Placenta accreta

Placenta percreta evaluated by MRI: correlation with maternal morbidity

PURPOSE

The purpose of this study was to evaluate the capability of MRI in depicting the topography of placenta percreta (PP) and to further explore the correlation between invasion topography and maternal outcomes.

METHODS

55 patients with histologically or surgically confirmed PP were included in this retrospective study. Two senior radiologists evaluated the topography of PP based on MR images: the invasion topography was depicted as S1, S2, parametrial, bladder, and cervical invasion. The correlation between invasion topography and maternal outcomes was analyzed using Chi-square statistic.

RESULTS

MRI showed high sensitivity and specificity in delineating the invasion topography of PP (ranging from 87.5 to 100%). MRI had 100% specificity for predicting the parametrial, bladder, and cervical invasion. The rate of cesarean hysterectomy, ureteral injuries and ICU administration, and the amount of blood transfusions in PP with S2 invasion were higher than S1 invasion (P < 0.05). In addition, all patients with bladder invasion (8/8) received partial bladder resection by urologists. All the patients with S2 parametrial invasion (12/12) or cervical invasion (9/9) underwent cesarean hysterectomy.

CONCLUSION

MRI was capable in predicting the invasion topography of PP patients. Moreover, PP patients with S2, parametrial, bladder or cervical invasion had more severe maternal morbidity.

Hemorrhagic morbidity in placenta accreta spectrum with and without placenta previa

PURPOSE

The incidence of placenta accreta spectrum (PAS; pathologic diagnosis of placenta accreta, increta or percreta) continues to rise in the USA. The purpose of this study is to compare the hemorrhagic morbidity associated with PAS with and without a placenta previa.

METHODS

This was a retrospective cohort study of 105 deliveries from 1997 to 2017 with histologically confirmed PAS comparing outcomes in women with and without a coexisting placenta previa. We used the Wilcoxon rank sum test to compare continuous data and Chi-square or Fisher's exact test for categorical data. We also performed log-binomial regression to calculate risk ratios adjusted for depth of invasion (aRR) and 95% confidence intervals (CI).

RESULTS

We identified 105 pregnancies with PAS. Antenatal diagnosis of PAS was higher in women with coexisting placenta previa (72.3%) than those without (6.9%, p < 0.001). Women with coexisting placenta previa had greater median estimated blood loss and more units of packed red blood cells transfused (both p ≤ 0.03). Women with placenta previa were more likely to undergo a hysterectomy (RR 2.7; 95% CI 1.8-3.8) and be admitted to the intensive care unit (aRR 3.3; 95% CI 1.1-9.6).

CONCLUSIONS

Among women with PAS, those with a coexisting placenta previa experienced greater hemorrhagic morbidity compared to those without. In addition, PAS without placenta previa typically was not diagnosed prior to delivery. This study further supports the recommendation for multi-disciplinary planning and assurance of resources for pregnancies complicated by PAS. In addition, our results highlight the need for mobilization of resources for those pregnancies where PAS is not diagnosed until delivery.

Placenta Accreta in a Woman with Childhood Uterine Irradiation: A Case Report and Literature Review

The pregnancies of childhood cancer survivors who have received uterine irradiation are associated with a high risk of several obstetrical complications, including placenta accreta. The present case was a 26-year-old pregnant woman with a history of myelodysplastic syndrome treated with umbilical cord blood transplantation following chemotherapy and total body irradiation at the age of 10. Despite every possible measure to prevent preterm labor, uterine contractions became uncontrollable and a female infant weighing 892 g was vaginally delivered at 27⁺⁴ weeks of gestation. Under the postpartum ultrasonographic diagnosis of placenta accreta, we selected to leave the placenta in situ. Although emergency bilateral uterine artery embolization was required, complete resorption of the residual placenta was accomplished on the 115^th day postpartum. Our experience highlighted the following points. (1) The expectant management of placenta accreta arising in an irradiated uterus may not only fulfill fertility preservation, but may also reduce possible risks associated with cesarean hysterectomy. (2) Due to extreme thinning of and a poor blood supply to the myometrium, reaching an antepartum diagnosis of placenta accreta in an irradiated uterus is difficult. (3) The recurrence of placenta accreta in subsequent pregnancies needs to be considered after successful preservation of the uterus.

Increased levels of serum IL-33 is associated with adverse maternal outcomes in placenta previa accreta

PURPOSE

IL-33 is associated with invasion, proliferation, and metastasis of various cancers. The trophoblastic cells of placenta previa accreta (PPA) invade into the myometrium in a similar way to the invasion of cancers. We studied the role of IL-33 in PPA and also aimed to investigate its relation with adverse maternal outcome in this placental disorder.

METHODS

A total of 87 pregnant patients were enrolled in this prospective case-control study [27 with PPA, 30 with placenta previa totalis (PPT; nonadherent placenta previa), and 30 controls]. IL-33 and IL-6 levels were studied in maternal serum at late preterm gestation weeks. Multiple logistic regression analyses analyzed the risk factors which are associated with PPA and adverse maternal outcomes. Adjusted odds ratios and 95% confidence intervals were also calculated. Enzyme-linked immunosorbent assay (ELISA) method was used to determine maternal serum IL-33 and IL-6 levels.

RESULTS

Serum IL-33 levels were significantly higher in PPA patients when compared with both nonadherent PPT and the control groups (p = .011, p = .010). Serum IL-6 and neutrophil/lymphocyte ratio levels were significantly higher than the control group's (p = .045, p = .028). IL-33 levels and history of previous cesarean section were found to be significantly associated with PPA (OR: 1.039, 95% CI: 1.004-1.075; p = .030 and OR: 0.067, 95% CI: 0.014-0.309, p = .001, respectively). Serum IL-33 levels were positively correlated with previous cesarean section history in PPA. Increased maternal serum IL-33 levels were found to be independently associated with a cesarean hysterectomy and massive transfusion in PPA patients (OR: 1.098, 95% CI: 0.998-1.207; p = .049 and OR: 1.162 95% CI: 1.010-1.337; p = .036).

CONCLUSION

Increased levels of maternal serum IL-33 and history of previous cesarean section were found to be significantly associated with PPA, and also increased maternal serum IL-33 levels were related to cesarean hysterectomy and massive blood transfusion in PPA. We suggest that IL-33 may have a role in abnormal placental invasion.

Assessing the multidisciplinary team approaches to placenta accreta spectrum across five institutions within the University of California fetal Consortium (UCfC)

PURPOSE

To describe the multidisciplinary approaches to placenta accreta spectrum (PAS) across five tertiary care centers that comprise the University of California fetal Consortium (UCfC) and to identify potential best practices.

MATERIALS AND METHODS

Retrospective review of all cases of pathologically confirmed invasive placenta delivered from 2009 to 2014 at UCfC. Differences in intraoperative management and outcomes based on prenatal suspicion were compared. Interventions assessed included ureteral stent use, intravascular balloon use, anesthetic type, gynecologic oncology (Gyn Onc) involvement, and cell saver use. Intervention variation by institution was also assessed. Analyses were adjusted for final pathologic diagnosis. Chi-square, Fisher's exact, Student's t-test, and Mann-Whitney's U-test were used as appropriate. Binary logistic regression and multivariable linear regression were used to adjust for confounders.

RESULTS

One hundred and fifty-one cases of pathologically confirmed invasive placenta were identified, of which 82% (123) were suspected prenatally. There was no correlation between the degree of invasion on prenatal imaging and use of each intervention. Ureteral stents were placed in 33% (41) of cases and did not reduce GU injury. Intravascular balloons were placed in 29% (36) of cases and were associated with shorter OR time (161 versus 236 min, p < .01) and lower estimated blood loss (EBL) (1800 versus 2500 ml, p < .01). General endotracheal anesthesia (GETA) was used in 70% (86). EBL did not differ between GETA and regional anesthesia. Gyn Onc was involved in 58% (71) of cases and EBL adjusted for final pathology was reduced with their involvement (2200 versus 2250 ml, p = .02) while OR time and intraoperative complications did not differ. Cell saver was used in 20% (24) and was associated with longer OR time (296 versus 200 min, p < .01). Use of cell saver was not associated with a difference in EBL or number of units of packed red cells transfused. All analyses were adjusted for pathologic severity of invasion.

CONCLUSIONS

Intravascular interventions such as uterine artery balloons and the inclusion of Gynecologic Oncologists as part of a multidisciplinary approach to treating PAS reduce EBL. Additionally, the placement of intravascular balloons may reduce OR time. No significant differences were seen in outcomes when comparing the use of ureteral stents, general anesthesia, or institutions. A team of experienced operators with a standard approach may be more significant than specific practices.

Triple P with T-shaped lower segment suture; an effective novel alternative to hysterectomy in morbidly adherent anterior placenta previa

PURPOSE

To evaluate the efficacy and safety of the Triple-P procedure as a conservative method in women with morbidly adherent placenta (MAP).

MATERIALS AND METHODS

A prospective trial conducted on 20 women performing elective cesarean sections (CS) at 37 weeks for anterior placenta previa accreta or increta. All women were young aged with low parity and previous CS deliveries. Triple-P procedure involved delivery of the fetus through a uterine incision placed above the upper border of the placenta, bilateral uterine arteries ligation immediately after delivery of the fetus followed by placental nonseparation and myometrial excision with reconstruction of the uterine wall in a T-shaped manner. The study outcome measures included duration of surgery, amount of intra and postoperative blood loss, Percentage of hemoglobin (Hb %) reduction, the need to perform hysterectomy and postoperative complications.

RESULTS

Mean duration of surgery was 58 ± 1.8 min, mean intraoperative blood loss was 1.3 ± 0.3 l, mean postoperative blood loss was 180 ± 94 ml and mean Hb % reduction was 1.5 ± 0.1 g/dl. Only one case necessitated hysterectomy for severe bleeding.

CONCLUSION

Triple-P procedure is a novel effective weapon that can replace hysterectomy in suitable women with MAP, especially in young patients with low parity.

The compliance with a patient-safety bundle for management of placenta accreta spectrum†

OBJECTIVE

Our objective was to evaluate the compliance with a patient-safety bundle for placenta accreta spectrum (PAS) by comparing the implementation of the components of the patient-safety bundle in the pre- and post-protocol time periods as a quality improvement project.

STUDY DESIGN

This is a before and after retrospective cohort study as a quality improvement report examining compliance with a multidisciplinary delivery approach for patients with suspected PAS between 2007 and 2018. This bundle involved a multidisciplinary approach with maternal-fetal medicine, gynecologic oncology, intervention radiology, obstetric anesthesia, neonatology, and blood bank. The primary outcome was incorporation of all six of the components of the bundle into a PAS procedure: (1) betamethasone, (2) gynecologic oncology intraoperative consult, (3) preoperative balloon catheters, (4) cell salvage technology in the operating room, (5) vertical skin incision, and (6) fundal or high transverse hysterotomy. Demographic, delivery, and patient outcome data were also collected.

RESULTS

There were 39 patients included in the study, 17 were pre-protocol and 22 were post-protocol. Patients were more likely to have a PAS suspected in the antenatal period during post protocol period (23.5 versus 90.9%, p < .0001), as well as having a placenta previa (35.3 versus 81.8%, p = .003), and receive betamethasone prior to delivery (23.5 versus 86.3%, p < .0001). Patients were delivered at an earlier gestational age in post protocol period (36.8 ± 2.52 versus 33.87 ± 2.4, p = .001). The primary outcome, adherence to all components of the patient-safety bundle, was more likely to occur in the post protocol period (0 versus 40.9%, p < .0001). Maternal and postoperative outcomes were not significantly different between groups.

CONCLUSIONS

We have successfully implemented a patient-safety bundle for PAS and have standardized the execution of multidisciplinary management for PAS at our institution.

Endometrium-free uterine closure technique and abnormal placental implantation in subsequent pregnancies

BACKGROUND

Abnormal placentation can result in massive hemorrhage, which is the leading cause of severe maternal morbidities and mortality in its management. Over the past 50 years, the incidence of placenta previa (PP), abnormal implantation of the placenta, and cesarean scar pregnancy have continued to rise. This coincides with the well-documented parallel rise in the rate of cesarean deliveries, the performance of multiple repeat cesarean deliveries and the adoption of newer uterine closure techniques. However, no studies have examined the role of uterine closure techniques in abnormal placentation in women with a history of a prior cesarean delivery.

OBJECTIVE

To assess the practicality of one specific uterine closure technique at cesarean delivery and to evaluate the relationship between previous cesarean delivery and subsequent development of abnormal implantation of the placenta, as well as neonatal and other perioperative outcomes after receiving an endometrium-free uterine closure technique.

METHODS

This retrospective observational study considered cesarean deliveries (n = 727) and subsequent vaginal births after cesarean delivery (n = 109) among total deliveries (n = 4496) performed in private practice at NYU Langone Health from 1985 to 2015. All cesarean deliveries were performed using the endometrium-free uterine closure technique. The primary outcome was the incidence of abnormal implantation of the placenta in subsequent pregnancies. The secondary outcomes were neonatal and maternal complications, specifically postoperative hemoglobin and hematocrit concentration losses. The association between independent variables and outcomes were evaluated using mixed-effect regression models.

RESULTS

In contrast to published data, independent of the number of repeat cesarean deliveries, the presence of 26 (3.1%) PPs and of 366 (43.8%) anterior placentas, there were no patients with abnormal implantation of the placenta in a cesarean scar, neither prenatally nor at delivery. Maternal hemorrhage, postoperative and neonatal complications did not reach clinical significance. The statistical analysis revealed that, when compared with women who had fewer repeat cesarean deliveries using endometrium-free uterine closure technique, those with the most had a lesser risk of forming PP and less blood loss, as measured by both hematocrit and hemoglobin evaluation.

CONCLUSION

In this retrospective cohort study, the exclusion of the endometrium during the endometrium-free uterine closure technique was associated with fewer placental abnormalities in subsequent pregnancies and reduced life-threatening maternal morbidity for future cesarean deliveries.

US and MR imaging findings to detect placental adhesion spectrum (PAS) in patients with placenta previa: a comparative systematic study

PURPOSE

To compare the performance US and MR in identifying placental adhesion spectrum (PAS) in placenta previa (PP) and to establish a potential method of image interpretation.

METHODS

US and MR examinations of 51 patients with PP were selected. The presence of imaging signs commonly used to detect PAS was assessed. Penalized logistic regression was performed considering histology as standard of reference; only signs statistically significant (p < 0.05) were considered for ROC and multivariate analysis. The probability of PAS according to the presence of US and/or MR signs was then assessed.

RESULTS

At univariate analysis, loss of retroplacental clear space, myometrial thinning (MT) and placenta lacunar spaces on US, intraplacental dark bands (IDBs), focal interruption of myometrial border (FIMB) and abnormal vascularity (AV) on MR were statistically significant (p < 0.01). Three diagnostic methods for PAS were then developed for both US and MR when at least one (Method 1), two (Method 2) or three (Method 3) imaging signs occurred, respectively. Method 2 for MR showed a significantly (p < 0.05) higher accuracy (91%) compared to the other methods. When MR IDBs and AV as well as IDBs and FIMB were present in combination with US MT the probability of PAS increased from 75 to 90% and from 80 to 91%, respectively.

CONCLUSION

MR demonstrated a higher diagnostic accuracy than US to detect PAS. However, since the combination of MR and US signs could improve the probability to detect PAS, a complementary diagnostic role of these techniques could be considered.

Maternal outcomes in unexpected placenta accreta spectrum disorders: single-center experience with a multidisciplinary team

OBJECTIVE

In a 2015 Maternal-Fetal Medicine Units Network study, only half of placenta accreta spectrum cases were suspected before delivery, and the outcomes in the anticipated cases were paradoxically poorer than in unanticipated placenta accreta spectrum cases. This was possibly because the antenatally suspected cases were of greater severity. We sought to compare the outcomes of expected vs unexpected placenta accreta spectrum in a single large US center with multidisciplinary management protocol.

STUDY DESIGN

This was a retrospective cohort study carried out between Jan. 1, 2011, and June 30, 2018, of all histology-proven placenta accreta spectrum deliveries in an academic referral center. Patients diagnosed at the time of delivery were cases (unexpected placenta accreta spectrum), and those who were antentally diagnosed were controls (expected placenta accreta spectrume). The primary and secondary outcomes were the estimated blood loss and the number of red blood cell units transfused, respectively. Variables are reported as median and interquartile range or number (percentage). Analyses were made using appropriate parametric and nonparametric tests.

RESULTS

Fifty-four of the 243 patients (22.2%) were in the unexpected placenta accreta spectrum group. Patients in the expected placenta accreta spectrum group had a higher rate of previous cesarean delivery (170 of 189 [89.9%] vs 35 of 54 [64.8%]; P < .001) and placenta previa (135 [74.6%] vs 19 [37.3%]; P < .001). There was a higher proportion of increta/percreta in expected placenta accreta spectrum vs unexpected placenta accreta spectrum (125 [66.1%] vs 9 [16.7%], P < .001). Both primary outcomes were higher in the unexpected placenta accreta spectrum group (estimated blood loss, 2.4 L [1.4-3] vs 1.7 L [1.2-3], P = .04; red blood cell units, 4 [1-6] vs 2 [0-5], P = .03).

CONCLUSION

Our data contradict the Maternal-Fetal Medicine Units results and instead show better outcomes in the expected placenta accreta spectrum group, despite a high proportion of women with more severe placental invasion. We attribute this to our multidisciplinary approach and ongoing process improvement in the management of expected cases. The presence of an experienced team appears to be a more important determinant of maternal morbidity in placenta accreta spectrum than the depth of placental invasion.

Management of patients with placenta accreta spectrum disorders who underwent pregnancy terminations in the second trimester: A retrospective study

PURPOSE

To analyse the management of patients with placenta accreta spectrum (PAS) disorders who underwent 2^nd trimester pregnancy terminations.

METHOD

The records of patients with PAS disorders who underwent 2^nd trimester pregnancy terminations were collected and analysed.

RESULTS

Twenty-eight patients were included; 8 (28.6%) patients received prenatal diagnoses and 20 (71.4%) patients received postnatal diagnoses. In the prenatal diagnosis group, scheduling hysterotomy and placenta removal were performed in 5 patients with complete placenta previa and previous caesarean delivery without hysterectomy or postpartum haemorrhage, and medical termination was performed in 3 patients, 2 of whom retained the placenta in situ. In the postnatal diagnosis group, the placenta remained in situ in 11 patients, and in 13 (46.4%) patients overall, adjuvant treatments were applied to the patients, and the abnormally implanted placenta was passed 43.5 (range: 7-102) days after termination. A complication associated with the placenta left in situ included intrauterine infection in one case. Uterus preservation was achieved in all the patients.

CONCLUSIONS

For patients with PAS disorders with complete placenta previa and previous caesarean delivery, hysterotomy is a safe choice for terminating a 2^nd trimester pregnancy. When it is impossible to manually remove the placenta, leaving the placenta in situ with the administration of adjuvant treatment is a good choice for uterus preservation.

Imaging findings of cesarean delivery complications: cesarean scar disease and much more

In the last years, there has been a significant increase in the number of cesarean deliveries and, with it, of the number of complications following the procedure. They can be divided into early and late ones. We will illustrate herein the most common complications following cesarean section to help radiologists to recognize them. To familiarize with these various pathologic conditions is crucial to alert referring clinicians for a prompt and appropriate maternal and fetal management. Special attention will be given to the cesarean scar defect (CSD), the most common but also the most unknown of such conditions. Although often asymptomatic, a severe CSD represents a predisposing factor for subsequent complications especially in future pregnancies.

Cervical length should be measured for women with placenta previa: cohort study

OBJECTIVES

To study the relevance between cervical length (CL) and different maternal/neonatal outcomes in pregnancies complicated with placenta previa/accreta.

METHODS

Three hundred twenty-eight women, who had medically free singleton live pregnancies with the diagnosis of placenta previa and/or accreta, were included and divided regarding their CL into two groups. Threatened preterm labor, maternal tocolysis, multiple gestations, polyhydramnios, ruptured fetal membranes, fetal complications, history of cervical conization, and the presence of cervical cerclage were the exclusion criteria. Demographic data, obstetric history, as well as, the courses of the complicated pregnancies were collected and statistically analyzed.

RESULTS

The short CL group had significantly less distance between the placenta and the internal cervical os (p-value < .001) Also, they showed more ultrasound parameters of complete placenta previa with anterior location (p-value < .001 and .003 respectively) and placental adherence (21.8 versus 41.1%). Women with short cervix had significantly higher rates of preterm birth, antepartum hemorrhage, emergency cesarean sections, intraoperative estimated blood loss, massive bleeding, prevalence of placental adherence and cesarean hysterectomy (p-value < .001 for the entire outcomes). Multivariable binary logistic regression showed that CL (<30 mm) was a significant independent risk factor in prediction of severe hemorrhage, PTB, emergency CS, placental adherence, cesarean hysterectomy (p-value < .001 for adverse maternal outcomes) and low cord Ph (p-value = .016).

CONCLUSIONS

Assessment of the cervical length could be a crucial step in the work-up and decision making for pregnancies complicated with abnormally situated and/or adherent placenta as it is strongly associated with a wide range of maternal and neonatal morbidities.

Texture analysis of placental MRI: can it aid in the prenatal diagnosis of placenta accreta spectrum?

PURPOSE

To determine if texture analysis can differentiate placenta accreta spectrum (PAS) from normal placenta on MRI.

METHODS

We performed retrospective image analysis of 80 patients, comprised of 46 patients with PAS and 34 patients without PAS. Histopathology was used as the reference standard. Sagittal single shot fast spin echo T2-weighted MRI sequences acquired from a single institution were analyzed. Placental heterogeneity was quantified using in-house software on a Matlab platform, including the standard deviation of pixel intensity, coefficient of variation, gray-level co-occurrence matrices (GLCM), histogram-oriented gradients (HOG), and fractal analysis with box sizes from 2 to 512. Two-tailed unpaired Student's t test was used with statistical significance of p < 0.05.

RESULTS

PAS was associated with higher values for standard deviation of pixel intensity and fractal analysis at every box size. Fractal analysis at box sizes 256 (p = 0.011) and 32 (p = 0.021), and standard deviation of pixel intensity (p = 0.023) were the most statistically significant. Fractal values at box size 256 for PAS was 0.13 versus 0.090 for patients without PAS, while standard deviation of pixel intensity was 3.7 for PAS versus 2.5 for patients without PAS. No statistically significant association between PAS and GLCM, coefficient of variation, and HOG was found.

CONCLUSION

Statistically significant differences were found between normal and abnormal groups using standard deviation of pixel intensity and fractal analysis.

A novel approach to reduce blood loss in patients with placenta accreta spectrum disorder

OBJECTIVE

Cesarean hysterectomy for the treatment of placenta accreta spectrum (PAS) disorders has the potential to be associated with significant blood loss, massive transfusion, and operative morbidity. Two major contributors to blood loss are the hysterotomy and the bladder dissection. We introduce a new surgical technique and hypothesize that developing the hysterotomy with a linear cutter and mobilization of the bladder using a vessel sealing system (VSS) before clamping uterine arteries will lead to a total reduction in blood loss and transfusion rates.

MATERIALS AND METHODS

This was a case series, which presents clinical outcomes according to our described surgical technique. The following surgical outcomes were collected: operation time (minutes), estimated blood loss (EBL), intraoperative complications, need for reoperation before discharge, and transfusion rates. Our surgical technique utilizes a linear cutter to create a bloodless hysterotomy and a VSS to dissect the vesicouterine tissue. The VSS cauterizes and transects the small vesicouterine and placental-vesical vascular anastomoses that are prone to bleeding. Once the bladder is mobilized below the level of the cervix, the uterine arteries are ligated to complete the key components of the hysterectomy.

RESULTS

Of the 23 cases, the median EBL was 1500 cubic centimeters and patients received a median of 1 unit of packed red blood cells. Eleven of the 23 cases did not require any blood transfusion and no patients required massive transfusion. The EBL did not differ between procedures that were performed emergently versus scheduled and it also did not differ between patients that had placenta increta versus placenta percreta, as diagnosed by histopathology.

CONCLUSION

Use of a linear cutter and closure of the lower anastomosis with VSS prior to clamping uterine artery during cesarean hysterectomy can significantly reduce blood loss and transfusion rates. This technique is applicable in emergent and nonemergent settings as well as for the most challenging procedures complicated by placenta percreta.

Neuraxial Anesthesia During Cesarean Delivery for Placenta Previa With Suspected Morbidly Adherent Placenta: A Retrospective Analysis

BACKGROUND

General anesthesia (GA) is often selected for cesarean deliveries (CD) with placenta previa and suspected morbidly adherent placenta (MAP) due to increased risk of hemorrhage and hysterectomy. We reviewed maternal outcomes and risk factors for conversion to GA in a cohort of patients undergoing CD and hysterectomy under neuraxial anesthesia (NA).

METHODS

We performed a single-center, retrospective cohort study of parturients undergoing nonemergent CD for placenta previa with suspected MAP from 1997 to 2015. Patients were classified according to whether they received GA, NA, or intraoperative conversion from NA to GA. The primary outcome measure was postoperative acuity, defined as the need for intensive care unit admission, arterial embolization, reoperation, or ongoing transfusion with ≥3 units packed red blood cells. We additionally identified variables positively associated with intraoperative conversion from NA to GA during hysterectomy. Confounding was controlled with logistic regression models.

RESULTS

Of 129 patients undergoing nonemergent CD for placenta previa with suspected MAP, 122 (95%) received NA as the primary anesthetic. NA was selected in the majority of patients with a body mass index ≥40 kg/m (9 of 10, 90%), a history of ≥3 prior CDs (18 of 20, 90%), suspected placenta increta or percreta (29 of 35, 83%), and Mallampati classification ≥3 (19 of 21, 90%). Of 72 patients with NA at the time of delivery who required hysterectomy, 15 (21%) required conversion to GA intraoperatively. Converted patients had a higher rate of major packed red blood cell transfusion (60% vs 25%; P = .01), with similar rates of massive transfusion (9% vs 7%; P = 1.0). Converted patients also had a higher incidence of postoperative acuity (47% vs 4%; P < .0001), including 5 intensive care unit admissions for airway management after large-volume resuscitation. After adjusting for multiple confounders, the only independent predictors of conversion among hysterectomy patients were longer surgical duration (adjusted odds ratio 1.54, 95% CI, 1.01-2.42) and a history of ≥3 prior CDs (adjusted odds ratio, 6.45; 95% CI, 1.12-45.03).

CONCLUSIONS

NA was applied to and successfully used in the majority of patients with suspected MAP. Our findings support selective conversion to GA during hysterectomy in these patients, focusing on those with the highest levels of surgical complexity.

Prenatal ultrasound staging system for placenta accreta spectrum disorders

OBJECTIVES

To develop a prenatal ultrasound staging system for placenta accreta spectrum (PAS) disorders in women with placenta previa and to evaluate its association with surgical outcome, placental invasion and the clinical staging system for PAS disorders proposed by the International Federation of Gynecology and Obstetrics (FIGO).

METHODS

This was a secondary retrospective analysis of prospectively collected data from women with placenta previa. We classified women according to the following staging system for PAS disorders, based upon the presence of ultrasound signs of PAS in women with placenta previa: PAS0, placenta previa with no ultrasound signs of invasion or with placental lacunae but no evidence of abnormal uterus-bladder interface; PAS1, presence of at least two of placental lacunae, loss of the clear zone or bladder wall interruption; PAS2, PAS1 plus uterovescical hypervascularity; PAS3, PAS1 or PAS2 plus evidence of increased vascularity in the inferior part of the lower uterine segment potentially extending into the parametrial region. We explored whether this ultrasound staging system correlates with surgical outcome (estimated blood loss (EBL, mL), units of packed red blood cells (PRBC), fresh frozen plasma (FFP) and platelets (PLT) transfused, operation time (min), surgical complications defined as the occurrence of any damage to the bladder, ureters or bowel, length of hospital stay (days) and admission to intensive care unit (ICU)) and depth of placental invasion. The correlation between the present ultrasound staging system and the clinical grading system proposed by FIGO was assessed. Prenatal and surgical management were not based on the proposed prenatal ultrasound staging system. Linear and multiple regression models were used.

RESULTS

Two-hundred and fifty-nine women were included in the analysis. Mean EBL was 516 ± 151 mL in women with PAS0, 609 ± 146 mL in those with PAS1, 950 ± 190 mL in those with PAS2 and 1323 ± 533 mL in those with PAS3, and increased significantly with increasing severity of PAS ultrasound stage. Mean units of PRBC transfused were 0.05 ± 0.21 in PAS0, 0.10 ± 0.45 in PAS1, 1.19 ± 1.11 in PAS2 and 4.48 ± 2.06 in PAS3, and increased significantly with PAS stage. Similarly, there was a progressive increase in the mean units of FFP transfused from PAS1 to PAS3 (0.0 ± 0.0 in PAS1, 0.25 ± 1.0 in PAS2 and 3.63 ± 2.67 in PAS3). Women presenting with PAS3 on ultrasound had significantly more units of PLT transfused (2.37 ± 2.40) compared with those with PAS0 (0.03 ± 0.18), PAS1 (0.0 ± 0.0) or PAS2 (0.0 ± 0.0). Mean operation time was longer in women with PAS3 (184 ± 32 min) compared with those with PAS1 (153 ± 38 min) or PAS2 (161 ± 28 min). Similarly, women with PAS3 had longer hospital stay (7.4 ± 2.1 days) compared with those with PAS0 (3.4 ± 0.6 days), PAS1 (6.4 ± 1.3 days) or PAS2 (5.9 ± 0.8 days). On linear regression analysis, after adjusting for all potential confounders, higher PAS stage was associated independently with a significant increase in EBL (314 (95% CI, 230-399) mL per one-stage increase; P < 0.001), units of PRBC transfused (1.74 (95% CI, 1.33-2.15) per one-stage increase; P < 0.001), units of FFP transfused (1.19 (95% CI, 0.61-1.77) per one-stage increase; P < 0.001), units of PLT transfused (1.03 (95% CI, 0.59-1.47) per one-stage increase; P < 0.001), operation time (38.8 (95% CI, 31.6-46.1) min per one-stage increase; P < 0.001) and length of hospital stay (0.83 (95% CI, 0.46-1.27) days per one-stage increase; P < 0.001). On logistic regression analysis, increased severity of PAS was associated independently with surgical complications (odds ratio, 3.14 (95% CI, 1.36-7.25); P = 0.007), while only PAS3 was associated with admission to the ICU (P < 0.001). All women with PAS0 on ultrasound were classified as having Grade-1 PAS disorder according to the FIGO grading system. Conversely, of the women presenting with PAS1 on ultrasound, 64.1% (95% CI, 48.4-77.3%) were classified as having Grade-3, while 35.9% (95% CI, 22.7-51.6%) were classified as having Grade-4 PAS disorder, according to the FIGO grading system. All women with PAS2 were categorized as having Grade-5 and all those with PAS3 as having Grade-6 PAS disorder according to the FIGO system.

CONCLUSION

Ultrasound staging of PAS disorders is feasible and correlates with surgical outcome, depth of invasion and the FIGO clinical grading system. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Role of interventional radiology in pregnancy complicated by placenta accreta spectrum disorder: systematic review and meta-analysis

OBJECTIVE

To evaluate the potential benefit of interventional radiology (IR) in improving the outcome of women undergoing surgery for a placenta accreta spectrum (PAS) disorder.

METHODS

MEDLINE, EMBASE and CINAHL databases were searched for studies comparing outcomes of women with a prenatal diagnosis of PAS who underwent an IR procedure before surgery vs those who did not, using a robust collection of terms relating to PAS. The primary outcome was intraoperative estimated blood loss (EBL). Secondary outcomes were the number of transfused units of packed red blood cells (PRBC), fresh frozen plasma (FFP), platelets and cryoprecipitate, operation time, length of hospital stay, EBL ≥ 2.5 L, PRBC transfused ≥ 5 units, surgical complications, bladder or ureteral injury, relaparotomy, infection, disseminated intravascular coagulation, and complications related to endovascular catheter placement. Only studies reporting on the incidence of, or the mean difference in, the observed outcomes in women affected by a PAS disorder who had vs those who did not have an IR procedure before surgery were considered for inclusion. All outcomes were explored in the overall population of women with a prenatally diagnosed PAS disorder and in those undergoing hysterectomy. Quality assessment of each included study was performed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. The GRADE methodology was used to assess the quality of the body of retrieved evidence.

RESULTS

Fifteen studies (958 women with PAS) were included. In women who underwent IR before surgery, compared with those who did not, mean EBL (mean difference (MD), -1.02 L; 95% CI, -1.60 to -0.43 L; P < 0.001) and the risk of EBL ≥ 2.5 L (odds ratio (OR), 0.18; 95% CI, 0.04-0.78; P = 0.02) were significantly lower. There was no significant difference between the two groups in the other outcomes explored. On subgroup analysis of pregnancies complicated by PAS undergoing hysterectomy, EBL (MD, -0.68 L; 95% CI, -1.24 to -0.12 L; P = 0.02) and the number of transfused FFP units (MD, -1.66; 95% CI, -2.71 to -0.61; P = 0.02) were significantly lower in women who had an endovascular IR procedure compared with controls. Furthermore, women undergoing IR had a significantly lower risk of EBL ≥ 2.5 L (OR, 0.10; 95% CI, 0.02-0.47; P = 0.004). Overall, complications related to the placement of an endovascular catheter occurred in 5.3% (95% CI, 2.6-8.9; I² , 65.3%) of pregnancies undergoing IR. Overall quality of evidence, as assessed by GRADE, was very low.

CONCLUSIONS

The current available data provide encouraging evidence that IR procedures may be associated with lower EBL and need for transfusion in pregnancies undergoing surgery for a PAS disorder. However, given the overall very low quality of the evidence, further large studies are needed in order to confirm the beneficial role of IR in improving the outcome of these women. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Conservative Management of Placenta Accreta Spectrum

The purpose of this review was to assist obstetricians and gynecologists in considering the most appropriate conservative treatment option to manage women with placenta accreta spectrum according to their individual need and local expertise of the heath care team. The issue is challenging, as the quality of evidence with regard to efficacy is poor, and is mainly based on retrospective studies with limited sample size.

The Placenta Accreta Spectrum: Epidemiology and Risk Factors

The placenta accreta spectrum has become an important contributor to severe maternal morbidity. The true incidence is difficult to ascertain, but likely falls near 1/1000 deliveries. This number seems to have increased along with the rate of risk factors. These include placenta previa, previous cesarean section, use of assisted reproductive technologies, uterine surgeries, and advanced maternal age. With increased uterine conservation, previous retained placenta or placenta accreta have become significant risk factors. Understanding placenta accreta spectrum risk factors facilitates patient identification and safe delivery planning. Patients considering elective uterine procedures or delayed childbirth should consider the impact on peripartum morbidity.

The Role of Centers of Excellence With Multidisciplinary Teams in the Management of Abnormal Invasive Placenta

Abnormal invasive placenta (AIP) causes significant maternal and perinatal morbidity and mortality. With the increasing incidence of cesarean delivery, this condition is dramatically more common in the last 20 years. Advances in grayscale and Doppler ultrasound have facilitated prenatal diagnosis of abnormal placentation to allow the development of multidisciplinary management plans. Outcomes are improved when delivery is accomplished in centers with multidisciplinary expertise and experience in the care of AIP. This article highlights the desired features for developing and managing a multidisciplinary team dedicated to the treatment of AIP in center of excellence.

Use of routine ureteral stents in cesarean hysterectomy for placenta accreta

Objective: To evaluate benefits of use of ureteral stents in association with cesarean hysterectomy in case of placenta accreta.Methods: This was a single center, cohort study. Clinical records of singleton pregnancies with placenta accreta who underwent cesarean hysterectomy were included in the study. For this study, pregnancies with diagnoses of placenta accreta, increta, or percreta were considered under the umbrella term of placenta accreta. For all women with placenta accreta, delivery was planned via cesarean hysterectomy at 34⁰-35⁶ weeks, without any attempt to remove the placenta. Reasons for earlier delivery included vaginal bleeding and spontaneous onset of labor. The primary outcome was the incidence of unintentional urinary tract injury. Outcomes were compared in a cohort of women who had planned the placement of ureteral stents and in those who did not.Results: Forty-four singleton gestations with confirmed placenta accreta at the time of cesarean hysterectomy were included in the study. Twenty-four (54.5%) of the included women had the placing of ureteral stents prior to cesarean, while 20 (45.5%) did not. At histological confirmation, most of them had placenta accreta (17/44, 38.6%), 14 placenta increta (31.8%), and 13 placenta percreta (29.6%). Urinary tract injuries occurred in eight cases (18.2%), six in the ureteral stents and two in the non-ureteral stents group (25 versus 10%; p = .21). All the injuries were bladder injuries, while no cases of ureteral injury were recorded. All injuries were recognized intraoperatively.Conclusion: In case of placenta accreta, the use of ureteral stents in association with cesarean hysterectomy does not reduce the risk of urinary tract injury.

Coagulopathy in surgical management of placenta accreta spectrum

BACKGROUND

One of the major complications of the placenta accreta spectrum (PAS) is the development of coagulopathy. The detection, prevention and prompt treatment of coagulopathy may be lifesaving.

OBJECTIVE

Our objective was to study selected factors associated with coagulopathy in the management of PAS by a well-established multidisciplinary team.

STUDY DESIGN

This is a retrospective review of all patients with pathologically proven PAS (including placenta accreta, increta or percreta) who underwent surgery by our multidisciplinary team between January 2011 and February 2017. Coagulopathy in this setting was defined as a platelet count of <100,000/mm³, international normalized ratio >1.5, and/or fibrinogen <300 mg/dL based on institutional protocols developed by our Division of Transfusion Medicine & Coagulation. The outcomes of those patients with and without coagulopathy were compared with appropriate adjustments. Receiver operating characteristics curves (ROCs) were constructed to assess the ability of select variables to discriminate between women with and without coagulopathy, and the area under the curves (AUCs) were calculated.

RESULTS

Of 123 singleton patients with PAS, 37 (30.1%; 95%CI 22.1-39.0) developed coagulopathy and 86 (69.9%; 95%CI 61.0-77.9) did not. Baseline patient demographic characteristics did not differ significantly between these groups. Estimated blood loss (median and Inter-quartile range) was 2100cc (1800, 400) and 1400 (1000, 2500) in the presence and absence of coagulopathy, respectively (P < 0.01). The overall number of units of red blood cells (RBC) transfused was greatest in the coagulopathy group [3 (2, 9) vs. 1 (0, 4); P < 0.01]. Univariate regression analysis confirmed the association between coagulopathy and (i) the number of units of RBC's transfused, and (ii) the estimated blood loss. ROC curves showed that an estimated blood loss ≥ 1500 mL had the best discriminating power. Depth and/or severity of placental invasion were not associated with coagulopathy in patients with PAS.

CONCLUSIONS

Coagulopathy in patients with PAS undergoing hysterectomy is strongly associated with blood loss and replacement. It may be prudent to establish protocols that aggressively monitor for, and treat, coagulopathy when EBL exceeds 1500 mL in such surgeries, prior to the development of clinical coagulopathy which if uncorrected may lead to massive blood loss.

Surgical Management of the Placenta Accreta Spectrum: An Institutional Experience

OBJECTIVE

The incidence of placenta accreta spectrum (PAS) has risen over the past decades, primarily in response to increasing Caesarean section rates. The surgical management of PAS is associated with significant morbidity, including hemorrhage and intensive care unit (ICU) admission. This study sought to evaluate the surgical outcomes of a PAS operative approach.

METHODS

A single-centre retrospective chart review of all Caesarean hysterectomies for PAS by an assigned surgeon over a 16-year period was performed. Surgical outcomes were described (Canadian Task Force Classification II-2).

RESULTS

The described surgical approach involves a midline skin incision, high midline hysterotomy, a rapid single-layer uterine closure with no placental removal attempt, constant cephalad uterine traction, and liberal choice of subtotal hysterectomy. A total of 47 patients were included: 19 (40.4%) with placenta accreta, 14 (29.8%) with placenta increta, and 14 (29.8%) with placenta percreta. Mean estimated blood loss was 1416 ± 699 mL, and mean operative time was 112 ± 49 minutes. Overall, 16 patients (34.0%) required blood transfusion, and 4 patients (8.5%) required ICU admission. The average hospitalization was 5.2 days, with no re-admission within 30 days. The use of internal iliac balloons did not result in a difference in blood loss or operative time (P > 0.05). Patients with placenta percreta had significantly more blood loss (P = 0.02) and longer operative time (P = 0.007) compared with those with placenta accreta and increta.

CONCLUSION

The current surgical model for planned Caesarean hysterectomy for PAS exhibits a low complication rate. Further research is needed for developing a standardized approach to the management of PAS.

A proposal for standardized magnetic resonance imaging (MRI) descriptors of abnormally invasive placenta (AIP) - From the International Society for AIP

Abnormally invasive placenta (AIP) is used to describe a placenta that does not separate naturally after delivery and cannot be extirpated without causing abnormally high blood loss. Recently, the use of a standardized terminology for descriptors of AIP signs seen on ultrasound has been prosed but to date no such unified descriptors have been developed for magnetic resonance imaging (MRI). The purpose of this paper is to propose a unified terminology based on a consensus opinion from the members of the International Society for AIP (IS-AIP) that include obstetricians, gynecologists, radiologists, pathologists, anesthesiologists and basic science researchers. We assume that using these standardized MRI descriptors for AIP will be useful for clinical use, education, teaching and future research projects, thus assumably improving care of patients with this condition. In addition, using a uniform terminology for AIP should become the first step of a standardized MRI report.

Vaginal Bleeding in Late Pregnancy

Bleeding in late-term pregnancy can present as an innocuous start to parturition or a catastrophic maternal-fetal hemorrhage masked by the physiologic adaptations of pregnancy. The emergency management of late-term bleeding can be challenging, especially when providing stabilizing care in a limited-resource environment. Early recognition of life-threatening vaginal bleeding, potential causes, and emergency management of maternal-fetal distress is reviewed. Maternal resuscitation with balanced versus targeted blood products replacement is presented for low-resource versus high-resource environments. Emergency department readiness for such a patient, in combination with appropriate consultation or transfer, is essential to the effective management of late-term vaginal bleeding.

Utilization and outcomes of massive transfusion protocols in women with and without invasive placentation

Objective: Our objective was to compare women with and without invasive placentation for whom the massive transfusion protocol (MTP) was activated. In addition, we evaluated the differences in clinical management and blood product utilization between the two groups and described the activation of MTP over time.Study design: This is a retrospective cohort study of women for whom the MTP was activated from January 2012 through July 2016. Two groups were compared, those with invasive placentation (accreta, increta, percreta) and those without.Results: We identified 87 women for whom the MTP was activated, the majority (62.1%) did not have invasive placentation. Women with invasive placentation were more likely to have had a prior cesarean delivery and placenta previa (both p < .001). Women with invasive placentation were more likely to undergo hysterectomy, experience more blood loss, and receive cell salvage (all p ≤ .04). Blood product utilization was similar between the two groups, with the exception of cell-salvage, which was more commonly used for women with invasive placentation. The proportion of deliveries necessitating MTP activation ranged from 1.4 to 2.6 per 1000 deliveries.Conclusion: Invasive placentation accounts for less than half of the cases complicated by activation of an MTP. Cases with invasive placentation were more likely to result in a vertical uterine and skin incision or a hysterectomy. With the exception of cell-salvage, blood product utilization was similar.

Abnormal placentation

The term "morbidly adherent placenta" has recently been introduced to describe the spectrum of disorders including placenta accreta, increta and percreta. Due to excessive invasion of the placenta into the uterus there is associated significant maternal morbidity and mortality. Most significant risk factors for morbidly adherent placenta include history of prior cesarean delivery as well as placenta previa in the current pregnancy. Ultrasound remains the gold standard for antenatal diagnosis, however, in recent years MRI has assisted in identifying complex parametrial involvement. Optimizing maternal and neonatal outcomes involves early prenatal diagnosis, a multi-disciplinary team-based approach, and referral to an experienced center.

Pre-clinical magnetic resonance imaging of retroplacental clear space throughout gestation

INTRODUCTION

Visualization of the retroplacental clear space (RPCS) may provide critical insight into the development of abnormally invasive placenta (AIP). In this pre-clinical study, we characterized the appearance of the RPCS on magnetic resonance imaging (MRI) during the second half of gestation using a liposomal gadolinium contrast agent (liposomal-Gd).

MATERIALS AND METHODS

Studies were performed in fifteen pregnant C57BL/6 mice at 10, 12, 14, 16, and 18 days of gestation. MRI was performed on a 1T permanent magnet scanner. Pre-contrast and post-contrast images were acquired using T1-weighted gradient-recalled echo (T1w-GRE) and T2-weighted fast spin echo (T2w-FSE) sequences. Animals were euthanized after imaging and feto-placental units harvested for histological examination. Visualization of the RPCS was scored by a maternal-fetal radiologist and quantified by measuring the contrast-to-noise ratio (CNR) on T1w images. Feto-placental features were segmented for analysis of volumetric changes during gestation.

RESULTS

Contrast-enhanced T1w images enabled the visualization of structural changes in placental development between days 10-18 of gestation. Although the placental margin on the fetal side was clearly visible at all time points, the RPCS was partially visible at day 10 of gestation, and clearly visible by day 12. Hematoxylin and eosin (H&E) staining of the placental tissue corroborated MRI findings of structural and morphological changes in the placenta.

CONCLUSIONS

Contrast-enhanced MR imaging using liposomal-Gd enabled adequate visualization of the retroplacental clear space starting at day 12 of gestation. The agent also enabled characterization of placental structure and morphological changes through gestation.

Two approaches for placenta accreta spectrum: B-lynch suture versus pelvic artery endovascular balloon

Purpose: Management of patients with placenta accreta spectrum (PAS) varies widely, and scarce data exist concerning its management. The current study compared two different surgical approaches in the management of PAS: the B-lynch approach (Group A) compared to the endovascular balloon catheters (Group B)Methods: A retrospective cohort study in two tertiary university-affiliated hospitals between the years 2004 and 2015. Elective cesarean section was planned at 35-37 weeks of gestation. One center utilized the B-lynch approach and the second utilized the endovascular balloon catheter approach.Results: The cesarean hysterectomy rate was significantly higher in the Group A approach compared to Group B (36.1 versus 29.2%, p = .00). The number of packed cells units administered during and postoperatively were higher in the Group A compared with Group B (p = .006 and .043, respectively). Overall, surgery length and hospitalization duration were shorter in patients who underwent cesarean hysterectomy compared with those who underwent uterine preservation (B-lynch or endovascular balloon catheters) (p = .000 and p = .004, respectively).Conclusions: The endovascular balloon technique seems to be a better option for uterine preservation due to less blood loss and higher postoperative hemoglobin level. Nevertheless, for those women who have completed their family planning, cesarean hysterectomy with the placenta left in situ is the safer and more suitable option.

Modified cesarean hysterectomy technique for management of cases of placenta increta and percreta at a tertiary referral hospital in Egypt

PURPOSE

To evaluate the effect of a modified type II radical hysterectomy on maternal morbidities and mortality in cases with abnormally invasive placenta (AIP).

METHODS

63 cases with AIP were managed at one of the largest referral centers in Egypt in a prospective study design. This technique entails devascularization of the uterus laterally on both sides and to clamp the uterus at the lowest possible point just below the level of the placenta while sparing the ureters.

RESULTS

The difference between pre- and post-operative hemoglobin was only about 1 gm/dl, and the mean blood loss was 1673 ± 958 ml. There was a significant drop in the post-operative need for blood and blood product replacement, packed red blood cells (p = 0.013), fresh red blood cells (p < 0.001), and plasma units (p = 0.012). Operative time (skin to skin) averaged 190 ± 58.2 min as the technique is slow and utilizes meticulous hemostatic steps. ICU admission was 4.8% with a mean total hospital stay of 8.6 ± 3.6 days. Histopathological examination revealed 58 cases of placenta increta and five percreta cases. We also had 16 bladder injuries (25.4%) and two ureteric injuries, and no maternal mortalities.

CONCLUSION

This technique reduces maternal morbidity and mortality while performing cesarean hysterectomy for cases with AIP.

The role of supracervical hysterectomy in reducing blood products requirement in the management of placenta accreta: a case-control study

Objective: While surgical management is the treatment of choice for abnormally invasive placenta, the role of supracervical hysterectomy in this setting is not well established. We aimed to compare supracervical versus total cesarean hysterectomy as a surgical option for abnormally invasive placenta.Methods: We carried out an 8-year retrospective case-control study. Six cases of a patient treated by total hysterectomy were matched and compared to 30 controls treated by supracervical hysterectomy. Matching of cases with controls was based on coexisting placenta previa, a number of previous cesarean sections, and age, with five controls per case. Cases and controls were comparable in placental invasion topography. We compared the operative approach in all histologically identified cases of abnormally invasive placenta.Results: Overall, 36 women with histologically proven abnormally invasive placenta were identified. Composite blood products morbidity was higher among total hysterectomy patients (p = .02). Freshly frozen plasma utilization was greater among total hysterectomy patients (p = .01). Median operative time (142 ± 48 versus 136 ± 58 minutes) and hospitalization time (8.9 ± 3.1 versus 7.3 ± 1.5 days) were comparable between those who underwent supracervical versus total hysterectomy (p > .05). No case of maternal or neonatal death was encountered.Conclusion: The favorable maternal and perinatal outcomes observed in our study, suggest that supracervical hysterectomy should be considered as the first-line approach in cases of abnormally invasive placenta managed operatively.

Clinical Diagnosis of Placenta Accreta and Clinicopathological Outcomes

OBJECTIVE

To investigate the association between the intraoperative diagnosis of placenta accreta at the time of cesarean hysterectomy and pathological diagnosis.

STUDY DESIGN

This is a retrospective cohort study of all patients undergoing cesarean hysterectomy for suspected placenta accreta from 2000 to 2016 at Barnes-Jewish Hospital. The primary outcome was the presence of invasive placentation on the pathology report. We estimated predictive characteristics of clinical diagnosis of placenta accreta using pathological diagnosis as the correct diagnosis.

RESULTS

There were 50 cesarean hysterectomies performed for suspected abnormal placentation from 2000 to 2016. Of these, 34 (68%) had a diagnosis of accreta preoperatively and 16 (32%) were diagnosed intraoperatively at the time of cesarean delivery. Two patients had no pathological evidence of invasion, corresponding to a false-positive rate of 4% (95% confidence interval [CI]: 0.5%, 13.8%) and a positive predictive value of 96% (95% CI: 86.3%, 99.5%). There were no differences in complications among patients diagnosed intraoperatively compared with those diagnosed preoperatively.

CONCLUSION

Most patients undergoing cesarean hysterectomy for placenta accreta do have this diagnosis confirmed on pathology. However, since the diagnosis of placenta accreta was made intraoperatively in nearly a third of cesarean hysterectomies, intraoperative vigilance is required as the need for cesarean hysterectomy may not be anticipated preoperatively.

New three-dimensional/four-dimensional volume rendering imaging software for detecting the abnormally invasive placenta

OBJECTIVE

This study aimed to determine the role of three-dimensional (3D)/four-dimensional (4D) volume rendering ultrasound (VRU) in the diagnosis of abnormally invasive placenta (AIP).

MATERIALS AND METHODS

Twelve consecutive patients strongly suspected of having AIP on the basis of conventional ultrasound (US) and clinical history performed between September 2016 and December 2016 in the main tertiary referral hospital in Surabaya, East Java were included in this prospective observational study. A Samsung WS 80A Elite US scanner with a 3D/4D "crystal vue" and "realistic vue" volume rendering mode was used to establish the diagnosis of AIP and evaluate the site, and depth of placental invasion. The VRU images were compared with the intraoperative findings.

RESULTS

Using this novel US technique, all cases of suspected AIP were subsequently confirmed during surgery. Importantly, the new US technique provided a correct diagnosis of the degree of invasion in 11 out of these 12 suspected AIP cases: 5/5 for placenta percreta, 3/3 for placenta increta, and 2/3 for placenta accreta; one patient was misdiagnosed in terms of the degree of placenta accreta, and one patient had normal implantation).

CONCLUSION

This new software of 3D/4D VRU represents a promising technique for the preoperative diagnosis and staging of AIP.

Screening for morbidly adherent placenta in early pregnancy

OBJECTIVE

To estimate the diagnostic accuracy of a two-stage strategy for early prediction of morbidly adherent placenta (MAP). In the first stage, at 11-13 weeks' gestation, women with low-lying placenta and history of uterine surgery are classified as being at high risk for MAP and, in the second stage, at 12-16 weeks, these high-risk pregnancies are assessed at a specialist MAP clinic.

METHODS

This was a prospective study in women having an ultrasound scan at 11-13 weeks' gestation as a part of routine pregnancy care. Women with low-lying placenta and a history of uterine surgery were followed up at a specialist MAP clinic at 12-16 weeks' gestation, 20-24 weeks and 28-34 weeks. At each visit to the MAP clinic, an ultrasound scan was carried out and the following features suggestive of MAP were recorded: non-visible Cesarean section scar; bladder wall interruption; thin retroplacental myometrium; presence of intraplacental lacunar spaces; presence of retroplacental arterial-trophoblastic blood flow; and irregular placental vascularization demonstrated by three-dimensional power Doppler.

RESULTS

Screening at 11-13 weeks was carried out in 22 604 singleton pregnancies, 1298 (6%) of which were considered to be at high risk of MAP because they had previous uterine surgery and low-lying placenta. At the MAP clinic at 12-16 weeks, the diagnosis of MAP was suspected in 14 cases and this was confirmed at delivery in 13. In the rest of the population, there were no cases of MAP.

CONCLUSION

Accurate prediction of MAP can be achieved by ultrasound examination at 12-16 weeks' gestation. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

A comprehensive severity score for the morbidly adherent placenta: combining ultrasound and magnetic resonance imaging

BACKGROUND

Ultrasound (US) is the first-line imaging modality to assess the morbidly adherent placenta, but sensitivity and specificity are lacking.

OBJECTIVE

This investigation aims to improve diagnostic accuracy with a comprehensive score using clinical history, US, and magnetic resonance imaging (MRI).

MATERIALS AND METHODS

We conducted a retrospective cohort study of pregnant women who received both transvaginal US and MRI with suspicion for morbidly adherent placenta between 2009 and 2016. US was scored with the following metrics: (i) previa, (ii) hypervascularity, (iii) loss of retroplacental clear space and (iv) lacunae. MRI was evaluated for (i) intraparenchymal vessels, (ii) abnormally dilated vessels, (iii) fibrin deposition, (iv) placental bulge and (v) bladder dome irregularity. Bayesian analysis was used to estimate the probability of morbidly adherent placenta for a given score. Diagnostic testing parameters were calculated.

RESULTS

Among the 41 women with concerning imaging, histologically identified disease was confirmed in 16. The probability of morbidly adherent placenta increased with the score. At the highest US score, the probability of disease was 63.7%. With the highest MRI score, the probability of adherent placentation was 90.5%. Combining the US and MRI findings had a sensitivity of 56% and a specificity of 92%.

CONCLUSION

A combined scoring system using MRI and US may accurately identify patients at risk for morbidity associated with morbidly adherent placenta.

Placenta Accreta Spectrum

Placenta accreta spectrum, formerly known as morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta. The most favored hypothesis regarding the etiology of placenta accreta spectrum is that a defect of the endometrial-myometrial interface leads to a failure of normal decidualization in the area of a uterine scar, which allows abnormally deep placental anchoring villi and trophoblast infiltration. Maternal morbidity and mortality can occur because of severe and sometimes life-threatening hemorrhage, which often requires blood transfusion. Although ultrasound evaluation is important, the absence of ultrasound findings does not preclude a diagnosis of placenta accreta spectrum; thus, clinical risk factors remain equally important as predictors of placenta accreta spectrum by ultrasound findings. There are several risk factors for placenta accreta spectrum. The most common is a previous cesarean delivery, with the incidence of placenta accreta spectrum increasing with the number of prior cesarean deliveries. Antenatal diagnosis of placenta accreta spectrum is highly desirable because outcomes are optimized when delivery occurs at a level III or IV maternal care facility before the onset of labor or bleeding and with avoidance of placental disruption. The most generally accepted approach to placenta accreta spectrum is cesarean hysterectomy with the placenta left in situ after delivery of the fetus (attempts at placental removal are associated with significant risk of hemorrhage). Optimal management involves a standardized approach with a comprehensive multidisciplinary care team accustomed to management of placenta accreta spectrum. In addition, established infrastructure and strong nursing leadership accustomed to managing high-level postpartum hemorrhage should be in place, and access to a blood bank capable of employing massive transfusion protocols should help guide decisions about delivery location.

Interpregnancy interval and abnormally invasive placentation

INTRODUCTION

The presence of a previous uterine scar is a strong risk factor for developing abnormally invasive placentation (AIP). We sought to determine whether a short interpregnancy interval predisposes to AIP. We hypothesized that a short interpregnancy interval after a previous cesarean delivery increases the risk of AIP in comparison with a longer interpregnancy interval.

MATERIAL AND METHODS

We performed a retrospective cohort study of women with a histological diagnosis of AIP and a history of a previous cesarean section. Women were included in the control group if they had a previous cesarean section with a placenta underlying the previous uterine scar or an anterior previa. The time interval between pregnancy and AIP data was analyzed using the chi-square test and two-tailed Fisher's exact test.

RESULTS

There was no statistical difference in the interpregnancy interval between women who had AIP vs the control group. Gravidity and parity were found to be significantly higher in the women with AIP vs the controls.

CONCLUSIONS

These results suggest that a short interpregnancy interval may not increase the risk of developing AIP.