Department of Medical Statistics, Peking University First Hospital, Beijing, China.
Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China.
JAMA Netw Open. 2022 Aug 1;5(8):e2228002. doi: 10.1001/jamanetworkopen.2022.28002.
Placenta previa is widely acknowledged as a risk factor for placenta accreta spectrum (PAS) disorders, which are severe maternal complications; however, data are limited regarding whether placenta previa is associated with a higher risk of worse maternal outcomes among patients with PAS disorders.
To examine the association between placenta previa and the risk of severe maternal morbidities (SMMs) and higher resource use among patients with PAS disorders.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study extracted records of 3793 patients with PAS diagnosis and delivery indicators between October 1, 2015, and December 31, 2019, from the US National Inpatient Sample database.
Placenta previa.
Data on 21 Centers for Disease Control and Prevention-defined SMMs and 25 study-defined surgical morbidities associated with PAS were extracted. Six surgical procedures (cystoscopy, intra-arterial balloon occlusion, cesarean delivery, hysterectomy, cystectomy, and oophorectomy), hospital length of stay, and inpatient costs were compared. Multivariable Poisson regression models built in the generalized estimating equation framework were used.
Among 3793 patients with PAS (median [IQR] age at admission, 33 [29-37] years), 621 women (16.4%) were Black, 765 (20.2%) were Hispanic, 1779 (46.9%) were White, 441 (11.6%) were of other races and/or ethnicities (47 [1.2%] were American Indian, 220 [5.8%] were Asian or Pacific Islander, and 174 [4.6%] were of multiple or other races and/or ethnicities), and 187 (4.9%) were of unknown race and ethnicity. A total of 1323 patients (34.9%) had placenta previa and 2470 patients (65.1%) did not; of those with placenta previa, 405 patients (30.6%) had invasive PAS. Patients with vs without placenta previa had a significantly higher rate and risk of any SMM (935 women [70.7%] vs 1087 women [44.0%]; P < .001; adjusted risk ratio [aRR], 1.19; 95% CI, 1.12-1.27) and any surgical morbidity (1170 women [88.4%] vs 1667 women [67.5%]; P < .001; aRR, 1.18; 95% CI, 1.13-1.23). With regard to specific outcomes, those with vs without placenta previa had a significantly higher rate of peripartum hemorrhage (878 patients [66.4%] vs 1217 patients [49.3%]; P < .001), blood product transfusion (413 patients [31.2%] vs 610 patients [24.7%]; P < .001), shock (83 patients [6.3%] vs 108 patients [4.4%]; P = .01), disseminated intravascular coagulation or other coagulopathy (77 patients [5.8%] vs 105 patients [4.3%]; P = .04), and urinary tract injury (44 patients [3.3%] vs 41 patients [1.7%]; P = .002). Patients with vs without placenta previa were more likely to undergo cesarean delivery (1292 patients [97.7%] vs 1787 patients [72.3%]; P < .001), hysterectomy (786 patients [59.4%] vs 689 patients [27.9%]; P < .001), cystoscopy (301 patients [22.8%] vs 203 patients [8.2%]; P < .001), cystectomy (157 patients [11.9%] vs 98 patients [4.0%]; P < .001), and intra-arterial balloon occlusion (121 patients [9.1%] vs 77 patients [3.1%]; P < .001) and to have significantly longer hospital length of stay (median [IQR], 5 [4-11] days vs 3 [3-5] days; P < .001) and total inpatient costs (median [IQR], $17 496 [$10 863-$30 619] vs $9728 [$6130-$16 790]; P < .001). Hypertensive disorder of pregnancy was associated with a decreased risk of placenta previa (aRR, 0.67; 95% CI, 0.46-0.96) among patients with PAS.
In this study, placenta previa was associated with an increased risk of maternal and surgical morbidities and higher resource use among women with PAS. These findings suggest that interventions to alleviate maternal and surgical morbidities are especially needed for patients with placenta previa-complicated PAS disorders.
重要性：胎盘前置广泛被认为是胎盘植入症谱（PAS）疾病的一个风险因素，这些疾病是严重的产妇并发症；然而，关于胎盘前置是否与 PAS 疾病患者更严重的产妇结局风险增加有关的数据有限。
目的：检查胎盘前置与 PAS 疾病患者严重产妇发病率（SMM）和更高资源使用之间的关系。
设计、地点和参与者：这项回顾性队列研究从美国国家住院患者样本数据库中提取了 2015 年 10 月 1 日至 2019 年 12 月 31 日期间 PAS 诊断和分娩指标的 3793 例患者记录。
暴露因素：胎盘前置。
主要结果和措施：提取了 21 种疾病控制和预防中心定义的 SMM 和 25 种 PAS 相关手术发病率数据。比较了六种手术（膀胱镜检查、动脉内球囊闭塞、剖宫产、子宫切除术、膀胱切除术和卵巢切除术）、住院时间和住院费用。使用广义估计方程框架构建了多变量泊松回归模型。
结果：在 3793 例 PAS 患者（入院时中位数[IQR]年龄，33[29-37]岁）中，621 例（16.4%）为黑人，765 例（20.2%）为西班牙裔，1779 例（46.9%）为白人，441 例（11.6%）为其他种族和/或族裔（47 例[1.2%]为美洲原住民，220 例[5.8%]为亚洲或太平洋岛民，174 例[4.6%]为多种或其他种族和/或族裔），187 例（4.9%）为未知种族和族裔。共有 1323 例（34.9%）患者有胎盘前置，2470 例（65.1%）患者没有；其中有 405 例（30.6%）患者有侵袭性 PAS。与无胎盘前置的患者相比，有胎盘前置的患者发生任何 SMM 的发生率和风险更高（935 例[70.7%]与 1087 例[44.0%]；P<0.001；调整风险比[aRR]，1.19；95%CI，1.12-1.27）和任何手术发病率（1170 例[88.4%]与 1667 例[67.5%]；P<0.001；aRR，1.18；95%CI，1.13-1.23）。具体而言，与无胎盘前置的患者相比，有胎盘前置的患者发生围产期出血的发生率更高（878 例[66.4%]与 1217 例[49.3%]；P<0.001）、输血（413 例[31.2%]与 610 例[24.7%]；P<0.001）、休克（83 例[6.3%]与 108 例[4.4%]；P=0.01）、弥散性血管内凝血或其他凝血障碍（77 例[5.8%]与 105 例[4.3%]；P=0.04）和尿路上皮损伤（44 例[3.3%]与 41 例[1.7%]；P=0.002）。与无胎盘前置的患者相比，有胎盘前置的患者更可能进行剖宫产（1292 例[97.7%]与 1787 例[72.3%]；P<0.001）、子宫切除术（786 例[59.4%]与 689 例[27.9%]；P<0.001）、膀胱镜检查（301 例[22.8%]与 203 例[8.2%]；P<0.001）、膀胱切除术（157 例[11.9%]与 98 例[4.0%]；P<0.001）和动脉内球囊闭塞（121 例[9.1%]与 77 例[3.1%]；P<0.001），住院时间更长（中位数[IQR]，5[4-11]天与 3[3-5]天；P<0.001），总住院费用更高（中位数[IQR]，$17496[$10863-$30619]与 $9728[$6130-$16790]；P<0.001）。妊娠高血压疾病与 PAS 患者胎盘前置的风险降低相关（aRR，0.67；95%CI，0.46-0.96）。
结论和相关性：在这项研究中，胎盘前置与 PAS 患者的产妇发病率和手术发病率增加以及资源使用增加相关。这些发现表明，需要特别干预来减轻胎盘前置合并 PAS 疾病患者的产妇和手术发病率。
