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Zhang J, Kong L, Qu F, Chen T, Zhou X, Ge Z, Jin B, Zhang X, Zhao M. The predictive value of conventional magnetic resonance imaging combined with intravoxel incoherent motion parameters for evaluating maternal and neonatal clinical outcomes in patients with placenta accreta spectrum disorders. Placenta 2024; 151:10-17. [PMID: 38631235 DOI: 10.1016/j.placenta.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/31/2024] [Accepted: 04/12/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION We aimed to identify factors predictive of adverse maternal and neonatal outcomes in patients with placenta accreta spectrum (PAS) disorders using magnetic resonance imaging (MRI) and intravoxel incoherent motion (IVIM) parameters. METHOD Fifty-six normal singleton pregnancies at 33-39 weeks of gestation underwent MRI examination at 1.5 T. The IVIM parameters were obtained from the placenta. The correlation between the f value and postpartum hemorrhage (PPH) and between the f value and transfused units of red blood cells (RBCs) was estimated by linear regression. The correlation between various influencing factors (clinical risk factors, MRI features, and IVIM parameters) and poor outcomes was investigated using univariate and multivariate analyses. RESULT The interobserver agreement ranged from fair to excellent (k = 0.30-0.88). Multivariate analyses showed that previous cesarean sections, low signal intensity bands on T2WI and the D value were independent risk factors for adverse outcomes. The combination of three risk factors demonstrated the highest AUC of 0.903, with a sensitivity and specificity of 73.10 % and 96.90 %, respectively. Last, f was positively correlated with PPH and units of RBCs transfused. DISCUSSION Preoperative MRI features and IVIM parameters may be used to predict poor outcomes in patients with invasive placental disorders like PAS.
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Affiliation(s)
- Jin Zhang
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Lingnan Kong
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Feifei Qu
- Research Collaboration Team, Siemens Healthineers Ltd, Shanghai, China
| | - Ting Chen
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Xin Zhou
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Zhiping Ge
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Bai Jin
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Xuan Zhang
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
| | - Meng Zhao
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
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Lutfi A, McElroy B, Greene RA, Higgins JR. Cost analysis of care and blood transfusions in patients with Major Obstetric Haemorrhage in Ireland. Transfus Med 2024; 34:182-188. [PMID: 38664599 DOI: 10.1111/tme.13042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 04/02/2024] [Accepted: 04/12/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND AND OBJECTIVES Obstetric haemorrhage is the leading cause of maternal morbidity and mortality worldwide. We aimed to estimate the economic cost of Major Obstetric Haemorrhage (MOH) and the cost of therapeutic blood components used in the management of MOH in Ireland. MATERIALS AND METHODS We performed a nationwide cross-sectional study utilising top-down and bottom-up costing methods on women who experienced MOH during the years 2011-2013. Women with MOH were allocated to Diagnostic Related Groups (DRGs) based on the approach to MOH management (MOH group). The total number of blood components used for MOH treatment and the corresponding costs were recorded. A control group representative of a MOH-free maternity population was designed with predicted costs. All costs were expressed in Euro (€) using 2022 prices and the incremental cost of MOH to maternity costs was calculated. Cost contributions are expressed as percentages from the estimated total cost. RESULTS A total of 447 MOH cases were suitable for sorting into DRGs. The estimated total cost of managing women who experienced MOH is approximately €3.2 million. The incremental cost of MOH is estimated as €1.87 million. The estimated total cost of blood components used in MOH management was €1.08 million and was based on an estimated total of 3997 products transfused. Red blood cell transfusions accounted for the highest contribution (20.22%) to MOH total cost estimates compared to other blood components. CONCLUSIONS The total cost of caring for women with MOH in Ireland was approximately €3.2 million with blood component transfusions accounting for between one third and one half of the cost.
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Affiliation(s)
- Ahmed Lutfi
- Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
| | | | - Richard A Greene
- Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
- National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
| | - John R Higgins
- Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
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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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Mitchell MI, Khalil M, Ben-Dov IZ, Alverez-Perez J, Illsley NP, Zamudio S, Al-Khan A, Loudig O. Customizing EV-CATCHER to Purify Placental Extracellular Vesicles from Maternal Plasma to Detect Placental Pathologies. Int J Mol Sci 2024; 25:5102. [PMID: 38791142 PMCID: PMC11121217 DOI: 10.3390/ijms25105102] [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: 03/15/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/26/2024] Open
Abstract
Placenta Accreta Spectrum (PAS) is a life-threatening condition in which placental trophoblastic cells abnormally invade the uterus, often up to the uterine serosa and, in extreme cases, tissues beyond the uterine wall. Currently, there is no clinical assay for the non-invasive detection of PAS, and only ultrasound and MRI can be used for its diagnosis. Considering the subjectivity of visual assessment, the detection of PAS necessitates a high degree of expertise and, in some instances, can lead to its misdiagnosis. In clinical practice, up to 50% of pregnancies with PAS remain undiagnosed until delivery, and it is associated with increased risk of morbidity/mortality. Although many studies have evaluated the potential of fetal biomarkers circulating in maternal blood, very few studies have evaluated the potential of circulating placental extracellular vesicles (EVs) and their miRNA contents for molecular detection of PAS. Thus, to purify placental EVs from maternal blood, we customized our robust ultra-sensitive immuno-purification assay, termed EV-CATCHER, with a monoclonal antibody targeting the membrane Placental Alkaline Phosphatase (PLAP) protein, which is unique to the placenta and present on the surface of placental EVs. Then, as a pilot evaluation, we compared the miRNA expression profiles of placental EVs purified from the maternal plasma of women diagnosed with placenta previa (controls, n = 16); placenta lying low in uterus but not invasive) to those of placental EVs purified from the plasma of women with placenta percreta (cases, n = 16), PAS with the highest level of invasiveness. Our analyses reveal that miRNA profiling of PLAP+ EVs purified from maternal plasma identified 40 differentially expressed miRNAs when comparing these two placental pathologies. Preliminary miRNA pathway enrichment and gene ontology analysis of the top 14 upregulated and top nine downregulated miRNAs in PLAP+ EVs, purified from the plasma of women diagnosed with placenta percreta versus those diagnosed with placenta previa, suggests a potential role in control of cellular invasion and motility that will require further investigation.
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Affiliation(s)
- Megan I. Mitchell
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110, USA;
- Hackensack University Medical Center, Department of Pediatrics, Hackensack Meridian Health, Hackensack, NJ 07601, USA;
- Hackensack Meridian School of Medicine (HMHSOM), Nutley, NJ 07110, USA; (J.A.-P.); (A.A.-K.)
| | - Marwa Khalil
- Hackensack University Medical Center, Department of Pediatrics, Hackensack Meridian Health, Hackensack, NJ 07601, USA;
- Hackensack Meridian School of Medicine (HMHSOM), Nutley, NJ 07110, USA; (J.A.-P.); (A.A.-K.)
| | - Iddo Z. Ben-Dov
- Laboratory of Medical Transcriptomics, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel;
| | - Jesus Alverez-Perez
- Hackensack Meridian School of Medicine (HMHSOM), Nutley, NJ 07110, USA; (J.A.-P.); (A.A.-K.)
- Hackensack University Medical Center, Department of Maternal and Fetal Medicine, Hackensack Meridian Health, Hackensack, NJ 07601, USA; (N.P.I.)
| | - Nicholas P. Illsley
- Hackensack University Medical Center, Department of Maternal and Fetal Medicine, Hackensack Meridian Health, Hackensack, NJ 07601, USA; (N.P.I.)
| | - Stacy Zamudio
- Hackensack University Medical Center, Department of Maternal and Fetal Medicine, Hackensack Meridian Health, Hackensack, NJ 07601, USA; (N.P.I.)
| | - Abdulla Al-Khan
- Hackensack Meridian School of Medicine (HMHSOM), Nutley, NJ 07110, USA; (J.A.-P.); (A.A.-K.)
- Hackensack University Medical Center, Department of Maternal and Fetal Medicine, Hackensack Meridian Health, Hackensack, NJ 07601, USA; (N.P.I.)
| | - Olivier Loudig
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ 07110, USA;
- Hackensack University Medical Center, Department of Pediatrics, Hackensack Meridian Health, Hackensack, NJ 07601, USA;
- Hackensack Meridian School of Medicine (HMHSOM), Nutley, NJ 07110, USA; (J.A.-P.); (A.A.-K.)
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Nguyen PN, Vuong ADB, Pham XTT. Neonatal outcomes in the surgical management of placenta accreta spectrum disorders: a retrospective single-center observational study from 468 Vietnamese pregnancies beyond 28 weeks of gestation. BMC Pregnancy Childbirth 2024; 24:228. [PMID: 38566074 PMCID: PMC10986094 DOI: 10.1186/s12884-024-06349-7] [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: 12/15/2023] [Accepted: 02/13/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Placenta accreta spectrum disorders (PASDs) increase the mortality rate for mothers and newborns over a decade. Thus, the purpose of the study is to evaluate the neonatal outcomes in emergency cesarean section (CS) and planned surgery as well as in Cesarean hysterectomy and the modified one-step conservative uterine surgery (MOSCUS). The secondary aim is to reveal the factors relating to poor neonatal outcomes. METHODS This was a single-center retrospective study conducted between 2019 and 2020 at Tu Du Hospital, in the southern region of Vietnam. A total of 497 pregnant women involved in PASDs beyond 28 weeks of gestation were enrolled. The clinical outcomes concerning gestational age, birth weight, APGAR score, neonatal intervention, neonatal intensive care unit (NICU) admission, and NICU length of stay (LOS) were compared between emergency and planned surgery, between the Cesarean hysterectomy and the MOSCUS. The univariate and multivariable logistic regression were used to assess the adverse neonatal outcomes. RESULTS Among 468 intraoperatively diagnosed PASD cases who underwent CS under general anesthesia, neonatal outcomes in the emergency CS (n = 65) were significantly poorer than in planned delivery (n = 403). Emergency CS increased the odds ratio (OR) for earlier gestational age, lower birthweight, lower APGAR score at 5 min, higher rate of neonatal intervention, NICU admission, and longer NICU LOS ≥ 7 days with OR, 95% confidence interval (CI) were 10.743 (5.675-20.338), 3.823 (2.197-6.651), 5.215 (2.277-11.942), 2.256 (1.318-3.861), 2.177 (1.262-3.756), 3.613 (2.052-6.363), and 2.298 (1.140-4.630), respectively, p < 0.05. Conversely, there was no statistically significant difference between the neonatal outcomes in Cesarean hysterectomy (n = 79) and the MOSCUS method (n = 217). Using the multivariable logistic regression, factors independently associated with the 5-min-APGAR score of less than 7 points were time duration from the skin incision to fetal delivery (min) and gestational age (week). One minute-decreased time duration from skin incision to fetal delivery contributed to reduce the risk of adverse neonatal outcome by 2.2% with adjusted OR, 95% CI: 0.978 (0.962-0.993), p = 0.006. Meanwhile, one week-decreased gestational age increased approximately two fold odds of the adverse neonatal outcome with adjusted OR, 95% CI: 1.983 (1.600-2.456), p < 0.0001. CONCLUSIONS Among pregnancies with PASDs, the neonatal outcomes are worse in the emergency group compared to planned group of cesarean section. Additionally, the neonatal comorbidities in the conservative surgery using the MOSCUS method are similar to Cesarean hysterectomy. Time duration from the skin incision to fetal delivery and gestational age may be considered in PASD surgery. Further data is required to strengthen these findings.
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Affiliation(s)
- Phuc Nhon Nguyen
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam.
- Tu Du Clinical Research Unit (TD-CRU), Tu Du Hospital, Ho Chi Minh City, Vietnam.
| | - Anh Dinh Bao Vuong
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Xuan Trang Thi Pham
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
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Dellapiana G, Mok T, Platt LD, Silverman NS, Han CS, Esakoff TF. Sensitivity of antenatal ultrasound in diagnosing posterior placenta accreta spectrum disorders. J Perinat Med 2024; 52:288-293. [PMID: 38243911 DOI: 10.1515/jpm-2023-0491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/01/2024] [Indexed: 01/22/2024]
Abstract
OBJECTIVES Optimal management of placenta accreta spectrum (PAS) requires antenatal diagnosis. We sought to evaluate the sensitivity of ultrasound findings suggestive of PAS in detecting posterior PAS. METHODS Cohort study of patients with posterior placentation and pathology-confirmed PAS from 2011 to 2020 at a tertiary center. Patients were excluded if ultrasound images were unavailable. Ultrasounds were reviewed for presence of lacunae, hypervascularity, myometrial thinning, loss of the hypoechoic zone, bridging vessels, abnormal uterine serosa-bladder interface, placental bulge, placental extension into/beyond the myometrium, and an exophytic mass. Risk factors, postpartum outcomes, and ultrasound findings were compared by antepartum suspicion for PAS. Sensitivity was calculated for each ultrasound finding. RESULTS Thirty-three patients were included. PAS was not suspected antenatally in 70 % (23/33). Patients with unsuspected PAS were more likely to be non-Hispanic, have in vitro fertilization, no prior Cesarean deliveries, no placenta previa, and delivered later in gestation. Depth of invasion and estimated blood loss were less for unsuspected PAS, but there was no difference in hysterectomy between groups. Ultrasound findings were less frequently seen in those who were not suspected antenatally: lacunae 17.4 vs. 100 % (p<0.001), hypervascularity 8.7 vs. 80 % (p<0.001), myometrial thinning 4.4 vs. 70 % (p<0.001), and placental bridging vessels 0 vs. 60 % (p<0.001). There was poor sensitivity (0-42.4 %) for all findings. CONCLUSIONS Posterior PAS is less likely to be detected antenatally due to a lower sensitivity of typical ultrasound findings in the setting of a posterior placenta. Further studies are needed to better identify reliable markers of posterior PAS.
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Affiliation(s)
- Gabriela Dellapiana
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Thalia Mok
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Lawrence D Platt
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Center for Fetal Medicine & Women's Ultrasound, Los Angeles, CA, USA
| | - Neil S Silverman
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Center for Fetal Medicine & Women's Ultrasound, Los Angeles, CA, USA
| | - Christina S Han
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Tania F Esakoff
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Jotwani AR, Lyell DJ, Butwick AJ, Rwigi W, Leonard SA. Validity of ICD-10 diagnosis codes for placenta accreta spectrum disorders. Paediatr Perinat Epidemiol 2024. [PMID: 38514907 DOI: 10.1111/ppe.13076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 03/06/2024] [Accepted: 03/09/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND The 10th revision of the International Classification of Diseases, Clinical Modification (ICD-10) includes diagnosis codes for placenta accreta spectrum for the first time. These codes could enable valuable research and surveillance of placenta accreta spectrum, a life-threatening pregnancy complication that is increasing in incidence. OBJECTIVE We sought to evaluate the validity of placenta accreta spectrum diagnosis codes that were introduced in ICD-10 and assess contributing factors to incorrect code assignments. METHODS We calculated sensitivity, specificity, positive predictive value and negative predictive value of the ICD-10 placenta accreta spectrum code assignments after reviewing medical records from October 2015 to March 2020 at a quaternary obstetric centre. Histopathologic diagnosis was considered the gold standard. RESULTS Among 22,345 patients, 104 (0.46%) had an ICD-10 code for placenta accreta spectrum and 51 (0.23%) had a histopathologic diagnosis. ICD-10 codes had a sensitivity of 0.71 (95% CI 0.56, 0.83), specificity of 0.98 (95% CI 0.93, 1.00), positive predictive value of 0.61 (95% CI 0.48, 0.72) and negative predictive value of 1.00 (95% CI 0.96, 1.00). The sensitivities of the ICD-10 codes for placenta accreta spectrum subtypes- accreta, increta and percreta-were 0.55 (95% CI 0.31, 0.78), 0.33 (95% CI 0.12, 0.62) and 0.56 (95% CI 0.31, 0.78), respectively. Cases with incorrect code assignment were less morbid than cases with correct code assignment, with a lower incidence of hysterectomy at delivery (17% vs 100%), blood transfusion (26% vs 75%) and admission to the intensive care unit (0% vs 53%). Primary reasons for code misassignment included code assigned to cases of occult placenta accreta (35%) or to cases with clinical evidence of placental adherence without histopatholic diagnostic (35%) features. CONCLUSION These findings from a quaternary obstetric centre suggest that ICD-10 codes may be useful for research and surveillance of placenta accreta spectrum, but researchers should be aware of likely substantial false positive cases.
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Affiliation(s)
- Anjali R Jotwani
- Department of Obstetrics and Gynecology, Stanford University, Stanford, California, USA
| | - Deirdre J Lyell
- Department of Obstetrics and Gynecology, Stanford University, Stanford, California, USA
| | - Alexander J Butwick
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Wanjiru Rwigi
- Department of Obstetrics and Gynecology, Stanford University, Stanford, California, USA
| | - Stephanie A Leonard
- Department of Obstetrics and Gynecology, Stanford University, Stanford, California, USA
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Yue Y, Song Y, Zhu L, Xu D, Li Z, Liu C, Liang B, Lu Y. The MRI estimations of placental volume, T2 dark band volume, and cervical length correlate with massive hemorrhage in patients with placenta accreta spectrum disorders. Abdom Radiol (NY) 2024:10.1007/s00261-024-04272-1. [PMID: 38451265 DOI: 10.1007/s00261-024-04272-1] [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: 08/02/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 03/08/2024]
Abstract
PURPOSE To identify whether placental volume, T2 dark band volume, and cervical length measured by MRI correlate with massive hemorrhage (MH) in patients with placenta accreta spectrum (PAS) disorders. METHODS A total of 163 pregnant women with PAS underwent preoperative MRI examination were divided into MH group and non-MH group. The placental volume, T2 dark band volume, and cervical length of PAS patients were measured and evaluated their ability to identify MH in patients with PAS. RESULTS Patients with MH had a significantly larger placental volume, larger T2 dark band volume, and shorter cervical length than patients without MH (all P < 0.001). Multivariable logistic regression showed that placental volume (> 890 cm3), T2 dark band volume (> 35 cm3), and cervical length (< 30 mm) were significant independent risk factor in identification of MH. In all PAS patients, a positive linear correlation was found between placental volume and amount of blood loss (r = 0.527), and between T2 dark band volume and amount of blood loss (r = 0.642), and a negative linear correlation was found between cervical length and amount of blood loss (r = - 0.597). When combined with the three MRI indicators, the sensitivity and specificity in identifying cases at high risk for MH were 91.638% and 94.051%, respectively, with area under the curve (AUC) of 0.923. CONCLUSION The placental volume, T2 dark band volume, and cervical length might be used to predict MH in patients with PAS.
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Affiliation(s)
- Yongfei Yue
- Department of Obstetrics and Gynecology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, No. 26 Daoqian Street, Gusu District, Suzhou, 215002, Jiangsu, China
| | - Ye Song
- Department of Obstetrics and Gynecology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, No. 26 Daoqian Street, Gusu District, Suzhou, 215002, Jiangsu, China.
| | - Liping Zhu
- Department of Obstetrics and Gynecology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, No. 26 Daoqian Street, Gusu District, Suzhou, 215002, Jiangsu, China
| | - Duo Xu
- Department of Obstetrics and Gynecology, Affiliated Shenzhen Maternity & Child Healthcare Hospital, Southern Medical University, Shenzhen, Guangdong, China
| | - Zhencheng Li
- Department of Obstetrics and Gynecology, Affiliated Shenzhen Maternity & Child Healthcare Hospital, Southern Medical University, Shenzhen, Guangdong, China
| | - Chengfeng Liu
- Department of Obstetrics and Gynecology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, No. 26 Daoqian Street, Gusu District, Suzhou, 215002, Jiangsu, China
| | - Baoquan Liang
- Department of Obstetrics and Gynecology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, No. 26 Daoqian Street, Gusu District, Suzhou, 215002, Jiangsu, China
| | - Yanli Lu
- Department of Medical Imaging, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
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Munoz JL, Ramsey PS, Greebon LJ, Salazar E, McCann GA, Byrne JJ. Risk factors of massive blood transfusion (MTP) in cesarean hysterectomy for placenta accreta spectrum. Eur J Obstet Gynecol Reprod Biol 2024; 293:32-35. [PMID: 38100939 DOI: 10.1016/j.ejogrb.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 10/31/2023] [Accepted: 12/04/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Placenta Accreta Spectrum (PAS) represents a particularly morbid condition for which blood transfusion is the leading cause. Delivery by cesarean hysterectomy is recommended for the management of PAS. Massive Transfusion Protocols (MTP) in obstetrics vary in definition and implementation. Given the significant blood loss during PAS cesarean hysterectomy, this is particularly important for surgeons and blood banks. Our objective was to identify risk factors for MTP in patients with antenatally suspected PAS. METHODS We performed a case-control study over a 11-year period from 2012 to 2022 at our center for Placenta Accreta Spectrum. MTP was defined by two methods, >4 units or > 10 units of red blood cells/whole blood transfused over 24 h. Antenatal, operative and post-operative outcomes were obtained from electronic medical records of these cases. RESULTS During the study time frame, 142 cases were managed by our PAS team and met all criteria. 85 % (120/142) of patients were transfused at least 1 unit of blood, 64 patients (45 %) received 0-3 units of blood, 50 patients (35 %) received 4-9 units of blood and 28 patients (19.7 %) were transfused > 10 units of blood. Pre-delivery vaginal bleeding, preterm labor and delivery < 34 weeks were independently significant in transfused patients. ROC analysis revealed an area under the curve (AUC) of 0.79 (p < 0.0001) in patients transfused > 10 units, showing predictive capability for this subgroup. DISCUSSION We here report pre-operative risk factors for MTP in patients undergoing cesarean hysterectomy for PAS. This allows for both resource utilization and patient counseling for this morbid maternal condition.
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Affiliation(s)
- Jessian L Munoz
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States.
| | - Patrick S Ramsey
- University of Texas Health Sciences Center at San Antonio, and the Department of Obstetrics & Gynecology, University Health System, San Antonio, TX, United States
| | - Leslie J Greebon
- University of Texas Health Sciences Center at San Antonio, and the Department of Pathology and Laboratory Medicine, University Health System, San Antonio, TX, United States
| | - Eric Salazar
- University of Texas Health Sciences Center at San Antonio, and the Department of Pathology and Laboratory Medicine, University Health System, San Antonio, TX, United States
| | - Georgia A McCann
- University of Texas Health Sciences Center at San Antonio, and the Department of Obstetrics & Gynecology, University Health System, San Antonio, TX, United States
| | - John J Byrne
- University of Texas Health Sciences Center at San Antonio, and the Department of Obstetrics & Gynecology, University Health System, San Antonio, TX, United States
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10
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Taman M, Mosa DM, Hashem HA, Samir K, Ibrahim EM, Abdelbar A, Mousa A, Elesawi M. Accuracy of Ultrasound in the Prediction of the FIGO Classification of Placenta Accreta Spectrum. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102262. [PMID: 37924943 DOI: 10.1016/j.jogc.2023.102262] [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: 06/09/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVES To evaluate the accuracy of greyscale ultrasound (US) and colour Doppler detecting placenta accreta spectrum (PAS) based on the newly recommended International Federation of Obstetrics and Gynaecology (FIGO) grading system. METHODS This prospective study was conducted on women diagnosed with placenta previa or low-lying placenta involving the anterior uterine wall and associated with PAS as identified by the US. Transabdominal and transvaginal greyscale US was performed on admission between 34 and 36 weeks of gestation and compared to clinical grading and histopathological examination after cesarean hysterectomy. RESULTS In total, 36 pregnant females who underwent a cesarean hysterectomy due to placenta previa complicated by PAS were included in this study. All patients had a history of previous cesarean deliveries, ranging from 1 to 5 deliveries. The US has an overall sensitivity of 33%, 55%, and 84.62%, and specificity of 100%, 75%, and 60% in detecting the 3 degrees of PAS, respectively. US cannot differentiate between the different subtypes of PAS grade 3 (a, b, and c). CONCLUSION The overall US evaluation was highly significant in predicting the FIGO diagnosis of PAS; however, all ultrasonographic signs were equally relevant in diagnosing grade 1 and/or 2 PAS and were inaccurate in differing the subtypes of PAS grade 3.
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Affiliation(s)
- Mohamed Taman
- Department of Obstetrics and Gynecology, Mansoura University Hospital, Mansoura Faculty of Medicine, Mansoura, Egypt
| | - Doaa Mosad Mosa
- Department of Rheumatology and Rehabilitation, Mansoura University Hospital, Mansoura Faculty of Medicine, Mansoura, Egypt.
| | - Hatem Abo Hashem
- Professor of Obstetrics and Gynecology, Mansoura University Hospital, Mansoura Faculty of Medicine, Mansoura, Egypt
| | - Khalid Samir
- Department of Obstetrics and Gynecology, Mansoura University Hospital, Mansoura Faculty of Medicine, Mansoura, Egypt
| | - Eman M Ibrahim
- Department of Pathology, Mansoura Faculty of Medicine, Mansoura, Egypt
| | - Ahmed Abdelbar
- Department of Obstetrics and Gynecology, Cairo University Hospital, Cairo, Egypt
| | - Abdalla Mousa
- Department of Obstetrics and Gynecology, Cairo University Hospital, Cairo, Egypt
| | - Maher Elesawi
- Department of Obstetrics and Gynecology, Mansoura University Hospital, Mansoura Faculty of Medicine, Mansoura, Egypt
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11
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Han L, Zhang B, Xu H, Yin H, Pang Y, Zhang X, Zhai Q, Liu X, Wang Y, Zhang C, Xu Y, Liu Y, Chen X. A new step-wise surgical technique of knapsack-like uterine compression sutures for intractable postpartum hemorrhage in cesarean section. BMC Pregnancy Childbirth 2024; 24:9. [PMID: 38166803 PMCID: PMC10759382 DOI: 10.1186/s12884-023-06208-x] [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: 06/16/2023] [Accepted: 12/15/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Intractable postpartum hemorrhage (PPH) during cesarean section has been a significant concern for obstetricians. We aimed to explore the effectiveness and safety of a new type of uterine compression suture, the step-wise surgical technique of knapsack-like sutures for treating intractable PPH caused by uterine atony and placenta factors in cesarean section. METHODS The step-wise surgical technique of knapsack-like sutures was established on the basis of the artful combination of vertical strap-like sutures and an annular suture-ligation technique. This novel surgical technique was applied to 34 patients diagnosed with PPH during cesarean section due to severe uterine atony and placental factors in our department. The hemostatic effects, clinical outcomes and follow-up visit results were all reviewed and analyzed. RESULTS This new uterine compression suture successfully stopped bleeding in 33 patients, and the effective rate was 97.06%. Only 1 patient failed and was changed to use bilateral uterine arterial embolization and internal iliac artery embolization. The follow-up visits indicated that 33 patients restored menstruation except for 1 who was diagnosed with amenorrhea. The gynecological ultrasound tests of all the patients suggested good uterine involutions, and they had no obvious complaints such as hypogastralgia. CONCLUSIONS This step-wise surgical technique of knapsack-like uterine compression sutures can compress the uterus completely. It is a technique that can conserve the uterus and fertility function without special equipment in caesarean section for PPH, with the characteristics of being safe, simple and stable (3 S) with rapid surgery, reliable hemostasis and resident doctor to operation (3R).
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Affiliation(s)
- Lei Han
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China.
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, 401120, China.
| | - Baolin Zhang
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
- Department of Obstetrics and Gynecology, Binzhou Central Hospital, Binzhou City, 251700, Shandong Province, P. R. China
| | - Huishu Xu
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
| | - Hongmei Yin
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
- Department of Obstetrics and Gynecology, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
| | - Yiwei Pang
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
- Department of Obstetrics and Gynecology, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
| | - Xianghui Zhang
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
- Department of Obstetrics and Gynecology, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
| | - Qingliang Zhai
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
- Department of Obstetrics and Gynecology, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
| | - Xiaofeng Liu
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
| | - Yanlin Wang
- Department of Reproductive Medicine, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
| | - Caiying Zhang
- Department of Postgraduate Student Office, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
| | - Yingjiang Xu
- Department of Interventional Vascular Surgery, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China
| | - Yanni Liu
- Department of Obstetrics and Gynecology, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China.
| | - Xuemei Chen
- Department of Obstetrics and Gynecology, Binzhou Medical University Hospital, Binzhou City, 256603, Shandong Province, P. R. China.
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12
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Li R, Tang X, Qiu X, Wang W, Wang Q. Associations of characteristics of previous induced abortion with different grades of current placenta accreta spectrum disorders. J Matern Fetal Neonatal Med 2023; 36:2253349. [PMID: 37648652 DOI: 10.1080/14767058.2023.2253349] [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: 06/15/2023] [Revised: 07/19/2023] [Accepted: 08/24/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE Induced abortion could increase the risk of placenta accreta spectrum (PAS) in the next pregnancy. We aimed to explore the associations between characteristics of previous induced abortion and grades of current PAS. METHODS A retrospective case-control study was performed in eligible pregnant women with PAS between January 2014 and June 2022. Data collected included demographics, obstetric characteristics, and information on previous induced abortion. RESULTS The study included 211 pregnant women, with 51 and 160 in the invasive (placenta increta or percreta) and adherence (placenta creta) PAS groups, respectively. The risk of invasive PAS was 14.3-fold higher in patients with abnormal vaginal bleeding after abortion (odds ratio = 14.3, 95% confidence interval 5.6-36.4, p < .01) than those without abnormal vaginal bleeding and approximately 5.8-fold higher in patients with the last induced abortion ≥5 years ago than those within 5 years (odds ratio = 5.8, 95% confidence interval 2.2-15.2, p < .01). The risk of invasive PAS was 13.4-fold higher in patients with placenta attached to uterine cornu than patients with the placenta attached to uterine wall (odds ratio = 17.5, 95% confidence interval 5.5-55.5, p < .01). The number of previous induced abortions, hospital grades, and gestational age at abortion were not different between two groups. CONCLUSION In pregnant women with a history of induced abortion, abnormal vaginal bleeding after induced abortion and prolonged duration after the last induced abortion increased the risk for invasive PAS in the current pregnancy. The number of previous induced abortions and gestational age at abortion had no relation to the grades of PAS.
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Affiliation(s)
- Rui Li
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xiaoqin Tang
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xia Qiu
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Wan Wang
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Qi Wang
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
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13
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Munoz JL, Ramsey PS, Byrne JJ. Risk of Severe Maternal Morbidity in Patients with Placenta Accreta Spectrum Disorders Referred from Rural Communities to a Regional Placenta Accreta Spectrum Center. Am J Perinatol 2023; 40:1738-1744. [PMID: 37433315 DOI: 10.1055/a-2126-7337] [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: 07/13/2023]
Abstract
OBJECTIVE The primary objective of this study was to assess the risk of severe maternal morbidity (SMM) experienced by patients residing in rural communities when delivered by a multidisciplinary team within a single urban academic center for placenta accreta spectrum (PAS). Subsequently, we aimed to determine a distance-dependent relationship between PAS morbidity and distance travelled by patients in rural communities. STUDY DESIGN This was a retrospective cohort study of patients who had PAS histopathological confirmation and delivery at our institution from 2005 to 2022. Our objective was to determine the relationship between patient locations (rural vs. urban) and maternal morbidity associated with PAS delivery. Sociogeographic determination of rurality was determined using the National Center for Health Statistics and most recent national census population data. Distance travelled was calculated by patient zip code to our PAS center using global positioning system data. RESULTS During the study period, 139 patients were managed by cesarean hysterectomy with confirmed PAS histopathology. Of these, 94 (67.6%) were from our urban community and 45 (32.4%) were from surrounding rural communities. The overall SMM incidence was 85% including blood transfusion and 17% without blood transfusions. Patient from rural communities were more likely to experience SMM (28.9 vs. 12.8%, p = 0.03) and this was driven by acute renal failure (1.1 vs. 11.1%, p = 0.01) and disseminated intravascular coagulopathy (1.1 vs. 8.8%, p = 0.04). SMM did reveal a distance-dependent relationship with SMM rates of 13.2, 33.3, and 43.8% at 50, 100, and 150 miles, respectively (p = 0.005). CONCLUSION Patients with PAS experience high rates of SMM. Geographic distance to a PAS center appears to significantly impact the overall morbidity a patient experiences. Further research is warranted to address this disparity and optimize patient outcomes for patients in rural communities KEY POINTS: · Patients from rural communities experience greater SMM in the setting of PAS.. · Intraoperative outcomes and interventions were similar, regardless of patient location.. · SMM may be related to the distance travelled by patients in rural communities..
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Affiliation(s)
- Jessian L Munoz
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Balor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Patrick S Ramsey
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Texas Health Sciences Center at San Antonio and University Health System, San Antonio, Texas
| | - John J Byrne
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Texas Health Sciences Center at San Antonio and University Health System, San Antonio, Texas
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14
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Fahad A, Fazari A, Al Fardan N, Abu-Nayla U, Haseep A, Alabdi N. Focal Placenta Accreta in a Congenitally Malformed Uterus: A Case Report. Cureus 2023; 15:e47618. [PMID: 38022269 PMCID: PMC10667619 DOI: 10.7759/cureus.47618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Placenta accreta is defined as an abnormal trophoblast invasion of part or all of the placenta into the myometrium of the uterine wall. It is a well-known cause of maternal morbidity and mortality. Here, we present a unique case of focal placenta accreta due to a bicornuate uterus and a history of septum resection. We also discuss its management and outcome. The patient underwent a classical cesarean section and reinforcement of the anterior and posterior uterine wall. The patient had a history of surgery for correction of uterine malformation, which may have resulted in an abnormal adherence of the placenta.
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Affiliation(s)
- Asma Fahad
- Obstetrics and Gynaecology, Latifa Hospital, Dubai Academic Health Corporation, Dubai, ARE
| | - Atif Fazari
- Obstetrics and Gynaecology, Latifa Hospital, Dubai Academic Health Corporation, Dubai, ARE
| | - Nahla Al Fardan
- Obstetrics and Gynaecology, Latifa Hospital, Dubai Academic Health Corporation, Dubai, ARE
| | - Umniyah Abu-Nayla
- Obstetrics and Gynaecology Residency Program, Dubai Academic Health Corporation, Dubai, ARE
| | - Ayat Haseep
- Obstetrics and Gynaecology Residency Program, Dubai Academic Health Corporation, Dubai, ARE
| | - Noor Alabdi
- Obstetrics and Gynaecology Residency Program, Dubai Academic Health Corporation, Dubai, ARE
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15
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Sanders TK, Stewart JK. Placenta Accreta Spectrum: The Role of Interventional Radiology in Multidisciplinary Management. Semin Intervent Radiol 2023; 40:349-356. [PMID: 37575347 PMCID: PMC10415058 DOI: 10.1055/s-0043-1771038] [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: 08/15/2023]
Abstract
Placenta accreta spectrum is increasing in prevalence and poses significant risks to obstetric patients. This article defines characteristics, diagnosis, management, and outcomes of placenta accreta spectrum, highlighting interventional radiology's role in its management as part of a multidisciplinary approach.
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Affiliation(s)
- Troy K. Sanders
- David Geffen School of Medicine at UCLA, Interventional Radiology, Los Angeles, California
| | - Jessica K. Stewart
- David Geffen School of Medicine at UCLA, Interventional Radiology, Los Angeles, California
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16
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Shaamash AH, AlQasem MH, Al Ghamdi DS, Mahfouz AA, Eskandar MA. Placenta accreta spectrum in major placenta previa diagnosed only by MRI: incidence, risk factors, and maternal morbidity. Ann Saudi Med 2023; 43:219-217. [PMID: 37554027 DOI: 10.5144/0256-4947.2023.219] [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: 08/10/2023] Open
Abstract
BACKGROUND Antenatal assessment of maternal risk factors and imaging evaluation can help in diagnosis and treatment of placenta accreta spectrum (PAS) in major placenta previa (PP). Recent evidence suggests that magnetic resonance imaging (MRI) could complement ultrasonography (US) in the PAS diagnosis. OBJECTIVES Evaluate the incidence, risk factors, and maternal morbidity related to the MRI diagnosis of PAS in major PP. DESIGN A 10-year retrospective cohort study. SETTING Tertiary care hospital. PATIENTS AND METHODS We report on patients with major PP who had cesarean delivery in Abha Maternity and Children's Hospital (AMCH) over a 10-year period (2012-2021). They were evaluated with ultrasonography (US) and color Doppler for evidence of PAS. Antenatal MRI was ordered either to confirm the diagnosis (if equivocal US) or to assess the depth of invasion/extra-uterine extension (if definitive US). MAIN OUTCOME MEASURES Risk factors for PAS in major PP and maternal complications. SAMPLE SIZE 299 patients RESULTS: Among 299 patients, MRI confirmed the PAS diagnosis in 91/299 (30.5%) patients. The independent risk factors for MRI diagnosis of PAS in major PP included only repeated cesarean sections and advanced maternal age. The commonest maternal morbidity in major PP with PAS was significantly excessive intraoperative bleeding. CONCLUSION MRI may be a valuable adjunct in the evaluation of PAS in major PP; as a complement, but not substitute US. MRI may be suitable in major PP/PAS patients who are older and have repeated cesarean deliveries with equivocal results or deep/extra-uterine extension on US. LIMITATION Single center, small sample size, lack of complete histopathological diagnosis. CONFLICT OF INTEREST None.
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Affiliation(s)
- Ayman Hussien Shaamash
- From the Department of Obstetrics and Gynecology, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Mehad H AlQasem
- From the Department of Obstetrics and Gynecology, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Deama S Al Ghamdi
- From the Department of Obstetrics and Gynecology, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Ahmed A Mahfouz
- From the Department of Community and Family Medicine, King Khalid University, Abha, Saudi Arabia
| | - Mamdoh A Eskandar
- From the Department of Obstetrics and Gynecology, College of Medicine, King Khalid University, Abha, Saudi Arabia
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17
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Wu X, Yang H, Yu X, Zeng J, Qiao J, Qi H, Xu H. The prenatal diagnostic indicators of placenta accreta spectrum disorders. Heliyon 2023; 9:e16241. [PMID: 37234657 PMCID: PMC10208845 DOI: 10.1016/j.heliyon.2023.e16241] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 04/29/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Placenta accreta spectrum (PAS) disorders refers to a heterogeneous group of anomalies distinguished by abnormal adhesion or invasion of chorionic villi through the myometrium and uterine serosa. PAS frequently results in life-threatening complications, including postpartum hemorrhage and hysterotomy. The incidence of PAS has increased recently as a result of rising cesarean section rates. Consequently, prenatal screening for PAS is essential. Despite the need to increase specificity, ultrasound is still considered a primary adjunct. Given the dangers and adverse effects of PAS, it is necessary to identify pertinent markers and validate indicators to improve prenatal diagnosis. This article summarizes the predictors regarding biomarkers, ultrasound indicators, and magnetic resonance imaging (MRI) features. In addition, we discuss the effectiveness of joint diagnosis and the most recent research on PAS. In particular, we focus on (a) posterior placental implantation and (b) accreta after in vitro fertilization-embryo transfer, both of which have low diagnostic rates. At last, we graphically display the prenatal diagnostic indicators and each diagnostic performance.
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Affiliation(s)
- Xiafei Wu
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Huan Yang
- Department of Obstetrics, Chongqing University Three Gorges Hospital, Chongqing 404100, China
| | - Xinyang Yu
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Jing Zeng
- Stomatological Hospital of Chongqing Medical University, Chongqing 401147, China
| | - Juan Qiao
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Hongbo Qi
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Women and Children's Hospital of Chongqing Medical University, Chongqing 401147, China
| | - Hongbing Xu
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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18
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Wang R, Zhao J, Liu C, Li S, Liu W, Cao Q. Decreased AGGF1 facilitates the progression of placenta accreta spectrum via mediating the P53 signaling pathway under the regulation of miR-1296-5p. Reprod Biol 2023; 23:100735. [PMID: 36753931 DOI: 10.1016/j.repbio.2023.100735] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 01/26/2023] [Accepted: 01/27/2023] [Indexed: 02/09/2023]
Abstract
Placenta accreta spectrum (PAS), an emerging health issue worldwide, is the major causative factor of maternal morbidity and mortality in modern obstetrics, but limited studies have contributed to our understanding of the molecular biology of PAS. This study addressed the expression of AGGF1 and its specific role in the etiology of PAS. The expression of AGGF1 in the placentas of PAS was determined by quantitative PCR, western blot and immunohistochemistry. CCK-8 assay, wound healing assay, Transwell invasion assay and flow cytometry assay were performed to monitor cell proliferation, migration, invasion and apoptosis. The interaction between miR-1296-5p and AGGF1 was detected by dual-luciferase reporter gene assay. Results showed that the mRNA and protein expression of AGGF1 was decremented in placental tissues of PAS patients, compared with samples from women with placenta previa and normal pregnant women. Downregulation of AGGF1 promoted cell proliferation, invasion and migration, inhibited apoptosis in vitro, decreased P53 and Bax expression, and simultaneously increased Bcl-2 expression, whereas overexpression of AGGF1 had the opposite results. Additionally, the dual-luciferase assay confirmed AGGF1 as a target gene of miR-1296-5p in placental tissues of PAS. Particularly, miR-1296-5p fostered HTR8/SVneo cell proliferation, invasion, repression of apoptosis and regulation of P53 signaling axis by downregulating AGGF1 expression. Collectively, our study accentuated that downregulation of placental AGGF1 promoted trophoblast over-invasion by mediating the P53 signaling pathway under the regulation of miR-1296-5p.
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Affiliation(s)
- Runfang Wang
- Department of Obstetrics and Gynecology, Hebei Medical University, Shijiazhuang, Hebei, China; Department of Obstetrics and Gynecology, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Jing Zhao
- Department of Obstetrics and Gynecology, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Cuilian Liu
- Department of Obstetrics and Gynecology, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Shengxian Li
- Department of Obstetrics and Gynecology, North China University of Science and Technology, Tangshan, Hebei, China
| | - Weifang Liu
- Department of Obstetrics and Gynecology, North China University of Science and Technology, Tangshan, Hebei, China
| | - Qinying Cao
- Department of Obstetrics and Gynecology, Hebei Medical University, Shijiazhuang, Hebei, China; Department of Obstetrics and Gynecology, Shijiazhuang People's Hospital, Shijiazhuang, Hebei, China.
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19
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Jariyawattanarat W, Thiravit S, Suvannarerg V, Srisajjakul S, Sutchritpongsa P. Bladder involvement in placenta accreta spectrum disorder with placenta previa: MRI findings and outcomes correlation. Eur J Radiol 2023; 160:110695. [PMID: 36657210 DOI: 10.1016/j.ejrad.2023.110695] [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: 05/02/2022] [Revised: 12/05/2022] [Accepted: 01/10/2023] [Indexed: 01/14/2023]
Abstract
BACKGROUND Placental accreta spectrum (PAS) disorder with bladder involvement can be associated with maternal and neonatal morbidity. Magnetic resonance imaging (MRI) may provide accurate preoperative diagnoses. OBJECTIVE This study had 2 aims: to retrospectively review the MRI findings for bladder involvement in PAS with placental previa and to correlate bladder involvement with maternal and neonatal outcomes. MATERIALS AND METHODS MRI images of 48 patients with severe PAS (increta and percreta) with placenta previa/low-lying placenta were evaluated by 2 experienced radiologists blinded to the final diagnoses. Nine MRI findings and stepwise logistic regression analysis were assessed to identify predictive MRI findings for bladder involvement. The correlations between PAS patients with bladder involvement and clinical outcomes were analyzed using Fisher's exact test. RESULTS Of the 48 patients, 27 did not have bladder involvement, while 21 did. Logistic regression analysis identified 2 predictive MRI features for bladder involvement. They were abnormal vascularization (OR,6.94; 95 %CI,1.05-45.75) and loss of the chemical shift line at the uterovesical interface (OR, 4.41; 95 %CI, 0.63-30.98). The sensitivity and specificity of the combined MRI features were 38.1 % and 100 %, respectively (p = 0.001). A significant correlation was found between bladder involvement and massive blood loss during surgery (p = 0.022). CONCLUSIONS PAS with bladder involvement was significantly correlated with massive surgical blood loss. Prenatally, the disorder was predicted with high specificity by the combination of loss of chemical shift artifacts in the steady-state free precession sequence and abnormal vascularization at the uterovesical interface on MRI.
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Affiliation(s)
- Watchaya Jariyawattanarat
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
| | - Shanigarn Thiravit
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
| | - Voraparee Suvannarerg
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
| | - Sitthipong Srisajjakul
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
| | - Pavit Sutchritpongsa
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
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20
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Capannolo G, D'Amico A, Alameddine S, Di Girolamo R, Khalil A, Calì G, Trish IT, Coutinho CM, Herrera M, Liberati M, Lucidi A, Palacios-Jaraquemada J, Buca D, D'Antonio F. Placenta accreta spectrum disorders clinical practice guidelines: A systematic review. J Obstet Gynaecol Res 2023; 49:1313-1321. [PMID: 36796351 DOI: 10.1111/jog.15544] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/28/2022] [Indexed: 02/18/2023]
Abstract
OBJECTIVES To objectively assess the quality of the published clinical practice guidelines (CPGs) on the management of pregnancies complicated by placenta accreta spectrum (PAS)disorders. METHODS MEDLINE, Embase, Scopus, and ISI Web of Science databases were searched. The following aspects related to the management of pregnancies with suspected PAS disorders were evaluated: risk factors for PAS, prenatal diagnosis, role of interventional radiology and ureteral stenting, and optimal surgical management. The assessment of risk of bias and quality assessment of the CPGs were performed using the (AGREE II) tool (Brouwers et al., 2010). To define a CPG as of good quality we adopted a cut-off score >60%. RESULTS Nine CPGs were included. Specific risk factors for referral were assessed by 44.4% (4/9) of CPGs, mainly consisting in the presence of placenta previa and a prior cesarean delivery or uterine surgery. About 55.6% of CPGs (5/9) suggested ultrasound assessment of women with risk factors for PAS in the second and third trimester of pregnancy and 33.3% (3/9) recommended magnetic resonance imaging (MRI); 88.9% (8/9) of CPGs recommended cesarean delivery at 34-37 weeks of gestation. There was not generally consensus on the use of interventional radiology and ureteral stenting before surgery for PAS. Finally, hysterectomy was the recommend surgical approach by 77.8% (7/9) of the included CPGs. CONCLUSION Most of the published CPGs on PAS are generally of good quality. There was general agreement among the different CPGs on PAS as a regard as risk stratification, timing at diagnosis and delivery but not on the indication for MRI, use of interventional radiology and ureteral stenting.
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Affiliation(s)
- Giulia Capannolo
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Alice D'Amico
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Sara Alameddine
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Raffaella Di Girolamo
- Department of Public Health, School of Medicine, Federico II, University of Naples, Naples, Italy
| | - Asma Khalil
- Fetal Medicine Unit, Saint George's Hospital, London, UK
| | - Giuseppe Calì
- Department of Obstetrics and Gynecology, Arnas Civico Hospital, Palermo, Italy
| | - Ilan T Trish
- Department of Obstetrics and Gynecology, NYU School of Medicine, NYU Langone Health, New York, New York, USA
| | - Conrado M Coutinho
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo: Ribeirão Preto, São Paulo, Brazil
| | - Mauricio Herrera
- Maternal fetal medicine, Obstetric Department, Clinica Colsanitas Bogotà, Bogota, Colombia
| | - Marco Liberati
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Alessandro Lucidi
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | | | - Danilo Buca
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Francesco D'Antonio
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
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Reyther RAC, Kway VB, Huerta MM, Labastida SDLM, Cruz EYT. The use of the double uterine segment tourniquet in obstetric hysterectomy for bleeding control in patients with placenta accreta spectrum. Int J Gynaecol Obstet 2023. [PMID: 36762582 DOI: 10.1002/ijgo.14720] [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: 12/14/2022] [Revised: 01/30/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVES To evaluate surgical outcomes of using a double uterine segment tourniquet in obstetric hysterectomy for bleeding control in patients with placenta accreta spectrum. METHODS Retrospective case-control study conducted at the Central Hospital of San Luis Potosi, Mexico. Patients with the diagnosis of placenta accreta spectrum who underwent obstetric hysterectomy were included. Two groups were formed: in the first, a double uterine segment tourniquet was used; and in the second, the hysterectomy was performed without a tourniquet. Primary surgical outcomes were compared. RESULTS Forty patients in each group were included. The use of a double uterine segment tourniquet had lower total blood loss compared with the non-tourniquet group (1054.00 ± 467.02 vs. 1528.75 ± 347.12 mL, P = 0.0171) and a lower drop in hemoglobin (1.74 ± 1.10 vs. 2.60 ± 1.25 mg/dL, P = 0.0486). Ten patients (23.80%) in the double tourniquet group required blood transfusion, compared with 26 (65.00%) in the non-tourniquet group (P = 0.0003). Surgical time did not show a statistical difference between groups. CONCLUSION The use of a uterine segment tourniquet in obstetric hysterectomy may improve surgical outcomes in patients with placenta accreta spectrum with no difference in surgical time and urinary tract lesions.
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Affiliation(s)
- Roberto Arturo Castillo Reyther
- Department of Obstetrics and Gynecology, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico.,Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
| | - Venance Basil Kway
- Department of Obstetrics and Gynecology, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico
| | - Manuel Mendoza Huerta
- Department of Obstetrics and Gynecology, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico.,Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
| | - Salvador De La Maza Labastida
- Department of Obstetrics and Gynecology, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico.,Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
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Wang R, Liu W, Zhao J, Liu L, Li S, Duan Y, Huo Y. Overexpressed LAMC2 promotes trophoblast over-invasion through the PI3K/Akt/MMP2/9 pathway in placenta accreta spectrum. J Obstet Gynaecol Res 2023; 49:548-559. [PMID: 36412218 DOI: 10.1111/jog.15493] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/19/2022] [Accepted: 10/26/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Placenta accreta spectrum (PAS) is an ongoing major iatrogenic public health challenge with devastating obstetric complications, but its underlying molecular pathogenesis remains poorly illuminated. LAMC2 is reported to regulate tumor cells proliferation and invasion, yet has not been explored in placenta trophoblast cells. This study investigated LAMC2 expression and its contribution in the etiology of PAS. METHODS Quantitative polymerase chain reaction, western blot, and immunohistochemistry were performed to detect the expression of LAMC2 in placentas. Cell proliferation, invasion, migration, and apoptosis were monitored by CCK8 assay, wound healing assay, transwell invasion assay, and flow cytometry assay. Western blot was conducted to confirm the pertinent proteins level of PI3K/Akt/MMP2/9 pathway in HTR8/SVneo cells. RESULTS LAMC2 was predominantly expressed in placental villous syncytiotrophoblasts and cytotrophoblasts. LAMC2 mRNA and protein expression were substantially upregulated in placental tissues with PAS compared to those with pernicious placenta previa without PAS. LAMC2 overexpression eminently boosted HTR8/SVneo cells proliferation, invasion, and migration, but inhibited apoptosis, accompanied by elevated protein expression of MMP2, MMP9, and phosphorylated Akt (pAkt). Knockdown of LAMC2 yielded the converse results. Additionally, when treated with LY294002, the effects of LAMC2 overexpression on proliferation, migration, invasion, and apoptosis of HTR8/SVneo cells were abolished and concomitantly the elevated pAkt, MMP2, and MMP9 proteins induced by LAMC2 overexpression were eliminated. CONCLUSION Our study highlighted the involvement of LAMC2 in the pathogenesis of PAS by activating the PI3K/Akt/MMP2/9 signaling pathway to stimulate trophoblast over-invasion. These findings provide a new target for the diagnosis and disease stratification of PAS.
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Affiliation(s)
- Runfang Wang
- Department of Obstetrics and Gynecology, Hebei General Hospital, Shijiazhuang, Hebei Province, China
| | - Weifang Liu
- Department of Obstetrics and Gynecology, North China University of Science and Technology, Tangshan, Hebei Province, China
| | - Jing Zhao
- Department of Obstetrics and Gynecology, Hebei General Hospital, Shijiazhuang, Hebei Province, China
| | - Li Liu
- Department of Obstetrics and Gynecology, Hebei General Hospital, Shijiazhuang, Hebei Province, China
| | - Shengxian Li
- Department of Obstetrics and Gynecology, North China University of Science and Technology, Tangshan, Hebei Province, China
| | - Ya Duan
- Department of Obstetrics and Gynecology, Hebei General Hospital, Shijiazhuang, Hebei Province, China
| | - Yan Huo
- Department of Obstetrics and Gynecology, Hebei General Hospital, Shijiazhuang, Hebei Province, China
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Ayalde J, Epee-Bekima M, Jansen B. A review of placenta accreta spectrum and its outcomes for perinatal mental health. Australas Psychiatry 2023; 31:73-75. [PMID: 36375814 DOI: 10.1177/10398562221139130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Placenta accreta spectrum conditions are rare, life-threatening disorders of placentation encountered in the perinatal period, with lasting impacts on maternal quality of life and psychological wellbeing. Although the obstetric outcomes are well-known, further review is warranted to explore the psychological sequelae that may accompany these conditions. CONCLUSIONS The occurrence of placenta accreta spectrum during pregnancy is a major life stressor that can contribute to the development of psychiatric co-morbidity including posttraumatic stress disorder, depression and anxiety disorders. Early recognition of psychological distress and symptomatic profile is recommended at all stages of perinatal care complicated by this rare spectrum of conditions.
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Affiliation(s)
- Jeremiah Ayalde
- Medical School, 172098The University of Western Australia, Crawley, WA, Australia
| | - Mathias Epee-Bekima
- Obstetrics and Gynaecology, 60082King Edward Memorial Hospital for Women Perth, Subiaco, WA, Australia
| | - Brendan Jansen
- Department of Psychological Medicine, Mother and Baby Unit, 60082King Edward Memorial Hospital for Women Perth, Subiaco, WA, Australia
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West S, Martin A, Copping R, Gard G, Maher R, Seeho S. Staged treatment of placenta accreta spectrum: A combined surgical and radiological approach. Aust N Z J Obstet Gynaecol 2023. [PMID: 36695433 DOI: 10.1111/ajo.13646] [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: 07/14/2022] [Accepted: 12/26/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Placenta accreta spectrum (PAS) is a rare but serious complication of pregnancy. AIMS The aim of this study was to determine maternal and neonatal outcomes following a combined surgical and interventional radiology (IR) approach to managing PAS, and the risks associated with this technique. METHODS AND MATERIALS Retrospective cohort study of all cases of PAS in a tertiary maternity centre between January 2001 and July 2020. Women who underwent caesarean hysterectomy for histologically confirmed PAS with a staged surgical and IR approach were compared with those who underwent caesarean hysterectomy without IR. Maternal, neonatal outcomes, surgical and radiological complications were assessed. RESULTS Forty-six women were included in the study, and 30/46 (65.2%) underwent the staged surgical and IR approach. Women in the staged group had less overall blood loss (1794 mL vs 3713 mL; P < 0.001), less requirement for blood transfusion (40% vs 75%; P < 0.001), and a lower mean volume of packed red cells transfused (2.5 vs 6.1 units). Anaesthetic and operative times were longer for the staged group (468 vs 189 min: 272 vs 141 min P < 0.001), respectively. There were no differences in rates of neonatal or maternal complications between the two groups. CONCLUSION This study demonstrates that a staged procedure combining surgery and IR for PAS results in a considerable reduction in blood loss, need for transfusion, and units of packed red cells transfused compared with surgery alone. The staged procedure required significantly longer anaesthetic and operative times; however, there were no differences in maternal and neonatal morbidity.
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Affiliation(s)
- Simon West
- Royal North Shore Hospital Department of Obstetrics and Gynaecology, Sydney, New South Wales, Australia.,University of Sydney Northern Clinical School, Sydney, New South Wales, Australia.,Womens and Babies Research, Kolling Institute of Medical Research, Sydney, New South Wales, Australia
| | - Amy Martin
- Royal North Shore Hospital Department of Obstetrics and Gynaecology, Sydney, New South Wales, Australia
| | - Ross Copping
- Liverpool Hospital Department of Medical Imaging, Sydney, New South Wales, Australia
| | - Greg Gard
- Royal North Shore Hospital Department of Obstetrics and Gynaecology, Sydney, New South Wales, Australia.,University of Sydney Northern Clinical School, Sydney, New South Wales, Australia
| | - Richard Maher
- Royal North Shore Hospital Department of Medical Imaging, Sydney, New South Wales, Australia
| | - Sean Seeho
- Royal North Shore Hospital Department of Obstetrics and Gynaecology, Sydney, New South Wales, Australia.,University of Sydney Northern Clinical School, Sydney, New South Wales, Australia.,Womens and Babies Research, Kolling Institute of Medical Research, Sydney, New South Wales, Australia
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25
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Zhang X, Cao H, Wang H, Li X, Chen L, Shi Q, Li J. Curative effect of cervical lifting suture combined with the improved Hayman suture in pernicious placenta previa under noninterventional conditions: A retrospective cohort study. Int J Gynaecol Obstet 2023. [PMID: 36637227 DOI: 10.1002/ijgo.14667] [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: 04/21/2022] [Revised: 12/13/2022] [Accepted: 01/04/2023] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To propose a novel operative strategy involving cervical lifting suture (CLS) in conjunction with the improved Hayman suture (CLS-Hayman) to apply in the cesarean section of pernicious placenta previa (PPP) under noninterventional conditions and evaluate the curative effect of the CLS-Hayman operation by comparing with conventional CLS. METHODS A retrospective cohort study was conducted on 119 pregnant women diagnosed with PPP, including 50 cases in the CLS-Hayman group and 69 cases in the CLS group. The authors used different statistical methods to compare intraoperative bleeding, 24-h postpartum bleeding, postoperative complication rates, and uterine involution between the two groups under noninterventional conditions. RESULTS The median intraoperative blood loss was 800 mL in the CLS-Hayman group versus 1000 mL in the CLS group. The amount of 24-h postpartum bleeding in the CLS-Hayman group was lower than that in the CLS group. The complication rates in the two groups were 12% and 27.5%, respectively (P = 0.04). B-ultrasound or magnetic resonance imaging data showed that the uterine involution was better in the CLS-Hayman group. CONCLUSION The CLS-Hayman suture achieves the desired intraoperative hemostasis and also stands out for its better prevention of postpartum hemorrhage, better prognosis at follow-up, and lower complication rates.
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Affiliation(s)
- Xuemei Zhang
- Department of Obstetrics and Gynecology, The Affiliated Hospital of North Sichuan Medical College, Nanchong, China.,Genetic and Prenatal Diagnosis Center, The Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Hongbin Cao
- School of Pharmacy, North Sichuan Medical College, Nanchong, China
| | - Hu Wang
- Department of Obstetrics and Gynecology, The Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xue Li
- Department of Obstetrics and Gynecology, The Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Liping Chen
- Genetic and Prenatal Diagnosis Center, The Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Qi Shi
- Department of Obstetrics and Gynecology, The Affiliated Hospital of North Sichuan Medical College, Nanchong, China.,Genetic and Prenatal Diagnosis Center, The Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Jiaping Li
- Department of Obstetrics and Gynecology, The Affiliated Hospital of North Sichuan Medical College, Nanchong, China
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Palacios-Jaraquemada JM, Basanta N, Nieto-Calvache Á, Aryananda RA. Comprehensive surgical staging for placenta accreta spectrum. J Matern Fetal Neonatal Med 2022; 35:10660-10666. [PMID: 36543387 DOI: 10.1080/14767058.2022.2154572] [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: 12/24/2022]
Abstract
OBJECTIVE To analyze how precise the surgical staging is after prenatal diagnosis of patients with placenta accreta spectrum (PAS). MATERIAL AND METHODS This was a retrospective cohort study that included 622 women diagnosed with placenta accreta spectrum who underwent surgery between 1 January 2000, and 1 January 2020, in public, private, and university hospitals in Buenos Aires, Argentina. Prenatal diagnosis included abdominal and transvaginal ultrasounds and T2-weighted MRI scans. Comprehensive surgical staging (CSS) was performed by dissecting the coalescence spaces of the pelvic fasciae, including the broad ligament and the colpouterine and retrouterine spaces. Once the compromised uterine wall (lateral, anterior or posterior) was identified, the characteristics of the lesion were evaluated. The lateral invasion was classified as type A when there was no placental tissue in the parametrial zone; type B when the placental tissue protruded laterally and was covered by serosa, and type C when the placental tissue included neoformed vessels. Involvement of the retrovesical space (anterior uterine wall) was classified as type A when no neoformed vessels and no firm adherence between nearby organs were present, type B when the retrovesical area partially adhered but the planes could be dissected, and type C when the lower dissection of the vesicouterine space was extremely adhered or impossible.The posterior uterine aspect was classified after exteriorizing the organ, with the placenta still inside. It was determined as type A when there was no evidence of placental invasion, type B when there was organ adherence or it showed a heterogeneous appearance of the posterior uterine wall above the peritoneal reflection, and type C when there was adherence to other organs or when the invasion or neovascularization was below the peritoneal reflection. RESULTS CSS increases the efficacy of prenatal studies, including ultrasound and MRI, by up to 50%. The diagnosis of type 2 (parametrial) PAS or low retrovesical invasion implied an immediate modification of the surgical tactics, vascular control, or a specific type of surgery. Additionally, deep interfacial dissection allowed the identification of healthy uterine tissue, modifying the initial indication of hysterectomy for a conservative reconstructive procedure. CONCLUSIONS Comprehensive surgical staging of PAS proved to be an excellent tool for determining the extent and specific topography of placental invasion.
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Affiliation(s)
- José M Palacios-Jaraquemada
- Department of Obgyn, CEMIC University Hospital and Universitas Airlangga, Surabaya, Indonesia.,1st Anatomy Chair, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina.,Department of Obgyn, Universitas Airlangga, Surabaya, Indonesia
| | - Nicolás Basanta
- 1st Anatomy Chair, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina.,Fernández Hospital and 1st Anatomy Chair, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | | | - Rozi Aditya Aryananda
- Department of Obgyn, Universitas Airlangga, Surabaya, Indonesia.,Department of Obgyn, Dr. Soetomo Academic General Hospital, Surabaya, Indonesia
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Placental and Umbilical Cord Anomalies Diagnosed by Two- and Three-Dimensional Ultrasound. Diagnostics (Basel) 2022; 12:diagnostics12112810. [PMID: 36428871 PMCID: PMC9689386 DOI: 10.3390/diagnostics12112810] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/27/2022] [Accepted: 10/01/2022] [Indexed: 11/18/2022] Open
Abstract
The aim of this review is to present a wide spectrum of placental and umbilical cord pathologies affecting the pregnancy. Placental and umbilical cord anomalies are highly associated with high-risk pregnancies and may jeopardize fetal well-being in utero as well as causing a predisposition towards poor perinatal outcome with increased fetal and neonatal mortality and morbidity. The permanent, computerized perinatology databases of different international centers have been searched and investigated to fulfil the aim of this manuscript. An extended gallery of prenatal imaging with autopsy correlation in specific cases will help to provide readers with a useful iconographic tool and will assist with the understanding and definition of this critical obstetrical and perinatological issue.
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Nieto-Calvache AJ, Sanín-Blair JE, Buitrago-Leal HM, Benavides-Serralde JA, Maya-Castro J, Rozo-Rangel AP, Messa-Bryon A, Colonia-Toro A, Gómez-Castro AR, Cardona-Ospina A, Caicedo-Cáceres CE, Dorado-Roncancio EF, Silva JL, Carvajal-Valencia JA, Velásquez-Penagos JA, Niño-González JE, Burgos-Luna JM, Rincón-García JC, Matera-Torres L, Villamizar-Galvis OA, Olaya-Garay SX, Medina-Palmezano VP, Castañeda J. Colombian Consensus on the Treatment of Placenta Accreta Spectrum (PAS). REVISTA COLOMBIANA DE OBSTETRICIA Y GINECOLOGIA 2022; 73:283-316. [PMID: 36331304 PMCID: PMC9674383 DOI: 10.18597/rcog.3877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/14/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Placenta accreta spectrum (PAS) is a condition associated with massive postpartum bleeding and maternal mortality. Management guidelines published in high income countries recommend the participation of interdisciplinary teams in hospitals with sufficient resources for performing complex procedures. However, some of the recommendations contained in those guidelines are difficult to implement in low and medium income countries. OBJECTIVES The aim of this consensus is to draft general recommendations for the treatment of PAS in Colombia. MATERIALS AND METHODS Twenty-three panelists took part in the consensus with their answers to 31 questions related to the treatment of PAS. The panelists were selected based on participation in two surveys designed to determine the resolution capabilities of national and regional hospitals. The modified Delphi methodology was used, introducing two successive discussion rounds. The opinions of the participants, with a consensus of more than 80%, as well as implementation barriers and facilitators, were taken into consideration in order to issue the recommendations. RESULTS The consensus draftedfive recommendations, integrating the answers of the panelists. Recommendation 1. Primary care institutions must undertake active search of PAS in patients with risk factors: placenta praevia and history of myomectomy or previous cesarean section. In case of ultrasound signs suggesting PAS, patients must be immediately referred, without a minimum gestational age, to hospitals recognized as referral centers. Online communication and care modalities may facilitate the interaction between primary care institutions and referral centers for PAS. The risks and benefits of telemedicine modalities must be weighed. Recommendation 2. Referral hospitals for PAS need to be defined in each region of Colombia, ensuring coverage throughout the national territory. It is advisable to concentrate the flow of patients affected by this condition in a few hospitals with surgical teams specifically trained in PAS, availability of specialized resources, and institutional efforts at improving quality of care with the aim of achieving better health outcomes in pregnant women with this condition. To achieve this goal, participants recommend that healthcare regulatory agencies at a national and regional level should oversee the process of referral for these patients, expediting administrative pathways in those cases in which there is no prior agreement between the insurer and the selected hospital or clinic. Recommendation 3. Referral centers for patients with PAS are urged to build teams consisting of a fixed group of specialists (obstetricians, urologists, general surgeons, interventional radiologists) entrusted with the care of all PAS cases. It is advisable for these interdisciplinary teams to use the “intervention bundle” model as a guidance for building PAS referral centers. This model comprises the following activities: service preparedness, disease prevention and identification, response to the occurrence of the disease, and debriefing after every event. Telemedicine facilitates PAS treatment and should be taken into consideration by interdisciplinary teams caring for this disease. Recommendation 4. Obstetrics residents must be instructed in the performance of maneuvers that are useful for the prevention and treatment of massive intraoperative bleeding due to placenta praevia and PAS, including manual aortic compression, uterine tourniquet, pelvic packing, retrovesical bypass, and Ward maneuver. Specialization Obstetrics and Gynecology programs in Colombia must include the basic concepts of the diagnosis and treatment of PAS. Referral centers for PAS must offer online and in-person training programs for professionals interested in improving their competencies in PAS. Moreover, they must offer permanent remote support (telemedicine) to other hospitals in their region for patients with this condition. Recommendation 5. Patients suspected of having PAS and placenta praevia based on imaging, with no evidence of active vaginal bleeding, must be delivered between weeks 34 and 36 6/7. Surgical treatment must include sequential interventions that may vary depending on the characteristics of the lesion, the clinical condition of the patient and the availability of resources. The surgical options (total and subtotal hysterectomy, one-stage conservative surgical management and watchful waiting) must be included in a protocol known by the entire interdisciplinary team. In situations in which an antepartum diagnosis is lacking, that is to say, in the face of intraoperative finding of PAS (evidence of purple bulging or neovascularization of the anterior aspect of the uterus), and the participation of untrained personnel, three options are considered: Option 1: In the absence of indication of immediate delivery or of vaginal delivery, the recommendation is to postpone the cesarean section (close the laparotomy before incising the uterus) until the recommended resources for safe surgery are secured. Option 2: If there is an indication for immediate delivery (e.g., non-reassuring fetal status) but there is absence of vaginal bleeding or indication for immediate PAS management, a two-stage management is suggested: cesarean section avoiding placental incision, followed by uterine repair and abdominal closure, until the availability of the recommended resources for safe surgery is ascertained. Option 3: In the event of vaginal bleeding that prevents definitive PAS management, the fetus must be delivered through the uterine fundus, followed by uterine repair and reassessment of the situation. Sometimes, fetal delivery diminishes placental flow and vaginal bleeding is reduced or disappears, enabling the possibility to postpone definitive management of PAS. In case of persistent significant bleeding, hysterectomy should be performed, using all available resources: manual aortic compression, immediate call to the surgeons with the best available training, telemedicine support from expert teams in other hospitals. If a patient with risk factors for PAS (e.g., myomectomy or previous cesarean section) has a retained placenta after vaginal delivery, it is advisable to confirm the possibility of such diagnosis (by means of ultrasound, for example) before proceeding to manual extraction of the placenta. CONCLUSIONS It is our hope that this first Colombian consensus on PAS will serve as a basis for additional discussions and collaborations that can result in improved clinical outcomes for women affected by this condition. Additional research will be required in order to evaluate the applicability and effectiveness of these recommendations.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jimmy Castañeda
- Federación Colombiana de Obstetricia y Ginecología (FECOLSOG), Bogotá (Colombia)..
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Abinader RR, Macdisi N, El Moudden I, Abuhamad A. First-trimester ultrasound diagnostic features of placenta accreta spectrum in low-implantation pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:457-464. [PMID: 34837427 DOI: 10.1002/uog.24828] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/09/2021] [Accepted: 11/23/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Low-implantation pregnancy (LIP) is an important marker for the diagnosis of placenta accreta spectrum (PAS) in the first trimester. Many grayscale and color Doppler ultrasound markers of PAS have been defined in the second and third trimesters of pregnancy, but have not been studied in the first trimester. The aim of this study was to determine whether PAS sonographic markers could be used in the first trimester to differentiate patients with LIP who develop PAS from those who do not. METHODS This was a retrospective case-control study of women who delivered at our institution between 2009 and 2019. Cases were women with PAS who delivered by Cesarean hysterectomy and who had undergone first-trimester ultrasound demonstrating LIP. Controls were women with persistent placenta previa without PAS who delivered by Cesarean section without postpartum hemorrhage and who had undergone first-trimester ultrasound demonstrating LIP. Sonographic images were reviewed by an investigator blinded to pregnancy outcome and ultrasound reports. Images were reviewed for presence of abnormal uteroplacental interface, increased lower uterine segment hypervascularity and placental lacunae, with or without swirling on grayscale or color Doppler ultrasound. RESULTS Following review of the electronic health records, 21 cases and 46 controls met the inclusion criteria. Placental lacunae were present in 18/21 (85.7%) cases and 7/46 (15.2%) controls (odds ratio (OR), 33.4; 95% CI, 7.7-144.4; P < 0.001). The number of lacunae was significantly higher in cases compared with controls, with a median of five lacunae present in cases compared with a median of one lacuna in controls (P < 0.001). The median size of the lacunae was also significantly larger in cases compared with controls, measuring 10.03 (interquartile range (IQR), 7.3-12.05) mm and 4.15 (IQR, 4.05-5.05) mm, respectively (P = 0.001). Lacunae swirling on grayscale or color Doppler ultrasound was noted only in PAS cases, with 10/12 (83.3%) having swirling on grayscale ultrasound and 12/12 (100%) having swirling on color Doppler (P < 0.001). Presence of an abnormal uteroplacental interface was also observed only in PAS cases, at a rate of 17/20 (85.0%) (P < 0.001). Lower uterine segment (uterovesical, subplacental and/or intraplacental) hypervascularity was present in 14/14 (100%) cases and only 1/12 (8.3%) controls (P < 0.001). CONCLUSION In women at risk of PAS, ultrasound markers of PAS can and should be assessed as early as in the first trimester. The use of a first-trimester prenatal ultrasound screening protocol and standardized approach to ultrasound examination in at-risk mothers may help increase detection of PAS and enable planning for optimal management of affected pregnancies. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R R Abinader
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - N Macdisi
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - I El Moudden
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - A Abuhamad
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
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MRI based morphological examination of the placenta. Placenta 2021; 115:20-26. [PMID: 34536809 DOI: 10.1016/j.placenta.2021.08.056] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 06/09/2021] [Accepted: 08/23/2021] [Indexed: 11/20/2022]
Abstract
Ultrasound is widely used as the initial diagnostic imaging modality during pregnancy with both high spatial and temporal resolution. Although MRI in pregnancy has long focused on the fetus, its use in placental imaging has greatly increased over recent years. In addition to the possibilities of evaluating function, MRI with a wide field of view and high contrast resolution allows characterization of placental anatomy, particularly in situations that are difficult to specify with ultrasound, especially for suspected placenta accreta. MRI also appears to be a particularly useful examination for the anatomical evaluation of the placenta independent of maternal body habitus or fetal position. Indeed, surprisingly little attention is paid to the placenta in MRI when the indication for the examination is fetal. Thus, some aspects of the placenta seem to us to be important to be recognized by the radiologist and to be described on the MRI report. In this review, we will describe MRI sequences used for, and common features seen in, imaging of i) the normal placenta, ii) abnormal aspects of the placenta that should be identified on MRI performed for fetal reason, and iii) placental anomalies for which placental MRI may be indicated.
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31
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Shazly SA, Hortu I, Shih JC, Melekoglu R, Fan S, Ahmed FUA, Karaman E, Fatkullin I, Pinto PV, Irianti S, Tochie JN, Abdelbadie AS, Salah MA, Elazeem HASA, Saad MM, Ergenoglu AM, Yeniel AO, Sagol S, Itil IM, Kang J, Huang KY, Yilmaz E, Liang Y, Aziz H, Akhter T, Ambreen A, Ateş Ç, Karaman Y, Khasanov A, Fatkullina L, Akhmadeev N, Vatanina A, Machado AP, Montenegro N, Effendi JS, Suardi D, Pramatirta AY, Aziz MA, Siddiq A, Ofakem I, Dohbit JS, Fahmy MS, Anan MA. Prediction of success of uterus-preserving management in women with placenta accreta spectrum (CON-PAS score): A multicenter international study. Int J Gynaecol Obstet 2021; 154:304-311. [PMID: 33278833 DOI: 10.1002/ijgo.13518] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/16/2020] [Accepted: 12/03/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To create a model for prediction of success of uterine-preserving procedures in women with placenta accreta spectrum (PAS). METHODS PAS-ID is a multicenter study that included 11 centers from 9 countries. Women with PAS, who were managed between January 1, 2010 and December 31, 2019, were retrospectively included. Data were split into model development and validation cohorts, and a prediction model was created using logistic regression. Main outcome was success of uterine preservation. RESULTS Out of 797 women with PAS, 587 were eligible. Uterus-preserving procedures were successful in 469 patients (79.9%). Number of previous cesarean sections (CS) was inversely associated with management success (adjusted odds ratio [aOR] 0.02, 95% confidence interval [CI] 0.001-3.63 with five previous CS). Other variables were complete placental invasion (aOR 0.14, 95% CI 0.05-0.43), type of CS incision (aOR 0.04, 95% CI 0.01-0.25 for classical incision), compression sutures (aOR 2.48, 95% CI 1.00-6.16), accreta type (aOR 3.76, 95% CI 1.13-12.53), incising away from placenta (aOR 5.09, 95% CI 1.52-16.97), and uterine resection (aOR 102.57, 95% CI 3.97-2652.74). CONCLUSION The present study provides a prediction model for success of uterine preservation, which may assist preoperative and intraoperative decisions, and promote incorporation of uterine preservation procedures in comprehensive PAS protocols.
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Affiliation(s)
- Sherif A Shazly
- Department of Obstetrics and Gynecology, Assiut University, Assiut, Egypt
| | - Ismet Hortu
- Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey
| | - Jin-Chung Shih
- Department of Obstetrics and Gynecology, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Rauf Melekoglu
- Department of Obstetrics and Gynecology, Inonu University, Malatya, Turkey
| | - Shangrong Fan
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Guangdong Province, China
| | - Farhat Ul Ain Ahmed
- Department of Obstetrics and Gynecology, Fatima Memorial Hospital, Punjab, Pakistan
| | - Erbil Karaman
- Department of Obstetrics and Gynecology, Yuzuncu Yil University, Van, Turkey
| | - Ildar Fatkullin
- Department of Obstetrics and Gynecology, Kazan State Medical University, Kazan, Republic of Tatarstan, Russia
| | - Pedro V Pinto
- Serviço de Ginecologia e Obstetrícia, Centro Hospitalar São João, Porto, Portugal
| | - Setyorini Irianti
- Taskforce of Placenta Accreta Spectrum, Universitas Padjadjaran Bandung, West Jawa, Indonesia
| | - Joel Noutakdie Tochie
- Department of Obstetrics and Gynecology, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Amr S Abdelbadie
- Department of Obstetrics and Gynecology, Aswan University Hospital, Aswan, Egypt
| | - Mohamed A Salah
- Department of Obstetrics and Gynecology, Assiut University, Assiut, Egypt
| | | | - Mahmoud M Saad
- Department of Obstetrics and Gynecology, Assiut University, Assiut, Egypt
| | - Ahmet M Ergenoglu
- Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey
| | - Ahmet O Yeniel
- Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey
| | - Sermet Sagol
- Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey
| | - Ismail M Itil
- Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey
| | - Jessica Kang
- Department of Obstetrics and Gynecology, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Kuan-Ying Huang
- Department of Obstetrics and Gynecology, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Ercan Yilmaz
- Department of Obstetrics and Gynecology, Inonu University, Malatya, Turkey
| | - Yiheng Liang
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Guangdong Province, China
| | - Hijab Aziz
- Department of Obstetrics and Gynecology, Fatima Memorial Hospital, Punjab, Pakistan
| | - Tayyiba Akhter
- Department of Obstetrics and Gynecology, Fatima Memorial Hospital, Punjab, Pakistan
| | - Afshan Ambreen
- Department of Obstetrics and Gynecology, Fatima Memorial Hospital, Punjab, Pakistan
| | - Çağrı Ateş
- Department of Obstetrics and Gynecology, Yuzuncu Yil University, Van, Turkey
| | - Yasemin Karaman
- Department of Obstetrics and Gynecology, Lokman Hekim Hayat Hospital, Van, Turkey
| | - Albir Khasanov
- Department of Obstetrics and Gynecology, Kazan State Medical University, Kazan, Republic of Tatarstan, Russia
| | - Larisa Fatkullina
- Department of Obstetrics and Gynecology, Kazan State Medical University, Kazan, Republic of Tatarstan, Russia
| | - Nariman Akhmadeev
- Department of Obstetrics and Gynecology, Kazan State Medical University, Kazan, Republic of Tatarstan, Russia
| | - Adelina Vatanina
- Republic Clinical Hospital of Ministry of Healthcare of Republic of Tatarstan, Republic of Tatarstan, Russia
| | - Ana Paula Machado
- Serviço de Ginecologia e Obstetrícia, Centro Hospitalar São João, Porto, Portugal
| | - Nuno Montenegro
- Serviço de Ginecologia e Obstetrícia, Centro Hospitalar São João, Porto, Portugal
| | - Jusuf S Effendi
- Taskforce of Placenta Accreta Spectrum, Universitas Padjadjaran Bandung, West Jawa, Indonesia
| | - Dodi Suardi
- Taskforce of Placenta Accreta Spectrum, Universitas Padjadjaran Bandung, West Jawa, Indonesia
| | - Ahmad Y Pramatirta
- Taskforce of Placenta Accreta Spectrum, Universitas Padjadjaran Bandung, West Jawa, Indonesia
| | - Muhamad A Aziz
- Taskforce of Placenta Accreta Spectrum, Universitas Padjadjaran Bandung, West Jawa, Indonesia
| | - Amilia Siddiq
- Taskforce of Placenta Accreta Spectrum, Universitas Padjadjaran Bandung, West Jawa, Indonesia
| | - Ingrid Ofakem
- Department of Obstetrics and Gynecology, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Julius Sama Dohbit
- Department of Obstetrics and Gynecology, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Mohamed S Fahmy
- Department of Obstetrics and Gynecology, Aswan University Hospital, Aswan, Egypt
| | - Mohamed A Anan
- Department of Obstetrics and Gynecology, Aswan University Hospital, Aswan, Egypt
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