Abstract
Background:
The nature of placenta previa can be unpredictable and harsh on the mother and baby. These complications are often unpredictable, unpreventable and often leave the labour ward team in a dilemma. This Obstetricians' nightmare is fortunately a rare complication. The frequency of placenta previa at the time of delivery average 1/200 births i.e. 0.5%. Placenta previa is still an important cause of maternal and fetal death in our country. The risk factors are Advanced Maternal age, Multi parity, Previous Cesarean Section, Multiple gestation, Previous Abortions, Previous intrauterine surgery, placenta previa in previous pregnancy, Smoking.
Objective:
Identification of risk factors, the feto-maternal outcome and complications of patients having placenta previa with previous caesarean section.
Methodology:
This cross sectional study was conducted from July 2012 to June 2015 in Obstetrics and Gynaecology department, Dhaka Medical College hospital. 100 patients of placenta previa were included in this study. Non-probability purposive sampling method was used for selection of patients.
Results:
In this study, Socio-demographic profiles, Identification of risk factors, the feto-maternal outcome and complications of patients having placenta previa were assessed. The frequency of placenta previa associated with previous cesarean section was 61%. In demographic profiles of the patients in this study - with a history of previous caesarean section, 78.7% patients were in the age group 26-35. Multiparity was predominant on scarred uterus group (63.9%). Here, demonstrated that > 2 previous history of caesarean section was associated with 80.3% of placenta previa. Regarding maternal outcome, complications like massive haemorrhage, ureteral injury, bladder injury, wound infection, DIC, maternal and perinatal mortality were more in the scarred patients than in the unscarred patients. In our study, 29.5% of morbid adhesion of placenta observed in scarred uterus.
Conclusions:
There is significant association of placenta previa with previous cesarean delivery. So, Careful monitoring of high risk pregnancies is of utmost importance. Avoidance of unnecessary caesarean sections and early week’s pregnancy terminations can minimize the Obstetricians' nightmare.
Author Contributions
Academic Editor: Qiuqin Tang, Obstetrics and Gynecology Hospital Affiliated to Nanjing Medical University
Checked for plagiarism: Yes
Review by: Single-blind
Copyright © 2017 Mazumder U, et al.
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Competing interests
The authors have declared that no competing interests exist.
Citation:
Introduction
The nature of placenta previa can be unpredictable and harsh on the mother and baby. These complications are often unpredictable, unpreventable and often leave the labour ward team in a dilemma. Nobody likes to be in the 'red' whether it is the bank account or in exam result. Similarly in obstetrics, doctors do not enjoy seeing abnormal vaginal bleeding in the antenatal period. Nerve wrecking decisions have to be taken depending on the severity. This Obstetricians' nightmare is fortunately a rare complication. 2 -5% of all pregnancies, approximately one-third are due to placenta previa. The frequency of placenta previa at the time of delivery average 1/200 births i.e. 0.5%. Placenta previa is still an important cause of maternal and fetal death in our country. The risk factors are Advanced Maternal age, Multiparity, Previous Cesarean Section, Multiple gestation, Previous Abortions, Previous intrauterine surgery, PP (placenta previa) in previous pregnancy, Smoking.
The Aim of the Present Study:
Identification of risk factors, the feto-maternal outcome and complications of patients having placenta previa with previous caesarean section.
Materials & Method
This cross sectional study was conducted from July 2012 to June 2015 in Obstetrics and Gynaecology department, Dhaka Medical College hospital. 100 patients of placenta previa were included in this study. It was non-probability purposive sampling method.
The diagnosis of placenta previa for this study was based on sonographic diagnosis during the third trimester at 28 wks gestation or more. Furthermore the diagnosis was confirmed by direct inspection of placental location at the time of caesarean section. The exclusion criteria were incomplete medical records, uncertain gestational age, and placental abruption.
After selection of patients, two groups were made.
Group A - Patients of placenta previa with history of previous caesarean delivery (Scarred Uterus)
Group B (Control)-Patients of placenta previa without history of previous caesarean delivery (Unscarred Uterus)-
Discussion
Placenta praevia is a major cause of morbidity and mortality in both the developed and developing countries like Bangladesh. The present study showed a strong association of placenta praevia with cesarean section. The frequency of placenta praevia with previous cesarean section came out 61% which is very high (Table 1), that is clearly consistent with other renowned studies regarding this topic. 1
Similar results were also obtained in a study during the period of 1977-1983 in Loss Angeles hospital series 2. These investigators found the incidence of placenta praevia to be 9.8 per 1000 among women with previous cesarean delivery and 2.6 per 1000 among women without such a history.
Table 1. Incidence of placenta previa(n=100)| Stages | Frequency | Percentage | P Value |
| Group A(Scarred Uterus) | 61 | 61% | <0.05 |
| Group B(Unscarred Uterus) | 39 | 39% | |
| Total | 100 |
| Parameters | Group A scarred Uterus(n=61) No.(%) | Group B Unscarred Uterus(n=39) No.(%) | P value |
| Age Group(years) | |||
| 16-25 | 11(18.0%) | 11(28.2%) | |
| 26-35 | 48(78.7%) | 27(69.2%) | 0.992ns |
| 36-45 | 02(3.3%) | 01(2.6%) | |
| Mean±SD | 28.16±3.96 | 28.15±6.12 | |
| Parity | |||
| Nulliparous | 00(00%) | 07(17.9%) | |
| 1-4 para | 39(63.9%) | 22(56.4%) | 0.164ns |
| >5 para | 22(36.1%) | 10(25.6%) | |
| Socio economic status | |||
| Low | 28(45.9%) | 17(17.9%) | |
| Middle | 22(36.1%) | 12(25.6%) | 0.463ns |
| Upper Middle | 11(57.4%) | 10(56.4%) | |
| Educational Status | |||
| Illiteracy | 5(8.2%) | 2(5.1%) | |
| Primary | 17(27.9%) | 14(35.9%) | |
| SSC | 21(34.4%) | 14(35.9%) | 0.597ns |
| HSC | 17(27.9%) | 7(17.9%) | |
| Graduate | 1(1.6%) | 2(5.1%) | |
| Parameters | Group A (Scarred Uterus) | Group B (Unscarred) | P value | |
|---|---|---|---|---|
| (n=61) | (n=39) | |||
| No. (%) | No. (%) | |||
| Antenatal Check Up Regular | 32 (52.5%) | 22 (56.4%) | 0.699NS | |
| Irregular | 29 (47.5%) | 17 (43.6%) | ||
| Gestational weeks | ||||
| <30 | 3(4.9%) | 5(12.8%) | ||
| 31-34 | 11(18.0%) | 5(12.8%) | 0.313ns | |
| 35-37 | 28(45.9%) | 21(53.8%) | ||
| <37 | 19(31.1%) | 8(20.5%) | ||
| Mean±SD | 35.87±2.55 | 35.21±3.08 | ||
| Location of Placenta | ||||
| Anterior | 32 (52.5%) | 22 (56.4%) | 0.699NS | |
| posterior | 29 (47.5%) | 17 (43.6%) | ||
| Total | 61 (100%) | 39 (100%) | ||
| Number of caesarean section | Group A (Scarred Uterus) | Percentage (%) | P value |
|---|---|---|---|
| (n=61) | |||
| No. (%) | |||
| Previous One | 12 | 19.70% | <0.05 |
| Previous Two | 33 | 54.10% | |
| Previous Three | 16 | 26.20% |
| Parameters | Group A (Scarred Uterus) | Group B (Unscarred) | P value |
|---|---|---|---|
| (n=61) | (n=39) | ||
| No. (%) | No. (%) | ||
| Previous abortion (Spontaneous/ Induced) | NS | ||
| Present | 12 | 19 | |
| Absent | 33 | 5 | |
| H/O previous Placenta Previa | NS | ||
| Present | 12 | 19 | |
| Absent | 33 | 5 |
| Parameters | Group A ( Scarred ) (n=61) No. (%) | Group B (Unscarred) (n=39) No. (%) | p value |
| Massive obstetric haemorrhage | 42(68.9%) | 23(59.0%) | 0.312ns |
| Bladder injury | 27(44.3%) | 14(35.9%) | 0.407ns |
| Ureteral injury | 3(4.9%) | 1(2.6%) | 0.558ns |
| Parameter | Group A (Scarred Uterus) | Percentage (%) | P value |
|---|---|---|---|
| (n=61) | |||
| No. (%) | |||
| P. Accreta | 12 | 19.70% | <0.05 |
| P. Increta | 33 | 54.10% | |
| P. Percreta | 16 | 26.20% | |
| Total | 61 | 100% |
| Foetal outcome | Group A (Scarred Uterus) (n=61) No. (%) | Group B (Unscarred Uterus) (n=39) No. (%) | p value |
| Preterm | 23(37.7%) | 20(51.3%) | 0.181ns |
| Low birth weight | 24(39.3%) | 19(48.7%) | 0.256ns |
If we look at the demographic profiles of the patients in this study - with a history of previous caesarean section, 78.7% patients were in the age group 26-35. Similar results were found by Tuzović et al.3. Sclerotic changes in the intramyometrial arteries with increasing age may contribute to placenta previa by reducing blood supply in the placenta. Moreover Hasegawa et al4. have mentioned that advanced maternal age is an independent risk factor of massive hemorrhage during cesarean section in women with placenta previa.
Multiparity was predominant on scarred uterus group (63.9%). It has been mentioned as a risk factor by previous studies 5, 3. No significant associations of placenta previa with socio-economic status or religion have been found in this study. Usta et al 6 have demonstrated parallel results.
In addition our study has also demonstrated that previous history of abortions was associated with placenta previa. 54.1% cases of the scarred group & 48.7% of the unscarred group had history of abortion previously. Johnson et al 7) and Hendricks et al8 also found similar results.
Regarding maternal outcome, complications like massive haemorrhage, ureteral injury, bladder injury were more in the scarred patients than in the unscarred patients. In our study, 54.1% were P. accreta type. Another study carried out in Jordan University of science and technology shows that placenta praevia is higher among gravida >4, para >3 and previous caesarean section and no increased in incidence of placenta praevia with increasing maternal age and previous abortion 9
Conclusion
The nature of placenta previa can be unpredictable and harsh on the mother and baby. It is concluded that there is significant association of placenta previa with previous cesarean delivery. Also It demonstrates the feto-maternal outcome and complications associated with placeta previa.
So, Careful monitoring of high risk pregnancies is of utmost importance. Avoidance of unnecessary caesarean sections and early week’s pregnancy terminations can minimize the Obstetricians' nightmare.
References
- 1.Dashe J S, McIntire D D, Ramus R M, Santos-Ramos R, Twickler D M. (2002) Persistence of placenta previa according to gestational age at ultrasound detection. , Obstet Gynecol 99, 692-697.
- 2.Clark S L, Koonings P P, Phelan J P. (1985) Placenta previa/accreta and prior cesarean section. , Obstet Gynecol 66, 89-92.
- 3.Tuzović L, Djelmis J, Ilijić M.Obstetric risk factors associated with placenta previa development: case-control study. , Croatian Medical Journal.2003Dec; 44(6), 728-33.
- 4.Hasegawa J, Matsuoka R, Ichizuka K, Mimura T, Sekizawa A et al.Predisposing factors for massive hemorrhage during Cesarean section in patients with placenta previa.UltrasoundObstetGynecol.2009Jul;34(1): 80-4.15.Usta IM,Hobeika EM,Musa AA,Gabriel GE,Nassar AH.Placenta previa-accreta:risk factors and complications.Am J Obstet Gynecol.2005Sep;193(3Pt2):. 1045-9.
- 5.Gilliam M, Rosenberg D, Davis F. (2002) The likelihood of placenta previa with greater number of cesarean deliveries and higher parity. , ObstetGynecol 99, 976-80.
- 6.Usta I M, Hobeika E M, Musa A A, Gabriel G E, Nassar A H.Placenta previa-accreta: risk factors and complications. , Am J Obstet Gynecol.2005Sep;193(3Pt2): 1045-9.
- 7.Johnson L G, Mueller B A, Daling J R.The relationship of placenta previa and history of induced abortion. , Int J Gynaecol Obstet.2003May; 81(2), 191-8.