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Miyashita Y, Mariya T, Someya M, Ishioka S, Saito T. Placenta Percreta Progression to Resistance Against Uterine Artery Embolization and Penetration Into the Bladder. Cureus 2024; 16:e55651. [PMID: 38586688 PMCID: PMC10995758 DOI: 10.7759/cureus.55651] [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: 03/06/2024] [Indexed: 04/09/2024] Open
Abstract
A 31-year-old female sought termination of pregnancy due to a fetal body stalk anomaly diagnosed at 18 weeks of gestation. Despite an anterior placenta previa, successful vaginal delivery occurred. However, placental adhesion over a previous cesarean scar occurred, and part of the placenta could not be removed. Immediate postpartum bleeding prompted imaging studies, revealing extravasation from adherent placental remnants. Uterine artery embolization (UAE) provided initial hemostasis, but recurrent bleeding necessitated re-embolization. Although conservative treatment was initially pursued, significant hematuria prompted reevaluation, revealing extensive uterine wall and bladder penetration. Surgical intervention with total hysterectomy and partial bladder resection was performed, leading to the successful recovery of bladder function following surgical repair. While this case achieved a positive outcome, there is a potential for permanent urinary dysfunction if lesions are more extensive. While achieving a conservative cure is ideal, it is essential to assess the timing for opting for surgical intervention.
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Affiliation(s)
- Yukiko Miyashita
- Department of Obstetrics and Gynecology, Sapporo Medical University, Sapporo, JPN
| | - Tasuku Mariya
- Department of Obstetrics and Gynecology, Sapporo Medical University, Sapporo, JPN
| | - Masayuki Someya
- Department of Obstetrics and Gynecology, Sapporo Medical University, Sapporo, JPN
| | - Shinichi Ishioka
- Department of Obstetrics and Gynecology, Sapporo Medical University, Sapporo, JPN
| | - Tsuyoshi Saito
- Department of Obstetrics and Gynecology, Sapporo Medical University, Sapporo, JPN
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Talal Almehzaa R, Sunder A, Bushaqer N. Pregnancy With a Bicornuate Uterus Complicated by Placenta Percreta and Intraperitoneal Hemorrhage. Cureus 2024; 16:e54519. [PMID: 38516427 PMCID: PMC10955673 DOI: 10.7759/cureus.54519] [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: 02/20/2024] [Indexed: 03/23/2024] Open
Abstract
Uterine malformations significantly affect the reproduction process, and such anomalies can affect the progression and prognosis of a pregnancy. A bicornuate uterus is a rare congenital uterine anomaly that occurs due to a defect in the fusion of Müllerian ducts. It is associated with severe maternal and fetal complications, such as uterine rupture, vascular-related pathologies, preterm labor and birth, recurrent early or late loss of pregnancy, and fetal growth restriction. In such scenarios, close monitoring and ultrasound screening are needed to prevent obstetric complications. We report a case of a bicornuate uterus complicated with placenta percreta and intraperitoneal hemorrhage.
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Affiliation(s)
| | - Amala Sunder
- Obstetrics and Gynaecology, Bahrain Defence Force Hospital, West Riffa, BHR
| | - Nayla Bushaqer
- Obstetrics and Gynaecology, Royal College of Surgeons in Ireland - Bahrain, Busaiteen, BHR
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3
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Einerson BD, Healy AJ, Lee A, Warrick C, Combs CA, Hameed AB. Society for Maternal-Fetal Medicine Special Statement: Emergency checklist, planning worksheet, and system preparedness bundle for placenta accreta spectrum. Am J Obstet Gynecol 2024; 230:B2-B11. [PMID: 37678646 DOI: 10.1016/j.ajog.2023.09.001] [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] [Indexed: 09/09/2023]
Abstract
Placenta accreta spectrum is a life-threatening complication of pregnancy that is underdiagnosed and can result in massive hemorrhage, disseminated intravascular coagulation, massive transfusion, surgical injury, multisystem organ failure, and even death. Given the rarity and complexity, most obstetrical hospitals and providers do not have comprehensive expertise in the diagnosis and management of placenta accreta spectrum. Emergency management, antenatal interdisciplinary planning, and system preparedness are key pillars of care for this life-threatening disorder. We present an updated sample checklist for emergent and unplanned cases, an antenatal planning worksheet for known or suspected cases, and a bundle of activities to improve system and team preparedness for placenta accreta spectrum.
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Daggez M, Aslanca T, Dursun P. Intraoperative temporary internal iliac arterial occlusion (Polat's technique) for severe placenta accreta spectrum: A description of the technique and outcomes in 61 patients. Int J Gynaecol Obstet 2024; 164:99-107. [PMID: 37377184 DOI: 10.1002/ijgo.14968] [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: 03/16/2023] [Revised: 05/27/2023] [Accepted: 06/10/2023] [Indexed: 06/29/2023]
Abstract
OBJECTIVE To report the results of prophylactic use of intraoperative temporary internal iliac arterial occlusion by Bulldog clamps in patients clinically diagnosed with abnormally invasive placenta. METHODS This retrospective study included 61 patients diagnosed with FIGO grade 3 abnormally invasive placenta between January 2018 and March 2022. After transfundal incision and fetal delivery, bilateral temporary internal iliac arterial occlusion by Bulldog clamps was performed in all patients. The grades 3b and 3c group underwent cesarean hysterectomy whereas selected cases of grade 3a abnormally invasive placenta underwent fertility-preserving procedures. Preoperative and postoperative findings were compared. RESULTS Cesarean hysterectomy was performed in 50 (82%) patients and cesarean plus conservative procedures were performed in 11 (18%) patients. Intraoperative blood replacement was not performed in 83.6% of all patients. Mean blood loss was 1.37 ± 0.53 L (range 0.5-2.5) in all patients. Estimated blood loss was significantly higher in cesarean hysterectomy group. There was no statistically significant difference between two groups in terms of peroperative blood replacement, bladder, and ureteral injury. CONCLUSION Prophylactic bilateral temporary internal iliac arterial occlusion by Bulldog clamps should be performed in cases of grade 3 abnormally invasive placenta. Fertility-preserving steps may be undertaken safely in selected cases with this approach.
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Affiliation(s)
- Mine Daggez
- Department of Gynecologic Oncology, University of Health Sciences Tekirdag City Hospital, Tekirdag, Turkiye
| | - Tufan Aslanca
- Department of Gynecologic Oncology, University of Health Sciences Ankara City Hospital, Ankara, Turkiye
| | - Polat Dursun
- Private Gynecologic Oncology Clinic, Ankara, Turkiye
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5
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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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Nardi E, Seravalli V, Abati I, Castiglione F, Di Tommaso M. Antepartum unscarred uterine rupture caused by placenta percreta: a case report and literature review. Pathologica 2023; 115:232-236. [PMID: 37711040 PMCID: PMC10688248 DOI: 10.32074/1591-951x-882] [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: 04/26/2023] [Accepted: 05/05/2023] [Indexed: 09/16/2023] Open
Abstract
The main risk for uterine rupture is the presence of a uterine scar due to prior cesarean delivery or other uterine surgery. However, rupture in an unscarred uterus is extremely rare, and risk factors include multiple gestations, trauma, congenital anomalies, use of uterotonics and placenta accreta spectrum. Placenta accreta spectrum, also known as morbidly adherent placenta, is becoming increasingly common and is associated with significant maternal and neonatal morbidity and mortality. We report a case of unscarred uterine rupture due to placenta percreta in a multiparous woman that required emergency peripartum hysterectomy.
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Affiliation(s)
- Eleonora Nardi
- Section of Anatomic Pathology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Viola Seravalli
- Department of Health Science, Division of Obstetrics & Gynecology, University of Florence, Florence, Italy
| | - Isabella Abati
- Department of Health Science, Division of Obstetrics & Gynecology, University of Florence, Florence, Italy
| | - Francesca Castiglione
- Section of Anatomic Pathology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Mariarosaria Di Tommaso
- Section of Anatomic Pathology, Department of Health Sciences, University of Florence, Florence, Italy
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7
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Wimmer J, Sattler L, Herb A, Pontvianne M, Boudier É, Hengen M, Thuet V, Feugeas O, Desprez D. [ Placenta percreta management in a patient with a severe congenital hypofibrinogenemia]. Ann Biol Clin (Paris) 2023; 81:210-216. [PMID: 37144786 DOI: 10.1684/abc.2023.1802] [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: 05/06/2023]
Abstract
The obstetrical follow-up of patients with a severe hypofibrinogenemia requires a multidisciplinary collaboration because of potential maternal-fetal complications (recurrent miscarriages, intrauterine fetal demise, post-partum hemorrhage, thrombosis). We report the obstetrical management of a multiparous patient with a severe congenital hypofibrinogenemia associated with a platelet disorder (abnormal phospholipid externalization). A therapeutic strategy based on a biweekly administration of fibrinogen concentrates associated with enoxaparin and aspirin allowed the maintenance of pregnancy. But this last one got complicated by a placenta percreta requiring a salvage hysterectomy with an appropriate hemorrhage prophylaxis.
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Affiliation(s)
- Jordan Wimmer
- Laboratoire d'hématologie biologique, Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Avenue Molière, 67000 Strasbourg, France
| | - Laurent Sattler
- Laboratoire d'hématologie biologique, Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Avenue Molière, 67000 Strasbourg, France
| | - Agathe Herb
- Laboratoire d'hématologie biologique, Hôpitaux Universitaires de Strasbourg, Hôpital de Hautepierre, Avenue Molière, 67000 Strasbourg, France
| | - Mary Pontvianne
- Service de gynécologie, Hôpitaux Universitaires de Strasbourg, France
| | - Éric Boudier
- Service de gynécologie, Hôpitaux Universitaires de Strasbourg, France
| | - Maryse Hengen
- Service d'anesthésiologie, Hôpitaux Universitaires de Strasbourg, France
| | - Vincent Thuet
- Service d'anesthésiologie, Hôpitaux Universitaires de Strasbourg, France
| | - Olivier Feugeas
- Centre de compétence des troubles de l'hémostase, Hôpitaux Universitaires de Strasbourg, France
| | - Dominique Desprez
- Centre de compétence des troubles de l'hémostase, Hôpitaux Universitaires de Strasbourg, France
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Rekowska AK, Obuchowska K, Bartosik M, Kimber-Trojnar Ż, Słodzińska M, Wierzchowska-Opoka M, Leszczyńska-Gorzelak B. Biomolecules Involved in Both Metastasis and Placenta Accreta Spectrum-Does the Common Pathophysiological Pathway Exist? Cancers (Basel) 2023; 15:cancers15092618. [PMID: 37174083 PMCID: PMC10177254 DOI: 10.3390/cancers15092618] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 03/31/2023] [Revised: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
The process of epithelial-to-mesenchymal transition (EMT) is crucial in the implantation of the blastocyst and subsequent placental development. The trophoblast, consisting of villous and extravillous zones, plays different roles in these processes. Pathological states, such as placenta accreta spectrum (PAS), can arise due to dysfunction of the trophoblast or defective decidualization, leading to maternal and fetal morbidity and mortality. Studies have drawn parallels between placentation and carcinogenesis, with both processes involving EMT and the establishment of a microenvironment that facilitates invasion and infiltration. This article presents a review of molecular biomarkers involved in both the microenvironment of tumors and placental cells, including placental growth factor (PlGF), vascular endothelial growth factor (VEGF), E-cadherin (CDH1), laminin γ2 (LAMC2), the zinc finger E-box-binding homeobox (ZEB) proteins, αVβ3 integrin, transforming growth factor β (TGF-β), β-catenin, cofilin-1 (CFL-1), and interleukin-35 (IL-35). Understanding the similarities and differences in these processes may provide insights into the development of therapeutic options for both PAS and metastatic cancer.
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Affiliation(s)
- Anna K Rekowska
- Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Karolina Obuchowska
- Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Magdalena Bartosik
- Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Żaneta Kimber-Trojnar
- Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Magdalena Słodzińska
- Chair and Department of Obstetrics and Perinatology, Medical University of Lublin, 20-090 Lublin, Poland
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9
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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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10
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Yang Z, Yang Y, Yin Z, Yao J. The role of internal iliac artery intraoperative vascular clamp temporary occlusion in abnormally invasive placenta. Int J Gynaecol Obstet 2023; 161:175-181. [PMID: 35986614 DOI: 10.1002/ijgo.14422] [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: 04/30/2022] [Revised: 07/22/2022] [Accepted: 08/15/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To investigate the efficacy of internal iliac artery intraoperative vascular clamp temporary occlusion in the treatment of abnormally invasive placenta. METHOD This retrospective study enrolled 153 patients diagnosed with abnormally invasive placenta between January 2018 and December 2021. The patients were divided into a study group (n = 88, undergoing cesarean section followed by internal iliac artery vascular clamp temporary occlusion) and a control group (n = 65, receiving routine cesarean section). The general situation, intraoperative conditions, postoperative complications, and neonatal outcomes were compared between the two groups. RESULTS The hysterectomy rate in the study group was significantly lower than that in the control group. However, there were no significant differences in intraoperative blood loss, blood transfusion, postoperative intensive care unit transfer rate, or neonatal outcome between the groups. Further subgrouping showed that in patients with placenta increta, the hysterectomy rate and intraoperative bleeding amount were significantly lower in the occlusion group. Nevertheless, these advantages were not significantly different between the groups in patients with placenta percreta. CONCLUSION Vascular clamp temporary occlusion of internal iliac artery is an effective method for controlling hemorrhage and decreasing the incidence of hysterectomy in patients with placenta increta. For patients with placenta percreta, the benefit is limited.
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Affiliation(s)
- Ziling Yang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yuanyuan Yang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zongzhi Yin
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China.,NHC Key Laboratory of the Study of Abnormal Gametes and the Reproductive Tract, Anhui Medical University, Hefei, China
| | - Jie Yao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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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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Ogoyama M, Yamamoto K, Suzuki H, Takahashi H, Fujiwara H. Uterine Rupture With Placenta Percreta Following Multiple Adenomyomectomies. Cureus 2023; 15:e34852. [PMID: 36923199 PMCID: PMC10009651 DOI: 10.7759/cureus.34852] [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: 02/11/2023] [Indexed: 02/13/2023] Open
Abstract
Pregnancy following adenomyomectomy is challenging because uterine rupture or placenta accreta spectrum (PAS) is more likely to occur; however, optimal management has not yet been established. We herein present a case of uterine rupture with placenta percreta in a pregnant woman who underwent adenomyomectomy twice before pregnancy. Magnetic resonance imaging (MRI) was performed in the second trimester and imminent uterine rupture concomitant with PAS was suspected. The patient was immediately admitted to hospital for careful management. Although failed tocolysis forced delivery at 29 weeks of gestation, managed hospitalization allowed cesarean hysterectomy to be performed uneventfully. Extensive PAS was proven pathologically in the removed uterus. Pregnancies following multiple adenomyomectomies are considered to be high-risk. Therefore, a sufficient explanation of the risks associated with future pregnancies is needed, particularly following second adenomyomectomy.
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Affiliation(s)
- Manabu Ogoyama
- Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, JPN
| | - Kazuki Yamamoto
- Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, JPN
| | - Hirotada Suzuki
- Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, JPN
| | | | - Hiroyuki Fujiwara
- Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, JPN
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13
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Baumann HE, Pawlik LKA, Hoesli I, Schoetzau A, Schoenberger H, Butenschoen A, Monod C, Manegold-Brauer G. Accuracy of ultrasound for the detection of placenta accreta spectrum in a universal screening population. Int J Gynaecol Obstet 2022; 161:920-926. [PMID: 36436922 DOI: 10.1002/ijgo.14595] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 08/04/2022] [Revised: 11/09/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The current study aimed to determine the sensitivity and specificity of ultrasound for the diagnosis of placenta accreta spectrum (PAS) in a universal screening population and assesses the added value of magnetic resonance imaging (MRI). METHODS This retrospective analysis evaluated 5219 patients with singleton pregnancies who had a standardized ultrasound (US) examination in our unit and delivered at our institution between 2014 and 2019. RESULTS A total of 181 (3.5%) of 5219 (100%) patients had a suspicion or diagnosis of PAS with US. The accuracy of US in detecting placenta increta/percreta showed a sensitivity of 100%, specificity of 99.9%, positive predictive value of 82.4%, and a negative predictive value of 100%. The diagnosis of all forms of PAS showed a sensitivity of 25.8%, specificity of 99.8%, positive predictive value of 80.8%, and a negative predictive value of 97.7%. MRI was concordant with US in 11 of 14 (78.5%) cases of severe forms of PAS and in three of 15 (20.0%) cases with placenta accreta. CONCLUSION A standardized US evaluation can be applied in a universal screening setting for the diagnosis of severe forms of PAS. MRI is a complementary examination in severe forms of PAS but seems of limited value to discriminate placenta accreta from placenta increta/percreta.
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Affiliation(s)
- Hanna Elise Baumann
- Department of Gynecologic and Prenatal Ultrasound, University of Basel, Women's Hospital, Basel, Switzerland
| | | | - Irene Hoesli
- Department of Obstetrics and Prenatal Medicine, University of Basel, Women's Hospital, Basel, Switzerland
| | | | - Heidrun Schoenberger
- Department of Gynecologic and Prenatal Ultrasound, University of Basel, Women's Hospital, Basel, Switzerland
| | - Annkathrin Butenschoen
- Department of Gynecologic and Prenatal Ultrasound, University of Basel, Women's Hospital, Basel, Switzerland
| | - Cécile Monod
- Department of Gynecologic and Prenatal Ultrasound, University of Basel, Women's Hospital, Basel, Switzerland.,Department of Obstetrics and Prenatal Medicine, University of Basel, Women's Hospital, Basel, Switzerland
| | - Gwendolin Manegold-Brauer
- Department of Gynecologic and Prenatal Ultrasound, University of Basel, Women's Hospital, Basel, Switzerland
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14
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Enste R, Cricchio P, Dewandre PY, Braun T, Leonards CO, Niggemann P, Spies C, Henrich W, Kaufner L. Placenta Accreta Spectrum Part II: hemostatic considerations based on an extended review of the literature. J Perinat Med 2022; 51:455-467. [PMID: 36181735 DOI: 10.1515/jpm-2022-0233] [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: 05/13/2022] [Accepted: 09/05/2022] [Indexed: 11/15/2022]
Abstract
"Placenta accreta spectrum" (PAS) is a rare but serious pregnancy condition where the placenta abnormally adheres to the uterine wall and fails to spontaneously release after delivery. When it occurs, PAS is associated with high maternal morbidity and mortality-as PAS management can be particularly challenging. This two-part review summarizes current evidence in PAS management, identifies its most challenging aspects, and offers evidence-based recommendations to improve management strategies and PAS outcomes. The first part of this two-part review highlighted the general anesthetic approach, surgical and interventional management strategies, specialized "centers of excellence," and multidisciplinary PAS treatment teams. The high rates of PAS morbidity and mortality are often provoked by PAS-associated coagulopathies and peripartal hemorrhage (PPH). Anesthesiologists need to be prepared for massive blood loss, transfusion, and to manage potential coagulopathies. In this second part of this two-part review, we specifically reviewed the current literature pertaining to hemostatic changes, blood loss, transfusion management, and postpartum venous thromboembolism prophylaxis in PAS patients. Taken together, the two parts of this review provide a comprehensive survey of challenging aspects in PAS management for anesthesiologists.
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Affiliation(s)
- Rick Enste
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Patrick Cricchio
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Pierre-Yves Dewandre
- Department of Anesthesia and Intensive Care Medicine, Université de Liège, Liege, Belgium
| | - Thorsten Braun
- Department of Obstetrics and 'Exp. Obstetrics', Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christopher O Leonards
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Phil Niggemann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Wolfgang Henrich
- Department of Obstetrics and 'Exp. Obstetrics', Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lutz Kaufner
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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15
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Enste R, Cricchio P, Dewandre PY, Braun T, Leonards CO, Niggemann P, Spies C, Henrich W, Kaufner L. Placenta accreta spectrum part I: anesthesia considerations based on an extended review of the literature. J Perinat Med 2022; 51:439-454. [PMID: 36181730 DOI: 10.1515/jpm-2022-0232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 05/13/2022] [Accepted: 09/05/2022] [Indexed: 11/15/2022]
Abstract
"Placenta accreta spectrum" (PAS) describes abnormal placental adherence to the uterine wall without spontaneous separation at delivery. Though relatively rare, PAS presents a particular challenge to anesthesiologists, as it is associated with massive peripartum hemorrhage and high maternal morbidity and mortality. Standardized evidence-based PAS management strategies are currently evolving and emphasize: "PAS centers of excellence", multidisciplinary teams, novel diagnostics/pharmaceuticals (especially regarding hemostasis, hemostatic agents, point-of-care diagnostics), and novel operative/interventional approaches (expectant management, balloon occlusion, embolization). Though available data are heterogeneous, these developments affect anesthetic management and must be considered in planed anesthetic approaches. This two-part review provides a critical overview of the current evidence and offers structured evidence-based recommendations to help anesthesiologists improve outcomes for women with PAS. This first part discusses PAS management in centers of excellence, multidisciplinary care team, anesthetic approach and monitoring, surgical approaches, patient safety checklists, temperature management, interventional radiology, postoperative care and pain therapy. The diagnosis and treatment of hemostatic disturbances and preoperative prepartum anemia, blood loss, transfusion management and postpartum venous thromboembolism will be addressed in the second part of this series.
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Affiliation(s)
- Rick Enste
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Patrick Cricchio
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Pierre-Yves Dewandre
- Department of Anesthesia and Intensive Care Medicine, Université de Liège, Liege, Belgium
| | - Thorsten Braun
- Department of Obstetrics and 'Exp. Obstetrics', Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christopher O Leonards
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Phil Niggemann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Wolfgang Henrich
- Department of Obstetrics and 'Exp. Obstetrics', Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lutz Kaufner
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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16
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Pain F, Dohan A, Grange G, Marcellin L, Uzan‐Augui J, Goffinet F, Soyer P, Tsatsaris V. Percreta score to differentiate between placenta accreta and placenta percreta with ultrasound and MR imaging. Acta Obstet Gynecol Scand 2022; 101:1135-1145. [PMID: 35822244 PMCID: PMC9812204 DOI: 10.1111/aogs.14420] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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] [Received: 02/21/2022] [Revised: 06/05/2022] [Accepted: 06/18/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The objective of this study was to assess the performance of ultrasound and magnetic resonance imaging (MRI) features in helping to classify the type of placenta accreta spectrum (PAS; accreta/increta vs percreta), alone or combined in a predictive score. MATERIAL AND METHODS We conducted a retrospective study in 82 pregnant women with PAS who underwent ultrasound and MRI examination of the pelvis before delivery (from an initial cohort of 185 women with PAS). We estimated the sensitivity, specificity and accuracy of MRI and ultrasound in the diagnosis of the type of PAS. We analyzed cesarean and imaging features using univariable logistic regression analysis. We constructed a nomogram to predict the risk of placenta percreta and validated it with bootstrap resampling, then used receiver operating characteristic curves to assess the performance of the model in distinguishing between placenta percreta and placenta accreta/increta. RESULTS Among the 82 patients, 29 (35%) had placenta accreta/increta and 53 (65%) had placenta percreta. The best features to discriminate between placenta accreta/increta and placenta percreta with ultrasound were increased vascularization at the uterine serosa-bladder wall interface (odds ratio [OR] 7.93; 95% confidence interval [CI] 2.78-24.99; p < 0.01) and the number of lacunae without a hyperechogenic halo (OR 1.36; 95% CI 1.14-1.67; p = 0.012). Concerning MRI markers, heterogeneous placenta (OR 12.89; 95% CI 3.05-89.16; p = 0.002), dark intraplacental bands (OR 12.89; 95% CI 3.05-89.16; p = 0.002) and bladder wall interruption (OR 15.89; 95% CI 4.78-73.33; p < 0.001) had a higher OR in discriminating placenta accreta/increta from placenta percreta. The nomogram yielded areas under the curve of 0.841 (95% CI 0.754-0.927) and 0.856 (95% CI 0.767-0.945), after bootstrap resampling, for the accurate prediction of placenta percreta. CONCLUSIONS The nomogram we developed to predict the risk of placenta percreta among patients with PAS had good discriminative capabilities. This performance and its impact on maternal morbidity should be confirmed by future prospective studies.
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Affiliation(s)
- Flore‐Anne Pain
- Department of Gynecology & Obstetrics, FHU PREMACochin HospitalParisFrance
| | - Anthony Dohan
- Faculty of MedicineUniversité Paris CentreParisFrance,Department of RadiologyCochin HospitalParisFrance
| | - Gilles Grange
- Department of Gynecology & Obstetrics, FHU PREMACochin HospitalParisFrance
| | - Louis Marcellin
- Department of Gynecology & Obstetrics, FHU PREMACochin HospitalParisFrance,Faculty of MedicineUniversité Paris CentreParisFrance
| | | | - François Goffinet
- Department of Gynecology & Obstetrics, FHU PREMACochin HospitalParisFrance,Faculty of MedicineUniversité Paris CentreParisFrance
| | - Philippe Soyer
- Faculty of MedicineUniversité Paris CentreParisFrance,Department of RadiologyCochin HospitalParisFrance
| | - Vassilis Tsatsaris
- Department of Gynecology & Obstetrics, FHU PREMACochin HospitalParisFrance,Faculty of MedicineUniversité Paris CentreParisFrance
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17
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Reeder CF, Sylvester-Armstrong KR, Silva LM, Wert EM, Smulian JC, Genc MR. Outcomes of pregnancies at high-risk for placenta accreta spectrum following negative diagnostic imaging. J Perinat Med 2022; 50:595-600. [PMID: 35218171 DOI: 10.1515/jpm-2021-0591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/10/2021] [Accepted: 02/07/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To assess the pretest and negative post-test probability for placenta accreta spectrum (PAS) in a group of patients with high-risk clinical factors. METHODS We included patients with suspected and/or confirmed PAS at our institution over 8 years. Sonography performed by maternal-fetal medicine specialists, and selected patients underwent MRI. Imaging was considered positive if either sonography or MRI suggested PAS. Histopathology was the gold standard for diagnosis of PAS. We assessed the pretest and negative imaging-test probability, and resources required. RESULTS We identified 82 high-risk patients with the following: (1) a history of ≥1 cesarean section and/or intrauterine gynecologic procedure and placenta previa in the index pregnancy; (2) a history of >3 cesarean deliveries and/or gynecologic procedures regardless of placental location; (3) prior PAS disorder, or retained placenta requiring manual extraction and/or curettage, complicated by postpartum hemorrhage; and (4) suspected cesarean section scar pregnancy. Histopathology confirmed PAS in 52 patients, with pretest probability of 63%. Imaging correctly identified 44/50 cases with PAS, and excluded this condition in 24/30 cases. Thus, the positive and negative post-test probability for PAS following negative imaging was 88 and 20%, respectively. Of the six patients with false-negative imaging, all had either surgical complications or required care beyond that for routine cesarean section. CONCLUSIONS Although diagnostic imaging is sensitive, the negative posttest probability remains high in women with high pretest probability for PAS. Therefore, women at high risk for PAS should be managed in experienced centers by a multidisciplinary team even if imaging is negative.
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Affiliation(s)
- Callie F Reeder
- University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Lauren M Silva
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Erika M Wert
- University of Florida College of Medicine, Gainesville, FL, USA
| | - John C Smulian
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Mehmet R Genc
- University of Florida College of Medicine, Gainesville, FL, USA
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18
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Jauniaux E, Hecht JL, Elbarmelgy RA, Elbarmelgy RM, Thabet MM, Hussein AM. Searching for placenta percreta: a prospective cohort and systematic review of case reports. Am J Obstet Gynecol 2022; 226:837.e1-837.e13. [PMID: 34973177 DOI: 10.1016/j.ajog.2021.12.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 10/15/2021] [Revised: 12/04/2021] [Accepted: 12/12/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Placenta percreta is described as the most severe grade of placenta accreta spectrum and accounts for a quarter of all cases of placenta accreta spectrum reported in the literature. OBJECTIVE We investigated the hypothesis that placenta percreta, which has been described clinically as placental tissue invading through the full thickness of the uterus, is a heterogeneous category with most cases owing to primary or secondary uterine abnormality rather than an abnormally invasive form of placentation. STUDY DESIGN We have evaluated the agreement between the intraoperative findings using the International Federation of Gynecology and Obstetrics classification with the postoperative histopathology diagnosis in a prospective cohort of 101 consecutive singleton pregnancies presenting with a low-lying placenta or placenta previa, a history of at least 1 prior cesarean delivery and ultrasound signs suggestive of placenta accreta spectrum. Furthermore, a systematic literature review of case reports of placenta percreta, which included histopathologic findings and gross images, was performed. RESULTS Samples for histologic examination were available in 80 of 101 cases of the cohort, which were managed by hysterectomy or partial myometrial resection. Microscopic examination showed evidence of placenta accreta spectrum in 65 cases (creta, 9; increta, 56). Of 101 cases included in the cohort, 44 (43.5%) and 54 (53.5%) were graded as percreta by observer A and observer B, respectively. There was a moderate agreement between observers. Of note, 11 of 36 cases that showed no evidence of abnormal placental attachment at delivery and/or microscopic examination were classified as percreta by both observers. The systematic literature review identified 41 case reports of placenta percreta with microscopic images and presenting symptomatology, suggesting that most cases were the consequence of a uterine rupture. The microscopic descriptions were heterogeneous, and all descriptions demonstrated histology of placenta creta rather than percreta. CONCLUSION Our study supported the concept that placenta accreta is not an invasive disorder of placentation but the consequence of postoperative surgical remodeling or a preexisting uterine pathology and found no histologic evidence supporting the existence of a condition where the villous tissue penetrates the entire uterine wall, including the serosa and beyond.
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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.
| | - Jonathan L Hecht
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA
| | - Rasha A Elbarmelgy
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
| | - Rana M Elbarmelgy
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
| | - Mohamed M Thabet
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
| | - Ahmed M Hussein
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
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19
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Overton E, Booker WA, Mourad M, Moroz L, Nhan Chang CL, Breslin N, Syeda S, Laifer-Narin S, Cimic A, Chung DE, Weiner DM, Smiley R, Sheikh M, Mobley DG, Wright JD, Gockley A, Melamed A, St Clair C, Hou J, D'Alton M, Khoury Collado F. Prophylactic endovascular internal iliac balloon placement during cesarean hysterectomy for placenta accreta spectrum. Am J Obstet Gynecol MFM 2022; 4:100657. [PMID: 35597402 DOI: 10.1016/j.ajogmf.2022.100657] [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: 02/08/2022] [Revised: 04/22/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The utility of prophylactic endovascular internal iliac balloon placement in the surgical management of placenta accreta spectrum is debated. OBJECTIVE In this study, we review outcomes of surgical management of placenta accreta spectrum with and without prophylactic endovascular internal iliac balloon catheter use at a single institution. STUDY DESIGN This is a retrospective cohort study of consecutive viable singleton pregnancies with a confirmed pathologic diagnosis of placenta accreta spectrum undergoing scheduled delivery from October 2018 through November 2020. In the T1 period (October 2018-August 2019), prophylactic endovascular internal iliac balloon catheters were placed in the operating room before the start of surgery. Balloons were inflated after neonatal delivery and deflated after hysterectomy completion. In the T2 period (September 2019-November 2020), endovascular catheters were not used. In both time periods, all surgeries were performed by a dedicated multidisciplinary team using a standardized surgical approach. The outcomes compared included the estimated blood loss, anesthesia duration, operating room time, surgical duration, and a composite of surgical complications. Comparisons were made using the Wilcoxon rank-sum test and the Fisher exact test. RESULTS A total of 30 patients were included in the study (T1=10; T2=20). The proportion of patients with placenta increta or percreta was 80% in both groups, as defined by surgical pathology. The median estimated blood loss was 875 mL in T1 and 1000 mL in T2 (P=.84). The proportion of patients requiring any packed red blood cell transfusion was 60% in T1 and 40% in T2 (P=.44). The proportion of patients requiring >4 units of packed red blood cells was 20% in T1 and 5% in T2 (P=.25). Surgical complications were observed in 1 patient in each group. Median operative anesthesia duration was 497 minutes in T1 and 296 minutes in T2 (P<.001). Median duration of operating room time was 498 minutes in T1 and 205 minutes in T2 (P<.001). Median surgical duration was 227 minutes in T1 and 182 minutes in T2 (P<.05). The median duration of time for prophylactic balloon catheter placement was 74 minutes (range, 46-109 minutes). The median postoperative length of stay was similar in both groups (6 days in T1 and 5.5 days in T2; P=.36). CONCLUSION The use of prophylactic endovascular internal iliac balloon catheters was not associated with decreased blood loss, packed red blood cell transfusion, or surgical complications. Catheter use was associated with increased duration of anesthesia, operating room time, and surgical time.
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Affiliation(s)
- Eve Overton
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado).
| | - Whitney A Booker
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Mirella Mourad
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Leslie Moroz
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Chia-Ling Nhan Chang
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Noelle Breslin
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Sbaa Syeda
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Sherelle Laifer-Narin
- Department of Diagnostic Radiology, Columbia University, New York, NY (Dr Laifer-Narin)
| | - Adela Cimic
- Department of Anatomic Pathology, Columbia University, New York, NY (Dr Cimic)
| | - Doreen E Chung
- Department of Urology, Columbia University, New York, NY (Drs Chung, and Weiner)
| | - David M Weiner
- Department of Urology, Columbia University, New York, NY (Drs Chung, and Weiner)
| | - Richard Smiley
- Department of Anesthesiology, Columbia University, New York, NY (Drs Smiley, and Sheikh)
| | - Maria Sheikh
- Department of Anesthesiology, Columbia University, New York, NY (Drs Smiley, and Sheikh)
| | - David G Mobley
- Division of Interventional Radiology, Columbia University, New York, NY (Dr Mobley)
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Allison Gockley
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Alexander Melamed
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Caryn St Clair
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - June Hou
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Mary D'Alton
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
| | - Fady Khoury Collado
- Department of Obstetrics and Gynecology, Columbia University, New York, NY (Drs Overton, Booker, Mourad, Moroz, Chang, Breslin, Syeda, Wright, Gockley, Melamed, St. Clair, Hou, D'Alton, and Collado)
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Hussein AM, Elbarmelgy RA, Elbarmelgy RM, Thabet MM, Jauniaux E. Prospective evaluation of impact of post-Cesarean section uterine scarring in perinatal diagnosis of placenta accreta spectrum disorder. Ultrasound Obstet Gynecol 2022; 59:474-482. [PMID: 34225385 PMCID: PMC9311077 DOI: 10.1002/uog.23732] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [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: 02/07/2021] [Revised: 06/17/2021] [Accepted: 06/29/2021] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Standardized ultrasound imaging and pathology protocols have recently been developed for the perinatal diagnosis of placenta accreta spectrum (PAS) disorders. The aim of this study was to evaluate prospectively the effectiveness of these standardized protocols in the prenatal diagnosis and postnatal examination of women presenting with a low-lying placenta or placenta previa and a history of multiple Cesarean deliveries (CDs). METHODS This was a prospective cohort study of 84 consecutive women with a history of two or more prior CDs presenting with a singleton pregnancy and low-lying placenta/placenta previa at 32-37 weeks' gestation, who were referred for perinatal care and management between 15 January 2019 and 15 December 2020. All women were investigated using the standardized description of ultrasound signs of PAS proposed by the European Working Group on abnormally invasive placenta. In all cases, the ultrasound features were compared with intraoperative and histopathological findings. Areas of abnormal placental attachment were identified during the immediate postoperative gross examination and sampled for histological examination. The data of a subgroup of 32 women diagnosed antenatally as non-PAS who had complete placental separation at birth were compared with those of 39 cases diagnosed antenatally as having PAS disorder that was confirmed by histopathology at delivery. RESULTS Of the 84 women included in the study, 42 (50.0%) were diagnosed prenatally as PAS and the remaining 42 (50.0%) as non-PAS on ultrasound examination. Intraoperatively, 66 (78.6%) women presented with a large or extended area of dehiscence and 52 (61.9%) with a dense tangled bed of vessels or multiple vessels running laterally and craniocaudally in the uterine serosa. A loss of clear zone was recorded on grayscale ultrasound imaging in all 84 cases, while there was no case with bladder-wall interruption or with a focal exophytic mass. Myometrial thinning (< 1 mm) in at least one area of the anterior uterine wall was found in 41 (97.6%) of the 42 cases diagnosed as non-PAS on ultrasound and 37 (88.1%) of the 42 diagnosed antenatally as PAS. Histological samples were available for all 48 hysterectomy specimens with abnormal placental attachment and for the three cases managed conservatively with focal myometrial resection and uterine reconstruction. Villous tissue was found directly attached to the superficial myometrium (placenta creta) in six of these cases and both creta villous tissue and deeply implanted villous tissue within the uterine wall (placenta increta) were found in the remaining 45 cases. There was no evidence of percreta placentation on histology in any of the PAS cases. Comparison of the main antenatal ultrasound signs and perioperative macroscopic findings between the two subgroups correctly diagnosed antenatally (32 non-PAS and 39 PAS) showed no significant difference with respect to the distribution of myometrial thinning and the presence of a placental bulge on ultrasound and of anterior uterine wall dehiscence intraoperatively. Compared with the non-PAS subgroup, the PAS subgroup showed significantly higher placental lacunae grade (P < 0.001) and more often hypervascularity of the uterovesical/subplacental area (P < 0.001), presence of bridging vessels (P = 0.027) and presence of lacunae feeder vessels (P < 0.001) on ultrasound examination, and increased vascularization of the anterior uterine wall intraoperatively (P < 0.001). CONCLUSIONS Remodeling of the lower uterine segment following CD scarring leads to structural abnormalities of the uterine contour on both ultrasound examination and intraoperatively, independently of the presence of accreta villous tissue on microscopic examination. These anatomical changes are often reported as diagnostic of placenta percreta, including cases with no histological evidence of PAS. Guided histological examination could improve the overall diagnosis of PAS and is essential to obtain evidence-based epidemiologic data. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A. M. Hussein
- Department of Obstetrics and GynecologyUniversity of CairoCairoEgypt
| | - R. A. Elbarmelgy
- Department of Obstetrics and GynecologyUniversity of CairoCairoEgypt
| | - R. M. Elbarmelgy
- Department of Obstetrics and GynecologyUniversity of CairoCairoEgypt
| | - M. M. Thabet
- Department of Obstetrics and GynecologyUniversity of CairoCairoEgypt
| | - E. Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health SciencesUniversity College LondonLondonUK
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21
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Skupski DW, Duzyj CM, Scholl J, Perez-Delboy A, Ruhstaller K, Plante LA, Hart LA, Palomares KTS, Ajemian B, Rosen T, Kinzler WL, Ananth C. Evaluation of classic and novel ultrasound signs of placenta accreta spectrum. Ultrasound Obstet Gynecol 2022; 59:465-473. [PMID: 34725869 DOI: 10.1002/uog.24804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 08/09/2021] [Revised: 10/07/2021] [Accepted: 10/13/2021] [Indexed: 05/26/2023]
Abstract
OBJECTIVES Improvement in the antenatal diagnosis of placenta accreta spectrum (PAS) would allow preparation for delivery in a referral center, leading to decreased maternal morbidity and mortality. Our objectives were to assess the performance of classic ultrasound signs and to determine the value of novel ultrasound signs in the detection of PAS. METHODS This was a retrospective cohort study of women with second-trimester placenta previa who underwent third-trimester transvaginal ultrasound and all women with PAS in seven medical centers. A retrospective image review for signs of PAS was conducted by three maternal-fetal medicine physicians. Classic signs of PAS were defined as placental lacunae, bladder-wall interruption, myometrial thinning and subplacental hypervascularity. Novel signs were defined as small placental lacunae, irregular placenta-myometrium interface (PMI), vascular PMI, non-tapered placental edge and placental bulge towards the bladder. PAS was diagnosed based on difficulty in removing the placenta or pathological examination of the placenta. Multivariate regression analysis was performed and receiver-operating-characteristics (ROC) curves were generated to assess the performance of combined novel signs, combined classic signs and a model combining classic and novel signs. RESULTS A total of 385 cases with placenta previa were included, of which 55 had PAS (28 had placenta accreta, 11 had placenta increta and 16 had placenta percreta). The areas under the ROC curves for classic markers, novel markers and a model combining classic and novel markers for the detection of PAS were 0.81 (95% CI, 0.75-0.88), 0.84 (95% CI, 0.77-0.90) and 0.88 (95% CI, 0.82-0.94), respectively. A model combining classic and novel signs performed better than did the classic or novel markers individually (P = 0.03). An increasing number of signs was associated with a greater likelihood of PAS. With the presence of 0, 1, 2 and ≥ 3 classic ultrasound signs, PAS was present in 5%, 24%, 57% and 94% of cases, respectively. CONCLUSIONS We have confirmed the value of classic ultrasound signs of PAS. The use of novel ultrasound signs in combination with classic signs improved the detection of PAS. These findings have clinical implications for the detection of PAS and may help guide the obstetric management of patients diagnosed with these placental disorders. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- D W Skupski
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, New York Presbyterian Queens, Flushing, NY, USA
- The Institute for Placental Medicine, New York Presbyterian Queens, Flushing, NY, USA
- Weill Cornell Medicine, New York, NY, USA
| | - C M Duzyj
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - J Scholl
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, New York Presbyterian Queens, Flushing, NY, USA
- The Institute for Placental Medicine, New York Presbyterian Queens, Flushing, NY, USA
- Weill Cornell Medicine, New York, NY, USA
| | - A Perez-Delboy
- Columbia University School of Medicine, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, New York, NY, USA
| | - K Ruhstaller
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, Christiana Care Health System, Wilmington, DE, USA
| | - L A Plante
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Drexel University School of Medicine, Philadelphia, PA, USA
| | - L A Hart
- Department of Obstetrics and Gynecology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - K T S Palomares
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Saint Peter's University Hospital, New Brunswick, NJ, USA
| | - B Ajemian
- Columbia University School of Medicine, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, New York, NY, USA
| | - T Rosen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - W L Kinzler
- Departments of Obstetrics and Gynecology and Graduate Medical Education, NYU Langone Hospital - Long Island and NYU Long Island School of Medicine, Mineola, NY, USA
| | - C Ananth
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
- Cardiovascular Institute of New Jersey (CVI-NJ), Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Environmental and Occupational Health Sciences Institute (EOHSI), Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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22
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Al-Khan A, Alshowaikh K, Krishnamoorthy K, Saber S, Alvarez M, Pappas L, Mannion C, Kayaalp E, Francis A, Alvarez-Perez J. Pulsatile vessel at the posterior bladder wall: A new sonographic marker for placenta percreta. J Obstet Gynaecol Res 2022; 48:1149-1156. [PMID: 35233884 DOI: 10.1111/jog.15208] [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: 12/08/2021] [Revised: 02/12/2022] [Accepted: 02/16/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We investigated using "pulsatile vessels at the posterior bladder wall" as a novel sonographic marker to demonstrate the severity of placenta accreta spectrum (PAS). METHODS This observational case-control study of 30 pregnant women was performed at Hackensack Meridian Health's Center for Abnormal Placentation in 2020. The case group was made up of women with historically described sonographic signs of PAS and was compared against two control groups: (1) women with uncomplicated placenta previa and (2) women with no evidence of placenta previa sonographically. All patients were evaluated with Color Flow Doppler ultrasound to assess the presence of arterial vessels at the posterior bladder wall. The flow characteristics and resistance indices (RI) were noted in the presence of pulsatile vessels. All patients' placentation was clinically confirmed at delivery. Patients with clinical invasive placentation underwent histopathological diagnosis to confirm disease presence. RESULTS Hundred percent of subjects in our series with suspected PAS exhibited pulsatile arterial vessels at the posterior bladder wall sonographically with a low RI of 0.38 ± 0.1 at an average of 24.6 ± 5.2 gestational weeks. Cases were histopathologically confirmed to have placenta percreta after delivery. Patients in either of the control groups did not display pulsatile vessels at the posterior bladder wall during antenatal sonographic evaluations and had no clinical evidence of PAS. CONCLUSION The presence of posterior urinary bladder wall pulsatile arterial vessels with low RI, in addition to traditional sonographic markers increases the suspicion of severe PAS. Thus, these findings allow for the greater opportunity for coordination of patient care prior to delivery.
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Affiliation(s)
- Abdulla Al-Khan
- Center for Abnormal Placentation, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Hackensack-Meridian Health, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Hackensack, New Jersey, USA
| | - Khadija Alshowaikh
- Center for Abnormal Placentation, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Hackensack-Meridian Health, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Hackensack, New Jersey, USA
| | - Kaila Krishnamoorthy
- Center for Abnormal Placentation, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Hackensack-Meridian Health, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Hackensack, New Jersey, USA.,Department of Obstetrics, Gynecology, and Women's Health, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Shelley Saber
- Center for Abnormal Placentation, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Hackensack-Meridian Health, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Hackensack, New Jersey, USA
| | - Manuel Alvarez
- Center for Abnormal Placentation, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Hackensack-Meridian Health, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Hackensack, New Jersey, USA
| | - Leigh Pappas
- Center for Abnormal Placentation, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Hackensack-Meridian Health, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Hackensack, New Jersey, USA
| | - Ciaran Mannion
- Center for Abnormal Placentation, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Hackensack-Meridian Health, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Hackensack, New Jersey, USA
| | - Emre Kayaalp
- Center for Abnormal Placentation, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Hackensack-Meridian Health, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Hackensack, New Jersey, USA
| | - Antonia Francis
- Center for Abnormal Placentation, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Hackensack-Meridian Health, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Hackensack, New Jersey, USA
| | - Jesus Alvarez-Perez
- Center for Abnormal Placentation, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Hackensack-Meridian Health, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Hackensack, New Jersey, USA
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Abstract
BACKGROUND Prenatal diagnosis of placenta percreta (PP) is important to be able to provide effective management and a multidisciplinary approach to minimize the complications. PURPOSE To evaluate the role of shear-wave elastography (SWE) in the prenatal diagnosis of PP. MATERIAL AND METHODS A total of 18 women with PP and 20 pregnant women with normal placenta in the second or third trimesters were included in this prospective study. SWE was used to determine the elasticities of the placenta (in the maternal edge of the placenta) and myometrium. The obstetric data regarding grayscale and Doppler ultrasonography, and perinatal outcomes were reviewed. A mean placental SW velocity (SWV) cut-off value was determined to predict the presence of placental adherence. RESULTS The SWV values of the PP group in the maternal edge of the placenta were significantly higher than those of the control group (1.95 ± 0.19 m/s and 1.69 ± 0.23 m/s; P = 0.001). Myometrial SWV was also higher in the PP group compared to the control group (2.25 ± 0.39 m/s and 1.90 ± 0.71 m/s; P = 0.002). A receiver operating characteristic (ROC) curve analysis was performed and the best cut-off value of placental SWV was determined as 1.92 m/s with sensitivity of 58% and specificity of 80%, to predict the placental adherence in patients with PP. CONCLUSION Placental stiffness was significantly higher in patients with PP than in pregnant women with normally localized placenta. Thus, we thought that SWE of the placenta might be used as an alternative method in the diagnosis of PP.
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Affiliation(s)
- Dilek Sen Dokumaci
- Harran University Medical Faculty, Department of Radiology, Sanliurfa, Turkey
| | - Hacer Uyanikoglu
- Harran University Medical Faculty, Department of Obstetrics and Gynecology, Sanliurfa, Turkey
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24
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Wang X, Yan J, Zhao X, Zheng W, Zhang H, Xin H, Zhang W, Hu Y, Yang H. Maternal outcomes of abnormally invasive placenta in China and their association with use of abdominal aortic balloon occlusion. J Matern Fetal Neonatal Med 2022; 35:9376-9382. [PMID: 35105248 DOI: 10.1080/14767058.2022.2035355] [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: 10/19/2022]
Abstract
OBJECTIVE To compare maternal outcomes of abnormally invasive placenta in China in 2012, 2015, and 2018, and further examine the association between use of abdominal aortic balloon occlusion (AABO) and the risk of maternal outcomes. MATERIALS AND METHODS A retrospective analysis included 830 women diagnosed as abnormally invasive placenta from 5 tertiary care centers in China in 2012, 2015 and 2018. Participants were divided into AABO group and non-AABO group according to whether they were treated with AABO or not. Logistic regression models were used to assess the association of use of AABO with postpartum hemorrhage, blood transfusion, hysterectomy and repeated surgery. RESULTS Among 830 participants, 66.0% (548/830) and 34.0% (282/830) of women were diagnosed with placenta increta and percreta, respectively; 33.3% (276/830) of women with abnormally invasive placenta were treated with AABO. In 2012, 2015, and 2018, the rate of blood transfusion was 83.1, 59.8, and 56.2%; the rate of hysterectomy was 50.8, 11.2, and 2.4%; and the rate of repeated surgery was 10.2, 9.4, and 0.9%. Use of AABO was associated with lower risk of postpartum hemorrhage (OR = 0.59, 95% CI: 0.35-0.99), blood transfusion (OR = 0.72, 95% CI: 0.52-0.99), hysterectomy (OR = 0.04, 95% CI: 0.01-0.14) and repeated surgery (OR = 0.14, 95% CI: 0.05-0.41) after adjustment for potential confounders. CONCLUSION The rates of blood transfusion, hysterectomy and repeated surgery progressively decreased from 2012 to 2018 in Chinese women with abnormally invasive placenta. Use of AABO was associated with lower risk of postpartum hemorrhage, blood transfusion, hysterectomy and repeated surgery.
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Affiliation(s)
- Xueyin Wang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Jie Yan
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Xianlan Zhao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Weiran Zheng
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Huijing Zhang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Hong Xin
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Hebei Medical University, Hebei Province, China
| | - Weishe Zhang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, Hunan, China
| | - Yali Hu
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
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25
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Abstract
Placenta percreta is the most severe form of placenta accreta and is characterized by placental invasion through the entirety of the myometrium and possibly into extrauterine tissues. It is associated with prior cesarean deliveries and placenta previa. Herein, we present the case of a patient who developed placenta percreta and experienced massive blood loss of 27 liters. She developed many complications over the next 11 months, including deep vein thrombosis, pulmonary embolism, preeclampsia after pregnancy, hematoma, blood clots in the bladder, lactation failure, ileus, vesicovaginal fistula, excessive scar tissue requiring surgery, loss of an ovary, and recurrent bladder perforation. We analyze the mechanisms of these complications and the most common complications associated with placenta percreta.
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Affiliation(s)
- Danyon J Anderson
- Medicine, School of Medicine, Medical College of Wisconsin, Wauwatosa, USA
| | - Hefei Liu
- Medicine, School of Medicine, Medical College of Wisconsin, Wauwatosa, USA
| | - Devesh Kumar
- Medicine, School of Medicine, Medical College of Wisconsin, Wauwatosa, USA
| | - Mit Patel
- Medicine, School of Medicine, Medical College of Wisconsin, Wauwatosa, USA
| | - Simon Kim
- Urology, University of Colorado, Aurora, USA
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Gulati A, Anand R, Aggarwal K, Agarwal S, Tomer S. Ultrasound as a Sole Modality for Prenatal Diagnosis of Placenta Accreta Spectrum: Potentialities and Pitfalls. Indian J Radiol Imaging 2021; 31:527-538. [PMID: 34790294 PMCID: PMC8590573 DOI: 10.1055/s-0041-1735864] [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: 11/06/2022] Open
Abstract
Background
Placenta accreta spectrum (PAS) is a significant cause of maternal and neonatal mortality and morbidity. Its prevalence has been rising considerably, primarily due to the increasing rate of primary and repeat cesarean sections. Accurate prenatal identification of PAS allows optimal management because the timing of delivery, availability of blood products, and recruitment of skilled anesthesia, and surgical team can be arranged in advance.
Aims and Objectives
This study aimed to (1) study the ultrasound and color Doppler features of PAS, (2) correlate imaging findings with clinical and per-operative/histopathological findings, and (3) evaluate the accuracy of ultrasound for the diagnosis of PAS in patients with previous cesarean section.
Materials and Methods
This prospective study was conducted in radiology department of a tertiary care hospital. After screening 1,200 pregnant patients, 50 patients of placenta previa with period of gestation ≥ 24 weeks and history of at least one prior cesarean section were included in the study. Following imaging features were evaluated: (1) gray scale covering intraplacental lacunae, disruption of uterovesical interface, myometrial thinning, loss of retroplacental clear space, and focal exophytic masses; and (2) color Doppler covering intraplacental lacunar flow, hypervascularity of uterine serosa–bladder wall interface, and perpendicular bridging vessels between placenta and myometrium.
Study Design
Present study is a prospective one in a tertiary care hospital.
Results
Of the 19 PAS cases, 18 were correctly diagnosed on ultrasonography (USG) and confirmed either by histopathological analysis of hysterectomy specimen or per-operatively due to difficulty in placental removal. PAS was correctly ruled out in 27 of 31 patients. The diagnostic accuracy of USG was 90%. The sensitivity, specificity, positive, and negative predictive values were 94.7, 87.1, 81.8, and 96.4%, respectively.
Conclusion
Ultrasound is indispensable for the evaluation of pregnant patients. It is an important tool for diagnosing PAS, thereby making the operating team more cautious and better equipped for difficult surgery and critical postoperative care. It can be relied upon as the sole modality to accurately rule out PAS in negative patients, thereby obviating unnecessary psychological stress among patients due to possible hysterectomy.
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Affiliation(s)
- Anshika Gulati
- Department of Radiology, Lady Hardinge Medical College, New Delhi, India
| | - Rama Anand
- Department of Radiology, Lady Hardinge Medical College, New Delhi, India
| | - Kiran Aggarwal
- Department of Obstetrics and Gynecology, Lady Hardinge Medical College, New Delhi, India
| | - Shilpi Agarwal
- Department of Pathology, Lady Hardinge Medical College, New Delhi, India
| | - Shaili Tomer
- Department of Radiology, Lady Hardinge Medical College, New Delhi, India
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Happe SK, Yule CS, Spong CY, Wells CE, Dashe JS, Moschos E, Rac MWF, McIntire DD, Twickler DM. Predicting Placenta Accreta Spectrum: Validation of the Placenta Accreta Index. J Ultrasound Med 2021; 40:1523-1532. [PMID: 33058255 DOI: 10.1002/jum.15530] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 07/11/2020] [Revised: 09/08/2020] [Accepted: 09/15/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES The placenta accreta spectrum (PAS) incidence has risen substantially over the past century, paralleling a rise in cesarean delivery (CD) rates. Prenatal diagnosis of PAS improves maternal outcomes. The Placenta Accreta Index (PAI) is a standardized approach to prenatal diagnosis of PAS incorporating clinical risk and ultrasound (US) findings suggestive of placental invasion. We sought to validate the PAI for prediction of PAS in pregnancies with prior CD. METHODS This work was a retrospective cohort study of pregnancies with 1 or more prior CDs that received a US diagnosis of placenta previa or low-lying placenta in the third trimester. Images of third-trimester US with a complete placental evaluation were read by 2 blinded physicians, and the PAI was applied. Surgical outcomes and pathologic findings were reviewed. Placenta accreta spectrum was diagnosed if clinical evidence of invasion was seen at time of delivery or if any placental invasion was identified histologically. International Federation of Gynecology and Obstetrics criteria were used. RESULTS A total of 194 women met inclusion criteria. Cesarean hysterectomy was performed in 92 (47%), CD in 97 (50%), and vaginal delivery in 5 (3%). Of those who underwent hysterectomy, PAS was histologically confirmed in 79 (85%) pregnancies. Of the remaining 13 who underwent hysterectomy, all met International Federation of Gynecology and Obstetrics grade 1 clinical criteria for PAS. With a threshold of greater than 4, the PAI has a sensitivity of 87%, specificity of 77%, positive predictive value of 72%, and negative predictive value of 90% for PAS diagnosis. CONCLUSIONS Contemporaneous application of the PAI, a standardized approach to US diagnosis, is useful in the prenatal prediction of PAS.
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Affiliation(s)
- Sarah K Happe
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Casey S Yule
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Catherine Y Spong
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - C Edward Wells
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jodi S Dashe
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Elysia Moschos
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Martha W F Rac
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Donald D McIntire
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Diane M Twickler
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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28
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Joshi VM, Otiv SR, Sovani YB, Kulat PK. Aortic clamping for limiting blood loss at cesarean hysterectomy for placenta percreta: A case series. Int J Gynaecol Obstet 2021; 157:289-295. [PMID: 34003498 DOI: 10.1002/ijgo.13746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 03/03/2021] [Revised: 05/01/2021] [Accepted: 05/14/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE In women with placenta percreta, cesarean hysterectomy is associated with massive blood loss during dissection of bladder from lower uterine segment. We studied the safety and effectiveness of temporary aortic clamping as a method of limiting blood loss at cesarean hysterectomy in women with placenta percreta. METHODS This was a retrospective case series of 15 women with placenta percreta who underwent cesarean section with total hysterectomy at KEM Hospital, Pune, India, with a technique of temporary clamping of the infra-renal aorta for reducing blood loss during hysterectomy. RESULTS Fifteen women with placenta percreta underwent classical cesarean section followed by total hysterectomy with temporary clamping of the aorta. The procedure was associated with median estimated intra-operative blood loss of 650 ml. No woman had ureteric injury or needed post-operative intensive care. Aortic clamping for 28-70 min was not associated with any intra-operative vascular complications or post-operative ischemic lesions in the lower limbs, kidneys, or bowel. CONCLUSION Aortic clamping safely and effectively limited blood loss during cesarean hysterectomy for placenta percreta and thereby reduced transfusion requirements. It compares favorably with reported outcomes of other strategies of managing placenta percreta.
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Liu Y, Shan N, Yuan Y, Tan B, Qi H, Che P. The clinical evaluation of preoperative abdominal aortic balloon occlusion for patients with placenta increta or percreta. J Matern Fetal Neonatal Med 2021; 35:6084-6089. [PMID: 33792459 DOI: 10.1080/14767058.2021.1906219] [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: 10/21/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of abdominal aortic balloon for pregnant women with placenta increta or percreta (PIP). METHODS Retrospective analysis of the parameters containing estimated blood loss, red cell suspension (RCS) transfusion volume, hysterectomy, surgery time, postoperative hospital days, neonatal status and complications between the two groups. RESULTS The patients with preoperative abdominal aortic balloon occlusion (AABO) had significant reduction in blood loss volume, red cell suspension transfusion volume and plasma transfusion volume compared to patients without balloon. Similarly, the surgery time and hysterectomy were obviously reduced in the AABO group. However, there were no difference in the Apgar scores and neonatal complications between the two groups, indicating that the abdominal aortic balloon has little adverse effect on the newborns. CONCLUSION AABO plays dramatic roles on reducing blood loss volume and blood transfusion volume and it is also a safe and effective technology providing new insight into the therapy of patient with PIP. SYNOPSIS Preoperative abdominal aortic balloon occlusion (AABO), as a new intravascular interventional therapy, is safe and effective in patients with placenta increta or percreta.
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Affiliation(s)
- Yangming Liu
- Department of Obstetrics, Hechuan People's Hospital, Chongqing, China
| | - Nan Shan
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yu Yuan
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bin Tan
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hongbo Qi
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ping Che
- Department of General Surgery, Chongqing Hechuan District Maternal and Child Health Care Hospital, Chongqing, China
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Bakacak Z, Bakacak M, Güzin K, Yazar FM, Yaylalı A, Uzkar A. An examination by year of cases applied with caesarean hysterectomy because of placenta percreta in a tertiary centre: a retrospective cohort study. Ginekol Pol 2021; 92:284-288. [PMID: 33751513 DOI: 10.5603/gp.a2020.0155] [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: 06/25/2020] [Revised: 08/19/2020] [Accepted: 09/09/2020] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To examine cases applied with caesarean hysterectomy because of placenta percreta by comparing changes in treatment strategies and complications according to year. MATERIAL AND METHODS A retrospective examination was made of 93 patients applied with caesarean hysterectomy with a diagnosis of placenta percreta in 5-year periods of 2005-2009, 2010-2014, and 2015-2019. Demographic characteristics were recorded, and previous caesareans, history of myomectomy and curettage, gestational weeks, and infant birthweight. Intraoperative and postoperative findings were recorded as operating time, length of stay in hospital and Intensive Care Unit (ICU), transfusion requirement, the amount of erythrocyte suspension (ES) and fresh frozen plasma (FFP) transfused, and requirement for massive transfusion. Anaesthesia type, complications, and the preferred skin-uterus incision were also recorded. RESULTS The 93 patients comprised 8 cases in the period 2005-2009, 23 in 2010-2014, and 62 in 2015-2019. The number of previous caesarean procedures was observed to increase in parallel with these case numbers. A significant increase was observed in the gestational week of birth, and infant birthweight, and a decrease in operating times. In later years there was seen to be a lower amount of ES and FFP transfused and fewer patients with massive transfusion. Preoperative diagnosis of placenta percreta, the highest preference for general anaesthesia, selection of midline vertical skin incision and uterine fundal incision were greatest in the period 2015-2019. CONCLUSIONS In cases with placenta percreta, of which there is an increasing incidence, maternal and infant outcomes can be optimised with prenatal diagnosis and planned caesarean hysterectomy by a multidisciplinary team with optimal prenatal preparation.
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Affiliation(s)
| | - Murat Bakacak
- Department of Obstetrics and Gynecology, Kahramanmaraş Sütçü İmam University, School of Medicine, Turkey.
| | - Kadir Güzin
- Department of Obstetrics and Gynecology, Kahramanmaraş Sütçü İmam University, School of Medicine, Turkey
| | - Fatih Mehmet Yazar
- Department of General Surgery, Kahramanmaraş Sütçü İmam University, School of Medicine, Turkey
| | - Aslı Yaylalı
- Department of Histology and Embriyology, Kahramanmaraş Sütçü İmam University, School of Medicine, Turkey
| | - Aytekin Uzkar
- Department of Obstetrics and Gynecology, Kahramanmaraş Sütçü İmam University, School of Medicine, Turkey
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Zheng W, Zhang H, Ma J, Dou R, Zhao X, Yan J, Yang H. Validation of a scoring system for prediction of obstetric complications in placenta accreta spectrum disorders. J Matern Fetal Neonatal Med 2021; 35:4149-4155. [PMID: 33685330 DOI: 10.1080/14767058.2020.1847077] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 10/22/2022]
Abstract
BACKGROUND Placenta accreta spectrum (PAS) refers to a spectrum of conditions characterized by the abnormal adherence of the placenta to the implantation site and has been a challenge due to the risk of postpartum hemorrhage, peripartum hysterectomy and maternal mortality. Despite of sonographic findings, no consensus on the prenatal evaluation of PAS has been established yet. We are aiming to establish a scoring system to increase the accuracy of prediction of PAS severity, especially to differentiate placenta percreta and placenta increta. METHODS We conducted a retrospective study and collected 2,219 cases of placenta increta and placenta percreta obtained from 20 tertiary care centers in China. Demographic information, clinical characteristics, and sonographic findings were collected. Logistic regression analysis was used to determine the risk factors and sonographic features that were significantly associated with a clinical diagnosis of placenta percreta. The formula and subsequent scoring system were generated. This scoring system was then verified in 67 cases of placenta increta or placenta percreta in Peking University First Hospital from 2016 to 2017. Diagnosis of placental invasion was confirmed by surgical findings or histopathologic results. The scoring system was evaluated using a receiver operating characteristic (ROC) curve. RESULTS The scoring system combined maternal risk factors and ultrasound features and was then verified in 67 cases. According to ROC curve, the area under the curve (AUC) of our scoring system for prenatal diagnosis of placenta percreta is 0.96 (95%CI, 0.91-1.00, p < .001), for severe postpartum hemorrhage (≥1500 ml) is 0.76 (95%CI, 0.62-0.91, p = .005), for hysterectomy is 0.98 (95%CI, 0.93-1.000, p = .023). CONCLUSIONS Our scoring system combining maternal risk factors and ultrasound features can improve the predictive accuracy of placenta percreta and obstetric outcomes (severe hemorrhage and hysterectomy).
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Affiliation(s)
- Weiran Zheng
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China.,Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Huijing Zhang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China.,Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Jingmei Ma
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China.,Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Ruochong Dou
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China.,Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Xianlan Zhao
- Department of Obstetrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jie Yan
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China.,Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China.,Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing, China
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Lu R, Chu R, Gao N, Li G, Tang H, Zhou X, Lan X, Li S, Zhang X, Xu Y, Ma Y. Development and validation of nomograms for predicting blood loss in placenta previa with placenta increta or percreta. Ann Transl Med 2021; 9:287. [PMID: 33708914 PMCID: PMC7944278 DOI: 10.21037/atm-20-5160] [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] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background To develop the risk prediction model of intraoperative massive blood loss in placenta previa with placenta increta or percreta. Methods This study included 260 patients, of whom 179 were allocated to the development group and 81 to the validation group. Univariate and multivariate logistic regression analyses were used to identify characteristics that were associated with massive blood loss (≥2,500 mL) during cesarean section. A nomogram was constructed based on regression coefficients. Receiver-operating characteristic curve, calibration curve, and decision curve analyses were applied to assess the discrimination, calibration, and performance of the model. Results Two models were constructed. The preoperative feature model (model A) consisted of vascular lacunae within the placenta and hypervascularity of the uterine-placental margin, uterine serosa-bladder wall interface, and cervix. The preoperative and surgical feature model (model B) consisted of an emergency cesarean section, no preoperative balloon placement of the abdominal aorta, and the previously mentioned four ultrasound signs. Model B had better discrimination than model A (area under the curve: development group: 0.839 vs. 0.732; validation group: 0.829 vs. 0.736). Model B showed a higher area under the decision curve than model A in both the training and validation groups. Conclusions The preoperative and surgical feature model for placenta previa with placenta increta or percreta can improve the early identification and management of patients who are at high risk of intraoperative massive blood loss.
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Affiliation(s)
- Ruihui Lu
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Jinan, China
| | - Ran Chu
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Jinan, China
| | - Na Gao
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Jinan, China
| | - Guiyang Li
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Jinan, China
| | - Haiyang Tang
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Jinan, China
| | - Xinxin Zhou
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Jinan, China
| | - Xiangxin Lan
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Jinan, China
| | - Shuyi Li
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Jinan, China.,Department of Radiology, Qilu Hospital, Shandong University, Jinan, China
| | - Xi Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Jinan, China
| | - Yintao Xu
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Jinan, China
| | - Yuyan Ma
- Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Jinan, China
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Sucu S, Özcan HÇ, Karuserci ÖK, Demiroğlu Ç, Tepe NB, Bademkıran MH. Is there a role of prophylactic bilateral internal iliac artery ligation on reducing the bleeding during cesarean hysterectomy in patients with placenta percreta? A retrospective cohort study. Ginekol Pol 2021; 92:137-142. [PMID: 33448009 DOI: 10.5603/gp.a2020.0145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 06/16/2020] [Accepted: 08/16/2020] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Our study aims to evaluate the effect of bilateral prophylactic internal iliac artery ligation (IIAL) on bleeding in patients with placenta percreta who undergo cesarean hysterectomy (CH) with the use of blunt dissection technique. MATERIAL AND METHODS This retrospective cohort study included 96 patients with placenta percreta who underwent planned CH with using the blunt dissection technique to allow better vesico-uterine dissection at the gynecology and obstetrics unit of a university hospital between the years 2017-2019. We carried out bilateral IIAL before CH in the study group (group 1) while we performed only CH in the control group (group 2). RESULTS Group 1 and Group 2 consisted of 50 and 46 patients; respectively. There was no statistical difference between the two groups as regards to the mean estimated blood loss, the mean transfused blood products, the mean operation time, and the number of complications. In total, 24 patients (25%) had complications with the finding that the most common one was bladder injury (16/96, 16,66%). CONCLUSIONS Routine bilateral prophylactic IIAL before CH in placenta percreta cases does not have a beneficial effect on decreasing the amount of bleeding and the amount blood transfusion.
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Affiliation(s)
- Seyhun Sucu
- Deparment of Obstetrics and Gynecology, Gaziantep Univercity, Medical Medicine, Turkey
| | | | | | - Çağdaş Demiroğlu
- SANKO University, Gaziantep Gazi Muhtarpaşa Bulvarı, Gaziantep, Turkey.
| | | | - Muhammed Hanifi Bademkıran
- Department of Obstetrics and Gynecology, Health Science University, Gazi Yasargil Education and Research Hospital, Diyarbakır, Turkey
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Saito K, Mariya T, Fujibe Y, Saito M, Hirokawa N, Ishioka S, Saito T. Common iliac artery dissection as a complication of common iliac artery balloon occlusion for placenta percreta: A case report. J Obstet Gynaecol Res 2020; 47:1172-1177. [PMID: 33319406 DOI: 10.1111/jog.14601] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 01/22/2020] [Revised: 10/11/2020] [Accepted: 11/30/2020] [Indexed: 11/28/2022]
Abstract
A 37-year-old pregnant woman who had undergone three previous cesarean sections was diagnosed as having placenta percreta. We decided to perform cesarean hysterectomy with bilateral common iliac artery balloon occlusion (CIABO). The duration of surgery was 2 h and 2 min and total estimated blood loss was 2600 mL. Surgery was completed without any surgical complications, but the pulse oximeter waveform of the left leg became undetectable during surgery. We immediately performed angiography after closure of laparotomy and found abnormal pooling of contrast media at the left common iliac artery in the region in which the balloon was positioned. We made a diagnosis of left common iliac artery dissection caused by CIABO. We performed emergent revascularization by intravascular stenting. We conclude that CIABO can cause common iliac artery dissection by mechanical stimulation of the inflated balloon. Careful intraoperative evaluation of limb ischemia and preparation of intravascular treatment is needed for a safe procedure.
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Affiliation(s)
- Kimihito Saito
- Department of Obstetrics and Gynecology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Tasuku Mariya
- Department of Obstetrics and Gynecology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yuya Fujibe
- Department of Obstetrics and Gynecology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Masato Saito
- Department of Radiology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Naoki Hirokawa
- Department of Radiology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Shinichi Ishioka
- Department of Obstetrics and Gynecology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Tsuyoshi Saito
- Department of Obstetrics and Gynecology, Sapporo Medical University School of Medicine, Sapporo, Japan
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Heena AB, Kumari G. Retrospective study of placenta accreta, placenta increta and placenta percreta in Peripartum hysterectomy specimens. INDIAN J PATHOL MICR 2020; 63:S87-S90. [PMID: 32108636 DOI: 10.4103/ijpm.ijpm_229_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 11/04/2022] Open
Abstract
Background Abnormal placentations such as placenta accreta, placenta increta and placenta percreta are important causes of hemorrhage after delivery causing maternal morbidity and mortality. Risk factors for abnormal placentation are prior caesarean section, placenta previa and pre-eclampsia. There is a need for reliable antenatal diagnosis for these serious conditions. If these pregnancies can be identified, antepartum, site and time of delivery as well as the surgical approach can be planned ahead; this decreases the incidence of maternal mortality due to massive hemorrhage. Aim (1) To study the incidence of abnormal placentation in emergency peripartum hysterectomy specimen. (2) To evaluate various risk factors associated with abnormal placentation. Materials and Method Retrospective cross-section study done in patients with abnormal placentation leading to emergency peripartum hysterectomy during a course of eight-year period. Result We received total of 18 emergency hysterectomy specimens during eight-year period of which placenta accreta accounts 55.5 percent (10/18), placenta increta upto 38.8 percent (7/18) and placenta percreta 5.5 percent (1/18). Analysis of result with parity shows uniparous women up to 22.2 percent (4/18), and multiparous women 77.7 percent (14/18). Risk factor analysis shows previous caesarean section in 55.5 percent (10/18), placenta previa in 33.3 percent (6/18) and pre-eclampsia in 11.1 percent (2/18). Conclusion In our study, among abnormal placentation, incidence of placenta accreta accounts for 55.5 percent and it is more common in multiparous women than uniparous women. Among risk factors in our study, previous caesarean section is commonly associated with abnormal placentation followed by a placenta previa and pre-eclampsia.
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Affiliation(s)
- Azam Begum Heena
- Department of Pathology, Dr. VRK Womens Medical College, Hyderabad, Telangana, India
| | - Gnana Kumari
- Department of Pathology, Dr. VRK Womens Medical College, Hyderabad, Telangana, India
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Jiang Q, Dai L, Chen N, Li J, Gao Y, Zhao J, Ding L, Xie C, Yi X, Deng H, Wang X. Integrative analysis provides multi-omics evidence for the pathogenesis of placenta percreta. J Cell Mol Med 2020; 24:13837-13852. [PMID: 33085209 PMCID: PMC7754008 DOI: 10.1111/jcmm.15973] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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] [Received: 06/17/2020] [Revised: 09/02/2020] [Accepted: 09/18/2020] [Indexed: 02/05/2023] Open
Abstract
Pernicious placenta previa with placenta percreta (PP) is a catastrophic condition during pregnancy. However, the underlying pathogenesis remains unclear. In the present study, the placental tissues of normal cases and PP tissues of pernicious placenta previa cases were collected to determine the expression profile of protein‐coding genes, miRNAs, and lncRNAs through sequencing. Weighted gene co‐expression network analysis (WGCNA), accompanied by miRNA target prediction and correlation analysis, were employed to select potential hub protein‐coding genes and lncRNAs. The expression levels of selected protein‐coding genes, Wnt5A and MAPK13, were determined by quantitative PCR and immunohistochemical staining, and lncRNA PTCHD1‐AS and PAPPA‐AS1 expression levels were determined by quantitative PCR and fluorescence in situ hybridization. The results indicated that 790 protein‐coding genes, 382 miRNAs, and 541 lncRNAs were dysregulated in PP tissues, compared with normal tissues. WGCNA identified coding genes in the module (ME) black and ME turquoise modules that may be involved in the pathogenesis of PP. The selected potential hub protein‐coding genes, Wnt5A and MAPK13, were down‐regulated in PP tissues, and their expression levels were positively correlated with the expression levels of PTCHD1‐AS and PAPPA‐AS1. Further analysis demonstrated that PTCHD1‐AS and PAPPA‐AS1 regulated Wnt5A and MAPK13 expression by interacting with specific miRNAs. Collectively, our results provided multi‐omics data to better understand the pathogenesis of PP and help identify predictive biomarkers and therapeutic targets for PP.
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Affiliation(s)
- Qingyuan Jiang
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.,Department of Obstetrics, Sichuan Provincial Hospital for Women and Children, Chengdu, China
| | - Lei Dai
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Na Chen
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Junshu Li
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Gao
- Department of Obstetrics, Sichuan Provincial Hospital for Women and Children, Chengdu, China
| | - Jing Zhao
- Imaging Center, Sichuan Provincial Hospital for Women and Children, Chengdu, China
| | - Li Ding
- Imaging Center, Sichuan Provincial Hospital for Women and Children, Chengdu, China
| | - Chengbin Xie
- Department of Laboratory Medicine, Sichuan Provincial Hospital for Women and Children, Chengdu, China
| | - Xiaolian Yi
- Pathology Department, Sichuan Provincial Hospital for Women and Children, Chengdu, China
| | - Hongxin Deng
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaodong Wang
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
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Stubbs MK, Wellbeloved MA, Vally JC. The management of patients with placenta percreta: A case series comparing the use of resuscitative endovascular balloon occlusion of the aorta with aortic cross clamp. Indian J Anaesth 2020; 64:520-523. [PMID: 32792719 PMCID: PMC7398021 DOI: 10.4103/ija.ija_121_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/12/2020] [Accepted: 04/22/2020] [Indexed: 12/03/2022] Open
Abstract
Due to the rising caesarean section (CS) rate, there has been an increase in placenta percreta (PP) cases. Resuscitative endovascular balloon occlusion of the aorta (REBOA) use has been successful in obstetric surgery for PP. In our institution, it has been introduced for prophylactic and therapeutic management in patients with PP. In our environment, the risks, benefits, and associated cost of REBOA use needed to be determined. In this case series, we report on five patients with PP where REBOA or aortic cross clamp were used and examine the associated outcomes.
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Affiliation(s)
- Melissa K Stubbs
- Department of Anaesthesia, Chris Hani Baragwanath Academic Hospital, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Megan A Wellbeloved
- Department of Anaesthesia, Chris Hani Baragwanath Academic Hospital, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Janine C Vally
- Department of Anaesthesia, Chris Hani Baragwanath Academic Hospital, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Cho SB, Hong SJ, Lee S, Won JH, Choi HC, Ha JY, Moon JI, Park JK, Park JE, Park SE. Preoperative Prophylactic Balloon-Assisted Occlusion of the Internal Iliac Arteries in the Management of Placenta Increta/Percreta. ACTA ACUST UNITED AC 2020; 56:E368. [PMID: 32717928 DOI: 10.3390/medicina56080368] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/22/2020] [Indexed: 11/18/2022]
Abstract
Background and Objectives: Preoperative prophylactic balloon-assisted occlusion (PBAO) of the internal iliac arteries minimizes blood loss and facilitates surgery performance, through reductions in the rate of uterine perfusion, which allow for better control in hysterectomy performance, with decreased rates of bleeding and surgical complications. We aimed to investigate the maternal and fetal outcomes associated with PBAO use in women with placenta increta or percreta. Material and Methods: The records of 42 consecutive patients with a diagnosis of placenta increta or percreta were retrospectively reviewed. Of 42 patients, 17 patients (40.5%) with placenta increta or percreta underwent cesarean delivery after prophylactic balloon catheter placement in the bilateral internal iliac artery (balloon group). The blood loss volume, transfusion volume, postoperative hemoglobin changes, rates of hysterectomy and hospitalization, and infant Apgar score in this group were compared to those of 25 similar women who underwent cesarean delivery without balloon placement (surgical group). Results: The mean intraoperative blood loss volume in the balloon group (2319 ± 1191 mL, range 1000–4500 mL) was significantly lower than that in the surgical group (4435 ± 1376 mL, range 1500–10,500 mL) (p = 0.037). The mean blood unit volume transfused in the balloon group (2060 ± 1154 mL, range 1200–8000 mL) was significantly lower than that in the surgical group (3840 ± 1464 mL, range 1800–15,200 mL) (p = 0.043). There was no significant difference in the postoperative hemoglobin change, hysterectomy rates, length of hospitalization, or infant Apgar score between the groups. Conclusion: PBAO of the internal iliac artery prior to cesarean delivery in patients with placenta increta or percreta is a safe and minimally invasive technique that reduces the rate of intraoperative blood loss and transfusion requirements.
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Piñas Carrillo A, Chandraharan E. Placenta accreta spectrum: Risk factors, diagnosis and management with special reference to the Triple P procedure. ACTA ACUST UNITED AC 2020; 15:1745506519878081. [PMID: 31578123 PMCID: PMC6777059 DOI: 10.1177/1745506519878081] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 11/16/2022]
Abstract
Abnormal invasion of placenta or placenta accreta spectrum disorders refer to the
penetration of the trophoblastic tissue through the decidua basalis into the
underlying uterine myometrium, the uterine serosa or even beyond, extending to
pelvic organs. It is classified depending on the degree of invasion into
placenta accreta (invasion <50% of the myometrium), increta (invasion >50%
of the myometrium) and percreta (invading the serosa and adjacent pelvic
organs). Clinical diagnosis is made intra-operatively; however, the confirmative
diagnosis can only be made after a histopathological examination. The incidence
of abnormal invasion of placenta has increased worldwide, mostly as a
consequence of the rise in caesarean section rates, from 1 in 2500 pregnancies
to 1 in 500 pregnancies. The importance of the disease is due to the increased
maternal and foetal morbidity and mortality. Foetal implications are mainly due
to iatrogenic prematurity, while maternal implications are mostly the increased
risk of obstetric haemorrhage and surgical complications. The average blood loss
is 3000–5000 mL, and up to 90% of the patients require a blood transfusion. An
accurate and timely antenatal diagnosis is essential to improve outcomes. The
traditional management of abnormal invasion of placenta has been a peripartum
hysterectomy; however, the increased incidence and the short- and long-term
consequences of a radical approach have led to the development of more
conservative techniques, such as the intentional retention of the placenta,
partial myometrial excision and the ‘Triple P procedure’. Irrespective of the
surgical technique of choice, women with a high suspicion or confirmed
abnormally invasive placenta should be managed in a specialist centre with
surgical expertise with a multi-disciplinary team who is experienced in managing
these complex cases with an immediate availability of blood products,
interventional radiology service, an intensive care unit and a neonatal
intensive care unit to optimize the outcomes.
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Affiliation(s)
| | - Edwin Chandraharan
- St George's University Hospitals NHS Foundation Trust and St George's, University of London, London, UK
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Wang Q, Ma J, Zhang H, Dou R, Huang B, Wang X, Zhao X, Chen D, Ding Y, Ding H, Cui S, Zhang W, Xin H, Gu W, Hu Y, Ding G, Qi H, Fan L, Ma Y, Lu J, Yang Y, Lin L, Luo X, Zhang X, Fan S, Yang H. Conservative management versus cesarean hysterectomy in patients with placenta increta or percreta. J Matern Fetal Neonatal Med 2020; 35:1944-1950. [PMID: 32498575 DOI: 10.1080/14767058.2020.1774871] [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: 10/24/2022]
Abstract
OBJECTIVE To compare conservative management and cesarean hysterectomy in patients with placenta increta or percreta. MATERIALS AND METHODS In this multicenter retrospective study, we recorded data on 2219 patients with placenta increta or percreta from 20 tertiary care centers in China from 1 January 2011 to 31 December 2015. Propensity score analysis was used to control for baseline characteristics. We divided patients into conservative management (C) and hysterectomy (H) groups. The primary outcome was operative/postoperative maternal morbidity; secondary outcomes were maternal-neonatal outcomes. RESULTS In total, 17.9% (398/2219) of patients had placenta increta and percreta; 82.1% (1821/2219) of the patients were in group C. After propensity score matching, 140 pairs of patients from the two groups underwent one-to-one matching. Group C showed less average blood loss within 24 h of surgery (1518 ± 1275 vs. 4309 ± 2550 ml in group H, p<.001). There were more patients with blood loss >1000 ml in group H than in group C (93.6% [131/140] vs. 61.4% [86/140], p<.001). More patients received blood transfusions in group H than in group C (p=.014). There was no significant difference between the groups in terms of bladder injury, postoperative anemia, fever, and disseminated intravascular coagulation. Neonatal outcomes in the two groups were similar. CONCLUSION Either conservative management or hysterectomy should be considered after thorough evaluation and detailed discussion of risks and benefits. A balance between bleeding control and fertility can be achieved.
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Affiliation(s)
- Qianyun Wang
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Jingmei Ma
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Huijing Zhang
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Ruochong Dou
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Beier Huang
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Xueyin Wang
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Xianlan Zhao
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Dunjin Chen
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Yilin Ding
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Hongjuan Ding
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Shihong Cui
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Weishe Zhang
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Hong Xin
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Weirong Gu
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Yali Hu
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Guifeng Ding
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Hongbo Qi
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Ling Fan
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Yuyan Ma
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Junli Lu
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Yue Yang
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Li Lin
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Xiucui Luo
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Xiaohong Zhang
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Shangrong Fan
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
| | - Huixia Yang
- Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, P. R. China
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Üstünyurt E. Local uterine resection with Bakri balloon placement in placenta accreta spectrum disorders. Turk J Obstet Gynecol 2020; 17:108-114. [PMID: 32850185 PMCID: PMC7406901 DOI: 10.4274/tjod.galenos.2020.82652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Received: 04/17/2020] [Accepted: 05/18/2020] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Placenta accreta spectrum (PAS) is a potentially life-threatening condition characterized by the abnormal adherence of the placenta to the implantation site. We sought to evaluate the efficacy, surgical feasibility, risks, and advantages of local uterine resection in cases complicated with PAS. MATERIALS AND METHODS This study included 97 patients with PAS, which was confirmed during surgery and by histopathological examination between January 2013 and December 2019. The patients were divided into two groups based on operative approach. The study population (local resection group) consisted of 30 cases in whom total resection of adherent placenta and myometrium was performed, whereas the control group (hysterectomy group) of 67 cesarean hysterectomy cases. RESULTS Patients who underwent hysterectomy had significantly more bleeding than the local resection group (1180±160 mL vs 877±484 mL; p=0.002). The mean number of transfused packed red blood cells (pRBCs) was greater in the hysterectomy group (4.5±2.3) than in the local resection group (2.6±3.1; p=0.001). Transfusion rate of four and/or more pRBCs was 67.2% in the hysterectomy group and 33.3% in the local resection group, which indicated a statistically significant difference (p=0.002). Of patients, 29.6% required intensive care unit in the hysterectomy group and 6.7% in the local resection group (p=0.023). CONCLUSION Local resection can be performed safely in selected PAS cases. In these cases, using a standardized protocol in terms of patient selection and surgical procedure will reduce morbidity and mortality.
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Affiliation(s)
- Emin Üstünyurt
- University of Health Sciences Turkey, Bursa Yüksek İhtisas Training and Research Hospital, Clinic of Gynecology, Bursa, Turkey
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Zuckerwise LC, Craig AM, Newton JM, Zhao S, Bennett KA, Crispens MA. Outcomes following a clinical algorithm allowing for delayed hysterectomy in the management of severe placenta accreta spectrum. Am J Obstet Gynecol 2020; 222:179.e1-179.e9. [PMID: 31469990 DOI: 10.1016/j.ajog.2019.08.035] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [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: 06/19/2019] [Revised: 08/12/2019] [Accepted: 08/20/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The incidence of placenta accreta spectrum is rising. Management is most commonly with cesarean hysterectomy. These deliveries often are complicated by massive hemorrhage, urinary tract injury, and admission to the intensive care unit. Up to 60% of patients require transfusion of ≥4 units of packed red blood cells. There is also a significant risk of death of up to 7%. OBJECTIVE The purpose of this study was to assess the outcomes of patients with antenatal diagnosis of placenta percreta that was managed with delayed hysterectomy as compared with those patients who underwent immediate cesarean hysterectomy. STUDY DESIGN We performed a retrospective study of all patients with an antepartum diagnosis of placenta percreta at our large academic institution from January 1, 2012, to May 30, 2018. Patients were treated according to standard clinical practice that included scheduled cesarean delivery at 34-35 weeks gestation and intraoperative multidisciplinary decision-making regarding immediate vs delayed hysterectomy. In cases of delayed hysterectomy, the hysterotomy for cesarean birth used a fetal surgery technique to minimize blood loss, with a plan for hysterectomy 4-6 weeks after delivery. We collected data regarding demographics, maternal comorbidities, time to interval hysterectomy, blood loss, need for transfusion, occurrence of urinary tract injury and other maternal complications, and maternal and fetal mortality rates. Descriptive statistics were performed, and Wilcoxon rank-sum and chi-square tests were used as appropriate. RESULTS We identified 49 patients with an antepartum diagnosis of placenta percreta who were treated at Vanderbilt University Medical Center during the specified period. Of these patients, 34 were confirmed to have severe placenta accreta spectrum, defined as increta or percreta at the time of delivery. Delayed hysterectomy was performed in 14 patients: 9 as scheduled and 5 before the scheduled date. Immediate cesarean hysterectomy was completed in 20 patients: 16 because of intraoperative assessment of resectability and 4 because of preoperative or intraoperative bleeding. The median (interquartile range) estimated blood loss at delayed hysterectomy of 750 mL (650-1450 mL) and the sum total for delivery and delayed hysterectomy of 1300 mL (70 -2150 mL) were significantly lower than the estimated blood loss at immediate hysterectomy of 3000 mL (2375-4250 mL; P<.01 and P=.037, respectively). The median (interquartile range) units of packed red blood cells that were transfused at delayed hysterectomy was 0 (0-2 units), which was significantly lower than units transfused at immediate cesarean hysterectomy (4 units [2-8.25 units]; P<.01). Nine of 20 patients (45%) required transfusion of ≥4 units of red blood cells at immediate cesarean hysterectomy, whereas only 2 of 14 patients (14.2%) required transfusion of ≥4 units of red blood cells at the time of delayed hysterectomy (P=.016). There was 1 maternal death in each group, which were incidences of 7% and 5% in the delayed and immediate hysterectomy patients, respectively. CONCLUSION Delayed hysterectomy may represent a strategy for minimizing the degree of hemorrhage and need for massive blood transfusion in patients with an antenatal diagnosis of placenta percreta by allowing time for uterine blood flow to decrease and for the placenta to regress from surrounding structures.
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Affiliation(s)
- Lisa C Zuckerwise
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Nashville, TN; Vanderbilt University Medical Center, and the Surgical Outcomes Center for Kids, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, TN.
| | - Amanda M Craig
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Nashville, TN
| | - J M Newton
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Nashville, TN
| | - Shillin Zhao
- Department of Biostatistics, Nashville, TN; Vanderbilt University Medical Center, and the Surgical Outcomes Center for Kids, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, TN
| | - Kelly A Bennett
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Nashville, TN
| | - Marta A Crispens
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Nashville, TN
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Liu J, Liu C, Zuo X, Teng Y. Pernicious placenta previa/ placenta percreta complicating active systemic lupus erythematosus resulting in postoperative artery thrombosis. J Int Med Res 2019; 47:6365-6373. [PMID: 31773999 PMCID: PMC7045675 DOI: 10.1177/0300060519886991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 01/02/2023] Open
Abstract
Systemic lupus erythematosus (SLE) increases the risk of adverse pregnancy outcomes and fetal complications. Placenta percreta, involving placental attachment to another organ, is a rare but severe placental abnormality. We report a 26-year-old woman, G2P1, with a 6-year history of SLE with coexisting pernicious placenta previa and placenta percreta detected by second trimester ultrasound. She discontinued prednisone 5 months before admission, without consultation, and active SLE was diagnosed on admission. Because of her progressive condition, the patient underwent infrarenal abdominal aorta balloon occlusion and double J ureteral catheter placement, followed by elective cesarean at 27+6 weeks gestation. Despite aggressive management, she experienced severe bleeding requiring internal iliac artery ligation and peripartum hysterectomy. The placenta had penetrated the uterus walls and attached to the bladder apex, necessitating bladder repair. Thrombosis was detected in the common iliac artery and common femoral artery in the right leg 1 day postoperatively. Conservative antithrombotic therapy had little effect, and embolectomy by arteriotomy was performed on the 6th post-cesarean day, and an arterial thrombus was removed. Infrarenal abdominal aorta balloon occlusion may increase the risk of postoperative thrombosis in pregnant women with active SLE and coagulation disorders. These patients therefore require close monitoring and timely anticoagulation.
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Affiliation(s)
- Jiahuang Liu
- Department of General Surgery, The First Affiliated Hospital of Xi' an Jiaotong University, Xi'an, China
| | - Chao Liu
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | | | - Yue Teng
- Department of Obstetrics and Gynecology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Fratto VM, Conturie CL, Ballas J, Pettit KE, Stephenson ML, Truong YN, Henry D, Afshar Y, Murphy A, Kim L, Field N, Wing DA, Norton ME, Ramos GA. Assessing the multidisciplinary team approaches to placenta accreta spectrum across five institutions within the University of California fetal Consortium (UCfC). J Matern Fetal Neonatal Med 2019; 34:2971-2976. [PMID: 31645153 DOI: 10.1080/14767058.2019.1676411] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [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: 10/25/2022]
Abstract
PURPOSE To describe the multidisciplinary approaches to placenta accreta spectrum (PAS) across five tertiary care centers that comprise the University of California fetal Consortium (UCfC) and to identify potential best practices. MATERIALS AND METHODS Retrospective review of all cases of pathologically confirmed invasive placenta delivered from 2009 to 2014 at UCfC. Differences in intraoperative management and outcomes based on prenatal suspicion were compared. Interventions assessed included ureteral stent use, intravascular balloon use, anesthetic type, gynecologic oncology (Gyn Onc) involvement, and cell saver use. Intervention variation by institution was also assessed. Analyses were adjusted for final pathologic diagnosis. Chi-square, Fisher's exact, Student's t-test, and Mann-Whitney's U-test were used as appropriate. Binary logistic regression and multivariable linear regression were used to adjust for confounders. RESULTS One hundred and fifty-one cases of pathologically confirmed invasive placenta were identified, of which 82% (123) were suspected prenatally. There was no correlation between the degree of invasion on prenatal imaging and use of each intervention. Ureteral stents were placed in 33% (41) of cases and did not reduce GU injury. Intravascular balloons were placed in 29% (36) of cases and were associated with shorter OR time (161 versus 236 min, p < .01) and lower estimated blood loss (EBL) (1800 versus 2500 ml, p < .01). General endotracheal anesthesia (GETA) was used in 70% (86). EBL did not differ between GETA and regional anesthesia. Gyn Onc was involved in 58% (71) of cases and EBL adjusted for final pathology was reduced with their involvement (2200 versus 2250 ml, p = .02) while OR time and intraoperative complications did not differ. Cell saver was used in 20% (24) and was associated with longer OR time (296 versus 200 min, p < .01). Use of cell saver was not associated with a difference in EBL or number of units of packed red cells transfused. All analyses were adjusted for pathologic severity of invasion. CONCLUSIONS Intravascular interventions such as uterine artery balloons and the inclusion of Gynecologic Oncologists as part of a multidisciplinary approach to treating PAS reduce EBL. Additionally, the placement of intravascular balloons may reduce OR time. No significant differences were seen in outcomes when comparing the use of ureteral stents, general anesthesia, or institutions. A team of experienced operators with a standard approach may be more significant than specific practices.
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Affiliation(s)
- Victoria M Fratto
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, CA, USA
| | - Charlotte L Conturie
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, CA, USA
| | - Jerasimos Ballas
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, CA, USA
| | - Kate E Pettit
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, CA, USA
| | - Megan L Stephenson
- Department of Obstetrics and Gynecology, University of California Irvine, Irvine, CA, USA
| | - Yen N Truong
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Dana Henry
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Yalda Afshar
- Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Aisling Murphy
- Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Lena Kim
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Nancy Field
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Deborah A Wing
- Department of Obstetrics and Gynecology, University of California Irvine, Irvine, CA, USA
| | - Mary E Norton
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Gladys A Ramos
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, CA, USA
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Abstract
Placenta percreta is a rare life-threatening condition associated with high morbidity and mortality due to severe obstetric hemorrhage. It can be associated with bladder invasion which leads to hematuria. Treatment is decided on a case-to-case basis, and there have been no guidelines proposed so far. Strategies include obstetric hysterectomy, leaving the placenta in situ with postoperative methotrexate therapy and removal of the placenta with bladder reconstruction in a single stage. An unusual case of a patient with placenta percreta and bladder invasion who presented with delayed hematuria after the placenta was left in situ has been reported. The patient was managed conservatively for 10 days postdelivery after which a decision to do an obstetric hysterectomy with focal cystectomy was taken in view of persistent hematuria. An algorithm for managing cases of placenta percreta with bladder invasion has been proposed to manage these difficult situations.
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Affiliation(s)
- Neeraja Tillu
- Department of Urology, Seth Gordhandas Sunderdas Medical College, King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Abhishek Savalia
- Department of Urology, Seth Gordhandas Sunderdas Medical College, King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Sujata Patwardhan
- Department of Urology, Seth Gordhandas Sunderdas Medical College, King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Bhushan Patil
- Department of Urology, Seth Gordhandas Sunderdas Medical College, King Edward Memorial Hospital, Mumbai, Maharashtra, India
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D'Antonio F, Iacovelli A, Liberati M, Leombroni M, Murgano D, Cali G, Khalil A, Flacco ME, Scutiero G, Iannone P, Scambia G, Manzoli L, Greco P. Role of interventional radiology in pregnancy complicated by placenta accreta spectrum disorder: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2019; 53:743-751. [PMID: 30255598 DOI: 10.1002/uog.20131] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [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: 03/30/2018] [Revised: 09/12/2018] [Accepted: 09/19/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To evaluate the potential benefit of interventional radiology (IR) in improving the outcome of women undergoing surgery for a placenta accreta spectrum (PAS) disorder. METHODS MEDLINE, EMBASE and CINAHL databases were searched for studies comparing outcomes of women with a prenatal diagnosis of PAS who underwent an IR procedure before surgery vs those who did not, using a robust collection of terms relating to PAS. The primary outcome was intraoperative estimated blood loss (EBL). Secondary outcomes were the number of transfused units of packed red blood cells (PRBC), fresh frozen plasma (FFP), platelets and cryoprecipitate, operation time, length of hospital stay, EBL ≥ 2.5 L, PRBC transfused ≥ 5 units, surgical complications, bladder or ureteral injury, relaparotomy, infection, disseminated intravascular coagulation, and complications related to endovascular catheter placement. Only studies reporting on the incidence of, or the mean difference in, the observed outcomes in women affected by a PAS disorder who had vs those who did not have an IR procedure before surgery were considered for inclusion. All outcomes were explored in the overall population of women with a prenatally diagnosed PAS disorder and in those undergoing hysterectomy. Quality assessment of each included study was performed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. The GRADE methodology was used to assess the quality of the body of retrieved evidence. RESULTS Fifteen studies (958 women with PAS) were included. In women who underwent IR before surgery, compared with those who did not, mean EBL (mean difference (MD), -1.02 L; 95% CI, -1.60 to -0.43 L; P < 0.001) and the risk of EBL ≥ 2.5 L (odds ratio (OR), 0.18; 95% CI, 0.04-0.78; P = 0.02) were significantly lower. There was no significant difference between the two groups in the other outcomes explored. On subgroup analysis of pregnancies complicated by PAS undergoing hysterectomy, EBL (MD, -0.68 L; 95% CI, -1.24 to -0.12 L; P = 0.02) and the number of transfused FFP units (MD, -1.66; 95% CI, -2.71 to -0.61; P = 0.02) were significantly lower in women who had an endovascular IR procedure compared with controls. Furthermore, women undergoing IR had a significantly lower risk of EBL ≥ 2.5 L (OR, 0.10; 95% CI, 0.02-0.47; P = 0.004). Overall, complications related to the placement of an endovascular catheter occurred in 5.3% (95% CI, 2.6-8.9; I2 , 65.3%) of pregnancies undergoing IR. Overall quality of evidence, as assessed by GRADE, was very low. CONCLUSIONS The current available data provide encouraging evidence that IR procedures may be associated with lower EBL and need for transfusion in pregnancies undergoing surgery for a PAS disorder. However, given the overall very low quality of the evidence, further large studies are needed in order to confirm the beneficial role of IR in improving the outcome of these women. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- F D'Antonio
- Department of Obstetrics and Gynaecology, University Hospital of Northern Norway, Tromsø, Norway
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
| | - A Iacovelli
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - M Liberati
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - M Leombroni
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - D Murgano
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - G Cali
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - A Khalil
- Fetal Medicine Unit, Division of Developmental Sciences, St George's University of London, London, UK
| | - M E Flacco
- Local Health Unit of Pescara, Pescara, Italy
| | - G Scutiero
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - P Iannone
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - G Scambia
- Department of Obstetrics and Gynaecology, Catholic University of The Sacred Heart, Rome, Italy
| | - L Manzoli
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - P Greco
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
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Abstract
RATIONALE Uterine rupture is a rare incidence but can lead to catastrophic maternal and fetal consequences. We still need to place a high premium on these cases. PATIENT CONCERNS The patients all showed hemodynamic shock with complaints of serious pain in the abdomen. They all had a history of laparoscopy or hysteroscopy procedures. DIAGNOSES Case 1 and 2 were diagnosed during surgery. Case 3 was diagnosed by an urgent abdominal ultrasonogram before surgery. INTERVENTIONS We performed emergency surgeries for the 3 cases. OUTCOMES Three patients all recovered well. But only the child in case 2 survived. LESSONS It must be emphasized that pregnant women with a history of such surgeries should be aware of uterine rupture during pregnancy.
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Affiliation(s)
- Baojing Zhao
- Department of Obstetrics and Gynecology, the First Affiliated Hospital of Anhui Medical University
- Anhui Province Key Laboratory of Reproductive Health and Genetics
- Biopreservation and Artificial Organs, Anhui Provincial Engineering Research Center, Anhui Medical University, Hefei, Anhui Province, China
| | - Yanling Wang
- Department of Obstetrics and Gynecology, the First Affiliated Hospital of Anhui Medical University
- Anhui Province Key Laboratory of Reproductive Health and Genetics
- Biopreservation and Artificial Organs, Anhui Provincial Engineering Research Center, Anhui Medical University, Hefei, Anhui Province, China
| | - Ying Zhang
- Department of Obstetrics and Gynecology, the First Affiliated Hospital of Anhui Medical University
- Anhui Province Key Laboratory of Reproductive Health and Genetics
- Biopreservation and Artificial Organs, Anhui Provincial Engineering Research Center, Anhui Medical University, Hefei, Anhui Province, China
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Abstract
Placenta accreta spectrum disorders, especially placenta percreta (PP) and placenta praevia (PLP), are major risk factors for massive obstetric haemorrhage which is a common cause of maternal morbidity and mortality in our environment. This risk becomes exponential and life-threatening when the two conditions co-exist in the same patient. Even in advanced countries with readily available expertise and state of the art resuscitative and supportive facilities, these conditions are associated with grave maternal and perinatal morbidity and mortality. We present a challenging case of PP co-existing with major PLP, which was diagnosed intraoperatively and the patient had total abdominal hysterectomy and bilateral internal iliac artery ligation to control haemorrhage.
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Affiliation(s)
- Adeyemi Adebola Okunowo
- Department of Obstetrics and Gynecology, College of Medicine, University of Lagos, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Ephraim Okwudiri Ohazurike
- Department of Obstetrics and Gynecology, College of Medicine, University of Lagos, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
| | - Fatimah Murtazha Habeebu-Adeyemi
- Department of Obstetrics and Gynecology, College of Medicine, University of Lagos, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
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Valentine S. Multidisciplinary Approach to Placenta Percreta: An Observational Case Study. J Perianesth Nurs 2019; 34:483-490. [PMID: 30665745 DOI: 10.1016/j.jopan.2018.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 11/05/2018] [Accepted: 11/11/2018] [Indexed: 10/27/2022]
Abstract
Abnormal placental implantations can result in postpartum hemorrhage and poor outcomes. With proper diagnosis and preplanning, complications can be minimized and aligned with maternal wishes of abstaining from blood and blood product transfusions.
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Çağlayan Özcan H, Gurol Uğur M, Sucu S, Balat Ö. Blunt dissection technique with finger and vessel skeletonization in the posterior vesical wall for abnormally invasive placenta previa. J Matern Fetal Neonatal Med 2019; 33:2441-2444. [PMID: 30486701 DOI: 10.1080/14767058.2018.1554043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 10/27/2022]
Abstract
Purpose: This study described a new technique to minimize the bleeding resulted from aberrant engorged vessels and unintended bladder injury in cases with abnormally invaded placenta adjacent to posterior bladder wall at cesarean hysterectomy.Methods: After filling the bladder with 300 ml saline aberrant engorged vessels were identified and skeletonized between lower uterine segment and bladder with blunt dissection by index finger down to the distal end point of cervix.Results: This technique has beneficial effect on preventing bladder injury and reduces bleeding resulting from the aberrant vessels and the communicating vessels that were based around the vesicouterine fold and the cervico-vesical interface (in the lower part of the cervix); respectively.Conclusion: Our procedure may have some benefits including shorter operation time, lower amount of hemorrhage, and less bladder injury where anatomical landmarks are unclear, especially in abnormally invasive placentation adjacent to posterior bladder wall at cesarean hysterectomy.
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Affiliation(s)
- Hüseyin Çağlayan Özcan
- Department of Obstetrics and Gynecology, School of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Mete Gurol Uğur
- Department of Obstetrics and Gynecology, School of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Seyhun Sucu
- Department of Obstetrics and Gynecology, School of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Özcan Balat
- Department of Obstetrics and Gynecology, School of Medicine, Gaziantep University, Gaziantep, Turkey
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