Introduction: Worldwide increasing cesarean section rates are expected to have a parallel increase in the number of cases of Placenta Previa with all the expected complications, including pathologically adherent placenta. This morbidly adherent placenta constitutes a serious and possibly a life threatening complication. An efficient team capable for managing possible complicated situations will be able to reduce mortality and morbidity. Objectives : The aim of o ur study was to evaluate maternal outcome in cases of Placenta Previa with and without morbidly adherent placenta. Methods : Analysis of all pregnancies complicated by antepartum hemorrhage during the period from January 2013 to September 2017 at King Abdul-Aziz University Hospital (KAUH), Jeddah, Kingdom of Saudi Arabia (KSA) was done. Cases of Placenta Previa with gestational age > 28 weeks were included. They were classified into 2 groups; Group (A) included Placenta Previa cases without morbidly adherent placenta and Group (B) included cases with morbidly adherent placenta . Maternal outcomes were recorded. Results : Placenta Previa was the leading cause of antepartum hemorrhage constituting 76.8%, out of them 52% were unbooked. Morbidly adherent placenta constituted 13.5% of total Placenta Previa cases and was diagnosed prenatally in only 1 case. Morbidity rate in placenta previa patients with adherent placenta (Group B) was higher than in placenta p r evia without adherent placenta (Group A). We considered the occurrence of intrapartum hypovolemic shock, Intensive care unit admission, surgical complications and peripartum hysterectomy as parameters for morbidity. P value for hypovolemic shock w as insignificant (P = 0.580), significant for Intensive care unit admission (P = 0.008), significant for surgical complications (P = 0.009) and significant for peripartum hysterectomy
Maternal and fetal mortality and morbidity due to Placenta Previa are considerable, and constitute too much burden on health care resources [
Surgical interference in these cases requires a competent multidisciplinary team including urologist, vascular surgeon and possibly interventional radiologist for possible selective artery embolization. An efficient team capable for managing possible complicated situations will reduce mortality and morbidity to the least possible [
The Ethical approval to conduct this work was obtained from the research ethical committee of King Abdul-Aziz University. The hospital records of all pregnancies complicated by antepartum hemorrhage during the period from January 2013to September 2017 among Saudi patients at KAUH, Jeddah, KSA, were obtained and analyzed. Cases of Placenta Previa with gestational age > 28 weeks were included. They were classified according to the reported surgical findings into 2 groups. Group (A) included Placenta Previa without morbidly adherent placenta and Group (B) including Placenta Previa with morbidly adherent placenta regardless of its type; Accreta, Increta or Percreta. Maternal outcomes we rerecorded. Results were analyzed and statistically evaluated by SPSS version 20. Significant P value < 0.05 by chi square test.
Our exclusions criteria in this study were:
• Any patients presented with bleeding before 28 weeks.
• Antepartum hemorrhage’s Patients diagnosed as accidental hemorrhage, hx of trauma or coagulopathy disorder.
Our variables used for the comparison between group A and group B were Age, Parity, Booking status, Previous c/s and Maternal outcomes (Hypovolemic shock, DIC, admission to ICU, surgical complication and Peripartum hysterectomy).
Total deliveries during the study period were 6000. Antepartum hemorrhage cases were 125 patients constituting 2.1% of admitted cases. Incidence of antepartum hemorrhage was 20.8/1000 live birth. Out of these cases, placenta Previa was the leading cause constituting 76.8% of antepartum hemorrhage cases (16/1000 live births). Cases with placenta Previa as a cause of antepartum hemorrhage were 96 constituting 76.8% of antepartum hemorrhage cases and 1.6% of total admissions during the study period. Cases with morbidly adherent placenta were 11 constituting 11.45% of placenta Previa cases, 8.8% of antepartum hemorrhage cases and 0.2% of total admissions. Only 1 out of 11 cases (9%) with morbidly adherent placenta were diagnosed preoperatively by an advanced ultrasound and Magnetic Resonance Imaging (MRI) and the rest were discovered accidently during caesarian section.
The mean age of all patients was 32.3 ± 5.1 years with a range of 20 - 44. There was no significant association between the age and the causes of antepartum hemorrhage (APH) (P = 0.278) (
Our cases were 52% booked patients and 48% unbooked, first seen during labor or emergency bleeding (
admission to intensive care as parameters for morbidity. Collectively, 36 patients out of 96 placenta Previa patients have morbidity compilations. Total number of patients who had hypovolemic shock was 7 patients. 5 of them from the patients had Placenta Previa without adherent placenta (group A). 2 of them were from the patients who had Placenta Previa with morbidly adherent placenta (group B). The P value was 0.580 indicating no statistical significance (
patients diagnosed with placenta previa with adherent placenta, 4 had surgical complications (P = 0.009). This indicates a relationship between the causes of APH and Surgical complications (
Comparison of the cases of placenta Previa with the cases of placenta previa with morbidly adherent placenta, revealed that morbidity rates were higher in cases with morbidly adherent placenta than cases with placenta Previa only. The difference between the two groups was statistically significant (P < 0.001) (
Only one case from the morbidly adherent placenta Previa cases, was diagnosed preoperatively by more professional ultrasound and confirmed by MRI (9%). Other cases were just diagnosed as placenta Previa by basic ultrasound and discovered accidently during caesarean section to be accreta, increta or percreta. Interestingly, revising this one previously diagnosed case, one of them went morbidly free but the other case had intraoperative hypovolemic shock, accidental bladder injury and postoperative admission to intensive care. Due to the small sample size, no statistical conclusion could be obtained.
Antepartum hemorrhage constitutes a major cause of maternal and fetal mortality and morbidity. In the existing study, the incidence of antepartum hemorrhage was 20.8/1000 live births. Out of these cases, placenta Previa was the leading cause constituting 76.8% of antepartum hemorrhage cases (16/1000 live births). Some studies agreed with our finding and in others, placental abruption was the leading cause [
Morbidity | Group A Placenta previa without adherent placenta | Group B Placenta previa with morbidly adherent placenta | P value* | ||
---|---|---|---|---|---|
N | % | N | % | ||
(85 cases) | 88.54% | (11 cases) | (11.46%) | ||
Hypovolemic shock | 5 | (5.88%) | 2 | (18.2%) | 0.580 |
ICU admission | 4 | (4.7%) | 3 | (27.3 %) | 0.008 |
Surgical complications | 5 | (5.88%) | 4 | (36.4%) | 0.009 |
Peripartum hysterectomy | 6 | (7%) | 7 | (63.6%) | <0.001 |
*Significance at P value < 0.05, using Chi-square Test.
prevalence rate of placenta Previa was 4.0/1000 live births [
In the present study, morbidity rates for all reported cases of placenta previa were 37.5%. This is comparable to a previous review in King Abdul-Aziz University Hospital analyzing Placenta Previa cases from the period 2001 To 2013.
They reported 11.3% cases of hypovolemic shock with massive blood transfusion and admission to the intensive care unit (ICU) and 6.5% cases of hysterectomy. Their cases were 82%unbooked patients compared to 48% in our study [
Although it is considered a rare pathology, there is a worldwide increased incidence of morbidly adherent placenta due to increasing caesarian section rates. In our study, morbidly adherent placenta was encountered in 11.46% of placenta Previa cases. This is comparable with other studies that revised 64,359 deliveries over 20 years and reported an overall incidence of placenta accreta to be 1 in 533 live births [
It is well known that cases with morbidly adherent placenta are associated with higher maternal mortality and morbidity rates. The American College of Obstetrics & Gynecology (ACOG) committee opinion on placenta accreta provides a review of literature on diagnosis and management of placenta accrete 2012 [
In our study, only 9% with morbidly adherent placenta was diagnosed prenatally by ultrasound and MRI. In a cohort study in the United Kingdom (UK) analyzing 134 cases with placenta accreta over 1 year study, 50% of these cases had been suspected by ultrasound in the antenatal period [
Our low rate of prenatal diagnosis could be explained by the fact that only 52% of these cases were booked patients and others were first in emergency labor pains and/or bleeding. Another possibility is a lack of a definite protocol during routine outpatient antenatal ultrasound to select cases that need a more professional, ultrasound or MRI especially for those with previous uterine scar and anterior placenta. Due to small number of prenatally diagnosed cases in our study (1 case), we cannot conclude whether prenatal diagnosis of morbidly adherent placenta can improve the maternal outcome and decrease complications rate. In previous studies, prenatal diagnosis decreased marked complications rate due to multidisciplinary team intervention in these cases [
The present study revealed an increase in the incidence of cases of placenta Previa with concomitant morbidly adherent placenta at King Abdul-Aziz University Hospital. Although we observed a low detection rate of this serious pathology in the prenatal period, it seems that presence of a multidisciplinary team and an available efficient blood bank counteracted the diagnostic pitfalls. A definite screening protocol during antenatal ultrasound is highly recommended to pick up suspicious cases for further confirmation by more professional ultrasound or by MRI if necessary. Whether prenatal diagnosis can further decrease morbidity rates, we cannot conclude an issue due to small number of prenatally diagnosed cases in our study and lack of precise recordings in patients’ files. Further multicenter studies are needed to evaluate this.
The authors declare no conflicts of interest regarding the publication of this paper.
Radwan, A., Abdou, A.M., Kafy, S., Sheba, M., Allam, H., Bokhari, M. and Almutairi, M. (2018) Maternal Outcome of Cases of Placenta Previa with and without Morbidly Adherent Placenta at King Abdul-Aziz University Hospital, Saudi Arabia. Open Journal of Obstetrics and Gynecology, 8, 1414-1422. https://doi.org/10.4236/ojog.2018.813142