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. 2020 Sep;136(3):458-465.
doi: 10.1097/AOG.0000000000003970.

Placenta Accreta Spectrum Without Placenta Previa

Daniela A Carusi  1 , Karin A Fox, Deirdre J Lyell, Nicola C Perlman, Soroush Aalipour, Brett D Einerson, Michael A Belfort, Robert M Silver, Alireza A Shamshirsaz
Affiliations

Placenta Accreta Spectrum Without Placenta Previa

Daniela A Carusi et al. Obstet Gynecol. 2020 Sep.

Abstract

Objective: To evaluate placenta accreta spectrum with and without placenta previa with regard to risk factors, antepartum diagnosis, and maternal morbidity.

Methods: We conducted a retrospective cohort study of pathology-confirmed placenta accreta spectrum deliveries with hysterectomy from two U.S. referral centers from January 2010-June 2019. Maternal, pregnancy, and delivery characteristics were compared among placenta accreta spectrum cases with (previa PAS group) and without (nonprevia PAS group) placenta previa. Surgical outcomes and a composite of severe maternal morbidities were evaluated, including eight or more blood cell units transfused, reoperation, pulmonary edema, acute kidney injury, thromboembolism, or death. Logistic regression was used with all analyses controlled for delivery location.

Results: Of 351 deliveries, 106 (30%) had no placenta previa at delivery. When compared with the previa group, nonprevia placenta accreta spectrum was less likely to be identified antepartum (38%, 95% CI 28-48% vs 87%, 82-91%), less likely to receive care from a multidisciplinary team (41%, 31-51% vs 86%, 81-90%), and less likely to have invasive placenta increta or percreta (51% 41-61% vs 80%, 74-84%). The nonprevia group had more operative hysteroscopy (24%, 16-33% vs 6%, 3-9%) or in vitro fertilization (31%, 22-41% vs 9%, 6-13%) and was less likely to have had a prior cesarean delivery (64%, 54-73% vs 93%, 89-96%) compared with the previa group, though the majority in each group had a prior cesarean delivery. Rates of severe maternal morbidity were similar in the two groups, at 19% (nonprevia) and 20% (previa), even after controlling for confounders (adjusted odds ratio for the nonprevia group 0.59, 95% CI 0.30-1.17).

Conclusion: Placenta accreta spectrum without previa is less likely to be diagnosed antepartum, potentially missing the opportunity for multidisciplinary team management. Despite the absence of placenta previa and less placental invasion, severe maternal morbidity at delivery was not lower. Broader recognition of patients at risk for placenta accreta spectrum may improve early clinical diagnosis and patient outcomes.

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References

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    1. Shamshirsaz AA, Fox KA, Erfani H, Clark SL, Salmanian B, Baker BW, et al. Multidisciplinary team learning in the management of the morbidly adherent placenta: outcome improvements over time. Am J Obstet Gynecol 2017;216:612.e1–5.
    1. Shamshirsaz AA, Fox KA, Salmanian B, Diaz-Arrastia CR, Lee W, Baker BW, et al. Maternal morbidity in patients with morbidly adherent placenta treated with and without a standardized multidisciplinary approach. Am J Obstet Gynecol 2015;212:218.e1–9.
    1. Collins SL, Alemdar B, van Beekhuizen HJ, Bertholdt C, Braun T, Calda P, et al. Evidence-based guidelines for the management of abnormally invasive placenta: recommendations from the International Society for Abnormally Invasive Placenta. Am J Obstet Gynecol 2019;220:511–26.
    1. Erfani H, Fox KA, Clark SL, Rac M, Rocky Hui SK, Rezaei A, et al. Maternal outcomes in unexpected placenta accreta spectrum disorders: single-center experience with a multidisciplinary team. Am J Obstet Gynecol 2019;221:337.e1–5.

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