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International Journal of Obstetric... Aug 2022Anaesthetic management strategies for Placenta Accreta Spectrum (PAS) remain diverse, and literature interpretation is complicated by a range of terminology. The... (Review)
Review
BACKGROUND
Anaesthetic management strategies for Placenta Accreta Spectrum (PAS) remain diverse, and literature interpretation is complicated by a range of terminology. The International Federation for Gynaecology and Obstetrics (FIGO) published guidance in 2018 to improve PAS diagnosis and management by standardising definitions. We mapped the range, clarity and consistency of terminology in literature pertaining to both PAS and anaesthesia, and determined whether this changed followed FIGO guidance.
METHODS
A literature search of four medical databases was performed. Papers included had PAS (or any 'synonym') in the title, and mode of anaesthesia in the title or abstract. Narrative reviews, and papers not containing original data, were excluded. Diagnostic terms, and evidence supporting their use, were described.
RESULTS
Among 680 abstracts identified, 62 papers were included. Thirty distinct terms were used to describe PAS and subtypes. Terminology was clearly defined 46% of the time and used consistently within a paper 47% of the time. Nine papers (15%) provided no diagnostic evidence to support the terminology used. In 14 (23%) papers published after FIGO guidelines, 14 terms were used to describe PAS. Two papers (14%) specified the diagnostic criteria used. Six (43%) confirmed diagnoses using pathology. Four (29%) were consistent in use of terminology throughout the paper.
CONCLUSIONS
Despite international consensus criteria for reporting PAS, the language pertaining to PAS and anaesthesia remains heterogeneous, inconsistent and variably defined. Reporting of PAS should adhere to FIGO criteria to allow unambiguous interpretation of work, and generation of evidence that is transferrable into clinical practice.
Topics: Female; Humans; Placenta Accreta; Pregnancy
PubMed: 35868995
DOI: 10.1016/j.ijoa.2022.103572 -
Ultrasound in Obstetrics & Gynecology :... Nov 2023To report on the occurrence of urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders (PAS). (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To report on the occurrence of urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders (PAS).
METHODS
MEDLINE, EMBASE and the Cochrane databases were searched electronically up to 1 November 2022. Studies reporting on the urological outcome of women undergoing Cesarean section for PAS were included. Two independent reviewers performed data extraction using a predefined protocol and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies, with disagreements resolved by consensus.The primary outcome was the overall occurrence of urological complications. Secondary outcomes were the occurrence of any cystotomy, intentional cystotomy, unintentional cystotomy, ureteral damage, ureteral fistula and vesicovaginal fistula. All outcomes were explored in the overall population of women undergoing surgery for PAS. In addition, we performed subgroup analyses according to the type of surgery (Cesarean hysterectomy, or conservative surgery or management), severity of PAS at histopathology (placenta accreta/increta and placenta percreta), type of intervention (planned vs emergency) and number of cases per year. Random-effects meta-analyses of proportions were used to analyze the data.
RESULTS
There were 62 studies included in the systematic review and 56 were included in the meta-analysis. Urological complications occurred in 15.2% (95% CI, 12.9-17.7%) of cases. Cystotomy complicated 13.5% (95% CI, 9.7-17.9%) of surgical operations. Intentional cystotomy was required in 7.7% (95% CI, 6.5-9.1%) of cases, while unintentional cystotomy occurred in 7.2% (95% CI, 6.0-8.5%) of cases. Urological complications occurred in 19.4% (95% CI, 16.3-22.7%) of cases undergoing hysterectomy and 12.2% (95% CI, 7.5-17.8%) of those undergoing conservative treatment. In the subgroup analyses, urological complications occurred in 9.4% (95% CI, 5.4-14.4%) of women with placenta accreta/increta and 38.5% (95% CI, 21.6-57.0%) of those described as having placenta percreta, and included mainly cystotomy (5.5% (95% CI, 0.6-15.1%) and 22.0% (95% CI, 5.4-45.5%), respectively). Urological complications occurred in 15.4% (95% CI, 8.1-24.6%) of cases undergoing a planned procedure and 24.6% (95% CI, 13.0-38.5%) of those undergoing an emergency intervention. In subanalysis of studies reporting on ≥ 12 cases per year, the incidence of urological complication was similar to that reported in the primary analysis.
CONCLUSIONS
Women undergoing surgery for PAS are at high risk of urological complication, mainly cystotomy. The incidence of these complications was particularly high in women described as having placenta percreta at birth and in those undergoing emergency surgical intervention. The high heterogeneity between the included studies highlights the need for a standardized protocol for the diagnosis of PAS to identify prenatal imaging signs associated with the increased risk of urological morbidity at delivery. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
Topics: Infant, Newborn; Pregnancy; Female; Humans; Cesarean Section; Placenta Accreta; Obstetrics; Ureter; Ultrasonography, Prenatal; Retrospective Studies; Hysterectomy; Placenta
PubMed: 37401769
DOI: 10.1002/uog.26299 -
The Journal of Maternal-fetal &... Nov 2022To compare the prevalence of placental abnormalities in pregnancy following different modes of operative myomectomy.
PURPOSE
To compare the prevalence of placental abnormalities in pregnancy following different modes of operative myomectomy.
METHODS
A retrospective cohort study, including all women after myomectomy that gave birth in a single tertiary care center from February 2011 to January 2019. Data was collected from the patients' medical files and completed by telephone questionnaire. Patients were stratified to 3 groups, according to the mode of operative myomectomy (laparotomy, laparoscopy, hysteroscopy). Groups were compared for women demographics, fibroid's characteristics, operative management, post-operative placental evaluation and delivery characteristics. Primary outcome was defined as the need for any intervention for placental separation during the third phase of the delivery.
RESULTS
Two hundred forty one women met inclusion criteria. Complete follow-up was achieved in 199 (82.57%) women, of whom 82, 89, and 28 underwent laparoscopic, laparotomy and hysteroscopic myomectomy, respectively. There were no in-between groups differences in women's age, BMI, and gravidity. Disruption of the endometrial cavity during laparoscopy and laparotomy was reported in 3 (3.6%) and 7 (7.8%) cases, respectively ( = .21). During the subsequent pregnancy following myomectomy, placenta accreta spectrum disorder was suspected in only one woman in each of the study groups ( = .63). Placenta previa was low and comparable between groups. Vaginal delivery rate was significantly higher in the hysteroscopy group, as compared to the laparoscopy or the laparotomy groups [11 (36.3%) vs. 5 (6.1%) vs. 4 (4.5%); = .001], with significantly lower need for manual lysis of the placenta [11(39.0%) vs. 51 (62.1%) vs. 62 (69.7%); = .01] and further interventions for blood loss control.
CONCLUSIONS
Subsequent pregnancy following surgical myomectomy was not found to be associated with higher prevalence placental abnormality. Furthermore, other than manual lysis, the different modes of myomectomy did not necessitate any further intervention for complications associated with abnormal placentation requiring intervention.
KEY MESSAGE
Subsequent pregnancy following surgical myomectomy is not associated with higher prevalence of placental abnormality.
Topics: Female; Humans; Hysteroscopy; Male; Placenta; Placenta Accreta; Pregnancy; Retrospective Studies; Uterine Myomectomy
PubMed: 33236944
DOI: 10.1080/14767058.2020.1849114 -
Placenta Sep 2021Placenta accreta spectrum (PAS) is a life-threating obstetric complication, and prenatal prediction of PAS can decrease maternal morbidity and mortality. The aim of this...
INTRODUCTION
Placenta accreta spectrum (PAS) is a life-threating obstetric complication, and prenatal prediction of PAS can decrease maternal morbidity and mortality. The aim of this prospective cohort study was to determine the clinical factors associated with PAS.
METHODS
Pregnant women who delivered at a university hospital were enrolled. Clinical data were collected from medical records, and logistic regression analyses were performed to determine which clinical factors were associated with PAS.
RESULTS
Eighty-seven (2.1%) of the 4146 pregnant women experienced PAS. Multivariable analyses revealed that a prior history of cesarean section (CS) (OR 3.3; 95% CI 1.9-5.7; p < 0.01), dilation and curettage (D&C) (OR 2.8; 95% CI 1.7-4.6; p < 0.01), hysteroscopic surgery (OR 5.7; 95% CI 2.3-14.4; p < 0.01), uterine artery embolization (UAE) (OR 44.1; 95% CI 13.8-141.0; p < 0.01), current pregnancy via assisted reproductive technology (ART) (OR 4.1; 95% CI 2.4-7.1; p < 0.01), and the presence of placenta previa in the current pregnancy (OR 13.1; 95% CI 7.9-21.8; p < 0.01) were independently associated with the occurrence of PAS.
CONCLUSION
Pregnant women who have a prior history of CS, D&C, hysteroscopic surgery, UAE, current pregnancy via ART, and the presence of placenta previa in the current pregnancy are high risk for PAS.
Topics: Adult; Female; Humans; Japan; Placenta Accreta; Pregnancy; Prospective Studies; Risk Factors; Uterine Artery Embolization
PubMed: 34375912
DOI: 10.1016/j.placenta.2021.08.001 -
American Journal of Perinatology Jan 2023Placenta accreta spectrum (PAS) covers a wide spectrum of placental adherence/invasion with varied clinical significance. Histopathologic examination is considered the...
OBJECTIVE
Placenta accreta spectrum (PAS) covers a wide spectrum of placental adherence/invasion with varied clinical significance. Histopathologic examination is considered the confirmatory gold standard, but is only obtained sometime after definitive treatment. The International Federation of Gynecology and Obstetrics (FIGO) has published a new clinical classification that can be assigned at delivery, and we aimed to investigate the association between this new FIGO classification and histopathology and also to assess its correlation with maternal outcomes.
STUDY DESIGN
We studied a retrospective cohort of 185 patients with histopathologically proven PAS managed at our referral center between September 2012 and January 2019. Two experienced surgeons retrospectively reviewed charts and assigned the FIGO grading based on findings reported at delivery. A third experienced reviewer adjudicated to determine the classification used for final analysis. Categorical outcomes were compared with the use of chi-squared and the Fisher exact test, as appropriate. A multivariate model was designed to adjust outcomes in different FIGO groups for the involvement of a formal multidisciplinary management team.
RESULTS
Among 185 patients, there were 41 (22%) placenta accreta, 44 (24%) placenta increta, and 100 (54%) placenta percreta on histopathology. The inter-rater reliability was found to be substantial with Kappa = 0.661 ( < 0.001), and 95% confidence interval (CI): 0.449-0.872. There was a significant association between all histopathology groupings and the FIGO clinical classification ( < 0.001). However, we found no association between FIGO classifications and maternal complications.
CONCLUSION
The new FIGO clinical classification is strongly associated with histopathologic findings. A better understanding of the depth and extent of invasion as afforded by the clinical classification system will help standardize reporting and future research.
KEY POINTS
· PAS includes a wide spectrum of placental invasion with varied clinical significance.. · Histopathological examination is considered the confirmatory gold standard.. · The new FIGO clinical classification is strongly associated with histopathologic findings..
Topics: Pregnancy; Humans; Female; Placenta Accreta; Retrospective Studies; Placenta; Reproducibility of Results; Placenta Previa
PubMed: 33934319
DOI: 10.1055/s-0041-1728834 -
BJOG : An International Journal of... Sep 2021To describe and compare the characteristics of women with placenta accreta spectrum (PAS) and their pregnancy outcomes according to the presence of placenta praevia and...
OBJECTIVE
To describe and compare the characteristics of women with placenta accreta spectrum (PAS) and their pregnancy outcomes according to the presence of placenta praevia and a prior caesarean section.
DESIGN
Prospective population-based study.
SETTING
All 176 maternity hospitals of eight French regions.
POPULATION
Two hundred and forty-nine women with PAS, from a source population of 520 114 deliveries.
METHODS
Women with PAS were classified into two risk-profile groups, with or without the high-risk combination of placenta praevia (or an anterior low-lying placenta) and at least one prior caesarean. These two groups were described and compared.
MAIN OUTCOME MEASURES
Population-based incidence of PAS, characteristics of women, pregnancies, deliveries and pregnancy outcomes.
RESULTS
The PAS population-based incidence was 4.8/10 000 (95% CI 4.2-5.4/10 000). After exclusion of women lost to follow up from the analysis, the group with placenta praevia and a prior caesarean included 115 (48%) women and the group without this combination included 127 (52%). In the group with both factors, PAS was more often suspected antenatally (77% versus 17%; P < 0.001) and more often percreta (38% versus 5%; P < 0.001). This group also had more hysterectomies (53% versus 21%, P < 0.001) and higher rates of blood product transfusions, maternal complications, preterm births and neonatal intensive care unit admissions. Sensitivity analysis showed similar results after exclusion of women who delivered vaginally.
CONCLUSION
More than half the cases of PAS occurred in women without the combination of placenta praevia and a prior caesarean delivery, and these women had better maternal and neonatal outcomes. We cannot completely rule out that some of the women who delivered vaginally had placental retention rather than PAS; however, we found similar results among women who delivered by caesarean.
TWEETABLE ABSTRACT
Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes.
Topics: Adult; Cesarean Section; Female; France; Humans; Placenta Accreta; Placenta Previa; Pregnancy; Pregnancy Outcome; Prospective Studies
PubMed: 33393174
DOI: 10.1111/1471-0528.16647 -
American Journal of Obstetrics and... Sep 2019The objective of this study was to evaluate the prevalence of placenta accreta spectrum in general population studies and the main maternal outcomes at delivery. (Meta-Analysis)
Meta-Analysis
OBJECTIVE DATA
The objective of this study was to evaluate the prevalence of placenta accreta spectrum in general population studies and the main maternal outcomes at delivery.
STUDY
We searched PubMed, Google Scholar, clinicalTrials.gov, and MEDLINE between 1982 and 2018. Articles that provided data on the number of cases of placenta accreta spectrum per pregnancies, births, or deliveries in a defined population were used.
STUDY APPRAISAL AND SYNTHESIS METHODS
Study characteristics were evaluated by 2 independent reviewers who used a predesigned protocol. Primary outcomes were the prevalence of placenta accreta spectrum and clinical diagnostic data at birth; the pathologic criteria were used to confirm the diagnosis. Secondary outcomes included cases that required transfusion, incidence of peripartum hysterectomy, and maternal mortality rates. Heterogeneity between studies was analyzed with the Cochran's Q-test and the I statistics.
RESULTS
Of the 98 full-text studies that were identified, 29 articles met the defined criteria and included 22 retrospective and 7 prospective studies comprising 7001 cases of placenta accreta spectrum of 5,719,992 births. Prevalence rates ranged from 0.01-1.1% with an overall pooled prevalence of 0.17% (95% confidence interval, 0.14-0.19). Only 10 studies provided detailed histopathologic data. The pool prevalence for the adherent vs the invasive grades was 0.5 (95% confidence interval, 0.3-0.36) and 0.3 (95% confidence interval, 0.2-0.4) per 1000 births, respectively. The pooled incidence for peripartum hysterectomy was 52.2% (95% confidence interval, 38.3-66.4; I=99.8%) and 46.9% (95 % confidence interval, 34-59.9; I=98.8%) for hemorrhage that required transfusion. The pooled estimate of maternal death was 0.05% (95% confidence interval, 0.06-0.69; I=73%). We found large amounts of heterogeneity between studies for all parameters and further quantification was limited because of methodologic inconsistencies between studies with regards to clinical criteria that were used for the diagnosis of the condition at birth and the histopathologic confirmation of the diagnosis and differential diagnosis between adherent and invasive accreta placentation.
CONCLUSION
This meta-analysis indicated wide variation between studies for the prevalence rate of placenta accreta spectrum and for the different grades of accreta placentation that highlighted the need for consistency in definitions that are used to describe placenta accreta spectrum at birth and in the reporting of this increasing common obstetric complication.
Topics: Developed Countries; Developing Countries; Female; Global Health; Humans; Placenta Accreta; Pregnancy; Pregnancy Outcome; Prevalence; Prognosis; Retrospective Studies
PubMed: 30716286
DOI: 10.1016/j.ajog.2019.01.233 -
Archives of Gynecology and Obstetrics Jun 2021Placenta accreta spectrum (PAS) disorders can cause major intrapartum haemorrhage. The optimal management approach is not yet defined. We analysed available cases from a...
PURPOSE
Placenta accreta spectrum (PAS) disorders can cause major intrapartum haemorrhage. The optimal management approach is not yet defined. We analysed available cases from a tertiary perinatal centre to compare the outcome of different individual management strategies.
METHODS
A monocentric retrospective analysis was performed in patients with clinically confirmed diagnosis of PAS between 07/2012 and 12/2019. Electronic patient and ultrasound databases were examined for perinatal findings, peripartum morbidity including blood loss and management approaches such as (1) vaginal delivery and curettage, (2) caesarean section with placental removal versus left in situ and (3) planned, immediate or delayed hysterectomy.
RESULTS
46 cases were identified with an incidence of 2.49 per 1000 births. Median diagnosis of placenta accreta (56%), increta (39%) or percreta (4%) was made in 35 weeks of gestation. Prenatal detection rate was 33% for all cases and 78% for placenta increta. 33% showed an association with placenta praevia, 41% with previous caesarean section and 52% with previous curettage. Caesarean section rate was 65% and hysterectomy rate 39%. In 9% of the cases, the placenta primarily remained in situ. 54% of patients required blood transfusion. Blood loss did not differ between cases with versus without prenatal diagnosis (p = 0.327). In known cases, an attempt to remove the placenta did not show impact on blood loss (p = 0.417).
CONCLUSION
PAS should be managed in an optimal setting and with a well-coordinated team. Experience with different approaches should be proven in prospective multicentre studies to prepare recommendations for expected and unexpected need for management.
Topics: Adult; Cesarean Section; Female; Germany; Humans; Hysterectomy; Incidence; Placenta; Placenta Accreta; Postpartum Hemorrhage; Pregnancy; Prenatal Care; Retrospective Studies; Severity of Illness Index; Treatment Outcome
PubMed: 33284419
DOI: 10.1007/s00404-020-05875-x -
Korean Journal of Radiology Feb 2021Placenta accreta spectrum (PAS) is an abnormal placental adherence or invasion of the myometrium or extrauterine structures. As PAS is primarily staged and managed... (Review)
Review
Placenta accreta spectrum (PAS) is an abnormal placental adherence or invasion of the myometrium or extrauterine structures. As PAS is primarily staged and managed surgically, imaging can only guide and facilitate diagnosis. But, imaging can aid in preparations for surgical complexity in some cases of PAS. Ultrasound remains the imaging modality of choice; however, magnetic resonance imaging (MRI) is required for evaluation of areas difficult to visualize on ultrasound, and the assessment of the extent of placenta accreta. Numerous MRI features of PAS have been described, including dark intraplacental bands, placental bulge, and placental heterogeneity. Failure to diagnose PAS carries a risk of massive hemorrhage and surgical complications. This article describes a comprehensive, step-by-step approach to diagnostic imaging and its potential pitfalls.
Topics: Female; Humans; Magnetic Resonance Imaging; Placenta; Placenta Accreta; Pregnancy; Ultrasonography
PubMed: 33169550
DOI: 10.3348/kjr.2020.0580 -
Placenta accreta spectrum in early and late pregnancy from an imaging perspective. A scoping review.Radiologia 2023Placenta accreta spectrum (PAS) disorders (with increasing order of the depth of invasion: accreta, increta, percreta) are quite challenging for the purpose of diagnosis... (Review)
Review
Placenta accreta spectrum (PAS) disorders (with increasing order of the depth of invasion: accreta, increta, percreta) are quite challenging for the purpose of diagnosis and treatment. Pathological examination or imaging evaluation are not very dependable when considered as stand-alone diagnostic tools. On the other hand, timely diagnosis is of great importance, as maternal and fetal mortality drastically increases if patient goes through the third phase of delivery in a not well-suited facility. A multidisciplinary approach for diagnosis (incorporating clinical, imaging, and pathological evaluation) is mandatory, particularly in complicated cases. For imaging evaluation, the diagnostic modality of choice in most scenarios is ultrasound (US) exam; patients are referred for MRI when US is equivocal, inconclusive, or not visualizing placenta properly. Herewith, we review the reported US and MRI features of PAS disorders (mainly focusing on MRI), going over the normal placental imaging and imaging pitfalls in each section, and lastly, covering the imaging findings of PAS disorders in the first trimester and cesarean section pregnancy (CSP).
Topics: Pregnancy; Humans; Female; Placenta Accreta; Placenta; Cesarean Section; Magnetic Resonance Imaging
PubMed: 38049252
DOI: 10.1016/j.rxeng.2023.02.001