1
|
Futterman ID, Conroy EM, Chudnoff S, Alagkiozidis I, Minkoff H. Complex obstetrical surgery: building a team and defining roles. Am J Obstet Gynecol MFM 2024; 6:101421. [PMID: 38969176 DOI: 10.1016/j.ajogmf.2024.101421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 05/23/2024] [Accepted: 06/26/2024] [Indexed: 07/07/2024]
Abstract
As the number of placenta accreta spectrum cases continues to rise, the gap in surgical skills in labor and delivery units becomes more apparent. Recent scholarly work has highlighted the diminishing advanced surgical skills among obstetrician-gynecologists, particularly among new graduates. Therefore, it has become a practice in many institutions to refer complex cesarean deliveries and obstetrical hysterectomies to subspecialists, specifically gynecologic oncologists. Hence, in this commentary, we propose a process through which key personnel within departments of obstetrics and gynecology are identified and their appropriate level of involvement in cases of complex obstetrical surgery is delineated. In doing so, we describe the surgical skills expected from each provider level so that the cesarean delivery complexity level can be matched with specific surgical expertise. Through this process, an obstetrician-led complex obstetrical surgery team is formed. Ultimately, the goal of this process is 2-fold; first, to return cases with higher levels of surgical complexity back to obstetricians and, second, to reduce the surgical back-up burden from gynecology subspecialists such as gynecologic oncologists.
Collapse
Affiliation(s)
- Itamar D Futterman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY (Futterman and Minkoff); Division of Complex Obstetrical Surgery, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY (Futterman and Conroy).
| | - Erin M Conroy
- Division of Complex Obstetrical Surgery, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY (Futterman and Conroy); Hospitalist Division, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY (Conroy)
| | - Scott Chudnoff
- Division of Minimally Invasive Gynecology, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY (Chudnoff)
| | - Ioannis Alagkiozidis
- Division of Gynecology Oncology, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY (Alagkiozidis)
| | - Howard Minkoff
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY (Futterman and Minkoff); Department of Obstetrics and Gynecology and School of Public Health, SUNY Downstate Health Sciences University, Brooklyn, NY (Minkoff)
| |
Collapse
|
2
|
Javinani A, Qaderi S, Hessami K, Shainker SA, Shamshirsaz AA, Fox KA, Mustafa HJ, Subramaniam A, Khandelwal M, Sandlin AT, Duzyj CM, Lyell DJ, Zuckerwise LC, Newton JM, Kingdom JC, Harrison RK, Shrivastava VK, Greiner AL, Loftin R, Genc MR, Atasi LK, Abdel-Razeq SS, Bennett KA, Carusi DA, Einerson BD, Gilner JB, Carver AR, Silver RM, Shamshirsaz AA. Delivery outcomes in the subsequent pregnancy following the conservative management of placenta accreta spectrum disorder: a systematic review and meta-analysis. Am J Obstet Gynecol 2024; 230:485-492.e7. [PMID: 37918506 DOI: 10.1016/j.ajog.2023.10.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/17/2023] [Accepted: 10/26/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE Cesarean hysterectomy is generally presumed to decrease maternal morbidity and mortality secondary to placenta accreta spectrum disorder. Recently, uterine-sparing techniques have been introduced in conservative management of placenta accreta spectrum disorder to preserve fertility and potentially reduce surgical complications. However, despite patients often expressing the intention for future conception, few data are available regarding the subsequent pregnancy outcomes after conservative management of placenta accreta spectrum disorder. Thus, we aimed to perform a systematic review and meta-analysis to assess these outcomes. DATA SOURCES PubMed, Scopus, and Web of Science databases were searched from inception to September 2022. STUDY ELIGIBILITY CRITERIA We included all studies, with the exception of case studies, that reported the first subsequent pregnancy outcomes in individuals with a history of placenta accreta spectrum disorder who underwent any type of conservative management. METHODS The R programming language with the "meta" package was used. The random-effects model and inverse variance method were used to pool the proportion of pregnancy outcomes. RESULTS We identified 5 studies involving 1458 participants that were eligible for quantitative synthesis. The type of conservative management included placenta left in situ (n=1) and resection surgery (n=1), and was not reported in 3 studies. The rate of placenta accreta spectrum disorder recurrence in the subsequent pregnancy was 11.8% (95% confidence interval, 1.1-60.3; I2=86.4%), and 1.9% (95% confidence interval, 0.0-34.1; I2=82.4%) of participants underwent cesarean hysterectomy. Postpartum hemorrhage occurred in 10.3% (95% confidence interval, 0.3-81.4; I2=96.7%). A composite adverse maternal outcome was reported in 22.7% of participants (95% confidence interval, 0.0-99.4; I2=56.3%). CONCLUSION Favorable pregnancy outcome is possible following successful conservation of the uterus in a placenta accreta spectrum disorder pregnancy. Approximately 1 out of 4 subsequent pregnancies following conservative management of placenta accreta spectrum disorder had considerable adverse maternal outcomes. Given such high incidence of adverse outcomes and morbidity, patient and provider preparation is vital when managing this population.
Collapse
Affiliation(s)
- Ali Javinani
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Shohra Qaderi
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Kamran Hessami
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Amir A Shamshirsaz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Karin A Fox
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Hiba J Mustafa
- Division of Maternal-Fetal Medicine, Indiana University School of Medicine, Indianapolis, IN; Fetal Center at Riley Children's Health, Indiana University Health, Indianapolis, IN
| | - Akila Subramaniam
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Adam T Sandlin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Christina M Duzyj
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA
| | - Deirdre J Lyell
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford School of Medicine, Stanford, CA
| | - Lisa C Zuckerwise
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - John C Kingdom
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Rachel K Harrison
- Department of Maternal-Fetal Medicine, Advocate Aurora Health, Chicago, IL
| | - Vineet K Shrivastava
- Miller Children's and Women's Hospital Long Beach, Long Beach Memorial Medical Center, Long Beach, CA
| | - Andrea L Greiner
- Department of Obstetrics and Gynecology, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - Ryan Loftin
- Department of Maternal-Fetal Medicine, Advocate Aurora Health, Chicago, IL; Allina Health System, Minneapolis, MN
| | - Mehmet R Genc
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL
| | - Lamia K Atasi
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mercy Hospital, St. Louis, MO
| | - Sonya S Abdel-Razeq
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University, New Haven, CT
| | - Kelly A Bennett
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford School of Medicine, Stanford, CA; Fetal Center at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
| | | | - Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
| | - Jennifer B Gilner
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University, Durham, NC
| | | | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
| | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| |
Collapse
|
3
|
Kayem G, Seco A, Vendittelli F, Crenn Hebert C, Dupont C, Branger B, Huissoud C, Fresson J, Winer N, Langer B, Rozenberg P, Morel O, Bonnet MP, Perrotin F, Azria E, Carbillon L, Chiesa C, Raynal P, Rudigoz RC, Patrier S, Beucher G, Dreyfus M, Sentilhes L, Deneux-Tharaux C. Risk factors for placenta accreta spectrum disorders in women with any prior cesarean and a placenta previa or low lying: a prospective population-based study. Sci Rep 2024; 14:6564. [PMID: 38503816 PMCID: PMC10951207 DOI: 10.1038/s41598-024-56964-9] [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: 05/24/2023] [Accepted: 03/13/2024] [Indexed: 03/21/2024] Open
Abstract
This study aimed to identify the risk factors for placenta accreta spectrum (PAS) in women who had at least one previous cesarean delivery and a placenta previa or low-lying. The PACCRETA prospective population-based study took place in 12 regional perinatal networks from 2013 through 2015. All women with one or more prior cesareans and a placenta previa or low lying were included. Placenta accreta spectrum (PAS) was diagnosed at delivery according to standardized clinical and histological criteria. Of the 520,114 deliveries, 396 fulfilled inclusion criteria; 108 were classified with PAS at delivery. Combining the number of prior cesareans and the placental location yielded a rate ranging from 5% for one prior cesarean combined with a posterior low-lying placenta to 63% for three or more prior cesareans combined with placenta previa. The factors independently associated with PAS disorders were BMI ≥ 30, previous uterine surgery, previous postpartum hemorrhage, a higher number of prior cesareans, and a placenta previa. Finally, in this high-risk population, the rate of PAS disorders varies greatly, not only with the number of prior cesareans but also with the exact placental location and some of the women's individual characteristics. Risk stratification is thus possible in this population.
Collapse
Affiliation(s)
- Gilles Kayem
- Trousseau Hospital, APHP, Sorbonne University, Paris, France.
- CRESS U1153, INSERM, Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé) Research Team, Paris University, Paris, France.
| | - Aurélien Seco
- Clinical Research Unit Necker Cochin, APHP, Paris, France
| | - Francoise Vendittelli
- Réseau de Santé en Périnatalité d'Auvergne, Clermont-Ferrand, France
- Université Clermont Auvergne, Clermont Auvergne INP, CHU Clermont-Ferrand, CNRS, Institut Pascal, 63000, Clermont-Ferrand, France
| | - Catherine Crenn Hebert
- APHP, Louis Mourier University Hospital, Colombes, France
- Réseau périnatal des Hauts de Seine, PERINAT92, 60 Rue du Général Leclerc, Issy-Les-Moulineaux, France
| | - Corinne Dupont
- University Claude Bernard Lyon 1, RESHAPE INSERM U1290, Univ. Lyon, 7425, Lyon, France
- Réseau Périnatal Aurore, Hospices Civils de Lyon, Hôpital de la Croix Rousse, Lyon, France
| | - Bernard Branger
- Réseau « Sécurité Naissance - Naître Ensemble » des Pays-de-la-Loire, Nantes, France
| | - Cyril Huissoud
- Réseau Périnatal Aurore, Hospices Civils de Lyon, Hôpital de la Croix Rousse, Lyon, France
- Maternité de la Croix Rousse, Lyon, France
| | - Jeanne Fresson
- CRESS U1153, INSERM, Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé) Research Team, Paris University, Paris, France
- CHRU Nancy, Réseau Périnatal Lorrain, Nancy, France
| | - Norbert Winer
- Service de Gynécologie Obstétrique HME Université de Nantes, NUN, INRA, UMR 1280, Phan, Université de Nantes, 44000, Nantes, France
| | | | | | | | - Marie Pierre Bonnet
- CRESS U1153, INSERM, Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé) Research Team, Paris University, Paris, France
- Anesthesia and Critical Care Department, Trousseau Hospital, APHP, Sorbonne University, Paris, France
| | | | - Elie Azria
- CRESS U1153, INSERM, Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé) Research Team, Paris University, Paris, France
- Maternity Unit, Paris Saint Joseph Hospital, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - Lionel Carbillon
- Réseau Périnatal NEF Naître dans l'Est Francilien, Paris 13 University, Villetaneuse, France
| | - Coralie Chiesa
- CRESS U1153, INSERM, Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé) Research Team, Paris University, Paris, France
| | - Pierre Raynal
- CH de Versailles, Site Andre Mignot, Versailles, France
| | - René Charles Rudigoz
- Réseau Périnatal Aurore, Hospices Civils de Lyon, Hôpital de la Croix Rousse, Lyon, France
- Maternité de la Croix Rousse, Lyon, France
| | | | - Gaël Beucher
- Service de Gynécologie Obstétrique et Médecine de la Reproduction, CHU de Caen, Avenue Côte de Nacre, Caen Cedex 9, France
| | - Michel Dreyfus
- Service de Gynécologie Obstétrique et Médecine de la Reproduction, CHU de Caen, Avenue Côte de Nacre, Caen Cedex 9, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Catherine Deneux-Tharaux
- CRESS U1153, INSERM, Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé) Research Team, Paris University, Paris, France
| |
Collapse
|
4
|
Levy RA, Diala PC, Rothschild HT, Correa J, Lehrman E, Markley JC, Poder L, Rabban J, Chen LM, Gras J, Sobhani NC, Cassidy AG, Chapman JS. Roadmap to safety: a single center study of evidence-informed approach to placenta accreta spectrum. Front Surg 2024; 11:1347549. [PMID: 38511075 PMCID: PMC10950927 DOI: 10.3389/fsurg.2024.1347549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 02/15/2024] [Indexed: 03/22/2024] Open
Abstract
Objective To assess the impact of an evidence-informed protocol for management of placenta accreta spectrum (PAS). Methods This was a retrospective cohort study of patients who underwent cesarean hysterectomy (c-hyst) for suspected PAS from 2012 to 2022 at a single tertiary care center. Perioperative outcomes were compared pre- and post-implementation of a standardized Multidisciplinary Approach to the Placenta Service (MAPS) protocol, which incorporates evidence-informed perioperative interventions including preoperative imaging and group case review. Intraoperatively, the MAPS protocol includes placement of ureteral stents, possible placental mapping with ultrasound, and uterine artery embolization by interventional radiology. Patients suspected to have PAS on prenatal imaging who underwent c-hyst were included in the analysis. Primary outcomes were intraoperative complications and postoperative complications. Secondary outcomes were blood loss, need for ICU, and length of stay. Proportions were compared using Fisher's exact test, and continuous variables were compared used t-tests and Mood's Median test. Results There were no differences in baseline demographics between the pre- (n = 38) and post-MAPS (n = 34) groups. The pre-MAPS group had more placenta previa (95% pre- vs. 74% post-MAPS, p = 0.013) and prior cesarean sections (2 prior pre- vs. 1 prior post-MAPS, p = 0.012). The post-MAPS group had more severe pathology (PAS Grade 3 8% pre- vs. 47% post-MAPS, p = 0.001). There were fewer intraoperative complications (39% pre- vs.3% post-MAPS, p < 0.001), postoperative complications (32% pre- vs.12% post-MAPS, p = 0.043), hemorrhages >1l (95% pre- vs.65% post-MAPS, p = 0.001), ICU admissions (59% pre- vs.35% post-MAPS, p = 0.04) and shorter hospital stays (10 days pre- vs.7 days post-MAPS, p = 0.02) in the post-MAPS compared to pre-MAPS patients. Neonatal length of stay was 8 days longer in the post-MAPS group (9 days pre- vs. 17 days post-MAPS, p = 0.03). Subgroup analyses demonstrated that ureteral stent placement and uterine artery embolization (UAE) may be important steps to reduce complications and ICU admissions. When comparing just those who underwent UAE, patients in the post-MAPS group experienced fewer hemorrhages greater five liters (EBL >5l 43% pre- vs.4% post-MAPS, p = 0.007). Conclusion An evidence-informed approach to management of PAS was associated with decreased complication rate, EBL >1l, ICU admission and length of hospitalization, particularly for patients with severe pathology.
Collapse
Affiliation(s)
- Rachel A. Levy
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States
| | - Prisca C. Diala
- School of Medicine, University of California, San Francisco, CA, United States
| | | | - Jasmine Correa
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States
| | - Evan Lehrman
- Department of Interventional Radiology, University of California, San Francisco, CA, United States
| | - John C. Markley
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, United States
| | - Liina Poder
- Department of Diagnostic Radiology, University of California, San Francisco, CA, United States
| | - Joseph Rabban
- Department of Pathology, University of California, San Francisco, CA, United States
| | - Lee-may Chen
- Divisionof Gynecologic Oncology, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States
| | - Jo Gras
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States
| | - Nasim C. Sobhani
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States
| | - Arianna G. Cassidy
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States
| | - Jocelyn S. Chapman
- Divisionof Gynecologic Oncology, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States
| |
Collapse
|
5
|
Araujo Júnior E, Caldas JVJ, Sun SY, Castro PT, Passos JP, Werner H. Placenta acrreta spectrum-first trimester, 2D and 3D ultrasound, and magnetic resonance imaging findings. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024; 52:321-330. [PMID: 38126224 DOI: 10.1002/jcu.23627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/23/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The term placenta accreta spectrum (PAS) is commonly used to describe abnormal trophoblastic invasion of the myometrium, serosa, or organs adjacent to the uterus. It is of great obstetric importance because of its high morbidity, risk of hemorrhage, admission to the intensive care unit, risk of hysterectomy, and high risk of iatrogenic pelvic lesions and even death. These risks are minimized when prenatal diagnosis is performed. Prenatal diagnosis of PAS is based on imaging findings suggestive of abnormal and pathologically adherent placentation, including placental lacunae (intraplacental sonolucent spaces), disruption of the bladder-uterine serosa interface, turbulent flow on color Doppler, and bridging vessels. OBJECTIVE In this article, we review the major prenatal imaging features of PAS using diagnostic modalities (first trimester, two-dimensional ultrasound, three-dimensional ultrasound, and magnetic resonance imaging) for the diagnosis of PAS.
Collapse
Affiliation(s)
- Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
- Discipline of Woman Health, Municipal University of São Caetano do Sul (USCS), São Caetano do Sul, SP, Brazil
| | - João Victor Jacomele Caldas
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Sue Yasaki Sun
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Pedro Teixeira Castro
- Department of Fetal Medicine, Biodesign Laboratory DASA/PUC, Rio de Janeiro-RJ, Brazil
| | - Jurandir Piassi Passos
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Heron Werner
- Department of Fetal Medicine, Biodesign Laboratory DASA/PUC, Rio de Janeiro-RJ, Brazil
| |
Collapse
|
6
|
Walker Z. The myometrium is resilient but not unyielding. Fertil Steril 2024; 121:48-49. [PMID: 37979609 DOI: 10.1016/j.fertnstert.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 11/20/2023]
Affiliation(s)
- Zachary Walker
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Brigham & Women's Hospital, Boston, Massachusetts
| |
Collapse
|
7
|
Fitzgerald GD, Newton JM, Atasi L, Buniak CM, Burgos-Luna JM, Burnett BA, Carver AR, Cheng C, Conyers S, Davitt C, Deshmukh U, Donovan BM, Easter SR, Einerson BD, Fox KA, Habib AS, Harrison R, Hecht JL, Licon E, Nino JM, Munoz JL, Nieto-Calvache AJ, Polic A, Ramsey PS, Salmanian B, Shamshirsaz AA, Shamshirsaz AA, Shrivastava VK, Woolworth MB, Yurashevich M, Zuckerwise L, Shainker SA. Placenta accreta spectrum care infrastructure: an evidence-based review of needed resources supporting placenta accreta spectrum care. Am J Obstet Gynecol MFM 2024; 6:101229. [PMID: 37984691 DOI: 10.1016/j.ajogmf.2023.101229] [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: 09/07/2023] [Revised: 11/02/2023] [Accepted: 11/15/2023] [Indexed: 11/22/2023]
Abstract
The incidence of placenta accreta spectrum, the deeply adherent placenta with associated increased risk of maternal morbidity and mortality, has seen a significant rise in recent years. Therefore, there has been a rise in clinical and research focus on this complex diagnosis. There is international consensus that a multidisciplinary coordinated approach optimizes outcomes. The composition of the team will vary from center to center; however, central themes of complex surgical experts, specialists in prenatal diagnosis, critical care specialists, neonatology specialists, obstetrics anesthesiology specialists, blood bank specialists, and dedicated mental health experts are universal throughout. Regionalization of care is a growing trend for complex medical needs, but the location of care alone is just a starting point. The goal of this article is to provide an evidence-based framework for the crucial infrastructure needed to address the unique antepartum, delivery, and postpartum needs of the patient with placenta accreta spectrum. Rather than a clinical checklist, we describe the personnel, clinical unit characteristics, and breadth of contributing clinical roles that make up a team. Screening protocols, diagnostic imaging, surgical and potential need for critical care, and trauma-informed interaction are the basis for comprehensive care. The vision from the author group is that this publication provides a semblance of infrastructure standardization as a means to ensure proper preparation and readiness.
Collapse
Affiliation(s)
- Garrett D Fitzgerald
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI (Dr Fitzgerald).
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN (Dr Newton)
| | - Lamia Atasi
- Department of Obstetrics and Gynecology, Mercy Hospital, St. Louis, MO (Dr Atasi)
| | - Christina M Buniak
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA (Dr Buniak)
| | | | - Brian A Burnett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Dr Burnett)
| | - Alissa R Carver
- Department of Obstetrics and Gynecology, Wilmington Maternal-Fetal Medicine, Wilmington, NC (Dr Carver)
| | - CeCe Cheng
- Department of Obstetrics and Gynecology, Health Science Center at San Antonio, University of Texas, San Antonio, TX (Dr Cheng)
| | - Steffany Conyers
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Caroline Davitt
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Davitt and Am Shamshiraz)
| | - Uma Deshmukh
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Bridget M Donovan
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Donovan and Shainker)
| | - Sara Rae Easter
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA (Dr Easter)
| | - Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT (Dr Einerson)
| | - Karin A Fox
- Baylor College of Medicine, Houston, TX (Dr Fox)
| | - Ashraf S Habib
- Duke University School of Medicine, Durham, NC (Dr Habib)
| | - Rachel Harrison
- Department of Obstetrics and Gynecology, Advocate Aurora Health, Chicago, IL (Dr Harrison)
| | - Jonathan L Hecht
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Ernesto Licon
- Miller Women's & Children's Hospital/Long Beach Memorial Medical Center, Orange, CA (Dr Licon)
| | - Julio Mateus Nino
- Department of Obstetrics and Gynecology, Atrium Health Wake Forest School of Medicine, Winston-Salem, NC (Dr Nino)
| | - Jessian L Munoz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX (Dr Munoz)
| | | | | | - Patrick S Ramsey
- University of Texas Health/University Health San Antonio, San Antonio, TX (Dr Ramsey)
| | - Bahram Salmanian
- Department of Obstetrics and Gynecology, University of Colorado Health Anschutz Medical Campus, Boulder, CO (Dr Salmanian)
| | | | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Davitt and Am Shamshiraz)
| | - Vineet K Shrivastava
- Miller Women's and Children's Hospital/Long Beach Memorial Medical Center, Orange, CA (Dr Shrivastava)
| | | | - Mary Yurashevich
- Department of Anesthesiology, Duke Health, Durham, NC (Dr Yurashevich)
| | - Lisa Zuckerwise
- and Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN (Dr Zuckerwise)
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Donovan and Shainker)
| |
Collapse
|
8
|
Sugai S, Yamawaki K, Sekizuka T, Haino K, Yoshihara K, Nishijima K. Comparison of maternal outcomes and clinical characteristics of prenatally vs nonprenatally diagnosed placenta accreta spectrum: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:101197. [PMID: 37865220 DOI: 10.1016/j.ajogmf.2023.101197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/14/2023] [Accepted: 10/16/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVE This study aimed to compare maternal outcomes of prenatally and nonprenatally diagnosed placenta accreta spectrum. DATA SOURCES A systematic literature search was performed in PubMed, the Cochrane database, and Web of Science until November 28, 2022. STUDY ELIGIBILITY CRITERIA Studies comparing the clinical presentation of prenatally and nonprenatally diagnosed placenta accreta spectrum were included. The primary outcomes were emergent cesarean delivery, hysterectomy, blood loss volume, number of transfused blood product units, urological injury, coagulopathy, reoperation, intensive care unit admission, and maternal death. In addition, the pooled mean values for blood loss volume and the number of transfused blood product units were calculated. The secondary outcomes included maternal age, gestational age at birth, nulliparity, previous cesarean delivery, previous uterine procedure, assisted reproductive technology, placenta increta and percreta, and placenta previa. METHODS Study screening was performed after duplicates were identified and removed. The quality of each study and the publication bias were assessed. Forest plots and I2 statistics were calculated for each study outcome for each group. The main analysis was a random-effects analysis. RESULTS Overall, 415 abstracts and 157 full-text studies were evaluated. Moreover, 31 studies were analyzed. Prenatally diagnosed placenta accreta spectrum was associated with a significantly lower rate of emergency cesarean delivery (odds ratio, 0.37; 95% confidence interval, 0.21-0.67), higher hysterectomy rate (odds ratio, 1.98; 95% confidence interval, 1.02-3.83), lower blood loss volume (mean difference, -0.65; 95% confidence interval, -1.17 to -0.13), and lower number of transfused red blood cell units (mean difference, -1.96; 95% confidence interval, -3.25 to -0.68) compared with nonprenatally diagnosed placenta accreta spectrum. The pooled mean values for blood loss volume and the number of transfused blood product units tended to be lower in the prenatally diagnosed placenta accreta spectrum groups than in the nonprenatally diagnosed placenta accreta spectrum groups. Nulliparity (odds ratio, 0.14; 95% confidence interval, 0.10-0.20), previous cesarean delivery (odds ratio, 6.81; 95% confidence interval, 4.12-11.25), assisted reproductive technology (odds ratio, 0.19; 95% confidence interval, 0.06-0.61), placenta increta and percreta (odds ratio, 3.97; 95% confidence interval, 2.24-7.03), and placenta previa (odds ratio, 6.81; 95% confidence interval, 4.12-11.25) showed statistical significance. No significant difference was found for the other outcomes. CONCLUSION Despite its severity, the positive effect of prenatally diagnosed placenta accreta spectrum on outcomes underscores the necessity of a prenatal diagnosis. In addition, the pooled mean values provide a preoperative preparation guideline.
Collapse
Affiliation(s)
- Shunya Sugai
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan.
| | - Kaoru Yamawaki
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Tomoyuki Sekizuka
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kazufumi Haino
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kosuke Yoshihara
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Koji Nishijima
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan.
| |
Collapse
|
9
|
Violette CJ, Mandelbaum RS, Matsuzaki S, Ouzounian JG, Paulson RJ, Matsuo K. Assessment of abnormal placentation in pregnancies conceived with assisted reproductive technology. Int J Gynaecol Obstet 2023; 163:555-562. [PMID: 37183534 DOI: 10.1002/ijgo.14850] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/14/2023] [Accepted: 04/21/2023] [Indexed: 05/16/2023]
Abstract
OBJECTIVE To examine the association between assisted reproductive technology (ART) and abnormal placentation. METHODS This is a retrospective cohort study querying the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. The study population included 14, 970, 064 deliveries for national estimates from January 2012 to September 2015. The exposure was 48, 240 pregnancies after ART. The main outcome measure encompassed three abnormal placentation pathologies (placenta previa [PP], placenta accreta spectrum [PAS], and vasa previa [VP]). Propensity score matching was performed to assess the exposure-outcome association. RESULTS Pregnancy after ART was more likely to have a diagnosis of PAS (2.8 vs 1.0 per 1000 deliveries; adjusted odds ratio [aOR], 2.06 [95% confidence interval (CI), 1.44-2.93]), PP (24.5 vs 8.6 per 1000; aOR, 2.98 [95% CI, 2.64-3.35]), and VP (2.3 vs <0.3 per 1000; aOR, 11.3 [95% CI, 5.86-21.8]) compared with pregnancy without ART. Similarly, pregnancy after ART was associated with an increased likelihood of having multiple types of abnormal placentation, including VP with PP (aOR, 15.4 [95% CI, 6.15-38.4]) and PAS with PP (aOR, 2.80 [95% CI, 1.32-5.92]) compared with non-ART pregnancy. CONCLUSIONS This national-level analysis suggests that pregnancy after ART is associated with a significantly increased risk of abnormal placentation, including PAS, PP, and VP.
Collapse
Affiliation(s)
- Caroline J Violette
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Rachel S Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Shinya Matsuzaki
- Department of Gynecology, Osaka International Cancer Institute, Osaka, Japan
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Richard J Paulson
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California, USA
| |
Collapse
|
10
|
Barnea ER, Inversetti A, Di Simone N. FIGO good practice recommendations for cesarean delivery: Prep-for-Labor triage to minimize risks and maximize favorable outcomes. Int J Gynaecol Obstet 2023; 163 Suppl 2:57-67. [PMID: 37807590 DOI: 10.1002/ijgo.15115] [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: 10/10/2023]
Abstract
Cesarean delivery is an abdominal surgical procedure performed for child delivery when the vaginal route is not feasible or desired due to maternal/fetal indications. All childbirth facilities should be able to safely perform a cesarean, which is not the current reality. For planned cesarean delivery, the facility must be prepared for the patient. In contrast, for unplanned arrivals at the facility, FIGO's Prep-for-Labor triage method allows rapid decision-making on whether cesarean delivery can be safely performed on site or whether transfer to an advanced care center is needed. A checklist of staff/tools for safe on-site cesarean delivery is provided to enable timely decision-making. Maternal complications following cesarean are three-fold higher than vaginal delivery. To prevent nonmedically indicated cesarean by favoring vaginal delivery, up-to-date safe and effective guidance is provided, defining labor, second stage length, and status before an arrested labor is confirmed. Whether cesarean delivery is planned or emergency, the Misgav Ladach simplified procedure is proposed as it is suitable for both low- and high-risk cases, including twins, thereby reducing both operative morbidity and postoperative recovery. A trial of labor after first cesarean (TOLAC) should be pursued when feasible, for which the indications, contraindications, safeguards, and steps of safe labor induction are delineated. Implementation of these good practice recommendations will improve childbirth by reducing excessive nonindicated cesareans, while precisely defining the resources and postoperative care required for safe performance on site. Enabling safe childbirth by cesarean and TOLAC, even at sites with low rates currently, will significantly improve maternal and fetal outcomes.
Collapse
Affiliation(s)
- Eytan R Barnea
- Society for the Investigation of Early Pregnancy (SIEP), New York, New York, USA
- Department of Obstetrics Gynecology & Reproductive Sciences, Miller School of Medicine University of Miami, Florida, USA
| | - Annalisa Inversetti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Humanitas San Pio X, Milan, Italy
- IRCCS Humanitas Clinical and Research Hospital, Milan, Italy
| | - Nicoletta Di Simone
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Humanitas San Pio X, Milan, Italy
- IRCCS Humanitas Clinical and Research Hospital, Milan, Italy
| |
Collapse
|
11
|
Adu-Bredu TK, Owusu YG. Prenatal diagnosis of focal placental invasion in upper uterine segment: is novel 'separation sign' key? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:442-444. [PMID: 36929627 DOI: 10.1002/uog.26203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/06/2023] [Accepted: 03/08/2023] [Indexed: 06/18/2023]
Affiliation(s)
- T K Adu-Bredu
- Department of Obstetrics and Gynecology, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Y G Owusu
- Department of Obstetrics and Gynecology, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| |
Collapse
|
12
|
Sugai S, Yamawaki K, Sekizuka T, Haino K, Yoshihara K, Nishijima K. Pathologically diagnosed placenta accreta spectrum without placenta previa: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:101027. [PMID: 37211089 DOI: 10.1016/j.ajogmf.2023.101027] [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: 01/11/2023] [Revised: 05/13/2023] [Accepted: 05/16/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE This systematic review and meta-analysis aimed to assess clinical characteristics related to pathologically proven placenta accreta spectrum without placenta previa. DATA SOURCES A literature search of PubMed, the Cochrane database, and Web of Science was performed from inception to September 7, 2022. STUDY ELIGIBILITY CRITERIA The primary outcomes were invasive placenta (including increta or percreta), blood loss, hysterectomy, and antenatal diagnosis. In addition, maternal age, assisted reproductive technology, previous cesarean delivery, and previous uterine procedures were investigated as potential risk factors. The inclusion criteria were studies evaluating the clinical presentation of pathologically diagnosed PAS without placenta previa. METHODS Study screening was conducted after duplicates were identified and removed. The quality of each study and the publication bias were assessed. Forest plots and I2 statistics were calculated for each study outcome for each group. The main analysis was a random-effects analysis. RESULTS Among 2598 studies that were initially retrieved, 5 were included in the review. With the exception of 1 study, 4 studies were included in the meta-analysis. This meta-analysis showed that placenta accreta spectrum without placenta previa was associated with less risk of invasive placenta (odds ratio, 0.24; 95% confidence interval, 0.16-0.37), blood loss (mean difference, -1.19; 95% confidence interval, -2.09 to -0.28) and hysterectomy (odds ratio, 0.11; 95% confidence interval, 0.02-0.53), and more difficult to diagnose prenatally (odds ratio, 0.13; 95% confidence interval, 0.04-0.45) than placenta accreta spectrum with placenta previa. In addition, assisted reproductive technology and a previous uterine procedure were strong risk factors for placenta accreta spectrum without placenta previa, whhereas previous cesarean delivery was a strong risk factor for placenta accreta spectrum with placenta previa. CONCLUSION The differences in clinical aspects of placenta accreta spectrum with and without placenta previa need to be understood.
Collapse
Affiliation(s)
- Shunya Sugai
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan.
| | - Kaoru Yamawaki
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Tomoyuki Sekizuka
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kazufumi Haino
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kosuke Yoshihara
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Koji Nishijima
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan.
| |
Collapse
|
13
|
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.
Collapse
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
| | | | | |
Collapse
|
14
|
Precision Medicine for Chronic Endometritis: Computer-Aided Diagnosis Using Deep Learning Model. Diagnostics (Basel) 2023; 13:diagnostics13050936. [PMID: 36900079 PMCID: PMC10000436 DOI: 10.3390/diagnostics13050936] [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: 02/01/2023] [Revised: 02/15/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023] Open
Abstract
Chronic endometritis (CE) is a localized mucosal infectious and inflammatory disorder marked by infiltration of CD138(+) endometrial stromal plasmacytes (ESPC). CE is drawing interest in the field of reproductive medicine because of its association with female infertility of unknown etiology, endometriosis, repeated implantation failure, recurrent pregnancy loss, and multiple maternal/newborn complications. The diagnosis of CE has long relied on somewhat painful endometrial biopsy and histopathologic examinations combined with immunohistochemistry for CD138 (IHC-CD138). With IHC-CD138 only, CE may be potentially over-diagnosed by misidentification of endometrial epithelial cells, which constitutively express CD138, as ESPCs. Fluid hysteroscopy is emerging as an alternative, less-invasive diagnostic tool that can visualize the whole uterine cavity in real-time and enables the detection of several unique mucosal findings associated with CE. The biases in the hysteroscopic diagnosis of CE; however, are the inter-observer and intra-observer disagreements on the interpretation of the endoscopic findings. Additionally, due to the variances in the study designs and adopted diagnostic criteria, there exists some dissociation in the histopathologic and hysteroscopic diagnosis of CE among researchers. To address these questions, novel dual immunohistochemistry for CD138 and another plasmacyte marker multiple myeloma oncogene 1 are currently being tested. Furthermore, computer-aided diagnosis using a deep learning model is being developed for more accurate detection of ESPCs. These approaches have the potential to contribute to the reduction in human errors and biases, the improvement of the diagnostic performance of CE, and the establishment of unified diagnostic criteria and standardized clinical guidelines for the disease.
Collapse
|