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Cande Ananth
Columbia University
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Division of Hematology, Department of Medicin e, Robert Wood J ohnson Medical School, University of Medicin e
and Dentistry of New J ersey, New Brunswick, New J ersey, USA
2
Section of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology and Reproductive Sciences,
Robert Wood J ohnson Medical School, University of Medicin e and Dentistry of New J ersey, New Brunswick,
New J ersey, USA
Objective: Several clinical and epidemiologic studies have reported disparate data on the preva-
lence rate as well as risk factors associated with placenta previa a major cause of third-trimester
bleeding. We performed a systematic literature review and identified 58 studies on placenta previa
published between 1966 and 2000.
Study design: Each study was reviewed independently by the two authors and was scored (on the
basis of established criteria) on method of diagnosis of placenta previa and on quality of study
design. We extracted data on the prevalence rate of placenta previa, as well as associations with
various risk factors from each study. A meta-analysis was then performed to determine the extent
to which different risk factors predispose women to placenta previa.
Results: Our results showed that the overall prevalence rate of placenta previa was 4.0 per 1000
births, with the rate being higher among cohort studies (4.6 per 1000 births), USA-based studies
(4.5 per 1000 births) and hospital-based studies (4.4 per 1000 births) than among casecontrol
studies (3.5 per 1000 births), foreign-based studies (3.7 per 1000 births) and population-based
studies (3.7 per 1000 births), respectively. Advancing maternal age, multiparity, previous Cesarean
delivery and abortion, smoking and cocaine use during pregnancy, and male fetuses all conferred
increased risk for placenta previa. Strong heterogeneity in the associations between risk factors
and placenta previa were noted by study design, accuracy in the diagnosis of placenta previa and
population-based versus hospital-based studies.
Conclusion: Future etiological studies on placenta previa must, at the very least, adjust for
potentially confounding effects of maternal age, parity, prior Cesarean delivery and abortions.
Key words: PLACENTA PREVIA ; ETIOLOGY ; EPIDEMIOLOGY ; META-ANALYSIS ; OVERVIEW
INTRODUCTION
natal care, it is still challenging to avoid maternal complications and to improve perinatal outcomes among women
with this condition.
The etiology of placenta previa remains largely obscure,
but several clinical and epidemiological studies have
observed increased occurrence of placenta previa among
women with advanced maternal age, multiparity, male
fetuses, multiple pregnancy, prior Cesarean delivery and
prior spontaneous or induced abortion. Furthermore,
behavioral factors that have been implicated with
increased occurrence of placenta previa include maternal
smoking and drug use during pregnancy. Finally, women
Corr espondence: Dr A. S. Faiz, Division of Hem atology, Room 378, One Robert Wood J ohnson Place, PO Box 19, New Brunswick,
NJ 08903, USA
2003 The Par thenon Publish ing Group
175
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Scoring of studies
Literature review
Table 1
Cohort
studies
4
3
2
1
4
3
2
1
Studies that controlled for maternal age, parity, previous Cesarean delivery, previous spontaneous or induced abortion were considered
as those without obvious biases (score of 5)
176
J ournal of MaternalFetal and Neonatal Medicin e
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The prevalence rate of placenta previa (per 1000 pregnancies) was either abstracted from the study directly or
derived by dividing the number of cases of placenta previa
by the total number of pregnancies. Data on placenta
previa cross-classified by the presence or absence of risk
factors were abstracted from every study, and were
organized in 2 2 tables. Odds ratios (OR) with associated
95% CI were computed as the measure of effect.
A meta-analysis was then performed by pooling the data
for each risk factor across all studies. We did not pool the
data for multiple pregnancies, recurrent placenta previa
and placental abruption as risk factors for placenta previa,
owing to lack of data. Prior to pooling data across studies,
we tested the homogeneity of studies being pooled. The test
statistic for homogeneity, Qh, was then compared with
the c2 distribution, with degrees of freedom equal to the
number of studies being pooled minus one. Random effect
ORs were computed after pooling the studies. Randomeffect analysis accounts for heterogeneity among studies
being pooled and assumes that these studies are a sample
from a larger population of similar but unidentified studies.
We also performed subgroup analysis for each risk factor
by grouping studies based on study design (cohort vs. case
control studies), geographic location (USA vs. foreignbased studies) and source of data (hospital vs. populationbased studies). The doseresponse effect of maternal
age and parity on the risk of placenta previa was also
evaluated from each study based on the covarianceadjusted method102.
RESULTS
Table 3 Description of studies conducted within the USA and scores assigned to each study based on study design and diagnosis of
placenta previa
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Author
Study years
Placenta
Number of previa (per
pregnancies 1000 births)
Scores assigned
Criteria
for inclusion
Criteria
for exclusion
multiple births
Study design
Diagnosis
nulliparous
5
5
4
4
4
1
2
2
2
2
Williams8
198788
Zhang 16
198890
309 320
Taylor7
198487
13
McMahon
1990
4.4
Parson45
198285
10 473
Wolf4
198090
54 969
Williams22
197780
12 718
Handler12
198890
55 314
Chelmow23
199294
Macones24
199296
30
Sauer
198184
10 822
3.4
7.7
3.9
5.5
5.9
4.0
singletons
singletons
births 20 weeks
births 20 weeks
multiple gestations
3
2
2
2
5
5
3
3
2
3
3
1
1
2
2
4
1
4
Iyasu41
197987
36
Demissie
198992
447 963
9.9
4.8
6.0
live births
live and stillbirths
singleton live births
1
2
4
2
1
2
17 265
102 670
6.0
4.6
2
2
1
2
208 837
31 070
38 398
3.7
6.0
4.5
singletons
1
2
1
2
2
2
3
4
16 029
21 217
97 799
42 058
6 576
93 384
4.3
4.5
3.0
3.5
16.8
5.5
> 20 weeks
1
1
1
2
1
1
1
2
4
4
4
4
4
4
Frederiksen44
197697
Table 4 Description of studies conducted outside the USA and scores assigned to each study based on study design and diagnosis
of placenta previa
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Author
Placenta
Number of previa (per
Study years pregnancies 1000 births)
Scores assigned
Criteria
for inclusion
Criteria
for exclusion
Study design
Diagnosis
2.8
29 486
20 377
49 765
15 255
27 483
5.4
3.9
5.0
2.8
5.8
3.1
multiple gestations
2
3
2
3
2
3
3
4
2
4
4
1
87 184
121 082
3.3
3.4
singletons
singletons
multiple gestations
multiple gestations
4
4
3
3
22 437
19 888
26 155
12 040
24 549
114 470
24 644
26 858
106 866
41 206
158 006
58 633
13 032
15 930
18 651
25 844
16 169
4.0
10.6
9.1
5.0
19.7
8.2
3.4
3.3
5.4
4.6
5.4
5.0
4.8
7.4
3.6
3.5
4.9
1.0
singletons
singletons, primigravida
singletons
twins
nulliparous
congenital anomaly
1
1
1
1
1
4
2
1
2
1
2
1
1
3
1
1
1
4
3
2
2
2
2
1
4
1
4
1
2
4
1
3
2
4
3
3
2
2
Table 5
Prevalence rate of placenta previa (per 1000 pregnancies) by type of study design and geographical location
Overall
Cohort studies
Casecontrol studies
USA studies
Foreign-based studies
Population-based studies
Hospital-based studies
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Number of studies
Number of studies
44
31
13
19
25
5
39
4.0
4.6
3.5
4.5
3.7
3.7
4.4
58
37
21
30
28
11
47
2.8 to 19.7
3.0 to 19.7
2.8 to 7.7
3.0 to 16.8
2.8 to 19.7
3.1 to 9.9
2.8 to 19.7
Table 6
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Number of studies
c Qh
Degrees of freedom
21
8
13
9
12
10
11
4
17
60.3
0.2
11.7
7.1
12.7
27.5
25.0
2.2
35.0
20
7
12
8
11
9
10
3
16
Overall
Cohort studies
Casecontrol studies
USA-based studies
Foreign-based studies
Definite previa
Probable previa
Well-designed studies
Poorly designed studies
p Value
< 0.001
0.999
0.470
0.525
0.313
0.001
0.009
0.531
0.006
Random-effects
pooled odds ratio
(95% CI)
2.7 (2.3, 3.2)
6.2 (3.6, 10.5)
2.0 (1.8, 2.3)
2.0 (1.7, 2.3)
4.8 (3.8, 6.2)
3.0 (2.3, 3.2)
2.3 (2.0, 2.7)
1.9 (1.7, 2.2)
3.5 (2.7, 4.6)
Table 7
c Qh
Degrees of freedom
p Value
Random-effects
pooled odds ratio
(95% CI)
8
1
7
4
4
3
5
2
6
13.4
12.8
3.0
4.5
0.0
13.4
1.7
5.7
6
3
3
2
4
1
5
0.063
0.046
0.391
0.212
1.000
0.009
0.192
0.336
Overall
Cohort studies
Casecontrol studies
USA-based studies
Foreign-based studies
Definite previa
Probable previa
Well-designed studies
Poorly designed studies
Table 8
c Qh
Degrees of freedom
p Value
Random-effects
pooled odds ratio
(95% CI)
7
6
1
3
4
4
3
6.6
6.6
6.5
1.2
5.0
5.0
1.2
6
5
2
3
3
2
0.359
0.359
0.261
0.548
0.172
0.172
0.753
Overall
Cohort studies
Casecontrol studies
USA-based studies
Foreign-based studies
Definite previa
Probable previa
Well-designed studies
Poorly designed studies
Table 9
c Qh
Degrees of freedom
p Value
Random-effects
pooled odds ratio
(95% CI)
8
8
3
5
4
4
12.1
12.1
12.1
5.1
5.5
5.5
5.1
7
7
2
4
3
3
0.097
0.097
0.097
0.078
0.239
0.139
0.164
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Overall
Cohort studies
Casecontrol studies
USA-based studies
Foreign-based studies
Definite previa
Probable previa
Well-designed studies
Poorly designed studies
Table 10
c Qh
Degrees of freedom
p Value
Random-effects
pooled odds ratio
(95% CI)
9
1
8
8
1
3
6
6
3
26.0
18.8
18.8
6.0
5.6
14.2
8.1
7
7
2
5
5
2
0.001
0.009
0.009
0.049
0.347
0.014
0.017
Overall
Cohort studies
Casecontrol studies
USA-based studies
Foreign-based studies
Definite previa
Probable previa
Well-designed studies
Poorly designed studies
Table 11
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c Qh
Degrees of freedom
p Value
Random-effects
pooled odds ratio
(95% CI)
3
3
1
2
1
2
2.0
2.0
2.0
2.0
0.0
2
2
0.368
0.368
0.368
0.157
1.000
Overall
Cohort studies
Casecontrol studies
USA-based studies
Foreign-based studies
Definite previa
Probable previa
Well-designed studies
Poorly designed studies
c Qh
Degrees of freedom
p Value
Random-effects
pooled odds ratio
(95% CI)
7
4
3
4
3
2
5
3
4
7.7
6.1
1.2
1.0
2.1
0.4
2.4
6.0
1.3
6
3
2
3
2
1
4
2
3
0.261
0.107
0.549
0.801
0.349
0.527
0.662
0.049
0.729
Overall
Cohort studies
Casecontrol studies
USA-based studies
Foreign-based studies
Definite previa
Probable previa
Well-designed studies
Poorly designed studies
c Qh
Degrees of freedom
p Value
Random-effects
pooled odds ratio
(95% CI)
3
2
1
2
1
2
1
1
2
2.4
0.4
2.3
2.0
2.2
2
1
0.301
0.527
0.129
0.157
0.138
Overall
Cohort studies
Casecontrol studies
USA-based studies
Foreign-based studies
Definite previa
Probable previa
Well-designed studies
Poorly designed studies
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DISCUSSION
Placenta previa is an obstetric condition that leads to
serious maternal and fetal complications. This condition
has been reported to occur in 320 per 1000 pregnancies.
The wide variation in the prevalence rate can be attributed
to inclusion of varying degrees of placenta previa, different
methods and timing of diagnosis, and diversity of the
patient population across studies. Many clinical and epidemiological studies have reported the rate of placenta
previa to be higher among older and multiparous women,
those with a previous Cesarean delivery, prior spontaneous
or induced abortion as well as among women who smoked
or used cocaine during pregnancy.
This meta-analysis confirms the higher risk of placenta
previa associated with advancing maternal age. Among
older women, there may be atherosclerotic changes in the
uterine blood vessels causing compromised uteroplacental
blood flow. This has been shown by microscopic studies of
c Qh
Degrees of freedom
p Value
Random-effects
pooled odds ratio
(95% CI)
3
2
1
3
4.8
4.8
4.8
4.7
4.8
2
1
0.091
0.091
0.091
0.030
0.091
Overall
Cohort studies
Casecontrol studies
USA-based studies
Foreign-based studies
Definite previa
Probable previa
Well-designed studies
Poorly designed studies
c Qh
Degrees of freedom
p Value
Random-effects
pooled odds ratio
(95% CI)
3
2
1
3
2
1
4.0
4.0
4.0
2.0
4.0
2
1
0.135
0.045
0.135
0.157
0.135
Overall
Cohort studies
Casecontrol studies
USA-based studies
Foreign-based studies
Definite previa
Probable previa
Well-designed studies
Poorly designed studies
Qh, test statistic for homogeneity
184
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placentae from older women that have revealed uteroplacental underperfusion and large placental infarcts8. To
maintain optimal blood flow, an increased surface area may
be required for placental attachment, and this may result in
placental encroachment on the lower uterine segment8.
Our results also show a greater risk of placenta previa with
higher parity, confirming findings from earlier studies. This
may be due to endometrial scarring at the site of prior
placental attachments resulting in lower placental
implantation. The other possibility may be that blood
vessels at the sites of prior placental attachments undergo
changes that may lead to decreased uteroplacental blood
flow3. This, in turn, may result in a larger placenta
encroaching on the cervical os with repeated pregnancies.
In this meta-analysis we analyzed only maternal age and
parity as independent risk factors for placenta previa.
However, since women with higher parity are likely to
be older, it is possible that advanced maternal age and
increased parity are not independent risk factors for the
placenta previa risk. This combined effect of age and
gravidity on the risk of placenta previa was demonstrated in
a large (n = 37 956 020), population-based, cohort study
of singleton births from the USA (198998)103. This
study showed that the risk of placenta previa was not
independent of maternal age and parity, but rather that
both factors exerted a joint influence on placenta previa
risk. In other words, increasing maternal age and increasing
parity conferred the greatest risk of placenta previa
compared with that of primigravid women aged < 20 years
(Table 16).
There is an increased risk of placenta previa among
women with a history of previous Cesarean delivery and
previous abortion. Our meta-analysis corroborates these
general findings reported in several previous studies as well
as a meta-analysis104. Damage and scarring to the endometrial and myometrial lining during Cesarean delivery
and spontaneous and induced abortion are known to pre-
Table 16
Joint effects of maternal age and gravidity on the risk of placenta previa: adjusted relative risks with 95% confidence intervals
Gravidity (number of pregnancies)
1.00 (referent)
1.61 (1.50, 1.72)
2.82 (2.63, 3.00)
4.71 (4.41, 5.03)
7.30 (6.78, 7.86)
10.41 (9.25, 11.72)
Table reprinted from reference 103, 2003, with permission of Elsevier Science
Relative risks were adjusted for the confounding effects of maternal anemia, intrapartum fever, preterm premature rupture of
membranes, hydramnios, maternal diabetes, placental abruption, unexplained uterine bleeding and male sex
185
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Strength and direction of association between various risk factors and conditions associated with placenta previa
Associations
Strength
Directionality
Population-attributable risk
(%)
+++
+++
+
+
+
++
+
+
+
++
+
+
++
+
-
25.7
6.7
10.2
16.0
2.7
0.3
1.4
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ACKNOWLEDGEMENTS
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J ournal of MaternalFetal and Neonatal Medicin e
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