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Abstract
Placenta accreta spectrum is a group of disorders involving abnormal trophoblastic invasion to the deep layers of endometrium and myometrium. Placenta accrete spectrum is one of the major causes of severe maternal morbidity, with increasing incidence in the past decade mainly secondary to an increase in cesarean deliveries. Severity varies depending on the depth of invasion, with the most severe form, known as percreta, invading uterine serosa or surrounding pelvic organs. Diagnosis is usually achieved by ultrasound, and MRI is sometimes used to assess invasion. Management usually involves a hysterectomy at the time of delivery. Other strategies include delayed hysterectomy or expectant management.
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Affiliation(s)
- Mahmoud Abdelwahab
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
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Wang Y, Huang G, Jiang T, Han X. Application of abdominal aortic balloon occlusion followed by uterine artery embolization for the treatment of pernicious placenta previa complicated with placenta accreta during cesarean section. J Interv Med 2019; 2:113-117. [PMID: 34805883 PMCID: PMC8562228 DOI: 10.1016/j.jimed.2019.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE This study aimed to investigate the clinical effects of abdominal aortic balloon occlusion followed by uterine artery embolization for the treatment of pernicious placenta previa complicated with placenta accreta during cesarean section. METHODS We performed a retrospective analysis of the clinical data for 623 patients who experienced pernicious placenta previa complicated with placenta accreta and received treatment in our hospital from January 2013 to January 2019. All patients underwent abdominal aortic balloon occlusion before their cesarean section. Seventy-eight patients received bilateral uterine artery embolization, and among them, placenta accreta was found at the opening of the cervix in 13 patients. Due to suturing difficulty after the removal of the placenta, gauze packing was used to temporarily compress the hemorrhage. As soon as the uterus was sutured, emergent bilateral uterine artery embolization was performed. Active bleeding was noted in the remaining 65 patients when the lower part of the uterus was pressed after the placenta was removed and the uterus was sutured, therefor, bilateral uterine artery embolization was performed urgently. RESULTS Of the 623 patients, 545 patients underwent only abdominal aortic balloon occlusion and 78 patients underwent additional emergent bilateral uterine artery embolization due to hemorrhaging during or after their cesarean section. No hysterectomies were performed. In the 78 patients, the amount of bleeding was 800-3,200 ml with an average of 1,650 ml during the operation; the volume of blood transfused was 360-1,750 ml (average: 960 ml). The fetal fluoroscopy time was 3-8 s (average: 5 s). The dose of radiation exposure was (4.2 ± 2.9) mGy. Fetal appearance, pulse, grimace, activity, and respiration (Apgar) score were normal. No serious complications were observed during or after the operation in the follow-up visits. Conclusion: For patients with pernicious placenta previa complicated with placenta accreta who experience active bleeding after cesarean section and abdominal aortic balloon occlusion, bilateral uterine artery embolization can effectively reduce blood loss and requirement of blood transfusion during the operation, and lowers the risk of hysterectomy.
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Affiliation(s)
- Yanli Wang
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, 450052, China
| | - Guohao Huang
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, 450052, China
| | - Tian Jiang
- Department of Radiology, Henan Provincial People’s Hospital, Department of Radiology of Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, Henan, 450003, China
| | - Xinwei Han
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, 450052, China
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Hussein AM, Kamel A, Elbarmelgy RA, Thabet MM, Elbarmelgy RM. Managing Placenta Accreta Spectrum Disorders (PAS) in Middle/Low-Resource Settings. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2019. [DOI: 10.1007/s13669-019-00263-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Chen L, Wang X, Wang H, Li Q, Shan N, Qi H. Clinical evaluation of prophylactic abdominal aortic balloon occlusion in patients with placenta accreta: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2019; 19:30. [PMID: 30646863 PMCID: PMC6332886 DOI: 10.1186/s12884-019-2175-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 01/03/2019] [Indexed: 12/03/2022] Open
Abstract
Background Severe obstetric hemorrhage caused by placenta accreta results in significant maternal morbidity and mortality. As a new technology, abdominal aortic balloon occlusion (AABO) is becoming an important treatment for patients with placenta accreta. To evaluate the safety and efficacy of AABO, we conducted a systematic review and meta-analysis of previous studies. Methods We used a three-check subset including placenta accreta (placenta previa, percreta, increta, etc.), balloon, and aortic (aortas, aorta, etc.) to form a retrieval formula and searched in MEDLINE, EMBASE, the Cochrane Library, clinicaltrials.gov and Web of Science. All articles regarding placenta previa or placenta accreta and including the use of abdominal aortic balloon occlusion were included in our screening. Two researchers selected articles and extracted data independently. Finally, the Newcastle-Ottawa Quality Assessment Scale was used for quality assessments. Results We retrieved 776 articles and eventually included 11 clinical studies. Meta-analysis showed that AABO significantly reduced the blood loss volume (MD − 1480 ml, 95% CI -1806 to − 1154 ml, P < 0.001) and blood transfusion volume (MD − 1125 ml, 95% CI -1264 to − 987 ml, P < 0.001). Similarly, obvious reductions in the hysterectomy rate (OR 0.30, 95% CI 0.19 to 0.48, P < 0.001), hospitalization duration (MD − 1.35 days, 95% CI -2.40 to − 0.31 days, P = 0.01), and operative time (MD − 29.23 min, 95% CI -46.04 to − 12.42 min, P < 0.001) were observed in the AABO group. Conclusion The prophylactic use of AABO in patients with placenta accreta is safe and effective.
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Affiliation(s)
- Li Chen
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.,State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, Chongqing Medical University, Chongqing, 400016, China.,International Collaborative Laboratory of Reproduction and Development of Chinese Ministry of Education, Chongqing Medical University, Chongqing, 400016, China
| | - Xiaodan Wang
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Hengyu Wang
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Qin Li
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Nan Shan
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China. .,State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, Chongqing Medical University, Chongqing, 400016, China. .,International Collaborative Laboratory of Reproduction and Development of Chinese Ministry of Education, Chongqing Medical University, Chongqing, 400016, China.
| | - Hongbo Qi
- The Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China. .,State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, Chongqing Medical University, Chongqing, 400016, China. .,International Collaborative Laboratory of Reproduction and Development of Chinese Ministry of Education, Chongqing Medical University, Chongqing, 400016, China.
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Abstract
Placenta accreta spectrum, formerly known as morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta. The most favored hypothesis regarding the etiology of placenta accreta spectrum is that a defect of the endometrial-myometrial interface leads to a failure of normal decidualization in the area of a uterine scar, which allows abnormally deep placental anchoring villi and trophoblast infiltration. Maternal morbidity and mortality can occur because of severe and sometimes life-threatening hemorrhage, which often requires blood transfusion. Although ultrasound evaluation is important, the absence of ultrasound findings does not preclude a diagnosis of placenta accreta spectrum; thus, clinical risk factors remain equally important as predictors of placenta accreta spectrum by ultrasound findings. There are several risk factors for placenta accreta spectrum. The most common is a previous cesarean delivery, with the incidence of placenta accreta spectrum increasing with the number of prior cesarean deliveries. Antenatal diagnosis of placenta accreta spectrum is highly desirable because outcomes are optimized when delivery occurs at a level III or IV maternal care facility before the onset of labor or bleeding and with avoidance of placental disruption. The most generally accepted approach to placenta accreta spectrum is cesarean hysterectomy with the placenta left in situ after delivery of the fetus (attempts at placental removal are associated with significant risk of hemorrhage). Optimal management involves a standardized approach with a comprehensive multidisciplinary care team accustomed to management of placenta accreta spectrum. In addition, established infrastructure and strong nursing leadership accustomed to managing high-level postpartum hemorrhage should be in place, and access to a blood bank capable of employing massive transfusion protocols should help guide decisions about delivery location.
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Wong AJ, Schlumbrecht M, Huang M. Management of placenta percreta in a Jehovah's Witness patient. BMJ Case Rep 2018; 2018:bcr-2018-225260. [PMID: 29895551 DOI: 10.1136/bcr-2018-225260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Placenta percreta is increasing in incidence and is associated with the risk of life-threatening haemorrhage. Patients who do not accept blood products present a unique challenge to obstetrician-gynaecologists. In this case report, we present the case of a 42-year-old pregnant Jehovah's Witness with a complete placenta previa and confirmed percreta at 26 weeks' gestation. Due to her religious beliefs against the use of blood products, she was managed with a stepwise surgical approach which involved caesarean delivery with internal iliac (hypogastric) artery ligation, weekly methotrexate and delayed hysterectomy 6 weeks later. Non-traditional, alternative approaches to the management of abnormal placentation in patients declining blood products warrant exploration.
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Affiliation(s)
- Adriana J Wong
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Matthew Schlumbrecht
- Obstetrics & Gynecology, Division of Gynecologic Oncology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Marilyn Huang
- Obstetrics & Gynecology, Division of Gynecologic Oncology, University of Miami Miller School of Medicine, Miami, Florida, USA
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Lee PS, Kempner S, Miller M, Dominguez J, Grotegut C, Ehrisman J, Previs R, Havrilesky LJ, Broadwater G, Ellestad SC, Secord AA. Multidisciplinary approach to manage antenatally suspected placenta percreta: updated algorithm and patient outcomes. GYNECOLOGIC ONCOLOGY RESEARCH AND PRACTICE 2017; 4:11. [PMID: 28852530 PMCID: PMC5567476 DOI: 10.1186/s40661-017-0049-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 08/10/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Due to the significant morbidity and mortality associated with placenta percreta, alternative management options are needed. Beginning in 2005, our institution implemented a multidisciplinary strategy to patients with suspected placenta percreta. The purpose of this study is to present our current strategy, maternal morbidity and outcomes of patients treated by our approach. METHODS From 2005 to 2014, a retrospective cohort study of patients with suspected placenta percreta at an academic tertiary care institution was performed. Treatment modalities included immediate hysterectomy at the time of cesarean section (CHYS), planned delayed hysterectomy (interval hysterectomy 6 weeks after delivery) (DH), and fertility sparing (uterine conservation) (FS). Prognostic factors of maternal morbidity were identified from medical records. Complications directly related to interventional procedures and DH was recorded. Descriptive statistics were utilized. RESULTS Of the 21 patients with suspected placenta percreta, 7 underwent CHYS, 13 underwent DH, and 1 had FS with uterine preservation. Of the 20 cases that underwent hysterectomy, final pathology showed 11 increta, 7 percreta, and 2 inconclusive. 19/20 cases underwent interventional radiology (IR) procedures. Selective embolization was utilized in 14 cases (2/7 CHYS; 12/13 DH). The median time from cesarean section (CS) to DH was 41 [26-68] days. There were no cases of emergent hysterectomy, delayed hemorrhage, or sepsis in the DH group. Both estimated blood loss and number of packed red blood cell transfusions were significantly higher in the CHYS group. 3/21 cases required massive transfusion (2 CHYS, 1 FS) with median total blood product transfusion of 13 units [12-15]. The four IR-related complications occurred in the DH group. Incidence of postoperative complications was similar between both groups. Median hospital length of stay (LOS) after CHYS was 4 days [3-8] compared to DH cohort: 7 days [3-33] after CS and 4 days [1 -10] after DH. The DH cohort had a higher rate of hospital readmission of 54% (7/13) compared to 14% (1/7) CHYS, most commonly due to pain. There were no maternal deaths. CONCLUSION This multidisciplinary strategy may appear feasible; however, further investigation is warranted to evaluate the effectiveness of alternative approaches to cesarean hysterectomy in cases of morbidly adherent placenta.
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Affiliation(s)
- Paula S. Lee
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
- Duke Cancer Institute, Durham, USA
| | - Samantha Kempner
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
| | - Michael Miller
- Department of Interventional Radiology, Duke University Hospital, Durham, USA
| | | | - Chad Grotegut
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
| | - Jessie Ehrisman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
| | - Rebecca Previs
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
- Duke Cancer Institute, Durham, USA
| | - Laura J. Havrilesky
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
- Duke Cancer Institute, Durham, USA
| | | | - Sarah C. Ellestad
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
| | - Angeles Alvarez Secord
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
- Duke Cancer Institute, Durham, USA
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Kellie FJ. Interventions for improving pregnancy outcomes in antenatally diagnosed or suspected morbidly adherent placenta. Hippokratia 2017. [DOI: 10.1002/14651858.cd012159.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Frances J Kellie
- The University of Liverpool; Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health; First Floor, Liverpool Women's NHS Foundation Trust Crown Street Liverpool UK L8 7SS
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Farasatinasab M, Moghaddas A, Dashti-Khadivaki S, Raoofi Z, Nasiripour S. Management of Abnormal Placenta Implantation with Methotrexate: A Review of Published Data. Gynecol Obstet Invest 2016; 81:481-496. [PMID: 27384687 DOI: 10.1159/000447556] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 06/13/2016] [Indexed: 04/13/2024]
Abstract
Abnormally invasive placenta is characterized by direct attachment of chorionic villi to the uterine wall. This adherent placenta traditionally has been managed by peripartum hysterectomy. Nowadays, there is a lot of interest toward gradual shift from traditional management of invasive placentation to conservative ones leaving the placenta in situ to avoid the surgical morbidity of hysterectomy and loss of future fertility. Administration of methotrexate (MTX), as an adjunctive antimetabolite drug, resulted in conflicting data during conservative management of abnormal placentation. This review assessed all published data on efficacy and safety of MTX therapy as conservative management of invasive placentation. Fifty-three articles including one prospective cohort study, 2 retrospective cohort studies, 10 case series and 40 case reports were identified. Conservative management has beneficial effects on the avoidance of major surgery with the consequent morbidity and the preservation of future fertility. Infection and vaginal bleeding were main complications of MTX therapy. Although MTX therapy may result in accelerated involution or expulsion of placenta and has some beneficial effects on hemorrhagic events, but there is not enough evidence on its efficacy and safety to recommend its routine uses in all cases of invasive placenta.
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Affiliation(s)
- Maryam Farasatinasab
- Department of Clinical Pharmacy, Isfahan University of Medical Sciences, Isfahan, Iran
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Fox KA, Shamshirsaz AA, Carusi D, Secord AA, Lee P, Turan OM, Huls C, Abuhamad A, Simhan H, Barton J, Wright J, Silver R, Belfort MA. Conservative management of morbidly adherent placenta: expert review. Am J Obstet Gynecol 2015; 213:755-60. [PMID: 25935779 DOI: 10.1016/j.ajog.2015.04.034] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 04/24/2015] [Accepted: 04/27/2015] [Indexed: 11/16/2022]
Abstract
Over the last century, the incidence of placenta accreta, increta, and percreta, collectively referred to as morbidly adherent placenta, has risen dramatically. Planned cesarean hysterectomy at the time of cesarean delivery is the standard recommended treatment in the United States. Recently, interest in conservative management has resurged, especially in Europe. The aims of this review are the following: (1) to provide an overview of methods used for conservative management, (2) to discuss clinical implications for both clinicians and patients, and (3) to identify areas in need of further research.
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Affiliation(s)
| | | | | | | | - Paula Lee
- Duke University Medical Center, Durham, NC
| | - Ozhan M Turan
- University of Maryland School of Medicine, Baltimore, MD
| | - Christopher Huls
- Phoenix Perinatal Associates/Medivax, Banner Good Samaritan Medical Center, University of Arizona, Phoenix, AZ
| | | | - Hyagriv Simhan
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Jason Wright
- Columbia University College of Physicians and Surgeons, New York, NY
| | - Robert Silver
- University of Utah Medical School, Salt Lake City, UT
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Kondoh E, Kawasaki K, Chigusa Y, Mogami H, Ueda A, Kawamura Y, Konishi I. Optimal strategies for conservative management of placenta accreta: a review of the literature. HYPERTENSION RESEARCH IN PREGNANCY 2015. [DOI: 10.14390/jsshp.3.19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Eiji Kondoh
- Department of Gynecology and Obstetrics, Kyoto University
| | - Kaoru Kawasaki
- Department of Gynecology and Obstetrics, Kyoto University
| | | | - Haruta Mogami
- Department of Gynecology and Obstetrics, Kyoto University
| | - Akihiko Ueda
- Department of Gynecology and Obstetrics, Kyoto University
| | | | - Ikuo Konishi
- Department of Gynecology and Obstetrics, Kyoto University
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Kim TH, Lee HH, Kwak JJ. Conservative management of abnormally invasive placenta: choriocarcinoma with uterine arteriovenous fistula from remnant invasive placenta. Acta Obstet Gynecol Scand 2013; 92:989-90. [DOI: 10.1111/aogs.12171] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 05/10/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Tae-Hee Kim
- Department of Obstetrics and Gynecology; Soonchunhyang University College of Medicine; Bucheon; Korea
| | - Hae-Hyeog Lee
- Department of Obstetrics and Gynecology; Soonchunhyang University College of Medicine; Bucheon; Korea
| | - Jeong Ja Kwak
- Department of Pathology; Soonchunhyang University College of Medicine; Bucheon; Korea
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