Morbid Adherence Research Articles

Near miss cases during cesarean hysterectomy due to morbid adherence of placenta at Al-Yarmouk Teaching Hospital

Near miss cases during cesarean hysterectomy due to morbid adherence of placenta at Al-Yarmouk Teaching Hospital

Diagnostic Accuracy of Placental Thickness in Lower Uterine Segment Measured by Ultrasound in Prediction of Placenta Accreta Spectrum in Patients with Placenta Previa. A Diagnostic Test Accuracy Study.

The aim of the study was to evaluate the association between placental thickness and placenta accreta spectrum (PAS) in patients with placenta previa. In this prospective study, 40 patients diagnosed with placenta previa were included. The maximum placental thickness in the lower uterine segment was obtained using a transabdominal scan. For the image to be deemed suitable, a midline sagittal section of the lower uterine segment (with the implanted placenta) and the cervical canal, with the intervening urinary bladder had been required. Intraoperative attendance was ensured for the detection of cases with spontaneous separation and cases with morbid adherence. All specimens removed were sent for histopathology to confirm PAS. The primary outcome of the study was to detect a threshold of placental thickness which can be used as a cut-off value in such screening test. The number of units of packed RBCs transfused during the operation and bladder injury were secondary measures of outcome. Forty patients were included in the study; 20 patients were ultimately diagnosed with PAS while 20 patients did not have PAS. Mean placental thickness was significantly higher in the PAS patients compared with those with no invasive placentation (61.00 mm Vs 43.00 mm, P value 0.000). Using receiver operating characteristic (ROC) curve, a threshold placental thickness of 58mm was associated with 55% sensitivity, 90% specificity, 84.6% positive predictive value, and 66.7% negative predictive value. Multivariate logistic regression showed that placental thickness more than 58mm and having past history of more than three cesarean sections were independent risk factors for PAS among patients with placenta previa. Placental thickness in the lower uterine segment is increased in patients with placenta previa with PAS compared to those with no PAS. Such finding can be implemented into clinical practice by using placental thickness as a screening test for PAS in patients with placenta previa. NCT05500404.

Foeto-Maternal Outcome in Women with Placenta Praevia and Morbidly Adherent Placenta Praevia

Objective: To determine the maternal and foetal outcome in pregnant women with placenta praevia and morbidly adherent placenta praevia Methodology: A prospective case series was carried out in a tertiary care institution between 2019 and 2021. All pregnant women with placenta praevia and placenta accreta spectrum who were over 28 weeks gestation were included, regardless of whether they received their diagnoses during pregnancy or during surgery. Data was collected on structured proforma regarding demographic characteristics, obstetric factors, management options, and intraoperative complications to determine foeto-maternal outcome in women with placenta praevia and morbidly adherent placenta praevia. Results: Total number of patients with placenta praevia was 140; out of which 31 (22.1%) had placenta accreta spectrum. All cases of morbid adherence were found in major degree placenta praevia (p= 0.00). Antepartum haemorrhage in current pregnancy was more associated with placenta praevia as compared to morbidly adherent placenta praevia (p=0.00). Both placenta praevia with and without morbid adherence led to preterm birth (p=0.00). LSCS as mode of delivery in previous pregnancy, step-wise-devascularization, caesarean hysterectomies, bladder injury, blood loss more than 1000ml, number of blood transfusions, and mothers required ICU care were significantly associated (p≤0.05) with morbidly adherent placenta praevia as compare to placenta praevia without morbid adherence. In cases of placenta accreta spectrum; 11(33.3%) babies were admitted in NICU as compare to 29(25.9%) in placenta praevia without placenta accreta spectrum. Conclusion: Placenta praevia is adversely affected by placenta accreta spectrum is associated with higher foeto-maternal morbidity as compared to placenta praevia without adherence.

Study on Frequency of Placenta Previa and Morbidly Adherent Placenta in Patients with Previous Cesarean Sections

Objective: To determine the frequency of different positions of placenta previa and morbidly adherent placenta in women who had previous multiple cesarean section reporting at Department of Gynecology and Obstetrics, Isra University Hospital.
 Patients and Method: This cross sectional was done at department of Gyne/Obs and department of Radiology ISRA University Hospital Hyderabad during one year. An informed consent was taken from pregnant women during antenatal diagnosed to have placenta previa or morbidly adherent placenta on ultrasound with history of previous C-section. The clinical / abdominal examination was done and proformas were filled, the location of placenta previa and morbid adherence was confirmed during C-section and observations were recorded for results. Data was collected via study proforma and analysis of data was done by using SPSS version 26.
 Results: The mean of the patients was 29.31+5.17years. Most of the study participating women 87(87%) gave the history of Cesarean sections during previous deliveries, while only 13(13%) women had history of NVDs (normal vaginal deliveries) and Cesarean sections both. Out of all 33% patients observed with placenta previa and morbidly adherent placenta in women who had previous multiple cesarean section, particularly the previa I to IV 22.0%, placenta accreta 4%, placenta percreta 4% and least common type was placenta increta 3%. Incidence of the placenta previa and morbidly adherent placenta in women who had previous multiple cesarean section was statistically insignificant according number of c-sections (p-0.39).
 Conclusion: As per study conclusion the placenta previa and morbidly adherent placenta was observed to be the highly frequent among women who had previous multiple cesarean section. There was no effect observed of the number of caesarean sections performed, implying that one previous caesarean may have caused placenta previa and morbidly adherent placenta.

Maternal Outcome in Patient having Morbid Adherence of Placenta after Hysterectomy

Maternal Outcome in Patient having Morbid Adherence of Placenta after Hysterectomy

Ureter injury in obstetric hysterectomy with placenta accreta spectrum: Case report.

Introduction and importancePlacenta accreta spectrum (PAS) is a state of abnormal attachment of the placenta, including placenta accreta, placenta increta, and placenta percreta. This condition can be life-threatening due to the placenta cannot spontaneously separated, resulting in continuous bleeding. Cesarean section followed by hysterectomy is one of the treatment options for PAS. There was a great liability for urinary tract injuries during the operation of PAS patient.Case presentationWe present the case of ureter injury during subtotal hysterectomy in patient with PAS. A 30-years-old female patient was diagnosed with recurrent antepartum hemorrhage due to placenta previa accreta spectrum on G2P1 33 weeks of gestational age, singleton live breech presentation, previous c-section 1×. After uterine transverse incision, the baby was delivered. We decided to perform subtotal hysterectomy. There was severe adhesion. On the exploration after subtotal hysterectomy was performed, we found ruptured of the right ureter.Clinical discussionHysterectomy peripartum is one of the treatment of PAS, either to prevent or to control postpartum hemorrhage. In pregnant women with morbid placental adherence, there was a great liability for urinary tract injuries. Distal ureters are the most commonly injured while hysterectomy. Injuries to the ureters in this patient occurred due to severe adhesions and unclear visual organ.ConclusionAlthough it is rare, ureter injury may occur during subtotal hysterectomy in patient with placenta accreta spectrum. To prevent that condition, inserting ureter stent can be perform before the operation. Multidisciplinary approach is carried out so that patient outcomes are good.

Diagnostic accuracy of doppler ultrasound scan in identifying morbid adherence in patients with placenta previa.

Diagnostic accuracy of doppler ultrasound scan in identifying morbid adherence in patients with placenta previa.

Placenta Increta Presenting as Retained Placenta: A Report of 3 Cases

Objectives: Morbid adherence is a risk factor for retained placenta (RP). We encountered three cases of placenta increta presenting clinically as delayed postpartum hemorrhage. Methods: This was a retrospective study of three cases of placenta increta presenting as RP. Results: One “routine” term placenta had heavy bleeding 2 weeks later; one missed abortion at 16 weeks with fetal and placental tissue submitted, had heavy bleeding 6 weeks later; and one elective abortion (no tissue submitted), had delayed postpartum bleeding leading to a curettage with blood only, then 6 weeks later a hysterectomy for menorrhagia. All 3 pathology specimens showed necrotic villi. However, all three also showed myometrium with keratin-positive interstitial trophoblasts in a zone of damaged myometrium, consistent with increta. All three cases had basal plate myofibers (BPMF) in the placenta, with BPMF recurrence in the two cases with another pregnancy. Conclusion: RP may be a presenting clinical manifestation of placenta increta.

Recurrence of Basal Plate Myofibers, with Further Consideration of Pathogenesis

Objectives: Basal plate myofibers (BPMF) may indicate morbid adherence. We assessed recurrence and clinical progression of BPMF. Methods: In 5 years, 135 BPMF placentas were reported. Controls were the first 50 placentas in 2009, none of which had reported BPMF. Results: 32% of BPMF patients had other placentas, with a recurrence rate of 100%. Actin stains were needed for diagnosis in 117/179 cases (65%). These cases had clinical features suggestive of morbid adherence in 69/117 (59%). 23/47 (49%) of BPMF recurrences progressed in severity, 5 to hysterectomy (11%). Thinning of the basal plate, perforating vessels, gaps in the basal plate, and villi under the basal plate were observed in BPMF placentas. Conclusions: These findings appear to validate screening for BPMF. The 100% recurrence rate suggests evaluation for a heritable factor, i.e., protease inhibitor deficiency, which may explain pre-delivery basal plate damage.

Incidence of Placenta Accreta and Its Complications in Cases of Previous Cesearean Sections with Placenta Praevia Anterior at El-Sayed Galal Hospital

Background: due to the increasing rate of cesarean delivery, there has been a 10-fold rise in the incidence of placenta accreta since the 1970. In a recent survey, placenta accreta was even found to become the leading cause of emergency peripartum hysterectomy which represented 40–60% of cases. Aim of the Work: the purpose of this study was to determine the incidence of placenta accreta and its complications in cases of previous cesarean sections with placenta praevia anterior at El-Sayed Galal Univerity Hospital. Patients and Methods: this prospective study was done at El-Sayed Galal Maternal Unevirsity Hospital during the period from March 2017 to March 2018 on 100 pregnant women diagnosed by ultrasound as placenta praevia or low lying placenta anterior with previous cesarean section, they were selected from Outpatient Clinic, Ultrasound Unit and women admitted in El-Sayed Galal Maternal University Hospital Departments. Results: the incidence of placenta accreta in cases of previous cesarean section with placenta praevia anterior were 63%. Risk factors of placenta accreta were: 1) Placenta praevia with prior cesarean section. All cases had placenta praevia and had at least one previous CS, 2) Increased maternal age (the mean age 32.60±5.018 years in cases of placenta accrete ), and 29.14±4.889 years in cases with normal placenta. 3) Multiparity [the median parity was 3 (range: 1-6). The ultrasonography and Doppler was suggestive of morbid adherence in 60 cases (95.2%)of cases approved with placenta accreta, with accuracy 96, sensiyivity 95.24, specificity 97.3, +ve predictive value 98.36, and -ve predictive value 92.31. The intraoperative data were:, - Cesarean hysterectomy performed in all cases of placenta accrete (63 cases), and 2 cases (5.4%) of normal placenta due to severe bleeding from placental ped and uterine atony. , - Bladder injury occured in 31 cases(49.2%) all of them approved placenta accreta, all of them do C.S hystrectomy and performed bladder repair. Bowel injury in 2 cases (3.2%) all of them have placenta accreta and C.S hysterectomy done. All cases of placenta accreta received intra operative blood transfusion. Uterine preserving procedures (Bakry balloon) done in one case after spontaneous separation of the placenta. The postoperative data were:, - ICU admission occurred in 40 cases (63.5%) of cases with placenta accrete, and in 2 cases (5.4%) of cases with normal placenta. 61 cases (96.8%) of cases with placenta accreta received postoperative blood transfusion. -No cases complicated with DIC or death. Conclusion: from the above our results showed that the incidence, risk factors and Feto-maternal outcome of management of Patients with placenta accreta at El-Sayed Galal University Maternity Hospital are comparable with those in the previous literatures.

Peripartum Hysterectomy and Analysis of Risk Factors

Aims: To determine the incidence and risk factors of women undergoing peripartum hysterectomy at BPKIHS, Dharan.Methods: A descriptive study was conducted for all women undergoing peripartum hysterectomy in two years from July 2012 to June 2014.Various maternal characteristics including demographic data, previous obstetric details, antepartum, intrapartum and postpartum data were collected and analysed.Results: There were 29 cases of peripartum hysterectomy among 19,539 births in 2 yrs (1.48 per 1000 births). Indications for peripartum hysterectomy were uterine rupture (65.5%), morbid adherence of the placenta (13.8%) and uterine atony (12.9%). Previous caesarean section was identified as independent risk factor with relative risk of 1.8 (95% CI 1.3-2.5, p< 0.003). Maternal morbidity was significant with febrile morbidity and urinary tract injury among the most common complications.Conclusions: Uterine rupture causing severe haemorrhage was the commonest indication for peripartum hysterectomy. Timely intervention reduces the peripartum maternal and perinatal morbidity and mortality.

Urinary tract injuries during cesarean section in patients with morbid placental adherence: retrospective cohort study

Background/objective: The purpose of this study is to evaluate the cases of lower urinary tract injuries during cesarean section with or without hysterectomy in cases with morbid placental adherence.Methods: This record based retrospective study was conducted at Ain Shams University Maternity Hospital in Cairo, Egypt during the period between January 2014 and December 2016. It included all patients who had urinary tract injuries during cesarean section with or without hysterectomy in the cases with morbid placental adherence and they were collected from files of pregnant women who were admitted at hospital planned for termination of pregnancy. Patients were enrolled in four groups, Group 1: cases without urinary tract injuries. Group 2: cases with injuries to the bladder. Group 3: cases with injuries of the ureter. Group 4: cases with injuries to the bladder and ureter.Results: This study gave us new information about the incidence of urinary tract injuries during cesarean section with morbid adherence placenta was 21.7% (Bladder 11.7%, Ureter 4.7%, and bladder with ureter 5.3%). There were various types of repair of urinary tract injury, as the following, bladder repair 10.8%, ureteric catheterization 0.9%, ureterovesical repair or reimplantation 1.5%, bladder repair and ureterovesical 1.2%, bladder repair and ureteric catheterization 2.3%, ureteric catheterization and ureterovesical 1.5 and 6.4% of cases needed urologic consultations. There is a real relation between urinary tract injury and obesity (55.3%). Bladder invasion was found in only 26.9% of all cases according to sonography findings. Most of the cases were delivered by cesarean section in 67.5%, and the remainders were delivered by cesarean hysterectomy 32.5%. About 96.5% of cases needed a blood transfusion.Conclusions: The morbid adherent placenta is still a challenge, which faces us as obstetricians, due to high morbidity and mortality. A multidisciplinary team is mandatory to avoid complications.

Association of Retroplacental Blood With Basal Plate Myofibers.

Objectives Diagnosed clinical abruption showing blood clot should be signed out in the pathology report as retroplacental hemorrhage with or without parenchymal indentation, and submitted clot separate from the placenta should be weighed. In our experience, some cases sent as clinical abruptions have been cases of morbid adherence. This study was undertaken to evaluate the association of retroplacental blood with basal plate myofibers (BPMF). Methods One hundred fifty-six placentas reviewed by a board-certified pediatric pathologist at a community hospital were evaluated for significant retroplacental blood. Basal plates were reviewed for deviations from normal. Results Of the 156 placentas, 33 (21%) had significant retroplacental blood; 21/156 (13%) had a separate clot, of which 11/21 (52%) had BPMF. Eleven BPMF-associated separate clots ranged from 10.5 to 60 g (average 23), while the clots of 10 cases with no demonstrated BPMF ranged from 19 to 440 g (average 82), tending to be larger ( p < .03). Basal plate damage prior to delivery was noted in both sets of placentas. BPMF placentas could have myometrial damage prior to delivery. Conclusions Since BPMF may confer a risk for accreta in a subsequent pregnancy, submission of a separate clot with the placenta should lead the pathologist to evaluate for basal plate myofibers on H&E and consider if there is an evidence-based indication to do an actin stain, before presuming a diagnosis of abruption.

Placenta Accreta and Placenta Increta: An Approach to Pathogenesis Based on the Trophoblastic Differentiation Pathway.

Morbid adherence remains a puzzling disease. This paper suggests that normal and morbidly adherent placentation may be viewed best in terms of trophoblastic stem cells and the mutually exclusive branches of the trophoblastic differentiation pathway-villous trophoblast (VT), interstitial and endovascular nonvillous trophoblast (NVT) at the implantation site, and a positional variation in the chorion. Based on cases of hysterectomies for morbid adherence seen over 30 years at a community hospital, analyzed with routine keratin stains, with actin and trichrome stains as indicated, and with attempts at ultrasonography-pathology correlation, we present selected observations. In true accreta, the site of morbid adherence was to dilated basal plate vessels infiltrated by endovascular NVT, with scant interstitial NVT, and normal myometrium. It appeared that excess blood flow into the placenta was due to excessively deep keratin-positive endovascular NVT that spread-independently of interstitial NVT-in an angiocentric fashion in both accreta and increta. Retroplacental abnormalities were due to myometrial destruction by interstitial NVT in increta, sometimes requiring actin stains for detection; and to an admixture of markedly dilated endometrial glands and vessels in true accreta, best appreciated with keratin stains. Variations of depth and extent in increta may be due to variations in myometrial tone, and in the protease-antiprotease balance. Morbidly adherent fetal membranes are described, and the role of caesarean section scars in incretas is addressed.

Surgical management of abnormally invasive placenta: a retrospective cohort study demonstrating the benefits of a standardized operative approach.

Abnormally invasive placenta is a major cause of maternal morbidity and mortality. The aim of this study was to assess the effectiveness of a standardized operative approach performed by gynecological oncologists in the surgical management of abnormally invasive placenta. We performed a retrospective analysis of all cases of morbid placental adherence managed at the Mater Mothers' Hospitals, Brisbane, Australia between January 2000 and June 2013. A standard operative approach involving extensive retro-peritoneal and bladder dissection before delivery of the fetus, was undertaken when a gynecological oncologist was present at the start of the procedure. Main outcome measures were estimated blood loss, transfusion requirements, and maternal and neonatal morbidity. The study includes 98 cases of histologically confirmed abnormally invasive placenta. Median estimated blood loss for the entire cohort was 2150 mL (range 300-11 500 mL). Women were divided into three groups, (1) those who had a gynecological oncologist present at the start of the procedure (group 1; n = 43), (2) those who had a gynecological oncologist called in during the procedure (group 2; n = 23), and (3) those who had no gynecological oncologist involved (group 3; n = 32). Group 2 had a significantly higher blood loss than the other groups (p = 0.001) (median 4400 mL). Transfusion requirements were higher in groups 2 and 3 compared with group 1 (p = 0.004). Other maternal and neonatal morbidity was similar across all three groups. This study supports the early presence of a gynecological oncologist at delivery when abnormally invasive placenta is suspected and demonstrates that a "call if needed" approach is not acceptable for these complex cases.

Morbid adherence of the placenta-a disease of nonvillous trophoblast?

Morbid adherence of the placenta-a disease of nonvillous trophoblast?

Peripartum hysterectomy in a tertiary hospital in Western Sydney

The aim of this study was to review the incidence, indication, management and complications of peripartum hysterectomy (PH) in a tertiary level hospital over a decade. A retrospective review of all cases of PH performed at Westmead Hospital, Western Sydney, 2003–2012, was undertaken. PH was defined as hysterectomy performed after 20 weeks’ gestation or any time after delivery but within 6 weeks’ postpartum (Awan et al. 2011). There were 56 cases of peripartum hysterectomy of 46,177 births, a rate of 1.22 per 1,000 births. The most common indication for PH was morbid adherence of the placenta (58.2%) followed by uterine atony. Having a history of both caesarean section and placenta praevia is highly associated with a morbidly adherent placenta in the index pregnancy (p = 0.002). The most common complication was coagulopathy followed by febrile illness and urinary tract injury. Our data showed previous caesarean section and placenta praevia to be associated with abnormal placentation, the leading indication for PH. Since there is an association between a planned caesarean hysterectomy and reduced amount of estimated blood loss and blood transfused, the knowledge of placentation and adequate preoperative planning and consideration for elective hysterectomy could be beneficial. The morbidity associated with PH is considerable.

Incidence of emergency peripartum hysterectomy in Ain-shams University Maternity Hospital, Egypt: a retrospective study.

To estimate the incidence of emergency peripartum hysterectomy over 6 years in Ain-shams University Maternity Hospital. Detailed chart review of all cases of emergency peripartum hysterectomy, 2003-2008, including previous obstetric history, details of the index pregnancy, indications for emergency peripartum hysterectomy, outcome of the hysterectomy and infant morbidity. The overall rate of emergency peripartum hysterectomy was 149 of 66,306 or 2.24 per 1,000 deliveries. The primary indications for hysterectomies were placenta accreta/increta 59 (39.6 %), uterine atony 37 (24.8 %), uterine rupture 35 (23.5 %) and placenta previa without accreta 18 (12.1 %). After hysterectomy, 115 (77 %) women were admitted to the intensive care unit. Women were discharged home after a mean 11.2 day length of stay. Using multifactorial logistic regression analysis, we found that woman's age, atonic uterus, placenta accreta/increta, previous cesarian section and ruptured uterus were independent predictors for peripartum hysterectomy Abnormal placentation was the main indication for peripartum hysterectomy. The risk factors for peripartum hysterectomy were morbid adherence of placentae in scared uteri, uterine atony and uterine rupture. The most important step in prevention of major postpartum hemorrhage is recognizing and assessing women's risk. The risk of peripartum hysterectomy seems to be significantly decreased by limiting the number of cesarean section deliveries, thus reducing the occurrence of abnormal placentation in the form of placenta accreta, increta or percreta.

Real increasing incidence of hysterectomy for placenta accreta following previous caesarean section

ObjectivePlacenta accreta, morbid adherence to the uterus to the myometrium, is commonest in association with placenta previa in women previously delivered by caesarean section (CS). It has become proportionally a greater cause of major maternal morbidity and mortality as the frequency of other serious obstetric complications has declined. The aim of this study was to examine the incidence of placenta accreta in the context of a rising caesarean delivery rate. Study designRetrospective review of the incidence of placenta accreta in parous women during the 36 years 1975–2010. Cases were identified from hospital records and then correlated with pathological reports. The incidence of placenta accreta was analysed in the context of women previously delivered by CS. ResultsDuring the 36-year period in our unit, 157,162 multiparous women delivered, of whom 15,151 (9.6%) had a previous CS scar. The institutional incidence of CS rose from 4.1% in 1975 to 20.7% in 2010. Twenty-five parous women, all with a previous CS, had placenta accreta requiring hysterectomy. The overall incidence of placenta accreta was 1.65 per 1000 parous women with a previous CS, but was low (1.06/1000) until 2002. From 2003 to 2010 the incidence rose to 2.37/1000 previous CS deliveries (OR 2.2; 95% CI 1.05–5.1). ConclusionThe frequency of placenta accreta correlated steadily with the CS rate until 2000. Since then, the incidence has nearly doubled in women with previous CS scars, suggesting an additional causative influence on risk.

Placenta and Transvaginal Sonography

ABSTRACT In recent years, transvaginal evaluation of the placenta has completely changed the way obstetricians need to perceive and assess a low-lying placenta. Additionally, the number of negative ultrasound examinations in morbid placental adherence has reduced. This article presents the evidence on the safety and accuracy of transvaginal placental evaluation and goes on to discuss the manner in which transvaginal findings should alter clinical protocols to optimize maternal and fetal outcomes. It also answers a very pertinent clinical question: How low is low? How to cite this article Khurana A. Placenta and Transvaginal Sonography. Donald School J Ultrasound Obstet Gynecol 2012;6(4):391-397.