Placenta Previa Accreta Research Articles

Intraoperative aorta balloon occlusion: fertility preservation in patients with placenta previa accreta/increta

Objective: To evaluate whether aorta balloon occlusion decreases the rate of hysterectomies and maternal morbidity during extirpative surgery of placenta previa accreta or increta. Methods: We prospectively assessed 33 consecutive patients with placenta praevia and MRI diagnosis of multifocal accreta or increta. Manual removal of the placenta was performed during a scheduled caesarean delivery. In 15 patients, surgery was preceded by balloon catheterization of the abdominal aorta (Intra Abdominal Balloon Occlusion: IABO); 18 patients refusing IABO were considered as controls. We used Fisher’s exact test for categorical variables and Mann–Whitney test for continuous variables. Results: In the IABO group we observed significant decreases in incidence of hysterectomy, estimated blood loss, number of transfused units of red blood cells, postoperative stay and admission to Intensive Care Unit. No IABO-related complications were reported. Conclusions: During scheduled caesarean section for placenta previa multifocally accreta or increta, IABO can prevent hysterectomy in many cases and improves perioperative outcome as it gives the operator time to achieve the haemostasis via curettage and oversewing of the implantation site with acceptable blood loss.

Role of transperineal sonography in diagnosis of placenta previa/accreta: A prospective study

PurposeTo evaluate the role of transperineal ultrasound (TPS) in the detection of morphological and vascular manifestations of placenta previa (PP)/accreta and to compare it with transabdominal sonography (TAS) and transvaginal sonography (TVS), with the clinical outcomes as the reference standards. Materials and methodsTPS, TVS, and TAS were carried on 134 patients after 28weeks’ gestation presented with antepartum hemorrhage. The final diagnosis was obtained from the obstetrician at time of delivery and from histopathological reports. ResultsOne hundred and three patients had PP, the sensitivity, specificity, and accuracy in diagnosing PP were 97.1%, 75% and 94% for TPS, 94.2%, 75% and 91.5% for TAS, and 98.1%, 93.8% and 97.4% for TVS respectively. PP accreta was present in 39 patients. The sensitivity, specificity, and accuracy in diagnosing PP accreta were 89.7%, 100% and 96% for TPS, 87%, 95% and 92.2% for TAS, and 94.9%, 100% and 98% for TVS respectively. ConclusionTPS is a valuable approach for evaluating patients with high risk of PP & PP accreta, it is a safe, rapid, & accurate technique with little patient discomfort.

Diagnosis of placenta previa accreta by two dimensional ultrasonography and color doppler in patients with cesarean section

To determine the accuracy of two dismensional sonography and color doppler in diagnosing placenta previa accreta in patients with previous cesarean section. Forty-one patients with previous cesarean sections were confirmed to have partial or total placenta previa in the current pregnancy and were given ultrasound examinations after the 28th week of gestation. Specific ultrasound features of the placenta and its interphase with the uterus and the bladder for placenta accreta were checked by two-dimensional ultrasonography and color Doppler. All the patients were traced until delivery. The golden standard in diagnosis was the intraoperative finding and the pathologic exam. Twenty-two patients had ultrasonographic evidence of placenta previa, 20 of which were later confirmed placenta previa accreta intraoperatively. Nineteen patients had no ultrasound evidence of placenta previa, and 1 of which was later confirmed placenta previa accreta. The sensitivity and specificity of antenatal ultrasound diagnosis of placenta previa accreta were 95.24% and 94.74% respectively. The most prominent feature to suggest placenta accreta in twodismensional sonography was the presence of multiple lakes that represented dilated vessels extending from the placenta through the myometrium. The most prominent color Doppler feature was the presence of interphase hypervascularity with abnormal vessels linking the placenta to the bladder, and the rate was 95.24%. Placenta previa accreta can be diagnosed made with a thorough two dimensional ultrasonographic and color Doppler examination in patients with previous cesarean scar and placenta previa.

Rare coexistence of placenta previa accreta and peritoneal adhesion: three-decade clinical observation

Peritoneal adhesion makes abdominal surgery difficult. The recent increase in cesarean section (CS) is considered a main culprit for increase of placenta previa accreta (PPA) (accreta, increata, or percreta), which usually requires cesarean hysterectomy (CH). A recent article in this journal demonstrated that of 247 patients with placenta previa, 12 (4.9 %) required hysterectomy; 11 out of 12 had histologically confirmed placenta accreta [1]. We have devised some measures for CH [2, 3], which I have also described in this journal [2]. Briefly, we avoid administering uterotonic agents after infant delivery [2] and we employ ‘‘double distal edge pickup’’ mass ligation to ligate the medial side of the incised uterus [2]. If the placenta invades the bladder, we, without separating the bladder, intentionally cut the bladder wall and remove the uterus with the posterior bladder wall kept adhering to the uterus [3]. Even with these techniques, CH for PPA is always challenging. If peritoneal adhesion exists, it will make this difficult surgery more difficult. Laparotomy including CS sometimes leads to peritoneal adhesion, which makes next CS difficult. Since PPA usually occurs in patients with previous CS, it is likely that peritoneal adhesion and PPA tend to coexist. This is contrary to my observation derived from my three-decade tertiary obstetric center practice. My observation is that PPA does not, or at least rarely, accompanies peritoneal adhesion. Fortunately, no patients had severe adhesion requiring its adhesiolysis. This is in stark contrast to both previous data and our own data. Previous reports indicated that adhesion requiring surgical intervention such as adhesiolysis occurred in approximately one quarter (21-27 %) [4, 5] in repeat CS. I have performed approximately 40 CH for PPA during three decades, with almost all having a previous history of CS. Although the detailed surgical data have been missing during three decades and adhesion was not scored, the uterus could be easily exteriorized without adhesiolysis in all patients. This indicated that no PPA patients had adhesion of more than stage 3, with stage 4 being the full mark, according to the Myers and Bennett adhesion staging system [4]. Usually stage 3 and 4 adhesion are referred to as ‘‘clinically significant’’ adhesion [4]. Thus, whereas approximately one quarter of repeat CS patients had significant adhesion [4, 5], no PPA patients had it even though almost all had a previous CS history. I examined the surgical records of patients who underwent repeat CS without current PPA from July to December 2011 in this institute. Excluding the patients with the abdominal surgery history other than CS and those under steroid administration, 64 patients received repeat CS. Although its degree was not staged [4], peritoneal adhesion was present in 47 % (30/64), with 13 % (8/64) requiring surgical intervention. The mechanism for this observation is unclear; however, decreased wound healing may, at least partly, account for this phenomenon. Not well-healed CS scar leads to insufficient decidualization, which results in trophoblasts invading the uterine muscle layers, causing PPA [6]. Thus, decreased wound healing is considered to be a possible culprit for PPA. Wound healing consists of several steps: inflammatory cell mobilization to the site, fibroblast mobilization, and finally proliferation and regeneration of the corresponding tissue. Peritoneal adhesion formation S. Matsubara (&) Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan e-mail: matsushi@jichi.ac.jp

“The eye of a typhoon” ultrasonograhic finding in a case of placenta previa accreta

“The eye of a typhoon” ultrasonograhic finding in a case of placenta previa accreta

Measures for peripartum hysterectomy for placenta previa accreta: avoiding uterotonic agents and “double distal edge pickup” mass ligation

Many studies have been attempting in identifying the risk factors of peripartum hysterectomy. Two recent articles published in the Journal [1, 2] also targeted them; placenta previa accreta was the leading condition requiring peripartum hysterectomy [1, 2]. Identification of risk factors of peripartum hysterectomy is important since it often leads to catastrophic hemorrhage and even maternal death, thus requiring an experienced staff and multidisciplinary approach. However, as even non-experienced obstetricians must handle acute unexpected peripartum hysterectomy, ‘‘everybody manageable’’ measures are needed. In my three-decade obstetrical practice, I have devised some measures for peripartum hysterectomy, which I had described [3–5]. Briefly, the cervix should be held by forceps before surgery, which indicates the vaginal site to be transected [3, 4]. Never-slip-off mass ligation, i.e., ‘‘M cross double ligation’’ should be employed in the transection of the ovarian ligament [5]. I hope to add two more measures, which, to my knowledge, have not been described in textbook or the literature. First, in cesarean section for placenta previa, uterotonic drugs should not be administered after infant delivery. Ultrasound and/or magnetic resonance imaging may predict the presence or absence of placenta previa accreta. Identification of its risk factors [1, 2] may also be useful in predicting it. However, its presence cannot be completely excluded. If uterotonic drugs are administered in case of undiagnosed accreta, the uterus may contract and part of the placenta will separate; a partial placental separation will cause massive hemorrhage. I usually wait until spontaneous placental delivery without administering uterotonics. In many cases without accreta, the placenta is spontaneously delivered. If undelivered, I lightly pull the cord, which will help start placental delivery. If still undelivered, I employ ultrasound and identify the presence/absence of the signs of accreta. Then, the next procedure depends on the presence/absence of accreta signs, and if accreta (?) signs are present, depends on the degree and location of accreta. This measure, even in an unexpected accreta case, affords us some time to prepare hysterectomy. Administration of uterotonics, inducing partial placental separation with hemorrhage, deprives us of this time. A recent meta-analysis [6] indicated that active management of the third stage of labor, including administration of uterotonics before placental delivery, reduced the risk of hemorrhage [1,000 mL in a population of women at mixed risk of excessive bleeding; however, data focusing to patients with possible placenta accreta have been lacking. Second, hemorrhage from the incised uterine side should be prevented, which typically occurs in transection of the parametrium or paracervix. In the non-pregnant uterus, their transection usually does not require medial (uterine) side clamping: hemorrhage does not, or only seldom, even without the clamping. However, in peripartum hysterectomy, the medial (uterine) side has abundant vasculature and thus will bleed from the cutting plane. Two measures may prevent it. One method is that medial forceps should remain clamped until hysterectomy completion (Fig. 1a). However, if the uterine (or cervical) part to be transected is long, many forceps are required and remain there (Fig. 1a). This may block the operation field. Another method is to tightly ligate the medial side. Figure 1b indicates the S. Matsubara (&) Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan e-mail: matsushi@jichi.ac.jp

Combination of B‐Lynch brace suture and uterine artery embolization for atonic bleeding after cesarean section in a patient with placenta previa accreta

We report the case of a patient with placenta previa accreta. A 29-year-old multipara, who had previously undergone a cesarean section, was admitted to our hospital for vaginal bleeding. An emergency cesarean section was carried out at the 33rd week of gestation. Uterine bleeding was uncontrollable, and hence, hysterectomy was planned. However, before hysterectomy, B-Lynch brace suture was carried out to control the massive bleeding; moreover, the suturing technique enabled uterine artery embolization to be carried out as an interventional radiological technique. A good postoperative course was observed, and thus, a secondary hysterectomy was not required. A combination of the B-Lynch brace suture technique and uterine artery embolization may be an alternative treatment for emergency bleeding during cesarean section in patients with placenta previa accreta.

Peripartum cesarean hysterectomy: critical analysis of risk factors and trends over the years

Objective. To investigate time trends and risk factors for peripartum cesarean hysterectomy.Methods. A population-based study comparing all deliveries that were complicated with peripartum hysterectomy to deliveries without this complication was conducted. Deliveries occurred during the years 1988–2007 at a tertiary medical center. A multiple logistic regression model was constructed to find independent risk factors associated with peripartum hysterectomy.Results. Emergency peripartum cesarean hysterectomy complicated 0.06% (n = 125) of all deliveries in the study period (n = 211,815). The incidence of peripartum hysterectomy increased over time (1988–1994, 0.04%; 1995–2000, 0.05%; 2001–2007, 0.095%). Independent risk factors for emergency peripratum hysterectomy from a backward, stepwise, multivariable logistic regression model were: uterine rupture (OR = 487; 95% CI 257.8–919.8, p < 0.001), placenta previa (OR = 66.4; 95% CI 39.8–111, p < 0.001), postpartum hemorrhage (PPH) (OR = 40.8; 95% CI 22.4–74.6, p < 0.001), cervical tears (OR = 22.3; 95% CI 10.4–48.1, p < 0.001), second trimester bleeding (OR = 6; 95% CI 1.8–20, p = 0.003), previous cesarean delivery (OR = 5.4; 95% CI 3.5–8.4, p < 0.001), placenta accreta (OR = 4.7; 95% CI 1.9–11.7, p = 0.001), and grand multiparity (above five deliveries, OR = 4.1; 95% CI 2.5–6.6, p < 0.001). Newborns of these women had lower Apgar scores (<7) at 1 and 5 min (32.7% vs.4.4%; p < 0.001, and 10.5% vs. 0.6%; p < 0.001, respectively), and higher rates of perinatal mortality (18.4% vs. 1.4%; p < 0.001) as compared to the comparison group.Conclusion. Significant risk factors for peripartum hysterectomy are uterine rupture, placenta previa, PPH, cervical tears, previous cesarean delivery, placenta accreta, and grand multiparity. Since the incidence rates are increasing over time, careful surveillance is warranted. Cesarean deliveries in patients with placenta previa-accreta, specifically those performed in women with a previous cesarean delivery, should involve specially trained obstetricians, following informed consent regarding the possibility of peripartum hysterectomy.

Limitations of internal iliac artery ligation for the reduction of intraoperative hemorrhage during cesarean hysterectomy in cases of placenta previa accreta

Our purpose was to evaluate the effect of internal iliac ligation as a bleeding control during cesarean hysterectomy for placenta accreta. We retrospectively reviewed the cases of placenta accreta receiving cesarean hysterectomy during the period of 1987-2006 in the Saitama Medical Center. The clinical outcomes of these patients either receiving or not receiving internal iliac artery ligation were compared in terms of bleeding amount, and length of hospitalization. The bleeding amounts in the variants of placenta accreta managed with internal iliac artery ligation were also analyzed to determine whether the different pathological findings would affect blood loss during cesarean hysterectomy. Among 23 cases, the mean blood loss during the operation and the length of hospitalization after the operation, with or without internal iliac artery ligation (IIAL) were not significantly different. There was no significant difference between the mean blood loss and the pathological findings of cases managed with IIAL. In cases of placenta previa accreta, ligation of the internal iliac artery did not significantly contribute to hemostasis during cesarean hysterectomy.

B-Lynch suture, intrauterine balloon, and endouterine hemostatic suture for the management of postpartum hemorrhage due to placenta previa accreta

Objective To report our experience with a new conservative management approach to treat postpartum hemorrhage (PPH) due to placenta previa accreta. Methods A retrospective study of 9 patients with placenta previa accreta who underwent a conservative management protocol. The protocol consists of preventive radiological catheterization of the descending aorta, cesarean delivery, use of Affronti endouterine square hemostatic sutures, and placement of an intrauterine Bakri balloon in conjunction with B-Lynch suture. In the event of failure of the protocol, subsequent management employs ligation and/or reversible embolization of the uterine arteries followed by hysterectomy if unsuccessful. Results Conservative management of PPH was successful in all 9 patients evaluated and avoided the need for ligation and/or reversible embolization of the uterine arteries. Conclusion Management of PPH is dictated by several considerations including hemodynamic status and desire to preserve fertility. The initial results of this conservative protocol for treatment of PPH in high-risk patients with placenta previa accreta are encouraging.

O53 Prenatal prediction of placenta praevia accreta

International Journal of Gynecology & ObstetricsVolume 107, Issue S2 p. S108-S108 Free communication (oral) presentations O53 Prenatal prediction of placenta praevia accreta G. Ara, G. AraSearch for more papers by this authorS. Nargis, S. NargisSearch for more papers by this authorA. Hoque, A. HoqueSearch for more papers by this authorZ. Sultana, Z. SultanaSearch for more papers by this author G. Ara, G. AraSearch for more papers by this authorS. Nargis, S. NargisSearch for more papers by this authorA. Hoque, A. HoqueSearch for more papers by this authorZ. Sultana, Z. SultanaSearch for more papers by this author First published: 20 November 2009 https://doi.org/10.1016/S0020-7292(09)60425-2AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume107, IssueS2Abstracts of XIX FIGO World Congress of Gynecology and ObstetricsOctober 2009Pages S108-S108 RelatedInformation

The endometrial–myometrial junction: a fresh look at a busy crossing

The endometrial–myometrial junction: a fresh look at a busy crossing

Postpartum Management of Placenta Previa Accreta Left In Situ

Placenta previa accreta may require hysterectomy because of the potential of massive obstetric hemorrhage. Overall, up to 92% of women require blood transfusion when traditional surgical management is used. 1 Hysterectomy may not be sought as a viable option for women requesting to preserve future fertility. Conservative management by leaving the placenta in utero and administration of methotrexate has been described in the literature. With the use of conservative management, the overall transfusion rate may be lowered substantially but still may be as high as 80%. 1 The problem faced at the conclusion of such management is when to proceed with removal of the placenta. This case report illustrates a new and objective way to determine when it is safest to surgically remove the placental tissue without the risk of excess bleeding in hopes of preserving reproductive function. The means to achieve this goal was the use of 3-dimensional (3D) power Doppler angiography to follow the receding blood vessels to the placenta by quantifying its amount of vascularization.

Circular isthmic-cervical sutures can be an alternative method to control peripartum haemorrhage during caesarean section for placenta praevia accreta

To study the control of peripartum bleeding in cases of caesarean section for placenta praevia accreta with the Circular isthmic-cervical sutures. Circular isthmic-cervical sutures were applied in six cases. To avoid ureter and bladder injury, the bladder was reflected downward. A silastic drain was inserted into internal and through the external os, so as to drain the uterine cavity and to keep the cervical canal open. Firstly, at the left side of the uterus, a Vicryl number two (No..2) stitch was inserted very close to the cervix from the anterior to the posterior side of the broad ligament. The stitch was then passed posteriorly to the right side of the uterus. The needle then was inserted again very close to the cervix from the posterior to the anterior wall of the broad ligament and was tightened on the anterior uterine surface, above the reflexion of the bladder as tightly as possible. Circular isthmic-cervical sutures were effective in all cases. Circular isthmic-cervical suture is a quick, safe, simple and effective technique for controlling peripartum haemorrhage during caesarean section for placenta praevia accreta.

272: Risk factors for placenta previa-accreta from a prior delivery: A pilot study

STUDY CHAVI KARKOWSKY, HILLARY KEENAN, B. SCOTT SEGAL, DANIELA CARUSI, Brigham and Women’s Hospital, Department of Obstetrics and Gynecology, Boston, Massachusetts, Brigham and Women’s Hospital, CCI Biostatistical Consulting Service, Boston, Massachusetts, Brigham and Women’s Hospital, Department of Anesthesiology, Perioperative and Pain Medicine, Boston, Massachusetts OBJECTIVE: A placenta previa in the setting of a prior uterine incision is the strongest risk factor for placenta accreta. However, no studies have examined how the environment in which that incision is created can affect the risk of developing a placenta previa-accreta. We undertook this study to evaluate the association of placenta previa-accreta after prior cesarean with characteristics of the prior delivery. STUDY DESIGN: We conducted a retrospective cohort study over a 12-year period at a single institution. The cohort consisted of all women undergoing delivery for a placenta previa who had one prior cesarean, and whose one prior cesarean was at the same institution. Our outcome variable was pathologic or clinical diagnosis of placenta accreta. Medical records were reviewed for details of the prior delivery, including whether the patient labored and presence of fever. Demographic details were also collected. The variables were analyzed in a logistic regression model. Power analysis showed that we would need 450 patients in order to reach 80% power at a 95% confidence level. RESULTS: There were 75 subjects who met eligibility criteria over the 12-year period; 19% of these were diagnosed with placenta previa-accreta. No association was found between demographic variables and the presence of accreta. Subjects with a placenta accreta were twice as likely to have labored prior to their first cesarean section (odds ratio 2.1, 95% CI 0.7 7.0) though the study was insufficiently powered to find a significant result. The odds ratio for fever at prior cesarean section was 1.2 (95% CI 0.3 5.3). CONCLUSION: In this pilot study, we found a trend towards placenta previaaccreta at repeat cesarean section when the patient had labored at the primary cesarean delivery. A larger study is warranted to confirm this association, as it may aid patient counseling and prediction of this serious outcome

P49.04: A clinical review of placenta previa and placanta accreta in previous Cesarean section

P49.04: A clinical review of placenta previa and placanta accreta in previous Cesarean section

Antenatal diagnosis of placenta previa accreta in patients with previous cesarean scar

To determine the accuracy of transabdominal and transvaginal gray-scale and color Doppler in diagnosing placenta previa accreta in patients with previous cesarean sections. Twenty-one patients who had undergone previous cesarean sections and were confirmed to have partial or total placenta previa in the current pregnancy were subjected to ultrasound examinations after the 28th week of gestation. Specific ultrasound features were looked for on gray-scale ultrasound and color Doppler examination of the placenta and its interphase with the uterus and the bladder. Seven of the 21 patients had ultrasound evidence of placenta accreta and all were later confirmed to have placenta previa accreta intraoperatively. The gray-scale positive findings were present in six out of the seven patients. The most prominent gray scale feature to suggest placenta accreta was the presence of multiple lakes that represent dilated vessels extending from the placenta through the myometrium. All seven patients had features of placenta accreta when examined with color Doppler. The most prominent color Doppler feature present in all seven patients was the presence of interphase hypervascularity with abnormal vessels linking the placenta to the bladder. The sensitivity and specificity of antenatal ultrasound diagnosis of placenta previa accreta was 100%. Antenatal diagnosis of placenta previa accreta can be made with a thorough ultrasound examination of the placenta in patients with previous cesarean scar and placenta previa.

P14.08: Reproductive function preservation in placenta previa accreta by uterine embolization after Cesarean section

P14.08: Reproductive function preservation in placenta previa accreta by uterine embolization after Cesarean section

Parallel Vertical Compression Sutures: A Technique to Control Bleeding from Placenta Previa or Accreta During Cesarean Section

Severe bleeding sometimes complicates removal of the placenta in women with placenta previa whether or not placenta accreta is also present. Traditional treatments include hypogastric artery ligation and cesarean hysterectomy. Hypogastric artery ligation is a difficult procedure and, if not successful, may lead to ureteral injury or cardiac arrest. Cho et al recently described a square suturing technique that compresses the anterior and posterior uterine walls to control postpartum bleeding. Four stitches are needed to form the square. A version now has been devised that substitutes simple vertical sutures for the square suturing method. Only one stitch is needed. Fourteen women with postpartum bleeding from placenta previa had the modified operation in the past few years. Hemostasis was achieved with vertical compression sutures placed in the lower uterine segment. After cesarean section using a Pfannenstiel incision, the placenta is removed and the bladder reflected downward behind a retractor. A no. 1 chromic catgut, 40-mm curved, round suturing needle is used to make a stitch through the anterior wall of the lower uterine segment approximately 3 cm medial to the right margin of the lower segment and 2 to 3 cm above the upper margin of the cervix. The incised edge of the anterior lower segment then is pulled forward and up to expose the lower segment uterine cavity. From inside the uterine cavity, the suture is threaded through the lower segment cavity and inserted into the middle layer of the posterior wall of the lower segment 2 to 3 cm above the upper cervical margin. The needle then is directed vertically upward about 3 to 4 cm within the middle layer of the posterior wall and pulled from back to front through the uterine cavity and anterior wall of the lower segment, exiting approximately 2 to 3 cm below the uterine incision. Another no. 1 chromic catgut needle is used in the same way to place a suture approximately 3 cm medial to the left edge of the lower segment. The sutures are knotted as tightly as possible to compress the lower segment of the uterine cavity. The uterine incision is closed in the usual manner. Blood loss in the 14 women having this operation ranged from 700 to 2500 mL, but there was a progressive decline in bleeding when surgery was done immediately when bleeding could not be controlled. The compression sutures caused no complications, and ultrasound studies done 3 days postoperatively showed no blood accumulating in the uterine cavity. At 1 month, all women had a patent uterine cavity. Subsequent menstrual flow was normal. Two women became pregnant 1 to 2 years after surgery. This is an effective, rapid, and relatively easily performed operation that controls bleeding in women with placenta previa or placenta accreta.

Successful Conservative Management of Placenta Previa Accreta During Cesarean Section

Successful Conservative Management of Placenta Previa Accreta During Cesarean Section