The frequency and complication rates of hysterectomy accompanying cesarean delivery

Prophylactic occlusion balloons of both internal iliac arteries in caesarean hysterectomy for placenta accreta spectrum disorder reduces blood loss: A retrospective comparative study

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.

Economic Analysis of Induction versus Elective Cesarean in Term Nulliparas with Supermorbid Obesity

OBJECTIVE

 We sought to evaluate the economic benefit of the induction of labor compared with elective cesarean delivery in individuals with supermorbid obesity (body mass index 60 kg/m2 or greater) at term.

STUDY DESIGN

 We developed an economic analysis model to compare induction of labor with elective cesarean delivery in nulliparous individuals with supermorbid obesity at term. The primary outcome was the total cost per strategy from a health system perspective with elective cesarean delivery as a reference group. Pregnancy outcomes for the index and subsequent pregnancies were considered. When available, probabilities of pregnancy outcomes were extracted from our institutions. Rare pregnancy outcomes, relative risks, and costs were derived from the literature. All costs in this analysis were inflated to 2022 USD (U.S. dollar). To determine the robustness of the decision model, we conducted one-way sensitivity analyses by changing point estimates of variables. We then performed a probabilistic sensitivity analysis using Monte Carlo simulation repeating 1,000 times to test the robustness of the results in the setting of simultaneous changes in probabilities, relative risks, and costs.

RESULTS

 In the base-case analysis, assuming that 72.7% of nulliparous individuals undergoing induction of labor would have a cesarean delivery, induction of labor would cost $41,084 compared with $40,742 for elective cesarean delivery, resulting in a higher cost of $342 per nulliparous individuals with supermorbid obesity. In a sensitivity analysis, we found that induction of labor compared with elective cesarean is less economical if the probability of cesarean delivery after induction of labor exceeds 71%. Monte Carlo simulation suggests that elective cesarean delivery was the preferred cost-beneficial strategy with a frequency of 53.5%.

CONCLUSION

Among our patient population, induction of labor was less economical compared with elective cesarean delivery at term for nulliparous individuals with supermorbid obesity.

KEY POINTS

· The prevalence of obesity in the United States continues to rise.. · Morbid obesity compared with normal weight is associated with increased risks of adverse pregnancy outcomes.. · Induction of labor was less economical compared with elective cesarean delivery at term for nulliparous individuals..

Efficacy and safety of prophylactic balloon occlusion in the management of placenta accreta spectrum disorder: a retrospective cohort study

OBJECTIVE

Placenta accreta spectrum disorder (PAS) is a serious obstetric complication associated with significant maternal morbidity and mortality. Prophylactic balloon occlusion (PBO), as an intravascular interventional therapies, has emerged as a potential management strategy for controlling massive hemorrhage in patients with PAS. However, current evidence about the clinical application of PBO in PAS patients are still controversial. This study aimed to evaluate the effectiveness and safety of PBO in the management of PAS.

METHODS

A retrospective cohort study including PAS patients underwent cesarean delivery was conducted in a tertiary hospital from January 2015 to March 2022. Included PAS patients were further divided into balloon and control groups by whether PBO was performed. Groups were compared for demographic characteristics, intraoperative and postoperative parameters, maternal and neonatal outcomes, PBO-related complication and follow up outcomes. Additionally, multivariate-logistic regression analysis was performed to determine the definitive associations between PBO and risk of massive hemorrhage and hysterectomy.

RESULTS

A total of 285 PAS patients met the inclusion criteria were included, of which 57 PAS patients underwent PBO (PBO group) and 228 women performed cesarean section (CS) without PBO (control group). Irrespective of the differences of baseline characteristics between the two groups, PBO intervention did not reduce the blood loss, hysterectomy rate and postoperative hospital stay, but it prolonged the operation time and increased the cost of hospitalization (All P < 0.05) Additionally, there were no significant differences in postoperative complications, neonatal outcomes, and follow-up outcomes(All P > 0.05). In particular, patients undergoing PBO were more likely to develop the venous thrombosis postoperatively (P = 0.001). However, multivariate logistic regression analysis showed that PBO significantly decreased the risk of massive hemorrhage (OR 0.289, 95%CI:0.109-0.766, P = 0.013). The grade of PAS and MRI with S2 invasion were the significant risk factors affecting massive hemorrhage(OR:6.232 and OR:5.380, P<0.001).

CONCLUSION

PBO has the potential to reduce massive hemorrhage in PAS patients undergoing CS. Obstetricians should, however, be aware of potential complications arising from the PBO. Additionally, MRI with S2 invasion and PAS grade will be useful to identify PAS patients who at high risk and may benefit from PBO. In brief, PBO seem to be a promising alternative for management of PAS, yet well-designed randomized controlled trials are needed to convincingly demonstrate its benefits and triage the necessity of PBO.

Psychological flexibility, birth satisfaction and postnatal trauma symptoms in women with abnormally invasive placenta

BACKGROUND

Abnormally Invasive Placenta is an obstetric condition resulting in significant physical complications and shown to increase the likelihood of developing Post Traumatic Stress Disorder. Dissatisfaction with the care experienced increases the likelihood of Post Traumatic Stress Disorder. Psychological flexibility has been shown to reduce the severity of Post Traumatic Stress Disorder, but there is no research regarding either of these in women with Abnormally Invasive Placenta.

AIM

To investigate if there is a relationship between trauma experience in women with a diagnosis of Abnormally Invasive Placenta, psychological flexibility, and birth satisfaction.

METHOD

Using a retrospective questionnaire, 126 participants age range 18-45, comprising the Birth Satisfaction Scale Revised Indicator (BSS-RI), Impact of Events Scale Revised (IES-R) and Acceptance and Action Questionnaire (AAQ-2) was completed. A hierarchical regression assessed the predictive relationship of Psychological Flexibility and Birth Satisfaction on Trauma symptoms.

RESULTS

The relationship between Birth Satisfaction measured using the BSS-RI and likelihood of Post Traumatic Stress Disorder (IES-R) was not supported (r (124) = -.08, p = .36). Results did show that Psychological Flexibility (AAQ-2) correlated with Trauma Score (IES-R) (r (124) = .68, p < .001) in women who had experienced Abnormally Invasive Placenta and explained 45.3% of the variance.

CONCLUSION

The results suggest that Post Traumatic Stress Disorder in those with Abnormally Invasive Placenta is as high as 1 in 2 and can be mediated by psychological flexibility. In turn, this suggests that interventions to increase Psychological Flexibility in those with the diagnosis may reduce trauma symptom severity.Abbreviations: AAQ-2 - Acceptance and Action QuestionnaireAIP - Abnormally Invasive PlacentaBAME - Black Asian or other Minority EthnicitiesBSS-RI Birth Satisfaction Scale Revised IndicatorEPH - EPH Gestosis (Pre eclampsia/Eclampsia)DSM - Diagnostic Statical ManualIES-R - Impact of Events Scale RevisedPAS - Placenta Accreta SpectrumPTSD - Post Traumatic Stress Disorder.

Uterine-sparing surgical procedures to control postpartum hemorrhage

Postpartum hemorrhage remains one of the principal causes of maternal mortality in the United States and throughout the world. Its management, which must be multidisciplinary (obstetrics, midwifery, anesthesiology, interventional radiology, and nursing), depends on the speed of both diagnosis and implementation of medical and surgical treatment to control the hemorrhage. The aim of this work is to describe the various techniques of vessel ligation and of uterine compression for controlling and treating severe hemorrhage, and to present the advantages and disadvantages of each. It is not difficult to perform vessel ligation of the uterine arteries: O'Leary's bilateral ligation of the uterine artery, Tsirulnikov's triple ligation, and AbdRabbo's stepwise uterine devascularization (that is, stepwise triple ligation). These procedures are associated with a high success rate (approximately 90%) and a low complication rate. Bilateral ligation of the internal iliac (hypogastric) arteries is more difficult to perform and potentially less effective (approximately 70% effectiveness) than the previously mentioned procedures. Its complication rate is low, but the complications are most often serious. There is no evidence that future fertility or subsequent obstetrical outcomes are impaired by ligation of either the uterine or internal iliac arteries. There are many techniques used for uterine compression sutures, and none has shown clear superiority to another. Uterine compression suture has an effectiveness rate of approximately 75% after failure of medical treatment and approximately 80% as a second-line procedure after unsuccessful vessel ligation. The risk of synechiae after uterine compression suture has not yet been adequately evaluated, but is probably around 5%. The risk of synechiae after uterine compression suture has not yet been adequately evaluated, but probably ranges between 5% and 10%. The methodologic quality of the studies assessing uterine-sparing surgical procedures remains limited, with no comparative studies. Accordingly, no evidence suggests that any one of these methods is better than any other. Accordingly, the choice of surgical technique to control hemorrhage must be guided firstly by the operator's experience. If the hemorrhage continues after a first-line uterine-sparing surgical procedure and the patient remains hemodynamically stable, a second-line procedure can be chosen. Nonetheless, the application of these procedures must not delay the performance of a peripartum hysterectomy in cases of hemodynamic instability.

A rare case of morbidly adherent placenta in a young Primigravida with RH negative pregnancy managed with peripartum subtotal hysterectomy

INTRODUCTION AND IMPORTANCE

Postpartum hemorrhage (PPH) can be defined as excessive bleeding (>500 ml) from the genital tract after the delivery of baby upto 6 weeks. PPH accounts for major cause of maternal mortality rate. Prevention and early intervention can prevent this complication of delivery. However condition like placenta accreta leads to retention of placenta and makes PPH inevitable.

CASE SUMMARY

We present the case of massive postpartum hemorrhage secondary to Placenta accreta in young primigravida with RH negative pregnancy. Clinical findings and investigations were not significant during her admission. She delivered the baby via vaginal route but placenta was not expelled till 30 min. Due to failed manual removal of placenta patient was shifted to OT.Manual vacuum aspiration was done in OT setting and chunks of placenta along with blood clots were obtained.Uterine balloon tamponade was inserted. Due to persistent PV bleeding subtotal hysterectomy was carried out in line for placenta accreta.

DISCUSSION

Placenta accreta being one of the life threatening obstetric condition, it should be diagnosed as early as possible and need prompt management so as to prevent maternal mortality. Due to increasing number of cesarean delivery the cases of placenta accreta has been rising but rarely in some cases can it present in young primigravida with Rh negative pregnancy.

CONCLUSION

In the cases of morbidly adherent placenta it is necessary for obstetrician to early identify such conditions and timely intervene to save the mother's life. Moreover Rh negative could be a hidden risk factor.

Unplanned hysterectomy: a comprehensive analysis of race, ethnicity, sociodemographic factors, pregnancy complications, and cardiovascular disease risk factors

OBJECTIVE

To understand the risk of unplanned hysterectomy (UH) in pregnant women better in association with maternal sociodemographic characteristics, cardiovascular disease (CVD) risk factors, and current pregnancy complications.

DESIGN

Using Florida birth data from 2005 to 2014, we investigated the possible interactions between known risk factors of having UH, including maternal sociodemographic characteristics, maternal medical history, and other pregnancy complications. Logistic regression models were constructed. Adjusted odds ratios and 95% confidence intervals were reported.

RESULTS

Several interactions were observed that significantly affected odds of UH. Compared to non-Hispanic White women, Hispanic minority women were more likely to have an UH. The overall risk of UH for women with preterm birth (<37 weeks) and concurrently had premature rupture of membranes (PRoM), uterine rupture, or a previous cesarean delivery was significantly higher than women who delivered to term and had no pregnancy complications. Women who delivered via cesarean who also had preeclampsia, PRoM, or uterine rupture had an overall increased risk of UH. Significantly decreased risk of UH was seen for Black women less than 20 years old, women of other minority races with either less than a high school degree or a college degree or greater, women of other minority races with PRoM, and women with preterm birth and diabetes compared to respective reference groups.

CONCLUSIONS

Maternal race, ethnicity, CVD risk factors, and current pregnancy complications affect the risk of UH in pregnant women through complex interactions that would not be seen in unadjusted models of risk analysis.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Risk of placenta accreta spectrum following myomectomy: a nationwide cohort study

BACKGROUND

Whether myomectomy increases the risk of placenta accreta spectrum in the following pregnancies remains controversial.

OBJECTIVE

This study aimed to investigate the effect of myomectomy on the risk of placenta accreta spectrum in the following pregnancies. Moreover, different methods of myomectomy on the risk of placenta accreta spectrum were explored.

STUDY DESIGN

A nationwide cohort study was conducted using data from the Taiwan National Health Insurance Research Database, including all pregnant patients in Taiwan who gave birth between January 2008 and December 2017. A 1:1 propensity score estimation matching was performed for the analysis of myomectomy on the risk of placenta accreta spectrum. Among pregnant patients who received myomectomy, different methods of myomectomy on the risk of placenta accreta spectrum were compared with the control group.

RESULTS

Among the 1,371,458 pregnant patients in this study, 11,255 pregnant patients had a history of myomectomy. The risk of placenta accreta spectrum was higher in pregnant patients with a history of myomectomy than in pregnant patients without a history of myomectomy (incidence: 0.96% vs 0.20%; adjusted odds ratio, 2.28; 95% confidence interval, 1.85-2.81; P<.01). Among pregnant patients with a history of myomectomy, 5045 (46.87%) received laparotomic myomectomy, 3973 (36.93%) received laparoscopic myomectomy, and 1742 (16.20%) received hysteroscopic myomectomy. The incidence of placenta accreta spectrum was higher in the hysteroscopic group than in the laparotomic group or the laparoscopic group (1.89% [hysteroscopic group] vs 0.71% [laparotomic group] and 0.81% [laparoscopic group]; P<.05). Compared with patients without a history of myomectomy, the adjusted odds ratio for placenta accreta spectrum was 3.88 (95% confidence interval, 2.68-5.63; P<.05) in the hysteroscopic group.

CONCLUSION

Myomectomy, especially hysteroscopic myomectomy, is associated with an increased risk of placenta accreta spectrum in the subsequent pregnancy.

Indications and Outcomes for Planned Cesarean Hysterectomy in Non-Placenta Accreta Spectrum Disorder Patients: A Systematic Review

OBJECTIVE

Planned hysterectomy at the time of cesarean delivery may be reasonable in cases other than placenta accreta spectrum disorders. Our objective was to synthesize the published literature on the indications and outcomes for planned cesarean hysterectomy.

DATA SOURCES

We performed a systematic review of published literature from the following databases from inception (1946) to June 2021: MEDLINE, PubMed, EMBASE, Cochrane CENTRAL, DARE, and clinicaltrials.gov.

STUDY SELECTION

We included all study designs where subjects underwent planned cesarean delivery with simultaneous hysterectomy. Emergency procedures and those performed for placenta accreta spectrum disorders were excluded.

DATA EXTRACTION AND SYNTHESIS

The primary outcome was surgical indication, though other surgical outcomes were evaluated when data permitted. Quantitative analysis was limited to studies published in 1990 or later. Risk of bias was assessed using an adaptation of the ROBINS-I tool.

CONCLUSION

The most common indication for planned cesarean hysterectomy was malignancy, with cervical cancer being the most frequent. Other indications included permanent contraception, uterine fibroids, menstrual disorders, and chronic pelvic pain. Common complications included bleeding, infection, and ileus. The surgical skill for cesarean hysterectomy continues to be relevant in contemporary obstetrical practice for reproductive malignancy and several benign indications. Although the data indicate relatively safe outcomes, these studies show significant publication bias and, therefore, further systematic study of this procedure is justified.

PROSPERO REGISTRATION NUMBER

CRD42021260545, registered June 16, 2021.

Diagnostic accuracy of ultrasound in the diagnosis of Placenta accreta spectrum: systematic review and meta-analysis

OBJECTIVE

To evaluate the diagnostic accuracy of ultrasound and in the diagnosis of Placenta accreta spectrum (PAS).

DATA SOURCES

Screening of MEDLINE, CENTRAL, other bases from inception to February 2022 using the keywords related to placenta accreta, increta, percreta, morbidly adherent placenta, and preoperative ultrasound diagnosis.

STUDY ELIGIBILITY CRITERIA

All available studies- whether were prospective or retrospective- including cohort, case control and cross sectional that involved prenatal diagnosis of PAS using 2D or 3D ultrasound with subsequent pathological confirmation postnatal were included. Fifty-four studies included 5307 women fulfilled the inclusion criteria, PAS was confirmed in 2025 of them.

STUDY APPRAISAL AND SYNTHESIS METHODS

Extracted data included settings of the study, study type, sample size, participants characteristics and their inclusion and exclusion criteria, Type and site of placenta previa, Type and timing of imaging technique (2D, and 3D), severity of PAS, sensitivity and specificity of individual ultrasound criteria and overall sensitivity and specificity.

RESULTS

The overall sensitivity was 0.8703, specificity was 0.8634 with -0.2348 negative correlation between them. The estimate of Odd ratio, negative likelihood ratio and positive likelihood ratio were 34.225, 0.155 and 4.990 respectively. The overall estimates of loss of retroplacental clear zone sensitivity and specificity were 0.820 and 0.898 respectively with 0.129 negative correlation. The overall estimates of myometrial thinning, loss of retroplacental clear zone, the presence of bridging vessels, placental lacunae, bladder wall interruption, exophytic mass, and uterovesical hypervascularity sensitivities were 0.763, 0.780, 0.659, 0.785, 0.455, 0.218 and 0.513 while specificities were 0.890, 0.884, 0.928, 0.809, 0.975, 0.865 and 0.994 respectively.

CONCLUSIONS

The accuracy of ultrasound in diagnosis of PAS among women with low lying or placenta previa with previous cesarean section scars is high and recommended in all suspected cases.

TRIAL REGISTRATION

Number CRD42021267501.

Animal models of the placenta accreta spectrum: current status and further perspectives

Placenta accreta spectrum disorder (PAS) is a kind of disease of placentation defined as abnormal trophoblast invasion of part or all of the placenta into the myometrium, even penetrating the uterus. Decidual deficiency, abnormal vascular remodeling in the maternal-fetal interface, and excessive invasion by extravillous trophoblast (EVT) cells contribute to its onset. However, the mechanisms and signaling pathways underlying such phenotypes are not fully understood, partly due to the lack of suitable experimental animal models. Appropriate animal models will facilitate the comprehensive and systematic elucidation of the pathogenesis of PAS. Due to the remarkably similar functional placental villous units and hemochorial placentation to humans, the current animal models of PAS are based on mice. There are various mouse models induced by uterine surgery to simulate different phenotypes of PAS, such as excessive invasion of EVT or immune disturbance at the maternal-fetal interface, which could define the pathological mechanism of PAS from the perspective of the "soil." Additionally, genetically modified mouse models could be used to study PAS, which is helpful to exploring the pathogenesis of PAS from the perspectives of both "soil" and "seed," respectively. This review details early placental development in mice, with a focus on the approaches of PAS modeling. Additionally, the strengths, limitations and the applicability of each strategy and further perspectives are summarized to provide the theoretical foundation for researchers to select appropriate animal models for various research purposes. This will help better determine the pathogenesis of PAS and even promote possible therapy.

Assessment of the self-confidence of obstetrics & gynecology fellows to perform a postpartum hemostasis hysterectomy

INTRODUCTION

Hemostasis Hysterectomy (HH) is a last resort surgical procedure performed in situations of uncontrolled post-partum hemorrhage in maternity wards. The chances of being confronted with this situation are scarce during residency, and the situation is not well suited for teaching. Nevertheless, every obstetrician-gynecologist can be confronted with this stressful situation, and should therefore possess the surgical competence required, regardless of his routine practice. The aim of the present study is to evaluate clinical exposure and self-awareness concerning HH amongst obstetrics and gynecology residents and fellows.

MATERIEL AND METHODS

We performed a survey amongst French obstetrics and gynecology fellows. An anonymous survey was sent by email between December 1, 2020 to July 1, 2021.

RESULTS

Half of the interrogated fellows had practiced (as operator) an HH during residency with a senior and only 22,6% in post-residency. During the last year of residency 70% of them had performed less than 10 scheduled hysterectomies as primary operator. The laparoscopic approach was the most frequently practiced. Very few hysterectomies were performed as primary operator. Fellows with a surgical or mixed activity (both gynecological surgery and obstetrical activity in current practice) felt significantly more capable of performing HH compared to those with exclusive obstetrical or reproductive medicine activity; respectively 60% vs 36%, p = 0.008; Odds Ratio: 2.629 (95% CI 1.2214; 5.8094).

CONCLUSION

The number of scheduled hysterectomies or HH performed as primary operator is very low during residency or fellowship. It remains largely inferior to the number deemed necessary in previous publications about the learning curve for scheduled hysterectomy, which varies from 18 to 80 interventions. Nowadays, the increasing number of residents, added to the decrease of hemostasis hysterectomies through better management of post-partum hemorrhage, pushes towards the development of specific training, such as "damage control simulation".

Circulating microparticle proteins predict pregnancies complicated by placenta accreta spectrum

Placenta accreta spectrum (PAS) is characterized by abnormal attachment of the placenta to the uterus, and attempts at placental delivery can lead to catastrophic maternal hemorrhage and death. Multidisciplinary delivery planning can significantly improve outcomes; however, current diagnostics are lacking as approximately half of pregnancies with PAS are undiagnosed prior to delivery. This is a nested case-control study of 35 cases and 70 controls with the primary objective of identifying circulating microparticle (CMP) protein panels that identify pregnancies complicated by PAS. Size exclusion chromatography and liquid chromatography with tandem mass spectrometry were used for CMP protein isolation and identification, respectively. A two-step iterative workflow was used to establish putative panels. Using plasma sampled at a median of 26 weeks' gestation, five CMP proteins distinguished PAS from controls with a mean area under the curve (AUC) of 0.83. For a separate sample taken at a median of 35 weeks' gestation, the mean AUC was 0.78. In the second trimester, canonical pathway analyses demonstrate over-representation of processes related to iron homeostasis and erythropoietin signaling. In the third trimester, these analyses revealed abnormal immune function. CMP proteins classify PAS well prior to delivery and have potential to significantly reduce maternal morbidity and mortality.

Fentanyl for labour pain management: a scoping review

BACKGROUND

Labour pain has been identified as an important reason for women to prefer caesarean section (CS). Fentanyl is one of the short acting opioids recommended by World Health Organization for pain relief during labour. This study aimed to identify and describe the available evidence on the use of fentanyl (monotherapy) for labour pain management by any routes of administration or regime.

METHODS

We included the records published until 31 December 2021 which reported administration of fentanyl to women with normal labour for labour pain relief. Data were extracted by one reviewer and checked by another reviewer using a standardised agreement form. We mapped and presented data descriptively in figure and tabular format.

RESULTS

We included 51 records from 49 studies in our scoping review. The studies were conducted in 12 countries, mostly high-income countries. The study designs of the 51 included records were varied as follows: 38 (74.5%) experimental studies (35 randomised controlled trials and three quasi-experimental studies), and 12 (23.5%) observational studies (five retrospective cohort studies, four prospective cohort studies, two retrospective descriptive studies, and one descriptive study) and one qualitative study. Of the included records, six used intranasal fentanyl, five used subcutaneous fentanyl, 18 (35.3%) used intravenous fentanyl, 18 (35.3%) used intrathecal fentanyl, and nine used epidural fentanyl. Many records compared fentanyl with another analgesic agent while five records (9.8%) had no comparison group and seven records (13.7%) compared with no analgesia group. The doses of fentanyl varied by routes, study and the requirement depended on the women. Pain assessment was the most frequent outcome measure presented in the records (78.4%). Only nine records (17.6%) investigated women's satisfaction about labour pain relief using fentanyl and seven records (13.7%) reported the effect of fentanyl on breastfeeding. The most common reported neonatal outcomes were foetal heart rate (33 records, 64.7%) and Apgar score (32 records, 62.7%).

CONCLUSION

There is limited primary evidence especially randomised controlled trials to evaluate the effectiveness and harms of different routes of fentanyl in low- or middle-income countries. There is a need for high-quality research to establish the most effective route of fentanyl and associated effects for evidence-based international guidelines.

Placenta Accreta Spectrum: Prenatal Diagnosis and Management

The incidence of placenta accreta spectrum (PAS) is increasing and is now about 3 per 1000 deliveries, largely due to the rising cesarean section rate. Ultrasound is the preferred method for diagnosis of PAS. Ultrasound markers include multiple vascular lacunae, loss of the hypoechoic retroplacental zone, abnormalities of the uterine serosa-bladder interface, retroplacental myometrial thickness less than 1 mm, increased placental vascularity, and observation of bridging vessels linking the placenta and bladder. Patients with PAS should be managed by experienced multidisciplinary teams. Hysterectomy is the accepted management of PAS and conservative or expectant management of PAS should be considered investigational.

Association of Placenta Previa With Severe Maternal Morbidity Among Patients With Placenta Accreta Spectrum Disorder

IMPORTANCE

Placenta previa is widely acknowledged as a risk factor for placenta accreta spectrum (PAS) disorders, which are severe maternal complications; however, data are limited regarding whether placenta previa is associated with a higher risk of worse maternal outcomes among patients with PAS disorders.

OBJECTIVE

To examine the association between placenta previa and the risk of severe maternal morbidities (SMMs) and higher resource use among patients with PAS disorders.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study extracted records of 3793 patients with PAS diagnosis and delivery indicators between October 1, 2015, and December 31, 2019, from the US National Inpatient Sample database.

EXPOSURES

Placenta previa.

MAIN OUTCOMES AND MEASURES

Data on 21 Centers for Disease Control and Prevention-defined SMMs and 25 study-defined surgical morbidities associated with PAS were extracted. Six surgical procedures (cystoscopy, intra-arterial balloon occlusion, cesarean delivery, hysterectomy, cystectomy, and oophorectomy), hospital length of stay, and inpatient costs were compared. Multivariable Poisson regression models built in the generalized estimating equation framework were used.

RESULTS

Among 3793 patients with PAS (median [IQR] age at admission, 33 [29-37] years), 621 women (16.4%) were Black, 765 (20.2%) were Hispanic, 1779 (46.9%) were White, 441 (11.6%) were of other races and/or ethnicities (47 [1.2%] were American Indian, 220 [5.8%] were Asian or Pacific Islander, and 174 [4.6%] were of multiple or other races and/or ethnicities), and 187 (4.9%) were of unknown race and ethnicity. A total of 1323 patients (34.9%) had placenta previa and 2470 patients (65.1%) did not; of those with placenta previa, 405 patients (30.6%) had invasive PAS. Patients with vs without placenta previa had a significantly higher rate and risk of any SMM (935 women [70.7%] vs 1087 women [44.0%]; P < .001; adjusted risk ratio [aRR], 1.19; 95% CI, 1.12-1.27) and any surgical morbidity (1170 women [88.4%] vs 1667 women [67.5%]; P < .001; aRR, 1.18; 95% CI, 1.13-1.23). With regard to specific outcomes, those with vs without placenta previa had a significantly higher rate of peripartum hemorrhage (878 patients [66.4%] vs 1217 patients [49.3%]; P < .001), blood product transfusion (413 patients [31.2%] vs 610 patients [24.7%]; P < .001), shock (83 patients [6.3%] vs 108 patients [4.4%]; P = .01), disseminated intravascular coagulation or other coagulopathy (77 patients [5.8%] vs 105 patients [4.3%]; P = .04), and urinary tract injury (44 patients [3.3%] vs 41 patients [1.7%]; P = .002). Patients with vs without placenta previa were more likely to undergo cesarean delivery (1292 patients [97.7%] vs 1787 patients [72.3%]; P < .001), hysterectomy (786 patients [59.4%] vs 689 patients [27.9%]; P < .001), cystoscopy (301 patients [22.8%] vs 203 patients [8.2%]; P < .001), cystectomy (157 patients [11.9%] vs 98 patients [4.0%]; P < .001), and intra-arterial balloon occlusion (121 patients [9.1%] vs 77 patients [3.1%]; P < .001) and to have significantly longer hospital length of stay (median [IQR], 5 [4-11] days vs 3 [3-5] days; P < .001) and total inpatient costs (median [IQR], $17 496 [$10 863-$30 619] vs $9728 [$6130-$16 790]; P < .001). Hypertensive disorder of pregnancy was associated with a decreased risk of placenta previa (aRR, 0.67; 95% CI, 0.46-0.96) among patients with PAS.

CONCLUSIONS AND RELEVANCE

In this study, placenta previa was associated with an increased risk of maternal and surgical morbidities and higher resource use among women with PAS. These findings suggest that interventions to alleviate maternal and surgical morbidities are especially needed for patients with placenta previa-complicated PAS disorders.

Procurement of Uterus in a Deceased Donor Multi-Organ Donation National Program in France: A Scarce Resource for Uterus Transplantation?

Uterus transplantation is a new possibility for women suffering from absolute uterine infertility to become pregnant and have children. In the case of a deceased donor, a list of exclusion criteria is defined to ensure the high quality of the uterus graft. This study evaluates the number of potentially available uterus grafts based on the pre-defined exclusion criteria in a national deceased donor multi-organ donation program in France. We analyzed the data reported in the CRISTAL database regarding all women aged 18 to 60 on whom organ procurement was performed between 2014 and 2019. Potential deceased women donors were classified into three categories: very ideal donor, ideal donor, and expanded criteria donor. Between 2014 and 2019, 4544 women underwent organ procurement. Using the very ideal donor, ideal donor, and expanded criteria donor classification, we found that, respectively, only 124, 264, and 936 donors were potentially eligible for UTx. This represents 2.8 per million people (PMP) very ideal donors, 3.8 PMP ideal donors, 8.6 PMP expanded criteria donors (ECDs). The restricted number of grafts requires a complementary strategy of living and deceased donors to meet the demand of all women with AUI.

Association between peripartum hysterectomy and venous thromboembolism

BACKGROUND

The risk of venous thromboembolism after delivery is modified by mode of delivery, with the risk of venous thromboembolism being higher after cesarean delivery than vaginal delivery. The risk of venous thromboembolism after peripartum hysterectomy is largely unknown.

OBJECTIVE

This study aimed to compare the incidence and risk of venous thromboembolism among women who had and did not have a peripartum hysterectomy. Furthermore, we sought to compare the risk of venous thromboembolism after hysterectomy with other patient, pregnancy, and delivery risk factors known to be associated with venous thromboembolism.

STUDY DESIGN

This was a cross-sectional study of women with delivery encounters identified in the Nationwide Readmissions Database from October 2015 to December 2017. Delivery encounters and all variables of interest were identified using the International Classification of Diseases, Tenth Revision diagnosis and procedure codes. The incidence of venous thromboembolism during delivery and rehospitalizations within 6 weeks after discharge was compared among women who had and did not have a peripartum hysterectomy. Multivariable logistic regressions were used to estimate associations between venous thromboembolism and hysterectomy, adjusted for the following characteristics: maternal age, payer at time of delivery, obesity, hypertension, diabetes mellitus, tobacco use, multifetal gestation, peripartum infection, and peripartum hemorrhage. Similarly, venous thromboembolism risk was compared by mode of delivery, including hysterectomy. Diagnoses that may have been indications for peripartum hysterectomy were identified among patients who underwent a hysterectomy and compared between those who did and did not have venous thromboembolism. Analyses used survey weights to obtain population estimates.

RESULTS

Of the 4,419,037 women with deliveries, 5098 (11.5 per 10,000 deliveries) underwent a hysterectomy. Moreover, 110 patients (215.8 per 10,000 deliveries) were diagnosed with venous thromboembolism after hysterectomy. The risk of venous thromboembolism was significantly higher in women who underwent a hysterectomy than in women who did not have a hysterectomy (unadjusted odds ratio, 25.1 [95% confidence interval, 20.0-31.5]; adjusted odds ratio, 11.2 [95% confidence interval, 8.7-14.5]; P<.001). Comparing the risk of venous thromboembolism by mode of delivery, the unadjusted and adjusted incidences of venous thromboembolism were 6.9 (95% confidence interval, 6.5-7.3) and 7.4 (95% confidence interval, 6.9-7.8) per 10,000 deliveries among women after vaginal delivery without peripartum hysterectomy, 12.5 (95% confidence interval, 11.8-13.1) and 11.3 (95% confidence interval, 10.7-12.0) per 10,000 deliveries after cesarean delivery without hysterectomy; and 217.2 (95% confidence interval, 169.1-265.2) and 96.9 (95% confidence interval 76.9-126.5) per 10,000 deliveries after hysterectomy, regardless of mode of delivery. Of the 110 diagnoses of venous thromboembolism with peripartum hysterectomy, 89 (81%) occurred during delivery admission. Of the remaining 21 cases, 50% occurred within the first 10 days after discharge from delivery, and 75% occurred within 25 days after discharge.

CONCLUSION

These findings have demonstrated that peripartum hysterectomy is associated with a markedly increased risk of venous thromboembolism in the postpartum period, even when controlling for other known risk factors for postpartum thromboembolic events. Here, the incidence of venous thromboembolism after peripartum hysterectomy (2.2%) met some guideline-based risk thresholds for routine thromboprophylaxis, potentially for at least 2 weeks after delivery. Further investigation into the role of routine venous thromboembolism prophylaxis during and after delivery is needed.

Placenta Accreta Spectrum Among Multiple Gestation: A Retrospective Analysis Based on a Chinese Population

BACKGROUND

It remained controversial whether women with multiple gestation are at higher risk of placenta accreta spectrum (PAS) disorders and large-scale studies are needed. This study aimed to assess whether PAS incidence is higher among women with multiple gestation than among singleton, as well as to compare the characteristics and outcomes of PAS in multiple and singleton gestation.

METHODS

Women who underwent cesarean section with live births at Peking University First Hospital from January 2015 to December 2020 were included. Demographic and clinical information was collected through chart review. Logistic regression models were used to analyze the associations between multiple gestation and PAS. The clinical characteristics and perioperative outcomes of PAS in multiple and singleton gestation were further compared.

RESULTS

Among the 14583 women included, 2.4% (352/14583) were diagnosed with PAS. PAS was slightly more prevalent among multiple gestations than among singletons (2.5% vs 2.4%, P=0.857). After adjusting for known risk factors and pregnancy complications, multiple gestation was associated with a higher risk of PAS (aOR=1.63, 95% CI 1.01-2.62). Among PAS patients, women who had multiple births had a significantly lower rate of previous cesarean deliveries (27.6% vs. 56.3%, P=0.003), placenta previa (17.2% vs. 56.3%, P<0.001) and invasive PAS (24.1% vs. 53.9, P=0.002) than singletons. There were no significant differences in perioperative outcomes between these two groups.

CONCLUSION

Multiple gestation could be independently associated with an elevated risk of PAS. The clinical characteristics of PAS in the multiple and singleton gestation groups differed significantly in cesarean delivery history and placenta previa. The results of this study may inform guidelines on the screening, early detection and timely intervention of PAS patients among women with multiple births.

Shared Decision-Making During Labor and Birth Among Low-Risk, Active Duty Women in the U.S. Military

INTRODUCTION

The cesarean birth rate of 24.7% in the Military Health System (MHS) is lower than the national rate of 31.7%. However, the MHS rate remains higher than the 15-19% threshold associated with optimal maternal and neonatal outcomes. For active duty servicewomen, increased morbidity associated with cesarean birth is likely to affect the ability to meet the demands of assigned missions. Several decision-points occur during pregnancy and after the onset of labor that can affect the likelihood of cesarean birth including choice of provider, choice of hospital, timing of admission, and type of fetal monitoring. Evidence suggests the overuse of labor interventions may be associated with cesarean birth. Shared decision-making (SDM) is a strategy that can be used to carefully consider the risks, benefits, and alternatives of each labor intervention and is shown to be associated with positive patient outcomes. Most existing evidence explores SDM as an interaction that occurs between women and their providers. Few studies have explored the role of stakeholders such as spouses, family members, friends, labor and delivery nurses, and doulas. Furthermore, little is known about the process of SDM during labor and childbirth in the hospital setting, particularly for active duty women in the U.S. military. The purpose of this study was to propose a framework that explains the process of SDM during labor and childbirth in the hospital setting for active duty women in the U.S. military.

MATERIALS AND METHODS

A qualitatively driven mixed-methods approach was conducted to propose a framework that explains the process of SDM during labor and childbirth in the hospital setting for active duty women in the U.S. military. Servicewomen were recruited from September 2019 to April 2020. Semi-structured interviews were analyzed using a constructivist grounded theory approach. Participants also completed the SDM Questionnaire (SDM-Q-9).

RESULTS

Interviews were conducted with 14 participants. The sample included servicewomen from the Air Force (n = 7), Army (n = 4), and Navy (n = 3). Two participants were enlisted and the remainder were officers. Ten births occurred at military treatment facilities (MTFs) and six births took place at civilian facilities. The mean score on the SDM Questionnaire was 86.7 (±11.6), indicating a high level of SDM. Various stakeholders (e.g., providers, labor and delivery nurses, doulas, spouses, family members, and friends) were involved in SDM at different points during labor and birth. The four stages of SDM included gathering information, identifying preferences, discussing options, and making decisions. Events that most often involved SDM were deciding when to travel to the hospital, deciding when to be admitted, and selecting a strategy for pain management. Military factors involved in SDM included sources of information, selecting and working with civilian providers, and delaying labor interventions to allow time for an active duty spouse to travel to the hospital.

CONCLUSIONS

SDM during labor and birth in the hospital setting is a multi-stage process that involves a variety of stakeholders, including the woman, members of her social and support network, and healthcare professionals. Future research is needed to explore perspectives of other stakeholders involved in SDM.

Placenta Accreta Spectrum

Placenta accreta spectrum (PAS) refers to the range of pathologic adherence of the placenta to the uterine myometrium, including the placenta accreta, increta, and percreta. The incidence of PAS is rising primarily because of an increase in related risk factors, such as the rate of cesarean deliveries and pregnancies resulting from assisted reproductive technology. The maternal risks associated with PAS are significant, including hemorrhage, hysterectomy, and death. Fetal and neonatal risks are primarily the result of premature delivery. Antenatal diagnosis via ultrasonography and magnetic resonance imaging remains imperfect. Management of PAS varies, however, and there is a clear improvement in maternal outcomes with an antenatal diagnosis compared with unexpected diagnosis at the time of delivery. Studies that evaluate the balance between maternal and fetal/neonatal risks of expectant management versus preterm delivery have found that planned delivery between 34 and 35 weeks' gestation optimizes outcomes. Multidisciplinary PAS care teams have become the norm and recommended approach to management, given the complexity of caring for this obstetrical condition. Although significant advances have been made over the years, large knowledge gaps remain in understanding the pathophysiology, diagnosis, and clinical management.

Early Gestational Age Placenta Accreta Case Report: Can We Avoid Missed Diagnosis?

Case series

Patients: Female, 34-year-old • Female, 35-year-old • Female, 32-year-old

Final Diagnosis: Placenta accrete

Symptoms: Vaginal bleeding

Medication: —

Clinical Procedure: —

Specialty: Obstetrics and Gynecology

Conservative stepwise surgical approach for management of placenta previa accreta: A prospective case series study

OBJECTIVE

To describe a stepwise surgical approach for conservative management of placenta previa accreta to preserve the uterus and to evaluate the efficacy and safety of this approach in controlling postpartum hemorrhage including intrapartum hemorrhage.

METHODS

A prospective case series study conducted on 62 pregnant women with one or more cesarean deliveries diagnosed with placenta previa accreta between January 2018 and June 2019 at Ain Shams University Maternity Hospital. All participants underwent a conservative stepwise surgical approach through Pfannenstiel skin incision with fetal delivery through a uterine incision just above the upper border of the placenta, followed by bilateral uterine artery ligation with myometrial excision of the remaining adherent placenta and cervico-isthmic sutures by MMG (the main surgeon) and MS.

RESULTS

Among 62 women, the surgical approach was successful in controlling postpartum hemorrhage and preserving the uterus in 50 (80.64%) participants. Three women (4.83%) had urinary bladder injuries, all were managed intraoperatively during the cesarean section. Five women (8%) had postpartum pyrexia and five women (8%) had postpartum endometritis, all were managed conservatively with broad-spectrum antibiotics.

CONCLUSION

The stepwise surgical approach can be applied to the conservative management of placenta previa accreta to avoid unnecessary cesarean hysterectomy.

The modified radical peripartum cesarean hysterectomy (Soleymani-Alazzam-Collins technique): a systematic, safe procedure for the management of severe placenta accreta spectrum

BACKGROUND

The prevalence of placenta accreta spectrum is rising worldwide. The severe end of the spectrum where the placenta has invaded other organs is fortunately rare, however, few surgical techniques for such a complex hysterectomy have been described in the literature.

OBJECTIVE

This study aimed to describe a stepwise, systematic technique for radical cesarean hysterectomy for placenta accreta spectrum to investigate outcomes for women with severe, invasive placenta accreta spectrum who were hysterectomized using this technique.

STUDY DESIGN

This was a retrospective cohort study undertaken at a large UK tertiary referral center. A total of 24 cases of elective primary cesarean hysterectomy with a confirmed intrapartum diagnosis of severe percreta (Federation of Gynecology and Obstetrics grades 3b and 3c) were identified between 2011 and 2020. Among those cases, 16 had standard care (surgical technique dependent on surgeon's preference), and 8 had a radical peripartum hysterectomy using the Soleymani-Alazzam-Collins technique as described. Nonparametric testing was used because of sample size.

RESULTS

The Soleymani-Alazzam-Collins technique resulted in significantly less blood loss (P=.032), more transverse incisions (P=.009), and less intensive care unit admissions (P=.046). Furthermore, there was no significant difference in theater time.

CONCLUSION

The Soleymani-Alazzam-Collins technique demonstrated a significant improvement in outcomes for women with severe placenta accreta spectrum, without increasing surgical time.

Complicated placenta accreta spectrum: identifying a high-risk cohort

OBJECTIVE

To assess differences in the perioperative complication rate between patients with placenta accreta spectrum (PAS) with and without complicating factors.

METHODS

This retrospective cohort study included subjects who underwent cesarean hysterectomy with histology-proven PAS between 23 0/7 and 42 0/7 weeks gestational age (GA) from 1 July 2008 to 11 April 2017. Perioperative outcomes were compared between those with uncomplicated PAS and "complicated PAS," defined as PAS subjects who experienced ≥2 bleeding episodes, preterm premature rupture of membranes (PPROM), or premature contractions requiring tocolysis.

RESULTS

Overall, 26 complicated PAS and 27 uncomplicated PAS cases were compared; no difference in the rate of perioperative complications was identified. An increased proportion of complicated PAS cases required blood product transfusion before delivery: 2 (40%), 3 (27.3%), and 2 patients (20%) for those with PPROM, preterm contractions, and ≥2 bleeding episodes respectively, compared to patients with uncomplicated PAS, having no transfusions (p = .001). Time of delivery was earlier for patients with complicated compared to uncomplicated PAS (median GA 30.9 [Q1 = 27.9; Q3 = 31.9] and 34.9 [Q1 = 32.1; Q3 = 35.7], p < .001). Median birthweights were lower (p < .0144) and maternal length of stay longer (p < .0012) for complicated PAS.

CONCLUSION

Patients with complicated PAS were not at higher risk for perioperative complications but were associated with earlier delivery, required more antenatal blood transfusions, and had a longer LOS.

Correlation of placental MR imaging signs and pathologic diagnosis of placenta accreta spectrum: Retrospective single center case series

INTRODUCTION

Alongside initial screening obstetric US, use of placental MRI has been increasing in the last few decades to aid with antenatal diagnosis and delivery planning in Placenta Accreta Spectrum (PAS). The aim of this study was to determine if the MRI pathophysiological sign subcategories described in the current literature can predict the severity of pathologic diagnosis.

METHODS

Institutional imaging records were reviewed for placental MRIs performed for suspicion of PAS in the last decade. Electronic health records were searched for patient history and pathology. The 59 MRI studies were reviewed using the 11 MRI signs described by the SAR and ESUR joint consensus statement. Further breakdown of the signs was divided by underlying pathophysiologic subcategories including gross morphologic, interface and tissue architecture signs.

RESULTS

Pathologic diagnosis yielded 34 cases: accreta 4/34, incerta 14/34, percreta 10/34 and normal 6/34. Of the accreta cases all of them demonstrated at least two interface and half of the cases had tissue architecture signs, 13/14 increta cases demonstrated interface signs and 12/14 demonstrated tissue architecture signs, 9/10 percreta cases had two interface and at least six demonstrated three tissue architecture signs. Statistical analysis showed significant difference between pathologic diagnosis and the number of positive interface signs with p = 0.02.

DISCUSSION

Interface signs were the most objective and sensitive MRI subcategory. Statistical analysis determined there was a significant difference between PAS diagnosis and number of interface signs present. This subcategory has the most overlap with classic US signs which are traditionally used before MRI referral.

Constructing a Novel 'Uterine Sandwich' with Simultaneous Intrauterine Balloon Tamponade and Uterine Compression Sutures to Manage Postpartum Bleeding

The uterine sandwich is a relatively new surgical technique for managing postpartum hemorrhage, which is the leading cause of maternal mortality worldwide. The purpose of this case series is to describe a novel method of constructing the uterine sandwich by simultaneously combining intrauterine balloon tamponade and uterine compression sutures. Six patients with postpartum bleeding refractory to medical management were successfully treated with this novel method and avoided hysterectomy. There were no additional complications. This novel method of constructing a uterine sandwich appears to be a simple, safe, and effective technique that could be considered in cases of persistent postpartum bleeding. More research is needed to compare the efficacy of various techniques.

Placenta Accreta Spectrum Among Women With Twin Gestations

OBJECTIVE

To assess whether placenta accreta spectrum occurs more frequently among women with twin gestations compared with singleton gestations.

METHODS

All live births in California from 2016 to 2017 were identified from previously linked records of birth certificates and birth hospitalization discharges. The primary outcome was placenta accreta spectrum (which includes placenta accreta, increta, and percreta), identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes (O43.2x) for placenta accreta, increta, and percreta. We analyzed the association between twin gestation and placenta accreta spectrum by using multivariable logistic regression and assessed whether our findings were replicated by using a previously validated International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)-based approach.

RESULTS

Among 918,452 live births, 1,126 were diagnosed with placenta accreta spectrum. The prevalence of placenta accreta spectrum was 11.8 per 10,000 among singleton pregnancies and 41.6 per 10,000 among twin pregnancies. In the unadjusted regression analysis, twin pregnancy was associated with higher relative risk of placenta accreta spectrum (RR 3.41, 95% CI 2.57-4.52). After adjusting the regression model for maternal age, previous cesarean birth, and sociodemographic factors, the association held with higher relative risk of placenta accreta spectrum (aRR 2.96, 95% CI 2.23-3.93). Women with twin compared with singleton gestations with placenta accreta spectrum were less likely to have placenta previa. When assessed using ICD-9-CM codes, placenta accreta spectrum was similarly more prevalent among twins than singletons, with an increase in the relative risk of placenta accreta spectrum (aRR 2.45, 95% CI 2.33-3.25).

CONCLUSION

Twin gestation conferred an increased risk for placenta accreta spectrum independent of measured risk factors, which may contribute to increased maternal morbidity in twin gestation compared with singleton gestation. Clinicians should be aware of the increased risk for placenta accreta spectrum in twin gestation and should consider it during ultrasonographic screening.

Experience of Managing Suspected Placenta Accreta Spectrum with or without Internal Iliac Artery Balloon Occlusion in Two Lithuanian University Hospitals

Background and objectives: Placenta previa and placenta accreta spectrum are considered major causes of massive postpartum hemorrhage. Objective: To determine whether the placement of an occlusion balloon catheter in the internal iliac artery could reduce bleeding and other related complications during cesarean delivery in patients with placenta previa and placenta accreta spectrum. Materials and Methods: A retrospective analysis was conducted at two tertiary obstetric units of Lithuania. From January 2016 to November 2019 patients with placenta previa and antenatally suspected invasive placenta were included in the intervention group and underwent cesarean delivery with endovascular procedure. From January 2014 to December 2015 patients with placenta previa and suspected placenta accreta spectrum were included in the non-intervention group. The primary outcomes were reduction in intraoperative blood loss and transfusion volumes in the intervention group. Secondary outcomes were the incidence of hysterectomy and maternal complications. Results: Nineteen patients underwent cesarean delivery with preoperative endovascular procedure, and 47 women underwent elective cesarean delivery. The median intraoperative blood loss (1000 (400–4500) mL vs. 1000 (400–5000) mL; p = 0.616) and the need for red blood cell transfusion during operation (26% vs. 23%; p = 0.517) did not differ significantly between the patients groups. Seven patients in the intervention group and two patients in the non-intervention group underwent perioperative hysterectomy (p = 0.002). None of the patients had complications related to the endovascular procedure. Conclusion: The use of intermittent balloon occlusion catheter in patients with placenta pathology is a safe method but does not significantly reduce intraoperative blood loss during cesarean delivery.

A double-blind randomized trial on subendometrial injection of vasopressin to control bleeding in postpartum hysterectomy due to abnormally invasive placenta

OBJECTIVE

To investigate the effect of subendometrial vasopressin injection in patients with abnormally invasive placenta (AIP), who underwent cesarean section and hysterectomy.

METHODS

This randomized double-blinded clinical trial was conducted on pregnant women diagnosed with AIP grade 4 and 5 by ultrasonography during cesarean section. Women were randomly divided into two equal groups including group 1 (vasopressin) and group 2 (control) who underwent 20 units of vasopressin and 20 cc normal saline injection, respectively. Vasopressin and placebo were injected subendometrially 1 cm medial to the uterine vessels into the lower uterine segment. The exclusion criteria include presence of myocardial infarction, cardiomyopathy, congestive heart failure, uncontrolled hypertension, chronic obstructive pulmonary disease, pelvic malignancy. The outcome of the study was total quantitative blood loss during the cesarean section. We estimated blood loss by measuring the blood volume in one of the suction bottles with addition for weight changes of mops, pads, and soaked linen savers.

RESULTS

Sixty patients were recruited into the study, 30 as the vasopressin group and 30 as the controls; with no excluded case. The amount of bleeding in the vasopressin group was significantly lower compared with that in the control group (P < 0.001). In the vasopressin group, 83.4% of patients had bleeding of less than 1.5 L, while only 3.3% of the control women had bleeding of less than 1.5 L (relative risk = 5). In addition, the number of injected packed cells was lower in the vasopressin group (P < 0.001).

CONCLUSION

It was shown that vasopressin injection can help prevent excess hemorrhage and the subsequent risks of anemia or blood transfusions during abdominal hysterectomy in women with AIP.

First trimester serum PAPP-A is associated with placenta accreta: a retrospective study

PURPOSE

Our objective of this study was to investigate whether first trimester serum pregnancy-associated plasma protein-A (PAPP-A) differed amongst pregnancies with placenta previa-accreta and non-adherent placenta previa and healthy pregnancies by a retrospective cohort analysis.

METHODS

A total of 177 pregnant females were included in the study, as follows: 35 cases of placenta previa-accreta, 30 cases of non-adherent placenta previa, and 112 cases of BMI and age matched, healthy pregnant controls. PAPP-A multiples of the median (MoM) were acquired from laboratory data files in 1 January 2017-30 September 2019. The probable maternal serum biochemical predictor of placenta accreta was analyzed by using multiple logistic regression analysis.

RESULTS

PAPP-A MoM of placenta previa-accreta group was significantly higher than those of the non-adherent placenta previa group and control group (p = 0.009 < 0.05, p < 0.001). Serum PAPP-A was found to be significantly positively associated with placenta accreta after adjusted gestational week at time of blood sampling, BMI, age, smoking, and previous cesarean section history (OR: 3.51; 95% CI: 1.77-6.94; p = 0.0003 < 0.05). In addition, smoking (OR: 9.17; 95% CI: 1.69-49.62; p = 0.010 < 0.05) and previous cesarean section history (OR: 2.75; 95% CI: 1.23-6.17; p = 0.014 < 0.05) were also significantly associated with placenta accreta.

CONCLUSION

Increased first trimester serum PAPP-A was significantly positively associated with placenta accreta, suggesting that the potential role of PAPP-A in identifying pregnancies at high risk for placenta accreta. Smoking and previous cesarean section history may be the risk factors for accreta in placenta previa patients.

Peripartum Hysterectomies over a Fifteen-year Period

OBJECTIVE

 To determine the indications and outcomes of peripartum hysterectomies performed at Hospital de Clínicas de Porto Alegre (a university hospital in Southern Brazil) during the past 15 years, and to analyze the clinical characteristics of the women submitted to this procedure.

METHODS

 A cross-sectional study of 47 peripartum hysterectomies from 2005 to 2019.

RESULTS

 The peripartum hysterectomies performed in our hospital were indicated mainly due to placenta accreta or suspicion thereof (44.7% of the cases), puerperal hemorrhage without placenta accreta (27.7%), and infection (25.5%). Total hysterectomies accounted for 63.8% of the cases, and we found no difference between total versus subtotal hysterectomies in the studied outcomes. Most hysterectomies were performed within 24 hours after delivery, and they were associated with placenta accreta, placenta previa, and older maternal age.

CONCLUSION

 Most (66.0%) patients were admitted to the intensive care unit (ICU). Those who did not need it were significantly older, and had more placenta accreta, placenta previa, or previous Cesarean delivery.

Uterine scar rupture at the site of the placenta accreta presenting as a case of sudden death

Uterine rupture during pregnancy is a known complication of placenta accreta. This paper presents a case of sudden maternal death in the 27^th week of gestation due to a ruptured uterine scar at the site of placenta accreta with a short inter-pregnancy period of 6 months with previous two C-sections. Autopsy findings revealed a massive hemoperitoneum and a thinned out anterolateral uterine wall. Internal examination revealed clotted and fluid blood in the peritoneal cavity with rupture of the anterior uterine wall at the site of the placenta accreta in a healed cesarean section scar. Placenta accreta is a rare complication of pregnancy. However, it is becoming more frequent and a significant risk factor with the increasing rate of C-section.

Review of MRI imaging for placenta accreta spectrum: Pathophysiologic insights, imaging signs, and recent developments

Placenta Accreta Spectrum (PAS) refers to the range of abnormally adhesive and penetrative placental tissue at a uterine scar. PAS is divided into accreta, increta, and percreta based on degree of myometrial invasion. Its incidence has increased, and PAS is now the leading indication for emergency peripartum hysterectomy in the setting of catastrophic hemorrhage from a non-separating placenta. The recent release of the International Federation of Gynecology and Obstetrics (FIGO) guidelines in 2018 coupled with the joint consensus statement from the Society of Abdominal Radiology (SAR) and European Society of Urogenital Radiology (ESUR) in 2020 reflect decades worth of diagnostic and therapeutic advances in this field. Although the increasing role of MRI in PAS diagnosis is evident, the literature on PAS reveals several disparate but conceptually overlapping MRI signs. Identifying and differentiating between placenta increta and percreta on imaging may be quite challenging even with MRI and sometimes even on final pathology. In this review, we aim to (i) provide a clarified understanding of PAS pathophysiology, (ii) comprehensively review and classify MRI signs based on pathophysiologic underpinnings, (iii) highlight shortcomings in the current PAS literature; and (iv) highlight best practice guidelines for imaging diagnosis of PAS.

First trimester serum PIGF is associated with placenta accreta

OBJECTIVES

In this retrospective study, we investigated whether first trimester serum placental growth factor (PIGF) differed amongst pregnancies with placenta previa-accreta and non-adherent placenta previa and healthy pregnancies.

METHODS

In 1 January 2017-30 September 2019, a total of 177 pregnant females were included in the study, as follows: 35 cases of placenta previa-accreta, 30 cases of non-adherent placenta previa, and 112 cases of age and BMI-matched, healthy pregnant controls. PIGF multiples of the median (MoM) were acquired from laboratory data files. The predictor of placenta accreta was analyzed by using multiple logistic regression analysis.

RESULTS

PIGF MoM of placenta previa-accreta group was significantly higher than those of the non-adherent placenta previa group and control group (p = 0.0098 < 0.01, p = 0.0002 < 0.01). Serum PIGF was found to be significantly positively associated with placenta accreta after adjusted gestational week at time of blood sampling, BMI, and age (OR: 4.83; 95% CI: 1.91-12.24；p = 0.0009 < 0.01). In addition, previous cesarean section history (OR: 2.75; 95% CI: 1.23-6.17; p = 0.014 < 0.05) and smoking (OR: 9.17; 95% CI: 1.69-49.62; p = 0.010 < 0.05) were also significantly associated with placenta accreta.

CONCLUSION

Increased first trimester serum PIGF was significantly positively associated with placenta accreta, suggesting that the potential role of PIGF in identifying pregnancies at high risk for placenta accreta. Previous cesarean section history and smoking may be the risk factors for accreta in placenta previa patients.

[Uterus transplantation, current prospect and future indications. State of art with review of literature]

OBJECTIVES

The aim of this review is to summarize the development of UT on worldwide and to develop the new questions posed by this technique in 2020.

METHODS

According to the PRISMA model, via Pubmed, we searched for publications containing the keywords: uterus transplantation; UT and cryopreservation from 2000 to 2020.

RESULTS

At least 76 UTx have been carried out around the world and 19 healthy babies were born. The main indication remains the uterine agenesis (MRKH Syndrome>85% cases) then the history of hysterectomy (hemorrhage of the delivery or cervical cancer) and the non-functional uterus (Asherman's syndrome, diffuse adenomyosis). The 2 types of donors (living and deceased) are developed representing respectively 75% and 25% of the TU; the success rate in terms of return of rules is better in the living donor group and is 79% vs 68% in the deceased donor group. The choice of donor type must take into account the constraints of both procedures. Surgical complications (grade III) for the donor are estimated to be 14% mainly represented by ureter wounds. Technical simplifications concerning the venous return of the graft but also the carrying out of robot-assisted surgery would reduce the operating time for the donor and facilitate the collection process.

CONCLUSION

TU is a complementary alternative to GPA and adoption allowing patients to be surrogates, legal and biological of the baby. An extension of the indications to patients with non absolute uterine infertility is in the process of democratization.

Management of abnormal invasive placenta in a low- and medium-resource setting

The purpose of this review is to describe the panorama of placenta accreta spectrum (PAS) disorder management in low- and middle-income countries, providing information that allows for the improvement of maternal and perinatal outcomes in the management of this pathology. This spectrum of disorders is associated with implications of high morbidity and mortality, both maternal and perinatal, which is why clinical practice guidelines based on management are produced in settings where there is a wide range of available resources. This situation often contrasts with what the reality is in low-resource countries. Prenatal diagnosis of placental accreta is essential to carry out adequate surgical planning in centres where multidisciplinary teams are in place, which improve results and reduce complications. These ideal scenarios should be developed in countries with more significant difficulties in the availability of human and technological resources, through teamwork in the different hospital centres and the adequate transfer of patients at higher risk to centres with the best interdisciplinary management skills.

Variation of intrapartum care and cesarean rates among practitioners attending births of low-risk, nulliparous women

BACKGROUND

Variation in hospital cesarean birth rates across the United States is likely because of differences in practitioner practice patterns. Yet, few studies conducted in the last twenty years have examined the relationships between practitioner characteristics and the use of intrapartum interventions and cesarean birth. The objective of this study was to examine associations among practitioner characteristics and the use of amniotomy, epidural, oxytocin augmentation, and cesarean birth in low-risk women with spontaneous onset of labor.

METHODS

A secondary analysis was performed using data collected by the Consortium on Safe Labor. The sample included nulliparous term singleton vertex (NTSV) births with spontaneous onset of labor (n = 13 196) from 2002 to 2007 across eight hospitals. Generalized linear mixed models were conducted to examine outcomes.

RESULTS

The cesarean birth rate ranged from 7.2% to 18.9% across hospitals and from 0% to 53.3% across physicians. Practice type (P < .05) and specialty type (P < .0001) were associated with physician cesarean birth rates. Compared with obstetrician/gynecologists, midwives were nearly twice as likely to use no intrapartum interventions (relative risk 1.80 [CI 95 1.45-2.24]) and 26% less likely to use amniotomy-epidural-oxytocin (0.74 [0.62-0.89]). Family practice physicians had a 21% lower likelihood of using amniotomy-epidural-oxytocin (0.79 [0.67-0.94]) and a 53% lower likelihood of performing cesarean births (0.47 [0.35-0.63]).

CONCLUSIONS

Wide variation in hospital and physician cesarean birth rates was observed in this sample of low-risk, nulliparous women. Practitioner practice type and specialty were significantly associated with the use of intrapartum interventions. Interprofessional practitioner education could be one strategy to reduce variation of intrapartum care and cesarean birth.

Clinical outcomes and anesthetic management of pregnancies with placenta previa and suspicion for placenta accreta undergoing intraoperative abdominal aortic balloon occlusion during cesarean section

Background

This retrospective study aimed to compare the clinical outcomes of parturients with placenta previa (PP) and placenta accreta (PA) according to their severity, when they were managed with intraoperative abdominal aortic balloon occlusion (IAABO) during cesarean section.

Methods

We retrospectively examined 57 cases of PP and suspicion for PA in which IAABO was performed during cesarean section between April 2014 and June 2016. Based on preoperative examination and clinical risk factors, patients were divided into the low suspicion PA group and the high suspicion PA group. We compared the demographic characteristics, methods of anesthesia, intra- and postoperative parameters, and maternal and neonatal outcomes.

Results

The two groups showed similar demographic characteristics and intraoperative outcomes. Four women underwent cesarean hysterectomy. Eight neonates were admitted to the neonatal intensive care unit and three did not survive. Neonatal Apgar scores were significantly higher in the low suspicion PA group. Eight patients experienced postoperative femoral artery thrombosis and one patient complicated hematoma in the front wall of the common femoral artery. Patients who received neuraxial anesthesia showed significantly lower intraoperative blood loss, lower intraoperative, postoperative and total blood transfusion and shorter surgery than patients who received general anesthesia.

Conclusions

Our data suggested that the severity of aberrant placental position does not affect intraoperative blood loss during a cesarean section while the IAABO is performed. We propose that neuraxial anesthesia is preferred for conducting these surgeries without contraindications.

Cesarean delivery with and without uterine artery embolization for the management of placenta accreta spectrum disorder-A comparative study

INTRODUCTION

The aim of this study is to compare immediate and long-term obstetrical outcomes of patients who underwent cesarean delivery with and without uterine artery embolization (UAE) for the management of placenta accreta spectrum disorder.

MATERIAL AND METHODS

A retrospective case control study including all pregnant women admitted to a single tertiary medical center between December 2001 and May 2018 with a diagnosis of placenta accreta spectrum disorder, who underwent cesarean delivery with and without UAE. Groups were compared for maternal characteristics, operative management, postoperative complication rate and long-term outcomes. Follow up on future obstetrical outcomes was conducted via telephone questionnaire. Non-parametric statistics were used.

RESULTS

During the study period, 272 women met the inclusion criteria: 64 (23.53%) and 208 (76.47%) underwent preservative cesarean section with and without UAE, respectively. UAE procedure was associated with a longer operative time (82.5 [68-110] vs 50.5 [39-77] minutes; P = .001), and higher blood loss (2000 (1500-3000) vs 1000 (600-2000) mL; P = .001). Hysterectomy rate was comparable between the groups (9 [14%] vs 35 [16.82%]; P = .88); however, multivariate logistic regression analysis found UAE to be an independent factor associated with lower hysterectomy rate (P = .02). Postoperative complications were more frequent in the UAE group. Follow up was achieved in 29 (59.18%) and 72 (51.79%) of the women with and without UAE, respectively (P = .36). No differences were found in rate of abortions, pregnancy and deliveries between the groups.

CONCLUSIONS

Cesarean delivery using UAE in placenta accreta spectrum disorder is associated with a higher rate of operative and postoperative complications. Nevertheless, in cases of severe adherence of the placenta, embolization reduces the need for hysterectomy, allowing future fertility.

Introducing an efficient model for the prediction of placenta accreta spectrum using the MCP regression approach based on sonography indexes: how efficient is sonography in diagnosing accreta?

Background

For the first time, we aimed to introduce a model for prediction of placenta accreta spectrum (PAS), using existing sonography indices.

Methods

Women with a history of Cesarean sections were included. Participants were categorized “high risk” for PAS if the placenta was previa or low-lying.

Sonography indices including abnormal placental lacuna, loss of clear zone, bladder wall interruption, myometrial thinning, placental bulging, exophytic mass, utero-vesical hypervascularity, subplacental hypervascularity, existence of bridging vessels, and lacunar flow, were registered.

To investigate simultaneous effects of 15 variables on PAS, Minimax Concave Penalty (MCP) was used.

Results

Among 259 participants, 74 (28.5%) were high risk and 43 individuals had PASs.

All sonography indices were higher among patient with PAS (p < 0.001) in the high risk group.

Our model showed that utero-vesical hypervascularity, bladder interruption and new lacunae have significant contribution in PAS. Optimal cut off point was p = 0.51 in ROC analysis. Probability of PAS for women with lacunae was between 96 and 100% and probability of PAS for women without lacunae was between 0 to 7%, therefore accuracy of the proposed model was equal to 100%.

Conclusions

Using the introduced model based on three factors of abnormal lacuna structures (grades 2 and 3), bladder wall interruption and utero-vesical vascularity, 100% of all cases of PASs are diagnosable. If supported by future studies our model eliminates the need for other imaging assessments for diagnosis of invasive placentation among high risk women with previous history of Cesarean sections.

Transverse versus vertical skin incision for planned cesarean hysterectomy: does it matter?

BACKGROUND

To investigate differences in perioperative outcomes by type of skin incision, transverse versus vertical, for planned cesarean hysterectomy for placenta accreta spectrum (PAS).

METHODS

A retrospective cohort study of all women who underwent a planned cesarean hysterectomy for abnormal placentation at a single academic medical center over 5 years. The Student's t-test was used for continuous variables and Fisher's exact test compared categorical variables. Continuous data were presented as median and compared using the Wilcoxon-rank sum test.

RESULTS

Forty-two planned cesarean hysterectomies were identified. A transverse skin incision was made in 43% (n = 18); a vertical skin incision was made in 57% (n = 24). Skin incision was independent of BMI (30.3 vs 30.8 kg/m2, p = 0.37), placental location (p = 0.82), and PAS-subtype (p = 0.26). Mean estimated blood loss (EBL) was 2.73 l (L) (range 0.5-20) and was not significantly different between transverse and vertical skin incision (2.6 L vs 2.8 L, p = 0.8). There was significantly shorter operative time with transverse skin incision (180 vs 238 min, p = 0.03), with no difference in intraoperative complications, including cystotomy (p = 0.22) and ureteral injury (p = 0.73). Postoperatively, there was no difference in maternal length of stay (4.8 vs 4.4 days, p = 0.74) or post-operative opioid use (117 vs 180 morphine equivalents, p = 0.31).

CONCLUSION

Transverse skin incision is associated with shorter operative time for patients undergoing planned cesarean hysterectomy. There was no difference in EBL, intraoperative complications, postoperative length of stay, or opioid use. Given an increasing rate of cesarean hysterectomy, we should consider variables that optimize maternal outcomes and resource utilization.

Efficacy of tranexamic acid in reducing blood loss, blood and blood products requirements in Cesarian sections for patients with placenta accreta

Background

Placenta accreta is an obstetric emergency and the main cause of maternal morbidity and mortality due to the associated bleeding and coagulopathy. Tranexamic acid has been widely used to decrease blood loss in trauma patients and patients with postpartum hemorrhage. We aimed at studying the effect of tranexamic acid in reducing blood loss and blood transfusion in patients with placenta accreta.

Methods

In a double-blinded randomized controlled study, 46 patients were recruited and divided into two groups, Group A is the tranexamic group where patients received 10 mg/kg tranexamic acid after cord clamping and continued on tranexamic infusion 10 mg/kg/h till the end of the surgery. Group B is the placebo where patients received normal saline instead. Primary outcome was the amount of intraoperative blood loss, and other outcomes included the number of blood and blood products transfused intraoperative and in the first 24 h postoperative, the immediate postoperative Hb level, platelet count, and coagulation profile. Data were collected, coded, tabulated, and then analyzed using Minitab® 16.1.0 statistics software package. Variables were presented as mean and standard deviation and analyzed using unpaired t test. Any difference with p value < 0.05 was considered statistically significant.

Results

Amount of intraoperative blood loss was significantly less in the tranexamic group 2232 ± 1204 ml compared to the placebo group 3405 ± 1193 ml (p value 0.002), and patients in the tranexamic group received less units of packed red blood cells, fresh frozen plasma, and platelets compared to those in the placebo group (4.2 ± 1.9 vs 6.1 ± 2.2 with p value 0.003, 3.4 ± 1.3 vs 4.2 ± 1.2 with P value 0.036 and 4.8 ± 2.1 vs 6.2 ± 2.4 with p value 0.041, respectively). There was no statistically significant difference in the first postoperative Hb level, platelet count, and coagulation profile between the two groups; however, the amount of blood and products transfused in the first 24 h postoperative were significantly less in the tranexamic group

Conclusion

Tranexamic acid infusion was effective in reducing intraoperative blood loss and intraoperative and postoperative blood and blood products’ transfusion.

No. 361-Caesarean Delivery on Maternal Request

A maternal request for an elective CS in the absence of a maternal or fetal indication may raise risk-benefit considerations and ethical concerns for a health care provider. Appropriate counselling of the patient on the risks and benefits in proceeding with a CDMR without medical indication is essential. Providers should have a clear knowledge of the risks and benefits of providing an elective CS without medical indications compared to the risks and benefits of supporting an attempt at vaginal delivery, so that the patient may reach an informed decision. The principle of patient autonomy should be respected but other ethical principles (beneficence, non-maleficence and justice) need to be taken into consideration during the counselling process. There are no studies to estimate maternal and neonatal risks in CDMR. Often studies on CS before the onset of labour are used as surrogates to determine risks and benefits. After exploring the reasons behind the patient's request, and discussing the risks and benefits, if a patient insists on her choice a physician may pursue one of the following two options: 1) Agree to perform the CS after 39+0 weeks gestation; 2) Disagree and refer the patient for a second opinion.

Endometrium-free uterine closure technique and abnormal placental implantation in subsequent pregnancies

BACKGROUND

Abnormal placentation can result in massive hemorrhage, which is the leading cause of severe maternal morbidities and mortality in its management. Over the past 50 years, the incidence of placenta previa (PP), abnormal implantation of the placenta, and cesarean scar pregnancy have continued to rise. This coincides with the well-documented parallel rise in the rate of cesarean deliveries, the performance of multiple repeat cesarean deliveries and the adoption of newer uterine closure techniques. However, no studies have examined the role of uterine closure techniques in abnormal placentation in women with a history of a prior cesarean delivery.

OBJECTIVE

To assess the practicality of one specific uterine closure technique at cesarean delivery and to evaluate the relationship between previous cesarean delivery and subsequent development of abnormal implantation of the placenta, as well as neonatal and other perioperative outcomes after receiving an endometrium-free uterine closure technique.

METHODS

This retrospective observational study considered cesarean deliveries (n = 727) and subsequent vaginal births after cesarean delivery (n = 109) among total deliveries (n = 4496) performed in private practice at NYU Langone Health from 1985 to 2015. All cesarean deliveries were performed using the endometrium-free uterine closure technique. The primary outcome was the incidence of abnormal implantation of the placenta in subsequent pregnancies. The secondary outcomes were neonatal and maternal complications, specifically postoperative hemoglobin and hematocrit concentration losses. The association between independent variables and outcomes were evaluated using mixed-effect regression models.

RESULTS

In contrast to published data, independent of the number of repeat cesarean deliveries, the presence of 26 (3.1%) PPs and of 366 (43.8%) anterior placentas, there were no patients with abnormal implantation of the placenta in a cesarean scar, neither prenatally nor at delivery. Maternal hemorrhage, postoperative and neonatal complications did not reach clinical significance. The statistical analysis revealed that, when compared with women who had fewer repeat cesarean deliveries using endometrium-free uterine closure technique, those with the most had a lesser risk of forming PP and less blood loss, as measured by both hematocrit and hemoglobin evaluation.

CONCLUSION

In this retrospective cohort study, the exclusion of the endometrium during the endometrium-free uterine closure technique was associated with fewer placental abnormalities in subsequent pregnancies and reduced life-threatening maternal morbidity for future cesarean deliveries.

Placenta Accreta Spectrum (PAS) disorders: incidence, risk factors and outcomes of different management strategies in a tertiary referral hospital in Minia, Egypt: a prospective study

Background

Placenta accreta spectrum (PAS) disorders have become a significant life-threatening issue due to its increased incidence, morbidity and mortality. Several studies have tried to identify the risk factors for PAS disorders. The ideal management for PAS disorders is a matter of debate. The study objectives were to evaluate the incidence and risk factors of PAS disorders and to compare different management strategies at a tertiary referral hospital, Minia, Egypt.

Methods

This prospective study included 102 women diagnosed with PAS disorders admitted to Minia Maternity university hospital, Egypt between January 2017 to August 2018. These cases were categorized into three groups according to the used approach for management: Group (A), (n = 38) underwent cesarean hysterectomy, group (B), (n = 48) underwent cesarean section (CS) with cervical inversion and ligation of both uterine arteries and group (C), (n = 16): the placenta was left in place.

Results

The incidence of PAS disorders during the study period was 9 / 1000 maternities (0.91%). The mean age of cases was 32.4 ± 4.2 years, 60% of them had a parity ≥3 and 82% of them had ≥2 previous CSs. Also, 1/3 of them had previous history of placenta previa. Estimated blood loss (EBL) and blood transfusion in group A were significantly higher than other groups. Group (C) had higher mean hospital stay duration. Group A was associated with significantly higher complication rate.

Conclusions

The incidence of PAS disorders was 0.91%. Maternal age > 32 years, previous C.S. (≥ 2), multiparity (≥ 3) and previous history of placenta previa were risk factors. The management of PAS disorders should be individualized. Women with PAS disorders who completed their family should be offered cesarean hysterectomy. Using the cervix as a tamponade combined with bilateral uterine artery ligation appears to be a safe alternative to hysterectomy in patients with focal placenta accreta and low parity desiring future fertility. Patients with diffuse placenta accreta keen to preserve the uterus could be offered the option of leaving the placenta aiming at conservative management after proper counseling.

Trial registration

Registered 28th October 2015, ClinicalTrials.gov NCT02590484.