Placenta accreta spectrum-a catastrophic situation in obstetrics

A Single-Centre Retrospective Analysis of Pregnancies with Placenta Accreta Spectrum (PAS): From One-Step Surgery towards Two-Step Surgical Approach

Background: Placenta accreta spectrum (PAS) can be the cause of major morbidity and its optimal management is still controversial. The aim of this study was to compare the traditional one-step surgery with a two-step surgical approach in which the placenta is left in situ and the second final operation is delayed to minimise blood loss. Methods: We conducted a single-centre retrospective cohort study including all patients managed for PAS between 2007 and 2023. The number of units of red blood cells (RBCs) needed during surgery was the primary outcome used to compare these two approaches. Results: A total of 43 cases were included in this analysis. Twenty of these were managed with the delayed two-step surgical approach, whereas 23 received one-step surgery. The median estimated blood loss during surgery was 2000 mL and 2800 mL for two-step and one-step surgery, respectively (p = 0.095). In the two-step surgical approach, the median number of RBC units transfused during surgery was significantly lower (p = 0.049) and the odds ratio for needing more than four units of RBCs was 0.28 (95%-CI: 0.08-0.98, p = 0.043). A longer interval between the caesarean section and the second operation showed a trend toward lower blood loss (p = 0.065) and was associated with a significantly lower number of RBC units needed during surgery (p = 0.019). Conclusions: Two-step surgery for the treatment of PAS was safe in our cohort and could lead to a reduction in blood transfusion. Leaving the placenta in situ and delaying the final operation represents a possible alternative to traditional caesarean hysterectomy.

Customizing EV-CATCHER to Purify Placental Extracellular Vesicles from Maternal Plasma to Detect Placental Pathologies

Placenta Accreta Spectrum (PAS) is a life-threatening condition in which placental trophoblastic cells abnormally invade the uterus, often up to the uterine serosa and, in extreme cases, tissues beyond the uterine wall. Currently, there is no clinical assay for the non-invasive detection of PAS, and only ultrasound and MRI can be used for its diagnosis. Considering the subjectivity of visual assessment, the detection of PAS necessitates a high degree of expertise and, in some instances, can lead to its misdiagnosis. In clinical practice, up to 50% of pregnancies with PAS remain undiagnosed until delivery, and it is associated with increased risk of morbidity/mortality. Although many studies have evaluated the potential of fetal biomarkers circulating in maternal blood, very few studies have evaluated the potential of circulating placental extracellular vesicles (EVs) and their miRNA contents for molecular detection of PAS. Thus, to purify placental EVs from maternal blood, we customized our robust ultra-sensitive immuno-purification assay, termed EV-CATCHER, with a monoclonal antibody targeting the membrane Placental Alkaline Phosphatase (PLAP) protein, which is unique to the placenta and present on the surface of placental EVs. Then, as a pilot evaluation, we compared the miRNA expression profiles of placental EVs purified from the maternal plasma of women diagnosed with placenta previa (controls, n = 16); placenta lying low in uterus but not invasive) to those of placental EVs purified from the plasma of women with placenta percreta (cases, n = 16), PAS with the highest level of invasiveness. Our analyses reveal that miRNA profiling of PLAP+ EVs purified from maternal plasma identified 40 differentially expressed miRNAs when comparing these two placental pathologies. Preliminary miRNA pathway enrichment and gene ontology analysis of the top 14 upregulated and top nine downregulated miRNAs in PLAP+ EVs, purified from the plasma of women diagnosed with placenta percreta versus those diagnosed with placenta previa, suggests a potential role in control of cellular invasion and motility that will require further investigation.

Modified one-step conservative uterine surgery (MOSCUS) versus cesarean hysterectomy in the management of placenta accreta spectrum: A single-center retrospective analysis based on 619 Vietnamese pregnant women

OBJECTIVES

To compare maternal outcome measures in surgical management of placenta accreta spectrum (PAS)-the modified one-step conservative uterine surgery (MOSCUS), a new approach at Tu Du Hospital in Vietnam, versus cesarean hysterectomy, and to identify factors that appear to contribute to the successful outcome of the MOSCUS.

METHODS

This retrospective study was conducted at Tu Du Hospital in southern Vietnam between January 2019 and December 2020. The study enrolled all pregnant women at more than 28 weeks of pregnancy with a diagnosis of PAS who underwent either a cesarean hysterectomy or a uterus-preserving approach using the MOSCUS method.

RESULTS

The prevalence of PAS at our single tertiary referral hospital was 0.4% (619 PAS cases/132 518 births) in 2 years. Among 296 patients, the surgical time duration, estimated blood loss, and red blood cell transfusion in the MOSCUS group (n = 217) were all significantly less than in the cesarean hysterectomy group (n = 79) (152.72 ± 42.23 vs 185.13 ± 58.22 min, 1000 vs 1500 mL, and 500 vs 710 mL, respectively). Intraoperatively, the rate of visceral injuries in the hysterectomy group was higher than that in the MOSCUS group (P < 0.001). However, the rate of postoperative infection was higher in the MOSCUS group than in the cesarean hysterectomy group (P = 0.012). Of a total of 217 cases managed using the MOSCUS management, 24 required a secondary hysterectomy; the success rate was 88.9% (95% confidence interval [CI] 84.3%-93.1%). Some of the primary factors associated with the success of MOSCUS included maternal age less than 35 years, planned surgery, severity of PAS, and estimated blood loss during surgery (odds ratio [OR] 5.16, 95% CI 1.96-13.59; OR 3.05, 95% CI 1.08-8.62; OR 3.62, 95% CI 1.19-10.98; and OR 49.66, 95% CI 11.16-221.02, respectively; P < 0.05).

CONCLUSION

MOSCUS is an acceptable alternative to cesarean hysterectomy in many patients diagnosed with PAS. This new surgical management of PAS resulted in the preservation of the uterus, and a favorable outcome in nearly 9 out of 10 pregnant women. We believe that MOSCUS can be safely offered for the management of PAS in referral hospital settings.

Neonatal outcomes in the surgical management of placenta accreta spectrum disorders: a retrospective single-center observational study from 468 Vietnamese pregnancies beyond 28 weeks of gestation

BACKGROUND

Placenta accreta spectrum disorders (PASDs) increase the mortality rate for mothers and newborns over a decade. Thus, the purpose of the study is to evaluate the neonatal outcomes in emergency cesarean section (CS) and planned surgery as well as in Cesarean hysterectomy and the modified one-step conservative uterine surgery (MOSCUS). The secondary aim is to reveal the factors relating to poor neonatal outcomes.

METHODS

This was a single-center retrospective study conducted between 2019 and 2020 at Tu Du Hospital, in the southern region of Vietnam. A total of 497 pregnant women involved in PASDs beyond 28 weeks of gestation were enrolled. The clinical outcomes concerning gestational age, birth weight, APGAR score, neonatal intervention, neonatal intensive care unit (NICU) admission, and NICU length of stay (LOS) were compared between emergency and planned surgery, between the Cesarean hysterectomy and the MOSCUS. The univariate and multivariable logistic regression were used to assess the adverse neonatal outcomes.

RESULTS

Among 468 intraoperatively diagnosed PASD cases who underwent CS under general anesthesia, neonatal outcomes in the emergency CS (n = 65) were significantly poorer than in planned delivery (n = 403). Emergency CS increased the odds ratio (OR) for earlier gestational age, lower birthweight, lower APGAR score at 5 min, higher rate of neonatal intervention, NICU admission, and longer NICU LOS ≥ 7 days with OR, 95% confidence interval (CI) were 10.743 (5.675-20.338), 3.823 (2.197-6.651), 5.215 (2.277-11.942), 2.256 (1.318-3.861), 2.177 (1.262-3.756), 3.613 (2.052-6.363), and 2.298 (1.140-4.630), respectively, p < 0.05. Conversely, there was no statistically significant difference between the neonatal outcomes in Cesarean hysterectomy (n = 79) and the MOSCUS method (n = 217). Using the multivariable logistic regression, factors independently associated with the 5-min-APGAR score of less than 7 points were time duration from the skin incision to fetal delivery (min) and gestational age (week). One minute-decreased time duration from skin incision to fetal delivery contributed to reduce the risk of adverse neonatal outcome by 2.2% with adjusted OR, 95% CI: 0.978 (0.962-0.993), p = 0.006. Meanwhile, one week-decreased gestational age increased approximately two fold odds of the adverse neonatal outcome with adjusted OR, 95% CI: 1.983 (1.600-2.456), p < 0.0001.

CONCLUSIONS

Among pregnancies with PASDs, the neonatal outcomes are worse in the emergency group compared to planned group of cesarean section. Additionally, the neonatal comorbidities in the conservative surgery using the MOSCUS method are similar to Cesarean hysterectomy. Time duration from the skin incision to fetal delivery and gestational age may be considered in PASD surgery. Further data is required to strengthen these findings.

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Management of critical bleeding

The management of major bleeding is a critical aspect of modern healthcare and it is imperative to emphasize the importance of applying Patient Blood Management (PBM) principles. Although transfusion support remains a vital component of bleeding control, treating severe bleeding goes beyond simply replacing lost blood. A more comprehensive, multidisciplinary approach is essential to optimize patient outcomes and minimize the risks associated with excessive transfusions.

Determination of biomarker candidates for the placenta accreta spectrum by plasma proteomic analysis

Placenta accreta spectrum (PAS) presents a significant obstetric challenge, associated with considerable maternal and fetal-neonatal morbidity and mortality. Nevertheless, it is imperative to acknowledge that a noteworthy subset of PAS cases remains undetected until the time of delivery, thereby contributing to an augmented incidence of morbidity among the affected individuals. The delayed identification of PAS not only hinders timely intervention but also exacerbates the associated health risks for both the maternal and fetal outcomes. This underscores the urgency to innovate strategies for early PAS diagnosis. In this study, we aimed to explore plasma proteins as potential diagnostic biomarkers for PAS. Integrated transcriptome and proteomic analyses were conducted to establish a novel diagnostic approach. A cohort of 15 pregnant women diagnosed with PAS and delivering at Inonu University Faculty of Medicine between 01/04/2021 and 01/01/2023, along with a matched control group of 15 pregnant women without PAS complications, were enrolled. Plasma protein identification utilized enzymatic digestion and liquid chromatography-tandem mass spectrometry techniques. Proteomic analysis identified 228 plasma proteins, of which 85 showed significant differences (P < 0.001) between PAS and control cases. We refined this to a set of 20 proteins for model construction, resulting in a highly accurate classification model (96.9% accuracy). Notable associations were observed for proteins encoded by P01859 (Immunoglobulin heavy constant gamma 2), P02538 (Keratin type II cytoskeletal 6A), P29622 [Kallistatin (also known as Serpin A4)], P17900 (Ganglioside GM2 activator Calmodulin-like protein 5), and P01619 (Immunoglobulin kappa variable 3-20), with fold changes indicating their relevance in distinguishing PAS from control groups. In conclusion, our study has identified novel plasma proteins that could serve as potential biomarkers for early diagnosis of PAS in pregnant women. Further research and validation in larger PAS cohorts are necessary to determine the clinical utility and reliability of these proteomic biomarkers for diagnosing PAS.

Fetal and maternal outcomes of segmental uterine resection in emergency and planned placenta percreta deliveries

OBJECTIVE

This study evaluated maternal and fetal outcomes of emergency uterine resection versus planned segmental uterine resection in patients with placenta percreta (PPC) and placenta previa (PP).

METHODS

Patients with PP and PPC who underwent planned or emergency segmental uterine resection were included in this study. Demographic data, hemorrhagic morbidities, intra- and postoperative complications, length of hospital stay, surgical duration, and peri- and neonatal morbidities were compared.

RESULTS

A total of 141 PPC and PP cases were included in this study. Twenty-five patients (17.73%) underwent emergency uterine resection, while 116 (82.27%) underwent planned segmental uterine resections. The postoperative hemoglobin changes, operation times, total blood transfusion, bladder injury, and length of hospital stay did not differ significantly between groups (P=0.7, P=0.6, P=0.9, P=0.9, and P=0.2, respectively). Fetal weights, 5-minute Apgar scores, and neonatal intensive care unit admission rates did not differ significantly between groups. The gestational age at delivery of patients presenting with bleeding was lower than that of patients who were admitted in active labor and underwent elective surgery (32 weeks [95% confidence interval [CI], 26-37] vs. 35 weeks [95% CI, 34-35]; P=0.037).

CONCLUSION

Using a multidisciplinary approach, this study performed at a tertiary center showed that maternal and fetal morbidity and mortality did not differ significantly between emergency versus planned segmental uterine resection.

New paradigm for cervico-isthmic pregnancy: conservative management of cervico-isthmic pregnancy leading to successful deliveries

OBJECTIVE

To establish a new treatment option for cervico-isthmic pregnancy (CIP) other than termination by maintaining pregnancy from diagnosis to delivery.

METHODS

This retrospective observational study included women diagnosed with CIP at Dongsan Medical Center, Daegu, Korea, from January 2014 to December 2019. Eight patients were diagnosed with CIP using transvaginal ultrasound and met the following inclusion criteria: (1) preserved and closed cervical canal; and (2) more than half of the uterine cavity above the sac was not involved in sac implantation. Five of the eight mothers decided to maintain their pregnancy after an adequate explanation of the possible risks. The same sonographer assessed fetal and maternal status every 1-2 weeks. Intra- and postoperative indicators, delivery information, and neonatal outcomes were also recorded.

RESULTS

The mean patient age was 36 years. In all cases, placenta accreta spectrum and placenta previa were detected using preoperative ultrasonography. A hysterectomy was performed in three cases, and all patients required intensive care unit (ICU) care. The mean operative time was 156 minutes. The rate of postpartum hemorrhage was 40%. Four viable fetuses were delivered. Birth preceding 34 weeks occurred in one patient, who required neonatal ICU hospitalization for 19 days.

CONCLUSION

Conservative treatment with careful diagnosis, management, and sufficient consultation could be an alternative treatment option in women with CIP, particularly older mothers, those with subfertility, and those who expect to have limited future opportunities for a successful pregnancy. Therefore, CIP should be treated as a separate disease entity.

Placenta Accreta Spectrum Diagnosis Challenges and Controversies in Current Obstetrics: A Review

Background

Placenta accreta spectrum (PAS) is the most common obstetric complication in current obstetrics in which the placenta is fully or partially attached to the uterine myometrial layer at delivery. This is commonly due to the deficiency of the uterine interface between the uterine endometrial and myometrial layers leading to abnormal decidualization at the uterine scar area, which permits the abnormally placental anchoring villous and trophoblasts, deeply invade the myometrium. The prevalence of PAS is globally at rising trends every day in modern obstetrics originally due to the high increasing rate of cesarean sections, placenta previa, and assisted reproductive technology (ART). Thus, the early and precise diagnosis of PAS is imperative to prevent maternal intrapartum or postpartum bleeding complications.

Objective

The main aim of this review is to debate the current challenges and controversies in the routine diagnosis of PAS diseases in obstetrics.

Data Source

We retrospectively reviewed the recent articles on different methods of diagnosing PAS in PubMed, Google Scholar, Web of Science, Medline, Embase, and other website databases.

Results

Despite that, the standard ultrasound is a reliable and key tool for the diagnosis of PAS, the lack of ultrasound features does not exclude the diagnosis of PAS. Therefore, clinical assessment of risk factors, MRI tests, serological markers, and placental histopathological tests are also indispensable for the prediction of PAS. Previously, limited studies reached a high sensitivity rate of diagnosis PAS in appropriate cases, while many studies recommended the inclusion of different diagnosis methods to improve the diagnosis accuracy.

Conclusion

A multidisciplinary squad with well-experienced obstetricians, radiologists, and histopathologists should be involved in the establishment of the early and conclusive diagnosis of PAS.

Development and Validation of a Prediction Model for Need for Massive Transfusion During Surgery Using Intraoperative Hemodynamic Monitoring Data

Importance

Massive transfusion is essential to prevent complications during uncontrolled intraoperative hemorrhage. As massive transfusion requires time for blood product preparation and additional medical personnel for a team-based approach, early prediction of massive transfusion is crucial for appropriate management.

Objective

To evaluate a real-time prediction model for massive transfusion during surgery based on the incorporation of preoperative data and intraoperative hemodynamic monitoring data.

Design, Setting, and Participants

This prognostic study used data sets from patients who underwent surgery with invasive blood pressure monitoring at Seoul National University Hospital (SNUH) from 2016 to 2019 and Boramae Medical Center (BMC) from 2020 to 2021. SNUH represented the development and internal validation data sets (n = 17 986 patients), and BMC represented the external validation data sets (n = 494 patients). Data were analyzed from November 2020 to December 2021.

Exposures

A deep learning-based real-time prediction model for massive transfusion.

Main Outcomes and Measures

Massive transfusion was defined as a transfusion of 3 or more units of red blood cells over an hour. A preoperative prediction model for massive transfusion was developed using preoperative variables. Subsequently, a real-time prediction model using preoperative and intraoperative parameters was constructed to predict massive transfusion 10 minutes in advance. A prediction model, the massive transfusion index, calculated the risk of massive transfusion in real time.

Results

Among 17 986 patients at SNUH (mean [SD] age, 58.65 [14.81] years; 9036 [50.2%] female), 416 patients (2.3%) underwent massive transfusion during the operation (mean [SD] duration of operation, 170.99 [105.03] minutes). The real-time prediction model constructed with the use of preoperative and intraoperative parameters significantly outperformed the preoperative prediction model (area under the receiver characteristic curve [AUROC], 0.972; 95% CI, 0.968-0.976 vs AUROC, 0.824; 95% CI, 0.813-0.834 in the SNUH internal validation data set; P < .001). Patients with the highest massive transfusion index (ie, >90th percentile) had a 47.5-fold increased risk for a massive transfusion compared with those with a lower massive transfusion index (ie, <80th percentile). The real-time prediction model also showed excellent performance in the external validation data set (AUROC of 0.943 [95% CI, 0.919-0.961] in BMC).

Conclusions and Relevance

The findings of this prognostic study suggest that the real-time prediction model for massive transfusion showed high accuracy of prediction performance, enabling early intervention for high-risk patients. It suggests strong confidence in artificial intelligence-assisted clinical decision support systems in the operating field.

Update on placenta accreta spectrum disorders by considering epidemiological factors, ultrasound diagnosis and pathological exam - literature review and authors' experience

The aim of this paper was to correlate the circumstances that could lead to an abnormal invasion of placenta with the updated requirements to perform screening by ultrasound for all pregnant women prone to develop this pathology. To screen in the middle trimester of gestation for placenta accreta spectrum (PAS) disorders sets up an in-time referral opportunity for pregnant women prenatally detected with this pathology to a medical center with elevated level of expertise in the management of PAS disorders, able to act permanently by a multidisciplinary team (MDT) and to have access at medical resources including blood bank available. The literature review reveals especially useful data for clinical practice as regards novel explanations related to the etiology and physiopathology of PAS disorders, the composition of the MDT and the relevance of an indispensable pathologist physician at the time of Cesarean hysterectomy involved in the selection of best samples with the purpose of avoiding the possibility of losing undiagnosed cases with litigation implications. Conclusions show that the prenatal diagnosis of PAS disorders is possible so decreasing the risk of mortality and morbidity of pregnant women. Screening in the second trimester of pregnancy for PAS disorders becomes mandatory as the number of births by Cesarean section is expected to rise past three-fold until 2030. The professional expertise of the pathologist physician could be enriched by immunohistochemical staining in all suspected cases of placental invasion in myometrium wall.