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Zhang ET, Wells KL, Bergman AJ, Ryan EE, Steinmetz LM, Baker JC. Uterine injury during diestrus leads to placental and embryonic defects in future pregnancies in mice†. Biol Reprod 2024; 110:819-833. [PMID: 38206869 PMCID: PMC11017118 DOI: 10.1093/biolre/ioae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 03/16/2023] [Accepted: 01/02/2024] [Indexed: 01/13/2024] Open
Abstract
Uterine injury from procedures such as Cesarean sections (C-sections) often have severe consequences on subsequent pregnancy outcomes, leading to disorders such as placenta previa, placenta accreta, and infertility. With rates of C-section at ~30% of deliveries in the USA and projected to continue to climb, a deeper understanding of the mechanisms by which these pregnancy disorders arise and opportunities for intervention are needed. Here we describe a rodent model of uterine injury on subsequent in utero outcomes. We observed three distinct phenotypes: increased rates of resorption and death, embryo spacing defects, and placenta accreta-like features of reduced decidua and expansion of invasive trophoblasts. We show that the appearance of embryo spacing defects depends entirely on the phase of estrous cycle at the time of injury. Using RNA-seq, we identified perturbations in the expression of components of the COX/prostaglandin pathway after recovery from injury, a pathway that has previously been demonstrated to play an important role in embryo spacing. Therefore, we demonstrate that uterine damage in this mouse model causes morphological and molecular changes that ultimately lead to placental and embryonic developmental defects.
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Affiliation(s)
- Elisa T Zhang
- Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA
| | - Kristen L Wells
- Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA
| | - Abby J Bergman
- Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA
| | - Emily E Ryan
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Lars M Steinmetz
- Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Genome Technology Center, Stanford University, Palo Alto, CA, USA
- European Molecular Biology Laboratory (EMBL), Genome Biology Unit, Heidelberg, Germany
| | - Julie C Baker
- Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA
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You H, Wang Y, Han R, Gu J, Zeng L, Zhao Y. Risk factors for placenta accreta spectrum without prior cesarean section: A case-control study in China. Int J Gynaecol Obstet 2024. [PMID: 38573157 DOI: 10.1002/ijgo.15493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/22/2024] [Accepted: 03/10/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVE To identify the risk factors for placenta accreta spectrum (PAS) disorders in women without prior cesarean section (CS). METHODS This retrospective case-control study investigated patients without prior CS who gave birth at Peking University Third Hospital between January 1, 2015 and December 31, 2021. Patients diagnosed with PAS according to the clinical diagnostic criteria of the 2019 International Federation of Gynecology and Obstetrics (FIGO) classification were included as the study group. Patients were matched as the control group according to delivery date and placenta previa, in a 1:2 allocation ratio. Maternal characteristics were compared between the two groups. RESULTS The study included 348 patients in the study group and 696 in the control group. The multivariate analysis showed that the independent risk factors of PAS consisted of operative hysteroscopy (once: adjusted odds ratio [aOR] 2.38, 95% CI 1.28-4.24, P = 0.006; twice or more: aOR 5.43, 95% CI 1.04-28.32, P = 0.045), uterine curettage (once: aOR 2.54, 95% CI 1.80-3.58, P < 0.001; twice: aOR 3.01, 95% CI 1.81-5.02, P < 0.001; three or more times: aOR 9.18, 95% CI 4.64-18.18, P < 0.001), multifetal pregnancy (aOR 5.64, 95% CI 3.01-10.57, P < 0.001), adenomyosis (aOR 2.77, 95% CI 1.23-6.22, P = 0.014), in vitro fertilization (aOR 1.51, 95% CI 1.04-2.20, P = 0.030) and pre-eclampsia (aOR 2.72, 95% CI 1.36-5.45, P = 0.005), and the independent protective factor was being multiparous (aOR 0.37, 95% CI 0.25-0.54, P < 0.001). CONCLUSION After controlling the effect of placenta previa, we found that patients with PAS without prior CS had unique maternal characteristics. Classification and quantification of the intrauterine surgeries they have undergone is essential for identifying high-risk patients. Early identification of high-risk groups by risk factors has the potential to improve the prognosis considerably.
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Affiliation(s)
- Huanyu You
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yan Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Centre for Healthcare Quality Management in Obsterics, Beijing, China
| | - Rui Han
- Department of Obstetrics, Maternal and Child Health Hospital of Changzhi, Changzhi, China
| | - Jinyu Gu
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Lin Zeng
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Centre for Healthcare Quality Management in Obsterics, Beijing, China
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Sharami SH, Milani F, Fallah Arzpeyma S, Fakour F, Jafarzadeh Z, Haghparast Z, Sedighinejad A, Attari SM. Placenta accreta outcomes and risk factors in a referral hospital in north of Iran: A case control study. Health Sci Rep 2024; 7:e2006. [PMID: 38605724 PMCID: PMC11006998 DOI: 10.1002/hsr2.2006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 03/11/2024] [Accepted: 03/13/2024] [Indexed: 04/13/2024] Open
Abstract
Background Placenta accreta syndrome (PAS) may led to heavy blood loss and maternal death. Here we analyzed the main risk factors of PAS+ pregnancies and its complications in a referral hospital in the north of Iran. Methods In a case control study, all pregnant women with PAS referred to our department during 2016 till 2021 were enrolled and divided in two groups case (PAS+) and control (PAS-) based on preoperative imaging, intraoperative findings, and pathological reports. The sociodemographic features and neonatal-maternal outcomes also were recorded. Results The most frequent reason for cesarean (C/S) was repeated C/S (62.9%, 56/89). A significant difference showed up in the time lag between previous C/S and the present delivery (p < 0.001) which shows that when the time distance is longer, the risk of PAS rises (OR: 1.01 [95% CI: 1.003-1.017]). Also, a positive history of prior abortion and elective type of previous C/S were related to PAS+ pregnancies. Our other finding showed that PAS+ pregnancies will end in lower gestational age and have a longer duration of operation and hospitalization, heavy blood transfusion, and hysterectomy. Also, PAS+ pregnancies were not related to poor neonatal outcomes. Conclusions It seems that, in addition to repeated C/S as a strong risk factor, previous abortion is a forgotten key which leads to incomplete evacuation or damage the endometrial-myometrial layers.
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Affiliation(s)
- Seyedeh Hajar Sharami
- Department of Obstetrics & Gynecology, Reproductive Health Research Center, Al‐Zahra Hospital, School of MedicineGuilan University of Medical SciencesRashtIran
| | - Forozan Milani
- Department of Obstetrics & Gynecology, Reproductive Health Research Center, Al‐Zahra Hospital, School of MedicineGuilan University of Medical SciencesRashtIran
| | - Sima Fallah Arzpeyma
- Department of Radiology, School of Medicine, Poursina HospitalGuilan University of Medical SciencesRashtIran
| | - Fereshteh Fakour
- Department of Obstetrics & Gynecology, Reproductive Health Research Center, Al‐Zahra Hospital, School of MedicineGuilan University of Medical SciencesRashtIran
| | - Zahra Jafarzadeh
- Department of Obstetrics & Gynecology, Reproductive Health Research Center, Al‐Zahra Hospital, School of MedicineGuilan University of Medical SciencesRashtIran
| | - Zahra Haghparast
- Department of Obstetrics & Gynecology, Reproductive Health Research Center, Al‐Zahra Hospital, School of MedicineGuilan University of Medical SciencesRashtIran
| | - Abbas Sedighinejad
- Department of Anesthesiology, Anesthesiology Research Center, Alzahra HospitalGuilan University of Medical SciencesRashtIran
| | - Seyedeh Maryam Attari
- Department of Midwifery and Reproductive Health, Reproductive Health Research Center, Al‐Zahra HospitalGuilan University of Medical SciencesRashtIran
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Lu X, Zhang H, Wu X, Chen X, Zhang Q, Song W, Jin Y, Yuan M. The value of the combined MR imaging features and clinical factors Nomogram model in predicting intractable postpartum hemorrhage due to placenta accreta. Medicine (Baltimore) 2024; 103:e37665. [PMID: 38552054 PMCID: PMC10977557 DOI: 10.1097/md.0000000000037665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 02/29/2024] [Indexed: 04/02/2024] Open
Abstract
To explore the value of the combined MR imaging features and clinical factors Nomogram model in predicting intractable postpartum hemorrhage (IPH) due to placenta accreta (PA). We conducted a retrospective study with 270 cases of PA patients admitted to our hospital from January 2015 to December 2022. The clinical data of these patients were analyzed, and they were divided into 2 groups: the IPH group and the non-IPH group based on the presence of IPH. The differences in data between the 2 groups were compared, and the risk factors for IPH were analyzed. A Nomogram model was constructed using independent high-risk factors, and the predictive value of this model for IPH was analyzed. The results of multivariable binary Logistic regression analysis showed higher number of cesareans, placenta previa, placenta accreta type (implantation, penetration), low signal strip on T2 weighted image (T2WI) were independent high-risk factor for IPH (P < .05). ROC analysis and Hosmer-Lemeshow goodness-of-fit test showed the Nomogram predictive model constructed with the high-risk factor has good discrimination and calibration. Decision curve analysis (DCA) showed that when the probability threshold for the Nomogram model's prediction was in the range from 0.125 to 0.99, IPH patients could obtain more net benefits, making it suitable for clinical application. The higher number of cesareans, placenta previa, placental accreta type (implantation, penetration), and low signal strip on T2WI are independent high-risk factor for IPH. The Nomogram predictive model constructed with the high-risk factor demonstrates good clinical efficacy in predicting the occurrence of IPH due to PA.
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Affiliation(s)
- Xian Lu
- Department of Radiology, Affiliated Maternity and Child Health Care Hospital of Nantong University, Nantong, China
| | - Haibo Zhang
- Department of Emergency Medicine, Affiliated Maternity and Child Health Care Hospital of Nantong University, Nantong, China
| | - Xianhua Wu
- Department of Radiology, Affiliated Hospital of Nantong University, Nantong, China
| | - Xianfeng Chen
- Department of Ultrasound, Affiliated Maternity and Child Health Care Hospital of Nantong University, Nantong, China
| | - Qin Zhang
- Department of Radiology, Affiliated Maternity and Child Health Care Hospital of Nantong University, Nantong, China
| | - Wei Song
- Department of Radiology, Affiliated Maternity and Child Health Care Hospital of Nantong University, Nantong, China
| | - Yanqi Jin
- Department of Obstetrics, Affiliated Maternity and Child Health Care Hospital of Nantong University, Nantong, China
| | - Mingming Yuan
- Department of Pathology, Affiliated Maternity and Child Health Care Hospital of Nantong University, Nantong, China
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Jotwani AR, Lyell DJ, Butwick AJ, Rwigi W, Leonard SA. Validity of ICD-10 diagnosis codes for placenta accreta spectrum disorders. Paediatr Perinat Epidemiol 2024. [PMID: 38514907 DOI: 10.1111/ppe.13076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 03/06/2024] [Accepted: 03/09/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND The 10th revision of the International Classification of Diseases, Clinical Modification (ICD-10) includes diagnosis codes for placenta accreta spectrum for the first time. These codes could enable valuable research and surveillance of placenta accreta spectrum, a life-threatening pregnancy complication that is increasing in incidence. OBJECTIVE We sought to evaluate the validity of placenta accreta spectrum diagnosis codes that were introduced in ICD-10 and assess contributing factors to incorrect code assignments. METHODS We calculated sensitivity, specificity, positive predictive value and negative predictive value of the ICD-10 placenta accreta spectrum code assignments after reviewing medical records from October 2015 to March 2020 at a quaternary obstetric centre. Histopathologic diagnosis was considered the gold standard. RESULTS Among 22,345 patients, 104 (0.46%) had an ICD-10 code for placenta accreta spectrum and 51 (0.23%) had a histopathologic diagnosis. ICD-10 codes had a sensitivity of 0.71 (95% CI 0.56, 0.83), specificity of 0.98 (95% CI 0.93, 1.00), positive predictive value of 0.61 (95% CI 0.48, 0.72) and negative predictive value of 1.00 (95% CI 0.96, 1.00). The sensitivities of the ICD-10 codes for placenta accreta spectrum subtypes- accreta, increta and percreta-were 0.55 (95% CI 0.31, 0.78), 0.33 (95% CI 0.12, 0.62) and 0.56 (95% CI 0.31, 0.78), respectively. Cases with incorrect code assignment were less morbid than cases with correct code assignment, with a lower incidence of hysterectomy at delivery (17% vs 100%), blood transfusion (26% vs 75%) and admission to the intensive care unit (0% vs 53%). Primary reasons for code misassignment included code assigned to cases of occult placenta accreta (35%) or to cases with clinical evidence of placental adherence without histopatholic diagnostic (35%) features. CONCLUSION These findings from a quaternary obstetric centre suggest that ICD-10 codes may be useful for research and surveillance of placenta accreta spectrum, but researchers should be aware of likely substantial false positive cases.
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Affiliation(s)
- Anjali R Jotwani
- Department of Obstetrics and Gynecology, Stanford University, Stanford, California, USA
| | - Deirdre J Lyell
- Department of Obstetrics and Gynecology, Stanford University, Stanford, California, USA
| | - Alexander J Butwick
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California, USA
| | - Wanjiru Rwigi
- Department of Obstetrics and Gynecology, Stanford University, Stanford, California, USA
| | - Stephanie A Leonard
- Department of Obstetrics and Gynecology, Stanford University, Stanford, California, USA
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Huang L, Ma L, Zhou Q, Hu Y, Hu L, Luo Y, Li Y. Accuracy of MRI-Based Radiomics in Diagnosis of Placenta Accreta Spectrum: A PRISMA Systematic Review and Meta-Analysis. Med Sci Monit 2024; 30:e943461. [PMID: 38486373 PMCID: PMC10949827 DOI: 10.12659/msm.943461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/15/2024] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND Placenta accreta syndrome (PAS) can lead to severe obstetric bleeding, and can be life-threatening. This study aimed to assess the precision of radiomics features derived from magnetic resonance imaging (MRI) for diagnosing PAS. MATERIAL AND METHODS A comprehensive search was conducted in the databases PubMed, Embase, Web of Science, and the Cochrane library from inception to October 2023. We included diagnostic accuracy studies utilizing radiomics-MRI in PAS patients, with histopathology serving as the reference standard. The overall diagnostic odds ratio (DOR), sensitivity, specificity, and area under the curve (AUC) were computed to gauge the diagnostic accuracy of MRI-based radiomic features in PAS patients. Quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies 2. Statistical analyses were carried out using Stata 14.2, MetaDiSc 1.4, and Review Manager 5.3 software. RESULTS Seven studies involving 672 patients were incorporated. The aggregated DOR, sensitivity, specificity, and AUC for radiomics in detecting PAS were 78% (confidence interval32, 191), 87% (76%, 93%), 92% (89%, 94%), and 0.93 (0.91-0.95), respectively. The meta-analysis revealed notable heterogeneity among the included studies, with no evidence of a threshold effect. Subgroup analysis demonstrated that, in comparison to manual segmentation and validation groups with ≤100 cases and internal validation datasets, automated segmentation, validation groups with >100 cases, and external validation datasets exhibited superior diagnostic performance . CONCLUSIONS Our findings indicate that MRI-based radiomic features perform well in assessing the diagnostic risk of PAS during prenatal diagnosis. This noninvasive and convenient tool may prove valuable in facilitating the identification of PAS.
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Wang C, Wang Z. Value of early pregnancy ultrasound combined with ultrasound score in the evaluation of placenta accreta in scar uterus: A retrospective cohort study. Medicine (Baltimore) 2024; 103:e37531. [PMID: 38489684 PMCID: PMC10939536 DOI: 10.1097/md.0000000000037531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 02/09/2024] [Accepted: 02/16/2024] [Indexed: 03/17/2024] Open
Abstract
The objective of this study is to investigate the value of early pregnancy ultrasound combined with ultrasound score (USS) for the evaluation of placenta accreta (PA) in scar uteri. Thirty cases of PA in scar uteri diagnosed by ultrasound at our hospital between June 2021 and June 2022 were selected retrospectively (observation group). In addition, 30 patients had placenta attached to the anterior wall of the uterus and covered the internal orifice of the cervix; however, no PA was selected in the same period (control group). The results of surgical pathology and ultrasound examination in the first trimester of pregnancy (11-14 weeks of pregnancy, fetal top hip length 4.5-8.4 cm) were analyzed. Ultrasonic image characteristics of the 2 groups were scored using an ultrasonic scoring scale. The ultrasonic signs and ultrasonic scores of the 2 groups were analyzed. The diagnostic value of ultrasound and USS for PA in the scarred uterus alone and in combination was analyzed based on the gold standard of surgical and pathological results. The rich blood flow signal at the junction of the uterine serosa and bladder, the rate of blood flow in the cavity of the placental parenchyma, the thinning rate of the myometrium after placenta, and the abnormal rate of the low echo area after placenta in the observation group were significantly higher than those in the control group (P < .05). The USS of the observation group was significantly higher than that of the control group (P < .05). The sensitivity (93.33%) and accuracy (95.00%) of the combined examinations were significantly higher than those of ultrasound (70.00% and 83.33%, respectively) (P < .05). The sensitivity and accuracy of combined examination were slightly higher than those of USS examination (83.33% and 90.00%), but the difference was not statistically significant (P > .05). There was no significant difference between the specificity of combined examination (93.33%) and ultrasound (96.67%) and USS (96.67%) (P > .05). Early pregnancy ultrasound and USS evaluation have high application value in the diagnosis and evaluation of early scar uterine PA. The combination of the 2 methods can further improve the sensitivity and accuracy of diagnosis.
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Affiliation(s)
- Cuigai Wang
- Department of Ultrasonography, Hebei reproductive maternity hospital, Shijiazhuang City, Hebei Province, China
| | - Zhiyuan Wang
- Department of Ultrasound, Zhengding County People’s Hospital, Shijiazhuang City, Hebei Province, China
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Adu-Bredu TK, Ridwan R, Aditiawarman A, Ariani G, Collins SL, Aryananda RA. Three-dimensional volume rendering ultrasound for assessing placenta accreta spectrum severity and discriminating it from simple scar dehiscence. Am J Obstet Gynecol MFM 2024; 6:101321. [PMID: 38460827 DOI: 10.1016/j.ajogmf.2024.101321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/17/2024] [Accepted: 02/25/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Prenatal ultrasound discrimination between placenta accreta spectrum and scar dehiscence with underlying nonadherent placenta is challenging both prenatally and intraoperatively, which often leads to overtreatment. In addition, accurate prenatal prediction of surgical difficulty and morbidity in placenta accreta spectrum is difficult, which precludes appropriate multidisciplinary planning. The advent of advanced 3-dimensional volume rendering and contrast enhancement techniques in modern ultrasound systems provides a comprehensive prenatal assessment, revealing details that are not discernible in traditional 2-dimensional imaging. OBJECTIVE This study aimed to evaluate the use of 3-dimensional volume rendering ultrasound techniques in determining the severity of placenta accreta spectrum and distinguishing between placenta accreta spectrum and scar dehiscence with underlying nonadherent placenta. STUDY DESIGN A prospective, cohort study was conducted between July 2022 and July 2023 in the fetal medicine unit of Dr Soetomo Academic General Hospital, Surabaya, Indonesia. All pregnant individuals with anterior low-lying placenta or placenta previa with a previous caesarean section who were referred with suspicion of placenta accreta spectrum were consented and screened using the standardised 2-dimensional and Doppler ultrasound imaging. Additional 3-dimensional volumes were obtained from the sagittal section of the uterus with a filled urinary bladder. These were analyzed by rotating the region of interest to be perpendicular to the uterovesical interface. The primary outcomes were the clinical and histologic severity in the cases of placenta accreta spectrum and correct diagnosis of dehiscence with nonadherent placenta underneath. The strength of association between ultrasound and clinical outcomes was determined. Multivariate logistic regression analyses and diagnostic testing of accuracy were used to analyze the data. RESULTS A total of 70 patients (56 with placenta accreta spectrum and 14 with scar dehiscence) were included in the analysis. Multivariate logistic regression of all 2-dimensional and 3-dimensional signs revealed the 3-dimensional loss of clear zone (P<.001) and the presence of bridging vessels on 2-dimensional Doppler ultrasound (P=.027) as excellent predictors in differentiating scar dehiscence and placenta accreta spectrum. The 3-dimensional loss of clear zone demonstrated a high diagnostic accuracy with an area under the curve of 0.911 (95% confidence interval, 0.819-1.002), with a sensitivity of 89.3% (95% confidence interval, 78.1-95.97%) and specificity of 92.9% (95% confidence interval, 66.1-99.8%). The presence of bridging vessels on 2-dimensional Doppler demonstrated an area under the curve of 0.848 (95% confidence interval, 0.714-0.982) with a sensitivity of 91.1% (95% confidence interval, 80.4-97.0%) and specificity of 78.6% (95% confidence interval, 49.2-95.3%). A subgroup analysis among the placenta accreta spectrum group revealed that the presence of a 3-dimensional disrupted bladder serosa with obliteration of the vesicouterine space was associated with vesicouterine adherence (P<.001). CONCLUSION Three-dimensional volume rendering ultrasound is a promising tool for effective discrimination between scar dehiscence with underlying nonadherent placenta and placenta accreta spectrum. It also shows potential in predicting the clinical severity with urinary bladder involvement in cases of placenta accreta spectrum.
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Affiliation(s)
- Theophilus K Adu-Bredu
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom (Mr Adu-Bredu and Prof Collins)
| | - Robert Ridwan
- Maternal Fetal Medicine, Obstetrics and Gynecology Department, Dr Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia (Dr Ridwan, Dr Aditiawarman, and Dr Aryananda)
| | - Aditiawarman Aditiawarman
- Maternal Fetal Medicine, Obstetrics and Gynecology Department, Dr Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia (Dr Ridwan, Dr Aditiawarman, and Dr Aryananda)
| | - Grace Ariani
- Anatomical Pathology Department, Dr Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia (Dr Ariani)
| | - Sally L Collins
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom (Mr Adu-Bredu and Prof Collins)
| | - Rozi A Aryananda
- Department of Obstetrics and Gynaecology, Erasmus, University Medical Center, Rotterdam, The Netherlands (Dr Aryananda).
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Dar P, Doulaveris G. First-trimester screening for placenta accreta spectrum. Am J Obstet Gynecol MFM 2024; 6:101329. [PMID: 38447672 DOI: 10.1016/j.ajogmf.2024.101329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/02/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
In recent years, there has been a significant rise in cases of placenta accreta spectrum, a group of life-threatening placental disorders that can arise during childbirth. Early detection plays a crucial role in facilitating meticulous delivery planning, ultimately leading to a reduction in mortality and morbidity rates and improved overall outcomes. Although third-trimester ultrasound has traditionally been the primary method for prenatal screening for placenta accreta spectrum, it often falls short in identifying cases or diagnosis is too late for optimal delivery planning. Emerging evidence has highlighted the option of early detection of placenta accreta spectrum indicators during the first trimester of pregnancy. This comprehensive review delves into our current knowledge of sonographic assessment of the uterine cervicoisthmic complex in the first trimester, examining the location and appearance of cesarean scars and exploring first-trimester screening strategies, ultimately paving the way for improved maternal and neonatal outcomes.
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Affiliation(s)
- Pe'er Dar
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine (Drs Dar and Doulaveris), Bronx, NY.
| | - Georgios Doulaveris
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine (Drs Dar and Doulaveris), Bronx, NY
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Chen F, Zhang C, Hu Y. Efficacy of Bakri Intrauterine Balloon in Managing Postpartum Hemorrhage: A Comparative Analysis of Vaginal and Cesarean Deliveries with Placenta Accreta Spectrum Disorders. Med Sci Monit 2024; 30:e943072. [PMID: 38433445 PMCID: PMC10921967 DOI: 10.12659/msm.943072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/03/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND The incidence of placenta accreta spectrum disorder (PAS) has been increasing in past decades, and women with PAS are a high-risk maternal population. This study aimed to explore the performance of Bakri intrauterine balloon tamponade (IUBT) in the treatment of postpartum hemorrhage (PPH), among those with and without PAS. MATERIAL AND METHODS The outcomes of 198 women who underwent treatment for PPH using IUBT were retrospectively analyzed. The demographics and maternal outcomes were analyzed for vaginal and cesarean births, with PAS and without PAS. RESULTS Compared to women with vaginal births (n=130), women who underwent cesarean births (n=68) showed a higher proportion of age ≥35 years (χ²=6.85, P=0.013), multiple births (χ²=13.60, P<0.001), preeclampsia (χ²=9.81, P=0.002), use of transabdominal IUBT (χ²=84.12, P<0.001) and pre-IUBT interventions (χ²=41.61, P<0.001), but had less infused volume of physiological saline (t=6.41, P<0.001). Women with PAS (n=105) showed a higher rate of pre-IUBT intervention (χ²=4.96, P=0.029) and transabdominal IUBT placement (χ²=9.37, P=0.002) than non-PAS women (n=93). The 36 women with PAS (n=36) showed a higher rate of preeclampsia (χ²=4.80, P=0.029), pre-IUBT intervention (χ²=5.90, P=0.015), and transabdominal IUBT placement (χ²=14.94, P<0.001) and a shorter duration from delivery to Bakri insertion (χ²=3.31, P=0.002), than non-PAS women (n=32). CONCLUSIONS PAS was a major cause of PPH at 198 vaginal and cesarean births. An accurate and timely pre-IUBT intervention and Bakri IUBT placement was critical for controlling PPH in cesarean births, especially in women with PAS.
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Bessar AA, Heraiz AI, Ibrahim AG, Salem MMA, Zaitoun MM, Aboelfateh AMK, Gad AH. Prophylactic common iliac artery temporary clamping versus balloon occlusion for management of placenta accreta spectrum disorders: A prospective clinical trial. J Obstet Gynaecol Res 2024; 50:373-380. [PMID: 38109908 DOI: 10.1111/jog.15856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 11/29/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVE The present study aims to compare prophylactic common iliac artery (CIA) temporary clamping and preoperative balloon occlusion for managing placenta accreta spectrum (PAS) disorders. STUDY DESIGN Between January 2019 and June 2020, 46 patients with PAS disorders were included. Of them, 26 patients were offered CIA balloon occlusion (Group A), while temporary CIA clamping was done for the other 20 patients (Group B). Primary outcomes were procedure-related complications, and secondary outcomes included intraoperative and postoperative complications, reoperation rates, total procedure time, blood loss, and amount of blood transfusion. RESULTS Blood loss was statistically non-significant higher in group B than in group A (p-value = 0.143). Only one patient in group A and three in group B needed reoperation. The bleeding continued for a mean of 1.6 days in group A and 1.7 days in group B, with non-significant statistical differences between both groups p value = 0.71. Nine patients in group A (34.6%) and four in group B (20%) required ICU admission. The mean Apgar score was 7 and 6.6 in babies of group A and group B patients, respectively. The median number of allogeneic blood transfusions performed was two in patients in group A and 1 in group B (p-value = 0.001). CONCLUSION Both techniques offer good choices for patients with PAS to decrease mortality and morbidity rates. The selection of a better technique depends on institutional references and physicians' experience.
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Affiliation(s)
- Ahmed Awad Bessar
- Department of Radiodiagnosis, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed Ismail Heraiz
- Department of Obstetrics and Gynecology, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed Gamil Ibrahim
- Department of Radiodiagnosis, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Mahmoud M A Salem
- Department of Vascular Surgery, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Mohamed Moustafa Zaitoun
- Department of Obstetrics and Gynecology, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | | | - Abdalla Hassan Gad
- Department of Obstetrics and Gynecology, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
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Munoz JL, Curbelo J, Ramsey PS. An obstetric-specific surgical Apgar score predicts maternal morbidity from cesarean hysterectomy for placenta accreta spectrum. Int J Gynaecol Obstet 2024; 164:912-917. [PMID: 37668180 DOI: 10.1002/ijgo.15069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 08/17/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVE Placenta accreta spectrum (PAS) is a continuum of placental conditions characterized by significant maternal and neonatal morbidity. Tools to accurately predict postoperative morbidity have been lacking due to the hemodynamic changes of pregnancy. The surgical Apgar score (SAS) is a 10-point scale that assesses heart rate, mean arterial pressure, and estimated blood loss. The SAS has been validated to predict morbidity such as blood transfusion and reoperation. METHODS We created an obstetric-specific SAS (ObSAS) scale for physiologic changes of pregnancy (two-fold increase in blood loss, 10% increased heart rate, and 5% decreased mean arterial pressure) and analyzed 110 cases of PAS who underwent cesarean hysterectomy. RESULTS An ObSAS of 0-4 (poorest score) was significantly associated with increased risk of intensive care unit (ICU) admission (odds ratio [OR] 40.6, 95% confidence interval [CI] 7.9-742.9), transfusion >4 units (26/26 patients), and greater surgical morbidity (OR 22.7, 95% CI 4.4-415.0). ObSAS of 9-10 resulted in no ICU admissions (0/12), fewer blood transfusions (OR 0.1, 95% CI 0.1-0.4). and less surgical morbidity (OR 0.09, 95% CI 0.01-0.37). CONCLUSION Given the overall surgical morbidity associated with PAS cesarean hysterectomy, the ObSAS score is a powerful tool with excellent predictive capabilities for ICU admission, blood transfusion, and surgical morbidity, allowing for resource allocation, prophylactic interventions, and optimal patient outcomes.
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Affiliation(s)
- Jessian L Munoz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Jacqueline Curbelo
- University of Texas Health Sciences, San Antonio, Texas, USA
- Department of Obstetrics & Gynecology, University Health System, San Antonio, Texas, USA
| | - Patrick S Ramsey
- University of Texas Health Sciences, San Antonio, Texas, USA
- Department of Anesthesiology, University Health System, San Antonio, Texas, USA
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Peng L, Yang Z, Liu J, Liu Y, Huang J, Chen J, Su Y, Zhang X, Song T. Prenatal Diagnosis of Placenta Accreta Spectrum Disorders: Deep Learning Radiomics of Pelvic MRI. J Magn Reson Imaging 2024; 59:496-509. [PMID: 37222638 DOI: 10.1002/jmri.28787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/02/2023] [Accepted: 05/02/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Diagnostic performance of placenta accreta spectrum (PAS) by prenatal MRI is unsatisfactory. Deep learning radiomics (DLR) has the potential to quantify the MRI features of PAS. PURPOSE To explore whether DLR from MRI can be used to identify pregnancies with PAS. STUDY TYPE Retrospective. POPULATION 324 pregnant women (mean age, 33.3 years) suspected PAS (170 training and 72 validation from institution 1, 82 external validation from institution 2) with clinicopathologically proved PAS (206 PAS, 118 non-PAS). FIELD STRENGTH/SEQUENCE 3-T, turbo spin-echo T2-weighted images. ASSESSMENT The DLR features were extracted using the MedicalNet. An MRI-based DLR model incorporating DLR signature, clinical model (different clinical characteristics between PAS and non-PAS groups), and MRI morphologic model (radiologists' binary assessment for the PAS diagnosis) was developed. These models were constructed in the training dataset and then validated in the validation datasets. STATISTICAL TESTS The Student t-test or Mann-Whitney U, χ2 or Fisher exact test, Kappa, dice similarity coefficient, intraclass correlation coefficients, least absolute shrinkage and selection operator logistic regression, multivariate logistic regression, receiver operating characteristic (ROC) curve, DeLong test, net reclassification improvement (NRI) and integrated discrimination improvement (IDI), calibration curve with Hosmer-Lemeshow test, decision curve analysis (DCA). P < 0.05 indicated a significant difference. RESULTS The MRI-based DLR model had a higher area under the curve than the clinical model in three datasets (0.880 vs. 0.741, 0.861 vs. 0.772, 0.852 vs. 0.675, respectively) or MRI morphologic model in training and independent validation datasets (0.880 vs. 0.760, 0.861, vs. 0.781, respectively). The NRI and IDI were 0.123 and 0.104, respectively. The Hosmer-Lemeshow test had nonsignificant statistics (P = 0.296 to 0.590). The DCA offered a net benefit at any threshold probability. DATA CONCLUSION An MRI-based DLR model may show better performance in diagnosing PAS than a clinical or MRI morphologic model. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY STAGE: 2.
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Affiliation(s)
- Lulu Peng
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Guangzhou Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Zehong Yang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Jue Liu
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Guangzhou Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Yi Liu
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Guangzhou Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Jianwei Huang
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Guangzhou Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
| | - Junwei Chen
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Yun Su
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Xiang Zhang
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 510120, People's Republic of China
| | - Ting Song
- Department of Radiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Guangzhou Institute of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510000, People's Republic of China
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Wang H, Wang Y, Zhang H, Yin X, Wang C, Lu Y, Song Y, Zhu H, Yang G. A Deep Learning Pipeline Using Prior Knowledge for Automatic Evaluation of Placenta Accreta Spectrum Disorders With MRI. J Magn Reson Imaging 2024; 59:483-493. [PMID: 37177832 DOI: 10.1002/jmri.28770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND The diagnosis of prenatal placenta accreta spectrum (PAS) with magnetic resonance imaging (MRI) is highly dependent on radiologists' experience. A deep learning (DL) method using the prior knowledge that PAS-related signs are generally found along the utero-placental borderline (UPB) may help radiologists, especially those with less experience, to mitigate this issue. PURPOSE To develop a DL tool for antenatal diagnosis of PAS using T2-weighted MR images. STUDY TYPE Retrospective. SUBJECTS Five hundred and forty pregnant women with clinically suspected PAS disorders from two institutions, divided into training (409), internal test (103), and external test (28) datasets. FIELD STRENGTH/SEQUENCE Sagittal T2-weighted fast spin echo sequence at 1.5 T and 3 T. ASSESSMENT An nnU-Net was trained for placenta segmentation. The UPB straightening approach was used to extract the utero-placental boundary region. The UPB image was then fed into DenseNet-PAS for PAS diagnosis. DenseNet-PP learnt placental position information to improve the PAS diagnosis performance. Three radiologists with 8, 10, and 12 years of experience independently evaluated the images. Two radiologists marked the placenta tissue. Histopathological findings were the reference standard. STATISTICAL TESTS Area under the curve (AUC) was used to evaluate the classification. Dice coefficient evaluated the segmentation between radiologists and the model performance. The Mann-Whitney U-test or the chi-squared test assessed the significance of differences. Decision curve analysis was used to determine clinical effectiveness. DeLong's test was used to compare AUCs. RESULTS Of the 540 patients, 170 had PAS disorders confirmed by histopathology. The DL model using UPB images and placental position yielded the highest AUC of 0.860 and 0.897 in internal test and external test cohorts, respectively, significantly exceeding the performance of three radiologists (internal test AUC, 0.737-0.770). DATA CONCLUSION By extracting the UPB image, this fully automatic DL pipeline achieved high accuracy and may assist radiologists in PAS diagnosis using MRI. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Haijie Wang
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, Shanghai, China
| | - Yida Wang
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, Shanghai, China
| | - He Zhang
- Department of Radiology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Xuan Yin
- Department of Radiology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Chenglong Wang
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, Shanghai, China
| | - Yuanyuan Lu
- Department of Radiology, Shanghai First Maternity and Infant Health Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yang Song
- MR Scientific Marketing, Siemens Healthineers China, Shanghai, China
| | - Hao Zhu
- Department of Obstetrics, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Guang Yang
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, Shanghai, China
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Sawant R, Patil S, Warghade SS, Shirsat SY. The Role of Ultrasonography and Magnetic Resonance Imaging in the Diagnosis of the Adherent Placenta: An Observational Study. Cureus 2024; 16:e53856. [PMID: 38465149 PMCID: PMC10924658 DOI: 10.7759/cureus.53856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/07/2024] [Indexed: 03/12/2024] Open
Abstract
Introduction Placenta accreta is an important factor responsible for maternal morbidity and mortality and is commonly associated with emergent postpartum hysterectomy. The precise prenatal diagnosis of affected pregnancies allows optimal obstetric management. Ultrasonography (USG) and magnetic resonance imaging (MRI) are the only diagnostic modalities available for the prenatal diagnosis of placenta accreta. Objective This study aims to evaluate the accuracy of USG and MRI in diagnosing adherent placenta. Methods Thirty females with placenta previa or a history of previous cesarean sections were evaluated with USG at 28-30 weeks, followed by MRI. The findings of USG and MRI were compared with the intra-operative findings (gold standard) as determined at surgery and by pathological examination. Results Abnormal bridging vessel (n = 24; 80%) was the most common finding seen on USG, whereas abnormal bulge (n = 22; 73.3%) and heterogenous placenta (n = 21; 70%) were the most common findings seen on MRI. The sensitivity of USG and MRI was in the range of 86.7%-92.9% and 92.9%-100%, respectively, in diagnosing three types of adherent placenta. The positive predictive values (PPV) of USG and MRI were in the range of 86.7%-86.7% and 93.8%-100%, respectively, in diagnosing three types of adherent placenta. The accuracy of USG and MRI was in the range of 86.7%-96.7% and 96.7%-100%, respectively, in diagnosing three types of adherent placenta. Conclusion MRI helps to accurately classify placental invasion according to depth, as can be seen from the results of the present study, where the MRI technique was more accurate in diagnosing three types of adherent placenta.
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Affiliation(s)
- Rahul Sawant
- Radiodiagnosis, Grant Government Medical College and Sir Jamshedjee Jeejeebhoy (JJ) Hospital, Mumbai, IND
| | - Swastika Patil
- Pathology, Smt. Kashibai Navale Medical College and General Hospital, Pune, IND
| | - Sanket S Warghade
- Radiology, Grant Government Medical College and Sir Jamshedjee Jeejeebhoy (JJ) Hospital, Mumbai, IND
| | - Siddhant Y Shirsat
- Radiodiagnosis, Grant Government Medical College and Sir Jamshedjee Jeejeebhoy (JJ) Hospital, Mumbai, IND
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Munoz JL, Einerson BD, Silver RM, Mulampurath S, Sherman LS, Rameshwar P, Prewit EB, Ramsey PS. Serum exosomal microRNA pathway activation in placenta accreta spectrum: pathophysiology and detection. AJOG Glob Rep 2024; 4:100319. [PMID: 38440154 PMCID: PMC10910333 DOI: 10.1016/j.xagr.2024.100319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Placenta accreta spectrum disorders are a complex range of placental pathologies that are associated with significant maternal morbidity and mortality. A diagnosis of placenta accreta spectrum relies on ultrasonographic findings with modest positive predictive value. Exosomal microRNAs are small RNA molecules that reflect the cellular processes of the origin tissues. OBJECTIVE We aimed to explore exosomal microRNA expression to understand placenta accreta spectrum pathology and clinical use for placenta accreta spectrum detection. STUDY DESIGN This study was a biomarker analysis of prospectively collected samples at 2 academic institutions from 2011 to 2022. Plasma specimens were collected from patients with suspected placenta accreta spectrum, placenta previa, or repeat cesarean deliveries. Exosomes were quantified and characterized by nanoparticle tracking analysis and western blotting. MicroRNA were assessed by polymerase chain reaction array and targeted single quantification. MicroRNA pathway analysis was performed using the Ingenuity Pathway Analyses software. Placental biopsies were taken from all groups and analyzed by polymerase chain reaction and whole cell enzyme-linked immunosorbent assay. Receiver operating characteristic curve univariate analysis was performed for the use of microRNA in the prediction of placenta accreta spectrum. Clinically relevant outcomes were collected from abstracted medical records. RESULTS Plasma specimens were analyzed from a total of 120 subjects (60 placenta accreta spectrum, 30 placenta previa, and 30 control). Isolated plasma exosomes had a mean size of 71.5 nm and were 10 times greater in placenta accreta spectrum specimens (20 vs 2 particles/frame). Protein expression of exosomes was positive for intracellular adhesion molecule 1, flotilin, annexin, and CD9. MicroRNA analysis showed increased detection of 3 microRNAs (mir-92, -103, and -192) in patients with placenta accreta spectrum. Pathway interaction assessment revealed differential regulation of p53 signaling in placenta accreta spectrum and of erythroblastic oncogene B2 or human epidermal growth factor 2 in control specimens. These findings were subsequently confirmed in placental protein analysis. Placental microRNA paralleled plasma exosomal microRNA expression. Biomarker assessment of placenta accreta spectrum signature microRNA had an area under the receiver operating characteristic curve of 0.81 (P<.001; 95% confidence interval, 0.73-0.89) with a sensitivity and specificity of 89.2% and 80%, respectively. CONCLUSION In this large cohort, plasma exosomal microRNA assessment revealed differentially expressed pathways in placenta accreta spectrum, and these microRNAs are potential biomarkers for the detection of placenta accreta spectrum.
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Affiliation(s)
- Jessian L. Munoz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Dr Munoz)
- Division of Fetal Intervention, Department of Obstetrics and Gynecology, Texas Children's Hospital, Houston, TX (Dr Munoz)
| | - Brett D. Einerson
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT (XX Einerson and Dr Silver)
| | - Robert M. Silver
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT (XX Einerson and Dr Silver)
| | - Sureshkumar Mulampurath
- Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio and the University Health System, San Antonio, TX (XX Mulampurath, XX Prewit, and Dr Ramsey)
| | - Lauren S. Sherman
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ (XX Sherman and XX Rameshwar)
| | - Pranela Rameshwar
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ (XX Sherman and XX Rameshwar)
| | - Egle Bytautiene Prewit
- Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio and the University Health System, San Antonio, TX (XX Mulampurath, XX Prewit, and Dr Ramsey)
| | - Patrick S. Ramsey
- Department of Obstetrics & Gynecology, University of Texas Health Sciences Center at San Antonio and the University Health System, San Antonio, TX (XX Mulampurath, XX Prewit, and Dr Ramsey)
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Determinants of emergency Cesarean delivery in pregnancies complicated by placenta previa with or without placenta accreta spectrum disorder: analysis of ADoPAD cohort. Ultrasound Obstet Gynecol 2024; 63:243-250. [PMID: 37698306 DOI: 10.1002/uog.27465] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/28/2023] [Accepted: 07/21/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVES To investigate the rate and outcome of emergency Cesarean delivery (CD) in women with placenta previa with or without placenta accreta spectrum disorders (PAS) and to elucidate the diagnostic accuracy of ultrasound in predicting emergency CD. METHODS This was a secondary analysis of a multicenter prospective study involving 16 referral hospitals in Italy (ADoPAD study). Inclusion criteria were women with placenta previa minor (< 20 mm from the internal cervical os) or placenta previa major (covering the os), aged ≥ 18 years, who underwent transabdominal and transvaginal ultrasound assessment at ≥ 26 + 0 weeks of gestation. The primary outcome was the occurrence of emergency CD, defined as the need for immediate surgical intervention performed for emergency maternal or fetal indication, including active labor, cumulative maternal bleeding > 500 mL, severe and persistent vaginal bleeding such that maternal hemodynamic stability could not be achieved or maintained, or category-III fetal heart rate tracing unresponsive to resuscitative measures. The primary outcome was reported separately in the population of women with placenta previa and no PAS confirmed after birth and in those with PAS. The secondary aim was to report on the strength of association and to test the diagnostic accuracy of ultrasound in predicting emergency CD. Univariate, multivariate and diagnostic accuracy analyses were used to analyze the data. RESULTS A total of 450 women, including 97 women with placenta previa and PAS and 353 with placenta previa only, were analyzed. In women with placenta previa and PAS, emergency CD was required in 20.6% (95% CI, 14-30%), and 60.0% (12/20) delivered before 34 weeks of gestation. The mean gestational age at delivery was 32.3 ± 2.7 weeks in women undergoing emergency CD and 34.9 ± 1.8 weeks in those undergoing elective CD (P < 0.001). Women undergoing emergency CD had a higher median estimated blood loss (2500 (interquartile range (IQR), 1350-4500) vs 1100 (IQR, 625-2500) mL; P = 0.012), mean units of blood transfused (7.3 ± 8.8 vs 2.5 ± 3.4; P = 0.02) and more frequent placement of a mechanical balloon (50.0% vs 16.9%; P = 0.002) compared with those undergoing elective CD. On univariate analysis, the presence of interrupted retroplacental space, interrupted bladder line and placental lacunae was more common in women not experiencing emergency CD. No comprehensive multivariate analysis could be performed in this subgroup of women. Ultrasound signs of PAS, including presence of interrupted retroplacental space, interrupted bladder line and placental lacunae, were not predictive of emergency CD. In women with placenta previa but no PAS, emergency CD was required in 31.2% (95% CI, 26.6-36.2%), and 32.7% (36/110) delivered before 34 weeks of gestation. The mean gestational age at delivery was lower in women undergoing emergency CD compared with those undergoing elective CD (34.2 ± 2.9 vs 36.7 ± 1.6 weeks; P < 0.001). Pregnancies complicated by emergency CD were associated with a lower birth weight (2330 ± 620 vs 2800 ± 480 g; P < 0.001) and had a higher risk of need for blood transfusion (22.7% vs 10.7%; P = 0.003) compared with those who underwent elective CD. On multivariate analysis, only placental thickness (odds ratio (OR), 1.02 (95% CI, 1.00-1.03); P = 0.046) and cervical length < 25 mm (OR, 3.89 (95% CI, 1.33-11.33); P = 0.01) were associated with emergency CD. However, a short cervical length showed low diagnostic accuracy for predicting emergency CD in these women. CONCLUSION Emergency CD occurred in about 20% of women with placenta previa and PAS and 30% of those with placenta previa only and was associated with worse maternal outcome compared with elective intervention. Prenatal ultrasound is not predictive of the risk of emergency CD in women with these disorders. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Alina WB, Elias C, Eran K, Lior F, Nizan M, Gabriel L, Hila LE, Raanan M. Outcomes of cesarean delivery in placenta accreta: conservative delivery vs. cesarean hysterectomy. J Perinat Med 2024; 52:22-29. [PMID: 37602708 DOI: 10.1515/jpm-2023-0154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 08/05/2023] [Indexed: 08/22/2023]
Abstract
OBJECTIVES To compare delivery outcomes of pregnancies diagnosed with placenta-accreta-syndrome (PAS) who underwent conservative treatment to patients who underwent cesarean hysterectomy. METHODS A retrospective study of all women diagnosed with PAS treated in one tertiary medical center between 03/2011 and 11/2020 was performed. Comparison was made between conservative management during cesarean delivery and cesarean hysterectomy. Conservative management included leaving uterus in situ with/without placenta and with/without myometrial resection. RESULTS A total of 249 pregnancies (0.25 % of all deliveries) were diagnosed with PAS, 208 underwent conservative cesarean delivery and 41 had cesarean hysterectomy, 31 of them were unplanned (75.6 %). The median number of previous cesarean deliveries was significantly higher in the cesarean hysterectomy group. There was no difference in the duration from the last cesarean delivery, the presence of placenta previa, pre-operative hemoglobin or platelets levels between the pregnancies with conservative management and the cesarean hysterectomy. Significantly more pregnancies with sonographic suspicion of placenta percreta and bladder invasion had cesarean hysterectomy. Cesarean hysterectomy was significantly associated with earlier delivery, with bleeding and required significantly more blood products. There was no statistically significant difference in the rate of relaparotomy following cesarean delivery or the rate of infections. Multivariable-regression-analysis revealed a significant odds ratio of 3.38 of blood loss of >3,000 mL following cesarean hysterectomy. CONCLUSIONS Conservative management in delivery of PAS pregnancies is associated with less bleeding complications during surgery compared to cesarean hysterectomy.
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Affiliation(s)
- Weissmann-Brenner Alina
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- The Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Castel Elias
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Kassif Eran
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- The Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Friedrich Lior
- The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Mor Nizan
- The Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Levin Gabriel
- The Department of Gynecologic Oncology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Lahav Ezra Hila
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Meyer Raanan
- The Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- The Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel
- The Dr. Pinchas Bornstein Talpiot Medical Leadership Program, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel
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Zhang K, Cheng S, Zhi Y, Lu L, Yi M, Cui S. Application of Uterine Artery Embolization in Patients With Placenta Accreta Spectrum After Abdominal Aortic Balloon Occlusion. Vasc Endovascular Surg 2024:15385744241229596. [PMID: 38252516 DOI: 10.1177/15385744241229596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
OBJECTIVE To evaluate the application of different uterine artery embolization procedures under balloon occlusion of the abdominal aorta in patients with Placenta Accreta Spectrum (PAS) undergoing cesarean section. MATERIALS AND METHODS A retrospective analysis was performed on clinical data from 72 patients who underwent uterine artery embolization for hemostasis during cesarean section with PAS. The patients were divided into two groups according to the embolization method used during surgery: group A (n = 43) underwent uterine artery embolization by withdrawing the balloon and inserting a Cobra catheter into the uterine artery for embolization, while group B (n = 29) underwent uterine artery embolization with a Cobra catheter inserted via contralateral puncture of the femoral artery and balloon occlusion. General information, surgical data, and postoperative recovery were compared between the 2 groups. RESULTS The bleeding and transfusion volumes were lower in group B than in group A and the differences between the 2 groups were statistically significant. There were no significant differences in surgical duration, number of embolized vessels, length of hospital stay, postoperative complications, or menstrual recovery between the 2 groups. CONCLUSION For patients with PAS undergoing cesarean section, uterine artery embolization for hemostasis is preferably performed by inserting a Cobra catheter via contralateral puncture of the femoral artery under abdominal aortic balloon occlusion.
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Affiliation(s)
- Kai Zhang
- Department of Obstetrics, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shuqin Cheng
- Department of Obstetrics, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yunxiao Zhi
- Department of Obstetrics, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lin Lu
- Department of Obstetrics, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mingsheng Yi
- Department of Obstetrics, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shihong Cui
- Department of Obstetrics, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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20
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Fitzgerald GD, Newton JM, Atasi L, Buniak CM, Burgos-Luna JM, Burnett BA, Carver AR, Cheng C, Conyers S, Davitt C, Deshmukh U, Donovan BM, Easter SR, Einerson BD, Fox KA, Habib AS, Harrison R, Hecht JL, Licon E, Nino JM, Munoz JL, Nieto-Calvache AJ, Polic A, Ramsey PS, Salmanian B, Shamshirsaz AA, Shamshirsaz AA, Shrivastava VK, Woolworth MB, Yurashevich M, Zuckerwise L, Shainker SA. Placenta accreta spectrum care infrastructure: an evidence-based review of needed resources supporting placenta accreta spectrum care. Am J Obstet Gynecol MFM 2024; 6:101229. [PMID: 37984691 DOI: 10.1016/j.ajogmf.2023.101229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/02/2023] [Accepted: 11/15/2023] [Indexed: 11/22/2023]
Abstract
The incidence of placenta accreta spectrum, the deeply adherent placenta with associated increased risk of maternal morbidity and mortality, has seen a significant rise in recent years. Therefore, there has been a rise in clinical and research focus on this complex diagnosis. There is international consensus that a multidisciplinary coordinated approach optimizes outcomes. The composition of the team will vary from center to center; however, central themes of complex surgical experts, specialists in prenatal diagnosis, critical care specialists, neonatology specialists, obstetrics anesthesiology specialists, blood bank specialists, and dedicated mental health experts are universal throughout. Regionalization of care is a growing trend for complex medical needs, but the location of care alone is just a starting point. The goal of this article is to provide an evidence-based framework for the crucial infrastructure needed to address the unique antepartum, delivery, and postpartum needs of the patient with placenta accreta spectrum. Rather than a clinical checklist, we describe the personnel, clinical unit characteristics, and breadth of contributing clinical roles that make up a team. Screening protocols, diagnostic imaging, surgical and potential need for critical care, and trauma-informed interaction are the basis for comprehensive care. The vision from the author group is that this publication provides a semblance of infrastructure standardization as a means to ensure proper preparation and readiness.
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Affiliation(s)
- Garrett D Fitzgerald
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI (Dr Fitzgerald).
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN (Dr Newton)
| | - Lamia Atasi
- Department of Obstetrics and Gynecology, Mercy Hospital, St. Louis, MO (Dr Atasi)
| | - Christina M Buniak
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA (Dr Buniak)
| | | | - Brian A Burnett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Dr Burnett)
| | - Alissa R Carver
- Department of Obstetrics and Gynecology, Wilmington Maternal-Fetal Medicine, Wilmington, NC (Dr Carver)
| | - CeCe Cheng
- Department of Obstetrics and Gynecology, Health Science Center at San Antonio, University of Texas, San Antonio, TX (Dr Cheng)
| | - Steffany Conyers
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Caroline Davitt
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Davitt and Am Shamshiraz)
| | - Uma Deshmukh
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Bridget M Donovan
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Donovan and Shainker)
| | - Sara Rae Easter
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA (Dr Easter)
| | - Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT (Dr Einerson)
| | - Karin A Fox
- Baylor College of Medicine, Houston, TX (Dr Fox)
| | - Ashraf S Habib
- Duke University School of Medicine, Durham, NC (Dr Habib)
| | - Rachel Harrison
- Department of Obstetrics and Gynecology, Advocate Aurora Health, Chicago, IL (Dr Harrison)
| | - Jonathan L Hecht
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Ernesto Licon
- Miller Women's & Children's Hospital/Long Beach Memorial Medical Center, Orange, CA (Dr Licon)
| | - Julio Mateus Nino
- Department of Obstetrics and Gynecology, Atrium Health Wake Forest School of Medicine, Winston-Salem, NC (Dr Nino)
| | - Jessian L Munoz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX (Dr Munoz)
| | | | | | - Patrick S Ramsey
- University of Texas Health/University Health San Antonio, San Antonio, TX (Dr Ramsey)
| | - Bahram Salmanian
- Department of Obstetrics and Gynecology, University of Colorado Health Anschutz Medical Campus, Boulder, CO (Dr Salmanian)
| | | | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Davitt and Am Shamshiraz)
| | - Vineet K Shrivastava
- Miller Women's and Children's Hospital/Long Beach Memorial Medical Center, Orange, CA (Dr Shrivastava)
| | | | - Mary Yurashevich
- Department of Anesthesiology, Duke Health, Durham, NC (Dr Yurashevich)
| | - Lisa Zuckerwise
- and Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN (Dr Zuckerwise)
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Donovan and Shainker)
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21
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Yao R, Nguyen HY, Hong L, Karagoyzyan D, Burruss S, Brar H, Staton M, Martin C, Balli K, Ioffe Y. Regional multidisciplinary team approach to the management of placenta accreta spectrum disorder. J Matern Fetal Neonatal Med 2023; 36:2190840. [PMID: 36927241 DOI: 10.1080/14767058.2023.2190840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
OBJECTIVE Patients with suspected placenta accreta spectrum (PAS) disorder are often referred to specialized medical centers for antepartum management and definitive treatment via cesarean hysterectomy. In 2019, our institution formed the only multidisciplinary team for the management of PAS within two of the largest counties in California. The purpose of this study was to evaluate the effects of the multidisciplinary team on patient volume and surgical outcomes for patients with PAS. METHODS This was a single center retrospective cohort study, based in the only tertiary referral center within two of the largest counties in California. Patients who underwent cesarean hysterectomy for suspected PAS from January 2014 to April 2021 were included and divided into two groups, based on management by the multidisciplinary team from January 2019 and onward or routine care prior to that time. The outcomes of interest were quantitative blood loss, total units of packed red blood cell transfusion, referral volume, and diagnostic accuracy as well as ICU admission, bladder injury, and postoperative length of stay. Furthermore, we wanted to determine if patient's distance to the hospital impacted outcomes. Normally distributed variables were compared between groups using the t-test. Categorical variables were compared between the two groups using the chi square test. RESULTS A total of 114 patients were included in the cohort, 59 patients were from January 2014 to December 2018 and 55 patients were from January 2019 to April 2021. Since the establishment of the multidisciplinary center, there was a 2.5-fold increase in the total patient volume (0.8 case/month to 2 cases/month) and a 2.8-fold increase in the referred patient volume. Patients undergoing cesarean hysterectomy since the establishment of the multidisciplinary team had less quantitative blood loss (1500 mL vs 2000 mL, p = .005) and required less units of packed red blood cell transfusion (2 vs 4 units, p < .001). In addition, blood loss of ≥2000 mL decreased from 57.6% to 38.2% (p = .04) and diagnostic accuracy improved from 35.6% to 83.6% (p < .001). Furthermore, we found that patient distance to the hospital did not significantly impact surgical outcomes. CONCLUSIONS Since the establishment of the multidisciplinary team, our center experienced an increase in PAS volume and was able to demonstrate a statistically significant improvement in patient outcomes.
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Affiliation(s)
- Ruofan Yao
- Department of Maternal-Fetal Medicine, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Hoang Yen Nguyen
- Department of Gynecology and Obstetrics, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Linda Hong
- Department of Gynecologic Oncology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Daniela Karagoyzyan
- Department of Perioperative Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Sigrid Burruss
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Herb Brar
- Department of Maternal-Fetal Medicine, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Michael Staton
- Department of Radiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Courtney Martin
- Department of Gynecology and Obstetrics, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Kevin Balli
- Department of Gynecology and Obstetrics, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Yevgeniya Ioffe
- Department of Gynecologic Oncology, Loma Linda University Medical Center, Loma Linda, CA, USA
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22
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Overton E, Wen T, Friedman AM, Azad H, Nhan-Chang CL, Booker WA, Khoury-Collado F, Mourad M. Outcomes associated with peripartum hysterectomy in the setting of placenta accreta spectrum disorder. Am J Obstet Gynecol MFM 2023; 5:101174. [PMID: 37802412 DOI: 10.1016/j.ajogmf.2023.101174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/01/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Although peripartum hysterectomy for placenta accreta spectrum disorder is known to be associated with complications at the time of delivery, there are limited data on postpartum outcomes and readmission risk in this population. OBJECTIVE This study aimed to analyze risks for adverse outcomes and postpartum readmissions in the setting of peripartum hysterectomy for placenta accreta spectrum disorder by severity of placenta accreta spectrum disorder subcategory. STUDY DESIGN Using the 2016-2020 Nationwide Readmissions Database, this retrospective cohort study identified peripartum hysterectomies with a diagnosis of placenta accreta spectrum disorder. The primary exposure was placenta accreta spectrum disorder, subcategorized as placenta accreta vs increta/percreta. The primary outcome was readmission rate and delivery complications. Complications evaluated included the following: (1) nontransfusion severe maternal morbidity (ntSMM), (2) venous thromboembolism, (3) reoperation, (4) intraoperative complications, (5) hemorrhage, (6) sepsis, and (7) surgical site complications. We additionally evaluated delivery hospitalization and readmission mean length of stay, and hospital costs. Unadjusted and adjusted logistic regression models were fit for outcomes adjusting for clinical, demographic, and hospital factors. The association measures were expressed as unadjusted and adjusted odds ratios with 95% confidence intervals. RESULTS Between 2016 and 2020, 7864 hysterectomies during a delivery hospitalization with a diagnosis of placenta accreta spectrum disorder were identified (66.5% with placenta accreta and 33.5% with placenta increta/percreta diagnoses). The overall 60-day all-cause readmission rate was 7.3%. Most readmissions (57.2%) occurred within 10 days of hospital discharge. Compared with peripartum hysterectomy with a diagnosis of placenta accreta, hysterectomies with placenta increta/percreta diagnoses carried significantly increased risk of 60-day readmission (adjusted odds ratio, 1.31; 95% confidence interval, 1.01-1.71), inpatient mortality (odds ratio, 13.23; 95% confidence interval, 3.35-52.30), nontransfusion severe maternal morbidity (adjusted odds ratio, 1.43; 95% confidence interval, 1.20-1.71), intraoperative complications (adjusted odds ratio, 2.31; 95% confidence interval, 1.93-2.77), and surgical site complications (adjusted odds ratio, 1.55; 95% confidence interval, 1.23-1.95). The median length of stay during delivery hospitalization was longer for placenta increta/percreta (5.8 days; 95% confidence interval, 5.4-6.1) than for placenta accreta (4.2 days; 95% confidence interval, 4.1-4.3; P<.05). In addition, delivery hospitalization costs were higher in cases of placenta increta/percreta (median, $30,686; 95% confidence interval, $28,922-$32,449) than placenta accreta (median, $21,321; 95% confidence interval, $20,480-$22,163). CONCLUSION Complication and readmission risks after peripartum hysterectomy with placenta accreta spectrum disorder are high. Compared with patients with placenta accreta, patients with placenta increta/percreta had increased risk for delivery and postoperative complications and postpartum readmission, and increased costs and length of stay.
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Affiliation(s)
- Eve Overton
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Friedman, Azad, Nhan-Chang, Booker, Khoury-Collado, and Mourad).
| | - Timothy Wen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, CA (Dr Wen)
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Friedman, Azad, Nhan-Chang, Booker, Khoury-Collado, and Mourad)
| | - Hooman Azad
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Friedman, Azad, Nhan-Chang, Booker, Khoury-Collado, and Mourad)
| | - Chia-Ling Nhan-Chang
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Friedman, Azad, Nhan-Chang, Booker, Khoury-Collado, and Mourad)
| | - Whitney A Booker
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Friedman, Azad, Nhan-Chang, Booker, Khoury-Collado, and Mourad)
| | - Fady Khoury-Collado
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Friedman, Azad, Nhan-Chang, Booker, Khoury-Collado, and Mourad)
| | - Mirella Mourad
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Friedman, Azad, Nhan-Chang, Booker, Khoury-Collado, and Mourad)
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23
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Liang S, Lyu J, Shi H, Zhao Y, Chong Y, Hou X, Chen L. Management strategy for urologic morbidity in surgery of placenta accreta spectrum: stents or catheters? J Matern Fetal Neonatal Med 2023; 36:2232076. [PMID: 37403369 DOI: 10.1080/14767058.2023.2232076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
OBJECTIVE Surgery for placenta accreta spectrum disorders is known to be associated with urologic morbidity. Although previous studies have shown preoperative ureteral stent placement might be useful for preventing the urologic morbidity, the patient's discomfort caused by it should not be ignored. Whether there is an alternative management strategy remains unknown. This study was to evaluate the effectiveness of ureteral stents and catheters in preventing urologic injury in patients with placenta accreta spectrum undergoing surgery. METHODS We conducted a retrospective cohort study. All cases with diagnosed placenta accreta spectrum who underwent surgery at Peking University Third Hospital between January 2018 and December 2020 were collected and reviewed. They were divided into two groups according to the different management strategies for preoperative placement of ureteral catheters or stents. The primary outcome was urologic injury, which was defined as the presence of ureteral or bladder injury during and after surgery. Secondary outcomes included urologic complications within the first three months after surgery. The median (interquartile range) or proportions were reported for variables. The Man Whitney U test, chi-square test and multivariate logistic regression were used for analysis. RESULTS Ultimately, 99 patients were included in this study. Ureteral catheters were placed in 52 patients and ureteral stents were placed in 47 patients. Placenta accreta, placenta increta, and placenta percreta were diagnosed in three, 19, and 77 women, respectively. The hysterectomy rate was 52.53%. Overall, urologic injuries occurred in three patients (3.03%), including one case of combined bladder and ureteral injury (1.01%) and two cases of bladder injuries (2.02%). Only one ureteral injury occurred in a patient with a ureteral stent, which was recognized postoperatively (p = .475). All bladder injuries were vesical rupture which were recognized and repaired intraoperatively; one patient in the catheter group and two patients in the stent group (p = .929). After adjusting for confounding variables, multinomial regression analysis revealed no significant differences between the two groups in the incidence of bladder injuries(aOR: 0.695, 95% CI: 0.035-13.794, p = .811). A lower risk of urinary irritation (aOR: 0.186, 95% CI: 0.057-0.605, p = .005), hematuria (aOR: 0.011, 95% CI: 0.001-0.136, p < .001), and lower back pain (aOR: 0.075, 95% CI: 0.022-0.261, p < .001) was found in patients with ureteral catheters than in those with ureteral stents. CONCLUSION The ureteral stents didn't confer a protective benefit in the surgical management for placenta accreta spectrum compare with catheters; however, they did result in a higher incidence of postoperative urologic complications. Ureteral temporal catheters may be an alternative strategy for placenta accreta spectrum cases suspected with urinary tract involved prenatally. Moreover, clearly and explicitly reporting "double J stent" or "temporal catheter" is necessary for future researches.
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Affiliation(s)
- Shuangyi Liang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Center for Healthcare Quality Management in Obstetrics, Beijing, China
| | - Jiaxin Lyu
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Center for Healthcare Quality Management in Obstetrics, Beijing, China
| | - Huifeng Shi
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Center for Healthcare Quality Management in Obstetrics, Beijing, China
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Center for Healthcare Quality Management in Obstetrics, Beijing, China
| | - Yiwen Chong
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Center for Healthcare Quality Management in Obstetrics, Beijing, China
| | - Xiaofei Hou
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Lian Chen
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Center for Healthcare Quality Management in Obstetrics, Beijing, China
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24
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Kyozuka H, Yasuda S, Murata T, Sugeno M, Fukuda T, Yamaguchi A, Nomura Y, Fujimori K. Prophylactic resuscitative endovascular balloon occlusion of the aorta use during cesarean hysterectomy for placenta accreta spectrum: a retrospective cohort study. J Matern Fetal Neonatal Med 2023; 36:2232073. [PMID: 37408127 DOI: 10.1080/14767058.2023.2232073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
OBJECTIVE Resuscitative endovascular balloon occlusion of the aorta for placenta accreta spectrum is used to control maternal hemorrhage during cesarean hysterectomy. This study aimed to assess the efficacy of resuscitative endovascular balloon occlusion of the aorta for placenta accreta spectrum by examines the change in the quantitative blood loss after applying resuscitative endovascular balloon occlusion of the aorta. METHODS This retrospective cohort study included patients with placenta accreta spectrum who required cesarean hysterectomy (n = 37) between 2003 and 2022 at a tertiary care center. Patients were divided into two groups (with resuscitative endovascular balloon occlusion of the aorta, n = 13; without resuscitative endovascular balloon occlusion of the aorta, n = 24). The quantitative blood loss was compared between the groups. Generalized linear mixed models were used to examine changes in quantitative blood loss during cesarean hysterectomy after resuscitative endovascular balloon occlusion of the aorta was applied. The operating surgeon was set as the random effect. RESULTS Operation time did not differ significantly between the groups (p = .09). The quantitative blood loss was significantly higher in patients who did not undergo resuscitative endovascular balloon occlusion of the aorta (2160 g) than in patients who did (1110 g; p < .01). Resuscitative endovascular balloon occlusion of the aorta significantly decreased the quantitative blood loss during cesarean hysterectomy (partial regression coefficient, 2312; 95% confidence interval, 49-4577; p < .05). CONCLUSION Resuscitative endovascular balloon occlusion of the aorta decreased the quantitative blood loss during cesarean hysterectomy in patients with placenta accreta spectrum without significantly increasing the operation time. This suggests that resuscitative endovascular balloon occlusion of the aorta is effective in patients with placenta accreta spectrum.
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Affiliation(s)
- Hyo Kyozuka
- Department of Obstetrics and Gynecology, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Shun Yasuda
- Department of Obstetrics and Gynecology, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Tsuyoshi Murata
- Department of Obstetrics and Gynecology, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Misa Sugeno
- Department of Obstetrics and Gynecology, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Toma Fukuda
- Department of Obstetrics and Gynecology, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Akiko Yamaguchi
- Department of Obstetrics and Gynecology, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Yasuhisa Nomura
- Department of Obstetrics and Gynecology, Fukushima Medical University, Fukushima City, Fukushima, Japan
| | - Keiya Fujimori
- Department of Obstetrics and Gynecology, Fukushima Medical University, Fukushima City, Fukushima, Japan
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25
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Sugai S, Yamawaki K, Sekizuka T, Haino K, Yoshihara K, Nishijima K. Comparison of maternal outcomes and clinical characteristics of prenatally vs nonprenatally diagnosed placenta accreta spectrum: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:101197. [PMID: 37865220 DOI: 10.1016/j.ajogmf.2023.101197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/14/2023] [Accepted: 10/16/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVE This study aimed to compare maternal outcomes of prenatally and nonprenatally diagnosed placenta accreta spectrum. DATA SOURCES A systematic literature search was performed in PubMed, the Cochrane database, and Web of Science until November 28, 2022. STUDY ELIGIBILITY CRITERIA Studies comparing the clinical presentation of prenatally and nonprenatally diagnosed placenta accreta spectrum were included. The primary outcomes were emergent cesarean delivery, hysterectomy, blood loss volume, number of transfused blood product units, urological injury, coagulopathy, reoperation, intensive care unit admission, and maternal death. In addition, the pooled mean values for blood loss volume and the number of transfused blood product units were calculated. The secondary outcomes included maternal age, gestational age at birth, nulliparity, previous cesarean delivery, previous uterine procedure, assisted reproductive technology, placenta increta and percreta, and placenta previa. METHODS Study screening was performed after duplicates were identified and removed. The quality of each study and the publication bias were assessed. Forest plots and I2 statistics were calculated for each study outcome for each group. The main analysis was a random-effects analysis. RESULTS Overall, 415 abstracts and 157 full-text studies were evaluated. Moreover, 31 studies were analyzed. Prenatally diagnosed placenta accreta spectrum was associated with a significantly lower rate of emergency cesarean delivery (odds ratio, 0.37; 95% confidence interval, 0.21-0.67), higher hysterectomy rate (odds ratio, 1.98; 95% confidence interval, 1.02-3.83), lower blood loss volume (mean difference, -0.65; 95% confidence interval, -1.17 to -0.13), and lower number of transfused red blood cell units (mean difference, -1.96; 95% confidence interval, -3.25 to -0.68) compared with nonprenatally diagnosed placenta accreta spectrum. The pooled mean values for blood loss volume and the number of transfused blood product units tended to be lower in the prenatally diagnosed placenta accreta spectrum groups than in the nonprenatally diagnosed placenta accreta spectrum groups. Nulliparity (odds ratio, 0.14; 95% confidence interval, 0.10-0.20), previous cesarean delivery (odds ratio, 6.81; 95% confidence interval, 4.12-11.25), assisted reproductive technology (odds ratio, 0.19; 95% confidence interval, 0.06-0.61), placenta increta and percreta (odds ratio, 3.97; 95% confidence interval, 2.24-7.03), and placenta previa (odds ratio, 6.81; 95% confidence interval, 4.12-11.25) showed statistical significance. No significant difference was found for the other outcomes. CONCLUSION Despite its severity, the positive effect of prenatally diagnosed placenta accreta spectrum on outcomes underscores the necessity of a prenatal diagnosis. In addition, the pooled mean values provide a preoperative preparation guideline.
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Affiliation(s)
- Shunya Sugai
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan.
| | - Kaoru Yamawaki
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Tomoyuki Sekizuka
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kazufumi Haino
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kosuke Yoshihara
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Koji Nishijima
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan.
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Machado M, Dionísio T, Rocha D, Campos M, Sousa P. Placenta Accreta: A Case Report on the Role of Interventional Radiology. Cureus 2023; 15:e47680. [PMID: 38022115 PMCID: PMC10673647 DOI: 10.7759/cureus.47680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Placenta accreta spectrum disorder is a pregnancy-related disorder responsible for important post-partum morbimortality, associated with intractable or massive hemorrhage, leading to uterine loss in up to 64% of women. Despite international recommendations advocating planned preterm cesarean hysterectomy for the management of these patients, uterus preservation management is being continuously reported with the implementation of minimally invasive bleeding reduction strategies, such as prophylactic balloon-assisted occlusion. We present the case of a 40-year-old pregnant woman with a previous cesarean, diagnosed with placenta previa and suspected placenta accreta on magnetic resonance after having second-trimester vaginal bleeding. A peri-operative multidisciplinary panel was involved, in collaboration with the interventional radiologist, and the c-section was scheduled for 36 weeks of gestation. The prophylactic balloon-assisted occlusion was successfully performed, minimizing the blood loss and allowing a uterus-preserving approach.
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Affiliation(s)
- Mafalda Machado
- Radiology, Centro Hospitalar Universitário do Algarve, Faro, PRT
| | - Teresa Dionísio
- Radiology, Centro Hospitalar Vila Nova de Gaia-Espinho, Vila Nova de Gaia, PRT
| | - Diogo Rocha
- Radiology, Centro Hospitalar Vila Nova de Gaia-Espinho, Vila Nova de Gaia, PRT
| | - Marta Campos
- Obstetrics and Gynaecology, Centro Hospitalar Vila Nova de Gaia-Espinho, Vila Nova de Gaia, PRT
| | - Pedro Sousa
- Radiology, Centro Hospitalar Vila Nova de Gaia-Espinho, Vila Nova de Gaia, PRT
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Létourneau I, Hobson SR, Moretti F, Kingdom JC, Murji A, Windrim RC, Allen LM, Werlang A, Vachon-Marceau C, Singh SS. Placenta Accreta Spectrum Disorders: A National Survey. J Obstet Gynaecol Can 2023; 45:102167. [PMID: 37315785 DOI: 10.1016/j.jogc.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/01/2023] [Accepted: 06/03/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Describe the current practice of Canadian obstetricians-gynaecologists in managing placenta accreta spectrum (PAS) disorders from suspicion of diagnosis to delivery planning and explore the impact of the latest national practice guidelines on this topic. METHODS We distributed a cross-sectional bilingual electronic survey to Canadian obstetricians-gynaecologists in March-April 2021. Demographic data and information on screening, diagnosis, and management were collected using a 39-item questionnaire. The survey was validated and pretested among a sample population. Descriptive statistics were used to present the results. RESULTS We received 142 responses. Almost 60% of respondents said they had read the latest Society of Obstetricians and Gynaecologists of Canada clinical practice guideline on PAS disorders, published in July 2019. Nearly 1 in 3 respondents changed their practice following this guideline. Respondents highlighted the importance of 4 key points: (1) limiting travel to thereby remain close to a regional care centre, (2) preoperative anemia optimization, (3) performance of cesarean-hysterectomy leaving the placenta in situ (83%), (4) access via midline laparotomy (65%). Most respondents recognized the importance of perioperative blood loss reduction strategies such as tranexamic acid and perioperative thromboprophylaxis via sequential compression devices and low-molecular-weight heparin until full mobilization. CONCLUSIONS This study demonstrates the impact of the Society of Obstetricians and Gynaecologists of Canada's PAS clinical practice guideline on management choices made by Canadian clinicians. Our study highlights the value of a multidisciplinary approach to reducing maternal morbidity in individuals facing surgery for a PAS disorder and the importance of regionalized care that is resourced to provide maternal-fetal medicine and surgical expertise, transfusion medicine, and critical care support.
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Affiliation(s)
- Isabelle Létourneau
- Department of Obstetrics, Gynecology and Newborn Care, University of Ottawa, The Ottawa Hospital, Ottawa, ON.
| | - Sebastian R Hobson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Toronto, Mount Sinai Hospital, Toronto, ON
| | - Felipe Moretti
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Ottawa, The Ottawa Hospital, Ottawa, ON
| | - John C Kingdom
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Toronto, Mount Sinai Hospital, Toronto, ON
| | - Ally Murji
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Toronto, Mount Sinai Hospital, Toronto, ON
| | - Rory C Windrim
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Toronto, Mount Sinai Hospital, Toronto, ON
| | - Lisa M Allen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Toronto, Mount Sinai Hospital, Toronto, ON
| | - Ana Werlang
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Ottawa, The Ottawa Hospital, Ottawa, ON
| | | | - Sukhbir S Singh
- Department of Obstetrics, Gynecology and Newborn Care, University of Ottawa, The Ottawa Hospital, Ottawa, ON
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Adu-Bredu TK, Collins SL, Nieto-Calvache AJ. Ultrasound discrimination between placenta accreta spectrum and urinary bladder varices. Aust N Z J Obstet Gynaecol 2023; 63:725-727. [PMID: 37872717 DOI: 10.1111/ajo.13703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 05/01/2023] [Indexed: 10/25/2023]
Abstract
Distinguishing between urinary bladder varices and retroplacental neovascularization in placenta accreta spectrum in high-risk patients with placental previa is a diagnostic challenge since they have similar appearances on prenatal ultrasound. Placenta accreta spectrum is associated with massive obstetric haemorrhage while the presence of urinary bladder varices in pregnancy poses a lower surgical risk. Since the clinical implications and management approach for both conditions are entirely different, false positive diagnoses have iatrogenic consequences. In this article, we share our experiences in differentiating these two phenomena on prenatal ultrasound supported by ultrasound and intraoperative images.
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Affiliation(s)
| | - Sally L Collins
- Nuffield Department of Women's and Reproductive Health, University of Oxford, UK
- Fetal Medicine Unit, John Radcliffe Hospital, Oxford, UK
| | - Albaro José Nieto-Calvache
- Fundación Valle del Lili, Abnormally Invasive Placenta Clinic, Cali, Colombia
- Clinical Postgraduate Department, Universidad Icesi, Cali, Colombia
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Alhashim ZG, Alzayer ZA, Alensaif AA, Al Darwish HA, Almomen MA, Alnsaif JM. Blood Transfusion Predictors in Cesarean Sections for Pregnancies With Placenta Accreta and Placenta Previa: A Monocentric Tertiary Experience. Cureus 2023; 15:e47648. [PMID: 38021778 PMCID: PMC10668624 DOI: 10.7759/cureus.47648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 12/01/2023] Open
Abstract
Objective The objective of this study was to analyze the possible predictors of the need for intraoperative blood transfusion in cesarean sections for pregnancies with abnormal placentation. Methods This was a retrospective study based on data from patients' electronic medical records. A total of 44 patients who were diagnosed as placenta previa or placenta accreta who delivered through cesarean section at King Fahad University Hospital, Al-Khobar, Saudi Arabia, from June 1997 to January 2021 were included in the study. Seventeen patients received intra-operative blood transfusion. The other 27 patients did not receive any blood transfusions and served as controls. Demographic data, antepartum profiles, and obstetric history were compared between the two groups. Univariate analysis and multivariate logistic regression were used to analyze the correlations between related risk factors and the need for intraoperative blood transfusion. Results Univariate analysis (χ2 test) has shown multiple factors that correlated significantly (p<0.05) with blood transfusion requirement. These factors include the presence of placenta accreta, general anesthesia, preoperative hematocrit < 33%, preoperative hemoglobin ≤ 10 g/dL, and preterm delivery at 35-36 weeks of gestation. None of these factors showed any statistical significance in multivariate analysis (logistic regression). Conclusion General anesthesia, placenta accreta, delivery at 35-36 weeks of gestation, and pre-operative anemia are possible risk factors for blood transfusion during cesarean sections for abnormal placentation. Identifying patients at increased risk is necessary to optimize pre-operative and intraoperative management.
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Affiliation(s)
- Zainab G Alhashim
- Department of Anesthesiology, Imam Abdulrahman Bin Faisal University College of Medicine, Dammam, SAU
- Department of Anesthesiology, King Fahad University Hospital, Al-Khobar, SAU
| | - Zainab A Alzayer
- Department of Anesthesiology, Imam Abdulrahman Bin Faisal University College of Medicine, Dammam, SAU
- Department of Anesthesiology, King Fahad University Hospital, Al-Khobar, SAU
| | - Alwi A Alensaif
- College of Medicine, Imam Abdulrahman Bin Faisal University College of Medicine, Dammam, SAU
| | - Hussain A Al Darwish
- College of Medicine, Imam Abdulrahman Bin Faisal University College of Medicine, Dammam, SAU
| | - Mohammed A Almomen
- College of Medicine, Imam Abdulrahman Bin Faisal University College of Medicine, Dammam, SAU
| | - Jawad M Alnsaif
- College of Medicine, Imam Abdulrahman Bin Faisal University College of Medicine, Dammam, SAU
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Fahad A, Fazari A, Al Fardan N, Abu-Nayla U, Haseep A, Alabdi N. Focal Placenta Accreta in a Congenitally Malformed Uterus: A Case Report. Cureus 2023; 15:e47618. [PMID: 38022269 PMCID: PMC10667619 DOI: 10.7759/cureus.47618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Placenta accreta is defined as an abnormal trophoblast invasion of part or all of the placenta into the myometrium of the uterine wall. It is a well-known cause of maternal morbidity and mortality. Here, we present a unique case of focal placenta accreta due to a bicornuate uterus and a history of septum resection. We also discuss its management and outcome. The patient underwent a classical cesarean section and reinforcement of the anterior and posterior uterine wall. The patient had a history of surgery for correction of uterine malformation, which may have resulted in an abnormal adherence of the placenta.
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Affiliation(s)
- Asma Fahad
- Obstetrics and Gynaecology, Latifa Hospital, Dubai Academic Health Corporation, Dubai, ARE
| | - Atif Fazari
- Obstetrics and Gynaecology, Latifa Hospital, Dubai Academic Health Corporation, Dubai, ARE
| | - Nahla Al Fardan
- Obstetrics and Gynaecology, Latifa Hospital, Dubai Academic Health Corporation, Dubai, ARE
| | - Umniyah Abu-Nayla
- Obstetrics and Gynaecology Residency Program, Dubai Academic Health Corporation, Dubai, ARE
| | - Ayat Haseep
- Obstetrics and Gynaecology Residency Program, Dubai Academic Health Corporation, Dubai, ARE
| | - Noor Alabdi
- Obstetrics and Gynaecology Residency Program, Dubai Academic Health Corporation, Dubai, ARE
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Gattani P, Nair P, Khandare S, Zade RD. Uterine Artery Embolisation: A Saviour for Central Placenta Previa. Cureus 2023; 15:e47168. [PMID: 38022047 PMCID: PMC10652055 DOI: 10.7759/cureus.47168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Central placenta previa is generally managed by caesarean section, uterotonic drugs, hemostatic sutures, and hemostatic balloon tamponade, and it usually ends in peripartum hysterectomy, with an incidence of 4% along with an increased incidence of maternal and neonatal morbidity or mortality. Selective uterine artery embolization (UAE) helps to prevent these complications while preserving future fertility. A 32-year-old patient was diagnosed as a case of a previous section with central placenta previa with accreta at 38 weeks and was planned for an elective caesarean section. A prophylactic selective bilateral internal iliac artery cannulation under sonographic guidance and subsequent cannulation and embolisation of bilateral uterine arteries under fluoroscopic guidance was done. It reduced the massive blood transfusions and operative time, preserved fertility without any maternal or foetal morbidity or mortality, and no other complications were reported.
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Affiliation(s)
- Preeti Gattani
- Obstetrics and Gynaecology, Datta Meghe Medical College, Datta Meghe Institute of Higher Education & Research (DU), Nagpur, IND
| | - Priya Nair
- Obstetrics and Gynaecology, Datta Meghe Medical College, Datta Meghe Institute of Higher Education and Research (DU), Nagpur, IND
| | - Sandeep Khandare
- Obstetrics and Gynaecology, Datta Meghe Medical College, Datta Meghe Institute of Higher Education and Research (DU), Nagpur, IND
| | - Rasika D Zade
- Obstetrics and Gynaecology, Datta Meghe Medical College, Datta Meghe Institute of Higher Education and Research (DU), Nagpur, IND
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Backer S, Khanna D, Sadr S, Khatibi A. Intra-operative Guidelines for the Prevention of Uterine Niche Formation in Cesarean Sections: A Review. Cureus 2023; 15:e44521. [PMID: 37790067 PMCID: PMC10544643 DOI: 10.7759/cureus.44521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
Formation of a uterine niche following a C-section can predispose the patient to future obstetric complications such as dehiscence, uterine rupture, ectopic pregnancy, and placenta accreta. The significant morbidity and mortality of these complications along with increasing C-section rates emphasizes the importance of prevention. However, there are no clear guidelines on intra-operative protocol to prevent postpartum niche formation. Besides surgical technique, the novel use of platelet-rich plasma (PRP) and mesenchymal stem cell (MSC) injections has demonstrated promising potential and may have applications in hysterotomy closures. The objective is to examine current research on optimal C-section procedures to prevent uterine niche formation and subsequent obstetric complications. A systematic review was conducted using PubMed and Google Scholar. Initial searches yielded 827 results. Inclusion criteria were human, animal, and in-vitro studies, peer-reviewed sources, and outcomes pertinent to the uterine niche. Exclusion criteria applied to articles with outcomes unrelated to myometrium and interventions outside of the intra-operative and immediate pre-/post-operative period. Based on the criteria, 41 articles were cited. Pathophysiology of uterine niche formation was associated with incisions through cervical tissue, adhesion formation, and poor approximation. Significant risk factors were low uterine incisions, advanced cervical dilatation, low station, non-closure of the peritoneum, and creation of a bladder flap. There was no consensus on uterine closure as it likely depends on surgical proficiency with the given technique, but a double-layered non-locking suture appears reliable to reduce niche severity. Recent trials indicate that intra-operative PRP/MSC injections may decrease niche incidence and severity, but more research is needed. If prevention or minimization of uterine niche is desired, the optimal C-section protocol should avoid low uterine incisions, choose uterine closure technique based on the surgeon's proficiency (double-layered non-locking is reliable), and close the peritoneum, and myometrial injection of PRP/MSC may be a useful adjunct intervention pending further clinical evidence.
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Affiliation(s)
- Sean Backer
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Tampa, USA
| | - Deepesh Khanna
- Foundational Sciences, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
| | - Sonia Sadr
- Foundational Sciences, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Ali Khatibi
- Obstetrics and Gynaecology, Sahlgrenska University Hospital, Gothenburg, SWE
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Lu T, Wu M, Wang Y, Li M, Li H, Zhang F, Yi Y, Zhu M, Zhao X. Association of MRI Features and Adverse Maternal Outcome in Patients With Placenta Accreta Spectrum Disorders After Abdominal Aortic Balloon Occlusion. J Magn Reson Imaging 2023; 58:817-826. [PMID: 36606736 DOI: 10.1002/jmri.28591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/27/2022] [Accepted: 12/27/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND MRI features may be associated with adverse maternal outcome in patients with placenta accreta spectrum (PAS) disorders even with abdominal aortic balloon occlusion (AABO). PURPOSE This study aimed to identify risk factors of MRI for association with adverse maternal outcome in patients with PAS disorders after AABO. STUDY TYPE Retrospective. POPULATION Clinical and MRI features of 80 patients were retrospectively reviewed from October 2016 to August 2021. A total of 40 patients had adverse maternal outcomes including intrapartum/peripartum bleeding >1000 mL and/or emergency hysterectomy after AABO. SEQUENCE Half-Fourier acquisition single-shot turbo spin echo and gradient echo imaging True fast imaging with steady-state precession (True-FISP) at 1.5T MR scanner. ASSESSMENT MRI features were evaluated by three radiologists and were tested for any association with adverse maternal outcome. STATISTICAL TESTS Interobserver agreement was calculated with kappa (k) statistics. Association between MRI features and adverse maternal outcomes were evaluated by univariate and multivariate analyses. A nomogram was constructed based on the logistic regression. RESULTS The interobserver agreement ranged from fair to substantial (k = 0.379-0.783). Multivariate analyses revealed that short cervical length (OR: 4.344), abnormal intraplacental vascularity (OR: 6.005), placental bulge (OR: 9.085), and myometrial interruption (OR: 9.550) were independent risk factors for adverse maternal outcomes. The combination of four risk factors together demonstrated the highest AUC of 0.851 (95% CI 0.769-0.933) with a sensitivity and specificity of 77.5% and 72.5%, respectively and then a nomogram composed of the above four risk factors was constructed to represent the probability of adverse maternal outcome. DATA CONCLUSION The nomogram demonstrated the association between MRI features and patient's poor outcome after undergoing AABO and C-section delivery for PAS. EVIDENCE LEVEL 4 TECHNICAL EFFICACY: Stage 3.
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Affiliation(s)
- Tao Lu
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Mingpeng Wu
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yishuang Wang
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Mou Li
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Hang Li
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Feng Zhang
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yuan Yi
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Meilin Zhu
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xinyi Zhao
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
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Komatsu H, Taniguchi F, Harada T. Impact of myomectomy on the obstetric complications: A large cohort study in Japan. Int J Gynaecol Obstet 2023; 162:977-982. [PMID: 36998147 DOI: 10.1002/ijgo.14767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/17/2023] [Accepted: 03/11/2023] [Indexed: 04/01/2023]
Abstract
OBJECTIVE The authors conducted a large-scale cohort study using the Japan Society of Obstetrics and Gynecology's perinatal registry database to determine the effect of myomectomy on perinatal outcomes. METHODS This retrospective cohort study enrolled 203 745 women who gave birth between January and December 2020 in Japan. The participants were classified into two groups based on their history of myomectomy (open/laparoscopic) to investigate fertility treatment, delivery information, obstetric complications, maternal treatment, infant information, fetal appendages, obstetric history, underlying disease, infectious disease, drugs used, and case information regarding maternal and infant death. RESULTS In total, 1161 pregnant women had a history of myomectomy and 202 584 did not. Compared with the nonmyomectomy group, the myomectomy group had a higher occurrence rate of uterine rupture (0.9% vs 0.06%, P < 0.01) and placenta accreta (1.5% vs 0.5%, P < 0.01). In addition, history of myomectomy (odds ratio [OR], 2.62 [95% confidence interval (CI), 1.500-4.226]; P < 0.001) was found to be an independent factor for placenta accrete and uterine rupture (OR, 14.4 [95% CI, 6.75-27.02]; P < 0.001). Furthermore, myomectomy increased the risk of uterine rupture by 14 times. CONCLUSION Postmyomectomy pregnancy may increase the risk of placenta accreta and uterine rupture.
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Affiliation(s)
- Hiroaki Komatsu
- Department of Obstetrics and Gynecology, Tottori University School of Medicine, Tottori, Japan
| | - Fuminori Taniguchi
- Department of Obstetrics and Gynecology, Tottori University School of Medicine, Tottori, Japan
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Maurer J, Ramani S, Xu B, Gallousis S, Clark M, Andikyan V. Delayed presentation of placenta accreta following a first-trimester medical abortion. Clin Case Rep 2023; 11:e7849. [PMID: 37636882 PMCID: PMC10457480 DOI: 10.1002/ccr3.7849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/05/2023] [Accepted: 08/11/2023] [Indexed: 08/29/2023] Open
Abstract
Placenta accreta can rarely present as a uterine mass on imaging months after a first trimester medical abortion, even in patients at low-risk for abnormal placentation. Early and accurate diagnosis can be crucial to reduce morbidity and mortality associated with this disease, particularly for those desiring fertility preservation.
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Affiliation(s)
- Jenna Maurer
- Department of Obstetrics and GynecologyStamford HospitalStamfordConnecticutUSA
| | - Sangeeta Ramani
- Department of Obstetrics and GynecologyStamford HospitalStamfordConnecticutUSA
| | - Bo Xu
- Department of PathologyStamford HospitalStamfordConnecticutUSA
| | - Stephen Gallousis
- Department of Obstetrics and GynecologyStamford HospitalStamfordConnecticutUSA
| | - Mitchell Clark
- Department of Obstetrics and GynecologyStamford HospitalStamfordConnecticutUSA
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive SciencesYale School of MedicineNew HavenConnecticutUSA
| | - Vaagn Andikyan
- Department of Obstetrics and GynecologyStamford HospitalStamfordConnecticutUSA
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive SciencesYale School of MedicineNew HavenConnecticutUSA
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Taskin II, Gurbuz S, Icen MS, Derin DC, Findik FM. Expression of sirtuin 2 and 7 in placenta accreta spectrum. Rev Assoc Med Bras (1992) 2023; 69:e20230360. [PMID: 37585995 PMCID: PMC10427185 DOI: 10.1590/1806-9282.20230360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/23/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVE This study aimed to investigate the expression levels of sirtuin 2 and sirtuin 7 in the placenta accreta spectrum to reveal their role in its pathogenesis. METHODS A total of 30 placenta accreta spectrum, 20 placenta previa, and 30 controls were experienced. The sirtuin 2 and sirtuin 7 expression levels in the placentas of these groups were determined by Western blot. sirtuin 2 and sirtuin 7 serum levels in the maternal and fetal cord blood were examined by enzyme-linked immunosorbent assay. RESULTS It was found that sirtuin 7 in placenta accreta spectrum was significantly lower in the placenta compared to the control and placenta previa groups (p<0.05). However, a significant difference was not observed between the sirtuin 2 and sirtuin 7 levels in the maternal and fetal cord serum samples of those three groups (p>0.05). CONCLUSION Sirtuin 7 may play an important role in the formation of placenta accreta spectrum. The effect of decreased expression of sirtuin 7 might be tissue-dependent in the placenta accreta spectrum and needs to be investigated further.
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Affiliation(s)
- Irmak Icen Taskin
- İnönü University, Faculty of Science and Art, Department of Molecular Biology and Genetics – Malatya, Turkey
| | - Sevim Gurbuz
- İnönü University, Faculty of Science and Art, Department of Molecular Biology and Genetics – Malatya, Turkey
| | - Mehmet Sait Icen
- Dicle University, Department of Obstetrics and Gynecology – Diyarbakir, Turkey
| | - Dilek Cam Derin
- İnönü University, Faculty of Science and Art, Department of Molecular Biology and Genetics – Malatya, Turkey
| | - Fatih Mehmet Findik
- Dicle University, Department of Obstetrics and Gynecology – Diyarbakir, Turkey
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Sugai S, Yamawaki K, Sekizuka T, Haino K, Yoshihara K, Nishijima K. Pathologically diagnosed placenta accreta spectrum without placenta previa: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:101027. [PMID: 37211089 DOI: 10.1016/j.ajogmf.2023.101027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/13/2023] [Accepted: 05/16/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE This systematic review and meta-analysis aimed to assess clinical characteristics related to pathologically proven placenta accreta spectrum without placenta previa. DATA SOURCES A literature search of PubMed, the Cochrane database, and Web of Science was performed from inception to September 7, 2022. STUDY ELIGIBILITY CRITERIA The primary outcomes were invasive placenta (including increta or percreta), blood loss, hysterectomy, and antenatal diagnosis. In addition, maternal age, assisted reproductive technology, previous cesarean delivery, and previous uterine procedures were investigated as potential risk factors. The inclusion criteria were studies evaluating the clinical presentation of pathologically diagnosed PAS without placenta previa. METHODS Study screening was conducted after duplicates were identified and removed. The quality of each study and the publication bias were assessed. Forest plots and I2 statistics were calculated for each study outcome for each group. The main analysis was a random-effects analysis. RESULTS Among 2598 studies that were initially retrieved, 5 were included in the review. With the exception of 1 study, 4 studies were included in the meta-analysis. This meta-analysis showed that placenta accreta spectrum without placenta previa was associated with less risk of invasive placenta (odds ratio, 0.24; 95% confidence interval, 0.16-0.37), blood loss (mean difference, -1.19; 95% confidence interval, -2.09 to -0.28) and hysterectomy (odds ratio, 0.11; 95% confidence interval, 0.02-0.53), and more difficult to diagnose prenatally (odds ratio, 0.13; 95% confidence interval, 0.04-0.45) than placenta accreta spectrum with placenta previa. In addition, assisted reproductive technology and a previous uterine procedure were strong risk factors for placenta accreta spectrum without placenta previa, whhereas previous cesarean delivery was a strong risk factor for placenta accreta spectrum with placenta previa. CONCLUSION The differences in clinical aspects of placenta accreta spectrum with and without placenta previa need to be understood.
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Affiliation(s)
- Shunya Sugai
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan.
| | - Kaoru Yamawaki
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Tomoyuki Sekizuka
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kazufumi Haino
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kosuke Yoshihara
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Koji Nishijima
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan.
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Munoz JL, Blankenship LM, Ramsey PS, McCann GA. Implementation and outcomes of a uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum. Am J Obstet Gynecol 2023; 229:61.e1-61.e7. [PMID: 36965865 DOI: 10.1016/j.ajog.2023.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Placenta accreta spectrum disorders are a continuum of placental pathologies with significant maternal morbidity and mortality. Morbidity is related to the overall degree of placental adherence, and thus patients with placenta increta or percreta represent a high-risk category of patients. Hemorrhage and transfusion of blood products represent 90% of placenta accreta spectrum morbidity. Both tranexamic acid and uterine artery embolization independently decrease obstetrical hemorrhage. OBJECTIVE This study aimed to provide an evidence-based intraoperative protocol for placenta accreta spectrum management. STUDY DESIGN This study was a pre- and postimplementation analysis of concomitant uterine artery embolization and tranexamic acid in cases of patients with antenatally suspected placenta increta and percreta over a 5-year period (2018-2022). For comparison, a 5-year (2013-2017) preimplementation group was used to assess the impact of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum. Patient demographics and clinically relevant outcomes were obtained from electronic medical records. RESULTS A total of 126 cases were managed by the placenta accreta spectrum team, of which 66 had suspected placenta increta/percreta over the 10-year time period. Two patients were excluded from the postimplementation cohort because they did not undergo both interventions. Thus, 30 (30/64; 47%) were treated after implementation of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum, and 34 (34/64; 53%) preimplementation patients did not undergo uterine artery embolization or tranexamic acid infusion. With the uterine artery embolization and tranexamic acid protocol, operative times were longer (416 vs 187 minutes; P<.01), and patients were more likely to receive general anesthesia (80% vs 47%; P<.01). However, blood loss was reduced by 33% (2000 vs 3000 cc; P=.03), overall blood transfusion rates decreased by 51% (odds ratio, 0.05 [95% confidence interval, 0.001-0.20]; P<.01), and massive blood transfusion (>10 units transfused) was reduced 5-fold (odds ratio, 0.17 [95% confidence interval, 0.02-0.17]; P=.02). Postoperative complication rates remained unchanged (4 vs 10 events; P=.14). Neonatal outcomes were equivalent. CONCLUSION The uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum is an effective approach to the standardization of complex placenta accreta spectrum cases that results in optimal perioperative outcomes and reduced maternal morbidity.
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Affiliation(s)
- Jessian L Munoz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Logan M Blankenship
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
| | - Patrick S Ramsey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
| | - Georgia A McCann
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
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Tipiani-Rodríguez O, Elías-Estrada JC, Bocanegra-Becerra YL, Ponciano-Biaggi MA. Treatment of ectopic pregnancy implanted on cesarea scar: cohort study 2018-2022, Lima, Peru. Rev Colomb Obstet Ginecol 2023; 74:15-30. [PMID: 37253244 PMCID: PMC10237182 DOI: 10.18597/rcog.3958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/21/2023] [Indexed: 06/01/2023]
Abstract
Objectives To describe the clinical characteristics and treatment of ectopic pregnancy arising in the cesarean section scar, as well as its complications and obstetric prognosis. Material and methods Retrospective cohort study of pregnant women with the diagnosis of a scar pregnancy in accordance with Maternal-Fetal Medicine Society criteria, seen between January 2018 and March 2022 in two high complexity institutions of the social security system, located in Lima, Peru. Consecutive sampling was used. Baseline sociodemographic and clinical variables were measured, including diagnosis, type of treatment, complications and obstetric prognosis. A descriptive analysis was performed. Results Out of 29,919 deliveries, 17 patients were included. Of these, 41.2 % received medical management and the rest were treated surgically. Successful management with intra-gestational sac methotrexate was performed in two patients with ectopic pregnancy type 2. Four patients required total hysterectomy. Six patients became pregnant after the treatment and 4 completed their pregnancy with healthy mother and neonate pairs. Conclusions Ectopic pregnancy implanted in a cesarean section scar is an infrequent occurrence for which medical and surgical management options are available with apparently good outcomes. Further studies of better methodological quality and random assignment are needed in order to help characterize the safety and effectiveness of the various therapeutic options for women with suspected scar pregnancy.
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Chen Y, Cao Y, She JY, Chen S, Wang PJ, Zeng Z, Liang CY. Spontaneous rupture of an unscarred uterus during pregnancy: A rare but life-threatening emergency: Case series. Medicine (Baltimore) 2023; 102:e33977. [PMID: 37327264 PMCID: PMC10270498 DOI: 10.1097/md.0000000000033977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/22/2023] [Indexed: 06/18/2023] Open
Abstract
RATIONALE In most cases, uterine rupture occurs during the third trimester of pregnancy or during labor. Even fewer reports have been published about the occurrence of this condition without a gynecologic history of any surgical procedure. Due to their scarcity and variable clinical presentation, early diagnosis of uterine rupture may be difficult, and if the diagnosis is not timely, the condition may be life-threatening. PATIENT CONCERNS Herein, 3 cases of uterine rupture from a single institution are described. Three patients are at different gestational weeks and all have no history of uterine surgery. They came to the hospital due to acute abdominal pain, which is characterized by severe and persistent pain in the abdomen, with no apparent vaginal bleeding. DIAGNOSES All 3 patients were diagnosed with uterine rupture during the operation. INTERVENTIONS One patient underwent uterine repair surgery; while the other 2 underwent subtotal hysterectomy due to persistent bleeding and pathological examination after surgery confirmed placenta implantation. OUTCOMES The patients recovered well after the operation, and no discomfort occurred in the follow-up. LESSONS Acute abdominal pain during pregnancy can pose both diagnostic and therapeutic challenges. It is important to consider the possibility of uterine rupture, even in cases where there is no history of prior uterine surgery. The key to the treatment of uterine rupture is to shorten the diagnosis time as much as possible, this potential complication should be carefully monitored for and promptly addressed to ensure the best possible outcomes for both the mother and the developing fetus.
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Affiliation(s)
- Yue Chen
- The Third Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
- Department of Obstetrics and Gynecology, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing Jiangsu, China
- Department of Obstetrics and Gynecology, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing, China
| | - Ying Cao
- Department of Obstetrics and Gynecology, Suzhou Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
| | - Jing-Yao She
- The Third Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Si Chen
- Department of Obstetrics and Gynecology, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing Jiangsu, China
- Department of Obstetrics and Gynecology, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing, China
| | - Pei-Juan Wang
- Department of Obstetrics and Gynecology, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing Jiangsu, China
- Department of Obstetrics and Gynecology, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing, China
| | - Zheng Zeng
- Department of Pathology, Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing, China
| | - Chun-Yun Liang
- The Third Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
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Buyukkurt S, Sucu M, Hatipoglu I, Ozlu F, Unlugenc H, Evruke C, Demir C. Placenta accreta spectrum surgery with the Joel Cohen incision for abdominal access: a single-center experience. Ginekol Pol 2023:VM/OJS/J/93564. [PMID: 37249265 DOI: 10.5603/gp.a2023.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 04/15/2023] [Accepted: 04/19/2023] [Indexed: 05/31/2023] Open
Abstract
OBJECTIVES Placenta accreta spectrum (PAS) is usually treated by hysterectomy performed through a midline incision. We hypothesize that PAS surgery can be performed through a Joel-Cohen incision with adequate sight and safety. MATERIAL AND METHODS The data on women having a hysterectomy due to PAS between 2013-2021 was collected retrospectively. Operation length, baby's pre-delivery general anesthesia exposure time, transfusion rates, complication rates, postoperative admission to the intensive care unit (ICU), postoperative hospital stay, and neonatal outcomes were collected. In addition, the data investigated whether the operation was performed under emergent conditions and in the early (2013-2016) or late (2017-2021) years. RESULTS 161 patients met the inclusion criteria. The median gestational age at delivery was 34 weeks (27-39). The mean operation length was 150 minutes (75-420), and the anesthesia-to-delivery interval was 32 minutes (5-95). Twenty-three (14%) patients did not receive any blood product, 73 (45%) received less than three packs of erythrocyte, and only seven (4%) had a massive transfusion. Bladder injuries occurred in 24 (15%). Preoperative anemia, hypogastric artery ligation, transfusion, ICU admission, and maternal and neonatal complications were more frequent in emergent cases. Comparison between the early and late groups showed a decrease in the rate of anemia, maternal ICU admission, hypogastric artery ligation, and neonatal complications. In addition, infectious complications were relatively rare in all groups. CONCLUSIONS The Joel-Cohen incision and bladder dissection before the baby's delivery reduce transfusion rates and avoid midline incision, which is prone to complications and unpleasant cosmetic appearance while performing a hysterectomy for PAS surgery.
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Affiliation(s)
- Selim Buyukkurt
- Department of Obstetrics and Gynecology, Cukurova University Faculty of Medicine, Turkiye.
| | - Mete Sucu
- Department of Obstetrics and Gynecology, Cukurova University Faculty of Medicine, Turkiye
| | - Irem Hatipoglu
- Department of Obstetrics and Gynecology, Cukurova University Faculty of Medicine, Turkiye
| | - Ferda Ozlu
- Department of Neonatology, Cukurova University Faculty of Medicine, Turkiye
| | - Hakki Unlugenc
- Department of Anesthesiology and Reanimation, Cukurova University Faculty of Medicine, Turkiye
| | - Cuneyt Evruke
- Department of Obstetrics and Gynecology, Cukurova University Faculty of Medicine, Turkiye
| | - Cansun Demir
- Department of Obstetrics and Gynecology, Cukurova University Faculty of Medicine, Turkiye
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Serrano C, Ehrig JC, Hofkamp MP. A 29-year-old woman presenting for urgent cesarean hysterectomy: a multidisciplinary care challenge. Proc AMIA Symp 2023; 36:528-529. [PMID: 37334093 PMCID: PMC10269407 DOI: 10.1080/08998280.2023.2210795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/26/2023] [Accepted: 05/02/2023] [Indexed: 06/20/2023] Open
Abstract
This case describes a patient who needed an urgent cesarean hysterectomy for new-onset fetal heart rate abnormalities and preexisting placenta accreta spectrum. Rapid assembly of a multidisciplinary team consisting of obstetrics, anesthesiology, neonatology, and nursing contributed to a favorable clinical outcome.
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Affiliation(s)
- Claudia Serrano
- Texas A&M Health Science Center College of Medicine, Temple, Texas
| | - Jessica C. Ehrig
- Department of Obstetrics and Gynecology, Baylor Scott & White Medical Center – Temple, Temple, Texas
| | - Michael P. Hofkamp
- Department of Anesthesiology, Baylor Scott & White Medical Center – Temple, Temple, Texas
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Jeon GU, Jeon GS, Kim YR, Ahn EH, Jung SH. Uterine artery embolization for postpartum hemorrhage with placenta accreta spectrum. Acta Radiol 2023:2841851231154675. [PMID: 37093745 DOI: 10.1177/02841851231154675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
BACKGROUND The reported success rate of uterine artery embolization (UAE) for postpartum hemorrhage (PPH) differs by the cause of bleeding; in some reports, UAE shows less successful results in patients with placenta accreta spectrum (PAS). PURPOSE To evaluate the outcome of UAE for treating PPH associated with PAS. MATERIAL AND METHODS From September 2011 to September 2021, 227 patients (mean age = 34.67±4.06 years; age range = 19-47 years) underwent UAE for managing intractable PPH. Patients were divided into two groups: those with PAS (n = 46) and those without PAS (n = 181). Delivery details, embolization details, and procedure-related outcomes were compared between the two groups. P values <0.05 were considered statistically significant. RESULTS The technical success rate was 96.9% (n = 222) and the clinical success rate was 93.8% (n = 215). There were no significant differences in outcome of UAE between the two patient groups. The technical success rate was 95.7% (n = 44) in patients with PAS and 98.3% (n = 178) in patients without PAS (P = 0.267). The clinical success rate was 91.3% (n = 42) in patients with PAS and 95.6% (n = 173) in patients without PAS (P = 0.269). There were 24 cases of immediate complications, including pelvic pain (n = 20), urticaria (n = 3), and puncture site hematoma (n = 1). No major complication was reported. CONCLUSION UAE is a safe and effective method to control intractable PPH for patients with or without PAS.
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Affiliation(s)
- Go Un Jeon
- Department of Radiology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Gyeong Sik Jeon
- Department of Radiology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Young Ran Kim
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Eun Hee Ahn
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Sang Hee Jung
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
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Berriozabal C, De La Rosa JH, Lobo I, Beiro E, Dehesa T. A rare case of placenta accreta after a first-trimester abortion. Int J Gynaecol Obstet 2023; 161:322-323. [PMID: 36399398 DOI: 10.1002/ijgo.14581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 11/05/2022] [Accepted: 11/15/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Cristina Berriozabal
- Department of Gynecologic Oncology, Hospital Universitario de Basurto, Bilbao, Spain
| | | | - Ignacio Lobo
- Department of Gynecologic Oncology, Hospital Universitario de Basurto, Bilbao, Spain
| | - Eva Beiro
- Department of Gynecologic Oncology, Hospital Universitario de Basurto, Bilbao, Spain
| | - Tamara Dehesa
- Department of Gynecologic Oncology, Hospital Universitario de Basurto, Bilbao, Spain
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Larish A, Horst K, Brunton J, Schenone M, Branda M, Mehta R, Packard A, VanBuren W, Norgan A, Shahi M, Missert A, Pompeian R, Greenwood J, Theiler R. Focal-occult placenta accreta: A clandestine source of maternal morbidity. Am J Obstet Gynecol MFM 2023; 5:100924. [PMID: 36934974 DOI: 10.1016/j.ajogmf.2023.100924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 03/19/2023]
Abstract
INTRODUCTION Focal-occult placenta accreta spectrum (PAS) is known to lead to adverse obstetric morbidity outcomes, however direct comparisons with previa-associated PAS morbidity are lacking. OBJECTIVE We sought to compare baseline characteristics, surgical and obstetric morbidity, and subsequent pregnancy outcomes of patients with focal occult PAS compared to patients with previa associated accreta. STUDY DESIGN A retrospective review was conducted of all pathologically confirmed PAS from 2018-2022 at a tertiary care center. Baseline characteristics, surgical, obstetric, and subsequent pregnancy outcomes were recorded. Focal-occult PAS was compared with previa-associated PAS across a range of morbidity characteristics including hemorrhagic factors, interventions, post-delivery re-operations, infections, and ICU admission. Statistical comparison was performed using Kruskal-Wallis/Chi-Square tests, and p <0.05 was considered significant. RESULTS 74 cases were identified; 43 focal-occult and 31 previa-associated PAS. 25.6% focal-occult vs 100% previa-associated PAS underwent hysterectomy. 1 focal-occult and 29 previa-associated PAS were diagnosed antenatally. Patients with focal-occult PAS did not differ from previa-associated PAS in mean maternal age (33.0 vs 33.1 years), BMI (Body Mass Index), or presence of previous dilation & curettage procedure (16.3% vs 25.8%) when compared to previa-associated PAS. Focal-occult PAS patients were significantly more likely to have a lower mean parity (1.5 vs 3.6 gestations), higher gestational age at delivery (36.1 vs 33.9 weeks), were less likely to have had a previous cesarean (12/43, 27.9% vs 30/31, 96.8%). Additionally, focal-occult PAS patients had fewer number of previous cesareans (mean 0.5 vs 2.3), were more likely to have had in-vitro fertilization (IVF) (20.9% vs 3.2%) and less likely to have anterior placentation. When contrasting clinical outcomes of focal-occult to previa-associated PAS, postpartum hemorrhage rates (71.0% vs 67.4%), mean quantitative blood loss 2099 mL (range 500-9516mL) vs 2119 mL (range 350-12,220 mL), mean units red blood cells transfused (1.4 vs 1.7), massive transfusion rate (9.3% vs 3.2%), ICU admission (11.6% vs 6.5%), were not significantly different, with a non-significant trend towards higher morbidity in focal-occult accreta patients. Focal occult accreta had higher incidence of reoperation/return to the OR (30.2 vs 6.5%, p=0.01). When comparing focal-occult to previa-associated PAS, the composite outcomes, including hemorrhagic morbidity (77.4% vs 74.4%), any maternal morbidity (83.9% vs 76.7%) and severe maternal morbidity (64.5% vs 65.1%) were not significantly different between groups. Nine focal-occult PAS patients had a subsequent pregnancy, and three of those had recurrent PAS. CONCLUSION/IMPLICATIONS Focal-occult PAS presents with fewer identifiable risk factors than placenta previa-associated PAS but may be associated with IVF pregnancy. Focal-occult PAS was observed to have higher incidence of reoperation when compared to previa-associated PAS, and no other statistically significant differences in morbidity outcomes were observed. The absence of different morbidity outcomes may be attributable to a lack of antenatal detection of focal occult accreta, and merits further investigation.
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Affiliation(s)
- Alyssa Larish
- Department of Obstetrics and Gynecology, Mayo Clinic Rochester, MN.
| | - Kelly Horst
- Department of Diagnostic Radiology, Mayo Clinic, Rochester, MN
| | - Joshua Brunton
- Department of Obstetrics and Gynecology, Mayo Clinic Rochester, MN
| | - Mauro Schenone
- Department of Obstetrics and Gynecology, Mayo Clinic Rochester, MN
| | - Megan Branda
- Department of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Ramila Mehta
- Department of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Annie Packard
- Department of Diagnostic Radiology, Mayo Clinic, Rochester, MN
| | | | - Andrew Norgan
- Department of Anatomic Pathology, Mayo Clinic, Rochester, MN
| | - Maryam Shahi
- Department of Anatomic Pathology, Mayo Clinic, Rochester, MN
| | - Andrew Missert
- Department of Diagnostic Radiology, Mayo Clinic, Rochester, MN
| | - Rochelle Pompeian
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Jason Greenwood
- Department of Clinical Informatics/Department of Family Medicine, Mayo Clinic, Rochester, MN
| | - Regan Theiler
- Department of Obstetrics and Gynecology, Mayo Clinic Rochester, MN
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Çetin F, Sucu S, Özcan HÇ, Kömürcü Karuserci Ö, Demiroğlu Ç, Bademkiran MH, Sevinçler E. The potential role of preoperative cystoscopy for determining the depth of invasion in the placenta accreta spectrum. Ginekol Pol 2023:VM/OJS/J/92908. [PMID: 36929798 DOI: 10.5603/gp.a2023.0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/27/2023] [Accepted: 02/06/2023] [Indexed: 03/18/2023] Open
Abstract
OBJECTIVES This study aims to determine the role of preoperative cystoscopy in specifying the degree of placental invasion to the bladder in the placenta accreta spectrum (PAS), especially in percreta. MATERIAL AND METHODS This prospective observational cohort study included 78 PAS patients. All included patients underwent the preoperative cystoscopy before the cesarean hysterectomy operation. The preoperative cystoscopy procedure identified markers of PAS as neovascularization, arterial pulsatility in neovascularized zones, and posterior bladder wall bulging. Then the patients were divided into subgroups according to the histopathological results of their cesarean hysterectomy specimens. Finally, the histopathological subgroups of PAS were estimated using preoperative cystoscopy signs in the designed logistic regression analysis model. RESULTS The preoperative cystoscopic signs such as neovascularization, the posterior bladder wall bulging, and the arterial pulsatility in neovascularized zones were approximately associated with a 17-fold [OR = 16.9 (95% CI, 5.7-49.8)], 26-fold [OR = 26.1 (95% CI, 8.17-83.8)], and 9-fold [OR = 8.94 (95% CI, 2.94-27.1)] increase in the likelihood of placenta percreta, respectively. CONCLUSIONS Preoperative cystoscopy may significantly contributions to other standard imaging modalities to identify the degree of placental invasion, especially placenta percreta. Experienced obstetricians trained in hysteroscopic visualization may safely perform this preoperative cystoscopy procedure under the guidance of a specialist urologist. Accordingly, it may be possible to estimate the degree of invasion and the course of surgery in patients with PAS using the preoperative cystoscopy procedure.
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Affiliation(s)
- Furkan Çetin
- Department of Obstetrics and Gynecology, Dr Ersin Arslan Education and Research Hospital, Gaziantep, Turkey. .,Department of Obstetrics and Gynecology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey.
| | - Seyhun Sucu
- Department of Obstetrics and Gynecology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Hüseyin Çağlayan Özcan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Özge Kömürcü Karuserci
- Department of Obstetrics and Gynecology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Çağdaş Demiroğlu
- Department of Obstetrics and Gynecology, Faculty of Medicine, SANKO University, Gaziantep, Turkey
| | | | - Emin Sevinçler
- Department of Obstetrics and Gynecology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
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48
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Jauniaux E, Fox KA, Einerson B, Hussein AM, Hecht JL, Silver RM. Perinatal assessment of complex cesarean delivery: beyond placenta accreta spectrum. Am J Obstet Gynecol 2023:S0002-9378(23)00137-0. [PMID: 36868338 DOI: 10.1016/j.ajog.2023.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/22/2023] [Accepted: 02/18/2023] [Indexed: 03/05/2023]
Abstract
Multiple cesarean deliveries are known to be associated with long-term postoperative consequences because of a permanent defect of the lower uterine segment wall and the development of thick pelvic adhesions. Patients with a history of multiple cesarean deliveries often present with large cesarean scar defects and are at heightened risk in subsequent pregnancies of cesarean scar ectopic pregnancy, uterine rupture, low-lying placenta or placenta previa, and placenta previa accreta. Moreover, large cesarean scar defects will lead to progressive dehiscence of the lower uterine segment with the inability to effectively reapproximate hysterotomy edge and repair at birth. Major remodeling of the lower uterine segment associated with true placenta accreta spectrum at birth, whereby the placenta becomes inseparable from the uterine wall, increases the rates of perinatal morbidity and mortality, especially when undiagnosed before delivery. Ultrasound imaging is currently not routinely used to evaluate the surgical risks of patients with a history of multiple cesarean deliveries, beyond the risk assessment of placenta accreta spectrum. Independent of accreta placentation, a placenta previa under a scarred, thinned partially disrupted lower uterine segment, covered by thick adhesions with the posterior wall of the bladder, poses a surgical risk and requires fine dissection and surgical expertise; however, data on the use of ultrasound to evaluate uterine remodeling and adhesions between the uterus and other pelvic organs are scarce. In particular, transvaginal sonography has been underused, including in patients with a high probability of placenta accreta spectrum at birth. Based on the best available knowledge, we discuss the role of ultrasound imaging in identifying the signs suggestive of major remodeling of the lower uterine segment and in mapping the changes in the uterine wall and pelvis, to enable the surgical team to prepare for all different types of complex cesarean deliveries. The need for postnatal confirmation of the prenatal ultrasound findings for all patients with a history of multiple cesarean deliveries, regardless of the diagnosis of placenta previa and placenta accreta spectrum, is discussed. We propose an ultrasound imaging protocol and a classification of the level of surgical difficulty at elective cesarean delivery to stimulate further research toward the validation of ultrasound signs by which these signs may be applied to improve surgical outcomes.
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Affiliation(s)
- Eric Jauniaux
- Faculty of Population Health Sciences, EGA Institute for Women's Health, University College London, London, United Kingdom.
| | - Karin A Fox
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Brett Einerson
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, UT
| | - Ahmed M Hussein
- Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt
| | - Jonathan L Hecht
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, UT
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49
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Adu-Bredu TK, Rijken MJ, Nieto-Calvache AJ, Stefanovic V, Aryananda RA, Fox KA, Collins SL. A simple guide to ultrasound screening for placenta accreta spectrum for improving detection and optimizing management in resource limited settings. Int J Gynaecol Obstet 2023; 160:732-741. [PMID: 35900178 PMCID: PMC10086861 DOI: 10.1002/ijgo.14376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/21/2022] [Indexed: 11/07/2022]
Abstract
Placenta accreta spectrum is a pregnancy complication associated with severe morbidity and maternal mortality especially when not suspected antenatally and appropriate management instigated. Women in resource-limited settings are more likely to face adverse outcomes due to logistic, technical, and resource inadequacies. Accurate prenatal imaging is an important step in ensuring good outcomes because it allows adequate preparation and an appropriate management approach. This article provides a simple three-step approach aimed at guiding clinicians and sonographers with minimal experience in placental accreta spectrum through risk stratification and basic prenatal screening for this condition both with and without Doppler ultrasound.
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Affiliation(s)
| | - Marcus J Rijken
- Julius Global Health, Julius Centre for Health Science and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Obstetrics and Gynecology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Albaro Jose Nieto-Calvache
- FundaciÓn Valle del Lili, Abnormally Invasive Placenta Clinic, Cali, Colombia.,Clinical Postgraduate Department, Universidad Icesi, Cali, Colombia
| | - Vedran Stefanovic
- Fetomaternal Medical Center, Department of Obstetrics and Gynecology, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland
| | - Rozi Aditya Aryananda
- Maternal - Fetal Medicine Division, Obstetrics and Gynecology Department, Dr Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia
| | - Karin Anneliese Fox
- Division of Maternal - Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Sally L Collins
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK.,Fetal Medicine Unit, John Radcliffe Hospital, Oxford, UK
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50
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Reyther RAC, Kway VB, Huerta MM, Labastida SDLM, Cruz EYT. The use of the double uterine segment tourniquet in obstetric hysterectomy for bleeding control in patients with placenta accreta spectrum. Int J Gynaecol Obstet 2023. [PMID: 36762582 DOI: 10.1002/ijgo.14720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/30/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVES To evaluate surgical outcomes of using a double uterine segment tourniquet in obstetric hysterectomy for bleeding control in patients with placenta accreta spectrum. METHODS Retrospective case-control study conducted at the Central Hospital of San Luis Potosi, Mexico. Patients with the diagnosis of placenta accreta spectrum who underwent obstetric hysterectomy were included. Two groups were formed: in the first, a double uterine segment tourniquet was used; and in the second, the hysterectomy was performed without a tourniquet. Primary surgical outcomes were compared. RESULTS Forty patients in each group were included. The use of a double uterine segment tourniquet had lower total blood loss compared with the non-tourniquet group (1054.00 ± 467.02 vs. 1528.75 ± 347.12 mL, P = 0.0171) and a lower drop in hemoglobin (1.74 ± 1.10 vs. 2.60 ± 1.25 mg/dL, P = 0.0486). Ten patients (23.80%) in the double tourniquet group required blood transfusion, compared with 26 (65.00%) in the non-tourniquet group (P = 0.0003). Surgical time did not show a statistical difference between groups. CONCLUSION The use of a uterine segment tourniquet in obstetric hysterectomy may improve surgical outcomes in patients with placenta accreta spectrum with no difference in surgical time and urinary tract lesions.
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Affiliation(s)
- Roberto Arturo Castillo Reyther
- Department of Obstetrics and Gynecology, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico.,Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
| | - Venance Basil Kway
- Department of Obstetrics and Gynecology, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico
| | - Manuel Mendoza Huerta
- Department of Obstetrics and Gynecology, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico.,Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
| | - Salvador De La Maza Labastida
- Department of Obstetrics and Gynecology, Hospital Central Dr Ignacio Morones Prieto, San Luis Potosi, Mexico.,Universidad Autonoma de San Luis Potosi, San Luis Potosi, Mexico
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