Placenta accreta spectrum disorder trends in the context of the universal two-child policy in China and the risk of hysterectomy

Local Resection After Cesarean Delivery for Placenta Accreta Spectrum Disorder: A Systematic Review and Meta-analysis

OBJECTIVE

To compare maternal and surgical outcomes between local resection and immediate hysterectomy after cesarean delivery in patients with placenta accreta spectrum.

DATA SOURCES

Four public databases (PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials) were systematically searched for relevant publications up to July 31, 2024. Because the Cochrane Library included all the identified clinical trials, it was unnecessary to search ClinicalTrials.gov. The search strategy included the terms "placenta accreta" or "placenta accreta spectrum" and "pregnancy outcomes" and related key words about local resection and cesarean hysterectomy.

METHODS OF STUDY SELECTION

With the use of established inclusion criteria, 4,889 studies were reviewed. The included studies evaluated surgical and maternal outcomes associated with immediate hysterectomy compared with local resection.

TABULATION, INTEGRATION, AND RESULTS

Data extraction was conducted with the Patient/Population, Intervention, Comparison, Outcome, and Study design framework. Both fixed-effects and random-effects models were used to synthesize the findings. A total of 11 studies published between 2018 and 2024 were analyzed (nine retrospective studies, one randomized controlled trial, and one prospective cohort study). The quality of the included studies was globally low, and 7 of 11 studies had severe bias. The immediate hysterectomy group had a significantly higher prevalence of placenta percreta compared with the local resection group (69.4% vs 44.3%, P<.01). In contrast to immediate hysterectomy, local resection yielded improved surgical outcomes, demonstrated by the following metrics: transfusion rate (six studies, 375 vs 205 patients, odds ratio [OR] 0.47, 95% CI, 0.29-0.75), estimated blood loss (seven studies, 416 vs 246 patients, mean difference -396 mL, 95% CI, -534 to -257), urologic complications (seven studies, 408 vs 241 patients, OR 0.18, 95% CI, 0.10-0.33), and intensive care unit admission (three studies, 87 vs 79 patients, OR 0.19, 95% CI, 0.07-0.53). One study recorded three maternal deaths: two in the immediate hysterectomy group and one in the local resection group. The results of subgroup analyses focused on patients with severe forms of placenta accreta spectrum (placenta increta and percreta) were similar in the overall analysis.

CONCLUSION

In this systematic review and meta-analysis, eligible studies comparing the local resection with immediate hysterectomy at cesarean hysterectomy for placenta accreta spectrum were overall low quality because of the lack of intention-to-treat information. Despite these limitations, local resection for placenta accreta spectrum may possibly be an option for appropriately selected patients to reduce surgical morbidity. Because the indication criteria, safety, surgical techniques, and necessity of adjunctive therapies for local resection remain understudied, further prospective studies are warranted.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42024594315.

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.

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.

The possible impact of the universal two-child policy on pregnancy outcomes

PURPOSE

The implementation of the universal two-child policy contributes to adverse pregnancy outcomes, but how the policy change leads to adverse pregnancy outcomes is not well elaborated. In this study, we aimed to compare maternal characteristics and complications, accessed the change in the proportion of maternal characteristics and maternal complications, and evaluated the mediation of maternal characteristics on maternal complications.

METHODS

Demographic and clinical data of three-level sample facilities were extracted from China's National Maternity Near Miss Obstetrics Surveillance System from Jan 1, 2012 to May 31, 2021. The associations between the universal two-child policy and maternal risk factors, the universal two-child policy and maternal complications, and maternal risk factors and maternal complications were evaluated using multivariate logistic regression analyses, with odds ratios (ORs) and 95% confidence intervals (CIs). Mediation analysis was used to estimate the potential mediation effects on the associations between the policy and maternal complications. Population-attributable fractions (PAF) were conducted to quantify the maternal complications burden attributable to the implementation of the universal two-child policy.

RESULTS

In the context of the universal two-child policy, the incidence of maternal near miss, antepartum or intrapartum complication, and post-partum complication increased at municipal- and county-level sample facilities. After adjusting for covariables, there were significant associations between the universal two-child policy and maternal risk factors (P < 0.001), the universal two-child policy and an increased risk of maternal complications (P < 0.001), and maternal risk factors and maternal complications(P < 0.001). The effects of the universal two-child policy on maternal near miss and medical disease were significantly mediated by maternal risk factors with mediation proportions of 19.77% and 4.07% at the municipal-level sample facility, and mediation proportions for 2.72% at the county-level sample facility on medical disease. The universal two-child policy contributed 19.34%, 5.82%, 8.29%, and 46.19% in the incidence of the maternal near miss, antepartum or intrapartum complication, post-partum complication, and medical disease at municipal-level sample facility, respectively. The corresponding PAF% at county-level sample facility was 40.49% for maternal near miss, 32.39% for the antepartum or intrapartum complication, 61.44% for post-partum complication, and 77.72% for medical disease. For provincial-level sample facility, the incidence of maternal near miss, antepartum or intrapartum complications, and medical diseases decreased (P < 0.05) and no statistically significant difference occurred in the incidence of post-partum complications.

CONCLUSIONS

In the context of the universal two-child policy, the incidence of maternal near miss, antepartum or intrapartum complication, and post-partum complication increased at municipal- and county-level sample facility. Maternal risk factors may play a mediating role in the effect of policy change and maternal complications. Provincial hospitals have been able to improve the quality of perinatal health care and reduce adverse pregnancy outcomes by adjusting their obstetric service strategies in the context of the new birth policy.

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.

Association between short inter-pregnancy interval and placenta previa and placenta accreta spectrum with respect to maternal age at first cesarean delivery

OBJECTIVE

To explore the association between inter-pregnancy intervals and placenta previa and placenta accreta spectrum among women who had prior cesarean deliveries with respect to maternal age at first cesarean delivery.

METHODS

This retrospective study included clinical data from 9981 singleton pregnant women with a history of cesarean delivery at 11 public tertiary hospitals in seven provinces of China between January 2017 and December 2017. The study population was divided into four groups (<2, 2-5, 5-10, ≥10 years of the interval) according to the inter-pregnancy interval. The rate of placenta previa and placenta accreta spectrum among the four groups was compared, and multivariate logistic regression was used to analyze the relationship between inter-pregnancy interval and placenta previa and placenta accreta spectrum with respect to maternal age at first cesarean delivery.

RESULTS

Compared to women aged 30-34 years old at first cesarean delivery, the risk of placenta previa (aRR, 1.48; 95% CI, 1.16-1.88) and placenta accreta spectrum (aRR, 1.74; 95% CI, 1.28-2.35) were higher among women aged 18-24. Multivariate regression results showed that women at 18-24 with <2 years intervals exhibited a 5.05-fold increased risk for placenta previa compared with those with 2-5-year intervals (aRR, 5.05; 95% CI, 1.13-22.51). In addition, women aged 18-24 with less than 2 years intervals had an 8.44 times greater risk of developing PAS than women aged 30-34 with 2 to 5 years intervals (aRR, 8.44; 95% CI, 1.82-39.26).

CONCLUSIONS

The findings of this study suggested that short inter-pregnancy intervals were associated with increased risks for placenta previa, and placenta accreta spectrum for women under 25 years at first cesarean delivery, which may be partly attributed to obstetrical outcomes.

Treatment of infected placenta accreta in the uterine horn by transabdominal temporary occlusion of internal iliac arteries: A case report and literature review

RATIONALE

This case report aims to describe the treatment of infected placenta accreta in the uterine horn by transabdominal temporary occlusion of internal iliac arteries.

PATIENT CONCERNS

A 29-year-old female patient had a history of retained placenta for 28 days after labor induction in the second trimester of pregnancy because of fetal malformation.

DIAGNOSES

Placenta accreta in the uterine horn was diagnosed by 3-dimensional ultrasound and magnetic resonance imaging, and the diagnosis was confirmed during the operation.

INTERVENTIONS

Laparotomy was performed to remove the placenta and repair the uterine defect after temporary occlusion of both internal iliac arteries.

OUTCOMES

Body temperature and inflammatory markers were elevated at admission but returned to normal on the second day after surgery. Normal menstruation resumed approximately 1 month postoperatively. Ultrasound examination showed that the shape of the uterine cavity was normal. No postoperative complications were observed.

LESSONS

Temporary occlusion of the internal iliac artery can help effectively manage infected placenta accreta in the uterine horn.

The role of internal iliac artery intraoperative vascular clamp temporary occlusion in abnormally invasive placenta

OBJECTIVE

To investigate the efficacy of internal iliac artery intraoperative vascular clamp temporary occlusion in the treatment of abnormally invasive placenta.

METHOD

This retrospective study enrolled 153 patients diagnosed with abnormally invasive placenta between January 2018 and December 2021. The patients were divided into a study group (n = 88, undergoing cesarean section followed by internal iliac artery vascular clamp temporary occlusion) and a control group (n = 65, receiving routine cesarean section). The general situation, intraoperative conditions, postoperative complications, and neonatal outcomes were compared between the two groups.

RESULTS

The hysterectomy rate in the study group was significantly lower than that in the control group. However, there were no significant differences in intraoperative blood loss, blood transfusion, postoperative intensive care unit transfer rate, or neonatal outcome between the groups. Further subgrouping showed that in patients with placenta increta, the hysterectomy rate and intraoperative bleeding amount were significantly lower in the occlusion group. Nevertheless, these advantages were not significantly different between the groups in patients with placenta percreta.

CONCLUSION

Vascular clamp temporary occlusion of internal iliac artery is an effective method for controlling hemorrhage and decreasing the incidence of hysterectomy in patients with placenta increta. For patients with placenta percreta, the benefit is limited.

Prediction of placenta accreta spectrum by combining deep learning and radiomics using T2WI: a multicenter study

PURPOSE

To achieve prenatal prediction of placenta accreta spectrum (PAS) by combining clinical model, radiomics model, and deep learning model using T2-weighted images (T2WI), and to objectively evaluate the performance of the prediction through multicenter validation.

METHODS

A total of 407 pregnant women from two centers undergoing preoperative magnetic resonance imaging (MRI) were retrospectively recruited. The patients from institution I were divided into a training cohort (n = 298) and a validation cohort (n = 75), while patients from institution II served as the external test cohort (n = 34). In this study, we built a clinical prediction model using patient clinical data, a radiomics model based on selected key features, and a deep learning model by mining deep semantic features. Based on this, we developed a combined model by ensembling the prediction results of the three models mentioned above to achieve prenatal prediction of PAS. The performance of these predictive models was evaluated with respect to discrimination, calibration, and clinical usefulness.

RESULTS

The combined model achieved AUCs of 0.872 (95% confidence interval, 0.843 to 0.908) in the validation cohort and 0.857 (0.808 to 0.894) in the external test cohort, both of which outperformed the other models. The calibration curves demonstrated excellent consistency in the validation cohort and the external test cohort, and the decision curves indicated high clinical usefulness.

CONCLUSION

By using preoperative clinical information and MRI images, the combined model can accurately predict PAS by ensembling clinical model, radiomics model, and deep learning model.

Ultrasound-based nomogram for postpartum hemorrhage prediction in pernicious placenta previa

Background: Pernicious placenta previa (PPP) is one of the most dangerous complications in pregnancy after cesarean section, with high perinatal mortality. This study aimed to develop a nomogram to predict postpartum hemorrhage in patients with PPP.

Methods: A total of 246 patients with confirmed PPP at Shengjing Hospital of China Medical University from January 2018 to December 2021 were included. Patients were divided into to two cohorts depending on a postpartum blood loss of > 1000 ml (n = 146) or ≤ 1000 ml (n = 100). Lasso regression analysis was performed on the risk factors screened by univariate analysis to screen out the final risk factors affecting postpartum hemorrhage. Based on the final risk factors, a Nomogram prediction model with excellent performance was constructed using Logistic regression. A nomogram was constructed with further screening of the selected risk factors of postpartum hemorrhage in PPP. A second nomogram based only on the total ultrasonic risk score was constructed. Decision curve analysis (DCA) was used to evaluate the clinical efficacy of the nomograms.

Results: Older age, larger gestational age, larger neonatal birth weight, presence of gestational diabetes mellitus, larger amniotic fluid index, absence of gestational bleeding, and higher ultrasonic risk single score were selected to establish a nomogram for postpartum hemorrhage in PPP. The area under the curve of the nomogram constructed by Lasso regression analysis was higher than that of the ultrasonic total score alone (0.887 vs. 0.833). Additionally, DCA indicated better clinical efficacy in the former nomogram than in the later nomogram. Furthermore, internal verification of the nomogram constructed by Lasso regression analysis showed good agreement between predicted and actual values.

Conclusion: A nomogram for postpartum hemorrhage in PPP was developed and validated to assist clinicians in evaluating postpartum hemorrhage. This nomogram was more accurate than using the ultrasonic score alone.

Dural puncture epidural technique provides better anesthesia quality in repeat cesarean delivery than epidural technique: Randomized controlled study

BACKGROUND

Repeat cesarean deliverys involve a longer surgery and more severe visceral traction than primary cesarean deliverys. The dural puncture epidural (DPE) technique provides faster and more effective analgesia for labor, but there is no sufficient evidence to indicate whether it is suitable for parturients undergoing repeat cesarean delivery.

AIM

To determine the efficacy and safety of the DPE anesthesia technique in patients undergoing repeat cesarean delivery.

METHODS

Patients undergoing repeat cesarean delivery were randomly divided into the DPE and epidural anesthesia (EA) groups. A 25-G spinal needle was used for dural puncture via a 19-G epidural needle. The patients in the two groups were injected with 5 mL of 2% lidocaine followed by 15 mL of a mixture of 1% lidocaine + 0.5% ropivacaine as the epidural dosage. The primary outcome was the onset time of sensory block to the T6 dermatome level and the sensory and motor block degree.

RESULTS

A total of 115 women were included (EA: 57, DPE: 58). The mean time to sensory block to the T6 Level was significantly shorter in the DPE group than in the EA group (14.7 min vs 16.6 min; 95% confidence interval, 13.9 to 15.4 vs 15.8 to 17.4; P = 0.001). The cranial sensory block level was significantly higher at 5, 10, and 15 min after the initial dose in the DPE group than in the EA group (P < 0.05). The sacral sensory block level was significantly higher and the modified bromage score was significantly lower in the DPE group at each time point (P < 0.05). Adverse effects and neonatal outcomes were comparable between the two groups (P > 0.05).

CONCLUSION

The DPE technique provided higher-quality anesthesia than the EA technique, with a rapid onset of surgical anesthesia, better cranial and sacral sensory block spread and a higher motor block degree, without increasing the incidence of maternal or fetal side effects in patients undergoing repeat cesarean delivery.

Cook Cervical Ripening Balloon for placenta accreta spectrum disorders with placenta previa: a novel approach to uterus preserving

PURPOSE

To evaluate the efficacy of intrauterine inflated Cook Cervical Ripening Balloon (ICRB) in postpartum hemorrhage (PPH) management and fertility preserving for placenta accreta spectrum disorders with placenta previa (previa PAS).

METHODS

At a tertiary referral center, 74 patients suffering with previa PAS were entered into this retrospective cohort study from January, 2016 to December, 2020, and were confirmed intraoperatively that abnormal invasive placenta reaches the cervical internal ostium and the upper part of the cervical canal. In control group (n = 39), the combination of infrarenal abdominal aorta balloon occlusion (IAABO) and longitudinal parallel compression suture to lower uterine segment were performed. In study group (n = 35), in addition to the aforementioned surgical techniques, ICRB was implemented at the cervical internal ostium and the outside of the cervix simultaneously.

RESULTS

Use of ICRB significantly reduced the rate of peripartum hysterectomy (2.9% vs 30.4%, p = 0.001), and associated with a reduction in surgical time and duration of IAABO (mean 172.7 min vs 206.6 min, p = 0.017; median 30 min vs 40 min, p < 0.001). Use of ICRB significantly reduced the estimated amount of blood loss (median 2500 ml vs 4000 ml, p < 0.001), amounts of packed red blood cells and fresh-frozen plasma transfusion (median 6 U vs 13.5 U, p < 0.001; median 450 ml vs 1200 ml, p < 0.001), postoperative hospital stay and the incidence of oligomenorrhea postoperatively (median 5 days vs 6 days, p = 0.009; 13.8% vs 61.1% p = 0.001). No significant difference was observed between both the groups regarding the use of cryo and PLT, injury of urinary system, relaparotomy, admission to the ICU, postpartum hematocele in uterine cavity, and postoperative complications (including incidence rate of DVT, incidence rate of femoral thrombosis, puerperal morbidity, intrauterine infection, surgical site infection, and deep tissue infection).

CONCLUSION

ICRB was a simple, effective procedure for PPH management and fertility preserving in some previa PAS cases in which abnormal invasive placenta reaches the cervical internal ostium and the upper part of the cervical canal, in tandem with IAABO and compression suture.

Risk management of pregnant women and the associated low maternal mortality from 2008-2017 in China: a national longitude study

BACKGROUND

Reducing maternal mortality is one of the key targets of the Sustainable Development Goals (SDGs). In response to the impact of increased birth rate on maternal and child safety following the implementation of the two-child policy in 2013, the Chinese government implemented the risk management strategy (namely Five Strategies for Maternal and Newborn Safety, FSMNS) to reduce maternal mortality ratio (MMR). We aimed to analyze the changes in the proportion of pregnant women at high risk screened before and after the implementation of the risk management strategy and the association with maternal mortality during the two-child policy era in China.

METHODS

We conducted a nationwide longitudinal study using data obtained from the National Statistical Yearbook and the National Health Statistics Yearbook for all 31 provinces from 2008-2017 to assess and analyze the changes in the proportion of pregnant women at high risk screened before (2008-2013) and after (2014-2017) the implementation of the risk management strategy during the two-child policy era. We used generalized estimating equation (GEE) models to analyze the relationship between the proportion of pregnant women at high risk and MMR after controlling for sociodemographic factors, health resources, and other maternal healthcare factors.

RESULTS

In the past decade, the number of livebirths in China increased by 32.3%, from 13.3 million in 2008 to 17.6 million in 2017. The median proportion of pregnant women at high risk in 31 provinces increased by 64.8%, from 14.87% in 2008 to 24.50% in 2017. The annual rate of increase in the median proportion of pregnant women at high risk after the implementation of risk management (1.33%) was higher than that before the implementation (0.74%). The median MMR in China decreased by 39.6%, from 21.7 per 100,000 livebirths in 2008 to 13.1 per 100,000 livebirths in 2017. The univariate GEE models showed that MMR decreased by 7.9% per year from 2008-2017 (cRR 0.92, 95% CI 0.91-0.93), and the proportion of pregnant women at high risk was negatively correlated with MMR (cRR 0.97, 95%CI 0.94-0.99; p = 0.001). In the multivariate GEE models, after adjusting for confounders, the proportion of pregnant women at high risk remained negatively correlated with MMR. In the subgroup analysis, the association of MMR with GDP per capita and government health expenditure per capita existed only prior to the implementation of risk management; while high MMR was associated with a low proportion of pregnant women at high risk after the implementation of risk management.

CONCLUSION

The national risk management strategy contributed to the stable decline of MMR in China during the two-child policy era. Further attention should be focused on pregnant women in China's central and western regions to ensure reaching SDGs targets and the 'Healthy China Plan' by 2030.

The incidence, risk factors and maternal and foetal outcomes of uterine rupture during different birth policy periods: an observational study in China

Background

Currently, there are no studies on changes in the incidence of uterine rupture or maternal and foetal outcomes in women with uterine rupture during different birth policy periods in China. Moreover, the results of association studies of maternal age, parity and previous caesarean section number with the risk of maternal and foetal outcomes in women with uterine rupture have not been consistent. This research aims to conduct and discuss the above two aspects.

Methods

We included singleton pregnant women with no maternal complications other than uterine rupture from January 2012 to June 2019 in China’s National Maternal Near Miss Surveillance System. The data in this study did not differentiate between complete and partial uterine rupture and uterine dehiscence. Through Poisson regression analysis with a robust variance estimator, we compared the incidences of uterine rupture and maternal and foetal outcomes in women with uterine rupture during different birth policy periods in China and determined the relationship between maternal age, parity or previous caesarean section number and uterine rupture or maternal and foetal outcomes in women with uterine rupture.

Results

This study included 8,637,723 pregnant women. The total incidences of uterine rupture were 0.13% (12,934) overall, 0.05% during the one-child policy, 0.12% during the partial two-child policy (aRR = 1.96; 95% CI: 1.53–2.52) and 0.22% (aRR = 2.89; 95% CI: 1.94 4.29) during the universal two-child policy. The maternal near miss and stillbirth rates in women with uterine rupture were respectively 2.35% (aRR = 17.90; 95% CI: 11.81–27.13) and 2.12% (aRR = 4.10; 95% CI: 3.19 5.26) overall, 5.46 and 8.18% during the first policy, 1.72% (aRR = 0.60; 95% CI: 0.32–1.17) and 2.02% (aRR = 0.57; 95% CI: 0.37–0.83) during the second policy, and 1.99% (aRR = 0.90; 95% CI: 0.52–1.53) and 1.04% (aRR = 0.36; 95% CI: 0.24–0.54) during the third policy. The risk of uterine rupture increased with parity and previous caesarean section number.

Conclusion

The uterine rupture rate in China continues to increase among different birth policy periods, and the risk of maternal near miss among women with uterine rupture has not significantly improved. The Chinese government, obstetricians, and scholars should work together to reverse the rising rate of uterine rupture and improve the pregnancy outcomes in women with uterine rupture.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03811-8.

High-intensity focused ultrasound in management of placenta accreta spectrum: A systematic review

BACKGROUND

High-intensity focused ultrasound (HIFU) is a non-invasive procedure that has been studied in the management of placenta accreta spectrum (PAS).

OBJECTIVE

To appraise HIFU in the management of PAS and highlight the restrictions on converting uterus-preserving studies into evidence-based practice.

SEARCH STRATEGY

A search on Scopus, Cochrane, PubMed and Web of Science was conducted from date of inception to January 2020.

SELECTION CRITERIA

Studies on using HIFU in the management of PAS were eligible. Review articles, conference papers, and case reports were excluded.

DATA COLLECTION

A standardized sheet was used to abstract data from eligible studies. CON-PAS registry was used to include studies on other conservative modalities.

RESULTS

Four studies were eligible (399 patients). Average residual placental volume was 61.74 cm³ (6.01-339 cm³ ). Treatment was successful in all patients. Normal menstruation recovered after 48.8 days (15-150 days). No major complications were encountered. Sixty-one studies were retrieved from the CON-PAS registry; uterine artery embolization (23 studies), balloon placement (15 studies), compression sutures (10 studies), placenta in situ (7 studies), and uterine resection (6 studies) were successful in 83.7%, 92.9%, 87.9%, 85.2%, and 79.3% of cases, respectively.

CONCLUSIONS

HIFU may fit certain clinical situations in the management of PAS. A global research strategy is recommended to incorporate conservative approaches within a comprehensive management protocol.

Conservative management versus cesarean hysterectomy in patients with placenta increta or percreta

OBJECTIVE

To compare conservative management and cesarean hysterectomy in patients with placenta increta or percreta.

MATERIALS AND METHODS

In this multicenter retrospective study, we recorded data on 2219 patients with placenta increta or percreta from 20 tertiary care centers in China from 1 January 2011 to 31 December 2015. Propensity score analysis was used to control for baseline characteristics. We divided patients into conservative management (C) and hysterectomy (H) groups. The primary outcome was operative/postoperative maternal morbidity; secondary outcomes were maternal-neonatal outcomes.

RESULTS

In total, 17.9% (398/2219) of patients had placenta increta and percreta; 82.1% (1821/2219) of the patients were in group C. After propensity score matching, 140 pairs of patients from the two groups underwent one-to-one matching. Group C showed less average blood loss within 24 h of surgery (1518 ± 1275 vs. 4309 ± 2550 ml in group H, p<.001). There were more patients with blood loss >1000 ml in group H than in group C (93.6% [131/140] vs. 61.4% [86/140], p<.001). More patients received blood transfusions in group H than in group C (p=.014). There was no significant difference between the groups in terms of bladder injury, postoperative anemia, fever, and disseminated intravascular coagulation. Neonatal outcomes in the two groups were similar.

CONCLUSION

Either conservative management or hysterectomy should be considered after thorough evaluation and detailed discussion of risks and benefits. A balance between bleeding control and fertility can be achieved.

Reducing maternal mortality in China in the era of the two-child policy

Reducing maternal mortality ratio (MMR) is of great concern worldwide. After the implementation of the two-child policy in 2013, the number of live births and the proportion of high-risk pregnancies both increased, and these bring new challenges to the reduction of MMR. China implemented a package of nationwide strategies in April 2016, the Five Strategies for Maternal and Newborn Safety (FSMNS). The FSMNS consists of five components: (1) pregnancy risk screening and assessment strategy, (2) case-by-case management strategy for high-risk pregnancies, (3) referral and treatment strategy for critically ill pregnant women and newborns, (4) reporting strategy for maternal deaths (and 5) accountability strategy. To better implement the FSMNS, China formulated a unified pregnancy risk screening form. After risk assessment and classification, medical records of all the pregnant women are labelled with green (low risk), yellow (moderate risk), orange (high risk), red (highest risk) or purple (infectious disease) for tailored management. By the implementation of FSMNS, China has already kept the MMR stable and cause it to enter a controlled decline. MMR in China has declined by 21.1%, from 23.2 per 100 000 live births in 2013 to 18.3 per 100 000 live births in 2018. The country's challenges and experience in reducing the MMR could provide useful lessons for other countries.

Intrauterine double-balloon tamponade vs gauze packing in the management of placenta previa: A multicentre randomized controlled trial

BACKGROUND

To evaluate the effectiveness and safety of a newly designed intrauterine double-balloon catheter to arrest postpartum hemorrhage (PPH) following cesarean delivery (CD) for placenta previa.

METHODS

We conducted an open-label, multicenter randomized controlled trial in two referral centers and one general hospital. Women with continuous bleeding after placental delivery following CD for placenta previa, who failed to respond to uterotonics, suturing and uterine devascularization, and in the absence of suspected deeply invasive accreta were eligible subjects. Eligible subjects were randomized to receive intrauterine double-balloon catheter (n = 102) or gauze packing (n = 102). The main outcome was the rate of successful hemostasis without the need for additional surgical interventions. The secondary outcomes included the volume of blood loss during and after CD, the rate of PPH, incidence and amount of blood transfusion, hysterectomy, surgical complications, intensive care unit admission, need for re-laparotomy, length of hospital stay, and readmission.

RESULTS

The 224 participants were recruited before delivery, with 20 excluded (14 cases bleeding stopped after uterotonics and/or local myometrium sutures and 6 patients with placental increta). Finally, 102 women were assigned in catheter group and 102 others in gauze group. There was no difference in the rate of successful hemostasis in the catheter and gauze groups (93.1% vs 91.2%, P = .80). Compared with those in the gauze group, women in the catheter group showed significantly less blood loss within 24 hours postpartum (895 [612.3-1297.8] vs 1156 [882.5-1453.3] ml, P < .01), lower rate of PPH ≥1000 ml (42.2% vs 63.7%, P < .01). Accordingly, women in the catheter group had significantly less maternal adverse events such as postpartum anemia, puerperal morbidity, and postpartum pain.

CONCLUSION

Uterine tamponade using a double-balloon catheter was as effective as gauze packing in hemostasis, and appeared to be superior in reducing postpartum blood loss and pain following CD for placenta previa. Using double-balloon catheter in managing PPH in this situation may be a preferable alternative to minimize maternal morbidity.

Changes in maternal age and prevalence of congenital anomalies during the enactment of China's universal two-child policy (2013-2017) in Zhejiang Province, China: An observational study

BACKGROUND

China implemented a partial two-child policy (2013) followed by a universal two-child policy (2015), replacing the former one-child policy mandated by the government. The changes affect many aspects of China's population as well as maternal and infant health, but their potential impact on birth defects (BDs) remains unknown. In this study, we investigated the associations of these policy changes with BDs in Zhejiang Province, China.

METHODS AND FINDINGS

We used data from the BD surveillance system in Zhejiang Province, China, which covers 90 hospitals in 30 urban districts and rural counties, capturing one-third of the total births in this province. To fully consider the time interval between conception and delivery, we defined the one-child policy period as data from 2013 (births from October 2012 to September 2013), the partial two-child policy period as data from 2015 (births from October 2014 to September 2015), and the universal two-child policy period as data from 2017 (births from October 2016 to September 2017). Data from 2009 and 2011 were also used to show the changes in the proportion of births to women with advanced maternal age (35 years and older) prior to the policy changes. Main outcome measures were changes in the proportion of mothers with advanced maternal age, prevalence of BDs, rankings of BD subtypes by prevalence, prenatal diagnosis rate, and live birth rate of BDs over time. A total of 1,260,684 births (including live births, early fetal losses, stillbirths, and early neonatal deaths) were included in the analyses. Of these, 644,973 (51.16%) births were to women from urban areas, and 615,711 (48.84%) births were to women from rural areas. In total, 135,543 (10.75%) births were to women with advanced maternal age. The proportion increased by 85.68%, from 8.52% in 2013 to 15.82% in 2017. However, it had remained stable prior to policy changes. Overall, 23,095 BDs were identified over the policy changes (2013-2017). The prevalence of BDs during 2013, 2015, and 2017 was 245.95, 264.86, and 304.36 per 10,000 births, respectively. Trisomy 21 and other chromosomal defects increased in both risk and ranking from 2013 to 2017 (crude odds ratio [95% confidence interval] 2.13 [1.75-2.60], from ranking 10th to 5th, and 3.63 [2.84-4.69], from ranking 16th to 6th, respectively). The prenatal diagnosis rate increased by 3.63 (2.2-5.1) percentage points (P < 0.001), from 31.10% to 34.72%, and identification of BDs occurred 1.88 (1.81-1.95) weeks earlier (P < 0.001). The live birth rate for infants with BDs born before 28 gestational weeks increased from 1.29% to 11.45%. The major limitations of this observational study include an inability to establish causality and the possible existence of unknown confounding factors, some of which could contribute to BDs.

CONCLUSIONS

In this study, we observed significant increases in maternal age and the prevalence of total and age-related anomalies following China's new two-child policy. Increases in live birth rate for infants with BDs born before 28 gestational weeks suggest that healthcare for very preterm births with BDs may be warranted in the future, as well as updating the definition of perinatal period.

Development of a Novel Nomogram for Predicting Placenta Accreta in Patients With Scarred Uterus: A Retrospective Cohort Study

Objective: The aim of this study was to develop a nomogram to predict the risk of placenta accreta in scarred uterus patients in China.

Methods: We retrospectively analyzed 8,371 singleton pregnancies with scarred uterus at Shengjing Hospital, affiliated with China Medical University. Two thirds of the patients were randomly assigned to the training set (n = 5,581), and one third were assigned to the validation set (n = 2,790). Multivariate logistic regression was performed by using the training set, and the nomogram was developed. Discrimination and calibration were performed by using both the training and validation sets.

Results: The multivariate logistic regression model identified number of previous cesarean section, number of vaginal bleeding, medication during pregnancy, and placenta previa as covariates associated with placenta accreta. A nomogram was developed to predict the risk of placenta accreta in the training set with a Harrell's C-index of 0.93 and 0.927 in the training set and validation set, respectively. Calibration of the nomogram predicted placenta accreta corresponding closely with the actual placenta accreta.

Conclusion: We developed a nomogram predicting the risk of placenta accreta in scarred uterus patients in China. Validation using both the training set and the validation set demonstrated good discrimination and calibration, suggesting good clinical utility.

Parallel transverse uterine incisions, a novel approach for managing heavy hemorrhage and preserving the uterus: A retrospective cohort study for patients with anterior placenta previa and accreta

Placenta previa and accreta with prior cesarean section is an extremely serious condition that is associated with maternal morbidity and mortality from obstetric hemorrhage. The aim of our study was to evaluate the efficacy and advantages of a novel surgical technique, parallel transverse uterine incisions (PTUI), during conservative cesarean delivery in patients with placenta previa and accreta.This was a retrospective cohort study including 124 pregnant women, who had at least 1 prior cesarean section and were diagnosed with anterior placenta previa and accreta between January 2014 and October 2017. Using the hospital's information system, patients were retrospectively classified into undergoing either the PTUI surgery (Group A) or the ordinary cesarean section (Group B). Surgical outcomes and maternal complications during hospitalization were collected. The results from 2 groups were compared and analyzed statistically. Multivariable regression analyses were further used to assess the effect of PTUI on severe maternal outcomes.Patients who underwent PTUI were not statistically different from patients who underwent the ordinary cesarean section in terms of maternal and infants' characteristics. However, PTUI was associated with remarkably reduced intraoperative blood loss (P = .005), related vaginal blood loss after surgery (P = .026), and transfusion requirement of packed red cells (P = .000), compared to the ordinary cesarean section. Moreover, cesarean hysterectomy (3.3% vs 21.9%; P = .002) and intensive care unit admission (1.7% vs 29.7%; P = .000) were significantly fewer among patients who underwent PTUI. Multivariable regression analyses further showed that the risk of intraoperative hemorrhage (β = -2343.299, P = .000) and cesarean hysterectomy (odds ratio = 0.027, P = .018) were both significantly decreased by PTUI.PTUI is a novel approach that may significantly reduce maternal complications, while preserving the uterus for patients with anterior placenta previa and accreta.

Clinical analysis of emergency exploratory laparotomy in patients with intractable postpartum hemorrhage

Objective

This study was performed to explore the causes and clinical characteristics of emergency exploratory laparotomy in patients with intractable postpartum hemorrhage.

Methods

This retrospective study was performed from January 2004 to December 2017. Patients with intractable postpartum hemorrhage were grouped according to the initial pathogenesis as determined by exploratory laparotomy: uterine atony, placental factors, coagulation dysfunction, or uterine rupture.

Results

This study involved 72 patients who underwent emergency exploratory laparotomy, accounting for 0.04% of total deliveries. Uterine preservation surgery and hysterectomy were performed in 31 and 41 patients, respectively. Abnormal events upon returning to the ward were primarily vaginal hemorrhage and pelvic hematoma. The frequency of uterine artery ligation was lower in the hysterectomy group than uterine preservation group. The prothrombin activity level, fibrinogen level, and platelet count before surgery were lower in the hysterectomy group than uterine preservation group. The international normalized ratio and activated partial thromboplastin time were higher in the hysterectomy group than uterine preservation group. In total, 44 patients developed complications.

Conclusion

Placental implantation is a primary cause of hysterectomy after emergency laparotomy. However, the possibility of postpartum hemorrhage caused by coagulation disorders should not be ignored.

Impact of the Universal Two-Child Policy on the Workload of Community-Based Basic Public Health Services in Zhejiang Province, China

We aimed to quantitatively estimate the amount of pressure that was placed on basic public health care services (BPHS) due to the universal two-child policy issued in 2015 by comparing the workload change in maternal and child health management and the immunization of children. BPHS performance surveillance data from 2014 to 2018 in Zhejiang Province, China were analyzed to calculate the workload of the above three services using the equivalent method of BPHS cost estimation of community health services. From 2014 to 2018, the numbers of births from the Statistical Yearbook in Zhejiang Province were 578,000, 581,000, 624,000, 670,000, and 628,000, respectively, and those from the surveillance data were 416,941, 41,490, 434,163, 546,816, and 45,964, respectively. The number of births reached a peak in 2017, with the yearbook and surveillance data showing increases of 15.92% and 31.15%, respectively, over 2014. The workload of maternal and child health management and children’s immunization also peaked in 2017, increasing by 30.37%, 12.70%, and 4.33% over 2014, respectively. In 2018, the workload of maternal and child health management and children’s immunization dropped to 107.34%, 107.73%, and 98.81% over 2014, respectively. The indicators of maternal and child health management and children’s immunization services remained stable, and the related services did not decline, even in 2017. The maternal health management workload was more affected by the universal two-child policy than child health management and children’s immunization.

Understanding and comparing practices of managing patients with hypertensive disorders of pregnancy in urban China and the United States

OBJECTIVES

To describe patient outcomes, management of hypertensive disorders of pregnancy, and evaluate provider knowledge of practice guidelines at a tertiary care center in urban China.

STUDY DESIGN

Retrospective chart review of patients admitted between September 2017 and March 2018 with a diagnosis of any hypertensive disorder at Zhongnan Hospital of Wuhan University Medical Center in China. Healthcare providers including physicians, midwives, nurses and medical students were surveyed. Patient outcomes were compared to those at the University of Chicago, USA.

MAIN OUTCOME MEASURES

Prevalence of hypertensive disorders of pregnancy, comparative rates of medication administration, mode of delivery, and other pregnancy characteristics were abstracted. Responses regarding definitions, treatment and outcomes of hypertension were analyzed using survey data.

RESULTS

Among 2834 patients, the prevalence of hypertensive disorders at the Zhongnan Hospital was 7.1%, with a 6.4% prevalence of preeclampsia. Compared to hypertensive women from the University of Chicago, hypertensive patients at Zhongnan Hospital were more likely to be older and weigh less but had higher rates of antihypertensive drug administration and delivery via cesarean section. Infants born at Zhongnan Hospital were less likely to be admitted to the neonatal intensive care unit. Survey respondents demonstrated poor knowledge of preeclampsia diagnoses and first line treatments for severe hypertension in pregnancy.

CONCLUSIONS

Although several clinical characteristics of preeclampsia were similar between hospitals, the rates of cesarean section were higher in China. Provider knowledge was most lacking in areas about diagnostic criteria and medication use for preeclampsia. Future studies are needed to explore these differences.

Scoring system for the prediction of the severity of placenta accrete spectrum in women with placenta previa: a prospective observational study

PURPOSE

The clinical outcomes are significantly different in accreta, increta, and percreta. There is currently no scoring system that can preoperatively distinguish its severity in an at-risk population. The aim of this study is to establish a scoring system for the prediction of the severity of placenta accrete spectrum (PAS) in women with placenta previa.

METHODS

A prospective observational study was conducted in patients with placenta previa who delivered at a Chinese tertiary care center between June 12, 2016 and June 30, 2018. Optimal scaling regression was performed to determine the parameters which really contribute to the prediction of PAS, and calculate percentage of contribution.

RESULTS

Among 392 cases with placenta previa, 79, 53, and 28 had been surgically and/or histologically confirmed as accreta, increta, or percreta, respectively. Seven parameters were scheduled for the estimated scores for PAS, and five of them were finally entered into the predictive model. Their percentage of contribution was as follows: placental lacunas (19%), vascularity at the uterus-bladder interface (17.5%), myometrial thickness and hypoechoic retroplacental zone (25.6%), bladder line (22.6%), and previous caesarean sections (15.3%). The thresholds of scores for the prediction of accreta, increta, and percreta yielded 2.25-6.2, 6.2-8.95, and ≧ 8.95, respectively, with the positive and negative predictive value, and false positive rates of the scoring system were 96.68%, 95.44%, and 3.32%, respectively.

CONCLUSIONS

The scoring system can predict the severity of PAS in women with placenta previa. This will help identify the actual high-risk patients and improve their treatment.

Changes of second-time mothers and their infants under the universal two-child policy in Changsha, China

BACKGROUND

China announced the implementation of the universal two-child policy in Oct, 2015; every couple was allowed to have two children. However, its influences on maternal well-being and infants' outcomes are still to be discovered.

OBJECTIVES

To detect influences of the universal two-child policy. To provide information for maternal health care under the new policy.

STUDY DESIGN

This study enrolled 859 and 1230 women who delivered their second child (hereafter second-time mothers) before and after the policy's implementation, respectively, and the data included maternal demographic characteristics, gestational complications, delivery mode and infants' outcomes.

RESULTS

After the policy's implementation, the proportion of second-time mothers with advanced age increased significantly. The advanced gestational age is well acknowledged to correlate with higher risk during the pregnancy, both for pregnant women and their babies. However, in our study, the incidence of hypertensive disorders in pregnancy, placenta previa and postpartum haemorrhage decreased significantly after the introduction of the policy and no differences were noted in other gestational complications. Moreover, the hospitalization time was shortened, and caesarean delivery was chosen less frequently. As for the infants, foetal distress exhibited an alleviation and the incidence of premature labour and low birth weight decreased as well.

CONCLUSIONS

Even though the age of second-time mothers increased after the introduction of the universal two-child policy, their general gestational health condition improved and their infants also exhibited a better outcome, which might be attributed to the improvement of China's maternal medical care system.

Downregulation of MicroRNA-125a in Placenta Accreta Spectrum Disorders Contributes Antiapoptosis of Implantation Site Intermediate Trophoblasts by Targeting MCL1

The typical hallmark of placenta accreta spectrum (PAS) disorders is increased implantation site intermediate trophoblast (ISIT) cell numbers. However, the extent of trophoblast proliferation and apoptosis have not been found to differ from those of normal placentation. MicroRNA-125a (miR-125a) induces apoptosis in colon cancer cell by targeting myeloid cell leukemia-1 gene (MCL1). We aimed to investigate the influence of miR-125a on ISIT cells in PAS disorders in 15 patients (self-paired trials) with placenta previa and PAS disorders. Expression of miR-125a and MCL1 were measured in villous trophoblasts and basal plate myometrial fibers from creta site and adjacent noncreta tissues by real-time quantitative polymerase chain reaction, and expression of the MCL1 protein was assayed by Western blotting. Flow-cytometry was used to examine the effect of miR-125a overexpression on apoptosis in vitro in HTR-8/SVneo cells, and luciferase activity assays was used to confirm miR-125a targeting of MCL1. In vivo, the expression levels of miR-125a was significantly lower in creta versus noncreta tissues, and the expression of MCL1 was upregulated; moreover, immunohistochemistry showed that the increased ISIT cells in the creta were positive for MCL1 protein. MCL1 was downregulated in the miR-125a-overexpressing HTR-8/SVneo cells in vitro, and overexpression of miR-125a-induced apoptosis in the HTR-8/SVneo trophoblast line. Finally, luciferase activity assays confirmed that miR-125a directly target the 3' untranslated region of MCL1 in the 293T cell line. In conclusion, downregulation of MCL1-targeting miR-125a exerts an antiapoptotic effect on ISIT cells in PAS disorders.