Prediction of maternal near-miss in placenta previa: a retrospective analysis from a tertiary center in Ankara, Turkey. Bora Coskun, Iltac Akkurt, Riza Dur, Mehmet Ozgur Akkurt, Seval Yilmaz Ergani, Bugra Coskun

Aim Placenta previa (PP) poses both maternal and fetal risks and its incidence has been increasing in parallel with the cesarean delivery (CD) rates. In the present study we aimed to determine the risk factors for complicated CD in placenta previa.

Methods This retrospective study was performed at Etlik Zubeyde Hanim Maternity and Women’s Health Teaching and Research Hospital during 6-year study period. Women with total and partial PP were included. Complicated CD was identified according to modified World Health Organization (WHO) maternal near-miss criteria.

WHO near-miss criteria Coagulation and hematological dysfunction defined as transfusion of 4 and more units of red blood cells, a rapid drop in hemoglobin levels (>4 g/dl) and acute thrombocytopenia <75.000/ml Reoperation, hysterectomy, balloon placement and uterine artery and/or hypogastric artery ligation for hemorrhage, Prolonged postoperative hospitalization (>4 days), Intra-and/or post-operative complications such as bladder, ureter, bowel injury, Renal dysfunction (creatinine >3.5 mg/dl), Admission to intensive care unit.

Comparison of variables between complicated and non-complicated groups p-value   Mean±SD median range mean±SD Maternal age (year) 30±5.6 30 21-40 30.7±5.5 31 19-44 0.909m Body mass index (kg/m2) 28.6±4.7 27 19-42 28.9±3.8 29 20-39 0.141m Number of previous CD 1.2±1.2 1 0-4 0.5±0.8 0-3 0.001m GA at birth (week) 35±3.5 36.3 24-39.3 36.2±2.9 37 24-39 0.009m Number of vaginal bleeding episode 3.7±1.2 3.5 0-5 0.8±0.9 0.000m Preoperative Hb (gr/dl) 10.7±1.3 10.5 8.6-14.1 11.5±1.4 11.5 8.2-15.7 Preoperative Htc 32.8±3.5 32.7 25-40 34.8±3.6 35 25-45 0.003m Preoperative thrombocyte (109/L) 240.2±85 220 106-457 239±68.8 232 98-536 0.881m Drop in Hb (gr/dl) 3.6±1 3.3 1.7-6 1.5±0.9 1.4 0.2-3.9 Drop in Htc 10.1±3.5 10.4 3.4-18 4.5±2.6 3.8 0.6-9.8 Drop in thrombocyte 23±6.6 25 22±5.5 22 5-55 0.112m Hospitalization length (day) 5.0±1.3 5 3-8 2.7±0.7 3 1-5 Number of erythrocyte transfusion 2.8±1.5 2 0-6 0.3±0.7 0-2 CL < 10. percentile 8/20 (40%) 3/48 (6%) 0.000 X² Anterior placentation 25 (67.6%) 51 (23.3%) 0.003 X² Coexistent abruption 9 (24.3%) 6 (2.7%) Adherent placenta 14 (37.8%) 3 (1.3%) General anesthesia 10 (27%) 24 (11%) 0.012 X² Weekend delivery 54 (24.7%) 0.102 X²

Multivariable analysis Logistic regression analysis for identification of independent risk factors for maternal near-miss in placenta previa   Univariate analysis Multivariable analysis OR 95% CI p Maternal age 1.00 0.93-1.06 0.903 Gravida 1.17 0.93-1.48 0.178 Parity 1.20 0.88-1.63 0.251 Smoking 2.61 0.95-7.17 0.064 Body mass index 0.92 0.83-1.01 0.082 General anesthesia 1.62 1.3-3.21 0.181 Weekend delivery 1.86 0.87-3.99 0.112 Adherent placenta 12.02 5.19-27-82 0.000 11.92 3.24-43.82 Anterior placentation 1.05 1.03-1.08 0.111 Previous cesarean delivery 2.05 1.4-3.01 Gestational age at birth 0.90 0.81-1.00 0.044 Cervical length < 10. percentile 8.1 3.1-22.5 5.5 2.1-15.4 <0.05 Coexistent abruption 18.1 7.1-97.8 13.2 5.8-75.3 Increased number of vaginal bleeding episodes (>3) 11.8 6.18-35.79 8.88 3.32-26.69 <0.001

Results 37 and 219 women formed complicated and non-complicated group, respectively. Logistic regression analysis demonstrated that following features were associated with complicated CD in PP; 1) coexistent abruption (aOR 13.2, 95% CI 5.8-75.3), 2) adherent placenta (aOR 11.92, 95% CI 3.24-43.82), 3) 3 and more hospitalization for vaginal bleeding (aOR 8.88, 95% CI 3.32- 26.69), 4) cervical length (CL) measurement < 10. Percentile (aOR 5.5, 95% CI 2.1-15.4).

Conclusion Short cervical length, recurrent vaginal bleeding, morbidly adherent placenta, and concurrent placental abruption are independent predictors for subsequent severe morbidity in women with placenta previa. Early identification of these factors during follow-up may improve outcome.

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