-
American Journal of Obstetrics and... Feb 2022Hysterectomy for placenta accreta spectrum may be associated with urologic morbidity, including intentional or unintentional cystostomy, ureteral injury, and bladder...
BACKGROUND
Hysterectomy for placenta accreta spectrum may be associated with urologic morbidity, including intentional or unintentional cystostomy, ureteral injury, and bladder fistula. Although previous retrospective studies have shown an association between placenta accreta spectrum and urologic morbidities, there is still a paucity of literature addressing these urologic complications.
OBJECTIVE
We sought to report a systematic description of such morbidity and associated factors.
STUDY DESIGN
This was a retrospective study of all histology-proven placenta accreta spectrum deliveries in an academic center between 2011 and 2020. Urologic morbidity was defined as the presence of at least one of the following: cystotomy, ureteral injury, or bladder fistula. Variables were reported as median (interquartile range) or number (percentage). Analyses were made using appropriate parametric and nonparametric tests. Multinomial regression analysis was performed to assess the association of adverse urologic events with the depth of placental invasion.
RESULTS
In this study, 58 of 292 patients (19.9%) experienced urologic morbidity. Patients with urologic morbidity had a higher rate of placenta percreta (compared with placenta accreta and placenta increta) than those without such injuries. Preoperative ureteral stents were placed in 54 patients (93.1%) with and 146 patients (62.4%) without urologic injury (P=.003). After adjusting for confounding variables, multinomial regression analysis revealed that the odds of having adverse urologic events was 6.5 times higher in patients with placenta percreta than in patients with placenta accreta.
CONCLUSION
Greater depth of invasion in placenta accreta spectrum was associated with more frequent and severe adverse urologic events. Whether stent placement confers any protective benefit requires further investigation.
Topics: Adult; Female; Humans; Hysterectomy; Intraoperative Complications; Placenta Accreta; Pregnancy; Retrospective Studies; Urologic Diseases
PubMed: 34391750
DOI: 10.1016/j.ajog.2021.08.010 -
Australasian Psychiatry : Bulletin of... Feb 2023Placenta accreta spectrum conditions are rare, life-threatening disorders of placentation encountered in the perinatal period, with lasting impacts on maternal quality... (Review)
Review
OBJECTIVES
Placenta accreta spectrum conditions are rare, life-threatening disorders of placentation encountered in the perinatal period, with lasting impacts on maternal quality of life and psychological wellbeing. Although the obstetric outcomes are well-known, further review is warranted to explore the psychological sequelae that may accompany these conditions.
CONCLUSIONS
The occurrence of placenta accreta spectrum during pregnancy is a major life stressor that can contribute to the development of psychiatric co-morbidity including posttraumatic stress disorder, depression and anxiety disorders. Early recognition of psychological distress and symptomatic profile is recommended at all stages of perinatal care complicated by this rare spectrum of conditions.
Topics: Pregnancy; Female; Humans; Placenta Accreta; Cesarean Section; Mental Health; Quality of Life; Retrospective Studies
PubMed: 36375814
DOI: 10.1177/10398562221139130 -
Minerva Ginecologica Apr 2019Placenta accreta spectrum (PAS) disorders is a multifactorial process that encompasses a heterogeneous group of conditions characterized by an abnormal invasion of... (Review)
Review
Placenta accreta spectrum (PAS) disorders is a multifactorial process that encompasses a heterogeneous group of conditions characterized by an abnormal invasion of trophoblastic tissue through the myometrium and uterine serosa. PAS is associated with a high burden of adverse maternal outcomes including severe life-threatening hemorrhage, need for blood transfusion, damage to adjacent organs, and death. Prenatal screening of PAS is mandatory so that women may be counselled about the severity of this condition to plan management with a multidisciplinary team and delivery in a specialized center. Ultrasound during the second and third trimester is the primary tool in diagnosing PAS, while magnetic resonance imaging is generally performed to confirm the diagnosis and to delineate the topography of placental invasion. Cesarean hysterectomy with placenta left in situ between 34 and 35 weeks of gestation is currently the gold standard surgical management of PAS disorders. Conservative management, such as uterine conservation with the placenta left in situ, or "Triple-P" procedure, should be restricted to a limited number of patients who desire to preserve fertility, after an extensive counselling regarding the high maternal morbidity and mortality risks. Finally, endovascular interventional radiology has been suggested to reduce the amount of blood loss, improve visualization of the operative field and reduce surgical complications, and its use is increasing in specialized centers.
Topics: Cesarean Section; Female; Humans; Hysterectomy; Magnetic Resonance Imaging; Patient Care Team; Placenta Accreta; Pregnancy; Prenatal Diagnosis; Severity of Illness Index; Ultrasonography, Prenatal
PubMed: 30486635
DOI: 10.23736/S0026-4784.18.04333-2 -
American Journal of Obstetrics and... Dec 2015Over the last century, the incidence of placenta accreta, increta, and percreta, collectively referred to as morbidly adherent placenta, has risen dramatically. Planned... (Review)
Review
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.
Topics: Balloon Occlusion; Blood Loss, Surgical; Enzyme Inhibitors; Female; Humans; Hysterectomy; Hysteroscopy; Ligation; Methotrexate; Myometrium; Organ Sparing Treatments; Placenta Accreta; Placenta, Retained; Postoperative Hemorrhage; Postpartum Hemorrhage; Pregnancy; Prenatal Diagnosis; Time-to-Treatment; Uterine Artery; Uterine Artery Embolization
PubMed: 25935779
DOI: 10.1016/j.ajog.2015.04.034 -
BMC Pregnancy and Childbirth May 2023To evaluate the diagnostic accuracy of ultrasound and in the diagnosis of Placenta accreta spectrum (PAS). (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To evaluate the diagnostic accuracy of ultrasound and in the diagnosis of Placenta accreta spectrum (PAS).
DATA SOURCES
Screening of MEDLINE, CENTRAL, other bases from inception to February 2022 using the keywords related to placenta accreta, increta, percreta, morbidly adherent placenta, and preoperative ultrasound diagnosis.
STUDY ELIGIBILITY CRITERIA
All available studies- whether were prospective or retrospective- including cohort, case control and cross sectional that involved prenatal diagnosis of PAS using 2D or 3D ultrasound with subsequent pathological confirmation postnatal were included. Fifty-four studies included 5307 women fulfilled the inclusion criteria, PAS was confirmed in 2025 of them.
STUDY APPRAISAL AND SYNTHESIS METHODS
Extracted data included settings of the study, study type, sample size, participants characteristics and their inclusion and exclusion criteria, Type and site of placenta previa, Type and timing of imaging technique (2D, and 3D), severity of PAS, sensitivity and specificity of individual ultrasound criteria and overall sensitivity and specificity.
RESULTS
The overall sensitivity was 0.8703, specificity was 0.8634 with -0.2348 negative correlation between them. The estimate of Odd ratio, negative likelihood ratio and positive likelihood ratio were 34.225, 0.155 and 4.990 respectively. The overall estimates of loss of retroplacental clear zone sensitivity and specificity were 0.820 and 0.898 respectively with 0.129 negative correlation. The overall estimates of myometrial thinning, loss of retroplacental clear zone, the presence of bridging vessels, placental lacunae, bladder wall interruption, exophytic mass, and uterovesical hypervascularity sensitivities were 0.763, 0.780, 0.659, 0.785, 0.455, 0.218 and 0.513 while specificities were 0.890, 0.884, 0.928, 0.809, 0.975, 0.865 and 0.994 respectively.
CONCLUSIONS
The accuracy of ultrasound in diagnosis of PAS among women with low lying or placenta previa with previous cesarean section scars is high and recommended in all suspected cases.
TRIAL REGISTRATION
Number CRD42021267501.
Topics: Pregnancy; Female; Humans; Placenta Accreta; Placenta; Placenta Previa; Cesarean Section; Retrospective Studies; Prospective Studies; Cross-Sectional Studies; Ultrasonography, Prenatal
PubMed: 37189095
DOI: 10.1186/s12884-023-05675-6 -
American Journal of Obstetrics and... Jul 2023Placenta accreta spectrum disorders are a continuum of placental pathologies with significant maternal morbidity and mortality. Morbidity is related to the overall...
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.
Topics: Placenta Accreta; Postpartum Hemorrhage; Uterine Artery Embolization; Tranexamic Acid; Hysterectomy; Cesarean Section; Blood Transfusion; Uterine Artery; Pregnancy Outcome
PubMed: 36965865
DOI: 10.1016/j.ajog.2023.03.028 -
American Journal of Obstetrics &... Jan 2024The incidence of placenta accreta spectrum, the deeply adherent placenta with associated increased risk of maternal morbidity and mortality, has seen a significant rise... (Review)
Review
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.
Topics: Pregnancy; Female; Humans; Placenta Accreta; Cesarean Section; Obstetrics; Postpartum Hemorrhage
PubMed: 37984691
DOI: 10.1016/j.ajogmf.2023.101229 -
BMC Pregnancy and Childbirth Aug 2023To develop an ultrasound scoring system for placenta accreta spectrum (PAS), evaluate its diagnostic value, and provide a practical approach to prenatal diagnosis of PAS.
BACKGROUND
To develop an ultrasound scoring system for placenta accreta spectrum (PAS), evaluate its diagnostic value, and provide a practical approach to prenatal diagnosis of PAS.
METHODS
A total of 532 pregnant women (n = 184 no PAS, n = 120 placenta accreta, n = 189 placenta increta, n = 39 placenta percreta) at high-risk for placenta accreta who delivered in the Third Affiliated Hospital of Zhengzhou University between January 2021 and December 2022 underwent prenatal ultrasound to evaluate placental invasion. An ultrasound scoring system that included placental and cervical morphology and history of cesarean section was created. Each feature was assigned a score of 0 ~ 2, according to severity. Thresholds for the total ultrasound score that discriminated between no PAS, placenta accreta, placenta increta, and placenta percreta were calculated.
RESULTS
Univariate and multivariate regression analysis identified seven indicators of PAS that were included in the ultrasound scoring system, including placental location, placental thickness, presence/absence of the retroplacental space, thickness of the retroplacental myometrium, presence/absence of placental lacunae, retroplacental myometrial blood flow and history of cesarean section. Using the final ultrasound scoring system, no PAS is diagnosed at a total score < 5, placenta accreta or placenta increta is diagnosed at a total score 5-10, and placenta percreta is diagnosed at a total score ≥ 10.
CONCLUSIONS
This study identified seven indicators of PAS and included them in an ultrasound scoring system that has good diagnostic efficacy and clinical utility.
TRIAL REGISTRATION
ChiCTR2300069261 (retrospectively registered on 10/03/2023).
Topics: Female; Pregnancy; Humans; Placenta Accreta; Placenta; Cesarean Section; Ultrasonography, Prenatal; Prenatal Diagnosis; Placenta Previa; Retrospective Studies
PubMed: 37550654
DOI: 10.1186/s12884-023-05886-x -
American Journal of Perinatology Jul 2023The rising in placenta accreta spectrum (PAS) incidence, highlights the need for critical care allotment for these patients. Due to risk for hemorrhage and possible...
The rising in placenta accreta spectrum (PAS) incidence, highlights the need for critical care allotment for these patients. Due to risk for hemorrhage and possible hemorrhagic shock requiring blood product transfusion, hemodynamic instability and risk of end-organ damage, having an intensive care unit (ICU) with surgical expertise (surgical ICU or equivalent based on institutional resources) is highly recommended. Intensive care units physicians and nurses should be familiarized with intraoperative anesthetic and surgical techniques as well as obstetrics physiologic changes to provide postpartum management of PAS. Validated tools such of bedside point of care ultrasound and viscoelastic tests such as thromboelastogram/rotational thromboelastometry (TEG/ROTEM) are clinically useful in the assessment of hemodynamic status (shock diagnosis, assessment of both fluid responsiveness and tolerance) and transfusion guidance (in patients requiring massive transfusion as opposed to tranditional hemostatic resuscitation) respectively. The future of PAS management lies in the collaborative and multidisciplinary environment. We recommend that women with high suspicion or a confirmed PAS should have a preoperative plan in place and be managed in a tertiary center who is experienced in managing surgically complex cases. KEY POINTS: · The rising in placenta accreta spectrum incidence highlights the need for critical care expertise.. · Emerging tools such as point-of-care ultrasound and thromboelastography/rotational thromboelastometry represent new avenues for real time optimization of hemodynamic and hematological care of patients with PAS.. · Patients with PAS should be referred to a tertiary center having an intensive care unit (ICU) with surgical expertise (or equivalent based on institutional resources)..
Topics: Pregnancy; Female; Humans; Placenta Accreta; Cesarean Section; Obstetrics; Blood Transfusion; Critical Care; Retrospective Studies; Hysterectomy; Placenta; Placenta Previa
PubMed: 37336216
DOI: 10.1055/s-0043-1761638 -
American Journal of Obstetrics and... Jun 2022Placenta percreta is described as the most severe grade of placenta accreta spectrum and accounts for a quarter of all cases of placenta accreta spectrum reported in the...
BACKGROUND
Placenta percreta is described as the most severe grade of placenta accreta spectrum and accounts for a quarter of all cases of placenta accreta spectrum reported in the literature.
OBJECTIVE
We investigated the hypothesis that placenta percreta, which has been described clinically as placental tissue invading through the full thickness of the uterus, is a heterogeneous category with most cases owing to primary or secondary uterine abnormality rather than an abnormally invasive form of placentation.
STUDY DESIGN
We have evaluated the agreement between the intraoperative findings using the International Federation of Gynecology and Obstetrics classification with the postoperative histopathology diagnosis in a prospective cohort of 101 consecutive singleton pregnancies presenting with a low-lying placenta or placenta previa, a history of at least 1 prior cesarean delivery and ultrasound signs suggestive of placenta accreta spectrum. Furthermore, a systematic literature review of case reports of placenta percreta, which included histopathologic findings and gross images, was performed.
RESULTS
Samples for histologic examination were available in 80 of 101 cases of the cohort, which were managed by hysterectomy or partial myometrial resection. Microscopic examination showed evidence of placenta accreta spectrum in 65 cases (creta, 9; increta, 56). Of 101 cases included in the cohort, 44 (43.5%) and 54 (53.5%) were graded as percreta by observer A and observer B, respectively. There was a moderate agreement between observers. Of note, 11 of 36 cases that showed no evidence of abnormal placental attachment at delivery and/or microscopic examination were classified as percreta by both observers. The systematic literature review identified 41 case reports of placenta percreta with microscopic images and presenting symptomatology, suggesting that most cases were the consequence of a uterine rupture. The microscopic descriptions were heterogeneous, and all descriptions demonstrated histology of placenta creta rather than percreta.
CONCLUSION
Our study supported the concept that placenta accreta is not an invasive disorder of placentation but the consequence of postoperative surgical remodeling or a preexisting uterine pathology and found no histologic evidence supporting the existence of a condition where the villous tissue penetrates the entire uterine wall, including the serosa and beyond.
Topics: Female; Humans; Placenta; Placenta Accreta; Placenta Previa; Pregnancy; Prospective Studies; Ultrasonography, Prenatal
PubMed: 34973177
DOI: 10.1016/j.ajog.2021.12.030