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Viana Pinto P, Kawka-Paciorkowska K, Morlando M, Huras H, Kołak M, Bertholdt C, Jaworowski A, Braun T, Fox KA, Morel O, Paping A, Stefanovic V, Mhallem M, Van Beekhuizen HJ. Prevalence of fetal anomalies, stillbirth, neonatal morbidity, or mortality in pregnancies complicated by placenta accreta spectrum disorders. Acta Obstet Gynecol Scand 2024. [PMID: 39004930 DOI: 10.1111/aogs.14919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION Placenta accreta spectrum disorders (PAS) lead to major complications in pregnancy. While the maternal morbidity associated with PAS is well known, there is less information regarding neonatal morbidity in this setting. The aim of this study is to describe the neonatal outcomes (fetal malformations, neonatal morbidity, twin births, stillbirth, and neonatal death), using an international multicenter database of PAS cases. MATERIAL AND METHODS This was a prospective, multicenter cohort study based on prospectively collected cases, using the international multicenter database of the International Society for PAS, carried out between January 2020 and June 2022 by 23 centers with experience in PAS care. All PAS cases were included, regardless of whether singleton or multiple pregnancies and were managed in each center according to their own protocols. Data were collected via chart review. Local Ethical Committee approval and Data Use Agreements were obtained according to local policies. RESULTS There were 315 pregnancies eligible for inclusion, with 12 twin pregnancies, comprising 329 fetuses/newborns; 2 cases were excluded due to inconsistency of data regarding fetal abnormalities. For the calculation of neonatal morbidity and mortality, all elective pregnancy terminations were excluded, hence 311 pregnancies with 323 newborns were analyzed. In our cohort, 3 neonates (0.93%) were stillborn; of the 320 newborns delivered, there were 10 cases (3.13%) of neonatal death. The prevalence of major congenital malformations was 4.64% (15/323 newborns), most commonly, cardiovascular, central nervous system, and gastrointestinal tract malformations. The overall prevalence of major neonatal morbidity in pregnancies complicated by PAS was 47/311 (15.1%). There were no stillbirths, neonatal deaths, or fetal malformations in reported twin gestations. CONCLUSIONS Although some outcomes may be too rare to detect within our cohort and data should be interpreted with caution, our observational data supports reassuring neonatal outcomes for women with PAS.
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Affiliation(s)
- Pedro Viana Pinto
- Gynecology Department, Centro Hospitalar e Universitário de São João, Porto, Portugal
| | | | - Maddalena Morlando
- Department of Women, Children and of General and Specialized Surgery, University "Luigi Vanvitelli", Naples, Italy
- Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy
| | - Hubert Huras
- Department of Obstetrics and Perinatology, Medical College, Jagiellonian University, Krakow, Poland
| | - Magdalena Kołak
- Department of Obstetrics and Perinatology, Medical College, Jagiellonian University, Krakow, Poland
| | - Charline Bertholdt
- Department of Obstetrics, Nancy Regional and University Hospital Center (CHRU), Université de Lorraine, Nancy, France
| | - Andrzej Jaworowski
- Department of Obstetrics and Perinatology, Medical College, Jagiellonian University, Krakow, Poland
| | - Thorsten Braun
- Department of Obstetrics, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Karin A Fox
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, University of Texas Medical Branch, Galveston, Texas, USA
| | - Olivier Morel
- Department of Obstetrics, Nancy Regional and University Hospital Center (CHRU), Université de Lorraine, Nancy, France
| | - Alexander Paping
- Department of Obstetrics, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Vedran Stefanovic
- Department of Obstetrics and Gynecology, Fetomaternal Medical Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mina Mhallem
- Department of Obstetrics, Clinqiues Universitaires Saint-Luc, Brussels, Belgium
| | - Heleen J Van Beekhuizen
- Department of Gynecological Oncology, Erasmus MC Cancer Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Pan S, Han M, Zhai T, Han Y, Lu Y, Huang S, Zuo Q, Jiang Z, Ge Z. Maternal outcomes of conservative management and cesarean hysterectomy for placenta accreta spectrum disorders: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2024; 24:463. [PMID: 38969992 PMCID: PMC11227152 DOI: 10.1186/s12884-024-06658-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 06/25/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND Cesarean hysterectomy as a traditional therapeutic maneuver for placenta accreta spectrum (PAS) has been associated with serious morbidity, conservative management has been used in many institutions to treat women with PAS. This systematic review aims to compare maternal outcomes according to conservative management or cesarean hysterectomy in women with placenta accreta spectrum disorders. METHODS A systematic literature search was performed in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, and four Chinese databases (Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Chinese Wanfang database and VIP database) to May 2024. Included studies were to be retrospective or prospective in design and compare and report relevant maternal outcomes according to conservative management (the placenta left partially or totally in situ) or cesarean hysterectomy in women with PAS. A risk ratio (RR) with 95% confidence interval (95% CI) was calculated for categorical outcomes and weighted mean difference (WMD) with 95% CI for continuous outcomes. The Newcastle-Ottawa Quality Assessment Scale was used to assess the observational studies. All analyses were performed using STATA version 18.0. RESULTS Eight studies were included in the meta-analysis. Compared with cesarean hysterectomy, PAS women undergoing conservative management showed lower estimated blood loss [WMD - 1623.83; 95% CI: -2337.87, -909.79], required fewer units of packed red blood cells [WMD - 2.37; 95% CI: -3.70, -1.04] and units of fresh frozen plasma transfused [WMD - 0.40; 95% CI: -0.62, -0.19], needed a shorter mean operating time [WMD - 73.69; 95% CI: -90.52, -56.86], and presented decreased risks of bladder injury [RR 0.24; 95% CI: 0.11, 0.50], ICU admission [RR 0.24; 95% CI: 0.11, 0.52] and coagulopathy [RR 0.20; 95% CI: 0.06, 0.74], but increased risk for endometritis [RR 10.91; 95% CI: 1.36, 87.59] and readmission [RR 8.99; 95% CI: 4.00, 12.21]. The incidence of primary or delayed hysterectomy rate was 25% (95% CI: 19-32, I2 = 40.88%) and the use of uterine arterial embolization rate was 78% (95% CI: 65-87, I2 = 48.79%) in conservative management. CONCLUSION Conservative management could be an effective alternative to cesarean hysterectomy when women with PAS desire to preserve the uterus and are informed about the limitations of conservative management. PROSPERO ID CRD42023484578.
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Affiliation(s)
- Siman Pan
- School of Nursing, Nanjing Medical University, Nanjing, China
| | - Minmin Han
- School of Nursing, Nanjing Medical University, Nanjing, China
| | - Tianlang Zhai
- Department of Obstetrics, Dongtai People's Hospital, Affiliated Hospital of Nantong University, Yancheng, China
| | - Yufei Han
- Department of Obstetrics, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, No.300, Guangzhou Avenue, Gulou District, Nanjing, Jiangsu, 210029, China
| | - Yihan Lu
- Department of Obstetrics, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, No.300, Guangzhou Avenue, Gulou District, Nanjing, Jiangsu, 210029, China
| | - Shiyun Huang
- Department of Obstetrics, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, No.300, Guangzhou Avenue, Gulou District, Nanjing, Jiangsu, 210029, China
| | - Qing Zuo
- Department of Obstetrics, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, No.300, Guangzhou Avenue, Gulou District, Nanjing, Jiangsu, 210029, China
| | - Ziyan Jiang
- Department of Obstetrics, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, No.300, Guangzhou Avenue, Gulou District, Nanjing, Jiangsu, 210029, China.
| | - Zhiping Ge
- Department of Obstetrics, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, No.300, Guangzhou Avenue, Gulou District, Nanjing, Jiangsu, 210029, China.
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Seoud M, Chahine R, Arab W, Jaafar I, Moubarak M, El Kassis N, Abdallah R, Ramadan MK, Nassar M, Nassar A, Ayoub EN, Atallah D. The Lebanese percreta group: A retrospective cohort study of both radical and conservative management outcomes of abnormally invasive placenta. Int J Gynaecol Obstet 2024. [PMID: 38798144 DOI: 10.1002/ijgo.15701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 05/07/2024] [Accepted: 05/11/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE The aim of the present study was to illustrate the outcomes of abnormally invasive placenta (AIP) cases managed in three leading centers in Lebanon. METHODS We conducted a retrospective multicenter cohort study. Patients managed conservatively (cesarean delivery with successful placental separation) or radically (cesarean hysterectomy) were included in the study. Data included patient characteristics, surgical outcomes (blood loss, operative time, transfusion, partial bladder resection), maternal outcomes (death, length of stay, ICU admission, postoperative hemoglobin level) and neonatal outcomes (Apgar score, neonatal weight, admission to neonatal intensive care unit, neonatal death). RESULTS The study included 189 patients. In the radical treatment subgroup (141/189), patients were para 3 and delivered at 34 4/7 weeks in average, bled 1.5 L and were transfused with three packed red blood cells, with operative time averaging 160 min. A total of 36% were admitted to the ICU and patients stayed on average for 1 week despite partial bladder resection in 19% of cases. Unscheduled radical delivery occurred at a lower gestational age, was associated with more blood loss, higher rate and volume of transfusion, and risk of maternal and neonatal death. In addition, patients delivered in an unscheduled fashion experienced higher rates of partial bladder resection and longer interventions. In the conservative treatment subgroup, on average patients were para 2 and delivered at 36 weeks, bled 800 mL on average with low rates of transfusion (35%) and ICU admission (22.9%). With regard to neonatal outcomes, the average neonatal birth weight was 2.4 kg in the radical subgroup and 2.5 kg in the conservative subgroup. Neonatal death occurred in 5.4% of cases requiring radical management while it occurred in 2% of patients treated conservatively. CONCLUSION Through their multidisciplinary approach, the three centers demonstrated that management of AIP in Lebanon has led to excellent outcomes with no maternal mortality occurring in scheduled radical treatment. By comparison of the three leading centers, pitfalls in each center were identified and addressed.
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Affiliation(s)
- Muhieddine Seoud
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
| | - Rabih Chahine
- Department of Obstetrics and Gynecology, Rafic Hariri University Hospital (RHUH), Beirut, Lebanon
| | - Wissam Arab
- Department of Obstetrics and Gynecology, Hotel-Dieu de France (HDF) University Hospital, Saint-Joseph University, Beirut, Lebanon
| | - Iman Jaafar
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
| | - Malak Moubarak
- Department of Obstetrics and Gynecology, Hotel-Dieu de France (HDF) University Hospital, Saint-Joseph University, Beirut, Lebanon
| | - Nadine El Kassis
- Department of Obstetrics and Gynecology, Hotel-Dieu de France (HDF) University Hospital, Saint-Joseph University, Beirut, Lebanon
| | - Reem Abdallah
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
| | - Mohamad K Ramadan
- Department of Obstetrics and Gynecology, Rafic Hariri University Hospital (RHUH), Beirut, Lebanon
| | - Malek Nassar
- Department of Obstetrics and Gynecology, Hotel-Dieu de France (HDF) University Hospital, Saint-Joseph University, Beirut, Lebanon
| | - Anwar Nassar
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
| | - Eliane Nasser Ayoub
- Intensive Care and Anesthesiology Department, Hotel-Dieu de France (HDF) University Hospital, Saint-Joseph University, Beirut, Lebanon
| | - David Atallah
- Department of Obstetrics and Gynecology, Hotel-Dieu de France (HDF) University Hospital, Saint-Joseph University, Beirut, Lebanon
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Munoz JL, Cheng C, McCann GA, Ramsey P, Byrne JJ. Risk factors for intensive care unit admission after cesarean hysterectomy for placenta accreta spectrum. Int J Gynaecol Obstet 2024. [PMID: 38757543 DOI: 10.1002/ijgo.15692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 04/29/2024] [Accepted: 05/07/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE Placenta accreta spectrum (PAS) is a complex disorder of uterine wall disruption with significant morbidity and mortality, particularly at time of delivery. Both physician and physical hospital resource allocation/utilization remains a challenge in PAS cases including intensive care unit (ICU) beds. The primary objective of the present study was to identify preoperative risk factors for ICU admission and create an ICU admission prediction model for patient counseling and resource utilization decision making in an evidence-based manner. METHODS This was a case-control study of 145 patients at our PAS referral center undergoing cesarean hysterectomy for PAS. Final confirmation by histopathology was required for inclusion. Patient disposition after surgery (ICU vs post-anesthesia care unit) was our primary outcome and pre-/intra-/postoperative variables were obtained via electronic medical records with an emphasis on the predictive capabilities of the preoperative variables. Uni- and multivariate analysis was performed to identify independent predictive factors for ICU admission. RESULTS In this large cohort of 145 patients who underwent cesarean hysterectomy for PAS, with histopathologic confirmation, 63 (43%) were admitted to the ICU following delivery. These patients were more likely to be delivered at an earlier gestational age (34 vs 35 weeks, P < 0.001), have had >2 episodes of vaginal bleeding and emergent delivery compared to patients admitted to patients with routine recovery care (44% vs 18.3%, P = 0.009). Uni- and multivariate logistic regression showed an area under the curve of 0.73 (95% CI: [0.63, 0.81], P < 0.001) for prediction of ICU admission with these three variables. Patients with all three predictors had 100% ICU admission rate. CONCLUSION Resource prediction, utilization and allocation remains a challenge in PAS management. By identifying patients with preoperative risk factors for ICU admission, not only can patients be counseled but this resource can be requested preoperatively for staffing and utilization purposes.
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Affiliation(s)
- Jessian L Munoz
- Divisions of Maternal Fetal Medicine and Fetal Intervention, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - CeCe Cheng
- Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas, USA
| | - Georgia A McCann
- Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas, USA
| | - Patrick Ramsey
- Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas, USA
| | - John J Byrne
- Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas, USA
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McCall SJ, Mansour S, Khazaal J, Kayem G, DeJong J, Chahine R. Obstetric and haematological management and outcomes of women with placenta accreta spectrum by planned or urgent delivery: Secondary data analysis of a public referral hospital in Lebanon. PLoS One 2024; 19:e0302366. [PMID: 38718031 PMCID: PMC11078361 DOI: 10.1371/journal.pone.0302366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 04/02/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Lebanon has a high caesarean section use and consequently, placenta accreta spectrum (PAS) is becoming more common. OBJECTIVES To compare maternal characteristics, management, and outcomes of women with PAS by planned or urgent delivery at a major public referral hospital in Lebanon. DESIGN Secondary data analysis of prospectively collected data. SETTING Rafik Hariri University Hospital (public referral hospital), Beirut, Lebanon. PARTICIPANTS 159 pregnant and postpartum women with confirmed PAS between 2007-2020. MAIN OUTCOME MEASURES Maternal characteristics, management, and maternal and neonatal outcomes. RESULTS Out of the 159 women with PAS included, 107 (67.3%) underwent planned caesarean delivery and 52 (32.7%) had urgent delivery. Women who underwent urgent delivery for PAS management were more likely to experience antenatal vaginal bleeding compared to those in the planned group (55.8% vs 28.0%, p<0.001). Median gestational age at delivery was significantly lower for the urgent group compared to the planned (34 vs. 36 weeks, p<0.001). There were no significant differences in terms of blood transfusion rates and major maternal morbidity between the two groups; however, median estimated blood loss was significantly higher for women with urgent delivery (1500ml vs. 1200ml, p = 0.011). Furthermore, the urgent delivery group had a significantly lower birth weight (2177.5g vs. 2560g, p<0.001) with higher rates of neonatal intensive care unit (NICU) admission (53.7% vs 23.8%, p<0.001) and perinatal mortality (18.5% vs 3.8%, p = 0.005). CONCLUSION Urgent delivery among women with PAS is associated with worse maternal and neonatal outcomes compared to the planned approach. Therefore, early referral of women with known or suspected PAS to specialized centres is highly desirable to maximise optimal outcomes for both women and infants.
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Affiliation(s)
- Stephen J. McCall
- Faculty of Health Sciences, Center for Research on Population and Health, American University of Beirut, Beirut, Lebanon
| | - Sara Mansour
- Faculty of Health Sciences, Center for Research on Population and Health, American University of Beirut, Beirut, Lebanon
| | - Janoub Khazaal
- Department of Obstetrics and Gynecology, Rafik Hariri University Hospital, Beirut, Lebanon
| | - Gilles Kayem
- Faculty of Health Sciences, Center for Research on Population and Health, American University of Beirut, Beirut, Lebanon
- Paris University, Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical Perinatal and Paediatric Epidemiology Research Team, EPOPé, INSERM, Paris, France
- Department of Obstetrics and Gynecology, Trousseau Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jocelyn DeJong
- Faculty of Health Sciences, Department of Epidemiology and Population Health, American University of Beirut, Beirut, Lebanon
| | - Rabih Chahine
- Department of Obstetrics and Gynecology, Rafik Hariri University Hospital, Beirut, Lebanon
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Huang YC, Yang CC. Impact of planned versus emergency cesarean delivery on neonatal outcomes in pregnancies complicated by abnormal placentation: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e34498. [PMID: 37565895 PMCID: PMC10419427 DOI: 10.1097/md.0000000000034498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/05/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Although planned cesarean delivery (PCD) is the mainstay of management for abnormal placentation, some patients still require emergency cesarean delivery (ECD). We aimed to systematically analyze the impact of various modes of delivery on neonatal outcomes. METHODS This study was complied with the PRISMA guidelines and was registered in the PROSPERO (code: CRD42022379487). A systematic search was conducted on Ovid MEDLINE and Embase, Web of Science, PubMed, and the Cochrane databases. Data extracted included gestational age at delivery, birth weight, the Apgar scores at 1 and 5 minutes, numbers of newborns with low Apgar score (<7) at 5 minutes, the rates of neonatal intensive care unit admission, and the rates of neonatal mortality. RESULTS Fifteen cohort studies met the inclusion criteria, comprising a total of 2565 women (2567 neonates) who underwent PCD (n = 1483) or ECD (n = 1082) for prenatally diagnosed placenta accreta spectrum (PAS) and/or placenta previa (PP). Compared with the ECD group, neonates in the PCD group had significantly higher gestational ages (standardized mean difference [SMD]: 2.20; 95% confidence interval [CI]: 1.25-3.15; P < .001), birth weights (SMD: 1.64; 95% CI: 1.00-2.27; P < .001), and Apgar scores at 1 minute (SMD: 0.51; 95% CI: 0.29-0.73; P < .001) and 5 minutes (SMD: 0.47; 95% CI: 0.25-0.70; P < .001). Additionally, the PCD group had significantly lower rates of neonatal intensive care unit admission (odds ratio [OR]: 0.21; 95% CI: 0.14-0.29; P < .001), low Apgar score at 5 minutes (OR: 0.27; 95% CI: 0.11-0.69; P = .01), and neonatal mortality (OR: 0.13; 95% CI: 0.05-0.33; P < .001). CONCLUSION When pregnancies are complicated by abnormal placentation, PCD is linked to noticeably better neonatal outcomes than emergent delivery.
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Affiliation(s)
- Yi-Chien Huang
- Division of Neonatology, Department of Pediatrics, Chi Mei Medical Center, Tainan, Taiwan
| | - Cheng-Chun Yang
- Department of Medical Imaging, Chi Mei Medical Center, Tainan, Taiwan
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Chang WP, Yang ST, Wang PH. Diagnosis of placenta accreta spectrum before delivery. Taiwan J Obstet Gynecol 2022; 61:199-200. [PMID: 35361376 DOI: 10.1016/j.tjog.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2021] [Indexed: 10/18/2022] Open
Affiliation(s)
- Wen-Pu Chang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Szu-Ting Yang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Female Cancer Foundation, Taipei, Taiwan; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan.
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