Placental Adhesion Research Articles

Peri-Operative Complications And Surgical Outcomes In Repeat Cesarean Section: A Retrospective Analysis

Introduction: Repeat cesarean sections are becoming increasingly common due to the global rise in cesarean deliveries. While cesarean sections can be life-saving for both mother and baby, the risks associated with multiple procedures tend to increase. This study aims to evaluate these complications and outcomes to guide safer practices. Methods: This observational cross-sectional study was conducted Department of Obstetrics & Gynaecology, Chittagong Medical College & Hospital, from December 16-June’17. All the pregnant women who underwent repeat Caesarean section in Chittagong Medical College Hospital, Chittagong during the study period were considered as the study population. A total of 100 study subjects were selected by consecutive convenient sampling techniques. Data analysis was done by SPSS (Statistical Package for Social Sciences) 16. In all cases, p-value <05 was considered significant. Result: most repeat cesarean sections (70%) lasted about 1 hour, with 99% utilizing the Pfannenstiel incision. Adhesions were observed primarily with the bladder (8%), peritoneum (5%), and omentum (5%). A lower transverse uterine incision was used in 99% of cases, while 5% experienced scar dehiscence. Challenges during fetal delivery occurred in 5% of cases, and 3% had difficulty entering the peritoneal cavity. Placental abnormalities like placenta previa were noted in 6% of cases, and placental adherence (accreta or percreta) was found in 3%. Urinary bladder injuries occurred in 2% of cases. Blood loss was below 1 liter in 95% of surgeries, but 3% required significant transfusions. Elective tubal ligation was performed in 15% of cases, and some patients underwent additional procedures like Lynch surgeries or uterine artery ligations (3%). Conclusion: Notable complications are observed in repeat cesarean sections, including adhesions with the bladder, scar dehiscence, and challenges during fetal delivery. Additionally, placental abnormalities, such as placenta previa and abnormal adherence, highlight the complexities associated with repeat procedures. Most patients experienced minimal blood loss, with 95% losing less than 1 liter.

Study on the correlation between endometriosis and adverse pregnancy outcomes

ObjectiveThis study aims to investigate the correlation between endometriosis (EMS) and adverse obstetric outcomes. MethodsIn this retrospective study 2,925 cesarean section cases were analyzed at the Women and Children’s Hospital of Ningbo University, Department of Obstetrics, between May 2019 and December 2023. The study included 1,363 women diagnosed with endometriosis during pregnancy at the time of surgery (study group) and 1,562 women without such a diagnosis (control group). The comparative assessment covered the age of first-time mothers, number of pregnancies and births, gestational age at delivery, incidence rates of assisted reproductive technology (ART), spontaneous abortion, preterm birth, placenta previa, placental adhesion, and postpartum hemorrhage. ResultsThe study group demonstrated a higher average age of first-time mothers, fewer pregnancies and births, and a significantly shorter gestational age at delivery (P < 0.05) compared to the control group. Incidences of primary infertility, spontaneous abortion, and ART utilization were higher in the study group. The occurrence of placenta previa, placental adhesion, and postpartum hemorrhage was also higher in the study group, indicating significant statistical differences (P < 0.05). No significant difference was observed in preterm birth rates between the groups (P > 0.05). ConclusionPregnancy in women with endometriosis is associated with a higher likelihood of adverse outcomes, therefore highlighting the need for increased clinical awareness.

Acute puerperal uterine inversion with successful manual transvaginal repositioning: A case report.

Uterine inversion is a rare medical condition that is categorized as puerperal and nonpuerperal. Repositioning of uterine involution can be done manually or surgically, the latter of which involves abdominal manipulation and disruption of the integrity of the uterine wall, which can lead to complications for the patient in subsequent pregnancies, such as uterine rupture. We report a case of acute puerperal uterine inversion that was manually repositioned transvaginally. An ultrasonogram and reset schematic were also presented. A 23-year-old woman (gravida 1 para 0) was admitted to the hospital with a full-term pregnancy. In the postpartum period, we found placental adhesions and uterine inversion into the uterine cavity, which was confirmed by bedside ultrasound. We administered analgesic, relieving uterine spasms, and antishock therapy along with manual stripping of the placenta and ultrasound-guided uterine repositioning. After successful repositioning the patient vaginal bleeding decreased rapidly and she was discharged 3 days after delivery. Early recognition, antishock therapy and prompt repositioning are key in the management of puerperal uterine inversion. We hope that this case will enable clinicians to better visualize the ultrasound imaging of uterine inversion and the process of manual repositioning.

Prevalence and outcome of chronic hypertension and its complications with gestational diabetes.

With the full liberalization of China's fertility policy, the gradual increase in maternal age during pregnancy, and the rising proportion of overweight and obesity among women of childbearing age, the number of pregnant women with chronic hypertension (CHTN) combined with gestational diabetes mellitus (GDM) is increasing, leading to a significantly increased risk of adverse pregnancy outcomes. This study aims to analyze the prevalence of CHTN and CHTN complications with GDM, and compare the adverse pregnancy outcomes between the 2 conditions, providing a basis for intervention measures. This study was a prospective cohort study. A total of 378 366 cases from a large cohort of pregnant women between January 1, 2016 to December 31, 2020 were screened to identify 1 418 cases of pregnant women with CHTN, among which 1 027 were cases of CHTN alone and 391 were cases of CHTN combined with GDM. SAS9.4 was used to statistically analyze the basic characteristics, clinical data, and pregnant outcomes of pregnant women and to analyze the risk factors affecting the pregnancy outcomes of patients with CHTN and its complications with GDM. The prevalence rate of CHTN with pregnancy was 3.8‰, and the prevalence rate of CHTN combined with GDM was 1.0‰. Patients with CHTN combined with GDM accounted for 27.57% (391/1 418) of all pregnant women with CHTN. Maternal age, number of pregnancies, parity, previous cesarean section, systolic blood pressure, diastolic blood pressure, and mean arterial pressure at the time of enrollment were statistically significant differences between the 2 groups (all P<0.05). After adjusting for potential confounding factors such as maternal age, parity, and number of pregnancies, binary Logistic regression analysis showed that pregnant women with CHTN combined with GDM had a 1.348 times higher risk of cesarean section (OR=1.348, 95% CI 1.043 to 1.741), a 2.029 times higher risk of placental adhesion (OR=2.029, 95% CI 1.190 to 3.462), a 1.540 times higher risk of preeclampsia (OR=1.540, 95% CI 1.101 to 2.152), and a 2.670 times higher risk of macrosomia (OR=2.670, 95% CI 1.398 to 5.100) compared to pregnant women with CHTN alone. Pregnant women with CHTN combined with GDM have a high risk, and their pregnancy outcomes differ from those of pregnant women with CHTN alone in terms of cesarean section, placental adhesion, preeclampsia, and macrosomia. Prenatal care for this population, especially the management of blood pressure and blood sugar, needs to be given special attention.

Validity of ICD-10 diagnosis codes for placenta accreta spectrum disorders.

The 10th revision of the International Classification of Diseases, Clinical Modification (ICD-10) includes diagnosis codes for placenta accreta spectrum for the first time. These codes could enable valuable research and surveillance of placenta accreta spectrum, a life-threatening pregnancy complication that is increasing in incidence. We sought to evaluate the validity of placenta accreta spectrum diagnosis codes that were introduced in ICD-10 and assess contributing factors to incorrect code assignments. We calculated sensitivity, specificity, positive predictive value and negative predictive value of the ICD-10 placenta accreta spectrum code assignments after reviewing medical records from October 2015 to March 2020 at a quaternary obstetric centre. Histopathologic diagnosis was considered the gold standard. Among 22,345 patients, 104 (0.46%) had an ICD-10 code for placenta accreta spectrum and 51 (0.23%) had a histopathologic diagnosis. ICD-10 codes had a sensitivity of 0.71 (95% CI 0.56, 0.83), specificity of 0.98 (95% CI 0.93, 1.00), positive predictive value of 0.61 (95% CI 0.48, 0.72) and negative predictive value of 1.00 (95% CI 0.96, 1.00). The sensitivities of the ICD-10 codes for placenta accreta spectrum subtypes- accreta, increta and percreta-were 0.55 (95% CI 0.31, 0.78), 0.33 (95% CI 0.12, 0.62) and 0.56 (95% CI 0.31, 0.78), respectively. Cases with incorrect code assignment were less morbid than cases with correct code assignment, with a lower incidence of hysterectomy at delivery (17% vs 100%), blood transfusion (26% vs 75%) and admission to the intensive care unit (0% vs 53%). Primary reasons for code misassignment included code assigned to cases of occult placenta accreta (35%) or to cases with clinical evidence of placental adherence without histopatholic diagnostic (35%) features. These findings from a quaternary obstetric centre suggest that ICD-10 codes may be useful for research and surveillance of placenta accreta spectrum, but researchers should be aware of likely substantial false positive cases.

Life-Threatening Obstetrical Emergency: Spontaneous Uterine Rupture Associated with Placenta Percreta in the First Trimester of Pregnancy—Case Report and Literature Review

Background: The greatest risk for the occurrence of the placenta accreta spectrum (PAS) is represented by uterine scars, which most frequently result after cesarean sections. Uterine rupture is a rare condition and appears mainly in the third trimester of pregnancy. The association between these two conditions is extremely rare in the first trimester of pregnancy. Methods: We performed a systematic review of abnormal placental adhesions and spontaneous uterine ruptures in the first trimester of pregnancy. We also reported a case of spontaneous uterine rupture in a 12-week pregnancy that presented with massive hemoperitoneum and hemorrhagic shock. Results: A 33-year-old patient with two previous cesarean sections, at the twelfth week of pregnancy at the time to this visit to the emergency room, presented with syncope and intense pelvic–abdominal pain. A clinical examination and ultrasound scan established the diagnosis of hemoperitoneum and hemorrhagic shock. Surgical exploration was performed, uterine rupture was identified, and hemostasis hysterectomy was necessary. The histopathological results showed placenta percreta. There have been eight reported cases of spontaneous uterine rupture in the first trimester of pregnancy associated with PAS. In these cases, it was found that 62.5% of the patients had undergone at least one cesarean section in the past; in 75% of the cases, hysterectomy was performed; and, in 87.5% of the cases, the presence of placenta percreta was confirmed. Conclusions: A high rate of cesarean sections determines the increase in the incidence of placenta accreta spectrum disorders. The possible life-threatening complications caused by this pathology can be observed in early pregnancies.

The Impact of Endometriosis on Pregnancy.

Despite the increased frequency of endometriosis, it remains one of the most enigmatic disorders regarding its effects on pregnancy. Endometriosis adversely affects both natural and assisted conception. Impaired folliculogenesis, which causes follicular dysfunction and low egg quality, as well as luteal phase problems, reduced fertilization, and abnormal embryogenesis, are some of the mechanisms advocated to explain reproductive dysfunction. There is a rising need for a comprehensive study of the potential negative consequences of this condition on pregnancy outcomes, including the postpartum period, as more women with a medical history of endometriosis become pregnant. Obstetrical complications (small for gestational age [SGA], cesarean section [CS], miscarriage, hemorrhage, low placental adhesion, and preterm delivery) are statistically elevated in women with endometriosis. Furthermore, ruptured ovarian endometrioma, appendicitis, intestinal perforation, and hemoperitoneum have been described in pregnancy. Obstetricians are largely unfamiliar with these complications, as they have not been thoroughly investigated. The development and pathogenesis of endometriosis is an important field of study and has not yet been fully elucidated. Finding these mechanisms is crucial for the development of new and more effective strategies to treat this condition. Endometriosis can have an impact on obstetric and neonatal outcomes of pregnancy, in addition to its potential effects on conception. To date, no additional monitoring is recommended for pregnancies with a history of endometriosis. However, more studies are urgently needed to assess the need for the tailored pregnancy monitoring of women with endometriosis.

Timing of four or more scheduled cesarean sections

Objective With the increasing number of cesarean sections worldwide, the need to determine the gestational age for scheduled cesarean sections has increased. The literature needs clear information, especially about cesarean sections four or more times. Our study aims to determine the ideal gestational week for mothers and babies in patients who are not in labor and who will have four or more cesarean sections. Methods In our retrospective study, the records of 2318 pregnant women were accessed, and those with singleton pregnancies, without medication use during pregnancy, and without any complicated pregnancies, such as newly defined preeclampsia, diabetes, and thyroid disease, and those over 18 years of age were included. All of the cesarean sections were under scheduled conditions (no beginning of labor and no pain/contraction). The exclusion criteria were patients with vaginal dilatation and effacement, a history of uterine rupture, and a diagnosis of placental adhesion spectrum disorder. Maternal and neonatal outcomes were evaluated. Results Although there was no significant difference in neonatal outcomes according to gestational week, regardless of the number of cesarean sections, transient tachypnea of the newborn increased significantly in scheduled cesareans performed at the 37th week compared with other weeks (p < 0.01). The results can be expected at 39 weeks and above. Conclusion As a result, patients should not undergo cesarean section before 39 weeks unless they are in labor, and it seems safe to wait until 39 weeks.

Perinatal complications and neonatal outcomes in in vitro fertilization/intracytoplasmic sperm injection: a propensity score matching cohort study.

The utilization of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) has witnessed a significant increase in recent years. However, the comparative perinatal and neonatal outcomes compared to natural pregnancies are unclear. This study aims to compare the outcomes of pregnancies from IVF and ICSI with natural pregnancies. This retrospective, propensity score-matched cohort study was conducted at the First People's Hospital of Shangqiu and The First Affiliated Hospital of Xinjiang Medical University, involving 5,628 patients from February 2019 to December 2022. It compared pregnancies achieved through IVF/ICSI with those conceived naturally. The primary outcomes assessed were perinatal complications and neonatal health parameters. Propensity score matching and multivariate logistic regression analysis were employed to adjust for potential confounders and identify independent associations. After propensity score matching, the IVF/ICSI group demonstrated significantly higher rates of placental adherence (12.1% vs. 7.4%, p < 0.001) and postpartum hemorrhage (11.1% vs. 7.6%, p = 0.002) compared to the NP group. Neonates in the IVF/ICSI group had a lower gestational age (38.21 ± 2.12 weeks vs. 38.63 ± 2.29 weeks, p < 0.001), reduced birth weight (3159.42 ± 722.75g vs. 3211.31 ± 624.42g, p = 0.032), and an increased preterm delivery rate (11.2% vs. 8.9%, p = 0.017). Multivariate analysis further confirmed these findings, highlighting the independent associations between IVF/ICSI and these adverse outcomes. This study suggests a potential correlation between the use of IVF/ICSI and unfavorable perinatal and neonatal outcomes. These findings underscore the critical need for ongoing monitoring and research efforts to enhance the safety and effectiveness of these reproductive technologies.

Placenta accreta spectrum disorder: An updated literature review

Placenta accreta spectrum disorder (PASD) refers to a range of pathological placental adhesions to the uterine wall, previously classified into three subtypes: placenta accreta, placenta increta, and placenta percreta, based on the invasiveness of the villous tissue. This article provides an updated review of the literature on PASD with new insights into the etiopathology of PASD. Recent evidence suggests that extravillous trophoblasts are not overly invasive and that accreta placentation is more likely due to decidualisation failure resulting from blastocyst implantation within a caesarean scar defect (CSD). Previous caesarean delivery has been the most well-known risk factor of PASD, with the increased occurrence of PASD along with the increased number of previous caesarean deliveries. Antenatal identification of PASD is strongly recommended to improve outcomes before the onset of labour or bleeding, so that placental abruption can be avoided. Ultrasonography can identify PASD in the first trimester with good sensitivity and specificity. A standardised approach with a comprehensive multidisciplinary care team is required to manage PASD effectively. The Royal College of Obstetricians and Gynaecologists (RCOG), along with The American College of Obstetricians and Gynaecologists (ACOG), have published guidelines for the best clinical management of PASD. Future research should concentrate on gathering prospective data on the diagnosis and management of PASD in order to assess the association between prenatal imaging, clinical grading, and histology findings. This will lead to more accurate PASD screening, reliable diagnostic criteria, and alternatives to prenatal treatment.

A Case Report: MRI versus Ultrasonography in Abdominal Pregnancy, Which One is Better?

Abdominal pregnancy is a rare potentially life-threatening form of ectopic pregnancy. First trimester sonography is very useful to identify an abdominal pregnancy earlier. However, cases of undiagnosed abdominal pregnancy at second and third trimesters are still reported in obstetric practice. Abdominal pregnancy is often missed during routine ultrasound examination that has classical findings such as the absence of myometrial tissue between the maternal bladder and the pregnancy, an empty uterus, poor visualization of the placenta, oligohydramnios, and abnormality of fetal lie. Magnetic Resonance Imaging (MRI) has been reported as the best abdominal pregnancy detection modality in a later gestational age due to its ability in detailing vascular and placental organ invasion. The reporting of a case of a patient with an abdominal pregnancy involves a diagnosis using abdominal ultrasound in the second trimester. A 38-year-old woman was admitted to RSUP Dr. Hasan Sadikin Bandung with suspected abdominal pregnancy at gestational age of 28 weeks. Due to unclear clinical manifestation, the diagnosis of abdominal pregnancy was not detected and there was a plan for vaginal termination of pregnancy by misoprostol induction in the hospital before. The patient complained about progressive abdominal pain and difficult of defecation for 2 months before and this condition worsened in the last 4 days. Ultrasound examination in RSHS revealed that there were one living fetus, extra-uterine pregnancy with estimated fetal weight of 664 grams, fetal heart rate (+), and transverse breech presentation. Congenital abnormality was difficult to assess due to oligohydramnios. MRI was performed and showed intra-abdomen pregnancy with one living fetus, breech presentation, and intact amniotic membrane with oligohydramnios which was superior to the uterus and attached along the anterior aspect of uterus. The placenta had the size os 11.52 x 7.02 x 13.07 cm, was diffusely heterogenous in shape, on the right superoanterolateral wall of the gestational sac, and seemed to be attached to the right anterior abdominal wall and part of the intestine in the superior part while no placental adherence was seen. The patient was successfully treated with exploratory laparotomy with complete removal of the fetus and placenta. This case was reported to compare the advantage of MRI and ultrasound examination in detecting abdominal pregnancy, especially in late gestational age.

PLACENTA ACCRETA SPECTRUM DISORDERS

Placenta accreta spectrum is a rare pathology, but there is an increase in the incidence of placenta accreta. In the accreta spectrum, abnormal placental adherence to the myometrium stems in part from partial or total absence of the decidua basalis and imperfect development of the fibrinoid or Nitabuch layer. This results in the absence of a physiological line of cleavage, so resulting in failure of separation of the placenta causing significant hemorrhage. This leads to maternal morbidity and mortality. 12 patients of placenta accreta managed at Government Medical College and Rajindra Hospital, Patiala, over 1 year (December 2021–November 2022) were reported. All cases had a histopathologically proven diagnosis of placenta accreta. The major risk factors identified were placenta previa, previous cesarean section, multiparity, advanced maternal age, previous uterine surgeries, or curettage. Ultrasound (USG) color Doppler and magnetic resonance imaging allowed us to strongly suspect the presence of placenta accreta in a pregnant woman with risk factors. Placenta accreta spectrum is associated with life-threatening hemorrhage, urinary bladder injury, intensive care unit admission, massive blood transfusion, and maternal death. The course of action in each and every patient varies according to whether the diagnosis of the placenta is made antenatal or during C-section and the amount of blood loss.

Accuracy of 2D Greyscale and 2D and 3D Color Power Doppler Ultrasound in the Diagnosis of Morbidly Adherent Placenta (MAP)

Background Prenatal diagnosis of placental accreta (PA) is essential to carry out adequate surgical planning in centers where multidisciplinary teams are in place, which improve results and reduce complications. These ideal scenarios should be developed in countries with more significant difficulties in the availability of human and technological resources, through teamwork in the different hospital centres and the adequate transfer of patients at higher risk to centres with the best interdisciplinary management skills. Objective To evaluate the diagnostic accuracy of each sign (2D grayscale US signs), 2D Doppler signs, and 3D Doppler signs modified from Collins SL in diagnosis of morbidly adherent placenta in patients with one or more previous cesarean section diagnosed as placenta previa. Methods The present study is a diagnostic test accuracy study was carried out at Ain Shams University Maternity Hospital during the period from January 2020 to March 2021. 126 women were recruited from Special Care Center of the fetus – Ain Shams University Maternity Hospital. All included women were scanned by 2D grayscale, 3D power Doppler ultrasound. Results The current study showed that cases underwent cesarean hysterectomy had significantly higher previous cesarean sections. The results of the current study showed a significant association between all criteria of the 2D grayscale, Color Doppler, 3D Power Doppler ultrasound and presence of placental adherence, considerable intraoperative blood loss, need for added surgical steps, CS hysterectomy and bladder injury with the presence of more than 4 sign or more are predictive for placental invasion with the need of emergency hysterectomy. Conclusion The result of the current study proves the diagnostic accuracy of the ultrasound concerning the prediction of difficult placental separation, considerable intraoperative blood loss, CS hysterectomy and bladder invasion.

Retrospective analysis of 277 cases of placenta accreta spectrum diagnosed with ultrasound at a single tertiary care center

Introduction :Â Placenta accreta spectrum (PAS) is characterized by abnormal placental adherence and failure to separate from the uterine wall after delivery. The PAS-associated morbidities include peripartum hysterectomy (loss of fertility), massive hemorrhage and the requirement of blood transfusion (leading to consumptive coagulopathy and multisystem organ failure), admission to the intensive care unit (ICU), injury to adjacent organs, and death. Its incidence is on the rise due to an increasing number of caesarean deliveries.Objective :Â The goal of our study is to analyze the characteristics and outcomes of PAS managed at a tertiary care center with a high volume of PAS.Methods :Â The design of analytic observation research with a retrospective cross sectional method with ultrasound diagnosis of PAS at M. Djamil Central General Hospital from January 2020 to December 2022 was reviewed. Details of obstetric backgrounds, predelivery diagnosis, peripartum management, and outcomes were analyzed with mean difference test and chi square.Results :Â Two hundred and seventy-seven women with PAS were identified with ultrasound from 4,500 deliveries during the study period (6.15%). Approximately 45.48% of women with PAS had hysterectomy, while 54.52% did not; 3 cases were conservatively performed. Emergency and elective caesarean sections were accomplished in 32.85% and 67.15%, respectively. There was 3.25% maternal mortality. Anterior PAS (83.3%) is associated with attachment to the previous uterine scar and intraoperative blood loss compared to posterior PAS (15.88%) (p&lt;0.05). The PAS patients with previous uterine surgery had the highest chance of peripartum hysterectomy (p&lt;0.001).Conclusion :Â The placenta accreta diagnosed by antepartum ultrasound is approximately 6.15%. Almost half of the women in the study had hysterectomies. Only one-third of women with PAS in our study underwent emergent surgery. Anterior PAS is associated with placental attachment to the previous uterine scar and greater intraoperative blood loss compared with posterior PAS. The history of previous uterine surgery in women with PAS increased the chance of peripartum hysterectomy even further. The placenta accreta spectrum should be managed in a center with a high level of surgical expertise.

Programmed frozen embryo transfer cycles are associated with a higher risk of abnormal placental development: a retrospective cohort study of singleton live births.

Abnormal placental development can lead to adverse outcomes for both mother and fetus. The effect of different types of endometrium preparation regimens of frozen-thawed cycles on the placental development features associated with the perinatal outcomes remains unclear. Hence, we conducted a retrospective cohort study to assess the impact of specific endometrial preparation regimens on placenta-mediated pregnancy complications in singleton live births. A retrospective cohort study was conducted evaluating data of all singleton live births both conceived naturally or by in vitro fertilization (IVF) therapy from 2018 to 2020 at our hospital. Two exposed groups of frozen-thawed embryo transfer (FET) were created by the endometrium preparation regimen as the modified natural cycles (mNC) and the programmed cycles. The nonexposed group was the singleton pregnancies conceived naturally. The obstetrical and perinatal outcomes were compared among the three groups using multivariate analysis to adjust the results for determinants potentially associated with the abnormal placental development. A total of 2186 pregnant women with singleton live births were included in our final analysis and were divided into three groups as naturally conceived group (n=1334), mNC-FETs group (n=217) and programmed-FETs group(n=635). After adjusting for maternal age and parity, no significant difference was observed on the risk of placental disorders between mNC-FET cycles and natural conceived pregnancies (aOR 1.16; 95%CI 1.31-7.01), while programmed-FET cycles were associated with a higher occurrence of placental disorders (aOR 5.36; 95%CI 3.63-8.05). Using the mNC-FET group as a reference and adjusting for confounders such as maternal age, parity, endometrial thickness, and number of embryos transferred, we found that the main manifestation of abnormal placentation in programmed FET cycles was abnormal placental attachment, including placental adhesion and placenta increta (aOR 2.50, 95%CI 1.36-4.90). The dysfunction of placentation in programmed-FET cycles was independently associated with the type of infertility, the total dose of Femostone and thinner endometrium. Additionally, placental disorders in the programmed-FET group were associated with higher rate of preeclampsia, postpartum hemorrhage and Cesarean section. Our retrospective study revealed that the programmed-FET has a substantial impact on placental development, resulting in a higher incidence of preeclampsia, postpartum hemorrhage and Cesarean section. These findings have significant implications on clinical decision-making.

Urinary tract injuries during surgery for placenta accreta spectrum disorders

ObjectiveThe main purpose of this study was to report the incidence of lower urinary tract injuries (UTI) during cesarean section (CS) hysterectomy in cases of Placenta Accreta Spectrum (PAS) disorders.Study designRetrospective analysis including all women with a prenatal diagnosis of PAS between January 2010 and December 2020. A dedicated multidisciplinary team was involved to define a tailored management for each patient. All relevant demographic parameters, risk factors, degree of placental adhesion, type of surgery, complications and operative outcomes were reported. ResultsOne hundred and fifty-six singleton gestations with a prenatal diagnosis PAS were included in the analysis. 32.7% of cases were classified as PAS 1 (grade 1-3a FIGO classification), 20.5% as PAS 2 (grade 3b FIGO classification) and 46.8% as PAS 3 (grade 3c FIGO classification). A CS hysterectomy was performed in all cases. Surgical complication occurred in seventeen cases (0% in PAS 1, 12.5% in PAS 2 cases and in 17.8% in PAS 3). The incidence of UTI in our series was 7.6% in all women with PAS, including 8 cases of bladder and 12 of ureteral lesion, and 13.7 % in those with PAS 3 only. ConclusionDespite advances in prenatal diagnosis and management, surgical complications, mainly those involving the urinary system, still occur in a significant proportion of women undergoing surgery for PAS. The findings from this study highlight the need for a multidisciplinary management of women with PAS in centers with high expertise in prenatal diagnosis and surgical management of these conditions.

Prophylactic bilateral internal iliac balloon occlusion to control hemorrhage in placenta accreta spectrum: a boon for obstetricians.

Placenta accreta spectrum (PAS) is abnormal placental adhesion beyond superficial myometrium, which may lead to severe life-threatening hemorrhage requiring massive blood transfusions in the peripartum period. Prophylactic balloon catheterization of bilateral internal iliac arteries with or without additional embolization with Cesarean hysterectomy in patients with PAS prevent excessive intraoperative hemorrhage and may also obviate the need for hysterectomy. To study the efficacy of intervention radiological procedures in controlling intraoperative hemorrhage in patients with PAS. This ethically approved prospective study was conducted between November 2017 and October 2019 and written informed consent was obtained from all patients. Consecutive patients diagnosed with PAS during the antepartum period were evaluated. A total of 18 patients with PAS underwent prophylactic balloon catheterization of the bilateral internal iliac arteries followed by delivery of the infant. Interventional and intraoperative data of these patients were collected and compared with retrospectively collected data of patients (control group) who underwent hysterectomy without prophylactic balloon occlusion over the past four years (January 2016-November 2019). Significantly lower intraoperative blood loss (2.8 L vs. 4.7 L; P = 0.048) and pure red blood cell (PRBC) requirement (P = 0.026) between patients who had hysterectomy with and without interventional radiological management was observed. Significantly higher blood loss (P = 0.006) and fluid requirement (P = 0.007) was observed with a higher degree of placental invasion. Only 1 (6%) major procedure-related complication was observed. Interventional radiological procedures are effective in significantly reducing intraoperative blood loss and blood product requirement in patients with PAS.

Hemorrhagic Morbidity in Nulliparous Patients with Placenta Previa without Placenta Accrete Spectrum Disorders

ABSTRACT Background: Placental adhesion spectrum (PAS) is a disease in which the trophoblast invades the myometrium, and is a well-known high-risk condition associated with placental previa. Aim: The morbidity of nulliparous women with placenta previa without PAS disorders is unknown. Patients and Methods: The data from nulliparous women who underwent cesarean delivery were collected retrospectively. The women were dichotomized into malpresentation (MP) and placenta previa groups. The placenta previa group was categorized into previa (PS) and low-lying (LL) groups. When the placenta covers the internal cervical os, it is called placenta previa, when the placenta is near the cervical os, it is called the low-lying placenta. Their maternal hemorrhagic morbidity and neonatal outcomes were analyzed and adjusted using multivariate analysis based on univariate analysis. Results: A total of 1269 women were enrolled: 781 women in the MP group and 488 women in the PP-LL group. Regarding packed red blood cell transfusion, PP and LL had adjusted odds ratio (aOR) of 14.7 (95% confidence interval (CI): 6.6 – 32.5), and 11.3 (95% CI: 4.9 – 26) during admission, and 51.2 (95% CI: 22.1 – 122.7) and 10.3 (95% CI: 3.9 – 26.6) during operation, respectively. For intensive care unit admission, PS and LL had aOR of 15.9 (95% CI: 6.5 – 39.1) and 3.5 (95% CI: 1.1 – 10.9), respectively. No women had cesarean hysterectomy, major surgical complications, or maternal death. Conclusion: Despite placenta previa without PAS disorders, maternal hemorrhagic morbidity was significantly increased. Thus, our results highlight the need for resources for those women with evidence of placenta previa including a low-lying placenta, even if those women do not meet PAS disorder criteria. In addition, placenta previa without PAS disorder was not associated with critical maternal complications.

Implementation and outcomes of a uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum

Placenta accreta spectrum disorders are a continuum of placental pathologies with significant maternal morbidity and mortality. Morbidity is related to the overall degree of placental adherence, and thus patients with placenta increta or percreta represent a high-risk category of patients. Hemorrhage and transfusion of blood products represent 90% of placenta accreta spectrum morbidity. Both tranexamic acid and uterine artery embolization independently decrease obstetrical hemorrhage. This study aimed to provide an evidence-based intraoperative protocol for placenta accreta spectrum management. This study was a pre- and postimplementation analysis of concomitant uterine artery embolization and tranexamic acid in cases of patients with antenatally suspected placenta increta and percreta over a 5-year period (2018-2022). For comparison, a 5-year (2013-2017) preimplementation group was used to assess the impact of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum. Patient demographics and clinically relevant outcomes were obtained from electronic medical records. A total of 126 cases were managed by the placenta accreta spectrum team, of which 66 had suspected placenta increta/percreta over the 10-year time period. Two patients were excluded from the postimplementation cohort because they did not undergo both interventions. Thus, 30 (30/64; 47%) were treated after implementation of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum, and 34 (34/64; 53%) preimplementation patients did not undergo uterine artery embolization or tranexamic acid infusion. With the uterine artery embolization and tranexamic acid protocol, operative times were longer (416 vs 187 minutes; P<.01), and patients were more likely to receive general anesthesia (80% vs 47%; P<.01). However, blood loss was reduced by 33% (2000 vs 3000 cc; P=.03), overall blood transfusion rates decreased by 51% (odds ratio, 0.05 [95% confidence interval, 0.001-0.20]; P<.01), and massive blood transfusion (>10 units transfused) was reduced 5-fold (odds ratio, 0.17 [95% confidence interval, 0.02-0.17]; P=.02). Postoperative complication rates remained unchanged (4 vs 10 events; P=.14). Neonatal outcomes were equivalent. The uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum is an effective approach to the standardization of complex placenta accreta spectrum cases that results in optimal perioperative outcomes and reduced maternal morbidity.

Maternal Serum Alpha Fetoprotien as a marker of Placental Adherence in Placenta Previa and Low Lying Placenta

Maternal Serum Alpha Fetoprotien as a marker of Placental Adherence in Placenta Previa and Low Lying Placenta