Prise en charge des placenta praevia et accreta

Interventional Radiology in Obstetrics and Gynecology: Updates in Women's Health

Interventional radiology has had an expanding role in women's health over the past few decades, with recent accelerated growth and development. Interventional radiology is fundamental in the treatment of multiple conditions that affect women, including pelvic venous disease, uterine fibroids, and adenomyosis, and in postpartum management. Patient workup, classification, and treatment techniques have continued to evolve as interventional radiology has become more prevalent in the treatment of patients affected by these conditions. The authors provide a review of the pathophysiology of, patient workup for, and treatment of pelvic venous disease and uterine artery embolization for various disease processes. The authors also highlight updates from the past 5-10 years in diagnosis, classification, and treatment strategies. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Staged treatment of placenta accreta spectrum: A combined surgical and radiological approach

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.

Clinical value of serum VEGF and sFlt-1 in pernicious placenta previa

This study was designed to explore the expression and the diagnostic value of vascular endothelial growth factor (VEGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) in pernicious placenta previa (PPP) combined placental accreta/increta. A total of 140 PPP patients were enrolled and divided into two groups: 56 patients with placenta accreta/increta (PA group), and 84 patients without placenta accreta/increta (non-PA group). In the same period, 46 pregnant women without PPP who had undergone caesarean section were selected as controls. The levels of VEGF and sFlt-1 in serum were detected by enzyme-linked immunosorbent assay. Diagnostic efficiency of VEGF and sFlt-1 in serum were evaluated by receiver operating characteristics curve. It was found that both VEGF and sFlt-1 had diagnostic value for PPP and placenta accreta/increta combined PPP. In addition, the levels of VEGF and sFlt-1 could be used to distinguish placenta accreta from placenta increta. VEGF was negatively correlated with sFlt-1 in PPP patients. In summary, the levels of VEGF and sFlt-1 could be used as auxiliary indicators to diagnose PPP and distinguish between placenta accreta and increta.KEY POINTSThe levels of VEGF and sFlt-1 could be used to distinguish placenta accreta from placenta increta.VEGF is negatively correlated with sFlt-1 in PPP patients.The levels of VEGF and sFlt-1 could be used as auxiliary indicators to diagnose PPP and distinguish between placenta accreta and increta.

Impact of the type of endometrial oestrogen preparation for frozen-thawed embryo (vaginal or transdermal) on perinatal outcomes in an artificial cycle

INTRODUCTION

Serum oestradiol concentration at the time of frozen embryo transfer (FET) in artificial cycle are lower when using transdermal administration of oestrogen for endometrial preparation compared to the vaginal route. This difference could have consequences for placentation and establishment of maternal-foetal circulation. The aim of our study was to compare the birth weight of newborns and the perinatal issues after FET in an artificial cycle with regard to the route of administration of oestrogens.

METHODS

Retrospective monocentric cohort study in the medically assisted reproduction department of the University Hospital of Angers, France, between January 2017 and October 2020. Inclusion criteria were age >18 years old and one live birth after FET in an artificial cycle. The main outcome was the birth weight of the newborns. The choice of oestrogens administration (transdermal or vaginal) was left to the patient.

RESULTS

804 FET in artificial cycle were included in our study. Oestrogens were administrated in 356/804(36.6%) patients using transdermal route and in 448/804(45.9%) patients using vaginal route. There were 68/345 (19.1%) live births in the transdermal group and 85/448 (19%) in the vaginal group. There was no difference in the birth weight of the newborns (3320[2100-4165] grams in the transdermal group vs 3327.5[915-4650] grams in the vaginal group, p=0.72). All the other perinatal issues were comparable between the two groups.

CONCLUSION

Birth weights and perinatal issues were comparable with regard to the route of administration of oestrogens (vaginal or transdermal) in the context of endometrial preparation before FET in an artificial cycle.

Efficacy of Intra-Uterine Tamponade Balloon in Post-Partum Hemorrhage after Cesarean Delivery: An Impact Study

Invasive therapies (surgery or radiological embolization) are used to control severe post-partum hemorrhage. The intra-uterine tamponade balloon is a potential alternative, well documented after vaginal delivery. However, available data on its use after cesarean delivery remain scarce. This study assessed the efficacy of the intra-uterine tamponade balloon during post-partum hemorrhage in a cesarean delivery setting. Using a retrospective impact design, post-partum hemorrhage-related outcomes before (“pre-balloon” period) versus after implementation of intra-uterine tamponade balloon (“post-balloon” period) were compared. All women with post-partum hemorrhage requiring potent uterotonic treatment with prostaglandins after cesarean delivery over a 9-year period were eligible. The primary outcome was the rate of invasive procedure (conservative surgery, radiological embolization and/or hysterectomy). p < 0.05 was considered statistically significant. A total of 279 patients were included (140 vs. 139). Most baseline characteristics were comparable between the two studied periods. The success rate of the intra-uterine tamponade balloon was 82%, and no related complications occurred. Rates of invasive procedures and transfusion were significantly reduced (28.6% vs. 11.5%, p < 0.001 and 44.3% vs. 28.1%, p = 0.006 respectively) during the “post-balloon” period, and length of hospital stay was shorter (p < 0.001). Implementation of intra-uterine tamponade balloon during post-partum hemorrhage after cesarean delivery appears to be safe and effective, with a decrease in both invasive procedures and transfusion rates.

Differential Diagnosis of Cesarean Scar Pregnancies and Other Pregnancies Implanted in the Lower Uterus by Ultrasound Parameters

Purpose

Cesarean scar pregnancy is an extremely rare type of ectopic pregnancy implanted in the myometrium at the site of a previous cesarean section scar. On the other hand, pregnancies are considered low implantations if they are identified in the lower third of the uterus without the sac implanted into the scar and have a better prognosis. Early diagnosis of both types of pregnancies can help avoid serious complications. This study is aimed at investigating the significance of transvaginal ultrasound in the differential diagnosis of cesarean scar pregnancies and pregnancies implanted in the lower uterus.

Methods

Ninety-three patients with an average age of 32.7 years (range, 24-43 years) were enrolled in this study, including 66 cesarean scar pregnancies and 27 other pregnancies implanted in the lower uterus, and they were examined by transvaginal ultrasound.

Results

We observed significant differences in the relationship between the cesarean sac and the scar, the source of the trophoblastic blood flow, and the thickness of the residual muscle between the cesarean scar pregnancy group and the lower uterus pregnancy group. We established the logistic model to improve the differential diagnosis of cesarean scar pregnancies and pregnancies implanted in the lower uterus.

Conclusions

Transvaginal ultrasound is recommended in early pregnancy, especially for patients who have undergone a previous cesarean section delivery.

Placenta Accreta Spectrum (PAS) disorders: incidence, risk factors and outcomes of different management strategies in a tertiary referral hospital in Minia, Egypt: a prospective study

Background

Placenta accreta spectrum (PAS) disorders have become a significant life-threatening issue due to its increased incidence, morbidity and mortality. Several studies have tried to identify the risk factors for PAS disorders. The ideal management for PAS disorders is a matter of debate. The study objectives were to evaluate the incidence and risk factors of PAS disorders and to compare different management strategies at a tertiary referral hospital, Minia, Egypt.

Methods

This prospective study included 102 women diagnosed with PAS disorders admitted to Minia Maternity university hospital, Egypt between January 2017 to August 2018. These cases were categorized into three groups according to the used approach for management: Group (A), (n = 38) underwent cesarean hysterectomy, group (B), (n = 48) underwent cesarean section (CS) with cervical inversion and ligation of both uterine arteries and group (C), (n = 16): the placenta was left in place.

Results

The incidence of PAS disorders during the study period was 9 / 1000 maternities (0.91%). The mean age of cases was 32.4 ± 4.2 years, 60% of them had a parity ≥3 and 82% of them had ≥2 previous CSs. Also, 1/3 of them had previous history of placenta previa. Estimated blood loss (EBL) and blood transfusion in group A were significantly higher than other groups. Group (C) had higher mean hospital stay duration. Group A was associated with significantly higher complication rate.

Conclusions

The incidence of PAS disorders was 0.91%. Maternal age > 32 years, previous C.S. (≥ 2), multiparity (≥ 3) and previous history of placenta previa were risk factors. The management of PAS disorders should be individualized. Women with PAS disorders who completed their family should be offered cesarean hysterectomy. Using the cervix as a tamponade combined with bilateral uterine artery ligation appears to be a safe alternative to hysterectomy in patients with focal placenta accreta and low parity desiring future fertility. Patients with diffuse placenta accreta keen to preserve the uterus could be offered the option of leaving the placenta aiming at conservative management after proper counseling.

Trial registration

Registered 28th October 2015, ClinicalTrials.gov NCT02590484.

Conservative Surgical Management of Placenta Accreta Spectrum: A Pragmatic Approach

In the last 30 years, with increasing cesarean section rates, the incidence of the placenta accreta spectrum has also increased. It is estimated that by the year 2020 there will be nearly 9000 cases annually in the United States. Currently, no consensus exists regarding optimal management. Conventional treatment by cesarean-hysterectomy is challenging, with a high maternal morbidity due to massive hemorrhage, and surgical complications such as urinary tract, bowel and pelvic nerve injury, in addition to loss of fertility and its accompanying psychological trauma. Innovative approaches seek to preserve the uterus with the adherent placenta in situ, thus maintaining fertility and potentially reducing hemorrhage and adjacent organ injury. This review reports strategies for conservative treatment of such conditions, based on the current literature.

Evidence-based guidelines for the management of abnormally invasive placenta: recommendations from the International Society for Abnormally Invasive Placenta

The worldwide incidence of abnormally invasive placenta is rapidly rising, following the trend of increasing cesarean delivery. It is a heterogeneous condition and has a high maternal morbidity and mortality rate, presenting specific intrapartum challenges. Its rarity makes developing individual expertise difficult for the majority of clinicians. The International Society for Abnormally Invasive Placenta aims to improve clinicians' understanding and skills in managing this difficult condition. By pooling knowledge, experience, and expertise gained within a variety of different healthcare systems, the Society seeks to improve the outcomes for women with abnormally invasive placenta globally. The recommendations presented herewith were reached using a modified Delphi technique and are based on the best available evidence. The evidence base for each is presented using a formal grading system. The topics chosen address the most pertinent questions regarding intrapartum management of abnormally invasive placenta with respect to clinically relevant outcomes, including the following: definition of a center of excellence; requirement for antenatal hospitalization; antenatal optimization of hemoglobin; gestational age for delivery; antenatal corticosteroid administration; use of preoperative cystoscopy, ureteric stents, and prophylactic pelvic arterial balloon catheters; maternal position for surgery; type of skin incision; position of the uterine incision; use of interoperative ultrasound; prophylactic administration of oxytocin; optimal method for intraoperative diagnosis; use of expectant management; adjuvant therapies for expectant management; use of local surgical resection; type of hysterectomy; use of delayed hysterectomy; intraoperative measures to treat life-threatening hemorrhage; and fertility after conservative management.

Retrospective analysis of 113 consecutive cases of placenta accreta spectrum from a single tertiary care center

Objective: Placenta accreta spectrum (PAS) remains a major cause of maternal morbidity. We sought to assess the characteristics and treatment outcomes of PAS managed at a tertiary care center with high volume of PAS.Study design: Electronic medical records of all patients with diagnosis of PAS from June 2010 to October 2016 were reviewed. Details of obstetric backgrounds, predelivery diagnosis, peripartum management, and outcomes were analyzed.Results: One hundred thirteen women with PAS were identified from 50,448 deliveries during the study period. Vaginal delivery, emergency, and elective cesarean section were accomplished in 41.6, 30.1, and 28.3%, respectively. There was no maternal mortality. Approximately 41.6% of women with PAS had peripartum hysterectomy. There was a fair inverse correlation between intraoperative blood loss and gestational weeks at delivery (r = -0.311; p=.001), but not gestational weeks at diagnosis (p = .249). Cases with predelivery diagnosis (n = 29) had higher intraoperative blood loss than those diagnosed postdelivery (n = 84) (p<.001). Anterior PAS (n = 58) is associated with attachment to previous uterine scar, antepartum bleeding, and intraoperative blood loss compared to posterior PAS (n = 44) (p<.05). The PAS patients with previous uterine surgery had the highest chance of peripartum hysterectomy (p<.001).Conclusions: Contradictory to previous reports, our data suggest a more severe spectrum of PAS in those with predelivery detection earlier gestational weeks at delivery. Peripartum hysterectomy was highest in anterior PAS that attached to the previous uterine scar.

Maintenance nifedipine therapy for preterm symptomatic placenta previa: A randomized, multicenter, double-blind, placebo-controlled trial

OBJECTIVE

To assess the impact of maintenance nifedipine therapy on pregnancy duration in women with preterm placenta previa bleeding.

METHODS

PPADAL was a randomized, double-blind, placebo-controlled trial conducted between 05/2008 and 05/2012 in five French hospitals. The trial included 109 women, aged ≥ 18 years, with at least one episode of placenta previa bleeding, intact membranes and no other pregnancy complication, at gestational age 24 to 34 weeks and after 48 hours of complete acute tocolysis. Women were randomly allocated to receive either 20 mg of slow-release nifedipine three times daily (n = 54) or placebo (n = 55) until 36 + 6 weeks of gestation. The primary outcome for the trial was length of pregnancy measured in days after enrolment. Main secondary outcomes were rates of recurrent bleeding, cesarean delivery due to hemorrhage, blood transfusion, maternal side effects, gestational age at delivery and adverse perinatal outcomes (perinatal death, chronic lung disease, neonatal sepsis, intraventricular hemorrhage > grade 2, perventricular leukomalacia > grade 1, or necrotizing enterocolitis). Analysis was by intention to treat.

RESULTS

Mean (SD) prolongation of pregnancy was not different between the nifedipine (n = 54) and the placebo (n = 55) group; 42.5 days ± 23.8 versus 44.2 days ± 24.5, p = 0.70. Cesarean due to hemorrhage performed before 37 weeks occurred more frequently in the nifedipine group in comparison with the placebo group (RR, 1.66; 95% confidence interval, 1.05-2.72). Adverse perinatal outcomes were comparable between groups; 3.8% for nifedipine versus 5.5% for placebo (relative risk, 0.52; 95% confidence interval 0.10-2.61). No maternal mortality or perinatal death occurred.

CONCLUSION

Maintenance oral nifedipine neither prolongs duration of pregnancy nor improves maternal or perinatal outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00620724.

[Conservative placenta percreta management using uterine arterial embolization procedure: A series of 12 cases]

We report a retrospective series of 12 placentas percreta with bladder invasion and for which an expected initially multidisciplinary conservative surgical treatment associated with uterine artery embolization was programmed. Conservative surgical treatment was only performed in 7 women. Radical surgical treatment was necessary during the caesarean section and complicated by massive hemorrhage in three women and secondary in two other women for infectious diseases. Radical surgical treatment was associated with partial cystectomy complicated with urinary disorder sequelae in three women. Maternal morbidity of the placenta percreta bladder remains high despite the establishment of a multidisciplinary care protocol.

Placenta Accreta and Total Placenta Previa in the 19th Week of Pregnancy

Placentation disorders are the result of impaired embedding of the placenta in the endometrium. The prevalence of these disorders is estimated to be around 0.3 %. A history of previous prior uterine surgery (especially cesarean section and curettage) is the most common risk factor. Impaired placentation is differentiated into deep placental attachment; marginal, partial and total placenta previa; and placenta accreta, increta and percreta. Treatment depends on the severity of presentation and ranges from expectant management to emergency hysterectomy. In most cases, preterm termination of pregnancy is necessary. We report here on the case of a 39-year-old woman with placenta accreta and total placenta previa who underwent hysterectomy in the 19th week of pregnancy.

[Anesthetic management of severe or worsening postpartum hemorrhage]

INTRODUCTION

Risk factors of maternal morbidity and mortality during postpartum hemorrhage (PPH) include non-optimal anesthetic management. As the anesthetic management of the initial phase is addressed elsewhere, the current chapter is dedicated to the management of severe PPH.

METHODS

A literature search was performed using PubMed and Medline databases, and the Cochrane Library, for articles published from 2003 up to and including 2013. Several keywords related to anesthetic and critical care practice, and obstetrical management were used, in various combinations. Guidelines from several societies and organisations were also read.

RESULTS

When PPH worsens, one should ask for additional team personnel (professional consensus). Patients should be monitored for heart rate, blood pressure, skin and mucosal pallor, bleeding at skin puncture sites, diuresis and the volume of genital bleeding (grade B). Because of the possible rapid worsening of coagulapathy, patients should undergo regular evaluation of coagulation status (professional consensus). Prevention and management of hypothermia should be considered (professional consensus), by warming intravenous fluids and blood products, and by active body warming (grade C). Antibiotics should be given, if not already administered at the initial phase (professional consensus). Vascular fluids must be given (grade B), the choice being left at the physician discretion. Blood products transfusion should be decided based on the clinical severity of PPH (professional consensus). Priority is given to red blood cells (RBC) transfusion, with the aim to maintain Hb concentration>8g/dL. The first round of products could include 3 units of RBC (professional consensus), and the following round 3 units of RBC, and 3 units of fresh frozen plasma (FFP). The FFP:RBC ratio should be kept between 1:2 and 1:1 (professional consensus). Depending on the etiology of PPH, the early administration of FFP is left at the discretion of the physician (professional consensus). Platelet count should be maintained at>50 G/L (professional consensus). During massive PPH, fibrinogen concentration should be maintained at>2g/L (professional consensus). Fibrinogen can be given without prior fibrinogen measurement in case of massive bleeding (professional consensus). General anesthesia should be considered in case of hemodynamic instability, even when an epidural catheter is in place (professional consensus).

CONCLUSION

The anesthetic management aims to restore and maintain optimal respiratory state and circulation, to treat coagulation disorders, and to allow invasive obstetrical and radiologic procedures. Clinical and instrumental monitoring are needed to evaluate the severity of PPH, to guide the choice of therapeutic options, and to assess treatments efficacy.