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Original Research
OBJECTIVE: To quantify the contribution of placenta RESULTS: The incidence of placenta accreta was 14.4
accreta to the rate of postpartum hemorrhage and severe (95% CI 13.415.4) per 10,000 deliveries (819 cases
postpartum hemorrhage. among 570,637 deliveries), whereas the incidence of pla-
METHODS: All hospital deliveries in Canada (excluding centa accreta with postpartum hemorrhage was 7.2 (95%
Quebec) for the years 2009 and 2010 (N5570,637) were CI 6.58.0) per 10,000 deliveries. Postpartum hemorrhage
included in a retrospective cohort study using data from among women with placenta accreta was predominantly
the Canadian Institute for Health Information. Placenta third-stage hemorrhage (41% of all cases). Although
accreta included placental adhesion to the uterine wall, placenta accreta was strongly associated with postpar-
musculature, and surrounding organs (accreta, increta, or tum hemorrhage (rate ratio 8.3, 95% CI 7.78.9), its low
percreta). Severe postpartum hemorrhage included post- frequency resulted in a small population-attributable
partum hemorrhage with blood transfusion, hysterectomy, fraction (1.0%, 95% CI 0.931.16). However, the strong
or other procedures to control bleeding (including uterine association between placenta accreta and postpartum
suturing and ligation or embolization of pelvic arteries). hemorrhage with hysterectomy (rate ratio 286, 95% CI
Rates, rate ratios, population-attributable fractions (ie, inci- 226361) resulted in a population-attributable fraction of
dence of postpartum hemorrhage attributable to placenta 29.0% (95% CI 24.334.3).
accreta), and 95% confidence intervals (CIs) were esti- CONCLUSION: Placenta accreta is too infrequent to
mated. Logistic regression was used to quantify associations account for the recent temporal increase in postpartum
between placenta accreta and risk factors. hemorrhage but contributes substantially to the pro-
portion of postpartum hemorrhage with hysterectomy.
(Obstet Gynecol 2015;0:18)
From the Department of Obstetrics and Gynaecology, University of British Columbia DOI: 10.1097/AOG.0000000000000722
and the Childrens and Womens Hospital & Health Centre of British
Columbia, and the School of Population and Public Health, University of LEVEL OF EVIDENCE: II
British Columbia, Vancouver, British Columbia, the Maternal and Infant Health
T
Section, Public Health Agency of Canada, Ottawa, Ontario, and the Departments
of Pediatrics and Epidemiology, Biostatistics and Occupational Health, McGill he increase in postpartum hemorrhage among
University, Montreal, Quebec, Canada. high-income countries such as Australia, Canada,
This work is supported by a Canadian Institutes of Health Research (CIHR) team Ireland, Norway, Scotland, and the United States over
grant in Severe Maternal Morbidity (MAH115445). Jennifer A. Hutcheon is the the past two decades remains unexplained.17 The sub-
recipient of a CIHR New Investigator Award and a Scholar Award from the
Michael Smith Foundation for Health Research. K.S. Joseph is supported by an
type of postpartum hemorrhage underlying the
Investigator award from the Child and Family Research Institute and a CIHR increase has been identified as atonic postpartum hem-
Chair in maternal, fetal, and infant health services research. orrhage2,4,7; in Canada, the rate of atonic postpartum
Corresponding author: Azar Mehrabadi, MSc, Room C403, 4500 Oak Street, hemorrhage increased by 29% (95% confidence inter-
Womens Hospital of British Columbia, Vancouver, British Columbia, Canada val [CI] 2633%) from 3.9% in 2003 to 5.0% in 2010.8
V6H 3N1; e-mail: azar@alumni.ubc.ca.
However, this increase could not be explained by
Financial Disclosure
The authors did not report any potential conflicts of interest. changes in maternal age, obesity, multifetal gestation,
2015 by The American College of Obstetricians and Gynecologists. Published
labor induction, oxytocin augmentation, and other
by Wolters Kluwer Health, Inc. All rights reserved. maternal, fetal, infant, and obstetric factors.9 The Inter-
ISSN: 0029-7844/15 national Postpartum Hemorrhage Collaborative Group
Table 1. Rate of Placenta Accreta Without Postpartum Hemorrhage and With Postpartum Hemorrhage and
Related Complications, Canada (Excluding Quebec), 20092010 (N5570,637 Deliveries)
Includes uterine suturing, pelvic artery ligation, and pelvic artery embolization.
VOL. 0, NO. 0, MONTH 2015 Mehrabadi et al Placenta Accreta and Postpartum Hemorrhage 3
Table 2. Placenta Accreta by Maternal and Obstetric Characteristics, Canada (Excluding Quebec),
20092010
Postpartum hemorrhage 412 (50.31) 34,543 (6.06) 8.30 (7.758.89) 1.0 (0.931.16)
With blood transfusion 157 (19.17) 2,653 (0.47) 41.2 (35.647.6) 5.5 (4.76.4)
With hysterectomy 92 (11.23) 224 (0.04) 285.8 (226361) 29.0 (24.334.3)
With other procedures 47 (5.74) 558 (0.10) 58.6 (43.978.3) 7.6 (5.810.1)
Atonic postpartum 59 (7.20) 28,253 (4.96) 1.45 (1.141.86) 0.07 (0.020.13)
hemorrhage
With blood transfusion 29 (3.54) 1,797 (0.32) 11.2 (7.8316.1) 1.4 (0.962.1)
With hysterectomy 17 (2.08) 156 (0.03) 75.8 (46.2124.5) 9.7 (6.115.1)
With other procedures 10 (1.22) 470 (0.08) 14.8 (7.9427.6) 1.9 (0.983.7)
3rd-stage postpartum 338 (41.27) 4,489 (0.79) 52.4 (48.057.1) 6.9 (6.27.6)
hemorrhage
With blood transfusion 121 (14.77) 542 (0.01) 155 (129187) 18.1 (15.421.3)
With hysterectomy 74 (9.04) 43 (0.01) 1,198 (8271,733) 63.2 (54.171.4)
With other procedures 35 (4.27) 60 (0.01) 405.9 (269612) 36.8 (27.746.9)
Secondary postpartum 29 (3.54) 1,757 (0.31) 11.5 (8.0116.5) 1.5 (0.992.2)
hemorrhage
With blood transfusion 12 (1.47) 293 (0.05) 28.5 (16.150.5) 3.8 (2.16.7)
With hysterectomy 4 (0.49) 11 (0) 253.0 (80.7793) 26.6 (10.353.2)
With other procedures 2 (0.24) 20 (0) 69.6 (16.3297) 9.0 (2.129.9)
Postpartum hemorrhage 9 (1.01) 288 (0.05) 21.7 (11.242.1) 2.9 (1.445.6)
resulting from
coagulation defects
With blood transfusion 7 (0.85) 122 (0.02) 39.9 (18.785.2) 5.3 (2.510.8)
With hysterectomy 8 (0.98) 41 (0.01) 135.8 (63.8289) 16.2 (8.329.3)
With other procedures 4 (0.49) 37 (0.01) 75.2 (26.9211) 9.6 (3.623.2)
CI, confidence interval.
Data are n (%) unless otherwise specified.
* Rate ratios were obtained by dividing the rate (risk) of the outcome among women with placenta accreta by the rate of the outcome among
women without placenta accreta.
hemorrhage with other procedures to control bleed- increases in postpartum hemorrhage. The frequency of
ing it was 36.8%, and for third-stage postpartum hem- placenta accreta and postpartum hemorrhage (7.2/
orrhage with blood transfusion it was 18.1%. 10,000 deliveries) is relatively low compared with the
magnitude of the absolute temporal increase in atonic
DISCUSSION postpartum hemorrhage (absolute increase of 1.1%
Our study showed that approximately 50% of the from 3.9% in 2003 to 5.0% in 2010).8 Together, these
patients with placenta accreta experienced postpartum findings suggest that potential temporal increases in
hemorrhage, and 22.6% experienced a severe form of placenta accreta frequency cannot explain the recent
postpartum hemorrhage (postpartum hemorrhage with rise in atonic postpartum hemorrhage.
blood transfusion, hysterectomy, or other procedures Our study showed that placenta accreta ac-
to control bleeding). Placenta accreta was strongly counted for 29% of the incidence of postpartum
associated with postpartum hemorrhage and most hemorrhage with hysterectomy, which increased sig-
strongly associated with third-stage hemorrhage. The nificantly in Canada from 4.9 to 5.8 per 10,000
relative infrequency of placenta accreta (14.4/10,000 deliveries between 2003 and 2010.8 Thus, an increase
deliveries) resulted in a low population-attributable in placenta accreta could have contributed signifi-
fraction for postpartum hemorrhage (1%). Given the cantly to the rising incidence of postpartum hemor-
modest association between placenta accreta and atonic rhage with hysterectomy in Canada. Our study also
postpartum hemorrhage (RR 1.45, 95% CI 1.141.86; suggests that increases in placenta accreta could have
population-attributable fraction 1%, 95% CI 0.010%), partly contributed to changes in the incidence of other
increases in placenta accreta cannot explain the recent severe forms of postpartum hemorrhage such as
VOL. 0, NO. 0, MONTH 2015 Mehrabadi et al Placenta Accreta and Postpartum Hemorrhage 5
VOL. 0, NO. 0, MONTH 2015 Mehrabadi et al Placenta Accreta and Postpartum Hemorrhage 7
Canadian Classification
Diagnosis and Procedure Code ICD-10 of Interventions