European Scientific Journal May 2018 edition Vol.14, No.

15 ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431

Statistical Data About Risk Factors and Pregnancy

Outcome of Placenta Previa

Kashami Arian (MD. PhD Candidate)

Troshani Amela (MD)
University Hospital of Obstetrics and Gynecology
“Koço Gliozheni”, Tirana, Albania
Shabani Zamira (MD. PhD. Prof. Assoc)
University of Shkodra “Luigj Gurakuqi”,
Faculty of Natural of Sciences, Shkoder, Albania

Doi: 10.19044/esj.2018.v14n15p27 URL:http://dx.doi.org/10.19044/esj.2018.v14n15p27

Abstract
Placenta previa is a placental location close to or over the internal
cervical os. The aim of this study was to evaluate: risk factors, maternal and
neonatal outcomes in patients with placenta previa. Material and methods:
We conducted a retrospective cohort study of 38 women who have had a
caesarean section for placenta previa at a tertiary referral University Hospital
of Obstetrics and Gynecology “Koço Gliozheni” in Tirana, Albania. The
period of this study was from January 2015 to March 2018. Maternal and
neonatal data were obtained from medical records and the hospital database
system. All cases of placenta previa were managed by medical team, obstetric
consultants and all data were calculated with SPSS.20 program. Results: In
total, 38 women with placenta previa were classified in three different types
of placenta previa: Marginal placenta previa occurred in 16 women(42.1%),
Complete placenta previa occurred in 19 women(50%) and with accreta
placenta previa in 3 women(7.9%). The mean age of mothers was 30,61 years
old, mode = 35, median = 30 and Std. deviation = 4.641 years. Conclusions:
The prevalence rate of section caesarean and placenta previa is increased
during the years. Several obstetrical factors have been found to be risk for
placenta previa including: advancing maternal age, previous caesarean
delivery, previous abortions, previous uterine surgery, multiparity, previous
placenta previa, low socio-economic status, mother’s cigarette smoking
/alcohol use. Placenta previa is associated with an increase in preterm birth
and neonatal and maternal outcome. Other complications of pregnancy can be
associated with placenta previa, but the majority of women deliver
healthy babies.

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 European Scientific Journal May 2018 edition Vol.14, No.15 ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431

Keywords: Placenta previa, placenta accreta, maternal outcome, neonatal

outcome

Introduction
Placenta previa (PP) is a placental location close to or over the internal
cervical os. (Cunningham,2010). Placenta previa is the most common cause
of painless bleeding in the later stages of pregnancy (after the 20th week),
because the placenta is rich in blood vessels, if it is implanted near the outlet
of the uterus, bleeding can occur when the cervix dilates or stretches. (James,
2007), (Milosevic,2009).
The exact etiology of placenta previa is unknown. However, it may be
associated with abnormal vascularization. (Charles et al, 2014). The condition
may be multifactorial and several obstetrical factors have been found to be risk
for placenta previa including:
Uterine factors: Previous Caesarean section, Previous Abortion -
curettage (such as D&C procedures for miscarriages or induced abortions) of
the uterine cavity, or any type of surgery involving the uterus (Myomectomy),
include scarring of the upper lining tissues of the uterus. (Ojha, 2012),
(Gulrukh,2006), (Ananth, et al. 1997).
Placental factors: multiple gestation, mother’s cigarette smoking/
alcohol use, and living at high altitude. So in these situations the placenta must
grow larger to compensate for decreased function (lowered ability to deliver
oxygen and/or nutrients). (Ananth, et al. 1997). It has also been observed that
women carrying male fetuses are at slightly greater risk for placenta previa
than are women carrying female fetuses. The risk of having placenta previa
increases with: advanced maternal age, the number of previous deliveries,
women with previous placenta previa. (Faiz, et al. 2003), (Ananth, et al.1996).
Transvaginal ultrasonography is more accurate in diagnosing placenta previa
than abdominal ultrasonography. However, with the technologic advances in
ultrasonography, the diagnosis of placenta previa is commonly made earlier in
pregnancy and then confirmation by magnetic resonance imaging (MRI).
(Williams, et al. 1993), (Sherman, et al. 1992), (Warshak, 2006).

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Fig. Nr. 1. Normal Placenta (Authors 2017)

Fig. Nr. 2. Complete Placenta Previa (Authors 2017)

Fig. Nr. 3. Marginal Placenta Previa (Authors 2017)

Fig. Nr. 4. Accreta Placenta Previa (Authors 2017)

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 European Scientific Journal May 2018 edition Vol.14, No.15 ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431

Historically, there have been three defined types of placenta previa:

Complete placenta previa in which the placenta completely covers the internal
os. Partial placenta previa in which the placenta partially covers the internal
os. Marginal placenta previa in which the placenta is located adjacent to, but
not covering, the internal os. (Smith, et al. 1997), (Creasy, et al.2014).
Placenta previa is associated with an increase in preterm birth and
neonatal and maternal outcome. (Bhide,2003). Fetal intrauterine growth
retardation (IUGR), Low birth weight (< 2500 g), low Apgar score which
needs admission in neonatal intensive care unit. Even neonatal death may
occur. (Zlatnik, et al.2006). Maternal complications are: massive hemorrhage,
emergency hysterectomy, multiple blood transfusions, urogenital injuries,
sepsis, prolonged intensive care unit (ICU) and hospital stay. Management of
placenta previa depends upon the extent and severity of bleeding, the
gestational age and condition of the fetus, the position of the placenta and
fetus, and whether the bleeding has stopped. (Eric. et al, 2001). Treatment of
placenta previa involves bed rest and limitation of activity. Tocolytic
medications, intravenous fluids, and blood transfusions may be required
depending upon the severity of the condition. A Caesarean delivery is usually
planned for women with placenta previa as soon as the baby can be safely
delivered (typically after 36 weeks' gestation), although an emergency
Caesarean delivery at any earlier gestational age may be necessary for heavy
bleeding that cannot be stopped after treatment in the hospital.(Ara, et al,
2009). The risk of requiring hysterectomy following a caesarean delivery for
patients with placenta previa (accreta if the placental tissue extends into the
superficial layer of the myometrium) is increased.(Blackwell,2011),
(Machado, 2011).

Materials and methods

We performed a retrospective cohort study, covering a period time
from January 1,2015, to March 31, 2018, of women who have had a caesarean
section for PP at a tertiary referral University Hospital of Obstetrics and
Gynecology “Koço Gliozheni” in Tirana, Albania. Maternal and neonatal data
were collected from the case notes (medical records and hospital database
system) of women who were found to have PP on transabdominal or
transvaginal ultrasound scanning and in whom the diagnosis was confirmed
during Caesarean section. The ultrasound machine used was Aloka Echo
Camera L. All ultrasound examinations were performed by an obstetrician.
The transabdominal ultrasound examinations were performed with the bladder
half-full and the transvaginal ultrasound examinations were performed with
the bladder empty. The internal os was visualized, and the distance between
the lower edge of the placenta and the internal os was measured.PP cases were

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 European Scientific Journal May 2018 edition Vol.14, No.15 ISSN: 1857 – 7881 (Print) e - ISSN 1857- 7431

managed by medical team, obstetric consultants. All data were calculated with
SPSS. 20. Program.
Data were collected on patient age, parity, gestational age at time of
caesarean delivery, history of previous PP, abortions, history of previous
surgery intervention in uterine cavity, smoking cigarette and alcohol use,
history of previous caesarean delivery, and degree of PP by ultrasound. The
evaluation also included whether caesarean section was done electively or as
an emergency, operative time. Neonatal evaluation included neonatal birth
weight, Apgar score at 1 and 5 minutes, neonatal gender, position of fetus,
generality admission to the neonatal intensive care unit, or any other
complications.

Results and discussions

In total, 38 women with PP were classified:Marginal PP occurred in
16 women(42.1%), Complete PP in 19 women(50%) and 3 women(7.9%) with
Accreta PP. The mean age of mothers was 30.61 years old; mode = 35; median
= 30 and Std. deviation = 4.641 years. Our results showed that the overall
prevalence rate of placenta previa was 1.6/1000 birth life in 2015; 2.6‰ in
2016 and 4.2‰ in 2017. Also we can see that prevalence rate of section
caesarean is increased during the years. Respectively this is 352.4 ‰ in 2015;
373.2‰ in 2016 and 403.5‰ in 2017.
Tab. Nr.1. Prevalence of S. Caesarean and Placenta Previa
Year Nr. of birth Nr. Prevalence of Nr. of P.P Prevalence of
Sec.Caes Sec. Caes P.P
2015 4279 1508 352,4‰ 7 1,6 ‰
2016 4223 1576 373,2‰ 11 2,6 ‰
2017 4037 1629 403,5‰ 17 4,2 ‰

In Tab Nr. 2 we can see examples of situations like as living at a low

socio-economic status. (57.9 %) and mother’s cigarette smoking/alcohol uses
(39.5%), increases risk for placenta previa.
Tab. Nr. 2. Mothers`demographic data and factors
Soc-eco. Status Nr % Story of alcohol/ cigarette Nr %
uses
Unemployed 22 57.9 No 23 60.5
Employer 16 42,1 Yes 15 39.5
Total 38 100 Total 38 100

As we can see at Tab Nr.3,4 that uterine factors can predispose to

placenta previa include scarring of the upper lining tissues of the uterus. So
placenta previa is more common among women who: Have had a baby (50%
second parity, 15.8% third parity, 10.5 % multiparity), Previous caesarean

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delivery, including first subsequent pregnancy following a caesarean

delivery(42.1% after 1s/caesarean, 5.3% after 2 s/caesarean, 5.3 % after 3
s/caesarean), Abortions(dilatation and curettage) (65.8 % had 1 abortion, 5.3%
2 abortions), had placenta previa with a previous pregnancy (15.8%), previous
uterine surgery (15.8%), number of fetus (94.7 % one fetus).
Tab. Nr. 3. Uterine factors
Parity Nr % Previous Nr % Story of Nr %
sec.caes abortion
0 3 7.9 0 18 47.4 0 12 28.9
1 6 15.8 1 16 42.1 1 25 65.8
2 19 50.0 2 2 5.3 2 2 5.3
3 6 15.8 3 2 5.3
Multiparity 4 10.5
Total 38 100 38 100 38 100

The mean age of mothers that are with PP and their have had previous
story with PP is 32.8 years old (SD=3,54 and SE =1,4), but mothers that didn’t
have previous story of PP, the mean age is 30.1 years old (SD=4.74 and
SE=0.83).
Tab. Nr. 4. Uterine factors
Nr. of fetus Nr % Previous Nr % Previous Nr %
intervention PP story
story
Unic 36 94.7 No 32 84.2 No 32 84.2
(Singleton)
Multiple 2 5.3 Yes 6 15.8 Yes 6 15.8
Gestation(Twins)
Total 38 100 Total 38 100 Total 38 100

As we can see at the Table Nr.5 that are three types of placenta previa
(42.1 % Marginal, 50% Complete and 7.9% Accreta).However, maternal and
fetal complications of placenta previa are well documented. Preterm birth is
highly associated with placenta previa, with 57.9 % of women delivering
between 32-36 weeks and 26.3% of them delivering > 36 weeks. Also from
these 38 patients: 26 (68.4%) delivered with emergency caesarean and 12
(31.6%) were planned.
Tab. Nr. 5 Position of P.P, Gestational Age of delivery and mode of S.C
Position of Nr % G. Age of Nr % S.CNr%
P.P Delivery
Marginal P. 16 42.1 28-32 6 15.8 Emergency 26 68.4
P weeks
Complete 19 50.0 32-36 22 57.9 Planned 12 31.6
P.P weeks
Accreta P.P 3 7.9 >36 weeks 10 26.3 Total 38 100
Total 38 100.0 Total 38 100

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At the Table Nr.6 are summarized some of the neonatal complications

of Placenta Previa: Abnormal fetal presentation (31.6% breech, 28.9 %
transverse), Low birth weight (34.2 % 2000-2400 g) and some of them IUGR.
It has also been observed that women carrying male fetuses (73.7%) are at
slightly greater risk for placenta previa than are women carrying female
fetuses (21.1%)
Tab. Nr. 6.Position, gender and weight of fetus
Position of Nr % Fetus Nr % Weight of fetus Nr %
fetus gender
Cephalic 13 34.2 M 28 73.7 1500-1900 gr 8 21.1
Breech 12 31.6 F 8 21.1 2000-2400 g 13 34.2

Transverse 11 28.9 M-M 1 2.6 2500-2900 gr 10 26.3

Twins 2 5.3 F-M 1 2.6 ≥3000 gr 7 18.4
Total 38 100 Total 38 100

Analyzing all cases with PP, using ANOVA test we didn’t evidenced
significant differences between weight of fetus, position of fetus position of
PP, GA and mother’s age. On the other hand we evidenced a very significant
positive correlation between fetus weight and gestational age at the moment
of birth. (p≤0.001, Pearson`s R =0.781). So increasing GA is increased also
the weight of fetus. This is represented in the table nr. 7.
Tab. Nr.7. Correlation between GA and fetus weight
Gestational Age (GA) Total
Weight 28-32 32-36 >36
weeks weeks weeks
1500-1900 gr Count 6 2 0 8
% within GA 100 9.1 0.0 21.1
2000-2400 gr Count 0 12 1 13
% within GA 0 54.5 10 34.2
2500-2900 gr Count 0 7 3 10
% within GA 0 31.8 30 26.3
>= 3000 gr Count 0 1 6 7
% within GA 0 4.5 60 18.4
Total Count 6 22 10 38
% within GA 100 100 100 100

Also we have evidenced that exists a very significant statistical

difference between gestational age and delivery mode, (emergency caesarean
section or planned caesarean section). So χ2= 21.84; df=2; p≤0,001. (see tab.
Nr. 8.)

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Tab. Nr. 8. Correlation between GA and mode of caesarean section

GA Section Caesarean Total
Urgency Planned
28-32 Count 6 0 6
weeks % within GA 100 0 100
% within Section Caesarean 23.1 0 15.8
% of Total 15.8 0 15.8
32-36 Count 19 3 22
weeks % within GA 86.4 13.6 100
% within Section Caesarean 73.1 25 57.9
% of Total 50 7.9 57.9
>36 Count 1 9 10
weeks % within GA 10 90 100
% within Section Caesarean 3.8 75 26.3

% of Total 2.6 23.7 26.3

Total Count 26 12 38
% within GA 68.4 31.6 100
% within Section Caesarean 100 100 100
% of Total 68.4 31.6 100

Conclusions
● The prevalence rate of section caesarean and placenta previa is
increased during the years 2015-2018. There are three types of placenta previa:
50% Complete, 42.1 % Marginal and 7.9% Accreta.
● Several obstetrical factors have been found to be risk for placenta
previa including: advancing maternal age (> 30 years), previous caesarean
delivery (42.1 % after 1 s/caesarean), previous abortions (65.8 % had 1
abortion), previous uterine surgery (myomectomy), multiparity (50% second
parity), previous placenta previa, low socio-economic status (57.9%) ,
mother’s cigarette smoking /alcohol use (39.5%).
● Placenta previa is associated with an increase in preterm birth and
neonatal and maternal outcome. Preterm birth with 57.9 % of women
delivering between 32-36 weeks, Abnormal fetal presentation (31.6% breech,
28.9 % transverse), Low birth weight (34.2 % 2000-2400 g) and some of them
IUGR. So 68.4% of women delivered with emergency caesarean and 31.6%
were planned. Also women carrying male fetuses (73.7%) are at slightly
greater risk for placenta previa. Other complications of pregnancy can be
associated with placenta previa, but the majority of women deliver
healthy babies.

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