A systematic review and meta-analysis of obstetric and maternal outcomes after prior uterine artery embolization

Effect of pelvic artery embolization for postpartum hemorrhage on subsequent pregnancies: a single-center retrospective cohort study

OBJECTIVE

Pelvic artery embolization (PAE) is a uterus-saving treatment for postpartum hemorrhage (PPH); however, subfertility or abnormal placentation for subsequent pregnancy has been a concern in several previous reports. This study aimed to investigate the impact of PAE on subsequent pregnancies in women with a history of PPH.

METHODS

A retrospective cohort study was conducted on women transferred to the tertiary center for PPH and delivered for the next pregnancy at the same center later. The study group was divided into two groups based on PAE application to treat previous PPH.

RESULTS

Of the 62 women included, 66% (41/62) had received PAE for the previous PPH, while 21 had not. Pregnancy outcomes for subsequent pregnancies were compared between the PAE and non-PAE groups. The PAE group had a higher estimated blood loss volume for the present delivery than the non-PAE group (600 vs. 300 mL, p = 0.008). The PAE group also demonstrated a higher incidence of placenta previa (4.8% vs. 24.4%, p = 0.080) and placenta accreta (0% vs. 14.6%, p = 0.082) than the non-PAE group, although the difference was not statistically significant.

CONCLUSION

These findings suggest that the use of PAE to treat PPH may increase the risk of bleeding, placenta previa, and placenta accreta spectrum in subsequent pregnancies.

Early identification and conservative treatment of postpartum hemorrhage in the lower uterine segment after vaginal delivery

OBJECTIVE

This study examined the efficacy of pulling down the cervix and packing it in the vaginal fornix (PC-PVF) on postpartum hemorrhage in the lower uterine segment (PPH-LUS).

METHODS

All cases of PPH-LUS after vaginal delivery at two tertiary hospitals between January 2019 and December 2022 were retrospectively investigated. Patients treated successfully with conservative measures were divided into routine treatment only (40 patients), routine treatment + early PC-PVF (33 patients), and routine treatment + late PC-PVF (51 patients) groups. Routine treatment consisted of uterine massage, uterotonics, and tranexamic acid administration. The therapeutic effect was evaluated by comparing the volume and rate of bleeding within 24 h after delivery.

RESULTS

A total of 124 patients were treated conservatively, except for three patients who underwent laparotomy for hemostasis after PC-PVF failed for incomplete rupture of the lower uterine segment. The efficacy of treatment was 44% (40/91) for routine treatment only and 100% when combined with PC-PVF for PPH-LUS. There was no significant difference in maternal age, gestational week, neonatal weight, and Apgar score. But the total blood loss in the conventional treatment + early PC-PVF group (657.27 ml ± 131.61 ml) was significantly lower than that in the other two groups, which was 847.13 ml ± 250.37 ml(p < .01) and 1040.78 ml ± 242.70 ml (p < .01), respectively. The bleeding rate in the routine treatment + early PC-PVF group decreased significantly after tamponade.

CONCLUSIONS

PC-PVF is a safe and effective treatment for PPH-LUS. Early identification of PPH-LUS and prompt application of PC-PVF can effectively reduce blood loss after vaginal delivery.

Acute cor pulmonale following uterine artery embolization

Uterine artery embolization (UAE) is a common procedure for controlling gynecological and obstetric bleeding. We report a case of a 38-year-old female with placenta increta who underwent UAE following a cesarean section and subsequently developed pulmonary embolism from nontarget embolization. Excellent CTPA images demonstrate embolization agents used in the procedure in the pulmonary vasculature. The patient developed acute cor pulmonale, an infrequent complication from the procedure. This case presents a rare and clear demonstration of a complication of uterine artery embolization with clear imaging evidence.

Application of Uterine Artery Embolization in Patients With Placenta Accreta Spectrum After Abdominal Aortic Balloon Occlusion

OBJECTIVE

To evaluate the application of different uterine artery embolization procedures under balloon occlusion of the abdominal aorta in patients with Placenta Accreta Spectrum (PAS) undergoing cesarean section.

MATERIALS AND METHODS

A retrospective analysis was performed on clinical data from 72 patients who underwent uterine artery embolization for hemostasis during cesarean section with PAS. The patients were divided into two groups according to the embolization method used during surgery: group A (n = 43) underwent uterine artery embolization by withdrawing the balloon and inserting a Cobra catheter into the uterine artery for embolization, while group B (n = 29) underwent uterine artery embolization with a Cobra catheter inserted via contralateral puncture of the femoral artery and balloon occlusion. General information, surgical data, and postoperative recovery were compared between the 2 groups.

RESULTS

The bleeding and transfusion volumes were lower in group B than in group A and the differences between the 2 groups were statistically significant. There were no significant differences in surgical duration, number of embolized vessels, length of hospital stay, postoperative complications, or menstrual recovery between the 2 groups.

CONCLUSION

For patients with PAS undergoing cesarean section, uterine artery embolization for hemostasis is preferably performed by inserting a Cobra catheter via contralateral puncture of the femoral artery under abdominal aortic balloon occlusion.

Association between uterine artery embolization for postpartum hemorrhage and second delivery on maternal and offspring outcomes: a nationwide cohort study

STUDY QUESTION

What are the maternal and neonatal outcomes of second delivery in women who underwent uterine artery embolization (UAE) during their first delivery?

SUMMARY ANSWER

Women who underwent UAE during their first delivery exhibited higher risks of placental problems, preterm births, and postpartum hemorrhage (PPH) in second delivery and the second offspring also showed increased risk of major congenital malformations, admission to the neonatal intensive care units (NICU), necrotizing enterocolitis, intraventricular hemorrhage, and bronchopulmonary dysplasia.

WHAT IS KNOWN ALREADY

UAE is a minimally invasive procedure used as an alternative to hysterectomy for managing severe PPH. However, recent studies have raised concerns about potential obstetric complications, including recurrent PPH, placenta accreta spectrum (PAS), and fetal growth restriction in subsequent delivery following UAE.

STUDY DESIGN SIZE DURATION

This was a nationwide retrospective cohort study using the Korean National Health Insurance Service (K-NHIS) database, covering 50 million individuals from 2004 to 2020. The cohort included 3 616 923 women with live births between 1 January 2005 and 31 December 2019 with follow-up data extending to 31 December 2020.

PARTICIPANTS/MATERIALS SETTING METHODS

The study included women who had their first live birth between 2005 and 2019, excluding those who underwent hysterectomy (without UAE = 3 612 389, UAE = 4534). Among them, we selected women who had single gestation secondary delivery (without UAE = 1 694 600, UAE = 1146). Propensity score matching was used to control for confounding factors, resulting in 11 184 women without UAE and 1119 women with UAE for subsequent analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Women in the UAE group had significantly higher risks of PAS (odds ratio (OR) = 38.91, 95% CI = 18.61-81.34), placenta previa (OR = 6.98, 95% CI = 5.57-8.75), and preterm birth (OR = 2.23, 95% CI = 1.71-2.90) during their second delivery. The risk of recurrent PPH was also significantly higher (OR = 8.94, 95% CI = 7.19-11.12). Their second offspring were more likely to have major congenital malformations (OR = 1.62, 95% CI = 1.25-2.11) and adverse neonatal outcomes, including NICU admissions (OR = 1.83, 95% CI = 1.48-2.25). Long-term outcomes showed a higher risk of attention-deficit/hyperactivity disorder (hazard ratio = 1.64, 95% CI = 1.03-2.63) but were otherwise comparable to those in the without UAE group.

LIMITATIONS REASONS FOR CAUTION

Retrospective nature of the study may have introduced exposure and outcome misclassifications, despite the reliability of the K-NHIS database. Unmeasured confounders and selection bias due to only including live births could also have influenced the results.

WIDER IMPLICATIONS OF THE FINDINGS

Women with a history of UAE require meticulous prenatal care and close monitoring during subsequent deliveries due to increased risks of complications. Counseling and referral to high-risk medical centers may improve outcomes. Further research is needed to understand the mechanisms of complications in both mothers and offspring at sequential delivery, as well as to refine UAE procedures.

STUDY FUNDING/COMPETING INTERESTS

This study supported by Patient-Centered Clinical Research Coordinating Center (PACEN) funded by the Ministry of Health & Welfare, Republic of Korea (HC21C0123). This study was funded by S.-Y.O. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

TRIAL REGISTRATION NUMBER

N/A.

Prognosis of subsequent pregnancy in uterine necrosis after uterine artery embolization

In an 8-year period at two medical center, 138 patients underwent uterine artery embolization, and 11 of them were diagnosed with uterine necrosis. Among them, three were successfully conceived. However, one of them developed an arteriovenous malformation after an artificial abortion, and another experienced complications, including placenta previa and placenta accreta spectrum, which resulted in early preterm delivery and recurrent postpartum hemorrhage, necessitating subtotal hysterectomy. Therefore, it is crucial to prepare for potential adverse pregnancy outcomes in subsequent pregnancies for patients with a history of uterine necrosis.

Fertility after Transcatheter Arterial Embolization for Obstetric Hemorrhage: An Urban Health Care System Observational Study

OBJECTIVE

This study aimed to investigate pregnancy rate, pregnancy outcomes, and resumption of menses after transcatheter arterial embolization (TAE) for obstetric hemorrhage (OH).

STUDY DESIGN

Sixty-seven patients who underwent TAE for OH from 2006 to 2020 within an urban, multihospital health care system were identified retrospectively. Selected patients were interviewed by phone to complete a survey with a primary outcome of self-reported pregnancy in those seeking pregnancy. Secondary outcomes included pregnancy outcomes and resumption of menses. Univariate testing of association of pregnancy and miscarriage rate with embolic agent was performed using Fisher's exact test.

RESULTS

Thirty-three of 50 patients (66%) meeting the inclusion criteria completed the survey on fertility, a median of 47 (range, 13-123) months after TAE for OH. Of the 13 patients who attempted pregnancy, there was a pregnancy rate of 77% and miscarriage rate of 38%. Those who delivered live newborns conceived spontaneously, carried to term, and delivered a healthy newborn via cesarean section at a weight appropriate for gestational age. Thirty (91%) patients resumed menstruation, and the majority with unchanged frequency. Most patients underwent bilateral uterine artery embolization with radial artery access (54%). The most common embolic agents used were gelfoam only (30%) and glue only (24%). There was no statistically significant association between embolic agent and pregnancy or miscarriage rate.

CONCLUSION

Spontaneous pregnancy with live birth and resumption of menses can occur in a majority of patients after TAE for OH.

KEY POINTS

· Most patients who attempted pregnancy after TAE for OH achieved pregnancy.. · Most patients who became pregnant conceived spontaneously and delivered healthy newborns at term.. · Most patients resumed menstruation after TAE for OH.. · There was no significant association between type of embolic and pregnancy or miscarriage rate..

Primary and secondary postpartum haemorrhage: a review for a rationale endovascular approach

Postpartum haemorrhage (PPH) is a significant cause of maternal mortality globally, necessitating prompt and efficient management. This review provides a comprehensive exploration of endovascular treatment dimensions for both primary and secondary PPH, with a focus on uterine atony, trauma, placenta accreta spectrum (PAS), and retained products of conception (RPOC). Primary PPH, occurring within 24 h, often results from uterine atony in 70% of causes, but also from trauma, or PAS. Uterine atony involves inadequate myometrial contraction, addressed through uterine massage, oxytocin, and, if needed, mechanical modalities like balloon tamponade. Trauma-related PPH may stem from perineal injuries or pseudoaneurysm rupture, while PAS involves abnormal placental adherence. PAS demands early detection due to associated life-threatening bleeding during delivery. Secondary PPH, occurring within 24 h to 6 weeks postpartum, frequently arises from RPOC. Medical management may include uterine contraction drugs and hemostatic agents, but invasive procedures like dilation and curettage (D&C) or hysteroscopic resection may be required.Imaging assessments, particularly through ultrasound (US), play a crucial role in the diagnosis and treatment planning of postpartum haemorrhage (PPH), except for uterine atony, where imaging techniques prove to be of limited utility in its management. Computed tomography play an important role in evaluation of trauma related PPH cases and MRI is essential in diagnosing and treatment planning of PAS and RPOC.Uterine artery embolization (UAE) has become a standard intervention for refractory PPH, offering a rapid, effective, and safe alternative to surgery with a success rate exceeding 85% (Rand T. et al. CVIR Endovasc 3:1-12, 2020). The technical approach involves non-selective uterine artery embolization with resorbable gelatine sponge (GS) in semi-liquid or torpedo presentation as the most extended embolic or calibrated microspheres. Selective embolization is warranted in cases with identifiable bleeding points or RPOC with AVM-like angiographic patterns and liquid embolics could be a good option in this scenario. UAE in PAS requires a tailored approach, considering the degree of placental invasion. A thorough understanding of female pelvis vascular anatomy and collateral pathways is essential for accurate and safe UAE.In conclusion, integrating interventional radiology techniques into clinical guidelines for primary and secondary PPH management and co-working during labour is crucial.

Factors and outcomes for placental anomalies: An umbrella review of systematic reviews and meta-analyses

Background

Placental anomalies, including placenta previa (PP), placenta accreta spectrum disorders (PAS), and vase previa (VP), are associated with several adverse foetal-neonatal and maternal complications. However, there is still a lack of robust evidence on the pathogenesis and adverse outcomes of the diseases. Through this umbrella review, we aimed to systematically review existing meta-analyses exploring the factors and outcomes for pregnancy women with placental anomalies.

Methods

We searched PubMed, Embase, Web of Science, and the Cochrane Library from inception to February 2023. We used AMSTAR 2 to assess the quality of the reviews and estimated the pooled risk and 95% confidence intervals (CIs) for each meta-analysis.

Results

We included 34 meta-analyses and extracted 55 factors (27 for PP, 22 for PAS, and 6 for VP) and 16 outcomes (12 for PP, and 4 for VP) to assess their credibility. Seven factors (maternal cocaine use (for PP), uterine leiomyoma (for PP), prior abortion (spontaneous) (PP), threatened miscarriage (PP), maternal obesity (PP), maternal smoking (PAS), male foetus (PAS)) had high epidemiological evidence. Twelve factors and six outcomes had moderate epidemiological evidence. Twenty-two factors and eight outcomes showed significant association, but with weak credibility.

Conclusions

We found varying levels of evidence for placental anomalies of different factors and outcomes in this umbrella review.

Registration

PROSPERO: CRD42022300160.

Pregnancy rate and outcomes after uterine artery embolization for women: a systematic review and meta-analysis with trial sequential analysis

Objective

The assessment of the relative impacts of uterine artery embolization (UAE) treatment for female patients is a critical field that informs clinical decisions, yet there is a noticeable scarcity of high-quality, long-term comparative studies. This meta-analysis aimed to focus on the pregnancy rate and outcomes in female patients following UAE and to conduct subgroup analyses based on different patient populations or various control treatments.

Methods

A systematic literature search was conducted on 2 August 2023 through the Web of Science, PubMed, Embase, and the Cochrane Library of Clinical Trials for all potential studies. Relative risks (RRs) with 95% confidence intervals (CIs) were applied to compare pregnancy rates and outcomes between the UAE group and the control group. Heterogeneity was evaluated statistically by using the chi-square-based Cochran's Q test and Higgins I2 statistics, and 95% prediction interval (PI). Software R 4.3.1 and Stata 12.0 were used for meta-analysis. The trial sequential analysis (TSA) was performed with TSA v0.9.5.10 Beta software.

Results

A total of 15 eligible studies (11 cohort studies, 3 randomized controlled trials, and 1 non-randomized clinical trial) were included in this meta-analysis. The overall results revealed that UAE significantly decreased postoperative pregnancy rate [RR (95% CI): 0.721 (0.531-0.979), 95% PI: 0.248-2.097] and was associated with an increased risk of postoperative PPH [RR (95% CI): 3.182 (1.319-7.675), 95% PI: 0.474-22.089]. Analysis grouped by population indicated that UAE decreased the risk of preterm delivery [RR (95% CI): 0.326 (0.128-0.831), p = 0.019] and cesarean section [RR (95% CI): 0.693 (0.481-0.999), p = 0.050] and increased the risk of placenta previa [RR (95% CI): 8.739 (1.580-48.341), p = 0.013] in patients with UFs, CSP, and PPH, respectively. When compared with myomectomy, HIFU, and non-use of UAE, UAE treatment was associated with the reduced risks of preterm delivery [RR (95% CI): 0.296 (0.106-0.826)] and cesarean section [(95% CI): 0.693 (0.481-0.999), p = 0.050] and increased placenta previa risk [RR (95% CI): 10.682 (6.859-16.636)], respectively.

Conclusion

UAE treatment was associated with a lower postoperative pregnancy rate and increased risk of PPH. Subgroup analysis suggested that UAE was shown to decrease the risk of preterm delivery and cesarean section and increase placenta previa risk.Systematic review registration:https://www.crd.york.ac.uk/prospero/, Identifier CRD42023448257.

Systematic Review of the Survival Outcomes of Neoadjuvant Chemotherapy in Women with Malignant Ovarian Germ Cell Tumors

Randomized clinical trials assessing the efficacy of neoadjuvant chemotherapy (NACT) for advanced epithelial ovarian cancer have predominantly included women with high-grade serous carcinomas. The response rate and oncological outcomes of NACT for malignant ovarian germ cell tumors (MOGCT) are poorly understood. This study aimed to examine the effects of NACT on women with MOGCT by conducting a systematic review of four public search engines. Fifteen studies were identified, and a further descriptive analysis was performed for 10 original articles. In those studies, most women were treated with a bleomycin, etoposide, and cisplatin regimen, and one to three cycles were used in most studies. Four studies comparing NACT and primary debulking surgery showed similar complete response rates (n = 2; pooled odds ratio [OR] 0.90, 95% confidence interval [CI] 0.15-5.27), comparable overall survival (n = 3; 87.0-100% versus 70.0-100%), disease-free survival (n = 3; 87.0-100% versus 70.0-100%), recurrence rate (n = 1; OR 3.50, 95%CI 0.38-32.50), and adverse events rate from chemotherapy between the groups. In conclusion, NACT may be considered for the management of MOGCT; however, possible candidates for NACT use and an ideal number of NACT cycles remain unknown. Further studies are warranted to validate the efficacy of NACT in advanced MOGCT patients.

Pathologically diagnosed placenta accreta spectrum without placenta previa: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to assess clinical characteristics related to pathologically proven placenta accreta spectrum without placenta previa.

DATA SOURCES

A literature search of PubMed, the Cochrane database, and Web of Science was performed from inception to September 7, 2022.

STUDY ELIGIBILITY CRITERIA

The primary outcomes were invasive placenta (including increta or percreta), blood loss, hysterectomy, and antenatal diagnosis. In addition, maternal age, assisted reproductive technology, previous cesarean delivery, and previous uterine procedures were investigated as potential risk factors. The inclusion criteria were studies evaluating the clinical presentation of pathologically diagnosed PAS without placenta previa.

METHODS

Study screening was conducted after duplicates were identified and removed. The quality of each study and the publication bias were assessed. Forest plots and I2 statistics were calculated for each study outcome for each group. The main analysis was a random-effects analysis.

RESULTS

Among 2598 studies that were initially retrieved, 5 were included in the review. With the exception of 1 study, 4 studies were included in the meta-analysis. This meta-analysis showed that placenta accreta spectrum without placenta previa was associated with less risk of invasive placenta (odds ratio, 0.24; 95% confidence interval, 0.16-0.37), blood loss (mean difference, -1.19; 95% confidence interval, -2.09 to -0.28) and hysterectomy (odds ratio, 0.11; 95% confidence interval, 0.02-0.53), and more difficult to diagnose prenatally (odds ratio, 0.13; 95% confidence interval, 0.04-0.45) than placenta accreta spectrum with placenta previa. In addition, assisted reproductive technology and a previous uterine procedure were strong risk factors for placenta accreta spectrum without placenta previa, whhereas previous cesarean delivery was a strong risk factor for placenta accreta spectrum with placenta previa.

CONCLUSION

The differences in clinical aspects of placenta accreta spectrum with and without placenta previa need to be understood.

Placenta Accreta Spectrum: The Role of Interventional Radiology in Multidisciplinary Management

Placenta accreta spectrum is increasing in prevalence and poses significant risks to obstetric patients. This article defines characteristics, diagnosis, management, and outcomes of placenta accreta spectrum, highlighting interventional radiology's role in its management as part of a multidisciplinary approach.

Asherman Syndrome after Uterine Artery Embolization: A Cohort Study about Surgery Management and Fertility Outcomes

STUDY OBJECTIVE

To study the severity of intrauterine adhesions (IUA) after uterine arterial embolization and to evaluate fertility, pregnancy, and obstetrical outcomes after hysteroscopic treatment.

DESIGN

Retrospective cohort.

SETTING

French University Hospital.

PATIENTS

Thirty-three patients under the age of 40 years who were treated by uterine artery embolization with nonabsorbable microparticles between 2010 and 2020 for symptomatic fibroids or adenomyosis, or postpartum hemorrhage.

INTERVENTIONS

All patients had a diagnosis of IUA after embolization. All patients desired future fertility. IUA was treated with operative hysteroscopy.

MEASUREMENTS AND MAIN RESULTS

Severity of IUA, number of operative hysteroscopies performed to obtain a normal cavity shape, pregnancy rate, and obstetrical outcomes. Of our 33 patients, 81.8% had severe IUA (state IV et V according to the European Society of Gynecological Endoscopy or state III according to the American fertility society classification). To restore fertility potential, an average of 3.4 operative hysteroscopies had to be performed [CI 95% (2.56-4.16)]. We reported a very low rate of pregnancy (8/33, 24%). Obstetrical outcomes reported are 50% of premature birth and 62.5% of delivery hemorrhage partly due to 37.5% of placenta accreta. We also reported 2 neonatal deaths.

CONCLUSION

IUA after uterine embolization is severe, and more difficult to treat than other synechiae, probably related to endometrial necrosis. Pregnancy and obstetrical outcomes have shown a low pregnancy rate, an increased risk of preterm delivery, a high risk of placental disorders, and very severe postpartum hemorrhage. Those results have to alert gynecologists and radiologists to the use of uterine arterial embolization in women who desire future fertility.

Relationship between Abnormal Placenta and Obstetric Outcomes: A Meta-Analysis

The placenta has several crucial physiological functions that help maintain a normal pregnancy. Although approximately 2-4% of pregnancies are complicated by abnormal placentas, obstetric outcomes remain understudied. This study aimed to determine the outcomes and prevalence of patients with abnormal placentas by conducting a systematic review of 48 studies published between 1974 and 2022. The cumulative prevalence of circumvallate placenta, succenturiate placenta, multilobed placenta, and placenta membranacea were 1.2%, 1.0%, 0.2%, and 0.004%, respectively. Pregnancies with a circumvallate placenta were associated with an increased rate of emergent cesarean delivery, preterm birth (PTB), and placental abruption compared to those without a circumvallate placenta. The succenturiate lobe of the placenta was associated with a higher rate of emergent cesarean delivery, whereas comparative results were observed in terms of PTB, placental abruption, and placenta previa in comparison to those without a succenturiate lobe of the placenta. A comparator study that examined the outcomes of multilobed placentas found that this data is usually unavailable. Patient-level analysis (n = 15) showed high-rates of abortion (40%), placenta accreta spectrum (40%), and a low term delivery rate (13.3%) in women with placenta membranacea. Although the current evidence is insufficient to draw a robust conclusion, abnormal placentas should be recognized as a high-risk factor for adverse outcomes during pregnancy.

Repeat uterine artery embolization (UAE) for recurrent postpartum hemorrhage in patients who underwent UAE after a previous delivery: a multicenter study

OBJECTIVE

To evaluate angiographic findings and outcomes of repeat uterine artery embolization (UAE) for recurrent postpartum hemorrhage (PPH) in patients who previously underwent UAE for PPH after a previous delivery.

MATERIALS AND METHODS

Among 1805 patients who underwent UAE for PPH from 2007 to 2020 at four participating hospitals, the data of 21 (1.16%) patients who underwent UAE for PPH after subsequent delivery were collected and analyzed retrospectively. The rate of placental abnormalities, causes of PPH, angiographic findings, and clinical success rate were evaluated.

RESULTS

The technical success rates were 100% and 95.2%, and clinical success rates were 85.7% and 95.2% in association with first and second UAEs, respectively. The time intervals between first and second UAEs ranged from 15.6 to 103.3 months (46.5 ± 25.0 months). The rate of placental abnormalities was significantly higher in association with second UAEs than with first UAEs (71.4% vs. 42.8%, p = 0.034). The causes of PPH were different between first and second UAEs with borderline significance (p = 0.049); uterine atony (81.0%) and placenta accreta spectrum (57.1%) were most common in association with first and second UAEs, respectively. During second UAEs, obliterated arteries were observed in 27 uterine arteries (27/42, 64.3%) of 16 patients (16/21, 76.2%), with partial obliteration predominating over total obliteration. Collateral arteries were observed in 15 patients during second UAEs.

CONCLUSION

Repeat UAE is safe and effective for recurrent PPH after subsequent delivery in patients with prior UAE. Obliteration of UAs and formation of collateral arteries are common at the second UAEs.

KEY POINTS

• The rate of placental abnormalities was significantly higher in association with second UAEs than with first UAEs (71.4% vs. 42.8%, p = 0.034). • Obliteration of UAs and formation of collateral arteries are common at the second UAEs. • Repeat UAE is safe and effective for recurrent PPH after subsequent delivery in patients with prior UAE.

Current Evidence on Vasa Previa without Velamentous Cord Insertion or Placental Morphological Anomalies (Type III Vasa Previa): Systematic Review and Meta-Analysis

Vasa previa carries a high risk of severe fetal morbidity and mortality due to fetal hemorrhage caused by damage to unprotected fetal cord vessels upon membrane rupture. Vasa previa is generally classified into types I and II. However, some cases are difficult to classify, and some studies have proposed a type III classification. This study aimed to review the current evidence on type III vasa previa. A systematic literature search was conducted, and 11 articles (2011-2022) were included. A systematic review showed that type III vasa previa accounts for 5.7% of vasa previa cases. Thirteen women with type III vasa previa were examined at a patient-level analysis. The median age was 35 (interquartile range [IQR] 31.5-38) years, and approximately 45% were assisted reproductive technology (ART) pregnancies. The median gestational week of delivery was 36 (IQR 34-37) weeks; the antenatal detection rate was 84.6%, and no cases reported neonatal death. The characteristics and obstetric outcomes (rate of ART, antenatal diagnosis, emergent cesarean delivery, gestational age at delivery, and neonatal mortality) were compared between types I and III vasa previa, and all outcomes of interest were similar. The current evidence on type III vasa previa is scanty, and further studies are warranted.

The Characteristics and Obstetric Outcomes of Type II Vasa Previa: Systematic Review and Meta-Analysis

Vasa previa is a rare fetal life-threatening obstetric disease classified into types I and II. This study aimed to examine the characteristics and obstetric outcomes of type II vasa previa. A systematic review was performed, and 20 studies (1998-2022) were identified. The results from six studies showed that type II vasa previa accounted for 21.3% of vasa previa cases. The characteristics and obstetric outcomes (rate of assisted reproductive technology (ART), antenatal diagnosis, emergent cesarean delivery, maternal transfusion, gestational age at delivery, and neonatal mortality) were compared between type I and II vasa previa, and all outcomes of interest were similar. The association between ART and abnormal placenta (bilobed placenta or succenturiate lobe) was examined in three studies, and the results were as follows: (i) increased rate of succenturiate lobes (ART versus non-ART pregnancy; OR (odds ratio) 6.97, 95% confidence interval (CI) 2.45-19.78); (ii) similar rate of abnormal placenta (cleavage-stage versus blastocyst embryo transfer); (iii) increased rate of abnormal placenta (frozen versus fresh embryo transfer; OR 2.97, 95%CI 1.10-7.96). Although the outcomes of type II vasa previa appear to be similar to those of type I vasa previa, the current evidence is insufficient for a robust conclusion.

Obstetric and Maternal Outcomes After B-Lynch Compression Sutures: A Meta-Analysis

This review article aimed to determine the obstetric and maternal outcomes after B-Lynch compression sutures to control atonic postpartum hemorrhage (PPH). This meta-analysis was performed after registering the protocol in the PROSPERO database with the registration number CRD42022355358. Two independent reviewers systematically searched electronic databases and search engines (PubMed, Cochrane Library, and Google Scholar) to retrieve published articles from inception to July 2022. The obstetric and maternal outcomes after the B-Lynch compression suture were computed using the random-effects model in pooled proportion with a 95% confidence interval (CI). Meta-regression analysis and subgroup analysis were performed to explain any source of possible heterogeneity. Quality assessment of the included studies was done using Joanna Briggs Institute (JBI) tools which are critical appraisal tools for systematic reviews and meta-analyses. This meta-analysis included a total of 30 studies involving 1,270 subjects. The pooled proportion of B-Lynch suture alone was 91% (95% CI = 82-97%). The combined proportion of B-Lynch suture plus another compression suture was 1% (95% CI = 0-3%), and the pooled proportion of B-Lynch suture plus vessel ligation was 3% (95% CI = 1-6%). The pooled proportions of PPH controlled and hysterectomies were 94% (95% CI = 91-97%, I² = 65.3%) and 7% (95% CI = 4-10%, I² = 72.13%), respectively. Therefore, B-Lynch suture (either alone or in combination with other techniques) is a simple and effective measure to control atonic PPH.

Unexpected uterine body placenta accreta spectrum with placenta previa in a subsequent pregnancy after uterine artery embolization: a case report

BACKGROUND

A subsequent pregnancy after uterine artery embolization (UAE) raises several concerns, one of which is placenta accreta spectrum (PAS). Placenta previa is the strongest risk factor for PAS, which is most likely to occur in the lower uterine segment. PAS without placenta previa (i.e., uterine body PAS) is considered relatively rare.

CASE PRESENTATION

A 35-year-old woman, gravida 2 para 1, had undergone UAE for postpartum hemorrhage due to uterine atony after vaginal delivery in her previous pregnancy. She developed placenta previa during her subsequent pregnancy and was therefore evaluated for PAS in the lower uterine segment. On the basis of examination findings, we considered PAS to be unlikely. During cesarean section, we found that the placenta was not detached from the uterine body, and the patient was determined to have uterine body PAS. Ultimately, a hysterectomy was performed.

CONCLUSIONS

PAS can occur in a subsequent pregnancy after UAE. When a subsequent pregnancy after UAE is accompanied by placenta previa, it is important to maintain a high index of suspicion of uterine body PAS without being misled by the presence of placenta previa.

Recurrent postpartum hemorrhage at subsequent pregnancy in patients with prior uterine artery embolization: angiographic findings and outcomes of repeat embolization

OBJECTIVE

To evaluate angiographic findings and outcomes of uterine artery embolization (UAE) for recurrent postpartum hemorrhage (PPH) in a subsequent pregnancy in patients with a history of prior UAE.

METHODS

Between March 2004 and February 2021, UAE was performed for PPH with gelatin sponge slurry in 753 patients. Among these, 13 underwent repeat UAE for recurrent PPH after subsequent delivery. The causes of PPH, angiographic findings, hemostasis, and adverse events were evaluated.

RESULTS

The causes of recurrent PPH included retained placental tissue (n = 9) and uterine atony (n = 4). On angiography, unilateral or bilateral uterine arteries were obliterated due to prior UAE in 10 patients (76.9%). The uterine collateral vessels were embolized (anterior division of the internal iliac artery [n = 10], round ligament [n = 5], and ovarian [n = 4] artery). In the remaining three patients with recanalized or patent (not embolized at prior UAE) uterine arteries, both uterine arteries were embolized. Immediate hemostasis was achieved in nine patients (69.2%). The remaining four patients (30.8%) with obliterated uterine arteries required hysterectomy. There were three mild adverse events (pelvic pain [n = 2] and fever [n = 1]).

CONCLUSION

UAE with gelatin sponge slurry frequently causes permanent uterine artery obliteration. In cases of recurrent PPH occurring in subsequent pregnancy, repeat UAE may be less likely to achieve hemostasis (69.2%).

ADVANCES IN KNOWLEDGE

1. UAE with gelatin sponge slurry frequently caused permanent uterine artery obliteration.2. In recurrent PPH occurring in subsequent pregnancy, the repeat UAE may be less likely to achieve hemostasis than initial UAE.

Association between Endometriosis and Delivery Outcomes: A Systematic Review and Meta-Analysis

Endometriosis is a common benign gynecological disorder; however, delivery outcomes concerning pregnancies with endometriosis remain understudied. This study aimed to assess the effect of endometriosis on delivery outcomes, including the rate of instrumental delivery, cesarean delivery (CD), postpartum hemorrhage (PPH), and perioperative complications during CD. A systematic literature review was conducted using multiple computerized databases, and 28 studies met the inclusion criteria. Pooled analysis showed that histologically diagnosed endometriosis was associated with an increased rate of instrumental delivery (odds ratio [OR] 1.26, 95% confidence interval [CI] 1.02-1.56) and an increased risk of CD (adjusted OR 2.59, 95%CI 1.32-5.07). In our analysis, histologically diagnosed endometriosis was not associated with an increased rate of PPH; however, one retrospective study reported that endometriosis increased the rate of PPH during CD (adjusted OR 1.7, 95%CI 1.5-2.0). Two studies examined perioperative complications during CD, and women with deep endometriosis had a higher rate of bowel resection or bladder injury than those without endometriosis. Our findings suggest that endometriosis is a significant risk factor for instrumental delivery and CD and may be associated with a higher rate of PPH and intraoperative complications during CD.

Placenta Accreta Spectrum Disorder Complicated with Endometriosis: Systematic Review and Meta-Analysis

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.

Maternal and Fetal Outcomes after Prior Mid-Trimester Uterine Rupture: A Systematic Review with Our Experience

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.

Placenta Previa Complicated with Endometriosis: Contemporary Clinical Management, Molecular Mechanisms, and Future Research Opportunities

Endometriosis is a common gynecological disease characterized by chronic inflammation, with an estimated prevalence of approximately 5–15% in reproductive-aged women. This study aimed to assess the relationship between placenta previa (PP) and endometriosis. We performed a systematic review of the literature until 30 June 2021, and 24 studies met the inclusion criteria. Using an adjusted pooled analysis, we found that women with endometriosis had a significantly increased rate of PP (adjusted odds ratio (OR) 3.17, 95% confidence interval (CI) 2.58–3.89) compared to those without endometriosis. In an unadjusted analysis, severe endometriosis was associated with an increased prevalence of PP (OR 11.86, 95% CI 4.32–32.57), whereas non-severe endometriosis was not (OR 2.16, 95% CI 0.95–4.89). Notably, one study showed that PP with endometriosis was associated with increased intraoperative bleeding (1.515 mL versus 870 mL, p < 0.01) compared to those without endometriosis. Unfortunately, no studies assessed the molecular mechanisms underlying PP in patients with endometriosis. Our findings suggest that there is a strong association between endometriosis and a higher incidence of PP, as well as poor surgical outcomes during cesarean delivery. Therefore, the development of novel therapeutic agents or methods is warranted to prevent PP in women with endometriosis.

Successful repeated uterine artery embolization in postpartum hemorrhage with disseminated intravascular coagulation: a case report and literature review

Background

Postpartum hemorrhage (PPH) is a potentially fatal condition requiring urgent and appropriate intervention. Uterine artery embolization (UAE) has a high hemostatic capacity for PPH, but it may fail. Disseminated intravascular coagulation (DIC) has been reported as a risk factor associated with the failure of UAE.

Case presentation

A 37-year-old primigravida with dichorionic diamniotic twins and placenta previa underwent cesarean section. The blood loss during surgery was 4950 mL. Hemostasis was achieved using an intrauterine balloon tamponade device. However, she lost a further 2400 mL of blood 5 h after surgery. We embolized both uterine arteries using gelatin sponges and confirmed hemostasis. She was suffering from DIC and received ample blood transfusions. However, a further 1300 mL of blood was lost 18 h after surgery and we performed repeated UAE, with complete recanalization of the uterine arteries on both sides and re-embolization with gelatin sponges. Her DIC was treated successfully by blood transfusions at this time, and she showed no further bleeding after the repeated UAE.

Conclusions

DIC is a risk factor for the failure of UAE. Repeated UAE may be effective after sufficient improvement of the hematological status in patients with PPH and DIC.

Minimally Invasive Surgery and Surgical Volume-Specific Survival and Perioperative Outcome: Unmet Need for Evidence in Gynecologic Malignancy

This study examined the effect of hospital surgical volume on oncologic outcomes in minimally invasive surgery (MIS) for gynecologic malignancies. The objectives were to assess survival outcomes related to hospital surgical volume and to evaluate perioperative outcomes and examine non-gynecologic malignancies. Literature available from the PubMed, Scopus, and the Cochrane Library databases were systematically reviewed. All surgical procedures including gynecologic surgery with hospital surgical volume information were eligible for analysis. Twenty-three studies met the inclusion criteria, and nine gastro-intestinal studies, seven genitourinary studies, four gynecological studies, two hepatobiliary studies, and one thoracic study were reviewed. Of those, 11 showed a positive volume–outcome association for perioperative outcomes. A study on MIS for ovarian cancer reported lower surgical morbidity in high-volume centers. Two studies were on endometrial cancer, of which one showed lower treatment costs in high-volume centers and the other showed no association with perioperative morbidity. Another study examined robotic-assisted radical hysterectomy for cervical cancer and found no volume–outcome association for surgical morbidity. There were no gynecologic studies examining the association between hospital surgical volume and oncologic outcomes in MIS. The volume–outcome association for oncologic outcome in gynecologic MIS is understudied. This lack of evidence calls for further studies to address this knowledge gap.