Routine Ultrasound at 30th-33rd weeks versus 30th-33rd and 35th-37th weeks in Low-Risk Pregnancies: A Randomized Trial.

INTRODUCTION: The aim of this study was to evaluate the accuracy of 35-37 weeks' ultrasound for fetal growth restriction (FGR) detection and the impact of 30th-33rd weeks versus 30th-33rd and 35th-37th weeks' ultrasound on perinatal outcomes. METHODS: This was a randomized controlled trial that enrolled 1,061 low-risk pregnant women: 513 in the control group (routine ultrasound performed at 30th-33rd weeks) and 548 in the study group (with an additional ultrasound at 35th-37th weeks). FGR was defined as a fetus with an estimated fetal weight (EFW) below the 10th percentile. p values < 0.05 were considered statistically significant. RESULTS: The ultrasound at 35-37 weeks had an overall accuracy of FGR screening of 94%. Spearman's correlation coefficient between EFW and birthweight centile was higher for at 35-37 weeks' ultrasound (ρ = 0.75) compared with 30-33 weeks' ultrasound (ρ = 0.44). The study group had a lower rate of operative vaginal deliveries (24.4% vs. 39.3%, p = 0.005) and cesarean deliveries for nonreassuring fetal status (16.8% vs. 38.8%, p < 0.001). DISCUSSION/CONCLUSION: A later ultrasound (35-37 weeks) had a high accuracy for detection of FGR and had a higher correlation between EFW and birthweight centiles. Furthermore, it was also associated with lower adverse perinatal outcomes compared to an earlier ultrasound.

Placenta Accreta Overlying a Caesarean Section Scar: A 10-Year Experience in a Tertiary-Care Centre in Portugal.

INTRODUCTION: Placenta accreta spectrum disorders are among the leading causes of maternal morbidity and mortality and their prevalence is likely to increase in the future. The risk of placenta accreta spectrum disorders is highest in cases of placenta previa overlying a previous cesarean section scar. Few studies have evaluated placenta accreta spectrum disorders in Portugal. The aim of this study was to review the cases of placenta accreta spectrum overlying a cesarean section scar managed in a Portuguese tertiary center over the last decade. MATERIAL AND METHODS: Retrospective, cross-sectional study, with data collected from hospital databases. Only cases with histopathological confirmation of placenta accreta spectrum were included. RESULTS: During the study period, 15 cases of placenta accreta spectrum overlying a cesarean section scar were diagnosed (prevalence 0.6/1000). All cases were diagnosed antenatally. A transverse cesarean section was present in all cases; 13 were managed by a scheduled multidisciplinary approach, while two required emergent management. Total or subtotal hysterectomy was performed in 12 cases. There were no cases of maternal or neonatal death. Histopathological evaluation confirmed nine cases of placenta accreta, three cases of placenta increta and three cases of placenta percreta. DISCUSSION: Early antenatal diagnosis is important for a programmed multidisciplinary management of these cases, which may reduce potential morbidity and mortality and ensure better obstetric outcomes. CONCLUSION: This case series of placenta accreta spectrum overlying a cesarean section scar reports the reality of a tertiary-care perinatal center in Portugal, in which no maternal or neonatal mortality due to placenta accreta spectrum was registered over the last decade; this may be attributed to prenatal diagnosis and a coordinated multidisciplinary team approach.

Introdução: O acretismo placentário está entre as principais causas de morbilidade e mortalidade materna, sendo provável que a sua prevalência venha a aumentar. O risco é máximo em casos de placenta prévia sobre cicatriz de cesariana. Existem poucos estudos sobre esta realidade em Portugal. O objetivo deste estudo foi rever os casos de acretismo placentário sobre cicatriz de cesariana prévia, ocorridos ao longo da última década num centro terciário português. Material e Métodos: Estudo retrospetivo, transversal, com dados recolhidos de bases de dados hospitalares; foram incluídos apenas casos com confirmação histopatológica de acretismo placentário. Resultados: Foram diagnosticados 15 casos durante o período do estudo (prevalência 0,6 / 1000). Todos os casos foram diagnosticados durante a gravidez. Em todos os casos foi realizada cesariana; 13 foram agendadas com base numa abordagem multidisciplinar, e duas foram emergentes. Em 12 casos foi realizada histerectomia total ou subtotal. Não se registaram casos de mortalidade materna ou neonatal. O estudo histopatológico confirmou nove casos de placenta acreta, três de placenta increta e três de placenta percreta. Discussão: O diagnóstico pré-natal precoce é fundamental para um planeamento multidisciplinar que permita reduzir a potencial morbilidade e mortalidade e garantir melhores desfechos obstétricos. Conclusão: Esta série de casos de acretismo placentário sobre cicatriz de cesariana relata a realidade de um centro de assistência perinatal terciário em Portugal, no qual não se registou mortalidade materna ou neonatal ao longo da última década; esta situação é atribuível ao diagnóstico pré-natal eficiente e à abordagem coordenada por uma equipa multidisciplinar.

Ability of women to self-classify into the Robson ten-group classification system.

OBJECTIVE: Recent guidelines from WHO and the International Federation of Gynecology and Obstetrics (FIGO) state that the Robson ten-group classification system (TGCS) should be universally applied to pregnant women. Such information might enable women to make an informed decision about the place and mode of delivery. We assessed whether women could self-classify correctly according to the TGCS. METHODS: A prospective study was conducted in a tertiary level maternity hospital between March 6 and July 31, 2017. We included post-partum women admitted to the puerperium ward. Participants were instructed to complete a multiple-choice questionnaire with a simplified description of TGCS and to classify themselves into one of the ten groups. A practitioner reclassified women into the correct TGCS group. Cohen κ was applied to measure the rate of agreement between these two evaluations. RESULTS: 400 women were enrolled, with a global rate of agreement of 81.8% between women's self-evaluation and the evaluation by the practitioner. A subanalysis showed that the highest rate of agreement was among the group with higher level education (84.0%). CONCLUSION: Women of different ages and education backgrounds were able to correctly classify themselves into the TGCS. The higher the educational level, the greater the rate of agreement.

International survey of practices used in the diagnosis and management of placenta accreta spectrum disorders.

OBJECTIVE: To identify geographic differences in diagnostic and treatment practices during the perinatal management of placenta accreta spectrum (PAS) disorders. METHODS: An online survey was conducted from May 1 to August 1, 2017. The 18-item questionnaire was emailed to all members of the expert panel for the 2018 International Federation of Gynecology and Obstetrics consensus guidelines on PAS (n=34), as well as international experts who had contributed to the content of these guidelines (n=16). RESULTS: Questionnaires were returned by 36 of the 50 experts (72% response rate). Most respondents were from Europe (n=22; 61%) or Asia (n=9; 25%). Despite large disparity in the number of patients with PAS disorders managed surgically or conservatively (range from 0 to >1000) and the different techniques used by the respondents, the screening and diagnostic methods used were similar, with transvaginal imaging used by 31 (86%) experts, and both ultrasonography and magnetic resonance imaging used by 22 (61%). In all, 22 (61%) experts indicated a preference for radical surgery, with primary cesarean hysterectomy leaving the placenta in situ reported as the most frequent approach (n=20; 55%). CONCLUSION: Wide variation found in global PAS practices indicated a need for standardized data and an evidence-based approach to the diagnosis and management of PAS disorders.