[Comparative study of patients with placenta accreta with or without a history of cesarean section]

Risk factors for placenta accreta spectrum without prior cesarean section: A case-control study in China

OBJECTIVE

To identify the risk factors for placenta accreta spectrum (PAS) disorders in women without prior cesarean section (CS).

METHODS

This retrospective case-control study investigated patients without prior CS who gave birth at Peking University Third Hospital between January 1, 2015 and December 31, 2021. Patients diagnosed with PAS according to the clinical diagnostic criteria of the 2019 International Federation of Gynecology and Obstetrics (FIGO) classification were included as the study group. Patients were matched as the control group according to delivery date and placenta previa, in a 1:2 allocation ratio. Maternal characteristics were compared between the two groups.

RESULTS

The study included 348 patients in the study group and 696 in the control group. The multivariate analysis showed that the independent risk factors of PAS consisted of operative hysteroscopy (once: adjusted odds ratio [aOR] 2.38, 95% CI 1.28-4.24, P = 0.006; twice or more: aOR 5.43, 95% CI 1.04-28.32, P = 0.045), uterine curettage (once: aOR 2.54, 95% CI 1.80-3.58, P < 0.001; twice: aOR 3.01, 95% CI 1.81-5.02, P < 0.001; three or more times: aOR 9.18, 95% CI 4.64-18.18, P < 0.001), multifetal pregnancy (aOR 5.64, 95% CI 3.01-10.57, P < 0.001), adenomyosis (aOR 2.77, 95% CI 1.23-6.22, P = 0.014), in vitro fertilization (aOR 1.51, 95% CI 1.04-2.20, P = 0.030) and pre-eclampsia (aOR 2.72, 95% CI 1.36-5.45, P = 0.005), and the independent protective factor was being multiparous (aOR 0.37, 95% CI 0.25-0.54, P < 0.001).

CONCLUSION

After controlling the effect of placenta previa, we found that patients with PAS without prior CS had unique maternal characteristics. Classification and quantification of the intrauterine surgeries they have undergone is essential for identifying high-risk patients. Early identification of high-risk groups by risk factors has the potential to improve the prognosis considerably.

Predictive factors for massive hemorrhage in women with retained products of conception: a prospective study

Retained products of conception (RPOC) is a common cause of postpartum bleeding, which may be life-threatening; however, no evidence-based guidelines exist to assist in evaluating the risk of massive hemorrhage in women with RPOC. In this prospective study, we aimed to evaluate the predictive factors for massive hemorrhage in women with RPOC. The primary and secondary endpoints were to validate the usefulness of power Doppler color scoring (PDCS) in evaluating hypervascularity and to identify other predictive factors (such as maximum RPOC diameter and serum βhCG and Hb level at first visit), respectively. Among the 51 women with RPOC included in this study, 16 (31.5%) experienced massive hemorrhage during follow-up. None of the women with PDCS 1 or 2 (18) experienced massive hemorrhage, whereas 16 (48.5%) women with PDCS 3 or 4 (33) did. Multiple logistic regression analysis showed that the odds ratio [95% confidence interval] (P value) for PDCS, assisted reproductive technology (ART), and low serum hemoglobin (Hb) levels were 22.39 [2.25 - 3087.92] (P = 0.004), 5.72 [1.28 - 33.29] (P = 0.022), and 4.24 [0.97 - 22.99] (P = 0.056), respectively. Further, the decision tree method identified PDCS, ART, and low serum Hb levels as potential predictive factors for massive hemorrhage. This study identified PDCS as useful predictor of massive hemorrhage in women with RPOC. With additional inclusion of factors such as ART and low serum Hb levels, the risk of massive hemorrhage may be effectively evaluated, leading to better management of women of reproductive age.

The effect of placental location in cases of placenta accreta spectrum

BACKGROUND

Placenta accreta spectrum affects approximately 3 in 1000 pregnancies. There is a paucity of data evaluating the effect of placental location on diagnosis, risk factors, and resultant outcomes in cases of placenta accreta spectrum.

OBJECTIVE

We analyzed placenta accreta spectrum cases to assess whether risk factors or maternal outcomes varied based on placental location.

MATERIALS AND METHODS

We performed a retrospective chart review of pathology-confirmed cases of placenta accreta spectrum from patients delivering at 2 large urban hospitals in the same healthcare system from 2007 to 2017. Placental location was defined by ultrasound images and confirmed by pathology reports. Location was categorized as anterior, posterior, or anterior/posterior for those with placental location at both sites. Fisher exact tests and analysis of variance were used to examine associations with measures of diagnosis, risk factors, and maternal outcomes.

RESULTS

A total of 86 pathology-confirmed placenta accreta spectrum cases were reviewed. The distribution of placental location on ultrasound was as follows: 19% posterior, 59% anterior, and 22% anterior/posterior. We found that prior cesarean delivery was lower with posterior placenta accreta spectrum (63% vs 94% vs 84% in the anterior and anterior/posterior groups respectively; (P = .007); however, in vitro fertilization rates were significantly higher (38% vs 2% vs 5% in the anterior and anterior/posterior groups respectively; P = .001). There was also lower incidence of percreta with posterior placenta accreta spectrum compared to the anterior and anterior/posterior groups (19% vs 47% vs 58% respectively; P = .055). Posterior cases were less likely to have placenta accreta spectrum suspected prenatally (50%) compared to anterior (80%) and anterior/posterior (89%) cases (P = .019). Despite late diagnosis, ureteral injury was the only surgical complication that was more common in patients with posterior placenta accreta spectrum (13% vs 0% vs 5% for anterior and anterior/posterior groups respectively; P = .037).

CONCLUSION

Placenta accreta spectrum with posterior placental location is associated with delayed diagnosis, surgical complications, assisted reproductive technology, and lower numbers of prior cesarean deliveries relative to anterior location. These differences in outcomes and risk factors based on placental location may allow for heightened clinical awareness, and improved diagnosis and management.

Influence of different preoperative fasting times on women and neonates in cesarean section: a retrospective analysis

Background

This study was to evaluate the impact of different preoperative fasting conditions on women and neonates through a retrospective analysis.

Methods

A total of 1599 women were divided into 5 groups according to different preoperative fasting times: group A: solid food ≥8 h; clear fluids ≥6 h; B: solid food ≥8 h; clear fluids ≥2 h < 6 h; C: solid food ≥6 h < 8 h; clear fluids < 2 h; D: solid food ≥2 h < 6 h; clear fluids < 2 h; E: solid food < 2 h; clear fluids < 2 h.

Results

Incidence rate of vomiting of women was lower in group C (solid food ≥6 h < 8 h and clear fluids < 2 h) than other groups (P <  0.05). Compared with the fasting for a long time (groups A and B: solid food > 8 h and clear fluids > 2 h at least), the incidence rate of hypoglycemia and acidosis of neonates in group C displayed a certain decrease (P <  0.05). Although shorter fasting times (solid food < 6 h at least) reduced the incidence of hypoglycemia and acidosis in neonates, it increased the risk of vomiting of women.

Conclusion

The preoperative fasting of solid food ≥6 h < 8 h and clear fluids < 2 h reduces the incidence of vomiting in women’s anesthesia and the risk of hypoglycemia and acidosis in neonates.

Teaching and performing audits on caesarean delivery reduce the caesarean delivery rate

Aim

To assess the factors associated with lower rate of caesarean deliveries in the South of France, based on the characteristics and organisation of the region’s 40 maternity facilities and the characteristics of the practitioners in these facilities.

Method

A retrospective study from 1 January 2012 to 31 December 2015. Data were collected by the Mediterranean network and a declarative survey was completed by each maternity facility in the region to study factor which could be associated with lower caesarean rate by univariate and multivariate analysis.

Results

250 564 women gave birth during this period, of which 55 097 by caesarean section. The mean caesarean delivery rate over the four years was 22.0%. The rate was significantly higher in private maternity facilities [23.9% (21.9%– 25.8%), p<0.05] and type III (maximum care level) maternity facilities [24.2% (21.3%– 27.1%), p<0.05]. After a stepwise regression, the factors associated with a decrease in the caesarean delivery rate were audits concerning caesarean delivery (19.83%, β = - 2.48, p = 0.03 over the four years) and the provision of training to trainee doctors at the maternity facility (20.28%, β = - 1.08, p = 0.04 over the four years).

Conclusion

Performing audits in relation to caesarean deliveries could affect the caesarean. Teaching trainee doctors could be an indicator of quality of caesarean practices. They should be encouraged in maternity facilities to reduce the rate of caesareans.