FIGO consensus guidelines on placenta accreta spectrum disorders: Nonconservative surgical management

Risk factors for severe postpartum hemorrhage in placenta accreta spectrum patients undergoing prophylactic resuscitative endovascular balloon occlusion of the aorta during cesarean delivery

OBJECTIVE

This study aims to investigate the risk factors for severe postpartum hemorrhage (SPPH) in patients with placenta accreta spectrum (PAS) undergoing cesarean delivery, despite the prophylactic use of resuscitative endovascular balloon occlusion of the aorta (REBOA).

MATERIALS AND METHODS

We conducted a retrospective case-control study on PAS patients who underwent cesarean delivery with prophylactic REBOA at the First Affiliated Hospital of Chongqing Medical University from January 2017 to December 2021. Prophylactic REBOA placement was determined by a prenatal ultrasound scoring system. Patients were divided into those who experienced SPPH (case group) and those who did not (control group), with SPPH defined by one or a combination of the following criteria: intraoperative blood loss ≥1500 mL, transfusion of ≥4 units of packed red blood cells, intraoperative hysterectomy, or sequential uterine artery embolization. Propensity score matching (PSM) was employed to minimize biases, and multivariate logistic regression was used to calculate adjusted odds ratios (aOR) for risk factors.

RESULTS

Of the 424 enrolled patients, 102 experienced SPPH (case group), while 322 did not (control group). After PSM, the case group comprised 79 patients, and the control group included 130. After adjusting for confounders, patients with placenta increta (aOR 3, 95% CI 1.49-6.03, p = 0.002), percreta (aOR 21.77, 95% CI 6.57-72.09, p < 0.001), lower hemoglobin levels (aOR 0.98, 95% CI 0.95-1, p = 0.050), and higher D-dimer levels (aOR 1.36, 95% CI 1.12-1.65, p = 0.002) had an elevated risk of SPPH. Threshold effect analysis indicated no significant nonlinear relationship between hemoglobin, D-dimer, and outcomes.

CONCLUSIONS

PAS patients, particularly those with placenta increta and percreta, lower hemoglobin levels, and elevated D-dimer levels, are at an increased risk of SPPH during cesarean delivery, even with REBOA intervention.

Perspective in diagnostic accuracy of prenatal ultrasound and MRI for placenta accreta

PURPOSE

Placenta accreta (PA) significantly increases the risk of life-threatening maternal outcomes, and its rising prevalence, driven by the increase in cesarean deliveries, underscores the need for precise diagnostic tools to improve clinical management and outcomes. This study aims to evaluate the advanced diagnostic capabilities of prenatal ultrasound and magnetic resonance imaging (MRI) in the detection of PA, a severe obstetric complication characterized by abnormal adherence of the placenta to the myometrium.

MATERIALS AND METHODS

The study utilized a review of current literature and clinical studies to assess the diagnostic accuracy and clinical utility of ultrasound and MRI in identifying PA. Both imaging modalities were evaluated for their ability to assess the depth and extent of placental invasion, as well as their complementary roles in prenatal diagnosis. The experimental system included detailed imaging protocols for ultrasound and MRI, focusing on placental and uterine structures, and their application in real-world clinical settings.

RESULTS

The findings demonstrate that ultrasound and MRI are highly effective in diagnosing PA, with each modality offering unique advantages. Ultrasound is widely accessible and serves as the first-line diagnostic tool, providing detailed visualization of placental adherence and vascular patterns. MRI, on the other hand, offers superior soft tissue contrast and is particularly valuable in complex cases or when ultrasound findings are inconclusive. Together, these imaging techniques enable accurate evaluation of placental invasion, facilitating timely and targeted prenatal interventions. The study also highlights the potential for improved maternal and fetal outcomes through early diagnosis and optimized pregnancy management.

CONCLUSIONS

Prenatal ultrasound and MRI are indispensable tools in the diagnosis and management of placenta accreta, offering complementary insights that enhance diagnostic precision. Their combined use allows for detailed assessment of placental and uterine structures, guiding clinical decision-making and improving outcomes for both mothers and infants. Future advancements in imaging technology and research hold promise for further enhancing diagnostic accuracy and expanding clinical applications, ultimately contributing to safer and more effective care for patients with PA.

Prophylactic internal iliac artery balloon for caesarean in placenta accreta reduces haemoglobin drop - Retrospective comparative study

BACKGROUND

This study compared maternal and foetal outcomes of managing placenta accreta spectrum (PAS) disease with and without prophylactic internal iliac balloon occlusion (IIABO) at a tertiary hospital between 2002 and 2021.

METHODS

This retrospective cohort study included patients with confirmed PAS disorder, comparing maternal and foetal outcomes between those who underwent IIABO before caesarean delivery and those who did not, both receiving standardised multidisciplinary care. Primary outcomes included perioperative haemoglobin drop. Secondary outcomes included estimated blood loss, transfusion rate, operative duration, ICU stay, hysterectomy rates, and newborns' Apgar scores.

RESULTS

Thirty-one antenatally diagnosed PAS patients were analysed (IIABO n = 21, non-IIABO n = 10). Over 90% had prior caesarean deliveries. IIABO is associated with lower intraoperative haemoglobin drop (p < .001) and higher postoperative haemoglobin (p = 0.047). The linear regression model demonstrated that IIABO and classical caesarean significantly reduced intraoperative blood loss (p = 0.019). No differences were seen in operative time, ICU stay, hysterectomy rates, or newborn Apgar scores. No IIABO-related complications were reported.

CONCLUSION

Prophylactic IIABO during caesarean delivery for PAS is associated with less haemoglobin drop and higher postoperative haemoglobin. IIABO under local anaesthesia was feasible, possibly reducing risks tied to extended general anaesthesia. Larger studies are recommended to support the role of IIABO in PAS disorders.

Risk factors for emergent delivery before 36 weeks among pregnant women with placenta accreta spectrum disorder

Recent studies evaluating risk factors for emergent delivery in women with placenta accreta spectrum disorders have yielded insufficient results. A limited number of studies have evaluated prenatal ultrasound signs of the placenta accreta spectrum as risk factors and have reported inconsistent outcomes. This retrospective study included women with suspected prenatal placenta accreta spectrum who delivered between January 2007 and December 2022 at a tertiary hospital in Southern Thailand. Women who delivered electively or for conditions unrelated to the placenta accreta spectrum before 36 weeks of gestation were excluded. Women who underwent emergent delivery before 36 weeks and delivery after 36 weeks were compared using univariate and multivariable analyses. Overall, 174 women with placenta accreta spectrum were included; 45 (25.0%) underwent emergent delivery before 36 weeks of gestation. Women who delivered before 36 weeks had significantly more premature uterine contractions (41.7% vs. 7.0%, P<0.001), premature rupture of membranes (8.3% vs. 0%, P<0.05), antepartum hemorrhage (75.0% vs. 27.9%, P<0.001), and sonographic findings of placental bulging (45.8% vs. 23.3%, P=0.003) than those who delivered after 36 weeks. The number of premature uterine contractions and antepartum hemorrhage episodes (P<0.001) and more severe placenta accreta spectrum (P=0.003) were significantly associated with emergent delivery. Significant predictors of emergent delivery before 36 weeks were a history of preterm birth (odds ratio: 10.1, 95% confidence interval: 1.0-97.4), presence of premature uterine contractions (9.7, 2.9-31.5), antepartum hemorrhage (6.4, 2.2-18.3), severe placenta accreta spectrum (6.1, 1.5-25.0), and placental bulging (4.4, 1.3-14.2). In conclusion, the significant predictors of emergent delivery before 36 weeks of gestation among women with placenta accreta spectrum were a history of preterm birth, premature uterine contractions or antepartum hemorrhage before 34 weeks, placental bulging, and prenatal diagnosis of severe placenta accreta spectrum.

The Management of Placenta Accreta Spectrum Disorder

This chapter provides insight into current management strategies for the placenta accreta spectrum (PAS). PAS is one of the most morbid conditions of pregnancy, with significant maternal hemorrhage and surgical morbidity risks, and its increasing incidence. Here, we review the available data to help guide the clinical management of PAS, from time of diagnosis through delivery and postpartum care, while acknowledging the many areas of continued uncertainty. The evidence is strong for the importance of team-based, patient-centered, and multidisciplinary care for patients with PAS. However, much else remains uncertain and is predominantly guided by expert opinion. Ultimately, we aim to provide a current understanding of available literature and to emphasize that continued research is paramount to explore management and surgical approaches to move toward optimization of patient outcomes, including the patient experience.

Management and outcomes of women with placenta accreta spectrum grade 3: an INOSS multicountry multiperiod population-based study

BACKGROUND

Management and outcomes in women with placenta accreta spectrum grade 3 are rarely reported from population-based studies. The objective of this study is to describe profiles, management, and outcomes, of women with placenta accreta spectrum (PAS) grade 3 from three multiperiod studies.

METHODS

This analysis used data from three multiperiod population-based cohort studies from the United Kingdom (UK) (May 2010-April 2011), France (November 2013-October 2015), and Italy (September 2014-August 2016) to compare the management and outcomes of women with grade 3 PAS. The main outcome measures were postpartum hemorrhage (PPH) ≥ 3000 mL, blood transfusion ≥ 4 units, and other severe maternal complications (death, damage to bowel or urinary tract).

RESULTS

This study included 39 women with PAS grade 3 in the UK, 51 in France, and 34 in Italy, a total of 124 women. PAS was suspected before birth in 59% of the UK cases, 88% in France, and 82% in Italy (P < .01). Conservative management was attempted only in the UK (38%) and in France (61%). PPH ≥ 3000 mL occurred in 54% of the UK women, 25% in France, and 12% in Italy (P < .01); 67% in the UK, 47% in France, and 41% in Italy received blood transfusion ≥ 4 units (P = .06). The final (immediate and secondary) hysterectomy rate differed significantly between the three countries: 69% in the UK, 57% in France, 100% in Italy (P < .01).

CONCLUSION

Maternal outcomes in women with grade 3 PAS varied between the three periods and countries, alongside the evolution in prenatal screening and peri-operative management.

TRIAL REGISTRATION

For the UK: reference number: RP-PG-0608-10038. For France: reference number: AOR12156. For Italy: reference number: Port. PRE-839/13.

The benefit of additional embolization after perioperative balloon occlusion of pelvic artery during cesarean hysterectomy in placenta accreta spectrum

BackgroundCesarean hysterectomy in the placenta accreta spectrum (PAS) remains challenging due to difficulty in controlling perioperative bleeding.PurposeTo compare the effectiveness and safety of perioperative balloon occlusion with versus without pelvic artery embolization in PAS women who underwent a cesarean hysterectomy.Material and MethodsA total of 26 pathological confirmed cases of PAS were retrospectively reviewed and categorized into two groups: perioperative balloon occlusion at either the anterior division of the internal iliac artery or uterine artery followed by gelfoam embolization (n = 12, study group) and perioperative balloon occlusion alone (n = 14, control group). Intraoperative estimated blood loss (EBL), a unit of packed red blood cell (pRBC) transfusion, surgical time, transfer to the intensive care unit (ICU), postoperative hospitalization days, postoperative complications, and Apgar scores were compared between the two groups.ResultsThe median and interquartile range (IQR) intraoperative EBL in the study group (1200 mL [700-2100 mLl]) was significantly lower compared to those in the control group (1900 mL [1300-3200 mL]) (P = 0.044). There was no significant difference between the study and control groups in units of pRBC blood transfusion, surgical time, transfer to the ICU, postoperative length of stay, postoperative complications, and mean Apgar score at 1 min and 5 min.ConclusionThe perioperative combination of balloon occlusion followed by embolization of the pelvic artery before cesarean hysterectomy is more effective in reducing blood loss than perioperative balloon occlusion alone in PAS with no difference in postoperative complications or neonatal outcomes.

A low-middle income country experience: conventional hysterectomy vs conservative placenta accreta spectrum management

BACKGROUND

Placenta accreta spectrum is one of the most dangerous complications of pregnancy, and its incidence has been rising in recent years. The standard management approach is an elective cesarean-hysterectomy, but it presents with its own set of risks and complications. Although conservative management options exist, there is a lack of definitive guidelines and must be considered on a case-by-case basis.

OBJECTIVE

This study aimed to describe and compare the outcomes (surgical duration, intraoperative blood loss volume, and maternal mortality) of patients with placenta accreta spectrum who were treated with a hysterectomy and those treated with conservative surgery in the Dr. Cipto Mangunkusumo General Hospital, a tertiary referral hospital in Indonesia.

STUDY DESIGN

Data from 271 patients with placenta accreta spectrum at the Dr. Cipto Mangunkusumo General Hospital that were collected over 3.5 years were taken and analyzed in this retrospective cohort study. Data collected included the patients' age, reproductive history, placenta accreta index score, gestational age, emergency status, management method, type of hysterectomy, surgery duration, intraoperative blood loss volume, histopathologic data, and maternal mortality. The data were analyzed using the Statistical Package for Social Sciences, version 29, with statistical significance set at P<.05. Mann-Whitney U tests, independent t tests, chi-square tests, and correlation tests were used where appropriate.

RESULTS

There were no significant differences in the demographics and reproductive history between the hysterectomy and conservative surgery groups. There was considerable difference in terms of surgical duration, intraoperative blood loss, and placenta accreta index score. The hysterectomy group had longer surgeries (median 180 minutes vs 135 minutes; P<.01), greater blood volume lost (median 1000 mL vs 700 mL; P<.01), and higher placenta accreta index scores (median 6.5 vs 5.5; P<.01). The maternal mortality rate of this study was 1.1%, all of whom were patients from the hysterectomy group, but this finding was not statistically significant.

CONCLUSION

In this study, patients who underwent conservative surgical management for placenta accreta spectrum experienced shorter surgeries with less bleeding and no maternal death. These patients typically had lower placenta accreta index scores, which may have influenced the choice of management methods and affected surgical outcomes. Although conservative surgery is a viable option, patients and surgeons must carefully weigh the risks and benefits before deciding on a treatment approach.

New surgical technique for managing placenta accreta spectrum and pilot study of the "CMNT PAS" study

Introduction

The gold standard for treating the placenta accreta spectrum (PAS) is a cesarean hysterectomy, which harms fertility. Another conservative surgical approach allows the uterus to be preserved: one-step conservative surgery. We will compare these two approaches through the "CMNT PAS" study. Before this main study, we conducted a pilot study to determine the required sample size.

Study Design

This pilot study, conducted over 31 months, included patients who underwent surgery for suspected PAS based on imaging findings. Participants were divided into the conservative surgery group (CSG: 6 patients) and the Caesarean Hysterectomy Group (control group [CG]: 6 patients). For the CSG, our team adapted the approach described in previous research by Palacios-Jaraquemada.

Results

The primary objective of our study is to ascertain the appropriate sample size for our main investigation on the conservative surgical management of PAS. Concerning the primary outcome, the estimated amount of blood loss was lower in CSG compared to CG, although this difference was not statistically significant (1298.04±556 mL vs 891.051±348 mL, P=.159). The mean decrease in hemoglobin (Δ Hb) was 2.8±1.3251 g/dL in the CG group compared to 1.933±1.0614 g/dL in the CSG group (P=.240). The mean number of transfused red blood cell units was 3±3.2249 in the CG group and 1.5±1.64317 in the CSG group (P=.334).

Conclusion

The estimated blood loss between the two groups is not statistically significant. The required sample size is 22 patients.

MRI Signs Associated With Bladder Injury During Cesarean Delivery in Severe Placenta Accreta Spectrum Disorders

BACKGROUND

Bladder injury during cesarean delivery (CD) in pregnant women with severe placenta accreta spectrum (PAS) disorders mostly occurs in the dissection of vesico-uterine space. Placental MRI may help to assess the risk of bladder injury preoperatively.

PURPOSE

To identify the high-risk MRI signs of bladder injury during CD in women with severe PAS.

STUDY TYPE

Retrospective.

SUBJECTS

One hundred sixty-seven women with surgically confirmed severe PAS, defined as to increta or percreta, who underwent planned CD and available placental MRI.

FIELD STRENGTH/SEQUENCE

1.5 Tesla, half-Fourier single-shot turbo spin echo sequence and true fast imaging with steady state free precession sequence.

ASSESSMENT

Presence of following imaging features of the vesico-uterine region were independently evaluated by three radiologists (with 8, 8, and 15 years of experience, respectively): vesico-uterine space hypervascularity, vesico-uterine space without chemical shift line, bladder wall interruption with hyperintense nodularity, bladder tenting, and uterine-placental bulge.

STATISTICAL TESTS

Univariable analyses (Chi-square or Fisher's exact test) and multivariable regression analyses were used. A P value <0.05 was considered significant.

RESULTS

Thirty-three of the women (19.8%) experienced bladder injury during CD. MRI features were significantly more frequent in the bladder injury group compared with the no bladder injury group: 69.7% vs. 26.9% in vesico-uterine space hypervascularity, 57.6% vs. 21.6% in absent chemical shift line in the vesico-uterine space, 18.2% vs. 1.5% in bladder wall interruption with hyperintense nodularity, 39.4% vs. 14.9% in bladder tenting, and 78.8% vs. 39.6% in uterine-placental bulging. Vesico-uterine space hypervascularity, absent chemical shift line, and uterine-placental bulge were independently associated with the risk of bladder injury (odds ratios: 4.190, 3.555, and 3.569, respectively).

DATA CONCLUSION

Vesico-uterine space hypervascularity, vesico-uterine space without chemical shift line and uterine-placental bulge were associated with bladder injury during CD in women with severe PAS.

PLAIN LANGUAGE SUMMARY

Bladder injury is a serious complication of cesarean delivery in pregnant women with severe placenta accreta spectrum, frequently resulting in massive hemorrhage, bladder dysfunction and severe infection. Accurate prenatal assessment is important to minimize these adverse consequences. This study showed that MRI features, including vesico-uterine space hypervascularity, vesico-uterine space without chemical shift line and uterine-placental bulge, were independently associated with bladder injury. These high-risk MRI signs may serve as effective means for prenatal assessment of bladder injury. This study would broaden the application of MRI in severe placenta accreta spectrum.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 2.

Pregnancy Outcomes after Uterine Preservation Surgery for Placenta Accreta Spectrum: A Retrospective Cohort Study

OBJECTIVE

 This study aimed to investigate maternal and neonatal outcomes in subsequent pregnancies of women with a history of placenta accreta spectrum (PAS) compared with women without history of PAS.

STUDY DESIGN

 A retrospective cohort study conducted at a single tertiary center between March 2011 and January 2022. We compared women with a history of PAS who had uterine preservation surgery and a subsequent pregnancy, to a control group matched in a 1:5 ratio. The primary outcome was the occurrence of a composite adverse outcome (CAO) including any of the following: uterine dehiscence, uterine rupture, blood transfusion, hysterectomy, neonatal intensive care unit admission, and neonatal mechanical ventilation. Multivariable logistic regression was performed to evaluate associations with the CAO.

RESULTS

 During the study period, 287 (1.1%) women were diagnosed with PAS and delivered after 25 weeks of gestation. Of these, 32 (11.1%) women had a subsequent pregnancy that reached viability. These 32 women were matched to 139 controls. There were no significant differences in the baseline characteristics between the study and control groups. Compared with controls, the proportion of CAO was significantly higher in women with previous PAS pregnancy (40.6 vs. 19.4%, p = 0.019). In a multivariable logistic regression analysis, previous PAS (adjusted odds ratio [aOR] = 3.31, 95% confidence interval [CI] = 1.09-10.02, p = 0.034) and earlier gestational age at delivery (aOR = 3.53, 95% CI = 2.27-5.49, p < 0.001) were independently associated with CAOs.

CONCLUSION

 A history of PAS in a previous pregnancy is associated with increased risk of CAOs in subsequent pregnancies.

KEY POINTS

· The uterine-preserving approach for PAS delivery is gaining more attention and popularity in recent years.. · Women with a previous pregnancy with PAS had higher rates of CAOs in subsequent pregnancies.. · Previous PAS pregnancy is an independent factor associated with adverse outcomes..

Predicting the risk of cesarean hysterectomy in the management of placenta accreta spectrum disorders: a new model based on clinical findings and ultrasonography

PURPOSE

To develop a nomogram to predict the probability of cesarean hysterectomy (CH) in placenta accreta spectrum disorders (PASD) patients.

METHODS

Data from 520 patients who underwent surgery with a preliminary diagnosis of PASD at a tertiary center in southeast Turkey between 2013 and 2023 were collected, and 302 patients were included in the study. A predictive model based on clinical and ultrasonographic variables was developed using penalized maximum likelihood estimation (PMLE) regression analysis.

RESULTS

Maternal age (aOR = 1.22, 95% CI 1.08-1.44, p = 0.001) and prior uterine surgeries (aOR = 3.18, 95% CI 1.57-8.29, p = 0.001) were identified as demographic factors with an increased likelihood of CH in the nomogram, and advanced gestational weeks demonstrated a negative correlation (aOR: 0.78, 95% CI 0.56-1.02, p = 0.07). Regarding the ultrasonographic findings, the presence of the "multiple lacunae within the placenta" (aOR = 48.53, 95% CI 18.42-257.40, p < 0.001) and the "anterior placental location" (aOR = 9.60, 95% CI 2.96-50.76, p < 0.001) significantly increased the probability of CH. In addition, "hypervascularization on Doppler flow with irregularity in the line between the bladder and uterine serosa" (aOR = 7.90, 95% CI 2.66-35.12, p < 0.001) and the "retroplacental myometrial thickness of < 1 mm" (aOR = 2.49, 95% CI 0.89-8.27, p = 0.08) were related to the probability of CH. Harrell's C-index was 0.974, and the kappa value was 0.819 for the prediction model's performance evaluation.

CONCLUSION

We developed a nomogram to predict the probability of cesarean hysterectomy in patients with PASD, incorporating maternal age, gestational weeks, prior uterine surgeries, ultrasound findings, and placental location. The most closely associated findings with CH in patients with PASD were the presence of multiple placental lacunae and the anterior location of the placenta.

Transverse versus Vertical Incision in the Surgical Management of Placenta Accreta Spectrum

OBJECTIVES

 Traditionally, midline vertical skin incisions have been utilized during surgery for placenta accreta spectrum (PAS), as it is considered to maximize exposure and allow for a uterine incision to avoid the placenta. However, literature directly comparing outcomes of vertical versus transverse incisions in PAS is sparse. Our objective was to compare maternal outcomes between patients who underwent a vertical versus a transverse skin incision for PAS.

STUDY DESIGN

 Retrospective review of patients with pathologically confirmed PAS undergoing scheduled surgery at our institution between September 2019 and November 2023. Starting in October 2021, select patients were offered a transverse skin approach. Patients were eligible if the surgery was scheduled, and the placenta was not entirely covering the anterior uterine wall. The transverse skin incision was approximately 18 to 20 cm and used the patient's prior scar. Primary outcomes included the rate of maternal transfusion >4 units of packed red blood cells (PRBCs), the incidence of surgical complications, and the need for conversion to general anesthesia (GETA).

RESULTS

 Seventy patients underwent scheduled surgery for PAS. Thirty-three patients had a vertical skin incision, and 37 had a transverse incision. After initiation of the transverse incision approach, 37/43 (86%) had a transverse incision and none required conversion to a vertical incision intraoperatively. The two groups were similar with regard to age, body mass index (BMI; kg/m2), and severity of PAS. There was no difference in the rate of transfusion of >4 units of PRBCs (vertical 12% vs. transverse 22%, p = 0.29), or in the rate of intraoperative complications (i.e., cystotomy; vertical 3% vs. transverse 14%, p = 0.20). In patients with a transverse incision, a significantly lower number of patients required conversion to GETA intraoperatively (vertical 70% vs. transverse 24%, p < 0.001).

CONCLUSION

 In appropriately selected patients, a transverse skin incision was associated with lower conversion to GETA without any difference in intraoperative outcomes.

KEY POINTS

· Transverse incision for PAS has equivalent surgical outcomes.. · Fewer patients require GETA with a transverse incision.. · Transverse incision for PAS may need fewer narcotics..

Bladder involvement in placenta accreta spectrum disorders: 2D US combined with the 3D crystal Vue and MRI comparative analysis

BACKGROUND

Placental accreta spectrum (PAS) disorder with bladder involvement is found to be associated with severe maternal and neonatal morbidity.When planning surgery or other treatments, a diagnosis and assessment of the invasiveness of placenta accreta spectrum disorder with bladder involvement are crucial.The detection of the depth of villi invasion can be accomplished with both MRI and US.The advent of three-dimensional Crystal Vue provides details additional information for scanning abnorma issue.

PURPOSE

Our goal was to compare and assess the diagnostic accuracy of 2D US combined with the 3D Crystal Vue and MRI in case of placenta accreta spectrum (PAS) involving the bladder.

MATERIALS AND METHODS

111 pregnancy patients between May 2019 and November 2023 at the First Affiliated Hospital of Anhui Medical University whether or not they had placenta previa were included in the study if they were diagnosed of having placenta increta (PI) or placenta percreta (PP).Both US and MRI were used to evaluate the pregnant women.Total 53 pregnant women were ultimately included in our analysis.53 patients were split into groups with and without bladder involvement. They underwent 2D US,3D Crystal Vue, and MRI.The visual features of every subject were noted. Next, we analyzed the fundamental information, associated medical history, pregnancy outcomes, and different US and MRI signals between the two groups. To determine the potential contributing factors of PAS complicated with bladder involvement, a univariate analysis was performed. A multivariable logistic regression analysis was performed to identify US and MRI findings predictive of bladder involvement in placenta accreta spectrum.

RESULTS

Multiple logistic regression analysis found that the bridging vessels (OR, 31.76,95% CI, 1.64-614.31,p = 0.022) and the tramline sign "fully" obliterated on Crystal Vue feature (OR, 68.92;95%CI,6.76-702.35,p < 0.001) were independently associated with an increased likelihood of bladder involvement. These findings when combined allowed for the prediction of bladder involvement with an 88.2% sensitivity, a 94.4% specificity, and an AUC of 0.933 (95% CI,0.829-0.983, p = 0.001). The results of the MRI logistic regression analysis were as follows: the three independent risk factors for bladder involvement were: Placental bulge (OR,57.99,95%CI,3.89-835.80,p = 0.003),Bladder wall interruption (OR,11.93, 95%CI, 1.60-88.85, p = 0.016), and Bladder vessel sign (OR, 9.75,95%CI, 1.43-66.21, p = 0.020).The joint diagnosis showed a sensitivity of 94.1% and specificity of 83.3%.The area under the curve was 0.942(95%CI,0.841-0.988). Regarding projected bladder involvement, there were no statistically significant differences between MRI and 2D integrated 3D Crystal Vue imaging.

CONCLUSION

Both 2D coupled 3D Crystal Vue imaging and MRI are highly effective for predicting bladder invasion.Ultrasound is preferred over MRI because it is more convenient and more affordable.Among them, the tramline sign "fully" obliterated on 3D Crystal Vue was a new and reliable US sign for detecting bladder involvement.

Psychological impact of Placenta Accreta Spectrum disorders (PAS) and risk of Post-Traumatic Stress Disorder (PTSD): A cross-sectional study

OBJECTIVE

Placenta Accreta Spectrum disorders (PAS) are a group of obstetric complications with an increasing incidence. The high maternal and neonatal morbidity and mortality associated with PAS leads to concerns about the negative psychological impact, and even the risk of developing Post-Traumatic Stress Disorder (PTSD). The aim of this study was to assess the psychological impact of PAS diagnosis and intervention during pregnancy and postpartum and its potential association with PTSD.

STUDY DESIGN

A cross-sectional study was conducted, including cases of PAS FIGO grade 2 and 3 treated at University Hospital Center São João, between 2010-2023. Only cases with histopathological confirmation after peripartum hysterectomy were included. Data were obtained from electronic medical records (Sclinic® and Obscare®). The impact of Event Scale - Revised (IES-R), a validated questionnaire, was applied, after surgery for PAS, to assess the psychological impact of PAS diagnosis and treatment.

RESULTS

Fourteen cases of PAS were identified. The mean maternal age was 36.8 years. Approximately 86 % of cases had antenatal suspicion. The mean gestational age at delivery was 34 weeks. Of the 14 women, only 11 responded to the request to participate in the study (7 interviewed in person and 4 remotely). Four women had IES-R scores indicative of high risk of PTSD (IES-R>33 points), one had an intermediate risk (IES-R between 24-32 points), and 6 fell into the low-risk category. The mean score was 22.4 points. The analysis of IES-R results by clusters showed higher scores in the intrusion category, which relates to intrusive and unwanted thoughts, images and memories.

CONCLUSION

Given the high morbidity and mortality described in women with PAS, the risk of PTSD should be acknowledged, motivating early intervention to prevent the development of severe and potentially chronic symptoms. Supportive measures and psychiatric and/or psychological follow-up should be promptly implemented, ideally by multidisciplinary teams.

Evidence-based surgery for cesarean hysterectomy secondary to placenta accreta spectrum: A systematic review

OBJECTIVE

In this systematic review, we aim to propose evidence-based management for perioperative care to improve outcomes at the time of planned cesarean hysterectomy for placenta accreta spectrum, a procedure associated with significant maternal and neonatal morbidity.

DATA SOURCES

We conducted a literature search for studies published in MEDLINE (via Ovid), Embase, CINAHL, and Cochrane/CENTRAL up until February 25, 2022. The search included free-text and controlled-vocabulary terms for cesarean section, cesarean delivery, and hysterectomy.

STUDY ELIGIBILITY CRITERIA

We included randomized controlled trials, prospective cohort, retrospective cohort, and case-control studies published in English that reported on a perioperative intervention in the performance of a planned CH for PAS. Studies must have included a comparator group. Of the 8,907 studies screened in this systematic review, 79 met the inclusion criteria.

STUDY APPRAISAL AND SYNTHESIS METHODS

Articles examining each step or intervention of the CH were grouped together and reviewed qualitatively as a group. Evidence levels and recommendations were made by consensus of all authors according to the terminology of the United States Preventive Services Task Force (USPSTF). We synthesized the results of 79 articles, and provided 28 recommendations.

RESULTS

Based on USPSTF criteria, 21.4 % of the recommendations were level B (n = 6), 39.3 % were C (n = 11), 10.7 % were D (n = 3) and 28.6 % were I (n = 8). The interventions with the highest level of recommendation included delivery at a hospital with high cesarean hysterectomy volume, implementation of a standardized hospital protocol, delivery via a planned procedure, neuraxial anesthesia, and transverse skin incision (all level B recommendations by USPSTF criteria).

CONCLUSIONS

Development of a standardized hospital protocol, delivery at a center with high CH surgical volume, and utilization of neuraxial anesthesia garnered B evidence levels. Recommendations were limited due to the lack of prospective trials. Further research into the technical aspects of this high-risk procedure is warranted.

[French survey on the management strategy for placenta accreta spectrum]

OBJECTIVE

Placenta accreta belongs to placenta accreta spectrum and is defined by an adhesion or even invasion of the placental villi in the myometrium. The main risk factor is a history of cesarean section. Its incidence is increasing following an increase in the cesarean section rate in recent years and the cause of severe maternal morbidity (hemorrhage, transfusions, hysterectomy). Treatment can be radical by cesarean section-hysterectomy or conservative with an attempt at uterine preservation. American, English, Canadian and international recommendations have been established but there are no French recommendations to date. The objective of this study was to investigate management strategy for placenta accreta in type III maternity hospitals in France.

MATERIALS AND METHODS

An anonymous questionnaire was sent by email to the obstetrics referents of the university hospital centers in France with type III maternity.

RESULTS

Forty-eight centers were approached, with a participation rate of 77%.

CONCLUSION

The management of placenta accreta spectrum in France is relatively heterogeneous on several points such as multidisciplinary management, evaluation by placental MRI, preoperative urological evaluation, treatment adopted as first-line, cesarean section-hysterectomy or conservative treatment, therapeutic strategy according to the placental invasion. However, the literature is currently poor, which may explain divergent treatment.

Peripartum Cesarean Hysterectomy for Placenta Percreta: A Retrospective Analysis of Cases With and Without Extrauterine Disease

Objective The aim of this study was to compare maternal morbidity and prenatal characteristics in placenta percreta cases with extrauterine disease and those with disease confined to the uterus. Methods A retrospective analysis of prospectively collected data was done at a large tertiary referral center in Egypt from October 2018 through February 2023. A total number of 73 cases who underwent primary cesarean hysterectomy with intrapartum confirmation of placenta previa percreta where there was evidence of at least placental invasion through uterine serosa (International Federation of Gynecology and Obstetrics (FIGO) grade 3) were included. Women without extrauterine disease (FIGO grade 3a) were compared to women with extrauterine disease where there was evidence of invasion of the bladder, parametrium, or both (FIGO grades 3b and 3c). Results Of 73 women included in the study, 46 women showed no evidence of extrauterine disease (group A), while the remaining 27 women had extrauterine disease (group B). The estimated amount of blood loss (mL) was 1,972 ± 671 in group A compared with 3,544 ± 899 in group B. There were no cases requiring massive transfusion in group A compared with eight of 27 cases (29.6%) in group B. Only two cases (4.3%) in group A had bladder injuries compared with 12 cases (44.4%) in group B. All 27 cases in group B required additional measures to control ongoing pelvic bleeding after hysterectomy compared with none of the cases in group A. The operating time (minutes) was 184 ± 30 in group A compared with 254 ± 42 in group B. Only five cases (10.9 %) in group A required postoperative intensive care unit admission, compared with 13 cases (48.1%) in group B. Conclusion Placenta accreta spectrum (PAS) with extrauterine disease represents the ultimate level of PAS surgery as it is more difficult, complex, and associated with the highest maternal morbidity. Highly specialized PAS centers are advised to categorize the disease into two different entities: PAS with extrauterine disease and PAS with disease confined to the uterus, as this may aid in improving the diagnostic accuracy of the severest PAS cases.

Conservative management or cesarean hysterectomy for placenta accreta spectrum in middle-income countries: A systematic review and meta-analysis

BACKGROUND

Cesarean hysterectomy is a dominant and effective approach during delivery in patients with placenta accreta spectrum (PAS). However, as hysterectomy results in a loss of fertility, conservative management is an alternative approach. However, management selection may be affected by a country's overall economic level. Thus the preferred treatment for PAS generates controversy in middle-income countries.

OBJECTIVES

We aimed to compare conservative management and cesarean hysterectomy for managing PAS in middle-income countries.

SEARCH STRATEGY

China National Knowledge Infrastructure, Wanfang Med Online Databases, Cochrane Library, Ovid MEDLINE, PubMed, Web of Science, EMBASE, clinicaltrials.gov, and Scopus were searched from inception through to October 1, 2022.

SELECTION CRITERIA

We included studies that evaluated at least one complication comparing conservative management and hysterectomy. All cases were diagnosed with PAS prenatally and intraoperatively.

DATA COLLECTION AND ANALYSIS

The primary outcomes were blood loss, adjacent organ damage, and the incidence of hysterectomy. Descriptive analyses were conducted for studies that did not meet the meta-analysis criteria. A fixed-effects model was used for studies without heterogeneity and a random-effects model was used for studies with statistical heterogeneity.

MAIN RESULTS

In all, 11 observational studies were included, with 975 and 625 patients who underwent conservative management and cesarean hysterectomy, respectively. Conservative management was significantly associated with decreased blood loss and lower risks of adjacent organ injury and hysterectomy. Conservative management significantly reduced blood transfusions, hospitalization duration, operative time, intensive care unit admission rates, and infections. There were no significant differences in the risks of coagulopathy, thromboembolism, or reoperation.

CONCLUSION

Given short-term complications and future fertility preferences for patients, conservative management appears to effectively manage PAS in middle-income countries. Owing to low levels of evidence, high heterogeneity and insufficient long-term follow-up data, further detailed studies are warranted.

Clinical evaluation of the effect for prophylactic balloon occlusion in pregnancies complicated with placenta accreta spectrum disorder: A systematic review and meta-analysis

BACKGROUND

Placenta accreta spectrum (PAS) disorder is a critical and severe obstetric condition associated with high risk of intraoperative massive hemorrhage and cesarean hysterectomy. Severe obstetric hemorrhage is currently one of the leading causes of maternal death worldwide. Prophylactic balloon occlusions, including prophylactic balloon occlusion of the abdominal aorta (PBOAA) and prophylactic balloon occlusion of the internal iliac arteries (PBOIIA), are the most common means of controlling hemorrhage in patients with PAS disorder, but their effectiveness is still debated.

OBJECTIVE

A systematic review and meta-analysis were conducted to evaluate the clinical effectiveness of prophylactic balloon occlusion during cesarean section (CS) in improving maternal outcomes for PAS patients.

SEARCH STRATEGY

MEDLINE, EMBASE, OVID, PubMed and the Cochrane Library were systematically searched from the inception dates to June 2022, using the keywords "placenta accreta spectrum disorder/morbidly adherent placenta (placenta previa, placenta accreta, placenta increta, placenta percreta), balloon occlusion, internal iliac arteries, abdominal aorta, hemorrhage, hysterectomy, estimated blood loss (EBL), packed red blood cells (PRBCs)" to identify the systematic reviews or meta-analyses.

SELECTION CRITERIA

All articles regarding PAS disorders and including the application of balloon occlusion were included in the screening.

DATA COLLECTION AND ANALYSIS

Two independent researchers performed the data extraction and assessed study quality. EBL volume and PRBC transfusion volume was regarded as the primary endpoints. Random and fixed effects models were used for the meta-analysis (RRs and 95% CIs), and the Newcastle-Ottawa Scale was used for quality assessments.

MAIN RESULTS

Of 429 studies identified, a total of 35 trials involving the application of balloon occlusion for patients with PAS disorder during CS were included. A total of 19 studies involving 935 patients who underwent PBOIIA were included in the PBOIIA group, and 851 patients were included in control 1 group. Ten studies including 428 patients with PAS who underwent PBOAA were allocated to the PBOAA group, and 324 patients without PBOAA were included in control 2 group. Simultaneously, we compared the effect on PBOAA and PBOIIA including seven studies, which referred to 267 cases in the PBOAA group and 313 cases in the PBOIIA group. The results showed that the PBOIIA group had a reduced EBL volume (MD: 342.06 mL, 95% CI: -509.90 to -174.23 mL, I2 = 77%, P < 0.0001) and PRBC volume (MD: -1.57 U, 95% CI: -2.49 to -0.66 U, I2 = 91%, P = 0.0008) than that in control 1 group. With regard to the EBL volume (MD: -926.42 mL, 95% CI: -1437.07 to -415.77 mL, I2 = 96%, P = 0.0004) and PRBC transfusion volume (MD: -2.42 U, 95% CI: -4.25 to -0.59 U, I2 = 99%, P = 0.009) we found significant differences between the PBOAA group and control 2 group. Prophylactic balloon occlusion (PBOAA and PBOIIA) had a significant effect on reducing intraoperative blood loss and blood transfusion volume in patients with PAS. Moreover, PBOAA was more effective than PBOIIA in reducing intraoperative blood loss (MD: -406.63 mL, 95% CI: -754.12 to -59.13 mL, I2 = 92%, P = 0.020), but no significant difference in controlling PRBCs (MD: -3.48 U, 95% CI: -8.90 to 1.95 U, I2 = 99%, P = 0.210) between the PBOIIA group and the PBOAA group. Hierarchical analysis was conducted by differentiating gestational weeks and maternal age to reduce the high heterogeneity of meta-analysis. Hierarchical analysis results demonstrated the heterogeneities of the study were reduced to some extent, and gestational weeks and maternal age might be the cause of increased heterogeneity.

CONCLUSION

Prophylactic balloon occlusion is a safe and effective method to control hemorrhage and reduce PRBC transfusion volume for patients with PAS, and PBOAA could reduce more intraoperative blood loss than PBOIIA. However, we found no statistical difference in lessening packed red blood cell transfusion volume for PAS patients. Hence, preoperative prophylactic balloon occlusion is the recommended application for PAS patients in obstetric CSs. Furthermore, PBOAA is preferred for controlling intraoperative bleeding in patients with corresponding medical conditions.

Identifying risk factors for urologic complications in placenta accreta spectrum surgical management

PURPOSE

To describe urologic complications associated with the surgical management of placenta accreta spectrum and determine their risk factors.

METHODS

A retrospective study was conducted on all patients diagnosed with abnormal invasive placentation who underwent surgery and delivered between 2002 and 2023 at a single expert maternity centre. Intra-operative and post-operative complications were described, with a special focus on urologic intra-operative injuries, including vesical or ureteral injuries. Univariate and multivariate analyses were performed to determine risk factors of intra-operative urologic injuries associated with placenta accreta spectrum surgical management. Additionally, using the Clavien-Dindo classification, the effects of intra-operative urologic injury and ureteral stent placement on post-operative outcome were evaluated.

RESULTS

A total of 216 patients were included, of which 47 (21.48%) had an intra-operative bladder and/or ureteral injury. Placenta percreta was associated with a higher rate of intra-operative urologic injury than placenta accreta (72.34% vs. 6.38%, p < 0.001). Multivariate analyses showed that patients who had placenta percreta and bladder invasion or emergency hysterectomy were associated with more intra-operative urologic injuries (OR = 8.07, 95% CI [2.44-26.75] and OR = 3.87, 95% CI [1.09-13.72], respectively). Patients with intra-operative urologic injuries had significantly more severe post-operative complications, which corresponds to a Clavien-Dindo score of 3 or more, at 90 days (21.28% vs. 5.92%, p = 0.004).

CONCLUSION

Surgical management of placenta accreta spectrum is associated with significant urologic morbidity, with a major impact on post-operative outcomes. Urologic complications seem to be correlated with the depth of invasion and the emergency of the hysterectomy.

Morbidity associated with emergency surgery versus scheduled surgery in patients with placenta accreta spectrum

Objective

This study aims to evaluate the clinical outcomes of surgical management for placenta accreta spectrum in a Latin American reference hospital specializing in this condition. The evaluation involves a comparison between surgeries performed on an emergent and scheduled basis.

Methods

A retrospective cohort study was conducted on patients with placenta accreta spectrum who underwent surgery between January 2011 and November 2021 at a hospital in Colombia, using data from the institutional PAS registry. The study included patients with intraoperative and/or histological confirmation of PAS, regardless of prenatal suspicion. Clinical outcomes were compared between patients who had emergent surgeries and those who had scheduled surgeries. Descriptive analysis involved summary measures and the Shapiro-Wilk test for quantitative variables, with comparisons made using Pearson's Chi-squared test and the Wilcoxon rank sum test, applying a significance level of 5%.

Results

A total of 113 patients were included, 84 (74.3%) of them underwent scheduled surgery, and 29 (25.6%) underwent emergency surgery. The emergency surgery group required more transfusions (72.4% vs 48.8%, p=0.047). Patients with intraoperative diagnosis of placenta accreta spectrum (21 women, 19.5%) had a greater volume of blood loss than patients taken into surgery with known presence of placenta accreta spectrum (3500 ml, IQR 1700 - 4000 vs 1700 ml, IQR 1195-2135. p <0.001).

Conclusion

Patients with placenta accreta spectrum undergoing emergency surgery require transfusions more frequently than those undergoing scheduled surgery.

Are international guideline recommendations for the management of placenta accreta spectrum applicable in low- and middle-income countries?

OBJECTIVE

The aim of this study was to explore how obstetricians-gynecologists in low- and middle-income countries (LMICs) can apply current international clinical practice guidelines (CPGs) for the management of placenta accreta spectrum (PAS) in limited resource settings.

METHODS

This was an observational, survey-based study. Clinicians with expertise in managing patients with PAS in LMICs were contacted for their evaluation of the recommendations included in four PAS clinical practice guidelines.

RESULTS

Out of the 158 clinicians contacted, we obtained responses from 65 (41.1%), representing 27 middle income countries (MICs). The results of this survey suggest that the care of PAS patients in middle income countries is very different from what is recommended by international CPGs. Participants in the survey identified that their practice was limited by insufficient availability of hospital infrastructure, low resources of local health systems and lack of trained multidisciplinary teams (MDTs) and this did not enable them to follow CPG recommendations. Two-thirds of the participants surveyed describe the absence of centers of excellence in their country. In over half of the referral hospitals with expertise in managing PAS, there are no MDTs. One-third of patients with intraoperative findings of PAS are managed by the team initially performing the surgery (without additional assistance).

CONCLUSION

The care of patients with PAS in middle income countries frequently deviates from established CPG recommendations largely due to limitations in local resources and infrastructure. New practical guidelines and training programs designed for low resource settings are needed.

Predictive Value and Limitations of the Placenta Accreta Index: A Systematic Review

Our systematic review highlights that multiparametric PAI score assessment is a consistent tool with high sensitivity and specificity for prenatal prediction for placenta accreta spectrum (PAS) in high-risk population with anterior placenta previa or low-lying placenta and prior cesarean deliveries. A systematic search was conducted on November 1, 2022, of MEDLINE via PubMed, Scopus, Web of Science Core Collection, Cochrane Library, and Google Scholar to identify relevant studies (PROSPERO ID # CRD42022368211). A total of 11 articles met our inclusion criteria, representing the data of a total of 1,044 cases. Women with PAS had an increased mean PAI total score, compared to those without PAS. Limitations of the PAI are most studies were conducted in developing countries in high-risk population which limit the global generalizability of findings. Heterogeneity of reported data did not allow to perform meta-analysis.

A Rare Case of Placenta Increta at Uterine Fundus

Adherent placenta means a placenta that is not delivered spontaneously or even after manual removal within 30 minutes of baby birth. It is an uncommon and frequently unanticipated event with serious potential health circumstances and it should be managed by the medical team. This case study presents a rare instance of placenta increta in a 25-year-old woman, second gravida, at 36 weeks of gestation, with a history of cesarean section 16 months prior due to chorioamnionitis. The patient presented to the labor room in active labor, and antenatal ultrasound indicated placental implantation on the posterior surface of the upper uterine segment. Given the short inter-delivery interval, an emergency preterm lower segment cesarean section (LSCS) was performed, resulting in the birth of a healthy baby girl weighing 1.8 kg. During surgery, a morbidly adherent placenta was found over the fundus of the uterus. Following consultations with the patient and her relatives, an emergency obstetric total hysterectomy was performed. Intraoperatively, the patient received one unit of packed cell volume (PCV) and, postoperatively, two additional units of PCV and two units of fresh frozen plasma (FFP) were administered. On the third postoperative day, the patient developed right lung consolidation, necessitating a five-day stay in the Obstetric Intensive Care Unit (OBICU). The remaining postoperative period was uneventful, and the patient was discharged on the 10th postoperative day with the healthy infant. Placenta accreta, including its variants increta and percreta, represents abnormal placental implantation into the uterine wall, a condition whose incidence is rising due to increased cesarean sections and improved imaging detection.

Intraoperative and Postoperative Outcomes of Pfannenstiel and Midline Skin Incisions in Placenta Accreta Spectrum Disorders: Single-Center Experience

Background: We compared Pfannenstiel and midline skin incisions for cesarean hysterectomy in women with confirmed Placenta Accreta Spectrum Disorders. Aims: A retrospective cohort study was conducted to evaluate the outcomes of Pfannenstiel and midline skin incisions in women undergoing cesarean section hysterectomy for suspected placenta accreta at Akdeniz University Hospital between January 2010 and February 2022. Histopathological confirmation was obtained for all cases. Demographic, perioperative, and postoperative data, along with neonatal outcomes, were extracted from the hospital's electronic database. Possible complaints related to the incision site or other issues (e.g., vaginal dryness or sexual life) were identified through telephone interviews. Subjects were stratified into Pfannenstiel and midline incision cohorts, with subsequent data comparison. Results: Data from 67 women with a histopathologically confirmed PAS diagnosis were analyzed. Of these, 49 (73.1%) underwent Pfannenstiel incision, and 18 (26.9%) had a midline skin incision. Incisions were based on the surgeon's experience. Pfannenstiel incision was more common in antepartum hemorrhage, preoperative hemorrhage, and emergency surgery (p = 0.02, p = 0.014, p = 0.002, respectively). Hypogastric artery ligation occurred in 30 cases (61.2%) in the Pfannenstiel group but none in the midline group. Cosmetic dissatisfaction and sexual problems were more prevalent in the midline group (p < 0.05, all). Preoperative and postoperative blood parameters, transfused blood products, and neonatal outcomes were similar between the two groups. Conclusions: Relaparotomy, bladder injury, blood loss, and need for blood transfusion were more prevalent in the Pfannenstiel group, while greater dissatisfaction with the incision was observed in the midline incision group. Midline incision seems to be more favorable in patients with Placenta Accreta Spectrum (PAS). Patients may be informed regarding the worse cosmetic outcomes and possible sexual problems related to vaginal dryness when midline laparotomy is planned. But before opting for a Pfannenstiel incision, patients should receive comprehensive information regarding the potential risks of relaparotomy and bladder injury.

Use of cell salvage in obstetrics in Germany: analysis of national database of 305 610 cases with peripartum haemorrhage

BACKGROUND

One of the leading causes of maternal death worldwide is severe obstetric haemorrhage after childbirth. Use of intraoperative cell salvage is strongly recommended by international guidelines on patient blood management. Recent data provide strong evidence that use of cell salvage in obstetrics is effective and safe in women with postpartum haemorrhage resulting in fewer transfusion-related adverse events and shorter hospital stay. We retrospectively analysed the use of cell salvage in bleeding women during delivery for a period of 10 yr in German hospitals.

METHODS

Data from the German Federal Statistical Office were used that covers all in-hospital birth deliveries from 2011 to 2020. Prevalence of peripartum haemorrhage (pre-, intra-, and post-partum haemorrhage), comorbidities, peripartum complications, administration of blood products, and use of cell salvage were analysed.

RESULTS

Of 6 356 046 deliveries in Germany, 305 610 women (4.8%) suffered from peripartum haemorrhage. Of all women with peripartum haemorrhage, postpartum haemorrhage was the main cause for major obstetric haemorrhage (92.33%). Cell salvage was used in only 228 (0.07%) of all women with peripartum haemorrhage (cell salvage group). In women undergoing Caesarean delivery with postpartum haemorrhage, cell salvage was used in only 216 out of 70 450 women (0.31%).

CONCLUSION

Cell salvage during peripartum haemorrhage is rarely used in Germany. There is tremendous potential for the increased use of cell salvage in peripartum haemorrhage nationwide.

A Novel Approach for Conservative Management of Placenta Accreta Spectrum Disorder Cases: Experience of a Single Surgeon: PAS Disorders and Conservative Management

Background: This study is aimed at evaluating the conservative surgical treatment of patients with placenta accreta spectrum (PAS) disorder and at presenting the experience of a single surgeon. Materials and Methods: This retrospective study included 245 patients with placenta previa accompanied by PAS disorders operated at a university hospital between June 2013 and December 2023. The diagnosis of PAS was made by a single perinatologist using a combination of transvaginal and transabdominal ultrasonography. All patients were operated with conservative surgical technique by the same surgeon. The demographic and clinical characteristics of the patients, the anesthesia and incision types used, and the details of the surgical technique were evaluated. Results: Of the patients, 165 were operated on at the scheduled time, 80 were operated on under emergency conditions, and 232 (94.69%) of them were operated on under spinal anesthesia. All patients were operated on with a Pfannenstiel incision followed by a transverse incision to the upper border of the placenta to enter into the uterus. An average of 0.52 units of red blood cells per patient was transfused to all patients. Spontaneous intra-abdominal bleeding developed in five patients, and surgical complications occurred in eight patients. No cesarean hysterectomy was performed, and no maternal mortality was detected in any of the cases. The mean time duration of surgery was 54.44 ± 11.37 (30-90) min, and the mean length of hospital stay was 1.71 ± 1.30 (1-9) days. Conclusions: We recommend this procedure as a novel technique and a robust and safe alternative to peripartum hysterectomy and other conservative surgical management procedures for cases with complete PP accompanied with PAS. This technique preserves the uterus as well as reduces blood loss, and transfusion requirement, and thus maternal morbidity and mortality in PAS cases.

Current concepts in the use of cell salvage in obstetrics

PURPOSE OF REVIEW

The worldwide leading cause of maternal death is severe maternal hemorrhage. Maternal hemorrhage can be profound leading to an entire loss of blood volume. In the past two decades, Patient Blood Management has evolved to improve patient's care and safety. In surgeries with increased blood loss exceeding 500 ml, the use of cell salvage is strongly recommended in order to preserve the patient's own blood volume and to minimize the need for allogeneic red blood cell (RBC) transfusion. In this review, recent evidence and controversies of the use of cell salvage in obstetrics are discussed.

RECENT FINDINGS

Numerous medical societies as well as national and international guidelines recommend the use of cell salvage during maternal hemorrhage.

SUMMARY

Intraoperative cell salvage is a strategy to maintain the patient's own blood volume and decrease the need for allogeneic RBC transfusion. Historically, cell salvage has been avoided in the obstetric population due to concerns of iatrogenic amniotic fluid embolism (AFE) or induction of maternal alloimmunization. However, no definite case of AFE has been reported so far. Cell salvage is strongly recommended and cost-effective in patients with predictably high rates of blood loss and RBC transfusion, such as women with placenta accreta spectrum disorder. However, in order to ensure sufficient practical experience in a multiprofessional obstetric setting, liberal use of cell salvage appears advisable.

One-step conservative surgery vs hysterectomy for placenta accreta spectrum: a feasibility randomized controlled trial

BACKGROUND

Placenta accreta spectrum is a serious condition associated with significant maternal morbidity and even mortality. The recommended treatment is hysterectomy. An alternative is 1-step conservative surgery, which involves the en bloc resection of the myometrium affected by placenta accreta spectrum along with the placenta, followed by uterine reconstruction. Currently, there are no studies comparing the 2 techniques in the setting of a randomized controlled trial.

OBJECTIVE

We performed a prospectively registered multicenter randomized controlled trial comparing hysterectomy with 1-step conservative surgery. The aim was to collect feasibility and clinical outcomes of the 2 techniques in women assigned to hysterectomy or 1-step conservative surgery. In addition to assessing participants' willingness to be randomized, we also collected data on intraoperative blood loss, transfusion requirement, serious adverse event, and other clinical outcomes.

STUDY DESIGN

Sixty women with strong antenatal suspicion of placenta accreta spectrum were assigned randomly to either hysterectomy (n=31) or 1-step conservative surgery (n=29).

RESULTS

During a 20-month period, 60 of the 64 eligible patients (93.7%) underwent randomization. Intention-to-treat analysis showed that the clinical outcomes for 1-step conservative surgery were comparable to those of hysterectomy (median intraoperative blood loss, 1740 mL [interquartile range, 1010-2410] vs 1500 mL [interquartile range, 1122-2753]; odds ratio, 1 [1-1]; P=.942; median duration of surgery, 135 minutes [interquartile range, 111-180] vs 155 minutes [interquartile range, 120-185]; odds ratio, 0.99 [0.98-1]; P=.151; transfusion rate, 58.6% vs 61.3%; odds ratio, 0.96 [0.83-1.76]; P=.768; and adverse event rate, 17.2% vs 9.7%; odds ratio, 1.77 [0.43-10.19]; P=.398; respectively). In the subgroup of women with type 1 class on topographic classification, all participants allocated to 1-step surgery had successful outcomes, which were superior to those of hysterectomy. This was evidenced by the shorter surgery duration (median, 125 [interquartile range, 98-128] vs 180 [129-226] minutes; P=.002), lower transfusion rates (46.2% vs 82.4%), and fewer units of red blood cells transfused (median, 1 [interquartile range, 1-1.8] vs 3 [interquartile range, 2-4] units; P=.007).

CONCLUSION

A randomized controlled trial comparing 2 surgical techniques for the treatment of placenta accreta spectrum is feasible. One-step conservative repair is a valid alternative to hysterectomy in the large majority of cases, but this can only be ascertained following intraoperative surgical staging. El resumen está disponible en Español al final del artículo.

Addressing Diagnosis, Management, and Complication Challenges in Placenta Accreta Spectrum Disorder: A Descriptive Study

INTRODUCTION

In light of increased cesarean section rates, the incidence of placenta accreta spectrum (PAS) disorder is increasing. Despite the establishment of clinical practice guidelines offering recommendations for early and effective PAS diagnosis and treatment, antepartum diagnosis of PAS remains a challenge. This ultimately risks poor mental health and poor physical maternal and neonatal health outcomes.

CASE DESCRIPTIONS

This case series details the experience of two high-risk patients who remained undiagnosed for PAS until they presented with antenatal hemorrhage, leading ultimately to necessary, complex surgical interventions, which can only be optimally provide in a tertiary care center. Patient 1 is a 37-year-old woman with a history of three cesarean sections, which elevates her risk for PAS. She had placenta previa detected at 19 weeks, and placenta percreta diagnosed upon hemorrhage. During a hysterectomy, invasive placenta was found in the patient's bladder, leading to a cystotomy and right ureteric reimplantation. After discharge, she was diagnosed with a vesicovaginal fistula, and is currently awaiting surgical repair. Patient 2 is a 34-year-old woman with two previous cesarean sections. The patient had complete placenta previa detected at 19- and 32-week gestation scans. She presented with antepartum hemorrhage at 35 weeks and 2 days. An ultrasound showed thin myometrium at the scar site with significant vascularity. A hysterectomy was performed due to placental attachment issues, with significant blood loss. Both patients were at high risk for PAS based on past medical history, risk factors, and pathognomonic imaging findings.

DISCUSSION

We highlight the importance of the implementation of clinical guidelines at non-tertiary healthcare centers. We offer clinical-guideline-informed recommendations for radiologists and antenatal care providers to promote early PAS diagnosis and, ultimately, better patient and neonatal outcomes through increased access to adequate care.

Opportunities for, and barriers to, uterus-preserving surgical techniques for placenta accreta spectrum

INTRODUCTION

Placenta accreta spectrum (PAS) can lead to major peripartum morbidity. Appropriate management approaches depend on the clinical severity, each individual's preference, and the treating team's expertise. Peripartum hysterectomy is the most frequently used treatment option. However, it can impact psychological well-being and fertility. We investigated whether conservative treatment with focal resection or leaving the placenta in situ is associated with comparable or lower maternal morbidity than hysterectomy in centers of excellence within the International Society for placenta accreta spectrum (IS-PAS). Furthermore, a survey was conducted to explore potential barriers to conservative management in antenatal counseling and intraoperative decision-making.

MATERIAL AND METHODS

Confirmed PAS cases in the prospective IS-PAS database from 22 registered centers between January 2020 and June 2022 were included in the analysis. A separate online survey with 21 questions was answered by the IS-PAS center experts about indications, diagnostic criteria, patient counseling, surgical practice, changes from the preoperative treatment plan, and why conservative management may not be offered.

RESULTS

A total of 234 cases were included in the analysis: 186 women received hysterectomy and 38 women were treated by focal resection, and 10 by leaving the placenta in situ. Blood loss was lower in the focal resection group and in the placenta in situ group compared to the hysterectomy group (p = 0.04). 46.4% of the women initially planned for focal resection, and 35.7% of those initially planned for leaving the placenta in situ were ultimately treated by hysterectomy. Our survey showed that the IS-PAS centers preferred hysterectomy according to a woman's wishes (64%) and when they expected less blood loss and morbidity (41%). Eighteen percent of centers did not offer focal resection at all due to a lack of experience with this technique. Reasons for not offering to leave the placenta in situ were avoidance of unexpected reoperation (36%), puerperal infection (32%), or skepticism about the method (23%).

CONCLUSIONS

Uterus-preserving treatment strategies such as focal resection appear to be safe alternatives to peripartum hysterectomy. However, less than half of the IS-PAS centers perform them. Acceptance of conservative treatments could be increased by standardized criteria for their implementation and by systematic training for PAS experts.

Leaving the Placenta In Situ in Placenta Accreta Spectrum Disorders: A Single-Center Case Series

OBJECTIVE

The most common treatment for placenta accreta spectrum (PAS) disorders is planned primary cesarean hysterectomy. However, other management strategies may improve outcomes and/or allow fertility preservation. The objective of this study was to describe the course and outcomes of patients with PAS managed by leaving the placenta in situ.

STUDY DESIGN

This is a series of 11 patients with PAS managed by leaving the placenta in situ at a single academic center in the United States from 2015 to 2022. The approach described involves delivery of the fetus via cesarean, no attempt at placental removal, closure of the hysterotomy, prophylactic intravenous antibiotics for up to 1 week, and close outpatient follow-up until the uterus is empty.

RESULTS

The uterus was successfully preserved in six (55%), minimally invasive hysterectomy was performed in four (36%), and abdominal hysterectomy was performed in 1 (9%). During cesarean delivery, the median estimated blood loss was 650mL (range: 200-1,000mL). The majority of patients had no vaginal discharge for several weeks after delivery, followed by brown or bloody discharge, and intermittent mild-to-moderate cramping. The median time to resolution of PAS was 18 weeks in patients with successful uterine preservation (range: 5-25 weeks). Indications for hysterectomy included hemorrhage (n=1), coagulopathy (n=1), endomyometritis (n=2), and pain (n=1), and these occurred at a median of 5 weeks postpartum (range: 1-25 weeks). Four patients had subsequent pregnancies of whom three were live births at or near term and one was a spontaneous abortion at 19 weeks.

CONCLUSION

Leaving the placenta in situ may be an appropriate management strategy for some carefully selected and counseled patients with PAS.

KEY POINTS

· Overall, 55% had uterine preservation (6/11).. · Minimally invasive approach in 80% of hysterectomies (4/5).. · Of patients, 67% with uterine preservation had subsequent pregnancies (4/6)..

Successful multidisciplinary team management of placenta accreta spectrum disorder: A referral center model in a middle-income country

OBJECTIVE

The aim of the study was to evaluate the outcomes of placenta accreta spectrum (PAS) disorder managed by a multidisciplinary care team (MCT) compared with a conventional care team (CCT) in a PAS referral center in Thailand.

METHODS

This retrospective single-center cohort study analyzed PAS management outcomes in the PSU PAS Center between January 2010 and December 2022. The incidence of hemorrhage ≥3500 mL and the composite maternal and neonatal outcomes of PAS were compared before and after the introduction of an MCT in 2016.

RESULTS

Of 227 PAS cases, 219 (96.5%) had pathological confirmation. There were 52 (22.9%) cases of placenta accreta, 119 (52.4%) cases of placenta increta, and 56 (24.7%) cases of placenta percreta. The incidence of estimated blood loss (EBL) ≥3500 mL decreased from 61.8% to 34.3% (P < 0.001) after the establishment of the MCT. The median EBL decreased from 4000 (IQR: 2600,7250) mL to 2250 (1300, 4750) mL (P < 0.001). EBL reduction was statistically significant in the accreta and increta groups (P < 0.001). Red blood cell transfusions decreased from five (3, 9) to two (1, 6) units (P < 0.001) per patient. The length of maternal hospital stays and ICU admissions were statistically shorter when PAS was managed by an MCT (P < 0.001). The length of newborn hospital and ICU stays decreased significantly (P < 0.001).

CONCLUSION

The incidence of massive postpartum hemorrhage and a composite of maternal and neonatal morbidities in pregnant women with PAS disorder improved significantly after the establishment of an MCT to manage PAS in a middle-income country setting.

Reflections on peripartum hysterectomy: A 10-year retrospective observational study in Northeast China

OBJECTIVE

To explore the change trends in incidence and leading factors to peripartum hysterectomy (PH) at a regional tertiary medical center in northeast China.

METHODS

This was a retrospective observational study of all PH cases conducted at Shengjing Hospital between January 1, 2012 and December 31, 2021. Information on maternal characteristics of pregnancy and delivery, indications of PH, inventions before hysterectomy, complications, and maternal and neonatal outcomes obtained from the Shengjing Hospital Information System were analyzed.

RESULTS

Among a total of 157 553 deliveries, there were 127 cases of PH (overall PH incidence: 0.85/1000 deliveries); 120 patients (94.49%) underwent hysterectomy after cesarean section, and seven (5.51%) underwent vaginal delivery (P < 0.001). Abnormal placentation was the leading indication for PH (101, 79.53%), including placenta previa (PP) with placenta accreta spectrum (PAS) (93, 73.23%), PP alone (5, 3.94%), and PAS alone (3, 2.36%). Among the patients who underwent PH with abnormal placentation, 92.08% had at least one cesarean section (P < 0.001) and 20.19% had bladder injury (P = 0.044). All maternal deaths (n = 2) occurred in referral patients, and the maternal mortality rate was 1.57/100 hysterectomies.

CONCLUSION

Abnormal placentation was the primary indication for PH. For such patients, adequate assessment of their condition and complete communication are strongly recommended. The identification of high-risk groups for postpartum hemorrhage, timely and effective rescue, and referral are equally important for avoiding PH.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Quality evaluation of clinical practice guidelines for placenta accreta spectrum disorders

Introduction

We evaluated the quality of the published clinical practice guidelines on placenta accreta spectrum (PAS) disorders to provide reference for the development of high-quality PAS guidelines.

Methods

China National Knowledge Infrastructure (CNKI), Wan Fang, PubMed, Embase, Web of Science, and Cochrane Library were systematically searched. Quality assessments were conducted using the appraisal of guidelines for research and evaluation (AGREE) II framework and Reporting Items for practice Guidelines in Healthcare (RIGHT) checklist. Intraclass correlation coefficients (ICCs) were used to measure the agreement among reviewers.

Results

In total, 13 guidelines from different countries, published between 2015 and 2021 were included. There included 9 official guidelines, 3 consensuses, and 1 standard reference and covered subjects including epidemiology, diagnosis and treatment. The mean standardized scores across 6 domains (scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence) were 53.63%, 27.35%, 33.57%, 72.01%, 19.39% and 41.02%, respectively. Of the 13 guidelines, 11 were classified as grade B, whereas 2 as grade C. According to the RIGHT checklist, the overall reporting rate of the 13 guidelines ranged from 28.57% to 54.29%.

Conclusion

The current guidelines for PAS demonstrate commendable methodological and reporting qualities. However, the methodological and reporting quality of PAS CPGs still need to be further improved, particularly in stakeholder involvement, the rigor of development, applicability, and editorial independence domains.

Efficacy and safety of prophylactic balloon occlusion in the management of placenta accreta spectrum disorder: a retrospective cohort study

OBJECTIVE

Placenta accreta spectrum disorder (PAS) is a serious obstetric complication associated with significant maternal morbidity and mortality. Prophylactic balloon occlusion (PBO), as an intravascular interventional therapies, has emerged as a potential management strategy for controlling massive hemorrhage in patients with PAS. However, current evidence about the clinical application of PBO in PAS patients are still controversial. This study aimed to evaluate the effectiveness and safety of PBO in the management of PAS.

METHODS

A retrospective cohort study including PAS patients underwent cesarean delivery was conducted in a tertiary hospital from January 2015 to March 2022. Included PAS patients were further divided into balloon and control groups by whether PBO was performed. Groups were compared for demographic characteristics, intraoperative and postoperative parameters, maternal and neonatal outcomes, PBO-related complication and follow up outcomes. Additionally, multivariate-logistic regression analysis was performed to determine the definitive associations between PBO and risk of massive hemorrhage and hysterectomy.

RESULTS

A total of 285 PAS patients met the inclusion criteria were included, of which 57 PAS patients underwent PBO (PBO group) and 228 women performed cesarean section (CS) without PBO (control group). Irrespective of the differences of baseline characteristics between the two groups, PBO intervention did not reduce the blood loss, hysterectomy rate and postoperative hospital stay, but it prolonged the operation time and increased the cost of hospitalization (All P < 0.05) Additionally, there were no significant differences in postoperative complications, neonatal outcomes, and follow-up outcomes(All P > 0.05). In particular, patients undergoing PBO were more likely to develop the venous thrombosis postoperatively (P = 0.001). However, multivariate logistic regression analysis showed that PBO significantly decreased the risk of massive hemorrhage (OR 0.289, 95%CI:0.109-0.766, P = 0.013). The grade of PAS and MRI with S2 invasion were the significant risk factors affecting massive hemorrhage(OR:6.232 and OR:5.380, P<0.001).

CONCLUSION

PBO has the potential to reduce massive hemorrhage in PAS patients undergoing CS. Obstetricians should, however, be aware of potential complications arising from the PBO. Additionally, MRI with S2 invasion and PAS grade will be useful to identify PAS patients who at high risk and may benefit from PBO. In brief, PBO seem to be a promising alternative for management of PAS, yet well-designed randomized controlled trials are needed to convincingly demonstrate its benefits and triage the necessity of PBO.

Perinatal outcomes comparison between neuraxial and general anesthesia in pregnant women with placenta accreta spectrum: a multicenter retrospective study

PURPOSE

We investigated the impact of anesthesia mode on perinatal outcomes in patients with placenta accreta spectrum (PAS) undergoing cesarean delivery and identified factors associated with adverse perinatal events.

METHODS

The multicenter retrospective analysis was conducted in patients with PAS who delivered at three medical centers. Patients were classified according to whether they received general anesthesia (GA) or neuraxial anesthesia (NA). We compared the basic clinical characteristics of patients in the pre-propensity score matching (PSM) and post-PSM cohorts and identified factors associated with a high risk of adverse maternal outcomes.

RESULTS

This study included a total of 425 patients, with 307 (72.2%) in the GA group and 118 (27.8%) in the NA group. After PSM, 162 patients were identified for analysis. In the post-matched cohort, the NA group exhibited shorter total operation time (P = 0.030) and postoperative length of hospital stay (P = 0.037). Additionally, the NA group experienced lower intraoperative blood loss (P < 0.001) and received fewer units of transfused packed red blood cells (PRBC) (P < 0.001). Multivariate logistic regression analysis indicated that GA (P < 0.001), emergency cesarean delivery (P = 0.010), vascular lacunae within the placenta (P < 0.001), hypervascularity of uterine-placental margin (P = 0.002), hypervascularity of the cervix (P = 0.014), and balloon placement in the abdominal aorta (P < 0.001) were associated with a high risk of adverse maternal events.

CONCLUSION

In comparison to GA, cesarean delivery with NA in PAS patients appears to be associated with reduced intraoperative blood loss, PRBC transfusion, operating duration, and postoperative hospital stay.

Management and Outcome of Women with Placenta Accreta Spectrum and Treatment with Uterine Artery Embolization

BACKGROUND

Placenta accreta spectrum (PAS) disorders are a continuum of placental pathologies with increased risk for hemorrhage, blood transfusion and maternal morbidity. Uterine artery embolization (UAE) is a safe approach to the standardization of complex PAS cases. The aim of this study is to analyze anemia and transfusion rate, outcome and anesthesiological management of women who underwent caesarean delivery with subsequent UAE for the management of PAS.

MATERIAL AND METHODS

This retrospective observational study included all pregnant women admitted to the University Hospital Frankfurt between January 2012 and September 2023, with a diagnosis of PAS who underwent a two-step surgical approach for delivery and placenta removal. Primary procedure included cesarean delivery with subsequent UAE, secondary procedure included placenta removal after a minim of five weeks via curettage or HE. Maternal characteristics, anesthesiological management, complications, anemia rate, blood loss and administration of blood products were analyzed.

RESULTS

In total, 17 women with PAS were included in this study. Of these, 5.9% had placenta increta and 94.1% had placenta percreta. Median blood loss was 300 (200-600) mL during primary procedure and 3600 (450-5500) mL during secondary procedure. In total, 11.8% and 62.5% of women received red blood cell transfusion during the primary and secondary procedures, respectively. After primary procedure, postpartum anemia rate was 76.5%. The HE rate was 64.7%. Regional anesthesia was used in 88.2% during primary procedure.

CONCLUSION

The embolization of the uterine artery for women diagnosed with PAS is safe. Anemia management and the implementation of blood conservation strategies are crucial in women undergoing UAE for the management of PAS.

Evaluation of the holding-up uterus technique for placenta accreta spectrum cesarean hysterectomy in shocked patients with a high shock index: a case series study

BACKGROUND

Placenta accreta spectrum (PAS) cesarean hysterectomy is performed under conditions of shock and can result in serious complications. This study aimed to evaluate the usefulness of the "Holding-up uterus" surgical technique with a shock index (S.I.) > 1.5.

METHODS

Twelve patients who underwent PAS cesarean hysterectomy were included in the study.

RESULTS

Group I had S.I. > 1.5, and group II had S.I. ≤ 1.5. Group I had more complications, but none were above Grade 3 or fatal. Preoperative scheduled uterine artery embolization did not result in serious complications, but three patients who had emergency common iliac artery balloon occlusion (CIABO) and a primary total hysterectomy with S.I. > 1.5 had postoperative Grade 2 thrombosis. Two patients underwent manual ablation of the placenta under CIABO to preserve the uterus, both with S.I. > 1.5.

CONCLUSIONS

The study found that the "Holding-up uterus" technique was safe, even in critical situations with S.I. > 1.5. CIABO had no intervention effect. The study also identified assisted reproductive technology pregnancies with a uterine cavity length of less than 5 cm before conception as a critical factor.

Placental volume as a novel sign for identifying placenta accreta spectrum in pregnancies with complete placenta previa

BACKGROUND

Placenta accreta spectrum (PAS) carries an increased risk of maternal-fetal mortality and morbidity, and magnetic resonance imaging (MRI) features for PAS have been used for preoperative identification. This study aims to investigate the role of placental volume evaluated by MRI in identifying PAS in pregnant women with complete placenta previa.

METHODS

Totally 163 cases of complete placenta previa pregnant women with a history of cesarean section underwent MRI for suspected PAS were included. We categorized the patients into two groups according to the presence or absence of PAS, and the maternal-fetal perinatal outcomes and placental volume analyzed by 3D Slice software were compared.

RESULTS

There were significantly more gravidity, parity, and number of previous cesarean delivery in the PAS group (P < 0.05). Significant differences were also found between the two groups with respect to the following baseline characteristics: gestational age at delivery, intraoperative blood loss, blood transfusion, and neonatal birth weight (P < 0.05). Of 163 women in the study, 7 (4.294%) required cesarean hysterectomy for high-grade PAS or pernicious bleeding during cesarean section, and PAS was confirmed with histologic confirmation in 6 (85.714%) cases. The placental volume in PAS group was greater than that in the non-PAS group (P < 0.05). With a threshold of more than 887 cm3, the sensitivity and specificity in identifying PAS were 85.531% and 83.907% respectively, with AUC 0.908 (95% CI: 0.853-0.948).

CONCLUSIONS

Placental volume may be a promising indicator of PAS in complete placenta previa patients with a history of cesarean section.

Transabdominal and transvaginal ultrasound findings help to guide the clinical management of placenta accreta spectrum cases

INTRODUCTION

The clinical management of placenta accreta spectrum (PAS) depends on placental topography and vascular involvement. Our aim was to determine whether transabdominal and transvaginal ultrasound signs can predict PAS management.

MATERIAL AND METHODS

We conducted a retrospective cohort study of consecutive prenatally suspected PAS cases in a single tertiary-care PAS center between January 2021 and July 2022. When PAS was confirmed during surgery, abdominal and transvaginal ultrasound scans were analyzed in relation to PAS management. The preferred surgical approach of PAS was one-step conservative surgery (OSCS). Massive blood loss and PAS topography in the lower bladder trigone necessitated cesarean hysterectomy. Transvaginal ultrasound-diagnosed intracervical hypervascularity was split into three categories based on their quantity. Anatomically, the internal cervical os is located at the level of the bladder trigone and was used as landmark for upper and lower bladder trigone PAS.

RESULTS

Ninety-one women underwent OSCS and 35 women underwent cesarean hysterectomy (total 126 women with PAS). Abdominal and transvaginal ultrasound features differed significantly between women that underwent OSCS and cesarean hysterectomy: decreased myometrial thickness (<1 mm), 82.4% vs. 100%, p = 0.006; placental bulge, 51.6% vs. 94.3%, p < 0.001; bladder wall interruption, 62.6% vs. 97.1%, p < 0.001; abnormal placental lacunae, 75.8% vs. 100%, p < 0.001; hypervascularity (large lacunae feeding vessels, 57.8% vs. 94.6%, p < 0.001; parametrial hypervascularity, 15.4% vs. 60%, p < 0.001; the rail sign, 6.6% vs. 28.6%, p = 0.003; three-dimensional Doppler intra-placental hypervascularity, 81.3% vs. 100%, p < 0.001; intracervical hypervascularity 60.4% vs. 94.3%, p < 0.001); and cervical length 2.5 ± 0.94 vs. 2.2 ± 0.73, p = 0.038. Other ultrasound signs were not significantly different. The results of multivariable logistic regression showed placental bulge (odds ratio [OR] 9.3; 95% CI 1.9-44.3; p = 0.005), parametrial hypervascularity (OR 4.1; 95% CI 1.541-11.085; p = 0.005), and intracervical hypervascularity (OR 9.2; 95% CI 1.905-44.056; p = 0.006) were weak predictors of OSCS. Intracervical hypervascularity Grade 1 (vascularity <50% of cervical tissue) was more present in OSCS than higher gradings two and three (91% vs. 27.6% vs. 14.3%; p < 0.001).

CONCLUSIONS

Cesarean hysterectomy is associated with the PAS signs of placental bulge and Grade 2 and 3 intracervical hypervascularity. OSCS is associated with intracervical hypervascularity Grade 1 on transvaginal ultrasound. Prospective validation is required to formulate predictors for PAS management.

Intraoperative temporary internal iliac arterial occlusion (Polat's technique) for severe placenta accreta spectrum: A description of the technique and outcomes in 61 patients

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.

Placenta Accreta Spectrum Prophylactic Therapy for Hyperfibrinolysis with Tranexamic Acid

BACKGROUND

To report on prophylactic therapy for hyperfibrinolysis with tranexamic acid (TXA) during expectant management (EM) in the placenta accreta spectrum (PAS).

METHODS

This is a monocentric retrospective study of women with PAS presenting at our hospital between 2005 and 2021. All data were retrospectively collected through the departmental database.

RESULTS

35 patients with PAS were included. EM was planned in 25 patients prior to delivery. Complete absorption of the retained placenta was seen in two patients (8%). Curettage was performed in 14 patients (56%). A hysterectomy (HE) was needed in seven (28%) patients; 18 patients (72%) underwent uterus-preserving treatment without severe complications. The mean duration of EM was 107 days. The mean day of onset of hyperfibrinolysis and beginning of TXA treatment was day 45. The mean nadir of fibrinogen level before TXA was 242.4 mg/dL, with a mean drop of 29.7% in fibrinogen level.

CONCLUSIONS

Our data support EM as a safe treatment option in PAS. Hyperfibrinolysis can be a cause of hemorrhage during EM and can be treated with TXA. To our knowledge, this is the first cohort of patients with EM of PAS in whom coagulation monitoring and use of TXA have been shown to successfully treat hyperfibrinolysis.

Regional multidisciplinary team approach to the management of placenta accreta spectrum disorder

OBJECTIVE

Patients with suspected placenta accreta spectrum (PAS) disorder are often referred to specialized medical centers for antepartum management and definitive treatment via cesarean hysterectomy. In 2019, our institution formed the only multidisciplinary team for the management of PAS within two of the largest counties in California. The purpose of this study was to evaluate the effects of the multidisciplinary team on patient volume and surgical outcomes for patients with PAS.

METHODS

This was a single center retrospective cohort study, based in the only tertiary referral center within two of the largest counties in California. Patients who underwent cesarean hysterectomy for suspected PAS from January 2014 to April 2021 were included and divided into two groups, based on management by the multidisciplinary team from January 2019 and onward or routine care prior to that time. The outcomes of interest were quantitative blood loss, total units of packed red blood cell transfusion, referral volume, and diagnostic accuracy as well as ICU admission, bladder injury, and postoperative length of stay. Furthermore, we wanted to determine if patient's distance to the hospital impacted outcomes. Normally distributed variables were compared between groups using the t-test. Categorical variables were compared between the two groups using the chi square test.

RESULTS

A total of 114 patients were included in the cohort, 59 patients were from January 2014 to December 2018 and 55 patients were from January 2019 to April 2021. Since the establishment of the multidisciplinary center, there was a 2.5-fold increase in the total patient volume (0.8 case/month to 2 cases/month) and a 2.8-fold increase in the referred patient volume. Patients undergoing cesarean hysterectomy since the establishment of the multidisciplinary team had less quantitative blood loss (1500 mL vs 2000 mL, p = .005) and required less units of packed red blood cell transfusion (2 vs 4 units, p < .001). In addition, blood loss of ≥2000 mL decreased from 57.6% to 38.2% (p = .04) and diagnostic accuracy improved from 35.6% to 83.6% (p < .001). Furthermore, we found that patient distance to the hospital did not significantly impact surgical outcomes.

CONCLUSIONS

Since the establishment of the multidisciplinary team, our center experienced an increase in PAS volume and was able to demonstrate a statistically significant improvement in patient outcomes.

YKL-40 promotes proliferation and invasion of HTR-8/SVneo cells by activating akt/MMP9 signalling in placenta accreta spectrum disorders

YKL-40 is a secreted glycoprotein that can promote invasion, angiogenesis and inhibit apoptosis, and was highly expressed in a variety of tumours. In this paper, we investigated the impacts of YKL-40 on proliferation and invasion in HTR-8/SVneo cells during placenta accreta spectrum disorders (PAS) development. The levels of YKL-40 protein in late-pregnant placental tissue were detected using immunohistochemistry and Western blotting, and gene expression using reverse transcription-quantitative polymerase chain reaction (RT-qPCR). The proliferation, migration, invasion and apoptosis abilities of HTR-8/SVneo cells were detected by cell counting kit-8 (CCK-8), Transwell, scratch assay, and flow cytometry, respectively. Our current results showed that YKL-40 was significantly increased in the PAS group compared to the normal control group (P < 0.01). Biological function experiments showed that YKL-40 significantly promoted the proliferation, migration and invasion of HTR-8/SVneo cells, and inhibited cell apoptosis. Knockdown of YKL-40 inhibited the activation of Akt/MMP9 signalling in trophoblast cells. These data suggested that YKL-40 might be involved in the progression of PAS, which may be attributed to the regulation of Akt/MMP9 signalling pathway.

Peripartum Haemorrhage, Diagnosis and Therapy. Guideline of the DGGG, OEGGG and SGGG (S2k, AWMF Registry No. 015-063, August 2022)

Aim This official guideline was coordinated and published by the German Society of Gynaecology and Obstetrics (DGGG). The guideline aims to provide a consensus-based overview of the diagnosis and management of peripartum bleeding based on an evaluation of the relevant literature. Methods This S2k-guideline was developed by representative members from different medical professions on behalf of the guidelines commission of the DGGG, OEGGG and SGGG using a structured consensus process. Recommendations Recommendations for the definition, risk stratification, prevention, treatment (general emergency procedures, medications, uterine tamponade, surgical measures, interventional-radiological procedures, haemostasis, and coagulation management), transportation, documentation and debriefing as well as training are presented. In addition, a PPH algorithm for action, "PPH 2022", is recommended.