Incidence Of Placenta Accreta Spectrum Research Articles

Risk factors, Diagnosis and Outcomes of Management Strategies of Placenta Accreta Spectrum (PAS) Disorders in Low-resources Settings: Case Report

Background: Placenta accreta spectrum disorder (PAS), such as placenta accreta, placenta increta, and placenta percreta are causes of post-partum hemorrhage causing maternal morbidity and mortality. The major risk issues are prior caesarean section, placenta previa, advanced maternal age, multiparity, and preeclampsia. A reliable antenatal diagnosis is required for this serious condition. To reduce the incidence of maternal morbidity and mortality due to massive bleeding, it is necessary to make an early diagnosis in order for the surgical approach can be planned in the future. High birth rates and cesarean delivery are the cause of an increase in the incidence of PAS in middle / low-income countries. Additional diagnostic methods, advanced surgical methods, and other interventional radiological methods can greatly contribute to reducing maternal morbidity and mortality in high-income countries but are frequently not available in low-resource settings. Therefore, an inexpensive management strategy is an important issue.Methods: This is a retrospective case series. The patients suspected of PAS are reassessed histologically for the diagnosis confirmation. The information about risk factors, time to decide a definite diagnosis, monitoring vital signs, resuscitation, blood transfusions, surgical management, and maternal outcomes are detailed in a table.Result: We reported five women with PAS, diagnosed and managed in our hospital, with different conditions at admission and a different risk factor for PAS. All of the patients undergoing subtotal hysterectomy and uterine tissue samples were sent to the anatomical pathology department for histopathological examination. Red blood cell transfusions were used in all patients and transfer of patients to the intensive care unit was carried out postoperatively. Complications related to monitoring occurred in one patient such as acute kidney injury. There was one maternal death that occurred.Conclusion: Antenatal diagnosis is essential in outlining the best management strategy in patients with PAS. The clinical approach was able to prove valuable when PAS is suspected before delivery. In low-resource settings, lack of interventional radiology services and prenatal diagnostic may probably impact patients management with PAS.International Journal of Human and Health Sciences Vol. 05 No. 04 October’21 Page: 503-509

Placenta accreta spectrum disorders – detection rate and maternal outcomes following implementation of an institutional protocol

Placenta accreta spectrum (PAS) disorders have been on the rise in recent years with increasing caesarean rates. The purpose of this prospective observational study was to describe our detection rates and to review outcomes in PAS after the introduction of an institutional screening and management protocol. Twenty-one patients with suspected PAS over 5 years were identified. 20/21 patients had an accurate determination of placental invasion and positive correlation with surgical and histopathological examination. Early morbidity (massive haemorrhage) was found in 7/21 patients, whilst late morbidity (hospital readmission) was found in 5/21 patients. There were no maternal deaths and admissions to intensive therapy unit (ITU). In summary, our centre demonstrated a high antenatal detection rate for PAS using an evidence-based protocol. This has led to timely intervention by an experienced multidisciplinary team and excellent outcomes. Immediate and delayed postoperative counselling was effective for optimal patient understanding and experience. Impact Statement What is already known on this subject? With rising caesarean section rates, the incidence of placenta accreta spectrum (PAS) disorders is increasing. Despite this, most obstetricians have personally managed only a small number of patients with PAS. Moreover, there appears to be some debate over the optimal diagnostic and management strategy. What do the results of this study add? As the incidence increases, development of institutional screening and management protocol is a necessity for large units. Timely diagnosis, extensive pre and postoperative counselling and multidisciplinary teamwork ensure reduced early and late morbidity. What are the implications of these findings for clinical practice and/or further research? Evidence based screening protocols for PAS disorders reduce the likelihood of undiagnosed cases and should be developed in every unit. Consideration must also be given to standardisation of the diagnostic and management protocols, including contingency plan for emergencies.

Placenta Accreta: Management by Peridural Anesthesia

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Advances in anesthetic and obstetric management of patients with placenta accreta spectrum.

The incidence of placenta accreta spectrum is increasing and it is a leading cause of peripartum hysterectomy and massive postpartum hemorrhage. The purpose of the present article is to provide a contemporary overview of placenta accreta spectrum pertinent to the obstetric anesthesiologist. Recent changes in the terminology used to report invasive placentation were proposed to clarify diagnostic criteria and guidelines for use in clinical practice. Reduced morbidity is associated with scheduled preterm delivery in a center of excellence using a multidisciplinary team approach. Neuraxial anesthesia as a primary technique is increasingly being used despite the known risk of major bleeding. The use of viscoelastic testing and endovascular interventions may aid hemostatic resuscitation and improve outcomes. Accurate diagnosis and early antenatal planning among team members are essential. Obstetric anesthesiologists should be prepared to manage a massive hemorrhage, transfusion, and associated coagulopathy. Increasingly, viscoelastic tests are being used to assess coagulation status and the ability to interpret these results is required to guide the transfusion regimen. Balloon occlusion of the abdominal aorta has been proposed as an intervention that could improve outcomes in women with placenta accreta spectrum, but high-quality safety and efficacy data are lacking.

Placenta accreta spectrum-a catastrophic situation in obstetrics.

Placenta accreta is a significant obstetric complication in which the placenta is completely or focally adherent to the myometrium. The worldwide incidence of placenta accreta spectrum (PAS) is increasing day by day, mostly due to the increasing trends in cesarean section rates. The accurate and timely diagnosis of placenta accreta is important to improve the feto-maternal outcome. Although standard ultrasound is a reliable and primary tool for the diagnosis of placenta accreta, the absence of ultrasound findings does not preclude the diagnosis of placenta accreta. Therefore, clinical evaluation of risk factors is equally essential for the prediction of abnormal placental invasion. Pregnant women with a high impression or established diagnosis of placenta accreta should be managed by a multidisciplinary team in a specialist center. Traditionally, PAS has been managed by an emergency obstetric hysterectomy. Previously, few studies suggested a satisfactory success rate of conservative management in well-chosen cases, whereas few studies recommended delayed hysterectomy to reduce the amount of bleeding. The continuously increasing trends of PAS and the challenges for its routine management are the main motives behind this literature review.

Clinical profiles of placenta accreta spectrum: the PACCRETA population-based study.

To describe and compare the characteristics of women with placenta accreta spectrum (PAS) and their pregnancy outcomes according to the presence of placenta praevia and a prior caesarean section. Prospective population-based study. All 176 maternity hospitals of eight French regions. Two hundred and forty-nine women with PAS, from a source population of 520114 deliveries. Women with PAS were classified into two risk-profile groups, with or without the high-risk combination of placenta praevia (or an anterior low-lying placenta) and at least one prior caesarean. These two groups were described and compared. Population-based incidence of PAS, characteristics of women, pregnancies, deliveries and pregnancy outcomes. The PAS population-based incidence was 4.8/10000 (95% CI 4.2-5.4/10000). After exclusion of women lost to follow up from the analysis, the group with placenta praevia and a prior caesarean included 115 (48%) women and the group without this combination included 127 (52%). In the group with both factors, PAS was more often suspected antenatally (77% versus 17%; P<0.001) and more often percreta (38% versus 5%; P<0.001). This group also had more hysterectomies (53% versus 21%, P<0.001) and higher rates of blood product transfusions, maternal complications, preterm births and neonatal intensive care unit admissions. Sensitivity analysis showed similar results after exclusion of women who delivered vaginally. More than half the cases of PAS occurred in women without the combination of placenta praevia and a prior caesarean delivery, and these women had better maternal and neonatal outcomes. We cannot completely rule out that some of the women who delivered vaginally had placental retention rather than PAS; however, we found similar results among women who delivered by caesarean. Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes.

124 Trends in unplanned peripartum hysterectomy in the United States, 2009 – 2018

Although the U.S. incidence of placenta accreta spectrum (PAS) is thought to be increasing, no nationwide vital statistics data exist to confirm this assumption. We sought to evaluate trends in incidence of unplanned peripartum hysterectomy, a surrogate marker for PAS, using vital statistics data. Trends for rates of unplanned peripartum hysterectomy were evaluated in the decade since this field was added to the national vital statistics form. PAS and planned peripartum hysterectomy are not recorded by vital statistics. Outcomes included unplanned hysterectomy: (1) alone, (2) without uterine rupture, (3) with transfusion, and (4) with history of cesarean. Planned hysterectomies, which occur in many cases of PAS are not captured in U.S. vital statistics. Rates over time were evaluated using tests of trend, with p value <0.05 considered statistically significant. From 2009 to 2018, the number of unplanned peripartum hysterectomies increased in the U.S., while the number of deliveries decreased (Table). Rates of all four unplanned hysterectomy outcomes increased over time (Figure). For example, unplanned hysterectomy occurred in 37 per 10,000 deliveries in 2009-2010 and in 47 per 10,000 deliveries in 2017-2018. The incidence of unplanned peripartum hysterectomy, an imperfect surrogate marker for PAS, increased in the past decade. Vital statistics likely do not adequately capture the rate of PAS. Modifying ICD codes to accurately capture PAS in U.S. vital statistics is necessary to ascertain the scope and impact of PAS nationally.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Special Report of the Society for Maternal-Fetal Medicine Placenta Accreta Spectrum Ultrasound Marker Task Force: Consensus on definition of markers and approach to the ultrasound examination in pregnancies at risk for placenta accreta spectrum

Placenta accreta spectrum includes the full range of abnormal placental attachment to the uterus or other structures, encompassing placenta accreta, placenta increta, placenta percreta, morbidly adherent placenta, and invasive placentation. The incidence of placenta accreta spectrum has increased in recent years, largely driven by increasing rates of cesarean delivery. Prenatal detection of placenta accreta spectrum is primarily made by ultrasound and is important to reduce maternal morbidity associated with the condition. Despite a large body of research on various placenta accreta spectrum ultrasound markers and their screening performance, inconsistencies in the literature persist. In response to the need for standardizing the definitions of placenta accreta spectrum markers and the approach to the ultrasound examination, the Society for Maternal-Fetal Medicine convened a task force with representatives from the American Institute of Ultrasound in Medicine, the American College of Obstetricians and Gynecologists, the American College of Radiology, the International Society of Ultrasound in Obstetrics and Gynecology, the Society for Radiologists in Ultrasound, the American Registry for Diagnostic Medical Sonography, and the Gottesfeld-Hohler Memorial Ultrasound Foundation. The goals of the task force were to assess placenta accreta spectrum sonographic markers on the basis of available data and expert consensus, provide a standardized approach to the prenatal ultrasound evaluation of the uterus and placenta in pregnancies at risk of placenta accreta spectrum, and identify research gaps in the field. This manuscript provides information on the Placenta Accreta Spectrum Task Force process and findings.

Placenta Accreta Spectrum Disorders: Challenges, Risks, and Management Strategies.

The worldwide incidence of placenta accreta spectrum (PAS) is rapidly increasing, following the trend of rising cesarean delivery. PAS is an heterogeneous condition associated with a high maternal morbidity and mortality rate, presenting unique challenges in its diagnosis and management. So far, the rarity of this condition, together with the absence of high quality evidence and the lack of a standardized approach in reporting PAS cases for the ultrasound, clinical, and pathologic diagnosis, represented the main challenges for a deep understanding of this condition. The study of the available management strategies of PAS has been hampered by the heterogeneity of the available epidemiological data on this condition. The aim of this review is to provide a critical view of the current available evidence on the screening, the diagnosis, and the management options for PAS disorders, with a special focus on the challenges we foresee for the near future.

A life changing experience: An interpretative phenomenological analysis of women’s experiences of placenta accreta spectrum

BackgroundThe incidence of Placenta Accreta Spectrum (PAS) is increasing. This study explores women’s personal experience of a pregnancy, birth and early postpartum period complicated by PAS. MethodsA qualitative study involving seven women (age range: 33–44 years) following a pregnancy in the previous two years complicated by PAS was conducted. Using an Interpretative Phenomenological Analysis approach data were collected and analysed in 2019 and 2020 through face-to-face interviews. Interviews were transcribed verbatim. ResultsWomen described their experience from diagnosis up to two years following the birth and focussed on the strategies they used to cope with an unexpected diagnosis of PAS. Six main themes emerged. In pregnancy, women were focussed on the diagnosis and managing family life from hospital “it’s not until you are told”, “sad but safe”, “relying on others can be unbearable”. In terms of the birth a ‘fear of dying’ related to self and baby was central. Postnatally key themes related to the ongoing consequences of the condition as “no one believed I could be feeling so much pain” and “it’s not all over when you go home”. DiscussionWomen who have experienced a pregnancy complicated by PAS experience significant challenges associated with long term hospitalization, post-operative pain and many express feelings of being generally worried lasting many months after their pregnancy. This study makes an important contribution to the growing body of research in PAS, namely that of the woman’s own voice.

The higher incision at upper part of lower uterine segment in caesarean section can decrease the incidence of placenta accreta spectrum

Caesarean section rate and placenta accreta spectrum prevalence are in continuous increase during last years. Multiple hypotheses can explain the abnormal adherence of placenta trophoblast to the myometrium. By reviewing the surgical techniques used in caesarean section, we hypothesize that the higher uterine incision at upper part of lower segment could decrease the abnormal placentation in next pregnancies.

Placenta accreta spectrum disorders - Peri-operative management: The role of the anaesthetist.

The incidence of placenta accreta spectrum (PAS) is increasing and will become more commonly encountered by obstetric anaesthetists in the elective and emergency settings. Significant maternal and neonatal morbidity is associated with these disorders, and hence it is important for anaesthetists to have early involvement in perioperative planning. Major haemorrhage should be anticipated and requires robust perioperative preparation including Patient Blood Management (PBM) and use of intraoperative strategies for haemorrhage management wherever possible. Several institutions have demonstrated good outcomes with regional anaesthesia alone, but the choice of anaesthetic technique requires individualised planning considering patient, anaesthetic and surgical factors. Optimisation of postoperative analgesia needs additional consideration; it is key to good recovery, minimising the impact on quality of life and reducing the risk of persistent post-surgical pain. Further research is required to ascertain the optimal multi-modal analgesic regime including the role of peripheral nerve blockade.

Etiopathogenesis and risk factors for placental accreta spectrum disorders.

Placenta accreta spectrum (PAS) disorders, comprising placenta accreta, increta, and percreta, are associated with serious maternal morbidity and mortality in both the developed and the developing world. The incidence of PAS has increased in the recent years, and the rising rates of cesarean section rate, placenta accreta in previous pregnancies, and other uterine surgeries including myomectomies and repeated endometrial curettage are implicated in its etiopathogenesis. The absolute risk of PAS increases with the number of previous cesarean sections. The PAS remains undiagnosed in one-half to two-thirds of cases, thus increasing maternal morbidity and mortality. Understanding etiopathogenesis and risk factors of this condition allows early diagnosis and planning of delivery, and thereby would help improve maternal and fetal outcomes.

How to set up a regional specialist referral service for Placenta Accreta Spectrum (PAS) disorders?

There has been an approximately fivefold increase in the incidence of placenta accreta spectrum (PAS) disorders during the last 30 years, believed to be secondary to increasing Caesarean section rates. PAS disorder is associated with significantly increased maternal morbidity and mortality worldwide. Antenatal diagnosis by foetal medicine teams that have a special expertise to diagnose PAS disorder by the use of ultrasound scan, and a dedicated, highly specialised multidisciplinary team (MDT) comprising surgeons who are skilled in complex pelvic surgery and obstetric anaesthetists who have an expertise in high-risk obstetric anaesthesia, supported by haematology, operating theatre, interventional radiology, midwifery, neonatology, high-dependency and intensive care teams have been recommended to improve maternal and perinatal outcomes. Setting up a specialist MDT regional referral service, PAS involves collaboration with all stakeholders, ensuring appropriate funding, developing MDT care pathways, continuously auditing patient outcomes and disseminating knowledge through research, innovation, education and publications.

Placenta Accreta Spectrum: In Vitro Fertilization and Non-In Vitro Fertilization and Placenta Accreta Spectrum in a Massachusetts Cohort.

The incidence of placenta accreta spectrum (PAS) has been increasing in the United States. In addition, there has also been an increase in the utilization of in vitro fertilization (IVF). The IVF pregnancies confer an increased risk of adverse obstetric and neonatal outcomes, but there is limited data on whether IVF is associated with PAS. The aim of this study is to assess the association between IVF and the risk of PAS. This was a retrospective cohort study of deliveries from January 1, 2013 to August 1, 2018 at a tertiary hospital in the Massachusetts. IVF pregnancies were compared with non-IVF pregnancies, and PAS diagnosis was confirmed by histopathology reports. Hospital administrative data and medical record review were used, and supplemented with data from birth certificates from the Massachusetts Department of Public Health. We identified 28,344 pregnancies that met inclusion criteria, of which 1,418 (5.0%) were IVF pregnancies. The overall incidence of PAS was 0.4% (2.2% in the IVF group and 0.3% in the non-IVF group). Women who underwent IVF had 5.5 times the risk of PAS (95% confidence interval [CI]: 3.4-8.7) compared with women in the non-IVF group, adjusted for maternal age, nulliparity, and year of delivery (Table 5). Compared with women in the non-IVF group, the IVF group had fewer prior cesarean deliveries (22.6 vs. 64.2%) and a lower prevalence of placenta previa (19.4 vs. 44.4%). Women with an IVF pregnancy carry an increased risk of PAS compared with non-IVF. Among women who underwent IVF, there was a lower prevalence of prior cesarean deliveries and placenta previa. Future work is needed to identify the mechanism of association for this increased risk as well as a reliable tool for antenatal detection in this cohort of women. · IVF pregnancies have higher risk of PAS than non-IVF pregnancies.. · IVF pregnancies with PAS do not exhibit common risk factors.. · IVF may be an independent risk factor for PAS..

Placenta Accreta spectrum (pas) disorders: A 10-year study at tertiary care center, Ahmedabad, western India

Background: The last 30 years have witnessed the dramatic increase in the incidence of placenta accreta spectrum (PAS) disorders from 0.12% to 0.31%. The spectrum of abnormal placental invasion ranges from the subclinical findings of adherent placental basal plate with the myometrial fibres to the substantial presentation of placenta percreta.Methods: In this retrospective study of 10 years, there were 81,650 deliveries at our tertiary care center and 28 patients were diagnosed with PAS disorders. The placental localization and diagnosis of placental spectrum disorders were confirmed with ultrasound and color doppler. Results: Total deliveries during the 10 years study were 81,650, out of which 27 cases met the diagnostic criteria of PAS with ultrasound and 1 case diagnosed intraoperatively resulting incidence of PAS to 0.035%. There is increase in incidence of PAS from 0.0125% in 2010 to 0.1% in 2019. All these patients were planned for elective cesarean section at 35 weeks gestation, but 2 of them presented in emergency with bouts of bleeding and required immediate intervention. Massive hemorrhage was reported in 12 (42.8%) cases and 26 (92.9%) cases required blood transfusion. Bladder injury was reported in 6 (21.4%) case. Maternal mortality has been noted in 1(3.5%) case which was complicated with disseminated intravascular coagulation and acute renal failure. Conclusions: Favorable outcome in PAS disorders can only be achieved with preoperative multidisciplinary input and perioperative measures require adequate time in order to be instituted.

Up-regulated cytotrophoblast DOCK4 contributes to over-invasion in placenta accreta spectrum

In humans, a subset of placental cytotrophoblasts (CTBs) invades the uterus and its vasculature, anchoring the pregnancy and ensuring adequate blood flow to the fetus. Appropriate depth is critical. Shallow invasion increases the risk of pregnancy complications, e.g., severe preeclampsia. Overly deep invasion, the hallmark of placenta accreta spectrum (PAS), increases the risk of preterm delivery, hemorrhage, and death. Previously a rare condition, the incidence of PAS has increased to 1:731 pregnancies, likely due to the rise in uterine surgeries (e.g., Cesarean sections). CTBs track along scars deep into the myometrium and beyond. Here we compared the global gene expression patterns of CTBs from PAS cases to gestational age-matched control cells that invaded to the normal depth from preterm birth (PTB) deliveries. The messenger RNA (mRNA) encoding the guanine nucleotide exchange factor, DOCK4, mutations of which promote cancer cell invasion and angiogenesis, was the most highly up-regulated molecule in PAS samples. Overexpression of DOCK4 increased CTB invasiveness, consistent with the PAS phenotype. Also, this analysis identified other genes with significantly altered expression in this disorder, potential biomarkers. These data suggest that CTBs from PAS cases up-regulate a cancer-like proinvasion mechanism, suggesting molecular as well as phenotypic similarities in the two pathologies.

Prognosticators of intravoxel incoherent motion (IVIM) MRI for adverse maternal and neonatal clinical outcomes in patients with placenta accreta spectrum disorders.

BackgroundThe incidence of placenta accreta spectrum (PAS) disorders has increased rapidly in recent years and is associated with several maternal and neonatal complications. Intravoxel incoherent motion (IVIM) imaging is a method which can assess placental perfusion quantitatively. Therefore, the first aim of this study was to investigate whether patients with adverse maternal and neonatal outcomes of PAS disorders differed in the parameters from IVIM. A second aim was to identify these parameters for adverse peripartum outcome in gravid patients at risk for PAS.MethodsThe subject group consisted of patients with placenta previa, in which 75 patients had PAS disorders and 24 patients did not have PAS disorders between 28+0 and 39+6 weeks, respectively. All women underwent magnetic resonance imaging (MRI) examination including an IVIM sequence with 8 b values on a 1.5T scanner. The perfusion fraction (f), pseudodiffusion coefficient (D*), and standard diffusion coefficient (D) were calculated. All medical records were received postpartum. The final degree of placental invasion was established either by placental villi alterations from a placental sample or from maternity records of the women’s general practitioners.ResultsWomen with PAS disorders had a higher perfusion fraction (34.12%) than women without the disease (29.39%) (P<0.05). The perfusion fraction was 36.86% in women with massive blood loss and was 35.15% in women requiring transfusion, which was higher than women without massive blood loss and not requiring transfusion (P<0.05). The D value was 1.65×10−3 mm2/s in women with low birth weight, which was lower than that in women with appropriate birth weight (1.70×10−3 mm2/s) (P<0.05).ConclusionsPatients with PAS disorders differed in placental perfusion fraction from women without PAS disorders. The f and D value may be used to recognize patients with certain adverse clinical outcomes.

CASE REPORT OF PLACENTA ACCRETA: SUCCESSFUL MANAGEMENT WITH CONSERVATIVE SURGERY

The incidence of placenta accreta spectrum (PAS) disorders has increased over the last decades due to increase in cesarean deliveries, resulting in increase in cesarean hysterectomies , maternal mortality and morbidity but since last few years there has been a gradual shift towards the idea of conservative management. Conservative management of PAS is known to reduce major obstetric hemorrhage and salvage hysterectomy. We present a case of placenta accreta diagnosed by ultrasound where management of post-partum hemorrhage was accomplished by conservative surgery. The concise steps taken in management of placenta accreta before and during cesarean section were: Availability of 4 donors with cross match; Stark cesarean section; atraumatic clamps around uterine arteries; ureterotonic drugs; external (B-Lynch suture); and application of diathermy where required. This experience indicates that few selected cases of PAS could be managed conservatively who are at risk of intra-partum hemorrhage and post-partum hemorrhage.

Hemorrhagic morbidity in placenta accreta spectrum with and without placenta previa.

The incidence of placenta accreta spectrum (PAS; pathologic diagnosis of placenta accreta, increta or percreta) continues to rise in the USA. The purpose of this study is to compare the hemorrhagic morbidity associated with PAS with and without a placenta previa. This was a retrospective cohort study of 105 deliveries from 1997 to 2017 with histologically confirmed PAS comparing outcomes in women with and without a coexisting placenta previa. We used the Wilcoxon rank sum test to compare continuous data and Chi-square or Fisher's exact test for categorical data. We also performed log-binomial regression to calculate risk ratios adjusted for depth of invasion (aRR) and 95% confidence intervals (CI). We identified 105 pregnancies with PAS. Antenatal diagnosis of PAS was higher in women with coexisting placenta previa (72.3%) than those without (6.9%, p < 0.001). Women with coexisting placenta previa had greater median estimated blood loss and more units of packed red blood cells transfused (both p ≤ 0.03). Women with placenta previa were more likely to undergo a hysterectomy (RR 2.7; 95% CI 1.8-3.8) and be admitted to the intensive care unit (aRR 3.3; 95% CI 1.1-9.6). Among women with PAS, those with a coexisting placenta previa experienced greater hemorrhagic morbidity compared to those without. In addition, PAS without placenta previa typically was not diagnosed prior to delivery. This study further supports the recommendation for multi-disciplinary planning and assurance of resources for pregnancies complicated by PAS. In addition, our results highlight the need for mobilization of resources for those pregnancies where PAS is not diagnosed until delivery.