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Vahdani FG, Shabani A, Haddadi M, Ghalandarpoor-Attar SM, Panahi Z, Hantoushzadeh S, Borna S, Deldar M, Ghashghaee S, Shariat M. Prediction of bleeding in placenta accrete spectrum with lacunar surface: a novel aspect. J Ultrasound 2024; 27:375-382. [PMID: 38551780 PMCID: PMC11178688 DOI: 10.1007/s40477-024-00878-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/08/2024] [Indexed: 06/15/2024] Open
Abstract
PURPOSE Diagnosing the placenta accreta spectrum is crucial to prevent morbidities and mortalities among women with the suspicion of this pathology. We aim to evaluate novel ultrasonography markers for these patients in diagnosing and predicting prognosis. METHODS This cross-sectional study was performed in a referral academic hospital. The population was composed of 51 pregnant women with a suspect of placenta accreta spectrum who had scheduled C-sections. Their primary information and past medical histories were documented. Then the ultrasonography markers, including the most bulging volume behind the bladder (area, perimeter, and volume), the Lacune (diameter, length, number, and surface of the largest lacuna obtained by multiplying the length by the width), the most considerable thickness of placenta on the cervix in patients with placenta previa, the most considerable thickness of the placenta behind the bladder, the Jellyfish sign, and sponge cervix were evaluated. Their comparison to the severity of the bleeding, the rate of the hysterectomy, and the following pathology of the placenta accreta spectrum were analyzed. RESULTS The results showed that 17 (33.3%) of patients had severe bleeding (more than 2500 cc). The diameter, length, and surface of the largest lacunae limited to women with severe bleeding were 13.50 (5.5-21) mm, 20.50 (11-56) mm, 273.00 (60-1176) mm2, and they were 11.00 (5-24) mm, 16.25 (10-39) mm, and 176.25 (50-744) mm2 for women without severe bleeding (P value = 0.039, 0.027, 0.021). 13 (76.5%) women with severe bleeding had Jellyfish signs,16 (94.2%) had bulging on the cervix, and 10(58.8%) had a sponge cervix (P value = 0.046, 0.036, 0.006). Also, 34 (66.66%) patients needed hysterectomy. The diameter, length, and surface of the largest lacunae limited to women with hysterectomy were 12.00 (5-24) mm, 18.00 (11-56) mm, 231.00 (60-1176) mm2, and they were 9.00 (5-18) mm, 15.00 (10-28) mm, and 136.00(50-504) mm2 for women without hysterectomy (P value = 0.012, 0.070, 0.021). 24(70.6%) women with hysterectomy had Jellyfish signs, 29 (85.3%) of them had bulging on the cervix, and 15 (44.1%) had sponge cervix (P value = 0.05, 0.036, 0.028). The cut-off associated with the Lacunar surface was 163.5 mm2. Its sensitivity was 80%, and its specificity was 48% (P value = 0.021). CONCLUSION The presence of single large lacunae could be a suitable predictive factor for bleeding in the placenta accreta spectrum; Moreover, there are some other US criteria, including the presence of a sponge cervix or the Jellyfish sign that are valuable predictive factors for negative outcomes for this spectrum, including hysterectomy.
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Affiliation(s)
- Fahimeh Ghotbizadeh Vahdani
- Maternal-Fetal and Neonatal Research Center, Family Health Research Institute, Tehran University of Medical Science, Tehran, Iran
| | - Azadeh Shabani
- Preventative Gynecology Research Center (PGRC), OBGYN Department, Shahid Beheshti University of Medical Science, Tehran, Iran.
- Taleghani Educational Hospital, Tabnak St. Velenjak Region, Chamran High Way, Tehran, Iran.
| | - Mohammad Haddadi
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Science, Tehran, Iran
| | | | - Zahra Panahi
- Maternal-Fetal and Neonatal Research Center, Family Health Research Institute, Tehran University of Medical Science, Tehran, Iran
| | - Sedigheh Hantoushzadeh
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Science, Tehran, Iran
| | - Sedigheh Borna
- Maternal-Fetal and Neonatal Research Center, Family Health Research Institute, Tehran University of Medical Science, Tehran, Iran
| | - Maryam Deldar
- Maternal-Fetal and Neonatal Research Center, Family Health Research Institute, Tehran University of Medical Science, Tehran, Iran
| | - Sanaz Ghashghaee
- Department of Obstetrics and Gynecology, Vali-E-Asr Hospital, Tehran University of Medical Science, Tehran, Iran
| | - Mamak Shariat
- Breastfeeding Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Takahashi J, Orisaka M, Inoue D, Kawamura H, Takahashi N, Tsuyoshi H, Shinagawa A, Kurokawa T, Yoshida Y. Evaluation of the holding-up uterus technique for placenta accreta spectrum cesarean hysterectomy in shocked patients with a high shock index: a case series study. BMC Surg 2024; 24:23. [PMID: 38218800 PMCID: PMC10787967 DOI: 10.1186/s12893-024-02311-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/02/2024] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Placenta accreta spectrum (PAS) cesarean hysterectomy is performed under conditions of shock and can result in serious complications. This study aimed to evaluate the usefulness of the "Holding-up uterus" surgical technique with a shock index (S.I.) > 1.5. METHODS Twelve patients who underwent PAS cesarean hysterectomy were included in the study. RESULTS Group I had S.I. > 1.5, and group II had S.I. ≤ 1.5. Group I had more complications, but none were above Grade 3 or fatal. Preoperative scheduled uterine artery embolization did not result in serious complications, but three patients who had emergency common iliac artery balloon occlusion (CIABO) and a primary total hysterectomy with S.I. > 1.5 had postoperative Grade 2 thrombosis. Two patients underwent manual ablation of the placenta under CIABO to preserve the uterus, both with S.I. > 1.5. CONCLUSIONS The study found that the "Holding-up uterus" technique was safe, even in critical situations with S.I. > 1.5. CIABO had no intervention effect. The study also identified assisted reproductive technology pregnancies with a uterine cavity length of less than 5 cm before conception as a critical factor.
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Affiliation(s)
- Jin Takahashi
- Department of Obstetrics and Gynecology, University of Fukui, Fukui, Japan
- Department of Obstetrics and Gynecology, Fukui Prefectural Hospital, Fukui, Japan
| | - Makoto Orisaka
- Department of Obstetrics and Gynecology, University of Fukui, Fukui, Japan
| | - Daisuke Inoue
- Department of Obstetrics and Gynecology, University of Fukui, Fukui, Japan
| | - Hiroshi Kawamura
- Department of Obstetrics and Gynecology, University of Fukui, Fukui, Japan
| | - Nozomu Takahashi
- Department of Obstetrics and Gynecology, University of Fukui, Fukui, Japan
| | - Hideaki Tsuyoshi
- Department of Obstetrics and Gynecology, University of Fukui, Fukui, Japan
| | - Akiko Shinagawa
- Department of Obstetrics and Gynecology, University of Fukui, Fukui, Japan
| | - Tetsuji Kurokawa
- Department of Obstetrics and Gynecology, University of Fukui, Fukui, Japan
| | - Yoshio Yoshida
- Department of Obstetrics and Gynecology, University of Fukui, Fukui, Japan.
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Palacios-Jaraquemada JM, Nieto-Calvache ÁJ, Aryananda RA, Basanta N, Campos CI, Ariani G. Placenta accreta spectrum with severe morbidity: fibrosis associated with cervical-trigonal invasion. J Matern Fetal Neonatal Med 2023; 36:2183741. [PMID: 37193605 DOI: 10.1080/14767058.2023.2183741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/20/2022] [Accepted: 02/18/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVE Describe the clinical-surgical results of patients with PAS in the low-posterior cervical-trigonal space associated with fibrosis (PAS type 4) compared with PAS types in other locations (Types 1, upper bladder, 2 in upper parametrium) and in particular with PAS type 3, corresponding to dissectible cervical-trigonal invasion. The clinical-surgical results of using a standard hysterectomy were analyzed with a modified subtotal hysterectomy (MSTH) in patients with PAS type 4. MATERIAL AND METHODS A descriptive, retrospective, multicenter study included 337 patients of PAS; thirty-two corresponding to PAS type 4, from three PAS reference hospitals, CEMIC, Buenos Aires, Argentina, Fundación Valle de Lili, Cali, Colombia, and Dr. Soetomo General Hospital, Surabaya, Indonesia, between January 2015 and December 2020. PAS was diagnosed by abdominal and transvaginal ultrasound and topographically characterized by ultrafast T2 weighted MRI. In persistent macroscopic hematuria after MSTH, the surgeon performs an intentional cystotomy and uses a square compression suture to achieve the hemostasis inside the bladder wall.According to a PAS topographical classification, the patients with low-vesical cervical involvement compared with PAS located in relation with the upper blader (type1), upper parametrium (type 2 upper), and also with PAS situated in the lower vesical-trigon space (type 3). PAS 3 and 4 are located in identical area, but in type 3, group A, the vesicouterine space was dissectible, and in type 4, group B, significant fibrosis made surgical dissection extremely challenging. Furthermore, group B was divided into patients treated with total hysterectomy (HT) and those treated with a modified subtotal hysterectomy (MSTH). The surgical requirements to perform an MSHT included the availability of proximal vascular control at the aortic level (internal manual aortic compression, aortic endovascular balloon, aortic loop, or aortic cross-clamping). Then surgeon performed an upper segmental hysterotomy, avoiding the abnormal placenta invasion area; after that, the fetus was delivered, and the umbilical cord was ligated.After uterine exteriorization, the surgeon applies a continuous circular suture with number 2 polyglactin 910, taking some portions of the myometrium -to avoid unintentional slipping- around the lower uterine segment and a 3-4 cm proximal to the abnormal adhesion of the placenta. After tightening hard the circular suture, the uterine segment was circumferentially cut, three centimeters proximal to the circular hemostatic sutures. Next, the surgery follows the upper steps of conventional hysterectomy without changes. Additionally, the histological presence of fibrosis was examined in all samples. RESULTS Modified subtotal hysterectomy in patients with PAS type 4 (cervical-trigonal fibrosis) resulted in a significant clínico-surgical improvement over total hysterectomy. The median operative time and intraoperative bleeding were 140 min (IQR 90--240) and 1895 mL (IQR 1300-2500) in patients undergoing modified subtotal hysterectomy, and 260 min (IQR 210-287) and 2900 mL (IQR 2150-5500) in patients treated with total hysterectomy, respectively. The complication rate was 20% for MSHT and 82.3% for patients with a total hysterectomy. CONCLUSIONS PAS in the cervical trigonal area associated with fibrosis implies a greater risk of complications due to uncontrollable bleeding and organ damage. MSTH is associated with lower morbidity and difficulties in PAS type 4. Prenatal or intrasurgical diagnosis is essential to plan surgical alternatives to improve the results.
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Affiliation(s)
| | | | - Rozi Aditya Aryananda
- Universitas Airlangga, Surabaya, Indonesia
- Placenta Accreta Spectrum Clinic, Fundación Valle del Lili, Cali, Colombia
- Dr. Soetomo Academic General Hospital, City of Buenos Aires, Argentina
| | | | - Clara Ivette Campos
- Department of Pathology and Clinical Laboratory, Fundación Valle del Lili, Cali, Colombia
| | - Grace Ariani
- Department of Pathology and Clinical Laboratory, Fundación Valle del Lili, Cali, Colombia
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Nieto-Calvache AJ, Sanín-Blair JE, Buitrago-Leal HM, Benavides-Serralde JA, Maya-Castro J, Rozo-Rangel AP, Messa-Bryon A, Colonia-Toro A, Gómez-Castro AR, Cardona-Ospina A, Caicedo-Cáceres CE, Dorado-Roncancio EF, Silva JL, Carvajal-Valencia JA, Velásquez-Penagos JA, Niño-González JE, Burgos-Luna JM, Rincón-García JC, Matera-Torres L, Villamizar-Galvis OA, Olaya-Garay SX, Medina-Palmezano VP, Castañeda J. Colombian Consensus on the Treatment of Placenta Accreta Spectrum (PAS). REVISTA COLOMBIANA DE OBSTETRICIA Y GINECOLOGIA 2022; 73:283-316. [PMID: 36331304 PMCID: PMC9674383 DOI: 10.18597/rcog.3877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/14/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Placenta accreta spectrum (PAS) is a condition associated with massive postpartum bleeding and maternal mortality. Management guidelines published in high income countries recommend the participation of interdisciplinary teams in hospitals with sufficient resources for performing complex procedures. However, some of the recommendations contained in those guidelines are difficult to implement in low and medium income countries. OBJECTIVES The aim of this consensus is to draft general recommendations for the treatment of PAS in Colombia. MATERIALS AND METHODS Twenty-three panelists took part in the consensus with their answers to 31 questions related to the treatment of PAS. The panelists were selected based on participation in two surveys designed to determine the resolution capabilities of national and regional hospitals. The modified Delphi methodology was used, introducing two successive discussion rounds. The opinions of the participants, with a consensus of more than 80%, as well as implementation barriers and facilitators, were taken into consideration in order to issue the recommendations. RESULTS The consensus draftedfive recommendations, integrating the answers of the panelists. Recommendation 1. Primary care institutions must undertake active search of PAS in patients with risk factors: placenta praevia and history of myomectomy or previous cesarean section. In case of ultrasound signs suggesting PAS, patients must be immediately referred, without a minimum gestational age, to hospitals recognized as referral centers. Online communication and care modalities may facilitate the interaction between primary care institutions and referral centers for PAS. The risks and benefits of telemedicine modalities must be weighed. Recommendation 2. Referral hospitals for PAS need to be defined in each region of Colombia, ensuring coverage throughout the national territory. It is advisable to concentrate the flow of patients affected by this condition in a few hospitals with surgical teams specifically trained in PAS, availability of specialized resources, and institutional efforts at improving quality of care with the aim of achieving better health outcomes in pregnant women with this condition. To achieve this goal, participants recommend that healthcare regulatory agencies at a national and regional level should oversee the process of referral for these patients, expediting administrative pathways in those cases in which there is no prior agreement between the insurer and the selected hospital or clinic. Recommendation 3. Referral centers for patients with PAS are urged to build teams consisting of a fixed group of specialists (obstetricians, urologists, general surgeons, interventional radiologists) entrusted with the care of all PAS cases. It is advisable for these interdisciplinary teams to use the “intervention bundle” model as a guidance for building PAS referral centers. This model comprises the following activities: service preparedness, disease prevention and identification, response to the occurrence of the disease, and debriefing after every event. Telemedicine facilitates PAS treatment and should be taken into consideration by interdisciplinary teams caring for this disease. Recommendation 4. Obstetrics residents must be instructed in the performance of maneuvers that are useful for the prevention and treatment of massive intraoperative bleeding due to placenta praevia and PAS, including manual aortic compression, uterine tourniquet, pelvic packing, retrovesical bypass, and Ward maneuver. Specialization Obstetrics and Gynecology programs in Colombia must include the basic concepts of the diagnosis and treatment of PAS. Referral centers for PAS must offer online and in-person training programs for professionals interested in improving their competencies in PAS. Moreover, they must offer permanent remote support (telemedicine) to other hospitals in their region for patients with this condition. Recommendation 5. Patients suspected of having PAS and placenta praevia based on imaging, with no evidence of active vaginal bleeding, must be delivered between weeks 34 and 36 6/7. Surgical treatment must include sequential interventions that may vary depending on the characteristics of the lesion, the clinical condition of the patient and the availability of resources. The surgical options (total and subtotal hysterectomy, one-stage conservative surgical management and watchful waiting) must be included in a protocol known by the entire interdisciplinary team. In situations in which an antepartum diagnosis is lacking, that is to say, in the face of intraoperative finding of PAS (evidence of purple bulging or neovascularization of the anterior aspect of the uterus), and the participation of untrained personnel, three options are considered: Option 1: In the absence of indication of immediate delivery or of vaginal delivery, the recommendation is to postpone the cesarean section (close the laparotomy before incising the uterus) until the recommended resources for safe surgery are secured. Option 2: If there is an indication for immediate delivery (e.g., non-reassuring fetal status) but there is absence of vaginal bleeding or indication for immediate PAS management, a two-stage management is suggested: cesarean section avoiding placental incision, followed by uterine repair and abdominal closure, until the availability of the recommended resources for safe surgery is ascertained. Option 3: In the event of vaginal bleeding that prevents definitive PAS management, the fetus must be delivered through the uterine fundus, followed by uterine repair and reassessment of the situation. Sometimes, fetal delivery diminishes placental flow and vaginal bleeding is reduced or disappears, enabling the possibility to postpone definitive management of PAS. In case of persistent significant bleeding, hysterectomy should be performed, using all available resources: manual aortic compression, immediate call to the surgeons with the best available training, telemedicine support from expert teams in other hospitals. If a patient with risk factors for PAS (e.g., myomectomy or previous cesarean section) has a retained placenta after vaginal delivery, it is advisable to confirm the possibility of such diagnosis (by means of ultrasound, for example) before proceeding to manual extraction of the placenta. CONCLUSIONS It is our hope that this first Colombian consensus on PAS will serve as a basis for additional discussions and collaborations that can result in improved clinical outcomes for women affected by this condition. Additional research will be required in order to evaluate the applicability and effectiveness of these recommendations.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jimmy Castañeda
- Federación Colombiana de Obstetricia y Ginecología (FECOLSOG), Bogotá (Colombia)..
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Hussein AM, Fox K, Bhide A, Elbarmelgy RA, Elbarmelgy RM, Thabet MM, Jauniaux E. The impact of preoperative ultrasound and intraoperative findings on surgical outcomes in patients at high‐risk of placenta accreta spectrum. BJOG 2022; 130:42-50. [DOI: 10.1111/1471-0528.17286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/26/2022] [Accepted: 08/13/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Ahmed M. Hussein
- Department of Obstetrics and Gynecology University of Cairo Cairo Egypt
| | - Karin Fox
- Division of Maternal–Fetal Medicine, Department of Obstetrics and Gynecology Baylor College of Medicine Houston Texas USA
| | - Amar Bhide
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, St George's Hospital London
| | | | | | - Mohamed M. Thabet
- Department of Obstetrics and Gynecology University of Cairo Cairo Egypt
| | - Eric Jauniaux
- EGA Institute for Women’s Health Faculty of Population Health Sciences, University College London (UCL), London UK
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Hussein AM, Elbarmelgy RA, Elbarmelgy RM, Thabet MM, Jauniaux E. Prospective evaluation of impact of post-Cesarean section uterine scarring in perinatal diagnosis of placenta accreta spectrum disorder. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:474-482. [PMID: 34225385 PMCID: PMC9311077 DOI: 10.1002/uog.23732] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 06/17/2021] [Accepted: 06/29/2021] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Standardized ultrasound imaging and pathology protocols have recently been developed for the perinatal diagnosis of placenta accreta spectrum (PAS) disorders. The aim of this study was to evaluate prospectively the effectiveness of these standardized protocols in the prenatal diagnosis and postnatal examination of women presenting with a low-lying placenta or placenta previa and a history of multiple Cesarean deliveries (CDs). METHODS This was a prospective cohort study of 84 consecutive women with a history of two or more prior CDs presenting with a singleton pregnancy and low-lying placenta/placenta previa at 32-37 weeks' gestation, who were referred for perinatal care and management between 15 January 2019 and 15 December 2020. All women were investigated using the standardized description of ultrasound signs of PAS proposed by the European Working Group on abnormally invasive placenta. In all cases, the ultrasound features were compared with intraoperative and histopathological findings. Areas of abnormal placental attachment were identified during the immediate postoperative gross examination and sampled for histological examination. The data of a subgroup of 32 women diagnosed antenatally as non-PAS who had complete placental separation at birth were compared with those of 39 cases diagnosed antenatally as having PAS disorder that was confirmed by histopathology at delivery. RESULTS Of the 84 women included in the study, 42 (50.0%) were diagnosed prenatally as PAS and the remaining 42 (50.0%) as non-PAS on ultrasound examination. Intraoperatively, 66 (78.6%) women presented with a large or extended area of dehiscence and 52 (61.9%) with a dense tangled bed of vessels or multiple vessels running laterally and craniocaudally in the uterine serosa. A loss of clear zone was recorded on grayscale ultrasound imaging in all 84 cases, while there was no case with bladder-wall interruption or with a focal exophytic mass. Myometrial thinning (< 1 mm) in at least one area of the anterior uterine wall was found in 41 (97.6%) of the 42 cases diagnosed as non-PAS on ultrasound and 37 (88.1%) of the 42 diagnosed antenatally as PAS. Histological samples were available for all 48 hysterectomy specimens with abnormal placental attachment and for the three cases managed conservatively with focal myometrial resection and uterine reconstruction. Villous tissue was found directly attached to the superficial myometrium (placenta creta) in six of these cases and both creta villous tissue and deeply implanted villous tissue within the uterine wall (placenta increta) were found in the remaining 45 cases. There was no evidence of percreta placentation on histology in any of the PAS cases. Comparison of the main antenatal ultrasound signs and perioperative macroscopic findings between the two subgroups correctly diagnosed antenatally (32 non-PAS and 39 PAS) showed no significant difference with respect to the distribution of myometrial thinning and the presence of a placental bulge on ultrasound and of anterior uterine wall dehiscence intraoperatively. Compared with the non-PAS subgroup, the PAS subgroup showed significantly higher placental lacunae grade (P < 0.001) and more often hypervascularity of the uterovesical/subplacental area (P < 0.001), presence of bridging vessels (P = 0.027) and presence of lacunae feeder vessels (P < 0.001) on ultrasound examination, and increased vascularization of the anterior uterine wall intraoperatively (P < 0.001). CONCLUSIONS Remodeling of the lower uterine segment following CD scarring leads to structural abnormalities of the uterine contour on both ultrasound examination and intraoperatively, independently of the presence of accreta villous tissue on microscopic examination. These anatomical changes are often reported as diagnostic of placenta percreta, including cases with no histological evidence of PAS. Guided histological examination could improve the overall diagnosis of PAS and is essential to obtain evidence-based epidemiologic data. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A. M. Hussein
- Department of Obstetrics and GynecologyUniversity of CairoCairoEgypt
| | - R. A. Elbarmelgy
- Department of Obstetrics and GynecologyUniversity of CairoCairoEgypt
| | - R. M. Elbarmelgy
- Department of Obstetrics and GynecologyUniversity of CairoCairoEgypt
| | - M. M. Thabet
- Department of Obstetrics and GynecologyUniversity of CairoCairoEgypt
| | - E. Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health SciencesUniversity College LondonLondonUK
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Huang J, Zhang X, Liu L, Duan S, Pei C, Zhao Y, Liu R, Wang W, Jian Y, Liu Y, Liu H, Wu X, Zhang W. Placenta Accreta Spectrum Outcomes Using Tourniquet and Forceps for Vascular Control. Front Med (Lausanne) 2021; 8:557678. [PMID: 34733857 PMCID: PMC8558214 DOI: 10.3389/fmed.2021.557678] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To evaluate the use of tourniquet and forceps to reduce bleeding during surgical treatment of severe placenta accreta spectrum (placenta increta and placenta percreta). Methods: A tourniquet was used in the lower part of the uterus during surgical treatment of severe placenta accreta spectrum. Severe placenta accreta spectrum was classified into two types according to the relative position of the placenta and tourniquet during surgery: upper-tourniquet type, in which the entire placenta was above the tourniquet, and lower-tourniquet type, in which part or all of the placenta was below the tourniquet. The surgical effects of the two types were retrospectively compared. We then added forceps to the lower-tourniquet group to achieve further bleeding reduction. Finally, the surgical effects of the two types were prospectively compared. Results: During the retrospective phase, patients in the lower-tourniquet group experienced more severe symptoms than did patients in the upper-tourniquet group, based on mean intraoperative blood loss (upper-tourniquet group 787.5 ml, lower-tourniquet group 1434.4 ml) intensive care unit admission rate (upper-tourniquet group 1.0%, lower-tourniquet group 33.3%), and length of hospital stay (upper-tourniquet group 10.2d, lower-tourniquet group 12.1d). During the prospective phase, after introduction of the revised surgical method involving forceps (in the lower-tourniquet group), the lower-tourniquet group exhibited improvements in the above indicators (intraoperative average blood loss 722.9 ml, intensive care unit admission rate 4.3%, hospital stays 9.0d). No increase in the rate of complications was observed. Conclusion: The relative positions of the placenta and tourniquet may influence the perioperative risk of severe placenta accreta spectrum. The method using a tourniquet (and forceps if necessary) can improve the surgical effect in cases of severe placenta accreta spectrum.
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Affiliation(s)
- Jingrui Huang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Xiaowen Zhang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Lijuan Liu
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Si Duan
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Chenlin Pei
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Yanhua Zhao
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Rong Liu
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Weinan Wang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Yu Jian
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Yuelan Liu
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Hui Liu
- Department of Radiology, Xiangya Hospital Central South University, Changsha, China
| | - Xinhua Wu
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Weishe Zhang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China.,Hunan Engineering Research Center of Early Life Development and Disease Prevention, Changsha, China
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Management of abnormal invasive placenta in a low- and medium-resource setting. Best Pract Res Clin Obstet Gynaecol 2020; 72:117-128. [PMID: 32900599 DOI: 10.1016/j.bpobgyn.2020.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/05/2020] [Accepted: 08/05/2020] [Indexed: 12/22/2022]
Abstract
The purpose of this review is to describe the panorama of placenta accreta spectrum (PAS) disorder management in low- and middle-income countries, providing information that allows for the improvement of maternal and perinatal outcomes in the management of this pathology. This spectrum of disorders is associated with implications of high morbidity and mortality, both maternal and perinatal, which is why clinical practice guidelines based on management are produced in settings where there is a wide range of available resources. This situation often contrasts with what the reality is in low-resource countries. Prenatal diagnosis of placental accreta is essential to carry out adequate surgical planning in centres where multidisciplinary teams are in place, which improve results and reduce complications. These ideal scenarios should be developed in countries with more significant difficulties in the availability of human and technological resources, through teamwork in the different hospital centres and the adequate transfer of patients at higher risk to centres with the best interdisciplinary management skills.
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Hussein AM, Momtaz M, Elsheikhah A, Abdelbar A, Kamel A. The role of ultrasound in prediction of intra-operative blood loss in cases of placenta accreta spectrum disorders. Arch Gynecol Obstet 2020; 302:1143-1150. [PMID: 32740869 DOI: 10.1007/s00404-020-05707-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 07/25/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE To assess the value of various grey-scale ultrasound, 2D color Doppler, and 3D power Doppler sonographic markers in predicting major intraoperative blood loss during planned cesarean hysterectomy for cases diagnosed with placenta accreta spectrum (PAS) disorders. METHODS 50 women diagnosed with PAS were scanned the day before planned delivery and hysterectomy for various sonographic markers indicative of placental invasion. These women were then later divided according to blood loss in two groups: group A (minor hemorrhage, < 2500 ml), and group B (major hemorrhage, > 2500 ml), and the data were analyzed. RESULTS The odds ratio (OR) for major hemorrhage was as follows for the following sonographic markers: 'number of lacunae > 4' OR 3.8 95% CI (1.0-13.8) (p = 0.047); 'subplacental hypervascularity' OR 10.8 95% CI (1.2-98.0) (p = 0.035); 'tortuous vascularity with 'chaotic branching' OR 10.8 95%CI (1.2-98.0) (p = 0.035); 'numerous coherent vessels involving the serosa-bladder interface OR 14.6 95% CI (2.7-80.5) (p = 0.002); and 'presence of bridging vessels OR 2.9 95% CI (1.4-6.9) (p = 0.005). Only the presence of numerous coherent vessels involving the bladder-serosal interface (p = 0.002) was proven to be independent predictor of major hemorrhage during hysterectomy. CONCLUSION The use of 2D color Doppler and 3D power Doppler can help predict massive hemorrhage in cases of PAS disorders.
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Affiliation(s)
- Ahmed M Hussein
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Mohamed Momtaz
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Ahmad Elsheikhah
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Ahmed Abdelbar
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Ahmed Kamel
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Giza, Egypt.
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Palacios-Jaraquemada JM. Conservative vs. Radical Management of Placenta Accreta Spectrum (PAS). CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2020. [DOI: 10.1007/s13669-019-00274-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Mohamed MA. Lower segment folding as novel technique to control bleeding in cases of morbidly adherent placenta. J Matern Fetal Neonatal Med 2019; 34:3397-3401. [PMID: 31722580 DOI: 10.1080/14767058.2019.1685971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
AIM To evaluate the effectiveness of lower segment folding in controlling lower segment bleeding and conserving uterus in cases with morbidly adherent placenta. METHODS This study was conducted on OB/GYN emergency unit of Sohag University hospital. The upper edge of lower segment was sutured to the internal os in continuous purse-string manner using delayed absorbable sutures "N0 2 vicryl (polyglactin 910)." The sutures incude both anterior and lateral aspects of lower uterine segment. Care was taken to maintain patency of endocervix. The folded lower segment was sutured to upper segment as ordinary closure of hysterectomy. RESULTS Thirty-two cases were included. The procedure was successful in all studied group to achieve good hemostasis and preservation of uterus. The estimated intraoperative blood loss was (1645 ± 318), there was no need for massive blood transfusion in all cases as number of blood units transfused ranged from 1 to 4 with mean (2.1 ± 0.53). Time required to perform lower segment folding was ranged from 3 to 8 min with mean (4.9 ± 1.1). CONCLUSION Lower segment folding is a good option for saving the uterus in cases of morbidly adherent placenta. The technique is rapid, easy to be performed without a need of special expertise nor special equipment's.
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Affiliation(s)
- Magdy A Mohamed
- Obstetrics and Gynecology Department, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt
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Jauniaux E, Hussein AM, Fox KA, Collins SL. New evidence-based diagnostic and management strategies for placenta accreta spectrum disorders. Best Pract Res Clin Obstet Gynaecol 2019; 61:75-88. [PMID: 31126811 PMCID: PMC6929563 DOI: 10.1016/j.bpobgyn.2019.04.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 04/17/2019] [Indexed: 10/26/2022]
Abstract
The increasing incidence of caesarean delivery (CD) has resulted in an increase in placenta accreta spectrum (PAS), adversely impacting maternal outcomes globally. Currently, more than 90% of women diagnosed with PAS present with a placenta praevia (praevia PAS). Praevia PAS can be reliably diagnosed antenatally with ultrasound, and it is unclear whether magnetic resonance imaging improves diagnosis beyond what can be achieved by skilled ultrasound operators. Therefore, any screening programme for PAS will require improved training in the diagnosis of placental disorders and development of targeted scanning protocols. Management strategies for praevia PAS vary depending on the accuracy of prenatal diagnosis, findings at laparotomy and local surgical expertise. Current epidemiological data for PAS are highly heterogeneous, mainly due to wide variation in the clinical criteria used to diagnose the condition at birth. This significantly impacts research into all aspects of the condition, especially comparison of the efficacy of different management strategies.
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Affiliation(s)
- Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
| | - Ahmed M Hussein
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
| | - Karin A Fox
- Division of Maternal-Fetal Medicine, Dept of OB-GYN Baylor College of Medicine/Texas Children Hospital Pavilion for Women, Houston, TX, USA
| | - Sally L Collins
- Nuffield Department of Women's and Reproductive Health, University of Oxford, and the Fetal Medicine Unit, John Radcliffe Hospital, Oxford, UK
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Hussein AM, Kamel A, Elbarmelgy RA, Thabet MM, Elbarmelgy RM. Managing Placenta Accreta Spectrum Disorders (PAS) in Middle/Low-Resource Settings. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2019. [DOI: 10.1007/s13669-019-00263-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Reply to: Modified cesarean hysterectomy technique for management of cases of placenta increta and percreta at a tertiary referral hospital in Egypt. Arch Gynecol Obstet 2019; 302:1545-1546. [PMID: 31197442 DOI: 10.1007/s00404-019-05219-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 06/07/2019] [Indexed: 10/26/2022]
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Reply to the comments on "Modified hysterectomy for placenta increta and percreta: modifications of what?". Arch Gynecol Obstet 2019; 299:1753-1755. [PMID: 30895372 DOI: 10.1007/s00404-019-05118-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 02/28/2019] [Indexed: 10/27/2022]
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Modified hysterectomy for placenta increta and percreta: modifications of what? Arch Gynecol Obstet 2019; 299:1751-1752. [PMID: 30859298 DOI: 10.1007/s00404-019-05114-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/04/2019] [Indexed: 10/27/2022]
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