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American Journal of Perinatology Jul 2023Since its first description early in the 20th Century, placenta accreta and its variants have changed substantially in incidence, risk factor profile, clinical...
Since its first description early in the 20th Century, placenta accreta and its variants have changed substantially in incidence, risk factor profile, clinical presentation, diagnosis and management. While systematic use of diagnostic tools and a multidisciplinary team care approach has begun to improve patient outcomes, the condition's pathophysiology, epidemiology, and best practices for diagnosis and management remain poorly understood. The use of large databases with broadly accepted terminology and diagnostic criteria should accelerate research in this area. Future work should focus on non-traditional phenotypes, such as those without placenta previa-preventive strategies, and long term medical and emotional support for patients facing this diagnosis. KEY POINTS: · Placenta accreta spectrum research may be improved with standardized terminology and use of large databases.. · Placenta accreta prediction should move beyond ultrasound with the addition of biomarkers, and needs to extend to those without traditional risk factors.. · Future research should identify practices that can prevent future accreta development..
Topics: Pregnancy; Female; Humans; Placenta Accreta; Cesarean Section; Ultrasonography, Prenatal; Placenta Previa; Placenta; Retrospective Studies
PubMed: 37336213
DOI: 10.1055/s-0043-1761635 -
American Journal of Obstetrics and... Sep 2022
Topics: Cesarean Section; Female; Humans; Placenta Accreta; Placenta Previa; Pregnancy; Urinary Bladder
PubMed: 35577012
DOI: 10.1016/j.ajog.2022.05.011 -
American Journal of Perinatology Oct 2023This study aimed to estimate the association between adverse maternal outcomes and the number of repeated cesarean deliveries (CDs) in a single obstetrical practice.
OBJECTIVE
This study aimed to estimate the association between adverse maternal outcomes and the number of repeated cesarean deliveries (CDs) in a single obstetrical practice.
STUDY DESIGN
Retrospective cohort study of all CDs between 2005 and 2020 in a single maternal fetal medicine practice. We used electronic records to get baseline characteristics and pregnancy/surgical outcomes based on the number of prior CDs. We performed two subgroup analyses for women with and without placenta previa. Chi-square for trend and one-way analysis of variance (ANOVA) were used.
RESULTS
A total of 3,582 women underwent CD and met inclusion criteria. Of these women, 1,852 (51.7%) underwent their first cesarean, 950 (26.5%) their second, 382 (10.7%) their third, 191 (5.3%) their fourth, 117 (3.3%) their fifth, and 84 (2.3%) their sixth or higher CDs. The incidence of adverse outcomes (placenta accreta, uterine window, uterine rupture, hysterectomy, blood transfusion, cystotomy, bowel injury, need for a ventilator postpartum, intensive care unit admission, wound complications, thrombosis, reoperation, and maternal death) increased with additional CDs. However, the absolute rates remained low. In women without a placenta previa, the likelihood of adverse outcome did not differ across groups. In women with a placenta previa, adverse outcomes increased with increasing CDs. However, the incidence of placenta previa did not increase with increasing CDs (<5% in each group). The incidence of a uterine dehiscence increased significantly with additional CDs: first, 0.2%; second, 2.0%; third, 6.6%; fourth, 10.3%; fifth, 5.8%; and sixth or higher, 10.4% ( < 0.001).
CONCLUSION
Maternal morbidity increases with CDs, but the absolute risks remain low. For women without placenta previa, increasing CDs is not associated with maternal morbidity. For women with placenta previa, risks are highest, but the incidence of placenta previa does not increase with successive CDs. The likelihood of uterine dehiscence increases significantly with increasing CDs which should be considered when deciding about timing of delivery in this population.
KEY POINTS
· Maternal morbidity increase with each CD.. · Absolute adverse outcomes remains low in highest order CDs.. · In women without placenta previa, there is no added morbidity with additional CDs..
Topics: Pregnancy; Female; Humans; Placenta Previa; Retrospective Studies; Cesarean Section; Pregnancy Outcome; Hysterectomy; Placenta Accreta; Surgical Wound Dehiscence
PubMed: 34583410
DOI: 10.1055/s-0041-1736183 -
American Journal of Obstetrics &... Aug 2020To systematically review published literature and calculate the prevalence of vasa previa and its known risk factors. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To systematically review published literature and calculate the prevalence of vasa previa and its known risk factors.
MATERIALS AND METHODS
MEDLINE, Embase, the Cochrane Library, PubMed (non-MEDLINE and in process), and www.clinicaltrials.gov were searched from inception to March 2018 using indexing terms "vasa previa," "placenta previa," "low lying placenta," "succenturiate lobe," "bilobate placenta," "bilobed placenta," and "velamentous insertion." All original research studies reporting on 5 or more pregnancies with vasa previa were included. The search was limited to studies on human data and those published in the English language. Two reviewers independently screened titles and abstracts, completed data extraction, and assessed reporting quality using the Study Quality Assessment Tool for Case Series Studies of the National Heart, Lung, and Blood Institute. Disagreements were discussed and resolved at each step of the process.
RESULTS
We included 21 studies that reported 428 pregnancies with vasa previa of 1,027,918 deliveries (0.46 cases of vasa previa per 1000 deliveries). These studies fared well on risk of bias assessment using the Study Quality Assessment Tool for Case Series Studies of the National Heart, Lung, and Blood Institute. The prevalence and 95% confidence intervals of known risk factors for vasa previa included a low-lying placenta (61.5%, 53.0%-70.0%), velamentous cord insertion (52.2%, 39.6%-64.7%), bilobed or succenturiate lobed placenta (33.3%, 20.9%-45.7%), use of in vitro fertilization (26.4%, 16.0%-36.8%), and multiple gestation (8.92%, 5.33%-12.5%).
CONCLUSION
Vasa previa affects 0.46 cases per 1000 pregnancies. Given the high prevalence of prenatally detectable risk factors in affected pregnancies, the cost-effectiveness of screening strategies for vasa previa either in isolation, using a risk factor-based approach, or universally, in tandem with cervical-length screening using transvaginal ultrasound, should be revisited.
Topics: Female; Humans; Placenta; Placenta Previa; Pregnancy; Risk Factors; Ultrasonography, Prenatal; Vasa Previa
PubMed: 33345868
DOI: 10.1016/j.ajogmf.2020.100117 -
Placenta Feb 2020Abnormally invasive placenta (AIP, aka placenta accreta spectrum; PAS) is an increasingly common pregnancy pathology, which, despite significant morbidity risk to the...
INTRODUCTION
Abnormally invasive placenta (AIP, aka placenta accreta spectrum; PAS) is an increasingly common pregnancy pathology, which, despite significant morbidity risk to the mother, is often undiagnosed prior to delivery. We tested several potential biomarkers in plasma from PAS mothers to determine whether any were sufficiently robust for a formal, diagnostic accuracy study.
METHODS
We examined hyperglycosylated hCG (h-hCG), decorin and IL-8, based on biological plausibility and literature indications that they might be altered in PAS. These analytes were assayed by ELISA in maternal plasma from five groups, comprising (1) normal term controls, (2) placenta previa controls, and cases of (3) placenta increta/percreta without placenta previa, (4) placenta previa increta/percreta and (5) placenta previa accreta.
RESULTS
There were no differences in h-hCG, ß-hCG or the h-hCG/ß-hCG ratio between the groups. Mean decorin levels were increased in previa controls (Group 2) compared to the other groups, but there was substantial overlap between the individual values. While an initial multiplex assay showed a greater value for IL-8 in the placenta previa increta/percreta group (Group 4) compared to placenta previa controls (Group 2), the subsequent validation ELISA for IL-8 showed no differences between the groups.
DISCUSSION
We conclude that the absence of differences and the extent of overlap between cases and controls does not justify further assessment of these biomarkers.
Topics: Adult; Biomarkers; Chorionic Gonadotropin; Decorin; Female; Humans; Interleukin-8; Placenta Accreta; Placenta Previa; Pregnancy
PubMed: 32174305
DOI: 10.1016/j.placenta.2020.01.007 -
Journal of Nepal Health Research Council Jun 2022Placenta previa is associated with poor maternal and fetal outcomes. Its complications are increasing due to the increased rate of cesarean deliveries. This study aimed...
BACKGROUND
Placenta previa is associated with poor maternal and fetal outcomes. Its complications are increasing due to the increased rate of cesarean deliveries. This study aimed to compare maternal and fetal outcomes in placenta previa with and without previous cesarean section.
METHODS
This study was conducted in the Department of Obstetrics and Gynecology at Patan Hospital, Nepal. Placenta previa cases were reviewed from 1st January 2010 to 31st December 2019, parted into Group 1 (placenta previa with previous cesarean section) and Group 2 (placenta previa with no prior cesarean section). Strength of association was measured as odds ratio and 95% confidence intervals. P-value at <0.05 was taken as statistically significant.
RESULTS
The total number of placenta previa were 348 (0.42%) of total deliveries (n=82,918) , but 72 charts/records were not found and six cases were excluded. Group 1 comprised 48 cases (0.86%) among prior cesarean section (n=5,581) and Group 2 consisted of 222 cases (0.28%) among those with no prior cesarean delivery (n=77,337) and it was statistically significant. Morbidly adherent placenta, postpartum hemorrhage, cesarean hysterectomy, and maternal deaths were higher in Group 1 and statistically significant. Preterm deliveries and neonatal intensive care unit admission were also more in Group 1 and statistically significant.
CONCLUSIONS
Maternal and fetal morbidity were higher in placenta previa with previous cesarean section than with no prior cesarean delivery. Therefore, it is advisable to try to reduce the rate of cesarean section as far as possible.
Topics: Cesarean Section; Female; Humans; Infant, Newborn; Nepal; Placenta Previa; Postpartum Hemorrhage; Pregnancy; Retrospective Studies
PubMed: 35945867
DOI: 10.33314/jnhrc.v20i01.3640 -
International Journal of Gynaecology... Jun 2022To examine the detection rate of placenta previa and placenta accreta spectrum (PAS) by routine mid-pregnancy obstetric ultrasound and to estimate risk factors and... (Observational Study)
Observational Study
OBJECTIVE
To examine the detection rate of placenta previa and placenta accreta spectrum (PAS) by routine mid-pregnancy obstetric ultrasound and to estimate risk factors and prevalence within this cohort.
METHODS
This was an observational cohort study with prospectively collected data. Women attending routine mid-pregnancy obstetric ultrasound at the Sahlgrenska University Hospital with a suspected cup-shaped placenta (cohort 1, n = 339) and women diagnosed with placenta previa or PAS (cohort 2, n = 227) were analyzed according to detection rate, risk factors, and prevalence.
RESULTS
The detection rates of placenta previa and PAS were 49% (98) and 25% (14), respectively. However, 216 (99%) women with placenta previa were diagnosed prenatally, as were 14 (50%) women with PAS. In vitro fertilization was identified as the strongest independent risk factor for placenta previa (odds ratio 6.96; 95% confidence interval 4.77-10.16, P < 0.001). Risk factors were present for all women with PAS. The prevalence of placenta previa was 44/10 000 deliveries, and for PAS, 5.6/10 000 deliveries.
CONCLUSION
The existing routine mid-pregnancy obstetric ultrasound screening showed low detection rate for placenta previa and PAS. Adding risk factors could improve the detection rate.
Topics: Female; Humans; Pregnancy; Cesarean Section; Placenta; Placenta Accreta; Placenta Previa; Retrospective Studies; Ultrasonography, Prenatal
PubMed: 34383328
DOI: 10.1002/ijgo.13876 -
The Journal of Maternal-fetal &... Oct 2020To evaluate the migration of low-placental implantation (LPI) during the third trimester of pregnancy and its effect on delivery and post-partum hemorrhage. We...
To evaluate the migration of low-placental implantation (LPI) during the third trimester of pregnancy and its effect on delivery and post-partum hemorrhage. We conducted a retrospective study at a level 3 maternity center including all cases of placenta previa (PP) and LPI between 1998 and 2014. The distance (d) between cervical internal os (CIO) and placental edge (PE) were measured by vaginal ultrasonography in the third trimester of pregnancy at 32 and 3 weeks after. We analyzed CIO-PE distance, volume of post-partum hemorrhage, delivery decision, and mode of delivery using Kruskall-Wallis test. In total, 319 patients presented with PP or LPI. All complete PP (121) and 90.6% (58 of 64) of the placentas less than 1 cm from the CIO did not migrate. Among the 138 placentas with an initial CIO-PE d greater than 1 cm, only 17 (12.3%) did not migrate above 2 cm. The patients for whom the decision to perform a cesarean section (C-section) was retained and realized had a CIO-PE d significantly lower than those who delivered vaginally ( < .001). The patients who delivered by C-section had a lower CIO-PE d when an emergency C-section was performed, specifically for hemorrhage ( < .001). The mean volume of hemorrhage was significantly higher for patients with a CIO-PE d less than 2 cm. Complete PP and the majority of the placentas less than 1 cm from the CIO did not migrate. Above 1 cm, the majority of the placentas migrated three to four weeks later. For the placentas less than 1 cm from the CIO, a significant risk of hemorrhage at delivery was observed. Thus, prophylactic cesarean section is required for CIO-PE distances <1 cm. For distances between 1 and 2 cm, the volume of blood loss tends to be more important than for distances >3 cm without statistical significance. A vaginal delivery could be tried after information of patients.
Topics: Cesarean Section; Female; Humans; Placenta; Placenta Previa; Pregnancy; Retrospective Studies; Ultrasonography, Prenatal
PubMed: 30688129
DOI: 10.1080/14767058.2019.1570118 -
BMC Surgery Jan 2021A diagnostic sign on magnetic resonance imaging, suggestive of posterior extrauterine adhesion (PEUA), was identified in patients with placenta previa. However, the...
BACKGROUND
A diagnostic sign on magnetic resonance imaging, suggestive of posterior extrauterine adhesion (PEUA), was identified in patients with placenta previa. However, the clinical features or surgical outcomes of patients with placenta previa and PEUA are unclear. Our study aimed to investigate the clinical characteristics of placenta previa with PEUA and determine whether an altered management strategy improved surgical outcomes.
METHODS
This single institution retrospective study examined patients with placenta previa who underwent cesarean delivery between 2014 and 2019. In June 2017, we recognized that PEUA was associated with increased intraoperative bleeding; thus, we altered the management of patients with placenta previa and PEUA. To assess the relationship between changes in practice and surgical outcomes, a quasi-experimental method was used to examine the difference-in-difference before (pre group) and after (post group) the changes. Surgical management was modified as follows: (i) minimization of uterine exteriorization and adhesion detachment during cesarean delivery and (ii) use of Nelaton catheters for guiding cervical passage during Bakri balloon insertion. To account for patient characteristics, propensity score matching and multivariate regression analyses were performed.
RESULTS
The study cohort (n = 141) comprised of 24 patients with placenta previa and PEUA (PEUA group) and 117 non-PEUA patients (control group). The PEUA patients were further categorized into the pre (n = 12) and post groups (n = 12) based on the changes in surgical management. Total placenta previa and posterior placentas were more likely in the PEUA group than in the control group (66.7% versus 42.7% [P = 0.04] and 95.8% versus 63.2% [P < 0.01], respectively). After propensity score matching (n = 72), intraoperative blood loss was significantly higher in the PEUA group (n = 24) than in the control group (n = 48) (1515 mL versus 870 mL, P < 0.01). Multivariate regression analysis revealed that PEUA was a significant risk factor for intraoperative bleeding before changes were implemented in practice (t = 2.46, P = 0.02). Intraoperative blood loss in the post group was successfully reduced, as opposed to in the pre group (1180 mL versus 1827 mL, P = 0.04).
CONCLUSIONS
PEUA was associated with total placenta previa, posterior placenta, and increased intraoperative bleeding in patients with placenta previa. Our altered management could reduce the intraoperative blood loss.
Topics: Adult; Blood Loss, Surgical; Cesarean Section; Female; Humans; Infant, Newborn; Middle Aged; Placenta Previa; Postpartum Hemorrhage; Pregnancy; Premature Birth; Retrospective Studies
PubMed: 33407322
DOI: 10.1186/s12893-020-01027-9 -
Best Practice & Research. Clinical... Apr 2021Antenatal diagnosis of placenta accreta spectrum (PAS) disorders allows planned management by a multidisciplinary team in a tertiary center, and thus can reduce... (Review)
Review
Antenatal diagnosis of placenta accreta spectrum (PAS) disorders allows planned management by a multidisciplinary team in a tertiary center, and thus can reduce hemorrhagic morbidity, compared with intrapartum diagnosis. Previous Cesarean section and placenta previa are the two most common risk factors. Prenatal ultrasound is a promising diagnostic tool for PAS in the second or third trimester. Recent evidence shows sonographic markers of PAS can be present in the first trimester. Prenatal ultrasound may help predict the depth and topography of placental invasion which are the major determinants of maternal morbidity. The presence of increased vascularity in the inferior part of the lower uterine segment and the parametrial region is associated with a more severe disorder according to a newly proposed staging system. In this chapter, we will discuss how to improve the prediction of PAS, the depth, and topography of placental invasion.
Topics: Cesarean Section; Female; Humans; Placenta Accreta; Placenta Previa; Pregnancy; Prenatal Diagnosis; Retrospective Studies; Ultrasonography, Prenatal
PubMed: 32747328
DOI: 10.1016/j.bpobgyn.2020.06.010