Incidence, risk factors, and maternal outcomes of major degree placenta previa: A 10-year retrospective analysis

Mehad H. AlQasem; Ayman H. Shaamash; Deama S. Al Ghamdi; Ahmed A. Mahfouz; Mamdoh A. Eskandar

doi:10.15537/smj.2023.44.9.20230112

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Table 1

- Magnitude of placenta previa and placenta accreta spectrum in the current study.

Variables	n (%)
Total number of deliveries	54,341 (-)
Total number of C-sections	21,708 (-)
General precentage of C-sections	21,708 (39.9)
Total number of PP patients	376 (0.69)
Minor degree PP	77 (20.5)
Major degree PP	299 (79.5)
Major degree PP/number of all deliveries	299 (0.5)
Numbers of C-sections for major degree PP	299 (1.4)
Emergency hysterectomy/major PP patients	29 (9.7)
Maternal mortality/major PP patients	1 (0.3)

Values are presented as numbers and precentages (%). PP: placenta previa

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Table 2

- Maternal admission characteristics (n=299).

Variables	n (%)	Mean±SD	Range (min-max)
Age (years)
≤20	4 (1.3)	33.3±5.7	17-47
21-30	93 (31.1)
31-40	178 (59.5)
≥41	24 (8.0)
Gravidity
1-4	140 (46.8)	5.1±2.7	1-13
≥5	159 (53.2)	5.1±2.7	1-13
Parity
Nullipara	22 (7.4)	3.3±2.2	0-12
1-4	205 (68.6)
Grand multipara (≥5)	72 (24.1)
Abortions
No abortion	170 (56.9)	0.8±1.1	0-6
1-2	104 (34.8)
Recurrent (≥3)	25 (8.4)
Previous C-sections
No	115 (38.5)	1.6±1.5	0-6
1	47 (15.7)
2	53 (17.7)
3	38 (12.7)
4	32 (10.7)
5	11 (3.7)
6	3 (1.0)
Previous uterine surgery
No uterine surgery	241 (80.6)
Dilatation and curettage	43 (14.4)
Dilatation and evacuation	12 (4.0)
Suction evacuation	2 (0.7)
Myomectomy	1 (0.3)
Clinical presentation
No bleeding	61 (20.4)
Bleeding	238 (79.6)

Values are presented as numbers and precentages (%). Min: minimum, max: maximum, SD: standard deviation

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Table 3

- Placental and fetal admission characteristics (n=299).

Variables	n (%)	Mean±SD	Range (min-max)
Placental location
Posterior	180 (60.2)
Anterior	119 (39.8)
Placenta accreta spectrum (by MRI)
No PAS	208 (69.6)
Yes	91 (30.5)
Current IVF pregnancy
No	291 (97.3)
Yes	8 (2.7)
Number of fetuses
Single	296 (99.0)
Twins	3 (1.0)
Fetal status
Living/normal	282 (94.3)
IUFD	7 (2.3)
IUGR	6 (2.0)
Malformed	4 (1.4)
Fetal presentation
Cephalic	230 (76.9)
Breech	53 (17.7)
Transverse/complex	16 (5.4)
Gestational age on admission (weeks)
24-32	98 (32.8)	31.7±3.3	25-37
33-36	167 (55.9)
≥37	34 (11.4)
Gestational age on termination (weeks)
24-32	43 (14.6)
33-36	162 (53.6)	34.6±5.5	27-39
≥37	94 (31.9)

Values are presented as numbers and precentages (%).
SD: standard deviation, min: minimum, max: maximum,
MRI: magnetic resonance imaging, IVF: in vitro fertilization,
PAS: placenta accreta spectrum, IUFD: intra uterine fetal death,
IUGR: intra uterine growth restriction

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Table 4

- Hemorrhagic morbidity.

Variables	n (%)	Mean±SD	Range (min-max)
Pre-operative (admission) hemoglobin (gm/dl)
<9 gm/dl	27 (9.0)	10.9±1.5	6.5-14.3
≥9 gm/dl	272 (91.0)	10.9±1.5	6.5-14.3
Post-operative hemoglobin (gm/dl)^*
<9	13 (4.4)	10.3±1.4	6.1-13.5
≥9	285 (95.6)	10.3±1.4	6.1-13.5
Packed RBCS transfusion (units)
No	38 (12.7)	1.9±1.7	0-13
1-3	227 (75.9)
4-6	23 (7.7)
≥7	11 (3.7)
Fresh frozen plasma transfusion (units)
No	186 (62.2)	1.1±2.1	0-21
1-3	89 (29.7)
4-6	22 (7.4)
≥7	2 (7.0)

Values are presented as numbers and precentages (%).
↵* N=298 (one maternal death). SD: standard deviation, min: minimum, max: maximum, RBCS: red blood cells

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Table 5

- Major peri-operative data.

Variables	n (%)
Timing of C-sections
Planned	196 (65.6)
Emergency	103 (34.4)
Intra operative bleeding ± hysterectomy
Normal blood loss (~1000 cc)	39 (13.0)
Mild bleeding (>1000-2000 cc; only medical treatment)	145 (48.5)
Moderate bleeding (>2000-3000 cc; medical treatment±balloon tamponade/b-lynch±vessel ligation)	86 (28.8)
Heavy bleeding (>3000 cc) + hysterectomy (failed all conservative treatment)	29 (9.7)
Intra operative visceral Injury ± hysterectomy
No hysterectomy or visceral injury	264 (88.3)
Bladder injury (isolated)	5 (1.7)
Intestinal injury	1 (0.3)
Emergency hysterectomy	17 (5.7)
Emergency hysterectomy + bladder injury	10 (3.3)
Emergency hysterectomy + bladder injury + ureteric injury	2 (0.7)
Post operative hospital stay (days), mean±SD^*	3.67±2.04
≤3	231 (77.6)
4-6	48 (16.2)
≥7	19 (6.1)

Values are presented as numbers and precentages (%).
↵* N=298 (one maternal death). SD: standard deviation

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Table 6

- Incidence, risk factors, and maternal outcomes of the placenta previa/accreta spectrum in the current study and in previous Saudi studies.

Variables	Current study	Mansour et al¹⁸	Radwan et al²⁰	Abduljabbar et al¹⁹	Kassem et al²²	Bahar et al²¹	Zaki et al²³
Population city	Abha	Al-Madinah Al-Munawarah	Jeddah	Jeddah	Taif	Abha	Abha
Total deliveries	54,341	31,296	6000	55,862	29,053	42,487	23,070
C-sections	21,708 (39.9)	-----	-----	11,412 (20.3)	-----	9620 (22.6)	-----
Total PP	376 (0.69)	200 (0.64)	96 (1.6)	230 (0.41)	122 (0.42)	306 (0.73)	110 (0.48)
Major degree PP	299/376 (79.5)	-----	-----	110/230 (47.8)	80/122 (65.5)	173/306 (56.5)	110 (100)
Minor degree PP	77/376 (20.5)	-----	-----	120/230 (52.2)	42/122 (34.5)	133/306 (43.5)	-----
PAS per PP	91/299 (30.5)	82/200 (41.0)	11/96 (11.5)	-----	25/122 (20.5)	45/173 (26.0)	12/110 (11.0)
PAS per all deliveries	91 (0.16)	82 (0.26)	11 (0.18)	-----	25 (0.09)	45 (0.11)	12 (0.05)
No PAS	208/299 (69.6)	118/200 (59.0)	85/96 (88.5)	-----	97/122 (79.5)	128/173 (74.0)	98/110 (89.0)
No APH (asymptomatic)	61/299 (20.4)	-----	-----	39/230 (17.0)	-----	26/173 (15.0)	-----
Age, mean±SD or median (range)	33.3±5.7 (17-47)	34.3±6.0	32.3±5.1	>35 Y: 79 (34.0)	32.9±5.06	31 (16-48)	34±5.4
parity, mean±SD or median (range)	3.3±2.2 (0-12)	---	3.0±1.5	-----	3.7±2.52 (0-10)	4 (0-15)	4.8±3.0
Grand multipara (≥5-6)	72/299 (24.1)	42/200 (21.0)	-----	35/230 (15.3)	-----	-----	-----
Previous C-sections in PP or PAS	PP: 184/299 (61.5)	PP: 147/200 (73.5)	PP: 73/96 (75.4)	PP: 105/230 (45.7)	PP: 70/122 (57.4)PAS: 24/25 (96.0)	PP: 100/173 (57.8)	PP: 27/98 (27.5) PAS: 9/12 (75.0)
C-sections (≥3)	84/299 (28.1)	67/200 (33.5)	-----	24/230 (10.5)	30/122 (24.5)	35/173 (20.2)	5/110 (4.5)
No C-sections	115/299 (38.5)	53/200 (26.5)	23/96 (25.6)	125/230 (54.3)	52/122 (42.6)	73/173 (42.2)	74/110 (67.3)
Previous uterine surgery	58/299 (19.4)	21/200 (10.5)	-----	47 (20.4)	-----	-----	-----
Cesarean hysterectomy with PP or PAS	PP: 29/299 (9.7)	PP: 9/200 (4.5) PAS: 9/82 (11.0)	PP: 13/96 (13.5) PAS: 7/11 (63.6)	PP: 22/230 (9.6)	PP: 24/122 (19.7) PAS: 21/25 (84.0)	PP: 38/173 (22.0)	PP: 2/98 (2.0) PAS: 6/12 (50.0)
Emergency cesarean Sec.	103/299 (34.4)	184/200 (92.0)	-----	130/230 (56.5)	56/122 (45.9)	112/173 (64.7)	-----
Planned cesarean Sec.	196/299 (65.6)	16/200 (8.0)	-----	100/230 (43.5)	66/122 (54.1)	61/173 (35.3)	-----
Urologic injuries (bladder/ureteric)	19/299 (6.3)	10/200 (5.0)	4/96 (4.1)	---	12/122 (9.8)	10/173 (5.8)	-----
Blood transfusion (RBCs)	PP: 261/299 (87.5)	PP: 134/200 (67.0)	-----	PP: 26/230 (11.3)	PP: 70/122 (57.3)	Intra: 35 (20.2) Post: 93 (53.8)	PP: 18/98 (18.3) PAS: 11/12 (91.5)
Pre-term delivery (<37 weeks)	205/299 (68.5)	-----	-----	110/230 (50.0)	82/122 (67.2)	98/173 (56.6)	---
Maternal mortality by PP	1/299 (0.3)	No mortality	No mortality	-----	No mortality	No mortality	1/110 (0.9)
Postoperative hospital stay, mean±SD	3.67±2.04 ≥4 D: 67 (22.4)	-----	-----	-----	4.9±1.83 >5 D: 22 (18.0)	≥14 D: 98 (56.6)	-----

Values are presented as numbers and precentages (%). Some percentages are calculated against the total number of patients with PP or against total number of patients with PAS. PP: placenta previa, PAS: placenta accreta spectrum, APH: antepartum haemorrhage, SD: standard deviation, Sec.: section, RBCs: red blood cells, D: days, Y: years