Objective: PP is associated with myometrial damage from previous operative interventions. By itself or in association with invasive placentation represents a source of significant maternal and neonatal mortality and morbidity. We aimed to identify risk factors associated with PH in patients presenting with PP.

Methods: A retrospective cohort study to evaluate the risks factors for PH in women diagnosed with PP. This study reviewed 73,249 births at one tertiary obstetric center (2005- 11) using a computerized perinatal database. The study group included all women with PP (complete, incomplete and low-lying) > 22 weeks gestation diagnosed either during pregnancy or at birth. Placental invasion was defined by clinical or histological criteria. PH (within 24 hrs of birth) was used as a primary outcome. Statistics: descriptive, comparisons; stepwise-logistic regression for risk factors for PH.

Results: PP was identified in 106 cases (0.14%); 43.3% were central. Planned Cesarean was performed in 55.7% of cases. PH was performed in 22 (20.8%) cases. Maternal age, parity, type of PP, gestational age at delivery, type of CS and antepartum hemorrhage were not associated with an increased risk for PH. However, history of a cesarean birth ever was significantly associated with PH (p<0.00001), 82% sensitivity and 72.6%specificity and NPV of 94%. Each added birth by CS carried an additional OR for PH of 3.1 (95%CI 1.9-4.9). Interestingly, among women with PP and PH, 82.4% had sonographic characteristics of placental invasion (p<0.00001).

Conclusions: The management of women with PP and past cesarean birth oblige sonographic assessment of placental invasion and delivery in an obstetrical surgical center adequately equipped for extensive peripartum surgery.

Authors

Tehila Avitan MD, Sarit Hellman MD, Aron Tevet MD, Michael Shaya MD, Faiz Hatib MD, Boris Zuckerman MD, Arnon Samueloff MD,
Sorina Grisaru-Granovsky MD PhD, Shaare Zedek Medical Center, the Hebrew University, Jerusalem