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Contribution of Placenta Accreta to the

Incidence of Postpartum Hemorrhage and
Severe Postpartum Hemorrhage

Article in Obstetrics and Gynecology March 2015

DOI: 10.1097/AOG.0000000000000722 Source: PubMed

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Original Research
Contribution of Placenta Accreta to the
Incidence of Postpartum Hemorrhage and
Severe Postpartum Hemorrhage
Azar Mehrabadi, MSc, Jennifer A. Hutcheon, PhD, Shiliang Liu, MD, PhD, Sharon Bartholomew, MHSc,
Michael S. Kramer, MD, Robert M. Liston, MB, and K.S. Joseph, MD, PhD, for the Maternal Health Study
Group of the Canadian Perinatal Surveillance System (Public Health Agency of Canada)
OBJECTIVE: To quantify the contribution of placenta
accreta to the rate of postpartum hemorrhage and severe
postpartum hemorrhage.
METHODS: All hospital deliveries in Canada (excluding
Quebec) for the years 2009 and 2010 (N5570,637) were
included in a retrospective cohort study using data from
the Canadian Institute for Health Information. Placenta
accreta included placental adhesion to the uterine wall,
musculature, and surrounding organs (accreta, increta, or
percreta). Severe postpartum hemorrhage included post-
partum hemorrhage with blood transfusion, hysterectomy,
or other procedures to control bleeding (including uterine
suturing and ligation or embolization of pelvic arteries).
Rates, rate ratios, population-attributable fractions (ie, inci-
dence of postpartum hemorrhage attributable to placenta
accreta), and 95% confidence intervals (CIs) were esti-
mated. Logistic regression was used to quantify associations
between placenta accreta and risk factors.
From the Department of Obstetrics and Gynaecology, University of British Columbia
and the Childrens and Womens Hospital & Health Centre of British
Columbia, and the School of Population and Public Health, University of
British Columbia, Vancouver, British Columbia, the Maternal and Infant Health
Section, Public Health Agency of Canada, Ottawa, Ontario, and the Departments
of Pediatrics and Epidemiology, Biostatistics and Occupational Health, McGill
University, Montreal, Quebec, Canada.
This work is supported by a Canadian Institutes of Health Research (CIHR) team
grant in Severe Maternal Morbidity (MAH115445). Jennifer A. Hutcheon is the
recipient of a CIHR New Investigator Award and a Scholar Award from the
Michael Smith Foundation for Health Research. K.S. Joseph is supported by an
Investigator award from the Child and Family Research Institute and a CIHR
Chair in maternal, fetal, and infant health services research.
Corresponding author: Azar Mehrabadi, MSc, Room C403, 4500 Oak Street,
Womens Hospital of British Columbia, Vancouver, British Columbia, Canada
V6H 3N1; e-mail: azar@alumni.ubc.ca.
Financial Disclosure
The authors did not report any potential conflicts of interest.
2015 by The American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/15
VOL. 0, NO. 0, MONTH 2015
Copyright by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
RESULTS: The incidence of placenta accreta was 14.4
(95% CI 13.415.4) per 10,000 deliveries (819 cases
among 570,637 deliveries), whereas the incidence of pla-
centa accreta with postpartum hemorrhage was 7.2 (95%
CI 6.58.0) per 10,000 deliveries. Postpartum hemorrhage
among women with placenta accreta was predominantly
third-stage hemorrhage (41% of all cases). Although
placenta accreta was strongly associated with postpar-
tum hemorrhage (rate ratio 8.3, 95% CI 7.78.9), its low
frequency resulted in a small population-attributable
fraction (1.0%, 95% CI 0.931.16). However, the strong
association between placenta accreta and postpartum
hemorrhage with hysterectomy (rate ratio 286, 95% CI
226361) resulted in a population-attributable fraction of
29.0% (95% CI 24.334.3).
CONCLUSION: Placenta accreta is too infrequent to
account for the recent temporal increase in postpartum
hemorrhage but contributes substantially to the pro-
portion of postpartum hemorrhage with hysterectomy.
(Obstet Gynecol 2015;0:18)
DOI: 10.1097/AOG.0000000000000722
LEVEL OF EVIDENCE: II
T
he increase in postpartum hemorrhage among
high-income countries such as Australia, Canada,
Ireland, Norway, Scotland, and the United States over
the past two decades remains unexplained.17 The sub-
type of postpartum hemorrhage underlying the
increase has been identified as atonic postpartum hem-
orrhage2,4,7; in Canada, the rate of atonic postpartum
hemorrhage increased by 29% (95% confidence inter-
val [CI] 2633%) from 3.9% in 2003 to 5.0% in 2010.8
However, this increase could not be explained by
changes in maternal age, obesity, multifetal gestation,
labor induction, oxytocin augmentation, and other
maternal, fetal, infant, and obstetric factors.9 The Inter-
national Postpartum Hemorrhage Collaborative Group
OBSTETRICS & GYNECOLOGY 1
recommended an investigation into the role of placenta
accreta,3 a severe and potentially life-threatening preg-
nancy complication, reported to have increased as
a consequence of the increase in cesarean deliveries
over the past 2030 years.10,11 The incidence of placenta
accreta ranges between 1 and 90 per 10,000 deliveries
and varies based on the population frequency of pre-
vious cesarean deliveries.12
The purpose of this study was to describe the
association between placenta accreta and postpartum
hemorrhage and severe postpartum hemorrhage (eg,
postpartum hemorrhage with blood transfusion, hys-
terectomy, or other procedures to control bleeding)
and to determine the population-attributable fraction
of placenta accreta related to postpartum hemorrhage
and severe postpartum hemorrhage (ie, to determine
the incidence of postpartum hemorrhage attributable
to placenta accreta). We also explored the relationship
between placenta accreta and risk factors for placenta
accreta such as older maternal age, grand multiparity,
multifetal gestation, cesarean delivery, and placenta
previa to provide a context for anticipating future
temporal trends in placenta accreta incidence.
MATERIALS AND METHODS
The study was based on all women delivering a live
birth or a stillbirth in the hospital in Canada (exclud-
ing Quebec) in 2009 and 2010. Data for the study
were obtained from the Canadian Institute for Health
Informations Discharge Abstract Database. This data-
base contains demographic information, medical his-
tory, and diagnoses and procedures associated with all
hospitalizations in Canada excluding Quebec. The
database has been validated for the accuracy of mater-
nal and other perinatal information; postpartum hem-
orrhage had high sensitivity (90.2%, 95% CI 86.2
93.3) and specificity (98.2%, 95% CI 97.898.5) and
procedures such as blood transfusion had reasonably
high sensitivity 85.7% (42.199.6) and very high spec-
ificity (99.8%, 95% CI 99.699.9).13 Our study used
a retrospective cohort design, including all hospital
deliveries in Canada (excluding Quebec) that resulted
in a live birth or a stillbirth between April 2009 and
March 2011 (referred to as calendar years 20092010).
The years of study were chosen since the Canadian
Institute for Health Information began to routinely col-
lect diagnostic information on placenta accreta in 2009.
Placenta accreta was defined using the Interna-
tional Statistical Classification of Diseases and Related
Health Problems (Canadian version) code for morbidly
adherent placenta (O43.2) and included placenta
accreta, increta, and percreta. The outcome of post-
partum hemorrhage was defined (using International
2 Mehrabadi et al Placenta Accreta and Postpartum Hemorrhage
Copyright by The American College of Obstetricians
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Unauthorized reproduction of this article is prohibited.
Statistical Classification of Diseases and Related Health
Problems [Canadian version] codes O72.0 to O72.3) as
a blood loss of 500 mL or greater after vaginal delivery
or 1,000 mL or greater after cesarean delivery or as
noted in the medical record by the health care
provider. Subtypes of postpartum hemorrhage were
identified based on the clinical diagnosis noted in the
medical record and included atonic postpartum hem-
orrhage (occurring within 24 hours after delivery),
third-stage hemorrhage (which included retained, trap-
ped, or adherent placenta occurring in the third stage of
labor), delayed and secondary postpartum hemorrhage
(occurring between 24 hours and 6 weeks after
delivery), and postpartum hemorrhage resulting from
coagulation defects. Severe postpartum hemorrhage
was defined as postpartum hemorrhage occurring in
conjunction with blood transfusion, hysterectomy, or
other procedures to control bleeding (ie, uterine
suturing, pelvic ligation, or pelvic embolization).
Retained placenta without hemorrhage referred to
retained placenta or portions of the placenta after
delivery that was not accompanied by hemorrhage.
Risk factors examined for placenta accreta included
maternal age (younger than 20, 2024, 2529, 3034,
3539, 40 years or older), parity (nulliparous, 1, 24, 5
or more, missing), multifetal gestation, placenta previa
plus previous cesarean delivery, placenta previa without
previous cesarean delivery, and previous cesarean deliv-
ery without placenta previa. International Statistical
Classification of Diseases and Related Health Problems
(Canadian version) codes used for the study are summa-
rized in Appendix 1. Rates and 95% CIs were calculated
for placenta accreta, placenta accreta with postpartum
hemorrhage, placenta accreta with severe postpartum
hemorrhage, and placenta accreta by subtype of post-
partum hemorrhage. Logistic regression analyses were
used to estimate crude and adjusted odds ratios for risk
factors of placenta accreta. The rate ratios and 95%
CIs for the association between placenta accreta and
postpartum hemorrhage and severe postpartum hemor-
rhage were estimated as was the population-attributable
fraction of postpartum hemorrhage and severe postpar-
tum hemorrhage resulting from placenta accreta. The
population-attributable fraction refers to the proportion
of the incidence of any disease or outcome (eg, post-
partum hemorrhage) in the population that is attribut-
able to the determinant (eg, placenta accreta). It is
affected by both the population-level rates of the deter-
minant and the strength of association between
the determinant and the disease or outcome. The
population-attributable fraction in this context provides
an estimate of the fraction of postpartum hemorrhage or
severe postpartum hemorrhage that would be prevented
OBSTETRICS & GYNECOLOGY
if placenta accreta was eliminated from the population.
Confidence intervals for the population-attributable frac-
tions were calculated using OpenEpi (www.OpenEpi.
com) as described by Abramsom and Gahlinger.14
The statistical software SAS 9.3, Stata 12.1, and
OpenEpi (www.OpenEpi.com) 3.01 were used for the
analyses. This study was carried out under the aus-
pices of the Public Health Agency of Canadas Cana-
dian Perinatal Surveillance System. The data source
included denominalized information, and the Public
Health Agency of Canada, which is mandated to mon-
itor maternal and infant health in the Canadian pop-
ulation, is not required to obtain ethics review board
approval for such studies.
RESULTS
The incidence of placenta accreta was 14.4 (95% CI
13.415.4) per 10,000 deliveries (819 cases among
570,637 deliveries), and the case fatality rate for pla-
centa accreta was 0.12%. The incidence of placenta
accreta with postpartum hemorrhage was 7.2 (95%
CI 6.58.0) per 10,000 deliveries (Table 1). One fourth
of all patients with placenta accreta required a blood
transfusion (incidence 3.5/10,000 deliveries, 95% CI
3.14.1/10,000); 19% had postpartum hemorrhage
and a blood transfusion (incidence 2.8/10,000 deliver-
ies, 95% CI 2.33.2/10,000; Table 1). Among patients
with placenta accreta, 17% underwent a hysterectomy
with or without postpartum hemorrhage (incidence
2.4/10,000, 95% CI 2.02.8/10,000), whereas 11.2%
had both postpartum hemorrhage and a hysterectomy
(incidence 1.6/10,000 deliveries, 95% CI 1.32.0/
10,000). Retained placenta without hemorrhage
occurred in 17% of patients. Although 50% of women
with placenta accreta had postpartum hemorrhage,
women with placenta accreta predominantly received
a clinical diagnosis of third-stage postpartum hemor-
rhage (41% of all cases), whereas a minority (7% of
all cases) were labeled with a clinical diagnosis of atonic
postpartum hemorrhage. Most cases of atonic postpar-
tum hemorrhage with placenta accreta were severe;
0.63 (95% CI 0.420.87) per 10,000 women had atonic
postpartum hemorrhage with blood transfusion, hyster-
ectomy, or other procedures to control bleeding.
Table 1 summarizes the rate of placenta accreta, post-
partum hemorrhage, and related complications.

Table 1. Rate of Placenta Accreta Without Postpartum Hemorrhage and With Postpartum Hemorrhage and
Related Complications, Canada (Excluding Quebec), 20092010 (N5570,637 Deliveries)

Rate/10,000 % Placenta Accreta

Outcome n Deliveries (95% CI) (95% CI)

Placenta accreta 819 14.4 (13.415.4) 100.0 (99.6100.0)

Placenta accreta without postpartum hemorrhage 407 7.13 (6.57.9) 49.7 (46.253.2)
Placenta accreta with
Postpartum hemorrhage 412 7.22 (6.547.95) 50.3 (46.853.8)
Severe postpartum haemorrhage* 185 3.24 (2.793.74) 22.6 (19.825.6)
Postpartum hemorrhage with blood transfusion 157 2.75 (2.343.22) 19.2 (16.522.0)
Postpartum hemorrhage with hysterectomy 92 1.61 (1.301.98) 11.2 (9.213.6)
Postpartum hemorrhage with procedures to control bleeding 47 0.82 (0.611.10) 5.7 (4.27.6)
Atonic postpartum hemorrhage 59 1.03 (0.791.33) 7.2 (5.59.2)
Severe atonic postpartum hemorrhage* 36 0.63 (0.420.87) 4.4 (3.16.0)
Atonic postpartum hemorrhage with blood transfusion 29 0.51 (0.340.73) 3.5 (2.45.0)
Atonic postpartum hemorrhage with hysterectomy 17 0.30 (0.170.48) 2.1 (1.23.3)
Atonic postpartum hemorrhage with procedures to control bleeding 10 0.18 (0.080.32) 1.2 (0.62.2)
Nonatonic postpartum hemorrhage 353 6.19 (5.566.87) 43.1 (39.746.6)
3rd-stage hemorrhage 338 5.92 (5.316.59) 41.3 (37.944.7)
Severe 3rd-stage hemorrhage* 143 2.49 (2.112.95) 17.5 (14.920.2)
Secondary postpartum hemorrhage 29 0.51 (0.340.73) 3.5 (2.45.0)
Postpartum hemorrhage resulting from coagulation defects 9 0.16 (0.070.30) 1.1 (0.52.1)
Retained placenta without hemorrhage 132 2.31 (1.942.74) 16.1 (13.718.8)
Blood transfusion 202 3.54 (3.074.06) 24.7 (21.727.8)
Hysterectomy 137 2.40 (2.022.84) 16.7 (14.219.5)
Cesarean hysterectomy 71 1.24 (0.971.57) 8.7 (6.810.8)
Other procedures to control bleeding 66 1.16 (0.901.47) 8.1 (6.310.1)
Placental abruption 30 0.53 (0.360.75) 3.7 (2.55.2)
CI, confidence interval.
Subcategories of severe postpartum hemorrhage were not mutually exclusive.
* In conjunction with blood transfusion, hysterectomy, or procedures to control bleeding.

Includes uterine suturing, pelvic artery ligation, and pelvic artery embolization.

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 Risk factors for placenta accreta were older
maternal age (3034 years, 3539 years, and 40 years
or older compared with 2024 years; Table 2) and low
and high parity (nulliparity, 24, and 5 or more). Mul-
tifetal gestation was also associated with a higher risk
of placenta accreta. Placenta previa (in the current
pregnancy) in conjunction with a previous cesarean
delivery was most strongly associated with placenta
accreta (adjusted odds ratio [OR] 91.6, 95% CI
70.5119.1) followed by placenta previa without pre-
vious cesarean delivery (adjusted OR 13.3, 95% CI
10.017.8). Previous cesarean delivery without pla-
centa previa was also associated with a significantly
increased risk of placenta accreta (adjusted OR 1.44,
95% CI 1.171.77).
Although placenta accreta was strongly associated
with postpartum hemorrhage (rate ratio 8.3, 95% CI
7.78.9; Table 3), the population-attributable fraction
was only 1.0%; that is, only 1.0% of the incidence of
postpartum hemorrhage was attributable to placenta
accreta. On the other hand, placenta accreta was
strongly associated with postpartum hemorrhage with
hysterectomy (rate ratio 286, 95% CI 226361) and
had a population-attributable fraction of 29%; that is,
29% of the incidence of postpartum hemorrhage with
hysterectomy was the result of placenta accreta. Pla-
centa accreta was strongly associated with all severe
forms of postpartum hemorrhage; however, the
population-attributable fraction was only 7.6% for
postpartum hemorrhage with procedures to control
bleeding and 5.5% for postpartum hemorrhage with
blood transfusion. Table 3 presents the rate ratios
(RRs) and population-attributable fractions for post-
partum hemorrhage and severe postpartum hemor-
rhage by subtype.
Of all the subtypes of postpartum hemorrhage,
placenta accreta was most strongly associated with
third-stage postpartum hemorrhage (RR 52.4, 95% CI
48.057.1), and the population-attributable fraction
was the highest at 6.9%. The population-attributable
fraction for third-stage postpartum hemorrhage with
hysterectomy was 63.2%, for third-stage postpartum

Table 2. Placenta Accreta by Maternal and Obstetric Characteristics, Canada (Excluding Quebec),
20092010

Placenta Total Rate of

Accreta Deliveries Placenta % of Crude OR Adjusted OR
Risk Factor (n5819) (N5570,637) Accreta/10,000 Patients (95% CI) (95% CI)*

Maternal Age (y)

Younger than 20 23 25,667 8.96 2.81 1.09 (0.681.74) 1.10 (0.691.76)
2024 73 87,892 8.31 8.91 Reference Reference
2529 160 168,296 9.51 19.5 1.21 (0.921.60) 1.16 (0.881.53)
3034 293 179,305 16.3 35.8 2.08 (1.612.69) 1.87 (1.442.42)
3539 213 90,328 23.6 26.0 3.09 (2.374.03) 2.44 (1.863.20)
40 or older 57 19,147 29.8 6.96 4.06 (2.875.74) 2.81 (1.974.01)
Parity
Nulliparous 271 207,036 13.1 33.1 1.04 (0.861.25) 1.48 (1.221.81)
1 186 153,428 12.1 22.7 Reference Reference
24 145 81,762 17.7 17.7 1.46 (1.181.80) 1.41 (1.131.74)
5 or more 18 6,906 26.1 2.20 2.27 (1.403.67) 1.70 (1.042.77)
Missing 199 121,505 16.4 24.3 1.27 (1.051.55) 1.41 (1.161.72)
Multifetal gestation
Yes 41 8,830 46.4 5.01 3.73 (2.725.10) 3.14 (2.294.31)
No 778 561,807 13.9 95.0 Reference Reference
Cesarean delivery or
placenta previa
Previous cesarean 125 76,888 16.3 15.3 1.49 (1.231.81) 1.44 (1.171.77)
delivery only
Placenta previa only 51 2,836 179.0 6.23 16.2 (12.221.6) 13.3 (10.017.8)
Placenta previa plus 72 685 1,051.1 8.79 107.8 (84.1138.2) 91.6 (70.5119.1)
previous cesarean
delivery
No previa or previous 571 490,228 11.7 69.7 Reference Reference
cesarean delivery
OR, odds ratio; CI, confidence interval.
Bold indicates significant ORs.
* Adjusted for all covariates listed in the table.

4 Mehrabadi et al Placenta Accreta and Postpartum Hemorrhage OBSTETRICS & GYNECOLOGY

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Table 3. Rate Ratios and Population-Attributable Fractions for the Effect and Contribution of Placenta
Accreta on Postpartum Hemorrhage and Severe Postpartum Hemorrhage by Subtype, Canada
(Excluding Quebec), 20092010

Women With Women Without Population-

Placenta Accreta Placenta Accreta Rate Ratio* Attributable Fraction
Outcome (n5819) (n5569,818) (95% CI) (95% CI)

Postpartum hemorrhage 412 (50.31) 34,543 (6.06) 8.30 (7.758.89) 1.0 (0.931.16)
With blood transfusion 157 (19.17) 2,653 (0.47) 41.2 (35.647.6) 5.5 (4.76.4)
With hysterectomy 92 (11.23) 224 (0.04) 285.8 (226361) 29.0 (24.334.3)
With other procedures 47 (5.74) 558 (0.10) 58.6 (43.978.3) 7.6 (5.810.1)
Atonic postpartum 59 (7.20) 28,253 (4.96) 1.45 (1.141.86) 0.07 (0.020.13)
hemorrhage
With blood transfusion 29 (3.54) 1,797 (0.32) 11.2 (7.8316.1) 1.4 (0.962.1)
With hysterectomy 17 (2.08) 156 (0.03) 75.8 (46.2124.5) 9.7 (6.115.1)
With other procedures 10 (1.22) 470 (0.08) 14.8 (7.9427.6) 1.9 (0.983.7)
3rd-stage postpartum 338 (41.27) 4,489 (0.79) 52.4 (48.057.1) 6.9 (6.27.6)
hemorrhage
With blood transfusion 121 (14.77) 542 (0.01) 155 (129187) 18.1 (15.421.3)
With hysterectomy 74 (9.04) 43 (0.01) 1,198 (8271,733) 63.2 (54.171.4)
With other procedures 35 (4.27) 60 (0.01) 405.9 (269612) 36.8 (27.746.9)
Secondary postpartum 29 (3.54) 1,757 (0.31) 11.5 (8.0116.5) 1.5 (0.992.2)
hemorrhage
With blood transfusion 12 (1.47) 293 (0.05) 28.5 (16.150.5) 3.8 (2.16.7)
With hysterectomy 4 (0.49) 11 (0) 253.0 (80.7793) 26.6 (10.353.2)
With other procedures 2 (0.24) 20 (0) 69.6 (16.3297) 9.0 (2.129.9)
Postpartum hemorrhage 9 (1.01) 288 (0.05) 21.7 (11.242.1) 2.9 (1.445.6)
resulting from
coagulation defects
With blood transfusion 7 (0.85) 122 (0.02) 39.9 (18.785.2) 5.3 (2.510.8)
With hysterectomy 8 (0.98) 41 (0.01) 135.8 (63.8289) 16.2 (8.329.3)
With other procedures 4 (0.49) 37 (0.01) 75.2 (26.9211) 9.6 (3.623.2)
CI, confidence interval.
Data are n (%) unless otherwise specified.
* Rate ratios were obtained by dividing the rate (risk) of the outcome among women with placenta accreta by the rate of the outcome among
women without placenta accreta.

hemorrhage with other procedures to control bleed-
ing it was 36.8%, and for third-stage postpartum hem-
orrhage with blood transfusion it was 18.1%.
DISCUSSION
Our study showed that approximately 50% of the
patients with placenta accreta experienced postpartum
hemorrhage, and 22.6% experienced a severe form of
postpartum hemorrhage (postpartum hemorrhage with
blood transfusion, hysterectomy, or other procedures
to control bleeding). Placenta accreta was strongly
associated with postpartum hemorrhage and most
strongly associated with third-stage hemorrhage. The
relative infrequency of placenta accreta (14.4/10,000
deliveries) resulted in a low population-attributable
fraction for postpartum hemorrhage (1%). Given the
modest association between placenta accreta and atonic
postpartum hemorrhage (RR 1.45, 95% CI 1.141.86;
population-attributable fraction 1%, 95% CI 0.010%),
increases in placenta accreta cannot explain the recent
increases in postpartum hemorrhage. The frequency of
placenta accreta and postpartum hemorrhage (7.2/
10,000 deliveries) is relatively low compared with the
magnitude of the absolute temporal increase in atonic
postpartum hemorrhage (absolute increase of 1.1%
from 3.9% in 2003 to 5.0% in 2010).8 Together, these
findings suggest that potential temporal increases in
placenta accreta frequency cannot explain the recent
rise in atonic postpartum hemorrhage.
Our study showed that placenta accreta ac-
counted for 29% of the incidence of postpartum
hemorrhage with hysterectomy, which increased sig-
nificantly in Canada from 4.9 to 5.8 per 10,000
deliveries between 2003 and 2010.8 Thus, an increase
in placenta accreta could have contributed signifi-
cantly to the rising incidence of postpartum hemor-
rhage with hysterectomy in Canada. Our study also
suggests that increases in placenta accreta could have
partly contributed to changes in the incidence of other
severe forms of postpartum hemorrhage such as

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postpartum hemorrhage with blood transfusion and
postpartum hemorrhage with other procedures to
control bleeding. Changes in placenta accreta rates
may have also contributed to severe forms of third-
stage hemorrhage, although the absolute rates of such
postpartum hemorrhage were low overall.
The strengths of our study were the population-
based design that included all hospital deliveries in
Canada (excluding Quebec), whereas most previous
studies on this topic have been restricted to tertiary
care centers.12,1517 Our data source has been previ-
ously validated and postpartum hemorrhage and sev-
eral other obstetric outcomes have been shown to have
high validity in our database.13 Some of the limitations
of our study included potential underdiagnoses or
underreporting of placenta accreta, which could have
led to its underrepresentation among cases of postpar-
tum hemorrhage. It is likely that pathologic confirma-
tion may be more commonly undertaken after severe
cases of placenta accreta that require hysterectomy.
Nevertheless, the rate of placenta accreta in our study
(14.4/10,000 deliveries) was higher than that reported
in another population-based study from Ireland, which
reported a rate of 8.5 per 10,000 deliveries between
2005 and 2009.7 The rate of placenta accreta is ex-
pected to vary based on the prevalence of previous
cesarean deliveries combined with the fertility rate of
women with previous cesarean deliveries.12 Our study
relied on clinical diagnoses of placenta accreta re-
corded in medical charts and this may have led to an
under- or overdiagnosis of placenta accreta. In addi-
tion, the validity of subcategories of postpartum hem-
orrhage is unclear with some evidence that the
contribution of atonic postpartum hemorrhage is over-
estimated.18 Other study limitations included the
restricted timeframe for the study, which precluded
our ability to study changes in placenta accreta fre-
quency over time. This limitation was the result of
routine collection of placenta accreta diagnosis only
becoming instituted in our data source in 2009. Finally,
we could not ascertain whether postpartum hemor-
rhage occurred before or after the hysterectomy, the
procedures to control bleeding, or blood transfusion.
For instance, some hysterectomies, uterine suturing,
and ligation and embolization of pelvic blood vessels
may have represented preemptive strategies to control
bleeding or could have followed antepartum hemor-
rhage. Regardless, our interest was in the population
rates of placenta accreta and associated postpartum
hemorrhage, and in all cases, it is clear that placenta
accreta preceded postpartum hemorrhage.
Our study revealed a case fatality rate of 0.12%,
whereas previous studies have reported mortality
6 Mehrabadi et al Placenta Accreta and Postpartum Hemorrhage
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rates that range from 0% to 0.3% and 7% for the most
severe forms of placenta accreta.12,15,16 In addition, half
the patients in our study did not have accompanying
postpartum hemorrhage. This finding may be a result
of less severe forms of placenta accreta being diag-
nosed, prenatal diagnosis of placenta accreta, and
prompt or prophylactic intervention to prevent bleed-
ing.15,19 Other studies have shown similar rates of post-
partum hemorrhage (51.5%) associated with placenta
previa that was managed conservatively.20 Currently,
the appropriate management of placenta accreta re-
mains controversial, particularly with regard to the
use of treatments designed to preserve fertility.21
Similar to other research, our study found that
concurrent placenta previa with a previous cesarean
delivery was most strongly associated with placenta
accreta (OR 91.6, 95% CI 70.5119.1). This finding
supports the American College of Obstetricians and
Gynecologists recommendation to offer ultrasound
screening for placenta accreta to women with a uterine
scar and placenta previa.21 However, only 8.8% of the
patients with placenta accreta in our study had both
risk factors, whereas a larger proportion of the pa-
tients with placenta accreta (15%) had only a previous
cesarean delivery with no placenta previa (implying
that such risk-based screening would miss most cases).
This finding supports the recommendation of the
Confidential Enquiries into Maternal Deaths in the
United Kingdom to screen all women with a previous
cesarean delivery to have their placental site deter-
mined.22 Our data source, the discharge abstract data-
base, did not have information on the number of
previous cesarean deliveries for each woman, but pre-
vious research has found an increasing risk of placenta
accreta with increasing number of previous cesarean
deliveries. For example, women with placenta previa
had a four times greater risk of placenta accreta given
one previous cesarean delivery, and this increased to
an 11 times higher risk with two or more previous
cesarean deliveries.16 Risk factors other than placenta
previa and previous cesarean delivery examined in
previous studies (some of which were not available
in the discharge abstract database) included previous
curettage, Ashermans syndrome, history of abortion
or miscarriage, other prior uterine surgery, or trauma
and also female fetal sex.11,1517,23
The finding that nulliparity was significantly asso-
ciated with placenta accreta in adjusted analyses was
unexpected and was possibly an artefact of adjustment
for previous caesarean delivery (a variable in the causal
pathway between other risk factors and placenta
accreta). Another unexpected finding in our study
was related to postpartum hemorrhage associated with
OBSTETRICS & GYNECOLOGY
placenta accreta and blood transfusion; not all women
who had severe postpartum hemorrhage received
a blood transfusion. This may have been because
severe postpartum hemorrhage in our study was
defined to include patients in whom any procedure
was used to control bleeding, some of which may have
been prophylactic intervention in patients in whom the
accreta was diagnosed antenatally. Of note, rates of
blood transfusion in Canada have remained low
relative to other countries.24
In conclusion, placenta accreta is too infrequent
a condition to account for the increase in postpartum
hemorrhage observed in Canada and elsewhere in
recent decades. However, potential temporal increases
in placenta accreta may have contributed to temporal
increases in postpartum hemorrhage with hysterectomy
and other severe forms of postpartum hemorrhage.
Placenta previa was most strongly associated with
placenta accreta, but the majority of patients with
placenta accreta had a previous cesarean delivery
without concurrent placenta previa, supporting the
practice of assessing placentation among all women
with a previous cesarean delivery. Future studies and
population surveillance are necessary for monitoring the
rates of placenta accreta and its contribution to severe
postpartum hemorrhage. In addition, studies should
explore other potential causes of the increase in post-
partum hemorrhage observed in high-income countries.
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Placenta Accreta and Postpartum Hemorrhage 7
Appendix 1: International Classification of Diseases, 10th Revision, and the Canadian Classification
of Interventions Diagnosis and Procedure Codes Used in the Study

Canadian Classification
Diagnosis and Procedure Code ICD-10 of Interventions

Morbidly adherent placenta O432

Postpartum hemorrhage Third stage (O720); atonic postpartum hemorrhage

(O721), secondary postpartum hemorrhage
(O722); resulting from coagulation defects (O723)

Blood transfusion 1LZ19HHU1; 1LZ19HHU9;

1LZ19HMU1; 1LZ19HMU9

Hysterectomy Cesarean hysterectomy (5MD60KE;

5MD60RC; 5MD60CB; 5MD60RD);
partial or total excision of uterus and
surrounding structures, open
approach (1RM87LAGX; 1RM89LA
[without 1PL74, bladder neck
fixation; 1RS80, vagina repair;
1RS74, vagina fixation])

Other procedures to control Suturing of uterus, eg, B-Lynch suture

bleeding (5PC91LA); control of postpartum
hemorrhage by ligation of pelvic
vessels (1KT51); control of
postpartum hemorrhage by
embolization of pelvic vessels
(1RM13); uterine (and vaginal)
packing (5PC91HT)

Placenta previa O44

Placental abruption O45

Antepartum hemorrhage O46

Retained placenta without O73

hemorrhage
ICD-10, International Classification of Diseases, 10th Revision.

8 Mehrabadi et al Placenta Accreta and Postpartum Hemorrhage OBSTETRICS & GYNECOLOGY

Copyright by The American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
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