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Clinical and Experimental Obstetrics & Gynecology  2020, Vol. 47 Issue (1): 41-46    DOI: 10.31083/j.ceog.2020.01.4984
Original Research Previous articles | Next articles
Does previous cesarean section per se, especially its number, increase the risk of allogeneic blood transfusion at cesarean section for placenta previa?
H. Takahashi1, Y. Baba1, *(), M. Ogoyama1, H. Suzuki1, A. Ohkuchi1, R. Usui1, S Matsubara1
1Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, Japan
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Abstract  

Objective: At cesarean section (CS) for placenta previa (PP), previous CS, especially multiple CS, is reported to be associated with massive bleeding. The authors attempted to determine which causes massive bleeding, previous CS per se or previous-CS-associated factors. The need for allogeneic blood transfusion (BT) at CS was set as a marker representing massive bleeding. Materials and Methods: This retrospective cohort study involved all 326 patients with PP who delivered in one institute using the same management protocol. The authors evaluated the associations between the number of previous CS, maternal characteristics, and perinatal outcomes, and calculated the odds ratio (OR) for allogeneic BT according to the number of previous CS. Results: With an increasing number of previous CS, the following significantly increased: abnormally invasive placenta, anterior placentation, total previa, and ultrasound-detectable lacunae. The rates of allogeneic BT for patients with previous CS of 0×, 1×, and >2× were 6% (16/273), 37% (14/38), and 60% (9/15), respectively (p < 0.001). On adjustment for anterior placentation, total previa, and lacunae, ORs (95% confidence interval) of allogeneic BT for previous CS 1× and >2× were 6.3 (2.5-16.4) and 11.4 (3.0-42.2), respectively, with CS 0× being referent. On analysis of 308 (326-18) patients excluding 18 with an abnormally invasive placenta, the adjusted ORs of allogeneic BT for CS 1× and >2× were 3.5 (1.1-10.8) and 6.2 (1.1-37.3), respectively, remaining high. Conclusion: The number of prior CS, and, thus the previous CS per se, increases the requirement for allogeneic BT, irrespective of the presence/absence of an AIP, anterior placentation, total previa, or lacunae. Management protocol of PP women with multiple CS should be adapted accordingly.

Key words:  Abnormally invasive placenta      Blood transfusion      Number of cesarean sections      Hemorrhage      Placenta previa     
Published:  15 February 2020     
*Corresponding Author(s):  Y. Baba     E-mail:  ybabati@jichi.ac.jp

Cite this article: 

H. Takahashi, Y. Baba, M. Ogoyama, H. Suzuki, A. Ohkuchi, R. Usui, S Matsubara. Does previous cesarean section per se, especially its number, increase the risk of allogeneic blood transfusion at cesarean section for placenta previa?. Clinical and Experimental Obstetrics & Gynecology, 2020, 47(1): 41-46.

URL: 

https://ceog.imrpress.com/EN/10.31083/j.ceog.2020.01.4984     OR     https://ceog.imrpress.com/EN/Y2020/V47/I1/41

Table 1  — Maternal characteristics by number of previous cesarean sections.
No previous CS (n=273) 1 time previous CS (n=38) 2 times or more previous CS (n=15) pa
Maternal age (years) 34.0 (19.0-45.0)b 35.5 (27.0-46.0)b 35.0 (27.0-43.0) 0.01
Maternal age >35 years 120 (44.0%) 22 (57.9%) 8 (53.3%) 0.229
BMI (kg/m2) 23.8 (17.0-41.4) 24.1 (19.8-33.6) 25.0 (19.2-30.5) 0.397
Multiparity 116 (42.5%) 38 (100.0%) 15 (100.0%) -
ART 39 (14.3%) 1 (2.6%) 0 (0.0%) -
Previous curettage 90 (33.0%) 18 (47.4%) 6 (40.0%) 0.2
Uterine myoma 18 (6.6%) 2 (5.3%) 0 (0.0%) 0.568
Anterior placentation 43 (15.8%)b, c 15 (39.5%)b 8 (53.3%)c <0.001
Total previa 128 (46.9%)b, c 26 (68.4%)b 12 (80.0%)c <0.001
Lacunae 45 (16.5%)b, c 13 (34.2%)b 9 (60.0%)c <0.001
Preoperative maternal Hb 10.5 (8.0-14.3) 10.4 (7.5-11.6) 10.1 (9.2-11.0) 0.079
Preoperative anemia (Hb<10) 60 (22.0%) 9 (23.7%) 6 (40.0%) 0.27
Preparation of autologous blood 223 (81.7%) 29 (76.3%) 9 (60.0%) 0.102
Table 2  — Maternal and perinatal outcomes by number of previous cesarean sections.
No previous CS (n=273) 1 time previous CS (n=38) 2 times or more previous CS (n=15) pa
Antepartum bleeding 119 (43.6%) 21 (55.3%) 7 (46.7%) 0.396
GA at antepartum
bleeding (days) 216.0 (151.0-261.0) 217.0 (148.0-252.0) 215.0 (185.0-242.0) 0.865
Transplacental approach 20 (7.3%) 4 (10.5%) 0 (0.0%) 0.417
Intraoperative
blood loss (mL) 1350 (280-5000)c, d 1730 (465-12 300)c 3400 (335-8500)d <0.001
Hysterectomy 3 (1.1%)c, d 10 (26.3%)c, e 11 (73.3%)d, e <0.001
Planned
Emergency
0 (0.0%)c, d
3 (1.1%)c
8 (21.1%)c
2 (5.3%)
7 (46.7%)d
4 (26.7%)c
<0.001
<0.001
AIPb 1 (0.4%)c, d 9 (23.7%)c, e 8 (53.3%)d, e <0.001
Autologous BT 125 (56.3%)d 21 (72.4%) 9 (100.0%)d 0.002
Allogeneic BT 16 (5.9%)c, d 14 (36.8%)c 9 (60.0%)d <0.001
GA at delivery (days) 260.0 (182.0-270.0) 251.50 (217.0-268.0) 246.0 (202.0-262.0) <0.001
< 34 weeks 30 (11.0%) 8 (21.1%) 4 (26.7%) 0.059
< 37 weeks 93 (34.1%)c, d 25 (65.8%)c 12 (80.0%)d <0.001
Birth weight (grams) 2620 (589-4258) 2545 (1322-3520) 2392 (1116-3152) 0.163
< 2, 500 grams 100 (36.6%) 18 (47.4%) 8 (53.3%) 0.217
Apgar Score 5 minutes 9.0 (4.0-9.0)c 9.0 (2.0-9.0) 7.0 (3.0-9.0)c <0.001
Apgar Score 5 minutes < 7 13 (4.8%)c, d 9 (23.7%)c 7 (46.7%)d <0.001
Umbilical arterial pH 7.30 (7.13-7.49) 7.32 (7.18-7.40) 7.29 (7.20-7.35) 0.597
Table 3  — Risk factors for allogeneic blood transfusion in all 326 cases.
Characteristics Allogeneic BT
(+)
(n=39)
(-)
(n=287)
Crude OR
(95% CI)
Adjusted ORa
(95% CI)
Number of previous CS
0 16 (41.0) 257 (89.5) 1.0 1.0
1 14 (35.9) 24 (8.4) 9.3 (4.0-21.5) 6.3 (2.5-16.4)
2 9 (23.1) 6 (2.1) 24.1 (7.6-76.1) 11.4 (3.042.2)
Anterior placentation 19 (48.7) 47 (16.4) 5.1 (2.6-10.2) 1.7 (0.7-4.1)
Total previa 33 (84.6) 133 (46.3) 6.6 (2.7-16.1) 2.9 (1.1-7.9)
Lacunae 24 (61.5) 43 (15.0) 9.5 (4.6-19.4) 4.7 (2.0-11.0)
Table 4  — Risk factors for abnormally invasive placenta in all 326 cases.
Characteristics Abnormally invasive placenta
(+)
(n=18)
(-)
(n=308)
Crude OR
(95% CI)
Adjusted ORa
(95% CI)
Number of previous CS
0 1 (5.6) 272 (88.3) 1.0 1.0
1 9 (50.0) 29 (9.4) 84.4 (10.3-690) 59.7 (6.3-567)
2 8 (44.4) 7 (2.3) 311.0 (34.1-2830) 166.0 (14.2-1940)
Anterior placentation 11 (61.1) 55 (17.9) 7.9 (3.0-20.9) 1.5 (0.3-6.7)
Total previa 17 (94.4) 149 (48.4) 19.2 (2.5-146) 2.9 (0.3-31.1)
Lacunae 16 (88.9) 51 (16.6) 42.8 (9.6-191) 21.4 (3.6-126)
Table 5  — Risk factors for allogeneic blood transfusion in 308 cases excluding 18 cases with an abnormally invasive placenta.
Characteristics Allogeneic BT
(+)
(n=23)
(-)
(n=285)
Crude OR
(95% CI)
Adjusted ORa
(95% CI)
Number of previous CS
0x 15 (65.2) 257 (90.2) 1.0 1.0
1x 6 (26.1) 23 (8.1) 4.5 (1.6-12.6) 3.5 (1.1-10.8)
2x 2 (8.7) 5 (1.8) 6.9 (1.2-38.3) 6.2 (1.1-37.3)
Anterior placentation 10 (43.5) 45 (15.8) 4.1 (1.7-9.9) 2.3 (0.8-6.2)
Total previa 18 (78.3) 131 (46.0) 4.2 (1.5-11.7) 3.0 (1.1-8.8)
Lacunae 9 (39.1) 42 (14.7) 3.7 (1.51-9.14) 2.4 (0.8-6.4)
Table 6  — Risk factors for allogeneic blood transfusion in 258 cases excluding 68 cases requiring additional hemostatic procedures.
Characteristics Allogeneic BT
(+)
(n=15)
(-)
(n=243)
Crude OR
(95% CI)
Adjusted ORa
(95% CI)
Number of previous CS
0x 10 (66.7) 219 (90.1) 1.0 1.0
1x 2 (13.3) 19 (7.8) 2.3 (0.4 -11.3) 1.7 (0.3-9.4 )
2x 3 (20.0) 5 (2.1) 13.1 (2.8-62.9) 9.9 (2.0-50.2)
Anterior placentation 5 (33.3) 32 (13.2) 3.3 (1.1-10.3) 2.2 (0.6-7.6)
Total previa 10 (66.7) 101(41.6) 2.8 (0.9-8.5) 2.1 (0.6-6.7)
Lacunae 6 (40.0) 34(14.0) 4.1 (1.4-12.2) 2.4 (0.7-8.2)
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