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Gatta LA, Grotegut CA, West Honart A, Craig AM, Salinaro JR, Weber JM, Alvarez Secord A, Habib AS, Pabon-Ramos W, Ronald J, Gilner JB. Multivessel embolization followed by immediate hysterectomy for placenta accreta spectrum. Am J Obstet Gynecol MFM 2024; 6:101466. [PMID: 39122210 DOI: 10.1016/j.ajogmf.2024.101466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 07/19/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024]
Affiliation(s)
- Luke A Gatta
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Vanderbilt University School of Medicine, Nashville, TN
| | - Chad A Grotegut
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Anne West Honart
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, NC
| | - Amanda M Craig
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, NC
| | - Julia R Salinaro
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Brown University School of Medicine, Providence, RI
| | - Jeremy M Weber
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Angeles Alvarez Secord
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, NC
| | - Ashraf S Habib
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Waleska Pabon-Ramos
- Department of Radiology and Medicine, Duke University School of Medicine, Durham, NC
| | - James Ronald
- Department of Radiology and Medicine, Duke University School of Medicine, Durham, NC
| | - Jennifer B Gilner
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, NC.
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Kloka JA, Friedrichson B, Jasny T, Blum LV, Choorapoikayil S, Old O, Zacharowski K, Neef V. Anaemia and red blood cell transfusion in women with placenta accreta spectrum: an analysis of 38,060 cases. Sci Rep 2024; 14:4999. [PMID: 38424178 PMCID: PMC10904858 DOI: 10.1038/s41598-024-55531-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 02/24/2024] [Indexed: 03/02/2024] Open
Abstract
Placenta accreta spectrum (PAS) has become a significant life-threatening issue due to its increased incidence and associated morbidity and mortality. Pregnancy is often associated with states of anaemia, and severe maternal haemorrhage represents a major risk factor for red blood cell (RBC) transfusion. The present study retrospectively analyzed the prevalence of anaemia, transfusion requirements and outcome in women with PAS. Using data from the German Statistical Office pregnant patients with deliveries hospitalized between January 2012 and December 2021 were included. Primary outcome was the prevalence of anemia and administration of RBCs. Secondary outcome were complications in women with PAS who received RBC transfusion. In total 6,493,606 pregnant women were analyzed, of which 38,060 (0.59%) were diagnosed with PAS. The rate of anaemia during pregnancy (60.36 vs. 23.25%; p < 0.0001), postpartum haemorrhage (47.08 vs. 4.41%; p < 0.0001) and RBC transfusion rate (14.68% vs. 0.72%; p < 0.0001) were higher in women with PAS compared to women without PAS. Women with PAS who had bleeding and transfusion experienced significantly more peripartum complications than those who did not. A multiple logistic regression revealed that the probability for RBC transfusion in all pregnant women was positively associated with anaemia (OR 21.96 (95% CI 21.36-22.58)). In women with PAS, RBC transfusion was positively associated with the presence of renal failure (OR 11.27 (95% CI 9.35-13.57)) and congestive heart failure (OR 6.02 (95% CI (5.2-7.07)). Early anaemia management prior to delivery as well as blood conservation strategies are crucial in women diagnosed with PAS.
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Affiliation(s)
- Jan Andreas Kloka
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital, Theodor-Stern Kai 7, 60590, Frankfurt, Germany
| | - Benjamin Friedrichson
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital, Theodor-Stern Kai 7, 60590, Frankfurt, Germany
| | - Thomas Jasny
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital, Theodor-Stern Kai 7, 60590, Frankfurt, Germany
| | - Lea Valeska Blum
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital, Theodor-Stern Kai 7, 60590, Frankfurt, Germany
| | - Suma Choorapoikayil
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital, Theodor-Stern Kai 7, 60590, Frankfurt, Germany
| | - Oliver Old
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital, Theodor-Stern Kai 7, 60590, Frankfurt, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital, Theodor-Stern Kai 7, 60590, Frankfurt, Germany
| | - Vanessa Neef
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital, Theodor-Stern Kai 7, 60590, Frankfurt, Germany.
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Neef V, Flinspach AN, Eichler K, Woebbecke TR, Noone S, Kloka JA, Jennewein L, Louwen F, Zacharowski K, Raimann FJ. Management and Outcome of Women with Placenta Accreta Spectrum and Treatment with Uterine Artery Embolization. J Clin Med 2024; 13:1062. [PMID: 38398377 PMCID: PMC10888708 DOI: 10.3390/jcm13041062] [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: 12/31/2023] [Revised: 02/02/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Placenta accreta spectrum (PAS) disorders are a continuum of placental pathologies with increased risk for hemorrhage, blood transfusion and maternal morbidity. Uterine artery embolization (UAE) is a safe approach to the standardization of complex PAS cases. The aim of this study is to analyze anemia and transfusion rate, outcome and anesthesiological management of women who underwent caesarean delivery with subsequent UAE for the management of PAS. MATERIAL AND METHODS This retrospective observational study included all pregnant women admitted to the University Hospital Frankfurt between January 2012 and September 2023, with a diagnosis of PAS who underwent a two-step surgical approach for delivery and placenta removal. Primary procedure included cesarean delivery with subsequent UAE, secondary procedure included placenta removal after a minim of five weeks via curettage or HE. Maternal characteristics, anesthesiological management, complications, anemia rate, blood loss and administration of blood products were analyzed. RESULTS In total, 17 women with PAS were included in this study. Of these, 5.9% had placenta increta and 94.1% had placenta percreta. Median blood loss was 300 (200-600) mL during primary procedure and 3600 (450-5500) mL during secondary procedure. In total, 11.8% and 62.5% of women received red blood cell transfusion during the primary and secondary procedures, respectively. After primary procedure, postpartum anemia rate was 76.5%. The HE rate was 64.7%. Regional anesthesia was used in 88.2% during primary procedure. CONCLUSION The embolization of the uterine artery for women diagnosed with PAS is safe. Anemia management and the implementation of blood conservation strategies are crucial in women undergoing UAE for the management of PAS.
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Affiliation(s)
- Vanessa Neef
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
| | - Armin N. Flinspach
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
| | - Katrin Eichler
- Department of Interventional Radiology, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany;
| | - Tirza R. Woebbecke
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
| | - Stephanie Noone
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
| | - Jan A. Kloka
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
| | - Lukas Jennewein
- Department of Obstetrics and Perinatal Medicine, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (L.J.); (F.L.)
| | - Frank Louwen
- Department of Obstetrics and Perinatal Medicine, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (L.J.); (F.L.)
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
| | - Florian J. Raimann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; (A.N.F.); (T.R.W.); (S.N.); (J.A.K.); (K.Z.); (F.J.R.)
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4
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Sebastian B, Rajesh U, Scott PM, Sayeed S, Robinson GJ, Ettles DF, Shrivastava V, Lakshminarayan R. Prophylactic Uterine Artery Embolization in Placenta Accreta Spectrum-An Active Intervention to Reduce Morbidity and Promote Uterine Preservation. J Vasc Interv Radiol 2023; 34:1922-1928. [PMID: 37517463 DOI: 10.1016/j.jvir.2023.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/11/2023] [Accepted: 07/21/2023] [Indexed: 08/01/2023] Open
Abstract
PURPOSE To evaluate the feasibility and safety of early and proactive involvement of interventional radiology (IR) in the management of placenta accreta spectrum (PAS) by performing the cesarean operation and prophylactic uterine artery embolization in the IR angiography suite as a combined procedure. MATERIALS AND METHODS This study evaluated the effectiveness and safety of prophylactic uterine artery embolization prior to placental separation in cases of antenatally proven or suspected abnormal placentation. Over a 5-year period, 16 consecutive patients with PAS underwent combined IR and obstetric intervention. In all cases, cesarean delivery was performed in the IR angiography suite. Vascular access was obtained prior to surgery with balloon placement into both internal iliac arteries. These balloons were inflated after delivery, followed by uterine artery embolization (14 of 16) if there was evidence of active postpartum bleeding or inability to deliver the placenta. RESULTS There was no fetal or maternal mortality and no significant IR or surgical adverse events. Mean blood loss was 1900 mL. Seven patients (44%) underwent hysterectomy. CONCLUSIONS In patients with PAS, cesarean section in the angiography suite preceded by prophylactic balloon placement and followed by uterine artery embolization was feasible, safe, and effective in preventing massive blood loss, with a 56% uterine sparing rate.
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Affiliation(s)
- Bibin Sebastian
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Uma Rajesh
- Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Paul M Scott
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Saira Sayeed
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Graham J Robinson
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Duncan F Ettles
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Vivek Shrivastava
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Raghuram Lakshminarayan
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom.
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5
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Einerson BD, Gilner JB, Zuckerwise LC. Placenta Accreta Spectrum. Obstet Gynecol 2023; 142:31-50. [PMID: 37290094 PMCID: PMC10491415 DOI: 10.1097/aog.0000000000005229] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/08/2023] [Indexed: 06/10/2023]
Abstract
Placenta accreta spectrum (PAS) is one of the most dangerous conditions in pregnancy and is increasing in frequency. The risk of life-threatening bleeding is present throughout pregnancy but is particularly high at the time of delivery. Although the exact cause is unknown, the result is clear: Severe PAS distorts the uterus and surrounding anatomy and transforms the pelvis into an extremely high-flow vascular state. Screening for risk factors and assessing placental location by antenatal ultrasonography are essential for timely diagnosis. Further evaluation and confirmation of PAS are best performed in referral centers with expertise in antenatal imaging and surgical management of PAS. In the United States, cesarean hysterectomy with the placenta left in situ after delivery of the fetus is the most common treatment for PAS, but even in experienced referral centers, this treatment is often morbid, resulting in prolonged surgery, intraoperative injury to the urinary tract, blood transfusion, and admission to the intensive care unit. Postsurgical complications include high rates of posttraumatic stress disorder, pelvic pain, decreased quality of life, and depression. Team-based, patient-centered, evidence-based care from diagnosis to full recovery is needed to optimally manage this potentially deadly disorder. In a field that has relied mainly on expert opinion, more research is needed to explore alternative treatments and adjunctive surgical approaches to reduce blood loss and postoperative complications.
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Affiliation(s)
- Brett D Einerson
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, Utah; Duke University, Durham, North Carolina; and Vanderbilt University Medical Center, Nashville, Tennessee
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