Lack of experience is a main cause of maternal death in placenta accreta spectrum patients.

INTRODUCTION: Placenta accreta spectrum (PAS) is a serious condition with a mortality as high as 7%. However, the factors associated with this type of death have not been adequately described, with an almost complete lack of publications analyzing the determining factors of death in this disease. The aim of our work is to describe the causes of death related to PAS and to analyze the associated diagnosis and treatment problems. MATERIAL AND METHODS: This is an inter-continental, multicenter, descriptive, retrospective study in low- and middle-income countries. Maternal deaths related to PAS between January 2015 and December 2020 were included. Crucial points in the management of PAS, including prenatal diagnosis and details of the surgical treatment and postoperative management, were evaluated. RESULTS: Eighty-two maternal deaths in 16 low- and middle-income countries, on three continents, were included. Almost all maternal deaths (81 cases, 98.8%) were preventable, with inexperience among surgeons being identified as the most relevant problem in the process that led to death among 87% (67 women) of the cases who had contact with health services. The main cause of death associated with PAS was hemorrhage (69 cases, 84.1%), and failures in the process leading to the diagnosis were detected among 64.6% of cases. Although the majority of cases received medical attention and 50 (60.9%) were treated at referral centers for severe obstetric disease, problems were identified during treatment in all cases. CONCLUSIONS: Lack of experience and inadequate surgical technique are the most frequent problems associated with maternal deaths in PAS. Continuous training of interdisciplinary teams is critical to modify this tendency.

Hypogastric artery ligation in postpartum haemorrhage: a ten-year experience at a tertiary care centre.

This study investigated patients who underwent bilateral hypogastric artery ligation (BHAL) due to postpartum haemorrhage (PPH). Patients who underwent BHAL because of PPH following a conservative treatment were included in this study. Placental abnormalities were referred to as placenta accreta. A total of 130 BHAL procedures took place at the study hospital as a result of PPH. Of these, 39 (30%) were referred to the hospital. The rate of BHAL requirement was 62 out of 10,000 births. Among the 130 patients, the most frequent indication for BHAL was placenta accreta (58.5%). Haematological parameters were poorer among the referral patients. Four of the exitus patients (80%) were referral patients. The mortality rate among the referral patients was 10.25%, whereas this rate was only 1.01% among the patients who gave birth at the hospital. PPH is a life-threatening condition that requires immediate medical attention. BHAL, with its fertility-preserving features, is a good option that can be employed in all PPH patients. BHAL not only preserves patients' fertility, but it also gives them a higher chance of survival.IMPACT STATEMENTWhat is already known on this subject? PPH is a life-threatening condition. Due to the worldwide increase in caesarean sections, placenta accreta has also increased. BHAL is a vital treatment method for PPH.What do the results of this study add? Placenta accreta is one of the most common causes of PPH. Traditional hysterectomy rates can be reduced by replacing this treatment with BHAL in this group of patients. Without early intervention in PPH, a patient's mortality risk can increase by up to 10 times. As research and surgeons' experience grows, PPH can be controlled with treatments with less complex modalities without the need for BHAL.What are the implications of these findings for clinical practice and/or further research? The need for BHAL should be kept in mind when addressing PPH, especially in cases of placenta accreta. The need for hypogastric artery ligation, which is a more aggressive treatment for the surgical correction of the pathology, can be reduced as surgeons' experience increases. Early intervention and/or referral in cases of PPH is of great importance.

Manejo del acretismo placentario en Servicios de Obstetricia de hospitales de alta complejidad Aplicación de un Proyecto de atención integral multidisciplinario / PLACENTA ACCRETA: MANAGEMENT AT OBSTETRIC SERVICES IN HIGH COMPLEXITY HOSPITALS

Objetivo: El objetivo del estudio fue describir el manejo de los Trastornos Adherenciales de la Placenta en la Maternidad de alta complejidad recabando los datos tanto del servicio de Obstetricia del Hospital Nacional Profesor Alejandro Posadas y Hospital Naval Pedro Mallo Buenos Aires. Diseño: Estudio de tipo observacional, descriptivo y transversal. Análisis estadístico mediante Stata 12.0. Resultados: Durante el período comprendido entre enero de 2010 y diciembre de 2014 fueron atendidas 30 pacientes con trastornos adherenciales placentarios. La incidencia de acretismo placentario en ese periodo fue de 0.18 (30/16210 nacimientos). El 56.67% (17/30) de las cirugías fueron programadas con Hemodinamia. En el 96.67% (N=29) el resultado anátomo-patológico final fue Acretismo Placentario. Hubo un caso falso positivo. Cuatro casos presentaron complicaciones potencialmente graves "near miss". No se presentaron muertes maternas. Conclusiones: Los trastornos adherenciales placentarios se presentan como un nuevo desafío para los Servicios de Obstetricia por la aparición en forma "epidémica" de una enfermedad que era infrecuente. El manejo multidisciplinario es la clave para un correcto tratamiento. El Obstetra cumple el rol de coordinación del mismo, convocando a las diferentes especialidades. Será entonces, de capital importancia el aporte de todos para la correcta resolución de los casos.

The aim of the present report was to describe the management of the adherencial disorders of the placenta in a high complexity maternity. During the period between January 2010 and December 2014, 30 patients with placental adherencial disorders were assisted. The incidence of placenta accreta during that period, was 0.18 (30/16210 deliveries). The 96.67 % of surgeries were programmed with Hemodinamia. In the 96.67 % (N= 29) the final anatomo-pathological result was Placentary Accretism. There was a false positive case. Four cases presented complications potentially severe "near miss". None maternal deaths were observed in the survey. The placental adherencial disorders present as a new challenge for the Obstetric Services because of their apparition in an "epidemic" way of a disease that was unfrequent. The multidisciplinary management is the key for an adequate treatment. Obstetricians play a roll for coordination of the team, convoking the different specialities. There will be then, of great importance, the contribution of the totality for the proper resolution of the cases

[Maternal morbidity and mortality associated with conservative management for placenta morbidly adherent (accreta) diagnosed during pregnancy. Report of 15 cases]. / Morbimortalité maternelle associée au traitement conservateur d'un placenta anormalement adhérent (accreta) diagnostiqué en anténatal. À propos d'une série continue de 15 cas.

BACKGROUND: High risk of morbidly adherent placenta increased during past years. Their management is controversial. Cesarean hysterectomy, considered the gold standard treatment by American Society, is associated with high risk of maternal morbimortality. Conservative management has been sought to reduce maternal morbidity associated with caesarean hysterectomy while maintaining fertility. It consists of leaving the placenta in place but long-term monitoring. Our main objective was to determine advantage/disadvantage of conservative management on patient with an antenatal diagnosis of placenta accreta, increta or percreta. MATERIAL AND METHODS: This retrospective study included all patients with an antenatal diagnosis of placenta accreta, increta or percreta between 2007 and 2014. Conservative treatment was systematically attempted according to our protocol. The primary outcome was defined as uterine conservation and the secondary outcome as maternal morbimortality defined as any medical or surgical condition occurring after childbirth. RESULTS: Fifteen patients (0.07 % of all living childbirths) were included. Conservative management was successful in 80 % of patients. There was no case of maternal death. Severe post-partum hemorrhage occurred in 4 patients (33.3 %) requiring uterine arteries embolization in one patient and hysterectomy in the 3 others. They underwent immediate blood transfusion of 13.5±4.5 average of red blood cell units. No severe septic condition occurred but 4 patients suffered from endometritis, 2.6±0.5 months after birth requiring intravenous antibiotics treatment in conventional hospitalization. Mean duration for spontaneous abortion of the placenta was 23.0±7.2 weeks. Three spontaneous pregnancies occurred in 2 patients after 19±16.9 months. CONCLUSION: Conservative management seems encouraging but is associated with a non-insignificant risk of secondary complication requiring long-term monitoring in conciliant patients.

Surgical management of 58 patients with placenta praevia percreta.

OBJECTIVE: The aim of this study is to present our experience with surgical management of placenta praevia percreta. METHODS: This study was conducted from January 2009 through March 2014 at Harran University Hospital and was a chart review of all patients who underwent caesarean hysterectomy with the placenta left in situ for placenta praevia percreta. RESULTS: The study group comprised 58 patients. All of the patients underwent ultrasound mapping of the placental area before surgery. Emergent caesarean hysterectomy was only performed in 9 patients; 49 patients underwent planned caesarean hysterectomy. Bilateral internal iliac artery ligation was performed in all cases. Four patients (6.9 %) had bladder damage, one patient (1.7 %) required cystotomy, and one patient (1.7 %) required re-operation because of postoperative hemorrhage. The mean operative time was 141.6 (range: 95-355) minutes. Only 17 (29.3 %) patients were administered more than four units of red blood cells. There was no ureteral damage or maternal death. Furthermore, there were no complications in 42 (72.4 %) patients. CONCLUSIONS: Caesarean hysterectomy for placenta praevia percreta is associated with increased maternal morbidity. However, preoperative diagnosis of placenta praevia percreta, ultrasound mapping of the placenta, and the presence of a multidisciplinary experienced team may decrease maternal morbidity and mortality. Moreover, the urinary system may be protected in the patients with placenta praevia percreta without serious morbidity.

Intrapartum hemorrhage.

Intrapartum hemorrhage is a serious and sometimes life-threatening event. Several etiologies are known and include placental abruption, uterine atony, placenta accreta, and genital tract lacerations. Prompt recognition of blood loss, identification of the source of the hemorrhage, volume resuscitation, including red blood cells and blood products when required, will result in excellent maternal outcomes.

Trauma during pregnancy.

Traumatic injuries in pregnancy are both common and burdensome. Optimal management includes proper triage, maternal resuscitation, fetal monitoring, and diagnostic imaging.

Placenta accreta, increta, and percreta.

Placenta accreta is an abnormal adherence of the placenta to the uterine wall that can lead to significant maternal morbidity and mortality. The incidence of placenta accreta has increased 13-fold since the early 1900s and directly correlates with the increasing cesarean delivery rate. The prenatal diagnosis of placenta accreta by ultrasound along with risk factors including placenta previa and prior cesarean delivery can aid in delivery planning and improved outcomes. Referral to a tertiary care center and the use of a multidisciplinary care team is recommended.

Effectiveness of timing strategies for delivery of individuals with placenta previa and accreta.

OBJECTIVE: To compare strategies for the timing of delivery in individuals with placenta previa and ultrasonographic evidence of placenta accreta, and to determine the optimal gestational age at which to deliver individuals. METHODS: A decision tree was designed comparing nine strategies for delivery timing in an individual with placenta previa and ultrasonographic evidence of placenta accreta. The strategies ranged from a scheduled delivery at 34, 35, 36, 37, 38, or 39 weeks of gestation to a scheduled delivery at 36, 37, or 38 weeks of gestation only after amniocentesis confirmation of fetal lung maturity. Outcomes factored into the model included maternal intensive care unit admission, perinatal mortality, infant mortality, respiratory distress syndrome, mental retardation, and cerebral palsy. RESULTS: A scheduled delivery at 34 weeks of gestation was the preferred strategy and resulted in the highest quality-adjusted life years under the base case assumptions. Strategies awaiting confirmation of fetal lung maturity failed to result in better outcome than strategies that delivered at the corresponding gestational age without amniocentesis. After sensitivity analyses, delivery at 37 weeks of gestation without amniocentesis was the preferred strategy in limited situations, and delivery at 39 weeks of gestation was the preferred strategy only in unlikely situations. CONCLUSION: This decision analysis suggests the preferred strategy for timing of delivery in individuals with ultrasonographic evidence of placenta previa and placenta accreta under a variety of circumstances is delivery at 34 weeks of gestation. At any given gestational age, incorporating amniocentesis for verification of fetal lung maturity does not assist in the management of such individuals. LEVEL OF EVIDENCE: III.

Peripartum hysterectomy in Aba southeastern Nigeria.

Emergency peripartum hysterectomy is a challenging but life-saving procedure. In this descriptive study carried out in a rural Nigerian hospital, we found an incidence of emergency peripartum hysterectomy of 5.4 per 1000 deliveries and a significant association with abdominal mode of delivery, unbooked status, previous caesarean section and placenta previa. The most common indications for peripartum hysterectomy were placenta accreta (47.6%) and uterine rupture (28.6%). There were five (23.8%) maternal deaths and other complications included sepsis (five), bladder injury (three) and prolonged hospital stay (11).

Placenta accreta--summary of 10 years: a survey of 310 cases.

The objective was to study the incidence, risk factors, and outcome of pregnancies complicated by placenta accreta in our population. Retrospective analysis of all deliveries between the years 1990-2000, and identification of all cases of placenta accreta, defined by clinical or histological criteria. For comparison purposes we defined two sub-groups: (i) all cases that ended with severe outcome and (ii) all patients who had a previous event of placenta accreta in one or more of their previous deliveries. We evaluated the potential risk factors leading to these conditions. The SPSS software package was used for statistical analysis. Univariate and multivariate analyses were performed by stepwise logistic regression. The study covered 34 450 deliveries from which 310 cases of placenta accreta were diagnosed (0.9 per cent). The risk factors associated with placenta accreta were previous cesarean delivery (12 per cent), advanced maternal age, high gravidity, multiparity, previous curettage and placenta previa (10 per cent). Hysterectomy was performed in 11 patients (3.5 per cent) with one case of maternal death, whereas 21 per cent of the patients required postpartum blood products transfusion. Antenatal diagnosis of placenta accreta or percreta by ultrasound or MRI, was achieved only in eight of the cases. In the sub-group of 15 patients (4.8 per cent) with severe outcome, the only significant risk factors were increased parity (O.R.=1.29, 95 per cent CI 1.056-1.585), anteriorly low placenta (O.R.=6.1, 95 per cent CI 1.4-25.3) and repeated cases of caesarean sections (O.R.=3.3, 95 per cent CI 0.9-12.5), whereas in the 49 (16 per cent) patients with repeated cases of placenta accreta the only significant risk factor was the number of deliveries (O.R.=1.5, 95 per cent CI 1.0-2.2). Repeated cesarean delivery, high parity, and anteriorly low placental location are associated with severe outcome in case of placenta accreta. Women with repeated events of placenta accreta may have better outcome and a genetic factor may serve as a cause for this condition.

An unusual cause of abdominal pain and shock in pregnancy: case report and review of the literature.

A near fatal case of spontaneous uterine rupture resulting from placenta percreta is presented. Placenta accreta refers to all conditions in which placental villi attach to, invade, or penetrate the myometrium. Placenta percreta is the most extreme form of morbid placental attachment and is said to exist when the uterine wall is completely breached by invading placental villi. Although uncommon, placenta percreta is an important entity of which the emergency physician should be aware because of its propensity to cause uterine rupture and catastrophic bleeding. This article reviews the pathophysiology, presentation, diagnosis, and emergency department management of placenta accreta, increta, and percreta.

Placenta accreta: changing clinical aspects and outcome.

In an effort to determine if a changing clinical picture for placenta accreta exists in the late 1970s, 22 cases from January 1, 1975, to May 30, 1979, at Los Angeles County/University of Southern California (LAC/USC) Medical Center were reviewed. An incidence of clinically diagnosed placenta accreta of 1 per 2562 deliveries for all cases and 1 per 4027 for pathologically confirmed cases (ie, hysterectomy specimens) was found. Mean age of the patients was 29.5 years, and mean gravidity, parity, and abortion were 3.4, 2, and 0.27, respectively. Placenta previa was found in 14 patients (63.6%), 6 of whom had previously undergone cesarean section. No obvious etiology was found in 1 patient. Sixteen patients underwent cesarean section. Hysterectomy was performed on 14 patients, and conservative measures were employed in 8 patients. One maternal death (4.5%) occurred, but there was no perinatal mortality. The clinical picture of placenta accreta today is one of higher reported incidence, lower parity, greater incidence of associated placenta previa, individualized management, and decreasing maternal and perinatal mortality.