[Placenta accreta: screening, management and complications]

Effects of Tobacco Consumption and Anxiety or Depression during Pregnancy on Maternal and Neonatal Health

This study analyzed the possible interaction effects between tobacco consumption and anxiety or depression during pregnancy on maternal and neonatal health. We recruited a sample of 807 pregnant Spanish women from public healthcare services. Women completed a questionnaire on sociodemographic variables, health status and tobacco consumption (continuous, quitting or no consumption) in the first and third trimester of pregnancy and at 2 months postpartum, and self-reported measures of anxiety and depression in the first trimester. Abstinence of tobacco consumption was verified through biochemical measurements. Interaction effects between tobacco consumption and anxiety were found for delivery (p < 0.001), neonatal health complications (p = 0.026) and gestational age at birth (p = 0.029). Interaction effects between tobacco consumption and depression were found for pregnancy (p = 0.032), delivery complications (p < 0.001) and weeks of gestation at birth (p = 0.031). This study suggests that there are different kinds of interaction effects between tobacco consumption and anxiety or depression. Smokers with high anxiety presented more delivery complications compared to quitters and non-smokers with high anxiety. There is a cumulative effect of anxiety on the effects of tobacco consumption on maternal health. The results highlighted the beneficial impact of quitting smoking during pregnancy to reduce the risk of suffering anxiety, depression and health complications.

[Prognostic significance of specific proteins of pregnancy in women with a uterine scar and placenta accreta.]

Comparative analysis of serum concentrations of chorionic gonadotropin (hCG) associated with the pregnancy of plasma protein A (PAPP-A) and alpha-fetoprotein (AFP), based on the results of a survey of women as part of a standard screening program (the results were expressed as a MoM - multiply of the median), found a significant increase in the performance of all the studied specific pregnancy proteins in women with a scar on the uterus and placenta acctera (75 patients) compared with the data of the group of pregnant women without scar on the uterus and without abnormalities of attachment of the placenta (150 women). AFP indices were 1.68 ± 0.76 and 1.19 ± 0.43 MoM (p = 0.0018), hCG - 1.62 ± 1.48 and 1.23 ± 0.76 MoM (p = 0, 0112), PAPP-A - 1.93 ± 1.24 and 1.23 ± 0.67 MoM (p <0.0001). Using the ROC analysis, the diagnostic thresholds for the concentrations of AFP, hCG and PAPP-A were calculated. The risk of placenta accreta in women with a scar on the uterus in cases of exceeding the diagnostic threshold of AFP concentration (1.64 MoM) increased 2.5 times (RR = 2.5; 95% CI 1.17-5.36, p = 0, 0185), hCG (1.41 MoM) - 1.6 times (RR = 1.59; 95% CI 1.09-2.32, p = 0.0147), PAPP-A (1.41 MoM) - 2.65 times (RR = 2.65; 95% CI 1.76-3.99, p <0.0001). Determination of the level of specific pregnancy proteins can be used in the system of complex prediction of placental growth in pregnant women with a scar on the uterus as an addition to the assessment of clinical and anamnestic risk factors.

Placenta accreta in the department of gynaecology and obstetrics in Rabat, Morocco: case series and review of the literature

Placenta accreta spectrum disorders is a rare pathology but the incidence has not stopped to increase in recent years. The purpose of our work was the analysis of the epidemiological profile of our patients, the circumstances of diagnosis, the interest of paraclinical explorations in antenatal diagnosis and the evaluation of the evolutionary profile. We hereby report a case series spread over a period of one year from 01/01/2015 to 01/01/2016 at the Gynaecology-Obstetrics department of the University Hospital Center IBN SINA of Rabat where we identified six cases of placenta accreta. We selected patients whose diagnosis was confirmed clinically and histologically. The major risk factors identified were a history of placenta previa, previous caesarean section, advanced maternal age, multiparity. 2D ultrasound and magnetic resonance imaging (MRI) allowed us to strongly suspect the presence of a placenta accreta in a pregnant woman with risk factor(s) but the diagnosis of certainty was always histological. Placenta accreta spectrum disorders were associated with a high risk of severe postpartum hemorrhage, serious comorbidities, and maternal death. Leaving the placenta in situ was an option for women who desire to preserve their fertility and agree to continuous long-term monitoring in centers with adequate expertise but a primary elective caesarean hysterectomy was the safest and most practical option. Placenta accreta spectrum disorders is an uncommon pathology that must be systematically sought in a parturient with risk factors, to avoid serious complications. In light of the latest International Federation of Gynecology and Obstetrics (FIGO) recommendations of 2018, a review of the literature and finally the experience of our center, we propose a course of action according to whether the diagnosis of the placenta is antenatal or perpartum.

[Fetal death beyond 14 weeks of gestation: induction of labor and obtaining of uterine vacuity]

The objective of this review was to assess benefits and harms of different management options for induction of labor and obtaining of uterine vacuity in case of fetal death beyond of 14 weeks of gestation. In second-trimester, the data are numerous but low methodological quality. In terms of efficiency (induction-expulsion time and uterine evacuation within 24 hours rate) and tolerance in the absence of antecedent of caesarean section, the best protocol for induction of labor in the second-trimester of pregnancy appears to be mifepristone 200mg orally followed 24-48 hours later by vaginal administration of misoprostol 200 to 400 μg every 4 to 6 hours. In third-trimester, there is very little data. The circumstances are similar to induction of labor with living fetus. A term or near term, oxytocin and dinoprostone have a marketing authorization in this indication but misoprostol may be an alternative as the Bishop score and dose of induction of labor with living fetus. In case of previous caesarean section, the risk of uterine rupture is increased in case of a medical induction of labor with prostaglandins. The lowest effective doses should be used (100 to 200 μg every 4 to 6 hours). Prior cervical preparation by the administration of mifepristone and possibly the use of laminar seems essential in this situation.