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The New England Journal of Medicine Sep 2021
Topics: Adult; Cesarean Section; Female; Humans; Obstetric Labor, Premature; Placenta Accreta; Postpartum Hemorrhage; Pregnancy; Uterus
PubMed: 34506088
DOI: 10.1056/NEJMicm2109363 -
American Journal of Obstetrics and... Sep 2020The evolution of multidisciplinary team-based care for women with placenta accreta spectrum disorder has delivered stepwise improvements in clinical outcomes. Central to... (Review)
Review
The evolution of multidisciplinary team-based care for women with placenta accreta spectrum disorder has delivered stepwise improvements in clinical outcomes. Central to this overall goal is the ability to limit blood loss at surgery. Placement of inflatable balloons within the pelvic arteries, most commonly in the anterior divisions of the internal iliac arteries, became popular in many centers, at the expense of prolonging surgical care and with attendant risks of vascular injury. In tandem, the need to expose pelvic sidewall anatomy to safely identify the course of the ureters re-popularized the alternative strategy of ligating the same anterior divisions of the internal iliac arteries. With incremental gains in surgical expertise, described in 5 steps in this review, our teams have witnessed a steady decline in surgical blood loss. Nevertheless, a subset of women has the most severe form of placenta accreta spectrum, namely placenta previa-percreta. Such women are at risk of major hemorrhage during surgery from vessels arising outside the territories of the internal iliac arteries. These additional blood supplies, mostly from the external iliac arteries, pose significant risks of major blood loss even in experienced hands. To address this risk, some centers, principally in China, have adopted an approach of routinely placing an infrarenal aortic balloon, with both impressively low rates of blood loss and an ability to conserve the uterus by resecting the placenta with the affected portion of the uterine wall. We review these literature developments in the context of safely performing elective cesarean hysterectomy for placenta previa-percreta, the most severe placenta accreta spectrum disorder.
Topics: Balloon Occlusion; Blood Loss, Surgical; Cesarean Section; Colpotomy; Female; Humans; Hysterectomy; Iliac Artery; Ligation; Magnetic Resonance Imaging; Placenta Accreta; Placenta Previa; Pregnancy; Risk Factors; Treatment Outcome
PubMed: 32007492
DOI: 10.1016/j.ajog.2020.01.044 -
NeoReviews Nov 2021Placenta accreta spectrum (PAS) refers to the range of pathologic adherence of the placenta to the uterine myometrium, including the placenta accreta, increta, and... (Review)
Review
Placenta accreta spectrum (PAS) refers to the range of pathologic adherence of the placenta to the uterine myometrium, including the placenta accreta, increta, and percreta. The incidence of PAS is rising primarily because of an increase in related risk factors, such as the rate of cesarean deliveries and pregnancies resulting from assisted reproductive technology. The maternal risks associated with PAS are significant, including hemorrhage, hysterectomy, and death. Fetal and neonatal risks are primarily the result of premature delivery. Antenatal diagnosis via ultrasonography and magnetic resonance imaging remains imperfect. Management of PAS varies, however, and there is a clear improvement in maternal outcomes with an antenatal diagnosis compared with unexpected diagnosis at the time of delivery. Studies that evaluate the balance between maternal and fetal/neonatal risks of expectant management versus preterm delivery have found that planned delivery between 34 and 35 weeks' gestation optimizes outcomes. Multidisciplinary PAS care teams have become the norm and recommended approach to management, given the complexity of caring for this obstetrical condition. Although significant advances have been made over the years, large knowledge gaps remain in understanding the pathophysiology, diagnosis, and clinical management.
Topics: Cesarean Section; Female; Gestational Age; Humans; Hysterectomy; Infant, Newborn; Placenta Accreta; Pregnancy; Prenatal Diagnosis
PubMed: 34725137
DOI: 10.1542/neo.22-11-e722 -
American Journal of Obstetrics and... Jun 2022Placenta accreta spectrum is a life-threatening condition that has increased dramatically in recent decades along with cesarean rates worldwide. Cesarean hysterectomy is...
BACKGROUND
Placenta accreta spectrum is a life-threatening condition that has increased dramatically in recent decades along with cesarean rates worldwide. Cesarean hysterectomy is widely practiced in women with placenta accreta spectrum; however, the maternal outcomes after cesarean hysterectomy have not been thoroughly compared with the maternal outcomes after alternative approaches, such as conservative management.
OBJECTIVE
This study aimed to compare the severe maternal outcomes between women with placenta accreta spectrum treated with cesarean hysterectomy and those treated with conservative management (leaving the placenta in situ).
STUDY DESIGN
From a source population of 520,114 deliveries in 176 hospitals (PACCRETA study), we designed an observational cohort of women with placenta accreta spectrum who had either a cesarean hysterectomy or a conservative management (the placenta left in situ) during cesarean delivery. Clinicians prospectively identified women meeting the inclusion criteria and included them at delivery. Data collection started only after the women had received information and agreed to participate in the study in the immediate postpartum period. The primary outcome was the transfusion of >4 units of packed red blood cells within 6 months after delivery. Secondary outcomes were other maternal complications within 6 months. We used propensity score weighting to account for potential indication bias.
RESULTS
Here, 86 women had conservative management and 62 women had cesarean hysterectomy for placenta accreta spectrum during cesarean delivery. The primary outcome occurred in 14 of 86 women in the conservative management group (16.3%) and 36 of 61 (59.0%) in the cesarean hysterectomy group (risk ratio in propensity score weighted model, 0.29; 95% confidence interval, 0.19-0.45). The rates of hysterectomy, total estimated blood loss exceeding 3000 mL, any blood product transfusion, adjacent organ injury, and nonpostpartum hemorrhage-related severe maternal morbidity were lower with conservative management than with cesarean hysterectomy (all adjusted, P≤.02); but, the rates of arterial embolization, endometritis, and readmission within 6 months of discharge were higher with conservative management than with cesarean hysterectomy.
CONCLUSION
Among women with placenta accreta spectrum who underwent cesarean delivery, conservative management was associated with a lower risk of transfusion of >4 units of packed red blood cells within 6 months than cesarean hysterectomy.
Topics: Cesarean Section; Conservative Treatment; Female; Humans; Hysterectomy; Placenta Accreta; Pregnancy; Prospective Studies; Retrospective Studies
PubMed: 34914894
DOI: 10.1016/j.ajog.2021.12.013 -
Radiographics : a Review Publication of... May 2023Placenta accreta spectrum (PAS) disorders are a major cause of maternal morbidity and mortality and are increasing in incidence owing to a rising rate of cesarean... (Review)
Review
Placenta accreta spectrum (PAS) disorders are a major cause of maternal morbidity and mortality and are increasing in incidence owing to a rising rate of cesarean delivery. US is the primary imaging tool for evaluation of PAS disorders, which are most often diagnosed during routine early second-trimester US to assess fetal anatomy. MRI serves as a complementary modality, providing value when the diagnosis is equivocal at US and evaluating the extent and topography of myoinvasion for surgical planning in severe cases. While the definitive diagnosis is established by a combined clinical and histopathologic classification at delivery, accurate antenatal diagnosis and multidisciplinary management are critical to guide treatment and ensure optimal outcomes for these patients. Many MRI features of PAS disorders have been described in the literature. To standardize assessment at MRI, the Society of Abdominal Radiology (SAR) and European Society of Urogenital Radiology (ESUR) released a joint consensus statement to provide guidance for image acquisition, image interpretation, and reporting of PAS disorders. The authors review the role of imaging in diagnosis of PAS disorders, describe the SAR-ESUR consensus statement with a pictorial review of the seven major MRI features recommended for use in diagnosis of PAS disorders, and discuss management of these patients. Familiarity with the spectrum of MRI findings of PAS disorders will provide the radiologist with the tools needed to more accurately diagnose this disease and make a greater impact on the care of these patients. RSNA, 2023 Quiz questions for this article are available through the Online Learning Center. See the invited commentary by Jha and Lyell in this issue.
Topics: Female; Humans; Pregnancy; Magnetic Resonance Imaging; Placenta Accreta; Prenatal Diagnosis; Radiography, Abdominal; Radiology; Retrospective Studies
PubMed: 37079459
DOI: 10.1148/rg.220090 -
The Pan African Medical Journal 2022hemostasis hysterectomy is the radical treatment for postpartum hemorrhage. The purpose of this study is to identify risk factors, indications and complications of...
INTRODUCTION
hemostasis hysterectomy is the radical treatment for postpartum hemorrhage. The purpose of this study is to identify risk factors, indications and complications of hemostasis hysterectomy and to determine factors influencing the types of approaches to hysterectomy.
METHODS
we conducted a monocentric descriptive and analytical retrospective study in the Department of Obstetrics and Gynecology at the Regional Hospital of Ben Arous from 2003 to 2019. Patients were classified according to the type of surgical treatment they received: total or subtotal hysterectomy.
RESULTS
seventy patients were included in the study. The rate of hemostasis hysterectomy was 1.3%. The average age of patients was 34.5 years (±5.1). Indications for hemostasis hysterectomy were dominated by placenta accreta (39% of cases; n=27), uterine inertia (34% of cases; n=24) and uterine rupture (16% of cases; n=11). Perioperative morbidity rate was 34 % (n=24). The most frequent complications were hemorrhagic shock (17%; n=12), disseminated intravascular coagulation (6%; n=4) and bladder lesions (6%; n=4). We reported six cases of maternal death, reflecting a rate of 8% (n=6). Subtotal hysterectomy was performed in 79% of patients (n=55) and 21% of women (n=15) underwent total hysterectomy. Placenta accreta was significantly associated with total hysterectomy group (aOR: 6.93, 95% CI: 1.07-44,80, p=0.042) and the average operation time was significantly shorter in subtotal hysterectomy group (aOR: 1.023; 95% CI: 1.009-1.03, p= 0.01).
CONCLUSION
hysterectomy is essential in certain patients with severe postpartum hemorrhage. Placenta accreta is the main indication for hysterectomy. Total hysterectomy is not associated with an increased risk of complications compared to subtotal hysterectomy.
Topics: Adult; Female; Gynecology; Hemostasis; Hospitals; Humans; Hysterectomy; Placenta Accreta; Postpartum Hemorrhage; Pregnancy; Retrospective Studies; Tunisia
PubMed: 36187026
DOI: 10.11604/pamj.2022.42.172.34423 -
Journal of Midwifery & Women's Health Mar 2021Placenta accreta spectrum is a term used to describe abnormal adherence and abnormal invasion of the placenta into the uterine wall during pregnancy. The incidence of...
Placenta accreta spectrum is a term used to describe abnormal adherence and abnormal invasion of the placenta into the uterine wall during pregnancy. The incidence of placenta accreta spectrum has steadily increased over the last 40 years and is most notably linked to rising cesarean birth rates. This condition is associated with increased maternal morbidity and mortality because of the high risk of severe hemorrhage and likely need for hysterectomy at the time of birth. Early diagnosis of abnormal placentation is preferable in order to coordinate birth planning with a interprofessional collaborative team within a high-level perinatal care center. This article describes the case of a woman diagnosed with placenta accreta spectrum and the clinical course of her pregnancy and birth.
Topics: Cesarean Section; Female; Humans; Hysterectomy; Placenta; Placenta Accreta; Placenta Previa; Pregnancy
PubMed: 33338302
DOI: 10.1111/jmwh.13182 -
The British Journal of Radiology Jul 2023The placenta is both the literal and metaphorical black box of pregnancy. Measurement of the function of the placenta has the potential to enhance our understanding of... (Review)
Review
The placenta is both the literal and metaphorical black box of pregnancy. Measurement of the function of the placenta has the potential to enhance our understanding of this enigmatic organ and serve to support obstetric decision making. Advanced imaging techniques are key to support these measurements. This review summarises emerging imaging technology being used to measure the function of the placenta and new developments in the computational analysis of these data. We address three important examples where functional imaging is supporting our understanding of these conditions: fetal growth restriction, placenta accreta, and twin-twin transfusion syndrome.
Topics: Pregnancy; Female; Humans; Placenta; Placenta Accreta; Pelvis
PubMed: 35234516
DOI: 10.1259/bjr.20211010 -
Current Opinion in Obstetrics &... Apr 2022Placenta accreta spectrum (PAS) is a major cause of severe maternal morbidity. Perinatal outcomes are significantly improved when PAS is diagnosed prenatally. However, a... (Review)
Review
PURPOSE OF REVIEW
Placenta accreta spectrum (PAS) is a major cause of severe maternal morbidity. Perinatal outcomes are significantly improved when PAS is diagnosed prenatally. However, a large proportion of cases of PAS remain undiagnosed until delivery.
RECENT FINDINGS
The prenatal diagnosis of PAS requires a high index of suspicion. The first step is identifying maternal risk factors. The most significant risk factor for PAS is the combination of a prior caesarean delivery and a placenta previa. Other major risk factors include a prior history of PAS, caesarean scar pregnancy (CSP), uterine artery embolization (UAE), intrauterine adhesions (Asherman syndrome) and endometrial ablation.Ultrasound is the preferred imaging modality for the prenatal diagnosis of PAS and can be highly accurate when performed by a provider with expertise. PAS can be diagnosed on ultrasound as early as the first trimester. MRI may be considered as an adjunct to ultrasound imaging but is not routinely recommended. Recent consensus guidelines outline the ultrasound and MRI markers of PAS.
SUMMARY
Patients with major risk factors for PAS warrant dedicated ultrasound imaging with a provider experienced in the prenatal diagnosis of PAS.
Topics: Female; Humans; Placenta Accreta; Placenta Previa; Pregnancy; Pregnancy Trimester, First; Prenatal Diagnosis; Uterine Artery Embolization
PubMed: 35230992
DOI: 10.1097/GCO.0000000000000773 -
Best Practice & Research. Clinical... Dec 2022Postpartum hemorrhage can occur unexpectedly and with high dynamics. The mother's life often depends on quick action and good communication within an interdisciplinary... (Review)
Review
Postpartum hemorrhage can occur unexpectedly and with high dynamics. The mother's life often depends on quick action and good communication within an interdisciplinary team. Knowledge of each other's therapeutic options plays a major role. Treatment procedures include obstetric, surgical, and radiologic techniques. In addition to availability and experience with the techniques, two important aspects must be considered in the selection process: the type of delivery and the cause of the hemorrhage. In particular, the distinction between pregnancies with or without disturbed placentation from the placenta accreta spectrum is crucial. From these two points of view, we discuss here different uterus-preserving and uterus-removing techniques. We describe in detail the advantages and disadvantages of each procedure. Because most therapeutic options are based on small case series and uncontrolled studies, local circumstances and physician experience are critical in setting internal standards.
Topics: Pregnancy; Female; Humans; Postpartum Hemorrhage; Placenta Accreta; Uterus
PubMed: 36513432
DOI: 10.1016/j.bpa.2022.09.002