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Journal of Investigative Surgery : the... Feb 2021In the last 30 years, with increasing cesarean section rates, the incidence of the placenta accreta spectrum has also increased. It is estimated that by the year 2020... (Review)
Review
In the last 30 years, with increasing cesarean section rates, the incidence of the placenta accreta spectrum has also increased. It is estimated that by the year 2020 there will be nearly 9000 cases annually in the United States. Currently, no consensus exists regarding optimal management. Conventional treatment by cesarean-hysterectomy is challenging, with a high maternal morbidity due to massive hemorrhage, and surgical complications such as urinary tract, bowel and pelvic nerve injury, in addition to loss of fertility and its accompanying psychological trauma. Innovative approaches seek to preserve the uterus with the adherent placenta , thus maintaining fertility and potentially reducing hemorrhage and adjacent organ injury. This review reports strategies for conservative treatment of such conditions, based on the current literature.
Topics: Cesarean Section; Conservative Treatment; Female; Humans; Hysterectomy; Placenta Accreta; Pregnancy
PubMed: 31429327
DOI: 10.1080/08941939.2019.1623956 -
American Journal of Obstetrics and... Feb 2022Hysterectomy for placenta accreta spectrum may be associated with urologic morbidity, including intentional or unintentional cystostomy, ureteral injury, and bladder...
BACKGROUND
Hysterectomy for placenta accreta spectrum may be associated with urologic morbidity, including intentional or unintentional cystostomy, ureteral injury, and bladder fistula. Although previous retrospective studies have shown an association between placenta accreta spectrum and urologic morbidities, there is still a paucity of literature addressing these urologic complications.
OBJECTIVE
We sought to report a systematic description of such morbidity and associated factors.
STUDY DESIGN
This was a retrospective study of all histology-proven placenta accreta spectrum deliveries in an academic center between 2011 and 2020. Urologic morbidity was defined as the presence of at least one of the following: cystotomy, ureteral injury, or bladder fistula. Variables were reported as median (interquartile range) or number (percentage). Analyses were made using appropriate parametric and nonparametric tests. Multinomial regression analysis was performed to assess the association of adverse urologic events with the depth of placental invasion.
RESULTS
In this study, 58 of 292 patients (19.9%) experienced urologic morbidity. Patients with urologic morbidity had a higher rate of placenta percreta (compared with placenta accreta and placenta increta) than those without such injuries. Preoperative ureteral stents were placed in 54 patients (93.1%) with and 146 patients (62.4%) without urologic injury (P=.003). After adjusting for confounding variables, multinomial regression analysis revealed that the odds of having adverse urologic events was 6.5 times higher in patients with placenta percreta than in patients with placenta accreta.
CONCLUSION
Greater depth of invasion in placenta accreta spectrum was associated with more frequent and severe adverse urologic events. Whether stent placement confers any protective benefit requires further investigation.
Topics: Adult; Female; Humans; Hysterectomy; Intraoperative Complications; Placenta Accreta; Pregnancy; Retrospective Studies; Urologic Diseases
PubMed: 34391750
DOI: 10.1016/j.ajog.2021.08.010 -
Australasian Psychiatry : Bulletin of... Feb 2023Placenta accreta spectrum conditions are rare, life-threatening disorders of placentation encountered in the perinatal period, with lasting impacts on maternal quality... (Review)
Review
OBJECTIVES
Placenta accreta spectrum conditions are rare, life-threatening disorders of placentation encountered in the perinatal period, with lasting impacts on maternal quality of life and psychological wellbeing. Although the obstetric outcomes are well-known, further review is warranted to explore the psychological sequelae that may accompany these conditions.
CONCLUSIONS
The occurrence of placenta accreta spectrum during pregnancy is a major life stressor that can contribute to the development of psychiatric co-morbidity including posttraumatic stress disorder, depression and anxiety disorders. Early recognition of psychological distress and symptomatic profile is recommended at all stages of perinatal care complicated by this rare spectrum of conditions.
Topics: Pregnancy; Female; Humans; Placenta Accreta; Cesarean Section; Mental Health; Quality of Life; Retrospective Studies
PubMed: 36375814
DOI: 10.1177/10398562221139130 -
European Journal of Radiology Nov 2023To build and validate a predictive model of placental accreta spectrum (PAS) in patients with placenta previa (PP) combining clinical risk factors (CRF) with US and MRI...
PURPOSE
To build and validate a predictive model of placental accreta spectrum (PAS) in patients with placenta previa (PP) combining clinical risk factors (CRF) with US and MRI signs.
METHOD
Our retrospective study included patients with PP from two institutions. All patients underwent US and MRI examinations for suspicion of PAS. CRF consisting of maternal age, cesarean section number, smoking and hypertension were retrieved. US and MRI signs suggestive of PAS were evaluated. Logistic regression analysis was performed to identify CRF and/or US and MRI signs associated with PAS considering histology as the reference standard. A nomogram was created using significant CRF and imaging signs at multivariate analysis, and its diagnostic accuracy was measured using the area under the binomial ROC curve (AUC), and the cut-off point was determined by Youden's J statistic.
RESULTS
A total of 171 patients were enrolled from two institutions. Independent predictors of PAS included in the nomogram were: 1) smoking and number of previous CS among CRF; 2) loss of the retroplacental clear space at US; 3) intraplacental dark bands, focal interruption of the myometrial border and placental bulging at MRI. A PAS-prediction nomogram was built including these parameters and an optimal cut-off of 14.5 points was identified, showing the highest sensitivity (91%) and specificity (88%) with an AUC value of 0.95 (AUC of 0.80 in the external validation cohort).
CONCLUSION
A nomogram-based model combining CRF with US and MRI signs might help to predict PAS in PP patients, with MRI contributing more than US as imaging evaluation.
Topics: Pregnancy; Humans; Female; Placenta Accreta; Placenta Previa; Placenta; Retrospective Studies; Cesarean Section; Magnetic Resonance Imaging
PubMed: 37801998
DOI: 10.1016/j.ejrad.2023.111116 -
The Journal of Maternal-fetal &... Dec 2022To describe the performance of ultrasound in detecting placenta accreta spectrum (PAS) in patients with history of prior myomectomy.
OBJECTIVE
To describe the performance of ultrasound in detecting placenta accreta spectrum (PAS) in patients with history of prior myomectomy.
METHODS
A retrospective cohort study of patients who were referred for sonographic evaluation of the placenta and delivered at a tertiary academic center from 2012 to 2019. Demographic, obstetric, sonographic findings, and pathology information were collected and analyzed using Chi-square, -tests, and ANOVA analysis.
RESULTS
640 patients met inclusion criteria, including 46 (7.2%) with histologically confirmed PAS. Groups for comparison included those with C-section only (CS), CS-Myomectomy, and Myomectomy-only. Those with CS-Myomectomy were older (38.7 years vs. 35.7 years or 35.5 years, = .003) and those with CS only were more likely to have an anterior placenta (63.4% vs. 54.5% or 41.8%, = .005). The rate of PAS was highest in those with Myomectomy only (14.5% vs. 6.1% or 11.4%, = 0.04). Sensitivity, Specificity, and Predictive Values were lowest in the CS-Myomectomy group, with detection rate and PPV of only 40%. Accuracy, defined as the rate of clinical outcome consistent with imaging, was significantly higher in those with CS only compared to the CS with myomectomy or myomectomy-only groups. Of the histologically confirmed PAS, 11 (23.9%) did not have a placenta previa, and the majority of these occurred in women with prior myomectomy. In the cohort with CS only, the proportion of cases with PAS without placenta previa was 5 of 33 (15.2%) compared to 6 of 13 (46.2%) of PAS in those with prior myomectomy, with or without CS ( = .05).
CONCLUSION
In patients with prior uterine surgery referred for sonographic evaluation of the placenta, rates of histology-confirmed PAS were highest in those with prior myomectomy, though ultrasound accuracy was lower in these patients. As ultrasound findings of PAS may be clearer in the presence of placenta previa, the absence of previa in a higher proportion of PAS with prior myomectomy may be related to the observed lower sonographic accuracy in these patients.
Topics: Pregnancy; Humans; Female; Placenta Accreta; Placenta Previa; Retrospective Studies; Uterine Myomectomy; Ultrasonography, Prenatal; Placenta
PubMed: 34763606
DOI: 10.1080/14767058.2021.2001800 -
BMC Pregnancy and Childbirth May 2023To evaluate the diagnostic accuracy of ultrasound and in the diagnosis of Placenta accreta spectrum (PAS). (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To evaluate the diagnostic accuracy of ultrasound and in the diagnosis of Placenta accreta spectrum (PAS).
DATA SOURCES
Screening of MEDLINE, CENTRAL, other bases from inception to February 2022 using the keywords related to placenta accreta, increta, percreta, morbidly adherent placenta, and preoperative ultrasound diagnosis.
STUDY ELIGIBILITY CRITERIA
All available studies- whether were prospective or retrospective- including cohort, case control and cross sectional that involved prenatal diagnosis of PAS using 2D or 3D ultrasound with subsequent pathological confirmation postnatal were included. Fifty-four studies included 5307 women fulfilled the inclusion criteria, PAS was confirmed in 2025 of them.
STUDY APPRAISAL AND SYNTHESIS METHODS
Extracted data included settings of the study, study type, sample size, participants characteristics and their inclusion and exclusion criteria, Type and site of placenta previa, Type and timing of imaging technique (2D, and 3D), severity of PAS, sensitivity and specificity of individual ultrasound criteria and overall sensitivity and specificity.
RESULTS
The overall sensitivity was 0.8703, specificity was 0.8634 with -0.2348 negative correlation between them. The estimate of Odd ratio, negative likelihood ratio and positive likelihood ratio were 34.225, 0.155 and 4.990 respectively. The overall estimates of loss of retroplacental clear zone sensitivity and specificity were 0.820 and 0.898 respectively with 0.129 negative correlation. The overall estimates of myometrial thinning, loss of retroplacental clear zone, the presence of bridging vessels, placental lacunae, bladder wall interruption, exophytic mass, and uterovesical hypervascularity sensitivities were 0.763, 0.780, 0.659, 0.785, 0.455, 0.218 and 0.513 while specificities were 0.890, 0.884, 0.928, 0.809, 0.975, 0.865 and 0.994 respectively.
CONCLUSIONS
The accuracy of ultrasound in diagnosis of PAS among women with low lying or placenta previa with previous cesarean section scars is high and recommended in all suspected cases.
TRIAL REGISTRATION
Number CRD42021267501.
Topics: Pregnancy; Female; Humans; Placenta Accreta; Placenta; Placenta Previa; Cesarean Section; Retrospective Studies; Prospective Studies; Cross-Sectional Studies; Ultrasonography, Prenatal
PubMed: 37189095
DOI: 10.1186/s12884-023-05675-6 -
American Journal of Obstetrics and... Jul 2023Placenta accreta spectrum disorders are a continuum of placental pathologies with significant maternal morbidity and mortality. Morbidity is related to the overall...
BACKGROUND
Placenta accreta spectrum disorders are a continuum of placental pathologies with significant maternal morbidity and mortality. Morbidity is related to the overall degree of placental adherence, and thus patients with placenta increta or percreta represent a high-risk category of patients. Hemorrhage and transfusion of blood products represent 90% of placenta accreta spectrum morbidity. Both tranexamic acid and uterine artery embolization independently decrease obstetrical hemorrhage.
OBJECTIVE
This study aimed to provide an evidence-based intraoperative protocol for placenta accreta spectrum management.
STUDY DESIGN
This study was a pre- and postimplementation analysis of concomitant uterine artery embolization and tranexamic acid in cases of patients with antenatally suspected placenta increta and percreta over a 5-year period (2018-2022). For comparison, a 5-year (2013-2017) preimplementation group was used to assess the impact of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum. Patient demographics and clinically relevant outcomes were obtained from electronic medical records.
RESULTS
A total of 126 cases were managed by the placenta accreta spectrum team, of which 66 had suspected placenta increta/percreta over the 10-year time period. Two patients were excluded from the postimplementation cohort because they did not undergo both interventions. Thus, 30 (30/64; 47%) were treated after implementation of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum, and 34 (34/64; 53%) preimplementation patients did not undergo uterine artery embolization or tranexamic acid infusion. With the uterine artery embolization and tranexamic acid protocol, operative times were longer (416 vs 187 minutes; P<.01), and patients were more likely to receive general anesthesia (80% vs 47%; P<.01). However, blood loss was reduced by 33% (2000 vs 3000 cc; P=.03), overall blood transfusion rates decreased by 51% (odds ratio, 0.05 [95% confidence interval, 0.001-0.20]; P<.01), and massive blood transfusion (>10 units transfused) was reduced 5-fold (odds ratio, 0.17 [95% confidence interval, 0.02-0.17]; P=.02). Postoperative complication rates remained unchanged (4 vs 10 events; P=.14). Neonatal outcomes were equivalent.
CONCLUSION
The uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum is an effective approach to the standardization of complex placenta accreta spectrum cases that results in optimal perioperative outcomes and reduced maternal morbidity.
Topics: Placenta Accreta; Postpartum Hemorrhage; Uterine Artery Embolization; Tranexamic Acid; Hysterectomy; Cesarean Section; Blood Transfusion; Uterine Artery; Pregnancy Outcome
PubMed: 36965865
DOI: 10.1016/j.ajog.2023.03.028 -
The Journal of Maternal-fetal &... Aug 2020To clarify perinatal outcomes of patients with placenta previa (PP) with the placenta mainly positioned in the lateral uterine wall (lateral PP), thereby clinically...
To clarify perinatal outcomes of patients with placenta previa (PP) with the placenta mainly positioned in the lateral uterine wall (lateral PP), thereby clinically characterizing this condition. The retrospective cohort study was performed involving patients with lateral PP between January 2006 and December 2016. The placental position was determined and classified by magnetic resonance imaging. This study included 98 patients with PP, which was classified into three types according to the main placental position sites: lateral ( = 30), anterior ( = 32), and posterior ( = 36) PP. Overall, the median blood loss at cesarean section (CS) was 1808 mL and transfusion was performed for 78 patients (80%). Univariate analysis showed that patients with lateral PP bled less at CS than those with non-lateral PP (anterior + posterior PP) [median 1510 (interquartile range 1080-2168) versus 1975 (1570-2860) mL: =.02]. The other parameters including rates of conception by assisted reproductive technology, prior CS, antepartum bleeding, and placenta accreta spectrum did not show the significances. Among the three groups of PP (lateral versus anterior versus posterior), patients with lateral PP bled less than those with anterior (=.05) or posterior (=.13) PP, but this was nonsignificant [lateral 1510 (1080-2168) versus anterior 2145 (1580-3348) versus posterior 1808 (1533-2555) mL]. When dividing into lateral PP to two types: placenta showing anterior dominancy versus posterior dominancy, patients with lateral PP and anterior dominancy bled more those with posterior dominancy [2430 (1410-3400) versus 1170 (1050-1588) mL: =.002]. Patients with lateral PP bled significantly less than those with non-lateral (anterior or posterior) PP. Patients with lateral PP and anterior dominancy bled more than those with posterior dominancy.
Topics: Cesarean Section; Female; Humans; Placenta; Placenta Accreta; Placenta Previa; Pregnancy; Retrospective Studies
PubMed: 30518276
DOI: 10.1080/14767058.2018.1556634 -
American Journal of Obstetrics &... Dec 2023Placenta accreta spectrum can lead to uncontrollable massive hemorrhage in the perinatal period. Currently, the first-line treatment for placenta accreta spectrum...
BACKGROUND
Placenta accreta spectrum can lead to uncontrollable massive hemorrhage in the perinatal period. Currently, the first-line treatment for placenta accreta spectrum recommended worldwide is hysterectomy. However, adverse outcomes after hysterectomy, including surgical complications, such as difficulty in performing the procedure, and sequelae, such as infertility and psychological issues, cannot be ignored. Several surgical approaches for conservative treatment have been proposed. There are few reports on the effectiveness, safety, and long-term complications of conservative treatments, especially subsequent pregnancy outcomes.
OBJECTIVE
This study aimed to investigate the clinical outcomes and identify risk factors of subsequent pregnancies among patients with placenta accreta spectrum who had undergone conservative surgery.
STUDY DESIGN
This was a retrospective cohort study of subsequent pregnancy cases after cesarean delivery with conservative treatment for placenta accreta spectrum from 2011 to 2019 at The First Affiliated Hospital of Zhengzhou University to identify clinical outcomes of subsequent pregnancies and the risk factors of adverse pregnancy outcomes.
RESULTS
A total of 883 patients undergoing conservative surgery were included in this study, among which 604 (68.4%) were successfully followed up. There were 75 successful pregnancies in 72 patients, including 22 full-term or near-term deliveries, 1 induced labor in the second trimester of pregnancy, 6 cesarean scar pregnancies (8.0%), 2 ectopic pregnancies, and 44 first-trimester pregnancies (3 miscarriages and 41 elective abortions and 12 medical abortions and 32 vacuum aspirations). All newborns survived in the 22 full-term or near-term deliveries. Moreover, 5 placenta accreta spectrum cases (22.7%) and 6 placenta previa cases were observed. Postpartum hemorrhage was observed in 2 cases, with an incidence rate of 9.1%. All parameters, including age at subsequent pregnancy, gravidity, number of cesarean deliveries, type of previous placenta accreta spectrum, gestational week of pregnancy termination, interpregnancy interval, and the use of vascular occlusion techniques, were not found to be associated with recurrent placenta accreta spectrum and cesarean scar pregnancy.
CONCLUSION
Our findings show that treatment for placenta accreta spectrum does not automatically preclude a subsequent pregnancy. However, patients should be fully informed about the risk of recurrent placenta accreta spectrum, scar pregnancy, and postpartum hemorrhage.
Topics: Pregnancy; Female; Infant, Newborn; Humans; Pregnancy Outcome; Placenta Accreta; Conservative Treatment; Retrospective Studies; Postpartum Hemorrhage; Cicatrix; Risk Factors
PubMed: 37832645
DOI: 10.1016/j.ajogmf.2023.101189 -
Irish Medical Journal Aug 2022Aims To assess the management and outcomes of Placenta Accreta Spectrum disorders and highlight the important management recommendations from international guidelines.... (Observational Study)
Observational Study
Aims To assess the management and outcomes of Placenta Accreta Spectrum disorders and highlight the important management recommendations from international guidelines. Methods A retrospective audit of women diagnosed with Placenta Accreta Spectrum disorder from January 2018 to December 2019. Results Nine cases (0.16%) of placenta accreta from 5695 births were identified. All women received caesarean section under general anaesthesia. Caesarean hysterectomy occurred in seven cases (78%). Mean (±SD) age of women was (34.4 ± 3.9 years) and mean parity score was (3.2 ± 1.2). Mean gestational age at birth was 35.1 ± 0.8 weeks. Bilateral iliac artery balloon occlusion occurred in eight (89%) cases. Median estimated blood loss [range] was 1700 mL [1000-7000] with only 11% of patients (1/9) experiencing more than 3L of blood loss. Intraoperative red blood cell transfusion occurred in six cases (67%). Median number of units of red cell transfusion [range] was four units [0-10]. Mean hospital length of stay was (6.7 ± 1.1 days) and there were no maternal deaths. Multidisciplinary team involvement of senior anaesthetists and obstetricians was noted in all cases. Discussion Placenta accreta spectrum is increasing in incidence in obstetric practice and is associated with significant maternal morbidity and mortality. Implementing national guidelines can improve patient outcomes.
Topics: Infant, Newborn; Humans; Female; Pregnancy; Adult; Infant; Placenta Accreta; Cesarean Section; Retrospective Studies; Postpartum Hemorrhage; Blood Loss, Surgical
PubMed: 36300594
DOI: No ID Found