Risk Of Placenta Accreta Research Articles

Prenatal identification of invasive placentation using ultrasound in women with placenta previa and prior cesarean delivery

ObjectiveTo evaluate the performance of ultrasound for antenatal identification of invasive placentation in women with placenta previa in the setting of prior cesarean delivery. Study designThis was a multicenter, retrospective, cohort study. Singleton pregnancies at risk of placenta accreta because of persistent placenta previa in the setting of prior cesarean delivery who delivered at four centers, from January 2010 to May 2020, were included in the study. For this study, pregnancies with diagnosis of accreta, increta, or percreta were considered under the umbrella term of placenta accreta. All women with placenta previa identified in the second trimester had a follow-up ultrasound at 32–34 weeks. Only those with prior cesarean delivery were considered at risk of placenta accreta. Women were considered with suspected accreta in case of suspected prenatal ultrasound. Women with suspected placenta accreta had delivery planned via cesarean hysterectomy at 34+0 – 35+6 weeks, without any attempt to remove the placenta. The primary endpoint of the study was the performance of ultrasound for antenatal identification of invasive placentation. The following ultrasound signs were evaluated: placenta lacunae; loss of clear space; increased vascularity between myometrium and placenta; intracervical lake; rail sign; uterovesical hypervascularity; increased vascularity in the inferior part of the lower uterine segment potentially extending into the parametrial region; and disruption of bladder-myometrial interface. Results180 singleton pregnancies with placenta previa in the setting of prior cesarean delivery were identified. Of them, 155 (86.1%) had antenatal suspected placenta accreta based on ultrasound, having at least one sign of invasive placentation. Of the 155 suspected cases, 99 had confirmed placenta accreta at the time of delivery. Among the 99 cases of confirmed placenta accreta, all of them had at least one sign of invasive placentation at ultrasound. Among the 81 cases with placenta previa, prior cesarean delivery, without placenta accreta, 25/81 (30.9%) had ultrasound scan negative for sign of invasive placentation, and 56/81 (69.1%) had at least one sign of invasive placentation). In particular, 12/81 (14.8%) had placenta lacunae, 16/81 (19.8%) had loss of clear space, 20/81 (24.7%) had increased vascularity between myometrium and placenta, 9/81 (11.1%) had intracervical lake, 14/81 (17.3%) had rail sign, 14 (17.3%) had uterovesical hypervascularity, 5/81 (6.2%) had increased vascularity in the inferior part of the lower uterine segment potentially extending into the parametrial region, 8/81 (9.9%) had disruption of bladder-myometrial interface. In the group of women with confirmed placenta accreta, the most common sign recorded was the disruption of bladder-myometrial interface, being recorded in 88/99 women. Disruption of bladder-myometrial interface had the highest sensitivity in detection placenta accreta. Women with disruption of bladder-myometrial interface at ultrasound had 73-fold increase in the risk of placenta accreta compared to those who did not. ConclusionPrenatal ultrasound has an excellent diagnostic accuracy in identifying invasive placentation in women with placenta previa and prior cesarean delivery.

Assisted reproductive technologies and the risk of placenta accreta

Assisted reproductive technologies and the risk of placenta accreta

Clinical risk factors for placenta accreta or placenta percreta: A case-control study

A previous cesarean performed before labor is a risk factor for both uterine scar defect and uterine rupture. We aimed to determine its association with the risk of placenta accreta.

Clinical Risk Factors for Placenta Accreta or Placenta Percreta: A Case-Control Study

Recent literature suggests that a previous cesarean performed before labour is a risk factor for both uterine scar defect and uterine rupture. Our goal is to determine whether there is an association between an elective cesarean performed before labour and the risk of placenta accreta in subsequent pregnancy.

Organ-preserving technologies and their effectiveness in patients with placenta accret

In recent years, in practical obstetrics, placental adherence into the myometrium, diagnosed after the birth of the fetus during caesarean section or in the 3rd period of labor, has become increasingly common. It causes massive bleeding, hysterectomy and maternal mortality. Purpose: To assess the outcome of childbirth with organ-preserving technology in cases of placenta accreta. Material and methods: 56 women in placenta accreta were observed and delivered for 2016-2018. 49 women delivered by Cesarean section and 7 women gave vaginal delivery. Two methods were used to preserve the uterus during placenta accreta: the first method -35 women who have laparotomy, a cesarean section with a section on the uterus above the scar and above the edge of the placenta, ligation of the uterine arteries, excision of the incremental area and metroplasty, imposition of compression sutures on the uterus. The second method -7 women after vaginal delivery left the whole or part of the placenta in the uterus - placenta in situ. The risk of placenta accreta was placenta previa, scar on the uterus, abortions in anamnesis, over 30 years of age third or more births. Results and discussion: From 35 pregnant women who underwent an organ-preserving procedure for caesarean section, 33 (94,3%) women managed to preserve the uterus, the remaining 2 (5,7%) women underwent hysterectomy Of 7 cases of placenta in situ, in 2 (28,6%) cases a hysterectomy was performed и. and uterus was preserved in 5 (71.4%) women. Conclusions: The effectiveness of improved organ-preserving technology to preserve the reproductive function of women with placenta accreta is high. In the group with the organ-preserving method with placenta, the volume of blood loss, the volume of transfusion of blood components is much lower than in the hysterectomy group.

Prognostic significance of specific proteins of pregnancy in women with a uterine scar and placenta accreta.

Comparative analysis of serum concentrations of chorionic gonadotropin (hCG) associated with the pregnancy of plasma protein A (PAPP-A) and alpha-fetoprotein (AFP), based on the results of a survey of women as part of a standard screening program (the results were expressed as a MoM - multiply of the median), found a significant increase in the performance of all the studied specific pregnancy proteins in women with a scar on the uterus and placenta acctera (75 patients) compared with the data of the group of pregnant women without scar on the uterus and without abnormalities of attachment of the placenta (150 women). AFP indices were 1.68 ± 0.76 and 1.19 ± 0.43 MoM (p = 0.0018), hCG - 1.62 ± 1.48 and 1.23 ± 0.76 MoM (p = 0, 0112), PAPP-A - 1.93 ± 1.24 and 1.23 ± 0.67 MoM (p <0.0001). Using the ROC analysis, the diagnostic thresholds for the concentrations of AFP, hCG and PAPP-A were calculated. The risk of placenta accreta in women with a scar on the uterus in cases of exceeding the diagnostic threshold of AFP concentration (1.64 MoM) increased 2.5 times (RR = 2.5; 95% CI 1.17-5.36, p = 0, 0185), hCG (1.41 MoM) - 1.6 times (RR = 1.59; 95% CI 1.09-2.32, p = 0.0147), PAPP-A (1.41 MoM) - 2.65 times (RR = 2.65; 95% CI 1.76-3.99, p <0.0001). Determination of the level of specific pregnancy proteins can be used in the system of complex prediction of placental growth in pregnant women with a scar on the uterus as an addition to the assessment of clinical and anamnestic risk factors.

Early first-trimester transvaginal ultrasound is indicated in pregnancy after previous Cesarean delivery: should it be mandatory?

Early first-trimester transvaginal ultrasound is indicated in pregnancy after previous Cesarean delivery: should it be mandatory?

The risk of placenta accreta following primary cesarean delivery.

To (a) evaluate the risk for placenta accreta following primary cesarean section (CS), in regard to the stage of labor, the cesarean section was taken (elective prelabor vs. unplanned during labor); and (b) investigate whether the association between placenta accreta and maternal and neonatal complications is modified by the type of the primary CS. In a population-based retrospective cohort study, we included all singleton deliveries occurred in Soroka University Medical Center between 1991 and 2015, of women who had a history of a single CS. The deliveries were divided into three groups according to the delivery stage the primary CS was carried out: 'Unplanned 1' (first stage-up to 10cm), 'Unplanned 2' (second stage-10cm) and 'Elective' prelabor CS. We assessed the association between the study group and placenta accreta using logistic generalized estimation equation (GEE) models. We additionally assessed maternal and neonatal complications associated with placenta accreta among women who had elective and unplanned CS separately. We included 22,036 deliveries to 13,727 women with a history of one CS, of which 0.9% (n=207) had placenta accreta in the following pregnancies: 12% (n=25) in the 'Unplanned 1' group, 7.2% (n=15) in the ' Unplanned 2' group and 80.8% (n=167) in the 'elective' group. We found no difference in the risk for subsequent placenta accreta between the groups. In a stratified analysis by the timing of the primary cesarean delivery, the risk for maternal complications, associated with placenta accreta, was more pronounced among women who had an unplanned CS (OR 27.96, P<0.01) compared to women who had an elective cesarean delivery (OR 13.72, P<0.01). The stage in which CS is performed has no influence on the risk for placenta accreta in the following pregnancies, women who had an unplanned CS are in a higher risk for placenta accrete-associated maternal complications. This should be taken into consideration while counselling women about their risk while considering trial of labor after cesarean section.

Cervical Length in Patients at Risk for Placenta Accreta.

To evaluate cervical length measurements in women with placenta accreta compared to women with a nonadherent low-lying placenta or placenta previa and evaluate this relationship in terms of vaginal bleeding, preterm labor, and preterm birth. We conducted a retrospective cohort study between 1997 and 2011 of gravidas with more than 1 prior cesarean delivery who had a transvaginal ultrasound examination between 24 and 34 weeks for a low-lying placenta or placenta previa. Cervical length was measured from archived images in accordance with national guidelines by a single investigator, who was blinded to outcomes and ultrasound reports. The diagnosis of placental accreta was based on histologic confirmation. For study purposes, preterm birth was defined as less than 36 weeks, and cervical lengths of 3 cm or less were considered short. Standard statistical analyses were used. A total of 125 patients met inclusion criteria. The cohort was divided into patients with (n = 43 [34%]) and without (n = 82 [66%]) placenta accreta and stratified by gestational age at the ultrasound examinations. Women with placenta accreta had shorter cervical length measurements during their 32- to 34-week ultrasound examinations (mean ± SD, 3.23 ± 0.98 versus 3.95 ± 1.0 cm; P < .01) and were more likely to have a short cervix of 3 cm or less (P = .001). However, these findings did not correlate with the degree of invasion (P = .3), or higher rates of vaginal bleeding and preterm labor (P = .19) resulting in preterm birth before 36 weeks (P = .64). Women with placenta accreta had shorter cervical lengths at 32 to 34 weeks than women with a nonadherent low-lying placenta or placenta previa, but this finding did not correlate with a higher risk of vaginal bleeding or preterm labor resulting in preterm birth before 36 weeks.

Uterine artery embolization for management of placenta accreta, a single-center experience and literature review

“Morbidly adherent placenta” is a term that describes the continuum of placenta accreta, increta, and percreta. Placenta accreta is the least invasive form, whereas placenta percreta represents a complete penetration of the trophoblast through the uterus that reaches the serosal surface and potentially invades the bladder, rectal wall, and pelvic vessels. Leaving the placenta in situ in the setting of abnormally invasive placenta is now widely practiced. We herein present three cases of abnormal placental implantation diagnosed by antenatal ultrasound and magnetic resonance imaging, in which uterine artery embolization was performed to induce placental infarction and eventually rapid regression but most importantly to minimize peripartum and postpartum bleeding. As we do this, we sought to review the risks of placenta accreta, increta, and percreta and evaluate the role of endovascular therapy to improve maternal outcomes when abnormal placental implantation occurs.

377: Prior unlabored cesarean and the risk for placenta accreta

377: Prior unlabored cesarean and the risk for placenta accreta

Cryopreserved embryo transfer is an independent risk factor for placenta accreta

To explore the association between cryopreserved embryo transfer (CET) and risk of placenta accreta among patients utilizing invitro fertilization (IVF) and/or intracytoplasmic sperm injection (ICSI). Case-control study. Academic medical center. All patients using IVF and/or ICSI, with autologous or donor oocytes, undergoing fresh or cryopreserved transfer, who delivered a live-born fetus at ≥24weeks of gestation at our center, from 2005 to 2011 (n = 1,571), were reviewed for placenta accreta at delivery. Cases of accreta (n = 50) were matched by age and prior cesarean section to controls (1:3) without accreta. The association between CET and accreta was modeled using conditional logistic regression, controlling a priori for age and placenta previa. Receiver operating characteristic curves were used to determine thresholds of endometrial thickness and peak serum E2 levels related to accreta. Placenta accreta. Univariate predictors of accreta were non-Caucasian race (odds ratio [OR] 2.85, 95% confidence interval [CI] 1.25-6.47); uterine factor infertility (OR 5.80, 95% CI 2.49-13.50); prior abdominal or laparoscopic myomectomy (OR 7.24, 95% CI 1.92-27.28); and persistent or resolved placenta previa (OR 4.25, 95% CI 1.94-9.33). In multivariate analysis, we observed a significant association between CET and accreta (adjusted OR 3.20, 95% CI 1.14-9.02), which remained when analyses were restricted to cases of accreta with morbid complications (adjusted OR 3.87, 95% CI 1.08-13.81). Endometrial thickness and peak serum E2 level were each significantly lower in CET cycles and those with accreta. Cryopreserved ET is a strong independent risk factor for accreta among patients using IVF and/or ICSI. A threshold endometrial thickness and a "safety window" of optimal peak E2 level are proposed for external validation.

The Risk of Placenta Accreta Following Primary Elective Caesarean Delivery

The Risk of Placenta Accreta Following Primary Elective Caesarean Delivery

Conservative management of placenta accreta with injection methotrexate to preserve fertility

Placenta accreta is described as anchoring placental villi directly contact the myometrium resulting in firm attachment of the placenta to the myometrium. The incidence of placenta accreta is increasing parallel to raising cesarean section rate. Women at greatest risk of placenta accreta are those who have myometrial damage caused by a previous cesarean delivery with either an anterior or posterior placenta previa overlying uterine scar. Control of bleeding is the main goal in such cases, which usually necessitates hysterectomy or hypogastric artery ligation; embolization of uterine artery that is done by expert interventional radiologists. However, alternative methods are useful when retaining fertility is important in young women with low parity. We present a 28-year old G5P2+0+2+2 who was admitted at 33 weeks of period of gestation for antepartum hemorrhage (APH) with previous cesarean. Even after conservative treatment for APH, she delivered still born preterm baby at 34 weeks with retained placenta where manual removal of placenta failed to remove the placenta. Placenta was removed piecemeal leaving major portion of placenta, which was morbidly adherent. After 13 days of delivery ultrasonography (USG) showed plenty of placental tissue in the uterine cavity with peripheral vascularity and increased serum beta-human chorionic gonadotrophin (β-hCG) level (1980mIU/ml). Injection methotrexate was administered on the 18 th post-partum day following the regime of 1, 3, 5 and 7 days. Repeat USG after 1 week of treatment showed decrease size in placental mass with a decrease in serum β-hCG level and after 6 th post-partum week D&E done with complete removal of placental tissue and at 8 th post-partum week USG shows normal with no retained products of conception and the patient was stable. Hence, methotrexate can thus be helpful as conservative treatment for placenta accreta in conserving the uterus and hence, the fertility.

The Risk of Placenta Accreta Following Primary Elective Caesarean Delivery

The rate of abnormal human placentation has risen dramatically, with an increased risk of placenta accreta in older women, women with placenta previa in the present pregnancy, and those with a previous cesarean delivery (CD). This case-control study was performed to determine the association between placenta accreta in a pregnancy complicated by placenta previa and the type of primary CD. Parturients with placenta accreta and placenta previa from 1993 to 2008 were included. Data analysis examined the effects of delivery mode for the primary CD on the development of placenta accreta or its variants in a pregnancy complicated by placenta previa. The primary outcome was the influence of the indication for the primary CD (elective without labor or emergency after some labor) on the subsequent risk of developing placenta accreta. Secondary outcomes were the risk of placenta accreta considering parity, gravidity, uterine surgery before the primary CD, and vaginal delivery before and after the primary CD. Criteria for controls included placenta previa, delivery during the study period, and a history of 1 or more CDs. Statistical analysis was performed using SPSS version 18 for Windows and Logxact 8.1. All tests were 2 sided, and P < 0.05 indicated statistical significance. From 82,667 live births, 88 cases of placenta accreta were identified. The final cohort included 65 women with placenta accreta or variants matched with 101 controls; 67% of cases and 38% of controls delivered at less than 37 weeks’ gestation. Thirty-seven cases (56.9%) had placenta accreta, 15 (23.1%) had placenta increta, and 13 (20.0%) had placenta percreta. Cases and controls differed neither in maternal age, gravidity, or parity nor in other demographic or socioeconomic factors (all P > 0.05). A primary elective CD was performed in 46.2% of the cases and 18.6% of controls (P < 0.001). For women with primary emergency CD, significant differences were noted between cases and controls neither in cervical dilatation or length of labor in the primary labor nor in gestational age or presentation when the primary CD occurred without labor. Compared with women in whom the primary CD occurred after some labor, women whose primary CD occurred without labor were significantly more likely to develop placenta accreta (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.47–6.12; P = 0.025). Gravidity (aOR, 0.79; 95% CI, 0.61–1.03, P = 0.063), parity (aOR, 1.12; 95% CI, 0.75–1.66; P = 0.588), previous vaginal delivery (aOR, 0.85; 95% CI, 0.60–1.21; P = 0.364), and previous uterine surgery (aOR, 1.06; 95% CI, 0.53–2.15; P = 0.866) were not associated with placenta accreta with coexisting placenta previa. Women who undergo a primary CD without labor are 3 times more likely to develop placenta accreta in a subsequent pregnancy complicated by placenta previa than women whose primary CD occurred after labor onset. Clinicians should be aware of this risk when counseling women for whom CD is an option. They should consider limiting the availability of elective CD as a choice to women in whom the alternatives of labor with vaginal delivery or the possibility of an emergency CD pose an unacceptable risk to her and the fetus’s well-being.

Practice patterns and knowledge of obstetricians and gynecologists regarding placenta accreta

Objective: We surveyed obstetricians to determine their knowledge, patterns of care and treatment preferences for women with placenta accreta.Methods: A 27-item survey was mailed to fellows of the American College of Obstetricians and Gynecologists. The survey included demographics, questions regarding knowledge and items to examine practice patterns.Results: Among 994 surveyed practitioners 508 responded including 338 who practiced obstetrics. Among generalists, 23.8% of respondents referred patients with placenta accreta to a sub-specialist. Overall, 20.4% referred women to the nearest tertiary center, and 7.1% referred to a regional center. Delivery was recommended at 34–36 weeks by 41.2%. Adjuvant interventions including ureteral stents (26.3%), iliac artery embolization catheters (28.1%), and balloon occlusion catheters (20.1%) were used infrequently. Six or more units of blood were crossed for delivery by only 29.0% of practitioners.Conclusion: There is widespread variation in the care of women with or at risk for placenta accreta.

Diagnostic value of ultrasonography and magnetic resonance imaging in pregnant women at risk for placenta accreta

Objective: The purpose of this study was to evaluate whether ultrasonography and magnetic resonance imaging can detect placenta accreta reliably in at-risk patients.Patients and methods: Thirty-nine gravid women with abnormal placentation and previous uterine surgery were collected after meeting the inclusion criteria depending on gray scale sonographic findings which suggested placenta accreta. Ultrasonography (US) and resonance imaging (MRI) findings were classified as positive and negative according to presence or absence of imaging criteria of placenta accreta.Results: The surgical findings of our patients confirmed placenta accreta in 8/39 (20.5%) patients. According to gray scale and color Doppler US 11/39 (28.2%) patients were positive and 28/39 (71.8%) were negative for placenta accreta. According to MRI findings, 12/39 (30.7%) patients were positive for placenta accreta and 27/39 (69.3%) were negative. Sensitivity, specificity, positive predictive value, negative predictive value of US and MRI were 82.0%, 89.6%, 72.7%, 92.8% and 88.8%, 86.8%, 66.6%, 96.2%, respectively.Conclusion: US and MRI were useful in the diagnosis of placenta accreta with lacunae and an abnormal color Doppler imaging pattern are the most helpful findings. MRI is most clearly indicated when US findings are ambiguous or there is a posterior placenta.

792: Maternal & fetal morbidity due to abdominal adhesions after repeated cesarean section

792: Maternal & fetal morbidity due to abdominal adhesions after repeated cesarean section

Case Scenario

P ERIPARTUM hemorrhage is responsible for 150,000 maternal deaths worldwide each year. Although the risk of maternal death has decreased over the preceding century, there has recently been a concerning suggestion of an increase in the overall incidence of hemorrhage. Despite multiple advances in medical and surgical care, a steady rise in hemorrhage has been noted within the developed world. Statistically significant increases in the incidence of maternal hemorrhage have been reported in retrospective studies in Canada (from 4.1% to 5.1%) and Australia (from 4.9% to 6.3%). Similarly, there was an increase in maternal deaths secondary to hemorrhage in the United Kingdom during the years 2000– 2002. This new uptick in the rate of peripartum hemorrhage has been attributed to increasing maternal age, multiple gestations, and the rise in the rate of cesarean sections. The most common cause of postpartum hemorrhage remains uterine atony. Disorders of placentation can be associated with either uterine atony or retained placenta. Importantly, in the developed world abnormal placentation is commonly diagnosed before delivery; with proper medical management and multidisciplinary planning, the associated morbidity and mortality can be minimized. During the past decade the rate of cesarean section has increased for multiple reasons, including an increase in maternal age, in vitro fertilization, multiple gestation, a decrease in vaginal breech delivery, and less frequent vaginal birth after cesarean section. A systematic review of 30 studies from 1997–2002 showed that nearly 90% of women chose to have a cesarean section after a previous cesarean section despite recent evidence for increased neonatal mortality. Repeated cesarean sections are a risk factor for abnormal placentation. Diagnosis of placenta previa is an indication of abnormal placentation. It is associated with an increased risk of postpartum hemorrhage due to inability of the lower uterine segment site of placental implantation to contract after placental delivery. In patients with placenta previa who have had previous cesarean delivery, each surgery is associated with an increased risk of placenta accreta. Placenta accreta, an abnormally deep attachment of the placenta into the endometrium and myometrium (the middle layer of the uterine wall), complicates 3% of primary, 11% of secondary, 40% of tertiary, 61% of quaternary, and 67% of higher-order cesarean sections for placenta previa. In this case scenario, a patient with suspected placenta accreta who required cesarean hysterectomy is presented. The risks and benefits of various anesthetic treatments and transfusion strategies are discussed with a multidisciplinary approach to delivery.

Assessing the Role of Magnetic Resonance Imaging in the Management of Gravid Patients at Risk for Placenta Accreta

The role of magnetic resonance imaging (MRI) in the diagnosis of placenta accreta remains uncertain. The purpose of this study was to evaluate the incremental benefit of MRI after ultrasound (US) for a large cohort of gravid patients at risk for a placenta accreta. A retrospective review of outcomes in women with risk factors for a placenta accreta between November 1995 and February 2008 was performed. Inclusion criteria were high-risk women with abnormal placenta implantation on US or operative diagnosis of placenta accreta, with or without a prenatal MRI. Delivery mode, diagnosis, and transfusion requirements were compared. Ranging in age from 19 to 43 years, with zero to five prior cesarean sections, 139 women met inclusion criteria. The MRI was performed in 28.7% (40/139). US, MRI, and operative diagnoses were highly correlated (P < .001). Women who underwent both US and MRI were more likely to deliver by cesarean hysterectomy (P < .001). When the cohort is stratified by outcome diagnosis (normal, previa, accreta), no difference in delivery mode is found; regardless of whether subjects were imaged by US alone or US and MRI. Transfusion requirements were highest in the US and MRI group (mean of 3.9 units vs. 0.9 units in the US only group, P < .001). This study fails to demonstrate that the incremental use of MRI for placenta accreta changes delivery mode in stratified analysis. Patients who underwent both US and MRI were most likely to have a cesarean hysterectomy delivery, and required more blood products, suggesting that undergoing tests may be indicative of an abnormal and at risk patient population.