Women Are Dying From This: Taking Cesareans Seriously

When women have cesareans, they are rarely warned that a possible complication can be placental problems in future pregnancies.

Many women (and especially higher weight women) are pressured into cesareans in their first pregnancy. Many of these same women are counseled away from Vaginal Birth After Cesarean (VBAC) and into repeat cesareans in subsequent pregnancies.

Few of these women have been told that cesareans raise the risk for Placenta Accreta, a very serious complication, and that every cesarean increases the risk for it. I know *I* wasn't told this. This is a tremendous disservice to parents and to the importance of informed consent.

About Accreta

In Placenta Accreta, the fertilized egg implants near or on scar tissue in the uterus. This scar tissue is usually from a prior cesarean, but can also be from a D&C procedure, fibroid removals, a perforation from an IUD, or any uterine surgery or instrumentation. The placenta then grows into the uterine wall in this scar tissue. After the baby is born (often prematurely), the placenta can't separate properly and bleeding can become prolific. If the bleeding is not resolved, the mother can die.

There are degrees of Placenta Accreta. When the placenta grows into the uterine wall, that's Placenta Accreta. 

When the placenta invades the muscles of the uterus, that's known as Placenta Increta.

When the placenta grows through the uterine wall and into nearby organs like the bladder, that's called Placenta Percreta. All are extremely serious conditions, but percreta is the most serious of all.

The accreta rate has risen over the years as the cesarean rate has increased. Doctors are seeing more and more cases these days of what used to be a very rare complication. Some data indicate that the accreta rate has risen from about 1 in 4000 in the 1970s to about 1 in 533 now.

You can read more about this in my blog series on Placenta Accreta.

• Part One - What Is Placenta Accreta?
• Part Two - Life-Threatening Complication of Prior Cesarean 
• Part Three - Risks to Mother and Baby
• Part Four - Diagnosis, Treatment, and a Cautionary Story

The absolute numerical risk of accreta occurring in any one person is low, even with prior cesareans. Most women who have had cesareans will not experience an accreta. However, it is such a life-threatening condition that even a relatively small incidence carries a tremendous burden of complications, cost, and potential loss of life.

The more cesareans you have had, the greater the risk for accreta. In one very large study (Silver 2006), accreta was present in:

• 0.24% of women undergoing their first cesarean (previously unscarred)
• 0.31% of women undergoing their second cesarean (one prior cesarean)
• 0.57% of women undergoing their third cesarean (two prior cesareans)
• 2.13% of women undergoing their fourth cesarean (three prior cesareans)
• 2.33% of women undergoing their fifth cesarean (four prior cesareans)
• 6.74% of women undergoing their sixth or more cesarean (five or more prior cesareans)

This is why it is important to avoid automatic repeat cesareans and to keep VBAC a viable choice. Multiple repeat cesareans are the single most preventable factor for accretas. 

Accreta does sometimes occur after only one cesarean, like the woman in the video below, and that's why it's important to prevent a first cesarean whenever possible as well.

One Mother's Accreta Story

This mother had only had ONE prior cesarean, but still developed accreta with baby #2. Her first cesarean was a planned cesarean, urged by her OB. She was never warned that her cesarean meant accreta was a potential risk for the future.

THIS is why the high cesarean rate matters. On a case-by-case basis, a cesarean can be a good thing. But the public health implication of a high cesarean rate is that more women will develop life-threatening complications like placenta accreta, more babies will be born prematurely, and more women will die or experience permanent damage. Sometimes even after only one cesarean.

If we want to decrease maternal mortality rates and prevent complications from accreta, we MUST decrease cesarean rates. As the mother in the video below states:

A cesarean can be a life-saving intervention. The goal is not to eliminate cesareans. The goal is to make decisions regarding cesareans appropriately, and to recognize that even an uncomplicated cesarean and recovery can still put the mother at significant future risk....

She continues:

"There are too many cesareans now, 1 in 3 births, and researchers estimate that as many as 50% of those are unnecessary. 

And since a prior cesarean is a significant risk factor for developing a future accreta, that means that there are women developing accreta when it could have been prevented. So the easiest way to reduce the amount of accretas is to reduce cesarean levels... 

Women are dying from this, and mothers are dying from this. We need to take the risks of a cesarean seriously."

Even "Complicated" Pregnancies Should Labor Whenever Possible

There's an interesting new study out from Finland. 

I haven't read the full study yet, but from the abstract it looks like the gist is that even in "complicated" pregnancies, women should be given a chance to labor and have a vaginal birth, not just scheduled for a cesarean. 

Many times, in "complicated" pregnancies, there are care providers who believe that there is no point in "trying" for a vaginal birth. They just plan to do a cesarean before labor. They feel they will minimize maternal morbidity that way. 

Not all providers are like this, by any means, but there certainly are quite a few out there that just jump from "complicated" to "planned cesarean."

This very large study shows that the best outcomes were associated with planning a vaginal birth. 

Of course, each case has to be judged on an individual basis. This study doesn't mean that a planned cesarean is never appropriate; just that outcomes were better on a population-wide basis if the women were usually given the chance to have a vaginal birth.

The only exception was in pre-eclampsia, which in severe cases can sometimes have very poor outcomes. But outcomes in women with pre-eclampsia were equivalent between vaginal birth and planned cesarean...so you could certainly make a case for laboring there too, as long as the condition of the mother and the baby allow it. 

Bottom line, care providers should utilize planned cesareans only when truly necessary. 

Reference

Arch Gynecol Obstet. 2014 Aug 13. [Epub ahead of print] The impact of maternal obesity, age, pre-eclampsia and insulin dependent diabetes on severe maternal morbidity by mode of delivery-a register-based cohort study. Pallasmaa N1, Ekblad U, Gissler M, Alanen A. PMID: 25115277

PURPOSE: To determine the rate of severe maternal morbidity related to delivery by delivery mode and to assess if the impact of studied risk factors varies by delivery mode. 

METHODS: A register-based study including all women having singleton delivery in Finland in 2007-2011, n = 292,253, data derived from the Finnish Medical Birth Registry and Hospital Discharge Registry. Diagnoses and interventions indicating a severe maternal complication were searched and the mode of delivery was assessed by data linkage. The impact of obesity, maternal age 35 years or more, pre-eclampsia and insulin dependent diabetes on severe maternal morbidity (all severe complications, severe infections and severe) was studied in each mode of delivery and calculated as Odds ratios.  

RESULTS: The overall incidence of severe complications was 12.8/1,000 deliveries. The total complication rate was lowest in vaginal deliveries (VD) in all risk groups. Obesity increased the risk for all severe complications and severe infections in the total population, but not significantly in specific delivery modes. Age increased the risk of hemorrhage in VD. Pre-eclampsia increased the risk for hemorrhage in all deliveries except elective CS. In women with pre-eclampsia, overall morbidity was similar in VD, attempted VD and elective CS. The presence of any studied risk factor increased the risk for complications within the risk groups by the high proportion of emergency CS performed.  

CONCLUSIONS: An attempt of VD is the safest way to deliver even for high-risk women with the exception of women with pre-eclampsia, who had a similar risk in an attempt of VD and elective CS.

Prenatal Vitamins, Pre-Eclampsia, and Obesity

Image from Wikimedia Commons

Here is the abstract for a recent study that found that use of a prenatal vitamin in the first trimester of pregnancy substantially reduced the risk for development of pre-eclampsia, especially in "overweight" and "obese" women. 

The most intriguing finding of the study was that taking a prenatal vitamin in the first trimester lowered the risk for pre-eclampsia by 55% in "overweight" women, and by 62% in "obese" women. 

Surprisingly, only about 1/3 of women of any size in this study actually took a prenatal vitamin during the first trimester. Other studies of relatively affluent first-world countries show that only about 30-60% of women routinely took prenatal vitamins before or in the first trimester. This is why improving prenatal vitamin use is a public health intervention which could have significant potential impact. 

This may be especially true in obese women, since women of size tend to have lower rates of prenatal or preconception supplement use (45% vs. 60% in one study). 

The $64,000 question is whether we can lower pregnancy complication rates in obese women by encouraging them to routinely take prenatal vitamins, even when not actively trying to get pregnant.

Caveats to the Study

The findings of this study are intriguing and deserve to be followed up. However, keep in mind that this is a relatively small study and that these results need to be duplicated multiple times before a true correlation can be established.

Also keep in mind that other studies on prenatal vitamin use (multiple or single vitamins) in the overall population have found more ambivalent results or even poorer outcomes with routine supplementation. 

So it's important not to over-interpret this one study or make broad policy recommendations based on it.

Still, it was significant that prenatal vitamin use made such a difference in women of size in this study. Why might this be?

Research suggests that many women of size have nutrient deficiencies such as low vitamin D, and some research suggests that low levels of vitamin D or other nutrients may be associated with higher risk for pre-eclampsia, so this could be explain why prenatal vitamin use was so helpful. However, not all research supports such an association, so again, caution is needed. 

It might be that supplementation is most beneficial only for those with significant nutrient deficits. A more sensible policy might be routine pre-conception nutrient testing for those most at risk rather than routine supplementation across the board for everyone. 

Since obese women are at significant risk for pre-eclampsia and certain birth defects, pre-conception nutrient testing is something that women of size who are considering pregnancy might want to consider. 

Personally, I favor pre-conception testing and emphasizing the use of whole foods and excellent nutrition as the best approach to lowering the risk for complications in women of size. 

To me, the best approach is always to emphasize nutrition before pills. I think artificial pills only go so far in helping nutrient deficiencies, and vitamin supplements of one or two particular vitamins can sometimes induce imbalances of other vitamins or minerals. Frankly, focusing on increasing dietary intake of fruits and vegetables may be the safest way to improve nutritional status and decrease risks before and during pregnancy.

Still, there is a place for vitamins and/or medications at times. A prenatal vitamin before pregnancy and during the first trimester might be helpful for many people. It seems like a common-sense public health strategy that might help and is at minimal risk for harm if it's done in moderation.

But the bottom line is that we need more studies showing the effect of routine prenatal vitamin use in subgroups such as overweight and obese women. I would particularly like to see research stratified by class of obesity, nutritional intake, pre-conception nutrient status, and insulin resistance status so we could have a more nuanced examination of potential confounders as well. 

Only when such nuanced research is done will we truly know for sure whether routine pre-conception and prenatal vitamin supplementation is an effective strategy for lowering the risk of complications in women of size. 

Reference

Matern Child Nutr. 2014 May 22. doi: 10.1111/mcn.12133. [Epub ahead of print] First trimester multivitamin/mineral use is associated with reduced risk of pre-eclampsia among overweight and obese women. Vanderlelie J1, Scott R, Shibl R, Lewkowicz J, Perkins A, Scuffham PA. PMID: 24847942

The use of pregnancy-specific multivitamin supplements is widely recommended to support maternal homeostasis during pregnancy. Our objective was to investigate whether multivitamin use during pregnancy is associated with a reduced risk of pre-eclampsia. 

The effect of multivitamin use on incidence of pre-eclampsia in lean and overweight/obese women was analysed using data collected between 2006 and 2011 as part of the Environments for Healthy Living Project, Griffith University, Australia. A total of 2261 pregnancies were included in the analysis with pre-eclampsia reported in 1.95% of subjects. 

Body mass index (BMI) ≥ 25 was associated with a 1.97-fold [95% confidence interval (CI): 0.93, 4.16] increase in pre-eclampsia risk. First trimester multivitamin use was reported by 31.8% of women and after adjustment, was associated with a 67% reduction in pre-eclampsia risk (95%CI: 0.14, 0.75). 

Stratification by BMI demonstrated a 55% reduction in pre-eclampsia risk (95%CI: 0.30, 0.86) in overweight (BMI: 25-29.9) and 62% risk reduction (95%CI: 0.16, 0.92) in obese (BMI: ≥30) cohorts that supplemented with multivitamins in the first trimester of pregnancy. This finding may be particular to the Australian population and reflect inherent nutritional deficits. 

First trimester folate supplementation was found to reduce pre-eclampsia incidence [adjusted odds ratios (AOR) 0.42 95%CI: 0.13, 0.98] and demonstrated significance upon stratification by overweight status for women with BMI >25 (AOR 0.55 95%CI: 0.31, 0.96). These results support the hypothesis that multivitamin supplementation may be beneficial in reducing the incidence of pre-eclampsia during pregnancy and be of particular importance for those with a BMI ≥25.

PCOS Treatment Options: Overview

In the past, we have talked about PCOS (Polycystic Ovarian Syndrome), its definition and symptoms, how it presents, its testing and diagnosis, and its possible causes.

Now, we are doing an overview of treatment options for PCOS (beyond fertility treatment options; fertility issues and their treatment will be discussed in a separate post later on).

The question on the mind of most women with PCOS is how to minimize the risks for long-term health problems, how to minimize the distressing symptoms, and what does research say about the benefits and risks of treatment options?

This mini-series on PCOS treatment protocols will discuss a wide variety of treatment options, from insulin-sensitizing medications, anti-androgenic medications, the Pill, and cosmetic treatments. In future posts, we will also cover nutritional/lifestyle and "alternative" medicine approaches, as well as fertility treatment and options.

Because of the lengthy nature of discussing these options, the PCOS Treatment Options posts will be broken down into sub-topics. The pros and cons of metformin treatment, for example, deserve a post all its own, as do other insulin-sensitizing drugs, anti-androgen drugs, cosmetic treatments, etc.

Therefore, this post serves only as an introduction to the treatment topic ─ an overview of the possibilities ─ and subsequent posts will have more in-depth coverage of various treatment options. Because of the in-depth nature of these posts, they may not all be in a continuous series but may be spread out over time.

Trigger Warning and Caveats

The purpose of this series is to provide a basic introduction to PCOS with a size-acceptance approach that is rare on PCOS websites. 

However, as we discussed previously, this presents a dilemma when exploring treatment protocols, since weight loss is considered the traditional first-line-of-treatment for "obese" women with PCOS, and fair coverage of the topic demands examining the pros and cons of all possible treatments. So to be fair, sometimes research will be quoted that promotes weight loss ─ not because I believe weight loss is the best treatment, but because this represents the typical treatment protocols recommended, and it's only fair to mention that when doing an overview of PCOS treatments.

This does not mean I endorse or promote weight loss as a treatment. Instead, we will try to disentangle weight loss agendas from other information about PCOS treatment, and we will also discuss the possible risks of weight loss regimens. Unlike most other PCOS articles, we will not promote weight loss as the "best" or "first" treatment, we will suggest care alternatives that do not have to involve weight loss, and we will offer support for women with PCOS who are not interested in pursuing weight loss. 

My intent is to have a size-friendly guide to PCOS, but intellectual ethics demands that the evidence both for and against weight loss as a treatment be discussed too. If this is too triggering for you, you might want to skip this post, the Fertility posts, and the Nutrition and Lifestyle Treatment Options post. Most of the other Treatment Options posts should be okay, but read the research references with caution, as official sources on PCOS are always full of weight-loss promotion. Any posts with more than a passing mention of weight loss will also have a trigger warning, so look for that as well, if you want to avoid any mention of such things.

You should know that this approach has been discussed with and approved by the Fatosphere monitors.  

The Goals of Treatment for PCOS

What treatments (if any) are selected for PCOS depend on the goals of the woman and her specific circumstances. As soulcysters.com notes:

Management of polycystic ovary syndrome focuses on each woman's main concerns...Long term, the most important aspect of treatment is managing cardiovascular risks.

Different women with PCOS will have different goals for treatment. Some desperately want children, and most of their focus is going to go to fertility-related treatments at first. Some don't want children but are concerned about the long-term consequences of PCOS, so their choice of treatment will probably be insulin-sensitizing agents. Others are most concerned with appearance issues such as facial hirsutism, and so they may prefer to concentrate on anti-androgen medications or cosmetic options.

There is no one "right" way to treat PCOS, and you have the right to opt into or out of any form of treatment, regardless of what the authorities or others tell you that you "should" do. 

For example, although metformin is an extremely effective insulin-sensitizing drug that lowers the risk for diabetes and other complications, it also has some distressing gastro-intestinal side effects in some people. Some women choose to opt out of metformin because of these side effects, despite the known risks of hyperinsulinemia and diabetes. To them, the effect on their quality of life overrides the possible benefits the drug might bring.

Similarly, there is nothing that says that you have to treat facial hair or thinning scalp hair. Treatments like anti-androgenic drugs are somewhat effective for this in some women, but are associated with severe birth defects. Because even the most efficient birth control method still has a small chance of pregnancy, some women choose to opt out of these drugs and simply address these issues cosmetically instead. Others chose not to address them at all because the treatments are too onerous or they reject society's outdated and sexist standard of feminine beauty.

Weight loss is another commonly-recommended treatment that many women opt out of. Many have a long personal history of yo-yo dieting and know that even the usual recommendation of  "a small, 5-10% weight loss" tends to trigger a far greater regain afterwards for them. Or they may have an eating disorder and find restrictive diet approaches to be triggering. Or because weight loss is rarely successful long-term and carries significant risks of its own, they may prefer to avoid something so unlikely to succeed and that may introduce additional risks.

The purpose of this post is merely to explore as many options for PCOS treatment as possible, not to imply that anyone "should" choose any particular option.  

The treatment plan for one woman with PCOS is likely different than someone else's treatment plan. It all depends on her symptoms, her goals, her values, and her tolerance of the various treatment options.

Summary of The Most Common Treatments

The most common treatment goals for PCOS usually involve:

• minimizing the effect of androgens in the body
• lessening hyperinsulinemia (excess insulin) and normalizing blood sugar 
• normalizing menstrual cycles as much as possible
• minimizing or concealing the cosmetic symptoms of PCOS
• preventing or minimizing the long-term health risks associated with PCOS

Meeting these treatment goals typically involves using drugs such as anti-androgen medications, insulin-sensitizing medications, and birth control pills. It also may involve cosmetic treatments for hirsutism or hair loss, or alternative treatments such as herbs and acupuncture.

Of course, we all know that weight loss is emphasized by doctors as the primary form of treatment for PCOS symptoms. Unfortunately, they rarely acknowledge that weight loss has its own risks, that it rarely lasts long-term, and that it often results in rebound gain. What they rarely mention to PCOS patients is that lifestyle and nutritional modifications can often help without having weight loss as a goal.

Here is a summary of the most common treatment options from one website (with a few edits, additions, and added emphasis by me). Because this is a quote from a mainstream website, be aware that it does emphasize weight loss (trigger warning).  However, this quote is included because it's important to point out the traditional approach to treating PCOS before discussing its pros and cons:

There is no cure for PCOS...Treatment of PCOS is aimed at reducing its symptoms and prevention of further complications. 

The goals are to promote ovulation, prevent endometrial hyperplasia, counterbalance the effects of androgens, and reduce insulin resistance. Treatment options depend on the type and severity of the individual woman's symptoms and her desire to become pregnant.

Low-dose oral contraceptives are often used to stabilize hormones and oppose estrogenic stimulation of the endometrium. Within several months, they can usually regulate menstrual periods, eliminate or minimize uterine bleeding, and reduce androgen levels - improving hirsutism and clearing up acne. 

Anti-androgens such as spironolactone, flutamide, and cyproterone are sometimes combined with oral contraceptives to help address more severe hirsutism and acne. Waxing, shaving, depilatory and electrolysis may be used to remove unwanted hair, and antibiotics or retinoic acids may be used to treat acne.

Metformin is being used to reduce insulin resistance. It has also shown promising initial results in women with PCOS hirsutism and in helping to regulate menstrual cycles, but its effects on infertility and other symptoms are not yet known. 

Fertility Drugs - If a woman with PCOS wants to become pregnant, she is usually given clomiphene citrate, a drug that helps induce ovulation. She may also be given human menstrual gonadotropin, although this drug increases the risk of multiple pregnancies. However, as with any drug regimen, certain side effects and risks may be present.

Surgery - Although sometimes performed in the past, surgery is a rare PCOS treatment option now. One surgical option, a "wedge resection," involves removing the part of the ovary that contains the cystic follicles to try to restore ovulation. Another option, ovarian drilling, involves using a needle with an electric current to make holes in the ovary. Both of these procedures may temporarily increase fertility but may also lead to scarring and adhesions; concerns in long-term ovarian function limit this practice. 

Lifestyle changes through better diet, weight loss, and exercise are recommended to help decrease insulin resistance and to minimize lipid abnormalities. Weight reduction can also decrease testosterone, insulin, and LH levels. Regular exercise and healthy foods, such as vegetables, fruits, nuts, and whole grains, will also lower blood pressure and cholesterol as well as improve sleep apnea problems. Smoke cessation also may lower androgen levels.

Again, these are the choices offered by a traditional approach to PCOS. But there are other choices.

Some women choose other insulin-sensitizing agents besides metformin, such as the glitazones or the inositols. Some emphasize Health At Every Size® via lifestyle choices like moderating carb intake, increasing exercise, or eliminating gluten/grains without focusing on weight loss. Other women find help for their PCOS through "alternative" medicine, like herbs or acupuncture.

There are many choices available for women with PCOS; there is no one "right" way in treating it. Again, the best approach depends on the needs and priorities of each individual woman. Most women with PCOS arrive at their optimal treatment plan after considerable experimentation, so it's important to learn as much as possible about the pros and cons of each option.

Concluding Thoughts

In future posts, we will look at most of these treatment options in a little more detail. As you read these, keep in mind the goals of treatment:

• to regulate the cycle (to restore menstruation and thereby lower the risk for endometrial cancer; also to increase ovulation/fertility if desired)
• to lessen the effects of androgens (to minimize the negative effects of hormonal imbalances in the body; to minimize distressing side-effects like hirsutism, thinning hair or cystic acne ─ or to utilize cosmetic treatments to lessen the social impact of these symptoms)
• to decrease insulin resistance (to lower the risk for diabetes and other long-term complications of the metabolic syndrome)

Treatment usually involves a combination of therapies; most often, a combination of medication, cosmetic treatments, and lifestyle modifications is utilized.

Remember, though, that you are your own boss. Only you get to decide what the right course of treatment is for your body.

References

*These references are included here because they are overviews of medical approaches to treating PCOS, which is the purpose of this post. However, most research studies strongly emphasize weight loss as the first line of treatment for PCOS. If you find discussion of this triggering or distressing, definitely don't read this reference list!

General Summary of Treatment Options 

• http://labtestsonline.org/understanding/conditions/pcos/?start=3 - summary of treatment options
• http://www.inciid.org/faq.php?cat=infertility101&id=2#89 - INCIID's PCOS FAQ, which discusses treatment options fairly extensively
• http://www.hormone.org/Polycystic/treatment.cfm - treatment options as summarized by The Hormone Foundation (an endocrinology educational group)

A Few Studies on Treatment Options

Int J Womens Health. 2011 Feb 8;3:25-35. Treatment options for polycystic ovary syndrome.Badawy A, Elnashar A. PMID: 21339935

...Management of women with PCOS depends on the symptoms. These could be ovulatory dysfunction-related infertility, menstrual disorders, or androgen-related symptoms. Weight loss improves the endocrine profile and increases the likelihood of ovulation and pregnancy...In PCOS, anovulation relates to low follicle-stimulating hormone concentrations and the arrest of antral follicle growth in the final stages of maturation. This can be treated with medications such as clomiphene citrate, tamoxifen, aromatase inhibitors, metformin, glucocorticoids, or gonadotropins or surgically by laparoscopic ovarian drilling. In vitro fertilization will remain the last option to achieve pregnancy when others fail. Chronic anovulation over a long period of time is also associated with an increased risk of endometrial hyperplasia and carcinoma, which should be seriously investigated and treated. There are androgenic symptoms that will vary from patient to patient, such as hirsutism, acne, and/or alopecia. These are troublesome presentations to the patients and require adequate treatment. Alternative medicine has been emerging as one of the commonly practiced medicines for different health problems, including PCOS. This review underlines the contribution to the treatment of different symptoms.

Womens Health (Lond Engl). 2009 Sep;5(5):529-40; quiz 541-2. Polycystic ovary syndrome, obesity and reproductive implications. Hirschberg AL. PMID: 19702452

...Lifestyle interventions resulting in weight loss comprise the most successful strategy to improve symptoms of PCOS. However, many patients fail to lose weight or may quickly regain weight. It is an important challenge to develop effective lifestyle programs and adjuvant pharmacologic treatments in order to improve reproductive and metabolic health among women with PCOS.

Minerva Med. 2007 Jun;98(3):175-89. Comprehensive clinical management of polycystic ovary syndrome. Setji TL, Brown AJ. PMID: 17592439

...Menstrual cycle control is necessary to prevent endometrial hyperplasia, and this can be accomplished with hormonal contraception, progesterone therapy, and weight loss (if overweight). In women desiring pregnancy, commonly used ovulation induction therapies include weight loss, clomiphene citrate, and/or metformin. Cosmetic issues such as hirsutism, acne and male-pattern hair loss can be challenging to cope with. Treatment options include estrogen-containing hormonal contraceptive agents, antiandrogens, and topical agents. More permanent hair reduction can be achieved with electrolysis and laser therapy. Evaluation of metabolic complications includes risk assessment for diabetes, dyslipidemia, hypertension, and nonalcoholic fatty liver disease. Women with PCOS should also be screened for sleep apnea, as this has been reported to occur more commonly in women with PCOS. Finally, mental health issues such as depression and eating disorders may be present. Many of the complications associated with PCOS can be managed with therapeutic lifestyle change, including a healthy diet, exercise, weight loss (if overweight), and psychological support. Pharmacological therapies are also available to effectively regulate menstrual cycles and manage cosmetic complications.

Exp Clin Endocrinol Diabetes. 2010 Oct;118(9):633-7. doi: 10.1055/s-0029-1237705. Epub 2009 Dec 8. The effect of metformin treatment for 2 years without caloric restriction on endocrine and metabolic parameters in women with polycystic ovary syndrome. Oppelt PG, Mueller A, Jentsch K, Kronawitter D, Reissmann C, Dittrich R, Beckmann MW, Cupisti S. PMID: 19998243

...MATERIAL AND METHODS: Twenty-six obese women with PCOS were treated with metformin over 2 years without caloric restriction. Clinical, metabolic and endocrine parameters and the body mass index were measured and an oral glucose tolerance test was carried out to calculate insulin resistance indices at the beginning and at the follow-up after 2 years. The Homeostatic Model for Assessment of Insulin Resistance (HOMA-IR) was calculated...CONCLUSIONS: Long-term treatment with metformin in women with PCOS appears to reduce androgen excess due to increased SHBG and decreased TT levels resulting in improvement of hirsutism as a clinical sign of androgen excess. Furthermore a significant decrease in fasting and 2-h insulin levels and slightly improved insulin resistance indices were observed.

PCOS Series: A Return

It's time to continue our series on PCOS, Polycystic Ovarian Syndrome.

For those not familiar with it, PCOS is an endocrine condition that affects many women of size (and some women of average size). Between 5-10% of women are thought to have this condition, but  many women go undiagnosed or undertreated.

Symptoms often include irregular or missing periods; hirsutism (excess body hair); significant weight gain and difficulty losing weight; cystic acne; alopecia (thinning hair on the scalp); acanthosis nigricans (dark patches of skin on the thighs, arms, breasts, or neck); and insulin resistance.

However, you don't have to have all of these symptoms to have PCOS, and the condition can present in many different ways. You can take a survey of possible symptoms here.

PCOS is often accompanied by other conditions like hypothyroidism, diabetes, high blood pressure, and many others.  Although many people focus mainly on its effect on childbearing and appearance, PCOS can have life-long health implications.  Therefore, treating it is critical, even if you don't want children or don't care about its cosmetic effects.

A while ago, we started a periodic series about PCOS. We talked about its definition and symptoms, how it presents, its testing and diagnosis, and its possible causes.

If you have not yet read these blog posts, I urge you to do so.  Even if you don't have PCOS, it's important for more people to learn about this condition, how it presents, and its many health implications.

Now it's time to expand the PCOS series with new installments.  This time, let's talk about treatment choices for PCOS.

We're going to do an overview of treatment options for PCOS, and then discuss treatment for the metabolic issues of PCOS and treatment for the cosmetic challenges of PCOS.

Future projected installments will address other aspects of PCOS, such as treatment for fertility concerns, potential pregnancy challenges with PCOS, potential breastfeeding challenges with PCOS, and the impact of PCOS on menopause. But let's focus on treatment of metabolic and cosmetic challenges first.

Why A Series About PCOS Here?

For a long time, I didn't write much about PCOS on my blog or website because there are plenty of other resources on the internet with PCOS information, and I saw no need to duplicate what was already out there.

However, I came back to writing about the topic here because most PCOS websites have a tremendous weight-loss emphasis, leading many fat-acceptance folk to avoid these sites and miss important information about the condition. I wanted to present good, in-depth information without pushing weight loss, something that is very missing in most PCOS resources.

Of course, this is going to displease the weight loss devotees in PCOS circles...both consumers and doctors. The weight-centric paradigm runs very strong in PCOS circles, both in medical research and consumer-based resources. Even the mere suggestion that dieting may be counter-productive is absolute heresy there.

To those folks, I say....Everyone is their own boss. If you wish, you can certainly pursue weight loss as a possible treatment for your PCOS; no one here is going to stop you.  Certainly, there is some research that weight loss can be helpful for PCOS, at least temporarily.  If you want to pursue that, go ahead. There are plenty of PCOS resources out there friendly to that approach.

The problem is that this research, like most research on weight loss, is short in duration, doesn't show long-term outcomes, and completely ignores the risks that can be associated with weight loss.  Does weight loss really benefit your health if you end up heavier afterwards and with more eating-disordered behaviors?  Or if you end up with gallstones or kidney cancer from weight cycling?

Given the overwhelming evidence of poor long-term success with weight loss and the significant harms that can come from yo-yo dieting, it's important to know that there is an alternative, that you can treat your PCOS without having to resort to yet another diet that is likely to fail. This series will not ignore the possibility of weight loss as treatment, but promoting weight loss will not be its focus, unlike 99% of the other PCOS resources out there.  It's vital that we have a resource like this so that folks with PCOS know there is an alternative.

As with any medical situation, readers will have to carefully consider the pros and cons of all their choices and decide what is right for themselves, whether that involves intentional weight loss or stepping into a Health At Every Size® paradigm instead. Whatever you decide for you is fine; just make that decision from an informed place.

But this series is intended to point out that there are treatment approaches that can help mitigate the risks of PCOS without emphasizing weight loss.  

TRIGGER WARNING: If you are a person who would find any mention of weight loss offensive or triggering, you might want to be cautious about the upcoming posts on PCOS Treatments.  Although these PCOS posts will not promote weight loss (most won't even discuss it), a few will mention it as one of the common treatments recommended and why. Those posts that do mention weight loss will have a Trigger Warning clearly posted near the beginning so those who want to avoid any weight loss discussion can do so. 

You should also be very cautious about reading the research summaries and links in all of the PCOS references; these are from traditional PCOS resources, and therefore are full of weight loss promotion.  I include them because I feel it is important to always include reference citations in articles that deal with medical issues, and I include abstracts (or portions of abstracts) so that consumers can quickly scan a summary of the research and vet these arguments for themselves.

It's never my intention to promote dieting in any way, but it's difficult to discuss PCOS adequately without at least passing mention of weight loss issues and posting the relevant references. I've discussed this with the fatosphere monitors and they approved this approach. This advance notification and trigger warnings in any post that touches on weight loss was their suggested way to manage any concerns.

Postscript

At some point, I'd also love to share some stories from PCOS women who follow a Health At Every Size® model. I'd like to see stories on how they manage their condition without a weight-loss emphasis, and how they manage their dealings with weight-centric medical authorities in a proactive and positive way.

If you'd like to share your story, please email me at kmom AT plus-size-pregnancy DOT  org to share your story. Be sure to give me permission to share your story, and let me know how you want it identified (pseudonyms or first names are fine; I strongly discourage use of full names).  Brevity is very important; just give a quick summary of how you manage PCOS without a weight-loss emphasis and why you do so. I reserve the right to edit submissions and to use the submission as needed. After the next series of PCOS posts (and when I have enough entries), I will publish a blog post sharing these stories.

References

Int J Obes Relat Metab Disord. 2000 Sep;24(9):1107-10. Can anyone successfully control their weight? Findings of a three year community-based study of men and women. Crawford D, Jeffery RW, French SA.   PMID: 11033978

This study examined the prevalence, distribution and correlates of successful weight loss and successful weight maintenance over three years in a community-based sample of 854 subjects aged 20-45 at baseline. More than half (53.7%) of the participants in the study gained weight within the first twelve months, only one in four (24.5%) successfully avoided weight gain over three years, and less than one in twenty (4.6%) lost and maintained weight successfully. The findings underscore the importance of current public health efforts to prevent weight gain, and suggest that without much greater efforts to promote and support weight control the prevalence of obesity will continue to rise.

Am Psychol. 2007 Apr;62(3):220-33. Medicare's search for effective obesity treatments: diets are not the answer. Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. PMID: 17469900

The prevalence of obesity and its associated health problems have increased sharply in the past 2 decades. New revisions to Medicare policy will allow funding for obesity treatments of proven efficacy. The authors review studies of the long-term outcomes of calorie-restricting diets to assess whether dieting is an effective treatment for obesity. These studies show that one third to two thirds of dieters regain more weight than they lost on their diets, and these studies likely underestimate the extent to which dieting is counterproductive because of several methodological problems, all of which bias the studies toward showing successful weight loss maintenance. In addition, the studies do not provide consistent evidence that dieting results in significant health improvements, regardless of weight change. In sum, there is little support for the notion that diets lead to lasting weight loss or health benefits.

J Am Diet Assoc. 1996 Jun;96(6):589-92; quiz 593-4. Psychological consequences of food restriction. Polivy J.  PMID: 8655907

A review of the literature and research on food restriction indicates that inhibiting food intake has consequences that may not have been anticipated by those attempting such restriction. Starvation and self-imposed dieting appear to result in eating binges once food is available and in psychological manifestations such as preoccupation with food and eating, increased emotional responsiveness and dysphoria, and distractibility. Caution is thus advisable in counseling clients to restrict their eating and diet to lose weight, as the negative sequelae may outweigh the benefits of restraining one's eating. Instead, healthful, balanced eating without specific food restrictions should be recommended as a long-term strategy to avoid the perils of restrictive dieting.

J Am Diet Assoc. 2007 Mar;107(3):448-55. Why does dieting predict weight gain in adolescents? Findings from project EAT-II: a 5-year longitudinal study. Neumark-Sztainer D, Wall M, Haines J, Story M, Eisenberg ME.   PMID: 17324664 

OBJECTIVE: Dieting has been found to predict weight gain in adolescents, but reasons for this association remain unclear. This study aimed to explore potential mechanisms by which dieting predicts weight gain over time in adolescents. DESIGN: Population-based, 5-year longitudinal study. PARTICIPANTS: Adolescents (n=2,516) from diverse ethnic and socioeconomic backgrounds who completed Project EAT (Eating Among Teens) surveys in 1999 (Time 1) and 2004 (Time 2). MAIN OUTCOME MEASURE: Body mass index (BMI) change over 5 years. STATISTICAL ANALYSIS: Multiple regressions were used to examine associations between Time 1 dieting and Time 2 binge eating, breakfast consumption, fruit and vegetable intake, and physical activity. Associations were then examined between these behaviors and BMI change. Finally, to test for mediating effects, associations between dieting and BMI change were examined with and without the inclusion of these behaviors, and regression coefficients were compared. RESULTS: In female adolescents, dieting predicted increased binge eating (P<0.001) and decreased breakfast consumption (P=0.030). In male adolescents, dieting predicted increased binge eating (P<0.001), decreased physical activity (P=0.006), and a trend toward decreased breakfast consumption (P=0.064). These behaviors were also associated with increases in BMI. The association between dieting and BMI increase was weakened, but still remained significant, after binge eating, breakfast consumption, fruit/vegetable intake, and physical activity were included in the model being tested. Thus, the longitudinal association between dieting and BMI increase was partially mediated by these behaviors. CONCLUSIONS: In part, dieting may lead to weight gain via the long-term adoption of behavioral patterns that are counterproductive to weight management.

Am J Epidemiol. 2007 Oct 1;166(7):752-9. Epub 2007 Jul 5. Body size, weight cycling, and risk of renal cell carcinoma among postmenopausal women: the Women's Health Initiative (United States). Luo J, Margolis KL, Adami HO, Lopez AM, Lessin L, Ye W; Women's Health Initiative Investigators. PMID: 17615089

Although obesity is an established risk factor for renal cell carcinoma, the possible effect of central adiposity and long-term variation in weight has yet to be established. The authors studied 140,057 women aged 50-79 years enrolled in the Women's Health Initiative in the United States to examine the role of obesity, especially abdominal obesity, and weight cycling in relation to risk of renal cell carcinoma among postmenopausal women. Cox models were used to estimate relative risks and their corresponding 95% confidence intervals. During an average of 7.7 years of follow-up through September 12, 2005, a total of 269 incident cases of renal cell carcinoma were identified. Central adiposity, as indicated by waist-to-hip ratio, was an important risk factor for developing renal cell carcinoma (highest vs. lowest quartile: relative risk = 1.8, 95% confidence interval: 1.2, 2.5; p for trend = 0.0003). Moreover, women who had experienced weight cycling more than 10 times were at 2.6 times (95% confidence interval: 1.6, 4.2) increased risk compared with women whose weight was stable. Results add evidence that obesity, particularly central adiposity, is associated with an increased risk of renal cell carcinoma among postmenopausal women. Furthermore, they indicate that weight cycling is independently associated with further increased risk of this malignancy.

Ann Intern Med. 1999 Mar 16;130(6):471-7. Long-term weight patterns and risk for cholecystectomy in women. Syngal S, Coakley EH, Willett WC, Byers T, Williamson DF, Colditz GA. PMID: 10075614

BACKGROUND: Obesity and rapid weight loss in obese persons are known risk factors for gallstones. However, the effect of intentional, long-term, moderate weight changes on the risk for gallstones is unclear...SETTING: 11 U.S. states. PARTICIPANTS: 47,153 female registered nurses who did not undergo cholecystectomy before 1988...RESULTS: During the exposure period (1972 to 1988), there was evidence of substantial variation in weight due to intentional weight loss during adulthood. Among cohort patients, 54.9% reported weight cycling with at least one episode of intentional weight loss associated with regain. Of the total cohort, 20.1% were light cyclers (5 to 9 lb of weight loss and gain), 18.8% were moderate cyclers (10 to 19 lb of weight loss and gain), and 16.0% were severe cyclers (> or = 20 lb of weight loss and gain). Net weight gain without cycling occurred in 29.3% of women; net weight loss without cycling was the least common pattern (4.6%). Only 11.1% of the cohort maintained weight within 5 lb over the 16-year period. In the study, 1751 women had undergone cholecystectomy between 1988 and 1994. Compared with weight maintainers, the relative risk for cholecystectomy (adjusted for body mass index, age, alcohol intake, fat intake, and smoking) was 1.20 (95% CI, 0.96 to 1.50) among light cyclers, 1.31 among moderate cyclers (CI, 1.05 to 1.64), and 1.68 among severe cyclers (CI, 1.34 to 2.10). CONCLUSION: Weight cycling was highly prevalent in this large cohort of middle-aged women. The risk for cholecystectomy associated with weight cycling was substantial, independent of attained relative body weight.

Placenta Previa and Prior Cesarean

Illustration of Complete Previa, with the placenta at
the bottom of the uterus, between baby and the cervix.
Image by Sigrid de Rooij,Wikimedia Commons

As a follow-up to Cesarean Awareness Month last month, we are talking about late complications from cesareans.

A cesarean section is surgery, and thus entails the usual immediate risks associated with surgery, including infection, hemorrhage, anesthesia problems, blood clots, and accidental damage to surrounding tissues.  These alone are substantial enough to warrant concern with the current high cesarean rate.

However, what many people don't realize is that a cesarean also has downstream health implications, long after the cesarean is over, particularly in women who have further pregnancies after the cesarean(s).

In particular, the risk for abnormal placentation rises with each successive cesarean. And abnormal placentation has a high risk for poor outcomes.

Today we are going to discuss the most common of the complications, Placenta Previa.

Placenta Previa

Placenta Previa is the term for a placenta that lies over or near the cervix at the bottom of the uterus instead of on the top or sides of the uterus (see diagram). It is a significant complication in pregnancy. The number of previas has increased in recent years in tandem with the rising cesarean rate and other factors.

Placentas usually implant higher in the uterus, either near the top (fundal), or on the sides (anterior/front side, posterior/back side).

A low-lying placenta is a problem because as the pregnancy progresses, the lower uterine segment (LUS) expands and develops and the cervix begins to thin. This can cause a part of the placenta to shear off (abrupt) and begin to bleed.

This partial abruption of the placenta is often minor at first, but can become major later on, endangering both baby and mother. In addition, in some previas the placenta can block the cervix, making vaginal birth dangerous.

Symptoms of previa include painless bleeding after 24 weeks or so of gestation. The most typical presentation of bleeding is around 32 weeks or so, although some previas never experience bleeding episodes at all. Elevated maternal alpha fetoprotein levels during prenatal testing may also be a sign of a possible previa.

Any woman who experiences bleeding episodes after about 20 weeks should be evaluated by a care provider.

If you are diagnosed with Placenta Previa, it is important for you to learn more about the condition so you can become a partner in your own care decisions.  In addition, it is very helpful to reach out to a support group so that you can get support as you deal with the previa experience.

If You Are Diagnosed with Placenta Previa

A transvaginal ultrasound is by far the best method of checking placental placement if previa is suspected. Research shows that a number of previas suspected with abdominal ultrasound are able to be ruled out with transvaginal ultrasound.

There are four grades of severity in previas:

• Type One - placenta is near but not touching mouth of cervix (low-lying placenta)
• Type Two - placenta reaches mouth of the cervix but doesn't cover it (marginal previa)
• Type Three - placenta partially covers the mouth of the cervix (partial previa)
• Type Four - placenta completely overlays the mouth of the cervix (complete or total previa)

It's important to note that a placenta can look low-lying in early pregnancy but "move up" in the uterus as the uterus grows and develops during pregnancy.

Most borderline previas in early or mid-pregnancy completely resolve by the end of pregnancy, or move up enough that the risk is lessened. 

Thus, it's important not to panic if you are told you have a previa early in pregnancy.  Most of the time it just bears watching and will resolve.

However, some never do resolve. This is called a persistent previa. A complete previa where the mouth of the cervix (the os) is completely covered is the most likely to persist until delivery, although it should be noted that some of these do resolve by term.

Posterior previas are less likely to resolve than anterior previas.  A prior cesarean has been shown to be a strong independent risk factor for a persistent previa. Complete previas that are very symmetrically over the os are also likely to persist to term.

All women with significant placenta previa should be evaluated for the possibility of Placenta Accreta (an abnormally adherent placenta) or Vasa Previa (where fetal blood vessels are situated in the membranes over the cervix without the protection of the cord or placenta). Women with a history of cesareans, D&Cs, or in-vitro fertilization should be particularly evaluated for these conditions.

Most of the time, previas completely resolve by term and labor proceeds normally. If the previa is still there by 35 weeks but is minor (2 cm or more from the os), vaginal birth is quite possible, and has a good success rate.

Some providers will also allow women with previas that are 1-2 cm from the os to try for vaginal birth, whereas others feel this is too risky. Even with a vaginal delivery, however, the mother with a marginal or low-lying placenta still needs to be watched carefully for postpartum hemorrhage.

If the placenta is very near or overlays the os at all by 35 weeks, then delivery needs to be by cesarean in order to prevent hemorrhage when the cervix begins to thin and dilate.  Although regional anesthesia (epidural or spinal) can be used, many providers prefer general anesthesia because of the unpredictability of surgery length and the potential for emotional trauma if complications occur.  Some providers start with regional anesthesia to minimize fetal exposure to drugs, then convert to general anesthesia after the baby is delivered.

A cesarean for an anterior previa is a difficult surgery with the potential for major hemorrhage because it can mean cutting through the placenta itself in order to get to the baby.  Many OBs decide to avoid the placenta altogether by doing a high vertical or transverse fundal incision instead, because this may lessen bleeding and make it easier if a hysterectomy is needed. However, it can also mean a more difficult recovery. Discuss the pros and cons of each choice with your provider ahead of time.

Postpartum, previa mothers need to be monitored for hemorrhage, infection, and anemia. In some mothers who experience very severe hemorrhage, milk supplies are impaired and the pituitary gland can be damaged (Sheehan's Syndrome).  Hypothyroidism and adrenal fatigue issues can occur secondary to Sheehan's Syndrome and should be monitored for carefully for years, as symptoms may not become clear until long after the birth.

Postpartum, some mothers have a tough time coping emotionally or may not feel they have enough emotional support after a difficult experience. Many find their experiences dismissed or shrugged off as if a healthy baby is the only thing that matters.  It's important to know that emotional support is available through Sidelines, ICAN, Solace for Mothers, and many other organizations.

Risks Associated with Placenta Previa

Although many women with previas have reasonably good outcomes, previas are associated with an increased risk of a number of complications.

The risk of hemorrhage is the most important of these complications. One study found that nearly 60% of women with previa experienced a significant hemorrhage, and nearly 12% required a blood transfusion.

However, a lot depends on how severe the previa is and whether it detaches normally. Women with low-lying previas (type 1), for example, had only a 7.6% rate of hemorrhage.  As you might expect, women with complete previas tend to have worse outcomes than those with more marginal previas, as would those who also have an accreta (abnormally adherent placenta).

Because of the risk of hemorrhage, it's important to have adequate blood products on hand at a previa birth. Women with a possible previa should try to boost their iron status during pregnancy in order to minimize the impact of significant blood loss during the birth, should it occur.

Women with high hemoglobin levels may want to look into donating and banking their own blood ahead of time in case a transfusion is needed.  They may also want to inquire about the possibility of recycling and re-using any of their blood lost during the cesarean.

In addition to bleeding, the risk for postpartum infection may be higher in women with previas. In some cases, hemorrhage or infection makes a hysterectomy necessary, thus ending the woman's fertility forever. Some sources even recommend a prophylactic cesarean hysterectomy as a precaution, especially if an accreta is also suspected. Multiple prior cesareans increase the chance that a hysterectomy may be needed.

Because the placenta (the source of oxygen and food for the baby) often begins to pull away from the lower uterine segment as pregnancy progresses, the baby in a previa pregnancy is endangered.  It often must be born prematurely and as a result, may need care in the Neonatal Intensive Care Unit (NICU).

Some studies (but not all) show an increase in the rate of Intrauterine Growth Retardation (IUGR) in babies of previa pregnancies. And the rate of perinatal mortality is three to four times higher in a previa pregnancy.  However, many babies of a previa pregnancy do just fine.

If you are diagnosed with a previa, complete pelvic rest will be prescribed (no sex, nothing in the vagina, no pelvic exams, etc.).  Bed rest is common, or at least restrictions from vigorous activity.

Some women with significant bleeding episodes are hospitalized until the baby is delivered, whereas others can be monitored as outpatients. Medicine to prevent premature labor and steroids to mature the baby's lungs early may be given if early delivery looks likely.

The optimal delivery time for women with a complete previa is difficult to know. Providers seek to find a balance between the risk of a severe hemorrhage in the mother versus increased problems in the baby from prematurity. A substantial number of complete previas are delivered before 34 weeks because of significant bleeding episodes during pregnancy. However, most previas are able to go longer.

A recent review recommended a delivery around 36-37 weeks in women with complete previa who are not experiencing severe bleeding episodes. Another review recommended delivery at 36 weeks (2 days after administration of steroids for the baby's lungs). However, RCOG (the British version of ACOG) states that women with uncomplicated cases of placenta previa can wait until 38-39 weeks. A lot depends on the circumstances of each individual case and the practices of attending physicians.

Because some studies have found an increased risk for perinatal mortality in deliveries after 37 weeks, the reality in most hospitals these days is that women with complete previas are usually delivered before term and must therefore deal with prematurity issues.

With significant previas, it is important to be in a hospital that specializes in high-risk deliveries so that a specialized team of surgeons, anesthesiologists, and neonatologists are nearby at all times, as well as the capability for major blood transfusions.  The mother needs to be ready for the possibility that a hysterectomy may become necessary.

Although most women with previas will have reasonably good outcomes, previa is definitely a high-risk condition that deserves careful monitoring and a thorough plan for optimizing outcomes.

Placenta Previa and Prior Cesareans

So why is a woman with a prior cesarean at greater risk for a previa?

The answer seems to be related to the damage done to the uterus from the surgery.

Placenta Previa develops when the uterine lining has been damaged somehow and the fertilized egg implants near this damaged area.

As one resource says:

It is hypothesized to be related to abnormal vascularisation of the endometrium caused by scarring or atrophy from previous trauma, surgery, or infection. These factors may reduce differential growth of lower segment, resulting in less upward shift in placental position as pregnancy advances.

Risk factors for developing Placenta Previa include the mother's age, prior cesareans, smoking or drug use, high number of prior pregnancies, closely-spaced pregnancies, prior uterine surgery, pregnancy with multiples, congenital anomalies (birth defects), assisted reproduction technology (assisted fertilization), endometriosis, and prior D&C procedures.

Although multiple risk factors are at work with Placenta Previa, it is clear that cesareans are one of the strongest risk factors.

Even only one prior cesarean raises the risk for previa significantly.  One large study found:

The rate of placenta previa at second birth for women with vaginal first births was 4.4 per 1000 births, compared to 8.7 per 1000 births for women with CS at first birth.

Another study (Getahun 2006) found that the incidence of previa was higher (0.63%) in women whose first birth was by cesarean than in women whose first birth was vaginal (0.38%).

The risk for previa is even higher with multiple prior cesareans.  As Getahun 2006 concluded:

There is a dose-response pattern in the risk of previa, with increasing number of prior cesarean deliveries.

A research review (Ananth 1997) looked at four studies that were able to stratify the relative risk of previa by number of prior cesareans. The relative risks were:

• 4.5 for one prior cesarean
• 7.4 for two prior cesareans
• 6.5 for three prior cesareans
• 44.9 for four or more prior cesareans

But what does that mean in actual numerical risk?  Most studies only show relative risk, but a few studies do have some hard numbers by number of prior cesareans.  For example, Clark (1985) found the following incidence of previa:

• unscarred uterus = 0.26% previa
• 1 c/s = 0.65% previa
• 2 c/s = 1.8% previa
• 3 c/s = 3.0% previa
• 4+c/s = 10.0% previa

Of course, exact numerical risk varies from study to study.  To 1995 found a previa incidence of:

• 0.75% in women with no prior cesareans
• 1.22% in women with one prior cesarean
• 2.11% in women with two or more prior cesareans

In Juntunen 2004, the previa rate was 0.5% in the general population, but was 5.4% among with four or more prior cesareans. Obviously, the exact rate depends on the study, but the trend is clear.  The more cesareans you have had, the greater your risk for developing previa. 

Although parity (number of prior pregnancies) and number of prior cesareans are both risk factors for previa, they interact to increase the risk even more. In Gilliam 2002, a woman who had 4+ pregnancies but only one cesarean had 1.72x the risk for previa, but a woman who had 4+ pregnancies and 4+ cesareans had 8.76x the risk for previa.

And when a previa is present, a history of multiple prior cesareans increases the risk for poor maternal outcome significantly, including transfusion, hysterectomy, operative injury, coagulopathy, venous thromboembolism, pulmonary edema, or death.

This points out the importance of VBAC access and avoiding multiple repeat cesareans whenever possible.

Unfortunately, that's the exact opposite of the trend in obstetrics these days.

My "Previa" Story

As many readers of this blog know, I had two cesareans and then two VBACs with my children.  What I haven't shared is that I had a previa scare with my third.

In that pregnancy, my placenta implanted in the front of the uterus (anterior), down low and near the scar, although we didn't know it at first. I chose not to have an early ultrasound, so it was not until my ultrasound near the end of the second trimester that we discovered that my placenta was anterior.

Anterior placentas are notorious for making it hard to hear the baby's heartbeat at first. That led to one midwife telling me (in a very callous way) that I had obviously miscarried the pregnancy. Fortunately, a different midwife was later able to find the baby's heartbeat and let me know that the pregnancy was still viable.  But it was an angst-filled time until we were able to know that for sure.

If we'd had an early ultrasound, I might have been able to confirm more easily that the pregnancy was still there despite the anterior placenta blocking the sound of the heartbeat, but we also would have experienced a big scare about placenta previa. That anterior placenta's location over my scars would have caused a lot of worry and panic to us all. By delaying the ultrasound till later, the placenta had "moved up" and we knew that neither previa nor accreta was present.

Although it's always a woman's choice whether or not to have prenatal testing, it may be prudent to consider at least one ultrasound to check placentation in women with a history of cesareans or other uterine instrumentation.

Prenatal testing always comes with pros and cons, but remember, some previas and accretas are not symptomatic before birth, and outcomes are improved if these conditions are discovered before birth.  Therefore, the more cesareans you have had, the more you might want to consider an ultrasound for placental placement. Such testing is never compulsory, mind, but it is probably strongly worth considering in this situation.

However, too many women with prior cesareans are subjected to unnecessary worry and additional testing by early ultrasounds that show a low placenta near the scar. Research shows that 90-95% of previas diagnosed by the second trimester will resolve by term.

So although an ultrasound to check placental placement is a prudent thing to consider in women with prior cesareans, women might want to consider waiting until later in pregnancy to do so unless there is bleeding or other issues that necessitate earlier testing.

Summary

Cesareans are not good or bad in and of themselves. Sometimes they can be life-saving, sometimes they are prudent, sometimes they are a choice. But the cesarean rate in many areas of the world is quite high, and this comes with consequences.

One of the major public health implications of a high cesarean rate is placental complications in subsequent pregnancies after the cesarean. Of these placental issues, Placenta Previa is the most common.

The incidence of Placenta Previa is generally cited in most sources these days as about 1 in 200 to 1 in 250 over the whole pregnant population (0.4 - 0.5%).

However, some earlier studies cite an incidence of between 0.2% to 0.5%. One meta-analysis from the 1990s states:

An examination for trends over time in the incidence of placenta previa revealed that the incidence of this disorder was almost similar until the mid-1980s (1966 to 1974: incidence was 0.36%; 1975 to 1984, 0.37%), but the incidence was 0.48% among studies conducted between 1985 and 1995.

Some studies now place the incidence between 0.5% and 1.5%. However, the prevalence varies greatly from study to study and area to area.  Much depends on the characteristics of the population being studied.

An increase in older mothers, an increased use of D&Cs, increased fertility treatments, and the huge increase in cesarean rates may explain the increased rate of previas in recent years. Yet it's important to note that of these influences, the high cesarean rate may be the most modifiable risk factor. 

The main risk of previa is significant bleeding issues with the placenta as the pregnancy progresses, and especially when the cervix begins to thin and dilate. Previa is associated with a significant risk for severe hemorrhage in the mother and may necessitate blood transfusions or hysterectomy. Although rare, sometimes the mother even dies, especially in third world countries.

In the baby, previa is associated with increased rates of prematurity, respiratory distress, NICU care, and congenital anomalies. The perinatal mortality rate is significantly higher in pregnancies complicated by previa.

When previa occurs, the more prior cesareans a woman has had, the worse her chances for a "morbidly adherent" placenta (an accreta), as well as for major maternal morbidity (hemorrhage, transfusions, blood clot, pulmonary edema, operative injury, hysterectomy, or death).

And the risk doesn't end there. A woman is at higher risk for another previa in future pregnancies after a first previa pregnancy, as well as for another premature birth (even with subsequent normal placentation).

In other words, lower the rate of unnecessary primary and repeat cesareans, and you may prevent quite a number of maternal hysterectomies, severe hemorrhages, premature babies, and perinatal deaths from previa down the road.

Clearly, Placenta Previa is a major potential complication of pregnancies after a prior cesarean. As the authors of one meta-analysis on previa and prior cesareans concluded:

This study provides yet another reason for reducing the rate of primary cesarean delivery and for advocating vaginal birth for women with prior cesarean delivery.

Care providers and hospitals, are you listening?


References

General Information on Placenta Previa

• http://www.nlm.nih.gov/medlineplus/ency/article/000900.htm
• http://www.ncbi.nlm.nih.gov/pubmed/17346497
• http://pregnancy.about.com/cs/placentaprevia/a/previa.htm
• http://www.patient.co.uk/doctor/placenta-praevia
• http://en.wikipedia.org/wiki/Placenta_praevia
• http://www.mayoclinic.com/health/placenta-previa/DS00588
• http://www.ncbi.nlm.nih.gov/pubmed/17346497
• http://www.obfocus.com/high-risk/placentaprevia.htm
• http://www.rcog.org.uk/files/rcog-corp/GTG27PlacentaPraeviaJanuary2011.pdf
• http://www.rcog.org.uk/womens-health/clinical-guidance/placenta-praevia-and-placenta-praevia-accreta-diagnosis-and-manageme
• http://americanpregnancy.org/pregnancycomplications/placentaprevia.html
• http://www.placentaprevia.org/

Resources

• Sidelines - support group for women with high-risk pregnancies, especially those on bedrest
• Coping with Bedrest - information from maternal-fetal medicine specialists about coping with bed rest proactively and staying sane
• Coping with Prematurity - links to organizations and books about dealing with preemies
• Miracle Babies - organization to support families with premature babies in the NICU
• International Cesarean Awareness Network (ICAN) - support for women who have experienced a cesarean or who will need a planned cesarean
• Solace For Mothers - support group for women who have experienced a traumatic birth
• www.tabs.org.nz – TABS (Trauma And Birth Stress support group)
• www.birthtraumaassociation.org.uk – info on PTSD after childbirth
• www.ptsdafterchildbirth.org – info on PTSD after childbirth
• www.emdria.org - Eye Movement Desensitization and Reprocessing International Association
• http://www.angelfire.com/moon2/jkluchar1995/my_emdr.html - information on the use of EMDR (Eye Movement Desensitization and Reprocessing) in treating PTSD
• http://health.groups.yahoo.com/group/ptsdafterchildbirth/ - support group for PTSD after birth
• http://www.mothering.com/community/forum/list/502 - forum to provide a place for healing spiritually, physically and mentally after birth as well as in preparation of birth or pregnancy

Placenta Previa Incidence Trends

Aust N Z J Obstet Gynaecol. 2012 Oct;52(5):483-6. doi: 10.1111/j.1479-828X.2012.01470.x. Epub 2012 Aug 2. Trends and recurrence of placenta praevia: a population-based study. Roberts CL, Algert CS, Warrendorf J, Olive EC, Morris JM, Ford JB. PMID: 22862285

We determined recent trends and recurrence rates of placenta praevia in 790,366 deliveries in NSW. From 2001 to 2009, the rate of placenta praevia increased by 26%, from 0. 69% to 0. 87% (trend P < 0.001). The placenta praevia recurrence rate in a second birth was 4.8%. Two-thirds of the increase in placenta praevia was accounted for by trends in known risk factors, and the unexplained portion may reflect changes in unidentified risk factors or in the threshold for placenta praevia diagnosis.

Placenta Previa Adverse Outcomes

Arch Gynecol Obstet. 2011 Jul;284(1):47-51. doi: 10.1007/s00404-010-1598-7. Epub 2010 Jul 22. Critical analysis of risk factors and outcome of placenta previa. Rosenberg T, Pariente G, Sergienko R, Wiznitzer A, Sheiner E. PMID: 20652281

...RESULTS: During the study period, there were 185,476 deliveries, of which, 0.42% were complicated with placenta previa. Using a multivariable analysis with backward elimination, the following risk factors were independently associated with placenta previa: infertility treatments (OR 1.97; 95% CI 1.45-2.66; P < 0.001), prior cesarean delivery (CD; OR 1.76; 95% CI 1.48-2.09; P < 0.001) and advanced maternal age (OR 1.08; 95% CI 1.07-1.09; P < 0.001). Placenta previa was significantly associated with adverse outcomes such as peripartum hysterectomy (5.3 vs. 0.04%; P < 0.001), previous episode of second trimester bleeding (3.9 vs. 0.05%; P < 0.001), blood transfusion (21.9 vs. 1.2%; P < 0.001), maternal sepsis (0.4 vs. 0.02%; P < 0.001), vasa previa (0.5 vs. 0.1%; P < 0.001), malpresentation (19.8 vs. 5.4%; P < 0.001), postpartum hemorrhage (1.4 vs. 0.5%; P = 0.001) and placenta accreta (3.0 vs. 1.3%; P < 0.001). Placenta previa was significantly associated with adverse perinatal outcomes such as higher rates of perinatal mortality (6.6 vs. 1.3%; P < 0.001), an Apgar score <7 after 1 and 5 min (25.3 vs. 5.9%; P < 0.001, and 7.1 vs. 2.6%, P < 0.001, respectively), congenital malformations (11.5 vs. 5.1%; P < 0.001) and intrauterine growth restriction (3.6 vs. 2.1%; P = 0.003). CONCLUSIONS: Infertility treatments, prior cesarean section, and advanced maternal age are independent risk factors for placenta previa. An increase in the incidence of these risk factors probably contributes to a rise in the number of pregnancies complicated with placenta previa and its association with adverse maternal and perinatal outcomes. Careful surveillance of these risk factors is recommended with timely delivery in order to reduce the associated complications.

Obstet Gynecol. 2007 Dec;110(6):1249-55. Pregnancy outcomes for women with placenta previa in relation to the number of prior cesarean deliveries. Grobman WA, Gersnoviez R, Landon MB, Spong CY, Leveno KJ, Rouse DJ, Varner MW, Moawad AH, Caritis SN, Harper M, Wapner RJ,Sorokin Y, Miodovnik M, Carpenter M, O'Sullivan MJ, Sibai BM, Langer O, Thorp JM, Ramin SM, Mercer BM; National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. PMID: 18055717

...METHODS: Women with a placenta previa and a singleton gestation were identified in a concurrently collected database of cesarean deliveries performed at 19 academic centers during a 4-year period. Maternal and perinatal outcomes were analyzed after stratifying by the number of cesarean deliveries before the index pregnancy. RESULTS:...Multiple measures of maternal morbidity (eg, coagulopathy, hysterectomy, pulmonary edema) increased in frequency as the number of prior cesarean deliveries rose. Even one prior cesarean delivery was sufficient to increase the risk of an adverse maternal outcome (a composite of transfusion, hysterectomy, operative injury, coagulopathy, venous thromboembolism, pulmonary edema, or death) from 15% to 23%, which corresponded, in multivariable analysis, to an adjusted odds ratio of 1.9 (95% confidence interval 1.2-2.9)...CONCLUSION: Among women with a placenta previa, an increasing number of prior cesarean deliveries is associated with increasing maternal, but not perinatal, morbidity.

Am J Obstet Gynecol. 2003 May;188(5):1299-304. The effect of placenta previa on neonatal mortality: a population-based study in the United States, 1989 through 1997. Ananth CV, Smulian JC, Vintzileos AM. PMID: 12748502

...STUDY DESIGN: A retrospective cohort study was performed of live births in the United States (1989-1991 and 1995-1997) that used the national linked birth/infant death records from 22,368,235 singleton pregnancies...RESULTS: Placenta previa was recorded in 2.8 per 1000 live births (n = 61,711). Neonatal mortality rate was 10.7 with previa, compared with 2.5 per 1,000 among other pregnancies (relative risk, 4.3; 95% confidence interval, 4.0,4.8). At 28 to 36 weeks, babies born to women with placenta previa weighed, on average, 210 g lower than babies born to women without placenta previa (P <.001)...CONCLUSION: The risk of neonatal mortality was higher for babies born to women with placenta previa than for babies born to women without placenta previa who were delivered at > or =37 weeks of gestation. Pregnancies that are diagnosed with placenta previa must be monitored carefully, especially as they approach term.

Obstet Gynecol. 1999 Apr;93(4):541-4. Neonatal outcomes with placenta previa. Crane JM, van den Hof MC, Dodds L, Armson BA, Liston R. PMID: 10214830

...METHODS: This was a population-based, retrospective cohort study involving all singleton deliveries in Nova Scotia from 1988 to 1995...RESULTS: Among 92,983 pregnancies delivered during the study period, 305 cases of placenta previa were identified (0.33%). After controlling for potential confounders, neonatal complications significantly associated with placenta previa included major congenital anomalies (odds ratio [OR] 2.48), respiratory distress syndrome (OR 4.94), and anemia (OR 2.65). The perinatal mortality rate associated with placenta previa was 2.30% (compared with 0.78% in controls) and was explained by gestational age at delivery, occurrence of congenital anomalies, and maternal age. Although there was a higher rate of preterm births in the placenta previa group (46.56% versus 7.27%), there was no difference in birth weights between groups after controlling for gestational age at delivery. CONCLUSION: Neonatal complications of placenta previa included preterm birth, congenital anomalies, respiratory distress syndrome, and anemia. There was no increased occurrence of fetal growth restriction.

Am J Obstet Gynecol. 2003 May;188(5):1305-9. Placenta previa: neonatal death after live births in the United States. Salihu HM, Li Q, Rouse DJ, Alexander GR. PMID: 12748503

...DESIGN: This was a population-based retrospective cohort study of 1997 United States singleton live births...RESULTS: Of 3,773,369 live births, 9656 were complicated by placenta previa (2.6 cases per 1000). Among cases of placenta previa, 114 neonatal deaths occurred (11.8 per 1000) versus 14951 (4 per 1000) among non-placenta previa neonates (P <.0001). The adjusted relative risk of death was three times higher among placenta previa neonates (hazard ratio, 3.06; 95% CI, 2.40-3.94). Placenta previa-related death was mediated through preterm delivery rather than small for gestational age. CONCLUSION:Placenta previa triples the rate of neonatal mortality, which is mediated mainly through preterm birth.

Placenta Previa and Prior Cesarean

BMC Pregnancy Childbirth. 2011 Nov 21;11:95. doi: 10.1186/1471-2393-11-95. Risk of placenta previa in second birth after first birth cesarean section: a population-based study and meta-analysis. Gurol-Urganci I, Cromwell DA, Edozien LC, Smith GC, Onwere C, Mahmood TA, Templeton A, van der Meulen JH. PMID: 22103697

...METHODS: Retrospective cohort study of 399,674 women who gave birth to a singleton first and second baby between April 2000 and February 2009 in England...RESULTS: The rate of placenta previa at second birth for women with vaginal first births was 4.4 per 1000 births, compared to 8.7 per 1000 births for women with CS at first birth. After adjustment, CS at first birth remained associated with an increased risk of placenta previa (odds ratio = 1.60; 95% CI 1.44 to 1.76)....

Am J Obstet Gynecol. 1997 Nov;177(5):1071-8. The association of placenta previa with history of cesarean delivery and abortion: a metaanalysis. Ananth CV, Smulian JC, Vintzileos AM. PMID: 9396896

...RESULTS:...The tabulation of 36 studies identified a total of 3.7 million pregnant women, of whom 13,992 patients were diagnosed with placenta previa. The reported incidence of placenta previa ranged between 0.28% and 2.0%, or approximately 1 in 200 deliveries. Women with at least one prior cesarean delivery were 2.6 (95% confidence interval 2.3 to 3.0) times at greater risk for development of placenta previa in a subsequent pregnancy...Four studies, encompassing 170,640 pregnant women, provided data on the number of previous cesarean deliveries. These studies showed a dose-response pattern for the risk of previa on the basis of the number of prior cesarean deliveries. Relative risks were 4.5 (95% confidence interval 3.6 to 5.5) for one, 7.4 (95% confidence interval 7.1 to 7.7) for two, 6.5 (95% confidence interval 3.6 to 11.6) for three, and 44.9 (95% confidence interval 13.5 to 149.5) for four or more prior cesarean deliveries. ...CONCLUSION: There is a strong association between having a previous cesarean delivery, spontaneous or induced abortion, and the subsequent development of placenta previa. The risk increases with number of prior cesarean deliveries. Pregnant women with a history of cesarean delivery or abortion must be regarded as high risk for placenta previa and must be monitored carefully. This study provides yet another reason for reducing the rate of primary cesarean delivery and for advocating vaginal birth for women with prior cesarean delivery.

Obstet Gynecol. 2002 Jun;99(6):976-80. The likelihood of placenta previa with greater number of cesarean deliveries and higher parity. Gilliam M, Rosenberg D, Davis F. PMID: 12052584

...METHODS: A hospital-based, case-control study was conducted in which 316 multiparous women with placenta previa were identified. Controls consisted of 2051 multiparous women with spontaneous vaginal deliveries...RESULTS: Women with a prior cesarean delivery were more likely to have a placenta previa than those without (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.21, 2.08). The likelihood of placenta previa increased as both parity and number of cesarean deliveries increased. Thus, the adjusted OR for a primiparous woman with one cesarean delivery was 1.28 (95% CI 0.82, 1.99). For a woman who has four or more deliveries with only a single cesarean delivery, the OR increases to 1.72 (95% CI 1.12, 2.64). This trend continues with greater parity and a greater number of cesarean deliveries such that the likelihood of placenta previa for a woman with parity greater than four and greater than four cesarean deliveries was OR 8.76 (95% CI 1.58, 48.53). CONCLUSION: This study supports the association between prior cesarean delivery and placenta previa and demonstrates that the joint effect of parity and prior cesarean delivery is greater than that of either variable alone.

Obstet Gynecol. 2006 Apr;107(4):771-8. Previous cesarean delivery and risks of placenta previa and placental abruption. Getahun D, Oyelese Y, Salihu HM, Ananth CV. PMID: 16582111

...METHODS: A retrospective cohort study of first 2 (n = 156,475) and first 3 (n = 31,102) consecutive singleton pregnancies using the 1989-1997 Missouri longitudinally linked data were performed...RESULTS: Rates of previa and abruption were 4.4 (n = 694) and 7.9 (n = 1,243) per 1,000 births, respectively. The pregnancy after a cesarean delivery was associated with increased risk of previa (0.63%) compared with a vaginal delivery (0.38%, RR 1.5, 95% confidence interval [CI] 1.3-1.8). Cesarean delivery in the first and second births conferred a two-fold increased risk of previa in the third pregnancy (RR 2.0, 95% CI 1.3-3.0) compared with first two vaginal deliveries...A second pregnancy within a year after a cesarean delivery was associated with increased risks of previa (RR 1.7, 95% CI 0.9-3.1) and abruption (RR 1.5, 95% CI 1.1-2.3). CONCLUSION: A cesarean first birth is associated with increased risks of previa and abruption in the second pregnancy. There is a dose-response pattern in the risk of previa, with increasing number of prior cesarean deliveries. A short interpregnancy interval is associated with increased risks of previa and abruption.

Obstet Gynecol. 2001 May;97(5 Pt 1):765-9. First-birth cesarean and placental abruption or previa at second birth (1). Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. PMID: 11339931

...METHODS: We conducted a population-based, retrospective cohort analysis using data from the Washington State Birth Events Record Database. The study cohort included all primiparas who gave birth to live singleton infants in nonfederal short-stay hospitals from January 1, 1987, through December 31, 1996, and who had second singleton births during the same period (n = 96,975)...RESULTS: Among our study cohort, abruptio placentae complicated 11.5 per 1000 and placenta previa 5.2 per 1000 singleton deliveries at second births. In logistic regression analyses adjusted for maternal age, women with first-birth cesareans had significantly increased risk of abruptio placentae (OR 1.3, 95% CI 1.1, 1.5), and placenta previa (OR 1.4, 95% CI 1.1, 1.6) at second births, compared with women with prior vaginal deliveries. CONCLUSION: We found moderately increased risk of placental abruption and previa as a long-term effect of prior cesarean delivery on second births.

BJOG. 2007 May;114(5):609-13. Epub 2007 Mar 12. Association of caesarean delivery for first birth with placenta praevia and placental abruption in second pregnancy. Yang Q, Wen SW, Oppenheimer L, Chen XK, Black D, Gao J, Walker MC. PMID: 17355267

...POPULATION: A total of 5,146,742 singleton second pregnancies were available for the final analysis after excluding missing information...RESULTS: Placenta praevia was recorded in 4.4 per 1000 second-birth singletons whose first births delivered by caesarean section and 2.7 per 1000 second-birth singletons whose first births delivered vaginally...The adjusted odds ratio (95% CIs) of previous caesarean section for placenta praevia in following second pregnancies was 1.47 (1.41, 1.52) after controlling for maternal age, race, education, marital status, maternal drinking and smoking during pregnancy, adequacy of prenatal care, and fetal gender...CONCLUSION: Caesarean section for first live birth is associated with a 47% increased risk of placenta praevia and 40% increased risk of placental abruption in second pregnancy with a singleton.

Obstet Gynecol. 1985 Jul;66(1):89-92. Placenta previa/accreta and prior cesarean section. Clark SL, Koonings PP, Phelan JP. PMID: 4011075

...the records of all patients presenting to labor and delivery with the diagnosis of placenta previa between 1977 and 1983 were examined. Of a total of 97,799 patients, 292 (0.3%) had a placenta previa. The risk of placenta previa was 0.26% with an unscarred uterus and increased almost linearly with the number of prior cesarean sections to 10% in patients with four or more. The effect of advancing age and parity on the incidence of placenta previa was much less dramatic. Patients presenting with a placenta previa and an unscarred uterus had a 5% risk of clinical placenta accreta. With a placenta previa and one previous cesarean section, the risk of placenta accreta was 24%; this risk continued to increase to 67% (two of three) with a placenta previa and four or more cesarean sections....

Int J Gynaecol Obstet. 1995 Oct;51(1):25-31. Placenta previa and previous cesarean section. To WW, Leung WC. PMID: 8582514

...METHOD: The records of all patients delivered with the diagnosis of placenta previa during the 10-year period from 1984 to 1993 were reviewed. RESULTS: From a total of 50,485 deliveries, 421 (0.83%) had placenta previa, 43 (10.2%) of whom had a history of previous cesarean section. The incidence of placenta previa was significantly increased in those with a previous cesarean section (1.31%) compared with those with an unscarred uterus (0.75%) (R.R. 1.64). This risk increased as the number of previous cesarean sections increased (R.R. 1.53 for one previous section, 2.63 for two or more). The incidence of an anterior placenta previa and placenta accreta was significantly increased in those with previous cesarean scars. The incidence of placenta accreta was 1.18% among patients with placenta previa, 80% being in patients with previous cesarean section. The relative risk for placenta accreta in patients with placenta previa was 35 times higher in those with a previous cesarean section than in those with an unscarred uterus. CONCLUSION: The association of previous cesarean section with placenta previa and placenta previa accreta is confirmed. Patients with an antepartum diagnosis of placenta previa who have had a previous cesarean section should be considered at high risk for developing placenta accreta.