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The Journal of Maternal-fetal &... Dec 2024The resolution of factors linked to the recurrence of cesarean section defects can be accomplished through a comprehensive technique that effectively addresses the...
BACKGROUND
The resolution of factors linked to the recurrence of cesarean section defects can be accomplished through a comprehensive technique that effectively addresses the dehiscent area, eliminates associated intraluminal fibrosis, and establishes a vascularized anterior wall by creating a sliding myometrial flap.
OBJECTIVE
Propose a comprehensive surgical repair for recurrent and large low hysterotomy defects in women seeking pregnancy or recurrent spotting.
STUDY DESIGN
A retrospective cohort analysis included 54 patients aged 25-41 with recurrent large cesarean scar defects treated at Otamendi, CEMIC, and Valle de Lili hospitals. Comprehensive surgical repair was performed by suprapubic laparotomy, involving a wide opening of the vesicouterine space, removal of the dehiscent cesarean scar and all intrauterine abnormal fibrous tissues, using a glide myometrial flap, and intramyometrial injection of autologous platelet-rich plasma. Qualitative variables were determined, and descriptive statistics were employed to analyze the data in absolute frequencies or percentages. The data obtained were processed using the Infostat statistic program.
RESULTS
Following the repair, all women experienced normal menstrual cycles and demonstrated an adequate lower uterine segment thickness, with no evidence of healing defects. All patients experienced early ambulation and were discharged within 24 h. Uterine hemostasis was achieved at specific points, minimizing the use of electrocautery. The standard duration of the procedure was 60 min (skin-to-skin), and the average bleeding was 80-100 ml. No perioperative complications were recorded. A control T2-weighted MRI was performed six months after surgery. All patients displayed a clean, unobstructed endometrial cavity with a thick anterior wall (Median: 14.98 mm, IQR 13-17). Twelve patients became pregnant again, all delivered by cesarean between 36.1 and 38.0 weeks, with a mean of 37.17 weeks. The thickness of the uterine segment before cesarean ranged between 3 and 7 mm, with a mean of 3.91 mm. No cases of placenta previa, dehiscence, placenta accreta spectrum (PAS), or postpartum hemorrhage were reported.
CONCLUSIONS
The comprehensive repair of recurrent low-large defects offers a holistic solution for addressing recurrent hysterotomy defects. Innovative repair concepts effectively address the wound defect and associated fibrosis, ensuring an appropriate myometrial thickness through a gliding myometrial flap.
Topics: Humans; Female; Adult; Retrospective Studies; Hysterotomy; Pregnancy; Cicatrix; Surgical Flaps; Cesarean Section; Myometrium; Recurrence
PubMed: 38945839
DOI: 10.1080/14767058.2024.2365344 -
The Pan African Medical Journal 2024Placenta accreta is a rare but serious placental attachment abnormality. The aim of this study is to analyze the epidemiological, clinical, para-clinical and...
[Placenta accreta: a retrospective descriptive study of 46 patients treated in the Obstetrics and Gynaecology Department of the Farhat Hached University Hospital in Sousse, Tunisia].
Placenta accreta is a rare but serious placental attachment abnormality. The aim of this study is to analyze the epidemiological, clinical, para-clinical and evolutionary features of placenta accreta, to investigate the therapeutic management and to assess maternal and neonatal morbidity and mortality. We conducted a retrospective, descriptive study of patients with histologically confirmed placenta accreta in the obstetrics and gynaecology department of the Farhat Hached University Hospital in Sousse, over a 4-year period from 1 January 2015 to 31 December 2019. The epidemiological, clinical, paraclinical, therapeutic and evolutionary data were collected from patients´ medical records and operative reports. In our series, we identified 46 cases of placenta accreta. The average age of our patients was 35±4.61 years. Each of our patients had a scarred uterus. The average term of delivery was 34 weeks of amenorrhoea and the mode of delivery was caesarean section for all our patients. First-line hysterectomy was performed in 40 patients and conservative treatment in 6. Sixteen patients developed maternal complications. No maternal death was observed. Placenta accreta is a rare condition associated with significant maternal and foetal morbidity.
Topics: Humans; Female; Retrospective Studies; Tunisia; Placenta Accreta; Adult; Pregnancy; Hospitals, University; Hysterectomy; Cesarean Section; Young Adult; Infant, Newborn; Conservative Treatment
PubMed: 38933434
DOI: 10.11604/pamj.2024.47.147.38111 -
AJOG Global Reports May 2024
PubMed: 38919708
DOI: 10.1016/j.xagr.2024.100327 -
Case Reports in Women's Health Jun 2024Caesarean scar pregnancy (CSP) occurs when the gestational sac implants in the region of a scar from a previous caesarean delivery. CSP can lead to life-threatening...
Caesarean scar pregnancy (CSP) occurs when the gestational sac implants in the region of a scar from a previous caesarean delivery. CSP can lead to life-threatening complications, including severe haemorrhage, uterine rupture, placenta accreta spectrum (PAS) and hysterectomy. A 40-year-old woman with one previous caesarean was referred to the specialist centre at 17 weeks of gestation with concerns about CSP. At 19 weeks, she was admitted with abdominal pain. Due to raised body habitus, accurate ultrasound assessment was challenging, necessitating reliance on magnetic resonance imaging (MRI). The patient desired to continue the pregnancy, but due to pain and concerns about uterine rupture she consented to a laparotomy to potentially terminate the pregnancy. Findings during the laparotomy were reassuring, leading to the decision not to terminate the pregnancy. The patient remained hospitalised until delivery by caesarean-hysterectomy at 33 weeks. Histopathology confirmed the PAS diagnosis. This case highlights the importance of achieving early diagnosis and obtaining clear sonographic findings. It emphasises the pitfalls of relying on MRI due to its tendency to over-diagnose severity. It emphasises the urgency for improved training in this domain. Early sonographic diagnosis allows safer performance of termination of pregnancy. It also provides women who continue with the pregnancy useful prognostic signs to facilitate decisions on the optimal gestation for delivery. Determining optimal conservative management for CSP remains an ongoing challenge. This case emphasises the importance of multidisciplinary discussion, comprehensive patient counselling and involving patients in their care planning, to create an individualised and adaptable treatment plan.
PubMed: 38911044
DOI: 10.1016/j.crwh.2024.e00626 -
Journal of Clinical Medicine May 2024: Placenta accreta spectrum (PAS) can be the cause of major morbidity and its optimal management is still controversial. The aim of this study was to compare the...
: Placenta accreta spectrum (PAS) can be the cause of major morbidity and its optimal management is still controversial. The aim of this study was to compare the traditional one-step surgery with a two-step surgical approach in which the placenta is left in situ and the second final operation is delayed to minimise blood loss. : We conducted a single-centre retrospective cohort study including all patients managed for PAS between 2007 and 2023. The number of units of red blood cells (RBCs) needed during surgery was the primary outcome used to compare these two approaches. : A total of 43 cases were included in this analysis. Twenty of these were managed with the delayed two-step surgical approach, whereas 23 received one-step surgery. The median estimated blood loss during surgery was 2000 mL and 2800 mL for two-step and one-step surgery, respectively ( = 0.095). In the two-step surgical approach, the median number of RBC units transfused during surgery was significantly lower ( = 0.049) and the odds ratio for needing more than four units of RBCs was 0.28 (95%-CI: 0.08-0.98, = 0.043). A longer interval between the caesarean section and the second operation showed a trend toward lower blood loss ( = 0.065) and was associated with a significantly lower number of RBC units needed during surgery ( = 0.019). : Two-step surgery for the treatment of PAS was safe in our cohort and could lead to a reduction in blood transfusion. Leaving the placenta in situ and delaying the final operation represents a possible alternative to traditional caesarean hysterectomy.
PubMed: 38892920
DOI: 10.3390/jcm13113209 -
Journal of Clinical Medicine May 2024In light of increased cesarean section rates, the incidence of placenta accreta spectrum (PAS) disorder is increasing. Despite the establishment of clinical practice...
INTRODUCTION
In light of increased cesarean section rates, the incidence of placenta accreta spectrum (PAS) disorder is increasing. Despite the establishment of clinical practice guidelines offering recommendations for early and effective PAS diagnosis and treatment, antepartum diagnosis of PAS remains a challenge. This ultimately risks poor mental health and poor physical maternal and neonatal health outcomes.
CASE DESCRIPTIONS
This case series details the experience of two high-risk patients who remained undiagnosed for PAS until they presented with antenatal hemorrhage, leading ultimately to necessary, complex surgical interventions, which can only be optimally provide in a tertiary care center. Patient 1 is a 37-year-old woman with a history of three cesarean sections, which elevates her risk for PAS. She had placenta previa detected at 19 weeks, and placenta percreta diagnosed upon hemorrhage. During a hysterectomy, invasive placenta was found in the patient's bladder, leading to a cystotomy and right ureteric reimplantation. After discharge, she was diagnosed with a vesicovaginal fistula, and is currently awaiting surgical repair. Patient 2 is a 34-year-old woman with two previous cesarean sections. The patient had complete placenta previa detected at 19- and 32-week gestation scans. She presented with antepartum hemorrhage at 35 weeks and 2 days. An ultrasound showed thin myometrium at the scar site with significant vascularity. A hysterectomy was performed due to placental attachment issues, with significant blood loss. Both patients were at high risk for PAS based on past medical history, risk factors, and pathognomonic imaging findings.
DISCUSSION
We highlight the importance of the implementation of clinical guidelines at non-tertiary healthcare centers. We offer clinical-guideline-informed recommendations for radiologists and antenatal care providers to promote early PAS diagnosis and, ultimately, better patient and neonatal outcomes through increased access to adequate care.
PubMed: 38892867
DOI: 10.3390/jcm13113155 -
Cureus Jun 2024Advances in assisted reproductive technologies have enabled postmenopausal women to achieve pregnancy beyond their reproductive lifespan. Although rare, these...
Advances in assisted reproductive technologies have enabled postmenopausal women to achieve pregnancy beyond their reproductive lifespan. Although rare, these pregnancies are challenging and require a multidisciplinary approach due to the higher prevalence of medical comorbidities in this population. The placenta accreta spectrum is characterized by an abnormal invasion of chorionic villi into the myometrium. Risk factors associated with the placenta accreta spectrum include prior uterine surgeries, advanced maternal age, multiparity, in vitro fertilization, and placenta previa. We present a case of a 59-year-old postmenopausal woman with chronic hypertension, stage II chronic kidney injury, and superimposed pre-eclampsia who underwent cesarean delivery complicated by suspected focal placenta accreta. Histopathological examination revealed significant deviations from normative placental architecture, emphasizing the invasion of the villi. Further, congested blood vessels and the presence of inflammatory cells, along with heightened collagen deposition, suggest an underlying pathological process affecting placental health. These findings underscore a perturbation of placental homeostasis, emphasizing the necessity for further investigation into the mechanisms contributing to placental pathology in postmenopausal pregnancies.
PubMed: 38882221
DOI: 10.7759/cureus.62332 -
Diagnosis of placenta accreta spectrum using ultrasound texture feature fusion and machine learning.Computers in Biology and Medicine Jun 2024Placenta accreta spectrum (PAS) is an obstetric disorder arising from the abnormal adherence of the placenta to the uterine wall, often leading to life-threatening...
INTRODUCTION
Placenta accreta spectrum (PAS) is an obstetric disorder arising from the abnormal adherence of the placenta to the uterine wall, often leading to life-threatening complications including postpartum hemorrhage. Despite its significance, PAS remains frequently underdiagnosed before delivery. This study delves into the realm of machine learning to enhance the precision of PAS classification. We introduce two distinct models for PAS classification employing ultrasound texture features.
METHODS
The first model leverages machine learning techniques, harnessing texture features extracted from ultrasound scans. The second model adopts a linear classifier, utilizing integrated features derived from 'weighted z-scores'. A novel aspect of our approach is the amalgamation of classical machine learning and statistical-based methods for feature selection. This, coupled with a more transparent classification model based on quantitative image features, results in superior performance compared to conventional machine learning approaches.
RESULTS
Our linear classifier and machine learning models attain test accuracies of 87 % and 92 %, and 5-fold cross validation accuracies of 88.7 (4.4) and 83.0 (5.0), respectively.
CONCLUSIONS
The proposed models illustrate the effectiveness of practical and robust tools for enhanced PAS detection, offering non-invasive and computationally-efficient diagnostic tools. As adjunct methods for prenatal diagnosis, these tools can assist clinicians by reducing the need for unnecessary interventions and enabling earlier planning of management strategies for delivery.
PubMed: 38878399
DOI: 10.1016/j.compbiomed.2024.108757 -
BMC Medical Imaging Jun 2024The incidence of placenta accreta spectrum (PAS) increases in women with placenta previa (PP). Many radiologists sometimes cannot completely and accurately diagnose PAS...
BACKGROUND
The incidence of placenta accreta spectrum (PAS) increases in women with placenta previa (PP). Many radiologists sometimes cannot completely and accurately diagnose PAS through the simple visual feature analysis of images, which can affect later treatment decisions. The study is to develop a T2WI MRI-based radiomics-clinical nomogram and evaluate its performance for non-invasive prediction of suspicious PAS in patients with PP.
METHODS
The preoperative MR images and related clinical data of 371 patients with PP were retrospectively collected from our hospital, and the intraoperative examination results were used as the reference standard of the PAS. Radiomics features were extracted from sagittal T2WI MR images and further selected by LASSO regression analysis. The radiomics score (Radscore) was calculated with logistic regression (LR) classifier. A nomogram integrating Radscore and selected clinical factors was also developed. The model performance was assessed with respect to discrimination, calibration and clinical usefulness.
RESULTS
A total of 6 radiomics features and 1 clinical factor were selected for model construction. The Radscore was significantly associated with suspicious PAS in both the training (p < 0.001) and validation (p < 0.001) datasets. The AUC of the nomogram was also higher than that of the Radscore in the training dataset (0.891 vs. 0.803, p < 0.001) and validation dataset (0.897 vs. 0.780, p < 0.001), respectively. The calibration was good, and the decision curve analysis demonstrated the nomogram had higher net benefit than the Radscore.
CONCLUSIONS
The T2WI MRI-based radiomics-clinical nomogram showed favorable diagnostic performance for predicting PAS in patients with PP, which could potentially facilitate the obstetricians for making clinical decisions.
Topics: Humans; Female; Placenta Accreta; Nomograms; Pregnancy; Placenta Previa; Magnetic Resonance Imaging; Adult; Retrospective Studies; Radiomics
PubMed: 38872133
DOI: 10.1186/s12880-024-01328-y -
European Journal of Obstetrics,... Jun 2024It is currently very difficult to compare different management strategies for complex obstetric surgery, such as hysterectomy for severe Placenta Accreta Spectrum (PAS),...
The Soleymani and Collins Obstetric morbidity score (SaCOMS): A quantitative tool for measuring maternal morbidity from complex obstetric surgery such as placenta accreta spectrum (PAS).
It is currently very difficult to compare different management strategies for complex obstetric surgery, such as hysterectomy for severe Placenta Accreta Spectrum (PAS), as there is no widely accepted consensus for the classification of maternal surgical morbidity. Many studies focus on the amount of blood products transfused or admission to intensive care units (ICU). However, these are dependent on local policies and available resources. It also gives an incomplete representation of the entire 'patient journey' after they leave the operating room. Subsequent repeat procedures for lower urinary track damage is arguably worse from the woman's perspective than a short stay on an intensive care unit (ICU) for observation. We suggest a version of the Clavien-Dindo morbidity classification specific to obstetrics. Then employ it to build a quantitative morbidity score which aims to reflect the whole 'patient experience' including the post-operative pathway. We then demonstrate the utility of this system in a cohort of women with Placenta Accreta Spectrum (PAS). The Clavien-Dindo classification was modified to reflect obstetric procedures and a quantitative morbidity measure, the Soleymani and Collins Obstetric Morbidity Score (SaCOMS), was developed based on this. Both were then validated using a survey-based consultation of a panel of experts in PAS and retrospectively applied to a cohort of 54 women who underwent caesarean hysterectomy for PAS. Clinicians with expertise in PAS believe that the Modified Obstetric Clavien-Dindo classification system and the novel SaCOMS tool can improve assessment of maternal morbidity, and better reflect the 'patient experience'. Application of the classification system to a single-centre PAS cohort suggested that surgery by gynecologic-oncology surgeons may be associated with decreased incidence and cumulative morbidity outcomes for women with PAS, especially those with the most severe presentation. This study presents a clinically useful obstetric-specific classification system for surgical morbidity. SaCOMS also provides a quantitative reflection of the full patient- journey experienced as a result of surgical complications enabling a more patient-centered representation of morbidity.
PubMed: 38870741
DOI: 10.1016/j.ejogrb.2024.06.005