Perioperative and transfusion outcomes in women undergoing cesarean hysterectomy for abnormal placentation

Clinical Characteristics, Prenatal Diagnosis and Outcomes of Placenta Accreta Spectrum in Different Placental Locations: A Retrospective Cohort Study

Objective

To explore the prenatal diagnosis, clinical characteristics, and perinatal outcomes of placenta accreta spectrum in different placental locations.

Methods

This was a retrospective cohort study. Pregnant women who delivered at two tertiary referral hospitals from January 2013 to December 2022 and were ultimately pathologically diagnosed with placenta accreta spectrum were included. They were divided into three groups based on different placental locations (anterior, posterior, and lateral wall/fundus). The differences in prenatal diagnosis, clinical characteristics, and perinatal outcomes among the three groups were compared.

Results

There were 115,470 deliveries in a ten-year period at the two hospitals, and 118 case patients were confirmed to have a pathologically diagnosed placenta accreta spectrum. The posterior placenta group had a lower rate of placenta previa (76.9% vs 94.9% vs 100%, p<0.05) and a higher gestational age at delivery (36.4±2.45 vs 34.91±1.76 vs 34.31±3.41, p<0.05) compared to the other two groups. The anterior placenta group had a significantly higher rate of invasive (increta/percreta) form placenta accreta spectrum (81.4% vs 36.5% vs 28.6%, p<0.05) and planned cesarean section (96.6% vs 80.8% vs 71.4%, p<0.05) compared to the other two groups. In terms of prenatal diagnosis, the anterior placenta group had a significantly higher rate of placenta accreta spectrum prenatal suspicion rate compared to the other two groups (86.4% vs 36.5% vs 57.1%, p<0.05). The posterior placenta group had a lower rate of preoperative abdominal aortic balloon placement compared to the other two groups (5.8% vs 28.8% vs 28.6%, p<0.05). There were no statistically significant differences among the three groups in primary perinatal outcomes, though the anterior placenta group had a longer postoperative hospital stay.

Conclusion

The prenatal diagnosis rate and proportion of invasive form of placenta accreta spectrum occurring in non-anterior placenta are relatively lower than anterior placenta. There were no significant differences in major perinatal outcomes among the three groups.

Incidence, risk factors and maternal outcomes of unsuspected placenta accreta spectrum disorders: a retrospective cohort study

BACKGROUND

To identify incidence and underlying risk factors for unsuspected placenta accreta spectrum (PAS) and compare the maternal outcomes between suspected and unsuspected cases in three large academic referral centers.

METHODS

A retrospective cohort study was conducted in three university-based tertiary referral centers from Jan 1st, 2013, to Dec 31st, 2022. All cases of PAS confirmed by pathology were included in the study. Unsuspected PAS cases were diagnosed at the time of delivery, while suspected cases served as the control group. Potential risk factors were compared between the two groups. Multivariable regression model was also performed to identify risk factors. Maternal outcomes were also evaluated.

RESULTS

A total of 339 pathology-confirmed PAS cases were included in the study out of 415,470 deliveries, of which 35.4% (n = 120) were unsuspected cases. Unsuspected PAS cases were 7.9 times more likely to have a history of intrauterine adhesions (adjusted odds ratio [aOR] 7.93; 95% confidence interval [CI] 2.35-26.81), 7.0 times more likely to have a history of clinically confirmed PAS (aOR, 6.99; 95% CI 2.85-17.18), 6.3 times more likely to have a posterior placenta (aOR, 6.30; 95% CI 3.48-11.40), and 3.4 times more likely to have a history of placenta previa (aOR, 3.41; 95% CI 1.18-9.82). On the other hand, cases with gravidity > 3, placenta previa, and/or a history of previous cesarean delivery were more likely to be diagnosed antenatally (aOR 0.40, 0.19, 0.36; 95% CI 0.22-0.74, 0.09-0.40, 0.19-0.70). Although the suspected PAS group had a higher proportion of invasive cases and abdominal and pelvic organ injuries (74.4% vs. 25.8%, p < 0.001; 6.8% vs. 1.7%, p = 0.037), the maternal outcomes were more favorable in the sPAS group, with a lower median volume of 24-hour blood loss and blood product transfusion (estimated blood loss in 24 h, 1000 [800-2000] vs. 2000 [1400-2400], p < 0.001; RBC unit transfusion, 0 [0-800] vs. 800 [600-1000], p < 0.001; fresh-frozen plasma transfusion, 0 [0-450] vs. 600 [400-800], p < 0.001).

CONCLUSIONS

Our findings indicate that 35% of patients with PAS were unsuspected prior to delivery. Factors associated with PAS being unsuspected prior to delivery include a history of intrauterine adhesions, a history of clinically confirmed PAS, a posterior placenta, and a history of placenta previa. Additionally, gravidity > 3, a history of previous cesarean delivery, and placenta previa increase the likelihood of antenatal diagnosis.

Urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders: systematic review and meta-analysis

OBJECTIVE

To report on the occurrence of urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders (PAS).

METHODS

MEDLINE, EMBASE and the Cochrane databases were searched electronically up to 1 November 2022. Studies reporting on the urological outcome of women undergoing Cesarean section for PAS were included. Two independent reviewers performed data extraction using a predefined protocol and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies, with disagreements resolved by consensus.The primary outcome was the overall occurrence of urological complications. Secondary outcomes were the occurrence of any cystotomy, intentional cystotomy, unintentional cystotomy, ureteral damage, ureteral fistula and vesicovaginal fistula. All outcomes were explored in the overall population of women undergoing surgery for PAS. In addition, we performed subgroup analyses according to the type of surgery (Cesarean hysterectomy, or conservative surgery or management), severity of PAS at histopathology (placenta accreta/increta and placenta percreta), type of intervention (planned vs emergency) and number of cases per year. Random-effects meta-analyses of proportions were used to analyze the data.

RESULTS

There were 62 studies included in the systematic review and 56 were included in the meta-analysis. Urological complications occurred in 15.2% (95% CI, 12.9-17.7%) of cases. Cystotomy complicated 13.5% (95% CI, 9.7-17.9%) of surgical operations. Intentional cystotomy was required in 7.7% (95% CI, 6.5-9.1%) of cases, while unintentional cystotomy occurred in 7.2% (95% CI, 6.0-8.5%) of cases. Urological complications occurred in 19.4% (95% CI, 16.3-22.7%) of cases undergoing hysterectomy and 12.2% (95% CI, 7.5-17.8%) of those undergoing conservative treatment. In the subgroup analyses, urological complications occurred in 9.4% (95% CI, 5.4-14.4%) of women with placenta accreta/increta and 38.5% (95% CI, 21.6-57.0%) of those described as having placenta percreta, and included mainly cystotomy (5.5% (95% CI, 0.6-15.1%) and 22.0% (95% CI, 5.4-45.5%), respectively). Urological complications occurred in 15.4% (95% CI, 8.1-24.6%) of cases undergoing a planned procedure and 24.6% (95% CI, 13.0-38.5%) of those undergoing an emergency intervention. In subanalysis of studies reporting on ≥ 12 cases per year, the incidence of urological complication was similar to that reported in the primary analysis.

CONCLUSIONS

Women undergoing surgery for PAS are at high risk of urological complication, mainly cystotomy. The incidence of these complications was particularly high in women described as having placenta percreta at birth and in those undergoing emergency surgical intervention. The high heterogeneity between the included studies highlights the need for a standardized protocol for the diagnosis of PAS to identify prenatal imaging signs associated with the increased risk of urological morbidity at delivery. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Improving blood product management in placenta accreta patients with severe bleeding: institutional experience

BACKGROUND

Placenta accrete spectrum (PAS) is a significant risk factor for postpartum hemorrhage and effective blood product management is critical in ensuring patient safety. In PAS patients undergoing cesarean section (CS) blood transfusion management guided by the combined clinical experience of the anesthesiologist and surgeon with point-of-care coagulation testing appears safe and effective. We describe and evaluate our experience and identify potential areas for improvement with blood product management in this patient population.

METHODS

A retrospective chart review of peri-operative demographic, anesthetic, and obstetric data was conducted for all patients with PAS undergoing CS between 2012 and 2018 at our center. To facilitate a practical evaluation of blood product management, we divided patients into two groups based on the severity of bleeding.

RESULTS

A total of 221 parturients with PAS underwent CS, with 133 in group 1 requiring excessive amounts of transfusion and 88 in group 2 requiring management similar to other uncomplicated CS cases. There were no deaths or instances of disseminated intravascular coagulation, and intensive care unit admission occurred in five cases (2.2%). Patients in group 1 had higher mean nadir values of intra-operative hemoglobin and platelet count. We observed a high rate of missing data for peri-operative measurement of lactate and fibrinogen, PAS grade documentation, and temperature monitoring.

CONCLUSION

Given no significant morbidity or mortality, clinical judgment in experienced centers appears safe for the management of PAS patients undergoing CS. The adoption of an institutional protocol and point-of-care coagulation testing could decrease over-transfusion and associated complications.

Knowledge Gaps in Placenta Accreta Spectrum

Since its first description early in the 20th Century, placenta accreta and its variants have changed substantially in incidence, risk factor profile, clinical presentation, diagnosis and management. While systematic use of diagnostic tools and a multidisciplinary team care approach has begun to improve patient outcomes, the condition's pathophysiology, epidemiology, and best practices for diagnosis and management remain poorly understood. The use of large databases with broadly accepted terminology and diagnostic criteria should accelerate research in this area. Future work should focus on non-traditional phenotypes, such as those without placenta previa-preventive strategies, and long term medical and emotional support for patients facing this diagnosis. KEY POINTS: · Placenta accreta spectrum research may be improved with standardized terminology and use of large databases.. · Placenta accreta prediction should move beyond ultrasound with the addition of biomarkers, and needs to extend to those without traditional risk factors.. · Future research should identify practices that can prevent future accreta development..

Red Blood Cell Transfusion in Patients With Placenta Accreta Spectrum: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate red blood cell use during delivery in patients with placenta accreta spectrum.

DATA SOURCES

We searched MEDLINE, EMBASE, CINAHL, Cochrane Central, ClinicalTrials.gov, and Scopus for clinical trials and observational studies published between 2000 and 2021 in countries with developed economies.

METHODS OF STUDY SELECTION

Abstracts (n=4,275) and full-text studies (n=599) were identified and reviewed by two independent reviewers. Data on transfused red blood cells were included from studies reporting means and SDs, medians with interquartile ranges, or individual patient data. The primary outcome was the weighted mean number of units of red blood cells transfused per patient. Between-study heterogeneity was assessed with an I2 statistic. Secondary analyses included red blood cell usage by placenta accreta subtype.

TABULATION, INTEGRATION, AND RESULTS

Of the 599 full-text studies identified, 20 met criteria for inclusion in the systematic review, comprising 1,091 cases of placenta accreta spectrum. The number of units of red blood cells transfused was inconsistently described across studies, with five studies (25.0%) reporting means, 11 (55.0%) reporting medians, and four (20.0%) reporting individual patient data. The weighted mean number of units transfused was 5.19 (95% CI 4.12-6.26) per patient. Heterogeneity was high across studies (I2=91%). In a sensitivity analysis of five studies reporting mean data, the mean number of units transfused was 6.61 (95% CI 4.73-8.48; n=220 patients). Further quantification of units transfused by placenta accreta subtype was limited due to methodologic inconsistencies between studies and small cohort sizes.

CONCLUSION

Based on the upper limit of the CI in our main analysis and the high study heterogeneity, we recommend that a minimum of 6 units of red blood cells be available before delivery for patients with placenta accreta spectrum. These findings may inform future guidelines for predelivery blood ordering and transfusion support.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021240993.

Reloadable Stapler Use during Peripartum Hysterectomy for Placenta Accreta Spectrum: A Novel Surgical Technique and Case Series

OBJECTIVE

This study aimed to describe a novel surgical technique for the management of antenatally suspected placenta accreta spectrum (PAS).

STUDY DESIGN

This is a retrospective, case series of patients with suspected PAS undergoing peripartum hysterectomy with a reloadable articulating stapler at a tertiary care center.

RESULTS

Eighteen patients with antenatally suspected PAS were identified and underwent peripartum hysterectomy with the aid of a reloadable stapler. Mean gestational age at delivery was 34^4/7 ± 1^1/7 weeks. Mean total operative time (skin-to-skin) was 117.3 ± 39.3 minutes, and 79.8 ± 19.8 minutes for the hysterectomy. Mean blood loss for the entire case was 1,809 ± 868 mL. Mean blood loss for the hysterectomy was 431 ± 421 mL. Mean units of intraoperative red blood cells transfused was 3 ± 1 units. Mean units of postoperative red blood cells transfused was 1 ± 0.5 units. Five cases were complicated by urological injury (two intentional cystotomies). Four patients were admitted to the intensive care unit (ICU) for a mean of ≤24 hours. Mean postoperative LOS was 4.11 ± 1.45 days. Three patients had final pathology that did not demonstrate PAS while four were consistent with accreta, six increta, and five percreta.

CONCLUSION

Use of a reloadable articulating stapler device as part of the surgical management of antenatally suspected PAS results in a shorter operative time (117 ± 39 minutes vs. 140-254 minutes previously reported), lower average blood loss (1,809 ± 868 mL vs. 2,500-5,000 mL previously reported) and shorter LOS (4.11 ± 1.45 days vs. 9.8 ± 13.5 days previously reported) compared with traditional cesarean hysterectomy. The reloadable stapling device offers an advantage of more rapidly achieving hemostasis in the surgical management of PAS.

KEY POINTS

· PAS is associated with severe maternal morbidity.. · Decreased operative time and blood loss have many clinical benefits.. · Reloadable stapler use for PAS decreases operative time.. · Reloadable stapler use for PAS decreases operative blood loss..

Pregnancy-Related Hysterectomy for Peripartum Hemorrhage: A Literature Narrative Review of the Diagnosis, Management, and Techniques

Postpartum hemorrhage is a life-threatening situation, in which hysterectomy can be performed to prevent maternal death. However, it is associated with high rates of maternal morbidity and mortality and permanent infertility. The incidence of pregnancy-related hysterectomy varies across countries, but its main indications are the following: uterine atony and placenta spectrum (PAS) disorders. PAS disorder prevalence is rising during the last years, mainly due to the increased number of cesarean sections. As a result, obstetricians should be aware of the difficulties of this emergent condition and improve its accurate antenatal diagnosis rates, as well as its modern management strategies. Of course, special skills are required during a pregnancy-related hysterectomy, so these patients should be referred to centers of excellence in antenatal care, where a multidisciplinary team approach is followed. This study is a narrative review of the literature of the last 5 years (PubMed, Cochrane) regarding postpartum hemorrhage to offer obstetricians up-to-date knowledge on this pregnancy-related life-threatening issue. However, there is a lack of available high-quality data, because most published papers are retrospective case series or observational cohorts.

Diagnostic Utility of MRI Features of Placental Adhesion Disorder for Abnormal Placentation and Massive Postpartum Hemorrhage

OBJECTIVE. The study's aim was to assess MRI, in cases in which MRI was deemed clinically necessary, to determine its diagnostic accuracy for placental adhesion disorder (PAD) and prognostic accuracy for massive postpartum hemorrhage (PPH). Additionally, we investigated the diagnostic utility of MRI in the antenatal workup of PAD as an adjunct to clinical assessment and ultrasound. MATERIALS AND METHODS. We retrospectively identified patients who underwent antenatal MRI for suspicion of PAD. Images were reviewed by two radiologists who were blinded to surgical and pathologic outcomes. Diagnostic utility of various clinical, ultrasound, and MRI features of PAD were estimated by ROC analysis. Logistic regression analysis was performed to assess various diagnostic models for PAD and prognostic models for massive PPH, with model selection based on Bayesian information criterion. RESULTS. Fifty-six patients met the inclusion criteria. Sensitivity and specificity of MRI in the diagnosis of PAD were 93% and 81%, respectively. The most accurate MRI features for PAD were myometrial thinning (AUC = 0.881), heterogeneous placenta (AUC = 0.864), and placental bulge (AUC = 0.845). The most accurate MRI features for massive PPH were heterogeneous placenta (AUC = 0.872) and dark intraplacental bands (AUC = 0.736). The addition of MRI to a model based on clinical and ultrasound features was preferred for both diagnosis of PAD and prognosis of massive PPH. CONCLUSION. This study shows the utility of certain MRI features for identification of PAD and massive PPH. Furthermore, our data show a substantial incremental benefit of the addition of MRI in the antenatal workup for PAD compared with clinical assessment and ultrasound alone.

Development and validation of nomograms for predicting blood loss in placenta previa with placenta increta or percreta

Background

To develop the risk prediction model of intraoperative massive blood loss in placenta previa with placenta increta or percreta.

Methods

This study included 260 patients, of whom 179 were allocated to the development group and 81 to the validation group. Univariate and multivariate logistic regression analyses were used to identify characteristics that were associated with massive blood loss (≥2,500 mL) during cesarean section. A nomogram was constructed based on regression coefficients. Receiver-operating characteristic curve, calibration curve, and decision curve analyses were applied to assess the discrimination, calibration, and performance of the model.

Results

Two models were constructed. The preoperative feature model (model A) consisted of vascular lacunae within the placenta and hypervascularity of the uterine-placental margin, uterine serosa-bladder wall interface, and cervix. The preoperative and surgical feature model (model B) consisted of an emergency cesarean section, no preoperative balloon placement of the abdominal aorta, and the previously mentioned four ultrasound signs. Model B had better discrimination than model A (area under the curve: development group: 0.839 vs. 0.732; validation group: 0.829 vs. 0.736). Model B showed a higher area under the decision curve than model A in both the training and validation groups.

Conclusions

The preoperative and surgical feature model for placenta previa with placenta increta or percreta can improve the early identification and management of patients who are at high risk of intraoperative massive blood loss.

Placenta Accreta Spectrum Without Placenta Previa

OBJECTIVE

To evaluate placenta accreta spectrum with and without placenta previa with regard to risk factors, antepartum diagnosis, and maternal morbidity.

METHODS

We conducted a retrospective cohort study of pathology-confirmed placenta accreta spectrum deliveries with hysterectomy from two U.S. referral centers from January 2010-June 2019. Maternal, pregnancy, and delivery characteristics were compared among placenta accreta spectrum cases with (previa PAS group) and without (nonprevia PAS group) placenta previa. Surgical outcomes and a composite of severe maternal morbidities were evaluated, including eight or more blood cell units transfused, reoperation, pulmonary edema, acute kidney injury, thromboembolism, or death. Logistic regression was used with all analyses controlled for delivery location.

RESULTS

Of 351 deliveries, 106 (30%) had no placenta previa at delivery. When compared with the previa group, nonprevia placenta accreta spectrum was less likely to be identified antepartum (38%, 95% CI 28-48% vs 87%, 82-91%), less likely to receive care from a multidisciplinary team (41%, 31-51% vs 86%, 81-90%), and less likely to have invasive placenta increta or percreta (51% 41-61% vs 80%, 74-84%). The nonprevia group had more operative hysteroscopy (24%, 16-33% vs 6%, 3-9%) or in vitro fertilization (31%, 22-41% vs 9%, 6-13%) and was less likely to have had a prior cesarean delivery (64%, 54-73% vs 93%, 89-96%) compared with the previa group, though the majority in each group had a prior cesarean delivery. Rates of severe maternal morbidity were similar in the two groups, at 19% (nonprevia) and 20% (previa), even after controlling for confounders (adjusted odds ratio for the nonprevia group 0.59, 95% CI 0.30-1.17).

CONCLUSION

Placenta accreta spectrum without previa is less likely to be diagnosed antepartum, potentially missing the opportunity for multidisciplinary team management. Despite the absence of placenta previa and less placental invasion, severe maternal morbidity at delivery was not lower. Broader recognition of patients at risk for placenta accreta spectrum may improve early clinical diagnosis and patient outcomes.

How do I manage severe postpartum hemorrhage?

In the United States, postpartum hemorrhage (PPH) accounts for 4.6% of all maternal deaths and is responsible for major peripartum medical and surgical morbidity. Therefore, a national health priority is to ensure that women who experience severe PPH receive timely, appropriate, and effective treatment. In this article, we describe our system-wide approach for the planning and delivery of women with suspected placenta accreta spectrum disorder, a condition associated with life-threatening blood loss at the time of delivery. We also highlight current evidence related to transfusion decision making and hemostatic monitoring during active postpartum bleeding. Specifically, we describe how we activate and use the massive transfusion protocol to obtain sufficient volumes and types of blood products. We also describe how we use viscoelastic monitoring (thromboelastography) and standard laboratory tests to assess the maternal coagulation profile. Finally, we review the findings of recent studies examining the potential efficacy of tranexamic acid and fibrinogen concentrate as adjuncts for PPH prevention and treatment. We describe how we have incorporated these drugs into PPH treatment protocols at our institution.

A systematic multidisciplinary initiative may reduce the need for blood products in patients with abnormally invasive placenta

Introduction: The main complication of the abnormally invasive placenta is massive bleeding, with transfusions required frequently. We aim to evaluate the impact of interdisciplinary management on transfusion practices in women with abnormally invasive placenta.Methodology: Clinical outcomes of women with abnormally invasive placenta treated between 2011 and 2019 were reviewed, including transfusion frequency. Patients divided into three groups: group A (women treated before the introduction of interdisciplinary management), group B (women attended to by a fixed interdisciplinary group), and group C (women with no accreta prenatal diagnosis).Results: Patients with prenatal diagnosis and attended by a fixed interdisciplinary group (group B) required fewer units of red blood cells to be prepared and transfused (median number of units, 0 versus 2 in group A and 3 in group C).Conclusion: The participation of an interdisciplinary group, with strict standards for transfusion, reduces the frequency of use of blood substitutes during the care of women with abnormally invasive placenta.

New evidence-based diagnostic and management strategies for placenta accreta spectrum disorders

The increasing incidence of caesarean delivery (CD) has resulted in an increase in placenta accreta spectrum (PAS), adversely impacting maternal outcomes globally. Currently, more than 90% of women diagnosed with PAS present with a placenta praevia (praevia PAS). Praevia PAS can be reliably diagnosed antenatally with ultrasound, and it is unclear whether magnetic resonance imaging improves diagnosis beyond what can be achieved by skilled ultrasound operators. Therefore, any screening programme for PAS will require improved training in the diagnosis of placental disorders and development of targeted scanning protocols. Management strategies for praevia PAS vary depending on the accuracy of prenatal diagnosis, findings at laparotomy and local surgical expertise. Current epidemiological data for PAS are highly heterogeneous, mainly due to wide variation in the clinical criteria used to diagnose the condition at birth. This significantly impacts research into all aspects of the condition, especially comparison of the efficacy of different management strategies.

The effect of placental location in cases of placenta accreta spectrum

BACKGROUND

Placenta accreta spectrum affects approximately 3 in 1000 pregnancies. There is a paucity of data evaluating the effect of placental location on diagnosis, risk factors, and resultant outcomes in cases of placenta accreta spectrum.

OBJECTIVE

We analyzed placenta accreta spectrum cases to assess whether risk factors or maternal outcomes varied based on placental location.

MATERIALS AND METHODS

We performed a retrospective chart review of pathology-confirmed cases of placenta accreta spectrum from patients delivering at 2 large urban hospitals in the same healthcare system from 2007 to 2017. Placental location was defined by ultrasound images and confirmed by pathology reports. Location was categorized as anterior, posterior, or anterior/posterior for those with placental location at both sites. Fisher exact tests and analysis of variance were used to examine associations with measures of diagnosis, risk factors, and maternal outcomes.

RESULTS

A total of 86 pathology-confirmed placenta accreta spectrum cases were reviewed. The distribution of placental location on ultrasound was as follows: 19% posterior, 59% anterior, and 22% anterior/posterior. We found that prior cesarean delivery was lower with posterior placenta accreta spectrum (63% vs 94% vs 84% in the anterior and anterior/posterior groups respectively; (P = .007); however, in vitro fertilization rates were significantly higher (38% vs 2% vs 5% in the anterior and anterior/posterior groups respectively; P = .001). There was also lower incidence of percreta with posterior placenta accreta spectrum compared to the anterior and anterior/posterior groups (19% vs 47% vs 58% respectively; P = .055). Posterior cases were less likely to have placenta accreta spectrum suspected prenatally (50%) compared to anterior (80%) and anterior/posterior (89%) cases (P = .019). Despite late diagnosis, ureteral injury was the only surgical complication that was more common in patients with posterior placenta accreta spectrum (13% vs 0% vs 5% for anterior and anterior/posterior groups respectively; P = .037).

CONCLUSION

Placenta accreta spectrum with posterior placental location is associated with delayed diagnosis, surgical complications, assisted reproductive technology, and lower numbers of prior cesarean deliveries relative to anterior location. These differences in outcomes and risk factors based on placental location may allow for heightened clinical awareness, and improved diagnosis and management.

A comparison of antenatally and intraoperatively diagnosed cases of placenta accreta spectrum

Objective

To assess the effect of antenatal diagnosis of placenta accreta spectrum (PAS) on fetomaternal outcomes.

Material and Methods

This was a retrospective cohort study conducted from January 2017 to December 2018. Women with PAS diagnosed antenatally were designated as group A and those where diagnosis was suspected during operation and confirmed on histopathology (PAS diagnosed perioperatively) were designated as group B. Outcome in terms of uterine conservation, maternal death, admission of mother to intensive care unit (ICU), perinatal death and neonatal ICU (NICU) admission were recorded.

Results

During the study, PAS was confirmed in 96 cases which were included. Out of these, 34 (35.4%) cases were included in group A while 62 (64.6%) were diagnosed intraoperatively (group B). The median number of units of blood transfused was lower in group A compared to group B (4 vs 6, p<0.001). The uterus was conserved more often in group A compared with group B (67.6% vs 43.5%, p=0.024) while admission to ICU occurred significantly more often in group B (26.5% vs 59.7%, p=0.002). Maternal death (p=0.038) and perinatal death (p=0.008) were also significantly higher in group B. More neonates delivered to mothers in group B were admitted to NICU (85.7% vs 24%, p=0.033). Survival analysis showed a statistically significant increase in uterine conservation rate in group A compared with group B (log rank, p=0.04).

Conclusion

PAS diagnosed antenatally has better fetomaternal outcome than intraoperative detection of PAS. Diagnosing PAS antenatally is therefore crucial to improve management and achieve a better outcome.

Placenta accreta spectrum: value of placental bulge as a sign of myometrial invasion on MR imaging

PURPOSE

To evaluate correlation of "placental bulge sign" with myometrial invasion in placenta accreta spectrum (PAS) disorders. Placental bulge is defined as deviation of external uterine contour from expected plane caused by abnormal outward bulge of placental tissue.

MATERIALS AND METHODS

In this IRB-approved, retrospective study, all patients undergoing MRI for PAS disorders between March 2014 and 2018 were included. Patients who delivered elsewhere were excluded. Imaging was reviewed by 2 independent readers. Surgical pathology from Cesarean hysterectomy or pathology of the delivered placenta was used as reference standard. Fisher's exact and kappa tests were used for statistical analysis.

RESULTS

Sixty-one patients underwent MRI for PAS disorders. Two excluded patients delivered elsewhere. Placental bulge was present in 32 of 34 cases with myometrial invasion [True positive 32/34 = 94% (95% CI 0.80-0.99)]. Placental bulge was absent in 24 of 25 cases of normal placenta or placenta accreta without myometrial invasion [True negative = 24/25, 96% (95% CI 80-99.8%)]. Positive and negative predictive values were 97% and 96%, respectively. Placental bulge in conjunction with other findings of PAS disorder was 100% indicative of myometrial invasion (p < 0.01). Kappa value of 0.87 signified excellent inter-reader concordance. In 1 false positive, placenta itself was normal but the bulge was present. Surgical pathology revealed markedly thinned, fibrotic myometrium without accreta. One false-negative case was imaged at 16 weeks and may have been imaged too early.

CONCLUSIONS

Placental bulge in conjunction with other findings of invasive placenta is 100% predictive of myometrial invasion. Using the bulge alone without other signs can lead to false-positive results.

Prophylactic use of resuscitative endovascular balloon occlusion of the aorta in women with abnormal placentation: A systematic review, meta-analysis, and case series

BACKGROUND

We describe intraoperative and postdischarge outcomes of a case series after the prophylactic use of resuscitative endovascular balloon occlusion of the aorta (REBOA) during elective cesarean delivery in pregnant women with morbidly adherent placenta (MAP). We furthermore performed a systematic review and meta-analysis to investigate the safety and effectiveness of the use of REBOA during elective cesarean delivery in pregnant women with MAP.

METHODS

Descriptive case series of REBOA (December 2015 to June 2017) used during elective cesarean delivery in pregnant women with MAP. The systematic review was conducted following PRISMA guidelines. We included studies involving pregnant women with a diagnosis of MAP who underwent an elective cesarean delivery with prophylactic REBOA placement. A meta-analysis was performed to assess the overall amount of transfusions and intraoperative hemorrhage of REBOA compared to NO-REBOA cases.

RESULTS

A total of 12 patients with MAP underwent elective cesarean delivery with REBOA deployment. The median (interquartile range) of packed red blood cells transfused during the first 24 hours following surgery was two units (0-3.5). The median (interquartile range) of intraoperative blood loss was 1,500 mL (900-2,750). At 28 days, all patients were alive, and no adverse outcomes were observed. Four articles were included in the systematic review and meta-analysis. These articles included a total of 441 patients. Quantitative synthesis (meta-analysis) found that the use of REBOA as prophylaxis for the prevention of major hemorrhage was associated with a lower amount of intraoperative hemorrhage (in milliliters) (weighted mean difference, -1,384.66; 95% confidence interval, -2,141.74 to -627.58) and lower requirements of blood products transfusions (in units) (weighted mean difference, -2.42; 95% confidence interval, -3.90 to -0.94).

CONCLUSION

We provide clinical data supporting the use of REBOA in the management of pregnant women with MAP undergoing elective cesarean delivery. Our findings demonstrate the feasibility of REBOA as a prophylactic intervention to improve outcomes in women at risk of catastrophic postpartum hemorrhage.

LEVEL OF EVIDENCE

Therapeutic study, level V; Systematic Review, level IV.

Modified cesarean hysterectomy technique for management of cases of placenta increta and percreta at a tertiary referral hospital in Egypt

PURPOSE

To evaluate the effect of a modified type II radical hysterectomy on maternal morbidities and mortality in cases with abnormally invasive placenta (AIP).

METHODS

63 cases with AIP were managed at one of the largest referral centers in Egypt in a prospective study design. This technique entails devascularization of the uterus laterally on both sides and to clamp the uterus at the lowest possible point just below the level of the placenta while sparing the ureters.

RESULTS

The difference between pre- and post-operative hemoglobin was only about 1 gm/dl, and the mean blood loss was 1673 ± 958 ml. There was a significant drop in the post-operative need for blood and blood product replacement, packed red blood cells (p = 0.013), fresh red blood cells (p < 0.001), and plasma units (p = 0.012). Operative time (skin to skin) averaged 190 ± 58.2 min as the technique is slow and utilizes meticulous hemostatic steps. ICU admission was 4.8% with a mean total hospital stay of 8.6 ± 3.6 days. Histopathological examination revealed 58 cases of placenta increta and five percreta cases. We also had 16 bladder injuries (25.4%) and two ureteric injuries, and no maternal mortalities.

CONCLUSION

This technique reduces maternal morbidity and mortality while performing cesarean hysterectomy for cases with AIP.

Resuscitative endovascular balloon occlusion of the aorta deployed by acute care surgeons in patients with morbidly adherent placenta: a feasible solution for two lives in peril

Morbidly adherent placenta (MAP), which includes accreta, increta, and percreta, is a condition characterized by the invasion of the uterine wall by placental tissue. The condition is associated with higher odds of massive post-partum hemorrhage. Several interventions have been developed to improve hemorrhage-related outcomes in these patients; however, there is no evidence to prefer any intervention over another. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular intervention that may be useful and effective to reduce hemorrhage and transfusions in MAP patients. The objective of this narrative review is to summarize the evidence for REBOA in patients with MAP. We posit that acute care surgeons can perform REBOA for patients with MAP.

Retrospective study to investigate fresh frozen plasma and packed cell ratios when administered for women with postpartum hemorrhage, before and after introduction of a massive transfusion protocol

BACKGROUND

Administration of packed red blood cells (PRBC) and fresh frozen plasma (FFP) to women with postpartum hemorrhage (PPH) before and after introduction of a massive transfusion protocol.

METHODS

The retrospective PPH study cohort of two tertiary centers was identified using blood bank records, verified by patient electronic medical records. We identified women transfused with ≥3 units PRBC in a short time period within 24 hours of delivery. Since 2010, both centers have used a protocol using 1:1 FFP:PRBC ratios. Demographic, obstetric, and blood management data were retrieved from medical records. Outcome measures included estimated blood loss, blood product administration, and hematologic variables.

RESULTS

273 women were included, 112 (41.0%) prior to introduction of the protocol (2004-2009) and 161 (59.0%) afterwards (2010-2014). The frequency of women managed with 1:1 FFP:PRBC ratios was similar before 55/112 (49.1%) and after 83/161 (51.6%) introduction of the protocol (P=0.69). There was strong correlation between PRBC units transfused and the FFP:PRBC transfusion ratio (R-square 0.866, P <0.0001), demonstrating that as the number of transfused PRBC units increased, FFP:PRBC ratios became closer to 1:1. There were no outcome differences between women managed before and after introduction of the protocol.

CONCLUSIONS

Among women with PPH receiving ≥3 PRBC units within a short period of time, it appears that factors other than the existence of our massive transfusion protocol influence the number and ratio of PRBC and FFP units transfused. Blood products were not transfused according to exact ratios, even when guided by a protocol.

A clinico-pathologic study of placenta percreta

OBJECTIVE

To review a single-center case series of placenta percreta and to evaluate risk factors and the impact of surgical techniques used in previous cesarean delivery.

METHODS

The present retrospective cohort study included pregnancies with placenta percreta managed between January 1, 2002, and March 31, 2017, at Saint Luc University Hospital, Brussels, Belgium. The data reviewed included demographics, outcomes, inter-pregnancy interval, and surgical techniques used for uterine closure in previous cesarean delivery. A cases series of non-accreta placenta previa was used as a control group.

RESULTS

There were 19 pregnancies included in the study. The most common ultrasonography signs in the study group were loss of the clear zone (14/17; 82%), placental lacunae (17/17; 100%), and subplacental hypervascularity (11/14; 79%). Median gravidity, parity, and number of previous cesarean deliveries were higher (P<0.05) and inter-pregnancy interval was longer (P<0.05) in the study group than the control group. There was no difference between the groups in the surgical techniques used for previous cesarean deliveries.

CONCLUSION

The prenatal ultrasonography diagnosis of placenta percreta is accurate and facilitates optimal management by a specialized multidisciplinary team. Multicenter studies are required to further evaluate the impact of the surgical techniques used for prior cesarean delivery on the risks of placenta percreta in subsequent pregnancies.

Obstetric interventions and maternal morbidity among women who experience severe postpartum hemorrhage during cesarean delivery

BACKGROUND

Compared to vaginal delivery, women undergoing cesarean delivery are at increased risk of postpartum hemorrhage. Management approaches may differ between those undergoing prelabor cesarean delivery compared to intrapartum cesarean delivery. We examined surgical interventions, blood component use, and maternal outcomes among those experiencing severe postpartum hemorrhage within the two distinct cesarean delivery cohorts.

METHODS

We performed secondary analyses of data from two cohorts who underwent prelabor cesarean delivery or intrapartum cesarean delivery at a tertiary obstetric center in the United States between 2002 and 2012. Severe postpartum hemorrhage was classified as an estimated blood loss ≥1500mL or receipt of a red blood cell transfusion up to 48h post-cesarean delivery. We examined blood component use, medical and surgical interventions and maternal outcomes.

RESULTS

The prelabor cohort comprised 269 women and the intrapartum cohort comprised 278 women. In the prelabor cohort, one third of women received red blood cells intraoperatively or postoperatively, respectively. In the intrapartum cohort, 18% women received red blood cells intraoperatively vs. 44% postoperatively (P<0.001). In the prelabor and intrapartum cohorts, methylergonovine was the most common second-line uterotonic (33% and 43%, respectively). Women undergoing prelabor cesarean delivery had the highest rates of morbidity, with 18% requiring hysterectomy and 16% requiring intensive care admission.

CONCLUSION

Our findings provide a snapshot of contemporary transfusion and surgical practices for severe postpartum hemorrhage management during cesarean delivery. To determine optimal transfusion and management practices in this setting, large pragmatic studies are needed.

Blood-Conservation Strategies in a Blood-Refusal Parturient with Placenta Previa and Placenta Percreta

Abnormal placentation can be associated with significant blood loss and massive blood transfusions. Caring for parturients with abnormal placentation who refuse blood transfusion is very challenging. We present a 35-year-old, gravida 3, para 1, Jehovah's Witness at 35 weeks of gestation with placenta percreta, who underwent cesarean delivery and delayed hysterectomy. A multidisciplinary team developed a plan, including the use of perioperative erythropoietin and IV iron dextran, intraoperative acute normovolemic hemodilution, cell salvage, tranexamic acid, and uterine artery embolization. This strategy was successful in avoiding the need for allogeneic transfusion and ensuring an uneventful recovery after both surgical procedures.

Israeli survey of anesthesia practice related to placenta previa and accreta

BACKGROUND

Anesthesia practices for placenta previa (PP) and accreta (PA) impact hemorrhage management and other supportive strategies. We conducted a survey to assess reported management of PP and PA in all Israeli labor and delivery units.

METHODS

After Institutional Review Board waiver, we surveyed all 26 Israeli hospitals with a labor and delivery unit by directly contacting the representatives of obstetric anesthesiology services in every department (unit director or department chair). Each director surveyed provided information about the anesthetic and transfusion management in their labor and delivery units for three types of abnormal placentation based on antenatal placental imaging: PP, low suspicion for PA, and high suspicion for PA. The primary outcome was use of neuraxial or general anesthesia for PP and PA Cesarean delivery. Univariate statistics were used for survey responses using counts and percentages.

RESULTS

The response rate was 100%. Spinal anesthesia is the preferred anesthetic mode for PP cases, used in 17/26 (65.4%) of labor and delivery units. By comparison, most representatives reported that they perform general anesthesia for patients with PA: 18/26 (69.2%) for all low suspicion cases of PA and 25/26 (96.2%) for all high suspicion cases of PA. Although a massive transfusion protocol was available in the majority of hospitals (84.6%), the availability of thromboelastography and cell salvage was much lower (53.8% and 19.2% hospitals respectively).

CONCLUSIONS

In our survey, representatives of anesthesia labor and delivery services in Israel are almost exclusively using general anesthesia for women with high suspicion for PA; however, almost two-thirds use spinal anesthesia for PP without suspicion of PA. Among representatives, we found wide variations in anesthesia practice patterns with regard to anesthesia mode, multidisciplinary management, and hemorrhage anticipation strategies.

Placenta accreta spectrum: accreta, increta, and percreta

Placenta accreta can lead to hemorrhage, resulting in hysterectomy, blood transfusion, multiple organ failure, and death. Accreta has been increasing steadily in incidence owing to an increase in the cesarean delivery rate. Major risk factors are placenta previa in women with prior cesarean deliveries. Obstetric ultrasonography can be used to diagnose placenta accreta antenatally, which allows for scheduled delivery in a multidisciplinary center of excellence for accreta. Controversies exist regarding optimal management, including optimal timing of delivery, surgical approach, use of adjunctive measures, and conservative (uterine-sparing) therapy. We review the definition, risk factors, diagnosis, management, and controversies regarding placenta accreta.

Morbidity associated with cesarean delivery in the United States: is placenta accreta an increasingly important contributor?

OBJECTIVE

The purpose of this study was to examine cesarean delivery morbidity and its predictors in the United States.

STUDY DESIGN

We used 2000-2011 Nationwide Inpatient Sample data to identify cesarean deliveries and records with 12 potential cesarean delivery complications, including placenta accreta. We estimated cesarean delivery morbidity rates and rate changes from 2000-2011, and fitted Poisson regression models to assess the relative incidence of morbidity among repeat vs primary cesarean deliveries and explore its predictors.

RESULTS

From 2000-2011, 76 in 1000 cesarean deliveries (97 in 1000 primary and 48 in 1000 repeat cesarean deliveries) were accompanied by ≥1 of 12 complications. The unadjusted composite cesarean delivery morbidity rate increased by 3.6% only among women with a primary cesarean delivery (P < .001); the unadjusted rate of placenta accreta increased by 30.8% only among women with a repeat cesarean deliveries (P = .025). The adjusted rate of overall composite cesarean delivery morbidity decreased by 1% annually from 2000-2011 (P < .001). Compared with women with a primary cesarean delivery, those women who underwent a repeat cesarean delivery were one-half as likely (incidence rate ratio, 0.50; 95% CI, 0.49-0.50) to experience a complication, but 2.13 (95% CI, 1.98-2.29) times more likely to have a placenta accreta diagnosis. Both cesarean delivery morbidity and placenta accreta were positively associated with age >30 years, non-Hispanic black race/ethnicity, the presence of a chronic medical condition, and delivery in urban, teaching, or larger hospitals.

CONCLUSION

Overall, cesarean delivery morbidity declined modestly from 2000-2011, but placenta accreta became an increasingly important contributor to repeat cesarean delivery morbidity. Clinicians should maintain a high index of suspicion for abnormal placentation and make adequate preparations for patients who need cesarean deliveries.