders remained signicant independent of maternal age. Identifying risk factors is important because sonographic, Doppler, and magnetic resonance imaging diagnosis of placenta accreta is now possible,17-19 and in settings where these diagnostic capabilities are available, clinical risk factors may be used as screening criteria for placenta accreta. In emergency situations or in settings in which ultrasonographic diagnosis is not available, awareness of clinical risk factors can aid in careful preoperative preparation and in counselling women with placenta previa regarding the likelihood of encountering placenta accreta with its attendant morbidity as recommended by ACOG and Royal College of Obstetricians and Gynaecologists (RCOG).6,20 Compared with previa patients, cases with PA had a higher incidence of bleeding complications and a longer maternal hospital stay. Our complication rate was higher than previously reported for cases of placenta accreta in general, where only 21% required transfusion and 3.5% ended in hysterectomy.8 Both patients that

Usta et al required hysterectomy had placenta accreta (9.1%). Patients with placenta previa and scarred uterus are reported to have a 16% chance of undergoing hysterectomy for accreta compared with 3.6% risk for hysterectomy in cases of placenta previa and an unscarred uterus.1 The rate of peripartum hysterectomy is 1.0 to 1.4 per thousand of deliveries,7,15,21,22 and placenta accreta is reported as the leading15,22 or the second most common indication for peripartum hysterectomy,7 constituting 23.8% to 64% of these cases.21 In one of the reports, PA constituted 8.5% of these cases.15 Although a few reports have been published documenting dierences in risk factors between patients with previa alone compared with patients with PA,11,14 little has been mentioned about dierences in perinatal outcome. Earlier reports have shown that placenta accreta was associated with higher rates of small-for-gestational age, preterm delivery, and perinatal mortality compared with normal pregnancies. Similar to Miller et al,11 our study shows a similar gestational age at delivery, comparable birth weight, and no dierence in perinatal morbidity and mortality between placenta previa and PA patients. Our perinatal mortality rates were relatively high in both cases and controls. This could be partially attributed to including older cases dating back to 1983 before the advances in neonatal care. In fact, this is one of the limitations of the present study that could have potentially skewed our results because the prevalence of risk factors like previous CS and AMA might have changed over time. In conclusion, hypertensive disorders, smoking, and previous cesarean are risk factors for placenta accreta in previa patients. Placenta previa-accreta is associated with a higher maternal morbidity compared with isolated previa without signicant dierences in the neonatal outcome.

Acknowledgments
We would like to acknowledge Dr Hala Tamim from the Department of Epidemiology and Population Health at the American University of Beirut for her assistance in the statistical analysis.

References
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