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Obstetrics & Gynecology Science May 2024In an 8-year period at two medical center, 138 patients underwent uterine artery embolization, and 11 of them were diagnosed with uterine necrosis. Among them, three...
In an 8-year period at two medical center, 138 patients underwent uterine artery embolization, and 11 of them were diagnosed with uterine necrosis. Among them, three were successfully conceived. However, one of them developed an arteriovenous malformation after an artificial abortion, and another experienced complications, including placenta previa and placenta accreta spectrum, which resulted in early preterm delivery and recurrent postpartum hemorrhage, necessitating subtotal hysterectomy. Therefore, it is crucial to prepare for potential adverse pregnancy outcomes in subsequent pregnancies for patients with a history of uterine necrosis.
PubMed: 38563044
DOI: 10.5468/ogs.23287 -
BMC Women's Health Apr 2024Placenta accreta spectrum disorder (PAS) is a serious obstetric complication associated with significant maternal morbidity and mortality. Prophylactic balloon occlusion...
OBJECTIVE
Placenta accreta spectrum disorder (PAS) is a serious obstetric complication associated with significant maternal morbidity and mortality. Prophylactic balloon occlusion (PBO), as an intravascular interventional therapies, has emerged as a potential management strategy for controlling massive hemorrhage in patients with PAS. However, current evidence about the clinical application of PBO in PAS patients are still controversial. This study aimed to evaluate the effectiveness and safety of PBO in the management of PAS.
METHODS
A retrospective cohort study including PAS patients underwent cesarean delivery was conducted in a tertiary hospital from January 2015 to March 2022. Included PAS patients were further divided into balloon and control groups by whether PBO was performed. Groups were compared for demographic characteristics, intraoperative and postoperative parameters, maternal and neonatal outcomes, PBO-related complication and follow up outcomes. Additionally, multivariate-logistic regression analysis was performed to determine the definitive associations between PBO and risk of massive hemorrhage and hysterectomy.
RESULTS
A total of 285 PAS patients met the inclusion criteria were included, of which 57 PAS patients underwent PBO (PBO group) and 228 women performed cesarean section (CS) without PBO (control group). Irrespective of the differences of baseline characteristics between the two groups, PBO intervention did not reduce the blood loss, hysterectomy rate and postoperative hospital stay, but it prolonged the operation time and increased the cost of hospitalization (All P < 0.05) Additionally, there were no significant differences in postoperative complications, neonatal outcomes, and follow-up outcomes(All P > 0.05). In particular, patients undergoing PBO were more likely to develop the venous thrombosis postoperatively (P = 0.001). However, multivariate logistic regression analysis showed that PBO significantly decreased the risk of massive hemorrhage (OR 0.289, 95%CI:0.109-0.766, P = 0.013). The grade of PAS and MRI with S2 invasion were the significant risk factors affecting massive hemorrhage(OR:6.232 and OR:5.380, P<0.001).
CONCLUSION
PBO has the potential to reduce massive hemorrhage in PAS patients undergoing CS. Obstetricians should, however, be aware of potential complications arising from the PBO. Additionally, MRI with S2 invasion and PAS grade will be useful to identify PAS patients who at high risk and may benefit from PBO. In brief, PBO seem to be a promising alternative for management of PAS, yet well-designed randomized controlled trials are needed to convincingly demonstrate its benefits and triage the necessity of PBO.
Topics: Infant, Newborn; Pregnancy; Humans; Female; Cesarean Section; Placenta Accreta; Retrospective Studies; Blood Loss, Surgical; Balloon Occlusion; Hysterectomy; Placenta
PubMed: 38561713
DOI: 10.1186/s12905-024-03049-4 -
Medicine Mar 2024To explore the value of the combined MR imaging features and clinical factors Nomogram model in predicting intractable postpartum hemorrhage (IPH) due to placenta...
To explore the value of the combined MR imaging features and clinical factors Nomogram model in predicting intractable postpartum hemorrhage (IPH) due to placenta accreta (PA). We conducted a retrospective study with 270 cases of PA patients admitted to our hospital from January 2015 to December 2022. The clinical data of these patients were analyzed, and they were divided into 2 groups: the IPH group and the non-IPH group based on the presence of IPH. The differences in data between the 2 groups were compared, and the risk factors for IPH were analyzed. A Nomogram model was constructed using independent high-risk factors, and the predictive value of this model for IPH was analyzed. The results of multivariable binary Logistic regression analysis showed higher number of cesareans, placenta previa, placenta accreta type (implantation, penetration), low signal strip on T2 weighted image (T2WI) were independent high-risk factor for IPH (P < .05). ROC analysis and Hosmer-Lemeshow goodness-of-fit test showed the Nomogram predictive model constructed with the high-risk factor has good discrimination and calibration. Decision curve analysis (DCA) showed that when the probability threshold for the Nomogram model's prediction was in the range from 0.125 to 0.99, IPH patients could obtain more net benefits, making it suitable for clinical application. The higher number of cesareans, placenta previa, placental accreta type (implantation, penetration), and low signal strip on T2WI are independent high-risk factor for IPH. The Nomogram predictive model constructed with the high-risk factor demonstrates good clinical efficacy in predicting the occurrence of IPH due to PA.
Topics: Pregnancy; Humans; Female; Nomograms; Retrospective Studies; Placenta Accreta; Placenta; Placenta Previa; Postpartum Hemorrhage; Risk Factors; Magnetic Resonance Imaging
PubMed: 38552054
DOI: 10.1097/MD.0000000000037665 -
Scientific Reports Mar 2024This study aimed to investigate assisted reproductive technology (ART) factors associated with placenta accreta spectrum (PAS) after vaginal delivery. This was a...
This study aimed to investigate assisted reproductive technology (ART) factors associated with placenta accreta spectrum (PAS) after vaginal delivery. This was a registry-based retrospective cohort study using the Japanese national ART registry. Cases of live singleton infants born via vaginal delivery after single embryo transfer (ET) between 2007 and 2020 were included (n = 224,043). PAS was diagnosed in 1412 cases (0.63% of deliveries), including 1360 cases (96.3%) derived from frozen-thawed ET cycles and 52 (3.7%) following fresh ET. Among fresh ET cycles, assisted hatching (AH) (adjusted odds ratio [aOR], 2.5; 95% confidence interval [CI] 1.4-4.7) and blastocyst embryo transfer (aOR, 2.2; 95% CI 1.3-3.9) were associated with a significantly increased risk of PAS. For frozen-thawed ET cycles, hormone replacement cycles (HRCs) constituted the greatest risk factor (aOR, 11.4; 95% CI 8.7-15.0), with PAS occurring in 1.4% of all vaginal deliveries following HRC (1258/91,418 deliveries) compared with only 0.11% following natural cycles (55/47,936). AH was also associated with a significantly increased risk of PAS in frozen-thawed cycles (aOR, 1.2; 95% CI 1.02-1.3). Our findings indicate the need for additional care in the management of patients undergoing vaginal delivery following ART with HRC and AH.
Topics: Pregnancy; Female; Humans; Retrospective Studies; Placenta Accreta; Reproductive Techniques, Assisted; Delivery, Obstetric; Risk Factors
PubMed: 38548810
DOI: 10.1038/s41598-024-57988-x -
Quantitative Imaging in Medicine and... Mar 2024
PubMed: 38545048
DOI: 10.21037/qims-24-164 -
Acta Obstetricia Et Gynecologica... Jul 2024Pregnant women with a fibrinogen level <2 g/L represent a high-risk group that is associated with severe postpartum hemorrhage and other complications. Women who would...
INTRODUCTION
Pregnant women with a fibrinogen level <2 g/L represent a high-risk group that is associated with severe postpartum hemorrhage and other complications. Women who would qualify for fibrinogen therapy are not yet identified.
MATERIAL AND METHODS
A population-based cross-sectional study was conducted using the UK Obstetric Surveillance System between November 2017 and October 2018 in any UK hospital with a consultant-led maternity unit. Any woman pregnant or immediately postpartum with a fibrinogen <2 g/L was included. Our aims were to determine the incidence of fibrinogen <2 g/L in pregnancy, and to describe its causes, management and outcomes.
RESULTS
Over the study period 124 women with fibrinogen <2 g/L were identified (1.7 per 10 000 maternities; 95% confidence interval 1.4-2.0 per 10 000 maternities). Less than 5% of cases of low fibrinogen were due to preexisting inherited dysfibrinogenemia or hypofibrinogenemia. Sixty percent of cases were due to postpartum hemorrhage caused by placental abruption, atony, or trauma. Amniotic fluid embolism and placental causes other than abruption (previa, accreta, retention) were associated with the highest estimated blood loss (median 4400 mL) and lowest levels of fibrinogen. Mortality was high with two maternal deaths due to massive postpartum hemorrhage, 27 stillbirths, and two neonatal deaths.
CONCLUSIONS
Fibrinogen <2 g/L often, but not exclusively, affected women with postpartum hemorrhage due to placental abruption, atony, or trauma. Other more rare and catastrophic obstetrical events such as amniotic fluid embolism and placenta accreta also led to low levels of fibrinogen. Maternal and perinatal mortality was extremely high in our cohort.
Topics: Humans; Female; Pregnancy; United Kingdom; Adult; Cross-Sectional Studies; Postpartum Hemorrhage; Fibrinogen; Cohort Studies; Afibrinogenemia; Pregnancy Outcome; Infant, Newborn; Postpartum Period
PubMed: 38519441
DOI: 10.1111/aogs.14828 -
Cureus Feb 2024Uterine malformations significantly affect the reproduction process, and such anomalies can affect the progression and prognosis of a pregnancy. A bicornuate uterus is a...
Uterine malformations significantly affect the reproduction process, and such anomalies can affect the progression and prognosis of a pregnancy. A bicornuate uterus is a rare congenital uterine anomaly that occurs due to a defect in the fusion of Müllerian ducts. It is associated with severe maternal and fetal complications, such as uterine rupture, vascular-related pathologies, preterm labor and birth, recurrent early or late loss of pregnancy, and fetal growth restriction. In such scenarios, close monitoring and ultrasound screening are needed to prevent obstetric complications. We report a case of a bicornuate uterus complicated with placenta percreta and intraperitoneal hemorrhage.
PubMed: 38516427
DOI: 10.7759/cureus.54519 -
Roadmap to safety: a single center study of evidence-informed approach to placenta accreta spectrum.Frontiers in Surgery 2024To assess the impact of an evidence-informed protocol for management of placenta accreta spectrum (PAS).
OBJECTIVE
To assess the impact of an evidence-informed protocol for management of placenta accreta spectrum (PAS).
METHODS
This was a retrospective cohort study of patients who underwent cesarean hysterectomy (c-hyst) for suspected PAS from 2012 to 2022 at a single tertiary care center. Perioperative outcomes were compared pre- and post-implementation of a standardized Multidisciplinary Approach to the Placenta Service (MAPS) protocol, which incorporates evidence-informed perioperative interventions including preoperative imaging and group case review. Intraoperatively, the MAPS protocol includes placement of ureteral stents, possible placental mapping with ultrasound, and uterine artery embolization by interventional radiology. Patients suspected to have PAS on prenatal imaging who underwent c-hyst were included in the analysis. Primary outcomes were intraoperative complications and postoperative complications. Secondary outcomes were blood loss, need for ICU, and length of stay. Proportions were compared using Fisher's exact test, and continuous variables were compared used -tests and Mood's Median test.
RESULTS
There were no differences in baseline demographics between the pre- ( = 38) and post-MAPS ( = 34) groups. The pre-MAPS group had more placenta previa (95% pre- vs. 74% post-MAPS, = 0.013) and prior cesarean sections (2 prior pre- vs. 1 prior post-MAPS, = 0.012). The post-MAPS group had more severe pathology (PAS Grade 3 8% pre- vs. 47% post-MAPS, = 0.001). There were fewer intraoperative complications (39% pre- vs.3% post-MAPS, < 0.001), postoperative complications (32% pre- vs.12% post-MAPS, = 0.043), hemorrhages >1l (95% pre- vs.65% post-MAPS, = 0.001), ICU admissions (59% pre- vs.35% post-MAPS, = 0.04) and shorter hospital stays (10 days pre- vs.7 days post-MAPS, = 0.02) in the post-MAPS compared to pre-MAPS patients. Neonatal length of stay was 8 days longer in the post-MAPS group (9 days pre- vs. 17 days post-MAPS, = 0.03). Subgroup analyses demonstrated that ureteral stent placement and uterine artery embolization (UAE) may be important steps to reduce complications and ICU admissions. When comparing just those who underwent UAE, patients in the post-MAPS group experienced fewer hemorrhages greater five liters (EBL >5l 43% pre- vs.4% post-MAPS, = 0.007).
CONCLUSION
An evidence-informed approach to management of PAS was associated with decreased complication rate, EBL >1l, ICU admission and length of hospitalization, particularly for patients with severe pathology.
PubMed: 38511075
DOI: 10.3389/fsurg.2024.1347549 -
Scientific Reports Mar 2024This study aimed to identify the risk factors for placenta accreta spectrum (PAS) in women who had at least one previous cesarean delivery and a placenta previa or...
This study aimed to identify the risk factors for placenta accreta spectrum (PAS) in women who had at least one previous cesarean delivery and a placenta previa or low-lying. The PACCRETA prospective population-based study took place in 12 regional perinatal networks from 2013 through 2015. All women with one or more prior cesareans and a placenta previa or low lying were included. Placenta accreta spectrum (PAS) was diagnosed at delivery according to standardized clinical and histological criteria. Of the 520,114 deliveries, 396 fulfilled inclusion criteria; 108 were classified with PAS at delivery. Combining the number of prior cesareans and the placental location yielded a rate ranging from 5% for one prior cesarean combined with a posterior low-lying placenta to 63% for three or more prior cesareans combined with placenta previa. The factors independently associated with PAS disorders were BMI ≥ 30, previous uterine surgery, previous postpartum hemorrhage, a higher number of prior cesareans, and a placenta previa. Finally, in this high-risk population, the rate of PAS disorders varies greatly, not only with the number of prior cesareans but also with the exact placental location and some of the women's individual characteristics. Risk stratification is thus possible in this population.
Topics: Pregnancy; Female; Humans; Placenta Previa; Placenta; Placenta Accreta; Prospective Studies; Cesarean Section; Risk Factors; Retrospective Studies
PubMed: 38503816
DOI: 10.1038/s41598-024-56964-9 -
Medicine Mar 2024The objective of this study is to investigate the value of early pregnancy ultrasound combined with ultrasound score (USS) for the evaluation of placenta accreta (PA) in...
The objective of this study is to investigate the value of early pregnancy ultrasound combined with ultrasound score (USS) for the evaluation of placenta accreta (PA) in scar uteri. Thirty cases of PA in scar uteri diagnosed by ultrasound at our hospital between June 2021 and June 2022 were selected retrospectively (observation group). In addition, 30 patients had placenta attached to the anterior wall of the uterus and covered the internal orifice of the cervix; however, no PA was selected in the same period (control group). The results of surgical pathology and ultrasound examination in the first trimester of pregnancy (11-14 weeks of pregnancy, fetal top hip length 4.5-8.4 cm) were analyzed. Ultrasonic image characteristics of the 2 groups were scored using an ultrasonic scoring scale. The ultrasonic signs and ultrasonic scores of the 2 groups were analyzed. The diagnostic value of ultrasound and USS for PA in the scarred uterus alone and in combination was analyzed based on the gold standard of surgical and pathological results. The rich blood flow signal at the junction of the uterine serosa and bladder, the rate of blood flow in the cavity of the placental parenchyma, the thinning rate of the myometrium after placenta, and the abnormal rate of the low echo area after placenta in the observation group were significantly higher than those in the control group (P < .05). The USS of the observation group was significantly higher than that of the control group (P < .05). The sensitivity (93.33%) and accuracy (95.00%) of the combined examinations were significantly higher than those of ultrasound (70.00% and 83.33%, respectively) (P < .05). The sensitivity and accuracy of combined examination were slightly higher than those of USS examination (83.33% and 90.00%), but the difference was not statistically significant (P > .05). There was no significant difference between the specificity of combined examination (93.33%) and ultrasound (96.67%) and USS (96.67%) (P > .05). Early pregnancy ultrasound and USS evaluation have high application value in the diagnosis and evaluation of early scar uterine PA. The combination of the 2 methods can further improve the sensitivity and accuracy of diagnosis.
Topics: Pregnancy; Humans; Female; Placenta Accreta; Placenta; Retrospective Studies; Cicatrix; Ultrasonography, Prenatal; Uterus
PubMed: 38489684
DOI: 10.1097/MD.0000000000037531