Journal of Obstetrics and Gynaecology

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Risk factors for severe postpartum haemorrhage

during caesarean section for placenta praevia

Choi Wah Kong & William Wing Kee To

To cite this article: Choi Wah Kong & William Wing Kee To (2019): Risk factors for severe
postpartum haemorrhage during caesarean section for placenta praevia, Journal of Obstetrics and
Gynaecology, DOI: 10.1080/01443615.2019.1631769

To link to this article: https://doi.org/10.1080/01443615.2019.1631769

Published online: 03 Sep 2019.

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY
https://doi.org/10.1080/01443615.2019.1631769

ORIGINAL ARTICLE

Risk factors for severe postpartum haemorrhage during caesarean section for
placenta praevia
Choi Wah Kong and William Wing Kee To
Department of Obstetrics and Gynaecology, United Christian Hospital, Kowloon, Hong Kong

ABSTRACT KEYWORDS
The objective of this study was to evaluate the value of clinical and ultrasound risk factors in predicting Placenta praevia;
severe postpartum haemorrhage (PPH) (
1.5 L) in pregnancies undergoing caesarean section for pla- postpartum haemorrhage;
centa praevia. This cohort consists of all cases of placenta praevia undergoing caesarean delivery over risk factor; low-lying
placenta; caesarean section
a period of 5 years in a service unit. Patients and their delivery data were retrieved from an obstetric
database. Ultrasound features were prospectively recorded before caesarean section. The incidence of
caesarean section for placenta praevia was 0.98% (n ¼ 215). Of these, 12.1% (n ¼ 26) had severe PPH. A
logistic regression model showed that major praevia, antepartum haemorrhage before delivery and
anterior placenta remained significant factors associated with severe PPH. The sensitivity/specificity and
positive/negative predictive value of the model are 96.2%, 59.8%, 24.8% and 99.1%, respectively. Our
model had high sensitivity and negative predictive value for severe PPH during caesarean section for
placenta praevia.

IMPACT STATEMENT
 What is already known on this subject? Placenta praevia is known to be one of the leading
causes of severe PPH. Many risk factors have been associated with severe bleeding during caesar-
ean section for placenta praevia. However, the importance of individual factors in predicting preg-
nancy outcome remains controversial.
 What the results of this study add? Our model includes only three simple parameters, namely
the presence of significant antepartum haemorrhage (APH) from the history, and anterior or poster-
ior placenta and major or minor praevia from ultrasound findings, but could predict up to 96.2% of
all severe PPH. More importantly, the absence of APH, a posterior minor praevia, was associated
with a negative predictive value of 99.1% of severe PPH, implying that such cases could be treated
as ‘normal’ low risk caesarean sections.
 What the implications are of these findings for clinical practice and/or further research? This
simple model would allow differential pre-operative counselling of patients on risks and complica-
tions, planning and preparation of operation, allocation of staff as well as in contingency measures
to be taken during operation. The establishment of a differential protocol for placenta praevia
based on these simple risks factors and a prospective trial of such a protocol is suggested.

Introduction approach involving experienced obstetricians, anaesthetists,

The incidence of postpartum haemorrhage (PPH) is increasing
worldwide and approximately 1–2% of deliveries in devel-
oped countries are associated with severe PPH (Karayalçın
et al. 2011; Laas et al. 2012). Placenta praevia is known to be
one of the leading causes of severe PPH. Placenta praevia
and morbidly adherent placenta were often the leading indi-
cations for peripartum hysterectomy due to increase in previ-
ous caesarean sections (Glaze et al. 2008; Imudia et al. 2009).
Many risk factors are associated with profuse bleeding during
caesarean section for placenta praevia. However, the import-
ance of individual factors in predicting pregnancy outcome
remains controversial. If a good predicting model for predict-
ing severe PPH during caesarean section for placenta praevia
is established, better preparation with multi-disciplinary
haematologists and radiologists can improve the maternal
outcomes. The objective of this study is to evaluate the value
of using clinical and ultrasound risk factors in predicting
severe PPH in women undergoing caesarean section for pla-
centa praevia.
Materials and methods
This study was a retrospective cohort of all patients with pla-
centa praevia who were delivered by caesarean section in an
obstetric training unit from January 2012 to December 2016.
According to our local protocol, if low-lying placenta was
detected during second trimester morphology scan or
detected when patient had antepartum haemorrhage (APH),

CONTACT Choi Wah Kong melizakong@gmail.com Department of Obstetrics and Gynaecology, United Christian Hospital, 130 Hip Wo Street, Kwun Tong,
Kowloon, Hong Kong
ß 2019 Informa UK Limited, trading as Taylor & Francis Group
2 C. W. KONG AND W. W. K. TO
follow up ultrasound scan would be arranged at 34 week of
gestations to review whether low-lying placenta still per-
sisted. Placenta praevia was defined as the placenta inserted
wholly or in part into the lower segment of the uterus. Major
praevia was defined as the placental edge covering the
internal os while minor was defined as the placental edge
was in the lower segment but did not cover the internal os
(Jauniaux et al. 2019). If the placental edge was
2 cm from
cervical os, vaginal delivery would be the planned mode of
delivery in the absence of other contraindications. If the pla-
cental edge was <2 cm from cervical os, caesarean sections
would be arranged after 37–38 week of gestations.
The data of all the patients with placenta praevia who
were delivered by caesarean section in United Christian
Hospital were retrospectively retrieved from a comprehensive
obstetric database. Both major and minor placenta praevia
were recruited. Severe PPH was defined as blood loss
1.5 L.
According to our department protocol during the study
period, all the patients with placenta praevia undergoing
either elective or emergency caesarean sections would have
transabdominal and/or transvaginal ultrasound assessment
one day before or on the day of operation as pre-operative
assessment. The shape of the placental edge was measured
and defined according to the Ghourab categorisation
(Ghourab 2001). The lower placenta edge was assessed by
measuring its maximum thickness within 1 cm of the meet-
ing point of the basal and chorionic plates and an estimation
of the angle between these plates. It was defined as ‘thin’ if
the thickness was 1 cm and/or the angle was <45 ; other-
wise it was defined as ‘thick’. The placental location, the dis-
tance of placental edge from internal os, the presence of
lacunae were documented prospectively in the medical notes
and these data were then retrieved from the medical records
subsequently for analysis. The maternal demographic data
and the maternal outcomes were retrieved from the obstetric
data base.
According to our department policy, all the caesarean sec-
tions with placenta praevia were performed by obstetricians
who were members of Royal College of Obstetricians and
Gynaecologists (MRCOG) or above. For caesarean section
with major placenta praevia, there would be the presence of
consultant in the operation theatre. The blood loss in caesar-
ean section was calculated from the amount of blood loss
from the suction bottle and from weighing the abdominal
pads and gauzes.
The SPSS for Windows package was used for data entry
and analysis (SPSS Inc., Chicago, IL). Continuous variables
were analysed by t-test and discrete variables by Chi-square
test or Fisher’s exact test when appropriate. p Value <.05
was considered statistically significant. Formal ethics approval
for this study was granted by the local Ethics Committee
Board of the Hospital Authority, Hong Kong.
Results
There were a total of 21,908 deliveries over the 5-year study
period and the incidence of caesarean section for placenta
praevia was 0.98% (n ¼ 215). Of these, 101 patients (46.9%)
had PPH with blood loss
500 ml and 26 patients (12.1%)
had severe PPH with blood loss
1500 ml. There were four
cases (1.85%) of peripartum hysterectomy and no cases of
maternal death. There were six cases of placenta accreta
(2.8%), in which four patients had severe PPH. For the other
two patients without severe PPH, one had classical caesarean
section with the placenta left in situ followed by uterine
artery embolisation, and the final blood loss was 1330 ml.
The other patient had classical caesarean section and direct
hysterectomy performed with blood loss 920 ml.
The epidemiological risk factors and the ultrasound fea-
tures between the group of patients without severe PPH and
the group of patients with severe PPH are shown in Table 1.
Univariate analysis showed that advanced maternal age, pre-
vious pregnancies with placenta praevia or PPH, the type of
praevia or distance of the placental edge from the cervical
os, occurrence of APH before delivery, anterior placenta, pres-
ence of sponge-lacunae signs on ultrasound, thick placental
edge and presence of accreta were all significantly associated
with severe PPH. The mean blood loss was 455 ml in the
group without severe PPH compared with 2439 ml in the
group with severe PPH (p < .001). The incidence of peripar-
tum hysterectomy was 0.5% in the group without severe PPH
versus 11.5% in the group with severe PPH (p ¼ .006). Other
pregnancy outcomes are shown in Table 2. A logistic regres-
sion model showed that major placenta praevia, APH before
delivery and anterior placenta remained significant factors
associated with severe PPH, whereas other parameters
(advanced maternal age, previous pregnancies with praevia
or PPH, presence of sponge-lacunae signs on ultrasound,
thick placenta and presence of accreta) were excluded
(Table 3). Due to the differential treatment for accreta cases,
placenta accreta was not a significant factor in the
final equation.
Based on the above model, with the presence of either
one of the three significant factors being categorised as posi-
tive for high risk of severe PPH, 25 of the 26 severe PPH
patients in the cohort would be categorised as high risk, giv-
ing a high detection rate of 96.2%, but with a lower specifi-
city of 59.8% (113/189). On the other hand, of the 114
patients that would be categorised as low risk with this
model, only one had severe PPH, giving a very high negative
predictive value of 99.1% (113/114), but a relatively low posi-
tive predictive value of 24.8% (25/101).
Discussion
Our data showed that there was a high association between
PPH and placenta praevia, however, severe PPH only
occurred in 10–15% of these cases. A predictive model can
be constructed based on the various clinical features of the
praevia to allow differential preparation and management of
the caesarean delivery of these patients.
In our cohort, only two epidemiological parameters associ-
ated with severe PPH were found to be significant on univari-
ate analysis, namely maternal age and previous PPH, while
the rest of the significant parameters including the type of
praevia or distance of the placental edge from the os,
 JOURNAL OF OBSTETRICS AND GYNAECOLOGY 3

Table 1. Epidemiological risk factors and ultrasound features.

No severe PPH (n ¼ 189) PPH > 1500 ml (n ¼ 26) p Value MD; 95% CI
Maternal age 34.6 (SD 4.9) 37.3 (SD 3.0) .007; –2.72 (–4.67 to –0.77)
Advanced maternal age
35 108 (57.1%) 21 (80.8%) .031
Parity .25
Nulliparous 85 (45.0%) 6 (23.1%)
Multiparous 104 (55.0%) 20 (76.9%)
Multiple pregnancy 5 (2.6%) 1 (3.8%) .54
Previous suction evacuation 54 (28.6%) 13 (50.0%) .38
Previous CS 46 (24.3%) 11 (42.3%) .35
Previous history of PPH/praevia 0 (0.0%) 2 (7.7%) .014
Antepartum APH before CS 23 (12.2%) 20 (76.9%) <.001
Type of praevia –> <.001
Minor 145 (76.7%) 6 (23.1%)
Major 44 (23.3%) 20 (76.9%)
Distance from os <.001
10–20 mm 62 (32.8%) 1 (3.8%)
0–10 mm 83 (43.9%) 5 (19.2%)
Reaching/touching os 38 (20.1%) 12 (46.2%)
Covering os 6 (3.2%) 8 (30.8%)
Location of praevia <.001
Anterior 37 (19.6%) 19 (73.1%)
Posterior 152 (80.4%) 7 (26.9%)
Sponge-lacuna signs on USG 3 (1.6%) 12 (46.2%) <.001
Placenta covering os .001
Thick 38 (20.1%) 17 (65.4%)
Thin 151 (79.9%) 9 (34.6%)
Type of CS .38
Elective CS 47 (24.9%) 9 (34.6%)
Emergency CS 142 (75.1%) 17 (65.4%)
Clinical accreta at CS 2 (1.1%) 4 (15.4%) .002
MD: mean difference; CI: confidence interval; PPH: postpartum haemorrhage; APH: antepartum haemorrhage; CS: caesarean section;
USG: ultrasound.
Statistically significant.

Table 2. Pregnancy outcomes.

No severe PPH (n ¼ 189) PPH>1500 ml (n ¼ 26) p Value MD; 95% CI
Gestation at delivery 37.4 (SD 1.35) 37.3 (SD 1.25) .71 –0.45 to 0.66
Preterm delivery 21 (11.1%) 5 (19.2%) .21
Birthweight 2967 (SD 433) 3000 (SD 543) .72 –33.4
–218 to 151
Apgar score < 4 at 1 min 1 (0.5%) 1 (3.8%) 1.00
Apgar score < 7 at 5 min 1 (0.5%) 0 (0.0%) 1.00
Type of uterine incision 1.00
–>Transverse Kerr 188(99.5%) 26 (100%)
–>Vertical DeLee 1 (0.5%) 0 (0.0%)
Placenta cut through at delivery 8 (4.23%) 5 (19.2%) .002 8 (4.23%)
Total blood loss 455 (SD 293) 2439 (SD 1063) <.001 –1983
–2172 to –1795
Peripartum hysterectomy 1 (0.5%) 3 (11.5%) .006
Additional procedures <.001
–>Intrauterine balloon 0 (0.0%) 11 (42.3%)
Compression sutures 0 (0.0%) 3 (11.5%)
Pelvic de-vascularisation 0 (0.0%) 0 (0.0%)
Radiological embolisation 1 (0.5%) 2 (7.7%)
MD: mean difference; CI: confidence interval; PPH: postpartum haemorrhage.
Statistically significant.

occurrence of APH before delivery, anterior placenta, pres-
ence of sponge-lacunae signs, thick placental edge and pres-
ence of accreta were all associated with clinical features of
the praevia. The epidemiological parameters were also subse-
quently excluded after logistic regression analysis; therefore,
only major placenta praevia, APH before delivery and anterior
placenta remained significant factors in the final regression
analysis. These findings were compatible with most of the
studies that available in the current literature (Baba et al.
2014; Yoon et al. 2014). A combined ultrasound and clinical
scoring model was made by Yoon to predict peripartum
complications for women with placenta praevia delivered by
caesarean section (Yoon et al. 2014). The type of praevia,
lacunae, uteroplacental hypervascularity, parity, history of
caesarean section and history of placenta praevia were asso-
ciated with higher incidence of blood transfusion, uterine
artery embolisation and caesarean hysterectomy. However,
due to the heterogeneous nature of the parameters analysed,
no factor can independently predict any complications in the
logistic regression analysis. Another retrospective cohort in
4 C. W. KONG AND W. W. K. TO
Table 3. Logistic regression for indicators for severe PPH.
Risk factors B Standard error
Parameters in the equation
Major vs. minor praevia 1.35 0.68
Significant APH before CS 2.14 0.64
Anterior vs. posterior placenta 1.55 0.67
Parameters excluded from equation
Advanced maternal age 0.57 0.67
History of PPH/praevia in previous pregnancies 19.08 28,248
USG sponge-lacuna signs 2.79 1.61
Thick versus thin placental edge 0.91 0.68
Presence of accreta 0.96 1.91
APH: antepartum haemorrhage; CS: caesarean section; PPH: postpartum haemorrhage; USG: ultrasound.
Statistically significant.
2014 recruited 205 patients and found that placenta accreta,
previous caesarean section, major placenta praevia and anter-
ior placenta were independent risk factors for massive haem-
orrhage during caesarean section in patients with placenta
praevia after multivariate logistic regression analysis (Baba
et al. 2014).
Major placenta praevia remained to be a significant factor
that affected the incidence of severe PPH after logistic
regression analysis in our cohort. Major placenta praevia was
found to have higher possibility of blood transfusion and
emergency peripartum hysterectomy in patients with pla-
centa praevia (Giambattista et al. 2012; Baba et al. 2014).
More severe bleeding in major placenta praevia was postu-
lated to be due to bleeding from the less contractile lower
uterine segment which is the placenta separation site in pla-
centa praevia. Therefore, if larger portion of the lower seg-
ment is attached to the placenta, more bleeding will be
encountered (Tuzovic 2006; Sekiguchi et al. 2013).
Our cohort found that thick placenta was associated with
higher incidence of severe PPH than thin placenta but it did
not reach statistically significant after logistic regression. The
first prospective observational study in 2001 which included
71 women with placenta praevia and showed that those with
thick placenta had higher incidence of APH, emergency cae-
sarean section before 36 week gestations, presence of pla-
centa accreta and peripartum blood transfusions than those
with thin edge (Ghourab 2001). It was speculated that this
was due to abundant vasculature of the lower placental edge
and the subplacental zone and the interference of a thick-
edge placenta with descent of the foetal head (Saitoh et al.
2002). Another prospective study in 2011 which included 54
women also showed that thick placenta was associated with
significantly higher incidence of APH, emergency caesarean
section before 36 week and more peripartum blood transfu-
sion and caesarean hysterectomy than thin placenta (Zaitoun
et al. 2011). Logically, it could be anticipated that a thick pla-
cental edge would be associated with increase in incidence
of APH due to progressive descent of the foetal head near
term or in labour, leading to APH which per se would be
associated with higher incidence of severe PPH. We also
observed that a thick placental edge would be more often
associated with major placenta praevia than minor praevia.
Therefore, the reason of thick placenta not being a significant
factor after our logistic regression model could be due to the
Wald Significance Odds ratio 95% confidence interval
3.95 0.047 3.85 1.01–14.59
11.19 0.001 8.47 2.42–29.66
5.34 0.021 4.71 1.27–17.56
0.73 0.39 1.77 0.48–6.54
0.001 0.99 1.94 0.001–21.4
2.99 0.08 16.39 0.69–390
1.77 0.18 2.47 0.65–9.36
0.25 0.61 2.62 0.06–111
confounding effects from its association with major praevia
and APH in the logistic regression analysis.
Anterior placenta is a significant factor for severe PPH in
our cohort. In a study in 2014, anterior placenta is an inde-
pendent risk factor for massive haemorrhage during caesar-
ean section in patients with placenta praevia irrespective of
placenta accreta, previous caesarean section or transplacental
approach to deliver the foetus (Baba et al. 2014). The pro-
posed theory was that the uterus was incised more cephalad
in anterior placenta than posterior patients in order to avoid
transplacental delivery of the foetus. As the uterine wall
would be thicker in uterine body than the lower segment,
incisions other than low transverse incision, such as high
transverse incisions or classical vertical incisions, would be
expected to be associated with more bleeding. There would
also be more blood vessels existing on the incision site for
anterior placenta than posterior placenta. In our cohort, only
one patient had DeLee vertical incision while the rest of the
patients had the transverse Kerr incision. Significantly more
patients in the severe PPH group had transplacental delivery
of the foetus compared with non-severe PPH group. While
transplacental approach to deliver the foetus will obviously
increase bleeding, it is impractical to totally avoid transpla-
cental approach to deliver the foetus in all cases of placenta
praevia. In addition, it is difficult to predict whether transpla-
cental approach can be avoided before caesarean section, as
such decisions were usually made on site at the operation.
This study aims to develop a model to identify the risk fac-
tors for severe PPH before operation, transplacental delivery
is not a factor that can be easily predicted before caesarean
section. Therefore, we analyse anterior placenta as an overall
risk factor as this can be easily determined by ultrasound
before operation.
Lacunae had been suggested as the most predictive ultra-
sound sign for placenta accreta (Finberg and Williams 1992;
Comstock et al. 2004; Hamada et al. 2011). This could be the
reason why ultrasound finding of lacunae was associated
with a higher incidence of severe PPH in our cohort on uni-
variate analysis and a higher incidence of peri-operative com-
plication in patients with placenta praevia in a cohort in
2014 (Yoon et al. 2014). With increasing overall caesarean
section rates, the incidence of placenta accreta was increas-
ing worldwide due to the increasing incidence of previous
caesarean section. It was reported that the risk of placenta
accreta was 3% after the first caesarean section but the risk

rose to 40% after the third caesarean section (Silver et al.
2006). Morbidly adherent placenta was found to be an inde-
pendent predictor for peripartum hysterectomy and severe
maternal morbidities in placenta praevia patients
(Giambattista et al. 2012; Coskun et al. 2018). Placenta
accreta was associated with severe PPH in placenta praevia
in univariate analysis but not after logistic regression analysis
due to other confounding factors in our cohort as well as in
a Japanese cohort (Hasegawa et al. 2009). In our six patients
with placenta praevia together with placenta accreta, three
of them were not suspected to have placenta accreta before
caesarean section and all of them had severe PPH. For the
three patients suspected to have placenta accreta before cae-
sarean section, only one of them had severe PPH due to the
differential management of the other two patients. Therefore,
if the diagnosis of morbidly adherence of placenta was made
before operation, proper planning of the caesarean section
to avoid cutting through the placenta and to avoid manually
separating the placenta could decrease the incidence of
severe PPH. Obstetricians should be aware of the possibility
of placenta accreta in patients having placenta praevia with
anterior-locating placenta and previous caesarean section.
Vigilant detection of lacunae and high level of suspicion of
accreta are crucial for better pre-operative planning and
offering alternative management strategies.
Our final model of including only three simple parameters,
namely presence of significant APH from the history, anterior
or posterior locating placenta and major or minor praevia
from ultrasound findings, could apparently predict up to
96.2% of all severe PPH. With the presence of either one of
these factors, better liaison with blood bank before operation
and adopting multi-disciplinary approach involving experi-
enced obstetricians, anaesthetists and radiologists should
improve the maternal outcomes. More importantly, the
absence of APH, a posterior minor praevia, was associated
with a negative predictive value of 99.1% of severe PPH,
implying that such cases could be treated as ‘normal’ low
risk caesarean sections, and senior obstetricians would only
need to be available for standby for contingencies. This sim-
ple model would allow differential pre-operative counselling
of patients on risks and complications, planning and prepar-
ation of operation, allocation of staff as well as in contin-
gency measures to be taken during operation. The
application of such a model should be particularly useful in
busy training and service units, as in our case, when effective
utilisation of limited resources and manpower expertise
are crucial.
The limitation of this study is its retrospective nature and
its relatively limited sample size. The next step appears to be
the establishment of a differential protocol for placenta prae-
via based on these simple risks factors, and a prospective
trial of such a protocol in a larger sample of patients.
In conclusion, our model consisting of the presence of
APH, major type of praevia and anterior locating placenta
had high sensitivity and negative predictive value for having
severe PPH during caesarean section for placenta praevia.
This model should be useful to triage ‘low risk’ and ‘high risk’
patients for severe PPH before operation.
JOURNAL OF OBSTETRICS AND GYNAECOLOGY 5
Disclosure statement
No potential conflict of interest was reported by the authors.
ORCID
Choi Wah Kong http://orcid.org/0000-0001-8889-4843
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