Placenta Accreta Research Articles

Conservative surgical repair of placenta increta invading into uterine septum: case report

Conservative surgical repair of placenta increta invading into uterine septum: case report

A case report of a first trimester missed abortion which unfolded into an emergency subtotal hysterectomy

Placenta Accreta Spectrum (PAS) encompasses various degrees of abnormal placental attachment, where the decidual basalis is compromised, allowing chorionic villi to invade into or beyond the myometrium. This invasion is difficult to diagnose in first trimester ultrasound. PAS results in incomplete separation of the placenta and subsequent hemorrhage which can be life threatening to the mother. We present a case of a woman with previous two LSCS presenting in first trimester with missed abortion wherein a Manual Vaccuum Aspiration was followed by uncontrollable hemorrhage necessitating a hysterectomy and a retrospective diagnosis of placenta increta. The primary modality of imaging in first trimester -the ultrasound - is not reliable to diagnose placenta accreta syndrome and additional inputs may be needed to make this diagnosis in the first trimester

A 5-years cross-sectional study of risk-factors feto-maternal outcomes in placenta accreta spectrum at single tertiary care centre in South India

: PAS is an abnormal placental trophoblastic invasion into the myometrium, serosa and surrounding structures causing severe maternal morbidity and mortality due to massive obstetric hemorrhage (MOH). The incidence of PAS is on the rise due to increasing rate of Cesarean Section (CS) worldwide. : This study aimed to assess the risk factors associated with Placenta accreta spectrum (PAS) and to compare the feto-maternal outcomes in elective and emergency delivery in PAS.This is a 5 years single centre cross-sectional study from 1st January 2018 to 31st December 2022. All diagnosed cases of PAS beyond 28 weeks of gestation were included. A total of 38 cases of PAS were studied. Chi-square test and T-test were used to compare the categorical variables with p value 0f <0.05 as statistically significant.The incidence of PAS was 1.85/1000 deliveries. Advanced maternal age, previous CS, placenta previa in current pregnancy were major risk factors. MOH was the commonest complication. The blood loss, increased operative time and need for blood transfusions was mainly dependent on the placental location. Prematurity and low birth weight were the most important perinatal outcomes. Adequate blood and blood products prior to surgery is important as even in expert hands blood loss can be massive. Early referral and specialized regional team to manage PAS at tertiary care are needed. Future studies should emphasize on easy and early detection of PAS.

PLACENTA ACCRETA SPECTRUM: CLINICAL PATHWAY OF A PATIENT IN THE PERINATAL CENTRE OF KYIV

There is no doubt about the danger of obstetric hemorrhage. For many years, the main preventable cause of maternal mortality has been peripartum hemorrhage. Pathology of the placenta – its location and attachment – is one of the main reasons for the development of obstetric hemorrhage, the frequency of which continues to increase, mainly due to the increase in the proportion of abdominal deliveries. For this reason, these conditions receive constant attention from scientists all over the world: there is a constant review of recommendations for the management of pregnant women with these pathologies, as well as the search for the optimal method and timing of delivery to ensure the best health of the mother and the newborn. To date, it has not been possible to reach an unequivocal consensus among diff erent world schools on these issues. Recently, there has been an increase in the number of cases of the placenta growing into the uterine wall – a condition called placenta accreta spectrum, as well as its special form, when the chorionic villi grow into the lower segment of the uterus – placenta previa accreta. These are particularly dangerous conditions that carry a double risk of massive obstetric hemorrhage. The article presents the latest views on the possibilities of organ- preserving surgery for these pathologies and reviews the recommendations of various major world schools of obstetrics and gynecology. We also present our own algorithms for the management and delivery of women withpathologically invasive placenta.

Survivors of Placenta Accreta: What Their Blogs Can Tell Us

Prior cesarean birth is the most significant predictor of placenta accreta which can place the woman and her infant’s lives at risk. With the continuing increase in cesarean birth rate, it is essential that childbirth educators inform women of this life-threatening risk. Insightful information from blogs written by survivors of placenta accreta pregnancies can help guide clinical practice and childbirth education. Content analysis of 22 blogs posted on the internet identified seven themes that provide an insider’s view of placenta accreta: the shock of it all, living in constant fear, advocate for yourself to get some sense of control, my mental health is deteriorating, you saved our lives!, recommendations, and posttraumatic growth.

Natural evolution of a cesarean scar pregnancy up to 34 weeks complicated by an early subserosal uterine rupture and placenta accreta spectrum disorders

Cesarean scar pregnancy (CSP) is an extremely rare form of ectopic pregnancy. A 39-year-old woman with a history of multiple uterine surgeries was diagnosed with a CSP at seven weeks by transvaginal ultrasound. The CSP was misdiagnosed at 13 weeks and 5 days during a second medical opinion. At 22 weeks of gestation, a 3.8 cm subserosal uterine rupture was visualized. Expectant management was decided. A live birth was achieved through an elective cesarean section at 34 weeks of gestation. The complications were early subserosal uterine rupture and placenta accreta spectrum that led to a hysterectomy. Due to risk of uterine rupture, management should consist of early termination of the pregnancy.

Case Report of Placenta Accreta Spectrum and Arteriovenous Malformations with Successful Preservation of Fertility After Birth

Uterine arteriovenous malformations (UAVMs) that occur after birth are a rare cause of late postpartum hemorrhage. Acquired UAVMs usually occur in conjunction with pathology of the placenta. In the spectrum of placenta accreta (PAS), subinvolution of the placental bed plays an important role in its pathophysiology. We present a case of UAVM in a pregnant woman with PAS who presented with marked metrorrhagia after delivery, which was treated with classical management. Then, 35 days later, she presented to the emergency room with severe metrorrhagia. As it was suspected that she had placental remnants, an instrumental uterine control was performed, but the bleeding persisted, requiring further uterine packing and blood administration. Later, uterine artery embolization was performed with good results. Color Doppler ultrasound, magnetic resonance imaging, and angiography were the methods with the greatest diagnostic value. The differential diagnosis was as complex as the treatment. We hypothesize that UAVM may develop from minimal residual PAS in this late postpartum period. Moreover, they may recover rapidly after local surgical ablation. Considering the clinical condition, hemodynamic status, and desire to preserve fertility, we were able to avoid a hysterectomy, which is often chosen in such cases of severe, life-threatening bleeding complications.

Placenta accreta spectrum (PAS) - prenatal diagnosis and management. The Polish Society of Gynecologists and Obstetricians Guidelines.

Placenta accreta spectrum (PAS) - prenatal diagnosis and management. The Polish Society of Gynecologists and Obstetricians Guidelines.

Usefulness of decision tree analysis of MRI features for diagnosis of placenta accreta spectrum in cases with placenta previa.

Placenta previa complicated by placenta accrete spectrum (PAS) is a life-threatening obstetrical condition; therefore, preoperative diagnosis of PAS is important to determine adequate management. Although several MRI features that suggest PAS has been reported, the diagnostic importance, as well as optimal use of each feature has not been fully evaluated. The occurrence of 11 PAS-related MRI features was investigated in MR images of 145 patients with placenta previa. The correlation between each MRI feature and pathological diagnosis of PAS was evaluated using univariate analysis. A decision tree model was constructed according to a random forest machine learning model of variable selection. Eight MRI features showed a significant correlation with PAS in univariate analysis. Among these features, placental/uterine bulge and myometrial thinning showed high odds ratios: 138.2 (95% CI: 12.7-1425.6) and 66.0 (95% CI: 18.01-237.1), respectively. A decision tree was constructed based on five selected MRI features: myometrial thinning, placental bulge, serosal hypervascularity, placental ischemic infarction/recess, and intraplacental T2 dark bands. The decision tree predicted the presence of PAS in the randomly assigned validation cohort with significance (p < 0.001). The sensitivity and the specificity of the decision tree for detecting PAS were 90.0% (95%CI: 53.2-98.9) and 95.5% (95%CI: 89.9-96.8), respectively. Among PAS-related MRI features, placental/uterine bulge and myometrial thinning showed high diagnostic values. In addition, the present decision tree model was shown to be effective in predicting the presence of PAS in cases with placenta previa.

Surgical management of delivery with placenta accreta spectrum from the perspective of perinatal obstetrics

Introduction. This article raises the issue of planning the timing and method of operative delivery in pregnant women with placenta accreta spectrum. Placenta accreta spectrum is one of the most formidable complications of pregnancy, the delivery of pregnant women with this pathology is accompanied by massive blood loss, and programmed late premature birth leads to an increase in perinatal morbidity.The objective was to evaluate the possibility of prolonging pregnancy to full term in patients with pathology of placenta accreta spectrum.Methods and materials. 94 histories of pregnant women with placenta accreta spectrum, delivered from 2017 to 2023, were analyzed. All patients were divided into 4 groups according to the topography of placenta accreta. According to the assessment of perinatal outcomes, pregnant women were divided into 2 groups: group 1 – pregnant women who delivered at 34–36 weeks of pregnancy (n=82; 87 %); group 2 – patients operated on from 37 to 39 weeks of gestation (n=12; 13 %). The statistical analysis was performed using the program StatTech v. 4.2.7.Results. Among pregnant women whose delivery ended with hysterectomy (n=32, 100 %), the largest proportion of patients had placenta accreta in the area of the parametrium and cervix (n=12, 43.75 %). The average score of newborns in group 1 was 7 points on the Apgar scale at 1 minute after extraction and 8 points on the Apgar scale at 5 minutes; in group2, the average score on the Apgar scale was 8 and 8 points at 1 and 5 minutes.Conclusion. If placenta accreta is suspected and involves the cervix, parametrium, and lower part of the posterior wall of the bladder, a hysterectomy is most likely to be performed. For such pregnant women, it is possible to shift the timing of surgical intervention to 37/38 weeks of gestation in order to improve neonatal outcomes.

Telemedicine ultrasound assessment for placenta accreta spectrum: Utility and interobserver reliability of asynchronous remote imaging review.

Management of patients with placenta accreta spectrum (PAS) by trained multidisciplinary teams is associated with improved outcomes. Ultrasound can predict intraoperative risks, but expert ultrasound imaging of PAS is often limited. Telemedicine is used increasingly in obstetrics, permitting expert consultation when essential resources are not available locally. Our objective was to evaluate the feasibility of teleconsultation using standardized ultrasound image acquisition and reporting, and to correlate prognosis with intraoperative findings in patients at risk for PAS. A total of 12 PAS imaging experts (teleconsultants) were selected to asynchronously review deidentified standardized grayscale and color Doppler ultrasound images for five patients who had completed treatment for PAS, resulting in 60 individual teleconsultations. All patients were managed at a center using standardized imaging acquisition and intraoperative topographic classification to individualize surgical management. Teleconsultants reported the predicted topographic classification and recommended a surgical approach based on the topographic classification algorithm. Prognoses were compared with that reported by the local sonologist and with intraoperative findings. In all five patients, local sonologist prognosis and antenatal topographic classification was confirmed during surgery and the final surgical approach matched that which was recommended preoperatively. Teleconsultant antenatal evaluation and management plans matched those of the local team in 71.7% of the cases. When reports differed, PAS severity was overestimated in nine reviews (16.9%) and was underestimated in six reviews (11.3%). Remote imaging teleconsultation provides accurate prenatal staging in most patients at risk for PAS. Teleconsultation is a feasible strategy to improve prenatal imaging, management planning, and guidance for local teams in settings with limited healthcare resources.

Comparative study of the prevalence of organ injury in placenta accreta spectrum disorder between posterior colpotomy and conventional peripartum hysterectomies at a single referral center in southern Thailand.

To compare the prevalence of adjacent organ injury in placenta accreta spectrum disorder (PAS) between the posterior colpotomy approach and conventional peripartum hysterectomy. This retrospective study analyzed the data of pregnant women diagnosed with PAS who underwent peripartum hysterectomy at Songklanagarind Hospital between January 2006 and December 2021. The patients were divided into two groups: posterior colpotomy and conventional approaches. The characteristics and surgical and obstetric outcomes were compared. Univariate and multivariate logistic regression was used to identify factors and risk of organ injury. Among 174 patients, 64 underwent conventional peripartum hysterectomy, and 110 underwent the posterior colpotomy approach. The overall incidence of adjacent organ injury was 17.82%. Organ injury prevalence was lower in the posterior colpotomy group (10%) than in the conventional group (31.25%), with no difference in operative time. Multivariate analysis showed that posterior colpotomy reduced adjacent organ injury (odds ratio [OR] 0.18, 95% confidence interval [CI] 0.06-0.54, P = 0.002). Placenta percreta was associated with increased injury risk (OR 6.83, 95% CI 2.53-18.44, P < 0.002). Subgroup analysis showed that the posterior approach reduced bladder injury in placenta increta (OR 0.14, 95% CI 0.04-0.57, P = 0.003) and percreta (OR 0.19, 95% CI 0.05-0.77, P = 0.017). Compared with conventional peripartum hysterectomy, the posterior colpotomy approach in patients with PAS reduced the risk of adjacent organ injury, particularly for placenta increta and percreta. This technique should be considered in PAS cases, but further investigations with a prospective study design are needed.

11744 Laparoscopically Managed Case of Postpartum Retained Placenta Accreta in Previous Two Caesarean Sections With a Trick Knot

11744 Laparoscopically Managed Case of Postpartum Retained Placenta Accreta in Previous Two Caesarean Sections With a Trick Knot

Gynecologic oncologist in cesarean hysterectomy for placenta accreta spectrum in the United States: A surgeon specialty-specific assessment

Gynecologic oncologist in cesarean hysterectomy for placenta accreta spectrum in the United States: A surgeon specialty-specific assessment

Prophylactic Radiologic Interventions for Postpartum Hemorrhage Control in Women with Placenta Accreta Spectrum Disorder a Systematic Review and Meta-analysis.

Prophylactic Radiologic Interventions for Postpartum Hemorrhage Control in Women with Placenta Accreta Spectrum Disorder a Systematic Review and Meta-analysis.

Early prediction of placenta accreta spectrum by evaluation of risk factors and ultrasound

IntroductionWe explored the predictive utility of clinical risk factors and first-trimester pregnancy ultrasound signs for severe placenta accreta spectrum.Material and methodsPatients with placenta accreta spectrum treated in our institution between March 1, 2017 and December 31, 2022 were analyzed. The patients were divided into those with mild and those with severe conditions. Univariate analysis was used to determine the clinical risk factors and first trimester ultrasound signs associated with severe placenta accreta spectrum. Receiver operating characteristic curves were drawn and the areas under the curves calculated.ResultsUnivariate analysis revealed significant between-group differences between the groups in the number of cesarean sections, scar pregnancy, low gestational sac position, abnormal placental position, focal exophytic mass and abnormal placental lacunae in placental parenchyma (p &lt; 0.05). The number of cesarean sections and first trimester ultrasound signs predicted severe placenta accreta spectrum, with areas under the curves of 0.66 and 0.75. When the number of cesarean sections was combined with low gestational sac position, the placenta position and related ultrasound signs, the areas under the curves for predicting severe placenta accreta spectrum were 0.78, 0.73, and 0.89, respectively.ConclusionsClinical risk factors and first-trimester ultrasound signs predicted severe placental accreta spectrum and their combinations had even greater clinical utility.

DETERMINANT FACTORS AFFECTING THE INCIDENCE OF PLACENTA ACCRETA

Background: Placenta accreta is a rare condition during pregnancy characterized by abnormal placentation that can increase maternal morbidity and mortality. The increase in the incidence of placenta accreta is directly related to the increase in section caesarean rates. The maternal mortality rate in NTB in 2021 was 15% due to hemorrhage, in 2022 there was an increase in the incidence of placenta accreta at the NTB Provincial Hospital. The aim of the research is to identify the determinant factors affecting the incidence of placenta accreta at the NTB Provincial Hospital in 2022. Methods: This was a descriptive observational study. The population in this study were all mothers who delivered at the NTB Provincial Hospital from January to December 2022. The sample number was 50 patients diagnosed with placenta accreta. The sampling technique used was total sampling with the research variable of maternal characteristics. Data were collected from the medical records of mothers with placenta accreta from January to December 2022, and the results were analyzed using descriptive analysis. Results: Placenta accreta patients were more common in mothers with age ≤ 35 years with a median of 34.34 ± 4.28, multiparous parity (76%), overweight BMI (54%), 3-9 years labour spacing (82%), history of SC ˂ 2 times (52%) and ≥ 2 times (48%), and with a history of uterine surgery 24%. Conclusion: Determinant factors that affect the incidence of placenta accreta in NTB Provincial Hospital in 2022 are mothers with age &lt; 35 years, multigravida, overweight body mass index, mostly with a parity of 3-9 years, without degenerative diseases, all have a history of cesarean section and almost a quarter have a history of other operations on the uterus.

Maternal Risk Conditions and Outcomes by Levels of Maternal Care.

Objectives: To (1) determine associations between maternal risk conditions and severe adverse outcomes that may benefit from risk-appropriate care and (2) assess whether associations between risk conditions and outcomes vary by level of maternal care (LoMC). Methods: We used the 2017-2019 National Inpatient Sample (NIS) to calculate associations between maternal risk conditions and severe adverse outcomes. Risk conditions included severe preeclampsia, placenta accreta spectrum (PAS) conditions, and cardiac conditions. Outcomes included disseminated intravascular coagulation (DIC) with blood products transfusion or shock, pulmonary edema or acute respiratory distress syndrome (ARDS), stroke, acute renal failure, and a composite cardiac outcome. Then we used 2019 delivery hospitalization data from five states linked to hospital LoMC. We calculated associations between risk conditions and outcomes overall and stratified by LoMC and assessed for effect modification by LoMC. Results: We found positive measures of association between risk conditions and outcomes. Among patients with severe preeclampsia or PAS, the magnitudes of the associations with DIC with blood products transfusion or shock, pulmonary edema or ARDS, and acute renal failure were lower in Level III/IV compared with <Level III facilities. Among patients with cardiac conditions, the magnitudes of the associations with these outcomes, along with stroke, were also lower in Level III/IV compared with <Level III facilities. The proportion of patients with risk conditions that delivered in <Level III facilities was 19.8-46.8%. Conclusions: Odds of severe adverse outcomes among women with selected risk conditions were lower for births occurring at higher-level facilities, supporting the benefit of risk-appropriate care.

Evaluation of fetal growth and birth weight in pregnancies with placenta previa with and without placenta accreta spectrum.

We evaluated fetal growth and birthweight in pregnancies with placenta previa with and without placenta accreta spectrum (PAS). We retrospectively studied pregnant patients with placenta previa with or without PAS diagnosed at 20-37weeks' gestation. Estimated fetal weight (EFW) percentile and fetal growth rate were calculated based on ultrasound at two timepoints: 20-24 and 30-34-weeks' gestation. Fetuses were small (SGA) or large for gestational age (LGA) when EFW or abdominal circumference was <10th or >90th percentile for gestational age, respectively. Fetal growth rate was estimated by subtracting EFW percentiles from the two ultrasounds. Birthweight in grams and percentiles were estimated via Anderson and INTERGROWTH-21 standards adjusted for neonatal sex. EFW percentiles, fetal growth rate, birth weight and birthweight percentiles were compared between patients with placenta previa with and without PAS. We studied 171 patients with and 146 patients without PAS. SGA rates did not differ between groups on first (PAS n=3, no-PAS n=3, p=0.8) or second ultrasound (PAS n=10, no-PAS n=8, p=0.8). LGA rates were similar between groups on first (PAS n=11, no-PAS n=9, p=0.8) and second ultrasound (PAS n=20, no-PAS n=12, p=0.6). The growth rate was higher in fetuses with PAS than placenta previa (1.22±22.3 vs.-4.1±18.1, p=0.07), but not significantly. The birthweight percentile was higher in the PAS than the placenta previa group (74 vs. 67, p=0.01). On multi-linear regression, birthweight percentile remained higher in the PAS group, but not significantly. Placenta previa with or without PAS is not associated with SGA, LGA or lower birthweight.

Incidence, Risk factors and Outcome of Morbidly Adherent Placenta at A Maternity Hospital

Incidence, Risk factors and Outcome of Morbidly Adherent Placenta at A Maternity Hospital