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Risk factors of placenta previa: a population based study and the review of the
literature

Article in Medicine Science | International Medical Journal · December 2016

DOI: 10.5455/medscience.2016.05.8477

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Medicine Science
ORIGINAL RESEARCH International
Medical Journal
Medicine Science 201..;..(..):…

Risk factors of placenta previa: a population based study and the review of the
literature
Cetin Aydin1, Serenat Eris Yalcin2, Yakup Yalcin3, Dilek Uysal1, Mehmet Ozgur Akkurt2, And Yavuz2,
Halime Sen selim4, Esra Nur Tola5
1
Gynecology and Obstetrics Department of Ataturk Training and Research Hospital,İzmir, Turkey
2
Perinatology Department of Suleyman Demirel University, İsparta, Turkey
3
Gynecologic Oncology Department of Suleyman Demirel University, İsparta, Turkey
4
Gynecology and Obstetrics Department of Gerede Hospital, Bolu, Turkey
5
Gynecology and Obstetrics Department of Suleyman Demirel University, İsparta, Turkey

Received 12 April 2016; Accepted 02 May 2016

Available online 11 May 2016 with doi: 10.5455/medscience.2016.05.8477

Abstract
The aim of our study is to provide a population-based risk factor profile for placenta previa and thereby enable early diagnosis plus the necessary management
for this risky group. Methods This research was a retrospective case control study including 25105 pregnancies in the period January 2000- December 2010.
The data of 25105 pregnancies were examined on the hospital database. A total of 139 single pregnancies complicated by placenta previa were compared with a
randomly selected control group of 1200 single pregnancies. Evaluation was made of risk factors for placenta previa. Results Of the 25105 pregnancies
presenting at our clinic during the 10-year period, placenta previa was determined in 139, giving an incidence rate of 0.55%. In the comparison of the two
groups; advanced maternal age, multiparity, a history of caesarean section, a history of abortion or uterine curettage, cigarette smoking and male gender were
found to be statistically significant as a risk factor for placenta previa. Conclusions The knowledge of the predisposing obstetric factors in respect of the
development of placenta previa on a population basis provides the possibility of a careful approach on an individual patient basis.

Keywords: Antepartum bleeding, placental pathology, placenta previa, risk factors

Introduction placenta previa and therefore the aim of our study was to
provide a population-based risk factor profile and thereby
Placenta previa is an obstetric complication in which the enable early diagnosis and the necessary management for
placenta is inserted partially or wholly in the lower uterine this risky group.
segment. It is a major cause of antepartum haemorrhage
[1]. Placenta previa is known to cause complications such Material and Methods
as abnormal presentation, intrauterine growth restriction,
prematurity and fetal death. Increased rates of peripartum This research was a retrospective case control study
bleeding, disseminated intravascular coagulation, including 25105 pregnancies in the period January 2000-
hypovolemic shock, caesarean section operation, December 2010. The data of 25105 pregnancies were
hysterectomy and maternal mortality have been reported in examined on the hospital database and placenta previa was
placenta previa [2-4]. determined in 144 patients. Gestational age was
determined from the first day of the last menstrual period
The incidence of placenta previa and complicated and was confirmed by ultrasonography applied at 8-12
pregnancy varies according to the population and has been weeks. The diagnosis of placenta previa was defined as
reported as approximately 0.3%-0.8% [5-7]. While the placental tissue partially or fully covering the cervical os
etiology of placenta previa has not been fully clarified, ultrasonographically and this was confirmed during
related risk factors are known to be a history of caesarean caesarean section operation. A control group was randomly
section, advanced maternal age, multiparity, history of selected to include 1255 pregnancies with vaginal or
abortion, cigarette smoking and male gender fetus [5, 6]. caesarean delivery. The study protocol was subject to local
ethics committee approval.
Several studies have researched the risk factors for
A total of 5 pregnancies were excluded from the placenta
*Coresponding Author: Serenat Eris Yalcin, Perinatology previa group due to multiple gestation. 55 patients from the
Department of Suleyman Demirel University, İsparta,
Turkey control group were excluded because of multiple gestation
E-mail: [email protected] and incomplete data.

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A total of 139 single pregnancies complicated by placenta The pregnancies of the placenta previa cases were all
previa were compared with a randomly selected control delivered by caesarean section and in the control group, the
group of 1200 single pregnancies. Evaluation was made of rate of caesarean deliveries was 20% as 240 cases. The
risk factors for placenta previa of maternal age, parity, gestational week at birth was determined as 38+1.5 weeks
cigarette smoking in pregnancy, working in pregnancy, a (range, 34-40 weeks) in the control group and 34.8+ 4
history of caesarean delivery, a history of abortion or weeks (range, 22-40 weeks)in the study group. Deliveries
uterine curettage, fetal gender, gestational diabetes, before the 30th gestational week were 10 in the placenta
diabetes mellitus or gestational hypertensive disease. previa group and 0 in the control group, and between
weeks 30-34 were 30 (21.5%) in the placenta previa group
Data analyses were performed using SPSS v.21.0 statistical and 102 (8.5%) in the control group.
software (SPSS Inc. IBM, Chicago, IL, USA). The Pearson
Chi-square test was applied with the Exact method. To In the evaluation of advanced maternal age, both groups
determine significant risk factors in the categorical data of were subdivided into 2 groups as 15-34 years, and ≥ 35
the groups, the odds ratio was used. Categorical data were years. The mean age of the placenta previa group was
stated as number (n) and percentage (%). Data were determined as 28.7+ 5.7 years (range, 16-42 years) and as
examined at a 95% confidence interval and a value of 26.2+ 4.7 years (range, 15-38 years) in the control group.
p<0.05 was accepted as statistically significant. In the comparison of the two groups, advanced maternal
age was found to be statistically significant as a risk factor
Results for placenta previa. In cases aged ≥35 years, the risk of
placenta previa was determined to be increased 2.67-fold
Of the 25105 pregnancies presenting at our clinic during (p<0.001, OR:2.67 [1.7-4.2]).
the 10-year period, placenta previa was determined in 139,
giving an incidence rate of 0.55%. Placenta previa totalis Multiparity, a history of caesarean section, a history of
was determined in 53 (38.1%) cases, placenta previa abortion or uterine curettage were found to be statistically
marginalis in 37 (26.6%), and placenta previa partialis in significant as a risk factor (p<0.001, OR:3.32 [2.1-5.2],
49 (35.2%). In 13 (9.3%) cases placenta accreata and in 10 p:0.038, OR: 1.5 [1.04-2.22], p<0.001, OR:2.2 [1.5-3.1];
(7.1%) cases, placenta increata were determined respectively).
concomitant to placenta previa.
Table 1. The results of the comparison between the study and control group

Placenta previa(139) Control(1200) P Value OR (%95 Cl)

n(%) n(%)
Age >35 29 (20,9%) 108 (9,0%) <0,001 2,67 (1,7-4,2)
[15-34] 110 (79,1%) 1092 (91,0%)
Parity Multipar 113 (81,3%) 680 (56,7%) <0,001 3,32 (2,1-5,2)
Primipar 26 (18,7%) 520 (43,3%)
Cigarette Smoker 51 (36,7%) 104 (8,7%) <0,001 6,1 (4,1-9,1)
Non-smoker 88 (63,3%) 1096 (91,3%)
Employment status No 135 (97,1%) 1158 (96,5%) 0,812 1,2 (0,4-3,5)
Yes 4 (2,9%) 42 (3,5%)
Fetal gender Male 85 (61,2%) 536 (44,7%) <0,001 2 (1,4-2,8)
Female 54 (38,8%) 664 (55,3%)
Hypertensive diseases of pregnancy Yes 9 (6,5%) 77 (6,4%) 1 1,01 (0,5-2,1)
No 130 (93,5%) 1123 (93,6%)
Abortion/ uterine curettage 0 81 (58,3%) 904 (75,3%) <0,001
1 13 (9,4%) 132 (11,0%) 1,1 (0,6-2,03)
2 18 (12,9%) 160 (13,3%) 1,3 (0,7-2,2)
3 27 (19,4%) 4 (0,3%) 75,3 (25,7-220,6)
Abortion/uterine curettage Yes 58 (41,7%) 296 (24,7%) <0,001 2,2 (1,5-3,1)
No 81 (58,3%) 904 (75,3%)
Number of birth 0 26 (18,7%) 520 (43,3%) <0,001
1 45 (32,4%) 391 (32,6%) 2,3 (1,4-3,8)
2 36 (25,9%) 198 (16,5%) 3,6 (2,1-6,2)
3 32 (23,0%) 91 (7,6%) 7 (4-12,4)
Parity + 113 (81,3%) 680 (56,7%) <0,001 3,3 (2,1-5,2)
- 26 (18,7%) 520 (43,3%)
Number of caesarean section 0 94 (67,6%) 912 (76,0%) 0,033
1 27 (19,4%) 192 (16,0%) 1,4 (0,9-2,2)
2 10 (7,2%) 70 (5,8%) 1,4 (0,7-2,8)
3 8 (5,8%) 26 (2,2%) 3 (1,3-6,8)
Caesarean section Yes 45 (32,4%) 288 (24,0%) 0,038 1,5 (1,04-2,22)
No 94 (67,6%) 912 (76,0%)
Gestational diabetes/diabetes mellitus Yes 8 (5,8%) 78 (6,5%) 0,856 0,9 (0,4-1,9)
No 131 (94,2%) 1122 (93,5%)
Pearson Chi-Square Test(Exact) - OR, Odds Ratio; Cl, confidence interval

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The effect of cigarette smoking on placenta previa was 3.3-fold in those with a history of previous births compared
investigated. In the study group, 51 cases (36.7%) had a to those with no previous births and as the number of births
history of cigarette smoking and in the control group, 104 increased, this was related to an increase in the risk of
(8.7%). When the two groups were compared, cigarette placenta previa. In multiparity, just as in the age risk, the
smoking was determined as a risk factor for placenta underlying pathophysiology may be infarct and
previa (p<0.001, OR:6.1 [4.1-9.1]). atherosclerotic changes in the uterus.

Fetal gender distribution was investigated and male gender A previous caesarean section scar is known to cause
of the fetus was determined to be statistically significant as pathological changes in endometrial and myometrial tissue.
a risk factor for placenta previa (p<0.001, OR:2 [1.4-2.8]). It is thought that this scar tissue prevents the migration of
the placenta to the uterine fundus [5, 9, 11, 15]. In a study
No statistically significant relationship was determined by Taylor et al [16], the placenta previa risk of women
between the development of placenta previa and with a history of caesarean delivery was found to be
hypertensive diseases of pregnancy, gestational increased 1.48-fold. In another study by Getahun et al [17],
diabetes/diabetes mellitus or employment status. it was shown that after a first and second pregnancy had
been concluded with a caesarean delivery, the risk of
The results of the comparison between the study and placenta previa in the third pregnancy increased by 50% .
control group are shown in Table 1. In the current study, the placenta previa risk was
determined to increase 1.5-fold in those with a history of
Discussion caesarean delivery, which was consistent with literature.
In literature, the prevalence of placenta previa has been Uterine curettage applied after spontaneous or induced
reported as 0.3%-0.8% [5-7]. In recent years, several abortion forms a basis for the development of placenta
studies have reported an increase in the prevalence of previa by damaging the uterine cavity [18-20]. In a study
placenta previa. This increase has been thought to be by Zhang et al [12], the placenta previa risk was shown to
related to the enhanced trend for caesarean deliveries and be increased 1.6-fold in those with a history of 1 abortion,
the possibilities for easier diagnosis of placenta previa by 2.3-fold in those with a history of 2, and 3.7-fold where
improved imaging modalities [7-9]. there was a history of 3 or more abortions. In the current
study, the risk of placenta previa was determined to
Advanced maternal age, which leads to several
increase 2.2-fold in those with a history of abortion or
fetomaternal problems such as premature labour, pre-
uterine curettage, which was consistent with the reports in
eclampsia, gestational diabetes mellitus and congenital
literature.
anomalies, also causes an increase in the prevalence of
placenta previa [10]. The mechanism by which advanced Some studies have reported a 2.4-fold increased risk of
maternal age impairs the development of normal placenta placenta previa in patients who smoke cigarettes [14,21-
is not clearly understood. In the pathophysiology, it has 23]. The placental growth in this situation can be explained
been suggested that as a result of atherosclerotic changes by the vasoactive properties of nicotine found in cigarettes
occurring in the uterine blood vessels at older ages, the and chronic hypoxia associated with carbon monoxide
blood supply is impaired and compensatory placental [22,23]. In the current study, a strong correlation was
hypertrophy develops secondary to this impaired found between cigarette smoking and the development of
vascularisation [8,11]. In some studies, the increased placenta previa.
likelihood of placenta previa has been associated with
increased parity at an older maternal age and therefore an The relationship between male gender fetus and placenta
increase in previous uterine interventions [8,12]. In 3 previa has been investigated in previous studies. Although
cohort studies, advanced maternal age has been reported as the underlying causes have not been clarified, it has been
the cause of a 1.2-2.7-fold increase in the incidence of suggested that there may be a relationship with maternal
placenta previa [13-15]. In the current study, advanced hormones or prematurity [24-26]. The findings of the
maternal age increased the likelihood of placenta previa current study are consistent with those in literature.
2.67-fold.
In employed women with placenta previa, there was
When parity is examined as a risk factor, atrophic determined to be a 2-fold increased risk of presentation
endometrium changes after frequent births, short intervals with bleeding. This could be related having less time to
between births and multiparity have been reported to have rest. Although there is insufficient data related to socio-
an effect on the development of placenta previa [5,8,11]. economic factors in respect of increased risk of placenta
Tuzovic et al [9] stated the risk of placenta previa to be previa, in a study in which an increased risk of placenta
related to a history of 3 or more previous births and Abu previa was determined in working women, it was
Heija et al [11] stated it as 5 or more. In the current study, suggested that this could be related to an increased rate of
the risk of placenta previa was determined to be increased dilatation and curettage in working women [27].

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factors affecting the Turkish population were found to be bleeding in pregnancy. Am J Epidemiol. 1996;144(9):881-9.
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We have no financial or commercial conflicts of interest.
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