Low-lying Placenta Research Articles

Autologous Blood Donation and Transfusion in Patients with Placental Malposition: A Single-Institution Pilot Study and Systematic Literature Review.

Autologous blood donation for placental malposition is common in Japan, but no studies have scientifically evaluated its usefulness. The purpose of this study was to evaluate the necessity for autologous blood donation for placental malposition. A retrospective study was conducted of patients who underwent autologous blood donation for placental malposition at Kindai University Hospital from 2012 to 2022. The primary outcome was the proportion of patients who were able to avoid allogeneic blood transfusion by autologous blood transfusion; secondary outcomes were autologous blood disposal rate, allogeneic blood transfusion rate, and complications of autologous blood donation and allogeneic blood transfusion. A systematic review of studies on autologous blood transfusion for placental malposition was conducted on PubMed. Fifty-two patients (total placenta previa 16; marginal placenta previa 20; low-lying placenta 16) were included. Eight (15%) had complications at the time of autologous blood donation, including non-reassuring fetal heart rate, but no sequelae. Allogeneic blood transfusion was avoided by autologous blood transfusion in only five cases (9.6%). Autologous blood was discarded in nine cases (17%), seven of which had a low-lying placenta positioned normally at delivery. Allogeneic blood transfusion was performed in eight cases (15%) with no complications. In the systematic review, seven articles that met the inclusion criteria were selected for further evaluation. The results showed that there were no publications that scientifically demonstrated the benefit of autologous blood transfusion. The results of this study indicate that autologous blood donation for placental malposition has little benefit.

Transvaginal sonographic screening of abnormal intra-amniotic structure around internal cervical os at 18-21+6 weeks of gestation.

To detect an abnormal intra-amniotic structure around the internal cervical os using transvaginal sonography at 18-21+6 weeks of gestation. In this cohort study, during a 12-month period from July 2022 to June 2023, 395 transvaginal scans were performed for second-trimester cervical-length screening in singleton pregnancies at 18-21+6 weeks of gestation. Nine abnormal intra-amniotic structures (AIAS), 87 low-lying placentas (LLP, second-trimester placenta previa or placental margin within 2 cm from internal cervical os), and 299 controls (not LLP and no abnormal finding around internal cervical os) were diagnosed. Sonographic features of AIAS and delivery outcomes in the three groups were compared. Sonographic features of nine AIAS cases were: two single bands, one single broad band, one multiple bands, one single tubular, and one multiple tubulars. Blood flow was noted in seven cases. Seven AIAS had disappeared by 26 weeks, one was resolved at 34 weeks, and one (vasa previa and parachute placenta) remained until delivery. Incidences of emergency cesarean section, abnormal placenta and umbilical cord, and abnormal deliveries in AIAS were significantly higher than those in LLP and control groups (P = 0.031). Blood losses during delivery in AIAS and LLP groups were significantly greater than in the control group (P = 0.004), but there was no significant difference in blood loss between AIAS and LLP groups. The incidence of AIAS around the internal cervical os in the second trimester was 2.28% (9/395 fetuses). Mid-second-trimester transvaginal sonographic screening for the detection of AIAS around the internal cervical os including vasa previa may be essential to reduce perinatal morbidity.

Risk factors of severe postpartum hemorrhage in pregnant women with placenta previa or low-lying placenta: a retrospective cohort study

BackgroundThe severe postpartum hemorrhage (SPPH) leads to dangerous maternal conditions, and its rate is still increasing and the trend in related risk factors is changing. Placenta-related problems remain the high-risk factor for SPPH. The object is to investigate the prevalence and the risk factors of the severe postpartum hemorrhage in pregnant women with placenta previa or low-lying placenta.MethodA retrospective analysis of pregnant women with placenta previa or low-lying placenta after 28 weeks gestation from May 2018 to May 2023 in the Peking Union Medical College Hospital was conducted. The primary outcome was severe postpartum hemorrhage defined as blood loss ≥ 1000 mL within 24 h of childbirth, or with signs or symptoms of low blood volume requiring transfusion of ≥ 4U of red blood cells. Univariate and multivariate logistic regression were used to identify potential risk factors of severe postpartum hemorrhage and receiver operating curve to evaluate the prediction performance.ResultsOf the 14,964 women, 201 met the inclusive criteria. SPPH rate was 1.3% overall and 18.9% in women with placenta previa or low-lying placenta. Weight (aOR = 0.93, 95%CI 0.87–0.99), increta or percreta placenta (aOR = 7.93, 95%CI 2.53–24.77) were the risk factors. The area under the ROC curve was 0.69(95%CI 0.59–0.80) for increta or percreta placenta alone, and 0.72(95%CI 0.62–0.82) for the combination of times of cesarean sections and anterior placenta.ConclusionsPlacenta accreta spectrum was the key independent risk factor of SPPH in women with placenta previa or low-lying placenta. Antenatal risk assessment of SPPH in these population is highly desirable and optimal intervention could be planned.

Incidence and Risk Factors for Severe Postpartum Hemorrhage in Women With Anterior Low-Lying or Previa Placenta and Prior Cesarean: Prospective Population-Based Study

Incidence and Risk Factors for Severe Postpartum Hemorrhage in Women With Anterior Low-Lying or Previa Placenta and Prior Cesarean: Prospective Population-Based Study

Inpatient Versus Outpatient Management of Prenatally Diagnosed Vasa Praevia: A Systematic Review and Meta-analysis

(Abstracted from Eur J Obstet Gynecol Reprod Biol 2024:293:156–166 Vasa previa is characterized by unprotected fetal blood vessels in close proximity to the internal cervical os and occurs in an estimated 1 in 1200 pregnancies. Risk factors for vasa previa include low-lying placenta, succenturiate or bilobed placenta, velamentous cord insertion, in vitro fertilization, and multiple pregnancies.

P-718 Risk of placenta previa in assisted reproduction: population study with sibling analyses from the committee of Nordic ART and safety

Abstract Study question Which treatment methods and causes of infertility contribute to the increased risk of placenta previa in assisted reproductive technology (ART)? Summary answer Risk was increased across all treatment methods and causes of infertility, but most strongly following fresh blastocyst transfer (fresh-BT) and in women with endometriosis. What is known already A higher risk of placenta previa after ART is well established. Recent studies indicate risk differences according to type of embryo transfer, with particularly high risk seen after fresh-BT. Underlying mechanisms are poorly understood, and maternal factors such as cause of infertility might contribute. Within-mother analyses, where each woman serves as her own control (i.e., sibling design), help disentangle treatment contributions from maternal confounders that are constant between pregnancies. Study design, size, duration The Committee of Nordic ART and Safety (CoNARTaS) cohort consists of linked nationwide data from health registries in four Nordic countries. Data on ART were from Medical Birth Registries (MBRs) and ART quality registries, and data on placenta previa were from MBRs and hospital discharge/specialist health care registries. We included singleton and multiple births after natural conception (NC, n = 5 614 512) and ART (n = 139 694) in Denmark (1994-2014), Finland (1990-2014), Norway (1988-2015) and Sweden (1988-2015). Participants/materials, setting, methods All women who gave their first birth during the study period, at ages 20-45 years, were included, and contributed ≤4 births at 22-44 gestational weeks. We used multilevel logistic regression to compare risk of placenta previa after ART vs NC, both at the population level and within mothers, adjusting for year, maternal age, parity and country. We categorized ART-conception according to embryo cryopreservation, culture duration, and by cause of infertility (any ART method). Main results and the role of chance Population level risk of placenta previa was higher for ART (any method) vs NC (adjusted odds ratio [aOR] 4.16, 95% confidence interval [CI] 3.96-4.37). Controlling for constant maternal factors, the association attenuated, but risk remained higher for ART vs NC (within mothers aOR 2.64, 95% CI 2.31-3.02). Compared to NC, pregnancies from fresh embryos had a higher risk increase (population level aOR 4.69, 95% CI 4.41-4.98; within mothers aOR 3.31, 95% CI 2.81-3.91) than from frozen embryos (population level aOR 2.71, 95% CI 2.35-3.13; within mothers aOR 1.59, 95% CI 1.19-2.13). Further categorization by culture duration showed highest risk increase after fresh-BT (population level aOR 11.51, 95% CI 9.75-13.57; within mothers aOR 7.80, 95% CI 4.59-13.27), and lowest risk increase after frozen cleavage stage embryo transfer (population level aOR 2.33, 95% CI 1.93-2.80; within mothers aOR 1.20, 95% CI 0.83-1.75). Similar results were found across sensitivity analyses, including restriction to singletons. Compared to NC, risk was higher across all causes of infertility, where women with endometriosis and ART-conception had the highest risk increase (aOR 9.35, 95% CI 8.50-10.29), and women with polycystic ovary syndrome who conceived by ART had the lowest risk increase (aOR 1.52, 95% CI 1.12-2.09). Limitations, reasons for caution Analyses within mothers require that women have several births, hence, results might not apply to women with a single birth. Missing data on ART method or cause of infertility made within-mother analyses by cause of infertility unfeasible. We lacked data on extent of placenta previa (low-lying placenta vs placenta previa). Wider implications of the findings Type of embryo transfer and underlying maternal factors, particularly fresh-BT and endometriosis, respectively, both contribute to the increased risk of placenta previa in ART-conceived pregnancies. Identifying the responsible mechanisms might provide opportunities for prevention. Choice of transfer type should incorporate risk of placenta previa as well as other adverse outcomes. Trial registration number NA

Evaluation of preoperative ultrasound signs associated with bladder injury during complex Cesarean delivery: case-control study.

Intraoperative hemorrhage and peripartum hysterectomy are the main complications in patients presenting with a low-lying placenta or placenta previa undergoing repeat Cesarean delivery (CD). Patients with a high probability of placenta accreta spectrum (PAS) at birth also have a higher risk of intraoperative urologic injury. The aim of this study was to evaluate the ultrasound signs and intraoperative features associated with these injuries. This was a retrospective case-control study of consecutive singleton pregnancies included in a prospective cohort of patients with a history of at least one prior CD and diagnosed prenatally with an anterior low-lying placenta or placenta previa at 32-36 weeks' gestation. All patients underwent investigational preoperative transabdominal and transvaginal ultrasound examination within 48 h prior to delivery. Ultrasound anomalies of uterine contour and uteroplacental vascularity, and gross anomalies of the lower uterine segment (LUS) and surrounding pelvic tissue at delivery, were recorded using a standardized protocol, which included evaluation of the extent of uterine contour anomalies. The diagnosis of PAS was established when one or more placental lobules could not be separated digitally from the uterine wall at delivery or during the gross examination of the hysterectomy or partial myometrial resection specimens, and was confirmed by histopathology. Data were compared between cases complicated by intraoperative bladder injury and controls from the same cohort matched at a 1:3 ratio by parity and the number of prior CDs using conditional logistic regression. There were 16 (9.4%) patients with an intraoperative bladder injury in a cohort of 170 managed by the same multidisciplinary team during the study period. There were no patients diagnosed with ureteric or bladder trigone damage. There were 14 (87.5%) patients with a bladder injury that had histopathologic evidence of PAS at birth, including 11 (68.8%) cases described on microscopic examination as placenta increta and three (18.8%) as placenta creta. There was a significant (P = 0.03) difference between cases and controls in the distribution of intraoperative LUS vascularity, whereby the higher the number of enlarged vessels, the higher the odds of bladder injury. Multivariable regression analysis revealed that both gestational age at delivery and LUS remodeling on transabdominal ultrasound were associated with bladder injury. A higher gestational age was associated with a lower risk of injury. A higher LUS remodeling grade on transabdominal ultrasound was associated with an increased risk of bladder injury. Patients with Grade-3 remodeling (involving > 50% of the LUS) had 9-times higher odds of a bladder injury compared to patients with Grade-1 remodeling (involving < 30% of the LUS). Preoperative ultrasound examination is useful in the evaluation of the risk of intraoperative bladder injury in patients with a history of prior CD presenting with a low-lying placenta or placenta previa. The larger the remodeling of the LUS on transabdominal ultrasound, the higher the risk of adverse urologic events. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Low-Lying Placenta and Pregnancy Outcomes in a Large National Cohort [ID 2683532

INTRODUCTION: We sought to understand the association of low-lying placenta and adverse pregnancy outcomes among those undergoing cesarean delivery. METHODS: This was a retrospective cohort study of persons undergoing cesarean delivery using the National Inpatient Sample from 2017 to 2019 through HCUP/AHRQ. Patients with placenta previa were excluded. Rates of adverse maternal outcomes were compared between patients undergoing cesaeran delivery with ICD-10 codes of low-lying placenta and those without. The outcomes included were preterm delivery, hemorrhage, hysterectomy, placenta accreta spectrum (PAS), sepsis, shock, disseminated intravascular coagulation (DIC), and transfusion. Groups were compared using ANOVA, chi-squared analysis, logistic and linear regressions to control for confounders. RESULTS: Over 700,000 participants underwent cesarean delivery. 2,664 (0.4%) had low-lying placenta. Affected patients were older, more likely to be anemic, privately insured, undergoing primary cesarean, and deliver at a large/urban teaching hospital. Those with low-lying placenta were more likely to deliver preterm (31.9% versus 14.3%), hemorrhage (27.8% versus 3.8%), undergo hysterectomy (2.0% versus 0.2%), have PAS (2.4% versus 0.2%), receive transfusion (5.4% versus 2.0%) (all P&lt;.001), and experience sepsis, shock, and DIC (all P&lt;.05). Many of these findings persisted after controlling for confounders—preterm delivery (adjusted odds ratio [aOR] 3.07; 95% CI, 2.81–3.35), hemorrhage (aOR 8.87; 95% CI, 8.10–9.73), hysterectomy (aOR 9.42; 95% CI, 7.11–12.47), PAS (aOR 13.41; 95% CI, 10.34–17.39), transfusion (aOR 2.56; 95% CI, 2.14–3.06), and shock (aOR 2.55; 95% CI, 1.44–4.52). CONCLUSION: Low-lying placenta at time of cesarean is associated with adverse outcomes and should be considered in counseling and delivery planning.

Caesarean Section Scar and Placental Location at the First Trimester of Pregnancy-A Prospective Longitudinal Study.

Background and Objectives: This study aims to report the location of the placenta in the first trimester of pregnancy in groups of women according to the number of previous caesarean deliveries and the visibility of the caesarean scar niche. Materials and Methods: The prospective observational research included adult women aged 18 to 41 years during pregnancy after one or more previous caesarean sections (CSs). Transvaginal (TVS) and transabdominal sonography (TAS) was used to examine the uterine scar and placental location during 11-14 weeks. The CS scar niche ("defect") was bordered in the sagittal plane as a notch at the previous CS scar's site with a depth of 2.0 mm or more. A comparative analysis of the placental location (high or low and anterior or posterior) was performed between groups of women according to the CS number and the CS scar niche. Results: A total of 122 participants were enrolled during the first-trimester screening. The CS scar defect ("niche") was visible in 40.2% of cases. In cases after one previous CS, the placenta was low in the uterine cavity (anterior or posterior) at 77.4%, and after two or more CSs, it was at 67.9%. Comparing the two groups according to the CS scar niche, the placenta was low in 75.5% of cases in the participant group with a CS scar niche and in 75% of cases without a CS scar niche (p = 0.949). Conclusions: The number of previous caesarean deliveries has no effect on the incidence rate of low-lying placentas in the first trimester. Moreover, the presence of the CS scar niche is not associated with anterior low-lying placentas.

Risk factors for placenta accreta spectrum disorders in women with any prior cesarean and a placenta previa or low lying: a prospective population-based study

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.

Catastrophic Morbidly Adherent Posterior Placenta: Case Reports, Literature Review Current Through at Long Time Since Cases Registration

There are analyzed the difficulties and accuracy of diagnosis, in conjunction to the moment technical opportunities at long interval after registration (2009, 2012) in two cases of posterior Morbidly Adherent Placenta/Placenta Accreta Spectrum (MAP/PAS), with deep myometrial invasion (grade 3B) and uterine serosa perforation (grade 3E), a contemporary serious disease generating severe maternal coagulation disorders, multiple organ failure and hemorrhagic shock up to death, after total hemostasis hysterectomy. Undiagnosed or suspicious second trimester posterior MAP/PAS, in low-lying placenta, morbid obesity (BMI&gt;40), in an intact uterus, or in a scar uterus post cesarean delivery (CD) were followed by maternal death. In countries with low-to-middle income/ resources, and few centers of excellence, medical staff surgical qualities, and well trained interdisciplinary team must meet patients’ and their families trust and cooperation, and timely available life-saving resources for complex therapies in critical care cases, and hospital infrastructure to benefit from actual expanded knowledge and guidelines.

Three-dimensional volume rendering ultrasound for assessing placenta accreta spectrum severity and discriminating it from simple scar dehiscence

Prenatal ultrasound discrimination between placenta accreta spectrum and scar dehiscence with underlying nonadherent placenta is challenging both prenatally and intraoperatively, which often leads to overtreatment. In addition, accurate prenatal prediction of surgical difficulty and morbidity in placenta accreta spectrum is difficult, which precludes appropriate multidisciplinary planning. The advent of advanced 3-dimensional volume rendering and contrast enhancement techniques in modern ultrasound systems provides a comprehensive prenatal assessment, revealing details that are not discernible in traditional 2-dimensional imaging. This study aimed to evaluate the use of 3-dimensional volume rendering ultrasound techniques in determining the severity of placenta accreta spectrum and distinguishing between placenta accreta spectrum and scar dehiscence with underlying nonadherent placenta. A prospective, cohort study was conducted between July 2022 and July 2023 in the fetal medicine unit of Dr Soetomo Academic General Hospital, Surabaya, Indonesia. All pregnant individuals with anterior low-lying placenta or placenta previa with a previous caesarean section who were referred with suspicion of placenta accreta spectrum were consented and screened using the standardised 2-dimensional and Doppler ultrasound imaging. Additional 3-dimensional volumes were obtained from the sagittal section of the uterus with a filled urinary bladder. These were analyzed by rotating the region of interest to be perpendicular to the uterovesical interface. The primary outcomes were the clinical and histologic severity in the cases of placenta accreta spectrum and correct diagnosis of dehiscence with nonadherent placenta underneath. The strength of association between ultrasound and clinical outcomes was determined. Multivariate logistic regression analyses and diagnostic testing of accuracy were used to analyze the data. A total of 70 patients (56 with placenta accreta spectrum and 14 with scar dehiscence) were included in the analysis. Multivariate logistic regression of all 2-dimensional and 3-dimensional signs revealed the 3-dimensional loss of clear zone (P<.001) and the presence of bridging vessels on 2-dimensional Doppler ultrasound (P=.027) as excellent predictors in differentiating scar dehiscence and placenta accreta spectrum. The 3-dimensional loss of clear zone demonstrated a high diagnostic accuracy with an area under the curve of 0.911 (95% confidence interval, 0.819-1.002), with a sensitivity of 89.3% (95% confidence interval, 78.1-95.97%) and specificity of 92.9% (95% confidence interval, 66.1-99.8%). The presence of bridging vessels on 2-dimensional Doppler demonstrated an area under the curve of 0.848 (95% confidence interval, 0.714-0.982) with a sensitivity of 91.1% (95% confidence interval, 80.4-97.0%) and specificity of 78.6% (95% confidence interval, 49.2-95.3%). A subgroup analysis among the placenta accreta spectrum group revealed that the presence of a 3-dimensional disrupted bladder serosa with obliteration of the vesicouterine space was associated with vesicouterine adherence (P<.001). Three-dimensional volume rendering ultrasound is a promising tool for effective discrimination between scar dehiscence with underlying nonadherent placenta and placenta accreta spectrum. It also shows potential in predicting the clinical severity with urinary bladder involvement in cases of placenta accreta spectrum.

A vaginal birth is a cost-reduction strategy for women with a low-lying placenta.

Alongside health consequences, cesarean delivery (CD) has been associated with increased healthcare resource utilization (HCRU). A CD should be performed in case of placenta previa; in turn, the most appropriate mode of birth in women with a low-lying placenta (LLP) is still controversial. Since no previous data are available on the topic, the aim of this study was to evaluate the HCRU and economic impact on the Italian HC system of vaginal birth (VB) and CD in women with a LLP. This retrospective study used patient-level real-world data of a cohort of women with a LLP confirmed at 28-30 weeks. A cost-minimization analysis (CMA) was conducted to compare VB and CD. Since Diagnosis-Related-Group payment may not reflect the actual use of hospital resources, a micro-costing analysis (MCA) was performed to more comprehensively evaluate the economic impact of VB and CD. The study included 86 women with a LLP at the third trimester scan, of which 49 (57%) had a VB and 37 (43%) underwent a CD. The CMA showed an economically marginal difference between VB and CD, especially when considering opportunity costs associated with the resources needed to look after women. However, the MCA identified charges for each VB being about half of those for each CD. The use of patient-level real-world data allowed to generate basic information to assess the value of available interventions in case of LLP. A VB should be promoted in women with LLP, avoiding further burden on the HC system's limited resources.

A Cross Sectional Study of Second Trimester Sonographically Diagnosed Low-Lying Placenta and Associated Maternal and Neonatal Outcomes at Delivery

A Cross Sectional Study of Second Trimester Sonographically Diagnosed Low-Lying Placenta and Associated Maternal and Neonatal Outcomes at Delivery

1122 Revisiting low-lying placenta: internal os distance and pregnancy outcomes

1122 Revisiting low-lying placenta: internal os distance and pregnancy outcomes

Risk factors for non-previa placenta accreta spectrum in pregnancies conceived through frozen embryo transfer during a hormone replacement cycle in Japan.

Non-previa placenta accreta spectrum (PAS) is associated with assisted reproductive technology (ART), particularly frozen embryo transfer during hormone replacement therapy (HRC-FET). We especially aimed to evaluate the prevalence and risk factors for non-previa PAS in HRC-FET pregnancies. Overall, 279 women who conceived through ART at three ART facilities and delivered at a single center were included in this retrospective study. Data regarding endometrial thickness at embryo transfer, previous histories, and type of embryo transfer-HRC-FET, frozen embryo transfer during a natural ovulatory cycle (NC-FET), and fresh embryo transfer (Fresh-ET)-were collected. Univariable logistic regression analyses were conducted. The prevalence of non-previa PAS was 27/192 (14.1%) in the HRC-FET group and 0 (0.0%) in both the NC-FET and Fresh-ET groups. Significantly high odds ratio [95% confidence interval] of non-previa PAS was associated with a history of artificial abortion (6.45 [1.98-21.02]), endometrial thickness <8.0 mm (6.11 [1.06-35.12]), resolved low-lying placenta (5.73 [2.13-15.41]), multiparity (2.90 [1.26-6.69]), polycystic ovarian syndrome (2.62 [1.02-6.71]), and subchorionic hematoma (2.49 [1.03-6.04]). A history of artificial abortion, endometrial thickness <8.0 mm, and resolved low-lying placenta may help in antenatal detection of a high-risk population of non-previa PAS in HRC-FET pregnancies.

Increased risk of placenta previa and preterm birth in pregnant women with endometriosis/adenomyosis: A propensity-score matching analysis of a nationwide perinatal database in Japan.

We aimed to investigate the associations of endometriosis and adenomyosis with pregnancy complications by using a large-scale Japanese database. We retrospectively analyzed 145 590 singleton pregnancies from the Japan Perinatal Registry Network Database. Pregnant women registered as having endometriosis or adenomyosis were designated as the case group (EA), whereas the control group (non-EA) was selected using propensity-score matching adjusted for variables such as age, parity, BMI, smoking history, and the use of assisted reproductive technology. The main outcomes included placental malposition, preterm birth, and hypertensive disorders of pregnancy (HDP). In total, 1203 patients from both the EA and non-EA groups were matched and evaluated. The EA group showed significantly higher rates of placenta previa (odds ratio [OR], 3.01; 95% confidence interval [CI], 1.84-4.92), low-lying placenta (OR, 2.02; 95% CI, 1.06-3.86), and preterm birth (OR, 1.44; 95% CI, 1.13-1.84) than the non-EA group. However, no significant difference was observed in the incidence of HDP (OR, 1.22; 95% CI, 0.90-1.66). The use of propensity-score matching to analyze a nationwide perinatal database in Japan clarified that EA was associated with increased pregnancy complications, specifically placental malposition, including placenta previa and low-lying placenta, and preterm birth, but not with HDP.

Accuracy of Ultrasound in the Prediction of the FIGO Classification of Placenta Accreta Spectrum

ObjectivesTo evaluate the accuracy of greyscale ultrasound (US) and colour Doppler detecting placenta accreta spectrum (PAS) based on the newly recommended International Federation of Obstetrics and Gynaecology (FIGO) grading system. MethodsThis prospective study was conducted on women diagnosed with placenta previa or low-lying placenta involving the anterior uterine wall and associated with PAS as identified by the US. Transabdominal and transvaginal greyscale US was performed on admission between 34 and 36 weeks of gestation and compared to clinical grading and histopathological examination after cesarean hysterectomy. ResultsIn total, 36 pregnant females who underwent a cesarean hysterectomy due to placenta previa complicated by PAS were included in this study. All patients had a history of previous cesarean deliveries, ranging from 1 to 5 deliveries. The US has an overall sensitivity of 33%, 55%, and 84.62%, and specificity of 100%, 75%, and 60% in detecting the 3 degrees of PAS, respectively. US cannot differentiate between the different subtypes of PAS grade 3 (a, b, and c). ConclusionThe overall US evaluation was highly significant in predicting the FIGO diagnosis of PAS; however, all ultrasonographic signs were equally relevant in diagnosing grade 1 and/or 2 PAS and were inaccurate in differing the subtypes of PAS grade 3.

Can the Pfannenstiel skin incision length be adjusted according to the fetal head during elective cesarean delivery?

The study aims to determine whether the Pfannenstiel skin incision can be adjusted according to the fetal head's occipitofrontal diameter (OFD) during primary cesarean delivery. Eligible 114 nulliparous women delivered at term by cesarean section in which Pfannenstiel skin incision was performed according to the OFD of the fetal head between June 2017 and September 2021 were included. Excluded cases were non-vertex presentations, all emergency cesarean sections, severe preeclampsia, women in an active phase of the first stage of labor and second stage of labor, placenta previa and low-lying placenta, multiple pregnancies, and uncontrolled gestational diabetes mellitus. Among 114 eligible nulliparous women, the mean OFD was 116.1 ± 7.2 (99-138) mm, and the measurement of the Pfannenstiel skin incision length, which was performed according to the OFD was found to be 122.8 ± 9.2 (100-155) mm. The difference between OFD and Pfannenstiel incision kept remained within 10 mm in 90 (82.5.2%), 10-20 mm in 17 (15.5%), and more than 20 mm in two women (1.8%). This technique was successful in 109 (95.6%) out of 114 women without extending the skin incision. In five women, skin incision needed to be extended up to 38 mm. In 10 women (8.7%), the rectus abdominis muscle was cut partially to deliver the fetal head. The mean fetal umbilical artery pH was 7.33 ± 0.05. No neonatal hypoxia was encountered in the study. Pfannenstiel skin incision can be adjusted according to the OFD with minimal margins of error. This technique may provide better cosmetic results by avoiding unnecessarily prolonged incisions with similar newborn outcomes. Clinicaltrials.gov, identifier [NCT05632796].

Prophylactic radiologic interventions to reduce postpartum hemorrhage in women with risk factors for placenta accreta spectrum disorder: a nationwide cohort study

Objective To quantify the association between prophylactic radiologic interventions and perioperative blood loss in women with risk factors for placenta accreta spectrum disorder (PAS) Methods We conducted a retrospective nationwide cohort study of women with risk factors for placenta accreta spectrum disorder who underwent planned cesarean section in 69 Dutch hospitals between 2008 and 2013. All women had two risk factors for PAS: placenta previa/anterior low-lying placenta and a history of cesarean section(s). Women with and without ultrasonographic signs of PAS were studied as two separate groups. We compared the total blood loss of women with prophylactic radiologic interventions, defined as preoperative placement of balloon catheters or sheaths in the internal iliac or uterine arteries, with that of a control group consisting of women without prophylactic radiologic interventions using multivariable regression. We evaluated maternal morbidity by the number of red blood cell (RBC) units transfused within 24 h following childbirth (categories: 0, 1–3, >4), duration of hospital admission, and need for intensive care unit (ICU) admission. Results A total of 350 women with placenta previa/anterior low-lying placenta and history of cesarean section(s) were included: 289 with normal ultrasonography, of whom 21 received prophylactic radiologic intervention, and 61 had abnormal ultrasonography, of whom 22 received prophylactic intervention. Among women with normal ultrasonography without prophylactic intervention (n = 268), the median blood loss was 725 mL (interquartile range (IQR) 500–1500) vs. 1000 mL (IQR 550–1750) in women with intervention (n = 21); the adjusted difference in blood loss was 9 mL (95% confidence interval (CI) −315–513), p = .97). Among women with abnormal ultrasonography, those without prophylactic intervention (n = 39) had a median blood loss of 2500 mL (IQR 1200–5000) vs. 1750 mL (IQR 775–4000) in women with intervention (n = 22); the adjusted difference in blood loss was −1141 mL (95% CI −1694– −219, p = .02). Results of outcomes on maternal morbidity were comparable among women with and without prophylactic intervention. Conclusion These findings suggest that prophylactic radiologic interventions prior to planned cesarean section may help to limit perioperative blood loss in women with clear signs of placenta accreta spectrum disorder on ultrasonography, but there was no evidence of a difference within the subgroup without such ultrasonographic signs. The use of these interventions should be discussed in a multidisciplinary shared decision-making process, including discussions of potential benefits and possible complications. Trial registration Netherlands Trial Registry, https://onderzoekmetmensen.nl/en/trial/28238, identifier NL4210 (NTR4363)