Morbidly adherent placenta previa: Clinical course and risk from emergency delivery in a series of 26 women that underwent hysterectomy

Abstract

Objectives: A retrospective review of morbidly adherent placenta previa (MAPP) to assess its clinical course and risk from emergency delivery. Study design: Data of all placenta previa (PP) delivered in this hospital over a period of >ten years were obtained from hospital register. Results: 91 women included, 26 MAPP and 65 PP. Emergent delivery and delivery for hemorrhage were significantly lower in MAPP (p = 0.033 and 0.046 respectively). In those beyond 35 weeks, one MAPP and 16 PP needed emergent delivery (p = 0.015). MAPP who needed emergent delivery had higher rate of bleeding during pregnancy and bleeding before 32 weeks (p= 0.034 and 0.01 respectively). Complications rate in MAPP were similar in emergency and elective delivery but for postoperative hospital stay (p = 0.042). All neonates delivered at ≤ 34 weeks and two out of six delivered at 35-36 weeks and admitted to NICU. Conclusion: The authors conclude that in this study group majority of MAPP were stable and emergent deliveries had more frequent history of bleeding before 32 weeks. Timing of delivery should take into consideration history of bleeding and availability of NICU resources in stable patients.

Full text

Introduction
Placenta previa (PP) and morbidly adherent placenta pre-
via (MAPP) (accreta, increta, and percreta) are high-risk
obstetric problems that are on the increase globally, with
the rising incidence of its main risk factor: repeat cesarean
section (CS) [1-3]. PP is a known risk factor for preterm
delivery. Causes for preterm delivery in PP include emer-
gency delivery for acute hemorrhage, onset of preterm
labor, and planned preterm delivery [4]. Major part of pa-
tients with PP is stable and pregnancy can be carried safely
to 37 weeks of gestation or more before delivery [5]. MAPP
has high maternal morbidity and mortality due to compli-
cated surgical procedures, severe hemorrhage, and massive
blood transfusion [6,7]. There is consensus to deliver
MAPP earlier. To reduce risk of emergency delivery inves-
tigators as Belfort et al. and Robinson et al. recommended
delivery at 34-35 weeks [8, 9]. Official bodies as Royal
College of Obstetricians and Gynaecologists (RCOG) rec-
ommend delivery before 36-37 and The American College
of Obstetricians and Gynecologists (ACOG) at 34-36
weeks [10, 11]. Elective cesarean delivery at early term or
late preterm is associated with increased admission to
neonatal intensive care units (NICU), and infant death
among others [12-14]. The present authors’ aim was to re-
view clinical course of pregnancy in patients with MAPP
that delivered in this hospital to assess if MAPP is as stable
as PP, and effect of emergency delivery on maternal out-
come. This may help in future planning of delivery of
MAPP in a matter that may improve neonatal outcome, es-
pecially in areas with limited neonatal care resources with-
out inflicting extra harm to the mother who is likely to
undergo hysterectomy.
Materials and Methods
A retrospective observational study was approved by the Insti-
tutional Review Board (IRB) of Jordan University of Science and
Technology and conducted at King Abdullah University Hospital
(KAUH) in north of Jordan. A search of the hospital registry for
all patients who underwent CS / hysterectomy for PP/MAPP dur-
ing the period from March 2003 to October 2013 was undertaken.
KAUH is a tertiary referral center for other peripheral and central
hospitals in the area with total number of deliveries over the same
period of just over 22,000. The department policy requires that
all women with potential risk of MAPP are counseled regarding
the risk related to MAPP and the need for hysterectomy and an in-
formed consent form signed. Planned delivery of patients with ul-
trasound diagnosis of MAPP is after completed 35 weeks. Stable
PP is routinely delivered after 37 weeks. Women at risk of emer-
gent delivery and those planned to be delivered at 35-36 weeks re-
ceived antenatal corticosteroids. Delivery involves multi-
disciplinary team with two consultant obstetricians to perform the
cesarean hysterectomy. Blood bank notified with sufficient
amount of PRBC and FFP are readily available. Uterine artery
Revised manuscript accepted for publication November 4, 2015
Summary
Objectives: A retrospective review of morbidly adherent placenta previa (MAPP) to assess its clinical course and risk from emergency
delivery. Study design: Data of all placenta previa (PP) delivered in this hospital over a period of >ten years were obtained from hos-
pital register. Results: 91 women included, 26 MAPP and 65 PP. Emergent delivery and delivery for hemorrhage were significantly lower
in MAPP (p = 0.033 and 0.046 respectively). In those beyond 35 weeks, one MAPP and 16 PP needed emergent delivery (p = 0.015).
MAPP who needed emergent delivery had higher rate of bleeding during pregnancy and bleeding before 32 weeks (p= 0.034 and 0.01
respectively). Complications rate in MAPP were similar in emergency and elective delivery but for postoperative hospital stay (p=
0.042). All neonates delivered at ≤ 34 weeks and two out of six delivered at 35-36 weeks and admitted to NICU. Conclusion: The au-
thors conclude that in this study group majority of MAPP were stable and emergent deliveries had more frequent history of bleeding
before 32 weeks. Timing of delivery should take into consideration history of bleeding and availability of NICU resources in stable pa-
tients.
Key words: Morbidly adherent placenta previa; Placenta previa; Late preterm delivery; Perinatal outcome.
Morbidly adherent placenta previa:
clinical course and risk from emergency delivery
in a series of 26 women that underwent hysterectomy
H. Alchalabi1, Y.S. Khader2, I. Lataifeh1, B. Obeidat1, F. Zayed1, W. Khriesat3, N. Obeidat1
1 Department of Obstetrics and Gynecology, 2 Department of Public Health, Community Medicine and Family Medicine,
3 Department of Pediatrics, Faculty of Medicine, Jordan University of Science and Technology, Irbid (Jordan)
CEOG Clinical and Experimental
Obstetrics & Gynecology
7847050 Canada Inc.
www.irog.net
Clin. Exp. Obstet. Gynecol. - ISSN: 0390-6663
XLIV, n. 4, 2017
doi: 10.12891/ceog3429.2017

H. Alchalabi, Y.S. Khader, I. Lataifeh, B. Obeidat, F. Zayed, W. Khriesat, N. Obeidat
catheterization and embolization used in some patients where at-
tempt to conserve the uterus is planned. In addition to well-trained
obstetric and anesthetic resident team to start emergency care, a
team of two consultant obstetricians is readily available for emer-
gency delivery with easy access to all the required assistance. De-
mographic data and antenatal course were obtained from the
records. Gestational age was calculated through accurate dating
and early ultrasound. The operative notes were carefully searched
for indication of delivery, procedure performed, type of resusci-
tation, and number of PRBC and FFP units the patient received.
Admission to ICU and cause were recorded. Neonatal outcome at
time of delivery including Apgar score at five minutes, birth
weight, and admission to NICU were obtained. Further details re-
garding neonatal course, surfactant, days in NICU, and outcome
were obtained from neonates medical records.
The Statistical Package for Social Sciences software was used
to analyze the data. Data were described using means and per-
centages. Differences between percentages were analyzed using
Chi-square test or Fisher’s exact test wherever appropriate. Dif-
ferences between two means were analyzed using independent t-
test. A p-value less than 0.05 was considered statistically
significant.
Results
A total of 91 patients were included (26 MAPP, all had
previous cesarean scar all underwent hysterectomy and 65
patients with PP used as control were all delivered by CS
apart from two that underwent hysterectomy). None of
these women had significant medical illness. The mean age
for women with MAPP was 34.9 (5.1) years, their mean
parity was four (1.6), and number of previous CS was 2.8
(1.5). The mean gestational age at delivery was 35.7 weeks,
the earliest was 26+6 weeks, 13 patients were at 37 weeks,
and one patient went beyond 38 weeks
Table 1 depicts the clinical course of pregnancy in MAPP
compared to those with PP. The mean gestational age at de-
livery was similar. The rate of bleeding during pregnancy
was not significantly different (p = 0.687) and so was the
onset of bleeding before 32 weeks gestation (p = 0.846).
Emergency deliveries were significantly higher in the PP
43.1% versus 19.2% (p= 0.033) also emergency delivery
because of hemorrhage (29.2%) in PP versus 7.7% (p =
0.046). Three patients in MAPP delivered because of labor
pain compared to nine in PP (p = 0.789). Scar dehiscence
was reported in one patient and ballooned thin lower seg-
ment in another MAPP in labor. Twenty-two out of 26 with
MAPP and 53 out of 65 with PP were delivered after com-
plete 35 weeks of gestation (84.6% and 81.5% respec-
tively). In women who went beyond 35 weeks, only one
(4.5%) in the MAPP needed emergency delivery versus 16
(30.2%) in the PP (p = 0.015). The rate of small for gesta-
tional age babies was similar in both groups.
Table 2 shows the maternal characteristics and outcomes
of women with MAPP in timed and emergency delivery.
The two groups differed significantly in the incidence of
Table 2. — Maternal characteristics and outcomes of
women with MAPP according to type of delivery.
Delivery pvalue
Timed Emergency
n = 21 n = 5
Age (years), mean (SD) 35.0 5.7 34.8 1.8 0.954
Parity, mean (SD) 4.2 1.4 3.0 1.9 0.128
Previous C/S, mean (SD) 3.0 1.5 2.0 1.6 0.177
Bleeding during pregnancy, n. (%) 6 28.6 4 80 0.034
Bleeding < 32 weeks gestation, n. (%)
2 9.5 3 60 0.010
FF plasma, mean (SD) 7.0 8.1 4.2 4.6 0.477
PRBC, mean (SD) 8.0 6.7 5.8 2.5 0.494
Bladder injury, n. (%) 5 23.8 1 20.0 0.682
ICU admission, n. (%) 5 23.8 1 20.0 0.682
DIC, n. (%) 2 9.5 0 .0 0.829
Length of stay in hospital post-
operatively (days), mean (SD) 5.1 2.1 8.0 4.6 0.042
Table 3. — Perinatal outcome in women with morbidly ad-
herent placenta previa delivered electively according to
gestational age at delivery.
35-36 weeks ≥ 37 weeks Total
n = 8 n = 14 n = 25
Apgar score at 5 min., 9.0 8.8 8.7
mean (SD) (0.8) (0.6) (0.8)
Birth weight (grams), 2755 2990 2675.7
mean (SD) (428.1) (428.1) (688.6)
Admission to NICU, 2 2 7
n. (%) (25) (14.3) (28.0)
Surfactant, 1 1 4
n. (%) (12.5) (7.1) (16)
Neonatal deaths, 0 1 3
n. (%) (0) (7.1)* (12)
NICU days, 8.5 16.5 13.3
mean (SD) (0.7) (14.8) (7.0)
* Delivered at 37 weeks, had omphalocele and low birth weight, developed
RDS, and died at 27 days because of infection.
Table 1. — Antenatal course of women with placenta pre-
via and those with morbidly adherent placenta previa.
PP MAPP pvalue
Number 65 26
Gestional age at delivery, mean (SD) 36.3 (1.9) 35.7 (2.6) 0.275
Bleeding during pregnancy, n. (%) 28 (43.1) 10 (38.5) 0.687
Gestional age at bleeding, n. (%) 0.846
< 32 weeks 15 (53.6) 5 (50.0)
≥ 32 weeks 13 (46.4) 5 (50.0)
Delivery type, no (%) 0.033
Timed 37 (56.9) 21(80.8)
Emergency 28 (43.1) 5 (19.2)
Delivery because of bleeding, n. (%) 17 (26.2) 2 (7.7) 0.046
Emergency delivery ≥ 35 weeks, n. (%)a
16 (30.2) 1 (4.5) 0.015
Birth weight <10th centile, n. (%) 59 (7.9) 4 (15.9) 0.275
MAPP = morbidly adherent placenta previa. PP = placenta previa.
a Calculation made from number of patients delivered after 35 gestional weeks
(53 for PP and 22 for MAPP).
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Morbidly adherent placenta previa: clinical course and risk from emergency delivery in a series of 26 women that underwent hysterectomy
bleeding during pregnancy, bleeding before 32 weeks, and
postoperative hospital stay. Four women (80%) in the emer-
gency delivery had bleeding during pregnancy versus six
(28.6%) in the timed delivery (p = 0.034). Also, women
who needed emergency delivery had more frequent history
of bleeding before 32 weeks than in timed delivery (60%
and 9.5% respectively (p = 0.010). Intrapartum complica-
tions and transfusion of PRBC and FFP were not signifi-
cantly different between emergency and timed delivery and
so was admission to ICU, but the average stay in hospital
after delivery was longer in the emergency group (p =
0.042). One women died in the timed delivery group on the
second day after delivery because of sever DIC and multi-
organ failure
Five babies delivered as emergency with a gestational
age range of 26+6 to 35+6 weeks. Table 3 shows neonatal
outcomes in relation to gestational age. Four neonates were
delivered as emergency at ≤ 34 weeks one at 26+6 weeks
gestation which did not respond to resuscitation, and the
other three (100%) admitted to NICU all needed surfactant
and there was one neonatal death because of RDS. Two out
of the eight delivered at 35-36 weeks gestation and two of
the 14 delivered at ≥ 37 weeks needed admission to NICU
(25% and 14.3%, respectively). Of the two 35-36 weeks
neonates, only one needed surfactant and there was no
neonatal death, while one neonatal death was reported in
37 weeks and over group (duodenal atresia died after 27
days). Average stay in the NICU for all groups was
14.3(1.5), 8.5(0.7), and 16.5(14.8) days, respectively.
Discussion
MAPP is on the rise globally. Knowing the antenatal
course of this problem as compared to PP may help to op-
timize timing of delivery. In the present study groups,
MAPP and PP were similar in the incidence of bleeding
during pregnancy and also bleeding before 32 weeks ges-
tation. MAPP had less emergency deliveries than PP (p =
0.033) and less emergency delivery because of bleeding (p
= 0.046). Patients with MAPP in whom pregnancy contin-
ued beyond 35 weeks had significantly less risk of emer-
gency delivery than PP of same gestational age as only
4.5% MAPP had emergency delivery compared to 30.2% in
PP (p = 0.015) (Table 1); this seems to disagree with find-
ings by Warshak et al. with a higher rate of bleeding after
36 weeks [15]. There was no significant difference in small
for gestational age in both groups. Ananth et al. [16] con-
cluded that low birth weight in PP is mainly due to prema-
turity and it seems that the same conclusion applies to
MAPP. These findings suggest that MAPP can be stable in
majority of women.
Five patients in the MAPP needed emergency delivery
Table 2. These patients had more frequent history of bleed-
ing during pregnancy than patients who had timed delivery
(p = 0.034). They also had more frequent history of bleed-
ing at < 32 weeks gestation where three out of five patients
had history of bleeding before 32 weeks (p = 0.046). This
agrees with Fishman et al. finding that bleeding before 32
weeks is a risk factor for preterm delivery in MAPP [17].
Bladder injury rate was similar in timed and emergency de-
livery. There was no increase in the amount of blood trans-
fusion in the emergency group unlike findings by others
[15]. Patients who had emergency delivery had longer hos-
pital stay after delivery. Though the numbers are too small
to draw firm conclusions, these findings however suggest
that emergency delivery of MAPP in a properly equipped
center is not necessarily associated with increased risk of
maternal morbidity, similar to findings by Eller et al. [6].
Neonatal outcome in Table 3 shows that babies born at 35-
36 weeks, although had higher admission to NICU than
those delivered at 37 weeks and over, but there was less use
of surfactant and no neonatal mortality as compared to
those delivered at ≥ 34 weeks. No conclusions could be
drawn from these small figures but probably supports the
suggestion by Zlatnic et al. of delivery at 36 weeks and two
days after steroid in stable PP [18]. Fourteen patients out
of 26 with MAPP completed 37 weeks and over of preg-
nancy and all delivered electively; this raises the issue of
the neonatal benefit versus maternal risk from waiting to
term in areas with limited NIC resources.
In the management of MAPP, many questions remain
unanswered. Of these among many others, what is the opti-
mum time for delivery? Should this timing be the same for
all populations irrespective of availability of NICU services
if patients are stable? The weakness of this study is its small
sample size and being a retrospective review. This makes
its power of strength low and many of the numbers in neona-
tal outcome too small for statistical significance.
The authors conclude that large proportion of MAPP in
this study were stable. Timing of delivery should take into
consideration history of bleeding. In stable patients,
planned late preterm delivery should be re-evaluated in
areas with limited NICU resources.
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Corresponding Author:
H. ALCHALABI, M.D.
Department of Obstetrics and Gynecology
Faculty of Medicine
Jordan University of Science and Technology
P.O.B. 3030, Irbid 22110 (Jordan)
e-mail: halchalabi@yahoo.com
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