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Best Practice & Research. Clinical... Apr 2021Antenatal diagnosis of placenta accreta spectrum (PAS) disorders allows planned management by a multidisciplinary team in a tertiary center, and thus can reduce... (Review)
Review
Antenatal diagnosis of placenta accreta spectrum (PAS) disorders allows planned management by a multidisciplinary team in a tertiary center, and thus can reduce hemorrhagic morbidity, compared with intrapartum diagnosis. Previous Cesarean section and placenta previa are the two most common risk factors. Prenatal ultrasound is a promising diagnostic tool for PAS in the second or third trimester. Recent evidence shows sonographic markers of PAS can be present in the first trimester. Prenatal ultrasound may help predict the depth and topography of placental invasion which are the major determinants of maternal morbidity. The presence of increased vascularity in the inferior part of the lower uterine segment and the parametrial region is associated with a more severe disorder according to a newly proposed staging system. In this chapter, we will discuss how to improve the prediction of PAS, the depth, and topography of placental invasion.
Topics: Cesarean Section; Female; Humans; Placenta Accreta; Placenta Previa; Pregnancy; Prenatal Diagnosis; Retrospective Studies; Ultrasonography, Prenatal
PubMed: 32747328
DOI: 10.1016/j.bpobgyn.2020.06.010 -
Placenta Aug 2020The objective of our study was to demonstrate planned conservative management of placenta increta and percreta in a single tertiary center.
Planned conservative management of placenta increta and percreta with prophylactic transcatheter arterial embolization and leaving placenta in situ for women who desire fertility preservation.
INTRODUCTION
The objective of our study was to demonstrate planned conservative management of placenta increta and percreta in a single tertiary center.
METHODS
From April 2005 to July 2019, patients with placenta increta and percreta were managed conservatively at the Kaohsiung Chang Gung Memorial Hospital in Taiwan. The severity of placenta invasion was diagnosed by magnetic resonance imaging (MRI). After delivery of the neonate, prophylactic transcatheter arterial embolization (TAE) was performed immediately. The placenta was left in situ and prophylactic antibiotics were administered during hospitalization. The patient profiles, outcomes, and complications were retrospectively reviewed.
RESULTS
Based on the MRI findings, twenty-one patients with placenta increta or percreta were included. With prophylactic TAE, the mean surgical blood loss was 854.7 ± 478.2 mL. The mean natural resorption time of residual placenta was 4.69 ± 1.65 months. Regarding maternal complications, 4 patients (19%) had delayed postpartum hemorrhage (PPH), 12 patients (57.1%) developed postpartum infections, 3 patients (14.3%) progressed to sepsis, 4 patients (19%) underwent surgical evacuation, and 4 patients (19%) underwent hysterectomy. No maternal mortality was reported. Main neonatal complications were prematurity and respiratory distress. Regarding fertility, 16 (76.1%) patients had return of menstruation, and one (4.7%) had a subsequent pregnancy resulting in a live birth.
DISCUSSION
Planned conservative management with prophylactic TAE and leaving placenta in situ is feasible and safe for women with placenta increta or percreta who desire fertility preservation. Delayed PPH and postpartum infection are common complications after conservative treatment.
Topics: Adult; Conservative Treatment; Embolization, Therapeutic; Female; Fertility Preservation; Humans; Infant, Newborn; Magnetic Resonance Imaging; Placenta; Placenta Accreta; Pregnancy; Retrospective Studies
PubMed: 32792063
DOI: 10.1016/j.placenta.2020.06.003 -
Obstetrics and Gynecology Aug 2013Most cases of abnormal placentation are associated with a history of one or more cesarean deliveries. Uterine leiomyomas and treatment for such a diagnosis are also risk...
BACKGROUND
Most cases of abnormal placentation are associated with a history of one or more cesarean deliveries. Uterine leiomyomas and treatment for such a diagnosis are also risk factors for placenta accreta and should be viewed as such.
CASE
A 34-year-old woman underwent a hysteroscopic myomectomy and became pregnant 6 months later. Ultrasonography and magnetic resonance imaging suggested a placenta percreta. Multidisciplinary care allowed for a safe delivery of her neonate and little maternal morbidity.
CONCLUSION
Patients with a history of hysteroscopic myomectomy or other uterine leiomyoma treatment are at an increased risk for abnormal placentation. Imaging studies are suggested in such patients to coordinate multidisciplinary care to decrease maternal and fetal morbidity and mortality.
Topics: Adult; Cesarean Section; Female; Humans; Hysterectomy; Hysteroscopy; Magnetic Resonance Imaging; Patient Care Team; Placenta Accreta; Pregnancy; Ultrasonography; Uterine Myomectomy
PubMed: 23884266
DOI: 10.1097/AOG.0b013e31828aef0a -
Placenta Feb 2020Abnormally invasive placenta (AIP, aka placenta accreta spectrum; PAS) is an increasingly common pregnancy pathology, which, despite significant morbidity risk to the...
INTRODUCTION
Abnormally invasive placenta (AIP, aka placenta accreta spectrum; PAS) is an increasingly common pregnancy pathology, which, despite significant morbidity risk to the mother, is often undiagnosed prior to delivery. We tested several potential biomarkers in plasma from PAS mothers to determine whether any were sufficiently robust for a formal, diagnostic accuracy study.
METHODS
We examined hyperglycosylated hCG (h-hCG), decorin and IL-8, based on biological plausibility and literature indications that they might be altered in PAS. These analytes were assayed by ELISA in maternal plasma from five groups, comprising (1) normal term controls, (2) placenta previa controls, and cases of (3) placenta increta/percreta without placenta previa, (4) placenta previa increta/percreta and (5) placenta previa accreta.
RESULTS
There were no differences in h-hCG, ß-hCG or the h-hCG/ß-hCG ratio between the groups. Mean decorin levels were increased in previa controls (Group 2) compared to the other groups, but there was substantial overlap between the individual values. While an initial multiplex assay showed a greater value for IL-8 in the placenta previa increta/percreta group (Group 4) compared to placenta previa controls (Group 2), the subsequent validation ELISA for IL-8 showed no differences between the groups.
DISCUSSION
We conclude that the absence of differences and the extent of overlap between cases and controls does not justify further assessment of these biomarkers.
Topics: Adult; Biomarkers; Chorionic Gonadotropin; Decorin; Female; Humans; Interleukin-8; Placenta Accreta; Placenta Previa; Pregnancy
PubMed: 32174305
DOI: 10.1016/j.placenta.2020.01.007 -
Obstetrics and Gynecology Sep 2020To evaluate placenta accreta spectrum with and without placenta previa with regard to risk factors, antepartum diagnosis, and maternal morbidity.
OBJECTIVE
To evaluate placenta accreta spectrum with and without placenta previa with regard to risk factors, antepartum diagnosis, and maternal morbidity.
METHODS
We conducted a retrospective cohort study of pathology-confirmed placenta accreta spectrum deliveries with hysterectomy from two U.S. referral centers from January 2010-June 2019. Maternal, pregnancy, and delivery characteristics were compared among placenta accreta spectrum cases with (previa PAS group) and without (nonprevia PAS group) placenta previa. Surgical outcomes and a composite of severe maternal morbidities were evaluated, including eight or more blood cell units transfused, reoperation, pulmonary edema, acute kidney injury, thromboembolism, or death. Logistic regression was used with all analyses controlled for delivery location.
RESULTS
Of 351 deliveries, 106 (30%) had no placenta previa at delivery. When compared with the previa group, nonprevia placenta accreta spectrum was less likely to be identified antepartum (38%, 95% CI 28-48% vs 87%, 82-91%), less likely to receive care from a multidisciplinary team (41%, 31-51% vs 86%, 81-90%), and less likely to have invasive placenta increta or percreta (51% 41-61% vs 80%, 74-84%). The nonprevia group had more operative hysteroscopy (24%, 16-33% vs 6%, 3-9%) or in vitro fertilization (31%, 22-41% vs 9%, 6-13%) and was less likely to have had a prior cesarean delivery (64%, 54-73% vs 93%, 89-96%) compared with the previa group, though the majority in each group had a prior cesarean delivery. Rates of severe maternal morbidity were similar in the two groups, at 19% (nonprevia) and 20% (previa), even after controlling for confounders (adjusted odds ratio for the nonprevia group 0.59, 95% CI 0.30-1.17).
CONCLUSION
Placenta accreta spectrum without previa is less likely to be diagnosed antepartum, potentially missing the opportunity for multidisciplinary team management. Despite the absence of placenta previa and less placental invasion, severe maternal morbidity at delivery was not lower. Broader recognition of patients at risk for placenta accreta spectrum may improve early clinical diagnosis and patient outcomes.
Topics: Adult; Cohort Studies; Female; Humans; Middle Aged; Placenta Accreta; Placenta Previa; Pregnancy; Retrospective Studies; Risk Factors; Young Adult
PubMed: 32769646
DOI: 10.1097/AOG.0000000000003970 -
Journal of Ayub Medical College,... 2019Placenta accreta is a serious obstetrical complication and is currently a very important indication for peripartum hysterectomy. The purpose of this study is to review...
BACKGROUND
Placenta accreta is a serious obstetrical complication and is currently a very important indication for peripartum hysterectomy. The purpose of this study is to review the frequency of Caesarean hysterectomies performed for placenta accreta and maternal, foetal outcome of these patient.
METHODS
In this cross-sectional study all the patients who underwent emergency hysterectomies for different obstetrical indications during this one year were included in this study. Among them the hysterectomies performed for massive antepartum haemorrhage due to placenta increta were reviewed in detail and risk factors were identified.
RESULTS
Caesarean hysterectomies performed for different obstetrical indications were 47 and 10 were due to placenta previa increta (21.2%). The mean age of the patients was 30±5.5 years. Majority of the patients were multigravidas between 26 and 35 years of age. 30% of patients were Para-3 and 70% of patients were Para-4 and above. One patient (10%) had previous one Caesarean section with placenta previa increta, 02 patients (20%) had previous 02 C-Sections and low-lying placenta adherent to it and 04 patients (40%) had previous 03 C-Sections and major degree placenta previa and 03 patients (30%) had 04 C-Sections with placenta increta. Among the foetal outcome 04 babies (40%) were delivered between 28-32 weeks of gestation. Five foetuses (50%) were delivered between 33-36 weeks of gestation and one foetus (10%) was delivered at term. 02 babies delivered at 28 weeks of gestation had early neonatal death due to prematurity. There were no maternal deaths in this time period.
CONCLUSION
placenta previa increta is a major obstetrical complication. Timely recognition and delivery in a tertiary care hospital with surgical expertise, blood bank facilities and intensive care facilities both for the mother and the baby are needed to improve maternal and foetal outcome.
Topics: Adult; Cesarean Section; Cross-Sectional Studies; Female; Humans; Hysterectomy; Placenta Accreta; Pregnancy; Pregnancy Outcome
PubMed: 31965771
DOI: No ID Found -
BJOG : An International Journal of... Jan 2014The incidence of placental attachment disorders continues to increase with rising caesarean section rates. Antenatal diagnosis helps in the planning of location, timing... (Review)
Review
The incidence of placental attachment disorders continues to increase with rising caesarean section rates. Antenatal diagnosis helps in the planning of location, timing and staffing of delivery. In at-risk women grey-scale ultrasound is quite sensitive, although colour ultrasound is the most predictive. Magnetic resonance imaging can add information in some limited instances. Patients who have had a previous caesarean section could benefit from early (before 10 weeks) visualisation of the implantation site. Current data refer only to placentas implanted in the lower anterior uterine segment, usually over a caesarean section scar.
Topics: Female; Humans; Imaging, Three-Dimensional; Magnetic Resonance Imaging; Myometrium; Placenta Accreta; Predictive Value of Tests; Pregnancy; Pregnancy Trimesters; Prenatal Diagnosis; Sensitivity and Specificity; Ultrasonography, Doppler, Color
PubMed: 24373591
DOI: 10.1111/1471-0528.12557 -
The Journal of Obstetrics and... May 2018To evaluate the efficacy of conservative treatment with methotrexate against placenta increta by two different routes of administration through retrospective analysis.
AIM
To evaluate the efficacy of conservative treatment with methotrexate against placenta increta by two different routes of administration through retrospective analysis.
METHODS
A total of 54 women diagnosed with placenta increta after vaginal delivery were enrolled in this retrospective study. The participants accepted conservative management with methotrexate through either intravenous injection or local multi-point injection under ultrasound guidance. The treatment was considered effective if no hysterectomy was mandatory during the follow-up period.
RESULTS
Out of the 54 cases, 21 patients were treated with methotrexate intravenously (group 1), and 33 patients received local multi-point injection to the placenta increta under ultrasound guidance (group 2). No maternal death occurred. In group 1, 10 patients expelled the placentas spontaneously, 7 patients underwent uterine curettage and 4 patients underwent hysterectomy for uncontrollable post-partum hemorrhage and infection. In group 2, 25 patients expelled placentas spontaneously and 8 patients underwent uterine curettage with no incidence of hysterectomy. The success rate in group 1 and group 2 was 17/21 and 33/33, respectively. The average time of the spontaneous placenta expulsion was 79.13 ± 29.87 days in group 1 and 42.42 ± 31.83 days in group 2.
CONCLUSION
Local multi-point methotrexate injection under ultrasound guidance is a better alternative for patients with placenta increta, especially for preserving fertility.
Topics: Abortifacient Agents, Nonsteroidal; Adult; Conservative Treatment; Female; Humans; Injections; Methotrexate; Placenta Accreta; Pregnancy; Retrospective Studies; Ultrasonography, Interventional; Young Adult
PubMed: 29484784
DOI: 10.1111/jog.13590 -
Obstetrics and Gynecology Jan 2021To assess whether placenta accreta spectrum occurs more frequently among women with twin gestations compared with singleton gestations.
OBJECTIVE
To assess whether placenta accreta spectrum occurs more frequently among women with twin gestations compared with singleton gestations.
METHODS
All live births in California from 2016 to 2017 were identified from previously linked records of birth certificates and birth hospitalization discharges. The primary outcome was placenta accreta spectrum (which includes placenta accreta, increta, and percreta), identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes (O43.2x) for placenta accreta, increta, and percreta. We analyzed the association between twin gestation and placenta accreta spectrum by using multivariable logistic regression and assessed whether our findings were replicated by using a previously validated International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)-based approach.
RESULTS
Among 918,452 live births, 1,126 were diagnosed with placenta accreta spectrum. The prevalence of placenta accreta spectrum was 11.8 per 10,000 among singleton pregnancies and 41.6 per 10,000 among twin pregnancies. In the unadjusted regression analysis, twin pregnancy was associated with higher relative risk of placenta accreta spectrum (RR 3.41, 95% CI 2.57-4.52). After adjusting the regression model for maternal age, previous cesarean birth, and sociodemographic factors, the association held with higher relative risk of placenta accreta spectrum (aRR 2.96, 95% CI 2.23-3.93). Women with twin compared with singleton gestations with placenta accreta spectrum were less likely to have placenta previa. When assessed using ICD-9-CM codes, placenta accreta spectrum was similarly more prevalent among twins than singletons, with an increase in the relative risk of placenta accreta spectrum (aRR 2.45, 95% CI 2.33-3.25).
CONCLUSION
Twin gestation conferred an increased risk for placenta accreta spectrum independent of measured risk factors, which may contribute to increased maternal morbidity in twin gestation compared with singleton gestation. Clinicians should be aware of the increased risk for placenta accreta spectrum in twin gestation and should consider it during ultrasonographic screening.
Topics: Adult; California; Female; Humans; Placenta Accreta; Pregnancy; Pregnancy, Twin; Retrospective Studies; Risk Factors
PubMed: 33278284
DOI: 10.1097/AOG.0000000000004204 -
American Journal of Obstetrics and... Jul 2018
Topics: Adult; Balloon Occlusion; Cesarean Section; Dysmenorrhea; Female; High-Intensity Focused Ultrasound Ablation; Humans; Iliac Artery; Leiomyoma; Magnetic Resonance Imaging; Menorrhagia; Placenta; Placenta Accreta; Postoperative Complications; Pregnancy; Ultrasonography, Prenatal; Uterine Neoplasms
PubMed: 29410151
DOI: 10.1016/j.ajog.2018.01.037