Previous Cesarean Delivery and Risks of
Placenta Previa and Placental Abruption
Darios Getahun, MD, MPH, Yinka Oyelese, MD, Hamisu M. Salihu,
and Cande V. Ananth, PhD, MPH
OBJECTIVE: To examine the association between cesar-
ean delivery and previa and abruption in subsequent
Downloaded from https://journals.lww.com/greenjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3Gamkn0m7hy57lK36ktvfnrg2h8T0sABBsh5Cl8UoK5w= on 03/22/2019
pregnancies.
METHODS: A retrospective cohort study of first 2 (n ⴝ
156,475) and first 3 (n ⴝ 31,102) consecutive singleton
pregnancies using the 1989 –1997 Missouri longitudinally
linked data were performed. Relative risk (RR) was used
to quantify the associations between cesarean delivery
and risks of previa and abruption in subsequent pregnan-
cies, after adjusting for several confounders.
RESULTS: Rates of previa and abruption were 4.4 (n ⴝ
694) and 7.9 (n ⴝ 1,243) per 1,000 births, respectively. The
pregnancy after a cesarean delivery was associated with
increased risk of previa (0.63%) compared with a vaginal
delivery (0.38%, RR 1.5, 95% confidence interval [CI]
1.3–1.8). Cesarean delivery in the first and second births
conferred a two-fold increased risk of previa in the third
pregnancy (RR 2.0, 95% CI 1.3–3.0) compared with first
two vaginal deliveries. Women with a cesarean first birth
were more likely to have an abruption in the second
pregnancy (0.95%) compared with women who had a
vaginal first birth (0.74%, RR 1.3, 95% CI 1.2–1.5). Two
consecutive cesarean deliveries were associated with a
30% increased risk of abruption in the third pregnancy
(RR 1.3, 95% CI 1.0 –1.8). A second pregnancy within a
See related editorial on page 752.
From the Division of Epidemiology and Biostatistics and Division of Maternal–
Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sci-
ences, Robert Wood Johnson Medical School, University of Medicine and
Dentistry of New Jersey, New Brunswick, New Jersey.
Drs. Getahun and Ananth are supported through a grant (R01-HD038902)
from the National Institutes of Health, awarded to Dr. Ananth.
The authors thank the Missouri Health Department for graciously allowing us to
utilize the state maternally linked longitudinal data file.
Corresponding author: Cande V. Ananth, PhD, MPH, Division of Epidemiology
and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive
Sciences, UMDNJ-Robert Wood Johnson Medical School, 125 Paterson Street,
New Brunswick NJ 08901-1977; e-mail: cande.ananth@umdnj.edu.
© 2006 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/06
VOL. 107, NO. 4, APRIL 2006
MD, PhD,
year after a cesarean delivery was associated with in-
creased risks of previa (RR 1.7, 95% CI 0.9 –3.1) and
abruption (RR 1.5, 95% CI 1.1–2.3).
CONCLUSION: A cesarean first birth is associated with
increased risks of previa and abruption in the second
pregnancy. There is a dose–response pattern in the risk of
previa, with increasing number of prior cesarean deliver-
ies. A short interpregnancy interval is associated with
increased risks of previa and abruption.
(Obstet Gynecol 2006;107:771–8)
LEVEL OF EVIDENCE: II-2
P lacenta previa complicates approximately 1 in 200
deliveries1,2 and is one of the leading causes of
vaginal bleeding in the second and third trimesters. It is
associated with increased risks of maternal and infant
morbidity and mortality.3,4 Placental abruption compli-
cates 1 in 100 pregnancies5,6 and is known to recur in
subsequent pregnancies.5,7 The recurrence rate after an
abruption is 15%, and after two previous episodes the
risk of recurrence approximates 20%.7 Placental abrup-
tion is a major cause of perinatal mortality, accounting
for 119 deaths per 1,000 live births.8
Surgical disruption of the uterine cavity is a
potential risk factor for placenta previa and placental
abruption.9,10 Cesarean delivery is the most common
of operative procedures in the United States, account-
ing for well over a fourth of all deliveries.11,12 It is
known to cause lasting damage to the myometrium
and endometrium.13 The first observation that re-
ported an association between prior cesarean delivery
and increased risk of placenta previa dates back to the
early 1950s.14 Several studies have since corroborated
the association both for placenta previa15–17 and pla-
cental abruption.9,10,17 These findings were subse-
quently confirmed through a large meta-analysis of
more than 3.7 million pregnant women.15 The fetus in
a pregnancy after a cesarean delivery or other uterine
surgical procedure may be at higher risk of morbidity
and mortality than one in a pregnancy in which there
OBSTETRICS & GYNECOLOGY 771
was no preceding cesarean delivery. The increased
risk of morbidity and mortality may partly be due to
the relative increase in abruption and previa to preg-
nant mothers with previous (obstetric) surgical proce-
dures.18,19 However, it remains unclear as to whether
these risks increase with the number of cesarean
deliveries in a dose-dependent fashion. For instance,
whether patients who have undergone a single cesar-
ean delivery run a similar risk of previa and abruption
as those patients who have undergone two or more
prior cesarean deliveries remains unexplored. This
information is important from the point of view of
assigning patients in terms of risk profiles and for
counseling.
Studies have reported that both short and long
interpregnancy intervals are associated with an array
of adverse pregnancy outcomes.20 –23 Increased risk of
abnormally adherent placentas has also been re-
ported among pregnancies with short interpregnancy
intervals.24 Interpregnancy interval–specific risks of
placenta previa and placental abruption among
women with previous cesarean deliveries have not
been examined; therefore, little is known regarding
their associations.
To address these issues, we undertook this study
with the following objectives: 1) to estimate if a
cesarean delivery is a risk factor for placenta previa
and placental abruption in subsequent pregnancies; 2)
to examine for the presence of a dose–response
relationship between prior cesarean deliveries and
risks of previa and abruption in subsequent pregnan-
cies; and 3) to examine if the risk of previa and
abruption in relation to prior cesarean delivery is
modified by the interval between pregnancies.
MATERIALS AND METHODS
Data for this study were obtained from the Missouri
longitudinally linked birth certificate and fetal mortal-
ity data files for the years 1989 to 1997, inclusive. In
this dataset, siblings are linked to their biological
mothers using unique identifiers. The methods and
algorithm used in linking birth certificate data into
sibships and the process of validation have been
described in detail previously.25 The Missouri vital
record system is considered very reliable and one that
has been adopted as a “gold standard” to validate U.S.
national datasets that involve matching and linking
procedures.26 The linked data essentially contains
information on both live birth and fetal death for each
sibling and provides a platform for a longitudinal
study of birth outcomes for each pregnancy. The
database comprised 706,075 live births and fetal and
infant deaths for which records were available be-
772 Getahun et al Prior Cesarean and Risks of Abruption and Previa
tween 1989 and 1997. Information on live birth and
fetal and infant death, as well as maternal sociodemo-
graphic and behavioral characteristics, medical his-
tory, and complications during labor and delivery
were included in the data files.
Using an analytic cohort of linked first two sin-
gleton births in the state of Missouri from 1989 to
1997 (n ⫽ 157,831) and the first three consecutive
singleton births (n ⫽ 31,699), we conducted an anal-
ysis to examine the association between previous
cesarean delivery and risks of placenta previa and
placental abruption in subsequent singleton pregnan-
cies, and if a short interpregnancy interval increases
the risk.
The study was approved by the ethics committee
of the Institutional Review Board of the University of
Medicine and Dentistry of New Jersey–Robert Wood
Johnson Medical School, New Brunswick, NJ. Statis-
tical analysis was performed using SAS 9.1 (SAS
Institute, Cary, NC).
Data on maternal characteristics were based on
the study cohort that comprised the first two births.
Self-reported maternal race was grouped as white,
black, Hispanic, and others races. Factors that were
considered potential confounders included maternal
age (⬍ 20, 20 –24, 25–29, 30 –34, ⱖ 35 years), marital
status (married/unmarried), late initiation of prenatal
care (after first trimester), maternal education (⬍ 12,
12, and ⱖ 13 years of completed schooling), maternal
smoking and alcohol use during pregnancy (yes/no),
and interval between a birth and a subsequent preg-
nancy lasting at least 20 weeks (interpregnancy inter-
vals of ⬍ 1, 1.0 –1.5, 1.5–2.0. . ., ⱖ 4 years). The
outcomes that were examined included risks of pla-
centa previa and placental abruption.
We first examined the distributions of maternal
sociodemographic and behavioral characteristics by
previous cesarean delivery. To examine the associa-
tion between abruption and previa in subsequent
pregnancies (first two and first three pregnancies) a
logistic regression model was fitted after controlling
for potential confounding variables (maternal age,
maternal race, maternal education, prenatal care,
marital status, interpregnancy interval, and smoking
and alcohol use during pregnancy). Relative risks
(RRs) and 95% confidence intervals (CIs) were used
to quantify the association. Because the incidence of
the outcome was fairly low in our study, odds ratios
derived from the logistic regression models were
interpreted as RRs. Potential confounding variables
were either chosen a priori or were factors that
resulted in a shift of at least 10% between the unad-
justed and adjusted RRs.
OBSTETRICS & GYNECOLOGY
 From a total of 711,015 births in the state of Table 1. Maternal Characteristics at Second Birth
Missouri between 1989 and 1997, we excluded the by Method of Delivery: Missouri , 1989 –
following categories: multiple births (n ⫽ 19,969), preg- 1997
nancies that ended at less than 20 weeks of gestation and Method of Delivery (%)
fetuses that weighed less than 500 g (n ⫽ 25,850), and
Vaginal Cesarean
births with missing method of delivery (n ⫽ 72).
Characteristics (n ⴝ 116,814) (n ⴝ 39,661)
Maternal age (y)
RESULTS ⬍ 20 23.7 16.7
Among the 156,475 women with their first two preg- 20–24 30.5 29.3
nancies, the overall incidence of previa and abruption 25–29 29.2 32.6
30–34 13.7 17.3
were 4.4 and 7.9 per 1,000 singleton births, respec- ⱖ 35 2.9 4.2
tively. The sociodemographic and behavioral charac- Maternal race
teristics of 39,661 (25% of 156,475) mothers with a White 80.7 83.8
history of cesarean are presented in Table 1. Women Black 16.6 13.6
Hispanic 1.3 1.3
with a cesarean delivery were more likely to be white, Other 1.4 1.3
married, of advanced maternal age, to have com- Maternal education (y)
pleted 12 years or more of schooling, and to have ⬍ 12 24.6 19.2
initiated prenatal care early in the pregnancy. 12 34.9 36.9
Table 2 outlines the risks of previa by previous ⱖ 13 40.5 43.9
Unmarried status 33.1 27.0
cesarean delivery histories. Risk for previa in the Late prenatal care initiation 18.9 15.5
second birth was 50% higher among women with a Smoking during pregnancy 20.6 20.3
prior cesarean delivery (RR 1.5, 95% CI 1.3–1.8). A Drinking during pregnancy 2.2 2.4
cesarean first birth and vaginal second birth and vice Birth interval (y)
⬍1 11.9 11.9
versa did not increase the risk of previa in the third 1.5 20.5 19.9
birth. However, the risk of previa was two-fold higher 2 17.1 16.7
(RR 2.0, 95% CI 1.3–3.0) in women with cesarean first 2.5 13.5 12.5
and second births, compared with women with vagi- 3 10.2 10.0
nal deliveries in the first and second births. 3.5 7.6 7.8
ⱖ4 19.2 21.2
Table 3 shows the risks of abruption by previous Gestational age (wk)
cesarean delivery histories. The risk of abruption in ⬍ 32 1.7 2.8
the second birth was 30% higher when first birth was ⬍ 34 3.0 4.5
cesarean (RR 1.3, 95% CI 1.2–1.5). Regardless of the ⬍ 37 9.7 11.2
mode of delivery of the first birth, a cesarean second Chronic hypertension 0.5 0.9
Preeclampsia 3.4 6.7
birth was associated with increased risk of abruption. Premature rupture of
A vaginal first birth followed by a cesarean birth membranes 3.3 4.4
conferred a nonsignificant increase in the risk of
abruption (RR 1.5, 95% CI 0.9 –2.2), whereas a cesar-
ean first birth followed by a cesarean second birth ery remained higher than the risk in the first preg-
conferred a marginally increased risk of abruption nancy (Fig. 1).
(RR 1.3, 95% CI 1.0 –1.8). The risks of abruption Irrespective of the method of delivery in the first
among cesarean first births and vaginal second births birth, a second pregnancy within the first year post-
were, however, similar. partum increased the risk of abruption. A second
A second pregnancy within a year after the first pregnancy within the first year postpartum increased
was not associated with an increased risk of previa the risk of abruption by 52% in a woman with a
among women whose first birth was vaginal, but the vaginal first birth and by 111% in a woman with a
risk was increased by 70% in women who had a cesarean first birth. Women with a cesarean first birth
cesarean first birth (RR 1.7, 95% CI 0.9 –3.1). Al- were more likely to have an abruption if the second
though there is clear evidence that the risk of previa pregnancy occurred within a year after the first com-
among women with or without previous cesarean pared with women with vaginal first birth (RR 1.5,
deliveries decreases between the first and second 95% CI 1.1–2.3). A decreasing risk of abruption in the
years of interpregnancy interval, the risk in second second pregnancy was noted among women with and
pregnancy among women with prior cesarean deliv- without previous cesarean in every interpregnancy

VOL. 107, NO. 4, APRIL 2006 Getahun et al Prior Cesarean and Risks of Abruption and Previa 773
Table 2. Association Between Cesarean Delivery and Placenta Previa in Subsequent Pregnancies:
Missouri 1989-1997
Risk of Placenta Previa in the
Subsequent Pregnancy

Median
Second Interpregnancy Total Unadjusted Adjusted
First Birth Birth Interval (y) Births (N) Previa (%) RR (95% CI) RR (95% CI)
First 2 pregnancies (n ⫽ 156,475)
Vaginal — 2.2 116,003 0.38 1.0 (Reference) 1.0 (Reference)
Cesarean — 2.4 40,472 0.63 1.6 (1.3–1.8) 1.5 (1.3–1.8)
First 3 pregnancies (n ⫽ 31,102)
Vaginal Vaginal 2.0 22,332 0.37 1.0 (Reference) 1.0 (Reference)
Vaginal Cesarean 2.1 1,826 0.38 1.0 (0.5–2.2) 1.0 (0.5–2.2)
Cesarean Vaginal 2.2 2,341 0.34 0.9 (0.4–1.9) 0.9 (0.5–2.0)
Cesarean Cesarean 2.2 4,603 0.72 1.9 (1.3–2.9) 2.0 (1.3–3.0)
RR, relative risk; CI, confidence interval.
Relative risks are adjusted for maternal age, race, education, prenatal care, marital status, interpregnancy interval, and smoking and drinking
during pregnancy.

Table 3. Association Between Cesarean Delivery and Placental Abruption in Subsequent Pregnancies:
Missouri 1989-97
Risk of Placental Abruption in
the Subsequent Pregnancy

Median
Second Interpregnancy Total Abruption Unadjusted Adjusted
First Birth Birth Interval (y) Births (N) (%) RR (95% CI) RR (95% CI)
First 2 pregnancies (n ⫽ 156,475)
Vaginal — 2.2 116,003 0.74 1.0 (Reference) 1.0 (Reference)
Cesarean — 2.4 40,472 0.95 1.3 (1.1–1.4) 1.3 (1.2–1.5)
First 3 pregnancies (n ⫽ 31,102)
Vaginal Vaginal 2.0 22,332 0.91 1.0 (Reference) 1.0 (Reference)
Vaginal Cesarean 2.1 1,826 1.31 1.5 (1.0–2.2) 1.5 (0.9–2.2)
Cesarean Vaginal 2.2 2,341 0.73 0.8 (0.5–1.3) 0.9 (0.5–1.4)
Cesarean Cesarean 2.2 4,603 1.06 1.2 (0.9–1.6) 1.3 (1.0–1.8)
RR, relative risk; CI, confidence interval.
Relative risks are adjusted for maternal age, race, education, prenatal care, marital status, interpregnancy interval, and smoking and drinking
during pregnancy.

interval between the first and the second years. Al-
though the risk of abruption in women with previous
vaginal birth is lower than risk in the first pregnancy,
when the second pregnancy is delayed by at least 1.5
years, the risk for those with previous cesarean deliv-
eries remained unchanged from the risk in the first
pregnancy (Fig. 2).
DISCUSSION
Many studies that have examined risks of uteropla-
cental bleeding disorders (placenta previa and placen-
tal abruption) have identified potential risk factors
including maternal age, race, marital status, parity,
prenatal care, cocaine use, and smoking during preg-
nancy.1– 8,15 The association between prior cesarean
delivery and risks of previa and abruption are, how-
ever, limited. With the increasing trend in cesarean
deliveries observed in recent years in the United
States,11,12 the incidence of previa and abruption is
expected to rise. In the present study, a cesarean first
birth was associated with an increased risk of placenta
previa and placental abruption in subsequent preg-
nancies. This observation concurs with those of Hem-
minki and Merilainen10 who reported that a cesarean
increased the risk of abruption in a subsequent preg-
nancy. Similarly, Lydon-Rochelle et al17 found an
increased risk of abruption in the second pregnancy
among women with a prior cesarean. These authors
used the linked birth certificate and hospital discharge
data to examine the association between prior cesar-
ean delivery and abruption, but they did not examine
the impact of a short interpregnancy interval and risk

774 Getahun et al Prior Cesarean and Risks of Abruption and Previa OBSTETRICS & GYNECOLOGY
Fig. 1. Risk (A) and adjusted RR (B) of placenta previa by previous cesarean delivery and interpregnancy interval: Missouri,
1989 –1997. Open circles correspond to no previous cesarean; solid circles correspond to women with previous cesarean.
Getahun. Prior Cesarean and Risks of Abruption and Previa. Obstet Gynecol 2006.

of previa and abruption. Our study extends these
observations to women in their first three pregnan-
cies. We observed a 30 –50% increase in the risk of
abruption in third birth among women with a cesar-
ean second birth, irrespective of the method of deliv-
ery in their first birth. To examine the possibility of
bias due to recurrence of abruption in subsequent
pregnancies, we repeated the analysis after excluding
observations with abruption in first and second births.
The magnitude of the estimates (shown in Table 3)
remained unchanged.
Using the 1984 –1987 Washington state birth
certificate data, Taylor et al16 found in their case-
control study an increased risk of previa in women

Fig. 2. Risk (A) and adjusted RR (B) of placental abruption by previous cesarean delivery and interpregnancy interval:
Missouri, 1989 –1997. Open circles correspond to no previous cesarean; solid circles correspond to women with previous
cesarean.
Getahun. Prior Cesarean and Risks of Abruption and Previa. Obstet Gynecol 2006.

VOL. 107, NO. 4, APRIL 2006 Getahun et al Prior Cesarean and Risks of Abruption and Previa 775
with previous cesarean delivery (odds ratio 1.48, 95%
CI 1.13–1.95). However, because they used birth
certificate data that was not linked to subsequent
pregnancies, they were not able to examine risks
between two consecutive pregnancies. Norwegian
investigators reported a 32% increase in the risk of
placenta previa in the second pregnancy in women
when the first birth was cesarean.27 We demonstrated
a 50% increase risk in previa in the second birth when
the first birth was cesarean. Furthermore, we showed
that this risk was doubled in the third birth when the
first birth and second birth were both cesarean,
suggesting a dose–response risk gradation. This find-
ing suggests that encouraging women to deliver vag-
inally may be an important step in lowering risk of
previa and abruption.
Pathological changes in the myometrium and
endometrium of the uterus have been described in the
presence of previous cesarean delivery scar. These
include polyp formation, lymphocyte infiltration, cap-
illary dilatation, and infiltration of the endometrial
tissue that surround the scar by free red blood cells.13
These observations suggest that the pathological
changes in the vicinity of cesarean delivery scars may
create suboptimal implantation of the placenta, in-
creased vascular malformations, and increased fragil-
ity of vessels that are known risk factors for abruption.
Furthermore, rupture of the spiral arteries may lead to
the formation of decidual hematomas, which may
likely culminate in placental abruption. The same
pathological changes of the endometrium and uterine
cavity may be responsible for the increased risk of
placenta previa among women with prior cesarean
delivery.
Previous studies have reported that both short
and long interpregnancy intervals are associated with
adverse pregnancy outcomes including stillbirth, pre-
term birth, small-for-gestational-age birth, and neona-
tal mortality.20 –23 Wax et al24 reported increased risk
of abnormally adherent placentas (placenta accreta,
increta, and percreta) among pregnancies with short
interpregnancy intervals. Our finding of increased
risk of placenta previa in women with cesarean first
delivery and increased risk of abruption in pregnancy
conceived within 2 years point toward the benefit of
postponing pregnancies by at least 2 years.
Median interpregnancy interval for the second
pregnancy among women with first vaginal birth and
first cesarean birth were 2.2 and 2.4, respectively. But
method of deliveries–specific interpregnancy inter-
vals was lower for the third pregnancy as compared
with second pregnancy. Although first two vaginal
births, regardless of the interpregnancy intervals, con-
776 Getahun et al Prior Cesarean and Risks of Abruption and Previa
fer no risk, first two cesarean births concurrently with
low interpregnancy interval is a significant risk factor
for previa and abruption and deserve special attention
in counseling.
The pathophysiologic conditions as to why a
short interpregnancy interval increases risk of adverse
pregnancy outcome is not fully understood. However,
this is probably explained by the maternal depletion
theory.28,29 Pregnancy is a physiologically demanding
condition to the mother that may lead to depletion of
stored nutritional elements. A pregnancy with a short
(interpregnancy) interval may deprive the mother
from restoring those nutritional elements needed to
support a normal pregnancy, full recovery of the
internal lining of the uterus.
Wilcox and Gladen30 proposed that investigators
studying successive pregnancies be aware of the role
of selective fertility, a phenomenon likely to occur
when couples attempt to replace a pregnancy loss
more quickly than those with normal outcomes. This
has implications to our study owing to the high rates
of perinatal mortality associated with placental abrup-
tion6,8 and placenta previa,31 and the desire to achieve
a completed family size quickly.30,32 If selective fertil-
ity were indeed likely to operate, it can be speculated
that the interpregnancy interval is shorter in such
couples.
To address this concern, we carried out a separate
analysis after limiting the study to all live births that
survived to infancy. The pattern of associations was
essentially unchanged (not shown) from those of our
original analysis (Tables 2 and 3), lending further
credibility and robustness to our findings. One plau-
sible reason for this is that our original analysis was
already restricted to women with only the first two
and first three pregnancies (ie, there was a smaller
“exposure” window). Second, acting on the specula-
tion that this approach will not completely address the
bias due to selective fertility (for example, a live birth
that was associated with a serious pregnancy compli-
cation may have forced the woman to decline an
attempt at vaginal birth in a subsequent pregnancy),
we repeated the analysis after excluding premature
rupture of membranes, eclampsia, maternal fever,
and excessive bleeding during delivery—factors neces-
sitating a cesarean delivery. The magnitude of the
estimates remained unchanged, suggesting that the ef-
fects of selective fertility, if present, are likely minimal.
Other biases and limitations of our study are those
typical of population-based studies that rely on vital
statistics data. The birth certificate data are prone to
some degree of under-reporting of certain variables (eg,
smoking during pregnancy, medical and obstetric risk
OBSTETRICS & GYNECOLOGY
factors), which could introduce systemic or random
bias.33,34 The vital statistics data are often collected after
the termination of the pregnancy, thereby introducing a
misclassification of certain risk factors (such as smoking)
in pregnancy. This misclassification is likely to be differ-
ential in nature, and if present, will bias the effect
measures away from the null.35 The possibility of our
results being affected by residual confounding due to
unmeasured factors (such as cocaine use) may have also
affected the associations noted here. Conversely, the
strengths of this study include the large population-
based study cohort and our controlling for a variety of
potential confounding variables.
A cesarean birth is an important risk factor for
placenta previa and placental abruption in a subse-
quent pregnancy. The presence of a dose-response
pattern in the risk of placenta previa with increasing
number of prior cesarean deliveries, coupled with a
biologically plausible association, provides compel-
ling evidence in support of the association. Irrespec-
tive of the method of delivery in the first pregnancy,
a short interpregnancy interval appears to be associ-
ated with increased risks of both placenta previa and
placental abruption. The effects of these associations
on adverse pregnancy outcomes remain unknown.
REFERENCES
1. Faiz AS, Ananth CV. Etiology and risk factors for placenta
previa: an overview and meta-analysis of observational studies.
J Matern Fetal Neonatal Med 2003;13:175–90.
2. Ananth CV, Demissie K, Smulian JC, Vintzileos AM. Placenta
previa in singleton and twin births in the United States, 1989
through 1998: a comparison of risk factor profiles and associ-
ated conditions. Am J Obstet Gynecol 2003;188:275–81.
3. Ananth CV, Smulian JC, Vintzileos AM. The effect of placenta
previa on neonatal mortality: a population-based study in the
United States, 1989 through 1997. Am J Obstet Gynecol
2003;188:1299–304.
4. Lavery JP. Placenta previa. Clin Obstet Gynecol 1990;33:
414–21.
5. Ananth CV, Savitz DA, Williams MA. Placental abruption and
its association with hypertension and prolonged rupture of
membranes: a methodologic review and meta-analysis. Obstet
Gynecol 1996;88:309–18.
6. Ananth CV, Berkowitz GS, Savitz DA, Lapinski RH. Placental
abruption and adverse perinatal outcomes. JAMA 1999;282:
1646–51.
7. Rasmussen S, Irgens LM, Dalaker K. The effect on the
likelihood of further pregnancy of placental abruption and the
rate of its recurrence. Br J Obstet Gynaecol 1997;104:1292–5.
8. Ananth CV, Wilcox AJ. Placental abruption and perinatal
mortality in the United States. Am J Epidemiol 2001;153:
332–7.
9. Barrett JM, Boehm FH, Killam AP. Induced abortion: a risk
factor for placenta previa. Am J Obstet Gynecol 1981;141:
769–72.
VOL. 107, NO. 4, APRIL 2006 Getahun et al
10. Hemminki E, Merilainen J. Long-term effects of cesarean
sections: ectopic pregnancies and placental problems. Am J
Obstet Gynecol 1996;174:1569–74.
11. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F,
Munson ML. Births: final data for 2003. Natl Vital Stat Rep
2005;54:1–116.
12. Meikle SF, Steiner CA, Zhang J, Lawrence WL. A national
estimate of the elective primary cesarean delivery rate. Obstet
Gynecol 2005;105:751–6.
13. Morris H. Surgical pathology of the lower uterine segment
caesarean section scar: is the scar a source of clinical symp-
toms? Int J Gynecol Pathol 1995;14:16–20.
14. Bender S. Placenta previa and previous lower segment cesar-
ean section. Surg Gynecol Obstet 1954;98:625–8.
15. Ananth CV, Smulian JC, Vintzileos AM. The association of
placenta previa with history of cesarean delivery and abortion:
a metaanalysis. Am J Obstet Gynecol 1997;177:1071–8.
16. Taylor VM, Kramer MD, Vaughan TL, Peacock S. Placenta
previa and prior cesarean delivery: how strong is the associa-
tion? Obstet Gynecol 1994;84:55–7.
17. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP.
First-birth cesarean and placental abruption or previa at sec-
ond birth. Obstet Gynecol 2001;97:765–9.
18. Lieberman E, Ernst EK, Rooks JP, Stapleton S, Flamm B.
Results of the national study of vaginal birth after cesarean in
birth centers. Obstet Gynecol 2004;104:933–42.
19. Juntunen K, Makarainen L, Kirkinen P. Outcome after a high
number (4 –10) of repeated caesarean sections. BJOG 2004;
111:561–3.
20. Zhu BP, Rolfs RT, Nangle BE, Horan JM. Effect of the interval
between pregnancies on perinatal outcomes. N Engl J Med
1999;340:589–94.
21. Khoshnood B, Lee KS, Wall S, Hsieh HL, Mittendorf R. Short
interpregnancy intervals and the risk of adverse birth outcomes
among five racial/ethnic groups in the United States. Am J
Epidemiol 1998;148:798–805.
22. Skjaerven R, Wilcox AJ, Lie RT. The interval between pregnan-
cies and the risk of preeclampsia. N Engl J Med 2002;346:33–8.
23. Basso O, Christensen K, Olsen J. Higher risk of pre-eclampsia
after change of partner: an effect of longer interpregnancy
intervals? Epidemiology 2001;12:624–9.
24. Wax JR, Seiler A, Horowitz S, Ingardia CJ. Interpregnancy
interval as a risk factor for placenta accreta. Conn Med
2000;64:659–61.
25. Herman AA, McCarthy BJ, Bakewell JM, Ward RH, Mueller
BA, Maconochie NE, et al. Data linkage methods used in
maternally-linked birth and infant death surveillance data sets
from the United States (Georgia, Missouri, Utah and Washing-
ton State), Israel, Norway, Scotland and Western Australia.
Paediatr Perinat Epidemiol 1997;11 (Suppl 1):5–22.
26. Martin J, Curtin S, Saulnier M, Mousavi J. Development of the
matched multiple birth file. In: 1995–1998 matched multiple
birth dataset. NCHS CD-ROM series 21, no. 13a. Hyattsville
(MD): National Center for Health Statistics; 2003.
27. Rasmussen S, Albrechtsen S, Dalaker K. Obstetric history and
the risk of placenta previa. Acta Obstet Gynecol Scand 2000;
79:502–7.
28. Miller JE. Birth intervals and perinatal health: an investigation
of three hypotheses. Fam Plann Perspect 1991;23:62–70.
29. Winkvist A, Rasmussen KM, Habicht JP. A new definition of
maternal depletion syndrome. Am J Public Health 1992;82:
691–4.
Prior Cesarean and Risks of Abruption and Previa 777
30. Wilcox AJ, Gladen BC. Spontaneous abortion: the role of
heterogeneous risk and selective fertility. Early Hum Dev
1982;7:165–78.
31. Ananth CV, Demissie K, Smulian JC, Vintzileos AM. Rela-
tionship among placenta previa, fetal growth restriction, and
preterm delivery: a population-based study. Obstet Gynecol
2001;98:299–306.
32. Skjaerven R, Wilcox AJ, Lie RT, Irgens LM. Selective fertility
and the distortion of perinatal mortality. Am J Epidemiol
1988;128:1352–63.
33. Parrish KM, Holt VL, Connell FA, Williams B, LoGerfo JP.
Variations in the accuracy of obstetric procedures and diag-
noses on birth records in Washington State, 1989. Am J
Epidemiol 1993;138:119–27.
34. Krakowiak P, Smith EN, de Bruyn G, Lydon-Rochelle MT.
Risk factors and outcomes associated with a short umbilical
cord. Obstet Gynecol 2004;103:119–27.
35. Rothman KJ, Greenland S. Modern Epidemiology. 2nd edi-
tion. Philadelphia (PA): Lippincott Williams & Wilkins; 1998;
p126–7.

Online Access to Obstetrics & Gynecology

ACOG Members: Link to full-text articles on the Green Journal web site
(www.greenjournal.org) through the Member Access area on www.acog.org. You do not
need to activate your online subscription. However, if you go directly to the Green Journal
site, you will need to follow the same activation instructions that apply to nonmembers.
Nonmember Subscribers: Activate your online subscription by following these steps:

· On the home page of www.greenjournal.org, select the “Subscriptions” button from the
menu bar on the left side of the page.

· At the top of the next page, click “ACTIVATE Your Member or Individual (Nonmember)
Subscription.”

· On the Activation page, enter your 7-digit ACOG Member ID number and click the “Sub-
mit” button. If you are not a member of ACOG, enter your 12-digit customer number . If
your customer number is less than 12 digits, you must precede it with zeros for the system
to recognize your account. Your ACOG Member ID or customer number can be found on
the mailing label of your print journal cover.

778 Getahun et al Prior Cesarean and Risks of Abruption and Previa OBSTETRICS & GYNECOLOGY