Diagnostic accuracy of magnetic resonance imaging to predict peripartum hysterectomy and neonatal mortality in total placenta previa: A retrospective cohort study

OBJECTIVES

To assess the reliability of placental magnetic resonance imaging measurements in predicting peripartum hysterectomy and neonatal outcomes in patients with total placenta previa.

STUDY DESIGN

This retrospective cohort study, conducted at a single tertiary center, identified 372 pregnant women diagnosed with placenta previa. 277 singleton pregnancies that met the inclusion criteria and were diagnosed with total placenta previa in the third trimester were divided into two groups according to whether a placental MRI was performed. Two radiologists analyzed the MRI findings of 150 pregnant women with total placenta previa. Measurements were conducted for the placental volume of the upper and lower uterine sectors, cervical canal length, and cervical canal dilatation. A comparison was made between the surgical progression of these pregnant women and 127 pregnant women with total placenta previa who did not undergo an MRI. After pathological examination, 122 (63.2%) of 193 pregnant women diagnosed with placenta accreta spectrum underwent peripartum total abdominal hysterectomy. The results were compared using logistic regression analysis.

RESULTS

Reduced placental volume in the upper uterine segment and increased volume in the lower uterine segment significantly correlated with a higher probability of peripartum hysterectomy (cut-off: ≤343.4 and ≥ 403.4 cm3; OR: 0.993, 95 % CI: 0.990-0.995 and OR: 1.007, 95 % CI: 1.005-1.009, respectively). Shortened cervical canal length and increased dilatation raise the risk of peripartum hysterectomy (cut-off: ≤34, ≥11 mm; OR: 0.82, 95 % CI: 0.77 - 0.88 and OR: 1.7, 95 % CI: 1.4 - 2.1, respectively). The risk of neonatal death is 32 times higher in those < 34 weeks than in those 34 weeks or higher (95 % CI: 4.2-250, p = 0.001).

CONCLUSIONS

Placental MRI significantly contributes to predicting peripartum total abdominal hysterectomy and neonatal mortality in patients with total placenta previa associated with placenta accreta spectrum.

Desenlaces maternos según el tipo de placenta previa en un hospital de alta complejidad en Cali, Colombia. Estudio de cohorte retrospectivo

Objetivos: describir la frecuencia de complicaciones maternas en mujeres gestantes con placenta previa (PP) mayor o menor y evaluar una posible de asociación entre tipo de PP y la presencia de hemorragia materna severa y otros resultados maternos asociados. Materiales y métodos: cohorte retrospectiva, descriptiva. Se incluyeron gestantes con 20 semanas o más de embarazo, con diagnóstico confirmado de placenta previa, quienes fueron atendidas en un hospital de alto nivel de complejidad localizado en Cali (Colombia), entre enero de 2011 y diciembre de 2020. Se excluyeron las gestantes con diagnóstico de placenta previa y acretismo placentario concomitante. Las variables recolectadas fueron: edad materna, índice de masa corporal, tabaquismo, obesidad, paridad, presencia de sangrado, hemorragia posparto, manejo de la hemorragia posparto, transfusión y admisión a UCI de la gestante. Se realizó análisis descriptivo. El protocolo fue aprobado por el comité de ética de la Fundación Valle de Lili. Resultados: 146 pacientes cumplieron con los criterios de inclusión. La población estuvo constituida por mujeres con una mediana de edad de 32 años, sin antecedente quirúrgico, con diagnóstico prenatal de placenta previa a la semana 22. En el 70,5 % de los casos se trató de pacientes con placenta previa mayor. Las complicaciones más frecuentes fueron hemorragia posparto (37,9 % vs. 16,3 % para pacientes con placenta previa mayor y menor, respectivamente), requerimiento de transfusión (23,3 y 9,3 %, respectivamente) y el ingreso materno a la UCI (40,8 % vs. 18,6 %, respectivamente). No se registraron muertes maternas. Conclusiones: las mujeres con placenta previa experimentan una frecuencia elevada de complicaciones; probablemente, dicha frecuencia es más alta cuando se documenta placenta previa mayor. Se requieren más estudios que comparen la frecuencia de complicaciones maternas según el tipo de placenta previa.

Hemostatic effect of combined procedures for placenta previa: cervix-holding, intrauterine balloon, and uterine compression suture

OBJECTIVES

Various procedures have been introduced to achieve hemostasis for postpartum hemorrhage (PPH) in placenta previa (PP). This study attempted to clarify the effectiveness of the combined use of three hemostatic procedures: Matsubara-Takahashi cervix-holding (MT-holding), intrauterine balloon (IUB), and uterine compression suture (UCS).

STUDY DESIGN

This was a historical cohort study on the hemostatic effect of combined procedures for patients with placenta previa (PP) undergoing cesarean section between April 2006 and December 2018. Until 2011 (2006-2011), we used MT-holding alone, whereas since 2012 we have also been using IUB and UCS: MT-holding alone was used in the former period whereas three procedures (MT-holding, IUB, UCS, and their combinations) have been used in the latter period. Perinatal outcomes were compared between 2006-2011 (before group) and 2012-2018 (after group).

RESULTS

Of 416 patients with PP, excluding 273 patients with cesarean hysterectomy or no hemostatic procedure, the remaining 143 patients were analyzed. In the after group, intraoperative blood loss, the percentage of patients with postoperative blood loss ≥ 500 ml, and incidence of autologous blood transfusion were significantly lower than in the before group. Multivariate analysis showed that postoperative blood loss ≥ 500 ml decreased in the after group (adjusted OR: 0.3, 95%CI: 0.1-0.8, compared with the before group).

CONCLUSION

PPH decreased after introducing the combination of hemostatic procedures in patients with PP. Further studies are needed to determine the best combination and optimal indication for combining hemostatic procedures for PP.

Effect of types of placenta previa on maternal and neonatal outcomes: a 10-year retrospective cohort study

PURPOSE

Through this study, we aimed to evaluate the effects of different types of placenta previa (PP) on maternal and neonatal outcomes.

METHODS

This study was conducted in The Third Affiliated Hospital of Guangzhou Medical University and Tongji Hospital between January 2009 and 2019. PP was traditionally classified into four types, namely low-lying placenta, marginal, partial, and complete PP. Previous studies have classified PP into two types, namely low-lying placenta and PP. Based on our clinical experience, we proposed the classification of PP into three types, for the first time, which included low-lying placenta, "marpartial" (marginal and partial) PP, and complete PP. Multivariate logistic regression analysis was performed to determine the effects of different types of PP on maternal and neonatal outcomes.

RESULTS

In total, 4490 singleton pregnancies were complicated with PP. In the four-classification method, compared with women with low-lying placenta, women with complete PP had a risk of placenta accrete spectrum disorders, postpartum hemorrhage (PPH), hemorrhagic shock, severe PPH, blood transfusion, hysterectomy, puerperal infection, preterm labor, NICU admission, and low birth weight. There was no difference in maternal and neonatal outcomes between marginal and partial PP, except for increased chances of preterm labor and low birth weight in partial PP. In the two-classification method, PP was the risk factor for most of the adverse maternal and neonatal outcomes, compared with low-lying placenta.

CONCLUSION

Complete PP and low-lying placenta were associated with the highest and lowest risks of adverse pregnancy outcomes, respectively, whereas clinically similar outcomes were observed between marginal and partial PP. The three-classification of PP may be practical from the clinical perspective.

Effect of the delivery way and number of parity in the subsequent incidence of placenta previa

Aim: To appraise the impact of previous birth type and the number of deliveries on placenta previa incidence and the extent of intrapartum massive hemorrhage.Materials: Placenta previa complications among healthy singleton subsequent pregnancies following previous pregnancies without placenta previa history were classified according to their birth types and previous numbers of parity. Subgroups of subsequent pregnancies with massive hemorrhage and placental adhesion anomalies were compared.Result: One, two, three or more previous cesarean births triggered a significant increase in the rate of massive hemorrhage when compared to subgroups of previous vaginal births (31.5% versus 50.9%, p = .02; 32.7% versus 69.0%, p = .001; and 42.9% versus 81.9%, p = .035, respectively). The rate of placental adhesion anomalies in all subgroups of previous cesarean births were statistically higher than subgroups of previous vaginal births (12.4 versus 32.7%, p = .003; 10.2% versus 52.2%, p = .001; and 9.5% versus 63.6%, p = .001, respectively). Urogenital complications in women with one previous cesarean birth were higher than those of the vaginal birth group (9.1 versus 0%, p = .004).Conclusion: Previous cesarean births are more frequently associated with increased massive hemorrhage and placental adhesion anomalies in subsequent pregnancies with placenta previa when compared to previous vaginal births.

Laterally-positioned placenta in placenta previa

Objectives: To clarify perinatal outcomes of patients with placenta previa (PP) with the placenta mainly positioned in the lateral uterine wall (lateral PP), thereby clinically characterizing this condition.Study design: The retrospective cohort study was performed involving patients with lateral PP between January 2006 and December 2016. The placental position was determined and classified by magnetic resonance imaging.Results: This study included 98 patients with PP, which was classified into three types according to the main placental position sites: lateral (n = 30), anterior (n = 32), and posterior (n = 36) PP. Overall, the median blood loss at cesarean section (CS) was 1808 mL and transfusion was performed for 78 patients (80%). Univariate analysis showed that patients with lateral PP bled less at CS than those with non-lateral PP (anterior + posterior PP) [median 1510 (interquartile range 1080-2168) versus 1975 (1570-2860) mL: p=.02]. The other parameters including rates of conception by assisted reproductive technology, prior CS, antepartum bleeding, and placenta accreta spectrum did not show the significances. Among the three groups of PP (lateral versus anterior versus posterior), patients with lateral PP bled less than those with anterior (p=.05) or posterior (p=.13) PP, but this was nonsignificant [lateral 1510 (1080-2168) versus anterior 2145 (1580-3348) versus posterior 1808 (1533-2555) mL]. When dividing into lateral PP to two types: placenta showing anterior dominancy versus posterior dominancy, patients with lateral PP and anterior dominancy bled more those with posterior dominancy [2430 (1410-3400) versus 1170 (1050-1588) mL: p=.002].Conclusion: Patients with lateral PP bled significantly less than those with non-lateral (anterior or posterior) PP. Patients with lateral PP and anterior dominancy bled more than those with posterior dominancy.