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Placenta previa: Incidence, risk factors and outcome

Article  in  Ultraschall in der Medizin · October 2013

DOI: 10.1055/s-0033-1354833

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ISSN: 1476-7058 (print), 1476-4954 (electronic)

J Matern Fetal Neonatal Med, Early Online: 1–4

! 2015 Informa UK Ltd. DOI: 10.3109/14767058.2015.1049152

ORIGINAL ARTICLE

Placenta praevia: incidence, risk factors and outcome

Martina Kollmann, Jakob Gaulhofer, Uwe Lang, and Philipp Klaritsch

Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Univeritaet Graz on 06/09/15

Abstract Keywords
Objective: Aim of this study was to evaluate the incidence, potential risk factors and the Incidence, maternal and neonatal outcome,
respective outcomes of pregnancies with placenta praevia. placenta praevia, risk factors
Methods: Data were prospectively collected from women diagnosed with placenta praevia in 10
Austrian hospitals in in the province of Styria between 1993 and 2012. We analyzed the History
incidence, potential risk factors and the respective outcomes of pregnancies with placenta
praevia. Differences between women with major placenta praevia (complete or partial placenta Received 1 May 2015
praevia) and minor placenta praevia (marginal placenta praevia or low-lying placenta) were Accepted 5 May 2015
evaluated. Published online 4 June 2015
Results: 328 patients with placenta praevia were identified. The province wide incidence of
placenta praevia was 0.15%. Maternal morbidity was high (ante-partum bleeding [42.3%], post-
partum hemorrhage [7.1%], maternal anemia [30%], comorbid adherent placentation [4%], and
hysterectomy [5.2%]) and neonatal complications were frequent (preterm birth [54.9%], low
For personal use only.

birth weight 52500 g [35.6%], Apgar-score after five minutes 57 [5.8%], and fetal mortality
[1.5%]. Women with major placenta praevia had a significant higher incidence of preterm
delivery, birthweight 52500 g and Apgar-score after five minutes 57.
Conclusions: Placenta praevia was associated with adverse maternal (34.15%) and neonatal
(60.06%) outcome. The extent of placenta praevia was not related with differences regarding
risk factors and maternal outcome.

Objective
Placenta praevia occurs with an incidence of 0.3–0.5% and is
defined by implantation of the placenta in the lower uterine
segment, thus partially or totally overlying the internal os [1].
Diagnosis is usually made during the second half of
pregnancy by vaginal or trans-abdominal sonography [2,3].
Terminology, however, is still inconsistent and a need for
adequate sonographic criteria has been addressed several
times [3,4]. The condition is frequently complicated by
invasion of placental villi beyond the decidua basalis causing
placenta accreta or increta [5]. Due to the abnormal location
and invasion of placental tissue, severe maternal bleeding is
likely to occur, especially in the third trimester of pregnancy
and with the onset of labor [1,5]. Such abnormal placentation
has been observed to be associated with previous caesarean
deliveries [5–7] or other uterine surgeries, such as myomect-
omy or curettage, advanced maternal age, multiparity and
smoking [5,6,8]. Whilst there has been a global rise in the
number of caesarean deliveries, rates vary considerably
within and between countries [9]. In Austria the caesarean
Address for correspondence: Philipp Klaritsch, Division of Obstetrics
and Maternal Fetal Medicine, Department of Obstetrics and Gynecology,
Medical University of Graz, Auenbruggerplatz 14, A-8036 Graz,
Austria. Tel: +43 316 385 81641. Fax: +43 316 385 13199. E-mail:
philipp.klaritsch@medunigraz.at
section rate has raised in the last decade from 22 to almost
30% [10], thus increasing the likelihood for abnormal
placentation.
We therefore aimed to evaluate the incidence and outcome
of placenta praevia in our institution, a tertiary referral center,
as well as in our associated province hospitals. Additionally
we intended to analyze the association with previously
reported risk factors.
Methods
We performed a study on frequency, perinatal complications,
and risk factors in a cohort of pregnant women diagnosed
with placenta praevia in our institution and nine referring
hospitals in our province. The overall study period covers the
time span between March 1993 and October 2012. Data were
retrospectively retrieved from the local perinatal database and
the medical documentation system or patient files. At our
institution, a tertiary referral hospital, data were collected in a
purpose designed database from 1993–2003. From 2003
onwards a new electronic perinatal database (PIA, ViewPoint,
GE Healthcare, Zipf, Austria) was implemented covering all
deliveries across the whole province. Therefore, the study
population comprises of women from two decades: the initial
population of our institution from 1993 to 2003, and the
province-wide population from 2003 to 2012. Our institution
 2 M. Kollmann et al.
acts as a referral center for pregnancies at risk and therefore
we were interested in the evolution of this condition at our
unit within the last decade.
The study was approved by the institutional review board
(Nr: 24-213 ex 11/12). All women diagnosed with any type of
placenta praevia including low-lying placenta, were identi-
fied. Maternal outcome parameters were comorbid abnormal
placentation (placenta accreta, increta or percreta), ante-
partum bleeding, post-partum hemorrhage of more than
2000 mL, anemia (5100 g/L/6.2 mmol), and intra- or post-
partum hysterectomy. Neonatal parameters were gestational
age at delivery, birth-weight and length, Apgar-scores after
five minutes, as well as neonatal mortality. Information on
prior uterine surgeries (caesarean section, myomectomy,
curettage with or without hysteroscopy), parity, and smoking
was collected.
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Univeritaet Graz on 06/09/15
The study population was stratified in two groups with
‘‘major placenta praevia’’ (complete or partial placenta
praevia) or ‘‘minor placenta praevia’’ (marginal placenta
praevia or low-lying placenta) and evaluated with regard to
risk factors and perinatal outcome [11].
Statistical analysis
Statistical analyses were performed by using descriptive
statistics, Chi-Square-Test and Mann–Whitney-Test, when
appropriate, applying a significance level of 50.05 (SPSS,
V20.0, IBM Analytics Software, Chicago, IL). Results are
For personal use only.
presented as odds ratios with 95% confidence intervals
(95% CI) and p values.
Results
Between January 1993 and October 2012 placenta praevia
was diagnosed in 328 women. In this time span a total of 218
876 deliveries occurred in the province resulting in an
incidence of 0.15%. Overall mean maternal age was 31.6
(17–46) years and 29.3% (n ¼ 96) were older than 35 years
at time of delivery. 187 (57%) women were multiparas. The
degree of placental pathology was documented in 209
patients. 82 (39%) presented with a low-lying placenta, 36
(17%) with a marginal placenta praevia, 18 (9%) with a
partial, and 73 (35%) with a complete placenta praevia.
Perinatal outcome was documented in 326 (99.4%)
patients, while information of the prenatal course of preg-
nancy was available in only 260 (79.3%) cases. In 110
Table 1. Evaluation with regard to maternal and fetal outcome after stratification to ‘‘major placenta praevia’’ (complete or partial placenta praevia) or
‘‘minor placenta praevia’’ (marginal placenta praevia or low-lying placenta).
Major placenta praevia
Pregnancy data and perinatal outcome n %
Maternal outcome
Antenatal bleeding 29/69 42.0
Anemia (requiring treatment) 29/90 32.2
Postnatal bleeding (42 l) 9/90 10
Hysterectomy 5/90 5.6
Fetal outcome
Preterm delivery 69/91 75.8
Birth weight 52500 g 42/90 46.7
Apgar-score after 5 min 57 9/90 10
J Matern Fetal Neonatal Med, Early Online: 1–4
(42.3%) patients ante-partum bleeding occurred while 23
(7.1%) had post-partum hemorrhage and 98 (30.1%) were
anemic. In 13 (4.0%) a comorbid abnormal placentation was
present and in 17 (5.2%) cases hysterectomy was performed.
There was no maternal death in the total population.
Mean gestational age at delivery was 35.6 (23–41) weeks
of gestation and a total of 179 (54.9%) infants were born 537
weeks of gestation. Mean birth-weight was 2692 g
(603–4500) and in 116 (35.6%) newborns it was below
2500 g. In 19 (5.8%) children Apgar-score after five minutes
was 57. Five (1.5%) infants died; two pre-natally and three
post-natally. Mode of delivery was documented in 297 cases
and revealed that 271 (91.2%) women had a caesarean
section. Women with a ‘‘major placenta praevia’’ were all
delivered by caesarean section and had a significant higher
incidence of preterm delivery (OR ¼ 6.04, CI 3.27–11.15,
p50.01), birth-weight 52500 g (OR ¼ 3.82, CI 2.05–7.11,
p50.01) and Apgar-score after five minutes 57 (OR ¼ 6.39,
CI 1.35–30.35, p50.01; Table 1). Delivery was per-
formed one week earlier on average if a ‘‘major placenta
praevia’’ was present (35.3 versus 36.4 weeks of gestation,
p50.01). We found similar results when comparing the
mean birth-weight (2619 versus 2783 g, p50.01), birth
length (47.5 versus 48.2 cm, p50.01), and head circumfer-
ence (33.0 versus 33.3 cm, p50.01).
Data on prior uterine surgeries and recurrent abortions
were available in 167 (50.9%) cases. 82 (49.1%) patients
had a history of uterine surgery, including caesarean
section, curettage and hysteroscopy. In our population
none had prior myomectomy. The major share were
previous caesarean sections, posing 22.8% (n ¼ 38) of the
population. Thirty-one (18.5%) patients had one prior
caesarean delivery, five (3.0%) two, and one (0.6%) four
and five, respectively. Thirty-eight (22.8%) women had
prior abortions treated with curettage. Placenta localization
in previous pregnancies was documented in 158 (48.2%)
cases and 17 (10.8%) of them had a preceding placenta
praevia. Risk factors and maternal outcome were not
related to the classification of placenta praevia (Tables 1
and 2). At our institution, the tertiary referral center of the
province, a total of 23 990 women were delivered from
March 2003 to October 2012 including 106 (0.44%) cases
with placenta praevia. The local annual incidence increased
from 0.36% in 2003 to 0.54% in 2012, with the lowest
rate in 2004 (0.26%) and the highest one in 2011 (0.74%).
Minor placenta praevia
n % p value Odds ratio 95% CI
39/102 38.2 n.s. 1.17 0.63–2.18
30/118 25.4 n.s. 1.39 0.76–2.56
6/118 5.1 n.s. 2.07 0.71–6.06
4/118 3.4 n.s. 1.68 0.44–6.43
40/117 34.2 50.01 6.04 3.27–11.15
22/118 18.6 50.01 3.82 2.05–7.11
2/117 1.7 50.01 6.39 1.35–30.35
 DOI: 10.3109/14767058.2015.1049152
Table 2. Evaluation with regard to risk factors after stratification to ‘‘major placenta praevia’’ (complete or partial placenta praevia) or ‘‘minor
placenta praevia’’ (marginal placenta praevia or low-lying placenta).
Major placenta praevia
Pregnancy data and perinatal outcome n %
Risk factors
Prior operations involving uterine cavity 43/90 47.8
Maternal age 435 25/91 27.5
Prior miscarriage with operative management 20/90 22.2
Prior placenta praevia 9/89 10.1
Figure 1. The incidence of placenta praevia
increased paralleled by an increase in the rate
of caesarean deliveries between 2003 and
2012.
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Univeritaet Graz on 06/09/15
For personal use only.
This was paralleled by an increase in the rate of caesarean
deliveries from 24.2 to 31.9% (Figure 1).
Conclusions
We evaluated the incidence and outcome of placenta praevia
as well as the association with previously reported risk
factors. Our finding, that the extent of placenta praevia did not
differ with regard to risk factors and maternal outcome is
important as one may underestimate the significance and risk
of a ‘‘minor placenta praevia’’ (low-lying placenta and
marginal placenta praevia).
The incidence of placenta praevia considerably increased
in our unit from 0.36% in 2003 to a maximum of 0.74% in
2011, paralleled by a raise of caesarean deliveries from 24.2
to 31.9%. The relatively high incidence in our center in
comparison to the one of the entire province (0.15%) is
mainly due to the fact that most complicated pregnancies are
referred to our institution, which is also equipped with a
neonatal intensive care unit.
Nearly half (49.1%) of our patients with a placenta praevia
had prior uterine surgery. The most frequent surgical history
was obviously caesarean section. In general it seems import-
ant to avoid uterine operations whenever possible, especially
if there is the wish to preserve fertility. In our institution,
caesarean deliveries are only performed when medically
indicated. However, in other provincial hospitals, especially
the private ones, a considerable number of caesarean
deliveries may have been performed on maternal request,
which obviously contributed to the increased number of this
intervention [9,12]. The increased risk of placental
Placenta praevia: incidence, risk factors and outcome 3
Minor placenta praevia
n % p value Odds ratio 95% CI
26/54 48.1 n.s. 0.99 0.59–1.94
27/118 22.9 n.s. 1.28 0.68–2.39
11/54 20.3 n.s. 1.12 0.49–2.56
4/53 7.5 n.s. 1.38 0.40–4.72
pathologies in subsequent pregnancies should be emphasized
during informed consent for caesarean section. Evidence
suggests a correlation between the number of previous
caesarean sections and the occurrence of a placenta praevia,
uterine rupture and hysterectomy [13]. Therefore, vaginal
birth after caesarean delivery may be offered and consenting
patients be transferred to institutions with adequate experi-
ence [13–16]. A recent review is reporting successful vaginal
delivery following one and two caesarean sections in 76.5 and
71.7%, while perinatal hysterectomy was required in only
0.19 and 0.55%, respectively [15].
A substantial number of women in our study population
previously underwent curettage due to abortions. These
patients may benefit from less invasive approaches [1,17],
like medical treatment of missed abortions with misoprostol
whenever this is in accordance with clinical and personal
prerequisites [18].
In our department, delivery between 35 + 0 and 36 + 0
weeks of gestation is pursued if major placenta praevia
(placenta praevia partialis and totalis) is present.
Nevertheless, still 42.3% of our patients presented with
antepartum bleeding. This number appears high, but we know
from other studies that this proportion may reach up to 90%
[19]; a strategy of elective preterm delivery seems to reduce
this risk.
Hysterectomy rate in patients with a placenta praevia
ranges between 5 and 19% according to previous studies
[20–23]. In 5.2% of our patients hysterectomy was necessary,
29.4% of these presented with a comorbid abnormal placen-
tation. Due to our retrospective study design we could not
differ between an anterior or posterior localization of the
 4 M. Kollmann et al.
placenta praevia. Jang et al. performed a study looking at
different localizations and found that anterior position
increases the incidence of excessive blood loss, massive
transfusion, placental accreta and hysterectomy. Therefore
detailed sonographic determination may contribute in predic-
tion of maternal outcome [22]. Maternal death in association
with the presence of a placenta praevia is rare in the western
word, but is still a substantial issue in developing countries
[5,20,21,23–25].
A major neonatal risk factor increasing adverse outcome is
preterm birth. Delivery prior to 37 weeks of gestation
occurred in 54.9% of our population. This is genuinely
related to elective preterm delivery and therefore unavoidable.
As the mean gestational age at delivery was 35.64 weeks of
gestation these babies are not extremely preterm. However,
recent studies demonstrate that even late preterm babies
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Univeritaet Graz on 06/09/15
may face substantial health problems in later life [26,27].
Neonates of women with ‘‘major placenta praevia’’ had a
significant worse outcome in our study.
It is noteworthy, that the extent of placenta praevia was not
related with differences regarding risk factors and maternal
outcome. In 3.4% of our patients with a ‘‘minor placenta
praevia’’ (low-lying placenta and placenta praevia marginalis)
hysterectomy was necessary. This is important as we often
tend to underestimate the significance and risk of these
entities.
We believe that reported numbers are of significance for
For personal use only.
physicians dealing with affected pregnancies and may help in
management of this condition. Placenta praevia is associated
with adverse maternal and neonatal outcome and detection
and, if possible, prevention of risk factors is therefore
important.
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of this article.
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