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PLoS Medicine Jan 2018Cesarean birth rates continue to rise worldwide with recent (2016) reported rates of 24.5% in Western Europe, 32% in North America, and 41% in South America. The... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Cesarean birth rates continue to rise worldwide with recent (2016) reported rates of 24.5% in Western Europe, 32% in North America, and 41% in South America. The objective of this systematic review is to describe the long-term risks and benefits of cesarean delivery for mother, baby, and subsequent pregnancies. The primary maternal outcome was pelvic floor dysfunction, the primary baby outcome was asthma, and the primary subsequent pregnancy outcome was perinatal death.
METHODS AND FINDINGS
Medline, Embase, Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were systematically searched for published studies in human subjects (last search 25 May 2017), supplemented by manual searches. Included studies were randomized controlled trials (RCTs) and large (more than 1,000 participants) prospective cohort studies with greater than or equal to one-year follow-up comparing outcomes of women delivering by cesarean delivery and by vaginal delivery. Two assessors screened 30,327 abstracts. Studies were graded for risk of bias by two assessors using the Scottish Intercollegiate Guideline Network (SIGN) Methodology Checklist and the Risk of Bias Assessment tool for Non-Randomized Studies. Results were pooled in fixed effects meta-analyses or in random effects models when significant heterogeneity was present (I2 ≥ 40%). One RCT and 79 cohort studies (all from high income countries) were included, involving 29,928,274 participants. Compared to vaginal delivery, cesarean delivery was associated with decreased risk of urinary incontinence, odds ratio (OR) 0.56 (95% CI 0.47 to 0.66; n = 58,900; 8 studies) and pelvic organ prolapse (OR 0.29, 0.17 to 0.51; n = 39,208; 2 studies). Children delivered by cesarean delivery had increased risk of asthma up to the age of 12 years (OR 1.21, 1.11 to 1.32; n = 887,960; 13 studies) and obesity up to the age of 5 years (OR 1.59, 1.33 to 1.90; n = 64,113; 6 studies). Pregnancy after cesarean delivery was associated with increased risk of miscarriage (OR 1.17, 1.03 to 1.32; n = 151,412; 4 studies) and stillbirth (OR 1.27, 1.15 to 1.40; n = 703,562; 8 studies), but not perinatal mortality (OR 1.11, 0.89 to 1.39; n = 91,429; 2 studies). Pregnancy following cesarean delivery was associated with increased risk of placenta previa (OR 1.74, 1.62 to 1.87; n = 7,101,692; 10 studies), placenta accreta (OR 2.95, 1.32 to 6.60; n = 705,108; 3 studies), and placental abruption (OR 1.38, 1.27 to 1.49; n = 5,667,160; 6 studies). This is a comprehensive review adhering to a registered protocol, and guidelines for the Meta-analysis of Observational Studies in Epidemiology were followed, but it is based on predominantly observational data, and in some meta-analyses, between-study heterogeneity is high; therefore, causation cannot be inferred and the results should be interpreted with caution.
CONCLUSIONS
When compared with vaginal delivery, cesarean delivery is associated with a reduced rate of urinary incontinence and pelvic organ prolapse, but this should be weighed against the association with increased risks for fertility, future pregnancy, and long-term childhood outcomes. This information could be valuable in counselling women on mode of delivery.
Topics: Asthma; Cesarean Section; Female; Humans; Infant; Infant, Newborn; Mothers; Pelvic Floor Disorders; Pregnancy; Pregnancy Outcome; Risk Assessment
PubMed: 29360829
DOI: 10.1371/journal.pmed.1002494 -
Acta Obstetricia Et Gynecologica... May 2018Accurate prenatal diagnosis of abnormally invasive placenta (AIP) is fundamental because it significantly reduces maternal morbidities. (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Accurate prenatal diagnosis of abnormally invasive placenta (AIP) is fundamental because it significantly reduces maternal morbidities.
MATERIAL AND METHODS
Medline, Embase, CINAHL and the Cochrane databases were searched. The primary aim of the present review was to elucidate the diagnostic accuracy of prenatal magnetic resonance imaging (MRI) in recognizing the severity of AIP, defined as the depth and topography of invasion. The secondary aim was to ascertain the strength of association between each MRI sign and the depth of placental invasion and to test their individual predictive accuracy in detecting such invasion. Inclusion criteria were studies on women who had prenatal MRI for ultrasound suspicion or the presence of clinical risk factors for AIP. Estimates of sensitivity, specificity, positive and negative likelihood ratios and diagnostic odds ratio were calculated using the hierarchical summary receiver characteristics curve model, and individual data random-effect logistic regression was used to calculate OR.
RESULTS
Twenty studies (1080 pregnancies undergoing MRI mainly for the ultrasound suspicion of AIP) were included. MRI showed a sensitivity of 94.4% [95% confidence interval (CI) 15.8-99.9], 100% (95% CI 75.3-100) and 86.5% (95% CI 74.2-94.4) for detection of placenta accreta, increta and percreta, respectively; the corresponding values for specificity were 98.8% (95% CI 70.7-100), 97.3% (95% CI 93.3-99.3), 96.8% (95% CI 93.5-98.7). MRI identified 100% of cases with S1 and 100% of those with S2 invasion confirmed at surgery. Among the different MRI signs, intra-placental dark bands showed the best sensitivity for the detection of placenta accreta, increta and percreta; as well as abnormal intra-placental vascularity, uterine bulging was associated with a higher risk of increta and percreta, exophitic mass and bladder tenting with placenta percreta.
CONCLUSION
Prenatal MRI has an excellent diagnostic accuracy in identifying the depth and the topography of placental invasion. However, these findings come mainly from studies in which MRI was performed as a secondary imaging tool in women already screened for AIP on ultrasound and might not reflect its actual diagnostic performance in detecting the severity of these disorders.
Topics: Female; Humans; Logistic Models; Magnetic Resonance Imaging; Placenta Diseases; Pregnancy; Prenatal Diagnosis; Sensitivity and Specificity
PubMed: 29136274
DOI: 10.1111/aogs.13258 -
Acta Obstetricia Et Gynecologica... Jan 2018Our objective was to elucidate the overall diagnostic accuracy of ultrasound in detecting the severity of abnormally invasive placentation (AIP). (Review)
Review
INTRODUCTION
Our objective was to elucidate the overall diagnostic accuracy of ultrasound in detecting the severity of abnormally invasive placentation (AIP).
MATERIAL AND METHODS
Medline, Embase, CINAHL and The Cochrane databases were searched. The ultrasound signs explored were: loss of hypoechoic (clear) zone in the placental-uterine interface, placental lacunae, bladder wall interruption, myometrial thinning, focal exophitic mass, placental lacunar flow, subplacental vascularity, and uterovesical hypervascularity.
RESULTS
Twenty studies (3209 pregnancies) were included. Ultrasound had an overall good diagnostic accuracy in identifying the depth of placental invasion with sensitivities of 90.6%, 93.0%, 89.5%, and 81.2% for placenta accreta, increta, accreta/increta, and percreta, respectively; the corresponding specificities were 97.1%, 98.4%, 94.7%, and 98.9%. Placental lacunae had sensitivities of 74.8%, 88.6%, and 76.3% for the detection of placenta accreta, increta, and percreta, respectively. Sensitivity and specificity of loss of the clear zone in identifying placenta accreta were 74.9% and 92.0%, whereas the corresponding figures for placenta increta and percreta were 91.6% and 76.9%, and 88.1% and 71.1%. Lacunar flow had sensitivities of 81.2%, 84.3%, and 45.2% for the detection of placenta accreta, increta, and percreta respectively; the corresponding figures for specificity were 84.0%, 79.7%, and 75.3%. Sensitivity of uterovesical hypervascularity was low for the detection of placenta accreta (12.3%) but high for placenta increta (94.4%) and percreta (86.2%); the corresponding figures for specificity were 90.8%, 88.0% and 88.2%, respectively.
CONCLUSIONS
Ultrasound has an overall good diagnostic accuracy in recognizing the depth and the topography of placental invasion.
Topics: Female; Humans; Myometrium; Placenta; Placenta Accreta; Pregnancy; Sensitivity and Specificity; Ultrasonography, Prenatal
PubMed: 28963728
DOI: 10.1111/aogs.13238 -
Ultrasound in Obstetrics & Gynecology :... Feb 2018The primary aim of this systematic review was to ascertain whether ultrasound signs suggestive of abnormally invasive placenta (AIP) are present in the first trimester... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
The primary aim of this systematic review was to ascertain whether ultrasound signs suggestive of abnormally invasive placenta (AIP) are present in the first trimester of pregnancy. Secondary aims were to ascertain the strength of association and the predictive accuracy of such signs in detecting AIP in the first trimester.
METHODS
An electronic search of MEDLINE, EMBASE, CINAHL and Cochrane databases (2000-2016) was performed. Only studies reporting on first-trimester diagnosis of AIP that was subsequently confirmed in the third trimester either during operative delivery or by pathological examination were included. Meta-analysis of proportions, random-effects meta-analysis and hierarchical summary receiver-operating characteristics curve analysis were used to analyze the data.
RESULTS
Seven studies, involving 551 pregnancies at high risk of AIP, were included. At least one ultrasound sign suggestive of AIP was detected in 91.4% (95% CI, 85.8-95.7%) of cases with confirmed AIP. The most common ultrasound feature in the first trimester of pregnancy was low implantation of the gestational sac close to a previous uterine scar, which was observed in 82.4% (95% CI, 46.6-99.8%) of cases. Anechoic spaces within the placental mass (lacunae) were observed in 46.0% (95% CI, 10.9-83.7%) and a reduced myometrial thickness in 66.8% (95% CI, 45.2-85.2%) of cases affected by AIP. Pregnancies with a low implantation of the gestational sac had a significantly higher risk of AIP (odds ratio, 19.6 (95% CI, 6.7-57.3)), with a sensitivity and specificity of 44.4% (95% CI, 21.5-69.2%) and 93.4% (95% CI, 90.5-95.7%), respectively.
CONCLUSIONS
Ultrasound signs of AIP can be present during the first trimester of pregnancy, even before 11 weeks' gestation. Low anterior implantation of the placenta/gestational sac close to or within the scar was the most commonly seen early ultrasound sign suggestive of AIP, although its individual predictive accuracy was not high. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
Topics: Female; Humans; Myometrium; Placenta; Placenta Accreta; Pregnancy; Pregnancy Trimester, First; Sensitivity and Specificity; Ultrasonography, Prenatal
PubMed: 28833750
DOI: 10.1002/uog.18840 -
Ultrasound in Obstetrics & Gynecology :... Feb 2018To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP). (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP).
METHODS
An electronic search of MEDLINE, EMBASE and ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for 'Cesarean scar pregnancy' and 'outcome'. Reference lists of relevant articles and reviews were hand-searched for additional reports. Observed outcomes included: severe first-trimester vaginal bleeding; clinical symptoms (abdominal pain, vaginal bleeding) requiring treatment; uncomplicated miscarriage; complicated miscarriage requiring intervention; first- or second-trimester uterine rupture or hysterectomy; third-trimester bleeding, uterine rupture or hysterectomy; maternal death; incidence of abnormally invasive placenta (AIP); prevalence of placenta percreta; ultrasound signs suggestive of AIP; and live birth. Meta-analyses of proportions using a random-effects model were used to combine data. Cases were stratified based on the presence or absence of embryonic/fetal heart activity at the time of diagnosis.
RESULTS
A total of 17 studies (69 cases of CSP managed expectantly, 52 with and 17 without embryonic/fetal heart beat) were included. In women with CSP and embryonic/fetal heart activity, 13.0% (95% CI, 3.8-26.7%) experienced an uncomplicated miscarriage, while 20.0% (95% CI, 7.1-37.4%) required medical intervention. Uterine rupture during the first or second trimester of pregnancy occurred in 9.9% (95% CI, 2.9-20.4%) of cases, while hysterectomy was required in 15.2% (95% CI, 3.6-32.8%) of all cases. Forty (76.9% (95% CI, 65.4-86.5%)) women progressed to the third trimester of pregnancy, of whom 39.2% (95% CI, 15.4-66.2%) experienced severe bleeding. Finally, 74.8% (95% CI, 52.0-92.1%) had a surgical or pathological diagnosis of AIP at delivery and around two-thirds (69.7% (95% CI, 42.8-90.1%)) of them had placenta percreta. In women with CSP but no embryonic/fetal cardiac activity, an uncomplicated miscarriage occurred in 69.1% (95% CI, 47.4-87.1%) of cases, while surgical or medical intervention during or immediately after miscarriage was required in 30.9% (95% CI, 12.9-52.6%). Uterine rupture during the first trimester of pregnancy occurred in 13.4% (95% CI, 2.7-30.3%) of cases, but hysterectomy was not required in any case.
CONCLUSIONS
CSP with positive embryonic/fetal heart activity managed expectantly is associated with a high burden of maternal morbidity including severe hemorrhage, early uterine rupture, hysterectomy and severe AIP. Despite this, a significant proportion of pregnancies complicated by CSP may progress to, or close to, term, thus questioning whether termination of pregnancy should be the only therapeutic option offered to these women. Expectant management of CSP with no cardiac activity may be a reasonable option in view of the low likelihood of maternal complications requiring intervention, although close surveillance is advisable to avoid adverse maternal outcome. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
Topics: Abortion, Spontaneous; Cesarean Section; Cicatrix; Female; Gestational Age; Humans; Pregnancy; Pregnancy Outcome; Pregnancy Trimesters; Pregnancy, Ectopic; Ultrasonography, Prenatal; Uterine Rupture
PubMed: 28661021
DOI: 10.1002/uog.17568 -
Medicine Apr 2017Abnormally invasive placenta (AIP) or placenta accreta (PA) is considered numerous adverse maternal and fetal-neonatal complications. There has been no detailed study to... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Abnormally invasive placenta (AIP) or placenta accreta (PA) is considered numerous adverse maternal and fetal-neonatal complications. There has been no detailed study to characterize the prevalence of AIP among deliveries in mainland China.
OBJECTIVES
We aimed to fill this gap and obtained overall and regional estimates of AIP prevalence via a systematic review and meta-analysis.
METHODS
This systematic review and meta-analysis was totally performed following the Meta-analysis of Observational Studies in Epidemiology guidelines for systematic reviews of observational studies, and the Preferred Reporting Items for Systematic reviews and Meta-Analysis statement for reporting systematic reviews and meta-analysis.
RESULTS
A total of 23 articles (including 350,939) were included. Most studies (22) focused on the placenta increta (PI), only 2 articles in PA, and none in placenta percreta (PP). In this meta-analysis, the overall prevalence of AIP was 0.22% (95% confidence interval 0.18%-0.27%) in a heterogeneous set of studies (I = 93.5%). In a subgroup, the prevalence of PA and PI was 0.48% and 0.23%, respectively. Stratified analyses of PI found that the prevalence was similar in North (0.23% [0.14%-0.32%]) and South (0.23% [0.15%-0.32%]), and lower in Central (0.20% [0.09-0.31%]); the inlanders (0.17% (0.12%-0.23%]) had a lower prevalence of PI than those living in coastal areas (0.24% [0.35%-0.63%]). As time goes on, the prevalence, from 0.03% (0.02%-0.04%) in 1970 to 1979 to 0.48% (0.30%-0.66%) in 2010 to present, was higher and higher. The different prevalence was also found in different in maternal age groups.
CONCLUSIONS
This first systematic review and meta-analysis found that the prevalence differed among different geographic areas and maternal age groups. The results would be useful for the design of abnormally invasive placenta planning and implementation adequate health care systems and treatment programs in mainland China.
Topics: China; Female; Humans; Maternal Age; Observational Studies as Topic; Placenta Accreta; Pregnancy; Prevalence; Residence Characteristics
PubMed: 28422862
DOI: 10.1097/MD.0000000000006636 -
American Journal of Obstetrics and... Jul 2017Women with a history of previous cesarean delivery, presenting with a placenta previa, have become the largest group with the highest risk for placenta previa accreta. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Women with a history of previous cesarean delivery, presenting with a placenta previa, have become the largest group with the highest risk for placenta previa accreta.
OBJECTIVE
The objective of the study was to evaluate the accuracy of ultrasound imaging in the prenatal diagnosis of placenta accreta and the impact of the depth of villous invasion on management in women presenting with placenta previa or low-lying placenta and with 1 or more prior cesarean deliveries.
STUDY DESIGN AND DATA SOURCES
We searched PubMed, Google Scholar, clinicalTrials.gov, and MEDLINE for studies published between 1982 and November 2016.
STUDY ELIGIBILITY CRITERIA
Criteria for the study were cohort studies that provided data on previous mode of delivery, placenta previa, or low-lying placenta on prenatal ultrasound imaging and pregnancy outcome. The initial search identified 171 records, of which 5 retrospective and 9 prospective cohort studies were eligible for inclusion in the quantitative analysis.
STUDY APPRAISAL AND SYNTHESIS METHODS
The studies were scored on methodological quality using the Quality Assessment of Diagnostic Accuracy Studies tool.
RESULTS
The 14 cohort studies included 3889 pregnancies presenting with placenta previa or low-lying placenta and 1 or more prior cesarean deliveries screened for placenta accreta. There were 328 cases of placenta previa accreta (8.4%), of which 298 (90.9%) were diagnosed prenatally by ultrasound. The incidence of placenta previa accreta was 4.1% in women with 1 prior cesarean and 13.3% in women with ≥2 previous cesarean deliveries. The pooled performance of ultrasound for the antenatal detection of placenta previa accreta was higher in prospective than retrospective studies, with a diagnostic odds ratios of 228.5 (95% confidence interval, 67.2-776.9) and 80.8 (95% confidence interval, 13.0-501.4), respectively. Only 2 studies provided detailed data on the relationship between the depth of villous invasion and the number of previous cesarean deliveries, independently of the depth of the villous invasion. A cesarean hysterectomy was performed in 208 of 232 cases (89.7%) for which detailed data on management were available. Positive correlations were found in the largest prospective studies between the cumulative rates of the more invasive forms of accreta placentation and the sensitivity and specificity of ultrasound imaging but not with diagnostic odds ratio values. We found no data on the ultrasound screening of placenta accreta at the routine midtrimester ultrasound examination from the nonexpert ultrasound units.
CONCLUSION
Planning individual management for delivery is possible only with accurate evaluation of prenatal risk of accreta placentation in women presenting with a low-lying placenta/previa and a history of prior cesarean delivery. Ultrasound is highly sensitive and specific in the prenatal diagnosis of accreta placentation when performed by skilled operators. Developing a prenatal screening protocol is now essential to further improve the outcome of this increasingly more common major obstetric complication.
Topics: Cesarean Section; Female; Humans; Hysterectomy; MEDLINE; Placenta Accreta; Placenta Previa; Placentation; Pregnancy; Pregnancy Outcome; Prospective Studies; Retrospective Studies; Risk Factors; Sensitivity and Specificity; Ultrasonography, Prenatal
PubMed: 28268196
DOI: 10.1016/j.ajog.2017.02.050 -
Ultrasound in Obstetrics & Gynecology :... Jul 2014To assess systematically the performance of prenatal magnetic resonance imaging (MRI) in diagnosing the presence, degree and topography of disorders of invasive... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To assess systematically the performance of prenatal magnetic resonance imaging (MRI) in diagnosing the presence, degree and topography of disorders of invasive placentation and to explore the role of the different MRI signs in predicting these disorders. The diagnostic accuracy of ultrasound and MRI in the detection of invasive placentation was also compared.
METHODS
MEDLINE, EMBASE, CINAHL and The Cochrane Library, including The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and The Cochrane Central Register of Controlled Trials, were searched electronically utilizing combinations of the relevant medical subject heading terms, keywords and word variants for 'invasive placentation' and 'magnetic resonance imaging'. Only prospective studies reporting a diagnosis of invasive placentation at the time of MRI and retrospective studies in which the radiologist was blinded to the final results were included in the analysis. The MRI signs explored were: uterine bulging, heterogeneous signal intensity, dark intraplacental bands on T2 weighted sequences, focal interruption of the myometrium and tenting of the bladder. Summary estimates of sensitivity, specificity, positive and negative likelihood ratios (LR+, LR-) and diagnostic odds ratio (DOR) were based, depending on the number of studies, upon DerSimonian-Laird random-effect or hierarchical summary receiver-operating characteristics models.
RESULTS
A total of 18 studies involving 1010 pregnancies at risk for invasive placentation were included. The overall diagnostic accuracy of MRI in detecting the presence of invasive placentation was: sensitivity, 94.4% (95% CI, 86.0-97.9%); specificity, 84.0% (95% CI, 76.0-89.8%); LR+, 5.91 (95% CI, 3.73-9.39); LR-, 0.07 (95% CI, 0.02-0.18); DOR, 89.0 (95% CI, 22.8-348.1). MRI had a high predictive accuracy in assessing both the depth and topography of placental invasion. All five MRI signs showed good predictive accuracy in the diagnosis of disorders of invasive placentation. There was no difference in either the sensitivity (P = 0.24) or the specificity (P = 0.91) between ultrasound and MRI for the detection of invasive placentation.
CONCLUSIONS
Prenatal MRI is highly accurate in diagnosing disorders of invasive placentation. Ultrasound and MRI have comparable predictive accuracy. Large population-based studies are needed in order to assess whether ultrasound can predict the depth and topography of placental invasion as reliably as can MRI.
Topics: Female; Humans; Magnetic Resonance Imaging; Models, Statistical; Placenta Accreta; Pregnancy; Prenatal Diagnosis; Sensitivity and Specificity
PubMed: 24515654
DOI: 10.1002/uog.13327 -
BJOG : An International Journal of... Apr 2014Caesarean section (CS) rates are increasing worldwide and maternal request is cited as one of the main reasons for this trend. Women's preferences for route of delivery... (Review)
Review
OBJECTIVES
Caesarean section (CS) rates are increasing worldwide and maternal request is cited as one of the main reasons for this trend. Women's preferences for route of delivery are influenced by popular media, including magazines. We assessed the information on CS presented in Spanish women's magazines.
DESIGN
Systematic review.
SETTING
Women's magazines printed from 1989 to 2009 with the largest national distribution.
SAMPLE
Articles with any information on CS.
METHODS
Articles were selected, read and abstracted in duplicate. Sources of information, scientific accuracy, comprehensiveness and women's testimonials were objectively extracted using a content analysis form designed for this study.
MAIN OUTCOME MEASURES
Accuracy, comprehensiveness and sources of information.
RESULTS
Most (67%) of the 1223 selected articles presented exclusively personal opinion/birth stories, 12% reported the potential benefits of CS, 26% mentioned the short-term and 10% mentioned the long-term maternal risks, and 6% highlighted the perinatal risks of CS. The most frequent short-term risks were the increased time for maternal recovery (n = 86), frustration/feelings of failure (n = 83) and increased post-surgical pain (n = 71). The most frequently cited long-term risks were uterine rupture (n = 57) and the need for another CS in any subsequent pregnancy (n = 42). Less than 5% of the selected articles reported that CS could increase the risks of infection (n = 53), haemorrhage (n = 31) or placenta praevia/accreta in future pregnancies (n = 6). The sources of information were not reported by 68% of the articles.
CONCLUSIONS
The portrayal of CS in Spanish women's magazines is not sufficiently comprehensive and does not provide adequate important information to help the readership to understand the real benefits and risks of this route of delivery.
Topics: Cesarean Section; Female; Humans; Length of Stay; Medicine in Literature; Pain, Postoperative; Periodicals as Topic; Pregnancy; Recovery of Function; Spain; Stress, Psychological; Uterine Rupture
PubMed: 24467797
DOI: 10.1111/1471-0528.12513 -
Ultrasound in Obstetrics & Gynecology :... Nov 2013The accuracy of prospective sonographic prenatal detection of invasive placentation is unclear. The objective of this study was to conduct a systematic review and... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The accuracy of prospective sonographic prenatal detection of invasive placentation is unclear. The objective of this study was to conduct a systematic review and meta-analysis to assess the performance of ultrasound in at-risk women for prenatal identification of invasive placentation.
METHODS
MEDLINE, EMBASE, The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE) and The Cochrane Central Register of Controlled Trials (CENTRAL) were searched using the search terms 'placenta accreta', 'placenta increta', 'placenta percreta', 'ultrasound', 'magnetic resonance imaging (MRI)', 'invasive placenta' and 'infiltrative placenta'. Two authors independently abstracted data from the articles. Sensitivity, specificity, positive and negative likelihood ratios (LR+ and LR-), the diagnostic odds ratio (DOR) and their 95% CIs for each study were calculated. Forest plots and summary receiver-operating characteristics curves were produced. Between-study heterogeneity was explored both graphically and statistically. The MOOSE (meta-analysis of observational studies in epidemiology) guidelines were followed.
RESULTS
Twenty-three studies involving 3707 pregnancies at risk for invasive placentation were included. The overall performance of ultrasound for the antenatal detection of invasive placentation was as follows: sensitivity, 90.72 (95% CI, 87.2-93.6)%; specificity, 96.94 (95% CI, 96.3-97.5)%; LR+, 11.01 (95% CI, 6.1-20.0); LR-, 0.16 (95% CI, 0.11-0.23); and DOR, 98.59 (95% CI, 48.8-199.0). Among the different ultrasound signs, color Doppler had the best predictive accuracy (sensitivity, 90.74 (95% CI, 85.2-94.7)%; specificity, 87.68 (95% CI, 84.6-90.4)%; LR+, 7.77 (95% CI, 3.3-18.4); LR-, 0.17 (95% CI, 0.10-0.29); and DOR, 69.02 (95% CI, 22.8-208.9)).
CONCLUSIONS
Ultrasound has a high accuracy for prenatal diagnosis of disorders of invasive placentation in high-risk women. The use of color Doppler improves the test performance.
Topics: Female; Humans; Placenta Accreta; Pregnancy; Sensitivity and Specificity; Ultrasonography, Doppler, Color; Ultrasonography, Prenatal
PubMed: 23943408
DOI: 10.1002/uog.13194