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American Journal of Obstetrics and... Apr 2023This study aimed to determine the incremental yield of prenatal exome sequencing over chromosomal microarray or G-banding karyotype in fetuses with: (1) intrauterine... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
This study aimed to determine the incremental yield of prenatal exome sequencing over chromosomal microarray or G-banding karyotype in fetuses with: (1) intrauterine growth restriction related to placental insufficiency or (2) short long bones, in isolated and nonisolated instances for both scenarios.
DATA SOURCES
Data were collected via electronic searches for relevant citations from January 2010 to April 10, 2022 in MEDLINE, Embase, Web of Science, and Cochrane, and using relevant bibliographies and data generated in-house.
STUDY ELIGIBILITY CRITERIA
Included were prospective or retrospective cohort studies and/or case series with: (1) n>5 cases of short long bones and/or intrauterine growth restriction undergoing prenatal sequencing with a clearly defined phenotype including assessment of placental function; (2) testing based on prenatal phenotype only; (3) a nondiagnostic chromosomal microarray/karyotype; and (4) known results of genetic testing.
METHODS
Incremental yield was calculated for each study and as a pooled value for the aforementioned groups using a random-effects model. Results were displayed in forest plots with 95% confidence intervals. Heterogeneity was assessed statistically using Higgins' I. Publication bias was assessed graphically using funnel plots. Quality assessment was performed using modified Standards for Reporting of Diagnostic Accuracy criteria (International Prospective Register of Systematic Reviews registration number CRD42022324680).
RESULTS
Nineteen studies were included (n=452 cases). The apparent incremental yields with prenatal sequencing were: (1) 4% (95% confidence interval, -5.0 to 12; I=0%) in isolated intrauterine growth restriction with evidence of placental insufficiency, (2) 30% (95% confidence interval, 13-47; I=1%) in intrauterine growth restriction with additional structural anomalies, (3) 48% (95% confidence interval, 26-70; I=73%) in isolated short long bones, and (4) 68% (95% confidence interval, 58-77; I=51%) in short long bones with additional skeletal anomalies. Of the 37 short long bone cases with a diagnosis, 32 had a skeletal dysplasia, with thanatophoric dysplasia and osteogenesis imperfecta being the most common (both 21.6% [n=8/37]). In fetuses with short long bones and additional skeletal features, osteogenesis imperfecta was the most common diagnosis (28% [n=57/204]). Where documented, the inheritance patterns were de novo in 75.4% (n=150) of cases.
CONCLUSION
Prenatal sequencing adds substantially to incremental yield over chromosomal microarray in fetuses with short long bones or multisystem intrauterine growth restriction. Robust studies are required to assess the utility of fetal sequencing in isolated intrauterine growth restriction with evidence of placental insufficiency, which cannot be recommended on the basis of current evidence.
Topics: Humans; Pregnancy; Female; Fetal Growth Retardation; Placental Insufficiency; Exome Sequencing; Retrospective Studies; Osteogenesis Imperfecta; Placenta; Prenatal Diagnosis; Ultrasonography, Prenatal
PubMed: 36209938
DOI: 10.1016/j.ajog.2022.09.045 -
The Cochrane Database of Systematic... Aug 2022Despite the widespread use of antenatal corticosteroids to prevent respiratory distress syndrome (RDS) in preterm infants, there is currently no consensus as to the type... (Review)
Review
BACKGROUND
Despite the widespread use of antenatal corticosteroids to prevent respiratory distress syndrome (RDS) in preterm infants, there is currently no consensus as to the type of corticosteroid to use, dose, frequency, timing of use or the route of administration. OBJECTIVES: To assess the effects on fetal and neonatal morbidity and mortality, on maternal morbidity and mortality, and on the child and adult in later life, of administering different types of corticosteroids (dexamethasone or betamethasone), or different corticosteroid dose regimens, including timing, frequency and mode of administration.
SEARCH METHODS
For this update, we searched Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (9 May 2022) and reference lists of retrieved studies.
SELECTION CRITERIA
We included all identified published and unpublished randomised controlled trials or quasi-randomised controlled trials comparing any two corticosteroids (dexamethasone or betamethasone or any other corticosteroid that can cross the placenta), comparing different dose regimens (including frequency and timing of administration) in women at risk of preterm birth. We planned to exclude cross-over trials and cluster-randomised trials. We planned to include studies published as abstracts only along with studies published as full-text manuscripts.
DATA COLLECTION AND ANALYSIS
At least two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of included studies. Data were checked for accuracy. We assessed the certainty of the evidence using GRADE.
MAIN RESULTS
We included 11 trials (2494 women and 2762 infants) in this update, all of which recruited women who were at increased risk of preterm birth or had a medical indication for preterm birth. All trials were conducted in high-income countries. Dexamethasone versus betamethasone Nine trials (2096 women and 2319 infants) compared dexamethasone versus betamethasone. All trials administered both drugs intramuscularly, and the total dose in the course was consistent (22.8 mg or 24 mg), but the regimen varied. We assessed one new study to have no serious risk of bias concerns for most outcomes, but other studies were at moderate (six trials) or high (two trials) risk of bias due to selection, detection and attrition bias. Our GRADE assessments ranged between high- and low-certainty, with downgrades due to risk of bias and imprecision. Maternal outcomes The only maternal primary outcome reported was chorioamnionitis (death and puerperal sepsis were not reported). Although the rate of chorioamnionitis was lower with dexamethasone, we did not find conclusive evidence of a difference between the two drugs (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.48 to 1.06; 1 trial, 1346 women; moderate-certainty evidence). The proportion of women experiencing maternal adverse effects of therapy was lower with dexamethasone; however, there was not conclusive evidence of a difference between interventions (RR 0.63, 95% CI 0.35 to 1.13; 2 trials, 1705 women; moderate-certainty evidence). Infant outcomes We are unsure whether the choice of drug makes a difference to the risk of any known death after randomisation, because the 95% CI was compatible with both appreciable benefit and harm with dexamethasone (RR 1.03, 95% CI 0.66 to 1.63; 5 trials, 2105 infants; moderate-certainty evidence). The choice of drug may make little or no difference to the risk of RDS (RR 1.06, 95% CI 0.91 to 1.22; 5 trials, 2105 infants; high-certainty evidence). While there may be little or no difference in the risk of intraventricular haemorrhage (IVH), there was substantial unexplained statistical heterogeneity in this result (average (a) RR 0.71, 95% CI 0.28 to 1.81; 4 trials, 1902 infants; I² = 62%; low-certainty evidence). We found no evidence of a difference between the two drugs for chronic lung disease (RR 0.92, 95% CI 0.64 to 1.34; 1 trial, 1509 infants; moderate-certainty evidence), and we are unsure of the effects on necrotising enterocolitis, because there were few events in the studies reporting this outcome (RR 5.08, 95% CI 0.25 to 105.15; 2 studies, 441 infants; low-certainty evidence). Longer-term child outcomes Only one trial consistently followed up children longer term, reporting at two years' adjusted age. There is probably little or no difference between dexamethasone and betamethasone in the risk of neurodevelopmental disability at follow-up (RR 1.02, 95% CI 0.85 to 1.22; 2 trials, 1151 infants; moderate-certainty evidence). It is unclear whether the choice of drug makes a difference to the risk of visual impairment (RR 0.33, 95% CI 0.01 to 8.15; 1 trial, 1227 children; low-certainty evidence). There may be little or no difference between the drugs for hearing impairment (RR 1.16, 95% CI 0.63 to 2.16; 1 trial, 1227 children; moderate-certainty evidence), motor developmental delay (RR 0.89, 95% CI 0.66 to 1.20; 1 trial, 1166 children; moderate-certainty evidence) or intellectual impairment (RR 0.97, 95% CI 0.79 to 1.20; 1 trial, 1161 children; moderate-certainty evidence). However, the effect estimate for cerebral palsy is compatible with both an important increase in risk with dexamethasone, and no difference between interventions (RR 2.50, 95% CI 0.97 to 6.39; 1 trial, 1223 children; low-certainty evidence). No trials followed the children beyond early childhood. Comparisons of different preparations and regimens of corticosteroids We found three studies that included a comparison of a different regimen or preparation of either dexamethasone or betamethasone (oral dexamethasone 32 mg versus intramuscular dexamethasone 24 mg; betamethasone acetate plus phosphate versus betamethasone phosphate; 12-hourly betamethasone versus 24-hourly betamethasone). The certainty of the evidence for the main outcomes from all three studies was very low, due to small sample size and risk of bias. Therefore, we were limited in our ability to draw conclusions from any of these studies.
AUTHORS' CONCLUSIONS
Overall, it remains unclear whether there are important differences between dexamethasone and betamethasone, or between one regimen and another. Most trials compared dexamethasone versus betamethasone. While for most infant and early childhood outcomes there may be no difference between these drugs, for several important outcomes for the mother, infant and child the evidence was inconclusive and did not rule out significant benefits or harms. The evidence on different antenatal corticosteroid regimens was sparse, and does not support the use of one particular corticosteroid regimen over another.
Topics: Adrenal Cortex Hormones; Betamethasone; Child; Child, Preschool; Chorioamnionitis; Dexamethasone; Female; Humans; Infant; Infant, Newborn; Infant, Premature; Lung; Pregnancy; Premature Birth; Respiratory Distress Syndrome, Newborn
PubMed: 35943347
DOI: 10.1002/14651858.CD006764.pub4 -
American Journal of Obstetrics and... Oct 2019Elective induction of labor at 39 weeks among low-risk nulliparous women has reduced the chance of cesarean and other adverse maternal and perinatal outcomes in a... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
Elective induction of labor at 39 weeks among low-risk nulliparous women has reduced the chance of cesarean and other adverse maternal and perinatal outcomes in a randomized trial, although its clinical effectiveness in nonresearch settings remains uncertain.
OBJECTIVE
To perform a systematic review of observational studies that compared elective induction of labor at 39 weeks among nulliparous women with expectant management and to use meta-analytic techniques to estimate the association of elective induction with cesarean delivery, as well as other maternal and perinatal outcomes.
STUDY DESIGN
Studies were eligible for this meta-analysis only if they: (1) were observational; (2) compared women undergoing labor induction at 39 weeks with women undergoing expectant management beyond that gestational age; (3) included women in the induction group only if they had no other indication for labor induction at 39 weeks; and (4) provided data specifically for nulliparous women. The predefined primary outcome was cesarean delivery, and secondary outcomes representing other maternal and perinatal morbidities also were evaluated. Outcome data from different studies were combined to estimate pooled relative risks with 95% confidence intervals using random-effects models.
RESULTS
Of 375 studies identified by the initial search, 6 cohort studies, which included 66,019 women undergoing elective labor induction at 39 weeks and 584,390 undergoing expectant management, met inclusion criteria. Elective induction of labor at 39 weeks was associated with a significantly lower frequency of cesarean delivery (26.4% vs 29.1%; relative risk, 0.83; 95% confidence interval, 0.74-0.93), as well as of peripartum infection (2.8% vs 5.2%; relative risk, 0.53; 95% confidence interval, 0.39-0.72). Neonates of women in the induction group were less likely to have respiratory morbidity (0.7% vs 1.5%; relative risk, 0.71; 95% confidence interval, 0.59-0.85); meconium aspiration syndrome (0.7% vs 3.0%; relative risk, 0.49; 95% confidence interval, 0.26-0.92); and neonatal intensive care unit admission (3.5% vs 5.5%; relative risk, 0.80; 95% confidence interval, 0.72-0.88). There also was a lower risk of perinatal mortality (0.04% vs 0.2%; relative risk, 0.27; 95% confidence interval, 0.09-0.76).
CONCLUSION
This meta-analysis of 6 cohort studies demonstrates that elective induction of labor at 39 weeks, compared with expectant management beyond that gestational age, was associated with a significantly lower risk of cesarean delivery, maternal peripartum infection, and perinatal adverse outcomes, including respiratory morbidity, intensive care unit admission, and mortality.
Topics: Cesarean Section; Chorioamnionitis; Cohort Studies; Continuous Positive Airway Pressure; Endometritis; Female; Humans; Infant, Newborn; Intensive Care Units, Neonatal; Labor, Induced; Lacerations; Meconium Aspiration Syndrome; Observational Studies as Topic; Oxygen Inhalation Therapy; Parity; Perinatal Mortality; Perineum; Postpartum Hemorrhage; Pregnancy; Respiration, Artificial; Respiratory Insufficiency; Surgical Wound Infection; Watchful Waiting
PubMed: 30817905
DOI: 10.1016/j.ajog.2019.02.046 -
Biomedicines Feb 2022This study aimed to assess the relationship between placenta accreta spectrum disorder (PASD) and endometriosis. The relationships among pregnancy, assisted reproductive... (Review)
Review
This study aimed to assess the relationship between placenta accreta spectrum disorder (PASD) and endometriosis. The relationships among pregnancy, assisted reproductive technology (ART), placenta previa, ART-conceived pregnancy and PASD were also determined. A systematic literature review was conducted using multiple computerized databases. Forty-eight studies (1990-2021) met the inclusion criteria. According to the adjusted pooled analysis ( = 3), endometriosis was associated with an increased prevalence of PASD (adjusted odds ratio [OR] 3.39, 95% confidence interval [CI] 1.96-5.87). In the included studies, the ART rate ranged from 18.2% to 37.2% for women with endometriosis. According to the adjusted pooled analysis, women who used ART were more likely to have placenta previa ( = 13: adjusted OR 2.96, 95%CI, 2.43-3.60) and PASD ( = 4: adjusted OR 3.54, 95%CI 1.86-6.76) than those who did not use ART. According to the sensitivity analysis using an unadjusted analysis accounting for the type of ART, frozen embryo transfer (ET) was associated with an increased risk of PASD ( = 4: OR 2.79, 95%CI, 1.22-6.37) compared to fresh ET. Endometriosis may be associated with an increased rate of PASD. Women with placenta previa complicated with endometriosis who conceived using frozen ET may be a high risk for PASD.
PubMed: 35203599
DOI: 10.3390/biomedicines10020390 -
Revista Panamericana de Salud Publica =... 2020To describe perinatal and neonatal outcomes in newborns exposed to SARS-CoV-2. (Review)
Review
OBJECTIVE
To describe perinatal and neonatal outcomes in newborns exposed to SARS-CoV-2.
METHODS
A systematic review was conducted by searching PubMed Central, LILACS, and Google Scholar using the keywords 'covid ' AND 'newborn' OR 'child' OR 'infant,' on 18 March 2020, and again on 17 April 2020. One researcher conducted the search and extracted data on demographics, maternal outcomes, diagnostic tests, imaging, and neonatal outcomes.
RESULTS
Of 256 publications identified, 20 met inclusion criteria and comprised neonatal outcome data for 222 newborns whose mothers were suspected or confirmed to be SARS-CoV-2 positive perinatally (17 studies) or of newborns referred to hospital with infection/pneumonia (3 studies). Most (12 studies) were case-series reports; all were from China, except three (Australia, Iran, and Spain). Of the 222 newborns, 13 were reported as positive for SARS-CoV-2; most of the studies reported no or mild symptoms and no adverse perinatal outcomes. Two papers among those from newborns who tested positive reported moderate or severe clinical characteristics. Five studies using data on umbilical cord blood, placenta, and/or amniotic fluid reported no positive results. Nine studies reported radiographic imaging, including 5 with images of pneumonia, increased lung marking, thickened texture, or high-density nodular shadow. Minor, non-specific changes in biochemical variables were reported. Studies that tested breast milk reported negative SARS-CoV-2 results.
CONCLUSIONS
Given the paucity of studies at this time, vertical transmission cannot be confirmed or denied. Current literature does not support abstaining from breastfeeding nor separating mothers and newborns. Further evidence and data collection networks, particularly in the Americas, are needed for establishing definitive guidelines and recommendations.
PubMed: 32454807
DOI: 10.26633/RPSP.2020.54 -
American Journal of Obstetrics &... Aug 2023This systematic review and meta-analysis aimed to assess clinical characteristics related to pathologically proven placenta accreta spectrum without placenta previa. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
This systematic review and meta-analysis aimed to assess clinical characteristics related to pathologically proven placenta accreta spectrum without placenta previa.
DATA SOURCES
A literature search of PubMed, the Cochrane database, and Web of Science was performed from inception to September 7, 2022.
STUDY ELIGIBILITY CRITERIA
The primary outcomes were invasive placenta (including increta or percreta), blood loss, hysterectomy, and antenatal diagnosis. In addition, maternal age, assisted reproductive technology, previous cesarean delivery, and previous uterine procedures were investigated as potential risk factors. The inclusion criteria were studies evaluating the clinical presentation of pathologically diagnosed PAS without placenta previa.
METHODS
Study screening was conducted after duplicates were identified and removed. The quality of each study and the publication bias were assessed. Forest plots and I statistics were calculated for each study outcome for each group. The main analysis was a random-effects analysis.
RESULTS
Among 2598 studies that were initially retrieved, 5 were included in the review. With the exception of 1 study, 4 studies were included in the meta-analysis. This meta-analysis showed that placenta accreta spectrum without placenta previa was associated with less risk of invasive placenta (odds ratio, 0.24; 95% confidence interval, 0.16-0.37), blood loss (mean difference, -1.19; 95% confidence interval, -2.09 to -0.28) and hysterectomy (odds ratio, 0.11; 95% confidence interval, 0.02-0.53), and more difficult to diagnose prenatally (odds ratio, 0.13; 95% confidence interval, 0.04-0.45) than placenta accreta spectrum with placenta previa. In addition, assisted reproductive technology and a previous uterine procedure were strong risk factors for placenta accreta spectrum without placenta previa, whhereas previous cesarean delivery was a strong risk factor for placenta accreta spectrum with placenta previa.
CONCLUSION
The differences in clinical aspects of placenta accreta spectrum with and without placenta previa need to be understood.
Topics: Pregnancy; Female; Humans; Placenta Accreta; Retrospective Studies; Placenta Previa; Hysterectomy; Risk Factors
PubMed: 37211089
DOI: 10.1016/j.ajogmf.2023.101027 -
European Journal of Radiology Oct 2022Ultrasound and magnetic resonance imaging are the imaging modalities of choice for placenta accrete spectrum (PAS) disorders assessment. Radiomics could further increase... (Review)
Review
PURPOSE
Ultrasound and magnetic resonance imaging are the imaging modalities of choice for placenta accrete spectrum (PAS) disorders assessment. Radiomics could further increase the value of medical images and allow to overcome the limitations linked to their visual assessment. Aim of this systematic review was to identify and appraise the methodological quality of radiomics studies focused PAS disorders applications.
METHOD
Three online databases (PubMed, Scopus and Web of Science) were searched to identify original research articles on human subjects published in English. For the qualitative synthesis of results, data regarding study design (e.g., retrospective or prospective), purpose, patient population (e.g., sample size), imaging modalities and radiomics pipelines (e.g., segmentation and feature extraction strategy) were collected. The appraisal of methodological quality was performed using the Radiomics Quality Score (RQS).
RESULTS
10 articles were finally included and analyzed. All were retrospective and MRI-powered. The majority included more than 100 patients (6/10). Four were prognostic (focused on either the prediction of bleeding volume or the prediction of needed management) while six diagnostic (PAS vs not PAS classification) studies. The median RQS was 8, with maximum and minimum respectively equal to 17/36 and - 6/36. Major methodological concerns were the lack of feature stability to multiple segmentation testing and poor data openness.
CONCLUSIONS
Radiomics studies focused on PAS disorders showed a heterogeneous methodological quality, overall lower than desirable. Furthermore, many relevant research questions remain unexplored. More robust investigations are needed to foster advancements in the field and possibly clinical translation.
Topics: Female; Humans; Magnetic Resonance Imaging; Placenta Accreta; Pregnancy; Prognosis; Prospective Studies; Retrospective Studies
PubMed: 36030661
DOI: 10.1016/j.ejrad.2022.110497 -
Human Reproduction Update Jul 2024With increasing significance of developmental programming effects associated with placental dysfunction, more investigations are devoted to improving the... (Meta-Analysis)
Meta-Analysis
BACKGROUND
With increasing significance of developmental programming effects associated with placental dysfunction, more investigations are devoted to improving the characterization and understanding of placental signatures in health and disease. The placenta is a transitory but dynamic organ adapting to the shifting demands of fetal development and available resources of the maternal supply throughout pregnancy. Trophoblasts (cytotrophoblasts, syncytiotrophoblasts, and extravillous trophoblasts) are placental-specific cell types responsible for the main placental exchanges and adaptations. Transcriptomic studies with single-cell resolution have led to advances in understanding the placenta's role in health and disease. These studies, however, often show discrepancies in characterization of the different placental cell types.
OBJECTIVE AND RATIONALE
We aim to review the knowledge regarding placental structure and function gained from the use of single-cell RNA sequencing (scRNAseq), followed by comparing cell-type-specific genes, highlighting their similarities and differences. Moreover, we intend to identify consensus marker genes for the various trophoblast cell types across studies. Finally, we will discuss the contributions and potential applications of scRNAseq in studying pregnancy-related diseases.
SEARCH METHODS
We conducted a comprehensive systematic literature review to identify different cell types and their functions at the human maternal-fetal interface, focusing on all original scRNAseq studies on placentas published before March 2023 and published reviews (total of 28 studies identified) using PubMed search. Our approach involved curating cell types and subtypes that had previously been defined using scRNAseq and comparing the genes used as markers or identified as potential new markers. Next, we reanalyzed expression matrices from the six available scRNAseq raw datasets with cell annotations (four from first trimester and two at term), using Wilcoxon rank-sum tests to compare gene expression among studies and annotate trophoblast cell markers in both first trimester and term placentas. Furthermore, we integrated scRNAseq raw data available from 18 healthy first trimester and nine term placentas, and performed clustering and differential gene expression analysis. We further compared markers obtained with the analysis of annotated and raw datasets with the literature to obtain a common signature gene list for major placental cell types.
OUTCOMES
Variations in the sampling site, gestational age, fetal sex, and subsequent sequencing and analysis methods were observed between the studies. Although their proportions varied, the three trophoblast types were consistently identified across all scRNAseq studies, unlike other non-trophoblast cell types. Notably, no marker genes were shared by all studies for any of the investigated cell types. Moreover, most of the newly defined markers in one study were not observed in other studies. These discrepancies were confirmed by our analysis on trophoblast cell types, where hundreds of potential marker genes were identified in each study but with little overlap across studies. From 35 461 and 23 378 cells of high quality in the first trimester and term placentas, respectively, we obtained major placental cell types, including perivascular cells that previously had not been identified in the first trimester. Importantly, our meta-analysis provides marker genes for major placental cell types based on our extensive curation.
WIDER IMPLICATIONS
This review and meta-analysis emphasizes the need for establishing a consensus for annotating placental cell types from scRNAseq data. The marker genes identified here can be deployed for defining human placental cell types, thereby facilitating and improving the reproducibility of trophoblast cell annotation.
Topics: Humans; Female; Pregnancy; Placenta; Single-Cell Analysis; Sequence Analysis, RNA; Trophoblasts; Transcriptome
PubMed: 38478759
DOI: 10.1093/humupd/dmae006 -
American Journal of Obstetrics &... Oct 2023Previous cesarean delivery is a risk factor for developing placenta accreta spectrum in a subsequent pregnancy and patients with antenatally suspected placenta accreta...
BACKGROUND
Previous cesarean delivery is a risk factor for developing placenta accreta spectrum in a subsequent pregnancy and patients with antenatally suspected placenta accreta spectrum frequently undergo planned cesarean hysterectomy. There is a paucity of data regarding unsuspected placenta accreta spectrum among patients undergoing trial of labor after cesarean delivery for attempted vaginal birth after cesarean delivery.
OBJECTIVE
This study aimed to investigate the incidence, characteristics, and delivery outcomes of patients with placenta accreta spectrum diagnosed at the time of vaginal birth after cesarean delivery.
STUDY DESIGN
The Healthcare Cost and Utilization Project's National Inpatient Sample was retrospectively queried to examine 184,415 patients with a history of low transverse cesarean delivery who had vaginal delivery in the current index hospital admission between 2017 and 2020. Those with placenta previa, previous vertical cesarean delivery, other uterine scars, and uterine rupture were excluded. This study identified placenta accreta spectrum cases using the World Health Organization International Classification of Disease, Tenth Revision, codes of O43.2. Coprimary outcomes were (1) the incidence rate of placenta accreta spectrum at vaginal birth after cesarean delivery; (2) clinical and pregnancy characteristics related to placenta accreta spectrum, assessed with multivariable binary logistic regression model; and (3) delivery outcomes associated with placenta accreta spectrum by fitting propensity score adjustment. The secondary outcome was to conduct a systematic literature review using 3 public search engines (PubMed, Cochrane, and Scopus). Data on incidence rate and maternal morbidity related to placenta accreta spectrum at vaginal birth after cesarean delivery were evaluated.
RESULTS
The incidence rate of placenta accreta spectrum at vaginal birth after cesarean delivery was 8.1 per 10,000 deliveries. Most placenta accreta spectrum cases were placenta accreta (83.3%). In a multivariable analysis, older maternal age, tobacco use, preeclampsia, multifetal pregnancy, fetal anomaly, preterm premature rupture of membrane, chorioamnionitis, low-lying placenta, and preterm delivery were associated with an increased risk of placenta accreta spectrum (all, P<.05). Of these factors, low-lying placenta had the largest odds for placenta accreta spectrum (526.3 vs 7.3 per 10,000 deliveries; adjusted odds ratio, 35.02; 95% confidence interval, 18.19-67.42). Patients in the placenta accreta spectrum group were more likely to have postpartum hemorrhage (80.0% vs 5.5%), blood product transfusion (23.3% vs 1.0%), shock or coagulopathy (20.0% vs 0.2%), and hysterectomy (43.3% vs <0.1%) than those without placenta accreta spectrum (all, P<.001). In a systematic literature review, a total of 212 studies were screened, and none of these studies examined the incidence and morbidity of placenta accreta spectrum at vaginal birth after cesarean delivery.
CONCLUSION
This nationwide assessment suggests that although placenta accreta spectrum with vaginal birth after cesarean delivery is uncommon (1 of 1229 cases), the diagnosis of placenta accreta spectrum at vaginal birth after cesarean delivery is associated with significant maternal morbidity. In addition, the data suggest that low-lying placenta in the setting of previous low transverse cesarean delivery warrants careful evaluation for possible placenta accreta spectrum before a trial of labor.
Topics: Pregnancy; Female; Infant, Newborn; Humans; Placenta Accreta; Vaginal Birth after Cesarean; Retrospective Studies; Cesarean Section; Delivery, Obstetric; Premature Birth
PubMed: 37543142
DOI: 10.1016/j.ajogmf.2023.101115 -
Ultrasound in Obstetrics & Gynecology :... Jun 2024Management of placenta accreta spectrum (PAS) with the placenta kept in situ aims to preserve fertility and minimize blood loss. However, this method is associated with... (Review)
Review
OBJECTIVE
Management of placenta accreta spectrum (PAS) with the placenta kept in situ aims to preserve fertility and minimize blood loss. However, this method is associated with a risk of coagulopathy and subsequent bleeding. The aim of this study was to evaluate the occurrence and pathophysiology of coagulopathy in cases of PAS managed conservatively.
METHODS
We reviewed our database for cases of PAS in which the placenta was kept in situ. In addition, we performed a systematic review of articles on PAS in which the placenta was left in situ and was complicated by coagulopathy. PubMed was searched for publications between 1980 and 2023. Our eligibility criteria included studies in which no additional interventions were performed other than keeping the placenta entirely in situ, and in which coagulopathy was reported.
RESULTS
After screening and selection of full-text articles, 10 studies were included in the review. A review of our databases yielded a case series of PAS managed conservatively with the placenta kept in situ. When adding our case series to the results of our systematic review, a total of 87 cases were found to have been managed conservatively, with 28 cases of coagulopathy. Of these, the time at which coagulopathy developed was known in 11 cases. The median time at development of coagulopathy was 58 (interquartile range, 50-67) days postpartum.
CONCLUSIONS
Our findings highlight that conservative management of PAS with the placenta in situ poses a risk of coagulopathy. Keeping the placenta in situ after delivery prolongs the risk factors that are integral to PAS. The pathophysiology behind coagulopathy is comparable with that of concealed placental abruption, due to the disrupted uteroplacental interface and the collection of blood in the placenta. Therefore, the presence of large placental lakes could be an indicator of developing coagulopathy. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
Topics: Humans; Female; Placenta Accreta; Pregnancy; Conservative Treatment; Blood Coagulation Disorders; Postpartum Hemorrhage; Adult; Placenta
PubMed: 38030960
DOI: 10.1002/uog.27547