Epidemiology, etiology, diagnosis, and management of placenta accreta

Placenta Accreta Spectrum (PAS): Diagnosis, Clinical Presentation, Therapeutic Approaches, and Clinical Outcomes

Placenta accreta spectrum (PAS) refers to the abnormal adhesion of the placenta to the myometrium, with varying degrees of severity. Placenta accreta involves adhesion to the myometrium, placenta increta invades the myometrium, and placenta percreta extends through the serosa to adjacent organs. The condition is linked to deficient decidualization in scarred uterine tissue, and the risk increases when placenta previa is present and with each prior cesarean delivery. Other risk factors include advanced maternal age, IVF, short intervals between cesareans, and smoking. PAS incidence has risen due to the increase in cesarean deliveries. Placenta previa combined with PAS significantly raises the risk of severe peripartum bleeding, often necessitating a cesarean section with a total hysterectomy. Recognizing PAS prepartum is essential, with sonographic indicators including intraplacental lacunae and uterovesical hypervascularization. However, PAS can be present without sonographic signs, making clinical risk factors crucial for diagnosis. Effective management requires a multidisciplinary approach and proper infrastructure. This presentation covers PAS cases treated at University Hospital Freiburg, detailing patient conditions, diagnostic methods, treatments and outcomes.

A Novel Approach for Conservative Management of Placenta Accreta Spectrum Disorder Cases: Experience of a Single Surgeon: PAS Disorders and Conservative Management

Background: This study is aimed at evaluating the conservative surgical treatment of patients with placenta accreta spectrum (PAS) disorder and at presenting the experience of a single surgeon. Materials and Methods: This retrospective study included 245 patients with placenta previa accompanied by PAS disorders operated at a university hospital between June 2013 and December 2023. The diagnosis of PAS was made by a single perinatologist using a combination of transvaginal and transabdominal ultrasonography. All patients were operated with conservative surgical technique by the same surgeon. The demographic and clinical characteristics of the patients, the anesthesia and incision types used, and the details of the surgical technique were evaluated. Results: Of the patients, 165 were operated on at the scheduled time, 80 were operated on under emergency conditions, and 232 (94.69%) of them were operated on under spinal anesthesia. All patients were operated on with a Pfannenstiel incision followed by a transverse incision to the upper border of the placenta to enter into the uterus. An average of 0.52 units of red blood cells per patient was transfused to all patients. Spontaneous intra-abdominal bleeding developed in five patients, and surgical complications occurred in eight patients. No cesarean hysterectomy was performed, and no maternal mortality was detected in any of the cases. The mean time duration of surgery was 54.44 ± 11.37 (30-90) min, and the mean length of hospital stay was 1.71 ± 1.30 (1-9) days. Conclusions: We recommend this procedure as a novel technique and a robust and safe alternative to peripartum hysterectomy and other conservative surgical management procedures for cases with complete PP accompanied with PAS. This technique preserves the uterus as well as reduces blood loss, and transfusion requirement, and thus maternal morbidity and mortality in PAS cases.

Is temporary clamping of the bilateral common iliac artery beneficial in reducing intraoperative blood loss in patients with segmental resected anterior placenta percreta?: A prospective observational study

OBJECTIVE

The aim of our study was to investigate whether temporary clamping of the bilateral common iliac artery (BCIA) has a role in reducing intraoperative blood loss in patients with segmentally resected anterior placenta percreta or not.

METHODS

This prospective observational study included patients with anterior placenta percreta who underwent cesarean segmental resection either with BCIA temporary clamping or without clamping between October 2022 and September 2023.

RESULTS

A comparison of demographic, obstetric, and surgical parameters and the need for transfusion (except for postoperative erythrocyte suspension transfusion) between the two groups revealed no significant difference (P > 0.05). In contrast, the amount of intraoperative blood loss (P = 0.001) (1974 ± 749 mL vs 2702 ± 615 mL) and postoperative erythrocyte suspension transfusion (P = 0.046) in patients who underwent BCIA temporary clamping were significantly lower than in those who did not undergo BCIA temporary clamping.

CONCLUSION

Temporary clamping of BCIA plays a significant favorable role both in reducing blood loss and the need for postoperative transfusion in patients with placenta percreta who underwent segmental uterine resection.

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.

Prophylactic Uterine Artery Embolization in Placenta Accreta Spectrum-An Active Intervention to Reduce Morbidity and Promote Uterine Preservation

PURPOSE

To evaluate the feasibility and safety of early and proactive involvement of interventional radiology (IR) in the management of placenta accreta spectrum (PAS) by performing the cesarean operation and prophylactic uterine artery embolization in the IR angiography suite as a combined procedure.

MATERIALS AND METHODS

This study evaluated the effectiveness and safety of prophylactic uterine artery embolization prior to placental separation in cases of antenatally proven or suspected abnormal placentation. Over a 5-year period, 16 consecutive patients with PAS underwent combined IR and obstetric intervention. In all cases, cesarean delivery was performed in the IR angiography suite. Vascular access was obtained prior to surgery with balloon placement into both internal iliac arteries. These balloons were inflated after delivery, followed by uterine artery embolization (14 of 16) if there was evidence of active postpartum bleeding or inability to deliver the placenta.

RESULTS

There was no fetal or maternal mortality and no significant IR or surgical adverse events. Mean blood loss was 1900 mL. Seven patients (44%) underwent hysterectomy.

CONCLUSIONS

In patients with PAS, cesarean section in the angiography suite preceded by prophylactic balloon placement and followed by uterine artery embolization was feasible, safe, and effective in preventing massive blood loss, with a 56% uterine sparing rate.

A quantitative analysis framework of placenta accreta spectrum: placenta subtype, intraoperative bleeding, and hysterectomy risk evaluation based on magnetic resonance imaging-anatomical-clinical features

Background

Placenta accreta spectrum (PAS) is a significant contributor to maternal morbidity and mortality. Our objective was to develop a quantitative analysis framework utilizing magnetic resonance imaging (MRI)-anatomical-clinical features to predict 3 clinically significant parameters in patients with PAS: placenta subtype (invasive vs. non-invasive placenta), intraoperative bleeding (≥1,500 vs. <1,500 mL), and hysterectomy risk (hysterectomy vs. non-hysterectomy).

Methods

A total of 125 pregnant women with PAS from 2 medical centers were enrolled into an internal training set and an external testing set. Some 21 MRI-anatomical-clinical features were integrated as input into the framework. The proposed quantitative analytic framework contains mainly 3 classifiers built by extreme gradient boosting (XGBoost) and their testing in external datasets. We also further compared the accuracy of placenta subtype prediction between the proposed model and 4 radiologists. A quantitative model interpretation method called SHapley Additive exPlanations (SHAP) was conducted to explore the contribution of each feature.

Results

The placenta subtype (invasive vs. non-invasive), intraoperative bleeding (≥1,500 vs. <1,500 mL), and hysterectomy risk (hysterectomy vs. non-hysterectomy) demonstrated impressive area under the receiver operating characteristic curve (AUROC) values of 0.93, 0.88, and 0.90, respectively, in the internal validation set. Even in the external testing set, these metrics maintained their strength, achieving AUROC values of 0.91, 0.82, and 0.82, respectively. Comparing our proposed framework to the 4 radiologists, our model exhibited superior accuracy, specificity, and sensitivity in predicting placental subtypes within the external testing cohort. The features associated with intraplacental dark T2 bands played a crucial role in the decision-making process of all 3 prediction models.

Conclusions

The quantitative analysis framework can provide a robust method for classification of placenta subtype (invasive vs. non-invasive placenta), intraoperative bleeding (≥1,500 vs. <1,500 mL), and hysterectomy risk (hysterectomy vs. non-hysterectomy) based on MRI-anatomical-clinical features in PAS.

Factors associated with poorer childbirth outcomes in pregnant women diagnosed with placenta previa

OBJECTIVE

Placenta previa is a health issue during pregnancy when the placenta wholly or partially covers the opening of the uterus. It can result in bleeding during pregnancy or after delivery, and preterm delivery. This study aimed to investigate the risk factors correlated with poorer childbirth outcomes of placenta previa.

MATERIALS AND METHODS

Between May 2019 and January 2021, pregnant women diagnosed with placenta previa in our hospital were enrolled. Outcomes were postpartum hemorrhage after childbirth, and lower Apgar score and preterm delivery of the neonate. Laboratory blood examination data preoperatively were collected from medical records.

RESULTS

A total of 131 subjects were included, with a median age 31 years. Multivariate analysis showed that fibrinogen reduced risk for postpartum hemorrhage (adjusted odds ratio (aOR): 0.45, 95% confidence interval (CI): 0.26-0.79, p = 0.005). Homocysteine (aOR: 0.73, 95% CI: 0.54-0.99, p = 0.04) reduced the risk while D-dimer (aOR: 1.19, 95% CI: 1.02-1.37, p = 0.02) increased the risk for low Apgar score. Age (aOR: 0.86, 95% CI: 0.77-0.96, p = 0.005) decreased the risk but history of full-term pregnancy more than twice (aOR: 8.58, 95% CI: 2.32-31.71, p = 0.001) increased the risk for preterm delivery.

CONCLUSION

The findings suggest that poorer childbirth outcomes in pregnant women with placenta previa are associated with young age, history of full-term pregnancy, and preoperative concentrations of low fibrinogen, low homocysteine and high D-dimer. This provides obstetricians adjunctive information for early screening of high-risk population and relevant treatment arrangement in advance.

A meta-analysis of obstetric and neonatal outcomes in patients after treatment of hysteroscopic adhesiolysis

Introduction

Hysteroscopic adhesiolysis is widely performed in women with intrauterine adhesions. Small observational studies have reported the obstetric and neonatal outcomes, but studies with larger sample sizes are few. The aim of this study is to evaluate the obstetric and neonatal outcomes in women after hysteroscopic adhesiolysis.

Methods

We conducted a literature search in July 2022 using the PubMed, Embase, the Cochrane Library, and Web of Science databases, and finally, 32 studies (N = 3812) were included. We did a meta-analysis to estimate the prevalence of placenta-related disorders, including placenta previa, placental abruption, placenta accreta, placenta increta, and retained placenta. We also included other obstetric and neonatal outcomes like postpartum hemorrhage, ectopic pregnancy, oligohydramnios, gestational hypertension, gestational diabetes mellitus, and intrauterine growth restriction. The results were presented as odds ratios (ORs) with 95% confidence intervals (CIs) in studies with a control group, but otherwise as prevalence (%) with 95% confidence intervals (CIs).

Results

The overall pregnancy and live birth rates were 58.97% and 45.56%, respectively. The prevalence of placenta previa differed in pregnant women who underwent hysteroscopic adhesiolysis compared with those who did not (OR, 3.27; 95% CI, 1.28-8.36). In studies without a comparative group, the pooled rate of placenta accreta was 7% (95% CI, 4-11) in 20 studies; placenta increta was 1% (95% CI, 0-4) in 5 studies; a retained placenta was 11% (95% CI, 5-24) in 5 studies; postpartum hemorrhage was 12% (95% CI, 8-18) in 12 studies; ectopic pregnancy was 1% (95% CI, 0-2) in 13 studies; oligohydramnios was 3% (95% CI, 1-6) in 3 studies; intrauterine growth restriction was 3% (95% CI, 1-8) in 3 studies; gestational hypertension was 5% (95% CI, 2-11) in 4 studies; and diabetes mellitus was 4% (95% CI, 2-7) in 3 studies.

Discussion

Due to the paucity of good quality comparative data, the question of whether there is an increased prevalence of obstetric and neonatal complications in women after hysteroscopic adhesiolysis compared with the general population remains unanswered. The findings from this review will provide a basis for more well-designed studies in the future.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=364021, identifier [CRD42022364021].

Performance of magnetic resonance imaging to predict maternal outcomes in patients at high risk for placenta accreta spectrum disorder

OBJECTIVE

The purpose of this study is to evaluate the diagnostic performance of MRI parameters to predict adverse maternal peripartum outcomes in pregnant females at high-risk for placenta accreta spectrum (PAS) disorder.

METHODS AND MATERIALS

This retrospective study evaluated 60 pregnant females who underwent MRI for placental assessment. MRI studies were reviewed by a radiologist blinded to all clinical data. MRI parameters were compared with five maternal outcomes: severe bleeding, cesarean hysterectomy, prolonged operation time, need for blood transfusion, and need for intensive care unit (ICU) admission. The MRI findings were associated with pathologic and/or intraoperative findings for PAS.

RESULTS

The study identified 46 cases of PAS disorder and 16 cases of placenta percreta. The agreement between the radiologist impression of PAS disorder and the intraoperative/histological findings was substantial (0.67, p < 0.001), and almost perfect for the presence of placenta percreta (0.87, p < 0.001). The presence of a placental bulge was highly associated with placenta percreta, with sensitivity of 87.5% and specificity of 90.9%. The MRI signs that associated with more maternal outcomes were myometrial thinning, with significant odds ratio for severe blood loss (20.2), hysterectomy (4.0), need for blood transfusion (4.8) and prolonged surgery time (4.9), and uterine bulging, with significant odds ratio for severe blood loss (11.9), hysterectomy (34.0), ICU admission (5.0), and need for blood transfusion (4.8).

CONCLUSION

MRI signs significantly correlated with invasive placenta and were independently associated with adverse maternal outcomes. The presence of a placental bulge was highly accurate in predicting placenta percreta.

ADVANCES IN KNOWLEDGE

First study to evaluate the strength of the association between individual MRI signs and five adverse maternal outcomes. Conclusions support published MRI signs associated with placental invasion, especially regarding the value placental bulging in predicting placenta percreta.

A novel approach in the management of placenta accreta spectrum disorders: A single-center multidisciplinary surgical experience at Tu Du Hospital in Vietnam

OBJECTIVE

Placenta accreta spectrum disorders (PASD) are the leading cause which results in highly maternal mortality during pregnancy. Although hysterectomy has been the gold standard for PASD, the recent study along with our experience has been demonstrated that the association between uterine myometrial resection and transverse B-Lynch suture in conservative management might be effective in the appropriate patients, thus we hereby attempted to determine this issue.

MATERIALS AND METHODS

A retrospective observational study enrolled 65 patients at Tu Du Hospital in Vietnam between January 2017 and December 2018. This study included all pregnant women above 28 weeks of gestational age, who had undergone cesarean delivery due to PASD diagnosed preoperatively by ultrasound or upon laparotomy. Additionally, all patients who desired uterine preservation underwent modified one-step conservative uterine surgery (MOSCUS), avoiding peripartum hysterectomy.

RESULTS

Overall, the rate of successful preservation was 93.8%. Other main outcomes such as average operative blood loss was 987 mL, mean blood transfusion was 831 ± 672 mL; mean operative time was 135 ± 31 min and average postoperative time was 5.79 days. Postoperative complications included six out of 65 cases due to intraoperative bleeding and postoperative infection, requiring hysterectomy in 4 patients.

CONCLUSION

MOSCUS was associated with less operative blood loss and blood transfusion amount. Its success rate of uterine preservation was approximately 94% in our study. Thus, this method can be acceptable in PASD management at our maternity health care center. Further studies might be necessary to evaluate the long-term effects of this method in PASD management.

Placenta Accreta Spectrum: Correlation between FIGO Clinical Classification and Histopathologic Findings

OBJECTIVE

Placenta accreta spectrum (PAS) covers a wide spectrum of placental adherence/invasion with varied clinical significance. Histopathologic examination is considered the confirmatory gold standard, but is only obtained sometime after definitive treatment. The International Federation of Gynecology and Obstetrics (FIGO) has published a new clinical classification that can be assigned at delivery, and we aimed to investigate the association between this new FIGO classification and histopathology and also to assess its correlation with maternal outcomes.

STUDY DESIGN

We studied a retrospective cohort of 185 patients with histopathologically proven PAS managed at our referral center between September 2012 and January 2019. Two experienced surgeons retrospectively reviewed charts and assigned the FIGO grading based on findings reported at delivery. A third experienced reviewer adjudicated to determine the classification used for final analysis. Categorical outcomes were compared with the use of chi-squared and the Fisher exact test, as appropriate. A multivariate model was designed to adjust outcomes in different FIGO groups for the involvement of a formal multidisciplinary management team.

RESULTS

Among 185 patients, there were 41 (22%) placenta accreta, 44 (24%) placenta increta, and 100 (54%) placenta percreta on histopathology. The inter-rater reliability was found to be substantial with Kappa = 0.661 (p < 0.001), and 95% confidence interval (CI): 0.449-0.872. There was a significant association between all histopathology groupings and the FIGO clinical classification (p < 0.001). However, we found no association between FIGO classifications and maternal complications.

CONCLUSION

The new FIGO clinical classification is strongly associated with histopathologic findings. A better understanding of the depth and extent of invasion as afforded by the clinical classification system will help standardize reporting and future research.

KEY POINTS

· PAS includes a wide spectrum of placental invasion with varied clinical significance.. · Histopathological examination is considered the confirmatory gold standard.. · The new FIGO clinical classification is strongly associated with histopathologic findings..

RU-Net: An improved U-Net placenta segmentation network based on ResNet

BACKGROUND

In recent years, with the increase of late puerperium, cesarean section and induced abortion, the incidence of placenta accreta has been on the rise. It has become one of the common clinical diseases in obstetrics and gynecology. In clinical practice, accurate segmentation of placental tissue is the basis for identifying placental accreta and assessing the degree of accreta. By analyzing the placenta and its surrounding tissues and organs, it is expected to realize automatic computer segmentation of placental adhesion, implantation, and penetration and help clinicians in prenatal planning and preparation.

METHODOLOGY

We propose an improved U-Net framework: RU-Net. The direct mapping structure of ResNet was added to the original contraction path and expansion path of U-Net. The feature information of the image was restored to a greater extent through the residual structure to improve the segmentation accuracy of the image.

RESULTS

Through testing on the collected placenta dataset, it is found that our proposed RU-Net network achieves 0.9547 and 1.32% on the Dice coefficient and RVD index, respectively. We also compared with the segmentation frameworks of other papers, and the comparison results show that our RU-Net network has better performance and can accurately segment the placenta.

CONCLUSION

Our proposed RU-Net network addresses issues such as network degradation of the original U-Net network. Good segmentation results have been achieved on the placenta dataset, which will be of great significance for pregnant women's prenatal planning and preparation in the future.

MRI-radiomics-clinical-based nomogram for prenatal prediction of the placenta accreta spectrum disorders

OBJECTIVES

To investigate whether an MRI-radiomics-clinical-based nomogram can be used to prenatal predict the placenta accreta spectrum (PAS) disorders.

METHODS

The pelvic MR images and clinical data of 156 pregnant women with pathologic-proved PAS (PAS group) and 115 pregnant women with no PAS (non-PAS group) identified by clinical and prenatal ultrasonic examination were retrospectively collected from two centers. These pregnancies were divided into a training (n = 133), an independent validation (n = 57), and an external validation (n = 81) cohort. Radiomic features were extracted from images of transverse oblique T2-weighted imaging. A radiomics signature was constructed. A nomogram, composed of MRI morphological findings, radiomic features, and prenatal clinical characteristics, was developed. The discrimination and calibration of the nomogram were conducted to assess its performance.

RESULTS

A radiomics signature, including three PAS-related features, was associated with the presence of PAS in the three cohorts (p < 0.001 to p = 0.001). An MRI-radiomics-clinical nomogram incorporating radiomics signature, two prenatal clinical features, and two MRI morphological findings was developed, yielding a higher area under the curve (AUC) than that of the MRI morphological-determined PAS in the training cohort (0.89 vs. 0.78; p < 0.001) and external validation cohort (0.87 vs. 0.75; p = 0.003), while a comparable AUC value in the validation cohort (0.91 vs. 0.81; p = 0.09). The calibration was good.

CONCLUSIONS

An MRI-radiomics-clinical nomogram had a robust performance in antenatal predicting the PAS in pregnancies.

KEY POINTS

• An MRI-radiomics-clinical-based nomogram might serve as an adjunctive approach for the treatment decision-making in pregnancies suspicious of PAS. • The radiomic score provides a mathematical formula that predicts the possibility of PAS by using the MRI data, and pregnant women with PAS had higher radiomic scores than those without PAS.

Placenta accreta spectrum on an unscarred uterus in the third-trimester pregnancy: two rare cases at Tu Du Hospital in Vietnam

Introduction and importance

Placenta accreta spectrum disorders (PASD) refer to an uncommon obstetrical conditions leading to significant life-threatening obstetrical issue for mothers and foetus during pregnancy. Rarely, this pathology can occur in the uterus without a history of uterine surgery, localize at unusual site of the uterus, and result in the spontaneous uterine rupture. We herein reported two unusual cases managed successfully in the third trimester of pregnancy at our tertiary referral hospital.

Case presentation

Two pregnant women were hospitalized at our maternity hospital for a dilemma diagnosis of PASD without history of previous caesarean scar. Following the suspected images of PASD on ultrasound combined with a hematoma anterior to the body of the uterus, especially a sudden onset of abdominal pain and intraperitoneal fluid without a clear etiology, we made the suspected diagnosis of uterine rupture associated with PASD. Moreover, a gradual reduction of hemoglobin concentration also supported this diagnosis. Both cases underwent immediately caesarean hysterectomy for saving the life of the mother and baby following suspicion.

Clinical discussion

PASD associated with an unscarred uterus is an uncommon placentation during pregnancy. Although an extremely rare cases, PASD may be present without association with placenta praevia. Timely management by caesarean hysterectomy can avoid adverse maternal-foetal outcomes.

Conclusion

PASD can be appeared on the uterus without a previous uterine scar, thus leading to unexpected complications during pregnancy. Closely strict monitoring helps avoiding the materno-foetal mortality. Further data is needed to summarize this rarely uncommon entity.

•

Physicians should be aware of PASD although unscarred uterus and without placenta previa.

•

A sudden onset of abdominal pain and intraperitoneal fluid, diagnosis of uterine rupture can be made.

•

Following image of PASD on ultrasound combined with a hematoma anterior to the body of uterus is potential.

•

Gradually decreased Hemoglobin concentration may support for this diagnosis.

•

Timely surgery by caesarean hysterectomy can save the life of mothers and infants.

Placenta accreta spectrum disorder in a primigravida with angular pregnancy: a case report

Placenta accreta spectrum (PAS) is characterized by abnormal invasion of placental tissue into the underlying uterine muscles and has an incidence of 1/533–1/251. The incidence of complications includes uterine rupture (14–29%), PAS (6–10%), and retained placenta or incomplete placenta removal (4%). Here, we described a rare case of PAS and angular pregnancy, including how to diagnose and manage it preoperatively. A 32-year-old primigravida diagnosed at 24 weeks of gestation with a right angular pregnancy was admitted due to preterm premature rupture of membrane (PPROM) with a singleton fetus. We decided to perform hysterotomy because of the PPROM and intrauterine infection. Intraoperatively, we found PAS in the right angular pregnancy; therefore, we performed uterine conservative management with wedge resection on the right uterine fundus. Intraoperative bleeding was 1,600 cc. Histopathological examination revealed placenta increta. The maternal prognosis was good, while the fetus was poor, with an APGAR score of 1/1/0.

Efficacy of low extra-abdominal aortic block in cesarean section for placenta accreta spectrum disorders and its effect on the expression of MDA and SOD

OBJECTIVES

Placenta accreta spectrum disorders (PAS) refers to a group of abnormalities in placental adhesion and invasion, which may lead to serious complications such as intractable postpartum hemorrhage. The use of low-level extra-abdominal aortic temporary block during cesarean section may reduce intraoperative bleeding in patients with PAS, but it may also cause ischemia-reperfusion injury. In this study, we intend to investigate the efficacy of low extra-abdominal aortic block in cesarean section for placental implantation disease and its effect on malondialdehyde (MDA) level and superoxide dismutase (SOD) activity, and analyze the severity of ischemia-reperfusion injury caused by them.

METHODS

Pregnant women with invasive placenta accreta spectrum disorders who delivered in the Department of Obstetrics and Gynecology of the Third Xiangya Hospital of Central South University from July 2017 to July 2021, were selected, and they were divided into 2 groups. Group A consisted of those who underwent low extra-abdominal aortic block during cesarean section (n=15) and group B consisted of those who did not undergo extra-abdominal aortic block (n=15). The intraoperative bleeding, blood transfusion, hysterectomy and complication rate, postoperative hospital stay and hospitalization expenses were compared between the 2 groups to analyze the efficacy of abdominal aortic block. The biochemical indexes related to ischemia-reperfusion, MDA content and total superoxide dismutase (T-SOD) activity, were measured at the corresponding time points in both groups. The time points of each test were: in group A, before the block of the low extra-abdominal aorta after delivery (A0), 0 h (A1, when the myometrium was started to be sutured), 0.5 h (A2), 2 h (A3), and 4 h (A4) after the open block; in group B, after delivery of the fetus (B0), 0 h (B1), 0.5 h (B2), 2 h (B3), and 4 h (B4) after the myometrium was started to be sutured. Total duration of abdominal aortic block in group A was also recorded. Both groups were observed for sings of edema, ischemia, necrosis and infection in the limbs after surgery. The severity of ischemia-reperfusion injury caused by abdominal aortic block were determined by detecting the relevant biochemical indexes at different moments of reperfusion.

RESULTS

The intraoperative bleeding and blood transfusion in group A were less than those in group B, and the difference was statistically significant (P<0.05). There was no significant difference in postoperative hospital stay and hospitalization expenses between the 2 groups (P>0.05). Surgical complications: in group A, the uterus was preserved in all cases, there was 1 bladder injury and 2 pelvic infections; while in group B, there was 1 hysterectomy, 3 bladder injuries, and 3 pelvic infections. Changes in T-SOD and MDA values: compared with A0 before block, the MDA level was significantly elevated in blood at time points A1, A2, and A3, while SOD activity was significantly decreased (P<0.05), and the 2 observed indexes basically returned to A1 level (ischemic period) at 4 h after open block (A4). There was no significant difference in the changes of T-SOD and MDA in group B (P>0.05). Comparison of T-SOD and MDA levels between group A and B: the difference of the 2 indexes was not statistically significant between A0 and B0 (P>0.05), MDA level was not statistically significant between A1 and B1, T-SOD activity at A1 was lower than B1, the difference was statistically significant, at the rest of the same time point, MDA level in group A were higher than that in group B, T-SOD activity in group A were lower than that in group B, the difference was statistically significant (P<0.05). No postoperative limb edema, ischemia, necrosis, or infection occurred in both groups.

CONCLUSIONS

Low-level extra-abdominal aortic block effectively reduces bleeding and transfusion during cesarean section for placenta accreta spectrum disorders, resulting in a transient MDA elevation and a decrease of SOD activity, which means causing transient ischemia-reperfusion injury without complications such as limb edema, ischemia, necrosis, and infection.

Prophylactic hypogastric arterial ligation before cesarean hysterectomy for controlling complications in pregnant women with placenta adherent abnormality: A randomized controlled clinical trial

BACKGROUND

Placenta adherent abnormality (PAA) is abnormal attachment of the placenta to the myometrium. This abnormal placenta binding has severe clinical consequences for the mother and the fetus. We investigated the outcomes of hypogastric arterial ligation (HAL) before hysterectomy compared to hysterectomy alone in pregnant women with PAA.

MATERIALS AND METHODS

In this randomized controlled clinical trial, 70 patients were randomly allocated to HAL along with hysterectomy and hysterectomy alone groups (35 in each Group). The total amount of intraoperative blood loss, the need for intraoperative blood products transfusion, frequency of deep vein thrombosis, duration of surgery, duration of hospitalization, and visceral trauma were compared between 2 Groups.

RESULTS

Finally, 64 patients completed the study protocol with mean age of 33.84 ± 4.25 years. The study groups were comparable in terms of basic baseline demographic and clinical characteristics. Visceral trauma was less frequently occurred in HAL group compared to hysterectomy alone (0% vs. 15.6%; P = 0.02). Intraoperative blood loss (1525 ± 536.41 cc vs. 2075 ± 889.36 cc; P = 0.001) and were significantly lower in HAL group compared to hysterectomy alone. Duration of operation (179.06 ± 36.28 vs. 197.66 ± 39.47; P = 0.05) and hospitalization (4.97 ± 2.20 vs. 6.10 ± 2.39; P = 0.03) also were significantly lower in HAL group.

CONCLUSION

Our findings suggest that prophylactic HAL has a protective effect on the reduction of blood loss and less visceral trauma in pregnant women with PAA.

Treatment of Placenta Increta With High-Intensity Focused Ultrasound Ablation and Leaving the Placenta in situ: A Multicenter Comparative Study

Objective

To explore the feasibility of simple high-intensity focused ultrasound (HIFU) ablation for placenta increta.

Methods

Ninety-five patients after a vaginal delivery were enrolled in this retrospective cohort study, 53 patients were treated with simple HIFU ablation, and 42 patients were treated with HIFU followed by uterine curettage.

Results

All 95 patients were successfully treated with a single-session HIFU procedure, and in the control group, the necrotic placental tissue was removed with curettage. Vaginal hemorrhage did not occur in either group. The duration of bloody lochia was 25.9 ± 8.6 days in the sHIFU group and 24.2 ± 8.8 days in the control group (P > 0.05). The median serum human chorionic gonadotropin (HCG) level was 3,222 mIU/mL and 2,838 mIU/mL in the sHIFU and control groups, respectively, which decreased and returned to normal within 30 days, and the differences were not significantly on comparing the blood HCG level in the two groups at 7, 15, and 30 days after HIFU (all P > 0.05). Decreased menstrual volume occurred in 85.71% of patients in the control group, which was higher than that in the sHIFU group (23.08%) (χ² = 6.839, P < 0.001). During 2–8 years of follow-up, six pregnancies occurred in the sHIFU group without any recurrence of placenta increta, three pregnancies occurred in the control group, and one patient developed a repeat placenta increta.

Conclusion

Simple HIFU treatment is safe and effective for postpartum placenta increta and leaving the placenta in situ. It is a promising option for patients who wish to preserve their fertility and conceive.

Placenta Accreta has a Low Association with Hypertensive Disease During Pregnancy: A Systematic Review Incorporating a Network Meta-analysis

A meta-analysis was performed to evaluate the potential relationship between hypertensive disease during pregnancy and placenta accreta. A systematic literature search in OVID, Embase, Cochrane Library, PubMed, and Google scholar up to May 2021 was done, and 4 studies were found including 47,353 pregnant women at the start of the study; 4283 of them had hypertensive disease during pregnancy and 493 had placenta accreta. They were reporting relationships between hypertensive disease during pregnancy and placenta accreta. The odds ratio (OR) with 95% confidence intervals (CIs) was calculated to assess the potential relationship between hypertensive disease during pregnancy and placenta accreta using the dichotomous with a random or fixed-effect model. Hypertensive disease during pregnancy was significantly related to lower prevalence of placenta accreta (OR, 0.60; 95% CI, .38-.94, p = 0.03) compared with control (no hypertensive disease during pregnancy). When looking at the result comparing the prevalence of hypertensive disease during pregnancy in women with placenta accreta compared with control (no placenta accreta), we found that the placenta accreta was significantly related to lower prevalence of hypertensive disease during pregnancy (OR, 0.59; 95% CI, 0.38-0.94, p = 0.03) compared with control. Hypertensive disease during pregnancy may have a lower prevalence of placenta accreta. Further studies are required to validate these findings.

Hypertension in pregnancy as a risk factor for placenta accreta spectrum: a systematic review incorporating a network meta-analysis

BACKGROUND

A meta-analysis was performed to evaluate the potential effects of hypertension in pregnancy on the placenta accreta spectrum.

METHODS

A systematic literature search in OVID, Embase, Cochrane Library, PubMed, and Google Scholar up to May 2021 was done, and six studies were found including 126,224 pregnant women; 7164 of them had hypertension in pregnancy and 816 had placenta accreta spectrum. They were reporting relationships between the potential effects of hypertension in pregnancy on the placenta accreta spectrum. The odds ratio (OR) with 95% confidence intervals (CIs) was calculated to assess the potential effects of hypertension in pregnancy on the placenta accreta spectrum using the dichotomous with a random- or fixed-effect model.

RESULTS

Pregnancy-induced hypertension was significantly related to lower prevalence of placenta accreta spectrum (OR 0.56; 95% CI 0.37-0.84, p = 0.005) with no heterogeneity (I² = 0%) compared to control (no hypertension in pregnancy). When looking at the result comparing the prevalence of hypertension in pregnancy in women with placenta accrete compared to control (no placenta accrete), we found that the placenta accreta spectrum was significantly related to lower prevalence of hypertension in pregnancy (OR 0.65; 95% CI 0.43-0.98, p = 0.04) compared to control.

CONCLUSIONS

Hypertension in pregnancy may have a lower prevalence of placenta accrete. Further studies are required to validate these findings.

A dual-path neural network fusing dual-sequence magnetic resonance image features for detection of placenta accrete spectrum (PAS) disorder

With the increase of various risk factors such as cesarean section and abortion, placenta accrete spectrum (PAS) disorder is happening more frequently year by year. Therefore, prenatal prediction of PAS is of crucial practical significance. Magnetic resonance imaging (MRI) quality will not be affected by fetal position, maternal size, amniotic fluid volume, etc., which has gradually become an important means for prenatal diagnosis of PAS. In clinical practice, T2-weighted imaging (T2WI) magnetic resonance (MR) images are used to reflect the placental signal and T1-weighted imaging (T1WI) MR images are used to reflect bleeding, both plays a key role in the diagnosis of PAS. However, it is difficult for traditional MR image analysis methods to extract multi-sequence MR image features simultaneously and assign corresponding weights to predict PAS according to their importance. To address this problem, we propose a dual-path neural network fused with a multi-head attention module to detect PAS. The model first uses a dual-path neural network to extract T2WI and T1WI MR image features separately, and then combines these features. The multi-head attention module learns multiple different attention weights to focus on different aspects of the placental image to generate highly discriminative final features. The experimental results on the dataset we constructed demonstrate a superior performance of the proposed method over state-of-the-art techniques in prenatal diagnosis of PAS. Specifically, the model we trained achieves 88.6% accuracy and 89.9% F1-score on the independent validation set, which shows a clear advantage over methods that only use a single sequence of MR images.

Cervical tourniquet during cesarean section to reduce bleeding in morbidly adherent placenta: a pilot study

Objective:

To evaluate a modified surgical technique aiming to reduce bleeding and preserve fertility in morbidly adherent placenta by cervical tourniquet in cesarean sections.

Methods:

The cesarean section operations and the cervical ligation approach were performed by a single expert consultant obstetrician. The general demographics and clinical characteristics for all participants were collected and studied.

Results:

Eleven participants were involved. The uterus was preserved in nine patients, whereas two patients had hysterectomy. The mean blood loss was 1688.8 ml for patients whose uterus was preserved. The mean length of stay was 5.5 days.

Conclusion:

Cervical ligation is a simple method that can be applied by junior and experienced obstetricians to preserve the uterus.

Placenta accreta is the abnormal adhesion of placenta into the uterine wall. It carries a significant risk for hysterectomy, intrapartum and postpartum hemorrhage, and maternal morbidity and mortality. As the preservation of fertility and femininity is desired by many women, numerous methods were adapted to avoid hysterectomy in patients with placenta accreta. In this study, we describe and evaluate a novel technique to preserve the uterus by ligating the cervix with a Foley catheter.

Association between Short Interpregnancy Interval and Placenta Accreta Spectrum

BACKGROUND

The incidence of placenta accreta spectrum is increasing in parallel with the growing number of cesarean deliveries performed. A shorter interpregnancy interval following cesarean delivery may prevent adequate scar healing, which could impact the risk of placenta accreta spectrum.

OBJECTIVE

We aimed to investigate the association between short interpregnancy intervals and placenta accreta spectrum.

STUDY DESIGN

We conducted a retrospective cohort study of patients at risk for placenta accreta spectrum at a tertiary academic center between 2002 and 2020. Our cohort was defined as pregnant individuals at risk for placenta accreta spectrum meeting the following criteria: placenta previa with previous cesarean delivery and/or uterine surgery, anterior low-lying placenta with previous cesarean delivery and/or uterine surgery, ≥3 previous cesarean deliveries, or any previous cesarean delivery with sonographic findings suspicious for placenta accreta spectrum. The primary outcome was surgically or histopathologically confirmed placenta accreta spectrum. Short interpregnancy interval was defined as <18 completed months from previous delivery and last menstrual period of the index pregnancy. Univariable analyses were performed with chi-square and Student's t-test, as appropriate, and Kruskal–Wallis for nonparametric variables. The unadjusted and adjusted odds ratios were calculated using multivariate logistic regression models. Covariates were selected if P<.2 in univariable analyses or defined a priori as clinically meaningful. The final models were derived using reverse stepwise selection of variables. We used Stata Statistical Software, version 15 (StataCorp, College Station, TX) to perform descriptive statistics.

RESULTS

Of 262 patients at risk of placenta accreta spectrum with complete records, 112 (42.7%) had placenta accreta spectrum. Pregnant individuals with short interpregnancy intervals of <18 months were no more likely than those with optimal interpregnancy intervals to have previa (58% [46/80] vs 46% [84/182]; P=.09) or placenta accreta spectrum (49% [39/80] vs 40% [73/182]; P=.19). Short interpregnancy interval of <18 months was not associated with placenta accreta spectrum (unadjusted odds ratio, 1.06; 95% confidence interval, 0.62–1.80). This association did not change when adjusting for previa and number of previous cesarean deliveries (adjusted odds ratio, 1.04; 95% confidence interval, 0.51–2.15). In a secondary analysis, an interpregnancy interval of <12 months was also not associated with placenta accreta spectrum (unadjusted odds ratio, 0.79; 95% confidence interval, 0.04–1.56; adjusted odds ratio, 0.52; 95% confidence interval, 0.21–1.27).

CONCLUSION

In patients at risk for placenta accreta spectrum, short interpregnancy intervals of <18 months or <12 months were not associated with placenta accreta spectrum, even when controlling for number of previous cesarean deliveries and previa. Short interpregnancy interval is not likely to be an important modifiable independent risk factor for placenta accreta spectrum.

Risk Factors for Urological Complications Associated with Caesarean Section—A Case-Control Study

Background and Objectives: Acute urologic complications, including bladder and/or ureteric injury, are rare but known events occurring at the time of caesarean section (CS). Delayed or inadequate management is associated with increased morbidity and poor long-term outcomes. We conducted this study to identify the risk factors for urologic injuries at CS in order to inform obstetricians and patients of the risks and allow management planning to mitigate these risks. Materials and Methods: We reviewed all cases of urological injuries that occurred at CS surgeries in a tertiary university centre over a period of four years, from January 2016 to December 2019. To assess the risk factors of urologic injuries, a case-control study of women undergoing caesarean delivery was designed, matched 1:3 to randomly selected women who had an uncomplicated CS. Electronic medical records and operative reports were reviewed for socio-demographic and clinical information. Descriptive and univariate analyses were used to characterize the study population and identify the risk factors for urologic complications. Results: There were 36 patients with urologic complications out of 14,340 CS patients, with an incidence of 0.25%. The patients in the case group were older, had a lower gestational age at time of delivery and their newborns had a lower birth weight. Prior CS was more prevalent among the study group (88.2 vs. 66.7%), as was the incidence of placenta accreta and central praevia. In comparison with the control group, the intraoperative blood loss was higher in the case group, although there was no difference among the two groups regarding the type of surgery (emergency vs. elective), uterine rupture, or other obstetrical indications for CS. Prior CS and caesarean hysterectomy were risk factors for urologic injuries at CS. Conclusions: The major risk factor for urological injuries at the time of CS surgery is prior CS. Among patients with previous CS, those who undergo caesarean hysterectomy for placenta previa central and placenta accreta are at higher risk of surgical haemostasis and complex urologic injuries involving the bladder and the ureters.

Prediction of placenta accreta spectrum using texture analysis on coronal and sagittal T2-weighted imaging

PURPOSE

To separately perform visual and texture analyses of the axial, coronal, and sagittal planes of T2-weighted images and identify the optimal method for differentiating between the normal placenta and placenta accreta spectrum (PAS).

METHODS

Eighty consecutive patients (normal group, n = 50; PAS group, n = 30) underwent preoperative MRI. A scoring system (0-2) was used to evaluate the degree of abnormality observed in visual analysis (bulging, abnormal vascularity, T2 dark band, placental heterogeneity). The axial, coronal, and sagittal planes were manually segmented separately to obtain texture features, and seven combinations were obtained: axial; coronal; sagittal; axial and coronal; axial and sagittal; coronal and sagittal; and axial, coronal, and sagittal. Feature selection using the least absolute shrinkage and selection operator method and model construction using a support vector machine algorithm with k-fold cross-validation were performed. AUC was used to evaluate diagnostic performance.

RESULTS

The AUC of visual analysis was 0.75. The model 'coronal and sagittal' had the highest AUC (0.98) amongst the seven combinations. The fivefold cross-validation for the model 'coronal and sagittal' showed AUCs of 0.85 and 0.97 in training and validation sets, respectively. The AUC of the model 'coronal and sagittal' for all subjects was significantly higher than that of visual analysis (0.98 vs. 0.75; p < 0.0001).

CONCLUSION

The model 'coronal and sagittal' can accurately differentiate between the normal placenta and PAS, with a significantly better diagnostic performance than visual analysis. Texture analysis is an optimal method for differentiating between the normal placenta and PAS.

The risk factors associated with placenta previa: An umbrella review

We evaluated in this umbrella review a systematic collection from meta-analyses conducted on risk factors associated with placenta previa. We searched PubMed, Scopus, and Web of Science until April 2021 assessing the risk factors associated with placenta previa. We calculated summary effect estimates odds ratio, relative risk, 95% CI, heterogeneity I², 95% prediction interval, small-study effects, excess significance biases, and sensitive analysis. The quality of the meta-analyses was evaluated with AMSTAR 2. We included nine studies in the present umbrella review. Seven risk factors including prior induced abortion (OR 1·36, 95% CI: 1·02, 1·69), prior spontaneous abortion (OR 1·77, 95% CI: 1·60, 1·94), male fetus (OR 1·2, 95% CI: 1·2, 1·3), smoking (OR 1·42, 95% CI 1·30, 1·54) (RR 1·27, 95% CI: 1·18, 1·35) advanced maternal age (OR 3·16, 95% CI: 2·79, 3·57), cesarean (OR 1·60, 95% CI: 1·44, 1·76) and ART (singleton pregnancy) (RR 3·71, 95% CI: 2·67, 5·16) were graded as highly suggestive evidence (class III). Endometriosis (OR 3·03, 95% CI: 1·50, 6·13) and maternal cocaine use (OR 2·9, 95% CI: 1·9, 4·3) were graded as risk factors with weak evidence (class IV). This study provides suggestive evidence about prior spontaneous abortion, prior induced abortion, male fetus, smoking, advanced maternal age, cesarean section, and assisted reproductive techniques (singleton pregnancy) as risk factors associated with placenta previa.

Maternal and Neonatal Outcomes After Planned or Emergency Delivery for Placenta Accreta Spectrum: A Systematic Review and Meta-Analysis

Objective: To compare maternal and neonatal outcomes for women with placenta accreta syndrome (PAS) delivering via a planned or emergent approach.

Methods: A systematic search for relevant studies was conducted by screening the PubMed, Scopus, Web of Science, and Google Scholar electronic databases. Included studies should have been retrospective record-based or prospective in design. They must have compared maternal and/or neonatal outcomes for PAS patients delivering via planned and emergency procedures. Strength of association was presented as pooled adjusted relative risk (RR) for categorical outcomes and weighted mean difference (WMD) for continuous outcomes. Statistical analysis was done using STATA version 16.0.

Results: Nine articles were included in the meta-analysis. PAS patients undergoing planned deliveries had increased gestational ages, required fewer units of transfused blood, experienced shorter hospital stay durations, and presented reduced risks for maternal ICU admission and severe maternal morbidity. Neonates born to mothers undergoing planned deliveries had increased birth weights and decreased NICU admission risk.

Conclusion: These findings indicate a planned approach for delivery is better for maternal and neonatal outcomes compared to urgent/emergency delivery for PAS patients.

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.

A modified suture technique for the treatment of patients with pernicious placenta previa and placenta accreta spectrum: a case series

Background

Pernicious placenta previa complicated by placenta accreta spectrum (PAS) often leads to hysterectomy or even maternal death due to massive bleeding. In recent years, the application of balloons has received increasing attention. It is easier to use and has reasonably good effect. However, for some patients, especially those who still have some placental residue, there might still be active bleeding. To solve this problem, we propose a method of pressure sutures around the balloon to provide a better hemostasis effect.

Methods

An observational study was conducted on patients with pernicious placenta previa and PAS at the Beijing Chaoyang Hospital, Beijing, China, between January 2018 and January 2021. During surgery, an intrauterine balloon was used to compress the hemorrhage site, and two or more absorbable sutures were placed around the uterus to apply strong pressure on the balloon. This method is an updated modification of the Lu-suture which uses a Foley catheter balloon and only one suture. The main improvements include choosing different kinds of balloons depending on various conditions and the addition of a suture below the balloon to provide much stronger pressure and prevent the balloon slipping out through the dilated cervix.

Results

A total of 10 women underwent the procedure. The mean estimated intraoperative blood loss was 1,190±548 mL. Post-surgery, the blood loss was less than 200 mL in all patients. The mean blood transfusion [packed red blood cells (pRBC)] required was 2.2±2.6 units. The mean hemostatic time was 8.1±3.4 minutes.

Conclusions

The modified suture technique provided an easy, cheap, and efficient surgical choice for patients with pernicious placenta previa and PAS.

Deep learning and radiomics analysis for prediction of placenta invasion based on T2WI

The purpose of this study was to explore whether the Nomogram, which was constructed by combining the Deep learning and Radiomic features of T2-weighted MR images with Clinical factors (NDRC), could accurately predict placenta invasion. This retrospective study included 72 pregnant women with pathologically confirmed placenta invasion and 40 pregnant women with normal placenta. After 24 gestational weeks, all participants underwent magnetic resonance imaging. The uterus and placenta regions were segmented in magnetic resonance images on sagittal T2WI. Ninety-three radiomics features were extracted from the placenta region, and 128 deep features were extracted from the uterus region using a deep neural network. The least absolute shrinkage and selection operator (LASSO) algorithm was used to filter these 221 features and to form the combined signature. Then the combined signature (CS) and clinical factors were combined to construct a nomogram. The accuracy, sensitivity, specificity and AUC of the nomogram were compared with four machine learning methods. The model NDRC was trained on the dataset of 78 pregnant women in the training cohort. Finally, the model NDRC was compared with four machine learning methods on the independent validation cohort of 34 pregnant women. The results showed that the prediction accuracy, sensitivity, specificity and AUC of the NDRC model were 0.941, 0.952, 0.923 and 0.985 respectively, which outperforms the traditional machine learning methods which rely on radiomics features and deep learning features alone.

Placenta accreta spectrum-a catastrophic situation in obstetrics

Placenta accreta is a significant obstetric complication in which the placenta is completely or focally adherent to the myometrium. The worldwide incidence of placenta accreta spectrum (PAS) is increasing day by day, mostly due to the increasing trends in cesarean section rates. The accurate and timely diagnosis of placenta accreta is important to improve the feto-maternal outcome. Although standard ultrasound is a reliable and primary tool for the diagnosis of placenta accreta, the absence of ultrasound findings does not preclude the diagnosis of placenta accreta. Therefore, clinical evaluation of risk factors is equally essential for the prediction of abnormal placental invasion. Pregnant women with a high impression or established diagnosis of placenta accreta should be managed by a multidisciplinary team in a specialist center. Traditionally, PAS has been managed by an emergency obstetric hysterectomy. Previously, few studies suggested a satisfactory success rate of conservative management in well-chosen cases, whereas few studies recommended delayed hysterectomy to reduce the amount of bleeding. The continuously increasing trends of PAS and the challenges for its routine management are the main motives behind this literature review.

What we know about placenta accreta spectrum (PAS)

Placenta accreta spectrum (PAS) is an umbrella term for a variety of pregnancy complications due to abnormal placental implantation, including placenta accreta, placenta increta and placenta percreta. During the past several decades, the prevalence of PAS has been increasing, and the clinical importance of this disease is significant because of the severe complications. In this review, we summarized the available evidence-based data for PAS in various aspects: prevalence, risk factors, pathogenesis, clinical presentation and prenatal screening, and clinical management. Meanwhile, we provided a series of prospects in each section for further studies on PAS. Moreover, we first present a visualized workflow for the management of PAS from three steps: predelivery, during delivery and postdelivery.

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.

A practical FIST maneuver to minimize the bleeding during cesarean hysterectomy for placenta percreta: a retrospective comparative study

BACKGROUND

Placenta percreta (PP) is a life-threatening condition and its surgery poses a very high potential for bleeding. The recommended treatment is a cesarean hysterectomy. There are several techniques reported in the literature to reduce the bleeding during percreta operations.

OBJECTIVE

To show and describe a practical and novel intraoperative maneuver to minimize the hemorrhage during cesarean hysterectomy for PP.

METHODS

The patients who were diagnosed with PP and underwent cesarean hysterectomy (CH) in our unit between 2016 and 2020 were retrospectively evaluated. These patients were divided into two groups. Group A included patients who underwent hysterectomy with intraoperative FIST maneuver. Group B included patients with ordinary cesarean hysterectomy. The groups were compared with regards to the intraoperative bleeding, surgical complications, and perioperative outcomes.

RESULTS

Seventy-two patients who had a cesarean hysterectomy and diagnosed with PP during the study period were included in this retrospective cohort. 22 patients underwent intraoperative FIST maneuver with CH as Group A and 50 patients underwent ordinary CH as Group B. The demographic variables including maternal age, gravida, number of previous cesarean sections, and body-mass index were not statistically different between the two groups. Intraoperative FIST maneuver was significantly associated with reduced operative hemorrhage, the need for transfusion of erythrocyte suspension, admission to intensive care unit, and hospitalization days (p < .005). The operative time was statistically significantly shorter in Group A than Group B, respectively (90 ± 18.6 vs 120 ± 20.5 min) (p < .05).

CONCLUSION

FIST maneuver is a very practical, easy to apply, and effective method that reduces the obstetrical bleeding during cesarean hysterectomy in placenta percreta cases.

Conservative Management of Placenta Accreta Using Helium Plasma Focused Radiofrequency Energy: A Surgical Technique

The incidence of abnormal placentation has escalated due to the increase in cesarean sections. Adherent placentas are associated with significant maternal morbidity and mortality and often result in cesarean hysterectomy due to life-threatening hemorrhage. The purpose of these case reports is to describe conservative management of placenta accreta by utilizing a helium plasma device to fulgurate the placental bed. Placenta accreta is associated with a 7% mortality rate and 60% morbidity rate. Conservative treatment for uterine preservation include embolization, placenta left in-situ, uterine balloon tamponade, and methotrexate. Complications of these options include hemorrhage, endometritis, and morbidly adherent placentas (MAP) recurrence in subsequent pregnancies.

The helium plasma device utilizes radiofrequency (RF) to ionize helium into a plasma beam capable of coagulating and fulgurating tissue with high precision and minimal thermal spread. This instrument is Food and Drug Administration (FDA) approved for surgical coagulation and fulguration, but has not been evaluated in the treatment of placenta accreta at the time of a cesarean section.

The helium plasma device was used to fulgurate the placenta accreta at 40% power 4 L/min gas flow for 30 seconds, providing adequate hemostasis to the 12.76 cc of retained placental bed. Estimated blood loss was 560 cc. The patient remained hemodynamically stable and had no complications at follow up. The device provided efficient management of placenta accreta. This approach offers a safer alternative management of abnormal placentation and avoiding a cesarean hysterectomy. This novel surgical technique allows women with morbidly adherent placentas to maintain reproductive capability.

Integrative analysis provides multi-omics evidence for the pathogenesis of placenta percreta

Pernicious placenta previa with placenta percreta (PP) is a catastrophic condition during pregnancy. However, the underlying pathogenesis remains unclear. In the present study, the placental tissues of normal cases and PP tissues of pernicious placenta previa cases were collected to determine the expression profile of protein‐coding genes, miRNAs, and lncRNAs through sequencing. Weighted gene co‐expression network analysis (WGCNA), accompanied by miRNA target prediction and correlation analysis, were employed to select potential hub protein‐coding genes and lncRNAs. The expression levels of selected protein‐coding genes, Wnt5A and MAPK13, were determined by quantitative PCR and immunohistochemical staining, and lncRNA PTCHD1‐AS and PAPPA‐AS1 expression levels were determined by quantitative PCR and fluorescence in situ hybridization. The results indicated that 790 protein‐coding genes, 382 miRNAs, and 541 lncRNAs were dysregulated in PP tissues, compared with normal tissues. WGCNA identified coding genes in the module (ME) black and ME turquoise modules that may be involved in the pathogenesis of PP. The selected potential hub protein‐coding genes, Wnt5A and MAPK13, were down‐regulated in PP tissues, and their expression levels were positively correlated with the expression levels of PTCHD1‐AS and PAPPA‐AS1. Further analysis demonstrated that PTCHD1‐AS and PAPPA‐AS1 regulated Wnt5A and MAPK13 expression by interacting with specific miRNAs. Collectively, our results provided multi‐omics data to better understand the pathogenesis of PP and help identify predictive biomarkers and therapeutic targets for PP.

Placenta accrete after a frozen-thawed embryo transfer in a systemic lupus erythematosus patient treated with hydroxychloroquine

Placenta accreta (PA) is a life-threatening disorder associated with decidual maldevelopment and a thin endometrium. Few cases of systemic lupus erythematosus (SLE) pregnancy complicated by PA have been reported, and the background pathophysiology remains elusive. Here, we report a case of PA in SLE pregnancy treated with hydroxychloroquine. A nulligravida woman with SLE, aged 41 years, visited our hospital because of infertility problems. Her SLE was treated with prednisolone and tacrolimus. We conducted assisted reproductive technology and gained several embryos. An artificial cycle successfully prepared the endometrium for embryo transfer with sufficient thickness. Over time, her SLE exacerbated, and we started hydroxychloroquine administration. Consequently, the endometrium did not respond to hormonal supplementation and remained thin, but we transferred the embryo and managed to achieve pregnancy. On the 38th week of gestation, we conducted labor induction because of elevated blood pressure. Induction was not effective, so we performed cesarean section; PA was observed. We performed compression suturing and were able to stop the hemorrhage. Postoperative uterine infarction and pelvic infection were successfully managed with conservative treatment. The present case highlights the use of hydroxychloroquine during endometrial development and contributes evidence regarding the pathogenesis of PA in pregnancy complicated by SLE.

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.

Prediction of Delivery Complications by First-Trimester Ultrasound Measurement of the Gestational Sac's Distance From a Previous Cesarean Section Scar

OBJECTIVES

This study was designed to investigate the clinical relationship between labor complications in the second and third trimesters and the distance from the gestational sac to a previous cesarean section (CS) scar.

METHODS

We conducted a retrospective review of the electronic medical records and included all 7- to 9-week transvaginal ultrasound examination reports from pregnancies with a history of a single cesarean delivery in our hospital between January 2015 and December 2017. Women were divided into 6 groups according to the distance of the gestational sac to the CS scar (groups A-F). A composite of pregnancy outcomes (gestational age at birth, delivery mode, placental abnormality, blood loss, uterine rupture, and hysterectomy) and other maternal and neonatal outcomes were assessed.

RESULTS

A total of 699 cases were included in our study. The median gestational age was 39.0 (range, 38.1-39.9) weeks. The median intrapartum blood loss volume was 400 (range, 300-500) mL. The results showed no statistically significant difference in blood loss (P = .297) or birth weight of the neonate (P = .318) among the distance subgroups. Overall, the fetuses were stillborn in 9 of 699 cases (1.29%). There was a statistically significant difference in a morbidly adherent placenta, placenta previa, and preterm labor, and their incidence increased with decreasing distance (P < .001; P for trend < .05). There was no statistically significant difference in uterine rupture (P = .597) or the delivery mode (P = .187) among the subgroups.

CONCLUSIONS

The relative positions of a CS scar and the gestational sac in the first trimester are associated with the incidence of placental abnormalities. As the distance decreases, the extent of a morbidly adherent placenta increases.

Impact of intramural non-cavity-distorting leiomyoma on placental histopathology and perinatal outcome in singleton live births resulting from in vitro fertilization treatment

PURPOSE

To evaluate the effect of non-cavity-distorting intramural leiomyomas on the placental histopathology pattern and perinatal outcome in singleton live births resulting from in vitro fertilization treatment.

METHODS

The study population included all singleton live births following in vitro fertilization treatment with autologous oocytes during the period from 2009 to 2017. Primary outcomes included anatomical, inflammation, vascular malperfusion, and villous maturation placental features. Secondary outcomes included fetal, maternal, delivery, and perinatal complications.

RESULTS

A total of 1119 live births were included in the final analysis and were allocated to the group of pregnancies with non-cavity-distorting intramural myomas (n = 101) and without myomas (n = 1018). After the adjustment for confounding factors, the non-cavity-distorting intramural myomas were found to be significantly associated with assisted placental delivery (OR 2.4; 95% CI 1.5-3.9), furcate cord insertion (OR 3.6; 95% CI 1.4-9.3), circumvallate membranes insertion (OR 5.2; 95% CI 1.4-19.3), chronic deciduitis (OR 8.2; 95% CI 1.6-42.2), focal intramural fibrin deposition (OR 25.1; 95% CI 2.1-306.2), subchorionic thrombi (OR 3.6; 95% CI 1.7-7.6), maternal vasculopathy (OR 2.5; 95% CI 1.2-5.5), and chorangioma (OR 5.9; 95% CI 1.4-25.2) as well as with the failure of labor progress (OR 2.4; 95% CI 1.3-4.4) and induction (OR 3.2; 95% CI 1.2-9.0).

CONCLUSION

Intramural non-cavity-distorting myomas have a significant impact on the placental histopathology with a higher incidence of dysfunctional labor.

Pregnancy and its Outcomes in Patients After Uterine Fibroid Embolization: A Systematic Review and Meta-Analysis

Uterine artery embolization (UAE) has been introduced for uterine fibroid treatment for two decades. Most of the patients are in reproductive age and many want future pregnancy. In this study, we will assess fertility, pregnancy and its outcomes in patients who have undergone UAE. In this systematic review, a systematic search was performed on important databases including PubMed and Medline, Web of Knowledge, Google Scholar, EMBASE and Scopus. Studies reported enough data about pregnancy after UAE were considered to be enrolled in the review. We assessed obstetric indices (pregnancy and delivery rates, pregnancy losses, complications and fetal outcomes). Study evaluation was done based on STROBE checklist by two reviewers. Totally, 24 original papers were included. Data were analyzed by Stata and MedCalc softwares. Among women wishing fertility, totally 40.5% experienced at least one pregnancy after UAE (95% confidence interval [CI]: 33.3%-48.2%). Pooled estimate of pregnancy loss rate was 33.5% (95% CI: 26.3-41%). Most pregnancy losses were due to spontaneous abortion (81.3% of all losses (95% CI = 76%-86.1%)). Rate of obstetrical complications was 25.4% (95% CI = 13-40.2%) among all finished pregnancies. Pooled estimate of preterm labor was 12.8% (95% CI = 8.7%-17.5%), and pooled estimate of low birth weight (LBW) was 10% (95% CI = 6.2-14.6%). Considering the findings of the study, a safe pregnancy after UAE is obviously possible resulting to a healthy and normal baby delivery. In addition, pooled obstetrical complication rates, pregnancy losses, preterm labor and LBW seem to be mostly similar to the general population. Registration: The study was registered in International Prospective Register of Systematic Reviews (PROSPERO) on Nov 3, 2017, and was confirmed with a registration code of CRD42017076074.

Maternal and neonatal outcomes of abnormal placentation: a case-control study

BACKGROUND

There is limited information on neonatal outcomes in complicated pregnancies with abnormal placentation. The aim of this study was to assess the neonatal outcomes of abnormal placentation.

METHODS

In this case-control study, known cases of abnormal placentation between the years 2010 and 2017 were extracted. The case group consisted of pregnant women with abnormal placentation (172 cases), while controls were selected from repeated cesarean section cases with normal placentation (341 people).

RESULTS

In the case group, 145 cases (84.3%) had placenta accreta, 12 cases (7.07%) had placenta increta and five cases (8.7%) had placenta percreta. Characteristics significantly more common in the case group included lower mean gestational age and average neonatal weight (p < .001), low birth weight (LBW) and small for gestational age (SGA) (p < .001), admission to the NICU (p < .001), higher average number of hospitalization days in the NICU (p < .05), lower average 5-minute Apgar scores (p < .001), neonatal seizure (p = .004), cranial hemorrhage (p = .037), anemia (p = .002) and thrombocytosis (p = .029). The occurrence of abnormal placentation was associated with some underlying maternal characteristics such as high maternal age (p = .34), lower maternal weight (p = .044), multiparity (p = .11), history of previous abortion (p = .036), and history of cesarean (p = .001). The prevalence of placenta previa was significantly higher in the case group (p < .001).

CONCLUSION

The presence of placenta previa has a close relationship with abnormal placentation and is considered to be a potential risk factor for LBW, SGA, lower 5 minutes Apgar scores, first-day seizure, cranial hemorrhage, the necessity for NICU admission and occurrence of anemia and thrombocytosis in neonates.

Long-term follow-up of abdominal aortic balloon occlusion for the treatment of pernicious placenta previa with placenta accreta

OBJECTIVE

To evaluate the efficacy and safety of balloon occlusion of the abdominal aorta for the treatment of pernicious placenta previa with placenta accreta.

METHODS

The clinical data of 623 patients with pernicious placenta previa combined with placenta accrete, who were admitted to our hospital from January 2013 to January 2019 were retrospectively analyzed. All patients underwent abdominal aortic balloon occlusion combined with cesarean section, and 78 patients underwent sequential bilateral uterine artery embolization. We analyzed the operation time, intraoperative blood loss, blood transfusion volume, intraoperative and postoperative complications, fetal radiation exposure time and dose, and the Apgar score of the newborns. We also performed other evaluations to ascertain the efficacy and safety of abdominal aortic balloon occlusion treatment for dangerous placenta previa with placenta accrete.

RESULTS

Of the 623 patients, 545 underwent only abdominal aortic balloon occlusion, and 78 underwent uterine artery embolization due to intraoperative or postoperative bleeding. The uterus was successfully preserved in all patients. Except for five cases of right lower extremity arterial thrombosis, the remaining patients did not have postoperative lower extremity arteriovenous thrombosis, renal insufficiency, late postpartum hemorrhage, ectopic embolism, spinal cord or peripheral nerve damage, pelvic infection, or other serious complications. The mean operative time was 65.3 (±14.5) min. The mean intraoperative blood loss was620 (±570) ml. Ninety-six patients (15.4%, 96/623) were treated with blood transfusion, and the average amount of blood transfused was 750 (±400) ml. The average number of hospitalization days was 6.8 (±3.4) days, the average time of fetal ray exposure was 5.2 (±1.6) s, and the average radiation dose was 4.1 (±2.7) mGy. The neonatal Apgar score, was 8.4 (±0.6) points at 1 ​min, and 9.6 (±0.4) points at 5 ​min. In the follow-up to May 31, 2019, 29 patients were lost to follow-up, 96 were lactating, and 498 were menstruating. Except for the cases lost to follow-up, the remaining 596 surviving newborns (including 2 twins) showed no abnormalities at the 42-day postnatal outpatient follow-up examination.

CONCLUSION

Balloon occlusion of the abdominal aorta is a safe and effective method for the treatment of pernicious placenta previa with placenta accreta.

Prophylactic uterine artery embolization during cesarean delivery for placenta previa complicated by placenta accreta

OBJECTIVE

To evaluate the efficacy and safety of prophylactic uterine artery embolization (UAE) during cesarean delivery for women with placenta previa complicated by placenta accreta.

METHODS

A retrospective analysis of women with placenta previa admitted to The Second Affiliated Hospital of Soochow University, Suzhou, China, for elective cesarean between February 2003 and July 2016. Postpartum estimated blood loss, blood transfusion, hysterectomy, disseminated intravascular coagulation (DIC) incidence, intensive care unit (ICU) duration, and postoperative stay were compared between control women who underwent cesarean delivery only and women who underwent prophylactic intraoperative UAE during cesarean.

RESULTS

There were 28 and 26 women in the UAE and control group, respectively. There were no differences in hysterectomy incidence (P=0.291), or duration of ICU stay (P=0.085), or postoperative hospitalization (P=0.668) between the groups; however, the incidence of DIC was lower in the UAE group (P=0.035). Mean estimated blood loss (P=0.018) and blood transfusion (P=0.011) were also lower in the UAE group. No serious complications were associated with the endovascular procedures.

CONCLUSION

Prophylactic intraoperative UAE seemed to effectively reduce blood loss, need for blood transfusion, and incidence of DIC among women with placenta previa complicated by placenta accreta.

Development of a Novel Nomogram for Predicting Placenta Accreta in Patients With Scarred Uterus: A Retrospective Cohort Study

Objective: The aim of this study was to develop a nomogram to predict the risk of placenta accreta in scarred uterus patients in China.

Methods: We retrospectively analyzed 8,371 singleton pregnancies with scarred uterus at Shengjing Hospital, affiliated with China Medical University. Two thirds of the patients were randomly assigned to the training set (n = 5,581), and one third were assigned to the validation set (n = 2,790). Multivariate logistic regression was performed by using the training set, and the nomogram was developed. Discrimination and calibration were performed by using both the training and validation sets.

Results: The multivariate logistic regression model identified number of previous cesarean section, number of vaginal bleeding, medication during pregnancy, and placenta previa as covariates associated with placenta accreta. A nomogram was developed to predict the risk of placenta accreta in the training set with a Harrell's C-index of 0.93 and 0.927 in the training set and validation set, respectively. Calibration of the nomogram predicted placenta accreta corresponding closely with the actual placenta accreta.

Conclusion: We developed a nomogram predicting the risk of placenta accreta in scarred uterus patients in China. Validation using both the training set and the validation set demonstrated good discrimination and calibration, suggesting good clinical utility.

Effectiveness of segmental resection technique in the treatment of placenta accreta spectrum

BACKGROUND

Placental accreta is a serious obstetrical entity and its management is challenging. The aim of this study was to evaluate and define our uterus sparing surgical technique in patients with placenta accreta spectrum.

METHODS

The data of 21 patients who underwent uterine segmental resection during cesarean section with a preliminary diagnosis of placenta accreta spectrum at Ege University between January 2017 and December 2018 were evaluated retrospectively.

RESULTS

Twenty-one patients were successfully treated with the segmental resection technique. In all cases, resected tissues were evaluated by histopathologically and the diagnosis of placenta accreta spectrum was confirmed. Hysterectomy was performed in two cases due to peri-partum hemorrhage that disrupted hemodynamics. None of the patients had complications such as visceral organ injury and wound infection.

CONCLUSION

Our technique of uterine sparing surgery seems to be safe and effective in the management of placenta accreta spectrum without increasing complication rates.

Uterine Preservation after Vaginal Delivery with Manual Extraction of Focal Placenta Accreta

Placenta accreta spectrum disorder (PASD) is the adherence of the placenta caused by an abnormal trophoblast invasion into the myometrium. It is classified as placenta accreta, placenta increta, and placenta percreta depending on the extent of the invasion. Placenta accreta, defined as the superficial invasion of the placenta to the myometrium, accounts for 75% of PASD. Placenta increta is characterized by chorionic villi invasion deep into the myometrium. Placenta percreta involves placental invasion through the uterus and serosa and into the peritoneal cavity or surrounding viscera. Maternal morbidity and mortality can occur secondary to hemorrhage, disseminated intravascular coagulation, risks associated with blood transfusion, and pelvic and abdominal viscera injury. The standard of care in a known diagnosis of PASD is a cesarean delivery followed by hysterectomy with the placenta in situ. We report a case in which the diagnosis of focal PASD was not known antenatally but suspected after vaginal delivery. The patient subsequently underwent conservative management with uterine preservation and did not require laparotomy.

Alalfy modified cervical inversion technique as a tamponade in controlling PPH in placenta previa, a multicentric double blind randomized controlled trial

INTRODUCTION

Postpartum hemorrhage that occurs frequently with placenta previa is one of the causes of maternal mortality in 14% in developing countries.

OBJECTIVE

To assess efficacy of cervical inversion as a tamponade in controlling bed of placenta in cases of placenta previa.

PATIENTS AND METHOD

A prospective randomized controlled study was conducted among a total of 240 pregnant women with placenta previa (120 subjected to Alalfy modified cervical inversion technique plus hemostatic sutures and 120 was not subjected cervical inversion and only was subjected to hemostatic sutures in Obstetrics and Gynecology Department at Suez Canal University hospital, Helwan University and Algezeerah hospital for a planned cesarean section).

RESULTS

The mean intraoperative blood loss, the intraoperative time, and the postoperative hemoglobin show a statistically significant difference between cases with placenta previa who were exposed to cervical inversion in comparison to cases that had no cervical inversion with a p-value <.001.

CONCLUSION

Modified cervical inversion (Alalfy technique) as a tamponade when added to hemostatic sutures to the placental bed is an easy, rapid, and efficient procedure that can decrease the amount of blood loss, time needed to stop bleeding per bed, total operative time, also it can decrease the need for blood transfusion.