Retracted: A randomized controlled study comparing two uterine sparing techniques in conservative management of placenta accreta spectrum

OBJECTIVES

To compare the efficacy and safety of two uterine sparing techniques in conservative management of placenta accreta spectrum (PAS).

METHODS

This multicenter randomized controlled study was conducted from January 1, 2017 to December 31, 2020 at two university hospitals. Patients were randomly allocated into two groups; Group 1 was managed by Assar's technique and Group 2 was managed by Shehata's technique. Operative time, blood loss, operative complications (organ or vessel injury), and postoperative complications (early and late) were reported. Success of the technique, units of blood transfusion, and intensive care unit admissions were recorded.

RESULTS

Demographic data in both groups were not significantly different. The mean gestational age at the delivery time was 36 weeks in both groups. Operative time was 120 (100-140) minutes and 75 (60-100) minutes in Assar's and Shehata's techniques, respectively (P < 0.001). Blood loss was higher in Shehata's technique than in Assar's (P < 0.001). Intensive care unit admissions were minimal in both groups. Operative complications were comparable in both groups. The success of Assar's and Shehata's techniques in uterine preservation was 85% and 95%, respectively.

CONCLUSION

Both techniques were safe and successful in uterine sparing. Therefore, we recommend these techniques for conservative management of PAS.

CLINICAL TRIAL REGISTRATION

The trial was registered on UMIN-CTR and had the unique ID: UMIN000025315 on the following link: https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000029120.

Termination of a second-trimester pregnancy with placenta accreta spectrum disorder

Background: The termination of pregnancy in patients with placenta accreta spectrum disorder (PASD) during the second trimester remains uncertain. In addition, interventional radiology techniques, such as arterial embolization and balloon placement, are potential options. We evaluated the outcomes of pregnancy termination in patients with PASD during the second trimester and the effectiveness of preoperative interventional radiology techniques.Methods: This retrospective study analyzed 48 PASD patients who underwent pregnancy termination during the second trimester between January 2016 and May 2021.Results: Of the 48 patients, 20 (41.67%) underwent transvaginal termination, whereas 28 (58.33%) underwent cesarean section. Notably, no significant differences were observed in success rates between the transvaginal termination and cesarean section groups (80.00% vs. 92.86%, P = 0.38). Furthermore, no statistically significant differences were observed in the success rates (94.12% vs 90.32%, P = 1.00) and blood loss (512.35 ± 727.00 ml vs 804.00 ± 838.98 ml, P = 0.23) between the artery embolization and non-embolization groups. In the vaginal termination group, statistically significant differences were observed in gestational weeks (16.70 ± 3.12 vs 22.67 ± 3.63, P < 0.01) and blood loss (165.00 ± 274.43 ml vs 483.64 ± 333.53 ml, P = 0.04) between the (artery embolization and non-embolization) subgroups. Conversely, in the cesarean section group, no significant differences were observed in gestational weeks (23.59 ± 3.14 vs 23.20 ± 4.37, P = 0.79) and blood loss (811.11 ± 879.55 ml vs 989.47 ± 986.52 ml, P = 0.76) between the subgroups.Conclusions: Further studies are needed to evaluate the efficacy of vaginal termination in PASD patients during the second trimester. Regarding cesarean termination, arterial embolization did not demonstrate increased effectiveness.

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.

Absence of abnormal vascular changes on prenatal imaging aids in differentiating simple uterine scar dehiscence from placenta accreta spectrum: a case series

Accurate prenatal discrimination between a simple, non-adherent uterine scar dehiscence with an underlying placenta and the severe end of the placenta accreta spectrum is problematic as the two can appear similar on prenatal imaging. This may lead to the false diagnosis of placenta accreta spectrum resulting obstetric anxiety, overtreatment and potential iatrogenic morbidity. Despite potential similarities in the etiology, the manifestation and management of these two conditions is very different. The prenatal sonographic features of seven confirmed cases of simple uterine scar dehiscence with an underlying placenta previa were examined. The common sonographic features found for scar dehiscence was a thinned myometrium (<1 mm) overlying a generally homogenous placenta and a placental bulge. There was absence of lacunae and features of hypervascularity including bridging vessels. Our findings suggest accurate discrimination between a simple scar dehiscence with the placenta underlying it and placenta accreta spectrum can be made on prenatal ultrasound if the placenta is carefully examined for the vascular features unique to PAS.

Placenta accreta spectrum disorders clinical practice guidelines: A systematic review

OBJECTIVES

To objectively assess the quality of the published clinical practice guidelines (CPGs) on the management of pregnancies complicated by placenta accreta spectrum (PAS)disorders.

METHODS

MEDLINE, Embase, Scopus, and ISI Web of Science databases were searched. The following aspects related to the management of pregnancies with suspected PAS disorders were evaluated: risk factors for PAS, prenatal diagnosis, role of interventional radiology and ureteral stenting, and optimal surgical management. The assessment of risk of bias and quality assessment of the CPGs were performed using the (AGREE II) tool (Brouwers et al., 2010). To define a CPG as of good quality we adopted a cut-off score >60%.

RESULTS

Nine CPGs were included. Specific risk factors for referral were assessed by 44.4% (4/9) of CPGs, mainly consisting in the presence of placenta previa and a prior cesarean delivery or uterine surgery. About 55.6% of CPGs (5/9) suggested ultrasound assessment of women with risk factors for PAS in the second and third trimester of pregnancy and 33.3% (3/9) recommended magnetic resonance imaging (MRI); 88.9% (8/9) of CPGs recommended cesarean delivery at 34-37 weeks of gestation. There was not generally consensus on the use of interventional radiology and ureteral stenting before surgery for PAS. Finally, hysterectomy was the recommend surgical approach by 77.8% (7/9) of the included CPGs.

CONCLUSION

Most of the published CPGs on PAS are generally of good quality. There was general agreement among the different CPGs on PAS as a regard as risk stratification, timing at diagnosis and delivery but not on the indication for MRI, use of interventional radiology and ureteral stenting.

Systematic review and meta-analysis on placenta accreta spectrum disorders in twin pregnancies: risk factors, detection rate and histopathology

INTRODUCTION

The occurrence of PAS has been recently associated with the presence of twin pregnancy. Aim of this review is to report the risk factors, histopathological correlation, diagnostic accuracy of prenatal ultrasound and clinical outcome of twin pregnancies complicated by placenta accreta spectrum (PAS) disorders.

EVIDENCE ACQUISITION

PubMed, Embase, Cinahl, Clinical Trial.Gov and Google Scholar databases were searched. Inclusion criteria were studies on twin pregnancies complicated by PAS. The outcomes explored were risk factors for PAS (including placenta previa, prior uterine surgery or assisted reproductive technology, ART), histopathology (placenta accreta and increta/percreta), detection rate of prenatal ultrasound and clinical outcome, including need for blood transfusion, hysterectomy, emergency or scheduled Cesarean delivery (CD), and maternal death. Random effect meta-analyses of proportions were sued to combine the data.

EVIDENCE SYNTHESIS

Two studies considering 103 pregnancies were included in this systematic review: 41.86% (95% CI 27.0-57.9) of twin pregnancies complicated by PAS disorders had a prior CD, 28.22% (95% CI 13.4-46.0) presented placenta previa and 58.14% (95% CI 42.1-73.0) of twin pregnancies were conceived by ART. 74.49% (95% CI 41.6-96.5) of PAS in twin pregnancies were placenta accreta, while 25.51% (95% CI 3.5-58.4) were placenta increta or percreta. Prenatal diagnosis of PAS in twin pregnancies was accomplished only in 27.91% (95% CI 15.3-43.7) of cases. Finally, only one study consistently reported the clinical outcome of PAS in twins. 31.67% (95% CI 20.3-45.0) of women required blood transfusion, 26.67% (95% CI 16.1-39.7) had hysterectomy, while there was no case of maternal death. 44.19% of women had an emergency CD.

CONCLUSIONS

There is still limited evidence on the clinical course of PAS disorders in twin pregnancies. Placenta previa, prior uterine surgery (mainly CD), and ART are the most commonly risk factors for PAS disorders in twins. Prenatal diagnosis of PAS in twins is lower compared to what reported in singleton. Finally, about 30% of women with a twin pregnancy complicated by PAS required blood transfusion and hysterectomy.

Placenta accreta spectrum: experience of conservative surgery during cesarean section and clinical and radiological management during pregnancy and follow-up

Placenta accreta spectrum (PAS) is a condition of abnormal placental invasion including placenta accreta, increta and percreta and is a major cause of maternal morbidity and mortality. Recently, a conservative surgical technique has been proposed as a valid alternative to peri-partum hysterectomy to reduce the short- and long-term risks for the mothers and to preserve fertility. Magnetic resonance imaging (MRI) seems to be useful first of all at the time of diagnosis and furthermore to investigate the course of conservative management of PAS. We describe three cases of PAS treated with conservative procedure and managed with clinic, ultrasound and MRI by a multidisciplinary equipe.

USMRI Features and Clinical Data-Based Model for Predicting the Degree of Placenta Accreta Spectrum Disorders and Developing Prediction Models

AIM

This study aimed to investigate the ability of ultrasound/magnetic resonance imaging (MRI) signature and clinical data-based model for preoperatively predicting the degree of placenta accreta spectrum disorders and develop combined prediction models.

METHODS

The clinicopathological characteristics, prenatal ultrasound images, and MRI features of 132 pregnant women with placenta accreta spectrum disorders at Xiangyang No. 1 People's Hospital were retrospectively reviewed from January 2016 to December 2020. In the training set of 99 patients, the ultrasound/MRI features model, clinical characteristics model, and combined model were developed by multivariate logistic regression analysis to predict the degree of placenta accreta spectrum disorders. The prediction performance of different models was compared using the Delong test. The developed models were validated by assessing their prediction performance in a test set of 33 patients.

RESULTS

The multivariate logistic regression analysis identified history of abortion, history of endometrial injury, and blurred boundary between the placenta and the myometrium/between the uterine serosa and the bladder to construct a combined model for predicting the degree of placenta accreta spectrum disorders (area under the curve (AUC) = 0.931; 95% confidence interval (CI): 0.882-0.980). The AUC of the clinical characteristics model and ultrasound/MRI features model was 0.858 (95% CI 0.794-0.921) and 0.709 (95% CI 0.624-0.798), respectively. The AUC of the combined model was significantly higher than that of the ultrasound/MRI features model (P < 0.001) or clinical characteristics model (P < 0.0015) in the training set. In the test set, the combined model also showed higher prediction performance.

CONCLUSIONS

Ultrasound/MRI-based signature is a powerful predictor for the degree of placenta accreta spectrum disorders in an early stage. A combined model (constructed with history of abortion, history of endometrial injury, and blurred boundary between the placenta and the myometrium/between the uterine serosa and the bladder) can improve the accuracy for predicting the degree of placenta accreta spectrum disorders in an early stage.

Placenta Percreta Complications

Placenta percreta is the most severe form of placenta accreta and is characterized by placental invasion through the entirety of the myometrium and possibly into extrauterine tissues. It is associated with prior cesarean deliveries and placenta previa. Herein, we present the case of a patient who developed placenta percreta and experienced massive blood loss of 27 liters. She developed many complications over the next 11 months, including deep vein thrombosis, pulmonary embolism, preeclampsia after pregnancy, hematoma, blood clots in the bladder, lactation failure, ileus, vesicovaginal fistula, excessive scar tissue requiring surgery, loss of an ovary, and recurrent bladder perforation. We analyze the mechanisms of these complications and the most common complications associated with placenta percreta.

Suspected Placenta Accreta: Using Imaging to Stratify Risk of Morbidity

OBJECTIVE

This study was aimed to compare clinical outcomes and use of interventions in women with suspected accreta based on the degree of antenatal suspicion.

STUDY DESIGN

This was a retrospective cohort study of women with suspected accreta from 2007 to 2019. Included patients had one or more imaging studies suggestive of accreta. Cases were classified as "lower risk" if imaging showed possible signs of accreta including mild or superficial myometrial infiltration, an abnormal uterine contour, an abnormal uteroplacental interface, or loss of the retroplacental hypoechoic zone and "higher risk" if there was clear evidence of more than superficial myometrial infiltration, placental tissue extruding beyond the uterine serosa, bridging vessel(s), or placental lacunae with high velocity and/or turbulent flow. The primary study outcome was a composite maternal morbidity including cesarean hysterectomy, transfusion of blood or blood products, unintentional cystotomy, or intensive care unit (ICU) admission. Chi-square, Fisher's exact test, and Mann-Whitney U-test were used for analysis.

RESULTS

A total of 78 women had a suspected accreta on imaging, 36 with "lower risk" features and 42 with "higher risk" features. There were no differences in baseline maternal demographics. Women in the "higher risk" group were more likely to have a placenta previa (p < 0.01) and preoperative consultation with gynecologic oncology (p = 0.04). There was a significant difference in composite maternal morbidity between patients with "lower risk" and "higher risk" features of accreta on imaging (50 vs. 92.9%, p < 0.01). Median gestational age at planned and actual delivery were earlier in the "higher risk" group (36.6 vs. 34.9 weeks, p < 0.01; 36.0 vs. 34.7 weeks, p < 0.01).

CONCLUSION

Stratification of women with suspected accreta based on imaging corresponded to rates of maternal morbidity and operative complications, and appears to have been used clinically in selecting timing of delivery and interventions.

KEY POINTS

· Increased morbidity with high risk accreta imaging.. · Interventions correlate with accreta imaging risk.. · Imaging can be used to stratify accreta cases..

Extreme enhanced myometrial vascularity following cesarean scar pregnancy: a new diagnostic entity

OBJECTIVE

To define, illustrate and to follow-up the diagnosis, pathophysiology and treatment of a subset of the known enhanced myometrial vascularity (EMV): its extreme form, associated with cesarean scar pregnancies (CSP) and with some cases pf placenta accreta spectrum being at increased risk of significant bleeding complications. We also aim to provide guidance to the management of such cases.

MATERIAL AND METHODS

This is an IRB-approved retrospective observational study of thirteen patients with an extreme form of EMV complicating CSPs. Patient's age, parity, number of cesarean deliveries, initial and time to negative serum hCG levels, primary and secondary diagnoses, blood flow peak systolic velocities, primary and secondary treatments, uterine artery embolization and outcomes were recorded.

RESULTS

Gestational ages ranged 6-11 weeks at initial presentation. Initial serum hCG was 20.0-102.48 mIU/L (mean 44.4 mIU/L). Diameter of EMV reached 20-75 mm (mean 46.8 mm). The mean peak systolic velocity (PSV) was 84.2 cm/s (range 46.7-118.0). Primary treatments were: systemic methotrexate (MTX) alone; D&C alone; MTX and D&C; local and systemic intra-gestational MTX injection; double cervical ripening balloon with systemic MTX; misoprostol and D&C; emergent UAE. UAE and hysterectomy were the two main secondary treatments in 10 women except 1 having a D&C after UAE, and in 1 the lesion regressed without secondary treatment. Mean time to nonpregnant hCG levels was 21-122 days (mean 67.2). Mean follow-up was 110.2 days (range 26-160). Ten women were treated with UAE, 6 had one, 3 had two embolizations. Two women had hysterectomies, one of these for persistent bleeding. Based upon the common denominators of the clinical and the US pictures, our definition of extreme EMV is sustained form of EMV associated with treated or untreated CSP, with peak systolic velocities of blood flow over 50 cm/s, slow return or plateauing serum hCG, with or without clinically significant vaginal bleeding, unresponsive to initial or secondary treatment requiring uterine artery embolization or hysterectomy.

CONCLUSION

The EMV developing in the background of retained placental tissue associated with CSP differs following the normal regression of the physiologically re-modelled, dilated vascular bed from the faulty "disrepair" of the vessel wall in in treated or untreated CSPs. The "threatening" appearance of the above EMVs warranted the term "extreme", creating their separate new sub-category." Extreme forms of CSP-related EMV pose significant diagnostic and management challenges. Prompt recognition and intervention, the proactive use of UAE, can maximize the outcome of women affected by this "extreme" form of EMV enabling to preserve reproductive potential. Obstetricians, gynecologists and interventional radiologists should be aware of this form of severe vascular complication.

Radical surgery including the role of an interval hysterectomy

The incidence of placenta accrete spectrum (PAS) disorders is increasing worldwide. Pregnancies complicated by PAS are at a high risk of intrapartum surgical complications, mainly due to severe maternal hemorrhage, potentially leading to death, thus highlighting the need for a tailored an appropriate surgical management for these women. Despite its clinical relevance, there are still unanswered questions regarding the surgical management of women with PAS. Hysterectomy has been considered as the gold standard for the surgical treatment of these women. However, the surgical approach has not yet been standardized, and several conservative surgical procedures such as the Triple P Procedure are also being performed for PAS. Interventional radiology techniques have been demonstrated to reduce the risk of severe blood loss in women with postpartum hemorrhage, but their role in the management of women with PAS has not yet been fully defined. The aim of this chapter is to provide an up-to-date insight on the radical surgical approach to adopt during cesarean delivery in pregnancies complicated by PAS disorders.

Outcome of cesarean scar pregnancy according to gestational age at diagnosis: A systematic review and meta-analysis

OBJECTIVE

The association between the most severe types of placenta accreta spectrum disorders and caesarean scar pregnancy (CSP) poses the question of whether early diagnosis may impact the clinical outcome of these anomalies. The aim of this study is to report the outcome of cesarean scar pregnancy (CSP) diagnosed in the early (≤9 weeks) versus late (>9 weeks) first trimester of pregnancy.

STUDY DESIGN

Medline, Embase and Clinicaltrail.gov databases were searched. Studies including cases of CSP with an early (≤9 weeks of gestation) compared to a late (>9 weeks) first trimester diagnosis of CSP, followed by immediate treatment, were included in this systematic review. The primary outcome was a composite measure of severe maternal morbidity including either severe first trimester bleeding, need for blood transfusion, uterine rupture or emergency hysterectomy. The secondary outcomes were the individual components of the primary outcome. Random-effect meta-analyses were used to combine data.

RESULTS

Thirty-six studies (724 women with CSP) were included. Overall, composite adverse outcome complicated 5.9 % (95 % CI 3.5-9.0) of CSP diagnosed ≤9 weeks and 32.4 % (95 % CI 15.7-51.8) of those diagnosed >9 weeks. Massive hemorrhage occurred in 4.3 % (95 % CI 2.3-7.0) of women with early and in 28.0 % (95 % CI 14.1-44.5) of those with late first trimester diagnosis of CSP, while the corresponding figures for the need for blood transfusion were 1.5 % (95 % CI 0.6-2.8) and 15.8 % (95 % CI 5.5-30.2) respectively. Uterine rupture occurred in 2.5 % (95 % CI 1.2-4.1) of women with a prenatal diagnosis of CSP ≤ 9 weeks and in 7.5 % (95 % CI 2.5-14.9) of those with CSP > 9 weeks, while an emergency intervention involving hysterectomy was required in 3.7 % (95 % CI 2.2-5.4) and 16.3 % (95 % CI5.9-30.6) respectively. When computing the risk, early diagnosis of CSP was associated with a significantly lower risk of composite adverse outcome, (OR: 0.14; 95 % CI 0.1-0.4 p < 0.001).

CONCLUSIONS

Early first trimester diagnosis of CSP is associated with a significantly lower risk of maternal complications, thus supporting a policy of universal screening for these anomalies in women with a prior cesarean delivery although the cost-effectiveness of such policy should be tested in future studies.

Diagnostic accuracy of prenatal ultrasound in identifying the level of the lesion in fetuses with open spina bifida: A systematic review and meta-analysis

INTRODUCTION

The role of prenatal ultrasound in correctly identifying the level of the lesion in fetuses with open spina bifida has yet to be determined. The primary aim of this systematic review was to report the diagnostic accuracy of ultrasound in determining the level of the lesion in fetuses with open spina bifida. The secondary aim was to elucidate whether prenatal magnetic resonance imaging (MRI) improves the diagnostic performance of prenatal imaging in correctly identifying the level of the lesion.

MATERIAL AND METHODS

Inclusion criteria were studies reporting the agreement between ultrasound, MRI and postnatal or postmortem assessment of fetuses with spina bifida. Agreement was defined as: complete (when the upper level of the lesion detected prenatally was the same recorded at postnatal or postmortem evaluation), within one (when the upper level of the lesion recorded prenatally was within one vertebral body higher or lower than that reported postnatally) and within two vertebral bodies (when the upper level of the lesion recorded prenatally was within two vertebral bodies higher or lower than that reported postnatally or postmortem evaluation). Meta-analyses of proportions were used to combine data.

RESULTS

Fourteen studies (655 fetuses) were included. Ultrasound was able to identify the correct level of the lesion in 40.9% (95% confidence interval [CI] 26.9-55.6) of cases. The upper level of the lesion recorded on ultrasound was within one vertebral body in 76.2% (95% CI 65.0-85.9) of cases and within two segments in 92.4% (95% CI 84.3-97.7). Fetal MRI detected the exact level of the lesion in 42.5% (95% CI 35.9-45.2) of cases; the level of the lesion recorded on MRI was higher in 26.4% (95% CI 20.0-33.3) of cases and lower in 32.4% (95% CI 25.5-39.7) than that confirmed postnatally. The upper level of the lesion recorded on MRI was within one vertebral body in 76.2% (95% CI 65.9-85.2) of cases and within two segments in 94.2% (95% CI 90.2-97.2).

CONCLUSIONS

Both ultrasound and MRI have a moderate diagnostic accuracy in identify the upper level of the lesion in fetuses with open spina bifida.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The efficacy of LigaSure™ open instruments in cases of cesarean hysterectomy due to placenta percreta: a retrospective, record-based, comparative study

OBJECTIVE

The standard treatment for patients with placenta percreta is cesarean hysterectomy that can cause severe bleeding. New-generation vessel sealing systems like LigaSure can cut and seal vascular structures and tissues. The aim of this study was to retrospectively compare hysterectomies performed with traditional instruments and those performed with LigaSure instruments to determine the possible advantages with the latter.

MATERIALS AND METHODS

Patients with placenta percreta who underwent elective cesarean hysterectomy by the same surgeon were divided into two groups based on the type of instruments used. Group 1, the standard conventional hysterectomy group, operated with conventional instruments for cutting and tying; and Group 2, the LigaSure hysterectomy group, operated with the new-generation bipolar sealing and cutting instruments. The groups were retrospectively compared for bleeding, operating time, and complications.

RESULTS

In Group 2, the operating time, intraoperative and total transfused erythrocyte suspension units, total fluid in the drain, and total hospital stay were lower than in Group 1 (p < .05), as was the need for internal iliac artery ligation (p = .013). The complication rates were similar between the two groups (p > .05).

CONCLUSION

The use of LigaSure open instruments in cesarean hysterectomies in patients with placenta percreta may reduce operating times and the amount of bleeding.

Pelvic arterial embolisation with cyanoacrylate during caesarean hysterectomy for placenta accreta

PURPOSE

To compare n-butyl cyanoacrylate (NBCA) and gelatine sponge (GS) as embolic materials for prophylactic pelvic arterial embolisation during caesarean hysterectomy for placenta accreta spectrum (PAS).

MATERIAL AND METHODS

This retrospective study comprised 12 women (age range, 23-42 years; mean, 34.1 years) who underwent caesarean hysterectomy for PAS. Following caesarean delivery, bilateral uterine and non-uterine parasitic arteries were embolized with GS in the first four cases (GS group) and primarily with NBCA mixed with iodized oil in the subsequent eight cases (NBCA group). Procedure time for embolisation and hysterectomy and total blood loss were compared between the two groups using Welch's t-test.

RESULTS

Although procedure time for embolisation tended to be longer in the NBCA group than in the GS group (111 ± 47 min versus 71 ± 32 min, p=.11), that for hysterectomy was significantly reduced in the NBCA group when compared to the GS group (158 ± 42 min versus 236 ± 39 min, p=.02). Total blood loss was significantly lower in the NBCA group than in the GS group (1375 ± 565 mL versus 2668 ± 587 mL, p=.01).

CONCLUSION

Procedure time for hysterectomy and total blood loss during caesarean hysterectomy can be reduced by using NBCA instead of GS in prophylactic pelvic arterial embolisation for PAS.

[Placenta accreta spectrum disorder: Management and morbidity in a French type-3 maternity]

OBJECTIVES

Placenta accreta spectrum disorder (PASD) is a rare obstetrical pathology, however its incidence is increasing. Morbidity associated with PASD is still high. Even if hysterectomy is considered to be the reference standard treatment, the conservative treatment by leaving the placenta in situ is now an approved option. The objective was to describe management and morbidity of patients with PASD, during the decade, in our French high-level maternity.

METHODS

It was a retrospective study of management and morbidity of PASD in our department between 2007 and 2017.

RESULTS

Forty-six PASD cases were admitted in our center. Thirty-three (71.7%) had a prenatal suspicion of PASD. Conservative treatment was considered for 22 patients (47.8%). It was successful in 12 cases (54.5%). Thirty-four (73.9%) had a primary hysterectomy, eight (17.3%) had a delayed hysterectomy, four (8.6%) had a uterine conservation. Primary Morbidity included 28 blood transfusions, 12 bladder injuries, 1 ureteral injury and 13 transfers to intensive care unit. Secondary morbidity after conservative treatment included two Hemorrhages (16.6%), five endometritis (41.6%) and three disseminated intravacular coagulations (25%).

CONCLUSIONS

Morbidity associated with this pathology is severe. Conservative treatment became an option for PASD. Thanks to a better antenatal diagnosis, it can be proposed to more women. Morbidity seems the same as other centers. Our rate of primary and secondary hysterectomy is higher than other centers. Conservative treatment seems an effective option for women who desire to preserve their fertility to avoid peripartum hysterectomy and its related morbidity and consequences on fertility.