American Journal of Obstetrics and Gynecology (2005) 193, 1045–9

www.ajog.org

Placenta previa-accreta: Risk factors and complications

Ihab M. Usta, MD, Elie M. Hobeika, MD, Antoine A. Abu Musa, MD,
Gaby E. Gabriel, MD, Anwar H. Nassar, MD

Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon

Received for publication March 1, 2005; revised May 18, 2005; accepted June 7, 2005

KEY WORDS Objective: The purpose of this study was to identify risk factors and complications of placenta
Placenta previa-accreta (PA).
Previa Study design: Patients with placenta previa (n = 347) delivered over 20 years were reviewed,
Accreta divided into PA (cases, n = 22) and no accreta (controls, n = 325), and compared.
Complications Results: Cases were older with a higher incidence of smoking and previous cesarean delivery
Risks (CS). Grandmultiparity, recurrent abortions, anterior/central placentae, and low socioeconomic
status were similar. PA incidence increased with the number of previous CS: 1.9%, 15.6%, 23.5%,
29.4%, 33.3%, and 50.0% after 0, 1, 2, 3, 4, and 5 previous CS, respectively. Hypertensive
disorders (odds ratio [OR] 13.9, 95%CI 2.1-91.2], P = .006), smoking (OR 3.4, 95%CI 1.1-10.2,
P = .031) and previous CS (OR 7.9, 95%CI 1.7-37.4, P = .009) were selected by the stepwise
logistic regression analysis as predictors of PA. Cases had a longer hospital stay, a higher
estimated blood loss, and need for transfusion. Cesarean hysterectomy and hypogastric artery
ligation were only performed in PA cases. The 2 groups had a similar delivery gestational age and
neonatal outcome.
Conclusion: Hypertensive disorders, smoking, and previous cesarean are risk factors for accreta
in placenta previa patients. Placenta previa-accreta is associated with higher maternal morbidity,
but similar neonatal outcome compared with patients with an isolated placenta previa.
Ó 2005 Mosby, Inc. All rights reserved.

The incidence of placenta previa which requires ab-
dominal delivery is 0.33% of all deliveries.1 Risk factors
for placenta previa include previous uterine scar, smok-
ing, maternal age over 35 years, grandmultiparity, recur-
rent abortions, low socioeconomic status, infertility
treatment, and male gender. In addition to hemorrhagic
complications, placenta previa is associated with abruptio
placentae, congenital malformations, abnormal presen-
tations, and preterm delivery.2-5
Presented at the Twenty-Fifth Annual Meeting of the Society for
Maternal Fetal Medicine, February 7-12, 2005, Reno, Nev.
Reprints not available from the authors.
Placenta accreta occurs when there is a defect of the
decidua basalis, resulting in abnormally invasive implan-
tation of the placenta.6 Risk factors for accreta include
placenta previa, maternal age over 35 years, grandmulti-
parity, previous curettage, previous myomectomy, previ-
ous uterine surgery, submucous myoma, Asherman’s
syndrome,6-8 a short caesarean-to-conception interval,9
and a female fetus.10 Placenta accreta is associated with
7% mortality rate, as well as intraoperative and postop-
erative morbidity caused by massive blood transfusions,
infection, and adjacent organ damage.6
The rate of placenta accreta in previa cases varies
between 1.18% and 9.3%.3,11 On the other hand, 10%

0002-9378/$ - see front matter Ó 2005 Mosby, Inc. All rights reserved.
doi:10.1016/j.ajog.2005.06.037
1046
of accreta cases have anterior previa.8 Some risk factors
and complications in patients with placenta accreta
might be attributed to the coexistence of the 2 entities.
We conducted our study to identify risk factors and
complications of placenta accreta in the presence of
placenta previa.
Material and methods
Our computer database was used to retrieve all cases
admitted with the diagnosis of placenta previa over 20
years (1983-2003). Charts were reviewed for maternal
demographics, including age, parity, gestational age,
previous cesarean delivery (CS), placental location, social
status, and history of smoking. Data on mode of delivery,
estimated blood loss, presence of placenta accreta, pla-
cental pathology, bleeding complications, procedures
needed to control bleeding, and transfusions were docu-
mented. Neonatal charts were reviewed for birth weights,
Apgar scores at 1 and 5 minutes, intensive care nursery
admission, respiratory distress, need for mechanical ven-
tilation, intraventricular hemorrhage, necrotizing enter-
ocolitis, suspected or confirmed sepsis, periventricular
leukomalacia, nursery stay, and perinatal mortality.
Patients were divided into those with placenta previa-
accreta (PA) (cases) and those without placenta accreta
(controls). The 2 groups were compared for maternal
demographics, intrapartum and postpartum complica-
tions, and neonatal outcome. Placenta accreta was
defined according to clinical or histologic criteria as
follows: 1) manual removal of the placenta partially or
totally impossible, and no cleavage plane between part
or all of the placenta and the uterus; 2) heavy bleed-
ing from the implantation site after forced placental
removal or piecemeal removal of the placenta; or 3)
histologic confirmation of placenta accreta.12 Advanced
maternal age (AMA) was defined as age R35 years and
grandmultiparity as parity R5.
Discrete variables were compared with the use of the
chi-square test or 2-tailed Fisher exact test if the expected
cell frequencies were small. Continuous variables were
compared by the Student t test. A P value ! .05
was considered statistically significant. Stepwise logistic
regression analysis was used to identify risk factors for
previa-accreta. Independent variables included in the
model were: AMA, grandmultiparity, recurrent abor-
tions, smoking, anterior or central placental location,
hypertensive disorders, and previous cesarean delivery
(0, 1, or R2).
Results
A total of 371 patients admitted with the diagnosis of
placenta previa were reviewed. Apart from the delivery
admission, 27.0% were admitted once, 20.8% twice,
Usta et al
3.8% 3 times, and .3% 4 times for bleeding, ruptured
membranes, or preterm labor. The mean predelivery
stay was 4.93 G 5.16 days (range 1-32) and the delivery
stay was 5.90 G 7.2 days (range 1-92). The previa was
complete in 24.0%, partial in 12.1%, marginal in 7.5%,
and low-lying in 15.4%. In 41.0%, the exact location of
the previa in relation to the cervix was not specified.
Risk factors including smoking, AMA, grandmultipar-
ity, recurrent abortions, and low socioeconomic status
were absent in 23.3% of patients.
After excluding 12 patients delivered in an outside
hospital and 12 delivered at !24 weeks of gestation, 347
patients were analyzed for their delivery admission. The
placenta was PA in 22 (cases) and non-accreta in 325
(controls), with a rate of placenta accreta in previa
patients of 6.3%.
Table I describes the demographic characteristics of
cases and controls. The incidence of PA was 12.2% in
smokers compared with 4.8% in nonsmokers (P = .041)
and 1.9% in those with no previous CS versus 21.0% in
the 81 patients with a previously scarred uterus (P !
.001). It increased with the number of previous CS at a
rate of 1.9%, 15.6%, 23.5%, 29.4%, 33.3%, and 50.0%
after 0, 1, 2, 3, 4, and 5 previous CS, respectively. The
incidence of PA was significantly higher in patients with
AMA compared with those !35 years (13.6% vs 4.1%,
P = .005). Accreta rate was 3.3% in those !25 years,
3.4% in those 25 to 29 years, 5.5% in those 30 to 34
years, and 13.6% in those with AMA. Although the
incidence of PA was higher in grandmultiparas (11.1%
vs 5.5%, P = .117), in patients with recurrent abortions
(13.0% vs 5.9%, P = .171), in those with low socioeco-
nomic status (5.2% vs 7.4%, P = .401), and in those
with anterior or central placental location (8.9% vs
5.1%, P = .258), the differences did not reach statistical
significance.
AMA was not found to be a significant risk factor for
PA when patients were subgrouped according to the
presence (30.3% vs 14.6%, P = .153) or absence (2.1%
vs 1.8%, P = 1.000) of a previous scar. Anterior or
central placental location was found to be a significant
risk factor in the presence of a previous scar (28.6% vs
1.9%, P ! .001), but not in its absence (2.4% vs 6.0%,
P = .239).
The variables selected using the stepwise logistic
regression analysis as predictors of PA were hyperten-
sive disorders (OR 13.9, 95%CI 2.1-91.2, P = .006),
smoking (OR 3.4, 95%CI 1.1-10.2, P = .031), and
previous CS (OR 7.9, 95%CI 1.7-37.4, P = .009);
more than 1 CS further increased the risk (OR 30.5,
95%CI 8.2-113.6, P ! .001).
Table II describes antepartum and peripartum com-
plications in cases and controls. The placenta was
removed piecemeal in 5 (22.7%), suturing of placental
bed was required in 4 (18.2%), hypogastric artery liga-
tion in 1 (4.5%), and hysterectomy in 2 (9.1%). Placenta
Usta et al 1047

Table I Demographic characteristics Table II Antepartum and peripartum events

Cases Controls P Cases Controls P
Characteristics (n = 22) (n = 325) value Characteristic (n = 22) (n = 325) value
Age (y)*y 32.6 G 4.80 30.0 G 5.77 .040 Needed antepartum 45.5 52.9 .210
R35 (%)* 50.0 21.5 .005 admission (%)
Parityy 3.25 G 2.43 2.54 G 2.51 .199 Bleeding as indication 31.8 34.5 .984
Grandmultiparity (%) 27.3 14.8 .207 for delivery (%)
Smoking (%)* 40.9 20.0 .041 Diabetes (%) 4.5 1.5 .327
Low socioeconomic 40.9 50.2 .536 Hypertensive 13.6 3.1 .042
status (%) disorders (%)*
Previous cesarean (%)* 77.3 19.7 ! .001 Vaginal delivery (%)* 0 24.3 .006
Recurrent abortions 13.6 6.2 .171 Abruptio (%) 0 7.7 .387
R3 (%) Maternal hospital 12.8 G 9.0 5.5 G 5.3 ! .001
Anterior or central 45.5 31.4 .258 stay (days)*y
placenta (%) Estimated blood 2262 G 1261 847 G 420 ! .001
* Statistically significant. loss (ml)*y
y
Data presented as mean G standard deviation. Transfusion (%)* 95.5 25.2 ! .001
Excessive bleeding (%)* 100.0 27.1 ! .001
* Statistically significant.
y
accreta was confirmed in both hysterectomy specimens. Data presented as mean G standard deviation; excessive
bleeding = postpartum hematocrit !25%, or blood loss O1200 mL,
Blood loss was estimated at R3000 mL in 22.7% cases
or drop in hematocrit R10 units or needed transfusion.
compared with only .3% controls (P ! .0001) and
transfusion with R5 units was needed in 9.1% cases
versus 3.1% controls (P = .172). We had no cases of
bladder or bowel invasion and no maternal mortalities. Table III Neonatal outcome
Table III describes the neonatal outcome in cases and
Cases Controls P
controls. The outcome was similar in all respects,
Characteristic (n = 22) (n = 325) value
including respiratory distress (9.1% and 11.1%), need
for mechanical ventilation (4.5% and 13.2%), intraven- Gestational age (wk)* 35.90 G 2.76 36.14 G 3.70 .808
Birth weight (g)* 2948 G 642 2753 G 800 .207
tricular hemorrhage (0% and 3.7%), necrotizing enter-
Preterm delivery
ocolitis (0% and 1.5%), suspected sepsis (13.6% and
!28 weeks (%) 4.5 4.3 1.000
14.2%), confirmed sepsis (0% and 2.2%), patent ductus !32 weeks (%) 9.1 12.6 1.000
(4.5% and 1.5%), periventricular leukomalacia (0% and !37 weeks (%) 45.5 37.2 .295
.6%), and retinopathy of prematurity (4.5% and .3%) in Apgar score at 6.52 G 2.36 6.50 G 2.64 .973
cases and controls, respectively. 1 min*
Apgar score at 8.52 G 2.04 8.13 G 2.42 .471
5 min*
ICN admission (%) 22.7 36.6 .278
Comment Perinatal mortality 45 110 .491
(per thousand)
The rate of placenta accreta in the literature varies
between 0.001% and 0.9% of deliveries, a rate that ICN, Intensive care nursery.
* Data presented as mean G standard deviation.
depends on the definition adopted for accreta (clinical or
histopathologic diagnosis) and the population studied.8
There has been an almost 10-fold increase in the
incidence of accreta in recent years compared with increase in the incidence of PA with 1 and 2 CS was
that reported in the 1950s, probably resulting from the lower than previously reported (3.3% and 11.0%,
increased cesarean section rate.6,11 respectively).13 Miller et al11 studied 590 cases of pla-
The rate of accreta in our previa cases was 6.3%. One centa previa and found a rate of PA of 4%, 14%, 23%,
of the factors highly associated with PA was previous 35%, 50% after 0, 1, 2, 3, and 4 CS, respectively. The
CS, where the rate of PA increased with the number of incidence of accreta was higher in other reports reaching
previous CS. The risk for PA in patients with one CS 4% to 5%, 24%, 60%, and 67% after 0, 1, R3, and R4
was w8-fold higher compared with those with an CS7,14 and even higher, reaching 34.8%, 56%, 75%, and
unscarred uterus and further increased w4-fold with 2 100% after 0, 1, 2, and R2 CS.15 The American College
or more CS. The same was observed in a recently of Obstetrics and Gynecology (ACOG) warns of a rate
published abstract from the Maternal Fetal Medicine of accreta of 40% in patients with more than 2 CS and
Unit Cesarean Section Registry, although the rate of anterior or central placenta previa.6
1048
Our study shows an almost stable rate of accreta until
maternal age exceeds 35 when the incidence of accreta
rises dramatically. Advanced age and previous uterine
scar seem to act synergistically to increase the risk of
PA. AMA was also an important risk factor for PA in
a study by Lachman et al.16 Miller et al11 reported an
increase in accreta incidence with age, but the increase
was progressive with a rate of PA of 3.2%, 6.2%,
10.2%, and 14.6% for those !25, 25 to 29, 30 to 34, and
R35 years, respectively.
The incidence of PA was not significantly higher in
grandmultiparous women. Zaki et al14 reached similar
conclusions where the effect of age and parity was less
dramatic than previous scar. Unlike previous reports,8,11
we did not find a higher incidence of accreta with an
anterior or central placenta; however, the location of the
placenta had an impact only in those with a previously
scarred uterus. Recurrent abortions were not associated
with a higher incidence of accreta, although previous
curettage was previously reported as an important risk
factor for PA, in which the incidence of accreta was
36%, 58%, and 70% in those with 0, 2, and 3 previous
curettages, respectively.15
Although peripartum complications were higher in
PA cases, the rate of antepartum complications, how-
ever, was similar, except for hypertensive disorders. It is
plausible that hypertensive disorders might be a risk
factor for accreta because of the possible vascular endo-
thelial damage in hypertension. On the other hand,
placenta accreta might increase the risk for preeclampsia
caused by abnormal trophoblastic invasion. Further
studies are needed to test this hypothesis and confirm
this association. The possible overlap between previous
CS, maternal age, parity, and hypertensive disorders was
accounted for using stepwise logistic regression analysis.
CS and hypertensive disorders remained significant
independent of maternal age.
Identifying risk factors is important because sono-
graphic, Doppler, and magnetic resonance imaging
diagnosis of placenta accreta is now possible,17-19 and
in settings where these diagnostic capabilities are avail-
able, clinical risk factors may be used as screening
criteria for placenta accreta. In emergency situations or
in settings in which ultrasonographic diagnosis is not
available, awareness of clinical risk factors can aid in
careful preoperative preparation and in counselling
women with placenta previa regarding the likelihood
of encountering placenta accreta with its attendant
morbidity as recommended by ACOG and Royal Col-
lege of Obstetricians and Gynaecologists (RCOG).6,20
Compared with previa patients, cases with PA had a
higher incidence of bleeding complications and a longer
maternal hospital stay. Our complication rate was
higher than previously reported for cases of placenta
accreta in general, where only 21% required transfusion
and 3.5% ended in hysterectomy.8 Both patients that
Usta et al
required hysterectomy had placenta accreta (9.1%).
Patients with placenta previa and scarred uterus are
reported to have a 16% chance of undergoing hysterec-
tomy for accreta compared with 3.6% risk for hyster-
ectomy in cases of placenta previa and an unscarred
uterus.1 The rate of peripartum hysterectomy is 1.0 to
1.4 per thousand of deliveries,7,15,21,22 and placenta
accreta is reported as the leading15,22 or the second
most common indication for peripartum hysterectomy,7
constituting 23.8% to 64% of these cases.21 In one of the
reports, PA constituted 8.5% of these cases.15
Although a few reports have been published docu-
menting differences in risk factors between patients with
previa alone compared with patients with PA,11,14 little
has been mentioned about differences in perinatal out-
come. Earlier reports have shown that placenta accreta
was associated with higher rates of small-for-gestational
age, preterm delivery, and perinatal mortality compared
with normal pregnancies. Similar to Miller et al,11 our
study shows a similar gestational age at delivery, com-
parable birth weight, and no difference in perinatal
morbidity and mortality between placenta previa and
PA patients. Our perinatal mortality rates were rela-
tively high in both cases and controls. This could be
partially attributed to including older cases dating back
to 1983 before the advances in neonatal care. In fact,
this is one of the limitations of the present study that
could have potentially skewed our results because the
prevalence of risk factors like previous CS and AMA
might have changed over time.
In conclusion, hypertensive disorders, smoking, and
previous cesarean are risk factors for placenta accreta in
previa patients. Placenta previa-accreta is associated
with a higher maternal morbidity compared with
isolated previa without significant differences in the
neonatal outcome.
Acknowledgments
We would like to acknowledge Dr Hala Tamim from the
Department of Epidemiology and Population Health at
the American University of Beirut for her assistance in
the statistical analysis.
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