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Hage L, Athiel Y, Barrois M, Cojocariu V, Peyromaure M, Goffinet F, Duquesne I. Identifying risk factors for urologic complications in placenta accreta spectrum surgical management. World J Urol 2024; 42:539. [PMID: 39325196 DOI: 10.1007/s00345-024-05239-z] [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: 08/05/2024] [Accepted: 08/26/2024] [Indexed: 09/27/2024] Open
Abstract
PURPOSE To describe urologic complications associated with the surgical management of placenta accreta spectrum and determine their risk factors. METHODS A retrospective study was conducted on all patients diagnosed with abnormal invasive placentation who underwent surgery and delivered between 2002 and 2023 at a single expert maternity centre. Intra-operative and post-operative complications were described, with a special focus on urologic intra-operative injuries, including vesical or ureteral injuries. Univariate and multivariate analyses were performed to determine risk factors of intra-operative urologic injuries associated with placenta accreta spectrum surgical management. Additionally, using the Clavien-Dindo classification, the effects of intra-operative urologic injury and ureteral stent placement on post-operative outcome were evaluated. RESULTS A total of 216 patients were included, of which 47 (21.48%) had an intra-operative bladder and/or ureteral injury. Placenta percreta was associated with a higher rate of intra-operative urologic injury than placenta accreta (72.34% vs. 6.38%, p < 0.001). Multivariate analyses showed that patients who had placenta percreta and bladder invasion or emergency hysterectomy were associated with more intra-operative urologic injuries (OR = 8.07, 95% CI [2.44-26.75] and OR = 3.87, 95% CI [1.09-13.72], respectively). Patients with intra-operative urologic injuries had significantly more severe post-operative complications, which corresponds to a Clavien-Dindo score of 3 or more, at 90 days (21.28% vs. 5.92%, p = 0.004). CONCLUSION Surgical management of placenta accreta spectrum is associated with significant urologic morbidity, with a major impact on post-operative outcomes. Urologic complications seem to be correlated with the depth of invasion and the emergency of the hysterectomy.
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Affiliation(s)
- Lory Hage
- Department of Urology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Yoann Athiel
- Department of Obstetrics and Gynaecology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Mathilde Barrois
- Department of Obstetrics and Gynaecology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Vlad Cojocariu
- Department of Urology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Michaël Peyromaure
- Department of Urology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - François Goffinet
- Department of Obstetrics and Gynaecology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Igor Duquesne
- Department of Urology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France.
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Zarudskaya OM, Boyd AR, Byrne JJ, Berkus MD, Ramsey PS. Predictive Value and Limitations of the Placenta Accreta Index: A Systematic Review. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:1579-1593. [PMID: 38888042 DOI: 10.1002/jum.16509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 05/19/2024] [Accepted: 05/27/2024] [Indexed: 06/20/2024]
Abstract
Our systematic review highlights that multiparametric PAI score assessment is a consistent tool with high sensitivity and specificity for prenatal prediction for placenta accreta spectrum (PAS) in high-risk population with anterior placenta previa or low-lying placenta and prior cesarean deliveries. A systematic search was conducted on November 1, 2022, of MEDLINE via PubMed, Scopus, Web of Science Core Collection, Cochrane Library, and Google Scholar to identify relevant studies (PROSPERO ID # CRD42022368211). A total of 11 articles met our inclusion criteria, representing the data of a total of 1,044 cases. Women with PAS had an increased mean PAI total score, compared to those without PAS. Limitations of the PAI are most studies were conducted in developing countries in high-risk population which limit the global generalizability of findings. Heterogeneity of reported data did not allow to perform meta-analysis.
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Affiliation(s)
- Oxana M Zarudskaya
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Angela R Boyd
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, Texas, USA
| | - John J Byrne
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Michael D Berkus
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Patrick S Ramsey
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, Texas, USA
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3
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Meyers ML, Mirsky DM. MR Imaging of Placenta Accreta Spectrum: A Comprehensive Literature Review of the Most Recent Advancements. Magn Reson Imaging Clin N Am 2024; 32:573-584. [PMID: 38944441 DOI: 10.1016/j.mric.2024.03.009] [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] [Indexed: 07/01/2024]
Abstract
This article delves into the latest MR imaging developments dedicated to diagnosing placenta accreta spectrum (PAS). PAS, characterized by abnormal placental adherence to the uterine wall, is of paramount concern owing to its association with maternal morbidity and mortality, particularly in high-risk pregnancies featuring placenta previa and prior cesarean sections. Although ultrasound (US) remains the primary screening modality, limitations have prompted heightened emphasis on MR imaging. This review underscores the utility of quantitative MR imaging, especially where US findings prove inconclusive or when maternal body habitus poses challenges, acknowledging, however, that interpreting placenta MR imaging demands specialized training for radiologists.
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Affiliation(s)
- Mariana L Meyers
- Department of Radiology, Pediatric Section, University of Colorado School of Medicine; Children's Hospital Colorado.
| | - David M Mirsky
- Department of Radiology, Pediatric Section, University of Colorado School of Medicine; Children's Hospital Colorado
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Naga Rachana P, Chennuru B, Kathpalia S, Kshirsagar S. A Rare Case of Placenta Increta at Uterine Fundus. Cureus 2024; 16:e67147. [PMID: 39295678 PMCID: PMC11410416 DOI: 10.7759/cureus.67147] [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] [Received: 07/22/2024] [Accepted: 08/18/2024] [Indexed: 09/21/2024] Open
Abstract
Adherent placenta means a placenta that is not delivered spontaneously or even after manual removal within 30 minutes of baby birth. It is an uncommon and frequently unanticipated event with serious potential health circumstances and it should be managed by the medical team. This case study presents a rare instance of placenta increta in a 25-year-old woman, second gravida, at 36 weeks of gestation, with a history of cesarean section 16 months prior due to chorioamnionitis. The patient presented to the labor room in active labor, and antenatal ultrasound indicated placental implantation on the posterior surface of the upper uterine segment. Given the short inter-delivery interval, an emergency preterm lower segment cesarean section (LSCS) was performed, resulting in the birth of a healthy baby girl weighing 1.8 kg. During surgery, a morbidly adherent placenta was found over the fundus of the uterus. Following consultations with the patient and her relatives, an emergency obstetric total hysterectomy was performed. Intraoperatively, the patient received one unit of packed cell volume (PCV) and, postoperatively, two additional units of PCV and two units of fresh frozen plasma (FFP) were administered. On the third postoperative day, the patient developed right lung consolidation, necessitating a five-day stay in the Obstetric Intensive Care Unit (OBICU). The remaining postoperative period was uneventful, and the patient was discharged on the 10th postoperative day with the healthy infant. Placenta accreta, including its variants increta and percreta, represents abnormal placental implantation into the uterine wall, a condition whose incidence is rising due to increased cesarean sections and improved imaging detection.
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Affiliation(s)
- Paidi Naga Rachana
- Obstetrics and Gynaecology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
| | - Bharathna Chennuru
- Obstetrics and Gynaecology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
| | - Sukesh Kathpalia
- Obstetrics and Gynaecology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
| | - Shilpa Kshirsagar
- Obstetrics and Gynaecology, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
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Kandemir H, Kirtis E, Bulbul GA, Dogan S, Mendilcioglu I, Sanhal CY, Sakinci M, Dogan NU. Intraoperative and Postoperative Outcomes of Pfannenstiel and Midline Skin Incisions in Placenta Accreta Spectrum Disorders: Single-Center Experience. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1102. [PMID: 39064531 PMCID: PMC11278527 DOI: 10.3390/medicina60071102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 06/18/2024] [Accepted: 06/27/2024] [Indexed: 07/28/2024]
Abstract
Background: We compared Pfannenstiel and midline skin incisions for cesarean hysterectomy in women with confirmed Placenta Accreta Spectrum Disorders. Aims: A retrospective cohort study was conducted to evaluate the outcomes of Pfannenstiel and midline skin incisions in women undergoing cesarean section hysterectomy for suspected placenta accreta at Akdeniz University Hospital between January 2010 and February 2022. Histopathological confirmation was obtained for all cases. Demographic, perioperative, and postoperative data, along with neonatal outcomes, were extracted from the hospital's electronic database. Possible complaints related to the incision site or other issues (e.g., vaginal dryness or sexual life) were identified through telephone interviews. Subjects were stratified into Pfannenstiel and midline incision cohorts, with subsequent data comparison. Results: Data from 67 women with a histopathologically confirmed PAS diagnosis were analyzed. Of these, 49 (73.1%) underwent Pfannenstiel incision, and 18 (26.9%) had a midline skin incision. Incisions were based on the surgeon's experience. Pfannenstiel incision was more common in antepartum hemorrhage, preoperative hemorrhage, and emergency surgery (p = 0.02, p = 0.014, p = 0.002, respectively). Hypogastric artery ligation occurred in 30 cases (61.2%) in the Pfannenstiel group but none in the midline group. Cosmetic dissatisfaction and sexual problems were more prevalent in the midline group (p < 0.05, all). Preoperative and postoperative blood parameters, transfused blood products, and neonatal outcomes were similar between the two groups. Conclusions: Relaparotomy, bladder injury, blood loss, and need for blood transfusion were more prevalent in the Pfannenstiel group, while greater dissatisfaction with the incision was observed in the midline incision group. Midline incision seems to be more favorable in patients with Placenta Accreta Spectrum (PAS). Patients may be informed regarding the worse cosmetic outcomes and possible sexual problems related to vaginal dryness when midline laparotomy is planned. But before opting for a Pfannenstiel incision, patients should receive comprehensive information regarding the potential risks of relaparotomy and bladder injury.
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Affiliation(s)
| | | | | | | | | | | | | | - Nasuh Utku Dogan
- The Department of Obstetrics and Gynecology, Akdeniz University Faculty of Medicine, Antalya 07070, Türkiye; (H.K.); (E.K.); (G.A.B.); (S.D.); (I.M.); (C.Y.S.); (M.S.)
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Yalınkaya A, Oğlak SC. A Novel Approach for Conservative Management of Placenta Accreta Spectrum Disorder Cases: Experience of a Single Surgeon: PAS Disorders and Conservative Management. J Pregnancy 2024; 2024:9910316. [PMID: 38961859 PMCID: PMC11221975 DOI: 10.1155/2024/9910316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/18/2024] [Accepted: 05/14/2024] [Indexed: 07/05/2024] Open
Abstract
Background: This study is aimed at evaluating the conservative surgical treatment of patients with placenta accreta spectrum (PAS) disorder and at presenting the experience of a single surgeon. Materials and Methods: This retrospective study included 245 patients with placenta previa accompanied by PAS disorders operated at a university hospital between June 2013 and December 2023. The diagnosis of PAS was made by a single perinatologist using a combination of transvaginal and transabdominal ultrasonography. All patients were operated with conservative surgical technique by the same surgeon. The demographic and clinical characteristics of the patients, the anesthesia and incision types used, and the details of the surgical technique were evaluated. Results: Of the patients, 165 were operated on at the scheduled time, 80 were operated on under emergency conditions, and 232 (94.69%) of them were operated on under spinal anesthesia. All patients were operated on with a Pfannenstiel incision followed by a transverse incision to the upper border of the placenta to enter into the uterus. An average of 0.52 units of red blood cells per patient was transfused to all patients. Spontaneous intra-abdominal bleeding developed in five patients, and surgical complications occurred in eight patients. No cesarean hysterectomy was performed, and no maternal mortality was detected in any of the cases. The mean time duration of surgery was 54.44 ± 11.37 (30-90) min, and the mean length of hospital stay was 1.71 ± 1.30 (1-9) days. Conclusions: We recommend this procedure as a novel technique and a robust and safe alternative to peripartum hysterectomy and other conservative surgical management procedures for cases with complete PP accompanied with PAS. This technique preserves the uterus as well as reduces blood loss, and transfusion requirement, and thus maternal morbidity and mortality in PAS cases.
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Affiliation(s)
- Ahmet Yalınkaya
- Department of Obstetrics and GynecologyDicle University Faculty of Medicine, Diyarbakır, Türkiye
| | - Süleyman Cemil Oğlak
- Department of Obstetrics and GynecologyHealth Sciences UniversityGazi Yaşargil Training and Research Hospital, Diyarbakır, Türkiye
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Einerson BD, Healy AJ, Lee A, Warrick C, Combs CA, Hameed AB. Society for Maternal-Fetal Medicine Special Statement: Emergency checklist, planning worksheet, and system preparedness bundle for placenta accreta spectrum. Am J Obstet Gynecol 2024; 230:B2-B11. [PMID: 37678646 DOI: 10.1016/j.ajog.2023.09.001] [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] [Indexed: 09/09/2023]
Abstract
Placenta accreta spectrum is a life-threatening complication of pregnancy that is underdiagnosed and can result in massive hemorrhage, disseminated intravascular coagulation, massive transfusion, surgical injury, multisystem organ failure, and even death. Given the rarity and complexity, most obstetrical hospitals and providers do not have comprehensive expertise in the diagnosis and management of placenta accreta spectrum. Emergency management, antenatal interdisciplinary planning, and system preparedness are key pillars of care for this life-threatening disorder. We present an updated sample checklist for emergent and unplanned cases, an antenatal planning worksheet for known or suspected cases, and a bundle of activities to improve system and team preparedness for placenta accreta spectrum.
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8
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Palacios-Jaraquemada JM, Nieto-Calvache Á, Aryananda RA, Basanta N. Placenta accreta spectrum into the parametrium, morbidity differences between upper and lower location. J Matern Fetal Neonatal Med 2023; 36:2183764. [PMID: 36966802 DOI: 10.1080/14767058.2023.2183764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
Abstract
OBJECTIVE To demonstrate the surgical and morbidity differences between upper and lower parametrial placenta invasion (PPI). MATERIALS AND METHODS Forty patients with placenta accreta spectrum (PAS) into the parametrium underwent surgery between 2015 and 2020. Based on the peritoneal reflection, the study compared two types of parametrial placental invasion (PPI), upper or lower. Surgical approach to PAS follows a conservative-resective method. Before delivery, surgical staging by pelvic fascia dissection established a final diagnosis of placental invasion. In upper PPI cases, the team attempted to repair the uterus after resecting all invaded tissues or performing a hysterectomy. In cases of lower PPI, experts performed a hysterectomy in all cases. The team only used proximal vascular (aortic occlusion) control in cases of lower PPI. Surgical dissection for lower PPI started finding the ureter in the pararectal space, ligating all the tissues (placenta and newly formed vessels) to create a tunnel to release the ureter from the placenta and placenta suppletory vessels. Overall, at least three pieces of the invaded area were sent for histological analysis. RESULTS Forty patients with PPI were included, 13 in the upper parametrium and 27 in the lower parametrium. MRI indicated PPI in 33/40 patients; in three, the diagnosis was presumed by ultrasound or medical background. The intrasurgical staging categorizes 13 cases of PPI performed and finds diagnosis in seven undetected cases. The expertise team completed a total hysterectomy in 2/13 upper PPI cases and all lower PPI cases (27/27). Hysterectomies in the upper PPI group were performed by extensive damage of the lateral uterine wall or with a tube compromise. Ureteral injury ensued in six cases, corresponding to cases without catheterization or incomplete ureteral identification. All aortic vascular proximal control (aortic balloon, internal aortic compression, or aortic loop) was efficient for controlling bleeding; in contrast, ligature of the internal iliac artery resulted in a useless procedure, resulting in uncontrollable bleeding and maternal death (2/27). All patients had antecedents of placental removal, abortion, curettage after a cesarean section, or repeated D&C. CONCLUSIONS Lower PAS parametrial involvement is uncommon but associated with elevated maternal morbidity. Upper and lower PPI has different surgical risks and technical approaches; consequently, an accurate diagnosis is needed. The clinical background of manual placental removal, abortion, and curettage after a cesarean or repeated D&C could be ideally studied to diagnose a possible PPI. For patients with high-risk antecedents or unsure ultrasound, a T2 weight MRI is always recommended. Performing comprehensive surgical staging in PAS allows the efficient diagnosis of PPI before using some procedures.
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Matsuo K, Sangara RN, Matsuzaki S, Ouzounian JG, Hanks SE, Matsushima K, Amaya R, Roman LD, Wright JD. Placenta previa percreta with surrounding organ involvement: a proposal for management. Int J Gynecol Cancer 2023; 33:1633-1644. [PMID: 37524496 DOI: 10.1136/ijgc-2023-004615] [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] [Indexed: 08/02/2023] Open
Abstract
Placenta accreta spectrum encompasses cases where the placenta is morbidly adherent to the myometrium. Placenta percreta, the most severe form of placenta accreta spectrum (grade 3E), occurs when the placenta invades through the myometrium and possibly into surrounding structures next to the uterine corpus. Maternal morbidity of placenta percreta is high, including severe maternal morbidity in 82.1% and mortality in 1.4% in the recent nationwide U.S. statistics. Although cesarean hysterectomy is commonly performed for patients with placenta accreta spectrum, conservative management is becoming more popular because of reduced morbidity in select cases. Treatment of grade 3E disease involving the urinary bladder, uterine cervix, or parametria is surgically complicated due to the location of the invasive placenta deep in the maternal pelvis. Cesarean hysterectomy in this setting has the potential for catastrophic hemorrhage and significant damage to surrounding organs. We propose a step-by-step schema to evaluate cases of grade 3E disease and determine whether immediate hysterectomy or conservative management, including planned delayed hysterectomy, is the most appropriate treatment option. The approach includes evaluation in the antenatal period with ultrasound and magnetic resonance imaging to determine suspicion for placenta previa percreta with surrounding organ involvement, planned cesarean delivery with a multidisciplinary team including experienced pelvic surgeons such as a gynecologic oncologist, intra-operative assessment including gross surgical field exposure and examination, cystoscopy, and consideration of careful intra-operative transvaginal ultrasound to determine the extent of placental invasion into surrounding organs. This evaluation helps decide the safety of primary cesarean hysterectomy. If safely resectable, additional considerations include intra-operative use of uterine artery embolization combined with tranexamic acid injection in cases at high risk for pelvic hemorrhage and ureteral stent placement. Availability of resuscitative endovascular balloon occlusion of the aorta is ideal. If safe resection is concerned, conservative management including planned delayed hysterectomy at around 4 weeks from cesarean delivery in stable patients is recommended.
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Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Rauvynne N Sangara
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Shinya Matsuzaki
- Department of Gynecology, Osaka International Cancer Institute, Osaka, Japan
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Sue E Hanks
- Department of Radiology, University of Southern California, Los Angeles, California, USA
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California, USA
| | - Rodolfo Amaya
- Department of Anesthesiology, University of Southern California, Los Angeles, California, USA
| | - Lynda D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
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Padilla C, Ortner C, Dennis A, Zieleskiewicz L. The need for maternal critical care education, point-of-care ultrasound and critical care echocardiography in obstetric anesthesiologists training. Int J Obstet Anesth 2023; 55:103880. [PMID: 37105833 DOI: 10.1016/j.ijoa.2023.103880] [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: 01/21/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 04/05/2023]
Abstract
Globally, the increase in medically complex obstetric patients is challenging the educational approach and clinical management of critically ill obstetric patients. This increase in medical complexity calls into question the educational paradigm in which future physicians are trained. Obstetric anesthesiologists, physician experts in the perio-perative planning and management of complex obstetric patients, represent an essential workforce in the strategies to address maternal mortality. Unfortunately, the development of peri-operative medicine and maternal critical care curricula has only received minor attention in most countries. Proposed guidelines and models highlight the existing need for tiered maternity care services in which critical care infrastructure plays a central role in the delivery of high-risk peripartum care. Therefore, the development of maternal critical care models designed to prepare obstetric anesthesiologists for the clinical challenges of a medically complex patient are warranted. Key critical care topics such as advanced ultrasonography, with the inclusion of quantitative echocardiographic assessments into obstetric anesthesiology educational curricula, will serve to better prepare physicians for the realities of an increasingly complex pregnant patient population, and further reinforce the critical care infrastructure detailed in the Levels of Maternal Care consensus. Despite an increasingly complex obstetric patient population, heterogeneity of maternal critical care practices exists across the globe, warranting standardization and further development of proposed curricula.
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Affiliation(s)
- C Padilla
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA, USA.
| | - C Ortner
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA, USA
| | - A Dennis
- Departments of Critical Care, Obstetrics and Gynecology, and Pharmacology, University of Melbourne, Australia
| | - L Zieleskiewicz
- Département d'Anesthésie-Réanimation, Médecine Péri-opératoire, Hôpital Nord, AP-HM Marseille, France
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11
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Padilla CR, Shamshirsaz AA, Easter SR, Hess P, Smith C, El Sharawi N, Sandlin AT. Critical Care in Placenta Accreta Spectrum Disorders-A Call to Action. Am J Perinatol 2023; 40:988-995. [PMID: 37336216 DOI: 10.1055/s-0043-1761638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
The rising in placenta accreta spectrum (PAS) incidence, highlights the need for critical care allotment for these patients. Due to risk for hemorrhage and possible hemorrhagic shock requiring blood product transfusion, hemodynamic instability and risk of end-organ damage, having an intensive care unit (ICU) with surgical expertise (surgical ICU or equivalent based on institutional resources) is highly recommended. Intensive care units physicians and nurses should be familiarized with intraoperative anesthetic and surgical techniques as well as obstetrics physiologic changes to provide postpartum management of PAS. Validated tools such of bedside point of care ultrasound and viscoelastic tests such as thromboelastogram/rotational thromboelastometry (TEG/ROTEM) are clinically useful in the assessment of hemodynamic status (shock diagnosis, assessment of both fluid responsiveness and tolerance) and transfusion guidance (in patients requiring massive transfusion as opposed to tranditional hemostatic resuscitation) respectively. The future of PAS management lies in the collaborative and multidisciplinary environment. We recommend that women with high suspicion or a confirmed PAS should have a preoperative plan in place and be managed in a tertiary center who is experienced in managing surgically complex cases. KEY POINTS: · The rising in placenta accreta spectrum incidence highlights the need for critical care expertise.. · Emerging tools such as point-of-care ultrasound and thromboelastography/rotational thromboelastometry represent new avenues for real time optimization of hemodynamic and hematological care of patients with PAS.. · Patients with PAS should be referred to a tertiary center having an intensive care unit (ICU) with surgical expertise (or equivalent based on institutional resources)..
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Affiliation(s)
- Cesar R Padilla
- Division of Obstetric Anesthesiology, Stanford University School of Medicine, Stanford, California
| | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology/Surgical Critical Care Texas Children's Hospital, Baylor College of Medicine, Texas
| | - Sarah R Easter
- Department of Obstetrics and Gynecology/Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Phillip Hess
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Carly Smith
- Department of Anesthesiology and Pain Management, Anesthesiology Institute, Cleveland Clinic, Ohio
| | - Nadir El Sharawi
- Division of Obstetrical Anesthesia, University of Arkansas for Medical Sciences, Fayetteville, Arkansas
| | - Adam T Sandlin
- Division of Maternal-Fetal Medicine, University of Arkansas for Medical Sciences, Fayetteville, Arkansas
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12
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Li H, Lu T, Li M, Wang Y, Zhang F, Yuan Y, Zhu M, Zhao X. Differentiation of placenta percreta through MRI features and diffusion-weighted magnetic resonance imaging. Insights Imaging 2023; 14:93. [PMID: 37222836 DOI: 10.1186/s13244-023-01448-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/09/2023] [Indexed: 05/25/2023] Open
Abstract
OBJECTIVES To identify whether parameters measured from diffusion kurtosis and intravoxel incoherent motion help diagnose placenta percreta. METHODS We retrospectively enrolled 75 patients with PAS disorders including 13 patients with placenta percreta and 40 patients without PAS disorders. Each patients underwent diffusion-weighted imaging (DWI), intravoxel incoherent motion (IVIM), and diffusion kurtosis imaging (DKI). The apparent diffusion coefficient (ADC), perfusion fraction (f), pure diffusion coefficient (D), pseudo-diffusion coefficient (D*), mean diffusion kurtosis (MK) and mean diffusion coefficient (MD) were measured by the volumetric analysis and compared. MRI features were also analyzed and compared. The receiver operating characteristic (ROC) curve and logistic regression analysis were used to evaluate the diagnostic efficiency of different diffusion parameters and MRI features for distinguishing placental percreta. RESULTS D* was an independent risk factor from DWI for predicting placenta percreta with sensitivity of 73% and specificity of 76%. Focal exophytic mass remained as independent risk factor from MRI features for predicting placenta percreta with sensitivity of 72.7% and specificity of 88.1%. When the two risk factors were combined together, the AUC was the highest, 0.880 (95% CI 0.8-0.96). CONCLUSION D* and focal exophytic mass were associated with placenta percreta. A combination of the 2 risk factors can be used to predict placenta percreta. CRITICAL RELEVANCE STATEMENT A combination of D* and focal exophytic mass can be used to differentiate placenta percreta.
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Affiliation(s)
- Hang Li
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32 West Second Section, First Ring Road, Chengdu, 610072, China
| | - Tao Lu
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32 West Second Section, First Ring Road, Chengdu, 610072, China.
| | - Mou Li
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32 West Second Section, First Ring Road, Chengdu, 610072, China
| | - Yishuang Wang
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32 West Second Section, First Ring Road, Chengdu, 610072, China
| | - Feng Zhang
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32 West Second Section, First Ring Road, Chengdu, 610072, China
| | - Yi Yuan
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32 West Second Section, First Ring Road, Chengdu, 610072, China
| | - Meilin Zhu
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32 West Second Section, First Ring Road, Chengdu, 610072, China
| | - Xinyi Zhao
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32 West Second Section, First Ring Road, Chengdu, 610072, China
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13
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Bartels HC, Horsch A, Cooney N, Brennan DJ, Lalor JG. Living with a diagnosis of Placenta Accreta Spectrum: Mothers' and Fathers' experience of the antenatal journey and the birth. PLoS One 2023; 18:e0286082. [PMID: 37216388 DOI: 10.1371/journal.pone.0286082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 05/09/2023] [Indexed: 05/24/2023] Open
Abstract
OBJECTIVE Much research into Placenta Accreta Spectrum (PAS) has focussed on the associated maternal morbidity and mortality. However, mothers' and fathers' lived experiences of the aftermath of a diagnosis of PAS up to the birth and beyond has received little attention. Therefore, the aim of this study was to increase our understanding of the psychological consequences of PAS on women and their partners during pregnancy, up to and including the birth. METHODS In-depth interviews were conducted with 29 participants; 6 couples were interviewed together (n = 12), 6 couples were interviewed separately (n = 12), and 5 women were interviewed without their partner. Data from the antenatal and intrapartum periods are presented. Couples were eligible for inclusion if they had a diagnosis of PAS within the previous 5 years. An Interpretative Phenomenological Analysis approach was used to gather and analyse data. Virtual interviews were conducted over a 3-month period from February to April 2021. RESULTS Themes emerged relating to two distinct timepoints, the antenatal period and birth. The antenatal period had two main themes: the first antenatal main theme was "Living with PAS", which had two sub-themes: "Lack of knowledge of PAS" and "Experiences of varied approaches to care". The second antenatal main theme was "Coping with uncertainty", which had two sub-themes of "Getting on with it", and "Emotional toll". Relating to birth, two main themes emerged. The first main theme was "A traumatic experience", with three sub-themes of "Saying goodbye", "Experiencing trauma" and the "Witnessing of trauma" (by fathers). The second main theme which emerged was "Feeling safe in the hands of experts", with two subthemes of "Safety in expert team" and "Relief at surviving". CONCLUSIONS This study highlights the significant psychological consequences a diagnosis of PAS has on mothers and fathers, how they try to come to terms with the diagnosis and the experience of a traumatic birth, and how management within a specialist team can alleviate some of these fears.
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Affiliation(s)
- Helena C Bartels
- Dept of UCD Obstetrics and Gynaecology, School of Medicine, National Maternity Hospital, University College Dublin, Dublin, Ireland
| | - Antje Horsch
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland
- Woman-Mother-Child Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Naomi Cooney
- Placenta Accreta Ireland, Patient support and advocacy group, Dublin, Ireland
| | - Donal J Brennan
- Dept of UCD Obstetrics and Gynaecology, School of Medicine, National Maternity Hospital, University College Dublin, Dublin, Ireland
| | - Joan G Lalor
- School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland
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14
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Aiob A, Gaziyev Z, Mikhail SM, Wolf M, Lowenstein L, Odeh M. The value of a simple sonographic screening test for placenta accreta spectrum prediction: A case-control study. Aust N Z J Obstet Gynaecol 2023; 63:228-233. [PMID: 36068725 DOI: 10.1111/ajo.13611] [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: 06/09/2022] [Accepted: 08/21/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Placenta accreta spectrum (PAS) represents life-threatening conditions; however, early diagnosis reduces complications and mortality rates. AIMS To develop and evaluate the accuracy of a simple sonographic screening test for PAS prediction. MATERIALS AND METHODS A retrospective case-control study of 481 women with singleton pregnancies at 28 weeks or later, with a scarred uterus or placenta praevia, who underwent sonographic testing for PAS detection during 2010-2020. We compared demographic and sonographic features, and delivery outcomes between women who were and were not confirmed to have a PAS condition at delivery. We evaluated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and predictive probability for the sonographic screening model. RESULTS Among all the women with at least one sonographic sign (large lacunae or loss of clear zone), the odds ratio (OR) of PAS was 21.7 (95% CI, 16.7-70.4), among those with placenta praevia (and at least one sonographic sign), the OR was 41.9 (95% CI, 15.8-111). For the screening model (the combinations of placental location (major or minor placenta praevia) with at least one sonographic sign (large lacunae or loss of clear zone)), sensitivity, specificity, PPV, NPV and predicted probability were 94.9% (85.8-98.9%), 91.5% (88.4-93.9%), 60.9% (50.1-70.9%), 99.2% (97.7-99.8%) and 92.3%, respectively. CONCLUSIONS A combination of simple ultrasound signs for PAS screening may be highly effective for prenatal assessment and prediction of placenta accreta. This screening test can be carried out as routine pregnancy follow-up for women with risk factors for PAS.
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Affiliation(s)
- Ala Aiob
- Department of Obstetrics and Gynaecology, Galilee Medical Centre, Nahariya and Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Ziyada Gaziyev
- Department of Obstetrics and Gynaecology, Galilee Medical Centre, Nahariya, Israel
| | - Susana Mustafa Mikhail
- Department of Obstetrics and Gynaecology, Galilee Medical Centre, Nahariya and Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Maya Wolf
- Department of Obstetrics and Gynaecology, Galilee Medical Centre, Nahariya and Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Lior Lowenstein
- Department of Obstetrics and Gynaecology, Galilee Medical Centre, Nahariya and Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Marwan Odeh
- Department of Obstetrics and Gynaecology, Galilee Medical Centre, Nahariya and Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
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15
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Einerson BD. Conservative management for placenta accreta spectrum: questions and barriers remain but are surmountable. Am J Obstet Gynecol MFM 2023; 5:100859. [PMID: 36717353 PMCID: PMC10324967 DOI: 10.1016/j.ajogmf.2023.100859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/27/2022] [Accepted: 12/31/2022] [Indexed: 01/30/2023]
Affiliation(s)
- Brett D Einerson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT.
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16
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Einerson BD, Kennedy A, Silver RM, Branch DW, Comstock J, Woodward PJ. Ultrasonography of the Explanted Uterus in Placenta Accreta Spectrum: Correlation With Intraoperative Findings and Gross Pathology. Obstet Gynecol 2023; 141:544-554. [PMID: 36735356 PMCID: PMC9974826 DOI: 10.1097/aog.0000000000005075] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/10/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To better understand placenta accreta spectrum (PAS) by correlating postoperative ultrasonographic findings of the explanted uteroplacental interface with intraoperative findings and gross pathology. METHODS We enrolled consecutive pregnant patients aged 18 years and older with a prior cesarean delivery and antenatal diagnosis of lower uterine segment PAS who planned to undergo hysterectomy into this prospective, descriptive study. All underwent cesarean hysterectomy with standardized intraoperative photography. Ultrasonography of explanted postsurgical uteruses was performed by expert radiologists to obtain standard detailed images of the myometrial-placental interface and other areas of interest. Sagittal views of the gross pathologic specimen were photographed. We correlated the intraoperative, ultrasonographic, and gross pathologic findings as a study team and report four consistent patterns that emerged from this systematic evaluation. RESULTS Thirty-four consecutive eligible patients were enrolled. The following consistent observations emerged: 1) The uteroplacental interface in the explanted specimen was smooth and distinct. At the point of maximal placental protrusion, the myometrium was imperceptible, but the placenta was confined by a smooth thin echogenic line of uterine serosa (the scar shell) unless surgically disrupted. 2) Every specimen of PAS grade 2-3 showed placenta bulging through the lower uterine segment in the region of prior hysterotomy. 3) Placentas extended to, but not through, the uterovesical interface or scar shell. Dense adhesive disease was found between the placenta and bladder. There were no cases of true bladder invasion. 4) Placental extension beyond the serosa (invasion) has a distinct appearance on postoperative ultrasonography with irregular frond-like protrusion of placental tissue. This appearance was always the result of surgical manipulation and was not present before delivery of the neonate. CONCLUSION These findings suggest that PAS severity is likely mediated by progressive scar dehiscence and uterine remodeling, not placental invasion. This challenges the existence of in situ invasive percreta as it is currently described.
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Affiliation(s)
- Brett D. Einerson
- University of Utah Health, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine
- Intermountain Healthcare
| | - Anne Kennedy
- University of Utah Health, Department of Radiology and Imaging Sciences
| | - Robert M. Silver
- University of Utah Health, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine
- Intermountain Healthcare
| | - D. Ware Branch
- University of Utah Health, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine
- Intermountain Healthcare
| | - Jessica Comstock
- Primary Children’s Hospital
- University of Utah Health, Department of Pathology
| | - Paula J. Woodward
- University of Utah Health, Department of Radiology and Imaging Sciences
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17
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Pineles BL, Sibai BM, Sentilhes L. Is conservative management of placenta accreta spectrum disorders practical in the United States? Am J Obstet Gynecol MFM 2023; 5:100749. [PMID: 36113717 DOI: 10.1016/j.ajogmf.2022.100749] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 08/31/2022] [Indexed: 10/14/2022]
Abstract
This commentary discusses the issues related to conservative management (also called leaving the placenta in situ or intentional retention of the placenta) of placenta accreta spectrum disorders. Considerations related to placenta accreta spectrum disorder management in the United States are compared with France, where conservative management is a well-accepted management option. The history of placenta accreta spectrum disorder treatment is reviewed, finding that since 1937, the most common treatment in the United States been cesarean-hysterectomy without placental removal. Although definitive studies have yet to be conducted, a growing body of evidence suggests that conservative management is able to reduce maternal morbidity, compared with cesarean-hysterectomy. International and national guidelines from several countries are examined. Comparisons between the United States and France that are addressed in the commentary include population and geography, structure of the healthcare system, physician training and acceptability, and patient acceptability. Considering the differences between the countries, conservative management is feasible in the United States. Different options for placenta accreta spectrum disorder management should be rigorously researched in multicenter international collaborations. Conservative management should be considered as an option for women with placenta accreta spectrum disorders in the United States, especially for those desiring fertility preservation.
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Affiliation(s)
- Beth L Pineles
- Department of Obstetrics, Gynecology & Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX (Drs Pineles and Sibai).
| | - Baha M Sibai
- Department of Obstetrics, Gynecology & Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX (Drs Pineles and Sibai)
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France (Dr Sentilhes)
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18
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Bartels HC, Walsh JM, O'Connor C, McParland P, Carroll S, Higgins S, Mulligan KM, Downey P, Brophy D, Colleran G, Thompson C, Walsh T, O'Brien DJ, Brennan DJ, McVey R, McAuliffe FM, Donnelly J, Corcoran SM. Placenta accreta spectrum ultrasound stage and fetal growth. Int J Gynaecol Obstet 2023; 160:955-961. [PMID: 35964250 PMCID: PMC10087882 DOI: 10.1002/ijgo.14399] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 07/27/2022] [Accepted: 08/05/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE to evaluate fetal growth in pregnancies complicated by placenta accreta spectrum (PAS) and to compare fetal growth between cases stratified by ultrasound stage of PAS. METHODS This was a prospective multicenter cohort study of women diagnosed with PAS between January 2018 and December 2021. We grouped participants into cases by ultrasound stage (PAS stage 1-3) and controls (PAS0). Fetal growth centiles at three timepoints with median gestational ages of 21 ± 1 weeks (interquartile range [IQR], 20 ± 1-22 ± 0 weeks), 28 ± 0 weeks (IQR, 27 ± 0-28 ± 5 weeks), and 33 ± 0 weeks (IQR, 32 ± 1-34 ± 0 weeks) and birth weight centiles were compared between cases and controls and between those with PAS stratified by ultrasound stage. RESULTS A total of 53 women met inclusion criteria, with a mean age of 37 years (standard deviation, ±4.0 years) and body mass index of 27 kg/m2 (standard deviation, ±5.8 kg/m2 ). Median (IQR) fetal weight centiles were around the 50th centile at each timepoint, with no difference between groups. The incidence of small for gestational age (birth weight ≤ 10th percentile) and large for gestational age (birth weight ≥ 90th percentile) was 11.3% (n = 6) and 15.1% (n = 8), respectively, with no differences by ultrasound stage. The median birth weight centile was 64 (IQR, 26-85), with no differences between cases and controls or by ultrasound stage. CONCLUSIONS In our cohort, a diagnosis of PAS was not associated with fetal growth restriction.
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Affiliation(s)
| | - Jennifer M Walsh
- National Maternity Hospital, Dublin 2, Ireland.,University College Dublin Gynaecological Oncology Group (UCD-GOG), Mater Misericordiae University Hospital and St Vincent's University Hospital, Dublin, Ireland
| | | | - Peter McParland
- National Maternity Hospital, Dublin 2, Ireland.,University College Dublin Gynaecological Oncology Group (UCD-GOG), Mater Misericordiae University Hospital and St Vincent's University Hospital, Dublin, Ireland
| | | | - Shane Higgins
- National Maternity Hospital, Dublin 2, Ireland.,University College Dublin Gynaecological Oncology Group (UCD-GOG), Mater Misericordiae University Hospital and St Vincent's University Hospital, Dublin, Ireland
| | | | - Paul Downey
- National Maternity Hospital, Dublin 2, Ireland
| | | | | | | | - Tom Walsh
- Rotunda Hospital, Parnell Square, Dublin 1, Ireland
| | - Donal J O'Brien
- National Maternity Hospital, Dublin 2, Ireland.,Rotunda Hospital, Parnell Square, Dublin 1, Ireland
| | - Donal J Brennan
- University College Dublin Gynaecological Oncology Group (UCD-GOG), Mater Misericordiae University Hospital and St Vincent's University Hospital, Dublin, Ireland.,Rotunda Hospital, Parnell Square, Dublin 1, Ireland
| | - Ruaidhri McVey
- National Maternity Hospital, Dublin 2, Ireland.,Rotunda Hospital, Parnell Square, Dublin 1, Ireland
| | - Fionnuala M McAuliffe
- National Maternity Hospital, Dublin 2, Ireland.,University College Dublin Gynaecological Oncology Group (UCD-GOG), Mater Misericordiae University Hospital and St Vincent's University Hospital, Dublin, Ireland
| | - Jennifer Donnelly
- Department of UCD Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Dublin 2, Ireland
| | - Siobhan M Corcoran
- National Maternity Hospital, Dublin 2, Ireland.,University College Dublin Gynaecological Oncology Group (UCD-GOG), Mater Misericordiae University Hospital and St Vincent's University Hospital, Dublin, Ireland
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19
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Adu-Bredu TK, Rijken MJ, Nieto-Calvache AJ, Stefanovic V, Aryananda RA, Fox KA, Collins SL. A simple guide to ultrasound screening for placenta accreta spectrum for improving detection and optimizing management in resource limited settings. Int J Gynaecol Obstet 2023; 160:732-741. [PMID: 35900178 PMCID: PMC10086861 DOI: 10.1002/ijgo.14376] [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: 05/25/2022] [Accepted: 07/21/2022] [Indexed: 11/07/2022]
Abstract
Placenta accreta spectrum is a pregnancy complication associated with severe morbidity and maternal mortality especially when not suspected antenatally and appropriate management instigated. Women in resource-limited settings are more likely to face adverse outcomes due to logistic, technical, and resource inadequacies. Accurate prenatal imaging is an important step in ensuring good outcomes because it allows adequate preparation and an appropriate management approach. This article provides a simple three-step approach aimed at guiding clinicians and sonographers with minimal experience in placental accreta spectrum through risk stratification and basic prenatal screening for this condition both with and without Doppler ultrasound.
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Affiliation(s)
| | - Marcus J Rijken
- Julius Global Health, Julius Centre for Health Science and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Obstetrics and Gynecology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Albaro Jose Nieto-Calvache
- FundaciÓn Valle del Lili, Abnormally Invasive Placenta Clinic, Cali, Colombia.,Clinical Postgraduate Department, Universidad Icesi, Cali, Colombia
| | - Vedran Stefanovic
- Fetomaternal Medical Center, Department of Obstetrics and Gynecology, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland
| | - Rozi Aditya Aryananda
- Maternal - Fetal Medicine Division, Obstetrics and Gynecology Department, Dr Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Karin Anneliese Fox
- Division of Maternal - Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Sally L Collins
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK.,Fetal Medicine Unit, John Radcliffe Hospital, Oxford, UK
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20
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Sargent W, Gerry S, Collins SL. A Risk-Prediction Model for Placenta Accreta Spectrum Severity From Standardized Ultrasound Markers. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:512-519. [PMID: 36347659 DOI: 10.1016/j.ultrasmedbio.2022.09.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 06/16/2023]
Abstract
We aimed to generate a model to predict the risk of a woman having normal, abnormally adherent (AAP) or abnormally invasive placentation (AIP) based on the presence of recently codified ultrasound (US) markers and disease definitions of placenta accreta spectrum (PAS). We recruited women with anterior low-lying placenta or placenta previa and a history of previous caesarean delivery to a prospective cohort study. US markers of abnormal placentation were recorded on a standardized pro forma. The presence and International Federation of Gynecology and Obstetrics grade of PAS was evaluated clinically and histologically at delivery. Markers demonstrating a predictive relationship to PAS were incorporated into a logistic regression model. A total of 106 women were included, of whom 42 (40%) were normal, 24 (23%) had AAP and 40 (38%) had AIP. A model including just four key variables (loss of clear zone, abnormal placental lacunae, placental bulge and bladder wall interruption) was shown to reliably predict presence and severity of PAS, with an optimism-corrected C-index of 0.901. A simple model incorporating four US markers can predict likelihood and severity of PAS with high accuracy. This is the first time this has been demonstrated using the recently codified definitions of the US signs and disease definitions. Further work will see our model applied prospectively to a large patient cohort, ideally through a smartphone-based application, for external validation.
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Affiliation(s)
- Will Sargent
- Medical Sciences Division, University of Oxford, Oxford, UK.
| | - Stephen Gerry
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Sally L Collins
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK; Fetal Medicine Unit, John Radcliffe Hospital, Oxford, UK
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21
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Golbasi H, Bayraktar B, Golbasi C, Omeroglu I, Sever B, Adiyaman D, Kayhan Omeroglu S, Ekin A, Özeren M. Expected Versus Unexpected Delivery for Placenta Accreta Spectrum (PAS) Disorders with Same Team in Single Tertiary Center. Z Geburtshilfe Neonatol 2022; 226:391-398. [PMID: 36100249 DOI: 10.1055/a-1915-5832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To evaluate the maternal and neonatal outcomes of expected and unexpected pathologically proven placenta accreta spectrum (PAS) cases in a single multidisciplinary center. MATERIAL AND METHODS This was a retrospective cohort study of 92 PAS cases from January 2011 until September 2021. Only cases with histopathologically invasive placentation were included in the study. The cases diagnosed at the time of delivery were defined as unexpected PAS (uPAS) and those diagnosed antenatally as expected PAS (ePAS). Maternal and neonatal outcomes of both groups were compared. RESULTS Thirty-five (38%) of 92 cases were in the uPAS group. Placenta previa and high-grade PAS (percreata) were significantly higher in the ePAS group (p=0.028, p<0.001; respectively). The mean packed red blood cell transfusion was significantly higher in the uPAS group (p=0.030) but transfusions of other blood products were similar in the two groups. There was no significant difference in intraoperative complication rates between the two groups. Preterm delivery (<37 weeks) was significantly higher in the ePAS group (p<0.001), but there was no significant difference between the two groups in terms of adverse neonatal outcomes. CONCLUSIONS Our single center data show that although ePAS cases include more highly invasive PAS cases, maternal hemorrhagic morbidity is lower than uPAS cases. Reducing maternal morbidity in PAS cases can be achieved by increasing antenatal diagnosis.
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Affiliation(s)
- Hakan Golbasi
- University of Health Sciences Tepecik Training and Research Hospital, Department of Perinatology, Izmir, Turkey
| | - Burak Bayraktar
- University of Health Sciences Tepecik Training and Research Hospital, Department of Obstetrics and Gynecology, Izmir, Turkey
| | - Ceren Golbasi
- Tinaztepe University Faculty of Health Sciences, Department of Obstetrics and Gynecology, Izmir, Turkey
| | - Ibrahim Omeroglu
- University of Health Sciences Tepecik Training and Research Hospital, Department of Perinatology, Izmir, Turkey
| | - Baris Sever
- University of Health Sciences Tepecik Training and Research Hospital, Department of Perinatology, Izmir, Turkey
| | - Duygu Adiyaman
- University of Health Sciences Tepecik Training and Research Hospital, Department of Perinatology, Izmir, Turkey
| | - Seyda Kayhan Omeroglu
- University of Health Sciences Suat Seren Chest Diseases and Surgery Training and Research Hospital, Department of Anesthesia and Reanimation, Izmir, Turkey
| | - Atalay Ekin
- University of Health Sciences Tepecik Training and Research Hospital, Department of Perinatology, Izmir, Turkey
| | - Mehmet Özeren
- University of Health Sciences Tepecik Training and Research Hospital, Department of Perinatology, Izmir, Turkey
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22
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Predicting Placenta Accreta Spectrum Disorders in a Cohort of Pregnant Patients in the North-East Region of Romania-Diagnostic Accuracy of Ultrasound and Magnetic Resonance Imaging. Diagnostics (Basel) 2022; 12:diagnostics12092130. [PMID: 36140531 PMCID: PMC9497951 DOI: 10.3390/diagnostics12092130] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/21/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Placenta accreta spectrum (PAS) disorders are associated with high mortality and morbidity due to postpartum hemorrhage, hysterectomy, and organ injury, and a multidisciplinary team is required for an individualized case management. In this study, we assessed the diagnostic and prognostic accuracy of the most important ultrasonographic (US) and magnetic resonance imagining (MRI) markers for PAS disorders. Material and Methods: The study included 39 adult pregnant patients with at least one previous cesarean delivery and both US and MRI investigations for placenta previa evaluated at the tertiary maternity hospital ‘Cuza Voda’, Iasi, between 2019 and 2021. The following US signs were evaluated: intra-placental lacunae, loss of the retroplacental hypoechoic zone, myometrial thinning < 1 mm, bladder wall interruption, placental bulging, bridging vessels, and the hypervascularity of the uterovesical or retroplacental space. The MRI signs that were evaluated were intra-placental dark T2 bands, placental bulging, loss of the retroplacental hypointense line on T2 images, myometrial thinning, bladder wall interruption, focal exophytic placental mass, and abnormal vascularization of the placental bed. Results: The US and MRI signs analyzed in our study presented adequate sensitivities and specificities for PAS, but no sign proved to be a useful predictor by itself. The presence of three or more US markers for accretion was associated with a sensitivity of 84.6.6% and a specificity of 92.3% (p < 0.001). The presence of three or more MRI signs supplemented these results and were associated with a sensitivity of 92.3% and a specificity of 61.5% for predicting PAS (p < 0.001). Moreover, US and MRI findings were correlated with FIGO grading and severity of PAS. Conclusions: Even though no US or MRI finding alone can predict PAS with high sensitivity and specificity, our study proves that the presence of three or more imagistic signs could significantly increase the diagnostic accuracy of this condition. Furthermore, US and MRI could be useful tools for evaluating prognostic and perinatal planning.
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23
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Bartels HC, Horsch A, Cooney N, Brennan DJ, Lalor JG. Living beyond placenta accreta spectrum: parent's experience of the postnatal journey and recommendations for an integrated care pathway. BMC Pregnancy Childbirth 2022; 22:397. [PMID: 35538441 PMCID: PMC9092796 DOI: 10.1186/s12884-022-04726-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Placenta Accreta Spectrum is associated with significant clinical maternal morbidity and mortality, which has been extensively described in the literature. However, there is a dearth of research on the lived experiences of pregnant people and their support partners. The aim of this study is to describe living beyond a pregnancy and birth complicated by PAS for up to four years postpartum. Participants experiences inform the development of an integrated care pathway of family centered support interventions. METHODS An Interpretative Phenomenological Analysis approach was applied to collect data through virtual interviews over a 3-month period from February to April 2021. Twenty-nine participants shared their stories; six people with a history of PAS and their support partners were interviewed together (n = 12 participants), six were interviewed separately (n = 12 participants), and five were interviewed without their partner. Pregnant people were eligible for inclusion if they had a diagnosis of PAS within the previous 5 years. This paper focuses on the postnatal period, with data from the antenatal and intrapartum periods described separately. RESULTS One superordinate theme "Living beyond PAS" emerged from interviews, with 6 subordinate themes as follows; "Living with a different body", "The impact on relationships", "Coping strategies", "Post-traumatic growth", "Challenges with normal care" and recommendations for "What needs to change". These themes informed the development of an integrated care pathway for pregnant people and their support partners to support them from diagnosis up to one year following the birth. CONCLUSION Parents described the challenges of the postnatal period in terms of the physical and emotional impact, and how some were able to make positive life changes in the aftermath of a traumatic event. An integrated care pathway of simple supportive interventions, based on participant recommendations, delivered as part of specialist multidisciplinary team care may assist pregnant people and their support partners in alleviating some of these challenges.
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Affiliation(s)
- Helena C Bartels
- Dept of UCD Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Holles Street, Dublin 2, Ireland
| | - Antje Horsch
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland.,Woman-Mother-Child Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Naomi Cooney
- Placenta Accreta Ireland, Patient Support and Advocacy Group, Dublin, Ireland
| | - Donal J Brennan
- Dept of UCD Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Holles Street, Dublin 2, Ireland
| | - Joan G Lalor
- School of Nursing and Midwifery, Trinity College Dublin, Dublin 2, Ireland.
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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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Hong S, Le Y, Lio KU, Zhang T, Zhang Y, Zhang N. Performance comparison of ultrasonography and magnetic resonance imaging in their diagnostic accuracy of placenta accreta spectrum disorders: a systematic review and meta-analysis. Insights Imaging 2022; 13:50. [PMID: 35316430 PMCID: PMC8940971 DOI: 10.1186/s13244-022-01192-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 02/23/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Accurate prenatal diagnosis of placenta accrete spectrum disorder (PAS) remains a challenge, and the reported diagnostic value of ultrasonography (US) and magnetic resonance imaging (MRI) varies widely. This study aims to systematically evaluate the diagnostic accuracy of US as compared with MRI in the detection of PAS within the identical patient population. METHODS Medline, EMBASE, Google scholar and Cochrane library were searched. Pooled sensitivity, specificity, diagnostic odds ratio (DOR) and the area under the summary receiver operating characteristic (SROC) curve were calculated. Subgroup analysis was also performed to elucidate the heterogeneity of results. RESULTS A total of 18 articles comprising 861 pregnancies were included in the study. The overall diagnostic accuracy of US for identification of PAS was as follows: sensitivity [0.90 (0.86-0.93)], specificity [0.83 (0.79-0.86)], DOR [39.5 (19.6-79.7)]. The overall diagnostic accuracy of MRI for identification of PAS was as follows: sensitivity [0.89 (0.85-0.92)], specificity [0.87 (0.83-0.89)], DOR [37.4 (17.0-82.3)]. The pooled sensitivity (p = 0.808) and specificity (p = 0.413) between US and MRI are not significantly different. SROC analysis revealed that there was no statistical difference (p = 0.552) in US and MRI for the overall predictive accuracy of PAS. Furthermore, in the subgroup analysis of between retrospective and prospective studies, between earlier and most recent studies, there was no statistical difference (p > 0.05) in diagnostic accuracy of US and MRI for the detection of PAS. CONCLUSIONS Both ultrasonography (US) and magnetic resonance imaging (MRI) showed comparable accuracy in the prenatal diagnosis of placenta accrete spectrum disorder (PAS). Routine employment of MRI with relatively high expense in the prenatal identification of PAS should not be recommended.
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Affiliation(s)
- Shibin Hong
- Department of Obstetrics and Gynecology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Pudong New District, Shanghai, 200127, China.,Shanghai Key Laboratory of Gynecologic Oncology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Shanghai, 200127, China
| | - Yiping Le
- Department of Obstetrics and Gynecology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Pudong New District, Shanghai, 200127, China
| | - Ka U Lio
- Department of Medicine, Temple University Hospital, Lewis Katz School of Medicine at Temple University, 3401 N Broad St, Philadelphia, PA, 19140, USA
| | - Ting Zhang
- Department of Obstetrics and Gynecology, Hainan Women and Children's Medical Center, Changbin Road, Haikou City, 570312, Hainan Province, China
| | - Yu Zhang
- Department of Obstetrics and Gynecology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Pudong New District, Shanghai, 200127, China. .,Shanghai Key Laboratory of Gynecologic Oncology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Shanghai, 200127, China.
| | - Ning Zhang
- Department of Obstetrics and Gynecology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Pudong New District, Shanghai, 200127, China. .,Shanghai Key Laboratory of Gynecologic Oncology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Shanghai, 200127, China.
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A Team Approach to Peripartum Hemorrhage Control Incorporating Resuscitative Endovascular Balloon Occlusion of the Aorta. J Trauma Acute Care Surg 2022; 93:e89-e94. [PMID: 35319543 DOI: 10.1097/ta.0000000000003612] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chao WT, Ke HH, Shen SH, Yeh CC, Wang PH, Ho CM, Horng HC. A theoretical analysis of prophylactic common iliac arterial occlusion for potential massive bleeding during cesarean delivery: Decision-making considerations — A 2-year retrospective study. Taiwan J Obstet Gynecol 2022; 61:282-289. [DOI: 10.1016/j.tjog.2022.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2021] [Indexed: 10/18/2022] Open
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Placenta Accreta Spectrum Disorder Complicated with Endometriosis: Systematic Review and Meta-Analysis. Biomedicines 2022; 10:biomedicines10020390. [PMID: 35203599 PMCID: PMC8962380 DOI: 10.3390/biomedicines10020390] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/24/2022] [Accepted: 02/03/2022] [Indexed: 02/06/2023] Open
Abstract
This study aimed to assess the relationship between placenta accreta spectrum disorder (PASD) and endometriosis. The relationships among pregnancy, assisted reproductive technology (ART), placenta previa, ART-conceived pregnancy and PASD were also determined. A systematic literature review was conducted using multiple computerized databases. Forty-eight studies (1990–2021) met the inclusion criteria. According to the adjusted pooled analysis (n = 3), endometriosis was associated with an increased prevalence of PASD (adjusted odds ratio [OR] 3.39, 95% confidence interval [CI] 1.96–5.87). In the included studies, the ART rate ranged from 18.2% to 37.2% for women with endometriosis. According to the adjusted pooled analysis, women who used ART were more likely to have placenta previa (n = 13: adjusted OR 2.96, 95%CI, 2.43–3.60) and PASD (n = 4: adjusted OR 3.54, 95%CI 1.86–6.76) than those who did not use ART. According to the sensitivity analysis using an unadjusted analysis accounting for the type of ART, frozen embryo transfer (ET) was associated with an increased risk of PASD (n = 4: OR 2.79, 95%CI, 1.22−6.37) compared to fresh ET. Endometriosis may be associated with an increased rate of PASD. Women with placenta previa complicated with endometriosis who conceived using frozen ET may be a high risk for PASD.
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Hong L, Chen A, Chen J, Li X, Zhuang W, Shen Y, Dai Q, Zhang L. The clinical evaluation of IIA balloon occlusion in caesarean delivery for patients with PAS: a retrospective study. BMC Pregnancy Childbirth 2022; 22:103. [PMID: 35123442 PMCID: PMC8817511 DOI: 10.1186/s12884-022-04434-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 01/27/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Objective
The aim of this study is the clinical evaluation of IIA balloon occlusion in the caesarean delivery in patients with a diagnosis of placenta accreta spectrum.
Background
High incidence of cesarean section leads to the increasing incidence of placenta accreta spectrum (PAS), which contributes to serious consequences such as severe obstetric postpartum hemorrhage or even maternal mortality.
Methods
Fifty-eight patients with a diagnosis of PAS were retrospectively reviewed. The balloon group consisted of 23 patients, who underwent a caesarean delivery with internal iliac artery occlusion. 35 patients were in the control group, who had a standard caesarean delivery. The primary outcomes were estimated blood loss (EBL). The secondary outcomes were cesarean hysterectomy, blood transferring volume, operating time, intraoperative hemostatic approaches, surgical complications, balloon catheter–related complications, length of maternal stay, cost of hospitalization, and neonatal outcomes.
Results
No difference was observed in estimated blood loss (EBL), blood transferring percentages and volume, additional measures to secure hemostasis, surgical complications, hospital stay postoperatively and newborn outcomes. More than 40% of the balloon group underwent hysterectomy because of uncontrollable postpartum bleeding (10 [43.48%] vs. 11 [31.43%], P=0.350). Complications related to occlusion of IIA did not occur. The duration of the surgery of the balloon group was significantly longer than that of the control group (123.52 min±74.76 versus 89.17±48.68, P=0.038), and the total hospitalization cost was also significantly higher than that of the control group (45116.67±9358.67 yuan versus 30615.41±11587.44 yuan, P=0.000).
Conclusion
It does not permit to draw final conclusions for us on the effectiveness of the balloons IIA given the heterogeneity of selection of cases undergoing the procedures in the retrospective design. However, it is possible that IIA balloon occlusion may contribute to limiting intraoperative blood loss in more severe cases, particularly those undergoing peripartum hysterectomy.
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Castro PT, Araujo Júnior E, Lopes J, Ribeiro G, Werner H. Placenta accreta: Virtual reality from 3D images of magnetic resonance imaging. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:119-120. [PMID: 34797577 DOI: 10.1002/jcu.23098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/05/2021] [Accepted: 11/10/2021] [Indexed: 06/13/2023]
Abstract
Image from a fragment of the video of virtual reality model evaluating a case of placenta accreta spectrum and placental invasion. In this image, the placenta (purple) goes through the uterus and reaches the bladder muscle and mucosa (pink).
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Affiliation(s)
- Pedro Teixeira Castro
- Department of Fetal Medicine, Clínica de Diagnóstico por Imagem (CDPI), Rio de Janeiro, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
- Medical course, Municipal University of São Caetano do Sul (USCS), São Paulo, Brazil
| | - Jorge Lopes
- Department of Arts and Design, Pontifícia Universidade Católica (PUC-Rio), Rio de Janeiro, Brazil
| | - Gerson Ribeiro
- Department of Arts and Design, Pontifícia Universidade Católica (PUC-Rio), Rio de Janeiro, Brazil
| | - Heron Werner
- Department of Fetal Medicine, Clínica de Diagnóstico por Imagem (CDPI), Rio de Janeiro, Brazil
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Expert opinion: Stepwise ultrasound assessment of suspected abnormal placental invasion using 2D, doppler and 3D imaging. Eur J Obstet Gynecol Reprod Biol 2021; 270:181-189. [DOI: 10.1016/j.ejogrb.2021.11.425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/12/2021] [Accepted: 11/19/2021] [Indexed: 11/22/2022]
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Matsuzaki S, Takiuchi T, Kanagawa T, Matsuzaki S, Lee M, Maeda M, Endo M, Kimura T. Maternal and Fetal Outcomes after Prior Mid-Trimester Uterine Rupture: A Systematic Review with Our Experience. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57121294. [PMID: 34946239 PMCID: PMC8704285 DOI: 10.3390/medicina57121294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 12/23/2022]
Abstract
Background and Objectives: Since spontaneous uterine rupture in the mid-trimester is rare, maternal and fetal outcomes in subsequent pregnancies remain unclear. Therefore, this study aimed to examine the maternal and fetal outcomes of subsequent pregnancies after prior mid-trimester uterine rupture. Materials and Methods: A systematic review using PubMed, the Cochrane Central Register of Controlled Trials, and Scopus until 30 September 2021, was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The studies that clarified the maternal and fetal outcomes after prior mid-trimester uterine rupture and our case (n = 1) were included in the analysis. Results: Among the eligible cases, there were five women with eight subsequent pregnancies after prior mid-trimester uterine rupture. The timing of prior mid-trimester uterine rupture ranged from 15 to 26 weeks of gestation. The gestational age at delivery in subsequent pregnancies was 23–38 gestational weeks. Among the included cases (n = 8), those involving prior mid-trimester uterine rupture appeared to be associated with an increased prevalence of placenta accreta spectrum (PAS) (n = 3, 37.5%) compared with those involving term uterine rupture published in the literature; moreover, one case exhibited recurrent uterine rupture at 23 weeks of gestation (12.5%). No maternal deaths have been reported in subsequent pregnancies following prior mid-trimester uterine rupture. Fetal outcomes were feasible, except for one pregnancy with recurrent mid-trimester uterine rupture at 23 weeks of gestation, whose fetus was alive complicated by cerebral palsy. Conclusions: Our findings suggest that clinicians should be aware of the possibility of PAS and possible uterine rupture in pregnancies after prior mid-trimester uterine rupture. Further case studies are warranted to assess maternal and fetal outcomes in pregnancies following prior mid-trimester prior uterine rupture.
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Affiliation(s)
- Shinya Matsuzaki
- Department of Gynecology, Osaka International Cancer Institute, Osaka 541-8567, Japan; (S.M.); (M.M.)
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan;
| | - Tsuyoshi Takiuchi
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan;
- Department of Clinical Genomics, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
- Correspondence: ; Tel.: +81-6-6879-3355; Fax: +81-6-6879-3359
| | - Takeshi Kanagawa
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi 594-1101, Japan;
| | - Satoko Matsuzaki
- Osaka General Medical Center, Department of Obstetrics and Gynecology, Osaka 558-8558, Japan;
| | - Misooja Lee
- Department of Obstetrics and Gynecology, Shibata Pediatrics Clinic, San Francisco, CA 94118, USA;
| | - Michihide Maeda
- Department of Gynecology, Osaka International Cancer Institute, Osaka 541-8567, Japan; (S.M.); (M.M.)
| | - Masayuki Endo
- Department of Health Science, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan;
| | - Tadashi Kimura
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan;
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Gao Y, Gao X, Cai J, Han F, Xu G, Zhang X, Zhang T, Yu L. Prediction of placenta accreta spectrum by a scoring system based on maternal characteristics combined with ultrasonographic features. Taiwan J Obstet Gynecol 2021; 60:1011-1017. [PMID: 34794730 DOI: 10.1016/j.tjog.2021.09.011] [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] [Accepted: 03/25/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE In order to create a comprehensive scoring system based on maternal characteristics and ultrasonographic features for predicting placenta accreta spectrum (PAS). MATERIALS AND METHODS This was a retrospective review of pregnant women who underwent routine ultrasound examination in the third trimester of pregnancy from January 2014 to November 2018 were used as a training set to establish the scoring system for PAS prediction while those who underwent examination from January 2019 to December 2019 served as a validation set.. Maternal characteristics including maternal age, parity, previous vaginal deliveries, previous curettage, previous cesarean section (CS), history of hypertension and diabetes mellitus, prenatal body mass index (BMI) were recorded. Ultrasonographic features including abnormal placental lacunae, subplacental hypervascularity, myometrial thinning, placental bulge, bladder wall interruption, location of placenta, placenta previa (yes or not) were recorded. Multivariate analysis was applied to analyze independent risk factors and assess the predictive power of selected parameters predicting PAS. Receiver operating characteristics (ROC) curve was used to evaluate the diagnosis power. RESULTS Parity, previous curettage and CS were independent risk factors. The best comprehensive scoring system was established as follow: the number of abnormal lacunae ≥3, 2 points; lacuna maximum dimension ≥2 cm, 5 points; subplacental hypervascularity (rich), 1 point; subplacental hypervascularity (extremely rich and disordered), 3 points; bladder wall interruption, 9 points; placental bulge, 9 points; placenta previa, 8 points; anterior placenta, 1 point; previous CS ≥ 1, 1 point; parity ≥ 4, 3 point; previous abortions ≥ 2, 1 point. The area under the ROC curve of the scoring system diagnosing PAS was 0.925. Sensitivity and specificity were 83.3% and 85.7%, respectively. Cross-validation for our model showed that sensitivity, specificity, positive predictive value and negative predictive value of the model in diagnosis of PAS were 82.6%, 81.8%, 82.6% and 81.8%, respectively. Diagnosis of 37 cases were consistent with the "gold standard", and the coincidence rate was 82.2% (37/45). CONCLUSION The comprehensive scoring system established in this study can effectively diagnose PAS.
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Affiliation(s)
- Yisu Gao
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, PR China.
| | - Xuejiao Gao
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, PR China.
| | - Jing Cai
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, PR China.
| | - Fang Han
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, PR China.
| | - Guixiang Xu
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, PR China.
| | - Xuan Zhang
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, PR China.
| | - Ting Zhang
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, PR China.
| | - Lili Yu
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, PR China.
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Evaluation of the diagnostic accuracy of a combination of first-trimester ultrasound and maternal demographic characteristics for detecting abnormally invasive placenta. Eur J Obstet Gynecol Reprod Biol 2021; 268:1-6. [PMID: 34788719 DOI: 10.1016/j.ejogrb.2021.11.006] [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: 09/14/2021] [Revised: 10/20/2021] [Accepted: 11/02/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of present study was to evaluate the diagnostic accuracy of using a combination of a first-trimester ultrasound and the maternal demographic characteristics in detecting abnormally invasive placenta (AIP). STUDY DESIGN This prospective case-control study comprised 540 women who meet the inclusion criteria and who were included in the final analysis. Patients scored points based on a range between 0 and 13 for the ultrasonographic and clinical findings within first trimester. The primary outcome of the study was whether placenta accreta, increta, and percreta could be predicted early in pregnancy. RESULTS The cutoff value of 5.5 provided a sensitivity of 100% and a specificity of 88% and the diagnostic odds ratio (DOR at 95% confidence interval [CI]) was 208 (12-3543), at 95%CI) was 0, and the positive likelihood ratio (LR + at 95%CI) was 8.25 for placenta percreta. The cutoff value of 6.5 provided a sensitivity of 92% and a specificity of 93% and DOR at 95%CI was 201.5 (25.5-1583.1), LR- at 95%CI was 0.08, and LR + at 95%CI was 15.32 for placenta percreta. The cutoff value of 4.5 provided a sensitivity of 100% and a specificity of 90% and DOR at 95%CI was 615 (37-10207), LR- at 95%CI was 0, and LR + at 95%CI was 11.7 for accreta and increta, respectively. The cutoff value of 5.5 provided a sensitivity of 87% and a specificity of 92% and DOR at 95%CI was 86.8 (28.9-260.8), LR- at 95%CI was 0.14, and LR + at 95%CI was 11.7 for placenta accreta and increta, respectively. CONCLUSION The results of the present study indicated that this novel scoring provided high diagnostic accuracy for detecting all types of AIP during the first trimester.
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Einerson BD, Watt MH, Sartori B, Silver R, Rothwell E. Lived experiences of patients with placenta accreta spectrum in Utah: a qualitative study of semi-structured interviews. BMJ Open 2021; 11:e052766. [PMID: 34732490 PMCID: PMC8572396 DOI: 10.1136/bmjopen-2021-052766] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To describe the lived experience of patients undergoing diagnosis and treatment of placenta accreta spectrum (PAS). DESIGN Qualitative study of semi-structured interviews. A content analysis was used to analyse interview data using a consistent set of codes to designate data segments that contain similar material. Codes were analysed and grouped based on thematic similarities. Thematic results were systematically reviewed, verified and audited to address trustworthiness and rigour of the data and analysis. SETTING A single PAS programme in Utah, USA, from 2017 to 2020. PARTICIPANTS Patients with PAS during the study period were eligible. Those experiencing fetal demise or termination were excluded. Of 25 patients contacted at random, 17 agreed to participate in interviews. Those included were predominantly non-Hispanic white, highly parous, with average age of 34.7 years. RESULTS The lived experiences of patients with PAS emerged across the time continuum from diagnosis, pregnancy, birth, to postpartum care and recovery. Themes common across the care continuum were: the emotional burden of diagnosis and management; fear and uncertainty related to health outcomes; and lack of autonomy and medical helplessness related to medical decision-making. Many patients experienced birth-related trauma, mourned the loss of future fertility and were dissatisfied with the lack of options for treatment for this serious pregnancy complication. CONCLUSIONS Patients undergoing diagnosis and treatment for PAS often experienced care that conflicted with their goals for pregnancy and birth. Clinical care for PAS would benefit from interventions aiming to engage patients and providers in shared decision-making and systems designed to address the social, psychological and emotional needs of patients with PAS.
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Affiliation(s)
- Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
| | - Melissa H Watt
- Department of Population Health Sciences, University of Utah Health, Salt Lake City, Utah, USA
| | - Brittney Sartori
- College of Nursing, University of Utah Health, Salt Lake City, Utah, USA
| | - Robert Silver
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
| | - Erin Rothwell
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
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Matsuzaki S, Mandelbaum RS, Sangara RN, McCarthy LE, Vestal NL, Klar M, Matsushima K, Amaya R, Ouzounian JG, Matsuo K. Trends, characteristics, and outcomes of placenta accreta spectrum: a national study in the United States. Am J Obstet Gynecol 2021; 225:534.e1-534.e38. [PMID: 33894149 DOI: 10.1016/j.ajog.2021.04.233] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/17/2021] [Accepted: 04/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although an infrequent occurrence, the placenta can adhere abnormally to the gravid uterus leading to significantly high maternal morbidity and mortality during cesarean delivery. Contemporary national statistics related to a morbidly adherent placenta, referred to as placenta accreta spectrum, are needed. OBJECTIVE This study aimed to examine national trends, characteristics, and perioperative outcomes of women who underwent cesarean delivery for placenta accreta spectrum in the United States. STUDY DESIGN This is a population-based retrospective, observational study querying the National Inpatient Sample. The study cohort included women who underwent cesarean delivery from October 2015 to December 2017 and had a diagnosis of placenta accreta spectrum. The main outcome measures were patient characteristics and surgical outcomes related to placenta accreta spectrum assessed by the generalized estimating equation on multivariable analysis. The temporal trend of placenta accreta spectrum was also assessed by linear segmented regression with log transformation. RESULTS Of 2,727,477 cases who underwent cesarean delivery during the study period, 8030 (0.29%) had the diagnosis of placenta accreta spectrum. Placenta accreta was the most common diagnosis (n=6205, 0.23%), followed by percreta (n=1060, 0.04%) and increta (n=765, 0.03%). The number of placenta accreta spectrum cases increased by 2.1% every quarter year from 0.27% to 0.32% (P=.004). On multivariable analysis, (1) patient demographics (older age, tobacco use, recent diagnosis, higher comorbidity, and use of assisted reproductive technology), (2) pregnancy characteristics (placenta previa, previous cesarean delivery, breech presentation, and grand multiparity), and (3) hospital factors (urban teaching center and large bed capacity hospital) represented the independent characteristics related to placenta accreta spectrum (all, P<.05). The median gestational age at cesarean delivery was 36 weeks for placenta accreta and 34 weeks for both placenta increta and percreta vs 39 weeks for non-placenta accreta spectrum cases (P<.001). On multivariable analysis, cesarean delivery complicated by placenta accreta spectrum was associated with increased risk of any surgical morbidities (78.3% vs 10.6%), Centers for Disease Control and Prevention-defined severe maternal morbidity (60.3% vs 3.1%), hemorrhage (54.1% vs 3.9%), coagulopathy (5.3% vs 0.3%), shock (5.0% vs 0.1%), urinary tract injury (8.3% vs 0.2%), and death (0.25% vs 0.01%) compared with cesarean delivery without placenta accreta spectrum. When further analyzed by subtype, cesarean delivery for placenta increta and percreta was associated with higher likelihood of hysterectomy (0.4% for non-placenta accreta spectrum, 45.8% for accreta, 82.4% for increta, 78.3% for percreta; P<.001) and urinary tract injury (0.2% for non-placenta accreta spectrum, 5.2% for accreta, 11.8% for increta, 24.5% for percreta; P<.001). Moreover, women in the placenta increta and percreta groups had markedly increased risks of surgical mortality compared with those without placenta accreta spectrum (increta, odds ratio, 19.9; and percreta, odds ratio, 32.1). CONCLUSION Patient characteristics and outcomes differ across the placenta accreta spectrum subtypes, and women with placenta increta and percreta have considerably high surgical morbidity and mortality risks. Notably, 1 in 313 women undergoing cesarean delivery had a diagnosis of placenta accreta spectrum by the end of 2017, and the incidence seems to be higher than reported in previous studies.
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Affiliation(s)
- Shinya Matsuzaki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Rachel S Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Rauvynne N Sangara
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Lauren E McCarthy
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Nicole L Vestal
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Rodolfo Amaya
- Department of Anesthesiology, University of Southern California, Los Angeles, CA
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA.
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Shih JC, Kang J, Tsai SJ, Lee JK, Liu KL, Huang KY. The "rail sign": an ultrasound finding in placenta accreta spectrum indicating deep villous invasion and adverse outcomes. Am J Obstet Gynecol 2021; 225:292.e1-292.e17. [PMID: 33744177 DOI: 10.1016/j.ajog.2021.03.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 03/10/2021] [Accepted: 03/12/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Ultrasound has demonstrated a high accuracy in the prenatal diagnosis of placenta accreta spectrum. However, it is not known whether ultrasound findings can pinpoint the depths of villous invasion, recommend surgical strategies, and predict clinical outcomes. OBJECTIVE We described an ultrasound descriptor for the placenta accreta spectrum and investigated whether it can predict the severity of villous invasion and clinical outcomes. STUDY DESIGN The patients with placenta accreta spectrum in this retrospective cross-sectional study were diagnosed and managed in our hospital from 2002 to 2017. The placenta, with overlying myometrium and bladder, was mapped with color Doppler sonography while the patient's bladder was full. A "rail sign" was defined as 2 parallel neovascularizations depicted by color Doppler sonography over the uterovesical junction and bladder mucosa, with interconnecting bridging vessels perpendicular to both. The patients received serial ultrasound examinations and surgery at our hospital. An unpaired t test and Pearson chi-square test compared the pathology subtypes, surgical strategies, and clinical outcomes in patients with or without a rail sign. RESULTS We enrolled 133 consecutive cases of placenta accreta spectrum confirmed either by surgical inspection or pathology examination. Patients with a rail sign had a significantly higher risk of an abnormally invasive placenta (placenta increta or placenta percreta) than those patients without a rail sign (83.3% [60 of 72] vs 27.9% [17 of 61]; odds ratio, 12.94; P<.001). In addition, patients with a rail sign had a higher probability of perioperative approaches, including preoperative vascular control (58.3% [42 of 72] vs 21.3% [13 of 61]; odds ratio, 5.17; P<.001) and uterine artery embolization (34.7% [25 of 72] vs 11.5% [7 of 61]; odds ratio, 4.1; P=.0002]. Furthermore, patients with a rail sign carried a higher risk of adverse clinical outcomes than patients without a rail sign, such as blood transfusion (80.6% [58 of 72] vs 36.1% [22 of 61]; odds ratio, 7.34; P<.001], admission to the intensive care unit (33.3% [24 of 72] vs 16.4% [10 of 61]; odds ratio, 2.55; P=.026), hysterectomy (75% [54 of 72] vs 24.6% [15 of 61]; odds ratio, 9.2; P<.001), and bladder invasion (16.7% [12 of 72] vs 4.9% [3 of 61]; odds ratio, 3.86; P=.033). Notably, the negative predictive value of bladder invasion was 95.1%, indicating a high confidence to reject bladder invasion while the rail sign was negative. When the rail sign was used as a screening test, the positive likelihood ratio of predicting deep villous invasion was 3.64 and correlated with an increased probability of 20% to 25%. Patients with a rail sign also had a greater blood loss (2944±2748 mL vs 1530±1895 mL; P<.001) and a longer hospital stay (11.9±10.9 days vs 8.6±7.1 days; P=.036) than patients without a rail sign. CONCLUSION A "rail sign" depicted by color Doppler sonography correlates with deeper villous invasion, additional perioperative approaches, and more adverse outcomes.
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Soleymani majd H, Collins SL, Addley S, Weeks E, Chakravarti S, Halder S, Alazzam M. The modified radical peripartum cesarean hysterectomy (Soleymani-Alazzam-Collins technique): a systematic, safe procedure for the management of severe placenta accreta spectrum. Am J Obstet Gynecol 2021; 225:175.e1-175.e10. [PMID: 33716074 DOI: 10.1016/j.ajog.2021.03.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The prevalence of placenta accreta spectrum is rising worldwide. The severe end of the spectrum where the placenta has invaded other organs is fortunately rare, however, few surgical techniques for such a complex hysterectomy have been described in the literature. OBJECTIVE This study aimed to describe a stepwise, systematic technique for radical cesarean hysterectomy for placenta accreta spectrum to investigate outcomes for women with severe, invasive placenta accreta spectrum who were hysterectomized using this technique. STUDY DESIGN This was a retrospective cohort study undertaken at a large UK tertiary referral center. A total of 24 cases of elective primary cesarean hysterectomy with a confirmed intrapartum diagnosis of severe percreta (Federation of Gynecology and Obstetrics grades 3b and 3c) were identified between 2011 and 2020. Among those cases, 16 had standard care (surgical technique dependent on surgeon's preference), and 8 had a radical peripartum hysterectomy using the Soleymani-Alazzam-Collins technique as described. Nonparametric testing was used because of sample size. RESULTS The Soleymani-Alazzam-Collins technique resulted in significantly less blood loss (P=.032), more transverse incisions (P=.009), and less intensive care unit admissions (P=.046). Furthermore, there was no significant difference in theater time. CONCLUSION The Soleymani-Alazzam-Collins technique demonstrated a significant improvement in outcomes for women with severe placenta accreta spectrum, without increasing surgical time.
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Adu-Bredu TK, Owusu-Bempah A, Collins S. Accurate prenatal discrimination of placenta accreta spectrum from uterine dehiscence is necessary to ensure optimal management. BMJ Case Rep 2021; 14:14/7/e244286. [PMID: 34244192 DOI: 10.1136/bcr-2021-244286] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Uterine scar dehiscence with underlying placenta is often misdiagnosed as placenta accreta spectrum both prenatally and intraoperatively due to the absence of myometrial tissue in the area. Misdiagnosis generates obstetric anxiety and results in overtreatment which carries a risk of iatrogenic injury. We present a case of the antenatal diagnosis of uterine dehiscence in a 36-year-old woman with a history of two caesarean deliveries and a low-lying placenta. We further describe the sonographic features useful for differentiating this condition from placenta accreta spectrum in instances where the placenta lies under an area of full thickness uterine scar dehiscence.
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Affiliation(s)
| | - Atta Owusu-Bempah
- Obstetrics and Gynaecology Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Sally Collins
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
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Pregnancy-Related Hysterectomy for Peripartum Hemorrhage: A Literature Narrative Review of the Diagnosis, Management, and Techniques. BIOMED RESEARCH INTERNATIONAL 2021; 2021:9958073. [PMID: 34307683 PMCID: PMC8282389 DOI: 10.1155/2021/9958073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/21/2021] [Indexed: 12/14/2022]
Abstract
Postpartum hemorrhage is a life-threatening situation, in which hysterectomy can be performed to prevent maternal death. However, it is associated with high rates of maternal morbidity and mortality and permanent infertility. The incidence of pregnancy-related hysterectomy varies across countries, but its main indications are the following: uterine atony and placenta spectrum (PAS) disorders. PAS disorder prevalence is rising during the last years, mainly due to the increased number of cesarean sections. As a result, obstetricians should be aware of the difficulties of this emergent condition and improve its accurate antenatal diagnosis rates, as well as its modern management strategies. Of course, special skills are required during a pregnancy-related hysterectomy, so these patients should be referred to centers of excellence in antenatal care, where a multidisciplinary team approach is followed. This study is a narrative review of the literature of the last 5 years (PubMed, Cochrane) regarding postpartum hemorrhage to offer obstetricians up-to-date knowledge on this pregnancy-related life-threatening issue. However, there is a lack of available high-quality data, because most published papers are retrospective case series or observational cohorts.
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Advances in anesthetic and obstetric management of patients with placenta accreta spectrum. Curr Opin Anaesthesiol 2021; 34:260-268. [PMID: 33935172 DOI: 10.1097/aco.0000000000000985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW The incidence of placenta accreta spectrum is increasing and it is a leading cause of peripartum hysterectomy and massive postpartum hemorrhage. The purpose of the present article is to provide a contemporary overview of placenta accreta spectrum pertinent to the obstetric anesthesiologist. RECENT FINDINGS Recent changes in the terminology used to report invasive placentation were proposed to clarify diagnostic criteria and guidelines for use in clinical practice. Reduced morbidity is associated with scheduled preterm delivery in a center of excellence using a multidisciplinary team approach. Neuraxial anesthesia as a primary technique is increasingly being used despite the known risk of major bleeding. The use of viscoelastic testing and endovascular interventions may aid hemostatic resuscitation and improve outcomes. SUMMARY Accurate diagnosis and early antenatal planning among team members are essential. Obstetric anesthesiologists should be prepared to manage a massive hemorrhage, transfusion, and associated coagulopathy. Increasingly, viscoelastic tests are being used to assess coagulation status and the ability to interpret these results is required to guide the transfusion regimen. Balloon occlusion of the abdominal aorta has been proposed as an intervention that could improve outcomes in women with placenta accreta spectrum, but high-quality safety and efficacy data are lacking.
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Nieto-Calvache AJ, Palacios-Jaraquemada JM, Osanan G, Cortes-Charry R, Aryananda RA, Bangal VB, Slaoui A, Abbas AM, Akaba GO, Joshua ZN, Vergara Galliadi LM, Nieto-Calvache AS, Sanín-Blair JE, Burgos-Luna JM. Lack of experience is a main cause of maternal death in placenta accreta spectrum patients. Acta Obstet Gynecol Scand 2021; 100:1445-1453. [PMID: 33896009 DOI: 10.1111/aogs.14163] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/15/2021] [Accepted: 04/18/2021] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Placenta accreta spectrum (PAS) is a serious condition with a mortality as high as 7%. However, the factors associated with this type of death have not been adequately described, with an almost total lack of publications analyzing the determining factors of death in this disease. The aim of our work is to describe the causes of death related to PAS and to analyze the associated diagnosis and treatment problems. MATERIAL AND METHODS This is an inter-continental, multicenter, descriptive, retrospective study in low- and middle-income countries. Maternal deaths related to PAS between January 2015 and December 2020 were included. Crucial points in the management of PAS, including prenatal diagnosis and details of the surgical treatment and postoperative management, were evaluated. RESULTS Eighty-two maternal deaths in 16 low- and middle-income countries, on three continents, were included. Almost all maternal deaths (81 cases, 98.8%) were preventable, with inexperience among surgeons being identified as the most relevant problem in the process that led to death among 87% (67 women) of the cases who had contact with health services. The main cause of death associated with PAS was hemorrhage (69 cases, 84.1%), and failures in the process leading to the diagnosis were detected among 64.6% of cases. Although the majority of cases received medical attention and 50 (60.9%) were treated at referral centers for severe obstetric disease, problems were identified during treatment in all cases. CONCLUSIONS Lack of experience and inadequate surgical technique are the most frequent problems associated with maternal deaths in PAS. Continuous training of interdisciplinary teams is critical to modify this tendency.
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Affiliation(s)
| | | | - Gabriel Osanan
- Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | | | | | - Vidyadhar B Bangal
- Department of Obstetrics and Gynecology, Pravara Institute of Medical Sciences, Loni, India
| | - Aziz Slaoui
- Gynecology-Obstetrics and Endoscopy Department, Maternity Souissi, University Hospital Center, IBN SINA, University Mohammed V, Rabat, Morocco.,Gynecology-Obstetrics and Endocrinology Department, Maternity Souissi, University Hospital Center, IBN SINA, University Mohammed V, Rabat, Morocco
| | - Ahmed Mohamed Abbas
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assuit, Egypt
| | - Godwin O Akaba
- College of Health sciences, University of Abuja, University of Abuja Teaching Hospital, Gwagwalada, Nigeria
| | - Zaman N Joshua
- Department of Obstetrics and Gynecology, University of Abuja Teaching Hospital, Gwagwalada, Nigeria
| | | | | | - José E Sanín-Blair
- Maternal Fetal Medicine Unit, Clinica Universitaria Bolivariana/Clinica el Rosario, Medellín, Colombia
| | - Juan M Burgos-Luna
- Clínica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia
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Placenta accreta spectrum-a catastrophic situation in obstetrics. Obstet Gynecol Sci 2021; 64:239-247. [PMID: 33757280 PMCID: PMC8138076 DOI: 10.5468/ogs.20345] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/16/2021] [Indexed: 01/24/2023] Open
Abstract
Placenta accreta is a significant obstetric complication in which the placenta is completely or focally adherent to the myometrium. The worldwide incidence of placenta accreta spectrum (PAS) is increasing day by day, mostly due to the increasing trends in cesarean section rates. The accurate and timely diagnosis of placenta accreta is important to improve the feto-maternal outcome. Although standard ultrasound is a reliable and primary tool for the diagnosis of placenta accreta, the absence of ultrasound findings does not preclude the diagnosis of placenta accreta. Therefore, clinical evaluation of risk factors is equally essential for the prediction of abnormal placental invasion. Pregnant women with a high impression or established diagnosis of placenta accreta should be managed by a multidisciplinary team in a specialist center. Traditionally, PAS has been managed by an emergency obstetric hysterectomy. Previously, few studies suggested a satisfactory success rate of conservative management in well-chosen cases, whereas few studies recommended delayed hysterectomy to reduce the amount of bleeding. The continuously increasing trends of PAS and the challenges for its routine management are the main motives behind this literature review.
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Pathiraja PDM, Jayawardane A. Evaluation of Peripartum Hysterectomy in a Tertiary Care Unit and Its Effect on Patients' Long-Term Physical and Mental Wellbeing: Quest Is Not Over When You Save the Life. Obstet Gynecol Int 2021; 2021:5720264. [PMID: 33679986 PMCID: PMC7906802 DOI: 10.1155/2021/5720264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/06/2021] [Accepted: 02/12/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Peripartum hysterectomy can be performed as an elective procedure or as a life-saving emergency procedure in obstetrics. It is associated with significant maternal morbidity and mortality. We report peripartum hysterectomies done during the study period in a tertiary referral centre, Colombo, Sri Lanka. Methodology. We collected data on all severe acute maternal morbidity and mortality events (SAMM) from June 01, 2014, to June 01, 2015, at De Soysa Hospital for Women (DSHW). We invited all women who underwent PPH to complete the 36-Item Short Form Health Survey questionnaire (SF-36) before hospital discharge and at six months after the hysterectomy date to assess their general and mental health before and after surgery. Focus group discussions (FGD) were used to further evaluate the patient experience and to identify service delivery improvements. RESULTS There were eleven peripartum hysterectomies done during the study period for 7160 deliveries. None were primigravida. Median age and gestation were 36 years and 37 weeks, respectively. The commonest indication for peripartum hysterectomy was a morbidly adherent placenta (seven). Nine of the deliveries were elective lower-segment caesarean section and two were vaginal deliveries. Four emergency peripartum hysterectomies were done for primary postpartum haemorrhage (PPH) and two for secondary PPH. All patients required intensive care and there were no maternal deaths. The analysis of SF-36 data revealed that all patients suffered a significant reduction in the quality of life at six months after the surgery. FGD highlighted that most patients needed further counselling and support to improve their physical, psychological, and social wellbeing. Some of the patients were willing to share their experience on voluntary basis to help those undergoing peripartum hysterectomies in the future. CONCLUSION Peripartum hysterectomy is an important life-saving procedure associated with severe maternal morbidity and mortality. This study reveals that the physical, psychological, and social adverse effects would remain in the long term.
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Bartels HC, Mulligan KM, Craven S, Rogers AC, Higgins S, O'Brien DJ, McVey R, McParland P, Walsh JM, Carroll S, Corcoran S, Robson M, Mahony R, Downey P, Brophy D, Colleran G, McAuliffe FM, Brennan DJ. Maternal morbidity in placenta accreta spectrum following introduction of a multi-disciplinary service compared to standard care: an Irish perspective. Ir J Med Sci 2021; 190:1451-1457. [PMID: 33449329 DOI: 10.1007/s11845-020-02473-3] [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: 09/03/2020] [Accepted: 12/14/2020] [Indexed: 12/01/2022]
Abstract
AIM The purpose of this study is to compare maternal outcomes in patients with placenta accreta spectrum (PAS) when managed as part of a multi-disciplinary team (MDT) compared to standard care. METHODS Patients in the standard care group were retrospectively identified from pathology records, with patients in the MDT group prospectively collected on an electronic database. Data on maternal demographics, delivery, estimated blood loss (EBL), transfusion requirements, and morbidity were recorded. RESULTS Sixty patients were diagnosed with PAS between 2006 and 2019, of whom 32 were part of the standard care group and 28 in the MDT group. Compared to standard care, MDT care was associated with an increase in antenatal diagnosis from 56.3 to 92.9% (p < 0.0001), a significant reduction in EBL (4150 mL (800-19500) vs 1975 (495-8500), p < 0.0001), and transfusion requirements (median 7 (0-30) units of RCC vs 1 (0-13), p < 0.0001). CONCLUSION PAS is associated with significant maternal morbidity and warrants management in an MDT setting with specialist input, which is associated with improved outcomes.
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Affiliation(s)
| | | | - Simon Craven
- National Maternity Hospital, Holles Street, Dublin 2, Ireland
| | - Ailin C Rogers
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, 7, Ireland
| | - Shane Higgins
- National Maternity Hospital, Holles Street, Dublin 2, Ireland
| | - Donal J O'Brien
- National Maternity Hospital, Holles Street, Dublin 2, Ireland
| | - Ruaidhri McVey
- National Maternity Hospital, Holles Street, Dublin 2, Ireland
| | - Peter McParland
- National Maternity Hospital, Holles Street, Dublin 2, Ireland
| | | | - Stephen Carroll
- National Maternity Hospital, Holles Street, Dublin 2, Ireland
| | | | - Mike Robson
- National Maternity Hospital, Holles Street, Dublin 2, Ireland
| | - Rhona Mahony
- National Maternity Hospital, Holles Street, Dublin 2, Ireland
| | - Paul Downey
- National Maternity Hospital, Holles Street, Dublin 2, Ireland
| | - David Brophy
- National Maternity Hospital, Holles Street, Dublin 2, Ireland
| | | | - Fionnuala M McAuliffe
- National Maternity Hospital, Holles Street, Dublin 2, Ireland.,Department of UCD Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Holles Street, Dublin 2, Ireland
| | - Donal J Brennan
- National Maternity Hospital, Holles Street, Dublin 2, Ireland. .,Department of UCD Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Holles Street, Dublin 2, Ireland.
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Coutinho CM, Giorgione V, Noel L, Liu B, Chandraharan E, Pryce J, Frick AP, Thilaganathan B, Bhide A. Effectiveness of contingent screening for placenta accreta spectrum disorders based on persistent low-lying placenta and previous uterine surgery. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:91-96. [PMID: 32865834 DOI: 10.1002/uog.23100] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/18/2020] [Accepted: 08/21/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Maternal mortality related to placenta accreta spectrum (PAS) disorders remains substantial when diagnosed unexpectedly at delivery. The aim of this study was to evaluate the effectiveness of a routine contingent ultrasound screening program for PAS. METHODS This was a retrospective study of data obtained between 2009 and 2019, involving two groups: a screening cohort of unselected women attending for routine mid-trimester ultrasound assessment and a diagnostic cohort consisting of women referred to the PAS diagnostic service with a suspected diagnosis of PAS. In the screening cohort, women with a low-lying placenta at the mid-trimester assessment were followed up in the third trimester, and those with a persistent low-lying placenta (i.e. placenta previa) and previous uterine surgery were referred to the PAS diagnostic service. Ultrasound assessment by the PAS diagnostic service consisted of two-dimensional grayscale and color Doppler ultrasonography, and women with a diagnosis of PAS were usually managed with conservative myometrial resection. The final diagnosis of PAS was based on a combination of intraoperative clinical findings and histopathological examination of the surgical specimen. RESULTS In total, 57 179 women underwent routine mid-trimester fetal anatomy assessment, of whom 220 (0.4%) had a third-trimester diagnosis of placenta previa. Seventy-five of these women were referred to the PAS diagnostic service because of a history of uterine surgery, and 21 of 22 cases of PAS were diagnosed correctly (sensitivity, 95.45% (95% CI, 77.16-99.88%) and specificity, 100% (95% CI, 99.07-100%)). Univariate analysis demonstrated that parity ≥ 2 (odds ratio (OR), 35.50 (95% CI, 6.90-649.00)), two or more previous Cesarean sections (OR, 94.20 (95% CI, 22.00-656.00)) and placenta previa (OR, 20.50 (95% CI, 4.22-369.00)) were the strongest risk factors for PAS. In the diagnostic cohort, there were 173 referrals, with one false-positive and three false-negative diagnoses, resulting in a sensitivity of 96.63% (95% CI, 90.46-99.30%) and a specificity of 98.81% (95% CI, 93.54-99.97%). CONCLUSIONS A contingent screening strategy for PAS is both feasible and effective in a routine healthcare setting. When linked to a PAS diagnostic and surgical management service, adoption of such a screening strategy has the potential to reduce the maternal morbidity and mortality associated with this condition. However, larger prospective studies are necessary before implementing this screening strategy into routine clinical practice. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C M Coutinho
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - V Giorgione
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - L Noel
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - B Liu
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - E Chandraharan
- Global Academy of Medical Education & Training, London, UK
| | - J Pryce
- Cellular Pathology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - A P Frick
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - A Bhide
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
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Lentz EJM, Park AL, Langlois AWR, Huang T, Meschino WS, Ray JG. Risk of Severe Maternal Morbidity or Death in Relation to Prenatal Biochemical Screening: Population-Based Cohort Study. Am J Perinatol 2021; 38:44-59. [PMID: 31412403 DOI: 10.1055/s-0039-1694731] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This study aimed to examine whether prenatal biochemical screening analytes are associated with an increased risk of severe maternal morbidity (SMM) or maternal mortality. STUDY DESIGN This population-based cohort study includes all women in Ontario, Canada, who underwent prenatal screening from 2001 to 2011. Increasing fifth percentiles of the multiple of the median (MoM) for alphafetoprotein (AFP), total human chorionic gonadotropin, unconjugated estriol (uE3), dimeric inhibin-A (DIA), and pregnancy-associated plasma protein A were evaluated. An abnormally high concentration (>95th percentile MoM) for each analyte, individually and combined, was also evaluated. The main outcome assessed was the adjusted relative risk (aRR) of SMM or maternal mortality from 20 weeks' gestation up to 26 weeks thereafter. RESULTS Among 748,972 pregnancies, 11,177 resulted in SMM or maternal mortality (1.5%). Except for uE3, the aRR of SMM or maternal mortality increased in association with increasing fifth percentiles of the MoM for all analytes. AFP (aRR: 2.10; 95% confidence interval [CI]: 1.97-2.25) and DIA (aRR: 2.33; 95% CI: 1.98-2.74) > 95th versus ≤ 5th percentile of the MoM were especially associated with SMM or death. CONCLUSION Women with abnormally high concentrations of certain prenatal biochemical analytes may be at a higher risk of SMM or death in pregnancy or postpartum.
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Affiliation(s)
- Eric J M Lentz
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Alison L Park
- Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Alec W R Langlois
- Faculty of Arts and Science, Queen's University, Kingston, Ontario, Canada
| | - Tianhua Huang
- Genetics Program, North York General Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Wendy S Meschino
- Genetics Program, North York General Hospital, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Joel G Ray
- Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, Health Policy Management and Evaluation, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Obstetrics and Gynaecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Srisajjakul S, Prapaisilp P, Bangchokdee S. Magnetic Resonance Imaging of Placenta Accreta Spectrum: A Step-by-Step Approach. Korean J Radiol 2020; 22:198-212. [PMID: 33169550 PMCID: PMC7817633 DOI: 10.3348/kjr.2020.0580] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/15/2020] [Accepted: 07/29/2020] [Indexed: 11/15/2022] Open
Abstract
Placenta accreta spectrum (PAS) is an abnormal placental adherence or invasion of the myometrium or extrauterine structures. As PAS is primarily staged and managed surgically, imaging can only guide and facilitate diagnosis. But, imaging can aid in preparations for surgical complexity in some cases of PAS. Ultrasound remains the imaging modality of choice; however, magnetic resonance imaging (MRI) is required for evaluation of areas difficult to visualize on ultrasound, and the assessment of the extent of placenta accreta. Numerous MRI features of PAS have been described, including dark intraplacental bands, placental bulge, and placental heterogeneity. Failure to diagnose PAS carries a risk of massive hemorrhage and surgical complications. This article describes a comprehensive, step-by-step approach to diagnostic imaging and its potential pitfalls.
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Affiliation(s)
- Sitthipong Srisajjakul
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Patcharin Prapaisilp
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sirikan Bangchokdee
- Department of Internal Medicine, Pratumthani Hospital, Pratumthani, Thailand
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ELÇİ E, SAYAN S, ELÇİ G, ÇİM N. Perinatal outcome of patients with placenta percreata. ARCHIVES OF CLINICAL AND EXPERIMENTAL MEDICINE 2020. [DOI: 10.25000/acem.768366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Cojocaru L, Lankford A, Galey J, Bharadwaj S, Kodali BS, Kennedy K, Goetzinger K, Turan OM. Surgical advances in the management of placenta accreta spectrum: establishing new expectations for operative blood loss. J Matern Fetal Neonatal Med 2020; 35:4496-4505. [PMID: 33272057 DOI: 10.1080/14767058.2020.1852213] [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: 10/22/2022]
Abstract
OBJECTIVE To evaluate whether the implementation of our surgical approach, referred to in the text as Linear Cutter Vessel Sealing System (LCVSS) technique, will improve perioperative outcomes in patients with placenta accreta spectrum (PAS), specifically by reducing blood loss and blood transfusion rates at the time of cesarean hysterectomy (C-HYST). The LCVSS technique integrates the following: (1) hysterotomy performed using the Linear Cutter, (2) no placental manipulation, (3) cauterization of anatomically prominent vascular anastomosis using the handheld vessel sealing system, and (4) completion of bladder dissection until the cervico-vaginal junction before ligation and division of uterine arteries. MATERIALS AND METHODS This is a retrospective cohort study that analyzed perioperative outcomes in patients undergoing C-HYST for PAS at a tertiary care center from 1 July 2014 to 1 December 2019. Comparisons were performed between cases managed with the use of the LCVSS technique (designated as LCVSS cohort) and those managed without the use of the LCVSS technique (designated as no technique cohort). The primary outcomes were cumulative blood loss (CBL) and total perioperative blood transfusion of ≥4 and ≥6 units of PRBCs. The secondary outcomes were intra- and postoperative complications. Continuous and categorical variables were compared according to the sample size and distribution. Binary logistic regression analysis was performed to predict confounders for blood transfusion of ≥4 units of PRBCs. RESULTS A total of 69 prenatally diagnosed PAS cases underwent C-HYST at the time of delivery. Forty-four cases that were performed using the LCVSS technique comprised the LCVSS cohort. The remaining 25 were marked as no technique cohort. CBL was significantly lower in the LCVSS cohort (1124 ml [300-4100] vs 3500 ml [650-10600]; p < .001). The rate of urinary tract injuries was similar (16%). The rate of postoperative complications and reoperation for intra-abdominal bleeding were lower but not significantly different in LCVSS cohort (9 vs 20% and 0 vs 8%, p = .26 and p = .12, respectively). There were no differences in neonatal outcomes. CONCLUSION Implementation of this advanced surgical approach for PAS management resulted in reduced blood loss and blood transfusion rates in comparison with no technique cohort.
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Affiliation(s)
- Liviu Cojocaru
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Allison Lankford
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jessica Galey
- Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shobana Bharadwaj
- Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bhavani S Kodali
- Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kelly Kennedy
- Department of Obstetrics, Gynecology and Reproductive Science, Center for Advanced Fetal Care, University of Maryland Medical Center, Baltimore, MD, USA
| | - Katherine Goetzinger
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ozhan M Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
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