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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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2
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Bartels HC, Downey P, Brennan DJ. Looking back to look forward: Has the time arrived for active management of obstetricians in placenta accreta spectrum? Int J Gynaecol Obstet 2024. [PMID: 39045676 DOI: 10.1002/ijgo.15826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 07/10/2024] [Accepted: 07/15/2024] [Indexed: 07/25/2024]
Abstract
Placenta accreta spectrum (PAS) is a relatively new obstetric condition which, until recently, was poorly understood. The true incidence is unknown because of the poor quality and heterogeneous diagnostic criteria. Classification systems have attempted to provide clarity on how to grade and diagnose PAS, but these are no longer reflective of our current understanding of PAS. This is particularly true for placenta percreta, which referred to extrauterine disease, as recent studies have demonstrated that placental villi associated with PAS have minimal potential to invade beyond the uterine serosa. It is accepted that PAS is a direct consequence of previous iatrogenic uterine injury, most commonly a previous cesarean section. Here, we "look back to look forwards"-starting with the primary predisposing factor for PAS, an iatrogenic uterine injury and subsequent wound healing. We then consider the evolution of definitions and diagnostic criteria of PAS from its first description over a century ago to current classifications. Finally, we discuss why modifications to the current classifications are needed to allow accurate diagnosis of this rare but life-threatening complication, while avoiding overdiagnosis and potential patient harm.
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Affiliation(s)
- Helena C Bartels
- Department of University College Dublin Obstetrics and Gynaecology, School of Medicine, National Maternity Hospital, Dublin, Ireland
| | - Paul Downey
- Department of Histopathology, National Maternity Hospital, Dublin, Ireland
| | - Donal J Brennan
- University College Dublin Gynaecological Oncology Group (UCD-GOG), Mater Misericordiae University Hospital and St Vincent's University Hospital, Dublin, Ireland
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Palacios-Jaraquemada JM, Nieto-Calvache AJ, Savukyne E, Pellegrinelli JM, de Tejada BM. Why isn't one-step conservative surgery used more frequently to treat women with placenta accreta spectrum? Acta Obstet Gynecol Scand 2024. [PMID: 38856302 DOI: 10.1111/aogs.14897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 05/28/2024] [Accepted: 05/29/2024] [Indexed: 06/11/2024]
Affiliation(s)
| | - Albaro Jose Nieto-Calvache
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cali, Colombia
- Amsterdam University Medical Center, Doctoral School, Amsterdam, The Netherlands
| | - Egle Savukyne
- Department of Obstetrics and Gynecology, Medicine Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jean-Maria Pellegrinelli
- Obstetrics Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Begoña Martinez de Tejada
- Obstetrics Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Abouda SH, Aloui H, JAOUAD H, MARZOUK SB, Frikha H, Hammami R, Channoufi MB, Maghrebi H. Prophylactic occlusion balloons of both internal iliac arteries in caesarean hysterectomy for placenta accreta spectrum disorder reduces blood loss: A retrospective comparative study. Eur J Obstet Gynecol Reprod Biol X 2024; 22:100310. [PMID: 38736526 PMCID: PMC11087949 DOI: 10.1016/j.eurox.2024.100310] [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: 03/31/2024] [Revised: 04/12/2024] [Accepted: 04/25/2024] [Indexed: 05/14/2024] Open
Abstract
Background The placenta accreta spectrum is a complex disorder characterized by abnormal invasion of the placenta into the uterine wall, posing a significant risk of life-threatening haemorrhage for patients. Its incidence is on the rise, largely attributed to the increasing rates of caesarean sections. Management of this spectrum involves a multidisciplinary approach, although standardized protocols are not yet established. While caesarean hysterectomy remains the standard Gold, several adjunctive treatments have emerged in recent years to mitigate bleeding risk and associated morbidity. Among these, prophylactic occlusion balloons placed in the internal iliac arteries have shown promise. The aim of our study is to demonstrate the effect of prophylactic occlusion balloons in both uterine iliac arteries in the management of placental accreta spectrum disorders. Methods A retrospective monocentric cohort study was conducted in the Department "C" of Gynaecology and Obstetrics at the Maternity Center of Tunis. The study spanned three years, from January 2nd, 2020, to December 31st, 2022. The study population consisted of two groups: Control Group (CG) comprised patients who underwent caesarean hysterectomy without internal-iliac prophylactic occlusion balloons, and Occlusion balloons of both internal iliac arteries Group (OBIIAG) included patients who underwent caesarean hysterectomy with internal-iliac prophylactic occlusion balloons. Results A total of 38 patients were included in the study, all of whom exhibited similar epidemiological characteristics and comparable personal and obstetric histories. The most prevalent risk factor among the patients was a history of caesarean section (92%). On average, patients were diagnosed at 30 weeks of gestation, with third-trimester bleeding being the most common presentation (71% of cases). The median gestational age at delivery was between 36 and 37 weeks. We observed a significant difference in blood loss between the two groups (2888 ml in the control group and 1828 ml in the group with internal-iliac prophylactic occlusion balloons, p < 0.05). Implementation of this technique resulted in a reduced need for massive transfusions (p < 0.01) and shorter operating times (126 min for the control group and 92 min for the group with internal-iliac prophylactic occlusion balloons; p = 0.04). There were no significant differences in morbidity between the two groups. Conclusion The intra-iliac prophylactic occlusion balloons can help reduce the risk of hemorrhage and the morbidities that come with the placenta accreta spectrum disorder.
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Affiliation(s)
- Saber Hassine Abouda
- Tunis Maternity and Neonatology Center/Department ‘C′of Gynecology and Obstetrics, Tunisia
| | - Haithem Aloui
- Tunis Maternity and Neonatology Center/Department ‘C′of Gynecology and Obstetrics, Tunisia
| | - Hadhami JAOUAD
- Tunis Maternity and Neonatology Center/Department ‘C′of Gynecology and Obstetrics, Tunisia
| | - Sofiene B. MARZOUK
- Tunis Maternity and Neonatology Center/Department of Anaesthesiology and Intensive Care, Tunisia
| | - Hatem Frikha
- Tunis Maternity and Neonatology Center/Department ‘C′of Gynecology and Obstetrics, Tunisia
| | - Rami Hammami
- Tunis Maternity and Neonatology Center/Department ‘C′of Gynecology and Obstetrics, Tunisia
| | | | - Hayen Maghrebi
- Tunis Maternity and Neonatology Center/Department of Anaesthesiology and Intensive Care, Tunisia
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Nieto-Calvache ÁJ, Aryananda RA, Palacios-Jaraquemada JM, Cininta N, Grace A, Benavides-Calvache JP, Campos CI, Messa-Bryon A, Vallecilla L, Sarria D, Galindo JS, Galindo-Velasco V, Rivera-Torres LF, Burgos-Luna JM, Bhide A. One-step conservative surgery vs hysterectomy for placenta accreta spectrum: a feasibility randomized controlled trial. Am J Obstet Gynecol MFM 2024; 6:101333. [PMID: 38458362 DOI: 10.1016/j.ajogmf.2024.101333] [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: 02/12/2024] [Accepted: 02/21/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Placenta accreta spectrum is a serious condition associated with significant maternal morbidity and even mortality. The recommended treatment is hysterectomy. An alternative is 1-step conservative surgery, which involves the en bloc resection of the myometrium affected by placenta accreta spectrum along with the placenta, followed by uterine reconstruction. Currently, there are no studies comparing the 2 techniques in the setting of a randomized controlled trial. OBJECTIVE We performed a prospectively registered multicenter randomized controlled trial comparing hysterectomy with 1-step conservative surgery. The aim was to collect feasibility and clinical outcomes of the 2 techniques in women assigned to hysterectomy or 1-step conservative surgery. In addition to assessing participants' willingness to be randomized, we also collected data on intraoperative blood loss, transfusion requirement, serious adverse event, and other clinical outcomes. STUDY DESIGN Sixty women with strong antenatal suspicion of placenta accreta spectrum were assigned randomly to either hysterectomy (n=31) or 1-step conservative surgery (n=29). RESULTS During a 20-month period, 60 of the 64 eligible patients (93.7%) underwent randomization. Intention-to-treat analysis showed that the clinical outcomes for 1-step conservative surgery were comparable to those of hysterectomy (median intraoperative blood loss, 1740 mL [interquartile range, 1010-2410] vs 1500 mL [interquartile range, 1122-2753]; odds ratio, 1 [1-1]; P=.942; median duration of surgery, 135 minutes [interquartile range, 111-180] vs 155 minutes [interquartile range, 120-185]; odds ratio, 0.99 [0.98-1]; P=.151; transfusion rate, 58.6% vs 61.3%; odds ratio, 0.96 [0.83-1.76]; P=.768; and adverse event rate, 17.2% vs 9.7%; odds ratio, 1.77 [0.43-10.19]; P=.398; respectively). In the subgroup of women with type 1 class on topographic classification, all participants allocated to 1-step surgery had successful outcomes, which were superior to those of hysterectomy. This was evidenced by the shorter surgery duration (median, 125 [interquartile range, 98-128] vs 180 [129-226] minutes; P=.002), lower transfusion rates (46.2% vs 82.4%), and fewer units of red blood cells transfused (median, 1 [interquartile range, 1-1.8] vs 3 [interquartile range, 2-4] units; P=.007). CONCLUSION A randomized controlled trial comparing 2 surgical techniques for the treatment of placenta accreta spectrum is feasible. One-step conservative repair is a valid alternative to hysterectomy in the large majority of cases, but this can only be ascertained following intraoperative surgical staging. El resumen está disponible en Español al final del artículo.
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Affiliation(s)
- Álbaro José Nieto-Calvache
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Benavides-Calvache, Messa-Bryon, and Burgos-Luna).
| | - Rozi Aditya Aryananda
- Obstetrics & Gynecology department of Dr. Soetomo General Academic Teaching Hospital, Universitas Airlangga, Surabaya, Indonesia (Drs Aryananda and Cininta)
| | | | - Nareswari Cininta
- Obstetrics & Gynecology department of Dr. Soetomo General Academic Teaching Hospital, Universitas Airlangga, Surabaya, Indonesia (Drs Aryananda and Cininta)
| | - Ariani Grace
- Anatomical Pathology Department, Dr. Soetomo General Hospital, Universitas Airlangga, Surabaya, Indonesia (Dr Grace)
| | - Juan Pablo Benavides-Calvache
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Benavides-Calvache, Messa-Bryon, and Burgos-Luna)
| | - Clara Ivette Campos
- Departamento de Patología, Fundación Valle del Lili, Cali, Colombia (Dr Campos)
| | - Adriana Messa-Bryon
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Benavides-Calvache, Messa-Bryon, and Burgos-Luna)
| | - Liliana Vallecilla
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia (Drs Vallecilla, Sarria, Galindo, and Galindo-Velasco)
| | - Daniela Sarria
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia (Drs Vallecilla, Sarria, Galindo, and Galindo-Velasco)
| | - Juan Sebastian Galindo
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia (Drs Vallecilla, Sarria, Galindo, and Galindo-Velasco)
| | - Valentina Galindo-Velasco
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia (Drs Vallecilla, Sarria, Galindo, and Galindo-Velasco)
| | | | - Juan Manuel Burgos-Luna
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Benavides-Calvache, Messa-Bryon, and Burgos-Luna)
| | - Amarnath Bhide
- Fetal Medicine Unit, Division of Developmental Sciences, St George's, University of London, London, United Kingdom (Dr Bhide)
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Nieto-Calvache AJ, Palacios-Jaraquemada JM, Hussein AM, Jauniaux E, Milani Coutinho C, Rijken M. Management of placenta accreta spectrum in low- and middle-income countries. Best Pract Res Clin Obstet Gynaecol 2024; 94:102475. [PMID: 38452606 DOI: 10.1016/j.bpobgyn.2024.102475] [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: 10/10/2023] [Revised: 01/16/2024] [Accepted: 02/05/2024] [Indexed: 03/09/2024]
Abstract
Placenta accreta spectrum (PAS) can be associated massive intra- and post-operative hemorrhage which when not controlled can lead to maternal death. Important advances have occurred in understanding the pathophysiology and therapeutic options for this condition. The prevalence of PAS at birth is direct association with the cesarean delivery (CD) rate in the corresponding population and is increasing worldwide. Limited health infrastructure in low- and middle-income countries increases the morbidity and mortality of patients with PAS at birth. In many cases, obstetricians working in limited resources settings cannot follow some of the international guideline's recommendations and have to opt for low-cost management procedures. In this review, we describe the particularities of managing PAS care in low- and middle-income countries from of prenatal evaluation of patients at risk of PAS at birth, therapeutic options, and inter-institutional collaboration. We also propose a management protocol based on training of the local obstetric teams rather than on sophisticated technological resources that are almost never available in low-resource scenarios.
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Affiliation(s)
- Albaro José Nieto-Calvache
- Fundación Valle Del Lili, Departamento de Ginecología y Obstetricia, Cra 98 No. 18 - 49, Cali, 760032, Colombia; Amsterdam University Medical Center, Amsterdam, 1007, the Netherlands.
| | | | - Ahmed M Hussein
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, 12613, Egypt; Faculty of Medicine, Department of Obstetrics and Gynecology, University of Cairo, Cairo, 12613, Egypt
| | - Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, WC1E 6AU, UK
| | - Conrado Milani Coutinho
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, 14040-900, SP, Brazil
| | - Marcus Rijken
- Amsterdam University Medical Center, Amsterdam, 1007, the Netherlands; Vrouw & Baby, University Medical Centre Utrecht, Utrecht University, Utrecht, 3584, the Netherlands; Antoni van Leeuwenhoek hospital, Amsterdam, the Netherlands
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Fox KA. Moving the needle forward in Evidence-Based Care for Placenta Accreta Spectrum. Am J Obstet Gynecol MFM 2024; 6:101365. [PMID: 38719699 DOI: 10.1016/j.ajogmf.2024.101365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 06/15/2024]
Affiliation(s)
- Karin A Fox
- Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, TX.
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Wagner W, Loichinger M, Sidebottom AC, Wunderlich WL, Vacquier M, Jentink T, Aguilera MN, Ahanya SN, Morgan E, Parker M, Wothe DD. Implementation and Outcomes of a Model of Care for Placenta Accreta Spectrum in a Community-Based Private Practice. Am J Perinatol 2024; 41:1008-1018. [PMID: 35815573 PMCID: PMC11105945 DOI: 10.1055/s-0042-1749664] [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: 03/16/2021] [Accepted: 02/17/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE The aim of the study is to describe a model of care and outcomes for placenta accreta spectrum (PAS) implemented in the context of a community based non-academic health system. STUDY DESIGN The program for management of PAS includes a multidisciplinary team approach with protocols for ultrasound assessment, diagnosis, and surgery. The program was implemented in the two largest private hospitals in the Twin Cities, Minnesota, United States. Maternal and fetal outcomes as well as cost were compared for histopathologic confirmed PAS cases before (2007-2014, n = 41) and after (2015-2017, n = 26) implementation of the PAS program. RESULTS Implementation of the PAS program was associated with ICU admission reductions from 53.7 to 19.2%, p = 0.005; a decrease of 1,682 mL in mean estimated blood loss (EBL) (p = 0.061); a decrease in transfusion from 85.4 to 53.9% (p = 0.005). The PAS program also resulted in a (non-significant) decrease in both surgical complications from 48.8 to 38.5% (p = 0.408) and postoperative complications from 61.0 to 42.3% (p = 0.135). The total cost of care for PAS cases in the 3 years after implementation of the program decreased by 33%. CONCLUSION The implementation of a model of care for PAS led by a perinatology practice at a large regional non-academic referral center resulted in reductions of ICU admissions, operating time, transfusion, selected surgical complications, overall postoperative complications, and cost. KEY POINTS · Implementation of a PAS care model resulted in reduced ICU admissions from 53.7% to 19.2%.. · Patient safety increased by reducing blood loss, transfusions and postoperative complications.. · This model decreased operating time, as well as total cost of care by 33%..
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Affiliation(s)
- William Wagner
- Minnesota Perinatal Physicians, Allina Health, Minneapolis, Minnesota
| | | | | | | | - Marc Vacquier
- Care Delivery Research, Allina Health, Minneapolis, Minnesota
| | - Theresa Jentink
- Minnesota Perinatal Physicians, Allina Health, Minneapolis, Minnesota
| | | | | | - Elizabeth Morgan
- Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Women's Health, University of Minnesota, Minneapolis, Minnesota
| | - Meiling Parker
- Health Partners Maternal Fetal Medicine, St. Paul, Minnesota
| | - Donald D Wothe
- Health Partners Maternal Fetal Medicine, St. Paul, Minnesota
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Vuong ADB, Pham TH, Pham XTT, Truong DP, Nguyen XT, Trinh NB, Nguyen DV, Nguyen YON, Nguyen TNTN, Ho QN, Nguyen PN. Modified one-step conservative uterine surgery (MOSCUS) versus cesarean hysterectomy in the management of placenta accreta spectrum: A single-center retrospective analysis based on 619 Vietnamese pregnant women. Int J Gynaecol Obstet 2024; 165:723-736. [PMID: 38009657 DOI: 10.1002/ijgo.15220] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 09/27/2023] [Accepted: 10/12/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVES To compare maternal outcome measures in surgical management of placenta accreta spectrum (PAS)-the modified one-step conservative uterine surgery (MOSCUS), a new approach at Tu Du Hospital in Vietnam, versus cesarean hysterectomy, and to identify factors that appear to contribute to the successful outcome of the MOSCUS. METHODS This retrospective study was conducted at Tu Du Hospital in southern Vietnam between January 2019 and December 2020. The study enrolled all pregnant women at more than 28 weeks of pregnancy with a diagnosis of PAS who underwent either a cesarean hysterectomy or a uterus-preserving approach using the MOSCUS method. RESULTS The prevalence of PAS at our single tertiary referral hospital was 0.4% (619 PAS cases/132 518 births) in 2 years. Among 296 patients, the surgical time duration, estimated blood loss, and red blood cell transfusion in the MOSCUS group (n = 217) were all significantly less than in the cesarean hysterectomy group (n = 79) (152.72 ± 42.23 vs 185.13 ± 58.22 min, 1000 vs 1500 mL, and 500 vs 710 mL, respectively). Intraoperatively, the rate of visceral injuries in the hysterectomy group was higher than that in the MOSCUS group (P < 0.001). However, the rate of postoperative infection was higher in the MOSCUS group than in the cesarean hysterectomy group (P = 0.012). Of a total of 217 cases managed using the MOSCUS management, 24 required a secondary hysterectomy; the success rate was 88.9% (95% confidence interval [CI] 84.3%-93.1%). Some of the primary factors associated with the success of MOSCUS included maternal age less than 35 years, planned surgery, severity of PAS, and estimated blood loss during surgery (odds ratio [OR] 5.16, 95% CI 1.96-13.59; OR 3.05, 95% CI 1.08-8.62; OR 3.62, 95% CI 1.19-10.98; and OR 49.66, 95% CI 11.16-221.02, respectively; P < 0.05). CONCLUSION MOSCUS is an acceptable alternative to cesarean hysterectomy in many patients diagnosed with PAS. This new surgical management of PAS resulted in the preservation of the uterus, and a favorable outcome in nearly 9 out of 10 pregnant women. We believe that MOSCUS can be safely offered for the management of PAS in referral hospital settings.
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Affiliation(s)
- Anh Dinh Bao Vuong
- Department of High-Risk Pregnancy, Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Thanh Hai Pham
- Tu Du Clinical Research Unit (TD-CRU), Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Xuan Trang Thi Pham
- Department of High-Risk Pregnancy, Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Diem Phuong Truong
- Department of Obstetrics Bloc M, Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Xuan Trang Nguyen
- Department of High-Risk Pregnancy, Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Ngoc Bich Trinh
- Department of High-Risk Pregnancy, Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Dinh Vinh Nguyen
- Department of High-Risk Pregnancy, Tu Du Hospital, Ho Chi Minh City, Vietnam
| | | | | | - Quang Nhat Ho
- Department of Postoperative Care Bloc A, Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Phuc Nhon Nguyen
- Department of High-Risk Pregnancy, Tu Du Hospital, Ho Chi Minh City, Vietnam
- Tu Du Clinical Research Unit (TD-CRU), Tu Du Hospital, Ho Chi Minh City, Vietnam
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Dawood AS, Dawood AS, Shazly SA, Assar TM, Soliman AS. Retracted: A randomized controlled study comparing two uterine sparing techniques in conservative management of placenta accreta spectrum. Int J Gynaecol Obstet 2024; 165:1-8. [PMID: 35986615 DOI: 10.1002/ijgo.14419] [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: 11/02/2021] [Revised: 07/30/2022] [Accepted: 08/10/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To compare the efficacy and safety of two uterine sparing techniques in conservative management of placenta accreta spectrum (PAS). METHODS This multicenter randomized controlled study was conducted from January 1, 2017 to December 31, 2020 at two university hospitals. Patients were randomly allocated into two groups; Group 1 was managed by Assar's technique and Group 2 was managed by Shehata's technique. Operative time, blood loss, operative complications (organ or vessel injury), and postoperative complications (early and late) were reported. Success of the technique, units of blood transfusion, and intensive care unit admissions were recorded. RESULTS Demographic data in both groups were not significantly different. The mean gestational age at the delivery time was 36 weeks in both groups. Operative time was 120 (100-140) minutes and 75 (60-100) minutes in Assar's and Shehata's techniques, respectively (P < 0.001). Blood loss was higher in Shehata's technique than in Assar's (P < 0.001). Intensive care unit admissions were minimal in both groups. Operative complications were comparable in both groups. The success of Assar's and Shehata's techniques in uterine preservation was 85% and 95%, respectively. CONCLUSION Both techniques were safe and successful in uterine sparing. Therefore, we recommend these techniques for conservative management of PAS. CLINICAL TRIAL REGISTRATION The trial was registered on UMIN-CTR and had the unique ID: UMIN000025315 on the following link: https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000029120.
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11
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Barinov SV, Di Renzo GC. A new technique to preserve the uterus in patients with placenta accreta spectrum disorders. Am J Obstet Gynecol 2024; 230:S1107-S1115. [PMID: 37661498 DOI: 10.1016/j.ajog.2023.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 07/07/2023] [Accepted: 07/09/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Placenta accreta spectrum disorders are associated with substantial maternal morbidity and mortality. Despite a preoperative diagnosis, the rate of complications remains high, and the condition is generally associated with the need for a hysterectomy. OBJECTIVE This study aimed to evaluate the outcomes of a new uterine-preserving technique (called the combined approach, including surgical hemostasis, bilateral ligation of the descending branches of the uterine arteries, and hemostatic external supraplacental stitch with the use of the Zhukovsky double-balloon tamponade in patients with placenta accreta spectrum disorders) during cesarean delivery in women with placenta accreta spectrum disorders vs the surgical technique used until 2014. STUDY DESIGN This retrospective cohort study included 147 patients with placenta accreta spectrum disorders who were divided into 2 groups: the study group (n=95) is to undergo cesarean delivery using the combined approach, and the control group (n=52) is to undergo the surgical technique used until 2014, which included bilateral uterine artery ligation, which is the transfusion of plasma, red blood cells, platelets, and protease inhibitors. RESULTS The volume of blood loss was 1.5-fold lower (P=.0010), the number of blood transfusions was 5.1-fold lower (P=.026), and the rate of bladder injuries was 19-fold lower (P=.012) in the study group than that in the control group. The duration of hospital stay after delivery was 4 days lesser (P=.001) and the number of hysterectomies was 4.5-fold lower in the study group than in the control group (P=.023). The study groups did not differ in terms of placenta accreta spectrum type. CONCLUSION The combined approach during cesarean delivery proved to be more effective than the surgical technique used until 2014 in reducing the number of hysterectomies, blood loss volume, number of blood transfusions, and duration of hospital stay in patients with placenta accreta spectrum disorders.
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Affiliation(s)
- Sergey V Barinov
- Department of Obstetrics and Gynecology No.2, Omsk State Medical University, Omsk, Russia
| | - Gian Carlo Di Renzo
- Department of Medicine, Centre of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy.
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Aryananda RA, Duvekot JJ, Van Beekhuizen HJ, Cininta NI, Ariani G, Dachlan EG. Transabdominal and transvaginal ultrasound findings help to guide the clinical management of placenta accreta spectrum cases. Acta Obstet Gynecol Scand 2024; 103:93-102. [PMID: 37968904 PMCID: PMC10755131 DOI: 10.1111/aogs.14715] [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: 06/30/2023] [Revised: 09/29/2023] [Accepted: 10/22/2023] [Indexed: 11/17/2023]
Abstract
INTRODUCTION The clinical management of placenta accreta spectrum (PAS) depends on placental topography and vascular involvement. Our aim was to determine whether transabdominal and transvaginal ultrasound signs can predict PAS management. MATERIAL AND METHODS We conducted a retrospective cohort study of consecutive prenatally suspected PAS cases in a single tertiary-care PAS center between January 2021 and July 2022. When PAS was confirmed during surgery, abdominal and transvaginal ultrasound scans were analyzed in relation to PAS management. The preferred surgical approach of PAS was one-step conservative surgery (OSCS). Massive blood loss and PAS topography in the lower bladder trigone necessitated cesarean hysterectomy. Transvaginal ultrasound-diagnosed intracervical hypervascularity was split into three categories based on their quantity. Anatomically, the internal cervical os is located at the level of the bladder trigone and was used as landmark for upper and lower bladder trigone PAS. RESULTS Ninety-one women underwent OSCS and 35 women underwent cesarean hysterectomy (total 126 women with PAS). Abdominal and transvaginal ultrasound features differed significantly between women that underwent OSCS and cesarean hysterectomy: decreased myometrial thickness (<1 mm), 82.4% vs. 100%, p = 0.006; placental bulge, 51.6% vs. 94.3%, p < 0.001; bladder wall interruption, 62.6% vs. 97.1%, p < 0.001; abnormal placental lacunae, 75.8% vs. 100%, p < 0.001; hypervascularity (large lacunae feeding vessels, 57.8% vs. 94.6%, p < 0.001; parametrial hypervascularity, 15.4% vs. 60%, p < 0.001; the rail sign, 6.6% vs. 28.6%, p = 0.003; three-dimensional Doppler intra-placental hypervascularity, 81.3% vs. 100%, p < 0.001; intracervical hypervascularity 60.4% vs. 94.3%, p < 0.001); and cervical length 2.5 ± 0.94 vs. 2.2 ± 0.73, p = 0.038. Other ultrasound signs were not significantly different. The results of multivariable logistic regression showed placental bulge (odds ratio [OR] 9.3; 95% CI 1.9-44.3; p = 0.005), parametrial hypervascularity (OR 4.1; 95% CI 1.541-11.085; p = 0.005), and intracervical hypervascularity (OR 9.2; 95% CI 1.905-44.056; p = 0.006) were weak predictors of OSCS. Intracervical hypervascularity Grade 1 (vascularity <50% of cervical tissue) was more present in OSCS than higher gradings two and three (91% vs. 27.6% vs. 14.3%; p < 0.001). CONCLUSIONS Cesarean hysterectomy is associated with the PAS signs of placental bulge and Grade 2 and 3 intracervical hypervascularity. OSCS is associated with intracervical hypervascularity Grade 1 on transvaginal ultrasound. Prospective validation is required to formulate predictors for PAS management.
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Affiliation(s)
- Rozi Aditya Aryananda
- Department of Obstetrics and Gynecology, Dr. Soetomo Academic General HospitalUniversitas AirlanggaSurabayaIndonesia
- Department of Obstetrics & GynecologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Johannes J. Duvekot
- Department of Obstetrics & GynecologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Heleen J. Van Beekhuizen
- Department of Obstetrics & GynecologyErasmus University Medical CenterRotterdamThe Netherlands
- Department of Gynecological Oncology, Erasmus MC Cancer CenterErasmus University Medical CenterRotterdamThe Netherlands
| | - Nareswari Imanadha Cininta
- Department of Obstetrics and Gynecology, Dr. Soetomo Academic General HospitalUniversitas AirlanggaSurabayaIndonesia
| | - Grace Ariani
- Department of Anatomical Pathology, Dr. Soetomo Academic General HospitalUniversitas AirlanggaSurabayaIndonesia
| | - Erry Gumilar Dachlan
- Department of Obstetrics and Gynecology, Dr. Soetomo Academic General HospitalUniversitas AirlanggaSurabayaIndonesia
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Nieto-Calvache AJ, Palacios-Jaraquemada JM. Is it appropriate to recommend prophylactic REBOA in PAS reference centers? J Trauma Acute Care Surg 2024; 96:e7-e8. [PMID: 37611046 DOI: 10.1097/ta.0000000000004044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
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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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Li Q, Zhang W, Hu C, Zhao Y, Pei C, Wu X, Fei K, Peng Q, Zhang J, Huang J. Termination of a second-trimester pregnancy with placenta accreta spectrum disorder. Libyan J Med 2023; 18:2258669. [PMID: 37722677 PMCID: PMC10512921 DOI: 10.1080/19932820.2023.2258669] [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: 05/02/2023] [Accepted: 09/08/2023] [Indexed: 09/20/2023] Open
Abstract
Background: The termination of pregnancy in patients with placenta accreta spectrum disorder (PASD) during the second trimester remains uncertain. In addition, interventional radiology techniques, such as arterial embolization and balloon placement, are potential options. We evaluated the outcomes of pregnancy termination in patients with PASD during the second trimester and the effectiveness of preoperative interventional radiology techniques.Methods: This retrospective study analyzed 48 PASD patients who underwent pregnancy termination during the second trimester between January 2016 and May 2021.Results: Of the 48 patients, 20 (41.67%) underwent transvaginal termination, whereas 28 (58.33%) underwent cesarean section. Notably, no significant differences were observed in success rates between the transvaginal termination and cesarean section groups (80.00% vs. 92.86%, P = 0.38). Furthermore, no statistically significant differences were observed in the success rates (94.12% vs 90.32%, P = 1.00) and blood loss (512.35 ± 727.00 ml vs 804.00 ± 838.98 ml, P = 0.23) between the artery embolization and non-embolization groups. In the vaginal termination group, statistically significant differences were observed in gestational weeks (16.70 ± 3.12 vs 22.67 ± 3.63, P < 0.01) and blood loss (165.00 ± 274.43 ml vs 483.64 ± 333.53 ml, P = 0.04) between the (artery embolization and non-embolization) subgroups. Conversely, in the cesarean section group, no significant differences were observed in gestational weeks (23.59 ± 3.14 vs 23.20 ± 4.37, P = 0.79) and blood loss (811.11 ± 879.55 ml vs 989.47 ± 986.52 ml, P = 0.76) between the subgroups.Conclusions: Further studies are needed to evaluate the efficacy of vaginal termination in PASD patients during the second trimester. Regarding cesarean termination, arterial embolization did not demonstrate increased effectiveness.
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Affiliation(s)
- Qi Li
- Reproductive Medicine Center, Xiangya Hospital Central South University, Changsha, China
| | - Weishe Zhang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
- Hunan Engineering Research Center of Early Life Development and Disease Prevention, Changsha, China
| | - Caihong Hu
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Yanhua Zhao
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Chenlin Pei
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Xinhua Wu
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Kuilin Fei
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Qiaozhen Peng
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Jiejie Zhang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
- Hunan Engineering Research Center of Early Life Development and Disease Prevention, Changsha, China
| | - Jingrui Huang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
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Zhao H, Liu C, Fu H, Abeykoon SDI, Zhao X. Subsequent pregnancy outcomes and risk factors following conservative treatment for placenta accreta spectrum: a retrospective cohort study. Am J Obstet Gynecol MFM 2023; 5:101189. [PMID: 37832645 DOI: 10.1016/j.ajogmf.2023.101189] [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: 07/28/2023] [Revised: 09/27/2023] [Accepted: 10/09/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Placenta accreta spectrum can lead to uncontrollable massive hemorrhage in the perinatal period. Currently, the first-line treatment for placenta accreta spectrum recommended worldwide is hysterectomy. However, adverse outcomes after hysterectomy, including surgical complications, such as difficulty in performing the procedure, and sequelae, such as infertility and psychological issues, cannot be ignored. Several surgical approaches for conservative treatment have been proposed. There are few reports on the effectiveness, safety, and long-term complications of conservative treatments, especially subsequent pregnancy outcomes. OBJECTIVE This study aimed to investigate the clinical outcomes and identify risk factors of subsequent pregnancies among patients with placenta accreta spectrum who had undergone conservative surgery. STUDY DESIGN This was a retrospective cohort study of subsequent pregnancy cases after cesarean delivery with conservative treatment for placenta accreta spectrum from 2011 to 2019 at The First Affiliated Hospital of Zhengzhou University to identify clinical outcomes of subsequent pregnancies and the risk factors of adverse pregnancy outcomes. RESULTS A total of 883 patients undergoing conservative surgery were included in this study, among which 604 (68.4%) were successfully followed up. There were 75 successful pregnancies in 72 patients, including 22 full-term or near-term deliveries, 1 induced labor in the second trimester of pregnancy, 6 cesarean scar pregnancies (8.0%), 2 ectopic pregnancies, and 44 first-trimester pregnancies (3 miscarriages and 41 elective abortions and 12 medical abortions and 32 vacuum aspirations). All newborns survived in the 22 full-term or near-term deliveries. Moreover, 5 placenta accreta spectrum cases (22.7%) and 6 placenta previa cases were observed. Postpartum hemorrhage was observed in 2 cases, with an incidence rate of 9.1%. All parameters, including age at subsequent pregnancy, gravidity, number of cesarean deliveries, type of previous placenta accreta spectrum, gestational week of pregnancy termination, interpregnancy interval, and the use of vascular occlusion techniques, were not found to be associated with recurrent placenta accreta spectrum and cesarean scar pregnancy. CONCLUSION Our findings show that treatment for placenta accreta spectrum does not automatically preclude a subsequent pregnancy. However, patients should be fully informed about the risk of recurrent placenta accreta spectrum, scar pregnancy, and postpartum hemorrhage.
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Affiliation(s)
- Huidan Zhao
- Department of Obstetrics and Gynecology, First affiliated hospital of Zhengzhou University, School of International Education, Zhengzhou University, Zhengzhou, China; Obstetric Emergency and Critical Care Medicine of Henan Province, Zhengzhou, China (Dr H Zhao, Ms Liu, and Dr X Zhao)
| | - Chuanna Liu
- Department of Obstetrics and Gynecology, First affiliated hospital of Zhengzhou University, School of International Education, Zhengzhou University, Zhengzhou, China; Obstetric Emergency and Critical Care Medicine of Henan Province, Zhengzhou, China (Dr H Zhao, Ms Liu, and Dr X Zhao)
| | - Hanlin Fu
- Department of Obstetrics and Gynecology, First affiliated hospital of Zhengzhou University, School of International Education, Zhengzhou University, Zhengzhou, China
| | | | - Xianlan Zhao
- Department of Obstetrics and Gynecology, First affiliated hospital of Zhengzhou University, School of International Education, Zhengzhou University, Zhengzhou, China; Obstetric Emergency and Critical Care Medicine of Henan Province, Zhengzhou, China (Dr H Zhao, Ms Liu, and Dr X Zhao).
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Palacios-Jaraquemada JM, Nieto-Calvache ÁJ, Aryananda RA, Basanta N, Campos CI, Ariani G. Placenta accreta spectrum with severe morbidity: fibrosis associated with cervical-trigonal invasion. J Matern Fetal Neonatal Med 2023; 36:2183741. [PMID: 37193605 DOI: 10.1080/14767058.2023.2183741] [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: 04/28/2022] [Revised: 07/20/2022] [Accepted: 02/18/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVE Describe the clinical-surgical results of patients with PAS in the low-posterior cervical-trigonal space associated with fibrosis (PAS type 4) compared with PAS types in other locations (Types 1, upper bladder, 2 in upper parametrium) and in particular with PAS type 3, corresponding to dissectible cervical-trigonal invasion. The clinical-surgical results of using a standard hysterectomy were analyzed with a modified subtotal hysterectomy (MSTH) in patients with PAS type 4. MATERIAL AND METHODS A descriptive, retrospective, multicenter study included 337 patients of PAS; thirty-two corresponding to PAS type 4, from three PAS reference hospitals, CEMIC, Buenos Aires, Argentina, Fundación Valle de Lili, Cali, Colombia, and Dr. Soetomo General Hospital, Surabaya, Indonesia, between January 2015 and December 2020. PAS was diagnosed by abdominal and transvaginal ultrasound and topographically characterized by ultrafast T2 weighted MRI. In persistent macroscopic hematuria after MSTH, the surgeon performs an intentional cystotomy and uses a square compression suture to achieve the hemostasis inside the bladder wall.According to a PAS topographical classification, the patients with low-vesical cervical involvement compared with PAS located in relation with the upper blader (type1), upper parametrium (type 2 upper), and also with PAS situated in the lower vesical-trigon space (type 3). PAS 3 and 4 are located in identical area, but in type 3, group A, the vesicouterine space was dissectible, and in type 4, group B, significant fibrosis made surgical dissection extremely challenging. Furthermore, group B was divided into patients treated with total hysterectomy (HT) and those treated with a modified subtotal hysterectomy (MSTH). The surgical requirements to perform an MSHT included the availability of proximal vascular control at the aortic level (internal manual aortic compression, aortic endovascular balloon, aortic loop, or aortic cross-clamping). Then surgeon performed an upper segmental hysterotomy, avoiding the abnormal placenta invasion area; after that, the fetus was delivered, and the umbilical cord was ligated.After uterine exteriorization, the surgeon applies a continuous circular suture with number 2 polyglactin 910, taking some portions of the myometrium -to avoid unintentional slipping- around the lower uterine segment and a 3-4 cm proximal to the abnormal adhesion of the placenta. After tightening hard the circular suture, the uterine segment was circumferentially cut, three centimeters proximal to the circular hemostatic sutures. Next, the surgery follows the upper steps of conventional hysterectomy without changes. Additionally, the histological presence of fibrosis was examined in all samples. RESULTS Modified subtotal hysterectomy in patients with PAS type 4 (cervical-trigonal fibrosis) resulted in a significant clínico-surgical improvement over total hysterectomy. The median operative time and intraoperative bleeding were 140 min (IQR 90--240) and 1895 mL (IQR 1300-2500) in patients undergoing modified subtotal hysterectomy, and 260 min (IQR 210-287) and 2900 mL (IQR 2150-5500) in patients treated with total hysterectomy, respectively. The complication rate was 20% for MSHT and 82.3% for patients with a total hysterectomy. CONCLUSIONS PAS in the cervical trigonal area associated with fibrosis implies a greater risk of complications due to uncontrollable bleeding and organ damage. MSTH is associated with lower morbidity and difficulties in PAS type 4. Prenatal or intrasurgical diagnosis is essential to plan surgical alternatives to improve the results.
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Affiliation(s)
| | | | - Rozi Aditya Aryananda
- Universitas Airlangga, Surabaya, Indonesia
- Placenta Accreta Spectrum Clinic, Fundación Valle del Lili, Cali, Colombia
- Dr. Soetomo Academic General Hospital, City of Buenos Aires, Argentina
| | | | - Clara Ivette Campos
- Department of Pathology and Clinical Laboratory, Fundación Valle del Lili, Cali, Colombia
| | - Grace Ariani
- Department of Pathology and Clinical Laboratory, Fundación Valle del Lili, Cali, Colombia
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Ghosh A, Lee S, Lim C, Vogelzang RL, Chrisman HB. Placenta Accreta Spectrum: An Overview. Semin Intervent Radiol 2023; 40:467-471. [PMID: 37927512 PMCID: PMC10622243 DOI: 10.1055/s-0043-1772815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Affiliation(s)
- Abheek Ghosh
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sean Lee
- Touro College of Osteopathic Medicine, New York City, New York
| | - Christina Lim
- Creighton University School of Medicine, Omaha, Nebraska
| | - Robert L. Vogelzang
- Division of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Howard B. Chrisman
- Division of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
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Bartels HC, O'Doherty J, Wolsztynski E, Brophy DP, MacDermott R, Atallah D, Saliba S, Young C, Downey P, Donnelly J, Geoghegan T, Brennan DJ, Curran KM. Radiomics-based prediction of FIGO grade for placenta accreta spectrum. Eur Radiol Exp 2023; 7:54. [PMID: 37726591 PMCID: PMC10509122 DOI: 10.1186/s41747-023-00369-2] [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: 03/22/2023] [Accepted: 06/26/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Placenta accreta spectrum (PAS) is a rare, life-threatening complication of pregnancy. Predicting PAS severity is critical to individualise care planning for the birth. We aim to explore whether radiomic analysis of T2-weighted magnetic resonance imaging (MRI) can predict severe cases by distinguishing between histopathological subtypes antenatally. METHODS This was a bi-centre retrospective analysis of a prospective cohort study conducted between 2018 and 2022. Women who underwent MRI during pregnancy and had histological confirmation of PAS were included. Radiomic features were extracted from T2-weighted images. Univariate regression and multivariate analyses were performed to build predictive models to differentiate between non-invasive (International Federation of Gynecology and Obstetrics [FIGO] grade 1 or 2) and invasive (FIGO grade 3) PAS using R software. Prediction performance was assessed based on several metrics including sensitivity, specificity, accuracy and area under the curve (AUC) at receiver operating characteristic analysis. RESULTS Forty-one women met the inclusion criteria. At univariate analysis, 0.64 sensitivity (95% confidence interval [CI] 0.0-1.00), specificity 0.93 (0.38-1.0), 0.58 accuracy (0.37-0.78) and 0.77 AUC (0.56-.097) was achieved for predicting severe FIGO grade 3 PAS. Using a multivariate approach, a support vector machine model yielded 0.30 sensitivity (95% CI 0.18-1.0]), 0.74 specificity (0.38-1.00), 0.58 accuracy (0.40-0.82), and 0.53 AUC (0.40-0.85). CONCLUSION Our results demonstrate a predictive potential of this machine learning pipeline for classifying severe PAS cases. RELEVANCE STATEMENT This study demonstrates the potential use of radiomics from MR images to identify severe cases of placenta accreta spectrum antenatally. KEY POINTS • Identifying severe cases of placenta accreta spectrum from imaging is challenging. • We present a methodological approach for radiomics-based prediction of placenta accreta. • We report certain radiomic features are able to predict severe PAS subtypes. • Identifying severe PAS subtypes ensures safe and individualised care planning for birth.
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Affiliation(s)
- Helena C Bartels
- Department of UCD Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Holles Street, Dublin 2, Ireland.
| | - Jim O'Doherty
- Siemens Medical Solutions, Malvern, PA, USA
- Department of Radiology & Radiological Science, Medical University of South Carolina, Charleston, SC, USA
- Radiography & Diagnostic Imaging, University College Dublin, Dublin, Ireland
| | - Eric Wolsztynski
- Statistics Department, University College Cork, Cork, Ireland
- Insight Centre for Data Analytics, Dublin, Ireland
| | - David P Brophy
- Department of Radiology, St. Vincent's University Hospital, Dublin, Ireland
| | - Roisin MacDermott
- Department of Radiology, St. Vincent's University Hospital, Dublin, Ireland
| | - David Atallah
- Department of Gynecology and Obstetrics, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Souha Saliba
- Department of Radiology: Fetal and Placental Imaging, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Constance Young
- Department of Histopathology, National Maternity Hospital, Dublin, Ireland
| | - Paul Downey
- Department of Histopathology, National Maternity Hospital, Dublin, Ireland
| | - Jennifer Donnelly
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland
| | - Tony Geoghegan
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Donal J Brennan
- Department of UCD Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Holles Street, Dublin 2, Ireland
- University College Dublin Gynaecological Oncology Group (UCD-GOG), Mater Misericordiae University Hospital and St Vincent's University Hospital, Dublin, Ireland
- Systems Biology Ireland, School of Medicine, University College Dublin, Dublin, Ireland
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Pan W, Chen J, Zou Y, Yang K, Liu Q, Sun M, Li D, Zhang P, Yue S, Huang Y, Wang Z. Uterus-preserving surgical management of placenta accreta spectrum disorder: a large retrospective study. BMC Pregnancy Childbirth 2023; 23:615. [PMID: 37633887 PMCID: PMC10464453 DOI: 10.1186/s12884-023-05923-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 08/14/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND The two-child policy implemented in China resulted in a surge of high-risk pregnancies among advanced maternal aged women and presented a window of opportunity to identify a large number of placenta accreta spectrum (PAS) cases, which often invoke severe blood loss and hysterectomy. We thus had an opportunity to evaluate the surgical outcomes of a unique conservative PAS management strategy for uterus preservation, and the impacts of magnetic resonance imaging (MRI) in PAS surgical planning. METHODS Cross-sectional study, comparing the outcomes of a new uterine artery ligation combined with clover suturing technique (UAL + CST) with the existing conservative surgical approaches in a maternal public hospital with an annual birth of more than 20,000 neonates among all placenta previa cases suspecting of PAS between January 1, 2015 and December 31, 2018. RESULTS From a total of 89,397 live births, we identified 210 PAS cases from 400 singleton pregnancies with placenta previa. Aside from 2 self-requested natural births (low-lying placenta), all PAS cases had safe cesarean deliveries without any total hysterectomy. Compared with the existing approaches, the evaluated UAL + CST had a significant reduction in intraoperative blood loss (β=-312 ml, P < .001), RBC transfusion (β=-1.08 unit, P = .001), but required more surgery time (β = 16.43 min, P = .01). MRI-measured placenta thickness, when above 50 mm, can increase blood loss (β = 315 ml, P = .01), RBC transfusion (β = 1.28 unit, P = .01), surgery time (β = 48.84 min, P < .001) and hospital stay (β = 2.58 day, P < .001). A majority of percreta patients resumed normal menstrual cycle within 12 months with normal menstrual fluid volume, without abnormal urination or defecation. CONCLUSIONS A conservative surgical management approach of UAL + CST for PAS is safe and effective with a low complication rate. MRI might be useful for planning PAS surgery. CLINICAL TRIAL REGISTRATION NUMBER ChiCTR2000035202.
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Affiliation(s)
- Wenxia Pan
- Department of Obstetrics, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Juan Chen
- Department of Obstetrics, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Yinrui Zou
- Havy International (Shanghai) Ltd, Building 25, No.1665, Kongjiang Road, Yangpu District, Shanghai, 200092, China
| | - Kun Yang
- Department of Obstetrics, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Qingfeng Liu
- Department of Obstetrics, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Meiying Sun
- Department of Obstetrics, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Dan Li
- Department of Radiology, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Ping Zhang
- Department of Ultrasound, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Shixia Yue
- Department of Nursery, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Yuqiang Huang
- Department of Pediatric Cardiology, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China.
| | - Zhaoxi Wang
- Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Kirstein 3, 02215, Boston, MA, USA
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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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Einerson BD, Sandlin AT, Afshar Y, Sharawi N, Fox KA, Newton JM, Shainker SA, Pezeshkmehr A, Carusi DA, Moroz L. General Management Considerations for Placenta Accreta Spectrum. Am J Perinatol 2023; 40:1026-1032. [PMID: 37336221 DOI: 10.1055/s-0043-1761915] [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 ideal management of a patient with placenta accreta spectrum (PAS) includes close antepartum management culminating in a planned and coordinated delivery by an experienced multidisciplinary PAS team. Coordinated team management has been shown to optimize outcomes for mother and infant. This section provides a consensus overview from the Pan-American Society for the Placenta Accreta Spectrum regarding general management of PAS.
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Affiliation(s)
| | - Adam T Sandlin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arizona
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Nadir Sharawi
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arizona
| | - Karin A Fox
- Division of Maternal-Fetal Medicine, Department of Obstetric and Gynecology, Baylor College of Medicine (Texas Children's Hospital Pavilion for Women), Houston, Texas
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center Nashville, Tennessee
| | - Scott A Shainker
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amir Pezeshkmehr
- Department of Radiology Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Daniela A Carusi
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Coutinho CM, Georg AV, Marçal LCA, Nieto-Calvache AJ, Adu-Bredu T, D'Antonio F, Palacios-Jaraquemada JM. Placenta Accreta Spectrum Disorders: Current Recommendations from the Perspective of Antenatal Imaging. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:297-302. [PMID: 37494571 PMCID: PMC10371071 DOI: 10.1055/s-0043-1770917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Affiliation(s)
- Conrado Milani Coutinho
- Departament of Ginecology and Obstetrics, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Alexia Viegas Georg
- Departament of Ginecology and Obstetrics, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Ligia Conceição Assef Marçal
- Departament of Ginecology and Obstetrics, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Albaro José Nieto-Calvache
- Clínica de Espectro de Acretismo Placentario, Hospital Universitario Fundación Valle del Lili, Cali, Colombia
- Universidad ICESI, Cali, Colombia
| | - Theophilus Adu-Bredu
- Obstetrics and Gynecology Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Francesco D'Antonio
- Center for Fetal Care and High Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
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Mousa A, Elkhateb IT, Gaafar HM, Elsherbini MM, Mousa H, Abdalla M, Abdelbar A, Rida D, Majd HS, Collins SL. Kasr Alainy simplified uterine preserving surgery for conservative management of placenta accreta spectrum (PAS): A modified surgical approach. Eur J Obstet Gynecol Reprod Biol 2023; 284:150-161. [PMID: 37001252 DOI: 10.1016/j.ejogrb.2023.03.026] [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: 10/15/2022] [Revised: 03/15/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVE The incidence of placenta accreta spectrum (PAS) is rising rapidly due to the global surge in Caesarean delivery. It is associated with significant maternal morbidity and mortality. It is usually managed with Caesarean hysterectomy. However, uterine preserving surgeries can have advantages over Caesarean hysterectomy and intentional placental retention techniques. STUDY DESIGN We present a modified technique of uterine preserving surgery that uses a safe approach for placental bed surgical devascularization. This is followed by resection of the invaded uterine segment and uterine wall reconstruction. RESULTS The technique was used in the management of 20 patients with antenatally suspected PAS that were confirmed at laparotomy. It was successful in preserving the uterus in 18/20 (90 %) women. The mean intraoperative blood loss in was 1305 CC (SD: +361.6) with a mean operative time of 123 min (SD: ±38.7). There was only one urinary bladder injury and no other maternal morbidity. CONCLUSION Our surgical technique is safe and may be useful for conservative surgical management of PAS, particularly in low- and middle-income countries, where access to complex resources, such as interventional radiology, is limited.
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Affiliation(s)
- Abdalla Mousa
- University Department of Obstetrics and Gynecology, Faculty of Medicine, Kasr Alainy Hospital, Cairo University, Cairo, Egypt.
| | - Islam T Elkhateb
- University Department of Obstetrics and Gynecology, Newgiza University School of Medicine, Giza, Egypt
| | - Hassan M Gaafar
- University Department of Obstetrics and Gynecology, Faculty of Medicine, Kasr Alainy Hospital, Cairo University, Cairo, Egypt
| | - Moutaz M Elsherbini
- University Department of Obstetrics and Gynecology, Faculty of Medicine, Kasr Alainy Hospital, Cairo University, Cairo, Egypt
| | - Hatem Mousa
- Leicester Obstetrics and Midwifery Centre for Women's Health Research, University Department of Obstetrics and Gynecology, University Hospital of Leicester NHS Trust, United Kingdom
| | - Mostafa Abdalla
- Department of Gynecological Oncology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Ahmed Abdelbar
- University Department of Obstetrics and Gynecology, Faculty of Medicine, Kasr Alainy Hospital, Cairo University, Cairo, Egypt; Department of Gynecological Oncology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Dana Rida
- Department of Radiology, Jordan University, Jordan
| | - Hooman Soleymani Majd
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom; Department of Gynecological Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Sally L Collins
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom; Fetal Medicine Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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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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How to perform the one-step conservative surgery for placenta accreta spectrum move by move. Am J Obstet Gynecol MFM 2023; 5:100802. [PMID: 36372188 DOI: 10.1016/j.ajogmf.2022.100802] [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: 09/02/2022] [Revised: 11/01/2022] [Accepted: 11/05/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND There are 3 treatment options for placenta accreta spectrum: cesarean delivery with hysterectomy, expectant management, and uterine-sparing surgical techniques. One-step conservative surgery is the most extensively described conservative surgical technique, and it has extensive evidence supporting its usefulness; however, few groups apply it, most likely because of the misconception that it is a complex procedure that requires extensive training and is applicable to only a few patients. OBJECTIVE This study aimed to evaluate the clinical outcomes of patients undergoing one-step conservative surgery in 4 placenta accreta spectrum reference hospitals and provided detailed steps for successfully applying this type of surgery. STUDY DESIGN This was a multicenter, descriptive, prospective study that described the outcomes of patients with placenta accreta spectrum treated in 4 reference hospitals for this condition. The patients were divided into those managed with one-step conservative surgery and those managed with cesarean delivery and hysterectomy. RESULTS Overall, 75 patients were included. One-step conservative surgery was possible in 85.3% of placenta accreta spectrum cases (64 patients). Intraoperative staging and placenta accreta spectrum topographic classification allowed for the selection of one-step conservative surgery candidates. The clinical outcomes of the 2 groups were similar, except for the frequency of transfusions (81.8% in the cesarean delivery and hysterectomy group vs 67.2% in the one-step conservative surgery group) and vascular interventions (27.3% in the cesarean delivery and hysterectomy group vs 4.7% in the one-step conservative surgery group), which were both higher in patients who underwent hysterectomy. In addition, the operation time was shorter in the one-step conservative surgery group (164.4 minutes vs 216.5 minutes). CONCLUSION One-step conservative surgery is a valid procedure in most patients with placenta accreta spectrum. It is an applicable technique even in scenarios with limited resources. However, its safe application requires knowledge of the topographic classification and the application of intraoperative staging.
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Palacios-Jaraquemada JM, Nieto-Calvache ÁJ, Aryananda RA, Basanta N. Advantages of individualizing the placenta accreta spectrum management. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 4:1096175. [PMID: 36685091 PMCID: PMC9853884 DOI: 10.3389/frph.2022.1096175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 11/28/2022] [Indexed: 01/07/2023] Open
Affiliation(s)
| | - Álbaro Jose Nieto-Calvache
- Clínica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia,Latin American Group for the Study of Placenta Accreta Spectrum, Cali, Columbia,Correspondence: Álbaro Jose Nieto-Calvache
| | | | - Nicolás Basanta
- Department of Obstetrics an Gynaecology, Hospital General de Agudos Juan A Fernández, Buenos Aires, Argentina
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Palacios-Jaraquemada JM, Basanta NA. Does a more exact definition mean being able to reduce maternal morbidity in placenta accreta spectrum? Am J Obstet Gynecol 2022; 227:931-932. [PMID: 35841939 DOI: 10.1016/j.ajog.2022.06.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/30/2022] [Indexed: 01/26/2023]
Affiliation(s)
- José Miguel Palacios-Jaraquemada
- Obstetric and Gynecologic Department, Center for Medical Education and Clinical Research "Norberto Quirno" Universitary Hospital, Galván 4102, C1431 Buenos Aires, Argentina.
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Advantages of intraoperative staging and topographic classification in placenta accreta spectrum. Am J Obstet Gynecol 2022; 227:934-935. [PMID: 35940224 DOI: 10.1016/j.ajog.2022.07.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 07/19/2022] [Indexed: 01/26/2023]
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Nieto-Calvache AJ, Aguilera LR. Simulation, A Fundamental Component of Training to Treat Placenta Accreta Spectrum. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2022; 44:1159-1160. [PMID: 36580943 PMCID: PMC9800142 DOI: 10.1055/s-0042-1760216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
| | - Lorgio Rudy Aguilera
- Departamento de Ginocología y Obstetricia, Hospital De La Mujer Dr. Percy Boland, Santa Cruz de la Sierra, Bolivia
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A Review and Comparison of the Efficacy of Prophylactic Interventional Radiological Arterial Occlusions in Placenta Accreta Spectrum Patients: A Meta-analysis. Acad Radiol 2022:S1076-6332(22)00575-X. [DOI: 10.1016/j.acra.2022.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 10/05/2022] [Accepted: 10/19/2022] [Indexed: 11/15/2022]
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Nieto-Calvache AJ, Sanín-Blair JE, Buitrago-Leal HM, Benavides-Serralde JA, Maya-Castro J, Rozo-Rangel AP, Messa-Bryon A, Colonia-Toro A, Gómez-Castro AR, Cardona-Ospina A, Caicedo-Cáceres CE, Dorado-Roncancio EF, Silva JL, Carvajal-Valencia JA, Velásquez-Penagos JA, Niño-González JE, Burgos-Luna JM, Rincón-García JC, Matera-Torres L, Villamizar-Galvis OA, Olaya-Garay SX, Medina-Palmezano VP, Castañeda J. Colombian Consensus on the Treatment of Placenta Accreta Spectrum (PAS). REVISTA COLOMBIANA DE OBSTETRICIA Y GINECOLOGIA 2022; 73:283-316. [PMID: 36331304 PMCID: PMC9674383 DOI: 10.18597/rcog.3877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/14/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Placenta accreta spectrum (PAS) is a condition associated with massive postpartum bleeding and maternal mortality. Management guidelines published in high income countries recommend the participation of interdisciplinary teams in hospitals with sufficient resources for performing complex procedures. However, some of the recommendations contained in those guidelines are difficult to implement in low and medium income countries. OBJECTIVES The aim of this consensus is to draft general recommendations for the treatment of PAS in Colombia. MATERIALS AND METHODS Twenty-three panelists took part in the consensus with their answers to 31 questions related to the treatment of PAS. The panelists were selected based on participation in two surveys designed to determine the resolution capabilities of national and regional hospitals. The modified Delphi methodology was used, introducing two successive discussion rounds. The opinions of the participants, with a consensus of more than 80%, as well as implementation barriers and facilitators, were taken into consideration in order to issue the recommendations. RESULTS The consensus draftedfive recommendations, integrating the answers of the panelists. Recommendation 1. Primary care institutions must undertake active search of PAS in patients with risk factors: placenta praevia and history of myomectomy or previous cesarean section. In case of ultrasound signs suggesting PAS, patients must be immediately referred, without a minimum gestational age, to hospitals recognized as referral centers. Online communication and care modalities may facilitate the interaction between primary care institutions and referral centers for PAS. The risks and benefits of telemedicine modalities must be weighed. Recommendation 2. Referral hospitals for PAS need to be defined in each region of Colombia, ensuring coverage throughout the national territory. It is advisable to concentrate the flow of patients affected by this condition in a few hospitals with surgical teams specifically trained in PAS, availability of specialized resources, and institutional efforts at improving quality of care with the aim of achieving better health outcomes in pregnant women with this condition. To achieve this goal, participants recommend that healthcare regulatory agencies at a national and regional level should oversee the process of referral for these patients, expediting administrative pathways in those cases in which there is no prior agreement between the insurer and the selected hospital or clinic. Recommendation 3. Referral centers for patients with PAS are urged to build teams consisting of a fixed group of specialists (obstetricians, urologists, general surgeons, interventional radiologists) entrusted with the care of all PAS cases. It is advisable for these interdisciplinary teams to use the “intervention bundle” model as a guidance for building PAS referral centers. This model comprises the following activities: service preparedness, disease prevention and identification, response to the occurrence of the disease, and debriefing after every event. Telemedicine facilitates PAS treatment and should be taken into consideration by interdisciplinary teams caring for this disease. Recommendation 4. Obstetrics residents must be instructed in the performance of maneuvers that are useful for the prevention and treatment of massive intraoperative bleeding due to placenta praevia and PAS, including manual aortic compression, uterine tourniquet, pelvic packing, retrovesical bypass, and Ward maneuver. Specialization Obstetrics and Gynecology programs in Colombia must include the basic concepts of the diagnosis and treatment of PAS. Referral centers for PAS must offer online and in-person training programs for professionals interested in improving their competencies in PAS. Moreover, they must offer permanent remote support (telemedicine) to other hospitals in their region for patients with this condition. Recommendation 5. Patients suspected of having PAS and placenta praevia based on imaging, with no evidence of active vaginal bleeding, must be delivered between weeks 34 and 36 6/7. Surgical treatment must include sequential interventions that may vary depending on the characteristics of the lesion, the clinical condition of the patient and the availability of resources. The surgical options (total and subtotal hysterectomy, one-stage conservative surgical management and watchful waiting) must be included in a protocol known by the entire interdisciplinary team. In situations in which an antepartum diagnosis is lacking, that is to say, in the face of intraoperative finding of PAS (evidence of purple bulging or neovascularization of the anterior aspect of the uterus), and the participation of untrained personnel, three options are considered: Option 1: In the absence of indication of immediate delivery or of vaginal delivery, the recommendation is to postpone the cesarean section (close the laparotomy before incising the uterus) until the recommended resources for safe surgery are secured. Option 2: If there is an indication for immediate delivery (e.g., non-reassuring fetal status) but there is absence of vaginal bleeding or indication for immediate PAS management, a two-stage management is suggested: cesarean section avoiding placental incision, followed by uterine repair and abdominal closure, until the availability of the recommended resources for safe surgery is ascertained. Option 3: In the event of vaginal bleeding that prevents definitive PAS management, the fetus must be delivered through the uterine fundus, followed by uterine repair and reassessment of the situation. Sometimes, fetal delivery diminishes placental flow and vaginal bleeding is reduced or disappears, enabling the possibility to postpone definitive management of PAS. In case of persistent significant bleeding, hysterectomy should be performed, using all available resources: manual aortic compression, immediate call to the surgeons with the best available training, telemedicine support from expert teams in other hospitals. If a patient with risk factors for PAS (e.g., myomectomy or previous cesarean section) has a retained placenta after vaginal delivery, it is advisable to confirm the possibility of such diagnosis (by means of ultrasound, for example) before proceeding to manual extraction of the placenta. CONCLUSIONS It is our hope that this first Colombian consensus on PAS will serve as a basis for additional discussions and collaborations that can result in improved clinical outcomes for women affected by this condition. Additional research will be required in order to evaluate the applicability and effectiveness of these recommendations.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jimmy Castañeda
- Federación Colombiana de Obstetricia y Ginecología (FECOLSOG), Bogotá (Colombia)..
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Habek D. Early placenta previa percreta and treatment with supracervical abortion hysterectomy. J Perinat Med 2022; 50:1005-1006. [PMID: 35596274 DOI: 10.1515/jpm-2022-0208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 04/30/2022] [Indexed: 11/15/2022]
Affiliation(s)
- Dubravko Habek
- University Department of Obstetrics and Gynecology Clinical Hospital "Sveti Duh" School of Medicine, Catholic University of Croatia, Zagreb, Croatia
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Hu Y, Wang Y, Weng Q, Wu X, Xia S, Wang H, Cheng X, Mao C, Li X, Zhou Z, Chen C, Xu M, Wang Z, Ji J. Intraplacental T2-hypointense bands may help predict placental invasion depth and postpartum hemorrhage in placenta accrete spectrum disorders in high-risk gravid patients. Magn Reson Imaging 2022; 94:73-79. [PMID: 36116713 DOI: 10.1016/j.mri.2022.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/17/2022] [Accepted: 09/13/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Accurate noninvasive prenatal diagnosis of placenta accreta spectrum (PAS) disorder is critical for delivery management. PURPOSE To evaluate the diagnostic ability of MRI features in predicting the PAS, invasive depth and postpartum hemorrhage (PPH) in high-risk gravid patients. MATERIALS AND METHODS Between February 2019 and November 2020, women with ultrasound (US)-suspected PAS were enrolled. With the exclusion criteria, 80 women were included in the study. Two experienced genitourinary radiologists reviewed and recorded the MRI features. The chi square test was used to compare the effectiveness of MRI features. Relative risk ratios were computed to test the association of intraplacental T2-hypointense bands with poor outcomes of cesarean section. Receiver operating characteristic (ROC) analyses based on the number and area of intraplacental T2-hypointense bands were used to predict PAS, invasion depth, and PPH. RESULTS PAS was diagnosed in 56 of 80 women (70%). At delivery, 24 of 80 women (30%) experienced PPH (≥1000 mL). Intraplacental T2-hypointense bands were detected at MRI in 28 of 56 women with PAS (50%). The relative risk ratio of intraplacental T2-hypointense bands was 1.51 for PAS, 3.17 for depth of PAS invasiveness and 4.74 for PPH. The largest areas of intraplacental T2-hypointense bands for predicting PAS, invasion depth and PPH were 0.66 cm2, 1.68 cm2 and 1.99 cm2, respectively. DISCUSSION The appearance of intraplacental T2-hypointense bands has important diagnostic value for PAS, its invasion depth and PPH. The area of the largest T2-hypointense band in the placenta can predict poor outcomes of cesarean section.
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Affiliation(s)
- Yumin Hu
- Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui Hospital of Zhejiang University, Lishui 323000, China
| | - Yi Wang
- Lishui Maternal and Child Health Hospital, Lishui 323000, China
| | - Qiaoyou Weng
- Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui Hospital of Zhejiang University, Lishui 323000, China
| | - Xulu Wu
- Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui Hospital of Zhejiang University, Lishui 323000, China
| | - Shuiwei Xia
- Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui Hospital of Zhejiang University, Lishui 323000, China
| | - Hailin Wang
- Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui Hospital of Zhejiang University, Lishui 323000, China
| | - Xue Cheng
- Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui Hospital of Zhejiang University, Lishui 323000, China
| | - Chenchen Mao
- Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui Hospital of Zhejiang University, Lishui 323000, China
| | - Xia Li
- Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui Hospital of Zhejiang University, Lishui 323000, China
| | - Zhangwei Zhou
- Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui Hospital of Zhejiang University, Lishui 323000, China
| | - Chunmiao Chen
- Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui Hospital of Zhejiang University, Lishui 323000, China
| | - Min Xu
- Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui Hospital of Zhejiang University, Lishui 323000, China.
| | - Zufei Wang
- Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui Hospital of Zhejiang University, Lishui 323000, China.
| | - Jiansong Ji
- Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, Lishui Hospital of Zhejiang University, Lishui 323000, China.
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Yin Y, Qu L, Jin B, Yang Z, Xia J, Sun L, Zhou X. Spiral Suture of the Lower Uterine Segment with Temporary Aortic Balloon Occlusion in Morbidly Adherent Placenta Previa Cases. Int J Womens Health 2022; 14:1161-1171. [PMID: 36046176 PMCID: PMC9422986 DOI: 10.2147/ijwh.s367654] [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: 03/23/2022] [Accepted: 08/03/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose We aimed to investigate the combined effect of spiral suture of the lower uterine segment with intraoperative aortic balloon occlusion in morbidly adherent placenta previa cases. Patient and Methods This retrospective, single-center study involved patients from 2017 to 2020. The study considered 68 cases of morbidly adherent placenta previa cases from medical records retrospectively with age ranging from 23 to 42 years. Bilateral uterine artery embolization was performed, to control excessive bleeding. Perioperative blood loss, hysterectomy rate, amount of blood transfusion, balloon occlusion time, fetal and maternal radiation dose, and postpartum complications were assessed. Results A total of 68 patients underwent surgery. Hysterectomy was performed in three patients and uterine artery embolization in 21 patients. Of 53 patients who required blood transfusions, the amount of packed red blood cells given was 800 mL and the amount of plasma given was 400 mL. Median abdominal aortic balloon occlusion time was 17 minutes. Fetal and maternal radiation doses were 5 mGy and 12 mGy, respectively. One patient experienced surgery-related complications, a bladder injury. No major catheterization-related and postpartum complications were observed. Conclusion Fertility-sparing surgery for women with morbidly adherent placenta could include abdominal aortic balloon occlusion and spiral suture of lower uterine segment.
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Affiliation(s)
- Yin Yin
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Nanjing Medical University Hospital, Nanjing, People's Republic of China
| | - Lin Qu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Nanjing Medical University Hospital, Nanjing, People's Republic of China
| | - Bai Jin
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Nanjing Medical University Hospital, Nanjing, People's Republic of China
| | - Zhengqiang Yang
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University Hospital, Nanjing, People's Republic of China
| | - Jinguo Xia
- Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University Hospital, Nanjing, People's Republic of China
| | - Lizhou Sun
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Nanjing Medical University Hospital, Nanjing, People's Republic of China
| | - Xin Zhou
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Nanjing Medical University Hospital, Nanjing, People's Republic of China
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Aryananda RA, Aditiawarman A, Gumilar KE, Wardhana MP, Akbar MIA, Cininta N, Ernawati E, Wicaksono B, Joewono HT, Dachlan EG, Bachtiar CA, Kurniawati D, Virdayanti DP, Ariani G, Dekker GA, Sulistyono A. Uterine conservative-resective surgery for selected placenta accreta spectrum cases: Surgical-vascular control methods. Acta Obstet Gynecol Scand 2022; 101:639-648. [PMID: 35301710 DOI: 10.1111/aogs.14348] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/22/2022] [Accepted: 02/25/2022] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The incidence of placenta accreta spectrum (PAS) has increased, but the optimal management and the optimal way to achieve vascular control are still controversial. This study aims to compare maternal outcomes between different methods of vascular control in surgical PAS management. MATERIAL AND METHODS A retrospective cohort study on consecutive cases diagnosed with PAS between 2013 and 2020 in single tertiary hospital. The final diagnosis of PAS was made following preoperative ultrasound and confirmation during surgery. Management of PAS using cesarean hysterectomy with internal iliac artery ligation (IIAL) was compared with two types of vascular control in uterine conservative-resective surgery (IIAL vs identification-ligation of the upper vesical, upper vaginal, and uterine arteries). RESULTS Over an 8-year period, 234 pregnant women were diagnosed with PAS meeting the inclusion criteria. Uterine conservative-resective surgery (200 cases) was associated with lower mean blood loss compared with cesarean hysterectomy with IIAL (34 cases) in all PAS cases (1379 ± 769 mL vs 3168 ± 1916 mL; p < 0.001). In sub-analysis of the two uterine conservative-resective surgery subgroups, the group with identification-ligation of the upper vesical, upper vaginal, and uterine arteries had a significantly lower blood loss compared with uterine conservative-resective surgery with IIAL (1307 ± 743 mL vs 1701 ± 813 mL; p = 0.005). Women in the hysterectomy with IIAL group had more massive transfusion (35.3% vs 2.5%; p < 0.001; odds ratio [OR] 21.3, 95% confidence interval [CI] 6.9-66), major blood loss (>1500 mL) (70.6% vs 34%, p < 0.001; OR 4.7; 95% CI 2.1-10.3), catastrophic blood loss (>2500 mL) (64.7% vs 12.5%;p < 0.001; OR 12.8, 95% CI 5.7-29.1), other complications (32% vs 12.4%; p = 0.007; OR 3.4, 95% CI 1.5-7.7), and intensive care unit admission (32.4% vs 1.5%; p < 0.001; OR 31.4, 95% CI 8.2-120.7) compared with the uterine conservative-resective surgery groups. The identification-ligation of the upper vesical, upper vaginal and uterine arteries had a significant lower risk for major blood loss (30.5% vs 50%; p = 0.041; OR 0.44, 95% CI = 0.2-0.9) compared with IIAL for vascular control of uterine conservative-resective surgery. CONCLUSIONS Cesarean hysterectomy is not the default treatment for PAS, PAS with invasion above the vesical trigone are suitable for uterine conservative-resective surgery with upper vesical, upper vaginal and uterine artery vascular control.
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Affiliation(s)
- Rozi Aditya Aryananda
- Maternal-Fetal Medicine Division, Obstetrics & Gynecology Department, Dr. Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Aditiawarman Aditiawarman
- Maternal-Fetal Medicine Division, Obstetrics & Gynecology Department, Dr. Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Khanisyah Erza Gumilar
- Maternal-Fetal Medicine Division, Obstetrics & Gynecology Department, Dr. Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Manggala Pasca Wardhana
- Maternal-Fetal Medicine Division, Obstetrics & Gynecology Department, Dr. Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - M Ilham Aldika Akbar
- Maternal-Fetal Medicine Division, Obstetrics & Gynecology Department, Dr. Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Nareswari Cininta
- Maternal-Fetal Medicine Division, Obstetrics & Gynecology Department, Dr. Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Ernawati Ernawati
- Maternal-Fetal Medicine Division, Obstetrics & Gynecology Department, Dr. Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Budi Wicaksono
- Maternal-Fetal Medicine Division, Obstetrics & Gynecology Department, Dr. Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Hermanto Tri Joewono
- Maternal-Fetal Medicine Division, Obstetrics & Gynecology Department, Dr. Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Erry Gumilar Dachlan
- Maternal-Fetal Medicine Division, Obstetrics & Gynecology Department, Dr. Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Citra Aulia Bachtiar
- Maternal-Fetal Medicine Division, Obstetrics & Gynecology Department, Dr. Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Devita Kurniawati
- Maternal-Fetal Medicine Division, Obstetrics & Gynecology Department, Dr. Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Dian Puspita Virdayanti
- Maternal-Fetal Medicine Division, Obstetrics & Gynecology Department, Dr. Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Grace Ariani
- Anatomical Pathology Department, Dr. Soetomo General Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Gustaaf Albert Dekker
- Maternal-Fetal Medicine Division, Obstetrics & Gynecology Department, Dr. Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia.,Women & Children's Division, Department of Obstetrics and Gynecology, Lyell McEwin Hospital, University of Adelaide, Adelaide, Australia
| | - Agus Sulistyono
- Maternal-Fetal Medicine Division, Obstetrics & Gynecology Department, Dr. Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia
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Hussein AM, Elbarmelgy RA, Elbarmelgy RM, Thabet MM, Jauniaux E. Prospective evaluation of impact of post-Cesarean section uterine scarring in perinatal diagnosis of placenta accreta spectrum disorder. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:474-482. [PMID: 34225385 PMCID: PMC9311077 DOI: 10.1002/uog.23732] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 06/17/2021] [Accepted: 06/29/2021] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Standardized ultrasound imaging and pathology protocols have recently been developed for the perinatal diagnosis of placenta accreta spectrum (PAS) disorders. The aim of this study was to evaluate prospectively the effectiveness of these standardized protocols in the prenatal diagnosis and postnatal examination of women presenting with a low-lying placenta or placenta previa and a history of multiple Cesarean deliveries (CDs). METHODS This was a prospective cohort study of 84 consecutive women with a history of two or more prior CDs presenting with a singleton pregnancy and low-lying placenta/placenta previa at 32-37 weeks' gestation, who were referred for perinatal care and management between 15 January 2019 and 15 December 2020. All women were investigated using the standardized description of ultrasound signs of PAS proposed by the European Working Group on abnormally invasive placenta. In all cases, the ultrasound features were compared with intraoperative and histopathological findings. Areas of abnormal placental attachment were identified during the immediate postoperative gross examination and sampled for histological examination. The data of a subgroup of 32 women diagnosed antenatally as non-PAS who had complete placental separation at birth were compared with those of 39 cases diagnosed antenatally as having PAS disorder that was confirmed by histopathology at delivery. RESULTS Of the 84 women included in the study, 42 (50.0%) were diagnosed prenatally as PAS and the remaining 42 (50.0%) as non-PAS on ultrasound examination. Intraoperatively, 66 (78.6%) women presented with a large or extended area of dehiscence and 52 (61.9%) with a dense tangled bed of vessels or multiple vessels running laterally and craniocaudally in the uterine serosa. A loss of clear zone was recorded on grayscale ultrasound imaging in all 84 cases, while there was no case with bladder-wall interruption or with a focal exophytic mass. Myometrial thinning (< 1 mm) in at least one area of the anterior uterine wall was found in 41 (97.6%) of the 42 cases diagnosed as non-PAS on ultrasound and 37 (88.1%) of the 42 diagnosed antenatally as PAS. Histological samples were available for all 48 hysterectomy specimens with abnormal placental attachment and for the three cases managed conservatively with focal myometrial resection and uterine reconstruction. Villous tissue was found directly attached to the superficial myometrium (placenta creta) in six of these cases and both creta villous tissue and deeply implanted villous tissue within the uterine wall (placenta increta) were found in the remaining 45 cases. There was no evidence of percreta placentation on histology in any of the PAS cases. Comparison of the main antenatal ultrasound signs and perioperative macroscopic findings between the two subgroups correctly diagnosed antenatally (32 non-PAS and 39 PAS) showed no significant difference with respect to the distribution of myometrial thinning and the presence of a placental bulge on ultrasound and of anterior uterine wall dehiscence intraoperatively. Compared with the non-PAS subgroup, the PAS subgroup showed significantly higher placental lacunae grade (P < 0.001) and more often hypervascularity of the uterovesical/subplacental area (P < 0.001), presence of bridging vessels (P = 0.027) and presence of lacunae feeder vessels (P < 0.001) on ultrasound examination, and increased vascularization of the anterior uterine wall intraoperatively (P < 0.001). CONCLUSIONS Remodeling of the lower uterine segment following CD scarring leads to structural abnormalities of the uterine contour on both ultrasound examination and intraoperatively, independently of the presence of accreta villous tissue on microscopic examination. These anatomical changes are often reported as diagnostic of placenta percreta, including cases with no histological evidence of PAS. Guided histological examination could improve the overall diagnosis of PAS and is essential to obtain evidence-based epidemiologic data. © 2021 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)
- A. M. Hussein
- Department of Obstetrics and GynecologyUniversity of CairoCairoEgypt
| | - R. A. Elbarmelgy
- Department of Obstetrics and GynecologyUniversity of CairoCairoEgypt
| | - R. M. Elbarmelgy
- Department of Obstetrics and GynecologyUniversity of CairoCairoEgypt
| | - M. M. Thabet
- Department of Obstetrics and GynecologyUniversity of CairoCairoEgypt
| | - E. Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health SciencesUniversity College LondonLondonUK
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Jauniaux E, Hussein AM, Einerson BD, Silver RM. Debunking 20 th century myths and legends about the diagnosis of placenta accreta spectrum. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:417-423. [PMID: 35363412 DOI: 10.1002/uog.24890] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 02/06/2022] [Accepted: 02/11/2022] [Indexed: 06/14/2023]
Affiliation(s)
- E Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - A M Hussein
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
| | - B D Einerson
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center (UUHSC), Salt Lake City, UT, USA
| | - R M Silver
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center (UUHSC), Salt Lake City, UT, USA
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Fox KA, Cassady CI, Collins S, Einerson BD, Hobson SR, Palacios-Jaraquemada JM, Shrivastava VK, Lee W. Placenta Accreta Spectrum 2021: Roundtable Discussion. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:7-15. [PMID: 33788320 DOI: 10.1002/jum.15685] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/30/2021] [Accepted: 02/01/2021] [Indexed: 06/12/2023]
Affiliation(s)
- Karin A Fox
- Baylor College of Medicine/Texas Children's Hospital and Fetal Center, Houston, Texas, USA
| | - Christopher I Cassady
- Baylor College of Medicine/Texas Children's Hospital and Fetal Center, Houston, Texas, USA
| | - Sally Collins
- Fetal Medicine Unit, John Radcliffe Hospital, Oxford, UK
- Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Brett D Einerson
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, Utah, USA
| | - Sebastian R Hobson
- Maternal Fetal Medicine, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Vineet K Shrivastava
- Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Miller Children's & Women's Hospital/ Long Beach Memorial Medical Center, Long Beach, California, USA
| | - Wesley Lee
- Baylor College of Medicine/Texas Children's Hospital and Fetal Center, Houston, Texas, USA
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40
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Nieto-Calvache AJ, Aryananda RA. The first step to evaluate the usefulness of arterial occlusion in placenta accreta spectrum is to establish its indications. Acta Obstet Gynecol Scand 2021; 101:379-380. [PMID: 34907527 DOI: 10.1111/aogs.14307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/13/2021] [Accepted: 12/03/2021] [Indexed: 02/03/2023]
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Barinov SV, Shmakov RG, Medyannikova IV, Tirskaya YI, Kadtsyna TV, Lazareva OV, Razdobedina IN, Neustroyeva TN, Stepanov SS. Efficacy of distal haemostasis during caesarean delivery in women with placenta accreta spectrum disorders. J Matern Fetal Neonatal Med 2021; 35:8778-8785. [PMID: 34794371 DOI: 10.1080/14767058.2021.2005019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pregnancies complicated by the placenta praevia are associated with an increased risk of massive obstetric bleeding and high rates of hysterectomy which are often caused by the placenta accreta. The aim of our study was to identify the risk factors for placenta praevia associated with PAS disorders and the efficacy of distal haemostasis during Cesarean delivery. METHODS This was a cohort study carried out between 2014 and 2020 in 532 women with abnormal placental localization and attachment. The placental attachment spectrum (PAS) disorder diagnosis was confirmed during the surgery and by the histology results in 164/532 participants. Depending on the surgical approach during the Cesarean delivery, patients were divided into three groups. In Group 1 (n = 52), patients underwent bilateral uterine artery ligation. In Group 2 (n = 33), we used the combined compression haemostasis approach including the placement of tourniquets and insertion of an intrauterine balloon for controlled tamponade. In Group 3 (n = 79), we used the combination of surgical haemostasis with the controlled intrauterine tamponade using the vaginal and intrauterine Zhukovsky balloon. RESULTS PAS was observed in 30.8% of the placenta praevia cases, and in 93.3% was associated with the presence of a uterine scar. Women with the placenta praevia and PAS had a significantly higher number of past deliveries (р = .001). According to the FIGO classification, 53.8% of women with placenta praevia observed during the Cesarean had РА1 and 46.2% PA2. With regards to the PAS disorders observed in 30.8% of patients, 38.4% had PAS3, 34.7% PAS4, 18.3% PAS5 and 8.5% PAS6. The histology analysis showed normal placental attachment in 42.9% of the total number of study participants, placenta accreta in 28.2%, placenta increta in 16.7%, and placenta percreta in 12.2%. In Group 1, we performed the resection of uterine wall with the attached portion of the placenta in 13.5% of women, in Group 2 in 30.3% women, and in Group 3 in 50.6% women. There was a significant 4.8-fold reduction in the number of hysterectomies in Group 3 versus Group 2 (р = .043) and a 4.4-fold reduction in Group 2 versus Group 1 (р = .003). In Group 2, the volume of blood loss was 1.3-fold lower and in Group 3 1.5-fold lower than in Group 1. Conclusion: The techniques of compression distal haemostasis evaluated in this study in women with PAS are efficacious in the reduction of adverse maternal outcomes and should be used more widely in clinical practice.
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Affiliation(s)
- S V Barinov
- Federal State Budget Institution of Higher Education "Omsk State Medical University" of the Russian Ministry of Health, Omsk, Russia
| | - R G Shmakov
- Federal State Budget Institution National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I.Kulakov of the Ministry of Healthcare of Russian Federation, Moscow, Russia
| | - I V Medyannikova
- Federal State Budget Institution of Higher Education "Omsk State Medical University" of the Russian Ministry of Health, Omsk, Russia
| | - Yu I Tirskaya
- Federal State Budget Institution of Higher Education "Omsk State Medical University" of the Russian Ministry of Health, Omsk, Russia
| | - T V Kadtsyna
- Federal State Budget Institution of Higher Education "Omsk State Medical University" of the Russian Ministry of Health, Omsk, Russia
| | - O V Lazareva
- Federal State Budget Institution of Higher Education "Omsk State Medical University" of the Russian Ministry of Health, Omsk, Russia
| | - I N Razdobedina
- Perinatal Centre of Omsk Regional Clinical Hospital, Omsk, Russia
| | - T N Neustroyeva
- Perinatal Center of the State Autonomous Institution of the Republic of Sakha (Yakutia) Republican Hospital No. 1, Yakutsk, Russia
| | - S S Stepanov
- Federal State Budget Institution of Higher Education "Omsk State Medical University" of the Russian Ministry of Health, Omsk, Russia
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Nieto-Calvache AJ, Palacios-Jaraquemada JM, Aguilera LR, Arriaga W, Colonia A, Aryananda RA, Nieto-Calvache AS, Maya J, Vergara-Galliadi LM, Messa Bryon A. Telemedicine facilitates surgical training in placenta accreta spectrum. Int J Gynaecol Obstet 2021; 158:137-144. [PMID: 34714947 DOI: 10.1002/ijgo.14000] [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: 08/27/2021] [Revised: 10/19/2021] [Accepted: 10/27/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The training of groups responsible for managing patients with placenta accreta spectrum (PAS) is complex because of the lack of hospitals with a high flow of patients and absence of formal educational programs. We report here the results of a virtual training program (VTP) that implemented one-step conservative surgery (OSCS). METHODS A prospective observation study of OSCS VTP between three expert groups and PAS reference hospitals without experience in OSCS was performed. Accessible or cost-efficient web meeting platforms were used to implement the VTP components: baseline observation of the participant's prior knowledge; instructions about essential PAS surgery topics; case selection and joint planning of surgery; expert group "telepresence" during surgery and postoperative debriefing. RESULTS One-step conservative surgery was performed successfully at six hospitals. All patients had increta/percreta with a median intraoperative bleeding of 1300 ml (IQR 825-2325) and surgical time of 184 min (IQR 113-240). All groups considered the VTP very useful (n = 33, 97%) or useful (n = 1, 3%), they would use it again (definitely: n = 27, 81.8%; or probably: n = 6, 18.2%), and they would recommend it to other colleagues. CONCLUSION Tele education and telepresence during PAS surgery facilitates the implementation of OSCS in selected cases.
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Affiliation(s)
- Albaro Jose Nieto-Calvache
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia.,Latin American Group for the Study of Placenta Accreta Spectrum, Cali, Colombia
| | | | - Lorgio Rudy Aguilera
- Latin American Group for the Study of Placenta Accreta Spectrum, Cali, Colombia.,Hospital de la Mujer Dr Percy Boland, Santacruz, Bolivia
| | - William Arriaga
- Latin American Group for the Study of Placenta Accreta Spectrum, Cali, Colombia.,Hospital Regional de Occidente, Quetzaltenango, Guatemala
| | - Alejandro Colonia
- Latin American Group for the Study of Placenta Accreta Spectrum, Cali, Colombia.,Hospital General de Medellín, Medellín, Colombia
| | | | | | - Juliana Maya
- Facultad de Ciencias de la Salud, Programa de Medicina, Universidad Icesi, Cali, Colombia
| | | | - Adriana Messa Bryon
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia.,Latin American Group for the Study of Placenta Accreta Spectrum, Cali, Colombia
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Nieto-Calvache AJ, Palacios-Jaraquemada JM, Aryananda RA, Rodriguez F, Ordoñez CA, Messa Bryon A, Calvache JPB, Lopez J, Campos CI, Mejia M, Rengifo M, Galliadi LMV, Maya J, Zambrano MA, Aguayo IP, Carabalí IG, Burgos JM. How to identify patients who require aortic vascular control in placenta accreta spectrum disorders? Am J Obstet Gynecol MFM 2021; 4:100498. [PMID: 34610485 DOI: 10.1016/j.ajogmf.2021.100498] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The placenta accreta spectrum disorder may lead to severe complications. Helpful interventions to prevent placenta accreta spectrum bleeding include vascular control procedures in the aorta or pelvic vessels. Although these procedures are related to lower intraoperative bleeding, they are associated with complications, so the possibility of selecting patients at highest risk of bleeding while avoiding vascular procedures for all cases is attractive. OBJECTIVE We describe an intraoperative staging protocol whose objective is to identify the need to use vascular control procedures in patients with placenta accreta spectrum. We also describe the results of its application in a placenta accreta spectrum referral hospital. STUDY DESIGN This descriptive, retrospective study included patients with suspected prenatal placenta accreta spectrum treated at a referral center for placenta accreta spectrum between April 2016 and June 2020. The use of the resuscitative endovascular balloon occlusion of the aorta allowed the prevention and treatment of excessive bleeding; its application was performed according to 3 approaches: (1) presurgical use in all placenta accreta spectrum patients (Group 1), (2) according to the prenatal placenta accreta spectrum topography (Group 2), and (3) according to the "intraoperative staging" (Group 3). In addition, the frequency of use of resuscitative endovascular balloon occlusion of the aorta and the clinical results in the management of placenta accreta spectrum were described in the 3 groups. RESULTS Seventy patients underwent surgery for a prenatal suspicion of placenta accreta spectrum. Of these, 16 underwent intraoperative staging (Group 3); in 20 cases, resuscitative endovascular balloon occlusion of the aorta was used based on the prenatal imaging topographic classification (Group 2), and in the remaining 34 patients (Group 1), it was always used before the laparotomy. The frequency of use of resuscitative endovascular balloon occlusion of the aorta was progressively lower in Groups 1 (32 patients, 94.1% of cases), 2 (11 patients, 75% of cases), and 3 (4 patients, 25% of cases). Similarly, resuscitative endovascular balloon occlusion of the aorta went from being applied predominantly before the laparotomy (all cases in Group 1) to being applied after intraoperative staging (all cases in Group 3). The percentage of endovascular devices applied but not used, decreased from 23.5% in Group 1 to 0% in Group 3. Complications related to the resuscitative endovascular balloon occlusion of the aorta were seen in 4 patients (2 women in Group 1, and 1 woman each in Groups 2 and 3). CONCLUSION The "intraoperative staging" of placenta accreta spectrum allows the optimization of the use of resuscitative endovascular balloon occlusion of the aorta, which decreases the frequency of its use without increasing the volume of blood loss.
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Affiliation(s)
- Albaro José Nieto-Calvache
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos).
| | | | - Rozi Aditya Aryananda
- Dr Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia (Dr Aryananda)
| | - Fernando Rodriguez
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); División de Trauma y Emergencias, Departamento de Cirugía General, Fundación Valle del Lili, Cali, Colombia (Drs Rodriguez and Ordoñez)
| | - Carlos A Ordoñez
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); División de Trauma y Emergencias, Departamento de Cirugía General, Fundación Valle del Lili, Cali, Colombia (Drs Rodriguez and Ordoñez)
| | - Adriana Messa Bryon
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos)
| | - Juan Pablo Benavides Calvache
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos)
| | - Jaime Lopez
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos)
| | - Clara Ivette Campos
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); Departamento de Patología y Laboratorio Clínico, Fundación Valle del Lili, Cali, Colombia (Dr Campos)
| | - Mauricio Mejia
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); Departamento de Radiología e Imágenes Diagnósticas, Fundación Valle del Lili, Cali, Colombia (Drs Mejia and Rengifo)
| | - Martin Rengifo
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); Departamento de Radiología e Imágenes Diagnósticas, Fundación Valle del Lili, Cali, Colombia (Drs Mejia and Rengifo)
| | | | - Juliana Maya
- Programa de Medicina, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia (Drs Maya, Aguayo, and Carabalí)
| | - Maria Andrea Zambrano
- Programa de Ginecología y Obstetricia, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia (Dr Zambrano)
| | - Isabella Prado Aguayo
- Programa de Medicina, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia (Drs Maya, Aguayo, and Carabalí)
| | - Isabella Gutierrez Carabalí
- Programa de Medicina, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia (Drs Maya, Aguayo, and Carabalí)
| | - Juan Manuel Burgos
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos)
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Posterior Placenta Accreta Spectrum Disorders: Risk Factors, Diagnostic Accuracy, and Surgical Management. MATERNAL-FETAL MEDICINE 2021. [DOI: 10.1097/fm9.0000000000000124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Chou MM, Yuan JC, Lu YA, Chuang SW. Recurrent severe placenta increta at 8 weeks of gestation in a twin pregnancy following uterus-conserving surgery for prior placenta accreta spectrum disorder. Taiwan J Obstet Gynecol 2021; 59:956-959. [PMID: 33218421 DOI: 10.1016/j.tjog.2020.09.028] [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] [Accepted: 08/04/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE We describe herein our experience of employing a hysterectomy and prophylactic internal iliac artery balloon occlusion (IIABO) strategy for the management of recurrent severe placenta increta at 8 weeks in a twin pregnancy following uterus-conserving surgery for prior placenta accreta spectrum (PAS) disorder. CASE REPORT A 40-year-old woman with a history of uterus-conserving surgery for PAS disorder underwent transvaginal ultrasound evaluation at 8 weeks of pregnancy, which showed a dichorionic/diamniotic pregnancy with viable embryos of a crown-rump length of 1.65 cm and 2.03 cm, respectively. Many irregularly-shaped grade 3+ lacunae were observed, and color Doppler imaging revealed diffuse intraplacental and perihypervascularity. A total abdominal hysterectomy was performed at 10 weeks, with an estimated blood loss of 1275 mL. Placenta increta was confirmed by histopathologic examination. CONCLUSION The high rate of recurrence of PAS disorder in a subsequent pregnancy should be discussed following an antenatal diagnosis of PAS disorder with patients who may be considering uterine conservation in order to retain the option of a future pregnancy.
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Affiliation(s)
- Min-Min Chou
- Center for High Risk Pregnancy and Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, China Medical University Hospital, Taichung, Taiwan.
| | - Jia-Chun Yuan
- Center for High Risk Pregnancy and Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, China Medical University Hospital, Taichung, Taiwan
| | - Yaw-An Lu
- Center for High Risk Pregnancy and Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, China Medical University Hospital, Taichung, Taiwan
| | - Sheng-Wei Chuang
- Center for High Risk Pregnancy and Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, China Medical University Hospital, Taichung, Taiwan
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Yang CC, Chou YC, Kuo TN, Liou JY, Cheng HM, Kuo YT. Prophylactic Intraoperative Uterine Artery Embolization During Cesarean Section or Cesarean Hysterectomy in Patients with Abnormal Placentation: A Systematic Review and Meta-Analysis. Cardiovasc Intervent Radiol 2021; 45:488-501. [PMID: 34282489 DOI: 10.1007/s00270-021-02921-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 07/05/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE To evaluate the effectiveness and safety of prophylactic intraoperative uterine artery embolization (UAE) performed immediately after fetal delivery during planned cesarean section or cesarean hysterectomy in patients with placenta accreta spectrum disorder or placenta previa. METHODS A systematic search was conducted on Ovid MEDLINE and Embase, PubMed, Web of Science, and Cochrane databases. Studies were selected using the Population/Intervention/Comparison/Outcomes (PICO) strategy. The intraoperative blood loss and the rate of emergent peripartum hysterectomy (EPH) were the primary outcomes, whereas the length of hospital stay and volume of blood transfused were the secondary outcomes. A random-effects model was employed to pool each effect size. The cumulative values of the primary outcomes were calculated using the generic inverse variance method. RESULTS Eleven retrospective cohort studies and five case series were included, recruiting 421 women who underwent prophylactic intraoperative UAE (UAE group) and 374 women who did not (control group). Compared with the control group, the UAE group had significantly reduced intraoperative blood loss (p = 0.020) during cesarean section or cesarean hysterectomy. Furthermore, the EPH rate was also significantly decreased (p = 0.020; cumulative rate: 19.65%), but not the length of hospital stay (p = 0.850) and volume of pRBC transfused (p = 0.140), after cesarean section in the UAE group. The incidence of major complications was low (3.33%), despite two patients with uterine necrosis. CONCLUSION The currently available data provides encouraging evidence that prophylactic intraoperative UAE may contribute to hemorrhage control and fertility preservation in women with abnormal placentation. REGISTRATION PROSPERO registration code: CRD42021230581. https://clinicaltrials.gov/ct2/show/CRD42021230581 LEVEL OF EVIDENCE: Level 2a, systematic review of retrospective cohort studies.
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Affiliation(s)
- Cheng-Chun Yang
- Department of Medical Imaging, Chi Mei Medical Center, NO. 901, Zhonghua Rd., Yongkang Dist., Tainan City, 710, Taiwan
| | - Yi-Chen Chou
- Department of Medical Imaging, Chi Mei Medical Center, NO. 901, Zhonghua Rd., Yongkang Dist., Tainan City, 710, Taiwan
| | - Tian-Ni Kuo
- Department of Obstetrics and Gynecology, Chi Mei Medical Center, Tainan, Taiwan
| | - Jyun-Yan Liou
- Department of Medical Imaging, Chi Mei Medical Center, NO. 901, Zhonghua Rd., Yongkang Dist., Tainan City, 710, Taiwan
| | - Hua-Ming Cheng
- Department of Medical Imaging, Chi Mei Medical Center, NO. 901, Zhonghua Rd., Yongkang Dist., Tainan City, 710, Taiwan
| | - Yu-Ting Kuo
- Department of Medical Imaging, Chi Mei Medical Center, NO. 901, Zhonghua Rd., Yongkang Dist., Tainan City, 710, Taiwan.
- Department of Radiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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van Beekhuizen HJ, Stefanovic V, Schwickert A, Henrich W, Fox KA, MHallem Gziri M, Sentilhes L, Gronbeck L, Chantraine F, Morel O, Bertholdt C, Braun T, Rijken MJ, Duvekot JJ. A multicenter observational survey of management strategies in 442 pregnancies with suspected placenta accreta spectrum. Acta Obstet Gynecol Scand 2021; 100 Suppl 1:12-20. [PMID: 33483943 PMCID: PMC8048500 DOI: 10.1111/aogs.14096] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/21/2020] [Accepted: 01/18/2021] [Indexed: 11/29/2022]
Abstract
Introduction Management options for women with placenta accreta spectrum (PAS) comprise termination of pregnancy before the viable gestational age, leaving the placenta in situ for subsequent reabsorption of the placenta or delayed hysterectomy, manual removal of placenta after vaginal delivery or during cesarean section, focal resection of the affected uterine wall, and peripartum hysterectomy. The aim of this observational study was to describe actual clinical management and outcomes in PAS in a large international cohort. Material and methods Data from women in 15 referral centers of the International Society of PAS (IS‐PAS) were analyzed and correlated with the clinical classification of the IS‐PAS: From Grade 1 (no PAS) to Grade 6 (invasion into pelvic organs other than the bladder). PAS was usually diagnosed antenatally and the operators performing ultrasound rated the likelihood of PAS on a Likert scale of 1 to 10. Results In total, 442 women were registered in the database. No maternal deaths occurred. Mean blood loss was 2600 mL (range 150‐20 000 mL). Placenta previa was present in 375 (84.8%) women and there was a history of a previous cesarean in 329 (74.4%) women. The PAS likelihood score was strongly correlated with the PAS grade (P < .001). The mode of delivery in the majority of women (n = 252, 57.0%) was cesarean hysterectomy, with a repeat laparotomy in 20 (7.9%) due to complications. In 48 women (10.8%), the placenta was intentionally left in situ, of those, 20 (41.7%) had a delayed hysterectomy. In 26 women (5.9%), focal resection was performed. Termination of pregnancy was performed in 9 (2.0%), of whom 5 had fetal abnormalities. The placenta could be removed in 90 women (20.4%) at cesarean, and in 17 (3.9%) after vaginal delivery indicating mild or no PAS. In 34 women (7.7%) with an antenatal diagnosis of PAS, the placenta spontaneously separated (false positives). We found lower blood loss (P < .002) in 2018‐2019 compared with 2009‐2017, suggesting a positive learning curve. Conclusions In referral centers, the most common management for severe PAS was cesarean hysterectomy, followed by leaving the placenta in situ and focal resection. Prenatal diagnosis correlated with clinical PAS grade. No maternal deaths occurred.
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Affiliation(s)
- Heleen J van Beekhuizen
- Department of Gynecological Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Vedran Stefanovic
- Department of Obstetrics and Gynecology, Fetomaternal Medical Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Alexander Schwickert
- Department of Obstetrics and Department of Experimental Obstetrics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Wolfgang Henrich
- Department of Obstetrics and Department of Experimental Obstetrics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Karin A Fox
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Mina MHallem Gziri
- Department of Obstetrics, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Lene Gronbeck
- Department of Obstetrics, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Frederic Chantraine
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire de Liège, Site CHR Citadelle, Liège, Belgium
| | - Oliver Morel
- Nancy Regional and University Hospital Center (CHRU, Women's Division, Université de Lorraine, Nancy, France.,Diagnosis and International Adaptive Imaging (IADI) Unit, Inserm, Université de Lorraine, Nancy, France
| | - Charline Bertholdt
- Nancy Regional and University Hospital Center (CHRU, Women's Division, Université de Lorraine, Nancy, France.,Diagnosis and International Adaptive Imaging (IADI) Unit, Inserm, Université de Lorraine, Nancy, France
| | - Thorsten Braun
- Department of Obstetrics and Department of Experimental Obstetrics, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Marcus J Rijken
- Department of Obstetrics, Division Women and Baby, Julius Global Health, The Julius center for Health Sciences and Primary Care, University Medical center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Johannes J Duvekot
- Department of Obstetrics and Gynecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical center Rotterdam, Rotterdam, the Netherlands
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Riveros-Perez E, Sanchez MG, Odo N, Shukla M, Rungruang B. Supra-massive transfusion and interdisciplinary approach to cesarean hysterectomy due to complex placenta percreta: Case report. SAGE Open Med Case Rep 2021; 9:2050313X211010011. [PMID: 33959282 PMCID: PMC8060747 DOI: 10.1177/2050313x211010011] [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: 12/04/2020] [Accepted: 03/22/2021] [Indexed: 11/29/2022] Open
Abstract
Placenta accreta spectrum encompasses a group of conditions of abnormal placental infiltration of the uterine wall and surrounding tissues. It is associated with significant blood loss, perioperative morbidity, and risk of death. A coordinated interdisciplinary approach to these complex cases and early resuscitation with blood products are critical factors in the successful management of patients affected by this disease. We describe the successful management of a patient with placenta percreta who required supra-massive transfusion of blood products and interventions by different specialized teams in a tertiary care center.
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Affiliation(s)
- Efrain Riveros-Perez
- Department of Anesthesiology and
Perioperative Medicine, Medical College of Georgia at Augusta University,
Augusta, GA, USA
- Outcomes Research Consortium,
Cleveland Clinic, Cleveland, OH, USA
| | - Maria Gabriela Sanchez
- Department of Anesthesiology and
Perioperative Medicine, Medical College of Georgia at Augusta University,
Augusta, GA, USA
| | - Nadine Odo
- Department of Anesthesiology and
Perioperative Medicine, Medical College of Georgia at Augusta University,
Augusta, GA, USA
| | - Mrinal Shukla
- Vascular Surgery Division,
Department of Surgery, Medical College of Georgia at Augusta University,
Augusta, GA, USA
| | - Bunya Rungruang
- Division of Gynecologic Oncology,
Department of Obstetrics and Gynecology, Medical College of Georgia at
Augusta University, Augusta, GA, USA
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49
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Do all patients with placenta accreta spectrum require endovascular balloons? Am J Obstet Gynecol MFM 2021; 3:100364. [PMID: 33785464 DOI: 10.1016/j.ajogmf.2021.100364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/07/2021] [Indexed: 12/21/2022]
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Ishibashi H, Miyamoto M, Iwahashi H, Matsuura H, Kakimoto S, Sakamoto T, Hada T, Takano M. Criteria for placenta accreta spectrum in the International Federation of Gynaecology and Obstetrics classification, and topographic invasion area are associated with massive hemorrhage in patients with placenta previa. Acta Obstet Gynecol Scand 2021; 100:1019-1025. [PMID: 33715171 DOI: 10.1111/aogs.14143] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Placenta previa with placenta accreta spectrum (PAS) is a life-threatening disease that results in massive hemorrhage. The clinical and histologic criteria of PAS were adopted according to the International Federation of Gynaecology and Obstetrics (FIGO) classification. We aimed to investigate whether FIGO criteria and topography were associated with maternal complications in patients with placenta previa. MATERIAL AND METHODS Patients with placenta previa who underwent cesarean section at our institution between January 2003 and December 2019 were identified. First, they were divided based on FIGO classification, as follows: Group A, with clinical criteria; Group B, with histologic criteria; and Group C: without clinical or histologic criteria. Next, cases with PAS were classified according to the topographic invasion area, as follows: type 1, upper posterior bladder; type 2, lower posterior bladder; type 3, parametrium; type 4, posterior lower uterine segment. Predictive factors for massive hemorrhage were retrospectively analyzed. RESULTS Among the 350 patients, 24 (6.9%) were classified as Group A, 16 (4.6%) as Group B and 310 (88.5%) as Group C. Regarding maternal history and hemostatic procedures, there were no significant factors other than hysterectomy (p < .01) in Groups A and B. The volume of blood loss in both Groups A and B was greater than in Group C (p < .01). The rates of uterine artery embolization and blood transfusion were higher in Groups A and B than in Group C (p < .01). In addition, there were no significant factors other than hysterectomy between Groups A and B. In the multivariate analysis for massive hemorrhage, Group A (odds ratio: 2.73, p = .04) and Group B (odds ratio: 12.69, p < .01) were identified as independent predictive factors. In addition, massive hemorrhage was closely related to the lower posterior bladder and parametrial invasion in both Groups A and B. CONCLUSIONS Both clinical and histologic criteria for PAS in the FIGO classification were associated with massive hemorrhage. Diagnosing clinical PAS using the FIGO classification, additional hemostatic procedures might be necessary according to the topographic invasion area.
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Affiliation(s)
- Hiroki Ishibashi
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, Saitama, Tokorozawa, Japan
| | - Morikazu Miyamoto
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, Saitama, Tokorozawa, Japan
| | - Hideki Iwahashi
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, Saitama, Tokorozawa, Japan
| | - Hiroko Matsuura
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, Saitama, Tokorozawa, Japan
| | - Soichiro Kakimoto
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, Saitama, Tokorozawa, Japan
| | - Takahiro Sakamoto
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, Saitama, Tokorozawa, Japan
| | - Taira Hada
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, Saitama, Tokorozawa, Japan
| | - Masashi Takano
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, Saitama, Tokorozawa, Japan
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