Association of Placenta Previa With Severe Maternal Morbidity Among Patients With Placenta Accreta Spectrum Disorder

Abstract

IMPORTANCE Placenta previa is widely acknowledged as a risk factor for placenta accreta spectrum (PAS) disorders, which are severe maternal complications; however, data are limited regarding whether placenta previa is associated with a higher risk of worse maternal outcomes among patients with PAS disorders. OBJECTIVETo examine the association between placenta previa and the risk of severe maternal morbidities (SMMs) and higher resource use among patients with PAS disorders. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study extracted records of 3793 patients with PAS diagnosis and delivery indicators between October 1, 2015, and December 31, 2019, from the US National Inpatient Sample database. EXPOSURES Placenta previa. MAIN OUTCOMES AND MEASURES Data on 21 Centers for Disease Control and Preventiondefined SMMs and 25 study-defined surgical morbidities associated with PAS were extracted. Six surgical procedures (cystoscopy, intra-arterial balloon occlusion, cesarean delivery, hysterectomy, cystectomy, and oophorectomy), hospital length of stay, and inpatient costs were compared. Multivariable Poisson regression models built in the generalized estimating equation framework were used. RESULTS Among 3793 patients with PAS (median [IQR] age at admission, 33 [29-37] years), 621women (16.4%) were Black, 765 (20.2%) were Hispanic, 1779 (46.9%) were White, 441 (11.6%) were of other races and/or ethnicities (47 [1.2%] were American Indian, 220 [5.8%] were Asian or Pacific Islander, and 174 [4.6%] were of multiple or other races and/or ethnicities), and 187 (4.9%) were of unknown race and ethnicity. A total of 1323 patients (34.9%) had placenta previa and 2470 patients (65.1%) did not; of those with placenta previa, 405 patients (30.6%) had invasive PAS. Patients with vs without placenta previa had a significantly higher rate and risk of any SMM (935 women [70.7%] vs 1087 women [44.0%];

The Evolution of Management Strategies for Placenta Accreta Spectrum

“…The three main selection criteria were developed for one-step conservative surgery: (1) the absence of vesicouterine fibrosis, (2) the presence of at least 2 cm of healthy myometrium above the cervix, and (3) more than 50% of the axial uterine circumference. The second criterion, relating to patients with cervix or uterine segment involvement, was in accordance with our own study in which we identified an association between PAS complicated with placenta previa and severe maternal morbidity 16 . With 3,793 PAS cases recorded in the National Inpatient Sample Database, it is clear that we need to develop specific interventions to alleviate maternal and surgical morbidities for this particular subgroup of PAS patients.…”

“…The second criterion, relating to patients with cervix or uterine segment involvement, was in accordance with our own study in which we identified an association between PAS complicated with placenta previa and severe maternal morbidity. 16 With 3,793 PAS cases recorded in the National Inpatient Sample Database, it is clear that we need to develop specific interventions to alleviate maternal and surgical morbidities for this particular subgroup of PAS patients. With further investigation and validation, it should be possible for surgeons to stratify cases of PAS in an objective manner while also protecting fertility requirements.…”

Characteristics and treatment for severe postpartum haemorrhage in different midwifery hospitals in one district of Beijing in China: an institution-based, retrospective cohort study

“…22 In tertiary hospitals, over 75% of patients with SPPH had antenatal PPH high-risk factors, particularly PAS, which is associated with a higher risk of overall maternal and surgical morbidities. 23 PAS, first reported in 1927 with an incidence of only 0.12 in 1000 women, 24 has risen about 13-fold due to a rapidly increasing rate of CS deliveries, 25 and it may increase to 1 in 200 women by 2025. 26 With the widespread use of prenatal ultrasound examinations, most cases of PAS were recognised and referred to higher-level hospitals.…”

Efficacy and safety of prophylactic balloon occlusion in the management of placenta accreta spectrum disorder: a retrospective cohort study

“…In recent decades, the global prevalence of PAS has increased from 0.01 to 1.1% [ 2 ]. Unmanageable and catastrophic hemorrhage is the most common and serious complication of PAS since it may easily lead to hysterectomy, hemorrhagic shock, and even maternal-fetal death [ 3 , 4 ]. PAS is strongly associated with the history of cesarean section (CS) [ 5 ].…”