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Givens M, Valcheva I, Einerson BD, Rogozińska E, Jauniaux E. Evaluation of maternal serum protein biomarkers in the prenatal evaluation of placenta accreta spectrum: A systematic scoping review. Acta Obstet Gynecol Scand 2024. [PMID: 39004916 DOI: 10.1111/aogs.14918] [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: 04/11/2024] [Revised: 05/29/2024] [Accepted: 06/26/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION Placenta accreta spectrum (PAS) is an increasingly commonly reported condition due to the continuous increase in the rate of cesarean deliveries (CD) worldwide; however, the prenatal screening for pregnant patients at risk of PAS at birth remains limited, in particular when imaging expertise is not available. MATERIAL AND METHODS Two major electronic databases (MEDLINE and Embase) were searched electronically for articles published in English between October 1992 and January 2023 using combinations of the relevant medical subject heading terms and keywords. Two independent reviewers selected observational studies that provided data on one or more measurement of maternal blood-specific biomarker(s) during pregnancies with PAS at birth. PRISMA Extension for Scoping Review (PRISMA-ScR) was used to extract data and report results. RESULTS Of the 441 reviewed articles, 29 met the inclusion criteria reporting on 34 different biomarkers. 14 studies were retrospective and 15 prospective overall including 18 251 participants. Six studies had a cohort design and the remaining a case-control design. Wide clinical heterogeneity was found in the included studies. In eight studies, the samples were obtained in the first trimester; in five, the samples were collected on hospital admission for delivery; and in the rest, the samples were collected during the second and/or third trimester. CONCLUSIONS Measurements of serum biomarkers, some of which have been or are still used in screening for other pregnancy complications, could contribute to the prenatal evaluation of patients at risk of PAS at delivery; however, important evidence gaps were identified for suitable cutoffs for most biomarkers, variability of gestational age at sampling and the potential overlap of the marker values with other placental-related complications of pregnancy.
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Affiliation(s)
- Matthew Givens
- Department of Obstetrics and Gynecology (Drs Givens and Einerson), University of Utah Health (UUH), Salt Lake City, Utah, USA
| | - Ivaila Valcheva
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Brett D Einerson
- Department of Obstetrics and Gynecology (Drs Givens and Einerson), University of Utah Health (UUH), Salt Lake City, Utah, USA
| | - Ewelina Rogozińska
- The EVIdencE Synthesis and Methodology Group for Women's Health Research (EVIE), Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
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Ohayon A, Castel E, Friedrich L, Mor N, Levin G, Meyer R, Toussia-Cohen S. Pregnancy Outcomes after Uterine Preservation Surgery for Placenta Accreta Spectrum: A Retrospective Cohort Study. Am J Perinatol 2024. [PMID: 38857622 DOI: 10.1055/s-0044-1787543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
OBJECTIVE This study aimed to investigate maternal and neonatal outcomes in subsequent pregnancies of women with a history of placenta accreta spectrum (PAS) compared with women without history of PAS. STUDY DESIGN A retrospective cohort study conducted at a single tertiary center between March 2011 and January 2022. We compared women with a history of PAS who had uterine preservation surgery and a subsequent pregnancy, to a control group matched in a 1:5 ratio. The primary outcome was the occurrence of a composite adverse outcome (CAO) including any of the following: uterine dehiscence, uterine rupture, blood transfusion, hysterectomy, neonatal intensive care unit admission, and neonatal mechanical ventilation. Multivariable logistic regression was performed to evaluate associations with the CAO. RESULTS During the study period, 287 (1.1%) women were diagnosed with PAS and delivered after 25 weeks of gestation. Of these, 32 (11.1%) women had a subsequent pregnancy that reached viability. These 32 women were matched to 139 controls. There were no significant differences in the baseline characteristics between the study and control groups. Compared with controls, the proportion of CAO was significantly higher in women with previous PAS pregnancy (40.6 vs. 19.4%, p = 0.019). In a multivariable logistic regression analysis, previous PAS (adjusted odds ratio [aOR] = 3.31, 95% confidence interval [CI] = 1.09-10.02, p = 0.034) and earlier gestational age at delivery (aOR = 3.53, 95% CI = 2.27-5.49, p < 0.001) were independently associated with CAOs. CONCLUSION A history of PAS in a previous pregnancy is associated with increased risk of CAOs in subsequent pregnancies. KEY POINTS · The uterine-preserving approach for PAS delivery is gaining more attention and popularity in recent years.. · Women with a previous pregnancy with PAS had higher rates of CAOs in subsequent pregnancies.. · Previous PAS pregnancy is an independent factor associated with adverse outcomes..
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Affiliation(s)
- Aviran Ohayon
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Elias Castel
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Lior Friedrich
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
- Joyce and Irving Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Nitzan Mor
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gabriel Levin
- Department of Gynecologic Oncology, Hadassah Medical Center, Jerusalem, Israel
| | - Raanan Meyer
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shlomi Toussia-Cohen
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Lu T, Wang L, Li M, Wang Y, Chen M, Xiao BH, Wáng YXJ. Diffusion-derived vessel density (DDVD) computed from a simple diffusion MRI protocol as a biomarker of placental blood circulation in patients with placenta accreta spectrum disorders: A proof-of-concept study. Magn Reson Imaging 2024; 109:180-186. [PMID: 38513786 DOI: 10.1016/j.mri.2024.03.028] [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: 12/26/2023] [Revised: 03/18/2024] [Accepted: 03/18/2024] [Indexed: 03/23/2024]
Abstract
OBJECTIVES Increasing trend of PAS (placenta accreta spectrum disorders) incidence is a major health concern as PAS is associated with high maternal morbidity and mortality during cesarean section. Prenatal identification of PAS is crucial for delivery planning and patients management. This study aims to explore whether diffusion-derived vessel density (DDVD) computed from a simple diffusion MRI protocol differs in PAS from normal placenta. METHODS We enrolled 86 patients with PAS disorders and 40 pregnant women without PAS disorders. Each patient underwent intravoxel incoherent motion (IVIM) MRI sequence with 11 b-values. Placenta diffusion-derived vessel density (DDVD-b0b50) was the signal difference between b = 0 and b = 50 s/mm2 images. DDVD(b0b50) A/N was calculated as [accreta lesion DDVD(b0b50)]/ [normal placenta DDVD(b0b50)]. The correlation between DDVD and gestational age was explored using Spearman rank correlation. Differences of DDVD(b0b50) A/N in patients with normal placentas and with PAS, and in patients with different subtypes of PAS were explored. RESULTS DDVD was negatively correlated with gestational age (p = 0.023, r = -0.359) in patients with normal placentas. DDVD(b0b50) A/N was significantly higher in patients with PAS (median:1.16, mean: 1.261) than normal placenta (median:1.02, mean: 1.032, p < 0.001) and especially higher in patients with placenta increta (median:1.14, mean: 1.278) and percreta (median: 1.20, mean: 1.396, p < 0.001). CONCLUSION As a higher DDVD indicates higher physiological volume of micro-vessels in PAS, this study suggests DDVD can be a potential biomarker to evaluate the placenta perfusion.
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Affiliation(s)
- Tao Lu
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32 West Second Section, First Ring Road, Chengdu 610072, China.
| | - Li Wang
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32 West Second Section, First Ring Road, Chengdu 610072, China
| | - Mou Li
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32 West Second Section, First Ring Road, Chengdu 610072, China
| | - Yishuang Wang
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32 West Second Section, First Ring Road, Chengdu 610072, China
| | - Meining Chen
- MR Research Collaboration, Siemens Healthineers Ltd., Area e, Tianfu Software Park, 1268 Tianfu Avenue Middle Section, Wuhou District, Chengdu 610041, China.
| | - Ben-Heng Xiao
- Department of Imaging and Interventional Radiology, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, New Territories, Hong Kong Special Administrative Region
| | - Yì Xiáng J Wáng
- Department of Imaging and Interventional Radiology, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, New Territories, Hong Kong Special Administrative Region.
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Hessami K, Horgan R, Munoz JL, Norooznezhad AH, Nassr AA, Fox KA, Di Mascio D, Caldwell M, Catania V, D'Antonio F, Abuhamad AZ. Trimester-specific diagnostic accuracy of ultrasound for detection of placenta accreta spectrum: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:723-730. [PMID: 38324675 DOI: 10.1002/uog.27606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/17/2024] [Accepted: 01/22/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVE To assess the diagnostic accuracy of ultrasound for detecting placenta accreta spectrum (PAS) during the first trimester of pregnancy and compare it with the accuracy of second- and third-trimester ultrasound examination in pregnancies at risk for PAS. METHODS PubMed, EMBASE and Web of Science databases were searched to identify relevant studies published from inception until 10 March 2023. Inclusion criteria were cohort, case-control or cross-sectional studies that evaluated the accuracy of ultrasound examination performed at < 14 weeks of gestation (first trimester) or ≥ 14 weeks of gestation (second/third trimester) for the diagnosis of PAS in pregnancies with clinical risk factors. The primary outcome was the diagnostic accuracy of sonography in detecting PAS in the first trimester, compared with the accuracy of ultrasound examination in the second and third trimesters. The secondary outcome was the diagnostic accuracy of each sonographic marker individually across the trimesters of pregnancy. The reference standard was PAS confirmed at pathological or surgical examination. The potential of ultrasound and different ultrasound signs to detect PAS was assessed by computing summary estimates of sensitivity, specificity, diagnostic odds ratio and positive and negative likelihood ratios. RESULTS A total of 37 studies, including 5764 pregnancies at risk of PAS, with 1348 cases of confirmed PAS, were included in our analysis. The meta-analysis demonstrated that ultrasound had a sensitivity of 86% (95% CI, 78-92%) and specificity of 63% (95% CI, 55-70%) during the first trimester, and a sensitivity of 88% (95% CI, 84-91%) and specificity of 92% (95% CI, 85-96%) during the second/third trimester. Regarding sonographic markers examined in the first trimester, lower uterine hypervascularity exhibited the highest sensitivity (97% (95% CI, 19-100%)), and uterovesical interface irregularity demonstrated the highest specificity (99% (95% CI, 96-100%)). In the second/third trimester, loss of clear zone had the highest sensitivity (80% (95% CI, 72-86%)), and uterovesical interface irregularity exhibited the highest specificity (99% (95% CI, 97-100%)). CONCLUSIONS First-trimester ultrasound examination has similar accuracy to second- and third-trimester ultrasound examinations for the diagnosis of PAS. Routine first-trimester ultrasound screening for patients at high risk of PAS may improve detection rates and allow earlier referral to tertiary care centers for pregnancy management. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- K Hessami
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - R Horgan
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - J L Munoz
- Division of Fetal Therapy and Surgery, Baylor College of Medicine, Houston, TX, USA
| | - A H Norooznezhad
- Medical Biology Research Centre, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - A A Nassr
- Division of Fetal Therapy and Surgery, Baylor College of Medicine, Houston, TX, USA
| | - K A Fox
- Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - D Di Mascio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - M Caldwell
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - V Catania
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - F D'Antonio
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - A Z Abuhamad
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
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Munoz JL, Cheng C, McCann GA, Ramsey P, Byrne JJ. Risk factors for intensive care unit admission after cesarean hysterectomy for placenta accreta spectrum. Int J Gynaecol Obstet 2024. [PMID: 38757543 DOI: 10.1002/ijgo.15692] [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: 11/09/2023] [Revised: 04/29/2024] [Accepted: 05/07/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE Placenta accreta spectrum (PAS) is a complex disorder of uterine wall disruption with significant morbidity and mortality, particularly at time of delivery. Both physician and physical hospital resource allocation/utilization remains a challenge in PAS cases including intensive care unit (ICU) beds. The primary objective of the present study was to identify preoperative risk factors for ICU admission and create an ICU admission prediction model for patient counseling and resource utilization decision making in an evidence-based manner. METHODS This was a case-control study of 145 patients at our PAS referral center undergoing cesarean hysterectomy for PAS. Final confirmation by histopathology was required for inclusion. Patient disposition after surgery (ICU vs post-anesthesia care unit) was our primary outcome and pre-/intra-/postoperative variables were obtained via electronic medical records with an emphasis on the predictive capabilities of the preoperative variables. Uni- and multivariate analysis was performed to identify independent predictive factors for ICU admission. RESULTS In this large cohort of 145 patients who underwent cesarean hysterectomy for PAS, with histopathologic confirmation, 63 (43%) were admitted to the ICU following delivery. These patients were more likely to be delivered at an earlier gestational age (34 vs 35 weeks, P < 0.001), have had >2 episodes of vaginal bleeding and emergent delivery compared to patients admitted to patients with routine recovery care (44% vs 18.3%, P = 0.009). Uni- and multivariate logistic regression showed an area under the curve of 0.73 (95% CI: [0.63, 0.81], P < 0.001) for prediction of ICU admission with these three variables. Patients with all three predictors had 100% ICU admission rate. CONCLUSION Resource prediction, utilization and allocation remains a challenge in PAS management. By identifying patients with preoperative risk factors for ICU admission, not only can patients be counseled but this resource can be requested preoperatively for staffing and utilization purposes.
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Affiliation(s)
- Jessian L Munoz
- Divisions of Maternal Fetal Medicine and Fetal Intervention, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - CeCe Cheng
- Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas, USA
| | - Georgia A McCann
- Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas, USA
| | - Patrick Ramsey
- Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas, USA
| | - John J Byrne
- Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas, USA
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McCall SJ, Mansour S, Khazaal J, Kayem G, DeJong J, Chahine R. Obstetric and haematological management and outcomes of women with placenta accreta spectrum by planned or urgent delivery: Secondary data analysis of a public referral hospital in Lebanon. PLoS One 2024; 19:e0302366. [PMID: 38718031 PMCID: PMC11078361 DOI: 10.1371/journal.pone.0302366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 04/02/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Lebanon has a high caesarean section use and consequently, placenta accreta spectrum (PAS) is becoming more common. OBJECTIVES To compare maternal characteristics, management, and outcomes of women with PAS by planned or urgent delivery at a major public referral hospital in Lebanon. DESIGN Secondary data analysis of prospectively collected data. SETTING Rafik Hariri University Hospital (public referral hospital), Beirut, Lebanon. PARTICIPANTS 159 pregnant and postpartum women with confirmed PAS between 2007-2020. MAIN OUTCOME MEASURES Maternal characteristics, management, and maternal and neonatal outcomes. RESULTS Out of the 159 women with PAS included, 107 (67.3%) underwent planned caesarean delivery and 52 (32.7%) had urgent delivery. Women who underwent urgent delivery for PAS management were more likely to experience antenatal vaginal bleeding compared to those in the planned group (55.8% vs 28.0%, p<0.001). Median gestational age at delivery was significantly lower for the urgent group compared to the planned (34 vs. 36 weeks, p<0.001). There were no significant differences in terms of blood transfusion rates and major maternal morbidity between the two groups; however, median estimated blood loss was significantly higher for women with urgent delivery (1500ml vs. 1200ml, p = 0.011). Furthermore, the urgent delivery group had a significantly lower birth weight (2177.5g vs. 2560g, p<0.001) with higher rates of neonatal intensive care unit (NICU) admission (53.7% vs 23.8%, p<0.001) and perinatal mortality (18.5% vs 3.8%, p = 0.005). CONCLUSION Urgent delivery among women with PAS is associated with worse maternal and neonatal outcomes compared to the planned approach. Therefore, early referral of women with known or suspected PAS to specialized centres is highly desirable to maximise optimal outcomes for both women and infants.
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Affiliation(s)
- Stephen J. McCall
- Faculty of Health Sciences, Center for Research on Population and Health, American University of Beirut, Beirut, Lebanon
| | - Sara Mansour
- Faculty of Health Sciences, Center for Research on Population and Health, American University of Beirut, Beirut, Lebanon
| | - Janoub Khazaal
- Department of Obstetrics and Gynecology, Rafik Hariri University Hospital, Beirut, Lebanon
| | - Gilles Kayem
- Faculty of Health Sciences, Center for Research on Population and Health, American University of Beirut, Beirut, Lebanon
- Paris University, Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical Perinatal and Paediatric Epidemiology Research Team, EPOPé, INSERM, Paris, France
- Department of Obstetrics and Gynecology, Trousseau Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jocelyn DeJong
- Faculty of Health Sciences, Department of Epidemiology and Population Health, American University of Beirut, Beirut, Lebanon
| | - Rabih Chahine
- Department of Obstetrics and Gynecology, Rafik Hariri University Hospital, Beirut, Lebanon
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Dar P, Doulaveris G. First-trimester screening for placenta accreta spectrum. Am J Obstet Gynecol MFM 2024; 6:101329. [PMID: 38447672 DOI: 10.1016/j.ajogmf.2024.101329] [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: 11/28/2023] [Revised: 02/02/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
In recent years, there has been a significant rise in cases of placenta accreta spectrum, a group of life-threatening placental disorders that can arise during childbirth. Early detection plays a crucial role in facilitating meticulous delivery planning, ultimately leading to a reduction in mortality and morbidity rates and improved overall outcomes. Although third-trimester ultrasound has traditionally been the primary method for prenatal screening for placenta accreta spectrum, it often falls short in identifying cases or diagnosis is too late for optimal delivery planning. Emerging evidence has highlighted the option of early detection of placenta accreta spectrum indicators during the first trimester of pregnancy. This comprehensive review delves into our current knowledge of sonographic assessment of the uterine cervicoisthmic complex in the first trimester, examining the location and appearance of cesarean scars and exploring first-trimester screening strategies, ultimately paving the way for improved maternal and neonatal outcomes.
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Affiliation(s)
- Pe'er Dar
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine (Drs Dar and Doulaveris), Bronx, NY.
| | - Georgios Doulaveris
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine (Drs Dar and Doulaveris), Bronx, NY
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You H, Wang Y, Han R, Gu J, Zeng L, Zhao Y. Risk factors for placenta accreta spectrum without prior cesarean section: A case-control study in China. Int J Gynaecol Obstet 2024. [PMID: 38573157 DOI: 10.1002/ijgo.15493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/22/2024] [Accepted: 03/10/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVE To identify the risk factors for placenta accreta spectrum (PAS) disorders in women without prior cesarean section (CS). METHODS This retrospective case-control study investigated patients without prior CS who gave birth at Peking University Third Hospital between January 1, 2015 and December 31, 2021. Patients diagnosed with PAS according to the clinical diagnostic criteria of the 2019 International Federation of Gynecology and Obstetrics (FIGO) classification were included as the study group. Patients were matched as the control group according to delivery date and placenta previa, in a 1:2 allocation ratio. Maternal characteristics were compared between the two groups. RESULTS The study included 348 patients in the study group and 696 in the control group. The multivariate analysis showed that the independent risk factors of PAS consisted of operative hysteroscopy (once: adjusted odds ratio [aOR] 2.38, 95% CI 1.28-4.24, P = 0.006; twice or more: aOR 5.43, 95% CI 1.04-28.32, P = 0.045), uterine curettage (once: aOR 2.54, 95% CI 1.80-3.58, P < 0.001; twice: aOR 3.01, 95% CI 1.81-5.02, P < 0.001; three or more times: aOR 9.18, 95% CI 4.64-18.18, P < 0.001), multifetal pregnancy (aOR 5.64, 95% CI 3.01-10.57, P < 0.001), adenomyosis (aOR 2.77, 95% CI 1.23-6.22, P = 0.014), in vitro fertilization (aOR 1.51, 95% CI 1.04-2.20, P = 0.030) and pre-eclampsia (aOR 2.72, 95% CI 1.36-5.45, P = 0.005), and the independent protective factor was being multiparous (aOR 0.37, 95% CI 0.25-0.54, P < 0.001). CONCLUSION After controlling the effect of placenta previa, we found that patients with PAS without prior CS had unique maternal characteristics. Classification and quantification of the intrauterine surgeries they have undergone is essential for identifying high-risk patients. Early identification of high-risk groups by risk factors has the potential to improve the prognosis considerably.
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Affiliation(s)
- Huanyu You
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yan Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Centre for Healthcare Quality Management in Obsterics, Beijing, China
| | - Rui Han
- Department of Obstetrics, Maternal and Child Health Hospital of Changzhi, Changzhi, China
| | - Jinyu Gu
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Lin Zeng
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Centre for Healthcare Quality Management in Obsterics, Beijing, China
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Sharami SH, Milani F, Fallah Arzpeyma S, Fakour F, Jafarzadeh Z, Haghparast Z, Sedighinejad A, Attari SM. Placenta accreta outcomes and risk factors in a referral hospital in north of Iran: A case control study. Health Sci Rep 2024; 7:e2006. [PMID: 38605724 PMCID: PMC11006998 DOI: 10.1002/hsr2.2006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 03/11/2024] [Accepted: 03/13/2024] [Indexed: 04/13/2024] Open
Abstract
Background Placenta accreta syndrome (PAS) may led to heavy blood loss and maternal death. Here we analyzed the main risk factors of PAS+ pregnancies and its complications in a referral hospital in the north of Iran. Methods In a case control study, all pregnant women with PAS referred to our department during 2016 till 2021 were enrolled and divided in two groups case (PAS+) and control (PAS-) based on preoperative imaging, intraoperative findings, and pathological reports. The sociodemographic features and neonatal-maternal outcomes also were recorded. Results The most frequent reason for cesarean (C/S) was repeated C/S (62.9%, 56/89). A significant difference showed up in the time lag between previous C/S and the present delivery (p < 0.001) which shows that when the time distance is longer, the risk of PAS rises (OR: 1.01 [95% CI: 1.003-1.017]). Also, a positive history of prior abortion and elective type of previous C/S were related to PAS+ pregnancies. Our other finding showed that PAS+ pregnancies will end in lower gestational age and have a longer duration of operation and hospitalization, heavy blood transfusion, and hysterectomy. Also, PAS+ pregnancies were not related to poor neonatal outcomes. Conclusions It seems that, in addition to repeated C/S as a strong risk factor, previous abortion is a forgotten key which leads to incomplete evacuation or damage the endometrial-myometrial layers.
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Affiliation(s)
- Seyedeh Hajar Sharami
- Department of Obstetrics & Gynecology, Reproductive Health Research Center, Al‐Zahra Hospital, School of MedicineGuilan University of Medical SciencesRashtIran
| | - Forozan Milani
- Department of Obstetrics & Gynecology, Reproductive Health Research Center, Al‐Zahra Hospital, School of MedicineGuilan University of Medical SciencesRashtIran
| | - Sima Fallah Arzpeyma
- Department of Radiology, School of Medicine, Poursina HospitalGuilan University of Medical SciencesRashtIran
| | - Fereshteh Fakour
- Department of Obstetrics & Gynecology, Reproductive Health Research Center, Al‐Zahra Hospital, School of MedicineGuilan University of Medical SciencesRashtIran
| | - Zahra Jafarzadeh
- Department of Obstetrics & Gynecology, Reproductive Health Research Center, Al‐Zahra Hospital, School of MedicineGuilan University of Medical SciencesRashtIran
| | - Zahra Haghparast
- Department of Obstetrics & Gynecology, Reproductive Health Research Center, Al‐Zahra Hospital, School of MedicineGuilan University of Medical SciencesRashtIran
| | - Abbas Sedighinejad
- Department of Anesthesiology, Anesthesiology Research Center, Alzahra HospitalGuilan University of Medical SciencesRashtIran
| | - Seyedeh Maryam Attari
- Department of Midwifery and Reproductive Health, Reproductive Health Research Center, Al‐Zahra HospitalGuilan University of Medical SciencesRashtIran
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Jwa SC, Tamaru S, Takamura M, Namba A, Kajihara T, Ishihara O, Kamei Y. Assisted reproductive technology-associated risk factors for placenta accreta spectrum after vaginal delivery. Sci Rep 2024; 14:7454. [PMID: 38548810 PMCID: PMC10978827 DOI: 10.1038/s41598-024-57988-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 03/24/2024] [Indexed: 04/01/2024] Open
Abstract
This study aimed to investigate assisted reproductive technology (ART) factors associated with placenta accreta spectrum (PAS) after vaginal delivery. This was a registry-based retrospective cohort study using the Japanese national ART registry. Cases of live singleton infants born via vaginal delivery after single embryo transfer (ET) between 2007 and 2020 were included (n = 224,043). PAS was diagnosed in 1412 cases (0.63% of deliveries), including 1360 cases (96.3%) derived from frozen-thawed ET cycles and 52 (3.7%) following fresh ET. Among fresh ET cycles, assisted hatching (AH) (adjusted odds ratio [aOR], 2.5; 95% confidence interval [CI] 1.4-4.7) and blastocyst embryo transfer (aOR, 2.2; 95% CI 1.3-3.9) were associated with a significantly increased risk of PAS. For frozen-thawed ET cycles, hormone replacement cycles (HRCs) constituted the greatest risk factor (aOR, 11.4; 95% CI 8.7-15.0), with PAS occurring in 1.4% of all vaginal deliveries following HRC (1258/91,418 deliveries) compared with only 0.11% following natural cycles (55/47,936). AH was also associated with a significantly increased risk of PAS in frozen-thawed cycles (aOR, 1.2; 95% CI 1.02-1.3). Our findings indicate the need for additional care in the management of patients undergoing vaginal delivery following ART with HRC and AH.
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Affiliation(s)
- Seung Chik Jwa
- Department of Obstetrics and Gynecology, Saitama Medical University, 38 Morohongo, Moroyama, Saitama, 350-0495, Japan.
- Department of Obstetrics and Gynecology, Jichi Medical University, Tochigi, Japan.
| | - Shunsuke Tamaru
- Department of Obstetrics and Gynecology, Saitama Medical University, 38 Morohongo, Moroyama, Saitama, 350-0495, Japan
| | - Masashi Takamura
- Department of Obstetrics and Gynecology, Saitama Medical University, 38 Morohongo, Moroyama, Saitama, 350-0495, Japan
| | - Akira Namba
- Department of Obstetrics and Gynecology, Saitama Medical University, 38 Morohongo, Moroyama, Saitama, 350-0495, Japan
| | - Takeshi Kajihara
- Department of Obstetrics and Gynecology, Saitama Medical University, 38 Morohongo, Moroyama, Saitama, 350-0495, Japan
| | - Osamu Ishihara
- Department of Obstetrics and Gynecology, Saitama Medical University, 38 Morohongo, Moroyama, Saitama, 350-0495, Japan
- Kagawa Nutrition University, Saitama, Japan
| | - Yoshimasa Kamei
- Department of Obstetrics and Gynecology, Saitama Medical University, 38 Morohongo, Moroyama, Saitama, 350-0495, Japan
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Peng L, Yang Z, Liu J, Liu Y, Huang J, Chen J, Su Y, Zhang X, Song T. Prenatal Diagnosis of Placenta Accreta Spectrum Disorders: Deep Learning Radiomics of Pelvic MRI. J Magn Reson Imaging 2024; 59:496-509. [PMID: 37222638 DOI: 10.1002/jmri.28787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/02/2023] [Accepted: 05/02/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Diagnostic performance of placenta accreta spectrum (PAS) by prenatal MRI is unsatisfactory. Deep learning radiomics (DLR) has the potential to quantify the MRI features of PAS. PURPOSE To explore whether DLR from MRI can be used to identify pregnancies with PAS. STUDY TYPE Retrospective. POPULATION 324 pregnant women (mean age, 33.3 years) suspected PAS (170 training and 72 validation from institution 1, 82 external validation from institution 2) with clinicopathologically proved PAS (206 PAS, 118 non-PAS). FIELD STRENGTH/SEQUENCE 3-T, turbo spin-echo T2-weighted images. ASSESSMENT The DLR features were extracted using the MedicalNet. An MRI-based DLR model incorporating DLR signature, clinical model (different clinical characteristics between PAS and non-PAS groups), and MRI morphologic model (radiologists' binary assessment for the PAS diagnosis) was developed. These models were constructed in the training dataset and then validated in the validation datasets. STATISTICAL TESTS The Student t-test or Mann-Whitney U, χ2 or Fisher exact test, Kappa, dice similarity coefficient, intraclass correlation coefficients, least absolute shrinkage and selection operator logistic regression, multivariate logistic regression, receiver operating characteristic (ROC) curve, DeLong test, net reclassification improvement (NRI) and integrated discrimination improvement (IDI), calibration curve with Hosmer-Lemeshow test, decision curve analysis (DCA). P < 0.05 indicated a significant difference. RESULTS The MRI-based DLR model had a higher area under the curve than the clinical model in three datasets (0.880 vs. 0.741, 0.861 vs. 0.772, 0.852 vs. 0.675, respectively) or MRI morphologic model in training and independent validation datasets (0.880 vs. 0.760, 0.861, vs. 0.781, respectively). The NRI and IDI were 0.123 and 0.104, respectively. The Hosmer-Lemeshow test had nonsignificant statistics (P = 0.296 to 0.590). The DCA offered a net benefit at any threshold probability. DATA CONCLUSION An MRI-based DLR model may show better performance in diagnosing PAS than a clinical or MRI morphologic model. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY STAGE: 2.
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Affiliation(s)
- Lulu Peng
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Guangzhou Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Zehong Yang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Jue Liu
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Guangzhou Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Yi Liu
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Guangzhou Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Jianwei Huang
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Guangzhou Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Junwei Chen
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Yun Su
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Xiang Zhang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Ting Song
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Guangzhou Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
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12
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Munoz JL, Einerson BD, Silver RM, Mulampurath S, Sherman LS, Rameshwar P, Prewit EB, Ramsey PS. Serum exosomal microRNA pathway activation in placenta accreta spectrum: pathophysiology and detection. AJOG GLOBAL REPORTS 2024; 4:100319. [PMID: 38440154 PMCID: PMC10910333 DOI: 10.1016/j.xagr.2024.100319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Placenta accreta spectrum disorders are a complex range of placental pathologies that are associated with significant maternal morbidity and mortality. A diagnosis of placenta accreta spectrum relies on ultrasonographic findings with modest positive predictive value. Exosomal microRNAs are small RNA molecules that reflect the cellular processes of the origin tissues. OBJECTIVE We aimed to explore exosomal microRNA expression to understand placenta accreta spectrum pathology and clinical use for placenta accreta spectrum detection. STUDY DESIGN This study was a biomarker analysis of prospectively collected samples at 2 academic institutions from 2011 to 2022. Plasma specimens were collected from patients with suspected placenta accreta spectrum, placenta previa, or repeat cesarean deliveries. Exosomes were quantified and characterized by nanoparticle tracking analysis and western blotting. MicroRNA were assessed by polymerase chain reaction array and targeted single quantification. MicroRNA pathway analysis was performed using the Ingenuity Pathway Analyses software. Placental biopsies were taken from all groups and analyzed by polymerase chain reaction and whole cell enzyme-linked immunosorbent assay. Receiver operating characteristic curve univariate analysis was performed for the use of microRNA in the prediction of placenta accreta spectrum. Clinically relevant outcomes were collected from abstracted medical records. RESULTS Plasma specimens were analyzed from a total of 120 subjects (60 placenta accreta spectrum, 30 placenta previa, and 30 control). Isolated plasma exosomes had a mean size of 71.5 nm and were 10 times greater in placenta accreta spectrum specimens (20 vs 2 particles/frame). Protein expression of exosomes was positive for intracellular adhesion molecule 1, flotilin, annexin, and CD9. MicroRNA analysis showed increased detection of 3 microRNAs (mir-92, -103, and -192) in patients with placenta accreta spectrum. Pathway interaction assessment revealed differential regulation of p53 signaling in placenta accreta spectrum and of erythroblastic oncogene B2 or human epidermal growth factor 2 in control specimens. These findings were subsequently confirmed in placental protein analysis. Placental microRNA paralleled plasma exosomal microRNA expression. Biomarker assessment of placenta accreta spectrum signature microRNA had an area under the receiver operating characteristic curve of 0.81 (P<.001; 95% confidence interval, 0.73-0.89) with a sensitivity and specificity of 89.2% and 80%, respectively. CONCLUSION In this large cohort, plasma exosomal microRNA assessment revealed differentially expressed pathways in placenta accreta spectrum, and these microRNAs are potential biomarkers for the detection of placenta accreta spectrum.
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Affiliation(s)
- Jessian L. Munoz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Dr Munoz)
- Division of Fetal Intervention, Department of Obstetrics and Gynecology, Texas Children's Hospital, Houston, TX (Dr Munoz)
| | - Brett D. Einerson
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT (XX Einerson and Dr Silver)
| | - Robert M. Silver
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT (XX Einerson and Dr Silver)
| | - Sureshkumar Mulampurath
- Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio and the University Health System, San Antonio, TX (XX Mulampurath, XX Prewit, and Dr Ramsey)
| | - Lauren S. Sherman
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ (XX Sherman and XX Rameshwar)
| | - Pranela Rameshwar
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ (XX Sherman and XX Rameshwar)
| | - Egle Bytautiene Prewit
- Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio and the University Health System, San Antonio, TX (XX Mulampurath, XX Prewit, and Dr Ramsey)
| | - Patrick S. Ramsey
- Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio and the University Health System, San Antonio, TX (XX Mulampurath, XX Prewit, and Dr Ramsey)
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13
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Feng X, Mao X, Zhao J. Clinical Characteristics, Prenatal Diagnosis and Outcomes of Placenta Accreta Spectrum in Different Placental Locations: A Retrospective Cohort Study. Int J Womens Health 2024; 16:155-162. [PMID: 38292300 PMCID: PMC10826409 DOI: 10.2147/ijwh.s439654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/22/2024] [Indexed: 02/01/2024] Open
Abstract
Objective To explore the prenatal diagnosis, clinical characteristics, and perinatal outcomes of placenta accreta spectrum in different placental locations. Methods This was a retrospective cohort study. Pregnant women who delivered at two tertiary referral hospitals from January 2013 to December 2022 and were ultimately pathologically diagnosed with placenta accreta spectrum were included. They were divided into three groups based on different placental locations (anterior, posterior, and lateral wall/fundus). The differences in prenatal diagnosis, clinical characteristics, and perinatal outcomes among the three groups were compared. Results There were 115,470 deliveries in a ten-year period at the two hospitals, and 118 case patients were confirmed to have a pathologically diagnosed placenta accreta spectrum. The posterior placenta group had a lower rate of placenta previa (76.9% vs 94.9% vs 100%, p<0.05) and a higher gestational age at delivery (36.4±2.45 vs 34.91±1.76 vs 34.31±3.41, p<0.05) compared to the other two groups. The anterior placenta group had a significantly higher rate of invasive (increta/percreta) form placenta accreta spectrum (81.4% vs 36.5% vs 28.6%, p<0.05) and planned cesarean section (96.6% vs 80.8% vs 71.4%, p<0.05) compared to the other two groups. In terms of prenatal diagnosis, the anterior placenta group had a significantly higher rate of placenta accreta spectrum prenatal suspicion rate compared to the other two groups (86.4% vs 36.5% vs 57.1%, p<0.05). The posterior placenta group had a lower rate of preoperative abdominal aortic balloon placement compared to the other two groups (5.8% vs 28.8% vs 28.6%, p<0.05). There were no statistically significant differences among the three groups in primary perinatal outcomes, though the anterior placenta group had a longer postoperative hospital stay. Conclusion The prenatal diagnosis rate and proportion of invasive form of placenta accreta spectrum occurring in non-anterior placenta are relatively lower than anterior placenta. There were no significant differences in major perinatal outcomes among the three groups.
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Affiliation(s)
- Xiaoling Feng
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, 401120, People’s Republic of China
| | - Xun Mao
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, 401120, People’s Republic of China
| | - Jianlin Zhao
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People’s Republic of China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing, 400016, People’s Republic of China
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14
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Zhao J, Li Q, Liao E, Shi H, Luo X, Zhang L, Qi H, Zhang H, Li J. Incidence, risk factors and maternal outcomes of unsuspected placenta accreta spectrum disorders: a retrospective cohort study. BMC Pregnancy Childbirth 2024; 24:76. [PMID: 38262978 PMCID: PMC10804779 DOI: 10.1186/s12884-024-06254-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 01/03/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND To identify incidence and underlying risk factors for unsuspected placenta accreta spectrum (PAS) and compare the maternal outcomes between suspected and unsuspected cases in three large academic referral centers. METHODS A retrospective cohort study was conducted in three university-based tertiary referral centers from Jan 1st, 2013, to Dec 31st, 2022. All cases of PAS confirmed by pathology were included in the study. Unsuspected PAS cases were diagnosed at the time of delivery, while suspected cases served as the control group. Potential risk factors were compared between the two groups. Multivariable regression model was also performed to identify risk factors. Maternal outcomes were also evaluated. RESULTS A total of 339 pathology-confirmed PAS cases were included in the study out of 415,470 deliveries, of which 35.4% (n = 120) were unsuspected cases. Unsuspected PAS cases were 7.9 times more likely to have a history of intrauterine adhesions (adjusted odds ratio [aOR] 7.93; 95% confidence interval [CI] 2.35-26.81), 7.0 times more likely to have a history of clinically confirmed PAS (aOR, 6.99; 95% CI 2.85-17.18), 6.3 times more likely to have a posterior placenta (aOR, 6.30; 95% CI 3.48-11.40), and 3.4 times more likely to have a history of placenta previa (aOR, 3.41; 95% CI 1.18-9.82). On the other hand, cases with gravidity > 3, placenta previa, and/or a history of previous cesarean delivery were more likely to be diagnosed antenatally (aOR 0.40, 0.19, 0.36; 95% CI 0.22-0.74, 0.09-0.40, 0.19-0.70). Although the suspected PAS group had a higher proportion of invasive cases and abdominal and pelvic organ injuries (74.4% vs. 25.8%, p < 0.001; 6.8% vs. 1.7%, p = 0.037), the maternal outcomes were more favorable in the sPAS group, with a lower median volume of 24-hour blood loss and blood product transfusion (estimated blood loss in 24 h, 1000 [800-2000] vs. 2000 [1400-2400], p < 0.001; RBC unit transfusion, 0 [0-800] vs. 800 [600-1000], p < 0.001; fresh-frozen plasma transfusion, 0 [0-450] vs. 600 [400-800], p < 0.001). CONCLUSIONS Our findings indicate that 35% of patients with PAS were unsuspected prior to delivery. Factors associated with PAS being unsuspected prior to delivery include a history of intrauterine adhesions, a history of clinically confirmed PAS, a posterior placenta, and a history of placenta previa. Additionally, gravidity > 3, a history of previous cesarean delivery, and placenta previa increase the likelihood of antenatal diagnosis.
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Affiliation(s)
- Jianlin Zhao
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing, 400016, China
| | - Qin Li
- Department of Obstetrics and Gynecology, Chongqing Health Center for Women and Children, Women and Children's Hospital of Chongqing Medical University, Chongqing, 401147, China
| | - E Liao
- Department of Obstetrics and Gynecology, Maternal and Child Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430070, Hubei Province, China
| | - Haijun Shi
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing, 400016, China
| | - Xin Luo
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing, 400016, China
| | - Lan Zhang
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing, 400016, China
| | - Hongbo Qi
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing, 400016, China
- Department of Obstetrics and Gynecology, Chongqing Health Center for Women and Children, Women and Children's Hospital of Chongqing Medical University, Chongqing, 401147, China
| | - Hua Zhang
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing, 400016, China.
| | - Junnan Li
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
- Chongqing Key Laboratory of Maternal and Fetal Medicine, Chongqing Medical University, Chongqing, 400016, China.
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15
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Doğru Ş, Akkuş F, Atci AA, Metin ÜS, Uyar M, Acar A. Fetal and maternal outcomes of segmental uterine resection in emergency and planned placenta percreta deliveries. Obstet Gynecol Sci 2024; 67:58-66. [PMID: 38044617 DOI: 10.5468/ogs.23154] [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: 06/10/2023] [Accepted: 10/24/2023] [Indexed: 12/05/2023] Open
Abstract
OBJECTIVE This study evaluated maternal and fetal outcomes of emergency uterine resection versus planned segmental uterine resection in patients with placenta percreta (PPC) and placenta previa (PP). METHODS Patients with PP and PPC who underwent planned or emergency segmental uterine resection were included in this study. Demographic data, hemorrhagic morbidities, intra- and postoperative complications, length of hospital stay, surgical duration, and peri- and neonatal morbidities were compared. RESULTS A total of 141 PPC and PP cases were included in this study. Twenty-five patients (17.73%) underwent emergency uterine resection, while 116 (82.27%) underwent planned segmental uterine resections. The postoperative hemoglobin changes, operation times, total blood transfusion, bladder injury, and length of hospital stay did not differ significantly between groups (P=0.7, P=0.6, P=0.9, P=0.9, and P=0.2, respectively). Fetal weights, 5-minute Apgar scores, and neonatal intensive care unit admission rates did not differ significantly between groups. The gestational age at delivery of patients presenting with bleeding was lower than that of patients who were admitted in active labor and underwent elective surgery (32 weeks [95% confidence interval [CI], 26-37] vs. 35 weeks [95% CI, 34-35]; P=0.037). CONCLUSION Using a multidisciplinary approach, this study performed at a tertiary center showed that maternal and fetal morbidity and mortality did not differ significantly between emergency versus planned segmental uterine resection.
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Affiliation(s)
- Şükran Doğru
- Division of Perinatology, Department of Obstetrics and Gynecology, Necmettin Erbakan University Medical School of Meram, Konya, Turkey
| | - Fatih Akkuş
- Division of Perinatology, Department of Obstetrics and Gynecology, Necmettin Erbakan University Medical School of Meram, Konya, Turkey
| | - Aslı Altinordu Atci
- Division of Perinatology, Department of Obstetrics and Gynecology, Necmettin Erbakan University Medical School of Meram, Konya, Turkey
| | - Ülfet Sena Metin
- Department of Obstetrics and Gynecology, Necmettin Erbakan University Medical School of Meram, Konya, Turkey
| | - Mehmet Uyar
- Department of public health, Necmettin Erbakan University Medical School of Meram, Konya, Turkey
| | - Ali Acar
- Department of Obstetrics and Gynecology, Necmettin Erbakan University Medical School of Meram, Konya, Turkey
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16
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Fitzgerald GD, Newton JM, Atasi L, Buniak CM, Burgos-Luna JM, Burnett BA, Carver AR, Cheng C, Conyers S, Davitt C, Deshmukh U, Donovan BM, Easter SR, Einerson BD, Fox KA, Habib AS, Harrison R, Hecht JL, Licon E, Nino JM, Munoz JL, Nieto-Calvache AJ, Polic A, Ramsey PS, Salmanian B, Shamshirsaz AA, Shamshirsaz AA, Shrivastava VK, Woolworth MB, Yurashevich M, Zuckerwise L, Shainker SA. Placenta accreta spectrum care infrastructure: an evidence-based review of needed resources supporting placenta accreta spectrum care. Am J Obstet Gynecol MFM 2024; 6:101229. [PMID: 37984691 DOI: 10.1016/j.ajogmf.2023.101229] [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: 09/07/2023] [Revised: 11/02/2023] [Accepted: 11/15/2023] [Indexed: 11/22/2023]
Abstract
The incidence of placenta accreta spectrum, the deeply adherent placenta with associated increased risk of maternal morbidity and mortality, has seen a significant rise in recent years. Therefore, there has been a rise in clinical and research focus on this complex diagnosis. There is international consensus that a multidisciplinary coordinated approach optimizes outcomes. The composition of the team will vary from center to center; however, central themes of complex surgical experts, specialists in prenatal diagnosis, critical care specialists, neonatology specialists, obstetrics anesthesiology specialists, blood bank specialists, and dedicated mental health experts are universal throughout. Regionalization of care is a growing trend for complex medical needs, but the location of care alone is just a starting point. The goal of this article is to provide an evidence-based framework for the crucial infrastructure needed to address the unique antepartum, delivery, and postpartum needs of the patient with placenta accreta spectrum. Rather than a clinical checklist, we describe the personnel, clinical unit characteristics, and breadth of contributing clinical roles that make up a team. Screening protocols, diagnostic imaging, surgical and potential need for critical care, and trauma-informed interaction are the basis for comprehensive care. The vision from the author group is that this publication provides a semblance of infrastructure standardization as a means to ensure proper preparation and readiness.
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Affiliation(s)
- Garrett D Fitzgerald
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI (Dr Fitzgerald).
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN (Dr Newton)
| | - Lamia Atasi
- Department of Obstetrics and Gynecology, Mercy Hospital, St. Louis, MO (Dr Atasi)
| | - Christina M Buniak
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA (Dr Buniak)
| | | | - Brian A Burnett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Dr Burnett)
| | - Alissa R Carver
- Department of Obstetrics and Gynecology, Wilmington Maternal-Fetal Medicine, Wilmington, NC (Dr Carver)
| | - CeCe Cheng
- Department of Obstetrics and Gynecology, Health Science Center at San Antonio, University of Texas, San Antonio, TX (Dr Cheng)
| | - Steffany Conyers
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Caroline Davitt
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Davitt and Am Shamshiraz)
| | - Uma Deshmukh
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Bridget M Donovan
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Donovan and Shainker)
| | - Sara Rae Easter
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA (Dr Easter)
| | - Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT (Dr Einerson)
| | - Karin A Fox
- Baylor College of Medicine, Houston, TX (Dr Fox)
| | - Ashraf S Habib
- Duke University School of Medicine, Durham, NC (Dr Habib)
| | - Rachel Harrison
- Department of Obstetrics and Gynecology, Advocate Aurora Health, Chicago, IL (Dr Harrison)
| | - Jonathan L Hecht
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Ernesto Licon
- Miller Women's & Children's Hospital/Long Beach Memorial Medical Center, Orange, CA (Dr Licon)
| | - Julio Mateus Nino
- Department of Obstetrics and Gynecology, Atrium Health Wake Forest School of Medicine, Winston-Salem, NC (Dr Nino)
| | - Jessian L Munoz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX (Dr Munoz)
| | | | | | - Patrick S Ramsey
- University of Texas Health/University Health San Antonio, San Antonio, TX (Dr Ramsey)
| | - Bahram Salmanian
- Department of Obstetrics and Gynecology, University of Colorado Health Anschutz Medical Campus, Boulder, CO (Dr Salmanian)
| | | | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Davitt and Am Shamshiraz)
| | - Vineet K Shrivastava
- Miller Women's and Children's Hospital/Long Beach Memorial Medical Center, Orange, CA (Dr Shrivastava)
| | | | - Mary Yurashevich
- Department of Anesthesiology, Duke Health, Durham, NC (Dr Yurashevich)
| | - Lisa Zuckerwise
- and Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN (Dr Zuckerwise)
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Donovan and Shainker)
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Salmanian B, Shamshirsaz AA, Fox KA, Asl NM, Erfani H, Detlefs SE, Coburn M, Espinoza J, Nassr A, Belfort MA, Clark SL, Shamshirsaz AA. Clinical Outcomes of a False-Positive Antenatal Diagnosis of Placenta Accreta Spectrum. Am J Perinatol 2024; 41:187-192. [PMID: 34666389 DOI: 10.1055/a-1673-5103] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Antenatal diagnosis of placenta accreta spectrum (PAS) is critical to reduce maternal morbidity. While clinical outcomes of women with PAS have been extensively described, little information is available regarding the women who undergo cesarean delivery with a presumptive PAS diagnosis that is not confirmed by histopathologic examination. We sought to examine resource utilization and clinical outcomes of this group of women with a false-positive diagnosis of PAS. STUDY DESIGN This is a retrospective analysis of patients with prenatally diagnosed PAS cared for between 2015 and 2020 by our multidisciplinary PAS team. Maternal outcomes were examined. Univariate analysis was performed and a multivariate model was employed to compare outcomes between women with and without histopathologically confirmed PAS. RESULTS A total of 162 patients delivered with the preoperative diagnosis of PAS. Of these, 146 (90%) underwent hysterectomy and had histopathologic confirmation of PAS. Thirteen women did not undergo the planned hysterectomy. Three women underwent hysterectomy but pathologic examination did not confirm PAS. In comparing women with and without pathologic confirmation of PAS, the false-positive PAS group delivered later in pregnancy (34 vs. 33 weeks of gestation, p = 0.015) and had more planned surgery (88 vs. 47%, p = 0.002). There was no difference in skin incision type or hysterotomy placement for delivery. No significant difference in either the estimated blood loss or blood components transfused was noted between groups. CONCLUSION Careful intraoperative evaluation of women with preoperatively presumed PAS resulted in a 3/149 (2%) retrospectively unnecessary hysterectomy. Management of women with PAS in experienced centers benefits patients in terms of both resource utilization and avoidance of unnecessary maternal morbidity, understanding that our results are produced in a center of excellence for PAS. We also propose a management protocol to assist in the avoidance of unnecessary hysterectomy in women with the preoperative diagnosis of PAS. KEY POINTS · Evaluation and delivery planning of patients with suspected placenta accreta spectrum in experienced centers provides acceptable outcomes.. · Under specific circumstances, delivery of placenta may be attempted if placenta accreta is suspected.. · Patients with suspected placenta accreta rarely undergo unindicated hysterectomy..
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Affiliation(s)
- Bahram Salmanian
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Karin A Fox
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | | | - Hadi Erfani
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Sarah E Detlefs
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Michael Coburn
- Department of Urology, Baylor College of Medicine, Houston, Texas
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Ahmed Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Steven L Clark
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
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Saxena U, Rana M, Tripathi S, Misra RN, Khambra P. Prediction of Placenta Accreta Spectrum by Prenatal Ultrasound Staging System in Women with Placenta Previa with Scarred Uterus. J Obstet Gynaecol India 2023; 73:191-198. [PMID: 38143989 PMCID: PMC10746622 DOI: 10.1007/s13224-023-01830-3] [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: 12/02/2022] [Accepted: 08/16/2023] [Indexed: 12/26/2023] Open
Abstract
Background Placenta accreta spectrum (PAS) disorders are defined as range of pathological adherence/invasion of placenta. Prenatal diagnosis of PAS disorders using ultrasound doppler can optimize fetomaternal outcome and reduce complications. Objectives To study the predictive value of prenatal ultrasound staging system for the presence and severity of placenta accreta spectrum and its correlation with fetomaternal outcomes. Method This was a prospective cohort study conducted in Obstetrics and Gynecology department at VMMC and Safdarjung Hospital, New Delhi, over a period of 18 months. It included 50 women with singleton pregnancy > 28 weeks with placenta previa with scarred uterus after taking informed consent and ethics committee approval. All the women underwent ultrasound and PAS score was assigned, which was correlated with intraoperative FIGO grade, histopathology and fetomaternal outcomes. Results In 50 women enrolled, prenatal ultrasound staging was performed and PAS score 0, 1, 2 and 3 was assigned. Cesarean hysterectomy was required in all 21(42%) women with PAS score > 0 (PAS 1, 2, 3). Intraoperative, focal and complete invasion was seen in 4% and 38%, respectively, and FIGO grade 1, 2, 3, 4, 5 and 6 was observed in 46%, 16%, 30%, 0%, 6% and 2%, respectively. On histopathology, 14.28% (3/21) with PAS > 0 did not have any invasion, while 85.71% (18/21) had invasion, i.e., accreta, increta and percreta in 57.14%, 19.05% and 9.52%, respectively. Considering histopathology as gold standard, the overall sensitivity, specificity, PPV, NPV and diagnostic accuracy of PAS score were 100%, 90.62%, 85.71%, 100% and 94%, respectively. Conclusion Prenatal ultrasound staging system is a simple and feasible screening modality. Hence, it should be used in all high-risk women with placenta previa and scarred uterus for definitive prenatal diagnosis of PAS.
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Affiliation(s)
- Upma Saxena
- Department of Obstetrics and Gynaecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029 India
| | - Monika Rana
- Department of Obstetrics and Gynaecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029 India
| | - Shiwani Tripathi
- Department of Obstetrics and Gynaecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029 India
| | - Ritu Nair Misra
- Department of Obstetrics and Gynaecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029 India
- Department of Radiodiagnosis, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029 India
| | - Poonam Khambra
- Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029 India
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19
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Sugai S, Yamawaki K, Sekizuka T, Haino K, Yoshihara K, Nishijima K. Comparison of maternal outcomes and clinical characteristics of prenatally vs nonprenatally diagnosed placenta accreta spectrum: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:101197. [PMID: 37865220 DOI: 10.1016/j.ajogmf.2023.101197] [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: 08/12/2023] [Revised: 10/14/2023] [Accepted: 10/16/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVE This study aimed to compare maternal outcomes of prenatally and nonprenatally diagnosed placenta accreta spectrum. DATA SOURCES A systematic literature search was performed in PubMed, the Cochrane database, and Web of Science until November 28, 2022. STUDY ELIGIBILITY CRITERIA Studies comparing the clinical presentation of prenatally and nonprenatally diagnosed placenta accreta spectrum were included. The primary outcomes were emergent cesarean delivery, hysterectomy, blood loss volume, number of transfused blood product units, urological injury, coagulopathy, reoperation, intensive care unit admission, and maternal death. In addition, the pooled mean values for blood loss volume and the number of transfused blood product units were calculated. The secondary outcomes included maternal age, gestational age at birth, nulliparity, previous cesarean delivery, previous uterine procedure, assisted reproductive technology, placenta increta and percreta, and placenta previa. METHODS Study screening was performed after duplicates were identified and removed. The quality of each study and the publication bias were assessed. Forest plots and I2 statistics were calculated for each study outcome for each group. The main analysis was a random-effects analysis. RESULTS Overall, 415 abstracts and 157 full-text studies were evaluated. Moreover, 31 studies were analyzed. Prenatally diagnosed placenta accreta spectrum was associated with a significantly lower rate of emergency cesarean delivery (odds ratio, 0.37; 95% confidence interval, 0.21-0.67), higher hysterectomy rate (odds ratio, 1.98; 95% confidence interval, 1.02-3.83), lower blood loss volume (mean difference, -0.65; 95% confidence interval, -1.17 to -0.13), and lower number of transfused red blood cell units (mean difference, -1.96; 95% confidence interval, -3.25 to -0.68) compared with nonprenatally diagnosed placenta accreta spectrum. The pooled mean values for blood loss volume and the number of transfused blood product units tended to be lower in the prenatally diagnosed placenta accreta spectrum groups than in the nonprenatally diagnosed placenta accreta spectrum groups. Nulliparity (odds ratio, 0.14; 95% confidence interval, 0.10-0.20), previous cesarean delivery (odds ratio, 6.81; 95% confidence interval, 4.12-11.25), assisted reproductive technology (odds ratio, 0.19; 95% confidence interval, 0.06-0.61), placenta increta and percreta (odds ratio, 3.97; 95% confidence interval, 2.24-7.03), and placenta previa (odds ratio, 6.81; 95% confidence interval, 4.12-11.25) showed statistical significance. No significant difference was found for the other outcomes. CONCLUSION Despite its severity, the positive effect of prenatally diagnosed placenta accreta spectrum on outcomes underscores the necessity of a prenatal diagnosis. In addition, the pooled mean values provide a preoperative preparation guideline.
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Affiliation(s)
- Shunya Sugai
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan.
| | - Kaoru Yamawaki
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Tomoyuki Sekizuka
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kazufumi Haino
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kosuke Yoshihara
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Koji Nishijima
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan.
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20
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Jauniaux E, Hussein AM, Thabet MM, Elbarmelgy RM, Elbarmelgy RA, Jurkovic D. The role of transvaginal ultrasound in the third-trimester evaluation of patients at high risk of placenta accreta spectrum at birth. Am J Obstet Gynecol 2023; 229:445.e1-445.e11. [PMID: 37187303 DOI: 10.1016/j.ajog.2023.05.004] [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: 04/08/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Transvaginal ultrasound imaging has become an essential tool in the prenatal evaluation of the lower uterine segment and anatomy of the cervix, but there are only limited data on the role of transvaginal ultrasound in the management of patients at high risk of placenta accreta spectrum at birth. OBJECTIVE This study aimed to evaluate the role of transvaginal sonography in the third trimester of pregnancy in predicting outcomes in patients with a high probability of placenta accreta spectrum at birth. STUDY DESIGN This was a retrospective analysis of prospectively collected data of patients presenting with a singleton pregnancy and a history of at least 1 previous cesarean delivery and patients diagnosed prenatally with an anterior low-lying placenta or placenta previa delivered electively after 32 weeks of gestation. All patients had a least 1 detailed ultrasound examination, including transabdominal and transvaginal scans, within 2 weeks before delivery. Of note, 2 experienced operators, blinded to the clinical data, were asked to make a judgment on the likelihood of placenta accreta spectrum as a binary, low or high-probability of placenta accreta spectrum, and to predict the main surgical outcome (conservative vs peripartum hysterectomy). The diagnosis of accreta placentation was confirmed when one or more placental cotyledons could not be digitally separated from the uterine wall at delivery or during the gross examination of the hysterectomy or partial myometrial resection specimens. RESULTS A total of 111 patients were included in the study. Abnormal placental tissue attachment was found in 76 patients (68.5%) at birth, and histologic examination confirmed superficial villous attachment (creta) and deep villous attachment (increta) in 11 and 65 cases, respectively. Of note, 72 patients (64.9%) had a peripartum hysterectomy, including 13 cases with no evidence of placenta accreta spectrum at birth because of failure to reconstruct the lower uterine segment and/or excessive bleeding. There was a significant difference in the distribution of placental location (X2=12.66; P=.002) between transabdominal and transvaginal ultrasound examinations, but both ultrasound techniques had similar likelihood scores in identifying accreta placentation that was confirmed at birth. On transabdominal scan, only a high lacuna score was significantly associated (P=.02) with an increased chance of hysterectomy, whereas on transvaginal scan, significant associations were found between the need for hysterectomy and the thickness of the distal part of the lower uterine segment (P=.003), changes in the cervix structure (P=.01), cervix increased vascularity (P=.001), and the presence of placental lacunae (P=.005). The odds ratio for peripartum hysterectomy were 5.01 (95% confidence interval, 1.25-20.1) for a very thin (<1-mm) distal lower uterine segment and 5.62 (95% confidence interval, 1.41-22.5) for a lacuna score of 3+. CONCLUSION Transvaginal ultrasound examination contributes to both prenatal management and the prediction of surgical outcomes in patients with a history of previous cesarean delivery with and without ultrasound signs suggestive of placenta accreta spectrum. Transvaginal ultrasound examination of the lower uterine segment and cervix should be included in clinical protocols for the preoperative evaluation of patients at risk of complex cesarean delivery.
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Affiliation(s)
- Eric Jauniaux
- Faculty of Population Health Sciences, EGA Institute for Women's Health, University College London, London, United Kingdom.
| | - Ahmed M Hussein
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
| | - Mohamed M Thabet
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
| | - Rana M Elbarmelgy
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
| | - Rasha A Elbarmelgy
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
| | - Davor Jurkovic
- Faculty of Population Health Sciences, EGA Institute for Women's Health, University College London, London, United Kingdom
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21
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Cheng C, Ramsey PS, Byrne JJ, Katabathina VS, Ireland KE, Munoz JL. Factors Limiting Magnetic Resonance Imaging Diagnosis of Placenta Accreta Spectrum. Am J Perinatol 2023; 40:1398-1405. [PMID: 37225128 DOI: 10.1055/a-2099-4542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Placenta accreta spectrum (PAS) disorders are characterized by an abnormal adherence of the placenta to the uterine myometrium. Magnetic resonance imaging (MRI) is an important adjunct in antenatal diagnosis. We sought to determine if there are patient and MRI characteristics that limit the accuracy of PAS diagnosis and degree of invasion. STUDY DESIGN We conducted a retrospective cohort analysis of patients who were evaluated for PAS by MRI from January 2007 to December 2020. Patient characteristics evaluated included number of prior cesarean deliveries, history of dilation and curettage (D&C) or dilation and evacuation (D&E), short interval pregnancy less than 18 months, and delivery body mass index (BMI). All patients were followed until delivery and MRI diagnosis was compared with final histopathology. RESULTS Of the 353 patients with suspected PAS, 152 (43%) underwent MRI evaluation and were included in the final analysis. In patients who underwent MRI evaluation, 105 (69%) had confirmed PAS on pathology. Patient characteristics were similar between groups and not associated with accuracy of MRI diagnosis. MRI was accurate in diagnosing PAS and the associated degree of invasion in 83 (55%) patients. Accuracy was associated with lacunae (8 vs. 0%, p = 0.02), abnormal bladder interface (25 vs. 6%, p = 0.002), and T1 hyperintensity (13 vs. 1%, p = 0.002). Of the 69 (45%) patients in whom MRI was inaccurate, overdiagnosis was seen in 44 (64%) patients and underdiagnosis in 25 (36%) patients. Overdiagnosis was significantly associated with dark T2 bands (45 vs. 22%, p = 0.005). Underdiagnosis was associated with earlier gestational age at MRI (28 vs. 30 weeks, p = 0.049) and lateral placentation (16 vs. 2.4%, p = 0.025). CONCLUSION Patient factors did not change MRI accuracy of PAS diagnosis. MRI is associated with a significant overdiagnosis of PAS when dark T2 bands are present, and underdiagnose PAS when performed earlier in gestation or when lateral placentation is present. KEY POINTS · Patient factors are not associated with MRI accuracy of PAS diagnosis.. · MRI overdiagnoses PAS invasion when there are dark T2 bands.. · MRI underdiagnoses PAS invasion when performed earlier in gestation.. · Underdiagnosis of PAS is associated with lateral placentation..
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Affiliation(s)
- CeCe Cheng
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, Texas
| | - Patrick S Ramsey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, Texas
| | - John J Byrne
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, Texas
| | - Venkata S Katabathina
- Department of Radiology, University of Texas Health Science Center at San Antonio, Texas
| | - Kayla E Ireland
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Methodist Hospital San Antonio, Texas
| | - Jessian L Munoz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
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22
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Zhang B, Liu H, Wang W, Wang J, Jiang Y, Jia W, Li H, Zhu H, Du X, Huang X. Impact of Maternal Preoperative Hemoglobin Levels on Intraoperative Hemorrhage Risk in Placenta Accrete Spectrum Disorders: A Retrospective Cross-Sectional Study. Med Sci Monit 2023; 29:e940443. [PMID: 37559346 PMCID: PMC10426315 DOI: 10.12659/msm.940443] [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: 03/21/2023] [Accepted: 05/25/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Placenta accreta spectrum (PAS) disorders involve abnormal adhesion or invasion of chorionic villi through the myometrium and uterine serosa. Maternal anemia during pregnancy is common and may contribute to complications during delivery, particularly with abnormal placentation. This study examines the association between preoperative maternal hemoglobin levels and the risk of intraoperative massive hemorrhage in pregnant women with PAS disorders. MATERIAL AND METHODS A retrospective study included 538 consecutive participants (mean age=31.12±4.68 years) who underwent cesarean sections and met the diagnostic criteria for PAS disorders. Logistic regression analysis was performed to investigate the relationship between maternal preoperative hemoglobin levels and the risk of massive intraoperative hemorrhage (blood loss ≥1500 mL). RESULTS The incidence of intraoperative massive hemorrhage among patients with PAS disorders was 38.66%. The mean preoperative maternal hemoglobin level was 10.99±1.39 g/dL, and overall anemia incidence (<11 g/dL) was 48.88% in our study. After adjusting for potential confounders, a non-linear relationship was observed between preoperative maternal hemoglobin levels and the risk of intraoperative massive hemorrhage. When the preoperative hemoglobin level of pregnant women was below 11.5 g/dL (OR=0.52, 95% CI 0.39-0.70), the lower hemoglobin level significantly increased the risk of intraoperative hemorrhage. CONCLUSIONS Maternal preoperative hemoglobin levels were inversely associated with the risk of massive intraoperative hemorrhage in PAS disorders. A non-linear relationship was identified, with a turning point at 11.5 g/dL. These findings emphasize the importance of monitoring and managing maternal hemoglobin levels to mitigate the risk of intraoperative hemorrhage in pregnant women with PAS disorders.
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Affiliation(s)
- Baolian Zhang
- Department of Physical Examination Center, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Hong Liu
- Department of Physical Examination Center, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Wenli Wang
- Department of Gynecology and Obstetrics, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Jia Wang
- Department of Quality Control, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Yuping Jiang
- Department of Gynecology and Obstetrics, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Wen Jia
- Department of Gynecology and Obstetrics, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Haiyan Li
- Department of Gynecology and Obstetrics, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - He Zhu
- Department of Gynecology and Obstetrics, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Xiaona Du
- Department of Gynecology and Obstetrics, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Xianghua Huang
- Department of Gynecology and Obstetrics, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, PR China
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23
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Gatta LA, Ellestad SC, Boyd BK, Collins S, Einerson BD, Stephenson ML, Hammad I, Varvoutis MS, Honart AW, Federspiel JJ, Craig AM, Swartz A, Salinaro JR, Unnithan S, Weber J, Erkanli A, Gilner JB. Validation of a sonographic checklist for the detection of histologic placenta accreta spectrum. Am J Obstet Gynecol MFM 2023; 5:101017. [PMID: 37178720 DOI: 10.1016/j.ajogmf.2023.101017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/02/2023] [Accepted: 05/09/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND To standardize research terminology and to reduce unanticipated placenta accreta spectrum, the European Working Group for Abnormally Invasive Placenta developed a consensus checklist for reporting suspected placenta accreta spectrum observed during an antenatal ultrasound. The diagnostic accuracy of the European Working Group for Abnormally Invasive Placenta checklist has not been assessed. OBJECTIVE This study aimed to test the performance of the European Working Group for Abnormally Invasive Placenta sonographic checklist in predicting histologic placenta accreta spectrum. STUDY DESIGN This was a multisite, blinded, retrospective review of transabdominal ultrasound studies performed between 26 to 32 weeks' gestation for subjects with histologic placenta accreta spectrum between 2016 and 2020. We matched a control cohort of subjects without histologic placenta accreta spectrum in a 1:1 ratio. To reduce reader bias, we matched the control cohort for known risk factors including previa, number of previous cesarean deliveries, previous dilation and curettage, in vitro fertilization, and clinical factors affecting image quality including multiple gestation, body mass index, and gestational age at the ultrasound. Nine sonologists from 5 referral centers, blinded to the histologic outcomes, interpreted the randomized ultrasound studies using the European Working Group for Abnormally Invasive Placenta checklist. The primary outcome was the sensitivity and specificity of the checklist to predict placenta accreta spectrum. Two separate sensitivity analyses were performed. First, we excluded subjects with mild disease (ie, only assessed subjects with histologic increta and percreta). Second, we excluded interpretations from the 2 most junior sonologists. RESULTS A total of 78 subjects were included (39 placenta accreta spectrum, 39 matched control). Clinical risk factors and image quality markers were statistically similar between the cohorts. The checklist sensitivity (95% confidence interval) was 76.6% (63.4-90.6) and the specificity (95% confidence interval) was 92.0% (63.4-99.9) with a positive and negative likelihood ratio of 9.6 and 0.3, respectively. When we excluded subjects with mild placenta accreta spectrum disease, the sensitivity (95% confidence interval) increased to 84.7% (73.6-96.4) and the specificity was unchanged at 92.0% (83.2-99.9). Sensitivity and specificity were unchanged when the interpretations from the 2 most junior sonologists were excluded. CONCLUSION The 2016 European Working Group for Abnormally Invasive Placenta checklist for interpreting placenta accreta spectrum has a reasonable performance in detecting histologic placenta accreta spectrum and excluding cases without placenta accreta spectum.
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Affiliation(s)
- Luke A Gatta
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Drs Gatta, Ellestad, Boyd, West Honart, Federspiel, and Craig, Mr Swartz, Drs Salinaro, Gilner). Department of Biostatistics, Duke University School of Medicine, Durham, NC (Ms Unnithan, Mr Weber, and Drs Erkanli).
| | - Sarah C Ellestad
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Drs Gatta, Ellestad, Boyd, West Honart, Federspiel, and Craig, Mr Swartz, Drs Salinaro, Gilner). Department of Biostatistics, Duke University School of Medicine, Durham, NC (Ms Unnithan, Mr Weber, and Drs Erkanli)
| | - Brita K Boyd
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Drs Gatta, Ellestad, Boyd, West Honart, Federspiel, and Craig, Mr Swartz, Drs Salinaro, Gilner). Department of Biostatistics, Duke University School of Medicine, Durham, NC (Ms Unnithan, Mr Weber, and Drs Erkanli)
| | - Sally Collins
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom (Dr Collins); John Radcliffe Hospital, Oxford, United Kingdom (Dr Collins)
| | - Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT (Dr Einerson)
| | - Megan L Stephenson
- Department of Obstetrics and Gynecology, Kaiser Permanente, Santa Clara, CA (Dr Stephenson)
| | - Ibrahim Hammad
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Murray, UT (Dr Hammad)
| | | | - Anne West Honart
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Drs Gatta, Ellestad, Boyd, West Honart, Federspiel, and Craig, Mr Swartz, Drs Salinaro, Gilner). Department of Biostatistics, Duke University School of Medicine, Durham, NC (Ms Unnithan, Mr Weber, and Drs Erkanli)
| | - Jerome J Federspiel
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Drs Gatta, Ellestad, Boyd, West Honart, Federspiel, and Craig, Mr Swartz, Drs Salinaro, Gilner). Department of Biostatistics, Duke University School of Medicine, Durham, NC (Ms Unnithan, Mr Weber, and Drs Erkanli)
| | - Amanda M Craig
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Drs Gatta, Ellestad, Boyd, West Honart, Federspiel, and Craig, Mr Swartz, Drs Salinaro, Gilner). Department of Biostatistics, Duke University School of Medicine, Durham, NC (Ms Unnithan, Mr Weber, and Drs Erkanli)
| | - Anthony Swartz
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Drs Gatta, Ellestad, Boyd, West Honart, Federspiel, and Craig, Mr Swartz, Drs Salinaro, Gilner). Department of Biostatistics, Duke University School of Medicine, Durham, NC (Ms Unnithan, Mr Weber, and Drs Erkanli)
| | - Julia R Salinaro
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Drs Gatta, Ellestad, Boyd, West Honart, Federspiel, and Craig, Mr Swartz, Drs Salinaro, Gilner). Department of Biostatistics, Duke University School of Medicine, Durham, NC (Ms Unnithan, Mr Weber, and Drs Erkanli)
| | - Shakthi Unnithan
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Drs Gatta, Ellestad, Boyd, West Honart, Federspiel, and Craig, Mr Swartz, Drs Salinaro, Gilner). Department of Biostatistics, Duke University School of Medicine, Durham, NC (Ms Unnithan, Mr Weber, and Drs Erkanli)
| | - Jeremy Weber
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Drs Gatta, Ellestad, Boyd, West Honart, Federspiel, and Craig, Mr Swartz, Drs Salinaro, Gilner). Department of Biostatistics, Duke University School of Medicine, Durham, NC (Ms Unnithan, Mr Weber, and Drs Erkanli)
| | - Alaattin Erkanli
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Drs Gatta, Ellestad, Boyd, West Honart, Federspiel, and Craig, Mr Swartz, Drs Salinaro, Gilner). Department of Biostatistics, Duke University School of Medicine, Durham, NC (Ms Unnithan, Mr Weber, and Drs Erkanli)
| | - Jennifer B Gilner
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Drs Gatta, Ellestad, Boyd, West Honart, Federspiel, and Craig, Mr Swartz, Drs Salinaro, Gilner). Department of Biostatistics, Duke University School of Medicine, Durham, NC (Ms Unnithan, Mr Weber, and Drs Erkanli)
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Einerson BD, Sandlin AT, Afshar Y, Sharawi N, Fox KA, Newton JM, Shainker SA, Pezeshkmehr A, Carusi DA, Moroz L. General Management Considerations for Placenta Accreta Spectrum. Am J Perinatol 2023; 40:1026-1032. [PMID: 37336221 DOI: 10.1055/s-0043-1761915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
The ideal management of a patient with placenta accreta spectrum (PAS) includes close antepartum management culminating in a planned and coordinated delivery by an experienced multidisciplinary PAS team. Coordinated team management has been shown to optimize outcomes for mother and infant. This section provides a consensus overview from the Pan-American Society for the Placenta Accreta Spectrum regarding general management of PAS.
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Affiliation(s)
| | - Adam T Sandlin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arizona
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Nadir Sharawi
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arizona
| | - Karin A Fox
- Division of Maternal-Fetal Medicine, Department of Obstetric and Gynecology, Baylor College of Medicine (Texas Children's Hospital Pavilion for Women), Houston, Texas
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center Nashville, Tennessee
| | - Scott A Shainker
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amir Pezeshkmehr
- Department of Radiology Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Daniela A Carusi
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Munoz JL, Blankenship LM, Ramsey PS, McCann GA. Implementation and outcomes of a uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum. Am J Obstet Gynecol 2023; 229:61.e1-61.e7. [PMID: 36965865 DOI: 10.1016/j.ajog.2023.03.028] [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: 12/09/2022] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Placenta accreta spectrum disorders are a continuum of placental pathologies with significant maternal morbidity and mortality. Morbidity is related to the overall degree of placental adherence, and thus patients with placenta increta or percreta represent a high-risk category of patients. Hemorrhage and transfusion of blood products represent 90% of placenta accreta spectrum morbidity. Both tranexamic acid and uterine artery embolization independently decrease obstetrical hemorrhage. OBJECTIVE This study aimed to provide an evidence-based intraoperative protocol for placenta accreta spectrum management. STUDY DESIGN This study was a pre- and postimplementation analysis of concomitant uterine artery embolization and tranexamic acid in cases of patients with antenatally suspected placenta increta and percreta over a 5-year period (2018-2022). For comparison, a 5-year (2013-2017) preimplementation group was used to assess the impact of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum. Patient demographics and clinically relevant outcomes were obtained from electronic medical records. RESULTS A total of 126 cases were managed by the placenta accreta spectrum team, of which 66 had suspected placenta increta/percreta over the 10-year time period. Two patients were excluded from the postimplementation cohort because they did not undergo both interventions. Thus, 30 (30/64; 47%) were treated after implementation of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum, and 34 (34/64; 53%) preimplementation patients did not undergo uterine artery embolization or tranexamic acid infusion. With the uterine artery embolization and tranexamic acid protocol, operative times were longer (416 vs 187 minutes; P<.01), and patients were more likely to receive general anesthesia (80% vs 47%; P<.01). However, blood loss was reduced by 33% (2000 vs 3000 cc; P=.03), overall blood transfusion rates decreased by 51% (odds ratio, 0.05 [95% confidence interval, 0.001-0.20]; P<.01), and massive blood transfusion (>10 units transfused) was reduced 5-fold (odds ratio, 0.17 [95% confidence interval, 0.02-0.17]; P=.02). Postoperative complication rates remained unchanged (4 vs 10 events; P=.14). Neonatal outcomes were equivalent. CONCLUSION The uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum is an effective approach to the standardization of complex placenta accreta spectrum cases that results in optimal perioperative outcomes and reduced maternal morbidity.
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Affiliation(s)
- Jessian L Munoz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Logan M Blankenship
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
| | - Patrick S Ramsey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
| | - Georgia A McCann
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
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Khoury-Collado F, Newton JM, Brook OR, Carusi DA, Shrivastava VK, Crosland BA, Fox KA, Khandelwal M, Karam AK, Bennett KA, Sandlin AT, Shainker SA, Einerson BD, Belfort MA. Surgical Techniques for the Management of Placenta Accreta Spectrum. Am J Perinatol 2023; 40:970-979. [PMID: 37336214 DOI: 10.1055/s-0043-1761636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
The surgical management of placenta accreta spectrum (PAS) is often challenging. There are a variety of techniques and management options described in the literature ranging from uterine sparing to cesarean hysterectomy. Following the inaugural meeting of the Pan-American Society for Placenta Accreta Spectrum a multidisciplinary group collaborated to describe collective recommendations for the surgical management of PAS. In this manuscript, we outline individual components of the procedure and provide suggested direction at key points of a cesarean hysterectomy in the setting of PAS. KEY POINTS: · The surgical management of PAS requires careful planning and expertise.. · Multidisciplinary team care for pregnancies complicated by PAS can decrease morbidity and mortality.. · Careful surgical techniques can minimize risk of significant hemorrhage by avoiding pitfalls..
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Affiliation(s)
- Fady Khoury-Collado
- Division of Gynecologic Oncology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Olga R Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Daniela A Carusi
- Department of Obstetrics and Gynecology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vineet K Shrivastava
- Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Memorial Care Miller Children's & Women's Hospital, University of California Irvine, Irvine, California
| | - Brian A Crosland
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Karin A Fox
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Meena Khandelwal
- Department of Obstetrics and Gynecology, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Amer K Karam
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Stanford University, Palo Alto, California
| | - Kelly A Bennett
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adam T Sandlin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Scott A Shainker
- Department of Obstetrics, Gynecology, and Reproductive Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Brett D Einerson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Michael A Belfort
- Departments of Obstetrics and Gynecology, Surgery, Anesthesiology and Neurosurgery, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
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Chung K, Yin O, Kallapur A, Bass L, Coscia L, Constantinescu S, Moritz M, Afshar Y. Emergent prelabor cesarean delivery in solid organ transplant recipients: associated risk factors and outcomes. Am J Obstet Gynecol MFM 2023; 5:100799. [PMID: 36368514 DOI: 10.1016/j.ajogmf.2022.100799] [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: 07/24/2022] [Revised: 10/19/2022] [Accepted: 11/03/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Pregnancies after solid organ transplant are at a higher risk of antepartum admission and pregnancy complications including cesarean delivery. Emergent prelabor cesarean delivery is associated with increased maternal and neonatal morbidity in other high-risk populations, but its incidence and impact in transplant recipients is not well-understood. OBJECTIVE This study aimed to characterize the risk factors and outcomes of emergency prelabor cesarean delivery in kidney and liver transplant recipients. STUDY DESIGN This was a retrospective cohort study of all kidney and liver transplant recipients at >20 weeks gestation enrolled in the Transplant Pregnancy Registry International between 1976 and 2019. Participants admitted antepartum who required emergency prelabor cesarean delivery were compared with those admitted antepartum who underwent nonemergent birth. The primary outcomes were severe maternal morbidity and neonatal composite morbidity. Multivariable logistic regression was conducted for neonatal composite morbidity. RESULTS Of 1979 births, 181 pregnancies (188 neonates) with antepartum admission were included. 51 pregnancies (53 neonates, 28%) were delivered by emergent prelabor cesarean delivery compared with 130 pregnancies (135 neonates, 72%) admitted antepartum who subsequently did not require emergent delivery. The most common indication for emergent delivery was nonreassuring fetal heart tracing (44 pregnancies /51 emergent deliveries = 86%). Pregnant people who underwent emergent prelabor cesarean delivery were less likely to deliver at a transplant center (37.3% vs 41.5%; P=.04) and had increased rates of chronic hypertension (33.3% vs 16.2%; P=.02). There was no significant difference in severe maternal morbidity (3.9% vs 4.6%; P=.84), though there was an increase in surgical site infection in the emergent prelabor cesarean delivery cohort (3.9% vs 0%; P=.02). Among those with emergent prelabor cesarean delivery, there was a significant increase in neonatal composite morbidity (43.4% vs 19.3%; P<.001) with earlier gestational age at delivery (33.4 vs 34.7 weeks; P=.02), lower birthweight (1899 g vs 2321 g; P<.001), lower birthweight percentile (30.3% vs 40.6%; P=.03), increased neonatal intensive care unit admission (52.8% vs 35.6%; P=.03), and increased neonatal mortality (11.3% vs 1.5%; P=.002). After adjusting for year of conception, race, hypertensive disorders, and fetal malformations, there was a persistent increased risk of neonatal morbidity (adjusted odds ratio, 3.01; 95% confidence interval, 1.50-6.08; P=.002) associated with emergent prelabor cesarean delivery after transplant. CONCLUSION Almost one-third of kidney and liver transplant recipients admitted antepartum had an emergency prelabor cesarean delivery, and 63% of this cohort delivered outside of a transplant center. Pregnancies after transplantation should involve multidisciplinary transplant-obstetrics collaboration to ensure optimal antepartum disease management, especially for preexisting hypertension, to prevent and mitigate obstetrical and neonatal morbidity in the setting of emergent cesarean delivery.
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Affiliation(s)
- Kathleen Chung
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar)
| | - Ophelia Yin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar)
| | - Aneesh Kallapur
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar)
| | - Lauren Bass
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar)
| | - Lisa Coscia
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, PA (Ms Coscia and Drs Constantinescu and Moritz)
| | - Serban Constantinescu
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, PA (Ms Coscia and Drs Constantinescu and Moritz); Section of Nephrology, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA (Dr Constantinescu)
| | - Michael Moritz
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, PA (Ms Coscia and Drs Constantinescu and Moritz); Department of Surgery, Lehigh Valley Health Network, Allentown, PA (Dr Moritz); Department of Surgery, Morsani College of Medicine, Tampa, FL (Dr Moritz)
| | - Yalda Afshar
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar).
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Rau AR, Youssefzadeh AC, Matsuzaki S, Mandelbaum RS, Ouzounian JG, Matsuo K. Unsuspected placenta accreta spectrum at vaginal delivery: assessment of incidence, characteristics, and maternal morbidity. Am J Obstet Gynecol MFM 2022; 5:100805. [PMID: 36774226 DOI: 10.1016/j.ajogmf.2022.100805] [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: 09/06/2022] [Revised: 10/31/2022] [Accepted: 11/05/2022] [Indexed: 02/11/2023]
Abstract
BACKGROUND Placenta accreta spectrum refers to morbidly adherent trophoblastic tissue invading into the gravid uterus and is associated with significant maternal morbidity. Most cases of placenta accreta spectrum are suspected antenatally, and most patients undergo planned, late-preterm cesarean hysterectomy to reduce the risk of morbidity. Rarely, however, placenta accreta spectrum is incidentally diagnosed at vaginal delivery, but there is a scarcity of data regarding these events. OBJECTIVE This study aimed to examine the incidence, characteristics, and outcomes of pregnant individuals with incidentally diagnosed placenta accreta spectrum at term vaginal delivery. STUDY DESIGN This was a retrospective cohort study investigating the Healthcare Cost and Utilization Project's National Inpatient Sample. The study population was 8,694,669 term vaginal deliveries from January 2016 to December 2019. Exclusion criteria included previous uterine scar, placenta previa, and preterm delivery. Exposure was assigned by the diagnosis of placenta accreta spectrum. The main outcomes were: (1) incidence rate, (2) clinical and pregnancy characteristics, and (3) maternal morbidity related to unsuspected placenta accreta spectrum at vaginal delivery. Multivariable binary logistic regression analysis and inverse probability of treatment weighting were fitted for statistical analysis. RESULTS Unsuspected placenta accreta spectrum was reported in 1 in 3797 vaginal deliveries. In a multivariable analysis, the following were associated with increased likelihood of unsuspected placenta accreta spectrum (all, P<.05): (1) patient factor with older age, (2) uterine factors such as uterine anomaly and uterine myoma, (3) pregnancy factors including early-term delivery and previous recurrent pregnancy losses, and (4) fetal factors of in utero growth restriction and demise. Of those, uterine anomaly had the greatest association with unsuspected placenta accreta spectrum (adjusted odds ratio, 6.23; 95% confidence interval, 4.20-9.26). In a propensity score-weighted model, patients in the unsuspected placenta accreta spectrum group were more likely to have hemorrhage (65.2% vs 4.1%), blood product transfusion (21.3% vs 0.6%), hysterectomy (14.9% vs <0.1%), coagulopathy (2.9% vs 0.1%), and shock (2.9% vs <0.1%) compared with those without placenta accreta spectrum. Patients in the unsuspected placenta accreta spectrum group were also more likely to receive manual removal of the placenta compared with those in the non-placenta accreta spectrum group (25.1% vs 0.6%). CONCLUSION This study suggests that although unsuspected placenta accreta spectrum among patients undergoing term vaginal delivery is rare, it is associated with significant morbidity. The observed association between uterine anomalies and placenta accreta spectrum warrants further investigation.
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Affiliation(s)
- Alesandra R Rau
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Ms Rau and Drs Youssefzadeh, Matsuzaki, Mandelbaum, and Matsuo); Keck School of Medicine, University of Southern California, Los Angeles, CA (Ms Rau)
| | - Ariane C Youssefzadeh
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Ms Rau and Drs Youssefzadeh, Matsuzaki, Mandelbaum, and Matsuo)
| | - Shinya Matsuzaki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Ms Rau and Drs Youssefzadeh, Matsuzaki, Mandelbaum, and Matsuo)
| | - Rachel S Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Ms Rau and Drs Youssefzadeh, Matsuzaki, Mandelbaum, and Matsuo); Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Dr Mandelbaum)
| | - Joseph G Ouzounian
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Dr Ouzounian)
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Ms Rau and Drs Youssefzadeh, Matsuzaki, Mandelbaum, and Matsuo); Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA (Dr Matsuo).
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29
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Munoz JL, Kimura AM, Julia J, Tunnell C, Hernandez B, Curbelo J, Ramsey PS, Ireland KE. Impact of placenta accreta spectrum (PAS) pathology on neonatal respiratory outcomes in cesarean hysterectomies. J Matern Fetal Neonatal Med 2022; 35:10692-10697. [PMID: 36521848 DOI: 10.1080/14767058.2022.2157716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Placenta accreta spectrum (PAS) is a continuum of disorders characterized by the pathologically adherent placenta to the uterine myometrium. Delivery by cesarean hysterectomy at 34-36 weeks is recommended to mitigate the risks of maternal morbidity. Iatrogenic preterm delivery, has potential neonatal implications; late preterm infants are at risk for significant respiratory morbidity. Neonatal outcomes in PAS neonates are not well described in the literature, we aimed to investigate these outcomes. METHODS A case-control study was performed with 107 cases of pathology-confirmed PAS patients with singleton, non-anomalous, viable pregnancies, compared to 76 cases of placenta previa with prior cesarean section who underwent repeat cesarean section. All patients were delivered through our institution's Placenta Accreta Program from 2005 to 2020. Rates of neonatal respiratory morbidity and related outcomes were analyzed. RESULTS Maternal characteristics and antenatal complications were similar between groups, as were gestational age, steroid exposure, and emergent delivery. PAS was associated with increased use of general anesthesia (20 vs. 54%, p = .001), larger estimated blood loss (1875 vs. 6077 ml, p = .008), and longer post-operative stays (4.8 vs. 7.3 days, p = .01). PAS was also associated with neonatal increased rates of high flow nasal cannula (HFNC) (41 vs. 58%, p = .02), intubation (17 vs. 37%, p = .008), and duration of respiratory support (0 vs. 2 days, p = .03). There were no differences in rates of continuous positive airway pressure (CPAP)/positive pressure ventilation (PPV) (21 vs. 22%, p = .85), anemia, hyperbilirubinemia, or NICU length of stay. Multivariate analysis adjusting for general anesthesia demonstrated this variable confounded the impact of PAS pathology in respiratory outcomes the risk of the respiratory composite (adjusted odds ratio (aOR) 0.57, 95% CI [0.11, 2.82]), use of HFNC (aOR 0.33, 95% CI [0.08-1.48]), and intubation (aOR 1.29, 95% CI [0.25-6.75]), were no longer significant. CONCLUSIONS Based on these results, we conclude that PAS neonates have higher rates of respiratory morbidity and that general anesthesia is a significant contributor to these respiratory outcomes. This is important for the antenatal counseling of cases of PAS, especially if general anesthesia is anticipated or requested. Furthermore, it supports efforts to limit general anesthesia exposure of neonates when necessary.
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Affiliation(s)
- Jessian L Munoz
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Alison M Kimura
- University of Texas Health Sciences Center at San Antonio, San Antonio, TX, USA.,Department of Obstetrics & Gynecology, University Health System, San Antonio, TX, USA
| | - Jacqueline Julia
- Department of Pediatrics, University of Texas Health Science Center-San Antonio, San Antonio, TX, USA
| | - Callie Tunnell
- University of Texas Health Sciences Center at San Antonio, San Antonio, TX, USA.,Department of Obstetrics & Gynecology, University Health System, San Antonio, TX, USA
| | - Brian Hernandez
- University of Texas Health Sciences Center at San Antonio, San Antonio, TX, USA.,Department of Obstetrics & Gynecology, University Health System, San Antonio, TX, USA
| | - Jacqueline Curbelo
- University of Texas Health Sciences Center at San Antonio, San Antonio, TX, USA.,Department of Anesthesiology, University Health System, San Antonio, TX, USA
| | - Patrick S Ramsey
- University of Texas Health Sciences Center at San Antonio, San Antonio, TX, USA.,Department of Obstetrics & Gynecology, University Health System, San Antonio, TX, USA
| | - Kayla E Ireland
- University of Texas Health Sciences Center at San Antonio, San Antonio, TX, USA.,Department of Obstetrics & Gynecology, University Health System, San Antonio, TX, USA
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Golbasi H, Bayraktar B, Golbasi C, Omeroglu I, Sever B, Adiyaman D, Kayhan Omeroglu S, Ekin A, Özeren M. Expected Versus Unexpected Delivery for Placenta Accreta Spectrum (PAS) Disorders with Same Team in Single Tertiary Center. Z Geburtshilfe Neonatol 2022; 226:391-398. [PMID: 36100249 DOI: 10.1055/a-1915-5832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To evaluate the maternal and neonatal outcomes of expected and unexpected pathologically proven placenta accreta spectrum (PAS) cases in a single multidisciplinary center. MATERIAL AND METHODS This was a retrospective cohort study of 92 PAS cases from January 2011 until September 2021. Only cases with histopathologically invasive placentation were included in the study. The cases diagnosed at the time of delivery were defined as unexpected PAS (uPAS) and those diagnosed antenatally as expected PAS (ePAS). Maternal and neonatal outcomes of both groups were compared. RESULTS Thirty-five (38%) of 92 cases were in the uPAS group. Placenta previa and high-grade PAS (percreata) were significantly higher in the ePAS group (p=0.028, p<0.001; respectively). The mean packed red blood cell transfusion was significantly higher in the uPAS group (p=0.030) but transfusions of other blood products were similar in the two groups. There was no significant difference in intraoperative complication rates between the two groups. Preterm delivery (<37 weeks) was significantly higher in the ePAS group (p<0.001), but there was no significant difference between the two groups in terms of adverse neonatal outcomes. CONCLUSIONS Our single center data show that although ePAS cases include more highly invasive PAS cases, maternal hemorrhagic morbidity is lower than uPAS cases. Reducing maternal morbidity in PAS cases can be achieved by increasing antenatal diagnosis.
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Affiliation(s)
- Hakan Golbasi
- University of Health Sciences Tepecik Training and Research Hospital, Department of Perinatology, Izmir, Turkey
| | - Burak Bayraktar
- University of Health Sciences Tepecik Training and Research Hospital, Department of Obstetrics and Gynecology, Izmir, Turkey
| | - Ceren Golbasi
- Tinaztepe University Faculty of Health Sciences, Department of Obstetrics and Gynecology, Izmir, Turkey
| | - Ibrahim Omeroglu
- University of Health Sciences Tepecik Training and Research Hospital, Department of Perinatology, Izmir, Turkey
| | - Baris Sever
- University of Health Sciences Tepecik Training and Research Hospital, Department of Perinatology, Izmir, Turkey
| | - Duygu Adiyaman
- University of Health Sciences Tepecik Training and Research Hospital, Department of Perinatology, Izmir, Turkey
| | - Seyda Kayhan Omeroglu
- University of Health Sciences Suat Seren Chest Diseases and Surgery Training and Research Hospital, Department of Anesthesia and Reanimation, Izmir, Turkey
| | - Atalay Ekin
- University of Health Sciences Tepecik Training and Research Hospital, Department of Perinatology, Izmir, Turkey
| | - Mehmet Özeren
- University of Health Sciences Tepecik Training and Research Hospital, Department of Perinatology, Izmir, Turkey
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31
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Ma J, Liu Y, Guo Z, Sun R, Yang X, Zheng W, Ma Y, Rong Y, Wang H, Yang H, Xiao Z. The diversity of trophoblast cells and niches of placenta accreta spectrum disorders revealed by single-cell RNA sequencing. Front Cell Dev Biol 2022; 10:1044198. [PMID: 36420138 PMCID: PMC9676682 DOI: 10.3389/fcell.2022.1044198] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/25/2022] [Indexed: 12/31/2023] Open
Abstract
Placenta accreta spectrum disorders (PAS) are severe pregnancy complications that occur when extravillous trophoblast cells (EVTs) invade beyond the uterine inner myometrium and are characterized by hypervascularity on prenatal ultrasound and catastrophic postpartum hemorrhage. The potential mechanisms remain incompletely understood. With single-cell RNA-sequencing analysis on the representative invasive parts and the normal part obtained from the same PAS placenta, we profiled the pathological landscape of invasive PAS placenta and deciphered an intensified differentiation pathway from progenitor cytotrophoblasts (CTBs) to EVTs via LAMB4 + and KRT6A + CTBs. In the absence of the decidua, the invasive trophoblasts of various differentiation states interacted with ADIRF + and DES + maternal stromal cells. The PAS-associated hypervascularity might be due to the enhanced crosstalk of trophoblasts, stromal cells and vascular endothelial cells. Finally, we presented an immune microenvironmental landscape of invasive PAS. The pathogenesis of PAS could be further explored with current resources for future targeted translational studies.
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Affiliation(s)
- Jingmei Ma
- State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Yawei Liu
- State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China
- Innovation Academy for Stem Cell and Regeneration, Chinese Academy of Sciences, Beijing, China
- Institute for Stem Cell and Regeneration, Chinese Academy of Sciences, Beijing, China
- University of Chinese Academy of Sciences, Beijing, China
- Dushu Lake Hospital Affiliated to Soochow University, Medical Center of Soochow University, Suzhou Dushu Lake Hospital, Suzhou, China
| | - Zhirong Guo
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Run Sun
- State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China
- Innovation Academy for Stem Cell and Regeneration, Chinese Academy of Sciences, Beijing, China
- Institute for Stem Cell and Regeneration, Chinese Academy of Sciences, Beijing, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Xinrui Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Weiran Zheng
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Yongdan Ma
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Yin Rong
- State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China
- Innovation Academy for Stem Cell and Regeneration, Chinese Academy of Sciences, Beijing, China
- Institute for Stem Cell and Regeneration, Chinese Academy of Sciences, Beijing, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Hongmei Wang
- State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China
- Innovation Academy for Stem Cell and Regeneration, Chinese Academy of Sciences, Beijing, China
- Institute for Stem Cell and Regeneration, Chinese Academy of Sciences, Beijing, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Zhenyu Xiao
- State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, China
- Innovation Academy for Stem Cell and Regeneration, Chinese Academy of Sciences, Beijing, China
- Institute for Stem Cell and Regeneration, Chinese Academy of Sciences, Beijing, China
- University of Chinese Academy of Sciences, Beijing, China
- School of Life Science, Beijing Institute of Technology, Beijing, China
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Salmanian B, Einerson BD, Carusi DA, Shainker SA, Nieto-Calvache AJ, Shrivastava VK, Subramaniam A, Zuckerwise LC, Lyell DJ, Khandelwal M, Fitzgerald GD, Hessami K, Fox KA, Silver RM, Shamshirsaz AA. Timing of delivery for placenta accreta spectrum: the Pan-American Society for the Placenta Accreta Spectrum experience. Am J Obstet Gynecol MFM 2022; 4:100718. [PMID: 35977702 DOI: 10.1016/j.ajogmf.2022.100718] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 08/10/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND The Society for Maternal-Fetal Medicine recommends cesarean delivery with potential hysterectomy scheduled in the late preterm period between 34 0/7 and 35 6/7 weeks of gestation for prenatally suspected placenta accreta spectrum. OBJECTIVES We aimed to investigate clinical compliance with the recommended delivery timing window for placenta accreta spectrum and its impact on maternal and neonatal outcomes. STUDY DESIGN We performed a retrospective multicenter review of data from referral centers within the Pan-American Society for Placenta Accreta Spectrum. Patients with placenta accreta spectrum with both antenatal diagnosis and confirmed histopathologic findings were included. We investigated adherence to the Society for Maternal-Fetal Medicine-recommended gestational age window for delivery, and compliance was further stratified by scheduled and unscheduled delivery. We compared the outcomes for patients with scheduled delivery within vs immediately 2 weeks outside the recommended window. RESULTS Among 744 patients with a prenatal diagnosis of placenta accreta spectrum and placental histopathologic confirmation, 488 (66%) had scheduled delivery. Among all prenatally diagnosed placenta accreta spectrum patients, 252 (39%) delivered within the recommended window of 34 0/7 and 35 6/7 weeks gestation. For the subgroup of patients who underwent scheduled delivery (n=426), 209 (49%) had delivery in this window, 120 (28%) delivered before 34 weeks, and 97 (23%) delivered at or later than 36 weeks. In the patients with scheduled delivery, 27% of placenta accreta spectrum patients with accreta delivered in the 2 weeks immediately after the recommended window (36 0/7-37 6/7 weeks), and 22% of placenta accreta spectrum pregnancies with increta/percreta delivered in the 2 weeks immediately before the recommended delivery (32 0/7-33 6/7 weeks). The maternal outcomes among those who delivered within the recommended range vs those delivering 2 weeks before and after the recommended range were similar, regardless of placenta accreta spectrum severity. CONCLUSION Less than half of placenta accreta spectrum patients had scheduled delivery within the recommended gestational age of 34 0/7 to 35 6/7 weeks. The reasons for deviation from recommendations and the risks and benefits of individualized timing of delivery on the basis of risk factors and predicted outcomes warrant further investigation.
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Affiliation(s)
- Bahram Salmanian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX (Drs Salmanian, Hessami, Fox, and Shamshirsaz)
| | - Brett D Einerson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Utah Health, Salt Lake City, UT (Drs Einerson and Silver)
| | - Daniela A Carusi
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA (Dr Carusi)
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Dr Shainker)
| | - Albaro J Nieto-Calvache
- Department of Obstetrics and Gynecology, Fundación Clínica Valle del Lili, Universidad ICESI, Cali, Colombia (Dr Nieto)
| | - Vineet K Shrivastava
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Miller Children's and Women's Hospital, Long Beach, CA (Dr Shrivastava)
| | - Akila Subramaniam
- Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL (Dr Subramaniam)
| | - Lisa C Zuckerwise
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN (Dr Zuckerwise)
| | - Deirdre J Lyell
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University, Palo Alto, CA (Dr Lyell)
| | - Meena Khandelwal
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Cooper University Hospital, Princeton, NJ (Dr Khandelwal)
| | - Garrett D Fitzgerald
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI (Dr Fitzgerald)
| | - Kamran Hessami
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX (Drs Salmanian, Hessami, Fox, and Shamshirsaz)
| | - Karin A Fox
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX (Drs Salmanian, Hessami, Fox, and Shamshirsaz)
| | - Robert M Silver
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Utah Health, Salt Lake City, UT (Drs Einerson and Silver)
| | - Alireza A Shamshirsaz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX (Drs Salmanian, Hessami, Fox, and Shamshirsaz).
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Gatta LA, Weber JM, Gilner JB, Lee PS, Grotegut CA, Herbert KA, Bashir M, Pieper CF, Ronald J, Pabon-Ramos W, Habib AS, Strickland KC, Secord AA, James AH. Transfusion Requirements with Hybrid Management of Placenta Accreta Spectrum Incorporating Targeted Embolization and a Selective Use of Delayed Hysterectomy. Am J Perinatol 2022; 29:1503-1513. [PMID: 35973741 PMCID: PMC10035416 DOI: 10.1055/s-0042-1754321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study compares the number of units of red blood cells (RBCs) transfused in patients with placenta accreta spectrum (PAS) treated with or without a multidisciplinary algorithm that includes placental uterine arterial embolization (P-UAE) and selective use of either immediate or delayed hysterectomy. STUDY DESIGN This is a retrospective study of deliveries conducted at a tertiary care hospital from 2001 to 2018 with pathology-confirmed PAS. Those with previable pregnancies or microinvasive histology were excluded. To improve the equity of comparison, analyses were made separately among scheduled and unscheduled cases, therefore patients were assigned to one of four cohorts as follows: (1) scheduled/per-algorithm, (2) scheduled/off-algorithm, (3) unscheduled/per-algorithm, or (4) unscheduled/off-algorithm. Primary outcomes included RBCs transfused and estimated blood loss (EBL). Secondary outcomes included perioperative complications and disposition. RESULTS Overall, 95 patients were identified, with 87 patients meeting inclusion criteria: 36 treated per-algorithm (30 scheduled and 6 unscheduled) and 51 off-algorithm patients (24 scheduled and 27 unscheduled). Among scheduled deliveries, 9 (30.0%) patients treated per-algorithm received RBCs compared with 20 (83.3%) patients treated off-algorithm (p < 0.01), with a median (interquartile range [IQR]) of 3.0 (2.0, 4.0) and 6.0 (2.5, 7.5) units transfused (p = 0.13), respectively. Among unscheduled deliveries, 5 (83.3%) per-algorithm patients were transfused RBCs compared with 25 (92.6%) off-algorithm patients (p = 0.47) with a median (IQR) of 4.0 (2.0, 6.0) and 8.0 (3.0, 10.0) units transfused (p = 0.47), respectively. Perioperative complications were similar between cohorts. CONCLUSION A multidisciplinary algorithm including P-UAE and selective use of delayed hysterectomy is associated with a lower rate of blood transfusion in scheduled but not unscheduled cases. KEY POINTS · An algorithm with delayed hysterectomy had less transfusion in scheduled, but not unscheduled, cases.. · Over time, more cases were managed per algorithm; among scheduled cases, the transfusion rate and volume transfused decreased.. · There were similar transfusion outcomes among off-algorithm cases, regardless if delivery was scheduled..
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Affiliation(s)
- Luke A. Gatta
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
| | - Jeremy M. Weber
- Department of Biostatistics and Bioinformatics, Duke University Hospital, Durham, North Carolina
| | - Jennifer B. Gilner
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
| | - Paula S. Lee
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Gynecologic Oncology, Duke University Hospital, Durham, North Carolina
| | - Chad A. Grotegut
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
| | | | - Mustafa Bashir
- Department of Radiology and Medicine, Duke University Hospital, Durham, North Carolina
| | - Carl F. Pieper
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
| | - James Ronald
- Department of Radiology and Medicine, Duke University Hospital, Durham, North Carolina
| | - Waleska Pabon-Ramos
- Department of Radiology and Medicine, Duke University Hospital, Durham, North Carolina
| | - Ashraf S. Habib
- Department of Anesthesiology, Duke University Hospital, Durham, North Carolina
| | - Kyle C. Strickland
- Department of Pathology, Duke University Hospital, Durham, North Carolina
| | - Angeles Alvarez Secord
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Gynecologic Oncology, Duke University Hospital, Durham, North Carolina
| | - Andra H. James
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
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Matsuo K, Vestal NL, Rau AR, Sangara RN, Youssefzadeh AC, Bainvoll L, Matsuzaki S, Roman LD, Ouzounian JG, Wright JD. Gynecologic oncologists in surgery for placenta accreta spectrum: a survey for practice, experience, and interest. Int J Gynecol Cancer 2022; 32:1433-1442. [PMID: 36167437 DOI: 10.1136/ijgc-2022-003830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Surgery for placenta accreta spectrum is associated with significant maternal morbidity and mortality. The role of gynecologic oncologists in the surgical management of placenta accreta spectrum is currently under investigation. This study examined the practices, experiences, and interests of gynecologic oncologists in placenta accreta spectrum surgeries. METHODS The intervention was an anonymous, cross-sectional, 20-question survey sent to 1084 members of the Society of Gynecologic Oncology in the USA. RESULTS A total of 184 gynecologic oncologists responded to the survey (response rate 17.0%). Most participating gynecologic oncologists have been practicing for >10 years after fellowship (53.2%), practice in urban-teaching hospitals (84.8%) with delivery volumes ≥3000/year (54.3%), and have a multidisciplinary approach (82.5%). Three-quarters (78.7%) feel that the rate of placenta accreta spectrum is increasing over time. One-third (35.5%) perform ≥6 hysterectomies for placenta accreta spectrum yearly. Less than half (45.5%) practice conservative management. Approximately half are involved from the beginning of the case (49.7%) and perform the surgery in the main operating room (59.4%). Almost three-quarters (71.6%) have experienced surgical blood loss >5 L and one-third (36.6%) have experienced cases with blood loss >10 L. About half (50.3%) of participants are interested in placenta accreta spectrum surgery for future practice. Gynecologic oncologists engaging in a multidisciplinary approach are more likely to practice in an urban-teaching hospital, have higher surgical volume, be involved from the beginning of the case, and be interested in placenta accreta spectrum surgery. Those >10 years post-training and in the Southern US region are more likely to practice conservative management or delayed hysterectomy. CONCLUSION This society-based cross-sectional survey suggests that gynecologic oncologists are actively involved in the surgical management of placenta accreta spectrum in the USA. Nearly half of gynecologic oncologists who responded to the survey expressed interest in surgery for placenta accreta spectrum.
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Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA .,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California, USA
| | - Nicole L Vestal
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Alesandra R Rau
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Rauvynne N Sangara
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Ariane C Youssefzadeh
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Liat Bainvoll
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Shinya Matsuzaki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Lynda D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA.,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California, USA
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and gynecology, Columbia University College of Physicians and Surgeons, New York City, New York, USA
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Sugai S, Yamawaki K, Haino K, Nishijima K. Unexpected uterine body placenta accreta spectrum with placenta previa in a subsequent pregnancy after uterine artery embolization: a case report. BMC Pregnancy Childbirth 2022; 22:706. [PMID: 36100926 PMCID: PMC9469599 DOI: 10.1186/s12884-022-05031-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 09/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A subsequent pregnancy after uterine artery embolization (UAE) raises several concerns, one of which is placenta accreta spectrum (PAS). Placenta previa is the strongest risk factor for PAS, which is most likely to occur in the lower uterine segment. PAS without placenta previa (i.e., uterine body PAS) is considered relatively rare. CASE PRESENTATION A 35-year-old woman, gravida 2 para 1, had undergone UAE for postpartum hemorrhage due to uterine atony after vaginal delivery in her previous pregnancy. She developed placenta previa during her subsequent pregnancy and was therefore evaluated for PAS in the lower uterine segment. On the basis of examination findings, we considered PAS to be unlikely. During cesarean section, we found that the placenta was not detached from the uterine body, and the patient was determined to have uterine body PAS. Ultimately, a hysterectomy was performed. CONCLUSIONS PAS can occur in a subsequent pregnancy after UAE. When a subsequent pregnancy after UAE is accompanied by placenta previa, it is important to maintain a high index of suspicion of uterine body PAS without being misled by the presence of placenta previa.
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Affiliation(s)
- Shunya Sugai
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, 1-757 Asahimachi-dori, Chuo-ku, Niigata, 951-8510, Japan.
| | - Kaoru Yamawaki
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, 1-757 Asahimachi-dori, Chuo-ku, Niigata, 951-8510, Japan
| | - Kazufumi Haino
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, 1-757 Asahimachi-dori, Chuo-ku, Niigata, 951-8510, Japan
| | - Koji Nishijima
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, 1-757 Asahimachi-dori, Chuo-ku, Niigata, 951-8510, Japan
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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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Han X, Guo Z, Yang X, Yang H, Ma J. Association of Placenta Previa With Severe Maternal Morbidity Among Patients With Placenta Accreta Spectrum Disorder. JAMA Netw Open 2022; 5:e2228002. [PMID: 35994286 PMCID: PMC9396360 DOI: 10.1001/jamanetworkopen.2022.28002] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
IMPORTANCE Placenta previa is widely acknowledged as a risk factor for placenta accreta spectrum (PAS) disorders, which are severe maternal complications; however, data are limited regarding whether placenta previa is associated with a higher risk of worse maternal outcomes among patients with PAS disorders. OBJECTIVE To examine the association between placenta previa and the risk of severe maternal morbidities (SMMs) and higher resource use among patients with PAS disorders. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study extracted records of 3793 patients with PAS diagnosis and delivery indicators between October 1, 2015, and December 31, 2019, from the US National Inpatient Sample database. EXPOSURES Placenta previa. MAIN OUTCOMES AND MEASURES Data on 21 Centers for Disease Control and Prevention-defined SMMs and 25 study-defined surgical morbidities associated with PAS were extracted. Six surgical procedures (cystoscopy, intra-arterial balloon occlusion, cesarean delivery, hysterectomy, cystectomy, and oophorectomy), hospital length of stay, and inpatient costs were compared. Multivariable Poisson regression models built in the generalized estimating equation framework were used. RESULTS Among 3793 patients with PAS (median [IQR] age at admission, 33 [29-37] years), 621 women (16.4%) were Black, 765 (20.2%) were Hispanic, 1779 (46.9%) were White, 441 (11.6%) were of other races and/or ethnicities (47 [1.2%] were American Indian, 220 [5.8%] were Asian or Pacific Islander, and 174 [4.6%] were of multiple or other races and/or ethnicities), and 187 (4.9%) were of unknown race and ethnicity. A total of 1323 patients (34.9%) had placenta previa and 2470 patients (65.1%) did not; of those with placenta previa, 405 patients (30.6%) had invasive PAS. Patients with vs without placenta previa had a significantly higher rate and risk of any SMM (935 women [70.7%] vs 1087 women [44.0%]; P < .001; adjusted risk ratio [aRR], 1.19; 95% CI, 1.12-1.27) and any surgical morbidity (1170 women [88.4%] vs 1667 women [67.5%]; P < .001; aRR, 1.18; 95% CI, 1.13-1.23). With regard to specific outcomes, those with vs without placenta previa had a significantly higher rate of peripartum hemorrhage (878 patients [66.4%] vs 1217 patients [49.3%]; P < .001), blood product transfusion (413 patients [31.2%] vs 610 patients [24.7%]; P < .001), shock (83 patients [6.3%] vs 108 patients [4.4%]; P = .01), disseminated intravascular coagulation or other coagulopathy (77 patients [5.8%] vs 105 patients [4.3%]; P = .04), and urinary tract injury (44 patients [3.3%] vs 41 patients [1.7%]; P = .002). Patients with vs without placenta previa were more likely to undergo cesarean delivery (1292 patients [97.7%] vs 1787 patients [72.3%]; P < .001), hysterectomy (786 patients [59.4%] vs 689 patients [27.9%]; P < .001), cystoscopy (301 patients [22.8%] vs 203 patients [8.2%]; P < .001), cystectomy (157 patients [11.9%] vs 98 patients [4.0%]; P < .001), and intra-arterial balloon occlusion (121 patients [9.1%] vs 77 patients [3.1%]; P < .001) and to have significantly longer hospital length of stay (median [IQR], 5 [4-11] days vs 3 [3-5] days; P < .001) and total inpatient costs (median [IQR], $17 496 [$10 863-$30 619] vs $9728 [$6130-$16 790]; P < .001). Hypertensive disorder of pregnancy was associated with a decreased risk of placenta previa (aRR, 0.67; 95% CI, 0.46-0.96) among patients with PAS. CONCLUSIONS AND RELEVANCE In this study, placenta previa was associated with an increased risk of maternal and surgical morbidities and higher resource use among women with PAS. These findings suggest that interventions to alleviate maternal and surgical morbidities are especially needed for patients with placenta previa-complicated PAS disorders.
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Affiliation(s)
- Xueyan Han
- Department of Medical Statistics, Peking University First Hospital, Beijing, China
| | - Zhirong Guo
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Peking University First Hospital, Beijing, China
| | - Xinrui Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Peking University First Hospital, Beijing, China
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Peking University First Hospital, Beijing, China
| | - Jingmei Ma
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Peking University First Hospital, Beijing, China
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Reeder CF, Sylvester-Armstrong KR, Silva LM, Wert EM, Smulian JC, Genc MR. Outcomes of pregnancies at high-risk for placenta accreta spectrum following negative diagnostic imaging. J Perinat Med 2022; 50:595-600. [PMID: 35218171 DOI: 10.1515/jpm-2021-0591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/07/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To assess the pretest and negative post-test probability for placenta accreta spectrum (PAS) in a group of patients with high-risk clinical factors. METHODS We included patients with suspected and/or confirmed PAS at our institution over 8 years. Sonography performed by maternal-fetal medicine specialists, and selected patients underwent MRI. Imaging was considered positive if either sonography or MRI suggested PAS. Histopathology was the gold standard for diagnosis of PAS. We assessed the pretest and negative imaging-test probability, and resources required. RESULTS We identified 82 high-risk patients with the following: (1) a history of ≥1 cesarean section and/or intrauterine gynecologic procedure and placenta previa in the index pregnancy; (2) a history of >3 cesarean deliveries and/or gynecologic procedures regardless of placental location; (3) prior PAS disorder, or retained placenta requiring manual extraction and/or curettage, complicated by postpartum hemorrhage; and (4) suspected cesarean section scar pregnancy. Histopathology confirmed PAS in 52 patients, with pretest probability of 63%. Imaging correctly identified 44/50 cases with PAS, and excluded this condition in 24/30 cases. Thus, the positive and negative post-test probability for PAS following negative imaging was 88 and 20%, respectively. Of the six patients with false-negative imaging, all had either surgical complications or required care beyond that for routine cesarean section. CONCLUSIONS Although diagnostic imaging is sensitive, the negative posttest probability remains high in women with high pretest probability for PAS. Therefore, women at high risk for PAS should be managed in experienced centers by a multidisciplinary team even if imaging is negative.
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Affiliation(s)
- Callie F Reeder
- University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Lauren M Silva
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Erika M Wert
- University of Florida College of Medicine, Gainesville, FL, USA
| | - John C Smulian
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Mehmet R Genc
- University of Florida College of Medicine, Gainesville, FL, USA
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Ming Y, Zeng X, Zheng T, Luo Q, Zhang J, Zhang L. Epidemiology of placenta accreta spectrum disorders in Chinese pregnant women: A multicenter hospital-based study. Placenta 2022; 126:133-139. [DOI: 10.1016/j.placenta.2022.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/26/2022] [Accepted: 06/20/2022] [Indexed: 01/10/2023]
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Mercier AM, Ramseyer AM, Morrison B, Pagan M, Magann EF, Phillips A. Secondary Postpartum Hemorrhage Due to Retained Placenta Accreta Spectrum: A Case Report. Int J Womens Health 2022; 14:593-597. [PMID: 35497261 PMCID: PMC9041597 DOI: 10.2147/ijwh.s359857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 04/12/2022] [Indexed: 11/23/2022] Open
Abstract
Background Retained products of conception and placenta accreta spectrum are causes of postpartum hemorrhage. Placenta accreta spectrum is frequently managed with cesarean hysterectomy, but conservative approaches are emerging. We present a case of delayed postpartum hemorrhage secondary to a retained placenta increta. Case A 29-year-old G3P2 presented with heavy vaginal bleeding 20 days postoperatively following an uncomplicated classical cesarean delivery at 27 5/7 weeks' gestation for preterm labor in the setting of a vasa previa. On workup, imaging showed retained products of conception and concern for placenta accreta. A hypervascular area in the lower uterine segment was identified at the time of postpartum laparotomy. Total abdominal hysterectomy was performed due to postpartum hemorrhage and clinical suspicion for placenta accreta spectrum disorder. Pathology confirmed a placenta increta. Conclusion Diagnosis of placenta accreta spectrum in the remote postpartum period is uncommon but should be a considered etiology in delayed postpartum hemorrhage. Careful inspection and documentation of the placenta implantation site should occur in cesarean sections because placenta accreta spectrum disorders can remain unnoticed during delivery.
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Affiliation(s)
- Ann Marie Mercier
- Department of Obstetrics and Gynecology at the University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Abigail M Ramseyer
- Department of Obstetrics and Gynecology, Maternal & Fetal Medicine at Sparrow Medical Group, Lansing, MI, USA
| | - Bethany Morrison
- Department of Obstetrics and Gynecology at the University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Megan Pagan
- Department of Obstetrics and Gynecology at the University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Everett F Magann
- Department of Obstetrics and Gynecology at the University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Amy Phillips
- Department of Obstetrics and Gynecology at the University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Saccone G, De Angelis MC, Zizolfi B, Gragnano E, Musone M, Zullo F, Bifulco G, Di Spiezio Sardo A. Monofilament vs multifilament suture for uterine closure at the time of cesarean delivery: a randomized clinical trial. Am J Obstet Gynecol MFM 2022; 4:100592. [PMID: 35131497 DOI: 10.1016/j.ajogmf.2022.100592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Different factors may influence the closure of the uterine wall, including suture material. Suture materials may indeed influence tissue healing and therefore the development of scar defects. OBJECTIVE To test whether uterine closure using synthetic absorbable monofilament sutures at the time of cesarean delivery would reduce the rate of cesarean scar defects compared with uterine closure using synthetic absorbable multifilament sutures. STUDY DESIGN Parallel-group, nonblinded, randomized clinical trial of women with singleton pregnancies undergoing cesarean delivery at term in a single center in Italy. The inclusion criteria were singleton pregnancy, first or second cesarean delivery, scheduled and emergent or urgent cesarean deliveries, and gestational age between 37 0/7 and 42 0/7 weeks. Eligible participants were randomly allocated in a 1:1 ratio to either the monofilament group (polyglytone 6211 [Caprosyn]; Covidien, Dublin, Ireland) or the multifilament suture group (coated polyglactin 910 suture with Triclosan [Vicryl Plus]; Ethicon, Inc, Raritan, NJ). The primary outcome was the incidence of cesarean scar defect at ultrasound at the 6-month follow-up visit. The secondary outcomes were residual myometrial thickness and symptoms. RESULTS Overall, 300 women were included in the trial. Of the randomized women, 151 were randomized to the monofilament group and 149 to the multifilament group. However, 27 women were lost to follow-up: 15 in the monofilament group and 12 in the multifilament group. Of note, 6 months after delivery, the incidence rates of cesarean scar defect were 18.4% (25 of 136 patients) in the monofilament group and 23.4% (32 of 137 patients) in the multifilament group (relative risk, 0.79; 95% confidence interval, 0.41-1.25; P=.31). The mean residual myometrial thicknesses were 7.6 mm in the monofilament group and 7.2 mm in the multifilament group (mean difference, +0.40 mm; 95% confidence interval, -0.23 to 1.03). There was no between-group substantial difference found in the incidence of symptoms, including pelvic pain, painful periods, and dyspareunia. CONCLUSION In singleton pregnancies undergoing primary or second cesarean delivery, the use of synthetic absorbable monofilament sutures at the time of uterine wall closure was not associated with a reduction in the rate of cesarean scar defect 6 months after delivery compared with the use of synthetic absorbable multifilament sutures.
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Affiliation(s)
- Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Drs Saccone and Zizolfi, Ms Gragnano, and Drs Musone, Zullo, and Bifulco).
| | - Maria Chiara De Angelis
- Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy (Drs Angelis and Di Spiezio Sardo)
| | - Brunella Zizolfi
- Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Drs Saccone and Zizolfi, Ms Gragnano, and Drs Musone, Zullo, and Bifulco)
| | - Elisabetta Gragnano
- Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Drs Saccone and Zizolfi, Ms Gragnano, and Drs Musone, Zullo, and Bifulco)
| | - Mariateresa Musone
- Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Drs Saccone and Zizolfi, Ms Gragnano, and Drs Musone, Zullo, and Bifulco)
| | - Fulvio Zullo
- Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Drs Saccone and Zizolfi, Ms Gragnano, and Drs Musone, Zullo, and Bifulco)
| | - Giuseppe Bifulco
- Department of Neuroscience, Reproductive Sciences, and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy (Drs Saccone and Zizolfi, Ms Gragnano, and Drs Musone, Zullo, and Bifulco)
| | - Attilio Di Spiezio Sardo
- Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy (Drs Angelis and Di Spiezio Sardo)
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Kyozuka H, Sugeno M, Murata T, Jin T, Ito F, Nomura Y, Hirano T, Shinohara K, Suzuki D, Ishida T. Introduction and utility of resuscitative endovascular balloon occlusion of the aorta for cases with a potential high risk of postpartum hemorrhage: A single tertiary care center experience of two cases. Fukushima J Med Sci 2022; 68:117-122. [PMID: 35444074 PMCID: PMC9493338 DOI: 10.5387/fms.2022-01] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Postpartum hemorrhage is an important obstetric complication and the leading cause of maternal mortality worldwide. Occasionally, we encounter unexpected massive postpartum hemorrhage diagnosed for the first time after delivery. Therefore, it is essential to pay attention to patients with a high risk of postpartum hemorrhage. The authors report two cases of patients at high risk of postpartum hemorrhage that were successfully managed by resuscitative endovascular balloon occlusion of the aorta before cesarean section. Case 1: A 32-year-old woman with a history of cesarean section and who conceived using assisted reproductive technology was diagnosed with partial placenta previa at 25 weeks of gestation. Because of tocolysis failure, emergent cesarean section with resuscitative endovascular balloon occlusion of the aorta was performed at 36 weeks of gestation. Natural placental resorption was observed. She was discharged at 5 days after delivery without significant hemorrhage. Case 2: A 41-year-old woman with suspected placenta accreta spectrum due to a cesarean scar pregnancy was referred to our hospital at 33 weeks of gestation. A planned cesarean section with resuscitative endovascular balloon occlusion of the aorta was conducted at 37 weeks of gestation. There was no visual evidence of abnormal placental invasion of the myometrium, and natural placental resorption was observed. She was discharged at 5 days after delivery without significant hemorrhage.
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Affiliation(s)
- Hyo Kyozuka
- Department of Obstetrics and Gynecology, Ohta Nishinouchi Hospital
| | - Misa Sugeno
- Department of Obstetrics and Gynecology, Ohta Nishinouchi Hospital
| | - Tsuyoshi Murata
- Department of Obstetrics and Gynecology, Shirakawa Kosei General Hospital
| | - Toki Jin
- Department of Obstetrics and Gynecology, Ohta Nishinouchi Hospital
| | - Fumihiro Ito
- Department of Obstetrics and Gynecology, Ohta Nishinouchi Hospital
| | - Yasuhisa Nomura
- Department of Obstetrics and Gynecology, Ohta Nishinouchi Hospital
| | - Takaki Hirano
- Department of Emergency and Critical Care, Ohta Nishinouchi Hospital
| | - Kazuaki Shinohara
- Department of Emergency and Critical Care, Ohta Nishinouchi Hospital
| | - Daisuke Suzuki
- Department of Obstetrics and Gynecology, Ohta Nishinouchi Hospital
| | - Tokiya Ishida
- Department of Emergency and Critical Care, Ohta Nishinouchi Hospital
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Bae JG, Kim YH, Kim JY, Lee MS. The Feasibility and Safety of Temporary Transcatheter Balloon Occlusion of Bilateral Internal Iliac Arteries during Cesarean Section in a Hybrid Operating Room for Placenta Previa with a High Risk of Massive Hemorrhage. J Clin Med 2022; 11:jcm11082160. [PMID: 35456251 PMCID: PMC9031967 DOI: 10.3390/jcm11082160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/08/2022] [Accepted: 04/10/2022] [Indexed: 11/16/2022] Open
Abstract
This study aimed to evaluate the feasibility and safety of temporary transcatheter balloon occlusion of bilateral internal iliac arteries (TBOIIA) during cesarean section in a hybrid operating room (OR) for placenta previa (PP) with a high risk of massive hemorrhage. This retrospective study analyzed the medical records of 62 patients experiencing PP with a high risk of massive hemorrhage (mean age, 36.2 years; age range 28-45 years) who delivered a baby via planned cesarean section with TBOIIA in a hybrid OR between May 2019 and July 2021. Operation time, estimated blood loss (EBL), amount of intra- and postoperative blood transfusion, perioperative hemoglobin level, hospital stay after operation, balloon time, fluoroscopy time, radiation dose, rate of uterine artery embolization (UAE) and hysterectomy, and complication-related TBOIIA were assessed. The mean operation time was 122 min, and EBL was 1290 mL. Nine out of sixty-two patients (14.5%) received a blood transfusion. The mean hemoglobin levels before surgery, immediately after surgery and within 1 week after surgery were 11.3 g/dL, 10.4 g/dL and 9.2 g/dL, respectively. In terms of radiation dose, the mean dose area product (DAP) and cumulative air kerma were 0.017 Gy/cm2 and 0.023 Gy, respectively. Ten out of sixty-two patients (16.1%) underwent UAE postoperatively in the hybrid OR. One out of sixty-two patients had been diagnosed with placenta percreta with bladder invasion based on preoperative ultrasound, and thus underwent cesarean hysterectomy following TBOIIA and UAE. While intra-arterial balloon catheter placement for managing PP with a high risk of hemorrhage remains controversial, a planned cesarean section with TBOIIA in a hybrid OR is effective in eliminating the potential risk of intra-arterial balloon catheter displacement, thus reducing intraoperative blood loss, ensuring safe placental removal and conserving the uterus.
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Affiliation(s)
- Jin-Gon Bae
- Department of Obstetrics and Gynecology, Keimyung University Dongsan Hospital, School of Medicine, Keimyung University, Daegu 42601, Korea;
| | - Young Hwan Kim
- Department of Radiology, Keimyung University Dongsan Hospital, School of Medicine, Keimyung University, Daegu 42601, Korea; (Y.H.K.); (J.Y.K.)
| | - Jin Young Kim
- Department of Radiology, Keimyung University Dongsan Hospital, School of Medicine, Keimyung University, Daegu 42601, Korea; (Y.H.K.); (J.Y.K.)
| | - Mu Sook Lee
- Department of Radiology, Keimyung University Dongsan Hospital, School of Medicine, Keimyung University, Daegu 42601, Korea; (Y.H.K.); (J.Y.K.)
- Correspondence: ; Tel.: +82-53-258-7862
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Sylvester-Armstrong K, Reeder C, Patrick K, Genc MR. Improved management of placenta accreta spectrum disorders: experience from a single institution. J Perinat Med 2022; 50:286-293. [PMID: 34905811 DOI: 10.1515/jpm-2021-0263] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 11/29/2021] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To assess the applicability of a standardized multidisciplinary protocol for managing placenta accreta spectrum (PAS) disorders and its impact on the outcomes. METHODS We compared patients with PAS manage by a standardized multidisciplinary protocol (T2) to historic controls managed on a case-by-case basis by individual physicians between (T1). The primary outcome is composite maternal morbidity. Secondary outcomes were the rates of surgical complications, estimated blood loss, number of blood products transfused, intensive care unit admissions, ventilator use, and birth weight. Multivariate logistic analysis was used to identify independent predictors of composite maternal morbidity. RESULTS During T1 and T2, we managed 39 and 36 patients with confirmed PAS, respectively. During T2, the protocol could be implemented in 21 cases (58%). Compared to T1, patients managed during T2 had 70% less composite maternal morbidity (95% CI: 0.11-0.82) and lower blood loss (median, 2,000 vs. 1,100 mL, p=0.008). Also, they were 68% less likely to require transfusion of blood products (95% CI: 0.12-0.81; p=0.01), including fewer units of packed red blood cells (median, 2 vs. 0, p=0.02). Management following the protocol was the only independent factor associated with lower composite maternal morbidity (OR: 0.22; 95% CI: 0.05-0.95; p=0.04). Selected maternal and neonatal outcomes were not different among 12 and 15 patients with suspected but unconfirmed PAS disorders managed during T1 and T2, respectively. CONCLUSIONS Most patients can be managed under a standardized multidisciplinary protocol for PAS disorders, leading to improved outcomes.
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Affiliation(s)
| | - Callie Reeder
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Kathryn Patrick
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Mehmet R Genc
- University of Florida College of Medicine, Gainesville, FL, USA
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Erfani H, Salmanian B, Fox KA, Coburn M, Meshinchiasl N, Shamshirsaz AA, Kopkin R, Gogia S, Patel K, Jackson J, Cadena M, Aalipour S, Sukumar S, Nassr AA, Espinoza J, Clark SL, Belfort MA, Shamshirsaz AA. Urologic morbidity associated with placenta accreta spectrum surgeries: single-center experience with a multidisciplinary team. Am J Obstet Gynecol 2022; 226:245.e1-245.e5. [PMID: 34391750 DOI: 10.1016/j.ajog.2021.08.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/15/2021] [Accepted: 08/10/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hysterectomy for placenta accreta spectrum may be associated with urologic morbidity, including intentional or unintentional cystostomy, ureteral injury, and bladder fistula. Although previous retrospective studies have shown an association between placenta accreta spectrum and urologic morbidities, there is still a paucity of literature addressing these urologic complications. OBJECTIVE We sought to report a systematic description of such morbidity and associated factors. STUDY DESIGN This was a retrospective study of all histology-proven placenta accreta spectrum deliveries in an academic center between 2011 and 2020. Urologic morbidity was defined as the presence of at least one of the following: cystotomy, ureteral injury, or bladder fistula. Variables were reported as median (interquartile range) or number (percentage). Analyses were made using appropriate parametric and nonparametric tests. Multinomial regression analysis was performed to assess the association of adverse urologic events with the depth of placental invasion. RESULTS In this study, 58 of 292 patients (19.9%) experienced urologic morbidity. Patients with urologic morbidity had a higher rate of placenta percreta (compared with placenta accreta and placenta increta) than those without such injuries. Preoperative ureteral stents were placed in 54 patients (93.1%) with and 146 patients (62.4%) without urologic injury (P=.003). After adjusting for confounding variables, multinomial regression analysis revealed that the odds of having adverse urologic events was 6.5 times higher in patients with placenta percreta than in patients with placenta accreta. CONCLUSION Greater depth of invasion in placenta accreta spectrum was associated with more frequent and severe adverse urologic events. Whether stent placement confers any protective benefit requires further investigation.
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Affiliation(s)
- Hadi Erfani
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Bahram Salmanian
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Karin A Fox
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Michael Coburn
- Department of Urology, Baylor College of Medicine, Houston, TX
| | | | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX.
| | - Rachel Kopkin
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Soumya Gogia
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Kunal Patel
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Josef Jackson
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Max Cadena
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Soroush Aalipour
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | | | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Steven L Clark
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
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Flores‐Mendoza H, Chandran AR, Hernandez‐Nieto C, Murji A, Allen L, Windrim RC, Kingdom JC, Hobson SR. Outcomes in emergency versus electively scheduled cases of placenta accreta spectrum disorder managed by cesarean‐hysterectomy within a multidisciplinary care team. Int J Gynaecol Obstet 2022; 159:404-411. [DOI: 10.1002/ijgo.14121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 01/21/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Homero Flores‐Mendoza
- Department of Obstetrics & Gynaecology University of Toronto & Mount Sinai Hospital Toronto ON Canada
| | - Anjana Ravi Chandran
- Department of Obstetrics & Gynaecology University of Toronto & Mount Sinai Hospital Toronto ON Canada
| | - Carlos Hernandez‐Nieto
- Department of Obstetrics & Gynaecology University of Toronto & Mount Sinai Hospital Toronto ON Canada
| | - Ali Murji
- Department of Obstetrics & Gynaecology University of Toronto & Mount Sinai Hospital Toronto ON Canada
| | - Lisa Allen
- Department of Obstetrics & Gynaecology University of Toronto & Mount Sinai Hospital Toronto ON Canada
| | - Rory C. Windrim
- Department of Obstetrics & Gynaecology University of Toronto & Mount Sinai Hospital Toronto ON Canada
| | - John C. Kingdom
- Department of Obstetrics & Gynaecology University of Toronto & Mount Sinai Hospital Toronto ON Canada
| | - Sebastian R. Hobson
- Department of Obstetrics & Gynaecology University of Toronto & Mount Sinai Hospital Toronto ON Canada
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Silveira C, Kirby A, Melov SJ, Nayyar R. Placenta accreta spectrum: We can do better. Aust N Z J Obstet Gynaecol 2022; 62:376-382. [PMID: 34984671 DOI: 10.1111/ajo.13471] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Placenta accreta spectrum (PAS) has a high risk of maternal morbidity, and requires meticulous antenatal and peripartum management. AIMS To compare the management and outcomes of PAS between women with and without antenatally suspected disease, and to evaluate the effect of multidisciplinary team (MDT) management. MATERIALS AND METHODS A retrospective cohort study identified all hysterectomy specimens with a histopathological diagnosis of PAS in the Western Sydney Local Health District between January 2006 and December 2019, and analysed each patient's clinical course. RESULTS Seventy patients had PAS diagnosed on hysterectomy specimens, of which 38 cases (54%) were antenatally suspected. Women with suspected PAS were more likely to have a previous caesarean section (100% vs 68%, P < 0.001), placenta praevia (92% vs 56%, P < 0.001) and anterior placenta (95% vs 66%. P = 0.011). Suspected PAS was associated with less maternal blood loss (median blood loss 2000 mL vs 4000 mL, P < 0.001), fewer red blood cell transfusions (median four units vs nine units, P < 0.001), and shorter intensive care or high dependency unit admission (mean stay one day vs three days, P = 0.037). There were no significant differences in other maternal morbidities. MDT management was associated with a clinically significant reduction in maternal blood loss (1500 mL vs 2520 mL, P = 0.09) and red blood cell transfusion (one unit vs six units, P = 0.04). The mean gestation of delivery was 37 weeks in both groups with no differences in neonatal morbidity. CONCLUSIONS Both antenatally diagnosed PAS and MDT management reduced blood loss and blood transfusion. Elective delivery at 37 weeks gestation reduces the neonatal risks of preterm delivery.
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Affiliation(s)
- Cheryl Silveira
- Department of Obstetrics and Gynaecology, Women's and Newborn Health, Westmead Hospital, Sydney, Australia
| | - Adrienne Kirby
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, Australia
| | - Sarah J Melov
- Westmead Institute for Maternal and Fetal Medicine, Women's and Newborn Health, Westmead Hospital, Sydney, Australia.,Discipline of Obstetrics, Gynaecology and Neonatology, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Roshini Nayyar
- Westmead Institute for Maternal and Fetal Medicine, Women's and Newborn Health, Westmead Hospital, Sydney, Australia
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48
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Guo Z, Han X, Zheng W, Yang H, Ma J. Placenta Accreta Spectrum Among Multiple Gestation: A Retrospective Analysis Based on a Chinese Population. Front Endocrinol (Lausanne) 2022; 13:862785. [PMID: 35663330 PMCID: PMC9158523 DOI: 10.3389/fendo.2022.862785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/11/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It remained controversial whether women with multiple gestation are at higher risk of placenta accreta spectrum (PAS) disorders and large-scale studies are needed. This study aimed to assess whether PAS incidence is higher among women with multiple gestation than among singleton, as well as to compare the characteristics and outcomes of PAS in multiple and singleton gestation. METHODS Women who underwent cesarean section with live births at Peking University First Hospital from January 2015 to December 2020 were included. Demographic and clinical information was collected through chart review. Logistic regression models were used to analyze the associations between multiple gestation and PAS. The clinical characteristics and perioperative outcomes of PAS in multiple and singleton gestation were further compared. RESULTS Among the 14583 women included, 2.4% (352/14583) were diagnosed with PAS. PAS was slightly more prevalent among multiple gestations than among singletons (2.5% vs 2.4%, P=0.857). After adjusting for known risk factors and pregnancy complications, multiple gestation was associated with a higher risk of PAS (aOR=1.63, 95% CI 1.01-2.62). Among PAS patients, women who had multiple births had a significantly lower rate of previous cesarean deliveries (27.6% vs. 56.3%, P=0.003), placenta previa (17.2% vs. 56.3%, P<0.001) and invasive PAS (24.1% vs. 53.9, P=0.002) than singletons. There were no significant differences in perioperative outcomes between these two groups. CONCLUSION Multiple gestation could be independently associated with an elevated risk of PAS. The clinical characteristics of PAS in the multiple and singleton gestation groups differed significantly in cesarean delivery history and placenta previa. The results of this study may inform guidelines on the screening, early detection and timely intervention of PAS patients among women with multiple births.
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Affiliation(s)
- Zhirong Guo
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Peking University First Hospital, Beijing, China
| | - Xueyan Han
- Department of Medical Statistics, Peking University First Hospital, Beijing, China
| | - Weiran Zheng
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Peking University First Hospital, Beijing, China
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Peking University First Hospital, Beijing, China
- *Correspondence: Huixia Yang, ; Jingmei Ma,
| | - Jingmei Ma
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Peking University First Hospital, Beijing, China
- *Correspondence: Huixia Yang, ; Jingmei Ma,
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49
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Modest AM, Toth TL, Johnson KM, Shainker SA. Placenta Accreta Spectrum: In Vitro Fertilization and Non-In Vitro Fertilization and Placenta Accreta Spectrum in a Massachusetts Cohort. Am J Perinatol 2021; 38:1533-1539. [PMID: 32623707 DOI: 10.1055/s-0040-1713887] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The incidence of placenta accreta spectrum (PAS) has been increasing in the United States. In addition, there has also been an increase in the utilization of in vitro fertilization (IVF). The IVF pregnancies confer an increased risk of adverse obstetric and neonatal outcomes, but there is limited data on whether IVF is associated with PAS. The aim of this study is to assess the association between IVF and the risk of PAS. STUDY DESIGN This was a retrospective cohort study of deliveries from January 1, 2013 to August 1, 2018 at a tertiary hospital in the Massachusetts. IVF pregnancies were compared with non-IVF pregnancies, and PAS diagnosis was confirmed by histopathology reports. Hospital administrative data and medical record review were used, and supplemented with data from birth certificates from the Massachusetts Department of Public Health. RESULTS We identified 28,344 pregnancies that met inclusion criteria, of which 1,418 (5.0%) were IVF pregnancies. The overall incidence of PAS was 0.4% (2.2% in the IVF group and 0.3% in the non-IVF group). Women who underwent IVF had 5.5 times the risk of PAS (95% confidence interval [CI]: 3.4-8.7) compared with women in the non-IVF group, adjusted for maternal age, nulliparity, and year of delivery (Table 5). Compared with women in the non-IVF group, the IVF group had fewer prior cesarean deliveries (22.6 vs. 64.2%) and a lower prevalence of placenta previa (19.4 vs. 44.4%). CONCLUSION Women with an IVF pregnancy carry an increased risk of PAS compared with non-IVF. Among women who underwent IVF, there was a lower prevalence of prior cesarean deliveries and placenta previa. Future work is needed to identify the mechanism of association for this increased risk as well as a reliable tool for antenatal detection in this cohort of women. KEY POINTS · IVF pregnancies have higher risk of PAS than non-IVF pregnancies.. · IVF pregnancies with PAS do not exhibit common risk factors.. · IVF may be an independent risk factor for PAS..
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Affiliation(s)
- Anna M Modest
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
| | - Thomas L Toth
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts.,Boston IVF Inc, Waltham, Massachusetts
| | - Katherine M Johnson
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
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50
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Yule CS, Lewis MA, Do QN, Xi Y, Happe SK, Spong CY, Twickler DM. Transvaginal Color Mapping Ultrasound in the First Trimester Predicts Placenta Accreta Spectrum: A Retrospective Cohort Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:2735-2743. [PMID: 33724510 DOI: 10.1002/jum.15674] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 02/01/2021] [Accepted: 02/14/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Ultrasound (US) prediction of placenta accreta spectrum (PAS) in the first trimester may be aided by postprocessing mechanisms employing color pixel quantification near the bladder-uterine serosal interface. Our objective was to create a postprocessing algorithm of color images to identify findings associated with PAS and compare quantification to sonologist impression in prospectively obtained cine US images. METHODS Transverse transvaginal (TV) US color cines obtained in the first trimester as part of a prospective study were reviewed. Investigators blinded to clinical outcomes reviewed anonymized cines that were archived and labeled the bladder-uterine serosal interface. Color pixels within 2 cm of the defined bladder-uterine serosal interface were ascertained using a Python-based plugin in the Horos open-source DICOM viewer. A sonologist classified the findings as suspicious for invasion, indeterminate, or normal. Statistical analysis was performed using Wilcoxon rank-sum test, Cochran-Armitage trend test, and calculation of receiver-operating characteristic (ROC) curves. RESULTS Fifty-four studies met inclusion criteria. Of those, six (11%) required hysterectomy with pathologic confirmation of PAS. Women requiring hysterectomy had a significantly higher color Doppler pixel area than those not requiring hysterectomy (P = .0205). A significant trend was identified in the sonologist impression of invasion (P = .0003). ROC's comparing sonologist impression to Doppler color imaging areas were comparable (P = .054). CONCLUSIONS Color Doppler mapping in the first trimester showed an increase in color pixel area near the bladder-uterine serosal interface in women requiring cesarean hysterectomy with histologically confirmed PAS at time of delivery, compared to women without hysterectomy or pathologic evidence of PAS.
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Affiliation(s)
- Casey S Yule
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
| | - Matthew A Lewis
- Department of Radiology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
| | - Quyen N Do
- Department of Radiology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
| | - Yin Xi
- Department of Radiology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
- Department of Clinical Science, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
| | - Sarah K Happe
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
| | - Catherine Y Spong
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
| | - Diane M Twickler
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
- Department of Radiology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
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