Placenta accreta spectrum disorders - detection rate and maternal outcomes following implementation of an institutional protocol

Conservative management or cesarean hysterectomy for placenta accreta spectrum in middle-income countries: A systematic review and meta-analysis

BACKGROUND

Cesarean hysterectomy is a dominant and effective approach during delivery in patients with placenta accreta spectrum (PAS). However, as hysterectomy results in a loss of fertility, conservative management is an alternative approach. However, management selection may be affected by a country's overall economic level. Thus the preferred treatment for PAS generates controversy in middle-income countries.

OBJECTIVES

We aimed to compare conservative management and cesarean hysterectomy for managing PAS in middle-income countries.

SEARCH STRATEGY

China National Knowledge Infrastructure, Wanfang Med Online Databases, Cochrane Library, Ovid MEDLINE, PubMed, Web of Science, EMBASE, clinicaltrials.gov, and Scopus were searched from inception through to October 1, 2022.

SELECTION CRITERIA

We included studies that evaluated at least one complication comparing conservative management and hysterectomy. All cases were diagnosed with PAS prenatally and intraoperatively.

DATA COLLECTION AND ANALYSIS

The primary outcomes were blood loss, adjacent organ damage, and the incidence of hysterectomy. Descriptive analyses were conducted for studies that did not meet the meta-analysis criteria. A fixed-effects model was used for studies without heterogeneity and a random-effects model was used for studies with statistical heterogeneity.

MAIN RESULTS

In all, 11 observational studies were included, with 975 and 625 patients who underwent conservative management and cesarean hysterectomy, respectively. Conservative management was significantly associated with decreased blood loss and lower risks of adjacent organ injury and hysterectomy. Conservative management significantly reduced blood transfusions, hospitalization duration, operative time, intensive care unit admission rates, and infections. There were no significant differences in the risks of coagulopathy, thromboembolism, or reoperation.

CONCLUSION

Given short-term complications and future fertility preferences for patients, conservative management appears to effectively manage PAS in middle-income countries. Owing to low levels of evidence, high heterogeneity and insufficient long-term follow-up data, further detailed studies are warranted.

Successful multidisciplinary team management of placenta accreta spectrum disorder: A referral center model in a middle-income country

OBJECTIVE

The aim of the study was to evaluate the outcomes of placenta accreta spectrum (PAS) disorder managed by a multidisciplinary care team (MCT) compared with a conventional care team (CCT) in a PAS referral center in Thailand.

METHODS

This retrospective single-center cohort study analyzed PAS management outcomes in the PSU PAS Center between January 2010 and December 2022. The incidence of hemorrhage ≥3500 mL and the composite maternal and neonatal outcomes of PAS were compared before and after the introduction of an MCT in 2016.

RESULTS

Of 227 PAS cases, 219 (96.5%) had pathological confirmation. There were 52 (22.9%) cases of placenta accreta, 119 (52.4%) cases of placenta increta, and 56 (24.7%) cases of placenta percreta. The incidence of estimated blood loss (EBL) ≥3500 mL decreased from 61.8% to 34.3% (P < 0.001) after the establishment of the MCT. The median EBL decreased from 4000 (IQR: 2600,7250) mL to 2250 (1300, 4750) mL (P < 0.001). EBL reduction was statistically significant in the accreta and increta groups (P < 0.001). Red blood cell transfusions decreased from five (3, 9) to two (1, 6) units (P < 0.001) per patient. The length of maternal hospital stays and ICU admissions were statistically shorter when PAS was managed by an MCT (P < 0.001). The length of newborn hospital and ICU stays decreased significantly (P < 0.001).

CONCLUSION

The incidence of massive postpartum hemorrhage and a composite of maternal and neonatal morbidities in pregnant women with PAS disorder improved significantly after the establishment of an MCT to manage PAS in a middle-income country setting.

Regional multidisciplinary team approach to the management of placenta accreta spectrum disorder

OBJECTIVE

Patients with suspected placenta accreta spectrum (PAS) disorder are often referred to specialized medical centers for antepartum management and definitive treatment via cesarean hysterectomy. In 2019, our institution formed the only multidisciplinary team for the management of PAS within two of the largest counties in California. The purpose of this study was to evaluate the effects of the multidisciplinary team on patient volume and surgical outcomes for patients with PAS.

METHODS

This was a single center retrospective cohort study, based in the only tertiary referral center within two of the largest counties in California. Patients who underwent cesarean hysterectomy for suspected PAS from January 2014 to April 2021 were included and divided into two groups, based on management by the multidisciplinary team from January 2019 and onward or routine care prior to that time. The outcomes of interest were quantitative blood loss, total units of packed red blood cell transfusion, referral volume, and diagnostic accuracy as well as ICU admission, bladder injury, and postoperative length of stay. Furthermore, we wanted to determine if patient's distance to the hospital impacted outcomes. Normally distributed variables were compared between groups using the t-test. Categorical variables were compared between the two groups using the chi square test.

RESULTS

A total of 114 patients were included in the cohort, 59 patients were from January 2014 to December 2018 and 55 patients were from January 2019 to April 2021. Since the establishment of the multidisciplinary center, there was a 2.5-fold increase in the total patient volume (0.8 case/month to 2 cases/month) and a 2.8-fold increase in the referred patient volume. Patients undergoing cesarean hysterectomy since the establishment of the multidisciplinary team had less quantitative blood loss (1500 mL vs 2000 mL, p = .005) and required less units of packed red blood cell transfusion (2 vs 4 units, p < .001). In addition, blood loss of ≥2000 mL decreased from 57.6% to 38.2% (p = .04) and diagnostic accuracy improved from 35.6% to 83.6% (p < .001). Furthermore, we found that patient distance to the hospital did not significantly impact surgical outcomes.

CONCLUSIONS

Since the establishment of the multidisciplinary team, our center experienced an increase in PAS volume and was able to demonstrate a statistically significant improvement in patient outcomes.

Expected Versus Unexpected Delivery for Placenta Accreta Spectrum (PAS) Disorders with Same Team in Single Tertiary Center

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.

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

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.

The role of fetal fibronectin and plasminogen activator inhibitor 1 biomarkers in antenatal prediction of placenta accreta spectrum

In this study, we aimed to assess the determining role of foetal fibronectin (FFN) and plasminogen activator inhibitor type (PAI-1) levels in the antenatal prediction of placenta accreta spectrum in cases with risk factors for placenta accreta spectrum. Singleton live pregnancies with placenta previa or low-lying placenta within 32-34 weeks of gestation were included in the study. The cases were divided into two groups after delivery as those with PAS and those with normal placentation. 54 cases diagnosed with placenta previa or low-lying placenta were included in the study. 17 of the cases underwent peripartum hysterectomy due to placenta accreta spectrum. 37 cases with normal placentation underwent caesarean delivery. Foetal fibronectin (p:.03) and PAI-1 (p:.02) levels were determined to be significantly different between cases with placenta accreta spectrum and cases with normal placentation. AUC for foetal FFN was calculated to be 0.69, while the AUC for, PAI-1was 0.66. Results for both FFN and PAI-1 were not found useful enough for the diagnosis of PAS. IMPACT STATEMENTWhat is already known on this subject? We lack biomarkers which can identify placenta accreta spectrum.What do the results of this study add? Maternal plasma levels of FFN and PAI-1 significantly altered in PASWhat are the implications of these findings for clinical practice and/or future research? If multiple of median values of FFN and PAI-1 levels in maternal blood are determined in future studies, it can be used in the antenatal diagnosis of PAS cases.

Neuraxial to general anesthesia conversion has equitable intraoperative and improved post-operative outcomes compared to general anesthesia in cesarean hysterectomy for placenta accreta spectrum (PAS)

OBJECTIVE

Placenta Accreta Spectrum (PAS) represents a series of placental disorders with an estimated incidence of 1:1000. Delivery and subsequent cesarean hysterectomy for PAS is associated with significant maternal morbidity and mortality. Neuraxial anesthesia may be utilized initially with subsequent conversion to general anesthesia after delivery of the fetus as an alternative to initiating with general anesthesia.

METHODS

We performed a case-control study and analyzed 85 cases of pathology-confirmed PAS patients who underwent a cesarean hysterectomy in singleton, non-anomalous, viable pregnancies. All patients were delivered at our institution's established Placenta Accreta Program from 2005 to 2020.

RESULTS

Fifty-two (61%) patients underwent general anesthesia and 33 (39%) patients underwent neuraxial anesthesia (collectively spinal, epidural, and combined spinal-epidural) converted to general anesthesia after cesarean delivery. Baseline demographics between groups were similar. Pre-operative ASA airway assessment of III/IV was equivalent between groups (94 and 82%, p = .08). Intraoperatively, neuraxial conversion and general anesthesia were equal with respect to operative time (241 vs. 261 min, p = .47), estimated blood loss (6039 vs. 8134 mL, p = .51), and composite maternal morbidity (84.6 vs. 75.8%, p = .40). Post-operatively, ICU admission (47 vs. 46%, p = 1.0) and intensive care length of stay was equivalent (p = .07), yet the total post-operative length of stay was significantly reduced in patients who underwent neuraxial anesthesia (3.76 vs. 6.35 days, p = .02). In addition, while general anesthesia was associated with a greater sonographic suspicion for placenta percreta (40 vs. 12%, p = .007), final pathology was equivalent (52 vs. 60%, p = .5).

CONCLUSIONS

Taken together, our data show neuraxial conversion to general anesthesia has equivalent intra-operative parameters with improved post-operative outcomes when compared to general anesthesia alone in the case of cesarean hysterectomy for Placenta Accreta Spectrum disorders.