Massive perivillous fibrin deposition: Diagnosis, obstetrical features, and treatment.

MPVFD (Massive perivillous fibrin deposition) is placental lesion characterized by extensive massive deposits of fibrin in the intervillous space, extending over at least 25 % of the placental volume. Currently, this pathology can only be detected through histopathological examination of the placenta after a pregnancy has ended. The underlying mechanisms are poorly studied, there is no biomarker available for the diagnosis of MPVFD and treatment protocols are experimental and still lacking. The objective of this study is to systematically review the literature on the associated clinicopathologic features, treatment, and prognosis of MPVFD. We ended up with 17 studies, of these 12 studies were considered relevant for this article and included in the final analysis. All studies reporting MPVFD are retrospective. MPVFD is associated with recurrent miscarriage, intra uterine fetal death (IUFD), intra uterine growth restriction (IUGR) and preterm delivery. The prevalence in pregnancies with a delivery after 22 weeks of gestation was at 1.1 % and even higher to 2.7 % in recurrent early miscarriages. The reported risk of fetal death in MPVFD ranges mainly from 15 to 80 %. Preterm delivery is spontaneous in 50 to 70 % of cases and induced by of a severe intrauterine growth restriction (IUGR) in 30 to 50 % of cases depending on the study. Its causes and treatment are still poorly understood, although several avenues have been explored. This review summarizes current understanding of the prevalence, diagnostic features, clinical consequences, immune pathology, and potential prophylaxis against recurrence in this chronic inflammatory placental syndrome.

Chorioangioma: a single tertiary care center retrospective study.

OBJECTIVES: Chorioangioma represents a challenge due to the rarity of the condition, paucity of sufficient management guidelines, and controversies regarding the best invasive fetal therapy option; most of the scientific evidence for clinical treatment has been limited to case reports. The aim of this retrospective study was to review the natural antenatal history, maternal and fetal complications, and therapeutic modalities used in pregnancies complicated with placental chorioangioma at a single Center. METHODS: This retrospective study was conducted at King Faisal Specialist Hospital and Research Center (KFSH&RC) in Riyadh, Saudi Arabia. Our study population included all pregnancies with ultrasound features of chorioangioma, or histologically confirmed chorioangiomas, between January 2010 and December 2019. Data were collected from the patients' medical records, including the ultrasound reports and histopathology results. All subjects were kept anonymous; case numbers were used as identifiers. Data collected by the investigators were entered into Excel worksheets in an encrypted format. A MEDLINE database was used to retrieve 32 articles for literature review. RESULTS: Over a 10-year period between January 2010 and December 2019, 11 cases of chorioangioma were identified. Ultrasound remains the gold standard for diagnosis and follow-up of the pregnancy. Seven of the 11 cases were detected by ultrasound, allowing proper fetal surveillance and antenatal follow-up. Of the remaining six patients, one underwent radiofrequency ablation, two underwent intrauterine transfusion for fetal anemia due to placenta chorioangioma, one had vascular embolization with an adhesive material, and two were managed conservatively until term with ultrasound surveillance. CONCLUSIONS: Ultrasound remains the gold standard modality for prenatal diagnosis and follow-up of pregnancies with suspected chorioangiomas. Tumor size and vascularity play a significant role in the development of maternal-fetal complications and the success of fetal interventions. To determine the superior modality of fetal intervention mandates more data and research; nevertheless, Fetoscopic Laser Photocoagulation and embolization with adhesive material seem to be a lead choice, with reasonable fetal survival.

Clinicopathological characteristics of placental chorioangioma: A clinicopathological study of 77 cases.

OBJECTIVE: To explore clinicopathological characteristics, diagnosis, differential diagnoses, treatment, and prognoses of placental chorioangioma (PCA). METHODS: Placenta of 77 cases of PCA firmly diagnosed by pathology from 2009 through 2019 were collected, and clinicopathological characteristics of the patients were retrospectively analyzed. RESULTS: Seventy-seven patients were 20-41 (mean age, 28.8) years old at onset. Thirty patients showed pregnancy comorbidity. In one patient with the largest tumor (diameter, 16 cm), intrauterine fetal demise occurred at 33 weeks of gestation. Tumors were macroscopically manifested. The placental fetal surface showed a raised dark red to a pale pink nodule, quasi-round, with a maximum diameter of 0.2-16 cm. Microscopically, the tumors had a lot of capillaries and some interstitial loose connective tissue. One case was of atypical cellular chorioangioma. Immunophenotypically, CD34 (+) and Ki-67 proliferation indexes were less than 10%. CONCLUSIONS: Large PCA often accompanies pregnancy comorbidity. Atypical cellular chorangioma is rare and may be misdiagnosed as a malignant tumor. Therefore, improvement of understanding of such tumors can provide a basis for clinical diagnosis and intervention.

Successful Treatment of Placental Chorangiomas by Ultrasound-Guided Percutaneous in utero Microcoil Embolization.

Placental chorangiomas can cause a high-output fetal state and increase neonatal morbidity and mortality. There is a paucity of data published describing the optimal treatment of these cases, and methods for occlusion to date include placement of vascular clips, bipolar cautery, injection of alcohol or surgical glue, interstitial laser, and microcoil embolization. We report 2 cases of prenatally diagnosed chorangiomas that caused a high-output fetal state and were successfully treated with microcoil embolization. This case series describes our technique and supports microcoil embolization as a potentially safe and effective antenatal treatment option in symptomatic chorangiomas.

Cell death mechanisms and their roles in pregnancy related disorders.

Autophagy and apoptosis are catabolic pathways essential for homeostasis. They play a crucial role for normal placental and fetal development. These cell death mechanisms are exaggerated in placental disorders such as preeclampsia, intrauterine growth restriction (IUGR) and gestational diabetes mellitus (GDM). Apoptosis is widely studied, highly controlled and regulated whereas; autophagy is an orderly degradation and recycling of the cellular components. Cellular senescence may be initiated by a variety of stimuli, including hypoxia, oxidative stress, reduction in survival signals and nutrition deprivation. Apoptosis is regulated by two types of pathways intrinsic and extrinsic. Extrinsic pathway is initiated by apoptosis inducing cells such as macrophages, natural killer cells whereas; intrinsic pathway is initiated in response to DNA damage, cell injury and lack of oxygen. In autophagy, the cell or organelles undergo lysosomal degradation. Placental apoptosis increases as the gestation progresses while autophagy plays a role in trophoblast differentiation and invasion. In pregnancy disorders like preeclampsia and IUGR, proapoptotic markers such as caspase 3, 8, BAX are higher and antiapoptotic markers like Bcl-2 are lower. In GDM, apoptotic markers are reduced resulting in increased placental mass and fetal macrosomia. Apoptosis in the pathological pregnancies is also influenced by the reduced levels of micronutrients and long chain polyunsaturated fatty acids resulting in disturbed placental biology. This chapter describes the role of various key molecular events involved in cellular senescence and the various factors influencing them. This will help identify future therapeutic strategies for better management of these processes.

Indications for Outpatient Antenatal Fetal Surveillance: ACOG Committee Opinion, Number 828.

ABSTRACT: The purpose of this Committee Opinion is to offer guidance about indications for and timing and frequency of antenatal fetal surveillance in the outpatient setting. Antenatal fetal surveillance is performed to reduce the risk of stillbirth. However, because the pathway that results in increased risk of stillbirth for a given condition may not be known and antenatal fetal surveillance has not been shown to improve perinatal outcomes for all conditions associated with stillbirth, it is challenging to create a prescriptive list of all indications for which antenatal fetal surveillance should be considered. This Committee Opinion provides guidance on and suggests surveillance for conditions for which stillbirth is reported to occur more frequently than 0.8 per 1,000 (the false-negative rate of a biophysical profile) and which are associated with a relative risk or odds ratio for stillbirth of more than 2.0 compared with pregnancies without the condition. Table 1 presents suggestions for the timing and frequency of testing for specific conditions. As with all testing and interventions, shared decision making between the pregnant individual and the clinician is critically important when considering or offering antenatal fetal surveillance for individuals with pregnancies at high risk for stillbirth or with multiple comorbidities that increase the risk of stillbirth. It is important to emphasize that the guidance offered in this Committee Opinion should be construed only as suggestions; this guidance should not be construed as mandates or as all encompassing. Ultimately, individualization about if and when to offer antenatal fetal surveillance is advised.

Successful expectant management of a giant chorioangioma.

Giant chorioangiomas are benign placental tumours, which can have potential severe fetal consequences. Complications in pregnancy include polyhydramnios, fetal hydrops and growth restriction. Such pregnancies can carry a significant risk of poor perinatal outcome and require close monitoring. Therapeutic options include fetoscopic or interstitial vessel ablation, chemosclerosis and embolisation. Where there is no evidence of fetal compromise, such pregnancies can successfully be managed conservatively.

Non-invasive fetal electrocardiography ameliorates fetal outcome in chorioangioma: A case report.

 Chorioangioma is a rare vascular placental tumour. Large chorioangiomas are known to have many maternal and perinatal complications. The case of placental chorioangioma detected via ultrasound is presented. This paper is focused on non-invasive fetal electrocardiography (NI-FECG) clinical use for diagnosing fetal anemia in chorioangioma.A 22-year-old primigravida was admitted to the department of fetomaternal medicine at 30 weeks of gestation. She had threatened preterm labour, polyhydramnios, and breech presentation. The large echogenic mass of 77 mm×66 mm×83 mm, located in the uterine bottom, protruded into the amniotic cavity, and connected to the marginal sinus of the placenta was determined via ultrasound. The sinusoidal pattern of beat-to-beat variations was diagnosed via NI-FECG in spite of normal blood flow velocity in the fetal middle cerebral artery. Therefore, NI-FECG was superior in the detection of fetal anemia. The female baby weighing 1500 g and measuring 42 cm in length, with a head circumference of 30 cm and Apgar score 3⟶5, was delivered by caesarean section. The baby had severe anemia and respiratory distress syndrome.NI-FECG was a good option for the clinician for the timely and accurate diagnosis of fetal anemia and fetal compromise in placental chorioangioma.

A giant symptomatic placental chorioangioma managed with a histoacryl injection.

Chorioangiomas are generally small and associated with favorable outcomes, but large tumors can cause serious fetal complications, such as polyhydramnios, fetal anemia, intrauterine growth restriction, cardiac failure, fetal hydrops, and intrauterine fetal death. Signs of fetal cardiac failure on ultrasonography are indications for urgent in utero interventions. We report a case of a giant chorioangioma causing fetal cardiac failure at 26+3 weeks' gestation, which was treated by embolization of the feeding vessels. We utilized a mixture of n-butyl cyanoacrylate (nBCA, Histoacryl®) and iodized oil (Lipiodol®) as an embolic agent. Fetal hydrops resolved in 4 weeks, and the cardiac size and function normalized 8 weeks after the embolization. A healthy male baby was born at the 37+5th gestational week by cesarean section.

Conservative management for adherent placenta after live birth in angular or interstitial pregnancies: A new entity "angular placenta attachment".

OBJECTIVE: Angular and interstitial pregnancies have been reported with live births and are often complicated by adherent placentas. Most cases had been treated with hysterectomy or corneal resection. CASE REPORT: We successfully treated four patients with conservative management (including one reported previously). Case 1 had a vaginal delivery, but the placenta remained attached. We maintained the patient under observation and delivered the placenta on postpartum day 9. Case 2 underwent a C-section. Uterine artery embolization controlled the hemorrhage without placenta removal. The placenta had disappeared by postpartum day 136. Case 3 underwent a C-section. The right uterine angle, where the placenta was attached, was bulging. We manually removed the placenta. CONCLUSION: We propose a new entity in angular or interstitial pregnancies called "angular placenta attachment" that could be diagnosed during C-sections or after vaginal delivery without placental separation. Expectant management may be considered for adherent placentas in these cases.

Development of placental abnormalities in location and anatomy.

Low-lying placentas, placenta previa and abnormally invasive placentas are the most frequently occurring placental abnormalities in location and anatomy. These conditions can have serious consequences for mother and fetus mainly due to excessive blood loss before, during or after delivery. The incidence of such abnormalities is increasing, but treatment options and preventive strategies are limited. Therefore, it is crucial to understand the etiology of placental abnormalities in location and anatomy. Placental formation already starts at implantation and therefore disorders during implantation may cause these abnormalities. Understanding of the normal placental structure and development is essential to comprehend the etiology of placental abnormalities in location and anatomy, to diagnose the affected women and to guide future research for treatment and preventive strategies. We reviewed the literature on the structure and development of the normal placenta and the placental development resulting in low-lying placentas, placenta previa and abnormally invasive placentas.

Pregnancy and Cancer: the INCIP Project.

PURPOSE OF REVIEW: Cancer diagnosis in young pregnant women challenges oncological decision-making. The International Network on Cancer, Infertility and Pregnancy (INCIP) aims to build on clinical recommendations based on worldwide collaborative research. RECENT FINDINGS: A pregnancy may complicate diagnostic and therapeutic oncological options, as the unborn child must be protected from potentially hazardous exposures. Pregnant patients should as much as possible be treated as non-pregnant patients, in order to preserve maternal prognosis. Some approaches need adaptations when compared with standard treatment for fetal reasons. Depending on the gestational age, surgery, radiotherapy, and chemotherapy are possible during pregnancy. A multidisciplinary approach is the best guarantee for experience-driven decisions. A setting with a high-risk obstetrical unit is strongly advised to safeguard fetal growth and health. Research wise, the INCIP invests in clinical follow-up of children, as cardiac function, neurodevelopment, cancer occurrence, and fertility theoretically may be affected. Furthermore, parental psychological coping strategies, (epi)genetic alterations, and pathophysiological placental changes secondary to cancer (treatment) are topics of ongoing research. Further international research is needed to provide patients diagnosed with cancer during pregnancy with the best individualized management plan to optimize obstetrical and oncological care.

Systematic review with meta-analysis: risk of adverse pregnancy-related outcomes in inflammatory bowel disease.

BACKGROUND: The effect of inflammatory bowel disease (IBD) on pregnancy-related outcomes remains unknown. AIM: To determine the risk of adverse maternal, placental and obstetric outcomes in IBD METHODS: We searched Medline, Embase and Cochrane library through May 2019 for studies reporting adverse maternal, placental and obstetric outcomes in patients with IBD. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for these outcomes in patients with IBD compared to healthy controls. RESULTS: Fifty-three studies were included (7917 IBD pregnancies and 3253 healthy control pregnancies). Caesarean delivery was more common in patients with IBD compared to healthy controls (OR 1.79, 95% CI, 1.16-2.77). This remained significant for UC (OR 1.80, 95% CI, 1.21-2.90) but not CD (OR 1.48, 95% CI, 0.94-2.34). Similarly, gestational diabetes occurred more commonly in IBD (OR 2.96, 95% CI, 1.47-5.98). The incidences of placental diseases were 2.0% (95% CI, 0.9%-3.1%) for pre-eclampsia, 3.3% (95% CI, 0%-7.2%) for placental abruption, 0.5% (95% CI, 0.2%-0.9%) for placenta previa and 0.3% (95% CI, 0%-0.5%) for chorioamnionitis. Patients with IBD were more likely to experience preterm prelabour rupture of membranes (OR 12.10, 95% CI, 2.15-67.98), but not early pregnancy loss (OR 1.63, 95% CI 0.49-5.43). Anti-tumour necrosis factor therapy was not associated with chorioamnionitis (OR 1.12, 95% CI, 0.16-7.67), early pregnancy loss (OR 1.49, 95% CI, 0.83-2.64) or placenta previa (OR 1.58, 95% CI, 0.30-8.47). CONCLUSIONS: Gestational diabetes and preterm prelabour rupture of membranes occurs more commonly in patients with IBD, although the incidence of placental diseases remains low.

Pregnancy complications and adverse outcomes in placental chorioangioma: a retrospective cohort analysis.

Objective: To measure the relative risk of pregnancy complications and adverse outcomes in women with placental chorioangioma, and postnatal developmental deficiencies in their offspring.Methods: We designed a retrospective cohort study using records from 140,387 pregnancies at our hospital between 1 January, 2008 and 1 July, 2017. Follow-up of children in the placental chorioangioma group was conducted by phone interview.Results: Placental chorioangioma was diagnosed in 56 patients (incidence = 0.04%). Fifty-one cases were detected during routine prenatal ultrasound. Placental chorioangioma patients were at increased risk for fetal loss or induced abortion (RR = 9.93, 95% CI [4.66, 21.20]), preterm birth (n = 13, RR = 2.45, 95% CI [1.52, 3.95]), birth by cesarean section (n = 45, RR = 1.62, 95% CI [1.42, 1.84]), and polyhydramnios (n = 9, RR = 9.98, 95% CI [5.48, 18.18]), but not fetal distress (n = 5, RR = 0.49, 95% CI [0.22, 1.15]) or preeclampsia (n = 5, RR = 1.61, 95% CI [0.70, 3.73]), although there was an increased risk for preeclampsia after controlling for preterm birth (n = 3, RR = 3.6, 95% CI [1.33, 9.74]). No developmental complications were reported in offspring.Conclusion: Placental chorioangioma increases the risk of fetal demise, pregnancy complications and adverse outcomes. In cases with mild complications or when early cesarean termination of pregnancy is feasible, the prognosis is excellent.

In utero embolization for placental chorioangioma and neonatal multifocal hemangiomatosis.

Placental chorioangioma is a limited non trophoblastic vascular tumour that may causes fetal complications as well as post-natal ones. We reported in here the first case of an in utero embolization of chorioangioma diagnosed at 22 W G with a post-natal diagnosis of neonatal multifocal hemangioma with a good outcome. The chorioangioma was embolized using GLUBRAN 2 ® (cyanolacrylate) a biologic surgical glue at 26 W G. Premature rupture of membrane occurred at 28 W G. A cesarean section at 32 W G was performed for retro placental hematoma. The neonate was 1400 g healthy girl with an anemia (hemoglobin 9.7 g/dl). After one month of life, the child met a neonatal multifocal hemangioma (skin and liver were involved) with superficial erosion of skin hemangiomas that required post-natal transfusions. We propose a literature review related to the various technics of in utero treatment of placental chorioangioma and the links with neonatal multifocal hemangiomatosis as well. The girl is now 7 year old and has a normal neurodevelopmental outcome.

The efficacy of pelvic arterial embolisation for the treatment in massive vaginal haemorrhage in obstetric and gynaecological emergencies: a single-centre experience.

This study aimed to identify the role, efficacy and safety of pelvic arterial embolisation (PAE) in the management of massive vaginal haemorrhage occurring in 25 patients with obstetric and gynaecological emergencies where bleeding could not be controlled by conservative treatment methods. Nine of the cases had disseminated intravascular coagulation (DIC) and eight were haemodynamically unstable. PAE was successful in 23 of 25 patients without any major complication. Vascular blush was the most common (100%) angiographic finding. Active extravasation was observed in 9 of 25 of the cases. Permanent embolic agents including polyvinyl alcohol (PVA) particles or N-butyl-2-cyanoacrylate (NBCA) were used in all cases. Technical success in patients with disseminated intravascular coagulation (DIC), and in patients who were haemodynamically unstable were 9 of 11 and 6 of 8 cases, respectively. PAE was successful in all seven patients who had hysterectomy before PAE. PAE is a safe and effective alternative to surgical hysterectomy in obstetric and gynaecological emergencies when conservative management failed to control haemorrhage. It is an effective treatment option in cases of coagulation impairment and when bleeding cannot be controlled despite hysterectomy. Impact statement What is already known on this subject: Postpartum haemorrhage (PPH) is one of the most common causes of maternal morbidity and mortality worldwide. Most patients with PPH are treated conservatively but where this approach fails, hysterectomy is the standard option with loss of reproductive ability. During the past 20 years, pelvic arterial embolisation (PAE) has emerged as a safe, effective and preferred minimally invasive technique in most tertiary centres as an alternative to surgical treatments including hypogastric artery ligation and hysterectomy. The reported success rate of PAE using temporary and permanent embolic agents is 75-90% in cases of massive vaginal bleeding due to obstetric and gynaecological reasons. What the results of this study add? PAE showed high success rate in patients with coagulation disorders and in haemodynamically unstable patients. Permanent embolic agents such as polyvinyl alcohol particles (PVAs) or, N-butyl-2-cyanoacrylate (NBCA) should be used for embolisation in coagulation disorders or haemodynamic instability. The most important advantage of NBCA is that the embolisation effect occurs independently of the inherent coagulation cascade. What are the implications of these findings for clinical practice and/or further research? PAE is an effective and minimally invasive treatment option in cases of coagulopathy and in patients with bleeding that cannot be controlled despite hysterectomy. Our results suggest that haemodynamic instability and DIC should not be considered a contraindication for PAE. Embolic agent selection and the long-term effects of permanent embolic agents on fertilisation is an important issue requiring further investigation.

Methotrexate infusion followed by uterine artery embolisation for the management of placental adhesive disorders: a case series.

AIM: To evaluate the efficacy and safety of the uterine artery embolisation (UAE) in combination with methotrexate (MTX) for conservative management of placental adhesive disorders. MATERIAL AND METHODS: Patients with placental adhesive disorders (including accreta, increta, and percreta lesions) that were treated with UAE in combination with MTX were identified and were followed prospectively for outcomes including uterine preservation and complications. RESULTS: Twenty-six patients were identified who had the diagnosis of abnormal placenta implantation during this study. Fourteen patients were excluded because they were treated by a caesarean hysterectomy. Among remaining 12 patients, the successful uterine preservation observed in seven (58%) cases. Menstruation cycles returned in all successfully treated patients, although they did not have desire to get pregnant. Five (42%) patients underwent primary or delayed hysterectomy due to severe post-partum haemorrhage in three cases, and intestinal adhesion/peritonitis and secondary post-partum haemorrhage/sepsis in two patients, respectively. CONCLUSION: Although this interventional method is relatively successful in uterine preservation, the possibility of treatment failure cannot be ignored. Given that there are too few data regarding its efficacy and safety, this method should be reserved to patients who have a strong desire to maintain the uterus and their fertility, or if it is technically difficult to perform hysterectomy due to the extent of the invasion.

Dysregulation of Complement Activation and Placental Dysfunction: A Potential Target to Treat Preeclampsia?

Preeclampsia is one of the leading causes of maternal and neonatal mortality and morbidity worldwide, affecting 2-8% of all pregnancies. Studies suggest a link between complement activation and preeclampsia. The complement system plays an essential role in the innate immunity, leading to opsonization, inflammation, and elimination of potential pathogens. The complement system also provides a link between innate and adaptive immunity and clearance of immune complexes and apoptotic cells. During pregnancy there is increased activity of the complement system systemically. However, locally at the placenta, complement inhibition is crucial for the maintenance of a normal pregnancy. Inappropriate or excessive activation of the complement system at the placenta is likely involved in placental dysfunction, and is in turn associated with pregnancy complications like preeclampsia. Therefore, modulation of the complement system could be a potential therapeutic target to prevent pregnancy complications such as preeclampsia. This review, based on a systematic literature search, gives an overview of the complement system and its activation locally in the placenta and systemically during healthy pregnancies and during complicated pregnancies, with a focus on preeclampsia. Furthermore, this review describes results of animal and human studies with a focus on the complement system in pregnancy, and the role of the complement system in placental dysfunction. Various clinical and animal studies provide evidence that dysregulation of the complement system is associated with placental dysfunction and therefore with preeclampsia. Several drugs are used for prevention and treatment of preeclampsia in humans and animal models, and some of these drugs work through complement modulation. Therefore, this review further discusses these studies examining pharmaceutical interventions as treatment for preeclampsia. These observations will help direct research to generate new target options for prevention and treatment of preeclampsia, which include direct and indirect modulation of the complement system.

Are women antenatally diagnosed with abnormally invasive placenta receiving optimal management in England? An observational study of planned place of delivery.

INTRODUCTION: The aim of this study was to investigate the planned place of delivery for women antenatally diagnosed with abnormally invasive placenta (AIP) in England and identify how many units regard themselves to be "specialist centers" for the management of AIP. MATERIAL AND METHODS: Observational study of obstetric-led units in England. An anonymous survey was sent to the delivery suite lead clinician in all 154 consultant-led units throughout England. The main outcome measures were whether each unit planned to manage AIP "in-house", the estimated number of AIP cases delivered in the previous 5 years and whether the unit considered itself a "specialist center" for AIP management. RESULTS: In all, 114 of 154 units responded (74%): 80 (70%) manage AIP cases "in-house", 23 (29%) of these report that they regard themselves "specialist centers" for AIP. The 23 "specialist centers" managed significantly more cases than "non-specialist centers" (5.4, 95% confidence interval (CI) 4.3-7.3 vs 2.3, 95% CI 1.5-3.1 cases/unit/year; P < .001); nearly one-third of "non-specialist centers" manage less than 1 case per year. Extrapolating the reported number of cases to all 154 obstetrician-led delivery units produces an estimate of 5.2 cases per 10 000 births over the last 5 years. CONCLUSIONS: Most units plan to manage AIP "in-house" despite encountering few cases each year. Centralizing care would allow the multidisciplinary team in each "specialist center" to develop significant experience in the management of this rare condition, leading to improved outcomes for the women.

Abnormal placentation.

The term "morbidly adherent placenta" has recently been introduced to describe the spectrum of disorders including placenta accreta, increta and percreta. Due to excessive invasion of the placenta into the uterus there is associated significant maternal morbidity and mortality. Most significant risk factors for morbidly adherent placenta include history of prior cesarean delivery as well as placenta previa in the current pregnancy. Ultrasound remains the gold standard for antenatal diagnosis, however, in recent years MRI has assisted in identifying complex parametrial involvement. Optimizing maternal and neonatal outcomes involves early prenatal diagnosis, a multi-disciplinary team-based approach, and referral to an experienced center.