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Lee KN, Kim MK, Choi BY, Lee GM, Kim HJ, Park JY. Effect of pelvic artery embolization for postpartum hemorrhage on subsequent pregnancies: a single-center retrospective cohort study. J Matern Fetal Neonatal Med 2024; 37:2296360. [PMID: 38146176 DOI: 10.1080/14767058.2023.2296360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/13/2023] [Indexed: 12/27/2023]
Abstract
OBJECTIVE Pelvic artery embolization (PAE) is a uterus-saving treatment for postpartum hemorrhage (PPH); however, subfertility or abnormal placentation for subsequent pregnancy has been a concern in several previous reports. This study aimed to investigate the impact of PAE on subsequent pregnancies in women with a history of PPH. METHODS A retrospective cohort study was conducted on women transferred to the tertiary center for PPH and delivered for the next pregnancy at the same center later. The study group was divided into two groups based on PAE application to treat previous PPH. RESULTS Of the 62 women included, 66% (41/62) had received PAE for the previous PPH, while 21 had not. Pregnancy outcomes for subsequent pregnancies were compared between the PAE and non-PAE groups. The PAE group had a higher estimated blood loss volume for the present delivery than the non-PAE group (600 vs. 300 mL, p = 0.008). The PAE group also demonstrated a higher incidence of placenta previa (4.8% vs. 24.4%, p = 0.080) and placenta accreta (0% vs. 14.6%, p = 0.082) than the non-PAE group, although the difference was not statistically significant. CONCLUSION These findings suggest that the use of PAE to treat PPH may increase the risk of bleeding, placenta previa, and placenta accreta spectrum in subsequent pregnancies.
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Affiliation(s)
- Kyong-No Lee
- Department of Obstetrics and Gynecology, Chungnam National University Hospital, Daejeon, Korea
| | - Min Kyung Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Bo Young Choi
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Guy Mok Lee
- Department of Radiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Hyeon Ji Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Jee Yoon Park
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
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Muadtongon K, Rattanaburi A, Ajimakul T, Suphasynth Y, Jiamset I, Nantamongkolkul K, Suntharasaj T, Suwanrath C, Pruksanusak N, Petpichetchian C, Suksai M, Chainarong N, Sawaddisan R, Pranpanus S. Successful multidisciplinary team management of placenta accreta spectrum disorder: A referral center model in a middle-income country. Int J Gynaecol Obstet 2024; 165:813-822. [PMID: 38189162 DOI: 10.1002/ijgo.15339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/12/2023] [Accepted: 12/14/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVE The aim of the study was to evaluate the outcomes of placenta accreta spectrum (PAS) disorder managed by a multidisciplinary care team (MCT) compared with a conventional care team (CCT) in a PAS referral center in Thailand. METHODS This retrospective single-center cohort study analyzed PAS management outcomes in the PSU PAS Center between January 2010 and December 2022. The incidence of hemorrhage ≥3500 mL and the composite maternal and neonatal outcomes of PAS were compared before and after the introduction of an MCT in 2016. RESULTS Of 227 PAS cases, 219 (96.5%) had pathological confirmation. There were 52 (22.9%) cases of placenta accreta, 119 (52.4%) cases of placenta increta, and 56 (24.7%) cases of placenta percreta. The incidence of estimated blood loss (EBL) ≥3500 mL decreased from 61.8% to 34.3% (P < 0.001) after the establishment of the MCT. The median EBL decreased from 4000 (IQR: 2600,7250) mL to 2250 (1300, 4750) mL (P < 0.001). EBL reduction was statistically significant in the accreta and increta groups (P < 0.001). Red blood cell transfusions decreased from five (3, 9) to two (1, 6) units (P < 0.001) per patient. The length of maternal hospital stays and ICU admissions were statistically shorter when PAS was managed by an MCT (P < 0.001). The length of newborn hospital and ICU stays decreased significantly (P < 0.001). CONCLUSION The incidence of massive postpartum hemorrhage and a composite of maternal and neonatal morbidities in pregnant women with PAS disorder improved significantly after the establishment of an MCT to manage PAS in a middle-income country setting.
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Affiliation(s)
- Kan Muadtongon
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Athithan Rattanaburi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thiti Ajimakul
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Yuthasak Suphasynth
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Ingporn Jiamset
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Kulisara Nantamongkolkul
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thitima Suntharasaj
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Chitkasaem Suwanrath
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Ninlapa Pruksanusak
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Chusana Petpichetchian
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Manaphat Suksai
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Natthicha Chainarong
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Rapphon Sawaddisan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Savitree Pranpanus
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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Afshar Y, Yin O, Jeong A, Martinez G, Kim J, Ma F, Jang C, Tabatabaei S, You S, Tseng HR, Zhu Y, Krakow D. Placenta accreta spectrum disorder at single-cell resolution: a loss of boundary limits in the decidua and endothelium. Am J Obstet Gynecol 2024; 230:443.e1-443.e18. [PMID: 38296740 DOI: 10.1016/j.ajog.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/25/2023] [Accepted: 10/01/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Placenta accreta spectrum disorders are associated with severe maternal morbidity and mortality. Placenta accreta spectrum disorders involve excessive adherence of the placenta preventing separation at birth. Traditionally, this condition has been attributed to excessive trophoblast invasion; however, an alternative view is a fundamental defect in decidual biology. OBJECTIVE This study aimed to gain insights into the understanding of placenta accreta spectrum disorder by using single-cell and spatially resolved transcriptomics to characterize cellular heterogeneity at the maternal-fetal interface in placenta accreta spectrum disorders. STUDY DESIGN To assess cellular heterogeneity and the function of cell types, single-cell RNA sequencing and spatially resolved transcriptomics were used. A total of 12 placentas were included, 6 placentas with placenta accreta spectrum disorder and 6 controls. For each placenta with placenta accreta spectrum disorder, multiple biopsies were taken at the following sites: placenta accreta spectrum adherent and nonadherent sites in the same placenta. Of note, 2 platforms were used to generate libraries: the 10× Chromium and NanoString GeoMX Digital Spatial Profiler for single-cell and spatially resolved transcriptomes, respectively. Differential gene expression analysis was performed using a suite of bioinformatic tools (Seurat and GeoMxTools R packages). Correction for multiple testing was performed using Clipper. In situ hybridization was performed with RNAscope, and immunohistochemistry was used to assess protein expression. RESULTS In creating a placenta accreta cell atlas, there were dramatic difference in the transcriptional profile by site of biopsy between placenta accreta spectrum and controls. Most of the differences were noted at the site of adherence; however, differences existed within the placenta between the adherent and nonadherent site of the same placenta in placenta accreta. Among all cell types, the endothelial-stromal populations exhibited the greatest difference in gene expression, driven by changes in collagen genes, namely collagen type III alpha 1 chain (COL3A1), growth factors, epidermal growth factor-like protein 6 (EGFL6), and hepatocyte growth factor (HGF), and angiogenesis-related genes, namely delta-like noncanonical Notch ligand 1 (DLK1) and platelet endothelial cell adhesion molecule-1 (PECAM1). Intraplacental tropism (adherent versus non-adherent sites in the same placenta) was driven by differences in endothelial-stromal cells with notable differences in bone morphogenic protein 5 (BMP5) and osteopontin (SPP1) in the adherent vs nonadherent site of placenta accreta spectrum. CONCLUSION Placenta accreta spectrum disorders were characterized at single-cell resolution to gain insight into the pathophysiology of the disease. An atlas of the placenta at single cell resolution in accreta allows for understanding in the biology of the intimate maternal and fetal interaction. The contributions of stromal and endothelial cells were demonstrated through alterations in the extracellular matrix, growth factors, and angiogenesis. Transcriptional and protein changes in the stroma of placenta accreta spectrum shift the etiologic explanation away from "invasive trophoblast" to "loss of boundary limits" in the decidua. Gene targets identified in this study may be used to refine diagnostic assays in early pregnancy, track disease progression over time, and inform therapeutic discoveries.
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Affiliation(s)
- Yalda Afshar
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA; Molecular Biology Institute, University of California, Los Angeles, Los Angeles, CA.
| | - Ophelia Yin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA; Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
| | - Anhyo Jeong
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Guadalupe Martinez
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Jina Kim
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Feiyang Ma
- Department of Molecular, Cell, and Developmental Biology, University of California, Los Angeles, Los Angeles, CA
| | - Christine Jang
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Sarah Tabatabaei
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Sungyong You
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA; Department of Computational Biomedicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Hsian-Rong Tseng
- Department of Molecular and Medical Pharmacology, California NanoSystems Institute, Crump Institute for Molecular Imaging, Los Angeles, CA
| | - Yazhen Zhu
- Department of Molecular and Medical Pharmacology, California NanoSystems Institute, Crump Institute for Molecular Imaging, Los Angeles, CA; Department of Pathology, University of California, Los Angeles, Los Angeles, CA
| | - Deborah Krakow
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA; Departments of Orthopedic Surgery and Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
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Chen F, Zhang C, Hu Y. Efficacy of Bakri Intrauterine Balloon in Managing Postpartum Hemorrhage: A Comparative Analysis of Vaginal and Cesarean Deliveries with Placenta Accreta Spectrum Disorders. Med Sci Monit 2024; 30:e943072. [PMID: 38433445 PMCID: PMC10921967 DOI: 10.12659/msm.943072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/03/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND The incidence of placenta accreta spectrum disorder (PAS) has been increasing in past decades, and women with PAS are a high-risk maternal population. This study aimed to explore the performance of Bakri intrauterine balloon tamponade (IUBT) in the treatment of postpartum hemorrhage (PPH), among those with and without PAS. MATERIAL AND METHODS The outcomes of 198 women who underwent treatment for PPH using IUBT were retrospectively analyzed. The demographics and maternal outcomes were analyzed for vaginal and cesarean births, with PAS and without PAS. RESULTS Compared to women with vaginal births (n=130), women who underwent cesarean births (n=68) showed a higher proportion of age ≥35 years (χ²=6.85, P=0.013), multiple births (χ²=13.60, P<0.001), preeclampsia (χ²=9.81, P=0.002), use of transabdominal IUBT (χ²=84.12, P<0.001) and pre-IUBT interventions (χ²=41.61, P<0.001), but had less infused volume of physiological saline (t=6.41, P<0.001). Women with PAS (n=105) showed a higher rate of pre-IUBT intervention (χ²=4.96, P=0.029) and transabdominal IUBT placement (χ²=9.37, P=0.002) than non-PAS women (n=93). The 36 women with PAS (n=36) showed a higher rate of preeclampsia (χ²=4.80, P=0.029), pre-IUBT intervention (χ²=5.90, P=0.015), and transabdominal IUBT placement (χ²=14.94, P<0.001) and a shorter duration from delivery to Bakri insertion (χ²=3.31, P=0.002), than non-PAS women (n=32). CONCLUSIONS PAS was a major cause of PPH at 198 vaginal and cesarean births. An accurate and timely pre-IUBT intervention and Bakri IUBT placement was critical for controlling PPH in cesarean births, especially in women with PAS.
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Kloka JA, Friedrichson B, Jasny T, Blum LV, Choorapoikayil S, Old O, Zacharowski K, Neef V. Anaemia and red blood cell transfusion in women with placenta accreta spectrum: an analysis of 38,060 cases. Sci Rep 2024; 14:4999. [PMID: 38424178 PMCID: PMC10904858 DOI: 10.1038/s41598-024-55531-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 02/24/2024] [Indexed: 03/02/2024] Open
Abstract
Placenta accreta spectrum (PAS) has become a significant life-threatening issue due to its increased incidence and associated morbidity and mortality. Pregnancy is often associated with states of anaemia, and severe maternal haemorrhage represents a major risk factor for red blood cell (RBC) transfusion. The present study retrospectively analyzed the prevalence of anaemia, transfusion requirements and outcome in women with PAS. Using data from the German Statistical Office pregnant patients with deliveries hospitalized between January 2012 and December 2021 were included. Primary outcome was the prevalence of anemia and administration of RBCs. Secondary outcome were complications in women with PAS who received RBC transfusion. In total 6,493,606 pregnant women were analyzed, of which 38,060 (0.59%) were diagnosed with PAS. The rate of anaemia during pregnancy (60.36 vs. 23.25%; p < 0.0001), postpartum haemorrhage (47.08 vs. 4.41%; p < 0.0001) and RBC transfusion rate (14.68% vs. 0.72%; p < 0.0001) were higher in women with PAS compared to women without PAS. Women with PAS who had bleeding and transfusion experienced significantly more peripartum complications than those who did not. A multiple logistic regression revealed that the probability for RBC transfusion in all pregnant women was positively associated with anaemia (OR 21.96 (95% CI 21.36-22.58)). In women with PAS, RBC transfusion was positively associated with the presence of renal failure (OR 11.27 (95% CI 9.35-13.57)) and congestive heart failure (OR 6.02 (95% CI (5.2-7.07)). Early anaemia management prior to delivery as well as blood conservation strategies are crucial in women diagnosed with PAS.
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Affiliation(s)
- Jan Andreas Kloka
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital, Theodor-Stern Kai 7, 60590, Frankfurt, Germany
| | - Benjamin Friedrichson
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital, Theodor-Stern Kai 7, 60590, Frankfurt, Germany
| | - Thomas Jasny
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital, Theodor-Stern Kai 7, 60590, Frankfurt, Germany
| | - Lea Valeska Blum
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital, Theodor-Stern Kai 7, 60590, Frankfurt, Germany
| | - Suma Choorapoikayil
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital, Theodor-Stern Kai 7, 60590, Frankfurt, Germany
| | - Oliver Old
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital, Theodor-Stern Kai 7, 60590, Frankfurt, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital, Theodor-Stern Kai 7, 60590, Frankfurt, Germany
| | - Vanessa Neef
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University Frankfurt, University Hospital, Theodor-Stern Kai 7, 60590, Frankfurt, Germany.
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Russo RM, Cohen RA. Aortic balloon occlusion in distal zone 3 reduces blood loss from obstetric hemorrhage in placenta accreta spectrum. J Trauma Acute Care Surg 2024; 96:e14. [PMID: 37851399 DOI: 10.1097/ta.0000000000004174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
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Einerson BD, Healy AJ, Lee A, Warrick C, Combs CA, Hameed AB. Society for Maternal-Fetal Medicine Special Statement: Emergency checklist, planning worksheet, and system preparedness bundle for placenta accreta spectrum. Am J Obstet Gynecol 2024; 230:B2-B11. [PMID: 37678646 DOI: 10.1016/j.ajog.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
Placenta accreta spectrum is a life-threatening complication of pregnancy that is underdiagnosed and can result in massive hemorrhage, disseminated intravascular coagulation, massive transfusion, surgical injury, multisystem organ failure, and even death. Given the rarity and complexity, most obstetrical hospitals and providers do not have comprehensive expertise in the diagnosis and management of placenta accreta spectrum. Emergency management, antenatal interdisciplinary planning, and system preparedness are key pillars of care for this life-threatening disorder. We present an updated sample checklist for emergent and unplanned cases, an antenatal planning worksheet for known or suspected cases, and a bundle of activities to improve system and team preparedness for placenta accreta spectrum.
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Russo RM, Cohen RA. Aortic balloon occlusion in distal zone 3 reduces blood loss from obstetric hemorrhage in placenta accreta spectrum. J Trauma Acute Care Surg 2024; 96:e8. [PMID: 38062572 DOI: 10.1097/ta.0000000000004165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
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Fitzgerald GD, Newton JM, Atasi L, Buniak CM, Burgos-Luna JM, Burnett BA, Carver AR, Cheng C, Conyers S, Davitt C, Deshmukh U, Donovan BM, Easter SR, Einerson BD, Fox KA, Habib AS, Harrison R, Hecht JL, Licon E, Nino JM, Munoz JL, Nieto-Calvache AJ, Polic A, Ramsey PS, Salmanian B, Shamshirsaz AA, Shamshirsaz AA, Shrivastava VK, Woolworth MB, Yurashevich M, Zuckerwise L, Shainker SA. Placenta accreta spectrum care infrastructure: an evidence-based review of needed resources supporting placenta accreta spectrum care. Am J Obstet Gynecol MFM 2024; 6:101229. [PMID: 37984691 DOI: 10.1016/j.ajogmf.2023.101229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/02/2023] [Accepted: 11/15/2023] [Indexed: 11/22/2023]
Abstract
The incidence of placenta accreta spectrum, the deeply adherent placenta with associated increased risk of maternal morbidity and mortality, has seen a significant rise in recent years. Therefore, there has been a rise in clinical and research focus on this complex diagnosis. There is international consensus that a multidisciplinary coordinated approach optimizes outcomes. The composition of the team will vary from center to center; however, central themes of complex surgical experts, specialists in prenatal diagnosis, critical care specialists, neonatology specialists, obstetrics anesthesiology specialists, blood bank specialists, and dedicated mental health experts are universal throughout. Regionalization of care is a growing trend for complex medical needs, but the location of care alone is just a starting point. The goal of this article is to provide an evidence-based framework for the crucial infrastructure needed to address the unique antepartum, delivery, and postpartum needs of the patient with placenta accreta spectrum. Rather than a clinical checklist, we describe the personnel, clinical unit characteristics, and breadth of contributing clinical roles that make up a team. Screening protocols, diagnostic imaging, surgical and potential need for critical care, and trauma-informed interaction are the basis for comprehensive care. The vision from the author group is that this publication provides a semblance of infrastructure standardization as a means to ensure proper preparation and readiness.
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Affiliation(s)
- Garrett D Fitzgerald
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI (Dr Fitzgerald).
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN (Dr Newton)
| | - Lamia Atasi
- Department of Obstetrics and Gynecology, Mercy Hospital, St. Louis, MO (Dr Atasi)
| | - Christina M Buniak
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA (Dr Buniak)
| | | | - Brian A Burnett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Dr Burnett)
| | - Alissa R Carver
- Department of Obstetrics and Gynecology, Wilmington Maternal-Fetal Medicine, Wilmington, NC (Dr Carver)
| | - CeCe Cheng
- Department of Obstetrics and Gynecology, Health Science Center at San Antonio, University of Texas, San Antonio, TX (Dr Cheng)
| | - Steffany Conyers
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Caroline Davitt
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Davitt and Am Shamshiraz)
| | - Uma Deshmukh
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Bridget M Donovan
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Donovan and Shainker)
| | - Sara Rae Easter
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA (Dr Easter)
| | - Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT (Dr Einerson)
| | - Karin A Fox
- Baylor College of Medicine, Houston, TX (Dr Fox)
| | - Ashraf S Habib
- Duke University School of Medicine, Durham, NC (Dr Habib)
| | - Rachel Harrison
- Department of Obstetrics and Gynecology, Advocate Aurora Health, Chicago, IL (Dr Harrison)
| | - Jonathan L Hecht
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Ernesto Licon
- Miller Women's & Children's Hospital/Long Beach Memorial Medical Center, Orange, CA (Dr Licon)
| | - Julio Mateus Nino
- Department of Obstetrics and Gynecology, Atrium Health Wake Forest School of Medicine, Winston-Salem, NC (Dr Nino)
| | - Jessian L Munoz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX (Dr Munoz)
| | | | | | - Patrick S Ramsey
- University of Texas Health/University Health San Antonio, San Antonio, TX (Dr Ramsey)
| | - Bahram Salmanian
- Department of Obstetrics and Gynecology, University of Colorado Health Anschutz Medical Campus, Boulder, CO (Dr Salmanian)
| | | | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Davitt and Am Shamshiraz)
| | - Vineet K Shrivastava
- Miller Women's and Children's Hospital/Long Beach Memorial Medical Center, Orange, CA (Dr Shrivastava)
| | | | - Mary Yurashevich
- Department of Anesthesiology, Duke Health, Durham, NC (Dr Yurashevich)
| | - Lisa Zuckerwise
- and Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN (Dr Zuckerwise)
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Donovan and Shainker)
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Salmanian B, Shamshirsaz AA, Fox KA, Asl NM, Erfani H, Detlefs SE, Coburn M, Espinoza J, Nassr A, Belfort MA, Clark SL, Shamshirsaz AA. Clinical Outcomes of a False-Positive Antenatal Diagnosis of Placenta Accreta Spectrum. Am J Perinatol 2024; 41:187-192. [PMID: 34666389 DOI: 10.1055/a-1673-5103] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Antenatal diagnosis of placenta accreta spectrum (PAS) is critical to reduce maternal morbidity. While clinical outcomes of women with PAS have been extensively described, little information is available regarding the women who undergo cesarean delivery with a presumptive PAS diagnosis that is not confirmed by histopathologic examination. We sought to examine resource utilization and clinical outcomes of this group of women with a false-positive diagnosis of PAS. STUDY DESIGN This is a retrospective analysis of patients with prenatally diagnosed PAS cared for between 2015 and 2020 by our multidisciplinary PAS team. Maternal outcomes were examined. Univariate analysis was performed and a multivariate model was employed to compare outcomes between women with and without histopathologically confirmed PAS. RESULTS A total of 162 patients delivered with the preoperative diagnosis of PAS. Of these, 146 (90%) underwent hysterectomy and had histopathologic confirmation of PAS. Thirteen women did not undergo the planned hysterectomy. Three women underwent hysterectomy but pathologic examination did not confirm PAS. In comparing women with and without pathologic confirmation of PAS, the false-positive PAS group delivered later in pregnancy (34 vs. 33 weeks of gestation, p = 0.015) and had more planned surgery (88 vs. 47%, p = 0.002). There was no difference in skin incision type or hysterotomy placement for delivery. No significant difference in either the estimated blood loss or blood components transfused was noted between groups. CONCLUSION Careful intraoperative evaluation of women with preoperatively presumed PAS resulted in a 3/149 (2%) retrospectively unnecessary hysterectomy. Management of women with PAS in experienced centers benefits patients in terms of both resource utilization and avoidance of unnecessary maternal morbidity, understanding that our results are produced in a center of excellence for PAS. We also propose a management protocol to assist in the avoidance of unnecessary hysterectomy in women with the preoperative diagnosis of PAS. KEY POINTS · Evaluation and delivery planning of patients with suspected placenta accreta spectrum in experienced centers provides acceptable outcomes.. · Under specific circumstances, delivery of placenta may be attempted if placenta accreta is suspected.. · Patients with suspected placenta accreta rarely undergo unindicated hysterectomy..
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Affiliation(s)
- Bahram Salmanian
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Karin A Fox
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | | | - Hadi Erfani
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Sarah E Detlefs
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Michael Coburn
- Department of Urology, Baylor College of Medicine, Houston, Texas
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Ahmed Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Steven L Clark
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
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Li Q, Zhang W, Hu C, Zhao Y, Pei C, Wu X, Fei K, Peng Q, Zhang J, Huang J. Termination of a second-trimester pregnancy with placenta accreta spectrum disorder. Libyan J Med 2023; 18:2258669. [PMID: 37722677 PMCID: PMC10512921 DOI: 10.1080/19932820.2023.2258669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 09/08/2023] [Indexed: 09/20/2023] Open
Abstract
Background: The termination of pregnancy in patients with placenta accreta spectrum disorder (PASD) during the second trimester remains uncertain. In addition, interventional radiology techniques, such as arterial embolization and balloon placement, are potential options. We evaluated the outcomes of pregnancy termination in patients with PASD during the second trimester and the effectiveness of preoperative interventional radiology techniques.Methods: This retrospective study analyzed 48 PASD patients who underwent pregnancy termination during the second trimester between January 2016 and May 2021.Results: Of the 48 patients, 20 (41.67%) underwent transvaginal termination, whereas 28 (58.33%) underwent cesarean section. Notably, no significant differences were observed in success rates between the transvaginal termination and cesarean section groups (80.00% vs. 92.86%, P = 0.38). Furthermore, no statistically significant differences were observed in the success rates (94.12% vs 90.32%, P = 1.00) and blood loss (512.35 ± 727.00 ml vs 804.00 ± 838.98 ml, P = 0.23) between the artery embolization and non-embolization groups. In the vaginal termination group, statistically significant differences were observed in gestational weeks (16.70 ± 3.12 vs 22.67 ± 3.63, P < 0.01) and blood loss (165.00 ± 274.43 ml vs 483.64 ± 333.53 ml, P = 0.04) between the (artery embolization and non-embolization) subgroups. Conversely, in the cesarean section group, no significant differences were observed in gestational weeks (23.59 ± 3.14 vs 23.20 ± 4.37, P = 0.79) and blood loss (811.11 ± 879.55 ml vs 989.47 ± 986.52 ml, P = 0.76) between the subgroups.Conclusions: Further studies are needed to evaluate the efficacy of vaginal termination in PASD patients during the second trimester. Regarding cesarean termination, arterial embolization did not demonstrate increased effectiveness.
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Affiliation(s)
- Qi Li
- Reproductive Medicine Center, Xiangya Hospital Central South University, Changsha, China
| | - Weishe Zhang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
- Hunan Engineering Research Center of Early Life Development and Disease Prevention, Changsha, China
| | - Caihong Hu
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Yanhua Zhao
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Chenlin Pei
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Xinhua Wu
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Kuilin Fei
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Qiaozhen Peng
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
| | - Jiejie Zhang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
- Hunan Engineering Research Center of Early Life Development and Disease Prevention, Changsha, China
| | - Jingrui Huang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, China
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Teixeira B, Pinto PV, Realista R, Silva M, Costa A, Machado AP, Moucho M. Placenta Accreta Spectrum Disorders - The Impact of the Creation of a Multidisciplinary Team on Maternal Outcomes in Portugal. Rev Bras Ginecol Obstet 2023; 45:e747-e753. [PMID: 38141594 DOI: 10.1055/s-0043-1772482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2023] Open
Abstract
OBJECTIVE To describe a cohort of placenta accreta spectrum (PAS) cases from a tertiary care institution and compare the maternal outcomes before and after the creation of a multidisciplinary team (MDT). METHODS Retrospective study using hospital databases. Identification of PAS cases with pathological confirmation between 2010 and 2021. Division in two groups: standard care (SC) group - 2010-2014; and MDT group - 2015-2021. Descriptive analysis of their characteristics and maternal outcomes. RESULTS During the study period, there were 53 cases of PAS (24 - SC group; 29 - MDT group). Standard care group: 1 placenta increta and 3 percreta; 12.5% (3/24) had antenatal suspicion; 4 cases had a peripartum hysterectomy - one planned due to antenatal suspicion of PAS; 3 due to postpartum hemorrhage. Mean estimated blood loss (EBL) was 2,469 mL; transfusion of packed red blood cells (PRBC) in 25% (6/24) - median 7.5 units. Multidisciplinary team group: 4 cases of placenta increta and 3 percreta. The rate of antenatal suspicion was 24.1% (7/29); 9 hysterectomies were performed, 7 planned due to antenatal suspicion of PAS, 1 after intrapartum diagnosis of PAS and 1 after uterine rupture following a second trimester termination of pregnancy. The mean EBL was 1,250 mL, with transfusion of PRBC in 37.9% (11/29) - median 2 units. CONCLUSION After the creation of the MDT, there was a reduction in the mean EBL and in the median number of PRBC units transfused, despite the higher number of invasive PAS disorders.
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Affiliation(s)
- Beatriz Teixeira
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Pedro Viana Pinto
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Anatomy, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Department of Obstetrics and Gynecology, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Rodrigo Realista
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Manuela Silva
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Antónia Costa
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Obstetrics and Gynecology, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Ana Paula Machado
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Marina Moucho
- Department of Obstetrics and Gynecology, Centro Hospitalar Universitário de São João, Porto, Portugal
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13
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Sugai S, Yamawaki K, Sekizuka T, Haino K, Yoshihara K, Nishijima K. Comparison of maternal outcomes and clinical characteristics of prenatally vs nonprenatally diagnosed placenta accreta spectrum: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:101197. [PMID: 37865220 DOI: 10.1016/j.ajogmf.2023.101197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/14/2023] [Accepted: 10/16/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVE This study aimed to compare maternal outcomes of prenatally and nonprenatally diagnosed placenta accreta spectrum. DATA SOURCES A systematic literature search was performed in PubMed, the Cochrane database, and Web of Science until November 28, 2022. STUDY ELIGIBILITY CRITERIA Studies comparing the clinical presentation of prenatally and nonprenatally diagnosed placenta accreta spectrum were included. The primary outcomes were emergent cesarean delivery, hysterectomy, blood loss volume, number of transfused blood product units, urological injury, coagulopathy, reoperation, intensive care unit admission, and maternal death. In addition, the pooled mean values for blood loss volume and the number of transfused blood product units were calculated. The secondary outcomes included maternal age, gestational age at birth, nulliparity, previous cesarean delivery, previous uterine procedure, assisted reproductive technology, placenta increta and percreta, and placenta previa. METHODS Study screening was performed after duplicates were identified and removed. The quality of each study and the publication bias were assessed. Forest plots and I2 statistics were calculated for each study outcome for each group. The main analysis was a random-effects analysis. RESULTS Overall, 415 abstracts and 157 full-text studies were evaluated. Moreover, 31 studies were analyzed. Prenatally diagnosed placenta accreta spectrum was associated with a significantly lower rate of emergency cesarean delivery (odds ratio, 0.37; 95% confidence interval, 0.21-0.67), higher hysterectomy rate (odds ratio, 1.98; 95% confidence interval, 1.02-3.83), lower blood loss volume (mean difference, -0.65; 95% confidence interval, -1.17 to -0.13), and lower number of transfused red blood cell units (mean difference, -1.96; 95% confidence interval, -3.25 to -0.68) compared with nonprenatally diagnosed placenta accreta spectrum. The pooled mean values for blood loss volume and the number of transfused blood product units tended to be lower in the prenatally diagnosed placenta accreta spectrum groups than in the nonprenatally diagnosed placenta accreta spectrum groups. Nulliparity (odds ratio, 0.14; 95% confidence interval, 0.10-0.20), previous cesarean delivery (odds ratio, 6.81; 95% confidence interval, 4.12-11.25), assisted reproductive technology (odds ratio, 0.19; 95% confidence interval, 0.06-0.61), placenta increta and percreta (odds ratio, 3.97; 95% confidence interval, 2.24-7.03), and placenta previa (odds ratio, 6.81; 95% confidence interval, 4.12-11.25) showed statistical significance. No significant difference was found for the other outcomes. CONCLUSION Despite its severity, the positive effect of prenatally diagnosed placenta accreta spectrum on outcomes underscores the necessity of a prenatal diagnosis. In addition, the pooled mean values provide a preoperative preparation guideline.
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Affiliation(s)
- Shunya Sugai
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan.
| | - Kaoru Yamawaki
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Tomoyuki Sekizuka
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kazufumi Haino
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Kosuke Yoshihara
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Koji Nishijima
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, Niigata, Japan.
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Fernández Rodríguez L, Novo Torres J, Ponce Dorrego MD, Rodríguez Díaz R, Collado Torres ML, Garzón Moll G, Hernández Cabrero T. Usefulness of resuscitative endovascular balloon occlusion of the aorta (REBOA) in controlling puerperal bleeding in patients with abnormal placental implantation. Radiologia (Engl Ed) 2023; 65:502-508. [PMID: 38049249 DOI: 10.1016/j.rxeng.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/12/2022] [Indexed: 12/06/2023]
Abstract
BACKGROUND AND AIMS Abnormalities of placental implantation, which make up the spectrum of placenta accreta, are associated with high maternal morbidity and mortality due to massive bleeding during delivery. Placing aortic occlusion balloons helps control the bleeding, facilitating surgical intervention. A new device, resuscitative endovascular balloon occlusion of the aorta (REBOA), minimizes the risks and complications associated with the placement of traditional aortic balloons and is also efficacious in controlling bleeding. The aim of this study is to evaluate the usefulness, efficacy, and safety of REBOA in puerperal bleeding due to abnormalities of placental implantation. MATERIAL AND METHODS Between November 2019 and November 2021, our interventional radiology team placed six REBOA devices in six women scheduled for cesarean section due to placenta accrete. RESULTS Mean blood loss during cesarean section after REBOA (3507.5 mL) was similar to the amounts reported for other aortic balloons. The mean number of units of packed red blood cells required for transfusion was 3.5. Using REBOA provided the surgical team with adequate conditions to perform the surgery. There were no complications derived from REBOA, and the mean ICU stay was <2 days. CONCLUSION The technical characteristics of the REBOA device make it a safe and useful alternative for controlling massive bleeding in patients with placenta accreta.
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Affiliation(s)
- L Fernández Rodríguez
- Sección de Radiología Vascular e Intervencionista, Hospital Universitario La Paz, Madrid, Spain.
| | - J Novo Torres
- Sección de Radiología Vascular e Intervencionista, Hospital Universitario La Paz, Madrid, Spain
| | - M D Ponce Dorrego
- Sección de Radiología Vascular e Intervencionista, Hospital Universitario La Paz, Madrid, Spain
| | - R Rodríguez Díaz
- Sección de Radiología Vascular e Intervencionista, Hospital Universitario La Paz, Madrid, Spain
| | - M L Collado Torres
- Sección de Radiología Vascular e Intervencionista, Hospital Universitario La Paz, Madrid, Spain
| | - G Garzón Moll
- Sección de Radiología Vascular e Intervencionista, Hospital Universitario La Paz, Madrid, Spain
| | - T Hernández Cabrero
- Sección de Radiología Vascular e Intervencionista, Hospital Universitario La Paz, Madrid, Spain
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15
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Sebastian B, Rajesh U, Scott PM, Sayeed S, Robinson GJ, Ettles DF, Shrivastava V, Lakshminarayan R. Prophylactic Uterine Artery Embolization in Placenta Accreta Spectrum-An Active Intervention to Reduce Morbidity and Promote Uterine Preservation. J Vasc Interv Radiol 2023; 34:1922-1928. [PMID: 37517463 DOI: 10.1016/j.jvir.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/11/2023] [Accepted: 07/21/2023] [Indexed: 08/01/2023] Open
Abstract
PURPOSE To evaluate the feasibility and safety of early and proactive involvement of interventional radiology (IR) in the management of placenta accreta spectrum (PAS) by performing the cesarean operation and prophylactic uterine artery embolization in the IR angiography suite as a combined procedure. MATERIALS AND METHODS This study evaluated the effectiveness and safety of prophylactic uterine artery embolization prior to placental separation in cases of antenatally proven or suspected abnormal placentation. Over a 5-year period, 16 consecutive patients with PAS underwent combined IR and obstetric intervention. In all cases, cesarean delivery was performed in the IR angiography suite. Vascular access was obtained prior to surgery with balloon placement into both internal iliac arteries. These balloons were inflated after delivery, followed by uterine artery embolization (14 of 16) if there was evidence of active postpartum bleeding or inability to deliver the placenta. RESULTS There was no fetal or maternal mortality and no significant IR or surgical adverse events. Mean blood loss was 1900 mL. Seven patients (44%) underwent hysterectomy. CONCLUSIONS In patients with PAS, cesarean section in the angiography suite preceded by prophylactic balloon placement and followed by uterine artery embolization was feasible, safe, and effective in preventing massive blood loss, with a 56% uterine sparing rate.
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Affiliation(s)
- Bibin Sebastian
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Uma Rajesh
- Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Paul M Scott
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Saira Sayeed
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Graham J Robinson
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Duncan F Ettles
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Vivek Shrivastava
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Raghuram Lakshminarayan
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom.
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Matsuo K, Sangara RN, Matsuzaki S, Ouzounian JG, Hanks SE, Matsushima K, Amaya R, Roman LD, Wright JD. Placenta previa percreta with surrounding organ involvement: a proposal for management. Int J Gynecol Cancer 2023; 33:1633-1644. [PMID: 37524496 DOI: 10.1136/ijgc-2023-004615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Abstract
Placenta accreta spectrum encompasses cases where the placenta is morbidly adherent to the myometrium. Placenta percreta, the most severe form of placenta accreta spectrum (grade 3E), occurs when the placenta invades through the myometrium and possibly into surrounding structures next to the uterine corpus. Maternal morbidity of placenta percreta is high, including severe maternal morbidity in 82.1% and mortality in 1.4% in the recent nationwide U.S. statistics. Although cesarean hysterectomy is commonly performed for patients with placenta accreta spectrum, conservative management is becoming more popular because of reduced morbidity in select cases. Treatment of grade 3E disease involving the urinary bladder, uterine cervix, or parametria is surgically complicated due to the location of the invasive placenta deep in the maternal pelvis. Cesarean hysterectomy in this setting has the potential for catastrophic hemorrhage and significant damage to surrounding organs. We propose a step-by-step schema to evaluate cases of grade 3E disease and determine whether immediate hysterectomy or conservative management, including planned delayed hysterectomy, is the most appropriate treatment option. The approach includes evaluation in the antenatal period with ultrasound and magnetic resonance imaging to determine suspicion for placenta previa percreta with surrounding organ involvement, planned cesarean delivery with a multidisciplinary team including experienced pelvic surgeons such as a gynecologic oncologist, intra-operative assessment including gross surgical field exposure and examination, cystoscopy, and consideration of careful intra-operative transvaginal ultrasound to determine the extent of placental invasion into surrounding organs. This evaluation helps decide the safety of primary cesarean hysterectomy. If safely resectable, additional considerations include intra-operative use of uterine artery embolization combined with tranexamic acid injection in cases at high risk for pelvic hemorrhage and ureteral stent placement. Availability of resuscitative endovascular balloon occlusion of the aorta is ideal. If safe resection is concerned, conservative management including planned delayed hysterectomy at around 4 weeks from cesarean delivery in stable patients is recommended.
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Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Rauvynne N Sangara
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Shinya Matsuzaki
- Department of Gynecology, Osaka International Cancer Institute, Osaka, Japan
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Sue E Hanks
- Department of Radiology, University of Southern California, Los Angeles, California, USA
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California, USA
| | - Rodolfo Amaya
- Department of Anesthesiology, University of Southern California, Los Angeles, California, USA
| | - Lynda D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California, USA
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
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Létourneau I, Hobson SR, Moretti F, Kingdom JC, Murji A, Windrim RC, Allen LM, Werlang A, Vachon-Marceau C, Singh SS. Placenta Accreta Spectrum Disorders: A National Survey. J Obstet Gynaecol Can 2023; 45:102167. [PMID: 37315785 DOI: 10.1016/j.jogc.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/01/2023] [Accepted: 06/03/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Describe the current practice of Canadian obstetricians-gynaecologists in managing placenta accreta spectrum (PAS) disorders from suspicion of diagnosis to delivery planning and explore the impact of the latest national practice guidelines on this topic. METHODS We distributed a cross-sectional bilingual electronic survey to Canadian obstetricians-gynaecologists in March-April 2021. Demographic data and information on screening, diagnosis, and management were collected using a 39-item questionnaire. The survey was validated and pretested among a sample population. Descriptive statistics were used to present the results. RESULTS We received 142 responses. Almost 60% of respondents said they had read the latest Society of Obstetricians and Gynaecologists of Canada clinical practice guideline on PAS disorders, published in July 2019. Nearly 1 in 3 respondents changed their practice following this guideline. Respondents highlighted the importance of 4 key points: (1) limiting travel to thereby remain close to a regional care centre, (2) preoperative anemia optimization, (3) performance of cesarean-hysterectomy leaving the placenta in situ (83%), (4) access via midline laparotomy (65%). Most respondents recognized the importance of perioperative blood loss reduction strategies such as tranexamic acid and perioperative thromboprophylaxis via sequential compression devices and low-molecular-weight heparin until full mobilization. CONCLUSIONS This study demonstrates the impact of the Society of Obstetricians and Gynaecologists of Canada's PAS clinical practice guideline on management choices made by Canadian clinicians. Our study highlights the value of a multidisciplinary approach to reducing maternal morbidity in individuals facing surgery for a PAS disorder and the importance of regionalized care that is resourced to provide maternal-fetal medicine and surgical expertise, transfusion medicine, and critical care support.
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Affiliation(s)
- Isabelle Létourneau
- Department of Obstetrics, Gynecology and Newborn Care, University of Ottawa, The Ottawa Hospital, Ottawa, ON.
| | - Sebastian R Hobson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Toronto, Mount Sinai Hospital, Toronto, ON
| | - Felipe Moretti
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Ottawa, The Ottawa Hospital, Ottawa, ON
| | - John C Kingdom
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Toronto, Mount Sinai Hospital, Toronto, ON
| | - Ally Murji
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Toronto, Mount Sinai Hospital, Toronto, ON
| | - Rory C Windrim
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Toronto, Mount Sinai Hospital, Toronto, ON
| | - Lisa M Allen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Toronto, Mount Sinai Hospital, Toronto, ON
| | - Ana Werlang
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Ottawa, The Ottawa Hospital, Ottawa, ON
| | | | - Sukhbir S Singh
- Department of Obstetrics, Gynecology and Newborn Care, University of Ottawa, The Ottawa Hospital, Ottawa, ON
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18
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Munoz JL, Blankenship LM, Ramsey PS, McCann GA. Implementation and outcomes of a uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum. Am J Obstet Gynecol 2023; 229:61.e1-61.e7. [PMID: 36965865 DOI: 10.1016/j.ajog.2023.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Placenta accreta spectrum disorders are a continuum of placental pathologies with significant maternal morbidity and mortality. Morbidity is related to the overall degree of placental adherence, and thus patients with placenta increta or percreta represent a high-risk category of patients. Hemorrhage and transfusion of blood products represent 90% of placenta accreta spectrum morbidity. Both tranexamic acid and uterine artery embolization independently decrease obstetrical hemorrhage. OBJECTIVE This study aimed to provide an evidence-based intraoperative protocol for placenta accreta spectrum management. STUDY DESIGN This study was a pre- and postimplementation analysis of concomitant uterine artery embolization and tranexamic acid in cases of patients with antenatally suspected placenta increta and percreta over a 5-year period (2018-2022). For comparison, a 5-year (2013-2017) preimplementation group was used to assess the impact of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum. Patient demographics and clinically relevant outcomes were obtained from electronic medical records. RESULTS A total of 126 cases were managed by the placenta accreta spectrum team, of which 66 had suspected placenta increta/percreta over the 10-year time period. Two patients were excluded from the postimplementation cohort because they did not undergo both interventions. Thus, 30 (30/64; 47%) were treated after implementation of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum, and 34 (34/64; 53%) preimplementation patients did not undergo uterine artery embolization or tranexamic acid infusion. With the uterine artery embolization and tranexamic acid protocol, operative times were longer (416 vs 187 minutes; P<.01), and patients were more likely to receive general anesthesia (80% vs 47%; P<.01). However, blood loss was reduced by 33% (2000 vs 3000 cc; P=.03), overall blood transfusion rates decreased by 51% (odds ratio, 0.05 [95% confidence interval, 0.001-0.20]; P<.01), and massive blood transfusion (>10 units transfused) was reduced 5-fold (odds ratio, 0.17 [95% confidence interval, 0.02-0.17]; P=.02). Postoperative complication rates remained unchanged (4 vs 10 events; P=.14). Neonatal outcomes were equivalent. CONCLUSION The uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum is an effective approach to the standardization of complex placenta accreta spectrum cases that results in optimal perioperative outcomes and reduced maternal morbidity.
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Affiliation(s)
- Jessian L Munoz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Logan M Blankenship
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
| | - Patrick S Ramsey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
| | - Georgia A McCann
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Texas Health Science Center at San Antonio, University Health System, San Antonio, TX
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Pini R, Latta M, Santonastaso DP, Antonazzo PGM, Giacomini G, Bisulli M, Bolondi G, Bissoni L, Agnoletti V. Management of postpartum hemorrhage in urgent cesarean delivery for placenta accreta by resuscitative endovascular balloon occlusion of the aorta (REBOA), a case report. Eur J Obstet Gynecol Reprod Biol 2023; 286:152-153. [PMID: 37217390 DOI: 10.1016/j.ejogrb.2023.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 05/12/2023] [Indexed: 05/24/2023]
Affiliation(s)
- Rita Pini
- Anesthesia and Intensive Care Unit, Ospedale Bufalini, Cesena, Italy
| | - Marina Latta
- Anesthesia and Intensive Care Medicine, University of Bologna, Italy
| | | | | | - Gloria Giacomini
- Obstetrics and Gynecology Unit, Ospedale Bufalini, Cesena, Italy
| | | | - Giuliano Bolondi
- Anesthesia and Intensive Care Unit, Ospedale Bufalini, Cesena, Italy.
| | - Luca Bissoni
- Anesthesia and Intensive Care Unit, Ospedale Bufalini, Cesena, Italy
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, Ospedale Bufalini, Cesena, Italy
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20
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Abstract
Placenta accreta spectrum is a group of disorders involving abnormal trophoblastic invasion to the deep layers of endometrium and myometrium. Placenta accrete spectrum is one of the major causes of severe maternal morbidity, with increasing incidence in the past decade mainly secondary to an increase in cesarean deliveries. Severity varies depending on the depth of invasion, with the most severe form, known as percreta, invading uterine serosa or surrounding pelvic organs. Diagnosis is usually achieved by ultrasound, and MRI is sometimes used to assess invasion. Management usually involves a hysterectomy at the time of delivery. Other strategies include delayed hysterectomy or expectant management.
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Affiliation(s)
- Mahmoud Abdelwahab
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
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21
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Hania A, Harnett C, Morrison J, Klemmer K, Costello J. Placenta Accreta Spectrum: A 2-year Retrospective Observational Study. Ir Med J 2022; 115:629. [PMID: 36300594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Aims To assess the management and outcomes of Placenta Accreta Spectrum disorders and highlight the important management recommendations from international guidelines. Methods A retrospective audit of women diagnosed with Placenta Accreta Spectrum disorder from January 2018 to December 2019. Results Nine cases (0.16%) of placenta accreta from 5695 births were identified. All women received caesarean section under general anaesthesia. Caesarean hysterectomy occurred in seven cases (78%). Mean (±SD) age of women was (34.4 ± 3.9 years) and mean parity score was (3.2 ± 1.2). Mean gestational age at birth was 35.1 ± 0.8 weeks. Bilateral iliac artery balloon occlusion occurred in eight (89%) cases. Median estimated blood loss [range] was 1700 mL [1000-7000] with only 11% of patients (1/9) experiencing more than 3L of blood loss. Intraoperative red blood cell transfusion occurred in six cases (67%). Median number of units of red cell transfusion [range] was four units [0-10]. Mean hospital length of stay was (6.7 ± 1.1 days) and there were no maternal deaths. Multidisciplinary team involvement of senior anaesthetists and obstetricians was noted in all cases. Discussion Placenta accreta spectrum is increasing in incidence in obstetric practice and is associated with significant maternal morbidity and mortality. Implementing national guidelines can improve patient outcomes.
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Affiliation(s)
- A Hania
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Galway
| | - C Harnett
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Galway
| | - J Morrison
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Galway
| | - K Klemmer
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Galway
| | - J Costello
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Galway
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Yao F, Ding H, Xiao L, Wang L. Prophylactic common iliac artery balloon occlusion for placenta accreta spectrum. Taiwan J Obstet Gynecol 2022; 61:733. [PMID: 35779936 DOI: 10.1016/j.tjog.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- FengXiang Yao
- Department of Obstetrics and Gynecology, Ningbo First Hospital, Ningbo, China
| | - HuiQing Ding
- Department of Obstetrics and Gynecology, Ningbo First Hospital, Ningbo, China.
| | - LiangLiang Xiao
- Department of Interventional Radiology, Ningbo First Hospital, Ningbo, China
| | - Li Wang
- Department of Radiology, Ningbo First Hospital, Ningbo, China
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23
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Lee M, Matsuzaki S, Kamiura S. Effect of in vitro fertilization-embryo transfer on placenta accreta spectrum according to treatment type. Am J Obstet Gynecol 2021; 225:461-462. [PMID: 34144019 DOI: 10.1016/j.ajog.2021.06.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/12/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Misooja Lee
- Department of Obstetrics and Gynecology, Shibata Pediatrics Clinic, San Francisco, CA
| | - Shinya Matsuzaki
- Department of Gynecology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka 541-8567, Japan; Department of Obstetrics and Gynecology, Faculty of Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Shoji Kamiura
- Department of Gynecology, Osaka International Cancer Institute, Osaka, Japan
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Panaitescu AM, Ciobanu AM, Gică N, Peltecu G, Botezatu R. Diagnosis and Management of Cesarean Scar Pregnancy and Placenta Accreta Spectrum: Case Series and Review of the Literature. J Ultrasound Med 2021; 40:1975-1986. [PMID: 33274770 DOI: 10.1002/jum.15574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/22/2020] [Accepted: 10/24/2020] [Indexed: 06/12/2023]
Abstract
With an increased cesarean delivery rate, the incidence of abnormal placentation is steadily rising, and it is estimated to be around 1.7 per 1000 pregnancies for cesarean scar pregnancy and 1 per 500 pregnancies for placenta accreta spectrum disorder. Current evidence considers cesarean scar pregnancy and placenta accreta spectrum as being the same condition, with different aspects, of the same spectrum, having higher risks with advancing gestation. We present 7 cases, diagnosed and managed in our hospital, at different gestational ages. Early diagnosis is essential for appropriate counseling and subsequent management, and an ultrasound examination is the reference standard for diagnosis. Screening for an abnormally implanted placenta in the first trimester of pregnancy might improve the perinatal outcome and reduce maternal morbidity and mortality.
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Affiliation(s)
- Anca M Panaitescu
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Filantropia Clinical Hospital, Bucharest, Romania
| | | | - Nicolae Gică
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Filantropia Clinical Hospital, Bucharest, Romania
| | - Gheorghe Peltecu
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Filantropia Clinical Hospital, Bucharest, Romania
| | - Radu Botezatu
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Filantropia Clinical Hospital, Bucharest, Romania
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Leanza V, Verzì MG, Genovese F, Colaleo FM, Leanza G, Palumbo M. Central placenta praevia accreta with focal bladder percretism. Conservative management. Ann Ital Chir 2021; 10:S2239253X21035386. [PMID: 33994388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Placenta praevia is a condition when placenta is inserted in an abnormal position near or over the internal cervical orifice (ICO). Abnormal placental attachment (placenta accreta, increta, percreta) is a wide spectrum disorder ranging from abnormal adherence to deeply invasive placental tissue. We report a very rare case of central placenta praevia accreta and focal bladder percretism in a 29 years old pregnant woman with an obstetrical history of one previous vaginal delivery and four curettages following miscarriage. She was taken in charge by Catania S. Marco' university-hospital at 20 weeks with diagnosis of Central Placenta Praevia and Accreta (CPPA) detected by means of ultrasounds (US). At 31 weeks Magnetic Resonance Imaging (MRI) confirmed CPPA with focal bladder percretism. After alerting multidisciplinary team and obtaining blood units available, a Caesarean Section (CS) at 34 weeks was planned, when by means of US a detachment area with bleeding was observed. An adequate informed consent was completed, where the pregnant woman and her husband accepted the risk of possible hysterectomy and blood transfusions. A Pfannestiel's laparotomy with transversal corporal uterine incision, bilateral uterine ligation, packed tamponage, removal of placental tissue separated during fetal extraction and leaving a portion of placenta only in the place of percretism, allowed conservative intervention (uterus preservation) ending in good results for both mother and fetus. KEY WORDS: Caesarean section, Curettage, Placenta praevia, Placenta accreta, Preterm birth.
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26
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Nankali A, Salari N, Kazeminia M, Mohammadi M, Rasoulinya S, Hosseinian-Far M. The effect prophylactic internal iliac artery balloon occlusion in patients with placenta previa or placental accreta spectrum: a systematic review and meta-analysis. Reprod Biol Endocrinol 2021; 19:40. [PMID: 33663536 PMCID: PMC7931359 DOI: 10.1186/s12958-021-00722-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Placenta previa describes a placenta that extends partially or completely over the internal cervical oss. Placenta previa is one of the leading causes of widespread postpartum hemorrhage and maternal mortality worldwide. Another cause of bleeding in pregnant women is Placenta accreta spectrum. Therefore, the aim of the present systematic review and meta-analysis is to determine the effect of prophylactic balloon occlusion of the internal iliac arteries in patients with placenta previa or placental accreta spectrum (PAS). METHODS In this systematic review and meta-analysis, to identify and select relevant studies, the SID, MagIran, ScienceDirect, Embase, Scopus, PubMed, Web of Science, and Google Scholar databases were searched, using the keywords of internal iliac artery balloon, placenta, previa, balloon, accreta, increta and percreta, without a lower time limit and until 2020. The heterogeneity of the studies was examined using the I2 index, and subsequently a random effects model was applied. Data analysis was performed within the Comprehensive Meta-Analysis software (version 2). RESULTS In the review of 29 articles with a total sample size of 1140 in the control group, and 1225 in the balloon occlusion group, the mean difference between the two groups was calculated in terms of Intraoperative blood loss index (mL) and it was derived as 3.21 ± 0.38; moreover, in 15 studies with a sample size of 887 in the control group, and 760 in the balloon occlusion group, the mean difference between the two groups in terms of gestation index (weeks) was found as 2.84 ± 0.49; and also with regards to hysterectomy balloon occlusion after prophylactic closure of the iliac artery, hysterectomy (%) balloon occlusion was calculated as 8.9 %, and this, in the hysterectomy control group (%) was obtained as 31.2 %; these differences were statistically significant and showed a positive effect of the intervention (P < 0.05). CONCLUSION The results of this study show that the use of prophylactic internal iliac artery balloon occlusion in patients with placenta previa or Placenta accreta spectrum has benefits such as reduced intraoperative blood loss, reduced hysterectomy and increased gestation (weeks), which can be considered by midwives and obstetricians.
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Affiliation(s)
- Anisodowleh Nankali
- grid.412112.50000 0001 2012 5829Department of Obstetrics and Gynecology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Nader Salari
- grid.412112.50000 0001 2012 5829Department of Biostatistics, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohsen Kazeminia
- grid.412112.50000 0001 2012 5829Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Masoud Mohammadi
- grid.412112.50000 0001 2012 5829Department of Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Samira Rasoulinya
- grid.412112.50000 0001 2012 5829Department of Obstetrics and Gynecology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Melika Hosseinian-Far
- grid.411301.60000 0001 0666 1211Department of Food Science & Technology, Faculty of Agriculture, Ferdowsi University of Mashhad (FUM), Mashhad, Iran
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Huang H, Wang J, Li K, Ma H. Successful conservative treatment of placenta accreta with traditional Chinese medicine: A case report. Medicine (Baltimore) 2021; 100:e24820. [PMID: 33607847 PMCID: PMC7899819 DOI: 10.1097/md.0000000000024820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 01/29/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Currently, placenta accreta treatment mainly includes nonconservative surgical and conservative treatments such as Traditional Chinese medicine (TCM). This report describes the case of a 37-year-old woman who suffered incomplete placenta accreta after vaginal delivery and was cured by TCM. TCM treatment of placenta accreta has its own unique advantages, including low toxicity and few side effects, unaffected breastfeeding, and retention of the uterus, which can ensure the expulsion of residual placenta and be beneficial to patients' physical and mental health. PATIENT CONCERNS Symptoms included a small amount of vaginal bleeding and occasional lesser abdominal pain. The patient showed lesser abdominal tenderness, a red tongue moss with petechial hemorrhage, and a hesitant pulse. The reproductive history was G3P2L2A1. In addition, the patient was afraid of having her uterus removed due to incomplete placental separation. DIAGNOSES The case was diagnosed as placental accreta. Ultrasound is the preferred method of diagnosis, and biomarkers, such as beta hCG, assist in screening for placental accreta. Doppler ultrasonography showed that in the bottom of the right uterine cavity, there was an uneven echo group of 7.6 × 4.6 cm, which was not clearly demarcated from the posterior wall; the muscle layer became thinner, with a thinnest part of 0.19 cm, and abundant blood flow signals were observed (Fig. 1JOURNAL/medi/04.03/00005792-202102190-00086/figure1/v/2021-02-16T234818Z/r/image-tiff). The beta hCG was 580.92 mIu/ml. INTERVENTIONS The patient initially underwent curettage therapy 9 days after delivery, but it failed due to excessive intraoperative bleeding. The patient then turned to TCM treatment. The doctor prescribed a multi-herbal formula. OUTCOMES After 4 months, the residual placenta was expelled, and the patient's symptoms disappeared completely. No adverse and unexpected events occurred during treatment. During 3 months of follow-up, the patient had no abdominal pain, abnormal vaginal bleeding, or other complications. LESSONS This study shows that TCM is safe and effective for treating placenta accreta, and it is worth recommending TCM as a conservative treatment along with other treatments. In practice, however, we find that the earlier TCM treatment is applied, the better the effect; therefore, early intervention with TCM is particularly important.
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Affiliation(s)
- Huamin Huang
- First College of Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong
| | - Jialin Wang
- The Affiliated Hospital of Shandong Academy of Chinese Medicine
| | - Keqin Li
- Shandong Provincial Hospital Affiliated to Shandong University, Jingwuweiqi Road, Jinan, Shandong, China
| | - Hongbo Ma
- Shandong Provincial Hospital Affiliated to Shandong University, Jingwuweiqi Road, Jinan, Shandong, China
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Berhan Y, Urgie T. A Literature Review of Placenta Accreta Spectrum Disorder: The Place of Expectant Management in Ethiopian Setup. Ethiop J Health Sci 2020; 30:277-292. [PMID: 32165818 PMCID: PMC7060376 DOI: 10.4314/ejhs.v30i2.16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 11/22/2019] [Indexed: 11/17/2022] Open
Abstract
In the last three to four decades, the increasing caesarean delivery rate has contributed to several fold increment in the incidence of placenta accreta spectrum disorders globally. Placenta accreta spectrum with its subtypes (accreta, increta and percreta) is one of the devastating obstetric complications. As a result, it is the commonest indication for peripartum hysterectomy and common cause of severe maternal morbidity. However, in recent years, there is a growing interest in and practice of expectant management either to minimize emergency hysterectomy related maternal complications or to preserve the fertility potential of a woman with an intact uterus. A large body of observational research findings has demonstrated the success rate of expectant management in many of well selected cases. Similarly, the experience on delayed hysterectomy was encouraging in order to have less hemorrhage. For the best success of placenta accreta spectrum management, multidisciplinary team approach, antenatal diagnosis and managing such cases in a hospital with center of excellence has been strongly recommended. This literature review provides a robust synthesis of up-to-date knowledge and practice on the challenges and successes of placenta accreta spectrum disorders management. The currently practiced management options in the high and middle income countries are also summarized under seven categories. Therefore, the purpose of this review was to shed light on the applicability of the PAS disorder management modalities in our setup.
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Affiliation(s)
- Yifru Berhan
- St. Paul's Hospital Millennium Medical College Ethiopia, Addis Ababa
| | - Tadesse Urgie
- St. Paul's Hospital Millennium Medical College Ethiopia, Addis Ababa
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Ma Y, You Y, Jiang X, Lin X. Use of nitroglycerin for parallel transverse uterine cesarean section in patients with pernicious placenta previa and placenta accrete and predicted difficult airway: A case report and review of literature. Medicine (Baltimore) 2020; 99:e18943. [PMID: 32000415 PMCID: PMC7004715 DOI: 10.1097/md.0000000000018943] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
RATIONALE The incidence of obstetric hemorrhage due to pernicious placenta previa (PPP) and placenta accreta is currently increasing in China. Parallel transverse uterine incision (PTUI) cesarean section (CS) is a novel technique designed to avoid transecting the placenta and control postpartum hemorrhage during CS in these patients in our hospital. A key point of anesthesia management related to PTUI CS involves keeping the uterus relaxed. General anesthesia (GA) has often been performed, and inhaled volatile anesthetics have traditionally been recommended for this purpose; however, GA may be contraindicated in patients with difficult airways. PATIENT CONCERNS The patient was predicted to have a difficult airway, and GA may have resulted in potentially life-threatening complications. An alternative and safer method of achieving uterine relaxation during PTUI CS was thus required. DIAGNOSES The patient was diagnosed with PPP, and a predicted difficult airway was suspected preoperatively. INTERVENTIONS PTUI CS was planned to control postpartum hemorrhage and preserve fertility during CS. Uterine relaxation during PTUI CS was achieved with intravenous nitroglycerin under combined spinal-epidural anesthesia. OUTCOME Intravenous nitroglycerin and combined spinal-epidural anesthesia achieved uterine relaxation during the time from delivery of the neonate to making the second transverse incision in the lower segment of the uterus during PTUI CS. Both the parturient and neonate were well and were discharged 4 days later. LESSIONS Intravenous nitroglycerin and combined spinal-epidural anesthesia may offer an alternative to GA for achieving uterine relaxation in patients with PPP and a predicted difficult airway undergoing PTUI CS to control postpartum hemorrhage.
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Affiliation(s)
- Yushan Ma
- Department of Anesthesiology, West China Second University Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education
| | - Yong You
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xiaoqin Jiang
- Department of Anesthesiology, West China Second University Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education
| | - Xuemei Lin
- Department of Anesthesiology, West China Second University Hospital, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education
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Abstract
OBJECTIVE To estimate the prevalence and incidence of placenta previa complicated by placenta accreta spectrum (PAS) and to examine the different criteria being used for the diagnosis. DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed, Google Scholar, ClinicalTrials.gov and MEDLINE were searched between August 1982 and September 2018. ELIGIBILITY CRITERIA Studies reporting on placenta previa complicated by PAS diagnosed in a defined obstetric population. DATA EXTRACTION AND SYNTHESIS Two independent reviewers performed the data extraction using a predefined protocol and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies, with difference agreed by consensus. The primary outcomes were overall prevalence of placenta previa, incidence of PAS according to the type of placenta previa and the reported clinical outcomes, including the number of peripartum hysterectomies and direct maternal mortality. The secondary outcomes included the criteria used for the prenatal ultrasound diagnosis of placenta previa and the criteria used to diagnose and grade PAS at birth. RESULTS A total of 258 articles were reviewed and 13 retrospective and 7 prospective studies were included in the analysis, which reported on 587 women with placenta previa and PAS. The meta-analysis indicated a significant (p<0.001) heterogeneity between study estimates for the prevalence of placenta previa, the prevalence of placenta previa with PAS and the incidence of PAS in the placenta previa cohort. The median prevalence of placenta previa was 0.56% (IQR 0.39-1.24) whereas the median prevalence of placenta previa with PAS was 0.07% (IQR 0.05-0.16). The incidence of PAS in women with a placenta previa was 11.10% (IQR 7.65-17.35). CONCLUSIONS The high heterogeneity in qualitative and diagnostic data between studies emphasises the need to implement standardised protocols for the diagnoses of both placenta previa and PAS, including the type of placenta previa and grade of villous invasiveness. PROSPERO REGISTRATION NUMBER CRD42017068589.
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Affiliation(s)
| | - Lene Grønbeck
- Department of Obstetrics, Rigshospitalet, University of Copenhagen, Kobenhavns, Denmark
| | - Catey Bunce
- Primary Care and Public Health Sciences, King's College London, London, UK
| | - Jens Langhoff-Roos
- Departement of Obstetrics, Rigshospitalet, University of Copenhagen, Kobenhavn, Denmark
| | - Sally L Collins
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
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Erfani H, Fox KA, Clark SL, Rac M, Rocky Hui SK, Rezaei A, Aalipour S, Shamshirsaz AA, Nassr AA, Salmanian B, Stewart KA, Kravitz ES, Eppes C, Coburn M, Espinoza J, Teruya J, Belfort MA, Shamshirsaz AA. Maternal outcomes in unexpected placenta accreta spectrum disorders: single-center experience with a multidisciplinary team. Am J Obstet Gynecol 2019; 221:337.e1-337.e5. [PMID: 31173748 DOI: 10.1016/j.ajog.2019.05.035] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/09/2019] [Accepted: 05/23/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE In a 2015 Maternal-Fetal Medicine Units Network study, only half of placenta accreta spectrum cases were suspected before delivery, and the outcomes in the anticipated cases were paradoxically poorer than in unanticipated placenta accreta spectrum cases. This was possibly because the antenatally suspected cases were of greater severity. We sought to compare the outcomes of expected vs unexpected placenta accreta spectrum in a single large US center with multidisciplinary management protocol. STUDY DESIGN This was a retrospective cohort study carried out between Jan. 1, 2011, and June 30, 2018, of all histology-proven placenta accreta spectrum deliveries in an academic referral center. Patients diagnosed at the time of delivery were cases (unexpected placenta accreta spectrum), and those who were antentally diagnosed were controls (expected placenta accreta spectrume). The primary and secondary outcomes were the estimated blood loss and the number of red blood cell units transfused, respectively. Variables are reported as median and interquartile range or number (percentage). Analyses were made using appropriate parametric and nonparametric tests. RESULTS Fifty-four of the 243 patients (22.2%) were in the unexpected placenta accreta spectrum group. Patients in the expected placenta accreta spectrum group had a higher rate of previous cesarean delivery (170 of 189 [89.9%] vs 35 of 54 [64.8%]; P < .001) and placenta previa (135 [74.6%] vs 19 [37.3%]; P < .001). There was a higher proportion of increta/percreta in expected placenta accreta spectrum vs unexpected placenta accreta spectrum (125 [66.1%] vs 9 [16.7%], P < .001). Both primary outcomes were higher in the unexpected placenta accreta spectrum group (estimated blood loss, 2.4 L [1.4-3] vs 1.7 L [1.2-3], P = .04; red blood cell units, 4 [1-6] vs 2 [0-5], P = .03). CONCLUSION Our data contradict the Maternal-Fetal Medicine Units results and instead show better outcomes in the expected placenta accreta spectrum group, despite a high proportion of women with more severe placental invasion. We attribute this to our multidisciplinary approach and ongoing process improvement in the management of expected cases. The presence of an experienced team appears to be a more important determinant of maternal morbidity in placenta accreta spectrum than the depth of placental invasion.
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Affiliation(s)
- Hadi Erfani
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Karin A Fox
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Steven L Clark
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Martha Rac
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Shiu-Ki Rocky Hui
- Department of Pathology and Immunology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Atefeh Rezaei
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Soroush Aalipour
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Bahram Salmanian
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Kelsey A Stewart
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Elizabeth S Kravitz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Catherine Eppes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Michael Coburn
- Department of Urology, Baylor College of Medicine, Houston, TX
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Jun Teruya
- Department of Pathology and Immunology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
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Abstract
RATIONALE Retained placenta accreta is an increasing obstetric problem in recent years, and pulmonary embolism (PE) during pregnancy and the postpartum period is a vital condition, but lack of standard therapy guidelines. This report describes a case of postpartum PE combined with retained placenta accreta. PATIENT CONCERNS A 27-year-old woman presenting with fever and dyspnea after delivery was admitted to our hospital with retained placenta accreta. DIAGNOSES The patient was diagnosed with the infection, postpartum PE, and residual placenta. INTERVENTIONS The antibiotics and low molecular weight heparin were initially started to cure the infection and control PE. Mifepristone was then used to promote the necrosis of residual placenta while long-term use of warfarin was served as continuous anticoagulant therapy. Hysteroscopic resection of retained placenta was not performed until thrombi had been almost disappeared after more than 2 months of anticoagulation therapy. OUTCOMES The patient's menstruation returned to normal within several weeks after hysteroscopic resection and she completely recovered from PE after 3 months of anticoagulant therapy. LESSONS Treatment of retained placenta accreta can be postponed when encountering complicated cases, such as postpartum PE. PE in perinatal stage can be managed referring to nonmaternal PE.
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Affiliation(s)
- An Tong
- Department of Gynecology and Obstetrics, Development and Related Diseases of Women and Children Key Laboratory of Sichuan Province, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education
| | - Fumin Zhao
- Department of Radiology, West China Second Hospital, Sichuan University, Chengdu, P.R. China
| | - Ping Liu
- Department of Gynecology and Obstetrics, Development and Related Diseases of Women and Children Key Laboratory of Sichuan Province, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education
| | - Xia Zhao
- Department of Gynecology and Obstetrics, Development and Related Diseases of Women and Children Key Laboratory of Sichuan Province, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education
| | - Xiaorong Qi
- Department of Gynecology and Obstetrics, Development and Related Diseases of Women and Children Key Laboratory of Sichuan Province, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education
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Katsogiannou M, Amar-Millet A, Muller C, Desbriere R. Radiofrequency ablation of retained placenta accreta after conservative management. Eur J Obstet Gynecol Reprod Biol 2019; 240:383-384. [PMID: 31337515 DOI: 10.1016/j.ejogrb.2019.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 07/15/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Maria Katsogiannou
- Hôpital Saint Joseph, Department of Obstetrics and Gynecology, FR-13008, Marseille, France
| | - Annie Amar-Millet
- Hôpital Saint Joseph, Department of Anesthetics, FR-13008, Marseille, France
| | - Cyrille Muller
- Hôpital Saint Joseph, Department of Radiology, FR-13008, Marseille, France
| | - Raoul Desbriere
- Hôpital Saint Joseph, Department of Obstetrics and Gynecology, FR-13008, Marseille, France.
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Waheed K, Sarwar A, Ejaz S. Conservative management of placenta increta in a primigravida: A case report. J PAK MED ASSOC 2019; 69:1049-1051. [PMID: 31983746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Morbidly adherent placenta in the absence of risk factors is a rare entity in primigravida, and its conservative management becomes important in such patients to preserve future fertility. We report a case where a primigravida was discovered accidentally having placenta increta while her caesarean section was being performed due to foetal distress (grade 2 meconium). There was unexpected delay in delivery of the placenta. It was managed conservatively by performing a bilateral uterine artery ligation and methotrexate post operatively. On weekly follow-ups serum beta Human Chorionic Gonadotropin(bHCG) levels were done as well as and two weekly ultrasounds. Conservative management of morbidly adherent placenta can be considered in primigravidas where there is a great need to preser ve fer tility and avoid hysterectomy.
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Affiliation(s)
| | | | - Sara Ejaz
- King Edward Medical University, Lahore
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Collins SL, Alemdar B, van Beekhuizen HJ, Bertholdt C, Braun T, Calda P, Delorme P, Duvekot JJ, Gronbeck L, Kayem G, Langhoff-Roos J, Marcellin L, Martinelli P, Morel O, Mhallem M, Morlando M, Noergaard LN, Nonnenmacher A, Pateisky P, Petit P, Rijken MJ, Ropacka-Lesiak M, Schlembach D, Sentilhes L, Stefanovic V, Strindfors G, Tutschek B, Vangen S, Weichert A, Weizsäcker K, Chantraine F. Evidence-based guidelines for the management of abnormally invasive placenta: recommendations from the International Society for Abnormally Invasive Placenta. Am J Obstet Gynecol 2019; 220:511-526. [PMID: 30849356 DOI: 10.1016/j.ajog.2019.02.054] [Citation(s) in RCA: 170] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/13/2019] [Accepted: 02/27/2019] [Indexed: 11/28/2022]
Abstract
The worldwide incidence of abnormally invasive placenta is rapidly rising, following the trend of increasing cesarean delivery. It is a heterogeneous condition and has a high maternal morbidity and mortality rate, presenting specific intrapartum challenges. Its rarity makes developing individual expertise difficult for the majority of clinicians. The International Society for Abnormally Invasive Placenta aims to improve clinicians' understanding and skills in managing this difficult condition. By pooling knowledge, experience, and expertise gained within a variety of different healthcare systems, the Society seeks to improve the outcomes for women with abnormally invasive placenta globally. The recommendations presented herewith were reached using a modified Delphi technique and are based on the best available evidence. The evidence base for each is presented using a formal grading system. The topics chosen address the most pertinent questions regarding intrapartum management of abnormally invasive placenta with respect to clinically relevant outcomes, including the following: definition of a center of excellence; requirement for antenatal hospitalization; antenatal optimization of hemoglobin; gestational age for delivery; antenatal corticosteroid administration; use of preoperative cystoscopy, ureteric stents, and prophylactic pelvic arterial balloon catheters; maternal position for surgery; type of skin incision; position of the uterine incision; use of interoperative ultrasound; prophylactic administration of oxytocin; optimal method for intraoperative diagnosis; use of expectant management; adjuvant therapies for expectant management; use of local surgical resection; type of hysterectomy; use of delayed hysterectomy; intraoperative measures to treat life-threatening hemorrhage; and fertility after conservative management.
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Affiliation(s)
- Sally L Collins
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK; The Fetal Medicine Unit, John Radcliffe Hospital, Oxford, UK.
| | - Bahrin Alemdar
- Department of Obstetrics and Gynecology, South General Hospital, Stockholm, Sweden
| | | | - Charline Bertholdt
- Centre Hospitalier Régional Universitaire de Nancy, Université de Lorraine, France
| | - Thorsten Braun
- Departments of Obstetrics and Division of Experimental Obstetrics, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Pavel Calda
- Department of Obstetrics and Gynecology, General Faculty Hospital, Charles University, Prague, Czech Republic
| | - Pierre Delorme
- Port-Royal Maternity Unit, Cochin Hospital, Paris-Descartes University, DHU Risk and Pregnancy, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Johannes J Duvekot
- Department of Obstetrics and Gynecology, Erasmus Medical Center Rotterdam, Rotterdam, Netherlands
| | - Lene Gronbeck
- Department of Obstetrics, Rigshospitalet, University of Copenhagen, Denmark
| | - Gilles Kayem
- Department of Obstetrics and Gynecology, Hôpital Trousseau, Assistance Publique des Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Jens Langhoff-Roos
- Department of Obstetrics, Rigshospitalet, University of Copenhagen, Denmark
| | - Louis Marcellin
- Department of Gynecology Obstetrics II and Reproductive Medicine, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, APHP; Sorbonne Paris Cité, Université Paris Descartes, Faculté de Médecine, Paris, France
| | - Pasquale Martinelli
- Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy
| | - Olivier Morel
- Centre Hospitalier Régional Universitaire de Nancy, Université de Lorraine, France
| | - Mina Mhallem
- Department of Obstetrics, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Maddalena Morlando
- Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy; Department of Women, Children and of General and Specialized Surgery, University "Luigi Vanvitelli", Naples, Italy
| | - Lone N Noergaard
- Department of Obstetrics, Rigshospitalet, University of Copenhagen, Denmark
| | - Andreas Nonnenmacher
- Departments of Obstetrics and Division of Experimental Obstetrics, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Petra Pateisky
- Department of Obstetrics and Gynecology, Division of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - Philippe Petit
- Department of Obstetrics and Gynecology, CHR Citadelle, University of Liege, Liege, Belgium
| | - Marcus J Rijken
- Vrouw & Baby, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
| | - Mariola Ropacka-Lesiak
- Department of Perinatology and Gynecology, University of Medical Sciences, Poznan, Poland
| | - Dietmar Schlembach
- Vivantes Network for Health, Clinicum Neukoelln, Clinic for Obstetric Medicine, Berlin, Germany
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - Vedran Stefanovic
- Department of Obstetrics and Gynecology, Fetomaternal Medical Center, Helsinki University Hospital and University of Helsinki, Finland
| | - Gita Strindfors
- Department of Obstetrics and Gynecology, South General Hospital, Stockholm, Sweden
| | - Boris Tutschek
- Prenatal Zurich, Zürich, Switzerland; Heinrich Heine University, Düsseldorf, Germany
| | - Siri Vangen
- Division of Obstetrics and Gynaecology, Norwegian National Advisory Unit on Women's Health, Oslo University Hospital, Rikshospitalet and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Alexander Weichert
- Departments of Obstetrics and Division of Experimental Obstetrics, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Katharina Weizsäcker
- Departments of Obstetrics and Division of Experimental Obstetrics, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Frederic Chantraine
- Department of Obstetrics and Gynecology, CHR Citadelle, University of Liege, Liege, Belgium
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Wang M, Ballah D, Wade A, Taylor AG, Rizzuto G, Li B, Lucero J, Chen LM, Kohi MP. Uterine Artery Embolization following Cesarean Delivery but prior to Hysterectomy in the Management of Patients with Invasive Placenta. J Vasc Interv Radiol 2019; 30:687-691. [PMID: 30922797 PMCID: PMC10468213 DOI: 10.1016/j.jvir.2018.12.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 12/04/2018] [Accepted: 12/06/2018] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To evaluate outcomes of patients with placenta accreta spectrum (PAS) disorders who underwent uterine artery embolization (UAE) following cesarean delivery but before hysterectomy. MATERIALS AND METHODS A retrospective review of patients with PAS treated with cesarean-hysterectomy (C-hyst) was performed. Patients in the UAE group underwent UAE after cesarean delivery but before hysterectomy; patients in the control group underwent C-hyst alone. Estimated blood loss (EBL), transfusion requirements, length of intensive care unit (ICU) stay, and adverse events were evaluated. RESULTS The study included 31 patients, 7 in the UAE group and 24 in the control group. Median EBL, transfusion requirements, and length of ICU stay in the UAE group compared with control group were 1,500 mL (range, 500-2,000 mL) vs 2,000 mL (range, 1,000-4,500 mL) (P = .04), 150 mL (range, 0-650 mL) vs 550 mL (range, 0-3,125 mL) (P = .10), and 0 d (range, 0-1 d) vs 0.5 d (range, 0-2 d) (P = .07). All patients in the UAE group had placenta increta; patients in the control group had placenta accreta (29%), increta (54%), and percreta (17%) (P = .10). Subgroup analysis of patients with placenta increta demonstrated that the UAE group had a significant decrease in median EBL (P = .004), transfusion requirements (P = .009), and length of ICU stay (P = .04). No adverse events following UAE were noted. CONCLUSIONS UAE following cesarean delivery but before hysterectomy in patients with placenta increta appears to be safe and effective in decreasing EBL, transfusion requirements, and length of ICU stay compared with C-hyst alone.
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Affiliation(s)
- Melinda Wang
- Weill Cornell Medical College, New York, New York
| | - Deddeh Ballah
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Alana Wade
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Andrew G Taylor
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Gabrielle Rizzuto
- Department of Pathology and Laboratory Medicine, University of California, San Francisco, San Francisco, California
| | - Benjamin Li
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - Jennifer Lucero
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
| | - Lee-May Chen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - Maureen P Kohi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California.
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Roziana R, Kamarul Azhar K, Lau JH, Aina MAA, Nadia R, Siti Nordiana A, Mohd Zulkifli K. Morbidly adherent placenta: One-year case series in a tertiary hospital. Med J Malaysia 2019; 74:128-132. [PMID: 31079123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To analyse the clinical characteristics of patients with morbidly adherent placenta (MAP). Findings of this study will be used to identify patients at risk of MAP and to outline the best management strategy to deal with this devastating condition. METHODS Delivery records in Hospital Sultanah Nur Zahirah, Terengganu from 1st. January 2016 until 31st. December 2016 were reviewed and analysed. RESULTS Out of the 15,837 deliveries, eight cases of MAP were identified. Six out of eight patients had previous caesarean scar with concomitant placenta praevia, the other two patients had previous caesarean scar with history of placenta praevia in previous pregnancies. Seven out of eight cases were suspected to have MAP based on risk factors. Correct diagnosis was made by ultrasound in five patients, all with histologically confirmed moderate/severe degree of abnormal placentation. The other two cases of 'unlikely MAP', demonstrated segmental MAP intra-operatively with histologically confirmed milder degree of abnormal placentation. Total intraoperative blood loss ranged from 0.8 to 20 litres. Prophylactic internal iliac artery balloon occlusion was associated with significantly less blood loss. CONCLUSION Antenatal diagnosis is essential in outlining the best management strategy in patients with MAP. Ultrasound may not be accurate in ruling out lower degree of MAP. Apart from having a scarred uterus with concomitant placenta praevia, history of having placenta praevia in previous pregnancy is also a risk factor for MAP. Prophylactic internal iliac artery balloon occlusion is associated with significantly less blood loss and should be considered in cases suspected with MAP.
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Affiliation(s)
- R Roziana
- Hospital Sultanah Nur Zahirah, Department of Obstetrics & Gynaecology, Kuala Terengganu, Terengganu, Malaysia.
| | - K Kamarul Azhar
- Hospital Sultanah Nur Zahirah, Department of Obstetrics & Gynaecology, Kuala Terengganu, Terengganu, Malaysia
| | - J H Lau
- Hospital Kuala Lumpur, Department of Radiology, Kuala Lumpur, Malaysia
| | - M A A Aina
- Hospital Sultanah Nur Zahirah, Department of Obstetrics & Gynaecology, Kuala Terengganu, Terengganu, Malaysia
| | - R Nadia
- Hospital Sultanah Nur Zahirah, Department of Obstetrics & Gynaecology, Kuala Terengganu, Terengganu, Malaysia
| | - A Siti Nordiana
- Hospital Sultanah Nur Zahirah, Department of Obstetrics & Gynaecology, Kuala Terengganu, Terengganu, Malaysia
| | - K Mohd Zulkifli
- Hospital Sultanah Nur Zahirah, Department of Obstetrics & Gynaecology, Kuala Terengganu, Terengganu, Malaysia
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Kudela M, Černá M, Hostinská E, Huml K, Grofová Š, Pilka R. Prophylactic bilateral iliac artery balloon occlusion during cesarean section in Jehova´s Witnesses patient. Ceska Gynekol 2019; 84:337-340. [PMID: 31826629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To describe a case report with prophylactic bilateral iliac artery balloon occlusion during cesarean section in Jehova´s Witnesses patient. DESIGN Case report. SETTING Department of Obstetrics and Gynecology, University Hospital, Olomouc; Department of Radiology, University Hospital, Olomouc; Department of Health Care Sciencies, Bata University, Zlín. CASE REPORT We describe case report with prophylactic bilateral iliac artery balloon occlusion during cesarean section in Jehova´s Witnesses patient in attempt to decrease the risk of heavy peroperative bleeding. Twenty eight years old primigravida underwent prophylactic internal iliac artery balloon catheterization with interventional radiology preoperatively. Two 6-Fr balloon catheters transfemorally bilaterally up to internal iliac artery with position a “cross over“ were introduced, according to Seldingers standard technique. The procedure was without complications, estimated blood loss was 500 ml. CONCLUSION Prophylactic placement of intravascular balloon catheters is a feasible treatment for Jehova´s Witnesses patients in efforts to decrease the risk of heavy bleeding during cesarean section.
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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] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Marcellin L, Delorme P, Bonnet MP, Grange G, Kayem G, Tsatsaris V, Goffinet F. Placenta percreta is associated with more frequent severe maternal morbidity than placenta accreta. Am J Obstet Gynecol 2018; 219:193.e1-193.e9. [PMID: 29733839 DOI: 10.1016/j.ajog.2018.04.049] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 04/17/2018] [Accepted: 04/26/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Abnormally invasive placentation is the leading cause of obstetric hysterectomy and can cause poor to disastrous maternal outcomes. Most previous studies of peripartum management and maternal morbidity have included variable proportions of severe and less severe cases. OBJECTIVE The aim of this study was to compare maternal morbidity from placenta percreta and accreta. STUDY DESIGN This retrospective study at a referral center in Paris includes all women with abnormally invasive placentation from 2003 through 2017. Placenta percreta and accreta were diagnosed histologically or clinically. When placenta percreta was suspected before birth, a conservative approach leaving the placenta in situ was proposed because of the intraoperative risk of cesarean delivery. When placenta accreta was suspected, parents were offered a choice of a conservative approach or an attempt to remove the placenta, to be followed in case of failure by hysterectomy. Maternal outcomes were compared between women with placenta percreta and those with placenta accreta/increta. The primary outcome measure was a composite criterion of severe acute maternal morbidity including at least 1 of the following: hysterectomy during cesarean delivery, delayed hysterectomy, transfusion of ≥10 U of packed red blood cells, septic shock, acute kidney injury, cardiovascular failure, maternal transfer to intensive care, or death. RESULTS Of the 156 women included, 51 had placenta percreta and 105 placenta accreta. Abnormally invasive placentation was suspected antenatally nearly 4 times more frequently in the percreta than the accreta group (96.1% [49/51] vs 25.7% [27/105], P < .01). Among the 76 women with antenatally suspected abnormally invasive placentation (48.7%), the rate of antenatal decisions for conservative management was higher in the percreta than the accreta group (100% [49/49] vs 40.7% [11/27], P < .01). The composite maternal morbidity rate was significantly higher in the percreta than the accreta group (86.3% [44/51] vs 28/105 [26.7%], P < .001). A secondary analysis restricted to women with an abnormally invasive placentation diameter >6 cm showed similar results (86.0% [43/50) vs 48.7% [19/38), P < .01). The rate of hysterectomy during cesareans was significantly higher in the percreta than the accreta group (52.9% [27/51] vs 20.9% [22/105], P < .01) as was the total hysterectomy rate (43/51 [84.3%] vs 23.8% [25/105], P < .01). CONCLUSION Severe maternal morbidity is much more frequent in women with placenta percreta than with placenta accreta, despite multidisciplinary planning, management in a referral center, and better antenatal suspicion.
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Affiliation(s)
- Louis Marcellin
- Port-Royal Maternity Unit, Department of Obstetrics Paris, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France; Department of Gynecology Obstetrics II and Reproductive Medicine, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France; Sorbonne Paris Cité, Université Paris Descartes, Faculté de Médecine, Paris, France.
| | - Pierre Delorme
- Port-Royal Maternity Unit, Department of Obstetrics Paris, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France; Sorbonne Paris Cité, Université Paris Descartes, Faculté de Médecine, Paris, France
| | - Marie Pierre Bonnet
- Départment d'Anesthesie Réanimation, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France; Sorbonne Paris Cité, Université Paris Descartes, Faculté de Médecine, Paris, France
| | - Gilles Grange
- Port-Royal Maternity Unit, Department of Obstetrics Paris, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France; Sorbonne Paris Cité, Université Paris Descartes, Faculté de Médecine, Paris, France
| | - Gilles Kayem
- Pierre-et-Marie-Curie University, Paris, France; Obstetrical, Perinatal, and Pediatric Epidemiology Research Team, Center for Epidemiology and Statistics Sorbonne Paris Cité, Inserm U1153, Paris, France; Obstetrics and Gynecology Department, Hôpital Armand-Trousseau, Paris, France
| | - Vassilis Tsatsaris
- Port-Royal Maternity Unit, Department of Obstetrics Paris, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France; Sorbonne Paris Cité, Université Paris Descartes, Faculté de Médecine, Paris, France
| | - François Goffinet
- Port-Royal Maternity Unit, Department of Obstetrics Paris, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France; Sorbonne Paris Cité, Université Paris Descartes, Faculté de Médecine, Paris, France
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Einerson BD, Rodriguez CE, Kennedy AM, Woodward PJ, Donnelly MA, Silver RM. Magnetic resonance imaging is often misleading when used as an adjunct to ultrasound in the management of placenta accreta spectrum disorders. Am J Obstet Gynecol 2018; 218:618.e1-618.e7. [PMID: 29572089 DOI: 10.1016/j.ajog.2018.03.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/05/2018] [Accepted: 03/14/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Magnetic resonance imaging is reported to have good sensitivity and specificity in the diagnosis of placenta accreta spectrum disorders, and is often used as an adjunct to ultrasound. But the additional utility of obtaining magnetic resonance imaging to assist in the clinical management of patients with placenta accreta spectrum disorders, above and beyond the information provided by ultrasound, is unknown. OBJECTIVE We aimed to determine whether magnetic resonance imaging provides data that may inform clinical management by changing the sonographic diagnosis of placenta accreta spectrum disorders. STUDY DESIGN In all, 78 patients with sonographic evidence or clinical suspicion of placenta accreta spectrum underwent magnetic resonance imaging of the abdomen and pelvis in orthogonal planes through the uterus utilizing T1- and T2-weighted imaging sequences at the University of Utah and the University of Colorado from 1997 through 2017. The magnetic resonance imaging was interpreted by radiologists with expertise in diagnosis of placenta accreta spectrum who had knowledge of the sonographic interpretation and clinical risk factors for placenta accreta spectrum disorders. The primary outcome was a change in diagnosis from sonographic interpretation that could alter clinical management, which was defined a priori. Diagnostic accuracy was verified by surgical and histopathologic diagnosis at the time of delivery. RESULTS A change in diagnosis that could potentially alter clinical management occurred in 28 (36%) cases. Magnetic resonance imaging correctly changed the diagnosis in 15 (19%), and correctly confirmed the diagnosis in 34 (44%), but resulted in an incorrect change in diagnosis in 13 (17%), and an incorrect confirmation of ultrasound diagnosis in 15 (21%). Magnetic resonance imaging was not more likely to change a diagnosis in the 24 cases of posterior and lateral placental location compared to anterior location (33% vs 37%, P = .84). Magnetic resonance imaging resulted in overdiagnosis in 23% and in underdiagnosis in 14% of all cases. When ultrasound suspected severe disease (percreta) in 14 cases, magnetic resonance imaging changed the diagnosis in only 2 cases. Lastly, the proportion of accurate diagnosis with magnetic resonance imaging did not improve over time (61-65%, P = .96 for trend) despite increasing volume and increasing numbers of changed diagnoses. CONCLUSION Magnetic resonance imaging resulted in a change in diagnosis that could alter clinical management of placenta accreta spectrum disorders in more than one third of cases, but when changed, the diagnosis was often incorrect. Given its high cost and limited clinical value, magnetic resonance imaging should not be used routinely as an adjunct to ultrasound in the diagnosis of placenta accreta spectrum until evidence for utility is clearly demonstrated by more definitive prospective studies.
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Affiliation(s)
- Brett D Einerson
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Utah Health, Salt Lake City, UT; Intermountain Healthcare, Salt Lake City, UT.
| | - Christina E Rodriguez
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Anne M Kennedy
- Department of Radiology, University of Utah Health, Salt Lake City, UT
| | - Paula J Woodward
- Department of Radiology, University of Utah Health, Salt Lake City, UT
| | - Meghan A Donnelly
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Robert M Silver
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Utah Health, Salt Lake City, UT; Intermountain Healthcare, Salt Lake City, UT
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Fan Y, Gong X, Wang N, Mu K, Feng L, Qiao F, Chen S, Zeng W, Liu H, Wu Y, Zhou Q, Tian Y, Li Q, Yang M, Li F, He M, Beejadhursing R, Deng D. A prospective observational study evaluating the efficacy of prophylactic internal iliac artery balloon catheterization in the management of placenta previa-accreta: A STROBE compliant article. Medicine (Baltimore) 2017; 96:e8276. [PMID: 29137011 PMCID: PMC5690704 DOI: 10.1097/md.0000000000008276] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We studied the efficacy of prophylactic internal iliac artery balloon catheterization for managing severe hemorrhage caused by pernicious placenta previa.This prospective observational study was conducted in Tongji Hospital, Wuhan, China. One hundred sixty-three women past 32-week's gestation with placenta previa-accreta were recruited and managed. Women in the balloon group accepted prophylactic internal iliac artery balloon catheterization before scheduled caesarean delivery and controls had a conventional caesarean delivery. Intraoperative hemorrhage, transfusion volume, radiation dose, exposure time, complications, and neonatal outcomes were discussed.Significant differences were detected in estimated blood loss (1236.0 mL vs 1694.0 mL, P = .01), calculated blood loss (CBL) (813.8 mL vs 1395.0 mL, P < .001), CBL of placenta located anteriorly (650.5 mL vs 1196.0 mL, P = .03), and anterioposteriorly (928.3 mL vs 1680.0 mL, P = .02). Prophylactic balloon catheterization could reduce intraoperative red blood cell transfusion (728.0 mL vs 1205.0 mL, P = .01) and lessen usage of perioperative hemostatic methods. The incidence of hysterectomy was lower in balloon group. Mean radiation dose was 29.2 mGy and mean exposure time was 92.2 seconds. Neonatal outcomes and follow-up data did not have significant difference.Prophylactic internal iliac artery balloon catheterization is an effective method for managing severe hemorrhage caused by placenta previa-accreta as it reduced intraoperative blood loss, lessened perioperative hemostatic measures and intraoperative red cell transfusions, and reduce hysterectomies.
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Affiliation(s)
- Yao Fan
- Department of Gynecology and Obstetrics
| | - Xun Gong
- Department of Gynecology and Obstetrics
| | - Nan Wang
- Department of Interventional Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Ketao Mu
- Department of Interventional Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Ling Feng
- Department of Gynecology and Obstetrics
| | | | | | | | - Haiyi Liu
- Department of Interventional Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | | | | | - Yuan Tian
- Department of Gynecology and Obstetrics
| | - Qiang Li
- Department of Gynecology and Obstetrics
| | | | - Fanfan Li
- Department of Gynecology and Obstetrics
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Shamshirsaz AA, Fox KA, Erfani H, Clark SL, Salmanian B, Baker BW, Coburn M, Shamshirsaz AA, Bateni ZH, Espinoza J, Nassr AA, Popek EJ, Hui SK, Teruya J, Tung CS, Jones JA, Rac M, Dildy GA, Belfort MA. Multidisciplinary team learning in the management of the morbidly adherent placenta: outcome improvements over time. Am J Obstet Gynecol 2017; 216:612.e1-612.e5. [PMID: 28213059 DOI: 10.1016/j.ajog.2017.02.016] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 02/06/2017] [Accepted: 02/08/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Morbidly adherent placenta (MAP) is a serious obstetric complication causing mortality and morbidity. OBJECTIVE To evaluate whether outcomes of patients with MAP improve with increasing experience within a well-established multidisciplinary team at a single referral center. STUDY DESIGN All singleton pregnancies with pathology-confirmed MAP (including placenta accreta, increta, or percreta) managed by a multidisciplinary team between January 2011 and August 2016 were included in this retrospective study. Turnover of team members was minimal, and cases were divided into 2 time periods so as to compare 2 similarly sized groups: T1 = January 2011 to April 2014 and T2 = May 2014 to August 2016. Outcome variables were estimated blood loss, units of red blood cell transfused, volume of crystalloid transfused, massive transfusion protocol activation, ureter and bowel injury, and neonatal birth weight. Comparisons and adjustments were made by use of the Student t test, Mann-Whitney U test, χ2 test, analysis of covariance, and multinomial logistic regression. RESULTS A total of 118 singleton pregnancies, 59 in T1 and 59 in T2, were managed during the study period. Baseline patient characteristics were not statistically significant. Forty-eight of 59 (81.4%) patients in T1 and 42 of 59 (71.2%) patients in T2 were diagnosed with placenta increta/percreta. The median [interquartile range] estimated blood loss (T1: 2000 [1475-3000] vs T2: 1500 [1000-2700], P = .04), median red blood cell transfusion units (T1: 2.5 [0-7] vs T2: 1 [0-4], P = .02), and median crystalloid transfusion volume (T1: 4200 [3600-5000] vs T2: 3400 [3000-4000], P < .01) were significantly less in T2. Also, a massive transfusion protocol was instituted more frequently in T1: 15/59 (25.4%) vs 3/59 (5.1%); P < .01. Neonatal outcomes and surgical complications were similar between the 2 groups. CONCLUSION Our study shows that patient outcomes are improved over time with increasing experience within a well-established multidisciplinary team performing 2-3 cases per month. This suggests that small, collective changes in team dynamics lead to continuous improvement of clinical outcomes. These findings support the development of centers of excellence for MAP staffed by stable, core multidisciplinary teams, which should perform a significant number of these procedures on an ongoing basis.
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Affiliation(s)
- Alireza A Shamshirsaz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
| | - Karin A Fox
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Hadi Erfani
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Steven L Clark
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Bahram Salmanian
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - B Wycke Baker
- Department of Anesthesiology and Obstetric and Gynecologic Anesthesiology, Texas Children's Hospital, Houston, TX
| | - Michael Coburn
- Department of Urology, Baylor College of Medicine, Houston, TX
| | - Amir A Shamshirsaz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Zhoobin H Bateni
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Jimmy Espinoza
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Ahmed A Nassr
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX; Department of Obstetrics and Gynecology, Women's Health Hospital, Assiut University, Assiut Egypt
| | - Edwina J Popek
- Department of Pathology & Transfusion Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Shiu-Ki Hui
- Department of Pathology & Transfusion Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Jun Teruya
- Department of Pathology & Transfusion Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Celestine Shauching Tung
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Jeffery A Jones
- Department of Urology, Baylor College of Medicine, Houston, TX
| | - Martha Rac
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Gary A Dildy
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Michael A Belfort
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
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Tan YL, Suharjono H, Lau NLJ, Voon HY. Prophylactic bilateral internal iliac artery balloon occlusion in the management of placenta accreta: A 36-month review. Med J Malaysia 2016; 71:111-116. [PMID: 27495883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND The contemporary obstetrician is increasingly put to the test by rising numbers of pregnancies with morbidly adherent placenta. This study illustrates our experience with prophylactic bilateral internal iliac artery occlusion as part of its management. METHODS Between January 2011 to January 2014, 13 consecutive patients received the intervention prior to scheduled caesarean delivery for placenta accreta. All cases were diagnosed by ultrasonography, color Doppler imaging and supplemented with MRI where necessary. The Wanda balloon(TM) catheter (Boston Scientific, Natick, MA, U.S.A) were placed in the proximal segment of the internal iliac arteries preceding surgery. This was followed by a midline laparotomy and classical caesarean section, avoiding the placenta. Both internal iliac balloons were inflated just before the delivery of fetus and deflated once haemostasis was secured. Primary outcomes measured were perioperative blood loss, blood transfusion requirement and the need for ICU admission. RESULTS The mean and median intraoperative blood loss were 1076mls±707 and 800mls (300-2500) respectively while mean perioperative blood loss was 1261mls±946. Just over half of the patients in our series required blood and/or blood products transfusion. Two patients (15.4%) required ICU admission. CONCLUSION Our study suggests that preoperative prophylactic balloon occlusion of bilateral internal iliac arteries reduces both blood loss and transfusion requirement in patients with placenta accreta, scheduled to undergo elective caesarean hysterectomy. It is an adjunct to be considered in the management of a modern day obstetric problem, although the authors are cautious about generalizing its benefit without larger, randomized trials.
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Affiliation(s)
- Y L Tan
- KPJ Kuching Specialist Centre, Kuching, Sarawak, Malaysia,.
| | - H Suharjono
- Sarawak General Hospital, Department of Obstetrics & Gynecology, 93586 Kuching, Sarawak, Malaysia
| | - N L J Lau
- Sarawak General Hospital, Department of Obstetrics & Gynecology, 93586 Kuching, Sarawak, Malaysia
| | - H Y Voon
- Sarawak General Hospital, Department of Obstetrics & Gynecology, 93586 Kuching, Sarawak, Malaysia
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Bai Y, Luo X, Li Q, Yin N, Fu X, Zhang H, Qi H. High-intensity focused ultrasound treatment of placenta accreta after vaginal delivery: a preliminary study. Ultrasound Obstet Gynecol 2016; 47:492-498. [PMID: 25846712 DOI: 10.1002/uog.14867] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 03/23/2015] [Accepted: 03/29/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To evaluate the safety and efficiency of high-intensity focused ultrasound (HIFU) in the treatment of placenta accreta after vaginal delivery. METHODS Enrolled into this study between September 2011 and September 2013 were 12 patients who had been diagnosed with placenta accreta following vaginal delivery and who had stable vital signs. All patients were treated using an ultrasound-guided HIFU treatment system. As indication of the effectiveness of the treatment we considered decreased vascular index on color Doppler imaging, decrease in size of residual placenta compared with pretreatment size on assessment by three-dimensional ultrasound with Virtual Organ Computer-aided Analysis, reduced signal intensity and degree of enhancement on magnetic resonance imaging and avoidance of hysterectomy following treatment. To assess the safety of HIFU treatment, we recorded side effects, hemorrhage, infection, sex steroid levels, return of menses and subsequent pregnancy. Patients were followed up in this preliminary study until December 2013. RESULTS The 12 patients receiving HIFU treatment had an average postpartum hospital stay of 6.8 days and an average period of residual placental involution of 36.9 days. HIFU treatment did not apparently increase the risk of infection or hemorrhage and no patient required hysterectomy. In all patients menstruation recommenced after an average of 80.2 days, and sex steroid levels during the middle luteal phase of the second menstrual cycle were normal. Two patients became pregnant again during the follow-up period. CONCLUSION This preliminary study suggests that ultrasound-guided HIFU is a safe and effective non-invasive method to treat placenta accreta patients after vaginal delivery who have stable vital signs and desire to preserve fertility. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- Y Bai
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - X Luo
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Q Li
- Department of Pathology, Chongqing Medical University, Chongqing, People's Republic of China
| | - N Yin
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - X Fu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - H Zhang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - H Qi
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
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Dimirov A, Garnizov T, Zlatkov V, Frundeva B, Masseva A. [CONSERVATIVE MANAGEMENT OF PLACENTA ACCRETE DURING VAGINAL DELIVERY]. Akush Ginekol (Sofiia) 2016; 55:39-44. [PMID: 27514130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Conservative management of placenta accrete consists in leaving the entire placenta accreta in situ after vaginal delivery of the fetus. This behavior requires active monitoring the vital signs of mother, genital status and paraclinical indicators for an extended period after birth. Monitoring is suspended after full absorption of the placenta. The success of the conservative approach depends on: the adopted protocol formanagement of placenta accreta, whether the diagnosis is known before birth, the possible of application techniques, reducing blood flow to the uterus, keeping the placental period and others. The smallest success with vaginal birth, is when the diagnosis of placenta accreta is not know in advance and proceed with aggressive attempts to extract the placenta, followed by profuse bleeding from the uterus. As additional methods of securing conservative management is reported use of Methotrexate, with unproven effectiveness and embolization of a. Iliaca interna and a. uterine, which require a qualified team and have a lot of complications. Complications of conservative management of placenta accreta are: febrility and genital bleeding, which are the cause of late hysterectomy in about 35% of cases. lnfestion may be not always prevent by application of broad spectrum antibiotics. Late bleeding is usually associated with an active inflammatory process. Low-grade and low grade temperature increase of leukocytes and CRP may be due to necrotic changes in the placenta without the infection process. Tracking involution of the placenta is through abdominal and transvaginal ultrasound, magnetic resonance, using hysteroscopy through serial monitoring the level of hCG. From literature data the time for resorption of the placenta varies from 4 months to 1 year. It is essential to determine the time when it is safely to extract the placenta move in order to prevent late complications of conservative management. Our experience and some authors suggest that there may be instrumental extraction under ultrasound control at 8-10 days after birth.
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Fox KA, Shamshirsaz AA, Carusi D, Secord AA, Lee P, Turan OM, Huls C, Abuhamad A, Simhan H, Barton J, Wright J, Silver R, Belfort MA. Conservative management of morbidly adherent placenta: expert review. Am J Obstet Gynecol 2015; 213:755-60. [PMID: 25935779 DOI: 10.1016/j.ajog.2015.04.034] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 04/24/2015] [Accepted: 04/27/2015] [Indexed: 11/16/2022]
Abstract
Over the last century, the incidence of placenta accreta, increta, and percreta, collectively referred to as morbidly adherent placenta, has risen dramatically. Planned cesarean hysterectomy at the time of cesarean delivery is the standard recommended treatment in the United States. Recently, interest in conservative management has resurged, especially in Europe. The aims of this review are the following: (1) to provide an overview of methods used for conservative management, (2) to discuss clinical implications for both clinicians and patients, and (3) to identify areas in need of further research.
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Affiliation(s)
| | | | | | | | - Paula Lee
- Duke University Medical Center, Durham, NC
| | - Ozhan M Turan
- University of Maryland School of Medicine, Baltimore, MD
| | - Christopher Huls
- Phoenix Perinatal Associates/Medivax, Banner Good Samaritan Medical Center, University of Arizona, Phoenix, AZ
| | | | - Hyagriv Simhan
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Jason Wright
- Columbia University College of Physicians and Surgeons, New York, NY
| | - Robert Silver
- University of Utah Medical School, Salt Lake City, UT
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Vintzileos AM, Ananth CV, Smulian JC. Using ultrasound in the clinical management of placental implantation abnormalities. Am J Obstet Gynecol 2015; 213:S70-7. [PMID: 26428505 DOI: 10.1016/j.ajog.2015.05.059] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 04/02/2015] [Accepted: 05/26/2015] [Indexed: 12/18/2022]
Abstract
Placental implantation abnormalities, including placenta previa, placenta accreta, vasa previa, and velamentous cord insertion, can have catastrophic consequences for both mother and fetus, especially as pregnancy progresses to term. In these situations, current recommendations for management usually call for an indicated preterm delivery even in asymptomatic patients. However, the recommended gestational age(s) for delivery in asymptomatic patients are empirically determined without consideration of the recent literature regarding the usefulness of specific ultrasound findings to help individualize management. The purpose of this article is to propose literature-supported guidelines to the current opinion-based management of asymptomatic patients with placental implantation abnormalities based on relevant and specific ultrasound findings such as cervical length, distance between the internal cervical os and placenta, and placental edge thickness.
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Affiliation(s)
- Anthony M Vintzileos
- Department of Obstetrics and Gynecology, Winthrop University Hospital, Mineola, NY.
| | - Cande V Ananth
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, and Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY
| | - John C Smulian
- Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA; Department of Obstetrics and Gynecology, University of South Florida-Morsani College of Medicine, Tampa, FL
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Nashar SV, Dimitrova V, Zlatkov V, Frandeva B, Dimitrov A. [PROLONGED RETAINED PLACENTA ACCRETA IN THE UTERUS AFTER VAGINAL DELIVERY (A CASE REPORT AND REVIEW OF LITERATURE)]. Akush Ginekol (Sofiia) 2015; 54:34-39. [PMID: 26137778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
A case of prolonged retention in the uterus of placenta accreta after vaginal delivery is reported in the paper. The patient was 20 years old G3, P0 with two pregnancy terminations on request. She was admitted to the obstetric department of a regional hospital one day after the EDD with irregular contractions and non reassuring CTG. A few hours later intrauterine fetal demise occurred. Spontaneous labor commenced and a stillborn growth retarded fetus was delivered. Methergin was administered during the third stage of labor, but the placenta was not separated even after repeated Crede maneuvers, the last one under anesthesia. Since cervical spasm was present, the attempts for manual or instrumental separation of the placenta were unsuccessful. There was no genital bleeding, so further conservative approach was followed including continuous IV infusion of uterotonics, combined antibiotic therapy, close observation of the vital signs and the laboratory indicators. Three days after delivery the patient was transferred to a University Hospital because of subfebrile temperature. Her general condition on admission, although subfebrile, was good, there was no genital bleeding, the cervix was closed. The subfebrile temperatrure persisted despite antibiotic treatment; CRP was elevated (51,9 mg/l.). Because of suspicion for endomyometritis, on day 8th after delivery instrumental extraction of the placenta was undertaken with preparedness for hysterectomy in case of need. Although the procedure was difficult, with the placenta being extracted in parts, bleeding was scarce. The post operative period was uneventful and the patient was discharged from hospital five days after the intervention. A review of literature on the obstetric management of cases with retained placenta accreta after vaginal delivery is presented. The existing therapeutic options are discussed including their advantages and complications.
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Abstract
BACKGROUND Placenta accreta is a condition of abnormal placental attachment that was usually treated by hysterectomy. Techniques to conserve the uterus are now commonly used and series of subsequent pregnancy outcomes have been reported. The recurrence risk of placenta accreta is now a relevant detail and is currently not known. This work was performed to calculate the recurrence risk by reviewing the published literature. METHODS A literature search using the terms "placenta accreta", "placenta percreta", "placenta increta", "abnormal placental attachment" and "placental attachment disorder" followed by hand-searching identified 6 papers that contained data concerning recurrence of placenta accreta in subsequent pregnancies following initial conservative treatment. RESULTS Overall 407 pregnancies were recorded and 85.7% of women reported achieved a subsequent pregnancy following conservative treatment. The risk of recurrence of placental attachment disorder in a subsequent pregnancy was 19.9% (weighted mean, 95% CI 12.2-27.7). CONCLUSIONS The recurrence risk of placental attachment disorder following uterine conservation treatments is 20% . This risk should be discussed with women with an antenatal diagnosis of a placental attachment disorder who may be considering uterine conservation in order to retain the option of a future pregnancy.
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Affiliation(s)
| | - A Anwar
- Cumberland Infirmary, Carlisle, UK
| | - S W Lindow
- Sidra Medical and Research Center, Doha, Qatar
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