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A Risk-Prediction Model for Placenta Accreta Spectrum Severity From Standardized Ultrasound Markers.Ultrasound in Medicine & Biology Feb 2023We aimed to generate a model to predict the risk of a woman having normal, abnormally adherent (AAP) or abnormally invasive placentation (AIP) based on the presence of...
We aimed to generate a model to predict the risk of a woman having normal, abnormally adherent (AAP) or abnormally invasive placentation (AIP) based on the presence of recently codified ultrasound (US) markers and disease definitions of placenta accreta spectrum (PAS). We recruited women with anterior low-lying placenta or placenta previa and a history of previous caesarean delivery to a prospective cohort study. US markers of abnormal placentation were recorded on a standardized pro forma. The presence and International Federation of Gynecology and Obstetrics grade of PAS was evaluated clinically and histologically at delivery. Markers demonstrating a predictive relationship to PAS were incorporated into a logistic regression model. A total of 106 women were included, of whom 42 (40%) were normal, 24 (23%) had AAP and 40 (38%) had AIP. A model including just four key variables (loss of clear zone, abnormal placental lacunae, placental bulge and bladder wall interruption) was shown to reliably predict presence and severity of PAS, with an optimism-corrected C-index of 0.901. A simple model incorporating four US markers can predict likelihood and severity of PAS with high accuracy. This is the first time this has been demonstrated using the recently codified definitions of the US signs and disease definitions. Further work will see our model applied prospectively to a large patient cohort, ideally through a smartphone-based application, for external validation.
Topics: Pregnancy; Female; Humans; Placenta Accreta; Placenta; Prospective Studies; Ultrasonography, Prenatal; Ultrasonography; Retrospective Studies
PubMed: 36347659
DOI: 10.1016/j.ultrasmedbio.2022.09.021 -
Placenta Aug 2023Chronic histiocytic intervillositis (CHI) is a rare histopathological lesion in the placenta characterized by an infiltrate of CD68 cells in the intervillous space. CHI...
INTRODUCTION
Chronic histiocytic intervillositis (CHI) is a rare histopathological lesion in the placenta characterized by an infiltrate of CD68 cells in the intervillous space. CHI is associated with adverse pregnancy outcomes such as miscarriage, fetal growth restriction, and (late) intrauterine fetal death. The adverse pregnancy outcomes and a variable recurrence rate of 25-100% underline its clinical relevance. The pathophysiologic mechanism of CHI is unclear, but it appears to be immunologically driven. The aim of this study was to obtain a better understanding of the phenotype of the cellular infiltrate in CHI.
METHOD
We used imaging mass cytometry to achieve in-depth visualization of the intervillous maternal immune cells and investigated their spatial orientation in situ in relation to the fetal syncytiotrophoblast.
RESULTS
We found three phenotypically distinct CD68HLA-DRCD38 cell clusters that were unique for CHI. Additionally, syncytiotrophoblast cells in the vicinity of these CD68HLA-DRCD38 cells showed decreased expression of the immunosuppressive enzyme CD39.
DISCUSSION
The current results provide novel insight into the phenotype of CD68 cells in CHI. The identification of unique CD68 cell clusters will allow more detailed analysis of their function and could result in novel therapeutic targets for CHI.
Topics: Pregnancy; Humans; Female; Placenta Diseases; Placenta; Pregnancy Outcome; Histiocytes; Abortion, Spontaneous; Chorionic Villi
PubMed: 37300938
DOI: 10.1016/j.placenta.2023.05.007 -
Obstetrics and Gynecology Aug 2022
Topics: Female; Humans; Pelvis; Placenta; Placenta Diseases; Pregnancy
PubMed: 35852286
DOI: 10.1097/AOG.0000000000004879 -
Biochimica Et Biophysica Acta.... Dec 2020Gestational diabetes mellitus (GDM) is a disease of pregnancy that is associated with d-glucose intolerance and foeto-placental vascular dysfunction. GMD causes... (Review)
Review
Gestational diabetes mellitus (GDM) is a disease of pregnancy that is associated with d-glucose intolerance and foeto-placental vascular dysfunction. GMD causes mitochondrial dysfunction in the placental endothelium and trophoblast. Additionally, GDM is associated with reduced placental oxidative phosphorylation due to diminished activity of the mitochondrial FF-ATP synthase (complex V). This phenomenon may result from a higher generation of reactive superoxide anion and nitric oxide. Placental mitochondrial biogenesis and mitophagy work in concert to maintain cell homeostasis and are vital mechanisms securing the efficient generation of ATP, whose demand is higher in pregnancy, ensuring foetal growth and development. Additional factors disturbing placental ATP synthase activity in GDM include pre-gestational maternal obesity or overweight, intracellular pH, miRNAs, fatty acid oxidation, and foetal (and 'placental') sex. GDM is also associated with maternal and foetal hyperinsulinaemia, altered circulating levels of adiponectin and leptin, and the accumulation of extracellular adenosine. Here, we reviewed the potential interplay between these molecules or metabolic conditions on the mechanisms of mitochondrial dysfunction in the foeto-placental unit in GDM pregnancies.
Topics: Animals; Diabetes, Gestational; Female; Humans; Mitochondria; Placenta Diseases; Pregnancy
PubMed: 32866635
DOI: 10.1016/j.bbadis.2020.165948 -
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 -
Placenta Jan 2022Massive perivillous fibrin deposition (MPVFD) in the placenta is associated with pregnancy complications and maternal disease. The aim of the current study was to... (Observational Study)
Observational Study
INTRODUCTION
Massive perivillous fibrin deposition (MPVFD) in the placenta is associated with pregnancy complications and maternal disease. The aim of the current study was to contribute with increased knowledge regarding MPVFD by comparing maternal characteristics, obstetric and perinatal outcome and recurrence rate according to the degree of MPVFD.
MATERIAL AND METHODS
This retrospective observational study included 141 cases of MPVFD collected between January 2003 to December 2018 in the Stockholm region, Sweden. The extent of fibrin deposition was assessed as low (20-32%), moderate (33-50%) or severe (>50%) according to macroscopic examination.
RESULTS
The study covered 48 placentas with low MPVFD, 41 with moderate and 52 with severe MPVFD. Severe MPVFD was associated with more prematurity than moderate and low MPVFDs (56.3% vs 34.2% and 34.0% respectively, p = 0.05 and p = 0.04). In cases with severe MPVFD, 72.3% of the liveborn infants were growth-restricted compared to 34.2% in the moderate group (p = 0.001) and 52.2% in the low group (p = 0.06). The incidence of intrauterine fetal death was 31.3% in the severe MPVFD group, which was significantly higher than in the low MPVFD group (8.5%, p = 0.01) and twice as much as in cases with moderate MPVFD (15.8%, p = 0.07). 105 subsequent pregnancies after an index pregnancy with MPVFD were identified. The outcome was favourable with a liveborn rate of 91-100%.
DISCUSSION
The extent of fibrin in the placenta plays a role in pregnancy outcome. Cases with severe MPVFD in the placenta was associated with more prematurity, fetal growth restriction and intrauterine fetal death.
Topics: Adult; Female; Fibrin; Humans; Placenta; Placenta Diseases; Pregnancy; Pregnancy Outcome; Retrospective Studies; Sweden
PubMed: 34959167
DOI: 10.1016/j.placenta.2021.12.013 -
Obstetrics and Gynecology Oct 2022To evaluate whether there are differences in risk factors and maternal outcomes of pregnancies complicated by placenta accreta spectrum depending on the presence or... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To evaluate whether there are differences in risk factors and maternal outcomes of pregnancies complicated by placenta accreta spectrum depending on the presence or absence of placenta previa.
DATA SOURCES
We performed a systematic search in Medline, EMBASE, ClinicalTrials.gov , and Web of Science from inception through April 25, 2022, without language or date restrictions. Search strategy included the key words "placenta accreta," "placenta increta," "placenta percreta," "adherent placenta," "invasive placenta," "abnormal placent*," "placenta previa," and "marginal placent*."
METHODS OF STUDY SELECTION
Of the 1,122 articles screened, seven studies were included in the final review. Studies were included if they compared the risk factors and maternal outcomes of pregnancies complicated by placenta accreta spectrum depending on the presence or absence of placenta previa.
TABULATION, INTEGRATION, AND RESULTS
A random-effects model was used to pool the mean differences or odds ratios (OR) and the corresponding 95% CIs using RevMan software. A total of 3,342 pregnancies complicated by placenta accreta spectrum were included in the meta-analysis (2,365 without previa and 977 with previa). Pregnancies complicated by placenta accreta spectrum without previa were more likely to have been conceived by in vitro fertilization (IVF) (OR 3.11, 95% CI 1.93-5.02, P <.001, I 2 =52.0%) and to be associated with prior dilation and curettage (D&C) (OR 1.60, 95% CI 1.15-2.22, P =.005, I 2 =0.0%) and myomectomy (OR 2.47, 95% CI 1.31-4.66, P =.005, I 2 =0.0%), but they were less likely to be associated with prior cesarean delivery (OR 0.15, 95% CI 0.06-0.37, P <.001, I 2 =87.0%). Placenta accreta spectrum without previa was less likely to be diagnosed antenatally (OR 0.07, 95% CI 0.04-0.11, P <.001, I 2 =38.0%). Also, women with pregnancies without previa had lower rates of red blood cell transfusion, intensive care unit admission, risk of hysterectomy, unscheduled delivery, and intraoperative bowel or bladder injuries.
CONCLUSION
Pregnancies complicated by placenta accreta spectrum without previa had a more prominent association with IVF and prior D&C and myomectomy but were much less likely to be associated with prior cesarean delivery. Further, placenta accreta spectrum without previa was less likely to be diagnosed antenatally, although it had better maternal outcomes as compared with placenta accreta spectrum with previa.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO, CRD42022307637.
Topics: Pregnancy; Female; Humans; Placenta Accreta; Placenta Previa; Retrospective Studies; Cesarean Section; Hysterectomy; Placenta
PubMed: 36075058
DOI: 10.1097/AOG.0000000000004923 -
Frontiers in Immunology 2019Preeclampsia is one of the leading causes of maternal and neonatal mortality and morbidity worldwide, affecting 2-8% of all pregnancies. Studies suggest a link between... (Review)
Review
Preeclampsia is one of the leading causes of maternal and neonatal mortality and morbidity worldwide, affecting 2-8% of all pregnancies. Studies suggest a link between complement activation and preeclampsia. The complement system plays an essential role in the innate immunity, leading to opsonization, inflammation, and elimination of potential pathogens. The complement system also provides a link between innate and adaptive immunity and clearance of immune complexes and apoptotic cells. During pregnancy there is increased activity of the complement system systemically. However, locally at the placenta, complement inhibition is crucial for the maintenance of a normal pregnancy. Inappropriate or excessive activation of the complement system at the placenta is likely involved in placental dysfunction, and is in turn associated with pregnancy complications like preeclampsia. Therefore, modulation of the complement system could be a potential therapeutic target to prevent pregnancy complications such as preeclampsia. This review, based on a systematic literature search, gives an overview of the complement system and its activation locally in the placenta and systemically during healthy pregnancies and during complicated pregnancies, with a focus on preeclampsia. Furthermore, this review describes results of animal and human studies with a focus on the complement system in pregnancy, and the role of the complement system in placental dysfunction. Various clinical and animal studies provide evidence that dysregulation of the complement system is associated with placental dysfunction and therefore with preeclampsia. Several drugs are used for prevention and treatment of preeclampsia in humans and animal models, and some of these drugs work through complement modulation. Therefore, this review further discusses these studies examining pharmaceutical interventions as treatment for preeclampsia. These observations will help direct research to generate new target options for prevention and treatment of preeclampsia, which include direct and indirect modulation of the complement system.
Topics: Complement Activation; Complement System Proteins; Female; Humans; Placenta; Placenta Diseases; Pre-Eclampsia; Pregnancy
PubMed: 32010144
DOI: 10.3389/fimmu.2019.03098 -
JAMA Network Open Aug 2022Placenta previa is widely acknowledged as a risk factor for placenta accreta spectrum (PAS) disorders, which are severe maternal complications; however, data are limited...
IMPORTANCE
Placenta previa is widely acknowledged as a risk factor for placenta accreta spectrum (PAS) disorders, which are severe maternal complications; however, data are limited regarding whether placenta previa is associated with a higher risk of worse maternal outcomes among patients with PAS disorders.
OBJECTIVE
To examine the association between placenta previa and the risk of severe maternal morbidities (SMMs) and higher resource use among patients with PAS disorders.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective cohort study extracted records of 3793 patients with PAS diagnosis and delivery indicators between October 1, 2015, and December 31, 2019, from the US National Inpatient Sample database.
EXPOSURES
Placenta previa.
MAIN OUTCOMES AND MEASURES
Data on 21 Centers for Disease Control and Prevention-defined SMMs and 25 study-defined surgical morbidities associated with PAS were extracted. Six surgical procedures (cystoscopy, intra-arterial balloon occlusion, cesarean delivery, hysterectomy, cystectomy, and oophorectomy), hospital length of stay, and inpatient costs were compared. Multivariable Poisson regression models built in the generalized estimating equation framework were used.
RESULTS
Among 3793 patients with PAS (median [IQR] age at admission, 33 [29-37] years), 621 women (16.4%) were Black, 765 (20.2%) were Hispanic, 1779 (46.9%) were White, 441 (11.6%) were of other races and/or ethnicities (47 [1.2%] were American Indian, 220 [5.8%] were Asian or Pacific Islander, and 174 [4.6%] were of multiple or other races and/or ethnicities), and 187 (4.9%) were of unknown race and ethnicity. A total of 1323 patients (34.9%) had placenta previa and 2470 patients (65.1%) did not; of those with placenta previa, 405 patients (30.6%) had invasive PAS. Patients with vs without placenta previa had a significantly higher rate and risk of any SMM (935 women [70.7%] vs 1087 women [44.0%]; P < .001; adjusted risk ratio [aRR], 1.19; 95% CI, 1.12-1.27) and any surgical morbidity (1170 women [88.4%] vs 1667 women [67.5%]; P < .001; aRR, 1.18; 95% CI, 1.13-1.23). With regard to specific outcomes, those with vs without placenta previa had a significantly higher rate of peripartum hemorrhage (878 patients [66.4%] vs 1217 patients [49.3%]; P < .001), blood product transfusion (413 patients [31.2%] vs 610 patients [24.7%]; P < .001), shock (83 patients [6.3%] vs 108 patients [4.4%]; P = .01), disseminated intravascular coagulation or other coagulopathy (77 patients [5.8%] vs 105 patients [4.3%]; P = .04), and urinary tract injury (44 patients [3.3%] vs 41 patients [1.7%]; P = .002). Patients with vs without placenta previa were more likely to undergo cesarean delivery (1292 patients [97.7%] vs 1787 patients [72.3%]; P < .001), hysterectomy (786 patients [59.4%] vs 689 patients [27.9%]; P < .001), cystoscopy (301 patients [22.8%] vs 203 patients [8.2%]; P < .001), cystectomy (157 patients [11.9%] vs 98 patients [4.0%]; P < .001), and intra-arterial balloon occlusion (121 patients [9.1%] vs 77 patients [3.1%]; P < .001) and to have significantly longer hospital length of stay (median [IQR], 5 [4-11] days vs 3 [3-5] days; P < .001) and total inpatient costs (median [IQR], $17 496 [$10 863-$30 619] vs $9728 [$6130-$16 790]; P < .001). Hypertensive disorder of pregnancy was associated with a decreased risk of placenta previa (aRR, 0.67; 95% CI, 0.46-0.96) among patients with PAS.
CONCLUSIONS AND RELEVANCE
In this study, placenta previa was associated with an increased risk of maternal and surgical morbidities and higher resource use among women with PAS. These findings suggest that interventions to alleviate maternal and surgical morbidities are especially needed for patients with placenta previa-complicated PAS disorders.
Topics: Cesarean Section; Female; Humans; Hysterectomy; Placenta Accreta; Placenta Previa; Pregnancy; Retrospective Studies; United States
PubMed: 35994286
DOI: 10.1001/jamanetworkopen.2022.28002 -
Placenta Aug 2022Preeclampsia (PE) is a leading condition threatening pregnant women and their offspring. The offspring of PE pregnancies have a high risk of poor neurodevelopmental... (Review)
Review
Preeclampsia (PE) is a leading condition threatening pregnant women and their offspring. The offspring of PE pregnancies have a high risk of poor neurodevelopmental outcomes and neuropsychological diseases later in life. However, the pathophysiology and pathogenesis of poor neurodevelopment remain undetermined. Abnormal placental functions are at the core of most PE cases, and recent research evidence supports that the placenta plays an important role in fetal brain development. Here, we summarize the relationship between abnormal fetal brain development and placental dysfunction in PE conditions, which include the dysfunction of nutrient and gas-waste exchange, impaired angiogenesis stimulation, abnormal neurotransmitter regulation, disrupted special protectors, and immune disorders. All these factors could lead to poor neurodevelopmental outcomes.
Topics: Female; Fetal Development; Fetus; Humans; Placenta; Placenta Diseases; Pre-Eclampsia; Pregnancy
PubMed: 35872512
DOI: 10.1016/j.placenta.2022.07.014