Predictors for Massive Haemorrhage during Caesarean Delivery Due to Placenta Praevia

Mara Burgers¹, Katrien Oude Rengerink¹, Sanne J. Eschbach², Moira M. Muller³, Marielle G. van Pampus⁴, Ben W. J. Mol⁵, Irene M. de Graaf¹

¹Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
²Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, The Netherlands.
³Department of Obstetrics and Gynaecology, Spaarne Ziekenhuis, Hoofddorp, The Netherlands.
⁴Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
⁵Department of Obstetrics and Gynaecology, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, Australia.

DOI: 10.4236/ijcm.2015.62014                

Abstract

Objectives: To describe the incidence and predictive factors for massive haemorrhage during a caesarean delivery in women with placenta praevia. Methods: We performed a retrospective cohort study among consecutive women with a placenta praevia planned for a caesarean delivery between 2001-2011 in one academic centre and two teaching hospitals in the Netherlands. Massive haemorrhage was defined as ≥1000 mL blood loss during caesarean section. We used logistic regression analysis to assess which maternal and pregnancy characteristics were predictors for massive haemorrhage during caesarean delivery. Results: Of 54,794 deliveries, we identified 215 (0.39%) women with placenta praevia who underwent a Caesarean delivery, of whom 94 (44%) had massive haemorrhage at or after surgery. After univariable preselection, multivariable logistic regression indicated that higher maternal age (OR 2.09; 95% CI 1.17 - 3.74), no Caucasian ethnicity (OR 1.73; 95% CI 0.92 - 3.27), multiple pregnancy (OR 3.92; 95% CI 0.72 - 21.28), lower systolic blood pressure during pregnancy (OR 1.03; 95% CI 1.00 - 1.07) and the placenta located at the anterior wall (OR 2.21; 95% CI 1.20 - 4.04) were independent predictors for massive haemorrhage during a caesarean delivery in women with placenta praevia. Predicted probabilities varied between 22% and 71%. The model has a reasonable discriminative ability and acceptable calibration. Conclusions: Women with placenta praevia are at high risk for massive haemorrhage during caesarean delivery. The risk profile can be used to identify extreme high-risk women in whom extensive preventive measures are justified.

Keywords

Placenta Praevia, Massive Haemorrhage, Caesarean Section, Predictors

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Oyelese, Y. and Smulian, J.C. (2006) Placenta Previa, Placenta Accreta, and Vasa Previa. Obstetrics & Gynecology, 107, 927-941. http://dx.doi.org/10.1097/01.AOG.0000207559.15715.98
[2]	Iyasu, S., Saftlas, A.K., Rowley, D.L., Koonin, L.M., Lawson, H.W. and Atrash, H.K. (1993) The Epidemiology of Placenta Previa in the United States, 1979 through 1987. American Journal of Obstetrics and Gynecology, 168, 1424-1429. http://dx.doi.org/10.1016/S0002-9378(11)90776-5
[3]	Faiz, A.S. and Ananth, C.V. (2003) Etiology and Risk Factors for Placenta Previa: An Overview and Meta-Analysis of Observational Studies. Journal of Maternal-Fetal and Neonatal Medicine, 13, 175-190. http://dx.doi.org/10.1080/jmf.13.3.175.190
[4]	Bhide, A., Prefumo, F., Moore, J., Hollis, B. and Thilaganathan, B. (2003) Placental Edge to Internal os Distance in the Late Third Trimester and Mode of Delivery in Placenta Praevia. BJOG, 110, 860-864. http://dx.doi.org/10.1111/j.1471-0528.2003.02491.x
[5]	Dawson, W.B., Dumas, M.D., Romano, W.M., Gagnon, R., Gratton, R.J. and Mowbray, R.D. (1996) Translabial Ultrasonography and Placenta Previa: Does Measurement of the os-Placenta Distance Predict Outcome? Journal of Ultrasound in Medicine, 15, 441-446.
[6]	Oppenheimer, L.W., Farine, D., Ritchie, J.W., Lewinsky, R.M., Telford, J. and Fairbanks, L.A. (1991) What Is a Low-Lying Placenta? American Journal of Obstetrics and Gynecology, 165, 1036-1038. http://dx.doi.org/10.1016/0002-9378(91)90465-4
[7]	Smith, R.S., Lauria, M.R., Comstock, C.H., Treadwell, M.C., Kirk, J.S., Lee, W., et al. (1997) Transvaginal Ultrasonography for All Placentas That Appear to Be Low-Lying or over the Internal Cervical os. Ultrasound in Obstetrics & Gynecology, 9, 22-24. http://dx.doi.org/10.1046/j.1469-0705.1997.09010022.x
[8]	Shellhaas, C.S., Gilbert, S., Landon, M.B., Varner, M.W., Leveno, K.J., Hauth, J.C., et al. (2009) The Frequency and Complication Rates of Hysterectomy Accompanying Cesarean Delivery. Obstetrics & Gynecology, 114, 224-229. http://dx.doi.org/10.1097/AOG.0b013e3181ad9442
[9]	Whiteman, M.K., Kuklina, E., Hillis, S.D., Jamieson, D.J., Meikle, S.F., Posner, S.F., et al. (2006) Incidence and Determinants of Peripartum Hysterectomy. Obstetrics & Gynecology, 108, 1486-1492. http://dx.doi.org/10.1097/01.AOG.0000245445.36116.c6
[10]	Frederiksen, M.C., Glassenberg, R. and Stika, C.S. (1999) Placenta Previa: A 22-Year Analysis. American Journal of Obstetrics and Gynecology, 180, 1432-1437. http://dx.doi.org/10.1016/S0002-9378(99)70031-1
[11]	Hasegawa, J., Matsuoka, R., Ichizuka, K., Mimura, T., Skizawa, A., Farina, A., et al. (2009) Predisposing Factors for Massive Hemorrhage during Cesarean Section in Patients with Placenta Previa. Ultrasound in Obstetrics & Gynecology, 34, 80-84. http://dx.doi.org/10.1002/uog.6426
[12]	Jang, D.G., We, J.S., Shin, J.U., Choi, Y.J., Ko, H.S., Park, I.Y., et al. (2011) Maternal Outcomes According to Placental Position in Placental Precia. International Journal of Medical Sciences, 8, 439-444. http://dx.doi.org/10.7150/ijms.8.439
[13]	Waranabe, T. and Matsubara, S. (2010) No Bleeding before, More Bleeding Later: The Relationship between the Presence of Warning Bleeding and the Amount of Bleeding during Caesarean Section in Placenta Praevia. Journal of Obstetrics and Gynaecology, 30, 836. http://dx.doi.org/10.3109/01443615.2010.509827
[14]	Afolabi, B.B. and Lesi, F.E.A. (2012) Regional versus General Anaesthesia for Caesarean Section. Cochrane Database of Systematic Reviews, Issue 10, Article ID: CD004350. http://dx.doi.org/10.1002/14651858.CD004350.pub3