Multidisciplinary management of placenta percreta complicated by embolic phenomena

Influencing factors for placenta accreta in recent 5 years: a systematic review and meta-analysis

Objective: Assess influencing factors for placenta accreta in pregnant women documented in recent literature.Methods: A systematic review and meta-analysis were conducted based on English- and Chinese-language articles published from January 2014 to June 2019. Articles were retrieved from the following Chinese databases, CNKI, Wanfang Data, China Science and Technology Journal Database, CBM and English databases, PubMed, Web of Science, the Cochrane Library and Embase.Results: Eleven studies with 2,152,014 cases were included in the meta-analysis. The odds ratios of influencing factors were as follows: hypertension 2.51 (95% CI, 1.50-4.20), multifetal gestations 1.90 (95% CI, 1.26-2.88), male fetus 0.79 (95% CI, 0.74-0.84), and low socioeconomic status 0.51 (95% CI, 0.37-0.71).Conclusion: Evidence from English- and Chinese-language literature indicates that hypertension and multifetal gestations are risk factors for placenta accreta, while male fetus and low socioeconomic status are protective factors.

"You only live twice": multidisciplinary management of catastrophic case in placenta Accreta Spectrum-a case report

Background

Placenta percreta is associated with high hemorrhagic risk and can be complicated with fatal thromboembolic events. Involving a multidisciplinary team in the treatment of these patients is mandatory to reduce morbidity and mortality.

Case presentation

This paper reports the case of a 22-year-old patient with placenta percreta who was referred to our tertiary care center for delivery. Few hours after undergoing a successful cesarean hysterectomy, the patient developed a pulmonary embolism and cardiac arrest. A transthoracic echocardiogram done in the intensive care unit (ICU) showed a thrombus in the right ventricle. After cardiac resuscitation, the patient underwent an urgent thoracotomy and a pulmonary artery thrombectomy; many clots were retrieved from the pulmonary artery. After weaning from extracorporeal circulation, an intraoperative transesophageal cardiac ultrasound enabled the medical team to detect a new free-floating thrombus in the right atrium and right ventricle, and consequently to perform an embolectomy and prevent the patient’s death.

Conclusion

This case emphasizes the role of multidisciplinary team in treating high-risk obstetric cases that could be complicated with massive and fatal thromboembolic events. The use of intraoperative transthoracic echocardiography helps in detecting a new thrombus and guides the anesthesiologist in the intra-operative monitoring.

Systematic review on near miss cases of placenta accreta spectrum disorders: correlation with invasion topography, prenatal imaging, and surgical outcome

Purpose of the article: Placental accreta spectrum (PAS) is the most dangerous iatrogenic complication of cesarean potentially leading to massive intra-partum haemorrhage and death. Despite this, identification of near miss cases of PAS has not been consistently reported in the published literature. The aim of this systematic review was to explore prenatal and surgical characteristics of near miss cases of PAS disorders.Materials and methods: Medline, Embase, CINAHL, SciELO, and Cochrane databases were searched. Only studies including near miss cases of PAS disorders in which a detailed description of the clinical course, severity of placental invasion, role of prenatal imaging, and surgical management were considered eligible for the inclusion in the present systematic review. Random-effect meta-analyses of proportions were used to pool the data.Results: Thirty-four studies were included in the systematic review. The incidence of placenta accreta, increta, and percreta in near miss cases of PAS disorders was 0% (95% CI 0-24.6), 17.3% (95% CI 8.4-28.6) and 82.7% (95% CI 71.4-91.6). S1 invasion, defined as invasion in the upper posterior bladder wall was present in none of the near miss cases of PAS while all included cases showed S2 invasion. Prenatal imaging, either ultrasound or magnetic resonance imaging, detected invasive placenta in 54.4% (95% CI 41.0-67.5). Clinical symptoms occurred in 65.3% (95% CI 52.1-77.4) of near miss cases of PAS before surgery, while the corresponding figures for symptoms occurring during and after surgery were 65.5% (95% CI 52.2-77.5) and 50.0% (95% CI 36.5-63.5) of cases, respectively. Invasion in the inferior part of the lower uterine segment, posterior bladder and parametria was associated with a high risk of morbidity.Conclusion: Near miss cases of PAS are commonly associated with posterior bladder or parametrial invasion and placenta percreta. Further studies are needed in order to identify women affected by PAS disorders at high risk of surgical complications.

Indicated preterm birth for placenta accreta

The purpose of this article is to review the risks and benefits of scheduled preterm delivery in patients with placenta accreta, increta, and percreta and to provide guidance regarding timing of delivery in such cases. Relevant documents for this opinion were identified through a search of the English literature for publications, including one or more of the keywords "accreta" or "increta" or "percreta" and "preterm" and "delivery time" by the use of PubMed (U.S. National Library Of Medicine, January 1990-January 2010), with results limited to studies involving humans. Additional information was obtained from references identified from within selected articles, from additional review articles, and from guidelines by organizations, including the American College of Obstetricians & Gynecologists. Each included article was evaluated according to study design and quality in accordance with scheme outlined by the U.S. Preventative Services Task Force, and final recommendations are provided based on the level of published evidence. On the basis of this search, we found that abnormal placentation, encompassing placenta accreta, increta, and percreta, is increasingly common. We also found that randomized controlled trials and well-controlled observational studies that can be used to define best practice in delivery time are lacking. Optimal delivery time must be determined from available case series, retrospective reviews and decision analysis studies. Given the best-available evidence, optimal time for delivery is believed to be between 34 and 35 weeks in most cases.

Aortic compression and cross clamping in a case of placenta percreta and amniotic fluid embolism: a case report

Amniotic fluid embolism (AFE, also known as anaphylactoid syndrome of pregnancy) at the time of surgery for placenta percreta has been previously reported. We report here a case in which AFE and associated cardiac arrest occurred following a hysterectomy for placenta percreta. In this case, subhepatic manual aortic compression during the cardiac arrest and chest compressions followed by infrarenal aortic cross-clamping during volume infusion and reversal of the coagulopathy were associated with a successful resuscitation and good maternal outcome.

Placenta accreta

OBJECTIVE

We sought to review the risks of placenta accreta, increta, and percreta, and provide guidance regarding interventions to improve maternal outcomes when abnormal placental implantation occurs.

METHODS

Relevant documents were identified through a search of the English-language literature for publications including ≥1 of the key words "accreta" or "increta" or "percreta" using PubMed (US National Library of Medicine; January 1990 through January 2010); with results limited to studies involving human beings. Additional information was obtained from references identified within selected articles; from additional review articles; and from guidelines by organizations including the American College of Obstetricians and Gynecologists. Each included article was evaluated according to study design and quality in accordance with the scheme outlined by the US Preventative Services Task Force.

RESULTS AND RECOMMENDATIONS

Abnormal placentation--encompassing placenta accreta, increta, and percreta--is increasingly common. While randomized controlled trials and large observational cohort studies that can be used to define best practice are lacking, strategies to enhance early diagnosis, enhance preparation, and coordinate peripartum management can be undertaken. Women with a placenta previa overlying a uterine scar should be evaluated for the potential diagnosis of placenta accreta. Women with a placenta previa or "low-lying placenta" overlying a uterine scar early in pregnancy should be reevaluated in the third trimester with attention to the potential presence of placenta accreta. When the diagnosis of placenta accreta is made remote from delivery, the need for hysterectomy should be anticipated and arrangements made for delivery in a center with adequate resources, including those for massive transfusion. Intraoperatively, attention should be paid to abdominal and vaginal blood loss. Early blood product replacement, with consideration of volume, oxygen-carrying capacity, and coagulation factors, can reduce perioperative complications.