Posted on Authorea 15 Apr 2020 — CC BY 4.0 — https://doi.org/10.22541/au.158698499.98583640 — This a preprint and has not been peer reviewed. Data may be preliminary. oe ihP h vrl rvlneo P a 16,rnigfo 0 o90%. to 20% from ranging ten- 51.6%, to was four- APH of a prevalence approximately overall globally the have PP praevia is with APH. placenta pregnancies. women APH of of with However, risk 3–5% those increased complicating women, severity. mortality, fold praevia maternal its non-placenta and describing to perinatal Compared for reported of definition cause a leading consistent with a which no os, as (PP), is regarded cervical praevia there internal Placenta that the worldwide. acknowledges is to pregnancies (APH) proximity 1000 haemorrhage close (RCOG) per antepartum in 5 placentation of of abnormal prevalence causes by important characterised most is the of One maternal postpartum or intra-operative serious INTRODUCTION of terms in difference no makes outcomes. praevia placenta in Bleeding No Funding: PP. morbidity in ABSTRACT maternal bleeding TWEETABLE serious of of outcomes. management lack maternal towards a Praevia, approach deaths. However, Placenta individualised Haemorrhage, maternal Antepartum an admissions. or Keywords: for hospital admissions greater body. longer support section, unit funding provides and caesarean care emergency women transfusion delivery, intensive preterm these blood no for among more tendency and a requiring hysterectomies had loss APH four experienced blood who of PP loss total with Women bloods a of Conclusions: was volume (IRR=3.36,p There greater transfusion techniques), blood surgical (IRR=1.27,p=0.001). of additional major or frequency of used increased proportion uterotonics (IRR=1.20,p=0.006), greater of blood (number a of intra-operatively of had number differences APH Type cant and (OR=3.14,p experienced loss anaesthesia Measures: who blood general Outcome women of of re- APH, Main volume without logistic complications, counts. women using (OR=2.88,p postpartum to for analysed (n=230) PP and Compared regressions were APH intra-operative into binomial database Results: delivery, divided negative obstetric of transfusions. and or institution-based mode recruited Poisson from and were and retrieved timing (PP) PP, outcomes Data praevia placenta Australia. binary Methods: with Hospital, for Women’s women gressions & (n=138). 368 Brisbane of APH Royal haemorrhage total No antepartum Setting: a and experience study. years, cohort who ten Retrospective those Over between Design: (PP) Population: APH. praevia without placenta those for and outcomes (APH) maternal compare To Objective: Abstract 2020 28, April 2 1 Chung Philip Study haemorrhage: Cohort without Retrospective those had to who compared previa haemorrhage placenta antepartum with women in Outcome Maternal IRBerghofer Hospital QIMR Women’s and Brisbane Royal 2 ensAHa leigfo ri otegntltatbyn 4weso rgac and pregnancy of weeks 24 beyond tract genital the to in or from bleeding as APH defines < .0) mrec oe trn emn (OR=6.24,p segment uterine lower emergency 0.001), 1 en Cheer Kenny , 4,5 n21,asseai eiwo 9suisb a tal. et Fan by studies 29 of review systematic a 2017, In < .0) rtr eiey(ein3. s3. ek,p weeks, 38.0 vs 35.4 (median delivery preterm 0.001), 1 v Malacova Eva , 1 h oa olg fOsercasadGynaecologists and Obstetricians of College Royal The 2 1 aoiOkan Satomi , < .0)adcascl(OR=14.9,p classical and 0.001) < .0) n ogrps-prtv optlstay hospital post-operative longer and 0.001), 2 n hnewrnRudra Thangeswaran and , < .0) hr a osignifi- no was There 0.001). 7,8 6 oe ihP who PP with Women eotdta among that reported < .0)scin,use sections, 0.001) 3 1 Posted on Authorea 15 Apr 2020 — CC BY 4.0 — https://doi.org/10.22541/au.158698499.98583640 — This a preprint and has not been peer reviewed. Data may be preliminary. w hrs(3)hdAH fwo 6 a ao rei.Wmnwt P a rae dso major of these, odds greater Of had 2018. APH with to Women 2009 praevia. from 1.79-4.28, major PP had CI: with 66% 95% diagnosed whom (OR=2.77, were of who PP APH, had women (63%) 368 were thirds of two analyses records All medical investigated obstetrics We various appropriate. the USA). as Texas, and regression Station, APH Poisson College RESULTS between Corporation, and (Stata association binomial 15.1 the version negative STATA for explore and using test logistic, To conducted percentages, U used and Mann-Whitney test. we counts a as using Chi-squared outcomes, compared summarised a were and using using variables used compared compared Categorical were and variables ranges variables. distributed interquartile distributed normally and non-normally summarise medians to while used t-test, were a deviations surgery. standard ethnicity, previous and of maternal Means history parity, a and age, section analysis maternal caesarean Statistical of included history demographics a maternal IVF, smoking, on maternal available was Information also were post-delivery stay The variables hospital transfusions. Other the and including techniques complications surgical postpartum additional and expended, loss recorded. uterotonics bleeding, blood of significant of number control volume general and and of total prevent type use delivery, to the of used mode as measures and such any timing PP, and of complications was type intraoperative APH the gestation. anaesthesia, included delivery. of investigated outcomes weeks of maternal 24 time main beyond The at from or tract ultrasound genital by Sets the pregnancy Outcome from of Core bleeding weeks of 34 episode after any made by was defined PP of carefully diagnosis also The were documentation anaesthetic and database notes Exposure period. obstetric operation retrieval institution-based data Surgeon the Ethics our in charts. Research during via Human examined patient unit institutional retrieved of referral the was by review tertiary approved Data and was thus largest research excluded, were This the (n=11) (LNR/2018/QRBW/43114). twins analysis. of to Committee the birth gave one for who time women those Hospital, 368 the for leaving Women’s records at duplicate & and praevia (n=65) placenta Brisbane disorders spectrum with Royal diagnosed 1 the were between at who Queensland, women delivery all their included of study cohort collection retrospective data This and population study design, complicated praevia Study placenta with women without. for with those outcomes literature, METHODS to obstetric the compared of in cases. episodes evaluated range 250 bleeding extensively a any than examine been by less to not of was has study it populations PP, spective small with recruiting hospitalisation. women to studies compared in previous outcomes common similar is with APH setting outpatient Although the in managed be can APH without eurn leigb ie alrdatntlcr ae nrcmedtosfo ohaesystematic Cochrane guidelines a from (2018) recommendations RCOG on recent based most admission care require antenatal the events tailored However, review bleeding given previous be weeks. and bleeding 34 recurrent PP after with women or that at recommended transfusion, has blood requiring RCOG of Previously, hysterectomy. risks emergency greater with and associated section, been caesarean have preterm APH of episodes increasing experience 10 htsoe ocerdsdatg oaplc fhm esshsia ae ieie oe ihPP with women Likewise, care. hospital versus home of policy a to disadvantage clear no showed that st aur 09ad31 and 2009 January p < .0) oe ihAHwr naeae14yasyugrthan younger years 1.4 average on were APH with Women 0.001). st eebr21.Wmndansdwt lcnaaccreta placenta with diagnosed Women 2018. December 2 9 12–14 h i fti ag cl retro- scale large this of aim The 2 eomn htwmnwith women that recommend 11 Posted on Authorea 15 Apr 2020 — CC BY 4.0 — https://doi.org/10.22541/au.158698499.98583640 — This a preprint and has not been peer reviewed. Data may be preliminary. oprdt io P hsrsl sspotdb nte ag ersetv ooto 0 oe by women 306 of cohort retrospective large another al. by Mastrolia et supported by Bhide is study by prior result no al. a This made et alike PP. Bahar praevia, praevia, minor placenta placenta to with of women compared praevia diagnosis in a placenta bleeding al. predispose with antepartum et may of solely though risk diagnosed in characteristics, al. women difference maternal et Fan of that by number found noted We largest article individual the previous al. examines any et to study Fan compared by our individuals 4687 cases, which with haemorrhage, accreta articles antenatal twenty-nine experienced of praevia meta-analysis study placenta and previous with a women with of consistent (62%) is majority the centre. study, literature our tertiary current In major the in a reported be incidence to the known to hospital compared 0.8%, was population 0.2–0.4%. our at in stay. PP with postpartum of and anaesthesia, incidence longer intraoperatively general The and mothers under transfusion, for sections requiring implications caesarean significant loss emergency has blood preterm PP for greater of tendency setting a the including in postpartum, APH that found study Our Findings Main DISCUSSION recorded. deaths maternal hospital or post-op < admissions of ICU length no were longer There and greater 4). 1.08-2.59) < slightly (Table CI: had 1.12-1.47) APH 95% were CI: 3 with RBCs (OR=1.67, Women 95% were packed complication (IRR=1.28, 3c). There more (Table stay postpartum expected, 1.96-7.21) 3b). any As CI: (Table 95% of hysterectomy. 1.34-78.1) (IRR=3.76, underwent odds APH who CI: surgicell with a APH 95% women for had without for (OR=10.2, notably APH 1 used balloon most with and Bakri women without, APH Overall, women and with different women to but 1.39-8.44) 3a). the higher (Table compared CI: 1.19-3.31), with uterotonics techniques had APH 95% CI: of surgical of APH (OR=3.43, 95% number additional association with higher 1.98, no of was a Women (OR= percentage There with higher infusion and 0.12-0.59). 3a). and transfusions CI: (Table 1.14-2.91) of 95% infusion) (OR=0.27, CI: APH types and carbetocin 95% without bolus of (OR=1.83, women (syntocinon odds lower bolus APH to syntocinon with compared of women carbetocin, among odds greater for was lower measures and medical blood of estimated percentage median The higher a had 1.06-1.39). statistical APH CI: than reach with earlier (95% 1.90- < not Women significantly IRR=1.22 was did CI: the 2). weeks) by this (Table 95% (35.4 reflected weeks) though APH (OR=3.14, as (38.0 with 0.44-30.81), loss, anaesthetics women APH CI: (RRR=14.9, for general without 95% delivery LSCS without women odds of elective (OR=3.67, for women timing greater to tear median to had relative uterine The was Compared CS APH of significance. anaesthetic classical with extension general 2). emergency Women and (Table of of 5.18), without use risk 3.37-66.0). women greater and CI: had to CS, 95% APH segment) compared with lower APH women and with APH, classical women (both among caesarean emergency greater of of history percentage a The parity, smoking, without IVF. maternal and and ethnicity, with surgery, < maternal women uterine between index, of history difference mass a significant body (CS), no mean section was the There in 1). APH (Table (p=0.01) without women al 4 Table al 3 Table 2 Table 1 Table 16 oee,tedansso ao Psgicnl nrae h iko P O 2.88 (OR APH of risk the increases significantly PP major of diagnosis the However, > > > > 17 8,15 O .8 5 I1.58–6.4, CI 95% 3.18, (OR 18 hsi ieydet h ag ubro ihrs btti eerl eevda h study the at received referrals obstetric high-risk of number large the to due likely is This oprn P nmjrvru io P(71 ess47.5% versus (57.1% PP minor versus major in APH comparing 14 n lgtygetrta eotd(16)wti h ytmtcreview systematic the within (51.6%) reported than greater slightly and p 001 n iial eotdi ouaino 2 women 121 of population a in reported similarly and =0.001) 3 6 6 ept xldn l placenta all excluding Despite p < .5.Bsdsthe Besides 0.05). p < 0.001) Posted on Authorea 15 Apr 2020 — CC BY 4.0 — https://doi.org/10.22541/au.158698499.98583640 — This a preprint and has not been peer reviewed. Data may be preliminary. h eiaa aaaeuiie nti td sotie rmoserca ouetto n routinely and and documentation misclassification obstetrician of from risk mitigate referred. obtained to are is accuracy cases for study praevia examination placenta this rigorous high-risk institution-based representative in rare large is these utilised undergoes hospital of database study majority the perinatal the because where The centres generalisable tertiary widely with able of surgically, are were type and results we the standby medically Our thus of on both and care. radiologists resourced hospital maternal interventional well tertiary optimise and is to and hospital specialists rare referral our gynae-oncology Additionally, placenta major a obstetricians, of a patients. maternal-fetal-medicine analyse representation 350 within true to over conducted a recruit able been provide to has were to study able we present were that The we therefore was and study years ten population-based outcomes. of praevia retrospective period this a over of condition strength major A study the of limitations and Strength APH. of absence and outcomes presence maternal difference postpartum the no on was focused there scarcely APH, PP, has experienced literature in current who The those for complications. stay postoperative hospital in postpartum longer post- marginally three-fold loss a Besides over blood studies. requiring previous of al. 1.05–1.37), unlike volume et APH, CI Mastrolia greater of 95% significantly transfusions. presence 1.20, have blood (IRR of to counterparts number likely the asymptomatic were their antenatally than bled operatively specialists. who skilled PP to hospital, with study trainees Women of the obstetric lack within be junior preferences the might from individual for required hysterectomy, and range explanation including techniques experience may plausible techniques, Bakri anaesthetic surgical which A surgical and and additional APH. additional surgical 1.45–8.73) of in without and heterogeneity CI those medical differences the versus 95% both no group in 3.56, were APH used significance (OR there the uterotonics statistical surgicell in of 1.35–78.2), bleeding of number CI managing median use 95% for the besides 10.3, in Likewise, (OR difference situations no in balloon cohorts. was intra-operatively compared frequently there more the Otherwise, with used between were occurred. associated infusions had is and bleeding sections bolus where syntocinon caesarean anaesthesia. both in neuroaxial that anaesthesia explained than found caesareans general We be loss emergency might of of blood This use proportion of greater The literature. volume and the greater cohort. gestations in a anaes- earlier bleeding before general by antepartum reported undergoing suggested the of as been in delivery risk not of increased has urgency three-fold that the of bleeding by finding al. with novel et women an a Love in was undergo by thesia there to findings study likely significant our in with more Interestingly, well were correlates 25%) APH which vs (61% experienced 1.4%), segment 25% vs had age uterine vs (8.5% lower gestational who for incisions and women counterparts bleeding classical asymptomatic antenatal population, and their of than our intensity sections In and caesarean bleed. frequency emergency to PP, bleed. tendency of sentinel the type the increases at incident on itself the based in with praevia which correlate PP, placenta to of al. nursery seems degree et required and praevia Pivano frequently placenta episode more in bleeding and delivery one bleeding smaller of least were without timing at APH of earlier those with the than mothers Therefore earlier from admission. deliver delivered to newborns likely that established. weeks, found more well 38.0 significantly is versus PP were 35.4 with bleeding (median women placental experienced in the delivery who to preterm related PP of be risk also increased might The APH of likelihood the that thickness suggests edge research developing PP, of degree 27,28 p < n o hs hthv vlae hsapc aeas on osgicn ieec between difference significant no found also have aspect this evaluated have that those for and .0)adFsmne al. et Fishman and 0.001) 23 19 ulse crn ytmta rdce h iko mrec asra o oe with women for caesarean emergency of risk the predicted that system scoring a published n cofe pc ntelwreg fteplacenta. the of edge lower the in space echo-free and p < 14 .0) hsfidn scnitn ihrslsb a tal., et Lam by results with consistent is finding This 0.001). 25 O 779%C 6.1–51.7). CI 95% 17.7 (OR 14,24 16 iial on ednyfrbodtasuin nthe in transfusions blood for tendency a found similarly 4 26 20 21,22 norsuy oe with women study, our In 14 h also who 24 (63% Posted on Authorea 15 Apr 2020 — CC BY 4.0 — https://doi.org/10.22541/au.158698499.98583640 — This a preprint and has not been peer reviewed. Data may be preliminary. h uhr aercie oseicfnigfrti work. this for funding REFERENCES specific no received have authors The ref- 2018, August 30 approved FUNDING Committee, Ethics Research LNR/2018/QRBW/43114 Human number: Hospital erence Women’s and Brisbane Royal APPROVAL ETHICS OF DETAILS Interpretation and ysis trieval exist. interests religious P.C. or intellectual political, AUTHORSHIP personal, TO financial, CONTRIBUTION no that declared have authors The INTEREST OF DISCLOSURE the on bleeding. placenta Nil. of focus to treatment to and ought linked prevention research directly the further is for praevia outcomes ACKNOWLEDGEMENTS collection strategies placenta maternal formulate data in and outcomes of of APH maternal representation method of optimise aetiology accurate validated to order single more In a a praevia. using provide studies to setting. women prospective encouraged outpatient managing the multicentre safely continue in large-scale, to episodes reasonable Further bleeding availability be the previous may and it and services rec- that praevia emergency suggest RCOG placenta access findings with episode. the to our ability bleeding strengthen Hence, their any further wishes, transportation. with patients’ of findings praevia account placenta our into managing taking Therefore towards advise complications, approach We morbidity. post-operative individualised maternal and an management serious of intra-operative ommendations pose to regards which in of differences none few a only are There longer as well as remain anaesthesia, CONCLUSION general who requiring and women loss section diag- to blood caesarean of woman Compared stay. risks emergency a postpartum increased delivery, consideration. have for preterm APH serious period transfusion, experience into antenatal who blood taken those the pregnancy, be during their should during episode asymptomatic praevia bleeding placenta any with that nosed demonstrate results in- our clinical the Overall, between new distributed with equally be years would the Interpretation effects as over results change the may influence cohorts. substantially practices comparison to clinical unlikely is though it that sights, studies. acknowledge retrospective with authors associated The limitations intrinsic are which bias, recall CleaAisJ ut ,BictM,CleaN lcna buto n lcnapava European praevia. praevia placenta Placenta and abruption Placental al. N. et Calleja MP, SL, Brincat R, Collins Custo GJ, J, Calleja-Agius Burton a 3. MA, region: Belfort world AG, by praevia Bhide placenta Z, of Alfirevic Prevalence ER, V. Jauniaux Filippi C, 2. Calvert C, Ronsmans JA, Cresswell 1. lnc nOserc n yaclg.20 o 1;2(3):121-7. Nov 2006 & Gynaecology. Obstetrics and Obstetrics of in Journal Clinics International An BJOG: management. and 2018. diagnosis Gynaecology. accreta: Jun;18(6):712-24. placenta 2013 and health. international & medicine Tropical meta-analysis. and review systematic ocpin rtn rgnldatpeaain aaRtivladInterpretation and Retrieval Data preparation, draft original – Writing Conception, E.M. rtn eiwn n dtn,Dt Interpretation Data Editing, and Reviewing – Writing T.R. ocpin uevso,Planning Supervision, Conception, 5 S.O. eiwn n dtn,Dt Anal- Data Editing, and Reviewing K.C. aaRe- Data Posted on Authorea 15 Apr 2020 — CC BY 4.0 — https://doi.org/10.22541/au.158698499.98583640 — This a preprint and has not been peer reviewed. Data may be preliminary. Lv D ennoK,SretL uhsR.Mjrpaet rei hudntpeld out- preclude not should praevia placenta Major predict RG. to Hughes score L, A Sargent al. KJ, et Fernando C, CD, d’Ercole Love P, Opinel 24. A, Agostini preterm R, of Desbriere risk the M, and Alessandrini previa Placenta A, AB. Pivano Caughey MP, 23. Thiet ME, Norton YW, Cheng MG, Zlatnik growth 22. fetal previa, on placenta based among Relationship previa AM. placenta Vintzileos in JC, bleeding Smulian K, uterine Demissie of CV, Anticipation Ananth T. 21. Araki T, the Sekiya of K, shape Ishihara M, the Saitoh does 20. previa: in placenta distance in os ultrasonography internal transvaginal to Third-trimester edge S. Placental Ghourab B. Thilaganathan 19. B, Hollis outcome J, pregnancy Moore and F, factors Prefumo Risk A, M. Bhide Alsunaidi 18. A, Sobande M, Eskandar A, Abusham asso- A, previa Bahar Placenta AY. obstetric 17. 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Russo hemorrhage P, antepartum of Beretta Prevalence I, al. Pozzi et S, X, Guo Ornaghi placenta W, P, Wang with Vergani Q, complications 7. Xia Maternal L, R. Liu and Liston S, BA, factors Wu Armson risk D, L, Fan of Dodds 6. analysis MC, Critical Hof E. den Van Sheiner JM, A, Crane Wiznitzer R, 5. Sergienko G, Pariente T, Rosenberg 4. ain aaeet uoenJunlo bttis&Gnclg n erdcieBooy 2004 Biology. Reproductive and Gynecology & Obstetrics praevia. of 1;195:173-6. placenta Journal Dec and European 2015 bleeding management. Biology. antepartum patient Reproductive and with Gynecology women & in Obstetrics delivery of caesarean Journal emergency European 1;20(10):719-23. of Jan risk 2007 the Aug Medicine. Neonatal 2001 & Maternal-Fetal Gynecology. of Journal & The Obstetrics delivery. study. population-based a delivery: 1;98(2):299-306. preterm and restriction, 2002;54(1):37-42. investigation. obstetric and Gynecologic evaluation. Aug;18(2):103-8. 2001 sonographic Official Gynecology. vaginal The and Obstetrics Gynecology: in and Ultrasound Obstetrics of in Society International Ultrasound the of outcome?. of Journal clinical Journal predict International edge An placental Feb BJOG: lower praevia. 2009 placenta in Sep;110(9):860-4. delivery Canada. 2003 of Gynaecology. Gynaecology mode & and and Obstetrics trimester Obstetrics third late of the Journal previa. placenta of 1;29(21):3467-71. 1;31(2):126-31. Nov types population-based 2016 different retrospective Medicine. in a Neonatal & delivery: Maternal-Fetal and of hospitalization Journal to The study. leading cohort bleeding severe 1;292(2):299-305. with Aug ciated 2015 obstetrics. and Gynaecology. gynecology and of obstetrics Archives of Journal population. delivery. before bleed not do 1;20(1):27-31. who Jan those 2000 May;34(2):130-4. than 1994 outcome gynaecology. worse and a obstetrics of journal Zealand New and Australian talization?. Feb;20(1):21-3. 1980 Gynaecology. and Obstetrics of Journal 1;126(3):654-68. Sep 2015 Gynecology. perinatology. 2003(2). of journal American previa. placenta with women Dec;33(14):1407-14. in 2016 delivery cesarean emergency for tors May;93(2):110-7. 2006 Obstetrics. & Gynecology of 1;201(3):266- Sep 2009 gynecology. and obstetrics of 9;7:40320. journal Jan American 2017 delivery. e1. of reports. mode Scientific and os meta-analysis. internal and review systematic a previa: placenta with 2000;17(02):101-6. perinatology. 1;284(1):47-51. of Jul journal 2011 American obstetrics. previa. and gynecology of Archives previa. placenta of outcome 6 Posted on Authorea 15 Apr 2020 — CC BY 4.0 — https://doi.org/10.22541/au.158698499.98583640 — This a preprint and has not been peer reviewed. Data may be preliminary. lcnaPavaAHv oAHTbe ac 00BJOG.docx 2020 March Tables APH haemorrhage-compared-to-those-without-haemorrhage-retrospective-cohort-study No vs users/311892/articles/442539-maternal-outcome-in-women-with-placenta-previa-who-had-antepartum- APH Praevia Placenta file Hosted MeaN aeA en ,MeaA hiatv .Ipc fpaet rei nosercoutcome. obstetric on praevia placenta of Impact mor- A. Shrivastava hemorrhagic A, maternal Meena and S, Meena previa A, Placenta Dave N, RM. Meena Silver anaesthesia 28. MW, general Varner Is BD, al. Einerson et KJ, J, Gibbins Deprest M, 27. Velde de van R, Rossaint S, Kloehr T, Journal Hofmann previa. M, placenta with Heesen delivery preterm 26. for factors Risk B. Maheshwari ST, Chasen SG, Fishman 25. n erdCnrcp bttGncl 2015;4(1):76-8o. Gynecol. Obstet Contracept 16;31(4):494-9. Reprod Feb J 2018 Int Medicine. Neonatal & Maternal-Fetal of Journal The bidity. meta-analysis. and Oct;57(9):1092-102. review Systematic 2013 haemorrhage? Scandinavica. postpartum Anaesthesiologica with Acta associated section caesarean for 1;40(1):39-42. Jan 2012 medicine. perinatal of 10;117(1):24-9. Nov 7 vial at available https://authorea.com/