TELAAH JURNAL CASE-CONTROL

Disusun Guna Memenuhi Tugas Mata Kuliah Berfikir Kritis

Dosen Pengampu : Sri Mulyati, SST., M.Keb

Disusun Oleh :
1. Venny Puspita 7. Nisyasita Valinda
2. Wardah Fajriah 8. Riska Septiani
3. Novi Wahyuni 9. Septi Eka Novela
4. Nanda Puspita 10. Davilla Pingkan A.Y
5. Retno Kurniawati 11. Dymas Putri Pratiwi
6. Shella Maret S 12. Faisa Salsabila

Kementerian Kesehatan Republik Indonesia

Poltekkes Bandung Jurusan Kebidanan
Program Studi Profesi Bidan
2021
 CRITICAL APPRAISAL SKILLS PROGRAMME (CASP): Making Sense Of Evidence

11 Questions to Help You Make

Sense of a Case Control Study
How to Use This Appraisal Tool
• Three broad issues need to be considered when appraising a case control study.
o Are the results of the study valid?
o What are the results?
o Will the results help locally?
• The 11 questions on the following pages are designed to help you think about
these issuessystematically.
• The first two questions are screening questions and can be answered quickly. If the
answer to both is“yes”, it is worth proceeding with the remaining questions.
• There is a fair degree of overlap between several of the questions.
• You are asked to record a “yes”, “no” or “can’t tell” to most of the questions.
A number of italicised prompts are given after each question. These are designed to remind you why the
question is important. Record your reasons for your answers in the spaces provided.

A. Are the results of the study Is it worth continuing?

valid? Detailed Questions
Screening Questions 3. Were the cases recruited in an acceptable way
1. Did the study address a clearly focusedissue □Yes ■ Can’t Tell □ No
■ Yes □ Can’t Tell □ No
HINT : We are looking for selection bias which might
compromise the validity of the findings:
HINT : A question can be focused in terms of:
 Are the cases defined precisely?
 the population studied
 Were the cases representative of a defined
 the risk factors studied population (geographically and/or
 whether the study tried to detect a beneficial temporally)?
or harmful effect?  Was there an established reliable system for
selecting all the cases?
2. Did the authors use an appropriate  Are they incident or prevalent?
method toanswer their question?  Is there something special about the cases?
■ Yes □ Can’t Tell □ No  Is the time frame of the study relevant to the
disease/exposure?
HINT : Consider:  Was there a sufficient number of cases
 is a case control study an appropriate way selected?
of answering the question under the  Was there a power calculation?
circumstances? (is the outcome rare or
harmful?) Dalam artikel ini tidak dijelaskan tentang
 did it address the study question? banyaknya kasus secara geografis dan
temporal pada lokasi penelitian. Dalam artikel
ini juga tidak disebutkan bahwa ibu dengan
plasenta abnormal memiliki sebuah penyakit.
4. Were the controls selected in an acceptable
way?
■ Yes □ Can’t Tell □ No
HINT : We are looking for selection bias which might
compromise the generalisability of the
findings:
 Were the controls representative of a
defined population (geographically and/or
temporally)?
 Was there something special about the
controls?
 Was the non-response high? Could non-
respondents be different in any way?
 Are they matched, population based or
randomly selected?
 Was there a sufficient number of controls
selected?
5. Was the exposure accurately measured to
minimise bias?
■ Yes □ Can’t Tell □ No
HINT : We are looking for measurement, recall or
classification bias:
 Was the exposure clearly defined and
accurately measured?
 Did the authors use subjective or objective
measurements?
 Do the measures truly reflect what they
are supposed to measure? (have they
been validated?)
 Were the measurement methods similar in
cases and controls?
 Did the study incorporate blinding where
feasible?
 Is the temporal relation correct? (does the
exposure of interest precede the
outcome?)
6. (A) What confounding factors have the authors
accounted for?
List the other ones you think might be important, that
the authors missed (genetic, environmental and
socio-economic)
 Variabel yang berperan sebagai variabel
pengganggu dalampenelitian tersebut adalah
plasenta previa dan berat badan ibu.
Sedangkan hal yang mungkin terlewatkan
oleh peneliti adalah genetic dan sosiol
ekonomi.
(B) Have the authors taken account of the
potential confounding factors in the design
and/or in their analysis?
■ Yes □ Can’t Tell □ No
HINT : Consider:
 Size of the P-value
 Size of the confidence intervals
 Have the authors considered all the
important variables?
 How was the effect of subjects refusing to
participate evaluated
B. What are the results?
7. What are the results of this study?
 Hasil penelitian menunjukan pada
kelompok kasus, 145 kasus (84,3%)
memiliki plasenta akreta, 12 kasus (7,07%)
memiliki plasenta inkreta dan lima kasus
(8,7%) memiliki plasenta perkreta.
Karakteristik yang secara signifikan lebih
umum pada kelompok kasus termasuk
usia kehamilan rata-rata yang lebih rendah
dan berat bayi rata-rata(p< .001), berat
badan lahir rendah (BBLR) dan kecil untuk
usia kehamilan (SGA) (p< .001), masuk ke
NICU (p< .001), jumlah rata-rata hari rawat
inap yang lebih tinggi di NICU (p< .05), skor
Apgar rata-rata 5 menit yang lebih rendah
(p< .001), kejang neonatus (P.004),
perdarahan kranial(P.037), anemia (P.002)
dan trombositosis (P.029). Terjadinya
plasentasi abnormal dikaitkan dengan
beberapa karakteristik ibu yang mendasari
seperti usia ibu yang tinggi (P.34),
menurunkan berat badan ibu (P.044),
multiparitas (P.11), riwayat aborsi
sebelumnya(P.036), dan riwayat operasi
caesar (P.001). Prevalensi plasenta previa
secara signifikan lebih tinggi pada
kelompok kasus (p< .001).
8. How precise are the results? How precise is
theestimate of risk?
 Hasil penelitian presisi, dikarenakan analisis
data dan perhitungan yang digunakan sudah
dijelaskan dengan rinci dalam artikel.
Penelitian ini tidak terlalu beresiko karena
 sampel yang terlibat hanya dilakukan One observational study rarely provides
pemeriksaan laboratorium sehingga tidak sufficiently robust evidence to recommend
membahayakan sampel dalam penelitian changes to clinical practice or within health policy
decision making.
9. Do you believe the results?
However, for certain questions observational
■ Yes □ Can’t Tell □ No
studiesprovide the only evidence.
HINT : Consider: Recommendations from observational studies
 Big effect is hard to ignore! are always stronger when supported by other
 Can it be due to chance, bias or evidence.
confounding?
 Are the design and methods of this study
© Public Health Resource Unit, England (2006).
sufficiently flawed to make the results
All rights reserved. No part of this publication may
unreliable?
 Consider Bradford Hills criteria (e.g. time be reproduced, stored in a retrieval system, or
sequence, dose-response gradient, transmitted in any form or by any means,
strength, biological plausibility) electronic, mechanical, photocopying, recording
or otherwise without the prior written permission
C. Will the results help me of the Public Health Resource Unit. If permission
is given, then copies must include this statement
locally? together with the words “© Public Health
Resource Unit, England 2006”. However,
10. Can the results be applied to the local NHS organisations may reproduce or use the
population? publication for non- commercial educational
■ Yes □ Can’t Tell □ No purposes provided the source is acknowledged

Consider whether
 The subjects covered in the study could be
sufficiently different from your population to cause
concern
 Your local setting is likely to differ much from that
of the study
 Can you estimate the local benefits and harms?

11. Do the results of this study fit with other

availableevidence?
■ Yes □ Can’t Tell □ No

HINT : Consider:
 What are the bottom line results?
 Is the analysis appropriate to the
design?
 How strong is the association between
exposure and outcome (look at the odds
ratio)?
 Are the results adjusted for confounding
and might confounding still explain the
association?
 Has adjustment made a big difference
to the OR ??
 The Journal of Maternal-Fetal & Neonatal Medicine

ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: https://www.tandfonline.com/loi/ijmf20

Maternal and neonatal outcomes of abnormal

placentation: a case–control study

Roksana Moeini, Hossein Dalili, Zeinab Kavyani, Mamak Shariat, Hasti

Charousaei, Afsaneh Akhondzadeh, Amir Naddaf & Fatemeh Sadat Nayyeri

To cite this article: Roksana Moeini, Hossein Dalili, Zeinab Kavyani, Mamak Shariat, Hasti
Charousaei, Afsaneh Akhondzadeh, Amir Naddaf & Fatemeh Sadat Nayyeri (2020): Maternal and
neonatal outcomes of abnormal placentation: a case–control study, The Journal of Maternal-Fetal &
Neonatal Medicine, DOI: 10.1080/14767058.2019.1678128

To link to this article: https://doi.org/10.1080/14767058.2019.1678128

Published online: 21 Apr 2020.

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THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE
https://doi.org/10.1080/14767058.2019.1678128

ORIGINAL ARTICLE

Maternal and neonatal outcomes of abnormal placentation: a

case–control study
Roksana Moeinia,b, Hossein Dalilia, Zeinab Kavyanic, Mamak Shariatc, Hasti Charousaeic,
Afsaneh Akhondzadehd, Amir Naddafb and Fatemeh Sadat Nayyeric
a
Breastfeeding Research Center, Tehran University of Medical Sciences, Tehran, Iran; bPediatrics Department, Vali-e-Asr Hospital,
Tehran University of Medical Sciences, Tehran, Iran; cMaternal, Fetal and Neonatal Research Center, Tehran University of Medical
Sciences, Tehran, Iran; dPediatrics Department, Arak University of Medical Sciences, Arak, Iran

ABSTRACT ARTICLE HISTORY

Background: There is limited information on neonatal outcomes in complicated pregnancies Received 20 February 2019
with abnormal placentation. The aim of this study was to assess the neonatal outcomes of Revised 29 September 2019
abnormal placentation. Accepted 6 October 2019
Methods: In this case–control study, known cases of abnormal placentation between the years
KEYWORDS
2010 and 2017 were extracted. The case group consisted of pregnant women with abnormal Abnormal placentation;
placentation (172 cases), while controls were selected from repeated cesarean section cases LBW; maternal outcomes;
with normal placentation (341 people). neonatal outcomes; NICU
Results: In the case group, 145 cases (84.3%) had placenta accreta, 12 cases (7.07%) had admission; thrombocytosis
placenta increta and five cases (8.7%) had placenta percreta. Characteristics significantly more
common in the case group included lower mean gestational age and average neonatal weight
(p < .001), low birth weight (LBW) and small for gestational age (SGA) (p < .001), admission to
the NICU (p < .001), higher average number of hospitalization days in the NICU (p < .05), lower
average 5-minute Apgar scores (p < .001), neonatal seizure (p ¼ .004), cranial hemorrhage
(p ¼ .037), anemia (p ¼ .002) and thrombocytosis (p ¼ .029). The occurrence of abnormal placen-
tation was associated with some underlying maternal characteristics such as high maternal age
(p ¼ .34), lower maternal weight (p ¼ .044), multiparity (p ¼ .11), history of previous abortion
(p ¼ .036), and history of cesarean (p ¼ .001). The prevalence of placenta previa was significantly
higher in the case group (p < .001).
Conclusion: The presence of placenta previa has a close relationship with abnormal placenta-
tion and is considered to be a potential risk factor for LBW, SGA, lower 5 minutes Apgar scores,
first-day seizure, cranial hemorrhage, the necessity for NICU admission and occurrence of anemia
and thrombocytosis in neonates.

Introduction intense and more extensive. In terms of pathogenesis,

Abnormal placentation has complicated a pregnancy
that may be associated with massive and potentially
life-threatening hemorrhage [1]. This can cause mater-
nal and neonatal mortality and morbidity. Maternal
morbidity had been reported in the literature to occur
in up to 60% and mortality in up to 7% of women
with placenta accreta [2] and at this time is the most
common indication for peripartum hysterectomy [3].
Also, the incidence of perinatal compilations is
also increased mainly due to preterm labor and small-
for-gestational-age neonates [2].
Three common forms for placentation disorders in
the uterus include placenta accreta, placenta increta,
and placenta percreta. The latter form is actually more
the major cause of disorder in abnormal placentation
is related to impaired and inadequate decidualiza-
tion [4].
In terms of incidence, the accreta form is much
more common than the other two forms of increta
and percreta. In 1950, placenta accreta was rare and
only occurred in the USA; the prevalence of the
accreta type was estimated at 1 in 30 000 cases [5].
During the 1980s and 1990s, the incidence of this
form increased more and more such that the inci-
dence of occurrence went up from 1 in 2510 cases to
1 in 533 cases [6,7].
Various risk factors have been mentioned for these
disorders. Existence of placenta previa, previous uter-
ine surgeries, higher parity, and the presence of thin

CONTACT Fatemeh Sadat Nayyeri nsnayeri@tums.ac.ir Maternal, Fetal and Neonatal Research Center, Vali-e-Asr Hospital, Tehran University of
Medical Sciences, Imam Khomeini Hospital Complex, Second Floor, Keshavarz Blvd. Tehran, Iran
ß 2020 Informa UK Limited, trading as Taylor & Francis Group
2 R. MOEINI ET AL.
decidua and high maternal age are mentioned [6];
however, perhaps the greatest risk factor is the previ-
ous history of cesarean, which doubles the risk with
one cesarean and increases the risk by eight times
with more than two cesarean sections [7]. In fact, the
most important risk factor for placenta accreta is the
occurrence of placenta previa after a cesarean section.
In women with placenta previa, the frequency of pla-
centa accreta increases positively with an increase in
the number of cesarean sections [8,9].
There is limited information on perinatal outcomes
in complicated pregnancies with placenta accreta. In
most studies performed to date, maternal outcomes
were investigated while neonatal outcomes were not
thoroughly investigated or had contradictory results in
various studies. With regard to these findings, the
decision was made to assess the neonatal outcomes
of these placental disorders at Valiasr Hospital of the
Imam Khomeini Hospital Complex in Tehran.
Materials and methods
The study performed at Valiasr Hospital of the Imam
Khomeini Hospital Complex with tertiary level NICU.
Our NICU admitted high-risk mothers from Tehran and
surrounding provinces. Neonate with serious problems
such as congenital anomalies and need to surgery
admitted to our NICU. Also, our NICU is a training cen-
ter for pediatric resident and neonatologist specialist.
In a case study research of registered records between
2011 and 2017, known cases of abnormal placentation
were first extracted from the files; the number of
mothers in the control group was selected two times
more than the case group. The case group included
pregnant women with abnormal placentation (172
cases) and the control group consisted of pregnant
women without uterine anomalies or placental vascu-
lar disorders (341 cases). In our center, placenta
accreta deliveries were operated on by the transverse
incision and placenta accreta with previa operated on
by the midline incision. Also, delayed cord clamp and
milking method are not used, but there is an instruc-
tion to keep the baby’s level above the mother’s level
and cut the umbilical cord immediately.
The abnormal placentation criterion was based on
confirmation diagnosis by a perinatologist, which was
recorded in the file. The criteria for this diagnosis were
based on a midwifery reference book, including substi-
tution diagnosis criteria that was performed by
second- or third-month ultrasonography and con-
firmed by a perinatologist. Grading and severity of the
disorder were similarly performed.
Measured variables in the test and control groups
included maternal age; midwifery history; neonatal
weight; pregnancy age during childbirth; 5- and 10-
min Apgar scores; umbilical cord ABG; hospitalization
in NICU; calcium and blood sugar; the first hemoglo-
bin measurement, WBC and blood platelets; the first
levels of sodium and potassium in the blood; seizure
on the first day; brain hemorrhage; and blood/urine/
CSF culture.
Neonatal outcomes and the following definitions
were considered for each outcome:
LBW (low birth weight): birth weight lower than 2.5 kg
SGA (small for gestational age): birth weight lower
than 10% of gestational age
Preterm labor: gestational age less than 37 weeks
Hospitalization in NICU: admission of the infant to
NICU immediately after birth
Low Apgar: 5-minute Apgar less than 7
Abnormal umbilical cord ABG: umbilical cords PH < 7
or BE  12
Sepsis positive blood/urine/CSF culture: bad general
conditions of the neonate with tachycardia or
Tachypnea associated with blood or urine or
CSF culture
Anemia: first day Hb < 12 g/dl
Leukopenia: WBC < 5000 per mm3
Leukocytosis: WBC  30 000 per mm3
Thrombocytopenia: platelet < 150 000 per mm3
Thrombocytosis: platelet  400 000 per mm3
Hypoglycemia: blood sugar 45mg/dl
Hyperglycemia: blood sugar 180mg/dl
Hypocalcemia: blood Ca 8md/dl
Electrolyte disturbances (Na, K)
(For the laboratory variables, the results of the first
three days of birth were evaluated.)
Brain hemorrhage: the presence of blood in germi-
nal matrix, ventricle, parenchyma, subarachnoid space,
and subdural space during hospitalization
Seizure: abnormal movements of facial organs and
eyes validated by the physician or EEG on the day
of birth
This study was performed under ethics license
number IR.TUMS.VCR.REC.1396.2302 of the Ethics
Committee of the Research Vice-Chancellor of Tehran
University of Medical Sciences. All ethical guidelines
were observed in this study. No trial or treatment was
imposed on patients, and each patient was examined
and treated according to their own requirements and
circumstances and the routines of the unit that was
under observation. Some tests were performed on a
 THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 3

Table 1. Comparison of maternal underlying indicators between the test and control groups.
Index Case group (n ¼ 172) Control group (n ¼ 341) p-Value
The average age of the mother 32:61 6 4:85 years 31:63 6 4:92 years .034
Abundance of Iranian race 168 cases (97.7%) 304 cases (97.4%) .999
The average weight of the mother 78:27 6 11:65 kg 81:13 6 14:24 kg .044
Average parity 1.84 ± .096 1.62 ± 0.90 .011
Average gravidity 2.33 ± 1.21 1.9 ± 1.12 .001
Rate of abortion .036
Once 48 cases (27.9%) 60 cases (17.6%)
Twice 10 cases (5.8%) 24 cases (7.1%)
Three times 4 cases (2.3%) 3 cases (0.9%)
Four times or more 0 2 cases (0.6%)
History of previous cesarean section .001
Once 66 cases (38.6%) 205 cases (60.3%)
Twice 72 cases (42.1%) 87 cases (25.6%)
Three times 23 cases (13.5%) 34 cases (10.0%)
Four times or more 1 case (0.6%) 8 cases (2.4%)
History of hypertension 21 cases (12.2%) 46 cases (13.5%) .685
History of diabetes 28 cases (16.3%) 61 cases (17.9%) .649
History of ART (Artificial Reproductive Technique) 3 cases (1.7%) 5 cases (1.5%) .999
History of preterm cases 9 cases (5.2%) 10 cases (2.9%) .193
Cesarean hysterectomy 102 cases (59.3%) 1 case (0.3%) .001
History of smoking 1 case (0.6%) 1 case (0.3%) .999
Abundance of previa 82 cases (47.7%) 6 cases (2.8%) <.001
Maternal mortality rate 0 0 .05<

number of neonates in the control group due to other
risk factors such as birth weight less than 2500 g, sys-
temic maternal diseases like asthma, ITP, mild cardio-
vascular disease, and so on.
The results for quantitative variables were
expressed as mean and standard deviation
(mean ± SD) and qualitative categorical variables were
expressed as percentages. Comparison of quantitative
variables was performed by the t-test or
Mann–Whitney test based on normal or abnormal dis-
tributions, respectively. The comparison between
qualitative variables was performed using the chi-
square test or Fisher’s exact test. In determining fac-
tors related to patient outcomes and in the presence
of basic characteristics of patients as confounding fac-
tors, regression analysis was performed and the results
were expressed as odds ratios (95% confidence inter-
val). Data were analyzed using SPSS version 20 and
SAS version 9.1. The significance level was considered
at less than 0.05.
Results
As indicated in Table 1, there are significant differen-
ces between the test and control groups in terms of
maternal underlying indicators including mean age of
the mother, average weight of the mother, mean par-
ity and gravidity, abortion frequency, history of cesar-
ean, cesarean hysterectomy and abundance of previa.
The case group displayed higher maternal age; lower
maternal weights; higher gravidity and parity; the his-
tory of abortion, higher cesarean rates, and cesarean
hysterectomy along with a higher frequency of pla-
centa previa.
As indicated in Table 2, there were significant dif-
ferences in terms of comparison of neonatal indicators
between the two groups in the areas of mean gesta-
tional age, average neonatal weight, frequency of
LBW, SGA prevalence, mean 5-min Apgar, frequency of
first day seizure, abnormal ABG, frequency of cranial
hemorrhage, frequency of hospitalized cases in the
NICU and average days of hospitalization in the NICU;
however, no significant correlation was found between
placenta disorder and cases of infant death.
According to Table 3, in the comparison of neo-
natal laboratory indicators between the test and con-
trol groups, there were significant differences in the
rate of incidence of anemia and thrombocytosis.
A binary regression model was used to determine
the factors associated with abnormal placentation
from the primary maternal underlying factors. In this
model, a relation between (1) the history of placenta
previa and (2) the primary indicators (maternal age,
maternal weight, parity, history of abortion, and cesar-
ean) was found. History of placenta previa and mater-
nal weight were related to the risk of abnormal
placentation. With regard to the presence of placenta
previa, the risk of abnormal placentation was
increased by 73 times (odds ratio equaled 598.73, p
values of .0001), and maternal weight increased the
risk by 1.02 (odds ratio equaled 1.049, p values less
than .046) (Table 4).
In order to eliminate the confounding effect of pre-
maturity, preterm infants (GA  37 W) were extracted
and correlations were retested. The results showed
4 R. MOEINI ET AL.

Table 2. Comparison of neonatal outcomes between the test and control groups.
Index Case group (n ¼ 172) Control group (n ¼ 341) p-Value
The average age of the pregnancy 35:81 6 2:29 weeks 38:02 6 1:14 weeks <.001
The average weight of the neonate 2702.77 ± 606.59 3273.35 ± 455.87 <.001
Rate of LBW 52 cases (30.4%) 11 cases (3.2%) <.001
Outbreak of SGA 8 cases (4.7%) 3 cases (0.9%) <.001
Average 5-minute Apgar 8.68 ± 1.18 9.39 ± 0.66 <.001
Average 10-minute Apgara 9.29 ± 0.46 9.75 ± 0.46 .036
Frequency of first-day seizure 5 cases (2.9%) No cases .004
Rate of abnormal ABG 3 cases (1.7%) No cases .037
Rate of sepsis 0 0 .05<
Rate of brain hemorrhage 3 cases (1.7%) No cases .037
Frequency of cases administrated to NICU 85 cases (49.7%) 2cases (0.6%) <.001
Average days of hospitalization in NICU 6.59 ± 3.99 0.27 ± 0.017 <.05
Neonatal mortality 2 cases (1.2%) 1 case (0.3%) .233
a
The 10-min Apgar was recorded for 14 cases from the case group and 8 cases from the control group but was not recorded for
the others because the 5-min Apgar was above 7.

Table 3. Comparison of laboratory indexes between the test Table 5. The outcomes of abnormal replacement of the pla-
and control groups. centa-independently of other factors (binary regression test).
Case group Control group 95% CI for OR
Index (n ¼ 172) (n ¼ 341) p-Value
Blood sugar: B p-Value OR Lower Upper
Hypoglycemia 3 cases (1.7%) 6 cases (1.8%) .35 Preterm delivery 2.493 .0001 12.101 5.716 25.619
Hyperglycemia 1 case (0.6%) No cases .05< LBW anemia 1.498 .008 4.47 1.467 13.640
Blood Ca: 2.227 .046 9.268 1.039 82.625
Hypocalcemia 20 cases (11.6%) 23 cases (6.7%) .133 NICU need 4.303 .0001 73.895 8.334 655.168
Hemoglobin:
Anemia 16 cases (9.3%) 1 case (0.3%) .002
WBC:
Leukopenia 1 case (0.6%) No cases .008
investigated with binary regression. The final result
Leukocytosis 1 case (0.6%) No cases .05< showed that abnormal placentation increased the
Platelet: probability of preterm labor (OR ¼ 12.1 and p val-
Thrombocytopenia 4 cases (2.3%) 3 cases (0.9%) .05<
Thrombocytosis 10 cases (5.8%) Na cases .029 ues<.0001), anemia in the infant in a way that no
Blood Na:a – other factor could cause (OR ¼ 9.2 and p values ¼
Hyponatremia 4 cases (2.3%) No cases
Hypernatremia 2 cases (0.6%) No cases .046), LBW (OR ¼ 47.4 and p values ¼ .08), and the
Blood Ka:a necessity of admission to the NICU (OR ¼ 73.89 and p
Hypokalemia No cases No cases –
Hyperkalemia 14 cases (8.1%) 1 case (0.3%) – values < .0001) (Table 5). In addition, higher maternal
a
Due to the inconsistency in checking Na and K in the control group and weight can bring on preterm delivery (OR ¼ 1.02 and
the absence of sufficient data, there were no comparisons made p values ¼ .029). Similarly, preterm labor independ-
between the groups.
ently increased the probability of LBW (OR ¼ 11.9 and
p values < .0001). LBW independently from other fac-
Table 4. Effective factors in abnormal implantation of the tors resulted in hospitalization in the NICU (OR ¼ 9.11
placenta (binary regression test). and p values < .0001). It should be noted that low
95% CI for OR
Apgar scores, neonatal seizure, cranial hemorrhage,
B p-Value OR Lower Upper and thrombocytosis in regression analysis did not
Placenta previa 4.299 .0001 73.598 25.857 209.485 show any correlation with abnormal placentation.
Weight of mother 0.027 .046 1.027 1.000 1.055

that the necessity for admission to the NICU was sig-
nificantly higher in the test group (34 versus 0.3%
p < .0001). Also, the differences in thrombocytosis (3%
in the case group versus 0% in the control group p
values of .002) and anemia (16% in the case group
versus 2% in the control group p values of .009) for
the control group compared with the test group were
significant.
However, with the purpose of covering the effects
of confounding and probable interrupting variables,
factors affecting the accrued outcomes were
Discussion
Findings of the study
In a review of previous studies, it was found that the
presence of disorders in the mode of implantation
and placement of the placenta relative to the position
of the uterus could be associated with an increased
incidence of morbidity and even mortality in the
mother. In some limited studies, the presence of these
disorders also contributed to neonatal morbidity,
although this relationship remains uncertain. In the
present study, the purpose of the first stage of the

study was to compare the two groups with and with-
out abnormal placentation in terms of the primary
characteristics of pregnant mothers and, in the second
stage, the goal was to evaluate the causal relationship
between abnormal placentation with adverse effects
in the infants of these mothers.
Maternal outcomes
First of all, this study has shown that the occurrence
of abnormal placentation was associated significantly
with some of the underlying features in the mother
such as high maternal age, low maternal weight, mul-
tiparity, history of abortion, history of cesarean and
cesarean hysterectomy. Frequent history of placenta
previa and lower pregnancy age were also statistically
significant. However, considering all the confounding
indicators of the study, it was observed that the only
factor associated with abnormal placentation was the
history of the presence of placenta previa, which
increased the risk of abnormal placentation by
73 times.
Previous studies have discussed at length the close
relationship between placenta previa and abnormal
placentation [6–9]. The possibility of the occurrence of
placenta previa after a cesarean section has been
demonstrated to be the most important risk factor for
placentas accreta. With an increase in the number of
cesarean sections the frequency of abnormal placenta-
tion also increases in women with placenta previa. In
studies by Clark et al. (1985) and Silver et al. (2006),
the abundance of abnormal placentation in cases
without cesarean was 1–5% while this frequency in
women with a history of one to 4 cesarean sections
was 11–25%, 35–47%, 40%, and 50–67%, respectively
[8,9]. In a survey conducted by Shih et al. in 2009 on
170 cases of placenta previa, 39 of these placenta pre-
via cases that had a history of cesarean section were
identified as accreta [8,10]. The presence of placenta
previa or a history of several cesarean sections
increases the diagnostic accuracy of these disorders.
Accordingly, when a woman with placenta previa or
with a previous history of uterine surgeries undergoes
ultrasound examination, especially at 18–24 weeks, the
possibility of detection of placenta implantation dis-
order is higher.
In a study by Fitzpatrick et al. in 2012, a
case–control study was performed on 134 patients
with placenta implantation disorder and 258 controls.
The occurrence of placenta accreta was equivalent to
1.7 in 10,000 cases. Higher maternal age at the time
of labor increased the risk of accreta up to 3.3 times,
THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 5
while the previous cesarean increased its risk to 14.2
fold [11]. In our study, the average maternal age in
the test group was higher and its relation with the
occurrence of placenta accreta was significant
(p ¼ .034). Postoperative cesarean and cesarean hyster-
ectomy was also higher in the case group. With the
increase in cesareans, abnormal placentation increased
as well.
In our study, maternal death was not seen.
In a study by Seet et al., patients were classified
into two groups of peripheral and internal penetration
of placenta. In general, cases with deep penetration
were associated with higher parity and higher cesar-
ean history. Mean gestational age was not significantly
different between the two groups. Preterm birth cases
in the two groups were 64.7% and 52.2%, respectively,
which was not a significant difference. There was also
no difference in low birth weight between the two
groups (24% and 29%) [12]. Although the present
study was divided according to the depth of placental
penetration, because there were few mothers with
internal placenta penetration that could be measured,
our comparisons were not the same as in the
study above.
Neonatal outcomes
We found in this study that abnormal placentation
was in turn an important factor associated with the
occurrence of some adverse effects in the newborn,
such as LBW, SGA, lower 5- and 10-min Apgar, fre-
quency of first day seizure, abundance of ABG abnor-
mality, frequency of brain hemorrhage, high rate of
NICU hospitalized cases and greater average days of
hospitalization in the NICU. However, we did not find
any relationship between abnormal placentation and
perinatal mortality. The possible reason for this differ-
ence between our study and the 2017 study by
Baldwin et al. [13] and the 2014 study of Vinograd
et al. [14] is that these studies were community-based
retrospective cohort studies on normal populations
and, as a result, included the births of infants in the
care levels of 1 and 2. While our study was carried out
at 3rd-level maternal and neonatal care centers, which
initially gave the control group some degree of risk
more than a normal population. On the other hand, in
our care units, a complete examination of infants took
place very early after birth which could have resulted
in different death rates. Furthermore, the small sample
size in our study could be another explanation for this
difference which would require further studies. In a
study by Baldwin et al., the presence of placenta
6 R. MOEINI ET AL.
accreta was associated with an increased risk of neo-
natal morbidity by 3.1%. In this regard, the risk of still-
birth was 5.4 times higher and the risk of neonatal
death increased by eight times [13]. In the study per-
formed by Vinograd et al., the presence of placenta
accreta increased the risk of perinatal mortality up to
2.8 times [14]. In our study, there were two neonatal
death cases in the case group (1.2%) and one case in
the control group (0.3%), which was not significant (p
values is equal to .233). One reason for this difference
could be the manner in which neonatal care
was provided.
In our study, the frequency of LBW was significantly
different in the case and control groups. Also, after
the regression analysis, it was shown that abnormal
placentation independently raised LBW. This finding
was not consistent with some studies, such as Ozer
et al. who showed no difference in this area between
the two groups [15].
Balayla et al. reviewed 34 studies from 1977 to
2012 that analyzed the effects of placenta accreta on
neonatal outcomes. A total of 508 617 labors, includ-
ing 865 cases of accreta, were included (Average
Pooled Incidence: 1.588) in this review. Neonatal fac-
tors (including preterm birth, LBW, small for gesta-
tional age, and lower 5-min Apgar) were analyzed and
it was concluded that in many cases, there is a contro-
versy about the neonatal outcome. Because of the
necessity for NICU admission, the administration of
corticosteroids and neonatal morbidity, which are
affected by prematurity, the relationship between the
neonatal outcome and these types of disorders is diffi-
cult to interpret [16]. However, in order to demon-
strate whether the results of the present study were
due to prematurity or abnormal placentation, preterm
infants (GA  37 W) were extracted from the test and
control groups and comparison of neonatal outcomes
were retested in term infants of the case and control
groups. The result of this comparison between the
two groups showed a significant difference in terms of
NICU admission, thrombocytosis, and anemia. This
demonstrated that these undesirable outcomes are
independent of prematurity and are the effects of
abnormal placentation.
In the case of SGA, in our study, there was a signifi-
cant difference between the two groups (4.7% versus
0.9%). In some studies results were similar to ours; for
example, in Gielchinsky et al. (2004), preterm labor
and the number of SGA infants with accreta form pla-
centation disorders were higher in the case group
than in the control group [17]. However, in a retro-
spective study, conducted by Kassem et al. in 2013 in
Egypt, 25 out of 122 placenta previa cases had pla-
centa accreta of which two cases had embryonic
growth restriction and four cases were SGA; further-
more, the indication rate of difference in fetal growth
restriction and SGA between placenta previa or pla-
centa accreta cases and the normal population was
not significant [18]. The fact that prevalence of SGA
varies from one country to another and is particularly
lower among developed countries than developing
countries may justify the absence of significant differ-
ence or higher overall SGA in the population of
Kassem et al.’s study. In addition, although the initial
results of the present study found a significantly
higher rate of SGA infants in the case group than in
the control group, in the secondary results, which
were obtained from the binary regression analysis, this
difference was not significant. Consequently, further
studies on the relationship between abnormal placen-
tation and SGA are still needed.
In a retrospective cohort study conducted by Eshkoli
et al. in 2013, out of a total of 34 869-C/S deliveries
over a period of 23 years there were 139 (0.4%) pla-
centa accreta deliveries with no significant difference in
the outcome of the infants, such as the low 1- and 5-
min Apgar scores and perinatal mortality [19]. In our
study, in the regression analysis, there was no relation
between low Apgar scores and abnormal placentation
and the results were the same for perinatal mortality.
In the study by Ozer et al. the difference between
the 5- and 7-min Apgar was not significant [15]. In our
study, four cases (2.3%) had 5-min Apgar scores below
7, while no cases with the mentioned condition were
observed in the control group. This was significant;
however, regression analysis revealed no relation
between low Apgar and abnormal placentation.
In the present study, there was a significant differ-
ence between the two groups in terms of first-day seiz-
ure and intraventricular hemorrhage (IVH), while
regression analysis exhibited no significant correlation
between the two groups for these factors. Since there
have been no previous studies regarding this matter, it
was not possible to compare our findings with
other studies.
The average NICU admission days and NICU admis-
sion rates were significantly different in our two groups.
Regression analysis also showed that abnormal placen-
tation independently increased the necessity for NICU
admission. It seems that factors involved in the increas-
ing rate of admissions were neonatal anemia, low birth
weight, and short pregnancy duration.
In our study, greater frequencies of anemia and
thrombocytosis in neonates from the case, the group

was found; these factors had not been investigated
and, therefore, these findings should be considered in
clinical studies. In our center, delayed cord clamp and
milking method are not used, and cut the umbilical
cord immediately. It may be argued that anemia can
be due to an immediate cord clamp, but since both
cases and control groups have used the same method,
it cannot cause of anemia. The increase in the fre-
quency of anemia for these neonates is somewhat
predictable; development of anemia by the infants
was the effect of abnormal placentation and bleeding
during labor. This was verified by regression analysis
which demonstrated the independent increase of
anemia in abnormal placentation. However, in terms
of the occurrence of thrombocytosis and its causes,
further studies are required especially since this find-
ing cannot be explained by low birth weight or pre-
maturity of the infant.
Finally, in order to obtain a more definitive out-
come in terms of controversies, it is proposed that
wider studies be carried out in the future.
Conclusion
As a general conclusion, the presence of placenta pre-
via has a close relationship with abnormal placenta-
tion and is a potential risk factor. In addition, the
presence of abnormal placentation increases the risks
of LBW, SGA, lower 5-min Apgar scores, first-day seiz-
ure, cranial hemorrhage, the necessity for NICU admis-
sion, and occurrence of anemia and thrombocytosis in
neonates who are born with the above-mentioned
conditions; therefore, clinical management and control
of these factors are absolutely necessary for preserva-
tion of the natural product of labor.
Disclosure statement
No potential conflict of interest was reported
the author(s).
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