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Journal of Clinical Medicine May 2024Transcervical fibroid ablation (TFA) is an incisionless method to treat symptomatic uterine fibroids. While safety regarding future pregnancy remains to be established,...
Transcervical fibroid ablation (TFA) is an incisionless method to treat symptomatic uterine fibroids. While safety regarding future pregnancy remains to be established, TFA does not preclude the possibility of pregnancy, and a previous 36-patient case series of post-TFA pregnancies reported normal outcomes. That prior series did not include postmarket cases in the United States, as the Sonata System was initially cleared and used in Europe. This is a substantive update of known pregnancies with the Sonata System since June 2011, and includes pregnancies in Europe, Mexico, and the US. : TFA was carried out under both clinical trial and postmarket use to treat symptomatic uterine fibroids. All post-TFA pregnancies reported by physicians with their patient's consent were included. : 89 pregnancies and 55 deliveries have occurred among 72 women treated with the Sonata System. This includes 8 women who conceived more than once after TFA. Completed pregnancies ( = 62 women) include 19 vaginal deliveries, 35 Cesarean sections, 5 therapeutic abortions, 1 ectopic pregnancy, and 1 delivery by an unknown route. Ten pregnancies are ongoing. Mean birthweight was 3276.7 ± 587.3 g. Ten women experienced 18 first-trimester spontaneous abortions (SAbs), with 10 of the 18 SAbs (55.6%) occurring between two patients with a history of recurrent abortion. The SAb rate was 22.8%, inclusive of these two patients, and 10.1% if they were excluded as outliers. There were no instances of uterine rupture, placenta accreta spectrum, or stillbirth. : This case series, the largest to date for any hyperthermic ablation modality, suggests that TFA with the Sonata System could be a feasible, safe treatment option regarding eventual pregnancy in women with symptomatic uterine fibroids.
PubMed: 38792434
DOI: 10.3390/jcm13102892 -
International Journal of Molecular... May 2024Placenta Accreta Spectrum (PAS) is a life-threatening condition in which placental trophoblastic cells abnormally invade the uterus, often up to the uterine serosa and,...
Placenta Accreta Spectrum (PAS) is a life-threatening condition in which placental trophoblastic cells abnormally invade the uterus, often up to the uterine serosa and, in extreme cases, tissues beyond the uterine wall. Currently, there is no clinical assay for the non-invasive detection of PAS, and only ultrasound and MRI can be used for its diagnosis. Considering the subjectivity of visual assessment, the detection of PAS necessitates a high degree of expertise and, in some instances, can lead to its misdiagnosis. In clinical practice, up to 50% of pregnancies with PAS remain undiagnosed until delivery, and it is associated with increased risk of morbidity/mortality. Although many studies have evaluated the potential of fetal biomarkers circulating in maternal blood, very few studies have evaluated the potential of circulating placental extracellular vesicles (EVs) and their miRNA contents for molecular detection of PAS. Thus, to purify placental EVs from maternal blood, we customized our robust ultra-sensitive immuno-purification assay, termed EV-CATCHER, with a monoclonal antibody targeting the membrane Placental Alkaline Phosphatase (PLAP) protein, which is unique to the placenta and present on the surface of placental EVs. Then, as a pilot evaluation, we compared the miRNA expression profiles of placental EVs purified from the maternal plasma of women diagnosed with placenta previa (controls, = 16); placenta lying low in uterus but not invasive) to those of placental EVs purified from the plasma of women with placenta percreta (cases, = 16), PAS with the highest level of invasiveness. Our analyses reveal that miRNA profiling of PLAP EVs purified from maternal plasma identified 40 differentially expressed miRNAs when comparing these two placental pathologies. Preliminary miRNA pathway enrichment and gene ontology analysis of the top 14 upregulated and top nine downregulated miRNAs in PLAP EVs, purified from the plasma of women diagnosed with placenta percreta versus those diagnosed with placenta previa, suggests a potential role in control of cellular invasion and motility that will require further investigation.
Topics: Humans; Female; Extracellular Vesicles; Pregnancy; Placenta; Placenta Accreta; Biomarkers; Adult; MicroRNAs; Placenta Previa; Alkaline Phosphatase; Isoenzymes; GPI-Linked Proteins
PubMed: 38791142
DOI: 10.3390/ijms25105102 -
Paediatric and Perinatal Epidemiology May 2024
PubMed: 38782405
DOI: 10.1111/ppe.13084 -
American Journal of Obstetrics and... May 2024Asherman syndrome refers to the presence of intrauterine adhesions, which have clinical implications, including infertility. There are few studies assessing the effect...
BACKGROUND
Asherman syndrome refers to the presence of intrauterine adhesions, which have clinical implications, including infertility. There are few studies assessing the effect of serial hysteroscopies for adhesiolysis on reproductive and pregnancy outcomes among women who subsequently undergo in vitro fertilization, and none have looked at maternal, neonatal, or placental pregnancy complications.
OBJECTIVE
This study aimed to explore the effect of hysteroscopic adhesiolysis among a cohort of patients who subsequently undergo in vitro fertilization.
STUDY DESIGN
This was a retrospective cohort study of all patients who underwent hysteroscopic adhesiolysis for intrauterine adhesions at our center between 2005-2020 and subsequently attempted conception by in vitro fertilization. A control group of patients who underwent in vitro fertilization for nonuterine factor infertility and had no history of intrauterine adhesions was chosen for comparison.
RESULTS
There were 691 patients included in this study, of whom 168 were intrauterine adhesion cases. The implantation rate (41.3% in both groups) and live birth rate (adjusted relative risk, 0.93 [95% confidence interval, 0.76-1.14]) were not statistically different between cases and controls. When grouped by number of previous adhesiolysis surgeries, patients who underwent ≥2 adhesiolysis surgeries had a lower live birth rate than controls (adjusted relative risk, 0.53 [95% confidence interval, 0.28-0.99]). Endometrial thickness before the transfer was significantly reduced in cases vs controls (8.23 vs 10.25 mm; adjusted relative risk, 0.84 [95% confidence interval, 0.78-0.90]). Adverse placental outcomes, including placenta accreta spectrum, placenta previa, or vasa previa, were significantly more likely to occur in cases than controls (adjusted relative risk, 2.08 [95% confidence interval, 1.25-3.46]). When grouped by the number of adhesiolysis surgeries, the risk appeared to increase as the number of prior surgeries increased. This is likely because of the increased severity of these adhesions.
CONCLUSION
Overall, patients with a history of treated intrauterine adhesions have the same live birth rate as patients undergoing in vitro fertilization for nonuterine factor indications. However, the subgroup of patients who require multiple surgeries for correction of intrauterine adhesions had a lower live birth rate after in vitro fertilization than controls. Patients with a history of treated intrauterine adhesions are at significantly greater risk of placenta accreta syndrome disorder than control patients who underwent in vitro fertilization for nonuterine factor indications.
PubMed: 38777163
DOI: 10.1016/j.ajog.2024.05.026 -
Journal of Minimally Invasive Gynecology May 2024
PubMed: 38761916
DOI: 10.1016/j.jmig.2024.05.014 -
American Journal of Obstetrics &... May 2024Placenta accreta spectrum is associated with significant maternal and neonatal morbidity and mortality. There is limited established data on healthcare inequities in the...
BACKGROUND
Placenta accreta spectrum is associated with significant maternal and neonatal morbidity and mortality. There is limited established data on healthcare inequities in the outcomes of patients with placenta accreta spectrum.
OBJECTIVE
This study aimed to investigate health inequities in maternal and neonatal outcomes of pregnancies with placenta accreta spectrum.
STUDY DESIGN
This multicentered retrospective cohort study included patients with a histopathological diagnosis of placenta accreta spectrum at 4 regional perinatal centers between January 1, 2013, and June 30, 2022. Maternal race and ethnicity were categorized as either Hispanic, non-Hispanic Black, non-Hispanic White, or Asian or Pacific Islander. The primary outcome was a composite adverse maternal outcome: transfusion of ≥4 units of packed red blood cells, vasopressor use, mechanical ventilation, bowel or bladder injury, or mortality. The secondary outcomes were a composite adverse neonatal outcome (Apgar score of <7 at 1 minute, morbidity, or mortality), gestational age at placenta accreta spectrum diagnosis, and planned delivery by a multidisciplinary team. Multivariable logistic regression was used to estimate the associations of race and ethnicity with maternal and neonatal outcomes.
RESULTS
A total of 408 pregnancies with placenta accreta spectrum were included. In 218 patients (53.0%), the diagnosis of placenta accreta spectrum was made antenatally. Patients predominantly self-identified as non-Hispanic White (31.6%) or non-Hispanic Black (24.5%). After adjusting for institution, age, body mass index, income, and parity, there was no difference in composite adverse maternal outcomes among the racial and ethnic groups. Similarly, adverse neonatal outcomes, gestational age at prenatal diagnosis, rate of planned delivery by a multidisciplinary team, and cesarean hysterectomy were similar among groups.
CONCLUSION
In our multicentered placenta accreta spectrum cohort, race and ethnicity were not associated with inequities in composite maternal or neonatal morbidity, timing of diagnosis, or planned multidisciplinary care. This study hypothesized that a comparable incidence of individual risk factors for perinatal morbidity and geographic proximity reduces potential inequities that may exist in a larger population.
PubMed: 38761887
DOI: 10.1016/j.ajogmf.2024.101386 -
International Journal of Surgery Case... Jun 2024Placenta Accreta Spectrum (PAS) stands out as one of the most significant complications in pregnancy, capable of causing maternal morbidity and mortality.
INTRODUCTION
Placenta Accreta Spectrum (PAS) stands out as one of the most significant complications in pregnancy, capable of causing maternal morbidity and mortality.
PRESENTATION OF CASE
In this report, we aim to discuss a case involving unsatisfactory conservative care coupled with uterine angioembolization, resulting in multiple hospitalizations due to placental infection and eventual hysterectomy.
DISCUSSION
Both conservative and non-conservative approaches have been utilized to mitigate maternal complications and mortality associated with Placenta Accreta Syndrome. While uterus-preserving methods play a crucial role, leaving the placenta in situ can lead to numerous severe long-term complications. Previous Research highlights the limitations of conservative management in the case of placenta accreta, necessitating careful patient selection due to potential morbidity and the risk of secondary hysterectomy.
CONCLUSION
invasive placentation poses challenges in obstetrics, presenting a risk of severe maternal morbidity and mortality. Conservative management poses limitations and risks, emphasizing the need for further research and evidence-based guidelines to enhance the management of PAS.
PubMed: 38761690
DOI: 10.1016/j.ijscr.2024.109774 -
International Journal of Gynaecology... May 2024Placenta accreta spectrum (PAS) is a complex disorder of uterine wall disruption with significant morbidity and mortality, particularly at time of delivery. Both...
OBJECTIVE
Placenta accreta spectrum (PAS) is a complex disorder of uterine wall disruption with significant morbidity and mortality, particularly at time of delivery. Both physician and physical hospital resource allocation/utilization remains a challenge in PAS cases including intensive care unit (ICU) beds. The primary objective of the present study was to identify preoperative risk factors for ICU admission and create an ICU admission prediction model for patient counseling and resource utilization decision making in an evidence-based manner.
METHODS
This was a case-control study of 145 patients at our PAS referral center undergoing cesarean hysterectomy for PAS. Final confirmation by histopathology was required for inclusion. Patient disposition after surgery (ICU vs post-anesthesia care unit) was our primary outcome and pre-/intra-/postoperative variables were obtained via electronic medical records with an emphasis on the predictive capabilities of the preoperative variables. Uni- and multivariate analysis was performed to identify independent predictive factors for ICU admission.
RESULTS
In this large cohort of 145 patients who underwent cesarean hysterectomy for PAS, with histopathologic confirmation, 63 (43%) were admitted to the ICU following delivery. These patients were more likely to be delivered at an earlier gestational age (34 vs 35 weeks, P < 0.001), have had >2 episodes of vaginal bleeding and emergent delivery compared to patients admitted to patients with routine recovery care (44% vs 18.3%, P = 0.009). Uni- and multivariate logistic regression showed an area under the curve of 0.73 (95% CI: [0.63, 0.81], P < 0.001) for prediction of ICU admission with these three variables. Patients with all three predictors had 100% ICU admission rate.
CONCLUSION
Resource prediction, utilization and allocation remains a challenge in PAS management. By identifying patients with preoperative risk factors for ICU admission, not only can patients be counseled but this resource can be requested preoperatively for staffing and utilization purposes.
PubMed: 38757543
DOI: 10.1002/ijgo.15692 -
American Journal of Obstetrics &... May 2024
PubMed: 38740088
DOI: 10.1016/j.ajogmf.2024.101380 -
Heliyon May 2024P-glycoprotein (P-gp) and Breast Cancer Resistance Protein (BCRP) multidrug resistance (MDR) transporters are localized at the luminal surface of the blood-brain barrier...
Hypoxia modulates P-glycoprotein (P-gp) and breast cancer resistance protein (BCRP) drug transporters in brain endothelial cells of the developing human blood-brain barrier.
P-glycoprotein (P-gp) and Breast Cancer Resistance Protein (BCRP) multidrug resistance (MDR) transporters are localized at the luminal surface of the blood-brain barrier (BBB). They confer fetal brain protection against harmful compounds that may be circulating in the peripheral blood. The fetus develops in low oxygen levels; however, some obstetric pathologies such as pre-eclampsia, placenta accreta/previa may result in even greater fetal hypoxic states. We investigated how hypoxia impacts MDR transporters in human fetal brain endothelial cells (hfBECs) derived from early and mid-stages of pregnancy. Hypoxia decreased BCRP protein and activity in hfBECs derived in early pregnancy. In contrast, in hfBECs derived in mid-pregnancy there was an increase in P-gp and BCRP activity following hypoxia. Results suggest a hypoxia-induced reduction in fetal brain protection in early pregnancy, but a potential increase in transporter-mediated protection at the BBB during mid-gestation. This would modify accumulation of various key physiological and pharmacological substrates of P-gp and BCRP in the developing fetal brain and potentially contribute to the pathogenesis of neurodevelopmental disorders commonly associated with hypoxia.
PubMed: 38737275
DOI: 10.1016/j.heliyon.2024.e30207