Risk of Subsequent Hysterectomy after Expectant Management in the Treatment of Placenta Accreta Spectrum Disorders.

Management strategies for pregnancies with abnormal adherence/invasion of the placenta (placenta accreta spectrum, PAS) vary between centers. Expectant management (EM), defined as leaving the placenta in situ after the delivery of the baby, until its complete decomposition and elimination, has become a potential option for PAS disorders in selected cases, in which the risk of Caesarean hysterectomy is very high. However, expectant management has its own risks and complications. The aim of this study was to describe the rates of subsequent hysterectomy (HT) in patients that underwent EM for the treatment of PAS disorders. We reviewed the literature on the subject and found 12 studies reporting cases of HT after initial intended EM. The studies included 1918 pregnant women diagnosed with PAS, of whom 518 (27.1%) underwent EM. Out of these, 121 (33.2%) required subsequent HT in the 12 months following delivery. The rates of HT after initial EM were very different between the studies, ranging from 0 to 85.7%, reflecting the different characteristics of the patients and different institutional management protocols. Prospective multicenter studies, in which the inclusion criteria and management strategies would be uniform, are needed to better understand the role EM might play in the treatment of PAS disorders.

"You only live twice": multidisciplinary management of catastrophic case in placenta Accreta Spectrum-a case report.

BACKGROUND: Placenta percreta is associated with high hemorrhagic risk and can be complicated with fatal thromboembolic events. Involving a multidisciplinary team in the treatment of these patients is mandatory to reduce morbidity and mortality. CASE PRESENTATION: This paper reports the case of a 22-year-old patient with placenta percreta who was referred to our tertiary care center for delivery. Few hours after undergoing a successful cesarean hysterectomy, the patient developed a pulmonary embolism and cardiac arrest. A transthoracic echocardiogram done in the intensive care unit (ICU) showed a thrombus in the right ventricle. After cardiac resuscitation, the patient underwent an urgent thoracotomy and a pulmonary artery thrombectomy; many clots were retrieved from the pulmonary artery. After weaning from extracorporeal circulation, an intraoperative transesophageal cardiac ultrasound enabled the medical team to detect a new free-floating thrombus in the right atrium and right ventricle, and consequently to perform an embolectomy and prevent the patient's death. CONCLUSION: This case emphasizes the role of multidisciplinary team in treating high-risk obstetric cases that could be complicated with massive and fatal thromboembolic events. The use of intraoperative transthoracic echocardiography helps in detecting a new thrombus and guides the anesthesiologist in the intra-operative monitoring.

The role of ultrasound in prediction of intra-operative blood loss in cases of placenta accreta spectrum disorders.

PURPOSE: To assess the value of various grey-scale ultrasound, 2D color Doppler, and 3D power Doppler sonographic markers in predicting major intraoperative blood loss during planned cesarean hysterectomy for cases diagnosed with placenta accreta spectrum (PAS) disorders. METHODS: 50 women diagnosed with PAS were scanned the day before planned delivery and hysterectomy for various sonographic markers indicative of placental invasion. These women were then later divided according to blood loss in two groups: group A (minor hemorrhage, < 2500 ml), and group B (major hemorrhage, > 2500 ml), and the data were analyzed. RESULTS: The odds ratio (OR) for major hemorrhage was as follows for the following sonographic markers: 'number of lacunae > 4' OR 3.8 95% CI (1.0-13.8) (p = 0.047); 'subplacental hypervascularity' OR 10.8 95% CI (1.2-98.0) (p = 0.035); 'tortuous vascularity with 'chaotic branching' OR 10.8 95%CI (1.2-98.0) (p = 0.035); 'numerous coherent vessels involving the serosa-bladder interface OR 14.6 95% CI (2.7-80.5) (p = 0.002); and 'presence of bridging vessels OR 2.9 95% CI (1.4-6.9) (p = 0.005). Only the presence of numerous coherent vessels involving the bladder-serosal interface (p = 0.002) was proven to be independent predictor of major hemorrhage during hysterectomy. CONCLUSION: The use of 2D color Doppler and 3D power Doppler can help predict massive hemorrhage in cases of PAS disorders.

MRI prognosticators for adverse maternal and neonatal clinical outcome in patients at high risk for placenta accreta spectrum (PAS) disorders.

BACKGROUND: Placenta accreta spectrum (PAS) disorders may be associated with significant mortality and morbidity for both mother and fetus. PURPOSE/HYPOTHESIS: To identify MRI risk factors for poor peripartum outcome in gravid patients at risk for PAS. STUDY TYPE: Prospective. POPULATION: One hundred gravid women (mean age: 34.9 years) at third trimester, with placenta previa. FIELD STRENGTH/SEQUENCE: T2 -SSTSE (single-shot turbo spin echo), T2 -TSE, T1 -TSEFS (TSE images with fat-suppression) at 1.5T. ASSESSMENT: Fifteen MRI features considered indicative of PAS were recorded by three radiologists and were tested for any association with the following adverse peripartum maternal and neonatal events: increased operation time, profound blood loss, hysterectomy, bladder repair, ICU admission, prematurity, low birthweight, and 5-minute APGAR score <7. STATISTICAL TESTS: Kappa (K) coefficients were computed as a measure of agreement between intraoperative information/histology and MRI results as well as for interobserver agreement; chi-square and Fisher's exact tests were used to explore the association of the MRI signs with clinical complications. A score was calculated by adding all recorded MRI signs and its predictive ability was tested using receiver operating characteristic (ROC) analysis, against all complications, separately; odds ratios (ORs) for optimal cutoffs were determined with logistic regression analysis. RESULTS: There was excellent agreement (K >0.75, P < 0.001) between MRI and intraoperative findings for invasive placenta, bladder and parametrial involvement. Intraplacental T2 dark bands, myometrial disruption, uterine bulge, and hypervascularity at the utero-placental interface or parametrium, showed significant association (P < 0.005) with poor clinical outcome for both mother and fetus. The MRI score showed significant predictive ability for each adverse maternal event (area under the curve [AUC]: 0.85-0.97, P < 0.001). The presence of ≥3 MRI signs was the cutoff point for a complicated delivery (OR: 19.08, 95% confidence interval [CI]: 6.05-60.13) and ≥6 MRI signs was the cutoff point for massive bleeding (OR: 90.93, 95% CI: 11.3-729.23), hysterectomy (OR: 72.5, 95% CI: 17.9-293.7), or extensive bladder repair (OR: 58.74, 95% CI: 7.35-469.32). The MRI score was not significant for predicting adverse neonatal events including preterm delivery (P = 0.558), low birthweight (P = 0.097), and 5-minute Apgar score (P = 0.078). DATA CONCLUSION: Preoperative identification of specific MRI features may predict peripartum course in high-risk patients for PAS. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2019;50:602-618.

Modified cesarean hysterectomy technique for management of cases of placenta increta and percreta at a tertiary referral hospital in Egypt.

PURPOSE: To evaluate the effect of a modified type II radical hysterectomy on maternal morbidities and mortality in cases with abnormally invasive placenta (AIP). METHODS: 63 cases with AIP were managed at one of the largest referral centers in Egypt in a prospective study design. This technique entails devascularization of the uterus laterally on both sides and to clamp the uterus at the lowest possible point just below the level of the placenta while sparing the ureters. RESULTS: The difference between pre- and post-operative hemoglobin was only about 1 gm/dl, and the mean blood loss was 1673 ± 958 ml. There was a significant drop in the post-operative need for blood and blood product replacement, packed red blood cells (p = 0.013), fresh red blood cells (p < 0.001), and plasma units (p = 0.012). Operative time (skin to skin) averaged 190 ± 58.2 min as the technique is slow and utilizes meticulous hemostatic steps. ICU admission was 4.8% with a mean total hospital stay of 8.6 ± 3.6 days. Histopathological examination revealed 58 cases of placenta increta and five percreta cases. We also had 16 bladder injuries (25.4%) and two ureteric injuries, and no maternal mortalities. CONCLUSION: This technique reduces maternal morbidity and mortality while performing cesarean hysterectomy for cases with AIP.

MRI Assessed Placental Location as a Diagnostic Tool of Placental Invasiveness and Maternal Peripartum Morbidity.

Placenta accreta spectrum (PAS) disorder is one of the leading causes of peripartum maternal morbidity and mortality; its early identification during pregnancy is of utmost importance to ensure the optimal clinical outcome. The aim of the present study is to investigate the possible association of the presence and type/location of placenta previa on MRI with PAS and maternal peripartum outcome. One hundred eighty-nine pregnant women (mean age: 35 years; mean gestational age: 32 weeks) at high risk for PAS underwent a dedicated placental MRI. All women underwent a C-section within 6 weeks from the MRI. All MRIs were evaluated by two experienced genitourinary radiologists for presence, type (complete/partial vs. marginal/low lying), and location (anterior vs. anterior-posterior vs. posterior) of placenta previa. Statistical analysis was performed for possible association of type/location of previa with placental invasiveness and peripartum outcomes. Intraoperative information was used as a reference standard. Complete/partial previa was detected in 143/189 (75.6%) and marginal/low lying previa in 33/189 (17.5%) women; in 88/189 (46.6%) women, the placenta had anterior-posterior, in 54/189 (28.6%) anterior and in 41/189 (21.7%) posterior. Complete/partial previa had an at least 3-fold probability of invasiveness and was more frequently associated with unfavorable peripartum events, including massive intraoperative blood loss or hysterectomy, compared to low-lying/marginal placenta. Posterior placental location was significantly associated with lower rates of PAS and better clinical outcomes. In conclusion, the type and location of placenta previa shown with MRI seems to be associated with severity of complications during delivery and should be carefully studied.

The predictive value of conventional magnetic resonance imaging combined with intravoxel incoherent motion parameters for evaluating maternal and neonatal clinical outcomes in patients with placenta accreta spectrum disorders.

INTRODUCTION: We aimed to identify factors predictive of adverse maternal and neonatal outcomes in patients with placenta accreta spectrum (PAS) disorders using magnetic resonance imaging (MRI) and intravoxel incoherent motion (IVIM) parameters. METHOD: Fifty-six normal singleton pregnancies at 33-39 weeks of gestation underwent MRI examination at 1.5 T. The IVIM parameters were obtained from the placenta. The correlation between the f value and postpartum hemorrhage (PPH) and between the f value and transfused units of red blood cells (RBCs) was estimated by linear regression. The correlation between various influencing factors (clinical risk factors, MRI features, and IVIM parameters) and poor outcomes was investigated using univariate and multivariate analyses. RESULT: The interobserver agreement ranged from fair to excellent (k = 0.30-0.88). Multivariate analyses showed that previous cesarean sections, low signal intensity bands on T2WI and the D value were independent risk factors for adverse outcomes. The combination of three risk factors demonstrated the highest AUC of 0.903, with a sensitivity and specificity of 73.10 % and 96.90 %, respectively. Last, f was positively correlated with PPH and units of RBCs transfused. DISCUSSION: Preoperative MRI features and IVIM parameters may be used to predict poor outcomes in patients with invasive placental disorders like PAS.

A quantitative analysis framework of placenta accreta spectrum: placenta subtype, intraoperative bleeding, and hysterectomy risk evaluation based on magnetic resonance imaging-anatomical-clinical features.

Background: Placenta accreta spectrum (PAS) is a significant contributor to maternal morbidity and mortality. Our objective was to develop a quantitative analysis framework utilizing magnetic resonance imaging (MRI)-anatomical-clinical features to predict 3 clinically significant parameters in patients with PAS: placenta subtype (invasive vs. non-invasive placenta), intraoperative bleeding (≥1,500 vs. <1,500 mL), and hysterectomy risk (hysterectomy vs. non-hysterectomy). Methods: A total of 125 pregnant women with PAS from 2 medical centers were enrolled into an internal training set and an external testing set. Some 21 MRI-anatomical-clinical features were integrated as input into the framework. The proposed quantitative analytic framework contains mainly 3 classifiers built by extreme gradient boosting (XGBoost) and their testing in external datasets. We also further compared the accuracy of placenta subtype prediction between the proposed model and 4 radiologists. A quantitative model interpretation method called SHapley Additive exPlanations (SHAP) was conducted to explore the contribution of each feature. Results: The placenta subtype (invasive vs. non-invasive), intraoperative bleeding (≥1,500 vs. <1,500 mL), and hysterectomy risk (hysterectomy vs. non-hysterectomy) demonstrated impressive area under the receiver operating characteristic curve (AUROC) values of 0.93, 0.88, and 0.90, respectively, in the internal validation set. Even in the external testing set, these metrics maintained their strength, achieving AUROC values of 0.91, 0.82, and 0.82, respectively. Comparing our proposed framework to the 4 radiologists, our model exhibited superior accuracy, specificity, and sensitivity in predicting placental subtypes within the external testing cohort. The features associated with intraplacental dark T2 bands played a crucial role in the decision-making process of all 3 prediction models. Conclusions: The quantitative analysis framework can provide a robust method for classification of placenta subtype (invasive vs. non-invasive placenta), intraoperative bleeding (≥1,500 vs. <1,500 mL), and hysterectomy risk (hysterectomy vs. non-hysterectomy) based on MRI-anatomical-clinical features in PAS.

Placenta Accreta Spectrum and Hysterectomy Prediction Using MRI Radiomic Features.

In women with placenta accreta spectrum (PAS), patient management may involve cesarean hysterectomy at delivery. Magnetic resonance imaging (MRI) has been used for further evaluation of PAS and surgical planning. This work tackles two prediction problems: predicting presence of PAS and predicting hysterectomy using MR images of pregnant patients. First, we extracted approximately 2,500 radiomic features from MR images with two regions of interest: the placenta and the uterus. In addition to analyzing two regions of interest, we dilated the placenta and uterus masks by 5, 10, 15, and 20 mm to gain insights from the myometrium, where the uterus and placenta overlap in the case of PAS. This study cohort includes 241 pregnant women. Of these women, 89 underwent hysterectomy while 152 did not; 141 with suspected PAS, and 100 without suspected PAS. We obtained an accuracy of 0.88 for predicting hysterectomy and an accuracy of 0.92 for classifying suspected PAS. The radiomic analysis tool is further validated, it can be useful for aiding clinicians in decision making on the care of pregnant women.

Effects and Long-Term Outcomes of a Modified Triple-P Procedure in Patients With Severe PAS: A Retrospective Cohort Study.

Background: The distinguished Triple-P procedure has been reported as a conservative surgical alternative to peripartum hysterectomy for placental accreta spectrum (PAS). In this study, we modified the procedure combined with prophylactic abdominal aorta balloon occlusion and/or tourniquet and evaluated the effect and long-term outcomes. Methods: This was a retrospective study involving pregnant patients with clinically confirmed severe PAS (including placenta increta and percreta) between January 1st, 2017 and June 30th, 2020 in the First Affiliated Hospital of Zhengzhou University. A total of 334 pregnant women were recruited in this study. The 142 women that were subjected to modified Triple P Procedure were regarded as the observation group while 194 pregnant women that were treated with other sutures were regarded as the control group. Demographic characteristics, placental accreta spectrum score (PAS score), estimated blood loss (EBL), operative time, blood transfusion rate and volume, neonatal weight, post-operative hospital stays and costs were evaluated. Short-term complications, including fever, hematoma, thrombus, bladder rupture and intensive care unit (ICU) transfer rate, as well as long-term outcomes including breast feeding, menstruation, intrauterine adhesion, and chronic abdominal pain among others were followed up in the outpatient clinic and by phone calls. Results: For all cases, EBL was lower in the observation group than in the control group, 1,200 (687-1,812) ml and 1,300 (800-2,500) ml, respectively. The difference was statistically significant (P < 0.05). Operative time were statistically significantly shorter in the observation group [99.5 (84.0-120.0) min and 109.0 (83.8-143.0) min, P < 0.05]. Lengths of postoperative hospital stays were 4 (4-7) and 5 (4-7) days in the observation and control group, which was significantly shorter in the observation group (P < 0.05). There were no significant differences in PAS scores, blood transfusion volume, neonatal weight, fever, hematoma, thrombus, bladder rupture and ICU transfer rates between the two groups. All patients, except one in control group, had preserved uterus. There were no statistically significant differences in short-term and long-term complications between two groups. Conclusion: In summary, when combined with tourniquet and/or prophylactic abdominal aorta balloon occlusion, modified Triple-P procedure may be effective in reducing intraoperative blood loss and hysterectomy in patients with placenta increta/percreta. It is a safe and effective surgical alternative to peripartum hysterectomy. However, the complications associated with interventional radiology service should be evaluated furthermore.

Placenta Accreta Spectrum Disorders and Radiomics: Systematic review and quality appraisal.

PURPOSE: Ultrasound and magnetic resonance imaging are the imaging modalities of choice for placenta accrete spectrum (PAS) disorders assessment. Radiomics could further increase the value of medical images and allow to overcome the limitations linked to their visual assessment. Aim of this systematic review was to identify and appraise the methodological quality of radiomics studies focused PAS disorders applications. METHOD: Three online databases (PubMed, Scopus and Web of Science) were searched to identify original research articles on human subjects published in English. For the qualitative synthesis of results, data regarding study design (e.g., retrospective or prospective), purpose, patient population (e.g., sample size), imaging modalities and radiomics pipelines (e.g., segmentation and feature extraction strategy) were collected. The appraisal of methodological quality was performed using the Radiomics Quality Score (RQS). RESULTS: 10 articles were finally included and analyzed. All were retrospective and MRI-powered. The majority included more than 100 patients (6/10). Four were prognostic (focused on either the prediction of bleeding volume or the prediction of needed management) while six diagnostic (PAS vs not PAS classification) studies. The median RQS was 8, with maximum and minimum respectively equal to 17/36 and - 6/36. Major methodological concerns were the lack of feature stability to multiple segmentation testing and poor data openness. CONCLUSIONS: Radiomics studies focused on PAS disorders showed a heterogeneous methodological quality, overall lower than desirable. Furthermore, many relevant research questions remain unexplored. More robust investigations are needed to foster advancements in the field and possibly clinical translation.

Comparison of One-Stage and Two-Stage Intraoperative Uterine Artery Embolization during Cesarean Delivery for Placenta Accreta: Report of Two Clinical Cases at a Tertiary Referral Medical Center.

Placenta accreta spectrum (PAS) described the anchoring placental villi attached or penetrating into/through the myometrium. PAS is clinically important because of the unpredictable bleeding amount when manually removing the defective decidualization at the endometrial-myometrial interface. Therefore, a multidisciplinary strategy for cesarean delivery with PAS is crucial. Postoperative embolization after cesarean hysterectomy in a hybrid suite was studied by many scientists. In this study, we demonstrated two cases of intraoperative embolization without hysterectomy in a hybrid operating room for cesarean delivery with placenta accreta. Our results show that intraoperative uterine artery embolization with a hybrid suite is a time-preserving and safe method for cesarean delivery with PAS owing to avoiding the risk of morbidity and mortality during patient transfer.

Expectant management of cesarean scar pregnancy in 13 patients.

OBJECTIVE: To monitor Cesarean scar pregnancy (CSP) patients preferring to continue their pregnancy and analyze their clinical characteristics as well as maternal and fetal outcomes. METHODS: A retrospective cohort study including 13 pregnant women diagnosed with CSP (including types I, II, III) and continued their pregnancy with cautious monitoring at Peking University First Hospital between January, 2014 and December, 2018. RESULTS: 8/13 (61.5%) of them delivered after 28 weeks and finally gave birth to healthy babies with 3 term births and 5 preterm births (one of them which suspected placenta percreta received hysterectomy for massive bleeding and hemorrhagic shock at 34 weeks). 2/13 (15.4%) of them terminated their pregnancy at second trimester by Cesarean section for ultrasonic manifestation of placenta percreta with or without threatened uterine rupture. 1/13 (7.7%) of them went through induced labor due to inevitable abortion and needed dilatation and evacuation afterwards at 20 weeks. 2/13 (15.4%) of those patients with twin pregnancy chose fetal reduction to keep the non-CSP fetus at 8 weeks and 11 weeks. No maternal or fetal death was observed. CONCLUSIONS: During expectant management, type I CSP patients were at little risk for developing into placenta percreta and rather save for continue pregnancy to having babies. Type II and type III CSP patients usually ended up with placenta percreta and better terminated their pregnancy immediately.

Retained Placenta Percreta with Acquired Uterine Arteriovenous Malformation-Case Report and Short Review of the Literature.

Placenta accreta spectrum disorder (PAS) has an increased frequency due to the high number of cesarean sections. The abnormal placentation associated with a retained placenta can cause persistent uterine bleeding, with ultrasound Doppler examination being the main choice to assess the uterine hemorrhage. An acquired uterine arteriovenous malformation (AVM) may occur because of uterine trauma, spontaneous abortion, dilation and curettage, endometrial carcinoma or gestational trophoblastic disease. The treatment for abnormal placentation associated with AVM can be conservative, represented by methotrexate therapy, arterial embolization, uterine curettage, hysteroscopic loop resection or radical, which takes into consideration total hysterectomy. Therapeutic management always considers the degree of placental invasion, the patient hemodynamic state and fertility preservation. Considering the aspects described, we present a case of retained placenta percreta associated with acquired uterine AVM, with imagistic and clinical features suggestive of a gestational trophoblastic disease, successfully treated by hysterectomy, along with a small review of the literature, as only a few publications have reported a similar association of diagnostics and therapy.

Triple P with T-shaped lower segment suture; an effective novel alternative to hysterectomy in morbidly adherent anterior placenta previa.

PURPOSE: To evaluate the efficacy and safety of the Triple-P procedure as a conservative method in women with morbidly adherent placenta (MAP). MATERIALS AND METHODS: A prospective trial conducted on 20 women performing elective cesarean sections (CS) at 37 weeks for anterior placenta previa accreta or increta. All women were young aged with low parity and previous CS deliveries. Triple-P procedure involved delivery of the fetus through a uterine incision placed above the upper border of the placenta, bilateral uterine arteries ligation immediately after delivery of the fetus followed by placental nonseparation and myometrial excision with reconstruction of the uterine wall in a T-shaped manner. The study outcome measures included duration of surgery, amount of intra and postoperative blood loss, Percentage of hemoglobin (Hb %) reduction, the need to perform hysterectomy and postoperative complications. RESULTS: Mean duration of surgery was 58 ± 1.8 min, mean intraoperative blood loss was 1.3 ± 0.3 l, mean postoperative blood loss was 180 ± 94 ml and mean Hb % reduction was 1.5 ± 0.1 g/dl. Only one case necessitated hysterectomy for severe bleeding. CONCLUSION: Triple-P procedure is a novel effective weapon that can replace hysterectomy in suitable women with MAP, especially in young patients with low parity.

Comparison of Ultrasound Descriptors of Abnormally Invasive Placenta (AIP) over the Course of the Second and Third Trimester-Is an Increase Verifiable?

Limited data exist regarding the course of abnormally invasive placentation (AIP) (=placenta accreta spectrum (PAS)) during the 2nd and 3rd trimester, although this knowledge would be important for optimal patient care. In this retrospective single-center longitudinal cohort study, potential aggravation of AIP was evaluated in 37 patients with ultrasound (US) pictures stored on a minimum of two visits. Five raters, blinded to diagnosis and gestational age, judged the degree of AIP as recommended by the International Society for PAS. The probability of invasiveness was estimated as absent, low, intermediate, severe (0-3 points), the extent as absent, focal, diffuse (0-2 points), and the presence and appearance of each US-sign as absent, mild, severe (0-3 points). None of the 10 judged signs appeared more severe (p ≥ 0.41) with progressing pregnancy. Neither the number of positively scored US-signs (earlier scan; 6.14 ± 2.06, later scan; 5.94 ± 2.16; p = 0.28), nor the estimated probability & extent of AIP rose (3.69 ± 1.15 vs. 3.67 ± 1.22; p = 1.0). Test-retest reliability corroborated excellent agreement between visits (mean number of positive US-signs ICC (3,1) = 0.94, 95% CI 0.91-0.97; p < 0.0001). Overall, there was no clinically detectable increase in invasiveness over the course of the 2nd and 3rd trimester. This should be further evaluated in prospective studies.

The Risk of Postpartum Hemorrhage Following Prior Prelabor Cesarean Delivery Stratified by Abnormal Placentation: A Multicenter Historical Cohort Study.

Background: Prior prelabor cesarean delivery (CD) was associated with an increase in the risk of placenta previa (PP) in a second delivery, whether it may impact postpartum hemorrhage (PPH) independent of abnormal placentation. This study aimed to assess the risk of PPH stratified by abnormal placentation following a first CD before the onset of labor (prelabor) or intrapartum CD. Methods: This multicenter, historical cohort study involved singleton, pregnant women at 28 weeks of gestation or greater with a CD history between January 2017 and December 2017 in 11 public tertiary hospitals within 7 provinces of China. PPH was analyzed in the subsequent pregnancy between women with prior prelabor CD and women with intrapartum CD. Furthermore, PPH was analyzed in pregnant women stratified by complications with PP alone [without placenta accreta spectrum (PAS) disorders], complications with PP and PAS, complications with PAS alone (without PP), and normal placentation. We performed multivariate logistic regression to calculate adjusted odds ratios (aOR) and 95% CI controlling for predefined covariates. Results: Out of 10,833 pregnant women, 1,197 (11%) women had a history of intrapartum CD and 9,636 (89%) women had a history of prelabor CD. Prior prelabor CD increased the risk of PP (aOR 1.91, 95% CI 1.40-2.60), PAS (aOR 1.68, 95% CI 1.11-2.24), and PPH (aOR 1.33, 95% CI 1.02-1.75) in a subsequent pregnancy. After stratification by complications with PP alone, PP and PAS, PAS alone, and normal placentation, prior prelabor CD only increased the risk of PPH (aOR 3.34, 95% CI 1.35-8.23) in a subsequent pregnancy complicated with PP and PAS. Conclusion: Compared to intrapartum CD, prior prelabor CD increased the risk of PPH in a subsequent pregnancy only when complicated by PP and PAS.

How to set up a regional specialist referral service for Placenta Accreta Spectrum (PAS) disorders?

There has been an approximately fivefold increase in the incidence of placenta accreta spectrum (PAS) disorders during the last 30 years, believed to be secondary to increasing Caesarean section rates. PAS disorder is associated with significantly increased maternal morbidity and mortality worldwide. Antenatal diagnosis by foetal medicine teams that have a special expertise to diagnose PAS disorder by the use of ultrasound scan, and a dedicated, highly specialised multidisciplinary team (MDT) comprising surgeons who are skilled in complex pelvic surgery and obstetric anaesthetists who have an expertise in high-risk obstetric anaesthesia, supported by haematology, operating theatre, interventional radiology, midwifery, neonatology, high-dependency and intensive care teams have been recommended to improve maternal and perinatal outcomes. Setting up a specialist MDT regional referral service, PAS involves collaboration with all stakeholders, ensuring appropriate funding, developing MDT care pathways, continuously auditing patient outcomes and disseminating knowledge through research, innovation, education and publications.

Development and validation of a four-microRNA signature for placenta accreta spectrum: an integrated competing endogenous RNA network analysis.

BACKGROUND: Placenta accreta spectrum (PAS) is a major cause of maternal morbidity and mortality in modern obstetrics, however, few studies have explored the underlying molecular mechanisms and biomarkers. In this study, we aimed to elucidate the regulatory RNA network contributing to PAS, comprising long non-coding (lnc), micro (mi), and messenger (m) RNAs, and identify biomarkers for the prediction of intraoperative blood volume loss. METHODS: Using RNA sequencing, we compared mRNA, lncRNA, and miRNA expression profiles between five PAS and five normal placental tissues. Furthermore, the miRNA expression profiles in maternal plasma samples from ten PAS and ten control participants were assessed. The data and clinical information were analyzed using R language and GraphPad Prism 7 software. RESULTS: Upon comparing PAS and control placentas, we identified 8,806 lncRNAs, 128 miRNAs, and 1,788 mRNAs that were differentially expressed. Based on a lasso regression analysis and correlation predictions, we developed a competing endogenous (ce) RNA network comprising 20 lncRNAs, 4 miRNAs, and 19 mRNAs. This network implicated a reduced angiogenesis pathway in PAS, and correlation analyses indicated that two miRNAs (hsa-miR-490-3p and hsa-miR-133a-3p) were positively correlated to operation-related blood volume loss. CONCLUSIONS: We identified a ceRNA regulatory mechanism in PAS, and two miRNAs that may potentially serve as biomarkers of PAS prognosis.

Indoleamine 2,3-dioxygenase and trophoblast invasion in caesarean scar pregnancy: Implications for the aetiopathogenesis of placenta accreta spectrum.

Immunohistochemical localisation of indoleamine 2,3-dioxygenase was studied in order to better understand the pathophysiology of placenta accreta spectrum. In the decidua staining for indoleamine 2,3-dioxygenase was found in the glandular epithelium with some additional positive cells. Extravillous cytotrophoblast invasion was present in the myometrium which was not covered by the decidual tissue whereas myometrial invasion of cytotrophoblasts was absent where this tissue lay deep to decidua. These results suggest that indoleamine 2,3-dioxygenase expression in the decidua may normally control trophoblast invasion and absence of its expression where decidua is absent may be involved in the pathogenesis of the over-invaded placenta.