Multidisciplinary protocol and outcomes in placenta accreta spectrum: a 12year cohort study.

Delivery timing at 34 to 36 weeks is nationally recommended for pregnancies complicated by placenta accreta spectrum (PAS). However, it has recently been suggested that those with ≥2 prior cesarean deliveries (CD) and PAS should be delivered earlier than 34 weeks because of a higher risk of unscheduled delivery and complications. We sought to evaluate whether the number of prior CD in women with PAS is associated with early preterm delivery (PTD) (<34 weeks). We also evaluated the same relationship in women with placenta previa alone (without PAS). This is a secondary analysis of a multicenter and observational study that included women with prior CD (maternal-fetal medicine unit cesarean registry). Women with a diagnosis of PAS (regardless of placenta previa) were included for our primary analysis, and women with known placenta previa (without a component of PAS) were independently analyzed in a second analysis. Two groups of patients from the registry were studied: patients with PAS (regardless of placenta previa) and patients with placenta previa without PAS. The exposure of interest was the number of prior CD: ≥2 CD compared with <2 CD. The primary outcome was PTD <34 weeks. Secondary outcomes included preterm labor requiring hospitalization or tocolysis, transfusion of blood products, composites of maternal and neonatal morbidities, and NICU admission. Outcomes by prior CD number groups were compared in both cohorts. Backward selection was used to identify parsimonious logistic regression models. There were 194 women with PAS, 97 (50%) of whom had <2 prior CD and 97 (50%) of whom had ≥2 prior CD. The rate of PTD <34 weeks in women with ≥2 prior CD compared with <2 in the setting of PAS was 23.7 versus 29.9%, p = 0.27; preterm labor requiring hospitalization was 24.7 versus 13.5%; p = 0.05. The rates of plasma transfusion were increased with ≥2 prior CD (29.9 vs. 17.5%, p = 0.04), but there were no differences in transfusion of other products or in composite maternal or neonatal morbidities. After multivariable adjustments, having ≥2 CDs was not associated with PTD <34 weeks in women with PAS (adjusted odds ratio (aOR): 0.73, 95% confidence interval [CI]: 0.39-13.8) despite an association with preterm labor requiring hospitalization (aOR: 2.69; 95% CI: 1.15-6.32). In our second analysis, there were 687 women with placenta previa, 633 (92%) with <2 prior CD, and 54 (8%) with ≥2 prior CD. The rate of PTD <34 weeks with ≥2 CD in the setting of placenta previa was not significantly increased (27.8 vs. 22.1%, aOR: 1.49; 95% CI: 0.77-2.90, p = 0.08); the maternal composite outcome (aOR: 4.85; 95% CI: 2.43-9.67) and transfusion of blood products (aOR: 6.41; 95% CI: 2.30-17.82) were noted to be higher in the group with ≥2 prior CD. Women with PAS who have had ≥2 prior CD as compared with women with <2 prior CD did not appear to have a higher risk of complications leading to delivery prior to 34 weeks. As such, considering the associated morbidity with early preterm birth, we would not recommend scheduled delivery prior to 34 weeks in this population. · We do not recommend delivery prior to 34 weeks of gestational age in PAS.. · PTD was not significantly increased in PAS with ≥2 CDs.. · PTD < 34 weeks of gestational age was not increased in placenta previa with ≥2 prior CDs..

Background: Prior prelabor cesarean delivery (CD) was associated with an increase in the risk of placenta previa (PP) in a second delivery, whether it may impact postpartum hemorrhage (PPH) independent of abnormal placentation. This study aimed to assess the risk of PPH stratified by abnormal placentation following a first CD before the onset of labor (prelabor) or intrapartum CD.Methods: This multicenter, historical cohort study involved singleton, pregnant women at 28 weeks of gestation or greater with a CD history between January 2017 and December 2017 in 11 public tertiary hospitals within 7 provinces of China. PPH was analyzed in the subsequent pregnancy between women with prior prelabor CD and women with intrapartum CD. Furthermore, PPH was analyzed in pregnant women stratified by complications with PP alone [without placenta accreta spectrum (PAS) disorders], complications with PP and PAS, complications with PAS alone (without PP), and normal placentation. We performed multivariate logistic regression to calculate adjusted odds ratios (aOR) and 95% CI controlling for predefined covariates.Results: Out of 10,833 pregnant women, 1,197 (11%) women had a history of intrapartum CD and 9,636 (89%) women had a history of prelabor CD. Prior prelabor CD increased the risk of PP (aOR 1.91, 95% CI 1.40–2.60), PAS (aOR 1.68, 95% CI 1.11–2.24), and PPH (aOR 1.33, 95% CI 1.02–1.75) in a subsequent pregnancy. After stratification by complications with PP alone, PP and PAS, PAS alone, and normal placentation, prior prelabor CD only increased the risk of PPH (aOR 3.34, 95% CI 1.35–8.23) in a subsequent pregnancy complicated with PP and PAS.Conclusion: Compared to intrapartum CD, prior prelabor CD increased the risk of PPH in a subsequent pregnancy only when complicated by PP and PAS.

Early first-trimester transvaginal ultrasound is indicated in pregnancy after previous Cesarean delivery: should it be mandatory?

Objective To explore the association between inter-pregnancy intervals and placenta previa and placenta accreta spectrum among women who had prior cesarean deliveries with respect to maternal age at first cesarean delivery. Methods This retrospective study included clinical data from 9981 singleton pregnant women with a history of cesarean delivery at 11 public tertiary hospitals in seven provinces of China between January 2017 and December 2017. The study population was divided into four groups (<2, 2–5, 5–10, ≥10 years of the interval) according to the inter-pregnancy interval. The rate of placenta previa and placenta accreta spectrum among the four groups was compared, and multivariate logistic regression was used to analyze the relationship between inter-pregnancy interval and placenta previa and placenta accreta spectrum with respect to maternal age at first cesarean delivery. Results Compared to women aged 30–34 years old at first cesarean delivery, the risk of placenta previa (aRR, 1.48; 95% CI, 1.16–1.88) and placenta accreta spectrum (aRR, 1.74; 95% CI, 1.28–2.35) were higher among women aged 18–24. Multivariate regression results showed that women at 18–24 with <2 years intervals exhibited a 5.05-fold increased risk for placenta previa compared with those with 2–5-year intervals (aRR, 5.05; 95% CI, 1.13–22.51). In addition, women aged 18–24 with less than 2 years intervals had an 8.44 times greater risk of developing PAS than women aged 30-34 with 2 to 5 years intervals (aRR, 8.44; 95% CI, 1.82–39.26). Conclusions The findings of this study suggested that short inter-pregnancy intervals were associated with increased risks for placenta previa, and placenta accreta spectrum for women under 25 years at first cesarean delivery, which may be partly attributed to obstetrical outcomes.

Assessment of placenta accreta spectrum at vaginal birth after cesarean delivery

Risk factors for placenta accreta spectrum disorder among patients with previa and prior cesarean delivery

This study aimed to evaluate whether a primary cesarean delivery (CD) performed during labor increases the risk of placenta accreta spectrum (PAS) disorders in a high-parity population with a low overall CD rate.This retrospective cohort study included singleton pregnancies with a confirmed International Federation of Gynecology and Obstetrics (FIGO) PAS diagnosis at a single tertiary center (2011-2022). Each PAS case was matched 1:1 to a control without PAS based on parity, number of previous CDs, and history of vaginal birth after cesarean. Multivariable logistic regression assessed the association between labored versus unlabored primary CD and PAS, adjusting for placenta previa, in vitro fertilization, prior postpartum hemorrhage, and prior dilation and curettage.Among 128,485 deliveries, 45 PAS cases (0.04%) were identified and matched to 45 controls. Median parity was 5.0; 34% had three or more prior CDs. Labored primary CD was associated with increased PAS risk (adjusted odds ratio: 6.3, 95% confidence interval [CI]: 1.7-23.3; p < 0.05). Placenta previa and prior postpartum hemorrhage were also independently associated with PAS. No significant differences in maternal or neonatal outcomes were observed between the labored and elective primary cesarean groups.Primary CD during labor increases PAS risk six-fold in subsequent pregnancies, warranting consideration in counseling and surgical decision-making. · A labored CD raises the risk of PAS in the next pregnancy by sixfold.. · No significant differences in maternal or neonatal outcomes in subsequent pregnancy between labored and unlabored cesarean sections.. · The study highlights the importance of recognizing labored cesarean section as a PAS risk factor in future pregnancies..

169: Unexpected Placenta Accreta Spectrum (PAS): Improved outcomes with Multidisciplinary Team Care

This study evaluated the efficacy of prophylactic uterine artery embolization (PUAE) during surgical termination of second-trimester pregnancies complicated by placenta previa and placenta accreta spectrum (previa PAS) following prior cesarean delivery (CD). A retrospective cohort study was conducted at a tertiary referral center in China between December 2016 and December 2022. A total of 92 patients were included, with 31 undergoing PUAE (study group) and 61 not (control group). Prophylactic uterine artery embolization did not significantly reduce intraoperative blood loss (p = 0.234) or the rate of peripartum hysterectomy (p = 0.331), but was associated with increased surgical duration, prolonged postoperative hospitalization, and a higher incidence of postoperative fever (p < 0.0001, p = 0.0004, and p = 0.002, respectively). No significant differences were observed between the two groups regarding the number of packed red blood cells or fresh frozen plasma transfused, cryoprecipitate use, urinary system injury, intensive care unit admissions, or postoperative complications (including intrauterine hematocele, intrauterine infection, surgical site infection, and deep tissue infection). In this retrospective analysis, PUAE was associated with increased febrile morbidity and prolonged recovery, without a significant reduction in blood loss or hysterectomy rates in second-trimester pregnancy terminations with previa PAS and prior CD.

To evaluate placenta accreta spectrum with and without placenta previa with regard to risk factors, antepartum diagnosis, and maternal morbidity. We conducted a retrospective cohort study of pathology-confirmed placenta accreta spectrum deliveries with hysterectomy from two U.S. referral centers from January 2010-June 2019. Maternal, pregnancy, and delivery characteristics were compared among placenta accreta spectrum cases with (previa PAS group) and without (nonprevia PAS group) placenta previa. Surgical outcomes and a composite of severe maternal morbidities were evaluated, including eight or more blood cell units transfused, reoperation, pulmonary edema, acute kidney injury, thromboembolism, or death. Logistic regression was used with all analyses controlled for delivery location. Of 351 deliveries, 106 (30%) had no placenta previa at delivery. When compared with the previa group, nonprevia placenta accreta spectrum was less likely to be identified antepartum (38%, 95% CI 28-48% vs 87%, 82-91%), less likely to receive care from a multidisciplinary team (41%, 31-51% vs 86%, 81-90%), and less likely to have invasive placenta increta or percreta (51% 41-61% vs 80%, 74-84%). The nonprevia group had more operative hysteroscopy (24%, 16-33% vs 6%, 3-9%) or in vitro fertilization (31%, 22-41% vs 9%, 6-13%) and was less likely to have had a prior cesarean delivery (64%, 54-73% vs 93%, 89-96%) compared with the previa group, though the majority in each group had a prior cesarean delivery. Rates of severe maternal morbidity were similar in the two groups, at 19% (nonprevia) and 20% (previa), even after controlling for confounders (adjusted odds ratio for the nonprevia group 0.59, 95% CI 0.30-1.17). Placenta accreta spectrum without previa is less likely to be diagnosed antepartum, potentially missing the opportunity for multidisciplinary team management. Despite the absence of placenta previa and less placental invasion, severe maternal morbidity at delivery was not lower. Broader recognition of patients at risk for placenta accreta spectrum may improve early clinical diagnosis and patient outcomes.

Objective Surgery for placenta accreta spectrum disorders is known to be associated with urologic morbidity. Although previous studies have shown preoperative ureteral stent placement might be useful for preventing the urologic morbidity, the patient’s discomfort caused by it should not be ignored. Whether there is an alternative management strategy remains unknown. This study was to evaluate the effectiveness of ureteral stents and catheters in preventing urologic injury in patients with placenta accreta spectrum undergoing surgery. Methods We conducted a retrospective cohort study. All cases with diagnosed placenta accreta spectrum who underwent surgery at Peking University Third Hospital between January 2018 and December 2020 were collected and reviewed. They were divided into two groups according to the different management strategies for preoperative placement of ureteral catheters or stents. The primary outcome was urologic injury, which was defined as the presence of ureteral or bladder injury during and after surgery. Secondary outcomes included urologic complications within the first three months after surgery. The median (interquartile range) or proportions were reported for variables. The Man Whitney U test, chi-square test and multivariate logistic regression were used for analysis. Results Ultimately, 99 patients were included in this study. Ureteral catheters were placed in 52 patients and ureteral stents were placed in 47 patients. Placenta accreta, placenta increta, and placenta percreta were diagnosed in three, 19, and 77 women, respectively. The hysterectomy rate was 52.53%. Overall, urologic injuries occurred in three patients (3.03%), including one case of combined bladder and ureteral injury (1.01%) and two cases of bladder injuries (2.02%). Only one ureteral injury occurred in a patient with a ureteral stent, which was recognized postoperatively (p = .475). All bladder injuries were vesical rupture which were recognized and repaired intraoperatively; one patient in the catheter group and two patients in the stent group (p = .929). After adjusting for confounding variables, multinomial regression analysis revealed no significant differences between the two groups in the incidence of bladder injuries(aOR: 0.695, 95% CI: 0.035–13.794, p = .811). A lower risk of urinary irritation (aOR: 0.186, 95% CI: 0.057–0.605, p = .005), hematuria (aOR: 0.011, 95% CI: 0.001–0.136, p < .001), and lower back pain (aOR: 0.075, 95% CI: 0.022–0.261, p < .001) was found in patients with ureteral catheters than in those with ureteral stents. Conclusion The ureteral stents didn’t confer a protective benefit in the surgical management for placenta accreta spectrum compare with catheters; however, they did result in a higher incidence of postoperative urologic complications. Ureteral temporal catheters may be an alternative strategy for placenta accreta spectrum cases suspected with urinary tract involved prenatally. Moreover, clearly and explicitly reporting “double J stent” or “temporal catheter” is necessary for future researches.

In vitro fertilization and placenta accreta spectrum in pregnancies with a history of cesarean delivery

Maternal circulating biomarkers associated with placenta accreta spectrum disorders.

Introducción: el espectro de acretismo placentario (EAP) es una condición asociada a sangrado masivo posparto y mortalidad materna. Las guías de manejo publicadas en países de altos ingresos recomiendan la participación de grupos interdisciplinarios en hospitales con recursos suficientes para realizar procedimientos complejos. Sin embargo, algunas de las recomendaciones de estas guías resultan difíciles de aplicar en países de bajos y medianos ingresos.Objetivos: este consenso busca formular recomendaciones generales para el tratamiento del EAP en Colombia.Materiales y métodos: en el consenso participaron 23 panelistas, quienes respondieron 31 preguntas sobre el tratamiento de EAP. Los panelistas fueron seleccionados con base en la participación en dos encuestas realizadas para determinar la capacidad resolutiva de hospitales en el país y la región. Se utilizó la metodología Delphi modificada, incorporando dos rondas sucesivas de discusión. Para emitir las recomendaciones el grupo tomó en cuenta la opinión de los participantes, que lograron un consenso mayor al 80 %, así como las barreras y los facilitadores para su implementación.Resultados: el consenso formuló cinco recomendaciones integrando las respuestas de los panelistas. Recomendación 1. Las instituciones de atención primaria deben realizar búsqueda activa de EAP en pacientes con factores de riesgo: placenta previa e historia de miomectomía o cesárea en embarazo previo. En caso de haber signos sugestivos de EAP por ecografía, las pacientes deben ser remitidas de manera inmediata, sin tener una edad gestacional mínima, a hospitales reconocidos como centros de referencia. Las modalidades virtuales de comunicación y atención en salud pueden facilitar la interacción entre las instituciones de atención primaria y los centros de referencia para EAP. Se debe evaluar el beneficio y riesgo de las modalidades de telemedicina. Recomendación 2. Es necesario que se definan hospitales de referencia para EAP en cada región de Colombia, asegurando el cubrimiento de la totalidad del territorio nacional. Es aconsejable concentrar el flujo de pacientes afectadas por esta condición en unos pocos hospitales, donde haya equipos de cirujanos con entrenamiento específico en EAP, disponibilidad de recursos especializados y un esfuerzo institucional por mejorar la calidad de atención, en busca de tener mejores resultados en la salud de las gestantes con esta condición. Para lograr ese objetivo los participantes recomiendan que los entes reguladores de la prestación de servicios de salud a nivel nacional, regional o local vigilen el proceso de remisión de estas pacientes, facilitando rutas administrativas en caso de que no exista contrato previo entre el asegurador y el hospital o la clínica seleccionada (IPS).Recomendación 3. En los centros de referencia para pacientes con EAP se invita a la creación de equipos que incorporen un grupo fijo de especialistas (obstetras, urólogos, cirujanos generales, radiólogos intervencionistas) encargados de atender todos los casos de EAP. Es recomendable que esos grupos interdisciplinarios utilicen el modelo de “paquete de intervención” como guía para la preparación de los centros de referencia para EAP. Este modelo consta de las siguientes actividades: preparación de los servicios, prevención e identificación de la enfermedad, respuesta ante la presentación de la enfermedad, aprendizaje luego de cada evento. La telemedicina facilita el tratamiento de EAP y debe ser tenida en cuenta por los grupos interdisciplinarios que atienden esta enfermedad.Recomendación 4. Los residentes de Obstetricia deben recibir instrucción en maniobras útiles para la prevención y el tratamiento del sangrado intraoperatorio masivo por placenta previa y EAP, tales como: la compresión manual de la aorta, el torniquete uterino, el empaquetamiento pélvico, el bypass retrovesical y la maniobra de Ward. Los conceptos básicos de diagnóstico y tratamiento de EAP deben incluirse en los programas de especialización en Ginecología y Obstetricia en Colombia. En los centros de referencia del EAP se deben ofrecer programas de entrenamiento a los profesionales interesados en mejorar sus competencias en EAP de manera presencial y virtual. Además, deben ofrecer soporte asistencial remoto (telemedicina) permanente a los demás hospitales en su región, en relación con pacientes con esa enfermedad.Recomendación 5. La finalización de la gestación en pacientes con sospecha de EAP y placenta previa, por imágenes diagnósticas, sin evidencia de sangrado vaginal activo, debe llevarse a cabo entre las semanas 34 y 36 6/7. El tratamiento quirúrgico debe incluir intervenciones secuenciales que pueden variar según las características de la lesión, la situación clínica de la paciente y los recursos disponibles. Las opciones quirúrgicas (histerectomía total y subtotal, manejo quirúrgico conservador en un paso y manejo expectante) deben incluirse en un protocolo conocido por todo el equipo interdisciplinario. En escenarios sin diagnóstico anteparto, es decir, ante un hallazgo intraoperatorio de EAP (evidencia de abultamiento violáceo o neovascularización de la cara anterior del útero), y con participación de personal no entrenado, se plantean tres situaciones:Primera opción: en ausencia de indicación de nacimiento inmediato o sangrado vaginal, se recomienda diferir la cesárea (cerrar la laparotomía antes de incidir el útero) hasta asegurar la disponibilidad de los recursos recomendados para llevar a cabo una cirugía segura.Segunda opción: ante indicación de nacimiento inmediato (por ejemplo, estado fetal no tranquilizador), pero sin sangrado vaginal o indicación de manejo inmediato de EAP, se sugiere realizar manejo en dos tiempos: se realiza la cesárea evitando incidir la placenta, seguida de histerorrafia y cierre de abdomen, hasta asegurar la disponibilidad de los recursos recomendados para llevar a cabo una cirugía segura.Tercera opción: en presencia de sangrado vaginal que hace imposible diferir el manejo definitivo de EAP, es necesario extraer el feto por el fondo del útero, realizar la histerorrafia y reevaluar. En ocasiones, el nacimiento del feto disminuye el flujo placentario y el sangrado vaginal se reduce o desaparece, lo que hace posible diferir el manejo definitivo de EAP. Si el sangrado significativo persiste, es necesario continuar con la histerectomía haciendo uso de los recursos disponibles: compresión manual de la aorta, llamado inmediato a los cirujanos con mejor entrenamiento disponible, soporte de grupos expertos de otros hospitales a través de telemedicina. Si una paciente con factores de riesgo para EAP (por ejemplo, miomectomía o cesárea previa) presenta retención de placenta posterior al parto vaginal, es recomendable confirmar la posibilidad de dicho diagnóstico (por ejemplo, realizando una ecografía) antes de intentar la extracción manual de la placenta.Conclusiones: esperamos que este primer consenso colombiano de EAP sirva como base para discusiones adicionales y trabajos colaborativos que mejoren los resultados clínicos de las mujeres afectadas por esta enfermedad. Evaluar la aplicabilidad y efectividad de las recomendaciones emitidas requerirá investigaciones adicionales.

Background:Placenta accreta spectrum (PAS) is a life-threatening obstetric condition characterized by abnormal placental adherence to the uterine wall, leading to severe maternal morbidity and mortality. Rising cesarean delivery rates have contributed to its increasing prevalence, yet recent national data on PAS trends and disparities remain limited. This study provides updated estimates of PAS prevalence, racial and geographic disparities, and associated maternal–fetal outcomes using a large, nationally representative dataset from 2016 to 2022.Method:We conducted a retrospective cross-sectional analysis using the Nationwide Inpatient Sample (NIS), capturing 27,339,861 pregnancy-related hospitalizations. PAS cases (n = 36,310) were identified using International Classification of Disease, Tenth Revision, codes. Temporal trends were assessed using joinpoint regression. Survey logistic regression models estimated associations between PAS and maternal–fetal outcomes, adjusting for demographic, clinical, and hospital factors.Results:PAS prevalence increased significantly between 2016 and 2022 (annual percent change: 2.9%, p < 0.05), with notable increases among Black and White individuals. PAS was strongly associated with prior cesarean delivery, placenta previa, advanced maternal age, and comorbidities including hypertension, diabetes, and obesity. PAS significantly increased the risk of severe maternal morbidity, including hysterectomy (adjusted odds ratio [aOR] range: 52.2–151.3), blood transfusion (aOR range: 4.3–7.1), and preterm birth (aOR range: 2.4–3.2).Conclusions:These findings highlight the growing burden of PAS and the urgent need for prevention strategies, such as reducing unnecessary cesarean deliveries, promoting vaginal birth after cesarean when appropriate, enhancing prenatal screening, and ensuring multidisciplinary care. Addressing racial and geographic disparities in PAS diagnosis and outcomes is essential to improve maternal and neonatal health.