Evaluation of maternal serum thiol and ischemia-modified albumin levels in cases of placenta previa: A case-control study in a tertiary center.

AIM: We aim to compare the maternal serum thiol and ischemia-modified albumin (IMA) levels between pregnant women with placenta previa and those with uncomplicated pregnancies and to determine whether changes in these levels were useful in predicting cases of abnormally invasive placenta (AIP). METHODS: Fifty-five pregnant women diagnosed with placenta previa according to the diagnostic criteria (case group) were compared to 100 women with uncomplicated pregnancies of similar demographic characteristics (control group). The patients with placenta previa were further divided into two subgroups: AIP (n = 20) and placenta previa without invasion (n = 35). The maternal serum native thiol, total thiol, disulfide, and IMA levels of the groups were evaluated. RESULTS: The native thiol, total thiol, and IMA values were significantly lower in the case group than in the control group (p < 0.001). The disulfide values were similar between the study and control groups (p = 0.488). When the AIP and placenta previa without invasion groups were compared, the levels of native thiol, total thiol, disulfide, and IMA were similar (p > 0.05). CONCLUSIONS: Maternal serum thiol and IMA levels were lower in placenta previa cases compared to the control group. However, these parameters were not useful in predicting AIP cases.

Evaluation of maternal serum VEGF, TNF-alpha, IL-4, and IL-10 levels in differentiating placenta accreta spectrum from isolated placenta previa.

OBJECTIVE: Our study aimed to differentiate patients with placenta accreta spectrum (PAS) from those with placenta previa (PP) using maternal serum levels of vascular endothelial growth factor (VEGF), tumor necrosis factor-alpha (TNF-alpha), interleukin-4 (IL-4), and IL-10. METHODS: The case group consisted of 77 patients with placenta previa, and the control group consisted of 90 non-previa pregnant women. Of the pregnant women in the case group, 40 were diagnosed with PAS in addition to placenta previa and 37 had placenta previa with no invasion. The maternal serum VEGF, TNF-alpha, IL-4, and IL-10 levels were compared between the case and control groups. Then the success of these markers in differentiating between PP and PAS was evaluated. RESULTS: We found the VEGF, TNF-alpha, and IL-4 levels to be higher and the IL-10 level to be lower in the case group compared to the control group (p < 0.001). We observed a statistically significantly lower IL-10 level in the patients with PAS than those with PP (p = 0.029). In the receiver operating characteristic analysis, the optimal cut-off of IL-10 in the detection of PAS was 0.42 ng/mL). In multivariate analysis, the risk of PAS was significant for IL-10 (odds ratio (OR) 0.45, 95 % confidence interval (CI) 0.25-0.79, p = 0.006) and previous cesarean section (OR 2.50, 95 % Cl 1.34-4.66, p = 0.004). The model's diagnostic sensitivity and specificity, including previous cesarean section, preoperative hemoglobin (Hb), TNF-alpha, and IL-10 were 75 % and 72.9 %, respectively. CONCLUSION: The study showed that the IL-10 level was lower in patients with PAS than in those with PP. A statistical model combining risk factors including previous cesarean section, preoperative Hb, TNF-alpha, and IL-10 may improve clinical diagnosis of PAS in placenta previa cases. Cytokines may be used as additional biomarkers to the clinical risk factors in the diagnosis of PAS.

Peripartum hysterectomy clinical characteristics and outcomes- a hospital based retrospective audit study.

INTRODUCTION: The study aims to evaluate and report on the clinical characteristics, incidence, risk factors and associated complications of emergency and planned peripartum hysterectomy in a single training and research tertiary health care centre in Malaysia. MATERIALS AND METHODS: We conducted a 6-year retrospective cross-sectional study from the 1st January 2016 until 31st December 2021. Clinical, demographic characteristics, perioperative parameters, operative indications, blood loss, maternal/neonatal outcomes and complications were analysed. Patients were subdivided, analysed and studied in two subgroups- emergency hysterectomy (EH) and planned hysterectomy (PH). RESULTS: There were 65 cases of peripartum hysterectomy out of total 100,567 deliveries, with a prevalence rate of 0.06%. Overall, the majority of patients were multiparous (96.9%), having previous caesarean scar (73.8%) or diagnosed with placenta praevia (75.4%). More than half of the total patients (61.5%) have both previous caesarean scar and concomitant placenta praevia. EH was carried out in 39(60%) patients while 26(40%) patients underwent PH. The only indication for surgery in the PH group (100%) was abnormal placentation while the most common indication for surgery in the EH group (53.8%) was postpartum haemorrhage related to abnormal placentation. Patients who underwent EH were more likely to have massive blood loss (p=0.001), require ICU admissions (p=0.001), have DIVC cycles transfused (mean [SD] regime: 1.35 [0.95] vs 0.54 [0.99]; p=0.002), have lower postoperative haemoglobin level (mean [standard deviation, SD] haemoglobin: 9.23g/l [SD1.8] vs. 10.8 g/l [SD1.86]; p=0.001) and have higher difference between pre/post operative haemoglobin level (mean [SD] haemoglobin difference: 1.78g/l [SD6.34] vs 0.32g/l [SD1.7]; p=0.008) compared to patients with PH. Red blood cell transfusion, operating time, length of stay, weight of babies and Apgar score between two groups showed no significant differences. A significant reduction of blood loss between the first and the second half duration of the study (mean [SD] blood loss: 6978 ml [SD 4999.45] vs. 4100ml [SD2569.48]; p=0.004) was also observed. In the emergency group, 'non-placental cause' EH required significantly more red blood cell transfusion than 'placental cause' (p<0.05) while in the PH group, no significant difference was observed between the occlusive internal iliac artery 'balloon' and 'no balloon' subgroup in terms of operating time, total blood loss or blood transfusion. Overall complications showed more cases of post operative fever and relaparotomy in the EH group (18.4% vs. 7.6%) while urinary tract injuries including injuries to bladder and ureter occurred only in the PH group (9.4% vs. 0%). CONCLUSION: The majority of peripartum hysterectomy cases are due to placenta accreta spectrum disorders. Planned peripartum hysterectomies have a lower morbidity rate compared to emergency hysterectomies. Therefore, early identification of placenta accreta spectrum disorders and timely planning for elective procedures are crucial to minimise the need for emergency surgery.

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.

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.

Tourniquet, Uterine Inversion, and Placental dissection （TURIP） procedure as a novel hemostatic technique to preserve fertility for placenta accreta spectrum disorders without placenta previa.

The number of cases of placenta accreta spectrum disorder has been increasing with the increase in in vitro fertilization and cesarean deliveries. In addition, placenta accreta spectrum without placenta previa is difficult to diagnose before delivery and sometimes requires a hysterectomy because of heavy bleeding. We have devised a uterus-preserving technique (referred to as the tourniquet, uterine inversion, and placental dissection procedure) for such cases. First, the bleeding is stopped by the tourniquet method, the uterus is relaxed with nitroglycerin, and the uterus is inverted to expose the adhesion site. After that, the placenta is detached by sharp dissection under direct visualization, and the detached areas are sutured, and then the tourniquet and internal rotation are released. This technique does not require advanced skills. Thus, a surgeon could avoid performing a hysterectomy and have a greater chance of uterus preservation when encountering massive hemorrhage caused by unpredictable placenta accreta spectrum without placenta previa in either cesarean deliveries or vaginal deliveries.

Pathologically diagnosed placenta accreta spectrum without placenta previa: a systematic review and meta-analysis.

OBJECTIVE: This systematic review and meta-analysis aimed to assess clinical characteristics related to pathologically proven placenta accreta spectrum without placenta previa. DATA SOURCES: A literature search of PubMed, the Cochrane database, and Web of Science was performed from inception to September 7, 2022. STUDY ELIGIBILITY CRITERIA: The primary outcomes were invasive placenta (including increta or percreta), blood loss, hysterectomy, and antenatal diagnosis. In addition, maternal age, assisted reproductive technology, previous cesarean delivery, and previous uterine procedures were investigated as potential risk factors. The inclusion criteria were studies evaluating the clinical presentation of pathologically diagnosed PAS without placenta previa. METHODS: Study screening was conducted 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: Among 2598 studies that were initially retrieved, 5 were included in the review. With the exception of 1 study, 4 studies were included in the meta-analysis. This meta-analysis showed that placenta accreta spectrum without placenta previa was associated with less risk of invasive placenta (odds ratio, 0.24; 95% confidence interval, 0.16-0.37), blood loss (mean difference, -1.19; 95% confidence interval, -2.09 to -0.28) and hysterectomy (odds ratio, 0.11; 95% confidence interval, 0.02-0.53), and more difficult to diagnose prenatally (odds ratio, 0.13; 95% confidence interval, 0.04-0.45) than placenta accreta spectrum with placenta previa. In addition, assisted reproductive technology and a previous uterine procedure were strong risk factors for placenta accreta spectrum without placenta previa, whhereas previous cesarean delivery was a strong risk factor for placenta accreta spectrum with placenta previa. CONCLUSION: The differences in clinical aspects of placenta accreta spectrum with and without placenta previa need to be understood.

Focal-occult placenta accreta: a clandestine source of maternal morbidity.

BACKGROUND: Focal-occult placenta accreta spectrum is known to cause adverse obstetrical morbidity outcomes, however, direct comparisons with previa-associated placenta accreta spectrum morbidity are lacking. OBJECTIVE: We sought to compare the baseline characteristics, surgical and obstetrical morbidity, and subsequent pregnancy outcomes of patients with focal-occult placenta accreta spectrum with those of patients with previa-associated accreta. STUDY DESIGN: A retrospective review was conducted of all pathologically confirmed placenta accreta spectrum cases from 2018 to 2022 at a tertiary care center. The baseline characteristics, surgical, obstetrical, and subsequent pregnancy outcomes were recorded. Cases of focal-occult placenta accreta spectrum was compared with cases of previa-associated placenta accreta spectrum across a range of morbidity characteristics including hemorrhagic factors, interventions, postdelivery reoperations, infections, and intensive care unit admission. Statistical comparison was performed using Kruskal-Wallis or chi-square tests, and a P value of <.05 was considered significant. RESULTS: A total of 74 cases were identified with 43 focal-occult and 31 previa-associated placenta accreta spectrum cases. Of those, 25.6% of the patients with focal-occult placenta accreta spectrum and 100% of the patients with previa-associated placenta accreta spectrum underwent a hysterectomy. One case of focal-occult placenta accreta spectrum and 29 cases of previa-associated placenta accreta spectrum were diagnosed antenatally. Patients with focal-occult placenta accreta spectrum did not differ from those with previa-associated placenta accreta spectrum in mean maternal age (33.0 vs 33.1 years), body mass index, or the incidence of previous dilation and curettage procedures (16.3% vs 25.8%). Patients with focal-occult placenta accreta spectrum were significantly more likely to have a lower mean parity (1.5 vs 3.6 gestations), higher gestational age at delivery (36.1 vs 33.9 weeks' gestation), and were less likely to have had a previous cesarean delivery (12/43, 27.9% vs 30/31, 96.8%). In addition, patients with focal-occult placenta accreta spectrum had less previous cesarean deliveries (mean, 0.5 vs 2.3), were more likely to have undergone in vitro fertilization (20.9% vs 3.2%), and less likely to have anterior placentation. When contrasting the clinical outcomes of patients with focal-occult placenta accreta spectrum with those with previa-associated placenta accreta spectrum, the postpartum hemorrhage rates (71.0% vs 67.4%), mean quantitative blood loss (2099 mL; range, 500-9516 mL vs 2119 mL; range 350-12,220 mL), mean units of red blood cells transfused (1.4 vs 1.7), massive transfusion rate (9.3% vs 3.2%), and intensive care unit admission rates (11.6% vs 6.5%) were not significantly different, but there was a nonsignificant trend toward higher morbidity among patients with focal-occult accreta. Patients with focal-occult accreta had a higher incidence of reoperations or return to the operating room (30.2 vs 6.5%; P=.01). When comparing focal-occult with previa-associated placenta accreta spectrum, the composite outcomes, including hemorrhagic morbidity (77.4% vs 74.4%), any maternal morbidity (83.9% vs 76.7%), and severe maternal morbidity (64.5% vs 65.1%), were not significantly different between the groups. Nine focal-occult placenta accreta spectrum patients had a subsequent pregnancy, and 3 of those had recurrent placenta accreta spectrum. CONCLUSION: Focal-occult placenta accreta spectrum presents with fewer identifiable risk factors than placenta previa-associated placenta accreta spectrum but may be associated with an in vitro fertilization pregnancy. Patients with focal-occult placenta accreta spectrum was observed to have a higher incidence of reoperation when compared with patients previa-associated placenta accreta spectrum, and no other statistically significant differences in morbidity outcomes were observed. The absence of differences in morbidity outcomes may be attributable to a lack of antenatal detection of focal-occult accreta and merits further investigation.

Ferumoxytol-enhanced MR demonstration of changes to internal placental structure in placenta accreta spectrum: Preliminary findings.

INTRODUCTION: The goal of this pilot study is to determine if ferumoxytol-enhanced MR might provide a new approach to the diagnosis of placenta accreta spectrum (PAS), and if so, to identify signs of PAS. METHODS: Ten pregnant women were referred for MRI evaluation for PAS. MR studies consisted of pre-contrast SSFSE, SSFP, DWI, and ferumoxytol-enhanced sequences. Post-contrast images were rendered as MIP and MinIP images to separately display the maternal and fetal circulations respectively. Two readers examined the images for architectural changes to placentone (fetal cotyledon) that might distinguish PAS cases from normal. Attention was given to the size and morphology of the placentone, villous tree, and vascularity. In addition, the images were examined for evidence of fibrin/fibrinoid, intervillous thrombus, basal and chorionic plate bulges. Interobserver agreement was characterized with kappa coefficients and levels of confidence for feature identification was recorded on a 10-point scale. RESULTS: At delivery, there were five normal placentas and five with PAS (one accreta, two increta, two percreta). The ten changes of placental architecture in PAS included: focal/regional expansion of placentone(s); lateral displacement and compression of the villous tree; disruption of a regular pattern of normal placentones; bulging of the basal plate; bulging of the chorionic plate; transplacental stem villi; linear/nodular bands at basal plate; non-tapering villous branches; intervillous hemorrhage; and dilated subplacental vessels. All these changes were more common in PAS; the first five achieved statistical significance in this small sample. The interobserver agreement and confidence for the identification of these features was good to excellent except for dilated subplacental vessels. DISCUSSION: Ferumoxytol-enhanced MR imaging appears to depict derangements of the internal architecture of placentas with PAS, thereby suggesting a promising new strategy to diagnose PAS.

Pregnancy outcomes at maternal age over 45 years: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to identify trends in pregnancy outcomes, especially delivery mode, among pregnant patients older than 45 years. DATA SOURCES: A literature search was performed using PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials for studies published between January 1, 2010, and June 30, 2022. STUDY ELIGIBILITY CRITERIA: The primary outcomes were cesarean delivery and assisted delivery. The secondary outcomes were preeclampsia, gestational diabetes mellitus, placenta previa, placental abruption, postpartum hemorrhage, and preterm birth. The inclusion criteria were studies examining the relationship between older age pregnancy and pregnancy outcomes, studies that compared pregnancy outcomes at maternal age ≥45 years and <45 years, and at least one of the primary and secondary pregnancy outcomes were included. METHODS: Study screening was performed after duplicates were identified and removed. The quality of each study and 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. The inverse variance method was used to integrate the results if studies had an adjusted analysis. RESULTS: Among 4209 studies initially retrieved, 24 were included in this review. All studies were retrospective, observational studies. Pregnant patients aged ≥45 years had a significantly higher cesarean delivery rate (odds ratio, 2.87; 95% confidence interval, 2.50-3.30; I2=97%) than those aged <45 years. However, the emergency cesarean delivery rate was lower in older pregnant patients (odds ratio, 0.61; 95% confidence interval, 0.47-0.79; I2=79%). Pregnancy in older individuals was associated with a lower assisted delivery rate than pregnancy in younger individuals (odds ratio, 0.85; 95% confidence interval, 0.75-0.97; I2=48%). Preeclampsia, gestational diabetes mellitus, placenta previa, placental abruption, postpartum hemorrhage, and preterm birth were more likely to occur in pregnant patients aged ≥45 years than in those aged <45 years. Adjusted pooled analyses showed trends similar to those in the unadjusted pooled analyses. CONCLUSION: Adverse pregnancy outcomes, typically cesarean delivery, were more likely to occur in older (≥45 years) pregnant patients than in younger pregnant patients. However, the assisted delivery rate was lower in older pregnant patients.

Placenta prévia: um estudo baseado nas teorias de enfermagem / Placenta previa: a study based on nursing theories / Placenta previa: un estudio basado en las teorías de enfermería

Introdução: A gestação, apesar de ser um processo fisiológico na saúde da mulher, é uma etapa complexa que exige atenção diferenciada na assistência à saúde. Outrossim, existem algumas condições que provocam danos durante essa fase, como a placenta prévia. Objetivo: Este estudo tem como escopo evidenciar o processo de enfermagem frente à assistência à gestante com tal diagnóstico. Metodologia: A pesquisa tem caráter qualitativo, teórico com subsídio na bibliografia científica, envolvendo a compreensão holística e integral da paciente para a implementação de estratégia para o processo de enfermagem. A partir do estudo das teorias e da fisiopatologia e impactos clínicos, empregou-se as taxonomias do NANDA-I para traçar os diagnósticos de enfermagens mais condizentes. Resultados: Foram identificados 15 diagnósticos que contemplaram os dez domínios encontrados no NANDA. Considerações Finais: Os dados eleitos e o confronto com a literatura enfatizam a relevância positiva na prescrição de diagnósticos de enfermagem na escolha dos cuidados prestados e as teorias subsidiam a assistência materno-fetal.

Introduction: Pregnancy, despite being a physiological process in women's health, is a complex stage that requires special attention in health care. Also, there are some conditions that cause damage during this phase, such as placenta previa. Objective: The purpose of this study is to highlight the nursing process regarding care for pregnant women with such a diagnosis. Methodology: The research is qualitative, theoretical with support in the scientific bibliography, involving the patients holistic and integral understanding for the implementation of a strategy for the nursing process. Based on the study of theories and pathophysiology and clinical impacts, the NANDA-I taxonomies were used to outline the most consistent nursing diagnoses. Results: 15 diagnoses were identified that included the ten domains found in NANDA. Final Considerations: The chosen data and the confrontation with the literature emphasize the positive relevance in the prescription of nursing diagnoses in the choice of care provided and the theories subsidize maternal-fetal assistance.

Introducción: El embarazo, a pesar de ser un proceso fisiológico en la salud de la mujer, es una etapa compleja que requiere especial atención en el cuidado de la salud. Además, existen algunas condiciones que causan daños durante esta fase, como la placenta previa. Objetivo: El propósito de este estudio es resaltar el proceso de enfermería en relación con la atención a las gestantes con dicho diagnóstico. Metodología: La investigación es cualitativa, teórica con apoyo en la bibliografía científica, involucrando la comprensión holística e integral de las pacientes para la implementación de una estrategia para el proceso de enfermería. Con base en el estudio de teorías y fisiopatología e impactos clínicos, se utilizaron las taxonomías NANDA-I para delinear los diagnósticos de enfermería más consistentes. Resultados: Se identificaron 15 diagnósticos que incluían los diez dominios encontrados en la NANDA. Consideraciones finales: Los datos escogidos y la confrontación con la literatura enfatizan la relevancia positiva en la prescripción de los diagnósticos de enfermería en la elección de los cuidados prestados y las teorías subsidian la asistencia materno-fetal.

The effect of abnormal placentation on maternal serum fetal fraction of cell-free DNA.

OBJECTIVES: Abnormal placentation may affect the maternal serum fraction of cell-free fetal DNA (fetal fraction) determined as part of non-invasive prenatal screening (NIPS). This study aimed to assess whether the fetal fraction can predict placenta accreta spectrum (PAS) with or without placenta previa (PP). We also investigated the impact of trophoblastic invasion depth on the fetal fraction. METHODS: This is a retrospective case-control study of pregnant women with and without abnormal placentation carrying a singleton and having undergone NIPS prior to 20 weeks of gestation. The eligible subjects were selected from a cohort managed at our institution for PAS suspected antenatally. We compared women with normal placentation (controls) to PAS, PP, or PAS + PP cases. Data were abstracted from electronic medical records, and PAS was confirmed histologically. RESULTS: Of the 146 patients in our cohort, 8 controls, 10 PP, 6 PAS, and 7 PAS + PP cases were eligible for the study. Among the groups, there were no significant differences in baseline demographic and clinical characteristics except the median number of prior uterine surgeries. Also, the groups did not significantly differ in their median fetal fraction. The fetal fraction did not discriminate any group when stratified according to the depth of placental invasion, i.e., no PAS, abnormally adherent, and abnormally invasive placenta. CONCLUSIONS: The maternal serum fraction of cell-free fetal DNA measured before 20 weeks of gestation is not predictive of PAS with or without concurrent PP or the depth of trophoblastic invasion.

Mode of conception in patients with endometriosis and adverse pregnancy outcomes: a population-based cohort study.

OBJECTIVE: To evaluate the association between endometriosis and adverse pregnancy outcomes. DESIGN: Population-based retrospective cohort study using linked universal health databases through ICES Ontario. PATIENT(S): All singleton pregnancies with an estimated date of confinement between October 2006 and February 2014. INTERVENTION(S): Endometriosis was determined based on a surgical and/or medical diagnosis (defined as an in-hospital admission or surgery with a diagnosis code of International Classification of Diseases [ICD]9-617 or ICD10-N80 and/or 2 medical consults billed as ICD9-617). MAIN OUTCOME MEASURE(S): The association between endometriosis and pregnancy outcomes was quantified by relative risks, derived using modified Poisson regression, and adjusted for maternal age, income quintiles, and history of fibroids (aRR). Mediation analysis was conducted to estimate direct effects of endometriosis diagnosis and indirect effects through mode of conception, namely: infertility without fertility treatment (known infertility but conceived without assistance), ovulation induction or intrauterine insemination, and in vitro fertilization or intracytoplasmic sperm injection, relative to unassisted conception. RESULT(S): A total of 19,099 pregnancies had an antecedent diagnosis of endometriosis, while 768,350 did not. Mean time (standard deviation) from endometriosis diagnosis to the index pregnancy was 5.6 (4.3) years. Endometriosis was associated with an increased risk of hypertensive disorders of pregnancy (aRR, 1.09; 95% confidence interval [CI], 1.02-1.16), preterm birth <37 weeks (aRR, 1.26; 95% CI, 1.20-1.33), early preterm birth <34 weeks (aRR, 1.33; 95% CI, 1.17-1.50), placenta previa (aRR, 2.07; 95% CI, 1.84-2.33), placenta abruption (aRR, 1.55; 95% CI, 1.31-1.83), other placental disorders (aRR, 1.77; 95% CI, 1.36-2.30), cesarean delivery (aRR, 1.18; 95% CI, 1.16-1.21), and stillbirth (aRR, 1.32; 95% CI, 1.09-1.59). Mediation analysis suggests that endometriosis directly affects most adverse pregnancy outcomes studied, except for stillbirth where infertility diagnosis or fertility treatment indirectly accounted for part of the increased risk. CONCLUSION(S): Endometriosis was associated with adverse pregnancy, independent of infertility diagnosis, or fertility treatment. Future studies should investigate the mechanisms of action and potential interventions.

A unique placenta previa risk factor profile for pregnancies conceived with assisted reproductive technology.

OBJECTIVE: To define specific risk factors for placenta previa in pregnancies conceived with assisted reproductive technology (ART). DESIGN: Retrospective cohort. SETTING: Fertility centers and inpatient obstetric units in Massachusetts. PATIENT(S): Patients conceiving with ART and delivering at 20 weeks gestation or later between 2011 and 2017 in Massachusetts. INTERVENTION(S): Patient demographic and medical factors and specific components of their cycles. Data were obtained by linking vital records of the State of Massachusetts to reproductive clinic data obtained from the Society for Assisted Reproductive Technology Clinic Outcome Reporting System, and then supplementing this information with laboratory and obstetric data from 2 large academic hospitals. MAIN OUTCOME MEASURE: Associations were tested between multiple cycle- and patient-related factors and placenta previa or low-lying placenta at delivery. After testing for confounders, multivariate models were adjusted for maternal age, history of prior cesarean delivery and birth plurality, and are reported as adjusted relative risks (aRR). RESULT(S): We included 18,939 pregnancies, with 553 (2.9%) having placenta previa at delivery. Advanced maternal age (aRR, 1.25; 95% confidence interval [CI], 1.06-1.48), endometriosis, (aRR, 2.22; 95% CI, 1.71-2.86), and controlled ovarian hyperstimulation (aRR, 1.33; 95% CI, 1.12-1.59) were associated with placenta previa, whereas multiple births (aRR, 0.63; 95% CI, 0.48-0.81) and a history of polycystic ovary syndrome or ovulation disorders (aRR, 0.59; 95% CI, 0.46-0.75) had negative associations. The endometriosis association was strong in nulliparas and the controlled ovarian hyperstimulation association was strong in parous patients in a stratified analysis. No association was seen with prior history of cesarean delivery. CONCLUSION(S): Patients conceiving with ART do not have the typical previa risk factors of prior cesarean delivery and multiple gestations, whereas endometriosis and fresh embryo transfers contributed moderate risk. The embryo transfer process itself may affect previa development in this population.

Radiomics analysis of T2 -weighted images for differentiating invasive placentas in women at high risks.

PURPOSE: To develop and validate an MRI-based radiomics model for differentiating invasive placentas in patients with high risks. METHODS: A total of 181 pregnant women suspected of placenta accreta spectrum (PAS) disorders and who underwent MRI for placenta evaluation were retrospectively enrolled. The data set was randomly divided into the training (n = 125; invasive = 63, noninvasive = 62) and test (n = 56; invasive = 28, noninvasive = 28) groups. Radiomics features were extracted from half-Fourier acquisition single-shot turbo spin echo (HASTE) and sagittal true fast imaging in steady-state precession (TRUFISP) sequences independently and mainly selected based on their correlations with invasive placentas to construct two radiomics signatures including HASTE-Radscore and TRUFISP-Radscore. Then, the predictive performance of radiomic signatures, clinical features, radiographic features, and their combination were evaluated. The model with the best predictive performance was validated with its discrimination ability, calibration, and clinical usefulness. RESULTS: Five radiomics features from HASTE and three radiomics features from TRUFISP were retained, respectively, for predicting invasive placentas. The combination of radiomics signatures and clinical features including prior cesarean delivery, placenta previa, and radiographic feature, the placental thickness resulted in the best discrimination ability, with area under the curve of 0.898 (95% confidence interval [CI] 0.844-0.9522) and 0.858 (95% confidence interval 0.7514-0.9655) in the training and test cohort, respectively. The combined model showed a significantly better area under the curve performance and clinical usefulness than independent clinical or radiographic model according to DeLong test (p < .05), net reclassification improvement and integrated discrimination improvement analysis (positive improvement) and decision curve analysis (higher net benefit). CONCLUSIONS: The T2 -weighted imaging MRI radiomics model could serve as a potential prenatal diagnosis tool for identifying invasive placentas in patients with high risks.

Potential resolution of placenta previa from the 28th-to the 36th-week of pregnancy: A retrospective longitudinal cohort study.

INTRODUCTION: Placenta previa greatly contributes to severe antenatal and post-partum hemorrhage. Previous studies have mainly focused on the risk factors of placenta previa, with very few studies reporting which factors may affect the potential resolution of 28th-week previa. This study aimed to investigate the impact of maternal characteristics on potential resolution of placenta previa from the 28th-to the 36th-week of pregnancy. METHODS: A retrospective longitudinal sub-cohort investigation was carried out among 368 pregnant women with 28th-week previa from the Longitudinal Placenta Previa Study (LoPPS). Logistic regression analysis was used to discover the connections between maternal covariates and the placental potential resolution. Multivariable linear regression analysis was used to detect the associations between perioperative characteristics and volume of intraoperative bleeding. RESULTS: Among pregnant women whose placenta completely or partially covered the internal os at the 28th-week of pregnancy, 37.5% were without placenta previa at the 36th-week and 25.8% converted into marginal placenta previa. There were significant correlation between placenta previa type and GHD (Beta: 2.808, 95% CI: 1.642, 7.138; p = 0.041), type of 28th-week previa (Beta: 6.767, 95% CI: 1.592, 18.767; p < 0.001), and number of prior cesarean sections (Beta: 3.326, 95% CI: 1.580, 9.081; p < 0.001). DISCUSSION: 62.5% of the pregnant women with 28th-week placenta previa were still with previa at the 36 weeks of gestation (25.8% with marginal and 36.7% with partial/complete placenta previa). This proportion is even higher for 28th-week complete placenta previa. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2100054068, December 8, 2021.

The role of fetal fibronectin and plasminogen activator inhibitor 1 biomarkers in antenatal prediction of placenta accreta spectrum.

In this study, we aimed to assess the determining role of foetal fibronectin (FFN) and plasminogen activator inhibitor type (PAI-1) levels in the antenatal prediction of placenta accreta spectrum in cases with risk factors for placenta accreta spectrum. Singleton live pregnancies with placenta previa or low-lying placenta within 32-34 weeks of gestation were included in the study. The cases were divided into two groups after delivery as those with PAS and those with normal placentation. 54 cases diagnosed with placenta previa or low-lying placenta were included in the study. 17 of the cases underwent peripartum hysterectomy due to placenta accreta spectrum. 37 cases with normal placentation underwent caesarean delivery. Foetal fibronectin (p:.03) and PAI-1 (p:.02) levels were determined to be significantly different between cases with placenta accreta spectrum and cases with normal placentation. AUC for foetal FFN was calculated to be 0.69, while the AUC for, PAI-1was 0.66. Results for both FFN and PAI-1 were not found useful enough for the diagnosis of PAS. IMPACT STATEMENTWhat is already known on this subject? We lack biomarkers which can identify placenta accreta spectrum.What do the results of this study add? Maternal plasma levels of FFN and PAI-1 significantly altered in PASWhat are the implications of these findings for clinical practice and/or future research? If multiple of median values of FFN and PAI-1 levels in maternal blood are determined in future studies, it can be used in the antenatal diagnosis of PAS cases.