The Risk of Postpartum Hemorrhage Following Prior Prelabor Cesarean Delivery Stratified by Abnormal Placentation: A Multicenter Historical Cohort Study.

Xin Zhao ,Zhao Yangyu,Zhang Lizi,Wen Suiwen,Chen Jingsi,Wang Zhijian,Du Lili,Qi Hongbo,Huang Baoying,Huang Lijun,Xiaowu Xu ,Wang Shaoshuai,Li Hongtian,Zhang Lanzhen,Chen Dunjin,Liang Yingyu,Qing Zhu ,Jinsong Jia ,Li Yulian,Sheng Bi ,Cao Yinli,Feng Li ,Huang Minshan

doi:10.3389/fmed.2021.745080

Abstract

Background: Prior prelabor cesarean delivery (CD) was associated with an increase in the risk of placenta previa (PP) in a second delivery, whether it may impact postpartum hemorrhage (PPH) independent of abnormal placentation. This study aimed to assess the risk of PPH stratified by abnormal placentation following a first CD before the onset of labor (prelabor) or intrapartum CD.Methods: This multicenter, historical cohort study involved singleton, pregnant women at 28 weeks of gestation or greater with a CD history between January 2017 and December 2017 in 11 public tertiary hospitals within 7 provinces of China. PPH was analyzed in the subsequent pregnancy between women with prior prelabor CD and women with intrapartum CD. Furthermore, PPH was analyzed in pregnant women stratified by complications with PP alone [without placenta accreta spectrum (PAS) disorders], complications with PP and PAS, complications with PAS alone (without PP), and normal placentation. We performed multivariate logistic regression to calculate adjusted odds ratios (aOR) and 95% CI controlling for predefined covariates.Results: Out of 10,833 pregnant women, 1,197 (11%) women had a history of intrapartum CD and 9,636 (89%) women had a history of prelabor CD. Prior prelabor CD increased the risk of PP (aOR 1.91, 95% CI 1.40–2.60), PAS (aOR 1.68, 95% CI 1.11–2.24), and PPH (aOR 1.33, 95% CI 1.02–1.75) in a subsequent pregnancy. After stratification by complications with PP alone, PP and PAS, PAS alone, and normal placentation, prior prelabor CD only increased the risk of PPH (aOR 3.34, 95% CI 1.35–8.23) in a subsequent pregnancy complicated with PP and PAS.Conclusion: Compared to intrapartum CD, prior prelabor CD increased the risk of PPH in a subsequent pregnancy only when complicated by PP and PAS.

Highlights

METHODSPostpartum hemorrhage (PPH) is a major contributor to maternal morbidity and death [1] and it exerts longterm overall impact on health of women [2]
After stratification by complications with placenta previa (PP) alone, PP and placenta accreta spectrum (PAS), PAS alone, and normal placentation, prior prelabor cesarean delivery (CD) only increased the risk of postpartum hemorrhage (PPH) in a subsequent pregnancy complicated with PP and PAS
Compared to intrapartum CD, prior prelabor CD increased the risk of PPH in a subsequent pregnancy only when complicated by PP and PAS

Summary

Introduction

METHODSPostpartum hemorrhage (PPH) is a major contributor to maternal morbidity and death [1] and it exerts longterm overall impact on health of women [2]. CD is a lifesaving procedure for women with complications, but the dramatic rise in the CD rate worldwide has raised concerns about the adverse maternal and neonatal outcomes and the long-term consequences [7,8,9]. It is, important to prevent the overuse of CD, especially primary CD. Prior prelabor cesarean delivery (CD) was associated with an increase in the risk of placenta previa (PP) in a second delivery, whether it may impact postpartum hemorrhage (PPH) independent of abnormal placentation. This study aimed to assess the risk of PPH stratified by abnormal placentation following a first CD before the onset of labor (prelabor) or intrapartum CD

Objectives

Methods

Results

Discussion

Conclusion