Placenta Invasion Anomaly without Placenta Previa in the First Trimester of Pregnancy and its Conservative Management: A Case Presentation.

Diagnosing placenta accreta spectrum (PAS) is rather difficult in the first trimester of pregnancy. Especially if the localization of the placenta is not in and around the cervical canal, this may not attract the attention of obstetricians. Early diagnosis can decrease bleeding during curettage or miscarriage, but there are no guidelines regarding its diagnosis in the first trimester. In addition, there is insufficient evidence-based knowledge in the literature on the management and treatment of PAS without placenta previa. In this article, conservative treatment without hysterectomy of a patient diagnosed with PAS in first trimester was presented.

Clinical analysis of prophylactic uterine artery embolization combined with double balloon catheter for second-trimester pregnancy termination in cases of complete placenta previa: A retrospective study.

Complete placenta previa often causes significant bleeding in a short period during second-trimester pregnancy termination. This can destabilize the mother's circulation, threatening her life. Furthermore, the condition is complicated by an immature cervix, making it a challenging clinical problem. The aim of this study was to investigate the effect of prophylactic uterine artery embolization (UAE) combined with double balloon catheter (DBC) deal with those cases. A total of 7 patients who underwent pregnancy termination in the second-trimester in Maternal and Child Health Hospital of Hubei Province between March 1st, 2021 and August 31st, 2023 were retrospectively analyzed in this study. All patients were diagnosed with complete placenta previa status and placenta accreta spectrum, and were treated with prophylactic UAE combined with DBC, and/or dilation and evacuation. All the patients received mifepristone, and 5 of them underwent medical termination with ethacridine lactate. Following prophylactic UAE combined with DBC, 6 patients underwent dilation and evacuation, which was monitored by ultrasound. And one patient experienced natural delivery of their fetus and placenta. Only one patient (patient 3) developed an intrapartum fever after prolonged duration of 18 hours from ethacridine to UAE and 56 hours from UAE to DBC. The amount of intrapartum hemorrhage ranged from 20 mL to 300 mL. The combined therapy of prophylactic UAE and DBC is a preferred option for patients with complete placenta previa undergoing second-trimester pregnancy termination. The use of dilation and evacuation may depend on the cervical condition, bleeding, or infection.

Overcoming challenges in managing a high-risk pregnancy with placenta previa and newly diagnosed Bombay phenotype.

BACKGROUND: Bombay phenotype is rare and characterized by a lack of H antigen on the surface of red blood cells (RBCs) with naturally occurring anti-H antibodies. The presence of anti-H necessitates the exclusive use of Bombay phenotype RBCs for transfusion. We present a case of a pregnant woman with Bombay phenotype who required urgent cesarean section delivery due to high-risk placenta previa. CASE DESCRIPTION: A 36-year-old G1P0 woman of Indian origin presented at 36 weeks and 4 days gestation for management of a high-risk pregnancy with complete placenta previa. Bombay phenotype was unexpectedly identified on routine testing. Given the rarity of the blood, advanced gestation, and risk of post-partum hemorrhage associated with complete placenta previa and spontaneous labor, prompt strategic planning commenced for a successful delivery. Two frozen allogeneic Bombay phenotype RBCs were available as part of a concise transfusion plan. Intraoperative cell salvage was successfully employed and allogeneic transfusion was not required. CONCLUSION: Management of patients with rare blood types can be extremely challenging and guidance for those presenting later in pregnancy is scarce. Our patient's gestational age precluded the use of well-known effective strategies, including hemoglobin optimization, autologous and directed donation, and procurement of large quantities of rare blood. Rather, our approach utilized multidisciplinary expertise and strategic planning to yield a successful outcome.

Comparison of maternal outcomes and clinical characteristics of prenatally vs nonprenatally diagnosed placenta accreta spectrum: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to compare maternal outcomes of prenatally and nonprenatally diagnosed placenta accreta spectrum. DATA SOURCES: A systematic literature search was performed in PubMed, the Cochrane database, and Web of Science until November 28, 2022. STUDY ELIGIBILITY CRITERIA: Studies comparing the clinical presentation of prenatally and nonprenatally diagnosed placenta accreta spectrum were included. The primary outcomes were emergent cesarean delivery, hysterectomy, blood loss volume, number of transfused blood product units, urological injury, coagulopathy, reoperation, intensive care unit admission, and maternal death. In addition, the pooled mean values for blood loss volume and the number of transfused blood product units were calculated. The secondary outcomes included maternal age, gestational age at birth, nulliparity, previous cesarean delivery, previous uterine procedure, assisted reproductive technology, placenta increta and percreta, and placenta previa. METHODS: Study screening was performed after duplicates were identified and removed. The quality of each study and the publication bias were assessed. Forest plots and I2 statistics were calculated for each study outcome for each group. The main analysis was a random-effects analysis. RESULTS: Overall, 415 abstracts and 157 full-text studies were evaluated. Moreover, 31 studies were analyzed. Prenatally diagnosed placenta accreta spectrum was associated with a significantly lower rate of emergency cesarean delivery (odds ratio, 0.37; 95% confidence interval, 0.21-0.67), higher hysterectomy rate (odds ratio, 1.98; 95% confidence interval, 1.02-3.83), lower blood loss volume (mean difference, -0.65; 95% confidence interval, -1.17 to -0.13), and lower number of transfused red blood cell units (mean difference, -1.96; 95% confidence interval, -3.25 to -0.68) compared with nonprenatally diagnosed placenta accreta spectrum. The pooled mean values for blood loss volume and the number of transfused blood product units tended to be lower in the prenatally diagnosed placenta accreta spectrum groups than in the nonprenatally diagnosed placenta accreta spectrum groups. Nulliparity (odds ratio, 0.14; 95% confidence interval, 0.10-0.20), previous cesarean delivery (odds ratio, 6.81; 95% confidence interval, 4.12-11.25), assisted reproductive technology (odds ratio, 0.19; 95% confidence interval, 0.06-0.61), placenta increta and percreta (odds ratio, 3.97; 95% confidence interval, 2.24-7.03), and placenta previa (odds ratio, 6.81; 95% confidence interval, 4.12-11.25) showed statistical significance. No significant difference was found for the other outcomes. CONCLUSION: Despite its severity, the positive effect of prenatally diagnosed placenta accreta spectrum on outcomes underscores the necessity of a prenatal diagnosis. In addition, the pooled mean values provide a preoperative preparation guideline.

Knowledge Gaps in Placenta Accreta Spectrum.

Since its first description early in the 20th Century, placenta accreta and its variants have changed substantially in incidence, risk factor profile, clinical presentation, diagnosis and management. While systematic use of diagnostic tools and a multidisciplinary team care approach has begun to improve patient outcomes, the condition's pathophysiology, epidemiology, and best practices for diagnosis and management remain poorly understood. The use of large databases with broadly accepted terminology and diagnostic criteria should accelerate research in this area. Future work should focus on non-traditional phenotypes, such as those without placenta previa-preventive strategies, and long term medical and emotional support for patients facing this diagnosis. KEY POINTS: · Placenta accreta spectrum research may be improved with standardized terminology and use of large databases.. · Placenta accreta prediction should move beyond ultrasound with the addition of biomarkers, and needs to extend to those without traditional risk factors.. · Future research should identify practices that can prevent future accreta development..

The method for termination of mid-trimester pregnancy with placenta previa: A case study.

BACKGROUND: Prenatal bleeding is very dangerous for pregnant women with placenta previa during termination of pregnancy in the mid-trimester. Traditionally, cesarean section or hysterectomy is used to stop bleeding. This study aims to investigate the method for termination of mid-trimester pregnancy with placenta previa, especially emergency uterine artery embolization (UAE) combined with cervical double balloon (CDB). METHODS: A retrospective study was conducted based on 261 cases of mid-pregnancy termination in our hospital, where 34 cases with placenta previa were set as the observation group, and the remaining 227 cases were set as control group. At first, the termination method of Mifepristone combined with Misoprostol/Ethacridine Lactate was adopted. If the volume of prenatal bleeding was up to 400 mL, emergency uterine artery embolization (UAE) was implemented to stop bleeding, then cervical double balloon (CDB) was used to promote cervical ripening. Receiver operating characteristic (ROC) curves analysis was performed to assess the accuracy in predicting the length of placental edge crossed the cervical os for prenatal bleeding. RESULTS: The number of gravidity/parities, the rate of cesarean section, the medical cost, the rate of previous cesarean section were all higher in the observation group than in the control group (P < .05). The volume of prenatal hemorrhage, postpartum hemorrhage, the rate of puerperal morbidity, emergency UAE rate and ICU rate were higher in the observation group than in the control group (P < .05). There were 4 cases showing prenatal hemorrhage up to 400 mL and undergoing emergency UAE + CDB in the observation group, while there were no such cases in the control group (P < .05). An optimal cut-off value of 1.7cm for the length of placental edge crossed the cervical os in diagnosing prenatal hemorrhage demonstrated sensitivity and specificity of 75.0% and 86.7%, respectively (area under the ROC curve, 0.858). CONCLUSION: The combined therapy of mifepristone and Misoprostol/Ethacridine Lactate was useful for termination of mid-trimester pregnancy with placenta previa, and attention needs to be attached to prenatal hemorrhage during labor induction. Emergency UAE + CDB is a good combination method to treat prenatal hemorrhage and promote cervical ripening during the induction.

Deep Learning Algorithm-Based Ultrasound Image Information in Diagnosis and Treatment of Pernicious Placenta Previa.

This study was to explore the value of the deep dictionary learning algorithm in constructing a B ultrasound scoring system and exploring its application in the clinical diagnosis and treatment of pernicious placenta previa (PPP). 60 patients with PPP were divided into a low-risk group (severe, implantable) and high-risk group (adhesive, penetrating) according to their clinical characteristics, B ultrasound imaging characteristics, and postpartum pathological examination results. Under PPP ultrasonic image information using the deep learning algorithm, the B ultrasound image diagnostic scoring system was established to predict the depth of various types of placenta accreta. The results showed that the cut-off values of severe, implantable, adhesive, and penetrating types were <2.3, 2.3-6.5, 6.5-9, and ≥9 points, respectively; there were significant differences in the termination of pregnancy and neonatal birth weight between the two groups (P < 0.05); the positive predictive value, negative predictive value, and false positive rate of ultrasound images based on the deep dictionary learning algorithm for PPP were 95.33%, 94.89%, and 3.56%, respectively. Thus, the ultrasound image diagnostic scoring system based on the deep learning algorithm has an important predictive role for PPP, which can provide a more targeted diagnosis and treatment plan for patients in clinical practice and improve the prediction and treatment efficiency.

Retained products of conception (RPOC) following delivery without placenta previa: Which patients with RPOC show postpartum hemorrhage?

INTRODUCTION: To clarify the perinatal outcome of retained products of conception (RPOC) after 22 weeks or more. METHODS: The retrospective cohort study reviewed medical records of patients with RPOC without placenta previa at 186 Japanese perinatal centers. RESULTS: Of the 323 patients with RPOC, pregnancies after assisted reproductive technology (ART) accounted for 43%. Transfusion at delivery was required in 33% of the patients. Logistic regression analyses revealed that transfusion was significantly required in the following situations: ART pregnancy (aOR: 6.0, 95%CI: 2.3-16, P < 0.001), and RPOC length ≥4 cm (aOR: 5.3, 95%CI: 2.1-13, P < 0.001). Transarterial embolization (TAE) and/or hysterectomy for subsequent RPOC-related bleeding was performed in 60 patients with RPOC. Logistic regression analysis revealed that additional interventions were significantly required in the following situations: multiparity (aOR: 6.1, 95%CI: 2.1-17.2, P < 0.001), and hypervascular RPOC (aOR: 12.8, 95%CI: 3.2-51.1, P < 0.001). TAE and/or hysterectomy was also frequently employed in ART pregnancy, although this was not significant (aOR: 2.8, 95%CI: 0.9-8.2, P = 0.063). DISCUSSION: Patients with RPOC were significantly more likely to require transfusion at delivery in the presence of large RPOC and ART. They were also more likely to require hemostatic procedures for subsequent bleeding in the presence of hypervascular RPOC and ART.

Effect of prophylactic balloon occlusion of internal iliac artery in pregnancies complicated by placenta previa and accreta.

BACKGROUND: Placenta previa and accreta are serious obstetric conditions that are associated with a high risk of intraoperative massive hemorrhage, the prophylactic intravascular balloon occlusion technique is increasingly used in managing uncontrolled hemorrhage in cesarean section (CS). We aim to examine the clinical effectiveness of prophylactic balloon occlusion of the internal iliac artery (PBOIIA) during CS in improving maternal outcomes for patients with placenta previa and accreta. METHODS: A total of 420 women with placenta previa and accreta who underwent CS from January 2014 to December 2018 were included retrospectively. Patients were divided into balloon group in which patients had PBOIIA (n = 248) and the control group in which patients did not have PBOIIA (n = 172). Meanwhile, we performed a subgroup analysis in whether taking parallel transverse uterine incision (PTUI) surgery. Information on conditions of patients and newborns, perioperative blood indicators, surgical outcomes were collected. RESULTS: Median estimated blood loss (mEBL) was 2200 mL in the balloon group and 2150 mL in the control group respectively, there was no significant difference between two-groups comparison (P > 0.05), and the rate of patients with hysterectomy was also has no difference between the two groups (36.3% verus 35.5%, P > 0.05), while there is a significant difference between two groups in the amount of PRBCs transfused [3 (0-31.5) verus 3 (0-39), P <0.05], moreover, the proportion of PRBCS> 8 units in the balloon group is significantly lower than that in control group (11.29% verus 23.26%, P <0.05).. However, the total hospitalization costs (45,624.4 ± 11,061.9 verus 37,523.1 ± 14,662.2, CYN) and surgery costs (19,910.6 ± 2622.6 verus 11,850.5 ± 3146.1, CYN) in balloon group were significantly higher than those in control group (P < 0.05). Subgroup analysis showed PTUI surgery had no significant differences in EBL (P >0.05), but it could significantly decrease hysterectomy rates (P <0.05). CONCLUSIONS: PBOIIA has no significant effect on reducing intraoperative EBL and hysterectomy rate in patients with placenta previa and accreta. and although it could reduce the intraoperative PRBCs in patients with massive hemorrhage, it significantly increases the financial cost for patients. Therefore, PBOIIA should not be routinely recommended to patients with placenta previa and accreta.

Clinical analysis of second-trimester pregnancy termination after previous caesarean delivery in 51 patients with placenta previa and placenta accreta spectrum: a retrospective study.

BACKGROUNDS: Pregnancy termination during the second trimester in patients with placenta previa and placenta accreta spectrum (PAS) is a complex and challenging clinical problem. Based on our literature review, there has been a relative increase in the number of such cases being treated by hysterotomy and/or local uterine lesion resection and repair. In the present study, a retrospective analysis was conducted to compare the clinical outcomes when different management strategies were used to terminate pregnancy in the patients with placenta previa and PAS. METHODS: A total of 51 patients who underwent pregnancy termination in the second trimester in Beijing Obstetrics and Gynecology Hospital between June 2013 and December 2018 were retrospectively analyzed in this study. All patients having previous caesarean delivery (CD) were diagnosed with placenta previa status and PAS. RESULTS: ① Among the 51 patients, 16 cases received mifepristone and misoprostol medical termination, 15 cases received mifepristone and Rivanol medical termination, but 1 of them was transferred to hysterotomy due to failed labor induction, another 20 cases were performed planned hysterotomy. There was no placenta percreta cases and uterine artery embolization (UAE) was all performed before surgery.② There were 31 cases who underwent medical termination and 30 cases were vaginal delivery. Dilation and evacuation (D&E) were used in 20 cases of medical abortion failure and in all 30 cases of difficult manual removal of placental tissue. ③ A statistically significant difference was found among the three different strategies in terms of gestational weeks, the type of placenta previa status, main operative success rate and ß-HCG regression time (P < 0.05). ④ There were 4(7.8%) cases who were taken up for hysterectomy because of life-threatening bleeding or severe bacteremia during or after delivery and hysterotomy. The uterus was preserved with the implanted placenta partly or completely left in situ in 47(92.2%) cases. Combined medical and/or surgical management were used for the residual placenta and the time of menstrual recovery was 52(range: 33 to 86) days after pregnancy termination. CONCLUSIONS: Terminating a pregnancy by vaginal delivery through medical induction of labor may be feasible if clinicians have an overall understanding of gestational age, the type of placenta previa status, the type of placenta accreta, and patients concerns about preserving fertility. A collaborative team effort in tertiary medical centers with a very experience MDT and combined application of multiple methods is required to optimize patient outcomes.

Central placenta praevia accreta with focal bladder percretism. Conservative management.

Placenta praevia is a condition when placenta is inserted in an abnormal position near or over the internal cervical orifice (ICO). Abnormal placental attachment (placenta accreta, increta, percreta) is a wide spectrum disorder ranging from abnormal adherence to deeply invasive placental tissue. We report a very rare case of central placenta praevia accreta and focal bladder percretism in a 29 years old pregnant woman with an obstetrical history of one previous vaginal delivery and four curettages following miscarriage. She was taken in charge by Catania S. Marco' university-hospital at 20 weeks with diagnosis of Central Placenta Praevia and Accreta (CPPA) detected by means of ultrasounds (US). At 31 weeks Magnetic Resonance Imaging (MRI) confirmed CPPA with focal bladder percretism. After alerting multidisciplinary team and obtaining blood units available, a Caesarean Section (CS) at 34 weeks was planned, when by means of US a detachment area with bleeding was observed. An adequate informed consent was completed, where the pregnant woman and her husband accepted the risk of possible hysterectomy and blood transfusions. A Pfannestiel's laparotomy with transversal corporal uterine incision, bilateral uterine ligation, packed tamponage, removal of placental tissue separated during fetal extraction and leaving a portion of placenta only in the place of percretism, allowed conservative intervention (uterus preservation) ending in good results for both mother and fetus. KEY WORDS: Caesarean section, Curettage, Placenta praevia, Placenta accreta, Preterm birth.

[Postpartum hemorrhage and need of blood transfusions]. / Postpartumblödningar med blodtransfusioner har ökat.

Postpartum hemorrhage is responsible for one fourth of the maternal mortality worldwide. In high resource countries there is an increasing trend in frequency of postpartum hemorrhage and need of blood transfusions. The reason for this increase is probably multifactorial. Major bleeding requires massive blood transfusion (MT), defined as transfusion of >10 units of erythrocytes within 24 hours. In Sweden the incidence of MT due to obstetric hemorrhage is reported to be 53 per 100 000 deliveries and the majority of the cases are due to placental complications, such as placenta previa and placenta accreta. These placental complications have increased over the past years as a consequence of a higher rate of cesarean deliveries. To reduce the number of deliveries requiring blood transfusion postpartum, prophylactic measures such as identification of women at increased risk, optimizing management of hemorrhage and evaluating the effect of every transfused unit of erythrocytes is important.

The effect prophylactic internal iliac artery balloon occlusion in patients with placenta previa or placental accreta spectrum: a systematic review and meta-analysis.

BACKGROUND: Placenta previa describes a placenta that extends partially or completely over the internal cervical oss. Placenta previa is one of the leading causes of widespread postpartum hemorrhage and maternal mortality worldwide. Another cause of bleeding in pregnant women is Placenta accreta spectrum. Therefore, the aim of the present systematic review and meta-analysis is to determine the effect of prophylactic balloon occlusion of the internal iliac arteries in patients with placenta previa or placental accreta spectrum (PAS). METHODS: In this systematic review and meta-analysis, to identify and select relevant studies, the SID, MagIran, ScienceDirect, Embase, Scopus, PubMed, Web of Science, and Google Scholar databases were searched, using the keywords of internal iliac artery balloon, placenta, previa, balloon, accreta, increta and percreta, without a lower time limit and until 2020. The heterogeneity of the studies was examined using the I2 index, and subsequently a random effects model was applied. Data analysis was performed within the Comprehensive Meta-Analysis software (version 2). RESULTS: In the review of 29 articles with a total sample size of 1140 in the control group, and 1225 in the balloon occlusion group, the mean difference between the two groups was calculated in terms of Intraoperative blood loss index (mL) and it was derived as 3.21 ± 0.38; moreover, in 15 studies with a sample size of 887 in the control group, and 760 in the balloon occlusion group, the mean difference between the two groups in terms of gestation index (weeks) was found as 2.84 ± 0.49; and also with regards to hysterectomy balloon occlusion after prophylactic closure of the iliac artery, hysterectomy (%) balloon occlusion was calculated as 8.9 %, and this, in the hysterectomy control group (%) was obtained as 31.2 %; these differences were statistically significant and showed a positive effect of the intervention (P < 0.05). CONCLUSION: The results of this study show that the use of prophylactic internal iliac artery balloon occlusion in patients with placenta previa or Placenta accreta spectrum has benefits such as reduced intraoperative blood loss, reduced hysterectomy and increased gestation (weeks), which can be considered by midwives and obstetricians.

The routine use of prophylactic Bakri balloon tamponade contributes to blood loss control in major placenta previa.

OBJECTIVE: To verify the blood loss control effect of routine prophylactic Bakri balloon tamponade on major and minor placenta previa (PP). METHODS: We conducted a retrospective cohort study of all singleton pregnancies that involved cesarean section (CS) for PP at our hospital. All participants were divided into Bakri balloon (underwent routine prophylactic use just after placenta removal) and non-balloon groups, and into major and minor PP groups. Clinical outcomes in major and minor PP were compared between balloon and non-balloon groups. RESULTS: The balloon and non-balloon groups contained 74 and 89 patients, respectively. There were 41 and 33 (balloon group) and 48 and 41 (non-balloon group) major and minor PP cases, respectively. Intraoperative and perioperative blood losses of major PP were significantly lower in the balloon group than the non-balloon group (1045 ml versus 1553 ml, P = 0.016; and 1189 ml versus 1810 ml, P = 0.006, respectively). The frequency of massive postpartum hemorrhage (>500 ml) with major PP was lower in the balloon group than in the non-balloon group (2.4% versus 16.7%, P = 0.027), but with no significant difference with minor PP. CONCLUSION: Routine prophylactic use of Bakri balloon tamponade during and after CS is effective in controlling blood loss in major PP.

Reproductive services for the patient at increased risk for morbidity and mortality during the second trimester.

Some complications of pregnancy that occur in the second trimester, such as preeclampsia, bleeding placenta previa, and preterm premature rupture of membranes, require delivery to avoid maternal morbidity and mortality. When these situations occur before fetal viability, pregnancy termination, either by induction of labor or dilation and evacuation, can be lifesaving. To optimize maternal health in these situations, Maternal Fetal Medicine providers should be trained to provide all needed medical services, including termination. Currently, only the minority of Maternal Fetal Medicine providers are skilled in dilation and evacuation. Training programs should focus on ways to facilitate training in second trimester dilation and evacuation to improve care access and quality when these medically necessary procedures are needed for women in whom a healthy pregnancy is no longer an option.