Epidemiology of placenta previa accreta: a systematic review and meta-analysis

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Abstract

Objective

To estimate the prevalence and incidence of placenta previa complicated by placenta accreta spectrum (PAS) and to examine the different criteria being used for the diagnosis.

Design

Systematic review and meta-analysis.

Data sources

PubMed, Google Scholar, ClinicalTrials.gov and MEDLINE were searched between August 1982 and September 2018.

Eligibility criteria

Studies reporting on placenta previa complicated by PAS diagnosed in a defined obstetric population.

Data extraction and synthesis

Two independent reviewers performed the data extraction using a predefined protocol and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies, with difference agreed by consensus. The primary outcomes were overall prevalence of placenta previa, incidence of PAS according to the type of placenta previa and the reported clinical outcomes, including the number of peripartum hysterectomies and direct maternal mortality. The secondary outcomes included the criteria used for the prenatal ultrasound diagnosis of placenta previa and the criteria used to diagnose and grade PAS at birth.

Results

A total of 258 articles were reviewed and 13 retrospective and 7 prospective studies were included in the analysis, which reported on 587 women with placenta previa and PAS. The meta-analysis indicated a significant (p<0.001) heterogeneity between study estimates for the prevalence of placenta previa, the prevalence of placenta previa with PAS and the incidence of PAS in the placenta previa cohort. The median prevalence of placenta previa was 0.56% (IQR 0.39–1.24) whereas the median prevalence of placenta previa with PAS was 0.07% (IQR 0.05–0.16). The incidence of PAS in women with a placenta previa was 11.10% (IQR 7.65–17.35).

Conclusions

The high heterogeneity in qualitative and diagnostic data between studies emphasises the need to implement standardised protocols for the diagnoses of both placenta previa and PAS, including the type of placenta previa and grade of villous invasiveness.

PROSPERO registration number

CRD42017068589

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Most cited references 57

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Maternal morbidity associated with multiple repeat cesarean deliveries.

Robert M Silver, Mark Landon, Dwight J Rouse … (2006)

Although repeat cesarean deliveries often are associated with serious morbidity, they account for only a portion of abdominal deliveries and are overlooked when evaluating morbidity. Our objective was to estimate the magnitude of increased maternal morbidity associated with increasing number of cesarean deliveries. Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999-2002). There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively. Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery. II-2.

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Abnormal placentation: twenty-year analysis.

Serena Wu, Masha Kocherginsky, Judith U Hibbard (2005)

This study was undertaken to determine whether the rate of abnormal placentation is increasing in conjunction with the cesarean rate and to evaluate incidence, risk factors, and outcomes. Cases from 1982-2002 were identified by histopathologic or strong clinical criteria. Risk factors were assessed in a matched case-control study, and analyzed using conditional logistic regression models. There were 64,359 deliveries, with cesarean rates increasing from 12.5% (1982) to 23.5% (2002). The overall incidence of placenta accreta was 1 in 533. Significant risk factors for placenta accreta in our final analysis included advancing maternal age (odds ratio [OR] 1.13, 95% CI 1.089-1.194, P < .0001), 2 or more cesarean deliveries (OR 8.6, 95% CI 3.536-21.078, P < .0001), and previa (OR 51.4, 95% CI: 10.646-248.390, P < .0001). The rate of placenta accreta increased in conjunction with cesarean deliveries; the most important risk factors were previous cesarean delivery, previa, and advanced maternal age.

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Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging

Eric Jauniaux, Sally Collins, Graham J. Burton (2018)

Placenta accreta spectrum is a complex obstetric complication associated with high maternal morbidity. It is a relatively new disorder of placentation, and is the consequence of damage to the endometrium-myometrial interface of the uterine wall. When first described 80 years ago, it mainly occurred after manual removal of the placenta, uterine curettage, or endometritis. Superficial damage leads primarily to an abnormally adherent placenta, and is diagnosed as the complete or partial absence of the decidua on histology. Today, the main cause of placenta accreta spectrum is uterine surgery and, in particular, uterine scar secondary to cesarean delivery. In the absence of endometrial reepithelialization of the scar area the trophoblast and villous tissue can invade deeply within the myometrium, including its circulation, and reach the surrounding pelvic organs. The cellular changes in the trophoblast observed in placenta accreta spectrum are probably secondary to the unusual myometrial environment in which it develops, and not a primary defect of trophoblast biology leading to excessive invasion of the myometrium. Placenta accreta spectrum was separated by pathologists into 3 categories: placenta creta when the villi simply adhere to the myometrium, placenta increta when the villi invade the myometrium, and placenta percreta where the villi invade the full thickness of the myometrium. Several prenatal ultrasound signs of placenta accreta spectrum were reported over the last 35 years, principally the disappearance of the normal uteroplacental interface (clear zone), extreme thinning of the underlying myometrium, and vascular changes within the placenta (lacunae) and placental bed (hypervascularity). The pathophysiological basis of these signs is due to permanent damage of the uterine wall as far as the serosa, with placental tissue reaching the deep uterine circulation. Adherent and invasive placentation may coexist in the same placental bed and evolve with advancing gestation. This may explain why no single, or set combination of, ultrasound sign(s) was found to be specific for the depth of abnormal placentation, and accurate for the differential diagnosis between adherent and invasive placentation. Correlation of pathological and clinical findings with prenatal imaging is essential to improve screening, diagnosis, and management of placenta accreta spectrum, and standardized protocols need to be developed.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open

Journal ID (iso-abbrev): BMJ Open

Journal ID (hwp): bmjopen

Journal ID (publisher-id): bmjopen

Title: BMJ Open

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2044-6055

Publication date Collection: 2019

Publication date (Electronic): 12 November 2019

Volume: 9

Issue: 11

Electronic Location Identifier: e031193

Affiliations

[1 ] departmentEGA Institute for Women Health , UCL , London, UK

[2 ] departmentDepartment of Obstetrics, Rigshospitalet , University of Copenhagen , Kobenhavns, Denmark

[3 ] departmentPrimary Care and Public Health Sciences , King's College London , London, UK

[4 ] departmentDepartement of Obstetrics , Rigshospitalet , University of Copenhagen, Kobenhavn, Denmark

[5 ] departmentNuffield Department of Women’s and Reproductive Health , University of Oxford , Oxford, UK

Author notes

[Correspondence to ] Professor Eric Jauniaux; e.jauniaux@ 123456ucl.ac.uk

Author information

Eric Jauniaux http://orcid.org/0000-0003-0925-7737

Catey Bunce http://orcid.org/0000-0002-0935-3713

Article

Publisher ID: bmjopen-2019-031193

DOI: 10.1136/bmjopen-2019-031193

PMC ID: 6858111

PubMed ID: 31722942

SO-VID: 0076ea80-b67d-4668-a6e7-55415c9f6e75

License:

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

History

Date received : 21 April 2019

Date revision received : 04 October 2019

Date accepted : 16 October 2019

Custom metadata

special-feature unlocked

ScienceOpen disciplines: Medicine

Keywords: placenta accreta spectrum,prevalence,incidence,low-lying placenta,placenta previa

Data availability:

ScienceOpen disciplines: Medicine

Keywords: placenta accreta spectrum, prevalence, incidence, low-lying placenta, placenta previa

Epidemiology of placenta previa accreta: a systematic review and meta-analysis

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Abstract

Objective

Design

Data sources

Eligibility criteria

Data extraction and synthesis

Results

Conclusions

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Related collections

UCL: UN SDG 03 Good Health and Well-Being

Most cited references 57

Maternal morbidity associated with multiple repeat cesarean deliveries.

Abnormal placentation: twenty-year analysis.

Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging

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