Objective This study aims to investigate the correlation of an ultrasonic scoring system with intraoperative blood loss(IBL) in placenta accreta spectrum(PAS) disorders.Methods A retrospective cohort study was conduct...Objective This study aims to investigate the correlation of an ultrasonic scoring system with intraoperative blood loss(IBL) in placenta accreta spectrum(PAS) disorders.Methods A retrospective cohort study was conducted between January 2015 and November 2019.Clinical data for patients with PAS have been obtained from medical records. Generalized additive models were used to explore the nonlinear relationships between ultrasonic scores and IBL. Logistic regressions were used to determine the differences in the risk of IBL ≥ 1,500 m L among groups with different ultrasonic scores.Results A total of 332 patients participated in the analysis. Generalized additive models showed a significant positive correlation between score and blood loss. The amount of IBL was increased due to the rise in the ultrasonic score. All cases were divided into three groups according to the scores(low score group: ≤ 6 points, n = 147;median score group: 7-9 points, n = 126;and high score group: ≥ 10 points, n = 59). Compared with the low score group, the high score group showed a higher risk of IBL≥ 1,500 m L [odds ratio, 15.09;95% confidence interval(3.85, 59.19);P ≤ 0.001] after a multivariable adjustment.Conclusions The risk of blood loss equal to or greater than 1,500 m L increases further when ultrasonic score greater than or equal to 10 points, the preparation for transfusion and referral mechanism should be considered.展开更多
Objective:This study aimed to investigate the clinical effects of abdominal aortic balloon occlusion followed by uterine artery embolization for the treatment of pernicious placenta previa complicated with placenta ac...Objective:This study aimed to investigate the clinical effects of abdominal aortic balloon occlusion followed by uterine artery embolization for the treatment of pernicious placenta previa complicated with placenta accreta during cesarean section.Methods:We performed a retrospective analysis of the clinical data for 623 patients who experienced pernicious placenta previa complicated with placenta accreta and received treatment in our hospital from January 2013 to January 2019.All patients underwent abdominal aortic balloon occlusion before their cesarean section.Seventyeight patients received bilateral uterine artery embolization,and among them,placenta accreta was found at the opening of the cervix in 13 patients.Due to suturing difficulty after the removal of the placenta,gauze packing was used to temporarily compress the hemorrhage.As soon as the uterus was sutured,emergent bilateral uterine artery embolization was performed.Active bleeding was noted in the remaining 65 patients when the lower part of the uterus was pressed after the placenta was removed and the uterus was sutured,therefor,bilateral uterine artery embolization was performed urgently.Results:Of the 623 patients,545 patients underwent only abdominal aortic balloon occlusion and 78 patients underwent additional emergent bilateral uterine artery embolization due to hemorrhaging during or after their cesarean section.No hysterectomies were performed.In the 78 patients,the amount of bleeding was 800-3,200 ml with an average of 1,650 ml during the operation;the volume of blood transfused was 360-1,750 ml(average:960 ml).The fetal fluoroscopy time was 3–8 s(average:5 s).The dose of radiation exposure was(4.2±2.9) m Gy.Fetal appearance,pulse,grimace,activity,and respiration(Apgar) score were normal.No serious complications were observed during or after the operation in the follow-up visits.Conclusion:For patients with pernicious placenta previa complicated with placenta accreta who experience active bleeding after cesarean section and abdominal aortic balloon occlusion,bilateral uterine artery embolization can effectively reduce blood loss and requirement of blood transfusion during the operation,and lowers the risk of hysterectomy.展开更多
BACKGROUND Mifepristone-induced abortion(MIA)has been used worldwide to terminate pregnancies.However,the association between placenta accrete(PA)and MIA has seldom been reported.CASE SUMMARY A 26-year-old pregnant wo...BACKGROUND Mifepristone-induced abortion(MIA)has been used worldwide to terminate pregnancies.However,the association between placenta accrete(PA)and MIA has seldom been reported.CASE SUMMARY A 26-year-old pregnant woman presented with painless vaginal bleeding at 35 wk of gestation.She had a medical abortion(mifepristone followed by misoprostol)1 year ago at the sixth week of gestation.Her personal history for previous surgery was negative.Abdominal ultrasonography showed a normal foetus with complete placenta previa.The foetal membrane ruptured with massive vaginal bleeding and severe abdominal pain.An emergency Caesarean section was performed,and the newborn was delivered.The placenta failed to expel and manual extraction was carried out.A large defect was noted in the uterine fundus and repair of the uterine rupture was conducted immediately.The postoperative pathology report showed placenta accreta.CONCLUSION The evidence suggests a possible etiologic role of MIA in PA,as the incidence of PA after MIA is much higher than general population.Millions of pregnancies are complicated by PA each year,some of which result in fatality.To prevent subsequent placental complications after MIA,hormonal supplementation might be a promising therapeutic options.However,further studies are needed to identify the high-risk factors and to confirm the effectiveness of estrogen supplement therapy.展开更多
Objective Abdominal aortic balloon occlusion(AABO)is a vascular intervention method that has been widely used in the treatment of severe placenta accreta spectrum(PAS).The aim of this study was to investigate the bene...Objective Abdominal aortic balloon occlusion(AABO)is a vascular intervention method that has been widely used in the treatment of severe placenta accreta spectrum(PAS).The aim of this study was to investigate the benefits,potential risks,and characteristics of AABO combined with tourniquet binding of the lower uterine segment(LUS)in treatment of pregnant women with PAS.Methods In this study,64 pregnant women with PAS scores greater than 5 were enrolled as research subjects and divided into two groups.Group A(n=34)underwent normal operative procedures including tourniquet binding of the LUS.Group B(n=30)underwent AABO combined with tourniquet binding of the LUS.General clinical characteristics,ultrasonography PAS score,intraoperative blood loss(IBL),blood loss within 24 h after surgery(24-h BL),postoperative complications,and neonatal data of the two groups were retrospectively reviewed.The influencing factors of IBL for the two groups were analyzed.Results The amounts of IBL,24-h BL,total input red blood cell,and the incidence of disseminated intravascular coagulation were significantly lower in group B than in group A(P<0.05),and this difference was even more significant in the subgroup of placenta percreta(PAS scores≥10).Further multivariate linear analysis showed that the combined therapy of AABO and tourniquet could independently predict lower IBL than normal operative procedures did(P=0.001).Conclusion AABO combined with tourniquet binding of the LUS could improve the outcomes of pregnant women with severe PAS and reduce serious peripartum complications of AABO.展开更多
Introduction: Placenta accreta is due to invasive placental implantation. It is diagnosed when there is failure of delivery of a retained placenta. This is usually complicated by massive intrapartum hemorrhage that en...Introduction: Placenta accreta is due to invasive placental implantation. It is diagnosed when there is failure of delivery of a retained placenta. This is usually complicated by massive intrapartum hemorrhage that ends by hysterectomy. Case: We report a case of conservative management in a case of placenta accreta involving an elliptical shape incision of the lower segment with removal of placenta with underlying lower uterine segment in a stable patient desiring future fertility. Conclusion: Conservative management may be valid in carefully selected cases of placenta accreta diagnosed pre-operatively in tertiary hospitals with availability of blood-bank and multi-disciplinary approach.展开更多
Introduction: Placenta Accreta Spectrum (PAS) is associated with significant maternal and fetal morbidity and mortality. The ideal conservative management still does not exist. We aimed to compare the outcome of cesar...Introduction: Placenta Accreta Spectrum (PAS) is associated with significant maternal and fetal morbidity and mortality. The ideal conservative management still does not exist. We aimed to compare the outcome of cesarean section for PAS by a gynecologic oncologist-led team using the modified triple P approach and by a non-gynecologic oncologist-led team. Material and Methods: This is non-randomized controlled trial. Group A had Cesarean Section by gynecologic oncologist. Gynecologic oncologist-led team did all Cesarean Section following a modified triple P approach. The first P is for “Plan” the uterine incision. The second P for “Pelvic” devascularization by internal iliac artery ligation. The third P is for Placenta non-separation with resection of the myometrium. Group B had Cesarean Section by non-gynecologic oncologist-led team. The main outcome measures were the need for hysterectomy, amount of blood loss, and the management-related complications. Results: Group A had significantly less estimated blood loss, and received less number of backed RBCs units, and less operative time than group B. The uterus is preserved in all cases of group A and in 50% of cases of group B. The overall maternal morbidity rate was 17.5% in group A and 72.2% in group B. Conclusion: This study provides evidence that the modified triple P approach for PAS by gynecologic oncologist-led team presents lower maternal morbidity in comparison to surgery by non-gynecologic oncologist-led team.展开更多
Objective: The aim of this study was to determine the incidence, risk factors, and outcomes of management of patients with placenta accreta. Background Placenta accreta occurs when the placental implantation is abnorm...Objective: The aim of this study was to determine the incidence, risk factors, and outcomes of management of patients with placenta accreta. Background Placenta accreta occurs when the placental implantation is abnormal. The marked increase in incidence has been attributed to the increasing prevalence of cesarean delivery in recent years. The most common theory is defective decidualization. The most important risk factor for placenta accreta is placenta previa after a prior cesarean delivery. The first clinical manifestation of placenta accreta is usually profuse, life-threatening hemorrhage. The recommended management of suspected placenta accreta is planned preterm cesarean hysterectomy with the placenta left in situ. Patients and methods: It’s a study of all cases of placenta accreta at El-Shatby Maternity University Hospital starting from 1/4/2016 till 1/10/2016. Selection of the cases will only be dependent upon their pregnancy gestational age above 28 weeks of gestation. Results: The incidence of placenta accreta was 1/75 cesarean deliveries. The ultrasonography and doppler had a false negative rate of 54.6% and a sensitivity of 45.2% in diagnosis of placenta accreta. The rate of blood transfusion was 79.6%. Uterine preserving procedures performed in 66%. Cesarean hysterectomy performed in 34%. Intensive care unit admission occurred in 27.3%. The mean gestational age at delivery was 33.8 ± 4.6 weeks’ gestation. 31.8% admitted to the neonatal intensive care unit. Conclusion: The incidence of placenta accreta increased due to the increasing rate of cesarean deliveries, prenatal diagnosis of placenta accreta is paramount, as most women are asymptomatic. Prenatal diagnosis allows time for a multidisciplinary team to make delivery plans, which will help decrease surgical complications.展开更多
Introduction: Placenta accreta is a potentially life threatening obstetrical condition. The incidence has increased. Diagnosis before delivery allows multidisciplinary planning in an attempt to minimize potential mate...Introduction: Placenta accreta is a potentially life threatening obstetrical condition. The incidence has increased. Diagnosis before delivery allows multidisciplinary planning in an attempt to minimize potential maternal or neonatal morbidity and mortality. Prenatal ultrasonography is used to support the diagnosis and guide clinical management leading probably to favorable outcomes. Actually a conservative option which includes leaving all or part of the placenta in situ when fertility preservation is desired is recommended. Methods: We retrospectively reviewed the medical records of all patients diagnosed with placenta accreta in gynecology-obstetrics department of the university hospital Mohammed the VI of Marrakesh;Morocco;from January the first 2014 to January the second 2016. Results: We found seven cases. We described: The epidemiological characteristics, risk factors, management of placenta accreta, outcomes and prognosis. The incidence of placenta accreta was 1/3847 deliveries. The mean term of delivery was 35 weeks. We have adopted a successful conservative treatment in six cases (71.4%). The radical treatment was adopted in one patient initially admitted for severe post-partum hemorrhage;the prognosis was good in 85.7% cases. Conclusion: Conservative management of placenta accreta is a safe and efficient and is an interesting alternative for hysterectomy.展开更多
Objective: To assess the effect of tourniquet application of intraoperative blood loss in placenta accreta cases undergoing cesarean hysterectomy. Materials and methods: Nine cases and twenty controls with USG and col...Objective: To assess the effect of tourniquet application of intraoperative blood loss in placenta accreta cases undergoing cesarean hysterectomy. Materials and methods: Nine cases and twenty controls with USG and colour Doppler diagnosed placenta accreta with previous cesarean section were chosen to utilize this novel approach. These cases were planned for elective cesarean section followed by hysterectomy. The twenty controls underwent a classical cesarean section followed by total abdominal hysterectomy with the placenta?in situ. Among the nine cases, after delivery of the fetus through upper segment cesarean section, a cotton gauze tourniquet was applied all around the lower pole of uterus. Hysterectomy was performed with placenta?in situ. Abdomen closed after achieving complete haemostasis. Results: The average operative time taken was 85 ± 11.72 minutes among cases and 98.25 ± 9.9 minutes among controls (p = 0.0039). Average blood loss was 1011.11 ± 99.3 ml among the cases and 1855 ± 222.95 ml among the controls (p ≤ 0.0001). Average requirement of blood transfusion required was two units for the cases and five units for the controls (p = 0.0002). No intra-operative or post-operative surgical complications were observed in any of the cases whereas the controls reportedly had a few. All the mothers and babies were healthy at the time of discharge. Conclusion: The presence of placenta accreta is associated with major fetal and maternal complications. The technique of tourniquet application is efficacious in minimizing the intra-operative blood loss and surgical complications due to obstruction of operative field by bleeding and also by preventing massive blood transfusion related complications.展开更多
Morbid Adherent Placenta (MAP)/Placenta Accreta Spectrum (PAS) is a serious diagnosis which has a risk of complications. Ultrasound scan helps in early diagnosis and has great value in further confirmation and follow ...Morbid Adherent Placenta (MAP)/Placenta Accreta Spectrum (PAS) is a serious diagnosis which has a risk of complications. Ultrasound scan helps in early diagnosis and has great value in further confirmation and follow up. Observed new clinical sign and associated clinical triad are discussed here.展开更多
Objectives: To describe a novel procedure to treat hemorrhage of placenta accreta spectrum disorders (PAS) or cesarean-scar pregnancy (CSP). Methods: This was a retrospective study of women under cesarean delivery wit...Objectives: To describe a novel procedure to treat hemorrhage of placenta accreta spectrum disorders (PAS) or cesarean-scar pregnancy (CSP). Methods: This was a retrospective study of women under cesarean delivery with PAS or placenta previa. Patients’ information was acquired from hospital records. A novel procedure of surgery is developed with seven major steps, including avoiding placenta incised, elevating upward the uterine, clamping the uterine arteries with sponge forceps, removing the placenta, opening the vesicouterine space and suture techniques. Results: A total of 38 patients were reviewed. Twenty-one patients diagnosed with placenta accrete syndrome and 3 patients with CSP were underwent surgery with the novel procedure of surgery and all severe hemorrhage was controlled without hysterectomy. There were 2 women with bladder injuries needing primary repair. Fourteen patients with placenta previa underwent cesarean delivery and there was no intraoperative complication of the total 14 patients. Conclusion: The seven-step approach is more secure and effective to control severe hemorrhage without other invasive procedures in cesarean delivery with PAS. It is technically easier to maintain and improve surgical skills.展开更多
Objective:To evaluate the diagnostic accuracy of magnetic resonance imaging(MRI)in diagnosing placenta accreta spectrum(PAS).Methods:We conducted a comprehensive literature search from database inception to November 2...Objective:To evaluate the diagnostic accuracy of magnetic resonance imaging(MRI)in diagnosing placenta accreta spectrum(PAS).Methods:We conducted a comprehensive literature search from database inception to November 2023 using terms such as placenta creta,increta,percreta,PAS,MRI,and their respective Medical Subject Headings terms.All prospective and retro-spective cohort,case-control,and cross-sectional studies involving prenatal magnetic resonance imaging diagnosis of PAS with subsequent pathological confirmation were included.Results:A total of 40 studies encompassing 3664 women met the inclusion criteria,with 1894 cases confirmed pathologically as PAS.The overall sensitivity of MRI was 0.867(95%confidence interval(CI):0.807–0.910),and the specificity was 0.860(95%CI:0.799–0.905),with a correlation of 0.693 between sensitivity and specificity.The estimated odds ratio was 28.693(95%CI:14.463–56.924),the negative likelihood ratio was 0.178(95%CI:0.122–0.258),and the positive likelihood ratio was 4.316(95%CI:3.186–5.846).Analysis of individual MRI criteria revealed estimates of sensitivity,specificity,odds ratio,negative likelihood ratio,and positive likelihood ratio for abnormal placental bed vascularization as 0.500,0.740,2.788,0.571,and 1.645 respectively;0.384,0.985,6.270,0.471,and 2.720 for bladder wall interruption;0.766,0.818,13.638,0.262,and 3.375 for the presence of dark intraplacental bands;0.691,0.913,10.828,0.352,and 3.361 for heterogeneous placenta;0.688,0.984,34.886,0.254,and 7.164 for indistinctive myometrium;0.757,0.864,8.496,0.362,and 2.778 for loss of retroplacental dark zone;0.828,0.593,5.829,0.329,and 1.766 for myometrial thinning;and 0.518,0.916,9.473,0.411,and 3.526 for placental bulge,respectively.Conclusion:MRI demonstrates significant utility in diagnosing PAS and its severity.It is recommended for use in all cases with inconclusive ultrasonographic findings.Registration:Registration number CRD42021267501.展开更多
The recent increase in placenta accreta spectrum has been correlated with a rise in the rate of cesarean sections.A recent study provides evidence that hampered wound healing results in cesarean scar defects that lead...The recent increase in placenta accreta spectrum has been correlated with a rise in the rate of cesarean sections.A recent study provides evidence that hampered wound healing results in cesarean scar defects that lead to a failure in the normal process of decidualization and deeper adherence of trophoblasts.Matrix metalloproteinase(MMP)is crucial in every step of wound healing as it alters the wound matrix,facilitating cell migration,as well as tissue remodeling.MMP-9 expression is higher in placental and decidual tissue in cases of placenta accreta.Based on these findings,assessment of MMP-9 expression can shed new light on the etiopathology of placenta accreta spectrum disorder and can be a potential diagnostic marker.展开更多
To editor:The disorders associated with placenta accreta spectrum(PAS)are potentially severe obstetric complications that should be managed by expert centers with substantial re-sources to provide both preoperative an...To editor:The disorders associated with placenta accreta spectrum(PAS)are potentially severe obstetric complications that should be managed by expert centers with substantial re-sources to provide both preoperative and intraoperative as-sessments and then prearrange a multidisciplinary team with an appropriate delivery plan.Placenta accreta spectrum was first described in 1937 as“attempts to remove the pla-centa led to major postpartum hemorrhage that required emergency or secondary hysterectomy to control bleeding.”1 In 1966,Luke et al-classified this condition into placenta creta(or vera,adherenta),increta,and perceta based on the depth of placenta villi adhesion or invasion,as determined by pathological features.Although infrequent,there have been significant advances in the global evolution of the strat-egies used to manage PAS,especially over the last decade.展开更多
Posterior placenta accreta spectrum(PAS)disorders are infrequent but potentially associated with significant maternal mortality and morbidity,especially if not diagnosed prenatally.Analysis of published literature is ...Posterior placenta accreta spectrum(PAS)disorders are infrequent but potentially associated with significant maternal mortality and morbidity,especially if not diagnosed prenatally.Analysis of published literature is problematic since most experiences included only a few cases.Knowledge of the risk factors associated with posterior PAS is crucial to identifying mothers at higher risk and ask for high sensitivity studies.Ultrasound has poor diagnostic accuracy in detecting posterior PAS,while magnetic resonance imaging better delineates the posterior uterine wall.In comparison,prenatal imaging’s diagnostic performance in detecting posterior PAS is significantly lower than anterior placenta invasion.Management of posterior PAS depends on several factors,including maternal hemodynamic status,available resources,clinical presentation,and invasion severity.For accreta or increta cases,a compression suture is habitually enough to perform hemostasis.Nevertheless,organ involvement habitually requires a multidisciplinary team with the assistant of a general or coloproctology surgeon.The present article aims to update the risk factors,prenatal diagnosis,and surgical management of pregnancies complicated by posterior PAS.展开更多
基金supported by The Capital health Development Research Project [2020-1-4039]Key Program for Clinical Projects of Hospital [BYSY2018002]。
文摘Objective This study aims to investigate the correlation of an ultrasonic scoring system with intraoperative blood loss(IBL) in placenta accreta spectrum(PAS) disorders.Methods A retrospective cohort study was conducted between January 2015 and November 2019.Clinical data for patients with PAS have been obtained from medical records. Generalized additive models were used to explore the nonlinear relationships between ultrasonic scores and IBL. Logistic regressions were used to determine the differences in the risk of IBL ≥ 1,500 m L among groups with different ultrasonic scores.Results A total of 332 patients participated in the analysis. Generalized additive models showed a significant positive correlation between score and blood loss. The amount of IBL was increased due to the rise in the ultrasonic score. All cases were divided into three groups according to the scores(low score group: ≤ 6 points, n = 147;median score group: 7-9 points, n = 126;and high score group: ≥ 10 points, n = 59). Compared with the low score group, the high score group showed a higher risk of IBL≥ 1,500 m L [odds ratio, 15.09;95% confidence interval(3.85, 59.19);P ≤ 0.001] after a multivariable adjustment.Conclusions The risk of blood loss equal to or greater than 1,500 m L increases further when ultrasonic score greater than or equal to 10 points, the preparation for transfusion and referral mechanism should be considered.
文摘Objective:This study aimed to investigate the clinical effects of abdominal aortic balloon occlusion followed by uterine artery embolization for the treatment of pernicious placenta previa complicated with placenta accreta during cesarean section.Methods:We performed a retrospective analysis of the clinical data for 623 patients who experienced pernicious placenta previa complicated with placenta accreta and received treatment in our hospital from January 2013 to January 2019.All patients underwent abdominal aortic balloon occlusion before their cesarean section.Seventyeight patients received bilateral uterine artery embolization,and among them,placenta accreta was found at the opening of the cervix in 13 patients.Due to suturing difficulty after the removal of the placenta,gauze packing was used to temporarily compress the hemorrhage.As soon as the uterus was sutured,emergent bilateral uterine artery embolization was performed.Active bleeding was noted in the remaining 65 patients when the lower part of the uterus was pressed after the placenta was removed and the uterus was sutured,therefor,bilateral uterine artery embolization was performed urgently.Results:Of the 623 patients,545 patients underwent only abdominal aortic balloon occlusion and 78 patients underwent additional emergent bilateral uterine artery embolization due to hemorrhaging during or after their cesarean section.No hysterectomies were performed.In the 78 patients,the amount of bleeding was 800-3,200 ml with an average of 1,650 ml during the operation;the volume of blood transfused was 360-1,750 ml(average:960 ml).The fetal fluoroscopy time was 3–8 s(average:5 s).The dose of radiation exposure was(4.2±2.9) m Gy.Fetal appearance,pulse,grimace,activity,and respiration(Apgar) score were normal.No serious complications were observed during or after the operation in the follow-up visits.Conclusion:For patients with pernicious placenta previa complicated with placenta accreta who experience active bleeding after cesarean section and abdominal aortic balloon occlusion,bilateral uterine artery embolization can effectively reduce blood loss and requirement of blood transfusion during the operation,and lowers the risk of hysterectomy.
文摘BACKGROUND Mifepristone-induced abortion(MIA)has been used worldwide to terminate pregnancies.However,the association between placenta accrete(PA)and MIA has seldom been reported.CASE SUMMARY A 26-year-old pregnant woman presented with painless vaginal bleeding at 35 wk of gestation.She had a medical abortion(mifepristone followed by misoprostol)1 year ago at the sixth week of gestation.Her personal history for previous surgery was negative.Abdominal ultrasonography showed a normal foetus with complete placenta previa.The foetal membrane ruptured with massive vaginal bleeding and severe abdominal pain.An emergency Caesarean section was performed,and the newborn was delivered.The placenta failed to expel and manual extraction was carried out.A large defect was noted in the uterine fundus and repair of the uterine rupture was conducted immediately.The postoperative pathology report showed placenta accreta.CONCLUSION The evidence suggests a possible etiologic role of MIA in PA,as the incidence of PA after MIA is much higher than general population.Millions of pregnancies are complicated by PA each year,some of which result in fatality.To prevent subsequent placental complications after MIA,hormonal supplementation might be a promising therapeutic options.However,further studies are needed to identify the high-risk factors and to confirm the effectiveness of estrogen supplement therapy.
基金2018 Applied Medicine Research Projects of Health and Family Planning Commission of Hubei(No.WJ2018H0139 and No.WJ2018H0133).
文摘Objective Abdominal aortic balloon occlusion(AABO)is a vascular intervention method that has been widely used in the treatment of severe placenta accreta spectrum(PAS).The aim of this study was to investigate the benefits,potential risks,and characteristics of AABO combined with tourniquet binding of the lower uterine segment(LUS)in treatment of pregnant women with PAS.Methods In this study,64 pregnant women with PAS scores greater than 5 were enrolled as research subjects and divided into two groups.Group A(n=34)underwent normal operative procedures including tourniquet binding of the LUS.Group B(n=30)underwent AABO combined with tourniquet binding of the LUS.General clinical characteristics,ultrasonography PAS score,intraoperative blood loss(IBL),blood loss within 24 h after surgery(24-h BL),postoperative complications,and neonatal data of the two groups were retrospectively reviewed.The influencing factors of IBL for the two groups were analyzed.Results The amounts of IBL,24-h BL,total input red blood cell,and the incidence of disseminated intravascular coagulation were significantly lower in group B than in group A(P<0.05),and this difference was even more significant in the subgroup of placenta percreta(PAS scores≥10).Further multivariate linear analysis showed that the combined therapy of AABO and tourniquet could independently predict lower IBL than normal operative procedures did(P=0.001).Conclusion AABO combined with tourniquet binding of the LUS could improve the outcomes of pregnant women with severe PAS and reduce serious peripartum complications of AABO.
文摘Introduction: Placenta accreta is due to invasive placental implantation. It is diagnosed when there is failure of delivery of a retained placenta. This is usually complicated by massive intrapartum hemorrhage that ends by hysterectomy. Case: We report a case of conservative management in a case of placenta accreta involving an elliptical shape incision of the lower segment with removal of placenta with underlying lower uterine segment in a stable patient desiring future fertility. Conclusion: Conservative management may be valid in carefully selected cases of placenta accreta diagnosed pre-operatively in tertiary hospitals with availability of blood-bank and multi-disciplinary approach.
文摘Introduction: Placenta Accreta Spectrum (PAS) is associated with significant maternal and fetal morbidity and mortality. The ideal conservative management still does not exist. We aimed to compare the outcome of cesarean section for PAS by a gynecologic oncologist-led team using the modified triple P approach and by a non-gynecologic oncologist-led team. Material and Methods: This is non-randomized controlled trial. Group A had Cesarean Section by gynecologic oncologist. Gynecologic oncologist-led team did all Cesarean Section following a modified triple P approach. The first P is for “Plan” the uterine incision. The second P for “Pelvic” devascularization by internal iliac artery ligation. The third P is for Placenta non-separation with resection of the myometrium. Group B had Cesarean Section by non-gynecologic oncologist-led team. The main outcome measures were the need for hysterectomy, amount of blood loss, and the management-related complications. Results: Group A had significantly less estimated blood loss, and received less number of backed RBCs units, and less operative time than group B. The uterus is preserved in all cases of group A and in 50% of cases of group B. The overall maternal morbidity rate was 17.5% in group A and 72.2% in group B. Conclusion: This study provides evidence that the modified triple P approach for PAS by gynecologic oncologist-led team presents lower maternal morbidity in comparison to surgery by non-gynecologic oncologist-led team.
文摘Objective: The aim of this study was to determine the incidence, risk factors, and outcomes of management of patients with placenta accreta. Background Placenta accreta occurs when the placental implantation is abnormal. The marked increase in incidence has been attributed to the increasing prevalence of cesarean delivery in recent years. The most common theory is defective decidualization. The most important risk factor for placenta accreta is placenta previa after a prior cesarean delivery. The first clinical manifestation of placenta accreta is usually profuse, life-threatening hemorrhage. The recommended management of suspected placenta accreta is planned preterm cesarean hysterectomy with the placenta left in situ. Patients and methods: It’s a study of all cases of placenta accreta at El-Shatby Maternity University Hospital starting from 1/4/2016 till 1/10/2016. Selection of the cases will only be dependent upon their pregnancy gestational age above 28 weeks of gestation. Results: The incidence of placenta accreta was 1/75 cesarean deliveries. The ultrasonography and doppler had a false negative rate of 54.6% and a sensitivity of 45.2% in diagnosis of placenta accreta. The rate of blood transfusion was 79.6%. Uterine preserving procedures performed in 66%. Cesarean hysterectomy performed in 34%. Intensive care unit admission occurred in 27.3%. The mean gestational age at delivery was 33.8 ± 4.6 weeks’ gestation. 31.8% admitted to the neonatal intensive care unit. Conclusion: The incidence of placenta accreta increased due to the increasing rate of cesarean deliveries, prenatal diagnosis of placenta accreta is paramount, as most women are asymptomatic. Prenatal diagnosis allows time for a multidisciplinary team to make delivery plans, which will help decrease surgical complications.
文摘Introduction: Placenta accreta is a potentially life threatening obstetrical condition. The incidence has increased. Diagnosis before delivery allows multidisciplinary planning in an attempt to minimize potential maternal or neonatal morbidity and mortality. Prenatal ultrasonography is used to support the diagnosis and guide clinical management leading probably to favorable outcomes. Actually a conservative option which includes leaving all or part of the placenta in situ when fertility preservation is desired is recommended. Methods: We retrospectively reviewed the medical records of all patients diagnosed with placenta accreta in gynecology-obstetrics department of the university hospital Mohammed the VI of Marrakesh;Morocco;from January the first 2014 to January the second 2016. Results: We found seven cases. We described: The epidemiological characteristics, risk factors, management of placenta accreta, outcomes and prognosis. The incidence of placenta accreta was 1/3847 deliveries. The mean term of delivery was 35 weeks. We have adopted a successful conservative treatment in six cases (71.4%). The radical treatment was adopted in one patient initially admitted for severe post-partum hemorrhage;the prognosis was good in 85.7% cases. Conclusion: Conservative management of placenta accreta is a safe and efficient and is an interesting alternative for hysterectomy.
文摘Objective: To assess the effect of tourniquet application of intraoperative blood loss in placenta accreta cases undergoing cesarean hysterectomy. Materials and methods: Nine cases and twenty controls with USG and colour Doppler diagnosed placenta accreta with previous cesarean section were chosen to utilize this novel approach. These cases were planned for elective cesarean section followed by hysterectomy. The twenty controls underwent a classical cesarean section followed by total abdominal hysterectomy with the placenta?in situ. Among the nine cases, after delivery of the fetus through upper segment cesarean section, a cotton gauze tourniquet was applied all around the lower pole of uterus. Hysterectomy was performed with placenta?in situ. Abdomen closed after achieving complete haemostasis. Results: The average operative time taken was 85 ± 11.72 minutes among cases and 98.25 ± 9.9 minutes among controls (p = 0.0039). Average blood loss was 1011.11 ± 99.3 ml among the cases and 1855 ± 222.95 ml among the controls (p ≤ 0.0001). Average requirement of blood transfusion required was two units for the cases and five units for the controls (p = 0.0002). No intra-operative or post-operative surgical complications were observed in any of the cases whereas the controls reportedly had a few. All the mothers and babies were healthy at the time of discharge. Conclusion: The presence of placenta accreta is associated with major fetal and maternal complications. The technique of tourniquet application is efficacious in minimizing the intra-operative blood loss and surgical complications due to obstruction of operative field by bleeding and also by preventing massive blood transfusion related complications.
文摘Morbid Adherent Placenta (MAP)/Placenta Accreta Spectrum (PAS) is a serious diagnosis which has a risk of complications. Ultrasound scan helps in early diagnosis and has great value in further confirmation and follow up. Observed new clinical sign and associated clinical triad are discussed here.
文摘Objectives: To describe a novel procedure to treat hemorrhage of placenta accreta spectrum disorders (PAS) or cesarean-scar pregnancy (CSP). Methods: This was a retrospective study of women under cesarean delivery with PAS or placenta previa. Patients’ information was acquired from hospital records. A novel procedure of surgery is developed with seven major steps, including avoiding placenta incised, elevating upward the uterine, clamping the uterine arteries with sponge forceps, removing the placenta, opening the vesicouterine space and suture techniques. Results: A total of 38 patients were reviewed. Twenty-one patients diagnosed with placenta accrete syndrome and 3 patients with CSP were underwent surgery with the novel procedure of surgery and all severe hemorrhage was controlled without hysterectomy. There were 2 women with bladder injuries needing primary repair. Fourteen patients with placenta previa underwent cesarean delivery and there was no intraoperative complication of the total 14 patients. Conclusion: The seven-step approach is more secure and effective to control severe hemorrhage without other invasive procedures in cesarean delivery with PAS. It is technically easier to maintain and improve surgical skills.
文摘Objective:To evaluate the diagnostic accuracy of magnetic resonance imaging(MRI)in diagnosing placenta accreta spectrum(PAS).Methods:We conducted a comprehensive literature search from database inception to November 2023 using terms such as placenta creta,increta,percreta,PAS,MRI,and their respective Medical Subject Headings terms.All prospective and retro-spective cohort,case-control,and cross-sectional studies involving prenatal magnetic resonance imaging diagnosis of PAS with subsequent pathological confirmation were included.Results:A total of 40 studies encompassing 3664 women met the inclusion criteria,with 1894 cases confirmed pathologically as PAS.The overall sensitivity of MRI was 0.867(95%confidence interval(CI):0.807–0.910),and the specificity was 0.860(95%CI:0.799–0.905),with a correlation of 0.693 between sensitivity and specificity.The estimated odds ratio was 28.693(95%CI:14.463–56.924),the negative likelihood ratio was 0.178(95%CI:0.122–0.258),and the positive likelihood ratio was 4.316(95%CI:3.186–5.846).Analysis of individual MRI criteria revealed estimates of sensitivity,specificity,odds ratio,negative likelihood ratio,and positive likelihood ratio for abnormal placental bed vascularization as 0.500,0.740,2.788,0.571,and 1.645 respectively;0.384,0.985,6.270,0.471,and 2.720 for bladder wall interruption;0.766,0.818,13.638,0.262,and 3.375 for the presence of dark intraplacental bands;0.691,0.913,10.828,0.352,and 3.361 for heterogeneous placenta;0.688,0.984,34.886,0.254,and 7.164 for indistinctive myometrium;0.757,0.864,8.496,0.362,and 2.778 for loss of retroplacental dark zone;0.828,0.593,5.829,0.329,and 1.766 for myometrial thinning;and 0.518,0.916,9.473,0.411,and 3.526 for placental bulge,respectively.Conclusion:MRI demonstrates significant utility in diagnosing PAS and its severity.It is recommended for use in all cases with inconclusive ultrasonographic findings.Registration:Registration number CRD42021267501.
文摘The recent increase in placenta accreta spectrum has been correlated with a rise in the rate of cesarean sections.A recent study provides evidence that hampered wound healing results in cesarean scar defects that lead to a failure in the normal process of decidualization and deeper adherence of trophoblasts.Matrix metalloproteinase(MMP)is crucial in every step of wound healing as it alters the wound matrix,facilitating cell migration,as well as tissue remodeling.MMP-9 expression is higher in placental and decidual tissue in cases of placenta accreta.Based on these findings,assessment of MMP-9 expression can shed new light on the etiopathology of placenta accreta spectrum disorder and can be a potential diagnostic marker.
基金the National Key Research and Development Program of China under grant number 2022YFC2704501.
文摘To editor:The disorders associated with placenta accreta spectrum(PAS)are potentially severe obstetric complications that should be managed by expert centers with substantial re-sources to provide both preoperative and intraoperative as-sessments and then prearrange a multidisciplinary team with an appropriate delivery plan.Placenta accreta spectrum was first described in 1937 as“attempts to remove the pla-centa led to major postpartum hemorrhage that required emergency or secondary hysterectomy to control bleeding.”1 In 1966,Luke et al-classified this condition into placenta creta(or vera,adherenta),increta,and perceta based on the depth of placenta villi adhesion or invasion,as determined by pathological features.Although infrequent,there have been significant advances in the global evolution of the strat-egies used to manage PAS,especially over the last decade.
文摘Posterior placenta accreta spectrum(PAS)disorders are infrequent but potentially associated with significant maternal mortality and morbidity,especially if not diagnosed prenatally.Analysis of published literature is problematic since most experiences included only a few cases.Knowledge of the risk factors associated with posterior PAS is crucial to identifying mothers at higher risk and ask for high sensitivity studies.Ultrasound has poor diagnostic accuracy in detecting posterior PAS,while magnetic resonance imaging better delineates the posterior uterine wall.In comparison,prenatal imaging’s diagnostic performance in detecting posterior PAS is significantly lower than anterior placenta invasion.Management of posterior PAS depends on several factors,including maternal hemodynamic status,available resources,clinical presentation,and invasion severity.For accreta or increta cases,a compression suture is habitually enough to perform hemostasis.Nevertheless,organ involvement habitually requires a multidisciplinary team with the assistant of a general or coloproctology surgeon.The present article aims to update the risk factors,prenatal diagnosis,and surgical management of pregnancies complicated by posterior PAS.
