Placenta Accreta Spectrum Research Articles

Evaluation of ProBNP and Troponin I in Cases of Placenta Accreta Spectrum Disorders and Placenta Praevia

Evaluation of ProBNP and Troponin I in Cases of Placenta Accreta Spectrum Disorders and Placenta Praevia

Surgical Outcomes and Associated Morbidity of Active and Expectant Management of Second-Trimester Placenta Accreta Spectrum (PAS)

Background and Objectives: Management of second-trimester placenta accreta spectrum (PAS) is currently center-dependent with minimal evidence-based practices. This study aims to analyze outcomes of hysterectomy as second-trimester active management (AM) versus cesarean hysterectomy as expectant management (EM) in cases of PAS with intraoperative and postoperative outcomes. Materials and Methods: This study is a retrospective case-control study of patients with a pathology-confirmed diagnosis of PAS managed at a single center over 16 years (2005–2020). All cases were diagnosed during the first or second trimester by ultrasonography and managed by the same multidisciplinary team with delivery within the second trimester. Results: Thirty-four patients with PAS were diagnosed and delivered by the second trimester. Of these, (41.1%) elected for active management and 20 (58.9%) for expectant management but ultimately required delivery prior to 28 weeks’ gestation. Baseline demographics were similar between groups. Intraoperatively, no differences were noted in operative time (191.5 vs. 203 min, p = 0.85), blood loss (2300 vs. 2600 cc, p = 0.85), or incidental cystotomy (1 vs. 7, p = 0.10). Postoperative length of stay was similar (3 vs. 3.5 days, p = 0.28), and ICU admission was not statistically different (6 vs. 12, p = 0.48). Conclusions: This retrospective study suggests that when hysterectomy is planned, there is no difference in maternal outcomes and morbidity with an expectant management with cesarean hysterectomy in the second trimester compared to proactive cesarean hysterectomy.

Development and validation of a prognostic nomogram forsevere postpartum hemorrhage after cesarean delivery: Atwo-center retrospective study.

To develop and validate a nomogram to predict severe postpartum hemorrhage following cesarean delivery. This is a two-center retrospective cohort study. Cesarean delivery patients from the First Affiliate Hospital of Jinan University were divided into a development cohort (n = 11 137) and an internal validation cohort (n = 4739). Cesarean delivery patients from the Dongguan Maternal and Child Health Care Hospital (n = 13 775) were enrolled in the external validation cohort. The nomogram was based on independent risk factors for severe postpartum hemorrhage obtained by multivariate logistic regression. We evaluated the discrimination and calibration of the nomogram in the development and validation cohorts. The nomogram used data including previous cesarean delivery, pre-pregnancy weight, preterm birth, placenta previa, placenta accreta spectrum disorders, placental abruption, and mode of anesthesia. The area under the curves of the nomogram in the internal and external validation cohorts were 0.922 (95% confidence interval [CI] 0.897-0.947) and 0.813 (95% CI 0.785-0.841), respectively. Consistency between the predicted and actual probabilities was observed in both validation cohorts. The nomogram displayed good calibration and discrimination and can be used for screening in clinical practice to enable clinicians to intervene appropriately.

Endometrium-Free Closure Technique During Cesarean Delivery for Reducing the Risk of Niche Formation and Placenta Accreta Spectrum Disorders.

To examine the prevalence and severity of postcesarean residual niche, evaluated using saline infusion sonohysterography, in an expanded cohort of women with one prior cesarean delivery and to assess the effect of uterine closure technique on the risk of placenta accreta spectrum (PAS) disorders. This secondary analysis includes 70 patients who underwent saline infusion sonohysterography after one prior cesarean delivery. Patients were grouped according to hysterotomy closure technique: two-layer endometrium-free closure (technique A), and two- or one-layer routine closures (technique B). Niche dimensions and residual myometrial thickness were measured. The primary outcome was clinically significant niche (depth larger than 2 mm), a risk factor for PAS. Groups were compared using χ2, unpaired t test, Kruskal-Wallis, and logistic regression with significance at P<.05. There were 33 patients in the technique A group and 37 patients in the technique B group. Technique A was associated with smaller niche dimensions (P=.018 for width, .005 for depth, and .002 for length), and exhibited thicker residual myometrial thickness (8.5 mm vs 5.5 mm, P=.041) and a lower incidence of clinically significant niches. The odds of having a clinically significant niche were 27 times higher in the technique B group (adjusted odds ratio 27.1, 95% CI, 4.35-168.81, P<.001). Uterine closure techniques are associated with the development and size of postcesarean residual niches, which are critical risk factors for PAS disorders. Use of an endometrium-free closure technique during primary cesarean delivery is associated with a reduced risk of future niche formation and PAS complications.

MRI Signs Associated With Bladder Injury During Cesarean Delivery in Severe Placenta Accreta Spectrum Disorders.

Bladder injury during cesarean delivery (CD) in pregnant women with severe placenta accreta spectrum (PAS) disorders mostly occurs in the dissection of vesico-uterine space. Placental MRI may help to assess the risk of bladder injury preoperatively. To identify the high-risk MRI signs of bladder injury during CD in women with severe PAS. Retrospective. One hundred sixty-seven women with surgically confirmed severe PAS, defined as to increta or percreta, who underwent planned CD and available placental MRI. 1.5 Tesla, half-Fourier single-shot turbo spin echo sequence and true fast imaging with steady state free precession sequence. Presence of following imaging features of the vesico-uterine region were independently evaluated by three radiologists (with 8, 8, and 15 years of experience, respectively): vesico-uterine space hypervascularity, vesico-uterine space without chemical shift line, bladder wall interruption with hyperintense nodularity, bladder tenting, and uterine-placental bulge. Univariable analyses (Chi-square or Fisher's exact test) and multivariable regression analyses were used. A P value <0.05 was considered significant. Thirty-three of the women (19.8%) experienced bladder injury during CD. MRI features were significantly more frequent in the bladder injury group compared with the no bladder injury group: 69.7% vs. 26.9% in vesico-uterine space hypervascularity, 57.6% vs. 21.6% in absent chemical shift line in the vesico-uterine space, 18.2% vs. 1.5% in bladder wall interruption with hyperintense nodularity, 39.4% vs. 14.9% in bladder tenting, and 78.8% vs. 39.6% in uterine-placental bulging. Vesico-uterine space hypervascularity, absent chemical shift line, and uterine-placental bulge were independently associated with the risk of bladder injury (odds ratios: 4.190, 3.555, and 3.569, respectively). Vesico-uterine space hypervascularity, vesico-uterine space without chemical shift line and uterine-placental bulge were associated with bladder injury during CD in women with severe PAS. Bladder injury is a serious complication of cesarean delivery in pregnant women with severe placenta accreta spectrum, frequently resulting in massive hemorrhage, bladder dysfunction and severe infection. Accurate prenatal assessment is important to minimize these adverse consequences. This study showed that MRI features, including vesico-uterine space hypervascularity, vesico-uterine space without chemical shift line and uterine-placental bulge, were independently associated with bladder injury. These high-risk MRI signs may serve as effective means for prenatal assessment of bladder injury. This study would broaden the application of MRI in severe placenta accreta spectrum. 3 TECHNICAL EFFICACY: Stage 2.

Risk Factors and Pregnancy Outcomes in Patients with Placenta Accreta Spectrum Disorder: A Case‐Series

Risk Factors and Pregnancy Outcomes in Patients with Placenta Accreta Spectrum Disorder: A Case‐Series

Hysteroscopic Endometrial Defect Following Adenomyomectomy and Incidence of Placenta Accreta Spectrum and Uterine Rupture Complications for Subsequent Pregnancy.

Adenomyomectomy, a therapeutic option for women with adenomyosis who wish to preserve their fertility, has been reported to pose a risk of developing placenta accreta spectrum (PAS) and uterine rupture in future pregnancies. However, the specific clinical factors contributing to these occurrences remain elusive. This study aimed to explore the association between hysteroscopic findings after adenomyomectomy and the incidence of PAS in subsequent pregnancies. We conducted a retrospective analysis of 10 patients (11 pregnancies) who had undergone hysteroscopy following adenomyomectomy and had later delivered at our hospital. In 6/10 patients, postoperative hysteroscopy revealed endometrial defects. However, subsequent evaluations confirmed endometrial restoration within 7-21months, with five patients achieving pregnancy afterward. The only other patient conceived naturally without waiting for endometrial restoration, resulting in uterine rupture from the site of the placenta percreta. The incidence of clinically diagnosed PAS during cesarean section was 100% (1/1) in pregnancies with preconceptional endometrial defects, 20% (1/5) in those with endometrial restoration, and 0% (0/5) in pregnancies without endometrial defects. Similarly, the incidence of pathologically diagnosed PAS was 100% (1/1), 60% (3/5), and 20% (1/5) in these groups, respectively. Thus, endometrial defects were frequently detected after adenomyomectomy and recovered over time, whereas one patient without endometrial restoration developed uterine rupture complicated by PAS. This study demonstrates that while the presence of an endometrial defect identified by postoperative hysteroscopy may be a risk factor for the occurrence of PAS in subsequent pregnancies, allowing sufficient recovery time for the endometrium may help reduce the risk of uterine rupture.

Early hematological indices as a predictor of placenta accreta in women with high suspicion of accreta

There is a lack of early biomarkers to predict the placenta accreta spectrum; thus, searching for available and easily obtained markers such as hematological indices is an attractive option. The current study is a diagnostic accuracy study included 198 women; all women underwent an assessment of their hematological indices during their first trimester as part of their routine antenatal care. All women included in the study had a high suspicion of developing placenta accreta spectrum; the women were followed up until their delivery. White blood cell, neutrophil count, and red cell distribution width (RDW) were significantly higher in the women with accreta than those without accreta. RDW had fair ability (area under the curve, 0.707) as a predictor of accreta. RDW had the highest positive and lowest negative likelihood ratios (indicating better value than the rest of the markers). In multivariate analysis, RDW and the platelet-lymphocyte ratio were independently associated with accreta after adjustment to the effects of age, gestational age, gravida, parity, abortion, and past medical/surgical history. In conclusion, simple, early blood count parameters may be utilized for placenta accreta; RDW appears to be the best predictor of placenta accreta.

The role of the intraplacental fetal artery in predicting the need for cesarean-hysterectomy in women at high risk for placenta accreta spectrum.

Prenatal determination of placenta accreta spectrum (PAS) and its severity is crucial, as it is a highly morbid condition. The aim was to investigate the intraplacental fetal artery (IFA) as a novel ultrasonographic marker in predicting cesarean-hysterectomy need in PAS. A prospective observational cohort study was conducted with a total of 62 women with placenta previa and ≥1 previous cesarean-section who were managed for PAS between September 2022 and January 2024. All women were classified according to the ultrasonographic classification system for prenatal PAS, and ultrasonographic assessments for IFA were performed. Odds ratios were calculated to test the association of IFA and other parameters related to PAS with cesarean-hysterectomy need. Receiver operating characteristic analysis was performed to evaluate the ability of maximum diameter (D-max) of IFA to predict cesarean-hysterectomy need. The study was completed with 49 women who underwent a cesarean-section with uterus-sparing surgery (n=22) and a cesarean-hysterectomy (n=27). Outer placental-half extension of IFA and each 1mm increase in IFA D-max >3.5mm were associated with a 58.82- and 3.52-fold increased risk of cesarean-hysterectomy, respectively. An IFA D-max of >3.5mm was associated with cesarean-hysterectomy need at any PAS stage [area under the curve (AUC)=0.845, 95% CI:0.71-0.93, p<0.001)] and in PAS 2 patients (AUC=0.750, 95% CI:0.56-0.89, p=0.010), in whom prenatal prediction of cesarean-hysterectomy need is difficult. Evaluation of D-max and outer placental-half extension of IFA along with other markers of PAS improved the ability of ultrasonography to predict cesarean-hysterectomy need.

Ferumoxytol-enhanced MRI of retroplacental clear space disruption in placenta accreta spectrum.

Placenta accreta spectrum (PAS) occurs when the placenta is pathologically adherent to the myometrium. An intact retroplacental clear space (RPCS) is a marker of normal placentation. In this study, we investigate use of the FDA-approved iron supplement ferumoxytol for contrast-enhanced MRI of the RPCS in mouse models of normal pregnancy and PAS. We then demonstrate the translational potential of this technique in human patients (n=6) presenting with severe PAS (FIGO Grade 3C), moderate PAS (FIGO Grade 1), and no PAS. T1-weighted sequences were used to determine the optimal dose of ferumoxytol in pregnant mice. Pregnant Gab3-/- mice which demonstrate adherent placentation were imaged alongside wild-type (WT) pregnant mice with non-adherent placentation. Fe-MRI was also performed in 6 pregnant subjects using standard T1 and T2 weighted sequences and a 3D magnetic resonance angiography (MRA) sequence. Ferumoxytol administered at 5mg/kg led to strong placental enhancement in Fe-MRI images. Gab3-/- mice demonstrated loss of the hypointense region characteristic of the RPCS relative to WT mice. In human patients, Fe-MRI enabled high uteroplacental vasculature signal and quantification of the volume and signal profile in severe and moderate invasion of the placenta relative to non-PAS cases. Ferumoxytol, an FDA-approved iron oxide nanoparticle formulation, enabled T1w MRI visualization of abnormal vascularization and loss of uteroplacental interface in a murine model of PAS. The potential of this non-invasive visualization technique was then further demonstrated in human subjects and suggests the possibility of PAS diagnosis using contrast enhanced MRI.

The Role of Maternal Blood Elabela Levels in the Prediction of Placenta Previa and Accreta

IntroductionPlacenta previa and Placenta Accreta Spectrum are life-threatening obstetric conditions that are challenging to diagnose accurately. Currently, there is no biochemical parameter available for their diagnosis. The aim of our study is to investigate the potential of Elabela as a laboratory marker that could predict placenta previa and placenta accreta, both of which can lead to severe, life-threatening complications for the mother. MethodsIn this study, which was conducted prospectively in two tertiary centers between 2020 and 2022, Elabela levels were examined in patient groups with placental insertion and invasion anomalies. SPSS program was used for comparative statistical analysis between groups. ResultsOf the 67 analyzed patients, 32 were in the control group, 12 were in the previa group, and 23 were in the accreta group. There was no statistically significant difference between the groups regarding age, BMI, number of curettages, presence of previous cesarean section, and smoking status. The Elabela level was measured at 135.6 ± 72.1 in the control group, 988.3 ± 925.5 in the previa group, and 376 ± 364.6 in the accreta group, with a statistically significant difference between the groups. The cut-off value of Elabela levels in the previa group was determined to be 304, with a sensitivity of 83.30% and a specificity of 83.60% (AUC = 0.909). In the accreta group, the cut-off value was 195.5, with a sensitivity of 60.90% and a specificity of 61.40% (AUC = 0.658). DiscussionBy showing that the prediction of placenta previa and placenta acreata can be made with a biochemical parameter in our study, young researchers will focus more on this subject and thus make many contributions to science.

PICC Lines in Pregnancy and Other Peripartum Vascular Access Considerations.

To decrease associated infectious and thrombotic morbidity, it is important to understand the indications and risks of peripherally inserted central catheters (PICCs) and other vascular access means in pregnancy. The objectives are 3-fold: (1) discuss indications and contraindications, approach to placement, and associated complications for PICC lines, arterial catheters, centrally inserted central catheters, and peripheral intravenous catheters; (2) review available data regarding complications associated with these catheters in pregnancy; and (3) propose an evidence-based approach to clinical decision making regarding vascular access in 2 clinical scenarios among pregnant patients. A literature review identified relevant research, review articles, textbook chapters, databases, and societal guidelines, with a focus on obstetrical anesthesia and obstetric literature. Data on vascular access complications in pregnancy are limited; therefore, rates of complications are extrapolated from studies including nonpregnant subjects. Catheter choice is dependent on resuscitation requirements, monitoring indications, parenteral therapeutic needs, need for inpatient versus outpatient care, and anticipated duration of use. All pregnant patients require vascular access. A subset requires more invasive catheters for management of specific conditions such as trauma in pregnancy, postpartum hemorrhage, and puerperal sepsis. In addition, vascular access plays an important role in operative planning for patients with placenta accreta spectrum disorder and fetal disorders requiring intrauterine surgery. Gaining an understanding of the types of catheters and their associated complications will allow obstetricians, family medicine physicians, midwives, nurses, intensivists, and anesthesiologists to make informed decisions regarding catheter selection and management.

PREVALENCE, RISK FACTORS AND FETO-MATERNAL OUTCOME OF PLACENTA ACCRETA SPECTRUM AT A TERTIARY CARE CENTRE

Introduction: Placenta Accreta Spectrum disorders, characterized by abnormal adherence of the placenta to the uterine wall, represent a significant obstetric challenge due to their association with severe maternal hemorrhage and increased maternal morbidity and mortality. Material and Methods: This ambispective observational study was conducted over 4.5 years at the Upper India Sugar Exchange Maternity Hospital, GSVM Medical College, Kanpur. The study included 70 patients diagnosed with Placenta Accreta Spectrum (PAS) disorders, with data collected retrospectively for January 2020 - December 2021 and prospectively for January 2022 - July 2024. Statistical analysis was performed to assess the prevalence, risk factors, and feto-maternal outcomes associated with placenta accreta spectrum. Results: The prevalence of PAS increased from 2.8% in the retrospective period to 6.9% in the prospective period, resulting in an overall prevalence of 4.9%. The most significant risk factor identified was a history of two or more cesarean sections, present in 36.84% of cases. Ultrasound was instrumental in antenatal diagnosis.The study also highlighted the common occurrence of preterm delivery, moderate anemia, and significant blood loss, averaging 1854.3 mL. Conclusion: The study underscores the rising prevalence of placenta accreta spectrum, driven by the increasing rate of cesarean sections. Early and accurate diagnosis, particularly through ultrasound, combined with a multidisciplinary approach to management, is crucial for improving maternal and fetal outcomes.

PLACENTA ACCRETA SPECTRUM: MODERN APPROACH TO ORGAN-PRESERVATION

Pathologically invasive placenta has been a problem in obstetrics for several centuries. Recently, its importance has increased due to the growing number of women with a previously operated or compromised uterus, which is a direct risk factor for placenta accreta. In addition to the unpleasant development of events during childbirth for the obstetrician-gynecologist, this pathology is a danger to the mother's health. And this is not surprising, because even with quick action of the surgeon and prevention of massive blood loss after hysterectomy - a classic surgical procedure for implantation of the placenta - such women lose their reproductive organ, which can cause social and psychological discomfort. That is why organ-preserving operations are being developed today, the results of the evaluation of the effectiveness of one of them are given in this work. Aim: to compare the effectiveness of the proposed organ-preserving CLAP technique in women with placenta accreta spectrum compared to classic hysterectomy. Materials and methods: Women with placenta accreta spectrum underwent cesarean section and CLAP in the main group (n=19) and classical hysterectomy in the control group (n=18). Blood loss, neonatal outcome, and length of hospital stay were compared. Statistical analysis was performed using MedStat and Microsoft Excel software. Patients' rights were respected in accordance with the Declaration of Helsinki and the Universal Declaration of Bioethics and Human Rights (UNESCO). All pregnant women signed an informed consent form to participate in the study. Results: The two groups did not differ in terms of age, medical history and comorbidities. Statistically less blood loss was found in the main group (2377±322 ml vs. 3339±358 ml in the control group, p&lt;0.001), while there was no difference in the condition of newborns, postpartum women, and length of hospital stay. Conclusions: The use of the CLAP technique in comparison with hysterectomy allows, in addition to the preservation of the female reproductive organ, to achieve less blood loss during surgical delivery of a pathologically invasive placenta, without changing the condition of the newborn, the postpartum woman, or the length of hospital stay. At the same time, in comparison with other organ-preserving techniques, CLAP does not require the use of special additional equipment and can be performed in any medical institution with sufficient qualifications of the surgeon.

Surgical Morbidity following Planned Hysterectomy versus Conservative Management for Placenta Accreta Spectrum: A Systematic Review and Meta-analysis.

In recent years, the management of placenta accreta spectrum (PAS) has fallen into two categories: planned hysterectomy and conservative management to preserve fertility. However, optimal management remains unclear. Therefore, we conducted a systematic review and meta-analysis comparing the two to evaluate which approach was associated with lower surgical morbidity. MEDLINE, Scopus, Cochrane Library, and ClinicalTrials.gov were searched from inception to July 31, 2023, for trials comparing conservative management versus planned hysterectomy. We included all prospective or retrospective cohort studies, case-control studies, and randomized control studies that reported outcomes related to surgical morbidity in cases of PAS. Surgical morbidity was defined as rates of intensive care unit (ICU) admission, disseminated intravascular coagulation (DIC)/coagulopathy, bladder injury, number of units of packed red blood cells (PRBCs) transfused, estimated blood loss (EBL), and maternal mortality. Odds ratios (ORs) were computed with 95% confidence intervals (CIs) using a fixed or random effects model. Among 839 studies initially retrieved, 12 were included with a total of 1,167 patients. Of these, 669 (57.3%) underwent conservative management and 498 (42.7%) underwent a planned hysterectomy. Conservative management resulted in lower rates of ICU admission (OR = 0.11; 95% CI: 0.04, 0.35), lower rates of bladder injury (OR = 0.31; 95% CI: 0.2, 0.48), lower incidence of DIC or coagulopathy (OR = 0.22; 95% CI: 0.10, 0.48), lower mean difference EBL (-1,292.81 mL; 95% CI: -1,922.16 to -593.46), as well as lower number of PRBC units transfused (-1.54 units; 95% CI: -2.29 to -0.78). Our findings suggest that conservative management of PAS may be associated with reduced surgical morbidity. · management of PAS has fallen into two categories: planned hysterectomy and conservative management.. · Optimal management for PAS remains unclear.. · conservative management of PAS may be associated with reduced surgical morbidity..

Navigating obstetric enigma: Placenta accreta spectrum masquerading as gestational trophoblastic neoplasia.

Placenta accreta spectrum (PAS) represents a complex obstetric condition characterised by the abnormal invasion of anchoring villi and trophoblast into the myometrium. This case report explores two instances where the diagnosis of PAS was overlooked during antenatal care leading to significant complications during conservative management. Both patients presented with heavy menstrual bleeding and raised beta human chorionic gonadotrophin (β-hCG), mimicking gestational trophoblastic disease. The report delves into the clinical presentations, diagnostic challenges, and outcomes of two cases, shedding light on the importance of effective communication and follow-up in the management of PAS.

Correlation between the severity of endometriosis and the occurrence of placenta accreta spectrum in the subsequent pregnancy

Objective: To investigate the correlation between endometriosis (EMs) severity and placenta accreta spectrum (PAS) risk in the subsequent pregnancy. Method: Clinical records of 2,142 patients who underwent laparoscopic surgery for EMs at Fujian Provincial Maternal and Child Health Hospital from January 2014 to January 2018, who had achieved pregnancy and were delivered, were analyzed. Baseline data, EMs stage, The Revised American Fertility Society (R-AFS) score, levels of serum indexes, and pregnancy and neonatal outcomes were recorded. The outcome of interest was the occurrence of PAS. The correlation between the R-AFS score, endometriosis staging, and PAS was explored, and the R-AFS threshold was identified. Results: PAS was associated with a higher incidence of chronic pelvic pain (OR = 8.68, 95%CI: 1.18-45.79, P = 0.014) and infertility for &gt;five years (OR = 2.5, 95%CI: 1.35-4.65, P = 0.003), elevated serum levels of cancer antigens, higher incidence of postpartum hemorrhage, and placenta previa (P &lt; 0.05). PAS rate was higher in women with higher EMs staging and R-AFS score and ovarian EMs combined with deep infiltrating endometriosis (DIE) (P &lt; 0.001). After adjusting for confounders, both R-AFS score (AOR = 1.02, 95%CI: 1.01-1.03, P &lt; 0.001) and ovarian EMs with DIE (AOR = 3.31, 95%CI: 1.54-6.67, P = 0.001) were independent risk factors for PAS. R-AFS score of 29 was identified as a threshold for an increased risk of PAS. Conclusion: The risk of PAS in patients with endometriosis increases with the R-AFS score. PAS is more likely to occur in women with ovarian EMs combined with DIE. It is necessary to implement a specific monitoring program during pregnancy in patients with a history of severe EMs doi: https://doi.org/10.12669/pjms.41.1.11145 How to cite this: Wang Z, Xie Y, Mao Y, Yan S, Huang J, Lin S. Correlation between the severity of endometriosis and the occurrence of placenta accreta spectrum in the subsequent pregnancy. Pak J Med Sci. 2025;41(1):55-63. doi: https://doi.org/10.12669/pjms.41.1.11145 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Prenatal ultrasound scoring in diagnosis and postpartum outcomes prediction for Placenta Accreta Spectrum (PAS): a systematic review

BackgroundPlacenta accreta spectrum (PAS) is one of the most dangerous pregnancy-related conditions. This study aims to conduct a systematic review of current research on the ultrasound scoring systems used in PAS patients with a comprehensive summarization of researches and comparison of prenatal ultrasound scoring in evaluating postpartum outcomes.MethodsThis systematic review was conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were retrieved from four databases (PubMed, Cochrane Library, Embase and Web of Science) up to December 2023. Original studies involving women diagnosed with PAS using ultrasound scoring for diagnosis or outcome evaluation were screened based on predefined inclusion and exclusion criteria. The primary outcome was the diagnostic performance of ultrasound scoring systems and their effectiveness in predicting labor outcomes. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool was utilized to assess the study quality. The study has been registered on the PROSPERO website with the registration number CRD42024507311.ResultsSixteen studies met the inclusion criteria. 3930 patients were included in the review, with 1693 participants in the control group. Included studies had a high risk of bias in patient selection, with a low risk in flow and timing and reference standards. Existing studies have reported several indicators that can be included in ultrasound scoring systems and tested their effectiveness in diagnosis and severity evaluation. The pool sensitivity, specificity, and area under the curve (AUC) of ultrasound scoring system in diagnosing PAS were 0.89 (95% confidence interval [CI]: 0.82–0.94), 0.85(95%CI: 0.80–0.90) and 0.93 (95%CI:0.91–0.95). Ultrasound scores are associated with PAS outcomes including intraoperative haemorrhage, postpartum haemorrhage, hysterectomy, length of hospital stay, and neonatal prognosis. Limitation is that the existing studies are wide-ranging but have low replication and association.ConclusionUltrasound scoring systems play a role in the prenatal diagnosis, management, and prediction of postnatal complications in PAS. Nevertheless, additional research is required to further evaluate the performance between different scoring systems to develop a unified consensus.

Beyond the Scalpel: Unravelling the Anaesthetic Maze in Elective C-Section for Placenta Accreta Spectrum

Placenta accreta spectrum (PAS) disorders pose significant challenges in the anaesthetic management of elective caesarean section. This article explores the anaesthetic considerations for patients with PAS focusing on the optimal techniques to ensure maternal safety and surgical success. The analysis examines the advantages and disadvantages of general anaesthesia, neuraxial anaesthesia, and combined techniques to inform considerations of anaesthetic management in this high-risk population.

Uterine artery embolisation in symptomatic patients with placenta accreta spectrum disorders.

Postpartum haemorrhage is the most common cause of mortality among women after childbirth. Therefore, this work aims to highlight the possibility of endovascular treatment of postpartum haemorrhage due to remnants in patients with placenta accreta spectrum disorders (PAS disorders) using selective UAE after failure of the standard management. This procedure is a relatively safe and technically nondemanding, with a low risk of recurrent vaginal bleeding. This article presents an evaluation of the results of eight patients (age between 19-39 years) who underwent selective transarterial embolisation of uterine arteries from January 2022 to August 2023 at the angio-interventional department of our university hospital center. Based on a multidisciplinary consensus of sonographically detected residues of placenta accreta with typical hypervascularisation, unilateral/bilateral embolisation of the uterine artery was performed with a microcatheter using polyvinyl alcohol embolisation particles, possibly in combination with gelatine foam. There were no periprocedural complications during embolisation, nor were there episodes of repeated bleeding or other postprocedural complications during the follow-up. Two patients underwent surgical revision of the uterine cavity with extirpation of devascularised residual tissue. Thus far, this procedure has proven to be a safe and relatively technically nondemanding method supplementing the management of symptomatic patients with PAS disorders with a low risk of rebleeding.