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Fitzgerald GD, Newton JM, Atasi L, Buniak CM, Burgos-Luna JM, Burnett BA, Carver AR, Cheng C, Conyers S, Davitt C, Deshmukh U, Donovan BM, Easter SR, Einerson BD, Fox KA, Habib AS, Harrison R, Hecht JL, Licon E, Nino JM, Munoz JL, Nieto-Calvache AJ, Polic A, Ramsey PS, Salmanian B, Shamshirsaz AA, Shamshirsaz AA, Shrivastava VK, Woolworth MB, Yurashevich M, Zuckerwise L, Shainker SA. Placenta accreta spectrum care infrastructure: an evidence-based review of needed resources supporting placenta accreta spectrum care. Am J Obstet Gynecol MFM 2024; 6:101229. [PMID: 37984691 DOI: 10.1016/j.ajogmf.2023.101229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/02/2023] [Accepted: 11/15/2023] [Indexed: 11/22/2023]
Abstract
The incidence of placenta accreta spectrum, the deeply adherent placenta with associated increased risk of maternal morbidity and mortality, has seen a significant rise in recent years. Therefore, there has been a rise in clinical and research focus on this complex diagnosis. There is international consensus that a multidisciplinary coordinated approach optimizes outcomes. The composition of the team will vary from center to center; however, central themes of complex surgical experts, specialists in prenatal diagnosis, critical care specialists, neonatology specialists, obstetrics anesthesiology specialists, blood bank specialists, and dedicated mental health experts are universal throughout. Regionalization of care is a growing trend for complex medical needs, but the location of care alone is just a starting point. The goal of this article is to provide an evidence-based framework for the crucial infrastructure needed to address the unique antepartum, delivery, and postpartum needs of the patient with placenta accreta spectrum. Rather than a clinical checklist, we describe the personnel, clinical unit characteristics, and breadth of contributing clinical roles that make up a team. Screening protocols, diagnostic imaging, surgical and potential need for critical care, and trauma-informed interaction are the basis for comprehensive care. The vision from the author group is that this publication provides a semblance of infrastructure standardization as a means to ensure proper preparation and readiness.
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Affiliation(s)
- Garrett D Fitzgerald
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI (Dr Fitzgerald).
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN (Dr Newton)
| | - Lamia Atasi
- Department of Obstetrics and Gynecology, Mercy Hospital, St. Louis, MO (Dr Atasi)
| | - Christina M Buniak
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA (Dr Buniak)
| | | | - Brian A Burnett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Dr Burnett)
| | - Alissa R Carver
- Department of Obstetrics and Gynecology, Wilmington Maternal-Fetal Medicine, Wilmington, NC (Dr Carver)
| | - CeCe Cheng
- Department of Obstetrics and Gynecology, Health Science Center at San Antonio, University of Texas, San Antonio, TX (Dr Cheng)
| | - Steffany Conyers
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Caroline Davitt
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Davitt and Am Shamshiraz)
| | - Uma Deshmukh
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Bridget M Donovan
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Donovan and Shainker)
| | - Sara Rae Easter
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA (Dr Easter)
| | - Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT (Dr Einerson)
| | - Karin A Fox
- Baylor College of Medicine, Houston, TX (Dr Fox)
| | - Ashraf S Habib
- Duke University School of Medicine, Durham, NC (Dr Habib)
| | - Rachel Harrison
- Department of Obstetrics and Gynecology, Advocate Aurora Health, Chicago, IL (Dr Harrison)
| | - Jonathan L Hecht
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Ernesto Licon
- Miller Women's & Children's Hospital/Long Beach Memorial Medical Center, Orange, CA (Dr Licon)
| | - Julio Mateus Nino
- Department of Obstetrics and Gynecology, Atrium Health Wake Forest School of Medicine, Winston-Salem, NC (Dr Nino)
| | - Jessian L Munoz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX (Dr Munoz)
| | | | | | - Patrick S Ramsey
- University of Texas Health/University Health San Antonio, San Antonio, TX (Dr Ramsey)
| | - Bahram Salmanian
- Department of Obstetrics and Gynecology, University of Colorado Health Anschutz Medical Campus, Boulder, CO (Dr Salmanian)
| | | | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Davitt and Am Shamshiraz)
| | - Vineet K Shrivastava
- Miller Women's and Children's Hospital/Long Beach Memorial Medical Center, Orange, CA (Dr Shrivastava)
| | | | - Mary Yurashevich
- Department of Anesthesiology, Duke Health, Durham, NC (Dr Yurashevich)
| | - Lisa Zuckerwise
- and Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN (Dr Zuckerwise)
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Donovan and Shainker)
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2
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Shub A. Gestation of delivery in people with antepartum hemorrhage and placenta previa. Am J Obstet Gynecol MFM 2023; 5:101191. [PMID: 37832644 DOI: 10.1016/j.ajogmf.2023.101191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/22/2023] [Accepted: 10/09/2023] [Indexed: 10/15/2023]
Affiliation(s)
- Alexis Shub
- Paediatric Infant Perinatal Emergency Retrieval, Royal Childrens Hospital, Parkville, Victoria, Australia.
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Einerson BD, Sandlin AT, Afshar Y, Sharawi N, Fox KA, Newton JM, Shainker SA, Pezeshkmehr A, Carusi DA, Moroz L. General Management Considerations for Placenta Accreta Spectrum. Am J Perinatol 2023; 40:1026-1032. [PMID: 37336221 DOI: 10.1055/s-0043-1761915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
The ideal management of a patient with placenta accreta spectrum (PAS) includes close antepartum management culminating in a planned and coordinated delivery by an experienced multidisciplinary PAS team. Coordinated team management has been shown to optimize outcomes for mother and infant. This section provides a consensus overview from the Pan-American Society for the Placenta Accreta Spectrum regarding general management of PAS.
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Affiliation(s)
| | - Adam T Sandlin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arizona
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Nadir Sharawi
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arizona
| | - Karin A Fox
- Division of Maternal-Fetal Medicine, Department of Obstetric and Gynecology, Baylor College of Medicine (Texas Children's Hospital Pavilion for Women), Houston, Texas
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center Nashville, Tennessee
| | - Scott A Shainker
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amir Pezeshkmehr
- Department of Radiology Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Daniela A Carusi
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Kishimoto N, Miyamoto M, Imauji A, Takada M, Nishitani S, Tanabe R, Ito T, Hada T, Otsuka Y, Takano M. Clinical significance of retained products of conception in placenta previa: a retrospective analysis. BMC Pregnancy Childbirth 2023; 23:481. [PMID: 37391723 DOI: 10.1186/s12884-023-05805-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 06/21/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Retained products of conception (RPOC) often cause severe postpartum hemorrhage (PPH) but the clinical significance of RPOC in placenta previa is unclear. This study aimed to investigate the clinical significance of RPOC in women with placenta previa. The primary outcome was to evaluate risk factors of RPOC and the secondary outcome was to consider risk factors of severe PPH. METHODS Singleton pregnant women with placenta previa who underwent cesarean section (CS) and placenta removal during the operation at the National Defense Medical College Hospital between January 2004 and December 2021 were identified. A retrospective analysis was performed to examine the frequency and risk factors of RPOC and the association of RPOC with severe PPH in pregnant women with placenta previa. RESULTS This study included 335 pregnant women. Among these, 24 (7.2%) pregnant women developed RPOC. Pregnant women with prior CS (Odds Ratio (OR) 5.98; 95% Confidence Interval (CI) 2.35-15.20, p < 0.01), major previa (OR 3.15; 95% CI 1.19-8.32, p < 0.01), and placenta accreta spectrum (PAS) (OR 92.7; 95% CI 18.39-467.22, p < 0.01) were more frequent in the RPOC group. Multivariate analysis revealed that prior CS (OR 10.70; 95% CI 3.47-33.00, p < 0.01,) and PAS (OR 140.32; 95% CI 23.84-825.79, p < 0.01) were risk factors for RPOC. In pregnant women who have placenta previa with RPOC or without RPOC, the ratio of severe PPH were 58.3% and 4.5%, respectively (p < 0.01). Furthermore, the occurrence of prior CS (OR 9.23; 95% CI 4.02-21.20, p < 0.01), major previa (OR 11.35; 95% CI 3.35-38.38, p < 0.01), placenta at the anterior wall (OR 3.44; 95% CI 1.40-8.44, p = 0.01), PAS (OR 16.47; 95% CI 4.66-58.26, p < 0.01), and RPOC (OR 29.70; 95% CI 11.23-78.55, p < 0.01) was more in pregnant women with severe PPH. In the multivariate analysis for severe PPH, prior CS (OR 4.71; 95% CI 1.29-17.13, p = 0.02), major previa (OR 7.50; 95% CI 1.98-28.43, p < 0.01), and RPOC (OR 13.26; 95% CI 3.61-48.63, p < 0.01) were identified as risk factors. CONCLUSIONS Prior CS and PAS were identified as risk factors for RPOC in placenta previa and RPOC is closely associated with severe PPH. Therefore, a new strategy for RPOC in placenta previa is needed.
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Affiliation(s)
- Naohisa Kishimoto
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, 3-2, Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Morikazu Miyamoto
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, 3-2, Namiki, Tokorozawa, Saitama, 359-8513, Japan.
| | - Akari Imauji
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, 3-2, Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Minori Takada
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, 3-2, Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Soko Nishitani
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, 3-2, Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Risa Tanabe
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, 3-2, Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Tsubasa Ito
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, 3-2, Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Taira Hada
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, 3-2, Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Yuka Otsuka
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, 3-2, Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Masashi Takano
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, 3-2, Namiki, Tokorozawa, Saitama, 359-8513, Japan
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Seguin N, Visintini S, Muldoon KA, Walker M. Use of tranexamic acid (TXA) to reduce preterm birth and other adverse obstetrical outcomes among pregnant individuals with placenta previa: a systematic review protocol. BMJ Open 2023; 13:e068892. [PMID: 36882250 PMCID: PMC10008160 DOI: 10.1136/bmjopen-2022-068892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
INTRODUCTION Placenta previa is a placental implantation pathology where the placenta overlies the internal endocervical os. Placenta previa affects approximately 4 per 1000 pregnancies and increases the risk of antepartum bleeding, emergent preterm labour and emergency caesarean sections. Currently, placenta previa is managed through expectant management. Guidelines primarily revolve around the mode and timing of delivery, in-hospital admissions and surveillance. However, the methods to prolong pregnancy have not proven to be clinically effective. Tranexamic acid (TXA), an antifibrinolytic agent, is effectively used to prevent and treat postpartum haemorrhage as well as menorrhagia, with limited adverse effect, and may prove to be an effective treatment for placenta previa. The objective of this systematic review protocol is to review and synthesise the evidence of TXA use for antepartum haemorrhage in placenta previa. METHODS AND ANALYSIS Preliminary searches were conducted on 12 July 2022. We will search MEDLINE, EMBASE, CINAHL, Scopus and the Cochrane Central Register of Controlled Trials. Grey literature resources such as clinical trials registries (ClinicalTrials.gov and the WHO's International Clinical Trials Registry) and preprint servers (Europe PMC and Open Science Framework) will also be searched. The search terms will comprise of index headings and keyword searches related to TXA and the placenta or antepartum bleeding. Cohort and randomised and non-randomised trials will be considered. The target population is pregnant people, of any age, with placenta previa. The intervention is TXA given in the antepartum period. The main outcome of interest is preterm birth before 37 weeks, however, all perinatal outcomes will be collected. Title and abstract will be screened by two reviewers and any conflict will be discussed and evaluated by a third reviewer. The literature will be summarised in narrative form. ETHICS AND DISSEMINATION No ethics approval is required for this protocol. Findings will be disseminated through peer-review publication, lay summaries and conference presentations. PROSPERO REGISTRATION NUMBER CRD42022363009).
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Affiliation(s)
- Niève Seguin
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sarah Visintini
- Berkman Library, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Katherine A Muldoon
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
| | - Mark Walker
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
- International and Global Health Office, University of Ottawa, Ottawa, Ontario, Canada
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6
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Chung K, Yin O, Kallapur A, Bass L, Coscia L, Constantinescu S, Moritz M, Afshar Y. Emergent prelabor cesarean delivery in solid organ transplant recipients: associated risk factors and outcomes. Am J Obstet Gynecol MFM 2023; 5:100799. [PMID: 36368514 DOI: 10.1016/j.ajogmf.2022.100799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 10/19/2022] [Accepted: 11/03/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Pregnancies after solid organ transplant are at a higher risk of antepartum admission and pregnancy complications including cesarean delivery. Emergent prelabor cesarean delivery is associated with increased maternal and neonatal morbidity in other high-risk populations, but its incidence and impact in transplant recipients is not well-understood. OBJECTIVE This study aimed to characterize the risk factors and outcomes of emergency prelabor cesarean delivery in kidney and liver transplant recipients. STUDY DESIGN This was a retrospective cohort study of all kidney and liver transplant recipients at >20 weeks gestation enrolled in the Transplant Pregnancy Registry International between 1976 and 2019. Participants admitted antepartum who required emergency prelabor cesarean delivery were compared with those admitted antepartum who underwent nonemergent birth. The primary outcomes were severe maternal morbidity and neonatal composite morbidity. Multivariable logistic regression was conducted for neonatal composite morbidity. RESULTS Of 1979 births, 181 pregnancies (188 neonates) with antepartum admission were included. 51 pregnancies (53 neonates, 28%) were delivered by emergent prelabor cesarean delivery compared with 130 pregnancies (135 neonates, 72%) admitted antepartum who subsequently did not require emergent delivery. The most common indication for emergent delivery was nonreassuring fetal heart tracing (44 pregnancies /51 emergent deliveries = 86%). Pregnant people who underwent emergent prelabor cesarean delivery were less likely to deliver at a transplant center (37.3% vs 41.5%; P=.04) and had increased rates of chronic hypertension (33.3% vs 16.2%; P=.02). There was no significant difference in severe maternal morbidity (3.9% vs 4.6%; P=.84), though there was an increase in surgical site infection in the emergent prelabor cesarean delivery cohort (3.9% vs 0%; P=.02). Among those with emergent prelabor cesarean delivery, there was a significant increase in neonatal composite morbidity (43.4% vs 19.3%; P<.001) with earlier gestational age at delivery (33.4 vs 34.7 weeks; P=.02), lower birthweight (1899 g vs 2321 g; P<.001), lower birthweight percentile (30.3% vs 40.6%; P=.03), increased neonatal intensive care unit admission (52.8% vs 35.6%; P=.03), and increased neonatal mortality (11.3% vs 1.5%; P=.002). After adjusting for year of conception, race, hypertensive disorders, and fetal malformations, there was a persistent increased risk of neonatal morbidity (adjusted odds ratio, 3.01; 95% confidence interval, 1.50-6.08; P=.002) associated with emergent prelabor cesarean delivery after transplant. CONCLUSION Almost one-third of kidney and liver transplant recipients admitted antepartum had an emergency prelabor cesarean delivery, and 63% of this cohort delivered outside of a transplant center. Pregnancies after transplantation should involve multidisciplinary transplant-obstetrics collaboration to ensure optimal antepartum disease management, especially for preexisting hypertension, to prevent and mitigate obstetrical and neonatal morbidity in the setting of emergent cesarean delivery.
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Affiliation(s)
- Kathleen Chung
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar)
| | - Ophelia Yin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar)
| | - Aneesh Kallapur
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar)
| | - Lauren Bass
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar)
| | - Lisa Coscia
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, PA (Ms Coscia and Drs Constantinescu and Moritz)
| | - Serban Constantinescu
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, PA (Ms Coscia and Drs Constantinescu and Moritz); Section of Nephrology, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA (Dr Constantinescu)
| | - Michael Moritz
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, PA (Ms Coscia and Drs Constantinescu and Moritz); Department of Surgery, Lehigh Valley Health Network, Allentown, PA (Dr Moritz); Department of Surgery, Morsani College of Medicine, Tampa, FL (Dr Moritz)
| | - Yalda Afshar
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar).
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Kanigalpula SPR, Murali A, Raveendranath A, Vadivelu P, Maurya DK, Keepanasseril A. Risk factors associated with unplanned caesarean section in women with placenta previa: a cohort study. J OBSTET GYNAECOL 2022; 42:1163-1168. [DOI: 10.1080/01443615.2022.2027892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Sri Padma Ravali Kanigalpula
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - Akshaya Murali
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - Anusha Raveendranath
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - Priyadarshini Vadivelu
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - Dilip Kumar Maurya
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - Anish Keepanasseril
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
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Ornaghi S, Vaglio Tessitore I, Vergani P. Pregnancy and Delivery Outcomes in Women With Persistent Versus Resolved Low-Lying Placenta in the Late Third Trimester. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:123-133. [PMID: 33675045 DOI: 10.1002/jum.15687] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/16/2021] [Accepted: 02/18/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES The safest mode of delivery in low-lying placenta is debatable. Little is known about outcomes in low-lying placenta resolved during the late third trimester. We compare outcomes of women with persistent versus resolved low-lying placenta. METHODS A retrospective analysis on a prospective cohort of women with low-lying placenta confirmed at 28-30 weeks sonography (01/2009 to 03/2018). Women were followed up serially every 2 to 3 weeks until delivery to assess the placental edge-to-internal os distance (IOD), and included if scan was performed within 28 days before delivery. RESULTS There were 86 women: in 21 the low-lying placenta resolved, whereas in 65 persisted (n = 15 IOD 1-10 mm, n = 50 IOD 11-20 mm). Antepartum bleeding associated with higher rates of urgent cesarean delivery in 1-10 mm (P = .041) but not in 11-20 mm (P = 1.000) and >20 mm (P = .333). Among women with IOD >10 mm allowed to labor, vaginal delivery occurred in 76.7% (11-20 mm) and 94.1% (>20 mm) (P = .155), with no difference according to parity (70% and 80% in multiparas, P = .696; 60% and 72.7% in nulliparas, P = .698). Severe PPH (P = .922) and hemoglobin drop (P = .109) were similar among groups. Women with IOD 11-20 mm and >20 mm and vaginal delivery bled less than women with similarly located placenta and cesarean delivery (P = .009 and P = .048). CONCLUSIONS Women with IOD >10 mm have high chances of deliver vaginally with no further increase of their hemorrhagic risk. Success of vaginal delivery is independent of parity and antepartum bleeding. Labor should be managed in an adequate hospital setting.
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Affiliation(s)
- Sara Ornaghi
- Department of Obstetrics and Gynecology, MBBM Foundation at San Gerardo Hospital, University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Isadora Vaglio Tessitore
- Department of Obstetrics and Gynecology, MBBM Foundation at San Gerardo Hospital, University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Patrizia Vergani
- Department of Obstetrics and Gynecology, MBBM Foundation at San Gerardo Hospital, University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
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9
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Febres-Cordero D, Young BC. Third-Trimester Vaginal Bleeding. Neoreviews 2021; 21:e580-e586. [PMID: 32737177 DOI: 10.1542/neo.21-8-e580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | - Brett C Young
- Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, Boston, MA
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10
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Karakoç G, Yalcin SE, Yavuz A, Sarsmaz K, Şengül M, Yucel A. Delta Neutrophil Index as a Promising Biomarker for Placental Implantation Disorders. Z Geburtshilfe Neonatol 2021; 225:412-417. [PMID: 34256391 DOI: 10.1055/a-1509-3676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We aimed to investigate the value of maternal serum delta neutrophil index (DNI) levels in predicting placenta accreta spectrum in patients with placenta previa. METHODS The patients who were found to have placenta previa totalis were included in our study. Location of placental implantation and depth of myometrial invasion were defined by transabdominal and transvaginal 2D gray scale and Doppler sonography and confirmed during cesarean section and histopathological evaluation. Patients were subjected to complete blood counts, including prenatal hemoglobin level, total white blood cell count, differential leukocyte count, and platelet count. The following formula was used to calculate the DNI level: DNI (%)=(leukocyte subfraction analyzed by cytochemical reaction in the MPO channel) - (leukocyte subfraction analyzed using the nuclear lobularity channel with reflected light beam measurements). RESULTS Placenta previa was detected in 295 patients; 31 of them had PAS. As the control group, 189 patients were evaluated. In the group with PAS, the DNI value was significantly higher (p<0.05) than the other groups. DNI value in the group with previa only was also significantly higher (p<0.05) than the control group. In the univariate model, a significant (p<0.05) effect of DNI value and number of cesarean sections was observed in separating patients with previa only and PAS. In the multivariate model, a significant independent (p>0.05) effect of the DNI value was observed in separating patients with previa only and PAS. Significant efficiency of DNI value [area under the curve 0.899 (0.814-0.984)] was observed in differentiating patients with previa only and PAS. Significant efficacy of DNI 5 cut-off value [area under the curve 0.858 (0.770-0.946)] was observed in distinguishing patients with previa only and PAS (sensitivity 80.0%, positive predictive value 64.9%, specificity 91.6%, negative predictive value 95.9%) CONCLUSION: Maternal DNI values seem to be beneficial with respect to both previa and invasion prediction. Although more comprehensive studies are needed to test this proposition, prediction studies of this practical test should be done in different trimesters and its usability with respect to preventing maternal-fetal morbidity should be investigated.
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Affiliation(s)
- Gökhan Karakoç
- Department of Perinatology, Izmir Katip Celebi University, Izmir, Turkey
| | - Serenat Eris Yalcin
- Department of Perinatology, Antalya Training and Research Hospital, Antalya, Turkey
| | - And Yavuz
- Department of Perinatology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Kemal Sarsmaz
- Etlik Zubeyde Hanim Women's Health Care, Training and Research Hospital, University of Heath Science, Ankara, Turkey
| | - Mustafa Şengül
- Department of Perinatology, Izmir Katip Celebi University, Izmir, Turkey
| | - Aykan Yucel
- Department of Perinatology, Ankara City Hospital, Ankara, Turkey
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Jain V, Bos H, Bujold E. Guideline No. 402: Diagnosis and Management of Placenta Previa. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 42:906-917.e1. [PMID: 32591150 DOI: 10.1016/j.jogc.2019.07.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 07/24/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To summarize the current evidence and to make recommendations for diagnosis and classification of placenta previa and for managing the care of women with this diagnosis. OPTIONS To manage in hospital or as an outpatient and to perform a cesarean delivery preterm or at term or to allow a trial of labour when a diagnosis of placenta previa or a low-lying placenta is suspected or confirmed. OUTCOMES Prolonged hospitalization, preterm birth, rate of cesarean delivery, maternal morbidity and mortality, and postnatal morbidity and mortality. INTENDED USERS Family physicians, obstetricians, midwives, and other maternal care providers. TARGET POPULATION Pregnant women with placenta previa or low-lying placenta. EVIDENCE Medline, PubMed, Embase, and the Cochrane Library were searched from inception to October 2018. Medical Subject Heading (MeSH) terms and key words related to pregnancy, placenta previa, low-lying placenta, antepartum hemorrhage, short cervical length, preterm labour, and cesarean. This document represents an abstraction of the evidence rather than a methodological review. VALIDATION METHODS This guideline has been reviewed by the Maternal-Fetal Medicine and Diagnostic Imaging committees of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and approved by the SOGC Board of Directors. BENEFITS, HARMS, AND/OR COSTS Women with placenta previa or low-lying placenta are at increased risk of maternal, fetal and postnatal adverse outcomes that include a potentially incorrect diagnosis and possibly unnecessary hospitalization, restriction of activities, early delivery, or cesarean delivery. Optimization of diagnosis and management protocols has potential to improve maternal, fetal and postnatal outcomes. SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES) RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).
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12
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Orgul G, Ayhan SG, Saracoglu GC, Yucel A. Is it Possible to Predict Massive Bleeding in Nulliparous Women with Placenta Previa? REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:9-13. [PMID: 33513630 PMCID: PMC10183915 DOI: 10.1055/s-0040-1721355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE We evaluated risk factors to determine if there were specific risk factors that could predict massive bleeding in nulliparous women with placenta previa. METHODS The participants were classified into two groups. Women with a calculated blood loss ≥ 1,000 mL were included in the massive bleeding group. Women without any signs or symptoms related with hypovolemia or with a calculated bleeding volume < 1,000 mL were categorized into the non-massive bleeding group. RESULTS There were 28 patients (40.6%) with massive bleeding and 41 cases (59.4%) with non-massive bleeding. The calculated blood loss and number of cases that required red cell transfusions were statistically different between the groups (< 0.005 and 0.002, respectively). There were no statistically significant differences in terms of maternal or fetal factors, placental location, or delivery characteristics between the two groups. CONCLUSION We could not determine the predictive features for massive hemorrhage based on clinical features, delivery features, or placental location.
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Affiliation(s)
- Gokcen Orgul
- Department of Perinatology, University of Health Sciences, Ankara, Turkey
| | - Sule Goncu Ayhan
- Department of Perinatology, University of Health Sciences, Ankara, Turkey
| | | | - Aykan Yucel
- Department of Perinatology, University of Health Sciences, Ankara, Turkey
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Jain V, Bos H, Bujold E. Directive clinique no 402 : Placenta prævia : Diagnostic et prise en charge. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:918-930.e1. [DOI: 10.1016/j.jogc.2020.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Retrospective Evaluation of Anesthetic Management in Cesarean Sections of Pregnant Women with Placental Anomaly. Anesthesiol Res Pract 2020; 2020:1358258. [PMID: 32411215 PMCID: PMC7210521 DOI: 10.1155/2020/1358258] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/09/2020] [Indexed: 11/17/2022] Open
Abstract
Background In this study, patients who underwent cesarean section and had placenta previa and placenta accreta were examined and compared in terms of haemorrhagic indicators and perioperative anesthetic management. Methods A retrospective study was conducted in a university hospital in Kahramanmaras, Turkey. It included 95 pregnant women who had placental anomaly and underwent cesarean section between December 15, 2014, and February 15, 2016. Results The pregnant women were divided into two groups: Group P (previa) (n = 67) and Group A (accreta) (n = 28). The types of anesthesia administered were general anesthesia (GA), which was administered to 50 patients (74.6%) in Group P and 27 patients (96.4%) in Group A, and spinal anesthesia (SA), which was administered to 17 patients (25.4%) in Group P and one patient (3.6%) in Group A.. The mean blood loss was 685.82 ± 262.82 in Group P and 1582.14 ± 790.71 in Group A, and the given amount of crystalloid was higher in Group A with an average of 1628.57 ± 728.19 ml. The use of erythrocyte and fresh frozen plasma solution was higher in Group A than Group P. Eleven patients were intubated and taken to the Intensive Care Unit (ICU) in Group A. Postoperative mechanical ventilation duration was significantly higher in Group A (75.14 ± 43.84 h) (p < 0.001). ICU stay was longer in Group A with 2.80 ± 1.13 days. (p < 0.001). Conclusion The intraoperative management and the availability of postoperative ICU conditions are important in placental anomalies cases. The communication between operation team with regard to the development of a standard protocol for these cases will be of great benefit in reducing morbidity and mortality.
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Kang J, Kim HS, Lee EB, Uh Y, Han KH, Park EY, Lee HA, Kang DR, Chung IB, Choi SJ. Prediction Model for Massive Transfusion in Placenta Previa during Cesarean Section. Yonsei Med J 2020; 61:154-160. [PMID: 31997624 PMCID: PMC6992462 DOI: 10.3349/ymj.2020.61.2.154] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/24/2019] [Accepted: 12/23/2019] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Recently, obstetric massive transfusion protocols have shifted toward early intervention. This study aimed to develop a prediction model for transfusion of ≥5 units of packed red blood cells (PRBCs) during cesarean section in women with placenta previa. MATERIALS AND METHODS We conducted a cohort study including 287 women with placenta previa who delivered between September 2011 and April 2018. Univariate and multivariate logistic regression analyses were used to test the association between clinical factors, ultrasound factors, and massive transfusion. For the external validation set, we obtained data (n=50) from another hospital. RESULTS We formulated a scoring model for predicting transfusion of ≥5 units of PRBCs, including maternal age, degree of previa, grade of lacunae, presence of a hypoechoic layer, and anterior placentation. For example, total score of 223/260 had a probability of 0.7 for massive transfusion. Hosmer-Lemeshow goodness-of-fit test indicated that the model was suitable (p>0.05). The area under the receiver operating characteristics curve (AUC) was 0.922 [95% confidence interval (CI) 0.89-0.95]. In external validation, the discrimination was good, with an AUC value of 0.833 (95% CI 0.70-0.92) for this model. Nomogram calibration plots indicated good agreement between the predicted and observed outcomes, exhibiting close approximation between the predicted and observed probability. CONCLUSION We constructed a scoring model for predicting massive transfusion during cesarean section in women with placenta previa. This model may help in determining the need to prepare an appropriate amount of blood products and the optimal timing of blood transfusion.
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Affiliation(s)
- Jieun Kang
- Department of Obstetrics and Gynecology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hye Sim Kim
- Center of Biomedical Data Science, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Eun Bi Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young Uh
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kyoung Hee Han
- Department of Obstetrics and Gynecology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Eun Young Park
- Department of Obstetrics and Gynecology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyang Ah Lee
- Department of Obstetrics and Gynecology, School of Medicine, Kangwon National University, Chuncheon, Korea
| | - Dae Ryong Kang
- Department of Precision Medicine and Biostatistics, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - In Bai Chung
- Department of Obstetrics and Gynecology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seong Jin Choi
- Department of Obstetrics and Gynecology, Yonsei University Wonju College of Medicine, Wonju, Korea.
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16
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Durukan H, Durukan ÖB, Yazıcı FG. Planned versus urgent deliveries in placenta previa: maternal, surgical and neonatal results. Arch Gynecol Obstet 2019; 300:1541-1549. [PMID: 31655886 DOI: 10.1007/s00404-019-05349-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 10/15/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Placenta previa is abnormal localization of the placenta, associated with high rates of maternal-fetal morbidity and mortality. This abnormal implantation may also be in the form of invasion to surroundings defined as placenta accreta spectrum (PAS). The increasing rates of cesarean section raise the frequency of placenta previa and PAS in recent years. Although there are some recommendations, the optimal timing of caesarean delivery concerning fetal and maternal benefits is still unclear. The aim of this study is to compare maternal, surgical and perinatal outcomes of placenta previa cases who underwent emergency or planned surgery. METHODS The women who underwent cesarean section for placenta previa between October 2013 and February 2019 at a tertiary care center were retrospectively analyzed. They were divided into two main groups as planned and urgent, and into two subgroups as complicated (PAS) and uncomplicated (non-PAS). RESULTS Of the 313 women who met the inclusion criteria, 176 were planned and 137 were urgent cesarean sections. In the urgent group, gestational age, duration of surgery, maternal preoperative and pre-discharge hemoglobin levels, requirement of blood and blood product, additional surgical interventions, length of maternal postoperative intensive care unit and hospital stay, neonatal birthweight, Apgar scores, length of the follow-up in neonatal intensive care unit, invasive and non-invasive mechanical ventilation were significantly different. CONCLUSIONS Maternal complication rates are increased in women who are operated on emergency conditions due to placenta previa. Perinatal outcomes are better in women who underwent planned surgery and in those with gestational age greater than 37 weeks.
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Affiliation(s)
- Hüseyin Durukan
- Obstetrics and Gynecology Department, Faculty of Medicine, Mersin University, 33343, Yenişehir, Mersin, Turkey.
| | - Ömer Birol Durukan
- Obstetrics and Gynecology Clinic, Mersin City Training and Research Hospital, Mersin, Turkey
| | - Faik Gürkan Yazıcı
- Obstetrics and Gynecology Department, Faculty of Medicine, Mersin University, 33343, Yenişehir, Mersin, Turkey
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Chen D, Xu J, Ye P, Li M, Duan X, Zhao F, Liu X, Wang X, Peng B. Risk scoring system with MRI for intraoperative massive hemorrhage in placenta previa and accreta. J Magn Reson Imaging 2019; 51:947-958. [PMID: 31507024 DOI: 10.1002/jmri.26922] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 08/21/2019] [Accepted: 08/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Placenta previa and accreta are serious obstetric conditions that are associated with a high risk of intraoperative massive hemorrhage. PURPOSE To develop a scoring system for intraoperative massive hemorrhage combining MRI and clinical characteristics to predict the risk of massive hemorrhage in placenta previa and accreta STUDY TYPE: Retrospective cohort study. SUBJECTS In all, 374 patients consisting of 259 patients with placenta previa and accreta after previous cesarean section (CS) for the derivation cohort and 115 patients for the validation cohort. FIELD STRENGTH/SEQUENCE 1.5T single-shot fast spin-echo sequence. [Correction added on October 23, 2019, after first online publication: The field strength in the preceding sentence was corrected.] ASSESSMENT: Using the derivation cohort, clinical and MRI data were collected and multivariable logistic regressions analysis was conducted to develop a scoring system for prediction of intraoperative massive bleeding (blood loss volume > 2000 mL). Finally, the scoring system was validated on 115 patients. STATISTICAL TESTS Student's t-test, Mann-Whitney U-test, X 2 statistics, multivariable analysis, and receiver operating characteristic (ROC) analysis. RESULTS Ten indicators, including clinically maternal age (1 point), preoperative hemoglobin level (1 point), gravidity number (1 point), number of CS (1 point), and MRI T2 dark intraplacental bands (4 points), cervical canal length (3 points), placenta thickness on the uterine scar area (4 points), empty vascular shadow of the uterus (1 point), low signal discontinuity in the muscular layer of the posterior wall of the bladder (6 points) and attachment position of the placenta (1 point) were imputed. From the ROC analysis, a total score of 7 points was identified as the optimal cutoff value, allowing good differentiation of intraoperative massive bleeding in the derivation cohort (AUC, 0.863; 95% confidence interval [CI]: 0.811-0.916) and in the validation cohort (AUC, 0.933; 95% CI: 0.885-0.980). DATA CONCLUSION The scoring system for intraoperative massive hemorrhage consists of MRI and clinical indicators, and using a cutoff value of 7 points for a high risk of massive bleeding, the developed scoring system could accurately assess the risk of intraoperative massive hemorrhage in patients with placenta previa and accreta. This scoring system can potentially reduce the incidence of intraoperative massive bleeding by identifying patients at high risk. LEVEL OF EVIDENCE 3 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2020;51:947-958.
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Affiliation(s)
- Daijuan Chen
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University and the Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China.,West China School of Medicine, Sichuan University, Sichuan, China
| | - Jinfeng Xu
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University and the Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China.,West China School of Medicine, Sichuan University, Sichuan, China
| | - Pengfei Ye
- Department of Radiology, West China Second University Hospital, Sichuan University, Sichuan, China
| | - Mier Li
- West China School of Medicine, Sichuan University, Sichuan, China.,West China School of Public Health, Sichuan University, Sichuan, China
| | - Xia Duan
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University and the Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China.,West China School of Medicine, Sichuan University, Sichuan, China
| | - Fumin Zhao
- Department of Radiology, West China Second University Hospital, Sichuan University, Sichuan, China
| | - Xinghui Liu
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University and the Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
| | - Xiaodong Wang
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University and the Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
| | - Bing Peng
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University and the Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
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18
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Grönvall M, Stefanovic V, Paavonen J, Loukovaara M, Tikkanen M. Major or minor placenta previa: Does it make a difference? Placenta 2019; 85:9-14. [DOI: 10.1016/j.placenta.2019.08.080] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/22/2019] [Accepted: 08/07/2019] [Indexed: 11/15/2022]
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Abstract
Bleeding in late-term pregnancy can present as an innocuous start to parturition or a catastrophic maternal-fetal hemorrhage masked by the physiologic adaptations of pregnancy. The emergency management of late-term bleeding can be challenging, especially when providing stabilizing care in a limited-resource environment. Early recognition of life-threatening vaginal bleeding, potential causes, and emergency management of maternal-fetal distress is reviewed. Maternal resuscitation with balanced versus targeted blood products replacement is presented for low-resource versus high-resource environments. Emergency department readiness for such a patient, in combination with appropriate consultation or transfer, is essential to the effective management of late-term vaginal bleeding.
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Affiliation(s)
- Janet S Young
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Carilion Medical Center, 1 Riverside Circle, 4th Floor Admin, Roanoke, VA 24016, USA.
| | - Lindsey M White
- Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, 1 Riverside Circle, 4th Floor Admin, Roanoke, VA 24016, USA
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21
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Abstract
Placenta accreta spectrum, formerly known as morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta. The most favored hypothesis regarding the etiology of placenta accreta spectrum is that a defect of the endometrial-myometrial interface leads to a failure of normal decidualization in the area of a uterine scar, which allows abnormally deep placental anchoring villi and trophoblast infiltration. Maternal morbidity and mortality can occur because of severe and sometimes life-threatening hemorrhage, which often requires blood transfusion. Although ultrasound evaluation is important, the absence of ultrasound findings does not preclude a diagnosis of placenta accreta spectrum; thus, clinical risk factors remain equally important as predictors of placenta accreta spectrum by ultrasound findings. There are several risk factors for placenta accreta spectrum. The most common is a previous cesarean delivery, with the incidence of placenta accreta spectrum increasing with the number of prior cesarean deliveries. Antenatal diagnosis of placenta accreta spectrum is highly desirable because outcomes are optimized when delivery occurs at a level III or IV maternal care facility before the onset of labor or bleeding and with avoidance of placental disruption. The most generally accepted approach to placenta accreta spectrum is cesarean hysterectomy with the placenta left in situ after delivery of the fetus (attempts at placental removal are associated with significant risk of hemorrhage). Optimal management involves a standardized approach with a comprehensive multidisciplinary care team accustomed to management of placenta accreta spectrum. In addition, established infrastructure and strong nursing leadership accustomed to managing high-level postpartum hemorrhage should be in place, and access to a blood bank capable of employing massive transfusion protocols should help guide decisions about delivery location.
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Jauniaux E, Alfirevic Z, Bhide AG, Belfort MA, Burton GJ, Collins SL, Dornan S, Jurkovic D, Kayem G, Kingdom J, Silver R, Sentilhes L. Placenta Praevia and Placenta Accreta: Diagnosis and Management: Green-top Guideline No. 27a. BJOG 2018; 126:e1-e48. [PMID: 30260097 DOI: 10.1111/1471-0528.15306] [Citation(s) in RCA: 218] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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da Cunha Castro EC, Popek E. Abnormalities of placenta implantation. APMIS 2018; 126:613-620. [DOI: 10.1111/apm.12831] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 02/12/2018] [Indexed: 12/27/2022]
Affiliation(s)
- Eumenia Costa da Cunha Castro
- Department of Pathology and Immunology; Texas Children's Hospital; Pavilion for Women; Baylor College of Medicine; Houston TX USA
| | - Edwina Popek
- Department of Pathology and Immunology; Texas Children's Hospital; Pavilion for Women; Baylor College of Medicine; Houston TX USA
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Alsayegh E, Barrett J, Melamed N. Optimal timing of antenatal corticosteroids in women with bleeding placenta previa or low-lying placenta. J Matern Fetal Neonatal Med 2018; 32:1971-1977. [DOI: 10.1080/14767058.2017.1422713] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Eman Alsayegh
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Jon Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
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Lee JY, Ahn EH, Kang S, Moon MJ, Jung SH, Chang SW, Cho HY. Scoring model to predict massive post-partum bleeding in pregnancies with placenta previa: A retrospective cohort study. J Obstet Gynaecol Res 2017; 44:54-60. [PMID: 29067758 DOI: 10.1111/jog.13480] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 07/17/2017] [Indexed: 11/29/2022]
Abstract
AIM We aimed to identify factors associated with massive post-partum bleeding in pregnancies with placenta previa and to establish a scoring model to predict post-partum severe bleeding. METHODS A retrospective cohort study was performed in 506 healthy singleton pregnancies with placenta previa from 2006 to 2016. Cases with intraoperative blood loss (≥2000 mL), packed red blood cells transfusion (≥4), uterine artery embolization, or hysterectomy were defined as massive bleeding. After performing multivariable analysis, using the adjusted odds ratios (aOR), we formulated a scoring model. RESULTS Seventy-three women experienced massive post-partum bleeding (14.4%). After multivariable analysis, seven variables were associated with massive bleeding: maternal old age (≥35 years; aOR 1.79, 95% confidence interval [CI] 1.00-3.20, P = 0.049), antepartum bleeding (aOR 4.76, 95%CI 2.01-11.02, P < 0.001), non-cephalic presentation (aOR 3.41, 95%CI 1.40-8.30, P = 0.007), complete placenta previa (aOR 1.93, 95%CI 1.05-3.54, P = 0.034), anterior placenta (aOR 2.74, 95%CI 1.54-4.89, P = 0.001), multiple lacunae (≥4; aOR 2.77, 95%CI 1.54-4.99, P = 0.001), and uteroplacental hypervascularity (aOR 4.51, 95%CI 2.30-8.83, P < 0.001). We formulated a scoring model including maternal old age (<35: 0, ≥35: 1), antepartum bleeding (no: 0, yes: 2), fetal non-cephalic presentation (no: 0, yes: 2), placenta previa type (incomplete: 0, complete: 1), placenta location (posterior: 0, anterior: 1), uteroplacental hypervascularity (no: 0, yes: 2), and multiple lacunae (no: 0, yes: 1) to predict post-partum massive bleeding. According to our scoring model, a score of 5/10 had a sensitivity of 81% and a specificity of 77% for predicting massive post-partum bleeding. The area under the receiver-operator curve was 0.856 (P < 0.001). The negative predictive value was 95.9%. CONCLUSION Our scoring model might provide useful information for prediction of massive post-partum bleeding in pregnancies with placenta previa.
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Affiliation(s)
- Ji Yeon Lee
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, South Korea
| | - Eun Hee Ahn
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, South Korea
| | - Sukho Kang
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, South Korea
| | - Myung Jin Moon
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, South Korea
| | - Sang Hee Jung
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, South Korea
| | - Sung Woon Chang
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, South Korea
| | - Hee Young Cho
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, South Korea
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Risk factors for massive postpartum bleeding in pregnancies in which incomplete placenta previa are located on the posterior uterine wall. Obstet Gynecol Sci 2017; 60:520-526. [PMID: 29184859 PMCID: PMC5694725 DOI: 10.5468/ogs.2017.60.6.520] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/15/2017] [Accepted: 04/20/2017] [Indexed: 11/17/2022] Open
Abstract
Objective To identify factors associated with massive postpartum bleeding in pregnancies complicated by incomplete placenta previa located on the posterior uterine wall. Methods A retrospective case-control study was performed. We identified 210 healthy singleton pregnancies with incomplete placenta previa located on the posterior uterine wall, who underwent elective or emergency cesarean section after 24 weeks of gestation between January 2006 and April 2016. The cases with intraoperative blood loss (≥2,000 mL) or transfusion of packed red blood cells (≥4) or uterine artery embolization or hysterectomy were defined as massive bleeding. Results Twenty-three women experienced postpartum profuse bleeding (11.0%). After multivariable analysis, 4 variables were associated with massive postpartum hemorrhage (PPH): experience of 2 or more prior uterine curettage (adjusted odds ratio [aOR], 4.47; 95% confidence interval [CI], 1.29 to 15.48; P=0.018), short cervical length before delivery (<2.0 cm) (aOR, 7.13; 95% CI, 1.01 to 50.25; P=0.049), fetal non-cephalic presentation (aOR, 12.48; 95% CI, 1.29 to 121.24; P=0.030), and uteroplacental hypervascularity (aOR, 6.23; 95% CI, 2.30 to 8.83; P=0.001). Conclusion This is the first study of cases with incomplete placenta previa located on the posterior uterine wall, which were complicated by massive PPH. Our findings might be helpful to guide obstetric management and provide useful information for prediction of massive PPH in pregnancies with incomplete placenta previa located on the posterior uterine wall.
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Orbach-Zinger S, Weiniger CF, Aviram A, Balla A, Fein S, Eidelman LA, Ioscovich A. Anesthesia management of complete versus incomplete placenta previa: a retrospective cohort study. J Matern Fetal Neonatal Med 2017; 31:1171-1176. [PMID: 28335653 DOI: 10.1080/14767058.2017.1311315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Placenta previa (PP) is a major cause of obstetric hemorrhage. Clinical diagnosis of complete versus incomplete PP has a significant impact on the peripartum outcome. Our study objective is to examine whether distinction between PP classifications effect anesthetic management. METHODS AND MATERIALS This multi-center, retrospective, cohort study was performed in two tertiary university-affiliated medical centers between the years 2005 and 2013. Electronic delivery databases were reviewed for demographic, anesthetic, obstetric hemorrhage, and postoperative outcomes for all cases. RESULTS Throughout the study period 452 cases of PP were documented. We found 134 women (29.6%) had a complete PP and 318 (70.4%) had incomplete PP. Our main findings were that women with complete PP intraoperatively had higher incidence of general anesthesia (p = .017), higher mean estimated blood loss (p < .001), increased blood components transfusions (p < .001), and significant increase in cesarean hysterectomy rate (p < .001) than women with incomplete PP. Additionally, complete PP was associated with more postoperative complications: higher incidence of admission to the intensive care unit (ICU) (p < .001), more mechanical ventilation (p = .02), a longer median postoperative care unit (PACU) (p = .02), ICU (p = .002), and overall length of stay in the hospital (p < .001). CONCLUSIONS Complete PP is associated with increased risk of hemorrhage compared with incomplete PP. Therefore distinction between classifications should be factored into anesthetic management protocols.
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Affiliation(s)
- Sharon Orbach-Zinger
- a Department of Anesthesia , Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University , Tel-Aviv , Israel
| | - Carolyn F Weiniger
- b Department of Anesthesia , Hadassah Hebrew University Medical Center , Jerusalem , Israel
| | - Amir Aviram
- c Lis Maternity and Women's Hospital, Tel-Aviv Sourasky Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University , Tel-Aviv , Israel
| | - Alexander Balla
- a Department of Anesthesia , Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University , Tel-Aviv , Israel
| | - Shai Fein
- a Department of Anesthesia , Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University , Tel-Aviv , Israel
| | - Leonid A Eidelman
- a Department of Anesthesia , Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University , Tel-Aviv , Israel
| | - Alexander Ioscovich
- d Department of Anesthesia , Shaare Zedek Medical Center , Jerusalem , Israel
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Gibbins KJ, Einerson BD, Varner MW, Silver RM. Placenta previa and maternal hemorrhagic morbidity. J Matern Fetal Neonatal Med 2017; 31:494-499. [PMID: 28140723 DOI: 10.1080/14767058.2017.1289163] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Placenta previa is associated with maternal hemorrhage, but most literature focuses on morbidity in the setting of placenta accreta. We aim to characterize maternal morbidity associated with previa and to define risk factors for hemorrhage. METHODS This is a secondary cohort analysis of the NICHD Maternal-Fetal Medicine Units Network Cesarean Section Registry. This analysis included all women undergoing primary Cesarean delivery without placenta accreta. About 496 women with previa were compared with 24,201 women without previa. Primary outcome was composite maternal hemorrhagic morbidity. Non-hemorrhagic morbidities and risk factors for hemorrhage were also evaluated. RESULTS Maternal hemorrhagic morbidity was more common in women with previa (19 versus 7%, aRR 2.6, 95% CI 1.9-3.5). Atony requiring uterotonics (aRR 3.1, 95% CI 2.0-4.9), red blood cell transfusion (aRR 3.8, 95% CI 2.5-5.7), and hysterectomy (aRR 5.1, 95% CI 1.5-17.3) were also more common with previa. For women with previa, factors associated with maternal hemorrhage were pre-delivery anemia, thrombocytopenia, diabetes, magnesium use, and general anesthesia. CONCLUSION Placenta previa is an independent risk factor for maternal hemorrhagic morbidity. Some risk factors are modifiable, but many are intrinsic to the clinical scenario.
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Affiliation(s)
- Karen J Gibbins
- a Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , University of Utah School of Medicine , Salt Lake City , UT , USA.,b Intermountain Healthcare Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , Salt Lake City , UT , USA
| | - Brett D Einerson
- a Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , University of Utah School of Medicine , Salt Lake City , UT , USA.,b Intermountain Healthcare Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , Salt Lake City , UT , USA
| | - Michael W Varner
- a Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , University of Utah School of Medicine , Salt Lake City , UT , USA.,b Intermountain Healthcare Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , Salt Lake City , UT , USA
| | - Robert M Silver
- a Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , University of Utah School of Medicine , Salt Lake City , UT , USA.,b Intermountain Healthcare Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , Salt Lake City , UT , USA
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Coskun B, Akkurt I, Dur R, Akkurt MO, Ergani SY, Turan OT, Coskun B. Prediction of maternal near-miss in placenta previa: a retrospective analysis from a tertiary center in Ankara, Turkey. J Matern Fetal Neonatal Med 2017; 31:370-375. [DOI: 10.1080/14767058.2017.1285896] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Bora Coskun
- Department of Obstetrics and Gynecology, Polatlı State Hospital, Ankara, Turkey
| | - Iltac Akkurt
- Department of Obstetrics and Gynecology, Isparta Maternity and Children’s Hospital, Isparta, Turkey
| | - Rıza Dur
- Department of Obstetrics and Gynecology, Etlik Zubeyde Hanim Maternity and Women’s Health Teaching and Research Hospital, Ankara, Turkey
| | - Mehmet O. Akkurt
- Faculty of Medicine, Department of Obstetrics and Gynecology, Division of Perinatology, Suleyman Demirel University, Isparta, Turkey
| | - Seval Y. Ergani
- Department of Obstetrics and Gynecology, Etlik Zubeyde Hanim Maternity and Women’s Health Teaching and Research Hospital, Ankara, Turkey
| | - Ozerk T. Turan
- College of Arts and Sciences, University of Miami, Coral Gables, FL, USA
| | - Bugra Coskun
- Department of Obstetrics and Gynecology, Sincan State Hospital, Ankara, Turkey
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Fan D, Wu S, Liu L, Xia Q, Wang W, Guo X, Liu Z. Prevalence of antepartum hemorrhage in women with placenta previa: a systematic review and meta-analysis. Sci Rep 2017; 7:40320. [PMID: 28067303 PMCID: PMC5220286 DOI: 10.1038/srep40320] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 12/05/2016] [Indexed: 01/20/2023] Open
Abstract
Antepartum hemorrhage (APH) is an important cause of perinatal mortality and maternal morbidity in pregnant women with placenta previa in the world. However, the epidemiological characteristics are not completely understood. We performed an initial systematic review and meta-analysis to assess the prevalence of APH in pregnant women with placenta previa. It was totally performed following the Preferred Reporting Items for Systematic reviews and Meta-Analysis statement. PubMed, Elsevier Science Direct, and the Cochrane Library were searched before April 2016. A meta-analysis with a random-effects model based on a proportions approach was performed to determine the prevalence. Stratified analyses, meta-regression method, and sensitivity analysis were utilized to analyze the heterogeneity. A total of 29 articles were included. The pooled overall prevalence of APH among pregnant women with placenta previa was 51.6% (95% CI 42.7-60.6) in a heterogeneous set of studies (I2 = 97.9). Correlation analysis found that there was a positive correlation between prevalence and percentage of multiparous (r = 0.534, P = 0.027) and a negative correlation between prevalence and survey year (r = -0.400, P = 0.031). In conclusion, the prevalence of APH was a high condition among pregnant women with placenta previa.
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Affiliation(s)
- Dazhi Fan
- Department of Obsterics, South Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, Guangdong, 528000, China
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, 230032, China
| | - Song Wu
- School of Integrated Traditional and Western Medicine, Anhui University of Chinese Medicine, Hefei, Anhui, 230038, China
| | - Li Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, 230032, China
- Department of Library, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, China
| | - Qing Xia
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, 230032, China
| | - Wen Wang
- Department of Obsterics, South Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, Guangdong, 528000, China
| | - Xiaoling Guo
- Department of Obsterics, South Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, Guangdong, 528000, China
| | - Zhengping Liu
- Department of Obsterics, South Medical University Affiliated Maternal & Child Health Hospital of Foshan, Foshan, Guangdong, 528000, China
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Mastrolia SA, Baumfeld Y, Loverro G, Yohai D, Hershkovitz R, Weintraub AY. Placenta previa associated with severe bleeding leading to hospitalization and delivery: a retrospective population-based cohort study. J Matern Fetal Neonatal Med 2016; 29:3467-71. [PMID: 26653989 DOI: 10.3109/14767058.2015.1131264] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION The aim of our study was to compare maternal and neonatal outcomes in women with placenta previa complicated with severe bleeding leading to hospitalization until delivery versus those without severe bleeding episodes. METHODS This is a population-based retrospective cohort study including all pregnant women with placenta previa who delivered at our medical center in the study period, divided into the following groups: 1) women with severe bleeding leading to hospitalization resulting with delivery (n = 32); 2) patients with placenta previa without severe bleeding episodes (n = 1217). RESULTS Out of all women with placenta previa who delivered at our medical center, 2.6% (32/1249) had an episode of severe bleeding leading to hospitalization and resulting with delivery. The rate of anemia was lower (43.8% versus 63.7%, p = 0.02) while the need for blood transfusion higher (37.5% versus 21.1%, p = 0.03) in the study group. The rate of cesarean sections was significantly different between the groups, and a logistic regression model was constructed in order to find independent risk factors for cesarean section in our patients. CONCLUSION To the best of our knowledge, this is the first study to evaluate the impact of severe bleeding on the outcome of pregnancies complicated with placenta previa. Our study demonstrates that, in women with placenta previa, severe bleeding does not lead to increased adverse maternal or neonatal outcomes.
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Affiliation(s)
- Salvatore Andrea Mastrolia
- a Department of Obstetrics and Gynecology, Faculty of Health Sciences , Soroka University Medical Center, Ben-Gurion University of the Negev , Be'er Sheva , Israel and.,b Department of Obstetrics and Gynecology , Azienda Ospedaliera Universitaria Policlinico Di Bari, School of Medicine, University of Bari "Aldo Moro" , Bari , Italy
| | - Yael Baumfeld
- a Department of Obstetrics and Gynecology, Faculty of Health Sciences , Soroka University Medical Center, Ben-Gurion University of the Negev , Be'er Sheva , Israel and
| | - Giuseppe Loverro
- b Department of Obstetrics and Gynecology , Azienda Ospedaliera Universitaria Policlinico Di Bari, School of Medicine, University of Bari "Aldo Moro" , Bari , Italy
| | - David Yohai
- a Department of Obstetrics and Gynecology, Faculty of Health Sciences , Soroka University Medical Center, Ben-Gurion University of the Negev , Be'er Sheva , Israel and
| | - Reli Hershkovitz
- a Department of Obstetrics and Gynecology, Faculty of Health Sciences , Soroka University Medical Center, Ben-Gurion University of the Negev , Be'er Sheva , Israel and
| | - Adi Yehuda Weintraub
- a Department of Obstetrics and Gynecology, Faculty of Health Sciences , Soroka University Medical Center, Ben-Gurion University of the Negev , Be'er Sheva , Israel and
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