-
Medicina (Kaunas, Lithuania) Apr 2024: Placenta accreta spectrum (PAS) disorders are placental conditions associated with significant maternal morbidity and mortality. While antenatal vaginal bleeding in...
: Placenta accreta spectrum (PAS) disorders are placental conditions associated with significant maternal morbidity and mortality. While antenatal vaginal bleeding in the setting of PAS is common, the implications of this on overall outcomes remain unknown. Our primary objective was to identify the implications of antenatal vaginal bleeding in the setting of suspected PAS on both maternal and fetal outcomes. : We performed a case-control study of patients referred to our PAS center of excellence delivered by cesarean hysterectomy from 2012 to 2022. Subsequently, antenatal vaginal bleeding episodes were quantified, and components of maternal morbidity were assessed. A maternal composite of surgical morbidity was utilized, comprised of blood loss ≥ 2 L, transfusion ≥ 4 units of blood, intensive care unit (ICU) admission, and post-operative length of stay ≥ 4 days. : During the time period, 135 cases of confirmed PAS were managed by cesarean hysterectomy. A total of 61/135 (45.2%) had at least one episode of bleeding antenatally, and 36 (59%) of these had two or more bleeding episodes. Increasing episodes of antenatal vaginal bleeding were associated with emergent delivery ( < 0.01), delivery at an earlier gestational age (35 vs. 34 vs. 33 weeks, < 0.01), and increased composite maternal morbidity (76, 84, and 94%, = 0.03). : Antenatal vaginal bleeding in the setting of PAS is associated with increased emergent deliveries, earlier gestational ages, and maternal composite morbidity. This important antenatal event may aid in not only counseling patients but also in the coordination of multidisciplinary teams caring for these complex patients.
Topics: Humans; Female; Placenta Accreta; Pregnancy; Case-Control Studies; Adult; Uterine Hemorrhage; Cesarean Section; Hysterectomy; Retrospective Studies; Pregnancy Outcome
PubMed: 38674323
DOI: 10.3390/medicina60040677 -
The Role of the Placental Enzyme Indoleamine 2,3-Dioxygenase in Normal and Abnormal Human Pregnancy.International Journal of Molecular... Apr 2024The biologically significant phenomenon that the fetus can survive immune attacks from the mother has been demonstrated in mammals. The survival mechanism depends on the... (Review)
Review
The biologically significant phenomenon that the fetus can survive immune attacks from the mother has been demonstrated in mammals. The survival mechanism depends on the fetus and placenta actively defending themselves against attacks by maternal T cells, achieved through the localized depletion of the amino acid L-tryptophan by an enzyme called indoleamine 2,3-dioxygenase. These findings were entirely unexpected and pose important questions regarding diseases related to human pregnancy and their prevention during human pregnancy. Specifically, the role of this mechanism, as discovered in mice, in humans remains unknown, as does the extent to which impaired activation of this process contributes to major clinical diseases in humans. We have, thus, elucidated several key aspects of this enzyme expressed in the human placenta both in normal and abnormal human pregnancy. The questions addressed in this brief review are as follows: (1) localization and characteristics of human placental indoleamine 2,3-dioxygenas; (2) overall tryptophan catabolism in human pregnancy and a comparison of indoleamine 2,3-dioxygenase expression levels between normal and pre-eclamptic pregnancy; (3) controlling trophoblast invasion by indoleamine 2,3-dioxygenase and its relation to the pathogenesis of placenta accrete spectrum.
Topics: Humans; Indoleamine-Pyrrole 2,3,-Dioxygenase; Pregnancy; Female; Placenta; Tryptophan; Pre-Eclampsia; Trophoblasts; Animals
PubMed: 38674162
DOI: 10.3390/ijms25084577 -
Ultrasound in Obstetrics & Gynecology :... Apr 2024
PubMed: 38669592
DOI: 10.1002/uog.27670 -
Current Protocols Apr 2024Uterine injury from procedures such as Cesarean sections (C-sections) often have severe consequences on subsequent pregnancies, leading to disorders such as uterine...
Uterine injury from procedures such as Cesarean sections (C-sections) often have severe consequences on subsequent pregnancies, leading to disorders such as uterine placenta previa, placenta accreta spectrum (PAS), and Cesarean scar pregnancy. With rates of C-section at ∼30% of deliveries in the US and projected to continue to climb, an understanding of the mechanisms by which these pregnancy disorders arise and opportunities for intervention are sorely needed. However, there are currently very few animal models of uterine injury and its subsequent impacts on maternal as well as in utero and postnatal fetal outcomes. Here, we describe a procedure for a novel model of surgically induced uterine injury in the genetically tractable laboratory mouse (Mus musculus). We describe preparatory steps for surgery, the induction of uterine injury itself, and post-surgical recovery. We then provide supporting information regarding downstream dissection of pregnant mice. Lastly, we include additional information regarding estrous cycle staging in order to perform surgeries and dissections at the relevant phase in non-pregnant mice. This procedure for incurring uterine injury in a mouse model presents an important step forward in understanding uterine damage and its associated pregnancy disorders. © 2024 Wiley Periodicals LLC. Basic Protocol 1: Preparation for surgery Basic Protocol 2: Surgery and induction of uterine injury Basic Protocol 3: Mating and dissection of pregnant mice as endpoint analyses Support Protocol: Estrous staging of animals.
Topics: Animals; Female; Mice; Uterus; Pregnancy; Disease Models, Animal; Cesarean Section
PubMed: 38666634
DOI: 10.1002/cpz1.1044 -
International Journal of Gynaecology... Apr 2024Cesarean hysterectomy is a dominant and effective approach during delivery in patients with placenta accreta spectrum (PAS). However, as hysterectomy results in a loss... (Review)
Review
BACKGROUND
Cesarean hysterectomy is a dominant and effective approach during delivery in patients with placenta accreta spectrum (PAS). However, as hysterectomy results in a loss of fertility, conservative management is an alternative approach. However, management selection may be affected by a country's overall economic level. Thus the preferred treatment for PAS generates controversy in middle-income countries.
OBJECTIVES
We aimed to compare conservative management and cesarean hysterectomy for managing PAS in middle-income countries.
SEARCH STRATEGY
China National Knowledge Infrastructure, Wanfang Med Online Databases, Cochrane Library, Ovid MEDLINE, PubMed, Web of Science, EMBASE, clinicaltrials.gov, and Scopus were searched from inception through to October 1, 2022.
SELECTION CRITERIA
We included studies that evaluated at least one complication comparing conservative management and hysterectomy. All cases were diagnosed with PAS prenatally and intraoperatively.
DATA COLLECTION AND ANALYSIS
The primary outcomes were blood loss, adjacent organ damage, and the incidence of hysterectomy. Descriptive analyses were conducted for studies that did not meet the meta-analysis criteria. A fixed-effects model was used for studies without heterogeneity and a random-effects model was used for studies with statistical heterogeneity.
MAIN RESULTS
In all, 11 observational studies were included, with 975 and 625 patients who underwent conservative management and cesarean hysterectomy, respectively. Conservative management was significantly associated with decreased blood loss and lower risks of adjacent organ injury and hysterectomy. Conservative management significantly reduced blood transfusions, hospitalization duration, operative time, intensive care unit admission rates, and infections. There were no significant differences in the risks of coagulopathy, thromboembolism, or reoperation.
CONCLUSION
Given short-term complications and future fertility preferences for patients, conservative management appears to effectively manage PAS in middle-income countries. Owing to low levels of evidence, high heterogeneity and insufficient long-term follow-up data, further detailed studies are warranted.
PubMed: 38650462
DOI: 10.1002/ijgo.15558 -
Gynecologic Oncology Reports Jun 2024Given the high risk of complications associated with cesarean hysterectomy for placenta accreta spectrum (PAS), any surgical approach and technique can yield utility in...
Given the high risk of complications associated with cesarean hysterectomy for placenta accreta spectrum (PAS), any surgical approach and technique can yield utility in reducing the surgical morbidity. Here, we propose the 3-2-1 approach as a schema to be implemented in the proper setting for the surgical management of a PAS cesarean hysterectomy. The 3-2-1 approach begins with the surgical dissection of three anatomical landmarks that ultimately facilitate a safe surgical site for the ligation and transection of the uterine vessels. First-step is identification of the three anatomical landmarks which are posterior lower uterine segment peritoneum de-serosalization, identification of the ureters laterally, and anterior bladder dissection. Posterior-to-anterior progression avoids encountering dense adhesions and hypervascularity in the anterior lower uterine segment early in the surgery. Further, allows better mobilization of the uterus to identify the anatomical landmarks laterally and anteriorly. Second-step is to deploy the 2-hand technique where the surgeon places one hand anteriorly and the other hand posteriorly in the lower uterine segment below the placental bed. The surgeon brings both hands together with flexed fingers perpendicular to the uterine tissue and gently elevates the uterus and placenta out of the pelvis and ensures safe anatomical distance to surrounding structures. Third-step is the consideration of a supracervical hysterectomy. In summary, this 3-2-1 approach to reflect the anatomy of enlarged lower uterine segment in PAS is a stepwise schema that can aid surgeons in the completion of a cesarean hysterectomy, with the goal to improve surgical outcomes.
PubMed: 38646446
DOI: 10.1016/j.gore.2024.101366 -
BMC Pregnancy and Childbirth Apr 2024Placenta accreta spectrum often leads to massive hemorrhage and even maternal shock and death. This study aims to identify whether cervical length and cervical area...
BACKGROUND
Placenta accreta spectrum often leads to massive hemorrhage and even maternal shock and death. This study aims to identify whether cervical length and cervical area measured by magnetic resonance imaging correlate with massive hemorrhage in patients with placenta accreta spectrum.
METHODS
The study was conducted at our hospital, and 158 placenta previa patients with placenta accreta spectrum underwent preoperative magnetic resonance imaging examination were included. The cervical length and cervical area were measured and evaluated their ability to identify massive hemorrhage in patients with placenta accreta spectrum.
RESULTS
The cervical length and area in patients with massive hemorrhage were both significantly smaller than those in patients without massive hemorrhage. The results of multivariate analysis show that cervical length and cervical area were significantly associated with massive hemorrhage. In all patients, a negative linear was found between cervical length and amount of blood loss (r =-0.613), and between cervical area and amount of blood loss (r =-0.629). Combined with cervical length and cervical area, the sensitivity, specificity, and the area under the curve for the predictive massive hemorrhage were 88.618%, 90.209%, and 0.890, respectively.
CONCLUSION
The cervical length and area might be used to recognize massive hemorrhage in placenta previa patients with placenta accreta spectrum.
Topics: Pregnancy; Female; Humans; Placenta Previa; Placenta Accreta; Cervix Uteri; Blood Loss, Surgical; Magnetic Resonance Imaging; Retrospective Studies; Placenta
PubMed: 38641821
DOI: 10.1186/s12884-024-06472-5 -
American Journal of Obstetrics &... Apr 2024Clinical-sonographic scoring systems, combining clinical features and ultrasound imaging markers have been proposed for the screening of placenta accreta spectrum (PAS)... (Review)
Review
OBJECTIVE
Clinical-sonographic scoring systems, combining clinical features and ultrasound imaging markers have been proposed for the screening of placenta accreta spectrum (PAS) but their usefulness in different set-ups remains limited. The aim of this study was to assess and compare different clinical-sonographic score systems performed from the midst of pregnancy for the prenatal evaluation of patients at risk of PAS at birth.
DATA SOURCES
PubMed/MEDLINE, Google Scholar, and Embase were searched between October 1982 and October 2022 to identify eligible studies.
STUDY ELIGIBILITY CRITERIA
Observational studies providing data on the use of a combined clinical-ultrasound score systems performed from the midst of pregnancy for the prenatal evaluation of PAS.
METHODS
Study characteristics were evaluated by two independent reviewers using a predesigned protocol PROSPERO (CRD CRD42022332486). Heterogeneity between studies was analysed with Cochran's Q-test and the I statistics. Statistical heterogeneity was quantified by estimating the variance between the studies using I statistics. The area under the receiver operating characteristic curve AUC of ROC of each score and their summary (SROC) was calculated with sensitivity and specificity, and the integrated score of the SROC of all sonographic markers was calculated. Forest Plots were used to develop the meta-analysis of each sonographic marker and for the integrated sonographic score.
RESULTS
Of 1028 articles reviewed, 12 cohorts and two case-control studies including 1630 patients screening for PAS by clinical-ultrasound scores met the eligibility criteria. A diagnosis of PAS was reported in 602 (36.9%) cases for which 547 (90.9%) intraoperative findings and/or histopathologic data were described. A wide variation in reported sensitivities and specificities was observed between studies and in thresholds used for the identification of patients with a high probability of PAS at birth. The SAUCs of the individual sonographic scores ranged between 0.85 (the lowest) for sub-placental hypervascularity to 0.91 for placental location in the lower uterine segment (LUS), myometrial thinning, and placental lacunae and 0.95 for the loss of clear zone. Only four studies included placental bulging in their sonographic score system and therefore no meta-analysis for this score was performed. The integrated SAUC was 0.83 [95% Confidence Interval (95% CI) 79 to 0.86). Forest Plot analysis revealed an integrated sensitivities and specificities of 0.68 [95% CI 0.53-0.80], and 0.88 [95% CI 0.68 to 0.96]), respectively.
CONCLUSIONS
Clinical-sonographic score systems can contribute to the prenatal screening of patients at risk of PAS at birth. While we included multiple sonographic studies from the midst of pregnancy, standardized evaluation should be performed not only with strict ultrasound criteria for the placental position, mid third trimester gestational age at examination, and sonographic markers associated with PAS. Numeric sensitivities, specificities, NPVs, PPV, LR-, and LR+ should be recorded prospectively to assess their accuracy in different set-ups and PTP should be verified at delivery. The variables recommended for most predictive screening are: loss of clear zone underneath the placental bed, placentation in the LUS, and placenta lacunae.
PubMed: 38636601
DOI: 10.1016/j.ajogmf.2024.101369 -
Placenta Jun 2024We aimed to identify factors predictive of adverse maternal and neonatal outcomes in patients with placenta accreta spectrum (PAS) disorders using magnetic resonance...
The predictive value of conventional magnetic resonance imaging combined with intravoxel incoherent motion parameters for evaluating maternal and neonatal clinical outcomes in patients with placenta accreta spectrum disorders.
INTRODUCTION
We aimed to identify factors predictive of adverse maternal and neonatal outcomes in patients with placenta accreta spectrum (PAS) disorders using magnetic resonance imaging (MRI) and intravoxel incoherent motion (IVIM) parameters.
METHOD
Fifty-six normal singleton pregnancies at 33-39 weeks of gestation underwent MRI examination at 1.5 T. The IVIM parameters were obtained from the placenta. The correlation between the f value and postpartum hemorrhage (PPH) and between the f value and transfused units of red blood cells (RBCs) was estimated by linear regression. The correlation between various influencing factors (clinical risk factors, MRI features, and IVIM parameters) and poor outcomes was investigated using univariate and multivariate analyses.
RESULT
The interobserver agreement ranged from fair to excellent (k = 0.30-0.88). Multivariate analyses showed that previous cesarean sections, low signal intensity bands on T2WI and the D value were independent risk factors for adverse outcomes. The combination of three risk factors demonstrated the highest AUC of 0.903, with a sensitivity and specificity of 73.10 % and 96.90 %, respectively. Last, f was positively correlated with PPH and units of RBCs transfused.
DISCUSSION
Preoperative MRI features and IVIM parameters may be used to predict poor outcomes in patients with invasive placental disorders like PAS.
Topics: Humans; Female; Placenta Accreta; Pregnancy; Magnetic Resonance Imaging; Adult; Predictive Value of Tests; Infant, Newborn; Postpartum Hemorrhage; Pregnancy Outcome; Placenta
PubMed: 38631235
DOI: 10.1016/j.placenta.2024.04.007 -
BMC Pregnancy and Childbirth Apr 2024Transverse uterine fundal incision (TUFI) is a beneficial procedure for mothers and babies at risk due to placenta previa-accreta, and has been implemented worldwide....
Evaluation of incision healing status after transverse uterine fundal incision for cesarean delivery and postoperative pregnancy: a ten-year single-center retrospective study.
BACKGROUND
Transverse uterine fundal incision (TUFI) is a beneficial procedure for mothers and babies at risk due to placenta previa-accreta, and has been implemented worldwide. However, the risk of uterine rupture during a subsequent pregnancy remains unclear. We therefore evaluated the TUFI wound scar to determine the approval criteria for pregnancy after this surgery.
METHODS
Between April 2012 and August 2022, we performed TUFI on 150 women. Among 132 of the 150 women whose uteruses were preserved after TUFI, 84 women wished to conceive again. The wound healing status, scar thickness, and resumption of blood flow were evaluated in these women by magnetic resonance imaging (MRI) and sonohysterogram at 12 months postoperatively. Furthermore, TUFI scars were directly observed during the Cesarean sections in women who subsequently conceived.
RESULTS
Twelve women were lost to follow-up and one conceived before the evaluation, therefore 71 cases were analyzed. MRI scans revealed that the "scar thickness", the thinnest part of the scar compared with the normal surrounding area, was ≥ 50% in all cases. The TUFI scars were enhanced in dynamic contrast-enhanced MRI except for four women. However, the scar thickness in these four patients was greater than 80%. Twenty-three of the 71 women conceived after TUFI and delivered live babies without notable problems until August 2022. Their MRI scans before pregnancy revealed scar thicknesses of 50-69% in two cases and ≥ 70% in the remaining 21 cases. And resumption of blood flow was confirmed in all patients except two cases whose scar thickness ≥ 90%. No evidence of scar healing failure was detected at subsequent Cesarean sections, but partial thinning was found in two patients whose scar thicknesses were 50-69%. In one woman who conceived seven months after TUFI and before the evaluation, uterine rupture occurred at 26 weeks of gestation.
CONCLUSIONS
Certain criteria, including an appropriate suture method, delayed conception for at least 12 months, evaluation of the TUFI scar at 12 months postoperatively, and cautious postoperative management, must all be met in order to approve a post-TUFI pregnancy. Possible scar condition criteria for permitting a subsequent pregnancy could include the scar thickness being ≥ 70% of the surrounding area on MRI scans, at least partially resumed blood flow, and no abnormalities on the sonohysterogram.
TRIAL REGISTRATION
Retrospectively registered.
Topics: Pregnancy; Female; Humans; Cicatrix; Retrospective Studies; Uterine Rupture; Uterus; Cesarean Section; Placenta Accreta; Surgical Wound
PubMed: 38622521
DOI: 10.1186/s12884-024-06446-7