Objective To describe the management and outcomes of placenta accreta, increta, and percreta in the UK. Design A population‐based descriptive study using the UK Obstetric Surveillance System (UKOSS). Setting All 221 UK hospitals with obstetrician‐led maternity units. Population All women diagnosed with placenta accreta, increta, and percreta in the UK between May 2010 and April 2011. Methods Prospective case identification through the monthly mailing of UKOSS. Main outcome measures Median estimated blood loss, transfusion requirements. Results A cohort of 134 women were identified with placenta accreta, increta, or percreta: 50% (66/133) were suspected to have this condition antenatally. In women with a final diagnosis of placenta increta or percreta, antenatal diagnosis was associated with reduced levels of haemorrhage (median estimated blood loss 2750 versus 6100 ml, P = 0.008) and a reduced need for blood transfusion (59 versus 94%, P = 0.014), possibly because antenatally diagnosed women were more likely to have preventative therapies for haemorrhage (74 versus 52%, P = 0.007), and were less likely to have an attempt made to remove their placenta (59 versus 93%, P < 0.001). Making no attempt to remove any of the placenta, in an attempt to conserve the uterus or prior to hysterectomy, was associated with reduced levels of haemorrhage (median estimated blood loss 1750 versus 3700 ml, P = 0.001) and a reduced need for blood transfusion (57 versus 86%, P < 0.001). Conclusions Women with placenta accreta, increta, or percreta who have no attempt to remove any of their placenta, with the aim of conserving their uterus, or prior to hysterectomy, have reduced levels of haemorrhage and a reduced need for blood transfusion, supporting the recommendation of this practice.

ObjectivesTo describe the characteristics, management and outcomes of women giving birth at advanced maternal age (≥48 years).DesignPopulation‐based cohort study using the UK Obstetric Surveillance System (UKOSS).SettingAll UK hospitals with obstetrician‐led maternity units.PopulationWomen delivering at advanced maternal age (≥48 years) in the UK between July 2013 and June 2014 (n = 233) and 454 comparison women.MethodsCohort and comparison group identification through the UKOSS monthly mailing.Main outcome measuresPregnancy complications.ResultsOlder women were more likely than comparison women to be overweight (33% versus 23%, P = 0.0011) or obese (23% versus 19%, P = 0.0318), nulliparous (53% versus 44%, P = 0.0299), have pre‐existing medical conditions (44% versus 28%, P < 0.0001), a multiple pregnancy (18% versus 2%, P < 0.0001), and conceived following assisted conception (78% versus 4%, P < 0.0001). Older women appeared more likely than comparison women to have pregnancy complications including gestational hypertensive disorders, gestational diabetes, postpartum haemorrhage, caesarean delivery, iatrogenic and spontaneous preterm delivery on univariable analysis and after adjustment for demographic and medical factors. However, adjustment for multiple pregnancy or use of assisted conception attenuated most effects, with significant associations remaining only with gestational diabetes (adjusted odds ratio [aOR] 4.81, 95% CI 1.93–12.00), caesarean delivery (aOR 2.78, 95% CI 1.44–5.37) and admission to an intensive care unit (aOR 33.53, 95% CI 2.73–412.24).ConclusionsWomen giving birth at advanced maternal age have higher risks of a range of pregnancy complications. Many of the increased risks appear to be explained by multiple pregnancy or use of assisted conception.Tweetable abstractThe pregnancy complications in women giving birth aged 48 or over are mostly explained by multiple pregnancy.

Objective To describe the incidence, risk factors, management and outcomes of amniotic-fluid embolism (AFE) over time.Design A population-based cohort and nested case-control study using the UK Obstetric Surveillance System (UKOSS).Setting All UK hospitals with obstetrician-led maternity units.Population All women diagnosed with AFE in the UK between February 2005 and January 2014 (n = 120) and 3839 control women.Methods Prospective case and control identification through UKOSS monthly mailing.Main outcome measures Amniotic-fluid embolism, maternal death or permanent neurological injury.Results The total and fatal incidence of AFE, estimated as 1.7 and 0.3 per 100 000, respectively, showed no significant temporal trend over the study period and there was no notable temporal change in risk factors for AFE. Twenty-three women died (case fatality 19%) and seven (7%) of the surviving women had permanent neurological injury. Women who died or had permanent neurological injury were more likely to present with cardiac arrest (83% versus 33%, P < 0.001), be from ethnicminority groups (adjusted odds ratio [OR] 2.85, 95% confidence interval [95% CI] 1.02-8.00), have had a hysterectomy (unadjusted OR 2.49, 95% CI 1.02-6.06), had a shorter time interval between the AFE event and when the hysterectomy was performed (median interval 77 minutes versus 248 minutes, P = 0.0315), and were less likely to receive cryoprecipitate (unadjusted OR 0.30, 95% CI 0.11-0.80).Conclusion There is no evidence of a temporal change in the incidence of or risk factors for AFE. Further investigation is needed to establish whether earlier treatments can reverse the cascade of deterioration leading to severe outcomes.Keywords Amniotic-fluid embolism, maternal morbidity, maternal mortality.Please cite this paper as: Fitzpatrick KE, Tuffnell D, Kurinczuk JJ, Knight M. Incidence, risk factors, management and outcomes of amniotic-fluid embolism: a population-based cohort and nested case-control study. BJOG 2016;123:100-109.

(BJOG 2016;123:100–109) Amniotic fluid embolism (AFE) is a rare disorder, but it remains a leading cause of maternal mortality in high-income countries. The typical presentation includes sudden cardiovascular collapse without an obvious etiology, respiratory distress and disseminated intravascular coagulation. Because AFE is a rare condition with its diagnosis being one of exclusion, it is difficult to obtain reliable data about the disease. The goal of this study was to report on the incidence, risk factors, management, and outcomes of AFE based on recent data.

Objective To estimate the incidence and describe the risk factors, management and outcomes of placenta accreta/increta/percreta. Methods A national population-based case-control study was undertaken using the UK Obstetric Surveillance System between May 2010-April 2011. Participants comprised 134 women with placenta accreta/increta/percreta and 258 controls. Results The estimated incidence of placenta accreta/increta/percreta was 1.7 per 10,000 maternities (95%CI 1.4-2.0). Older women had raised odds of having placenta accreta/increta/percreta (aOR 3.3, 95%CI 1.4-7.6 in women 35+yrs) as did women who had a previous caesarean (aOR 14.2, 95%CI 5.5-36.5), other previous uterine surgery (aOR 2.8, 95%CI 1.1-7.7), placenta praevia diagnosed antepartum (aOR 69.5, 95%CI 17.7–273.0) and an IVF pregnancy (aOR 43.8, 95%CI 2.7–699.5). Placenta accreta/increta/percreta was suspected in 50% of women antenatally. Of the 27(20%) women who had their complete placenta left in situ, 15(56%) had a hysterectomy. Of the 107(80%) women who did not have their complete placenta left in situ, 63(59%) had a hysterectomy. Overall, 61% had other therapies to treat haemorrhage prior to hysterectomy and 5% had methotrexate used. There were no maternal deaths, but women with placenta accreta/increta/percreta were more likely to deliver preterm (aOR 16.9, 95%CI 7.5–38.1) and 70% were admitted to ITU/HDU. Conclusions Placenta accreta/increta/percreta is uncommon but associated with preterm delivery and significant maternal morbidity. This study confirms previously reported associations including with prior caesarean delivery; the association with IVF pregnancy requires confirmation in other studies. Treatment varied and further investigation of the clinical effectiveness of different management strategies is warranted.