Innovative hemostasis technique for cesarean section in placenta previa: A retrospective study.

OBJECTIVE: To evaluate hemostatic efficacy, complications, and subsequent pregnancy outcomes in women with placenta previa who underwent combined vertical compression sutures in the lower uterine segment and intrauterine balloon tamponade (Hot-Dog method) to achieve hemostasis after cesarean section. METHODS: We retrospectively reviewed data for 117 women with singleton pregnancy diagnosed with placenta previa who underwent cesarean section between 29 and 38 weeks' gestation. Treatments were as follows: (1) conventional-intravenous oxytocin administration after placental detachment and suturing of bleeding points at the detachment site as needed (conventional group) (n = 47). (2) Intrauterine balloon tamponade alone (balloon group) (n = 41). (3) Vertical compression sutures + intrauterine balloon tamponade (Hot-Dog group) (n = 29). RESULTS: The placenta accreta spectrum prevalence was significantly higher in the balloon and Hot-Dog groups versus the conventional group. The prevalence of anteriorly located placenta was significantly higher in the Hot-Dog versus balloon groups. Intraoperative and total blood loss were significantly higher in the Hot-Dog versus conventional groups. Postoperative blood loss was significantly lower in the Hot-Dog versus balloon groups. Fewer additional procedures for managing postoperative hemorrhage were required in the Hot-Dog versus conventional and balloon groups. The number of subsequent pregnancies in the conventional, balloon, and Hot-Dog groups was 11 (23.4%), 8 (19.5%), and 4 (13.8%), respectively; all resulted in live births at term without serious obstetric complications. CONCLUSION: The Hot-Dog method is a straightforward and safe hemostasis technique for placenta previa that preserves fertility and controls severe bleeding.

Prophylactic occlusion balloons of both internal iliac arteries in caesarean hysterectomy for placenta accreta spectrum disorder reduces blood loss: A retrospective comparative study.

Background: The placenta accreta spectrum is a complex disorder characterized by abnormal invasion of the placenta into the uterine wall, posing a significant risk of life-threatening haemorrhage for patients. Its incidence is on the rise, largely attributed to the increasing rates of caesarean sections. Management of this spectrum involves a multidisciplinary approach, although standardized protocols are not yet established. While caesarean hysterectomy remains the standard Gold, several adjunctive treatments have emerged in recent years to mitigate bleeding risk and associated morbidity. Among these, prophylactic occlusion balloons placed in the internal iliac arteries have shown promise. The aim of our study is to demonstrate the effect of prophylactic occlusion balloons in both uterine iliac arteries in the management of placental accreta spectrum disorders. Methods: A retrospective monocentric cohort study was conducted in the Department "C" of Gynaecology and Obstetrics at the Maternity Center of Tunis. The study spanned three years, from January 2nd, 2020, to December 31st, 2022. The study population consisted of two groups: Control Group (CG) comprised patients who underwent caesarean hysterectomy without internal-iliac prophylactic occlusion balloons, and Occlusion balloons of both internal iliac arteries Group (OBIIAG) included patients who underwent caesarean hysterectomy with internal-iliac prophylactic occlusion balloons. Results: A total of 38 patients were included in the study, all of whom exhibited similar epidemiological characteristics and comparable personal and obstetric histories. The most prevalent risk factor among the patients was a history of caesarean section (92%). On average, patients were diagnosed at 30 weeks of gestation, with third-trimester bleeding being the most common presentation (71% of cases). The median gestational age at delivery was between 36 and 37 weeks. We observed a significant difference in blood loss between the two groups (2888 ml in the control group and 1828 ml in the group with internal-iliac prophylactic occlusion balloons, p < 0.05). Implementation of this technique resulted in a reduced need for massive transfusions (p < 0.01) and shorter operating times (126 min for the control group and 92 min for the group with internal-iliac prophylactic occlusion balloons; p = 0.04). There were no significant differences in morbidity between the two groups. Conclusion: The intra-iliac prophylactic occlusion balloons can help reduce the risk of hemorrhage and the morbidities that come with the placenta accreta spectrum disorder.

Neonatal outcomes in the surgical management of placenta accreta spectrum disorders: a retrospective single-center observational study from 468 Vietnamese pregnancies beyond 28 weeks of gestation.

BACKGROUND: Placenta accreta spectrum disorders (PASDs) increase the mortality rate for mothers and newborns over a decade. Thus, the purpose of the study is to evaluate the neonatal outcomes in emergency cesarean section (CS) and planned surgery as well as in Cesarean hysterectomy and the modified one-step conservative uterine surgery (MOSCUS). The secondary aim is to reveal the factors relating to poor neonatal outcomes. METHODS: This was a single-center retrospective study conducted between 2019 and 2020 at Tu Du Hospital, in the southern region of Vietnam. A total of 497 pregnant women involved in PASDs beyond 28 weeks of gestation were enrolled. The clinical outcomes concerning gestational age, birth weight, APGAR score, neonatal intervention, neonatal intensive care unit (NICU) admission, and NICU length of stay (LOS) were compared between emergency and planned surgery, between the Cesarean hysterectomy and the MOSCUS. The univariate and multivariable logistic regression were used to assess the adverse neonatal outcomes. RESULTS: Among 468 intraoperatively diagnosed PASD cases who underwent CS under general anesthesia, neonatal outcomes in the emergency CS (n = 65) were significantly poorer than in planned delivery (n = 403). Emergency CS increased the odds ratio (OR) for earlier gestational age, lower birthweight, lower APGAR score at 5 min, higher rate of neonatal intervention, NICU admission, and longer NICU LOS ≥ 7 days with OR, 95% confidence interval (CI) were 10.743 (5.675-20.338), 3.823 (2.197-6.651), 5.215 (2.277-11.942), 2.256 (1.318-3.861), 2.177 (1.262-3.756), 3.613 (2.052-6.363), and 2.298 (1.140-4.630), respectively, p < 0.05. Conversely, there was no statistically significant difference between the neonatal outcomes in Cesarean hysterectomy (n = 79) and the MOSCUS method (n = 217). Using the multivariable logistic regression, factors independently associated with the 5-min-APGAR score of less than 7 points were time duration from the skin incision to fetal delivery (min) and gestational age (week). One minute-decreased time duration from skin incision to fetal delivery contributed to reduce the risk of adverse neonatal outcome by 2.2% with adjusted OR, 95% CI: 0.978 (0.962-0.993), p = 0.006. Meanwhile, one week-decreased gestational age increased approximately two fold odds of the adverse neonatal outcome with adjusted OR, 95% CI: 1.983 (1.600-2.456), p < 0.0001. CONCLUSIONS: Among pregnancies with PASDs, the neonatal outcomes are worse in the emergency group compared to planned group of cesarean section. Additionally, the neonatal comorbidities in the conservative surgery using the MOSCUS method are similar to Cesarean hysterectomy. Time duration from the skin incision to fetal delivery and gestational age may be considered in PASD surgery. Further data is required to strengthen these findings.

Diffusion-derived vessel density (DDVD) computed from a simple diffusion MRI protocol as a biomarker of placental blood circulation in patients with placenta accreta spectrum disorders: A proof-of-concept study.

OBJECTIVES: Increasing trend of PAS (placenta accreta spectrum disorders) incidence is a major health concern as PAS is associated with high maternal morbidity and mortality during cesarean section. Prenatal identification of PAS is crucial for delivery planning and patients management. This study aims to explore whether diffusion-derived vessel density (DDVD) computed from a simple diffusion MRI protocol differs in PAS from normal placenta. METHODS: We enrolled 86 patients with PAS disorders and 40 pregnant women without PAS disorders. Each patient underwent intravoxel incoherent motion (IVIM) MRI sequence with 11 b-values. Placenta diffusion-derived vessel density (DDVD-b0b50) was the signal difference between b = 0 and b = 50 s/mm2 images. DDVD(b0b50) A/N was calculated as [accreta lesion DDVD(b0b50)]/ [normal placenta DDVD(b0b50)]. The correlation between DDVD and gestational age was explored using Spearman rank correlation. Differences of DDVD(b0b50) A/N in patients with normal placentas and with PAS, and in patients with different subtypes of PAS were explored. RESULTS: DDVD was negatively correlated with gestational age (p = 0.023, r = -0.359) in patients with normal placentas. DDVD(b0b50) A/N was significantly higher in patients with PAS (median:1.16, mean: 1.261) than normal placenta (median:1.02, mean: 1.032, p < 0.001) and especially higher in patients with placenta increta (median:1.14, mean: 1.278) and percreta (median: 1.20, mean: 1.396, p < 0.001). CONCLUSION: As a higher DDVD indicates higher physiological volume of micro-vessels in PAS, this study suggests DDVD can be a potential biomarker to evaluate the placenta perfusion.

Standard diffusion-weighted, diffusion kurtosis and intravoxel incoherent motion in differentiating invasive placentas.

PURPOSE: To investigate the diagnostic value of monoexponential, biexponential, and diffusion kurtosis MR imaging (MRI) in distinguishing invasive placentas. METHODS: A total of 53 patients with invasive placentas and 47 patients with noninvasive placentas undergoing conventional diffusion-weighted imaging (DWI), intravoxel incoherent motion (IVIM), and diffusion kurtosis imaging (DKI) were retrospectively enrolled. The mean, minimum, and maximum parameters including the apparent diffusion coefficient (ADC) and exponential ADC (eADC) from standard DWI, diffusion kurtosis (MK), and diffusion coefficient (MD) from DKI and pure diffusion coefficient (D), pseudo-diffusion coefficient (D*), and perfusion fraction (f) from IVIM were measured and compared from the volumetric analysis. Receiver operating characteristics (ROC) curve and logistic regression analyses were conducted to evaluate the diagnostic efficiency of different diffusion parameters for distinguishing invasive placentas. RESULTS: Comparisons between accreta lesions in patients with invasive placentas (AL) and lower 1/3 part of the placenta in patients with noninvasive placentas (LP) demonstrated that MD mean, D mean, and D* mean were significantly lower while ADC max and D max were significantly higher in invasive placentas (all p < 0.05). Multivariate analysis demonstrated that D mean, D max and D* mean differed significantly among all the studied parameters for invasive placentas. A combined use of these three parameters yielded an AUC of 0.86 with sensitivity, specificity, and accuracy of 84.91%, 76.60%, and 80%, respectively. CONCLUSION: The combined use of different IVIM parameters is helpful in distinguishing invasive placentas.

Sonographic Findings of Vascular Signals for Retained Products of Conception in Women Following First-Trimester Termination of Pregnancy.

OBJECTIVES: To evaluate the occurrence of retained products of conception (RPOC) after termination of pregnancy in the first trimester and to assess the vascular signals with transvaginal ultrasonography (TVUS) examination in the detection of retained products. METHODS: A retrospective cohort study was performed using TVUS examination in patients following termination of pregnancy. In cases of RPOC, 3 scales of vascular signal were identified: type 1, no or small amount, spot flow signals; type 2, medium amount, strip-like flow signals; type 3, rich amount, circumferential-like flow signals. The correlation between vascular signals and placenta accreta spectrum (PAS) staging was proposed by sonography and histopathology findings. RESULTS: The 3 vascular patterns were differently distributed within non-RPOC as well as RPOC patients with and without PAS: type 1 vascular signal detection rates of non-RPOC and RPOC were 97.8% (262/268) and 28.1% (18/64), respectively. Of 64 cases of RPOC, 48.4% (31/64) of the patients had type 2 vascular signals. Vascular signals were enhanced in RPOC with PAS patients whose diagnosis was confirmed by histopathology. CONCLUSIONS: The vascularity (amount of flow), vascular pattern (spot, strip- or circumferential-like flow), and the flow penetrating myometrium were significant findings for distinguishing concomitant RPOC with and without PAS. Additionally, RPOC may contribute to PAS progression, or PAS and RPOC in coordination strengthen the observed vascular signals.

Placenta Accreta Spectrum Disorders - The Impact of the Creation of a Multidisciplinary Team on Maternal Outcomes in Portugal / Patologia do espectro do acretismo placentário - O impacto da criação de uma equipa multidisciplinar nos desfechos maternos em Portugal

Abstract Objective To describe a cohort of placenta accreta spectrum (PAS) cases from a tertiary care institution and compare the maternal outcomes before and after the creation of a multidisciplinary team (MDT). Methods Retrospective study using hospital databases. Identification of PAS cases with pathological confirmation between 2010 and 2021. Division in two groups: standard care (SC) group - 2010-2014; and MDT group - 2015-2021. Descriptive analysis of their characteristics and maternal outcomes. Results During the study period, there were 53 cases of PAS (24 - SC group; 29 - MDT group). Standard care group: 1 placenta increta and 3 percreta; 12.5% (3/24) had antenatal suspicion; 4 cases had a peripartum hysterectomy - one planned due to antenatal suspicion of PAS; 3 due to postpartum hemorrhage. Mean estimated blood loss (EBL) was 2,469 mL; transfusion of packed red blood cells (PRBC) in 25% (6/24) - median 7.5 units. Multidisciplinary team group: 4 cases of placenta increta and 3 percreta. The rate of antenatal suspicion was 24.1% (7/29); 9 hysterectomies were performed, 7 planned due to antenatal suspicion of PAS, 1 after intrapartum diagnosis of PAS and 1 after uterine rupture following a second trimester termination of pregnancy. The mean EBL was 1,250 mL, with transfusion of PRBC in 37.9% (11/29) - median 2 units. Conclusion After the creation of the MDT, there was a reduction in the mean EBL and in the median number of PRBC units transfused, despite the higher number of invasive PAS disorders.

Resumo Objetivo Descrever uma coorte de casos do espectro do acretismo placentário (PAS) de uma instituição terciária e comparar os resultados maternos antes e depois da criação de uma equipa multidisciplinar (MDT). Métodos Estudo retrospectivo utilizando bancos de dados hospitalares. Identificação de casos de PAS com confirmação patológica entre 2010 e 2021. Divisão em dois grupos: grupo Standard Care (SC) - 2010-2014; e grupo MDT - 2015-2021. Análise descritiva de suas características e desfechos maternos. Resultados Durante o período do estudo, houve 53 casos de PAS (24 - grupo SC; 29 - grupo MDT). Grupo Standard Care: 1 placenta increta e 3 percretas; 12,5% (3/24) tiveram suspeita anteparto; 4 casos tiveram histerectomia periparto - uma eletiva devido à suspeita anteparto de PAS; 3 devido a hemorragia pós-parto. A média de perda hemática estimada (EBL) foi de 2.469 mL; transfusão de concentrado eritrocitário (PRBC) em 25% (6/24) - mediana 7,5 unidades. Equipa multidisciplinar: 4 casos de placenta increta e 3 percretas. A taxa de suspeita anteparto foi de 24,1% (7/29); foram realizadas 9 histerectomias, 7 eletivas por suspeita anteparto de PAS, 1 após diagnóstico intraparto de PAS e 1 após rotura uterina após interrupção da gravidez no segundo trimestre. A EBL média foi de 1.250 mL, com transfusão de PRBC em 37,9% (11/29) - mediana de 2 unidades. Conclusão Após a criação da MDT, houve redução na média de EBL e na mediana do número de unidades de PRBC transfundidas, apesar do maior número de PAS invasivos.

Risk factors for postpartum haemorrhage in women with histologically verified placenta accreta spectrum disorders: a retrospective single-centre cross-sectional study.

BACKGROUND: Placenta accreta spectrum (PAS) disorders have been reported with an increasing frequency of up to 3%. The increase in the incidence can be explained by the rising rate of Caesarean section (CS), assisted reproductive technology (ART) and previous uterine surgeries. PAS disorders are usually associated with postpartum haemorrhage (PPH). In our study, we investigated the risk factors for increased blood loss in women with histologically verified PAS disorders independent of delivery mode. METHODS: In a retrospective single-centre cross-sectional study, 2,223 pregnant women with histologically verified PAS disorders were included. Risk factors for PPH in women with PAS disorders were examined and compared between women with PPH (study group; n = 879) and women with normal blood loss (control group; n = 1150), independent of delivery mode. PAS disorders were diagnosed histologically from the following specimens: placenta, placental-bed specimens, uterine curettage, uterine resection and/or total/partial hysterectomy. Medical data were extracted from clinical records of pregnant women with PAS disorders delivering at the University Hospital Basel between 1986 and 2019. The placenta data of women with PAS disorders were obtained and identified through a search from the database of the Department of Pathology, University Hospital Basel. RESULTS: Between 1986 and 2019, there were 64,472 deliveries at the University Hospital Basel. PAS disorders were histologically verified in 2,223 women (2,223/64,472), and the prevalence of PAS disorders was 3.45%. A total of 879 women with PAS disorders showed PPH, independent of delivery mode (43.3%). Due to missing data for 194 women, the final analysis was conducted with the remaining 2,029 women. Placenta praevia (O.R. = 6.087; 95% CI, 3.813 to 9.778), previous endometritis (O.R. = 3.011; 95% CI, 1.060 to 9.018), previous manual placenta removal (O.R. = 2.530; 95% CI, 1.700 to 3.796), ART (O.R. = 2.169; 95% CI, 1.593 to 2.960) and vaginal operative birth (O.R. = 1.715; 95% CI, 1.225-2.428) can be considered important risk factors, and previous CS (O.R. = 1.408; 95% CI, 1.016 to 1.950) can be considered a moderate potential risk factor of PPH in women with PAS disorders. CONCLUSIONS: Placenta praevia, previous endometritis, previous placenta removal, ART and vaginal operative birth can be considered important risk factors of PPH in women with PAS disorders. STUDY REGISTRATION: The study was registered under http://www. CLINICALTRIALS: gov (NCT05542043) on 15 September 2022.

Diffusion kurtosis and intravoxel incoherent motion in predicting postpartum hemorrhage in patients at high risk for placenta accreta spectrum disorders.

Background: Placenta accreta spectrum (PAS) disorder encompasses a spectrum of pathologies, from placenta accreta to placenta percreta, which is usually associated with postpartum hemorrhage (PPH). Methods: This cross-sectional study enrolled 109 patients suspected of having PAS disorders based on previous ultrasound results or clinical risk factors from November 2018 to March 2022 in Sichuan Provincial People's Hospital. Of the 109 patients, 34 had PPH and 75 did not have PPH. Magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI), intravoxel incoherent motion (IVIM), and diffusion kurtosis imaging (DKI) was performed for each patient and the apparent diffusion coefficient (ADC) from DWI, perfusion fraction (f), pure diffusion coefficient (D), and pseudo-diffusion coefficient (D*) from IVIM, and mean diffusion kurtosis (MK) and mean diffusion coefficient (MD) from DKI were measured and compared. The correlation between the DWI parameters and estimated blood loss (EBL) during surgery was identified using correlation analysis. The diagnostic performance for predicting PPH was compared between the two methods. Results: The amount of bleeding during delivery was positively correlated with D [r=0.331, P<0.001, 95% confidence interval (CI): 0.170 to 0.477], D* (r=0.389, P<0.001, 95% CI: 0.207 to 0.527), f (r=0.222, P=0.02, 95% CI: 0.036 to 0.398), and MD (r=0.277, P=0.003, 95% CI: 0.108 to 0.439), but negatively correlated with MK (r=-0.280, P=0.003, 95% CI: -0.431 to -0.098). In predicting PPH, multivariate analyses showed the independent risk factors were placenta previa and D; the area under the curve (AUC) was 0.795 (95% CI: 0.711 to 0.878) when the two risk factors were combined together. Conclusions: IVIM and DKI parameters are correlated with EBL. The combined use of placenta previa and D are helpful for predicting PPH in patients at high risk of PAS disorders.

Urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders: systematic review and meta-analysis.

OBJECTIVE: To report on the occurrence of urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders (PAS). METHODS: MEDLINE, EMBASE and the Cochrane databases were searched electronically up to 1 November 2022. Studies reporting on the urological outcome of women undergoing Cesarean section for PAS were included. Two independent reviewers performed data extraction using a predefined protocol and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies, with disagreements resolved by consensus.The primary outcome was the overall occurrence of urological complications. Secondary outcomes were the occurrence of any cystotomy, intentional cystotomy, unintentional cystotomy, ureteral damage, ureteral fistula and vesicovaginal fistula. All outcomes were explored in the overall population of women undergoing surgery for PAS. In addition, we performed subgroup analyses according to the type of surgery (Cesarean hysterectomy, or conservative surgery or management), severity of PAS at histopathology (placenta accreta/increta and placenta percreta), type of intervention (planned vs emergency) and number of cases per year. Random-effects meta-analyses of proportions were used to analyze the data. RESULTS: There were 62 studies included in the systematic review and 56 were included in the meta-analysis. Urological complications occurred in 15.2% (95% CI, 12.9-17.7%) of cases. Cystotomy complicated 13.5% (95% CI, 9.7-17.9%) of surgical operations. Intentional cystotomy was required in 7.7% (95% CI, 6.5-9.1%) of cases, while unintentional cystotomy occurred in 7.2% (95% CI, 6.0-8.5%) of cases. Urological complications occurred in 19.4% (95% CI, 16.3-22.7%) of cases undergoing hysterectomy and 12.2% (95% CI, 7.5-17.8%) of those undergoing conservative treatment. In the subgroup analyses, urological complications occurred in 9.4% (95% CI, 5.4-14.4%) of women with placenta accreta/increta and 38.5% (95% CI, 21.6-57.0%) of those described as having placenta percreta, and included mainly cystotomy (5.5% (95% CI, 0.6-15.1%) and 22.0% (95% CI, 5.4-45.5%), respectively). Urological complications occurred in 15.4% (95% CI, 8.1-24.6%) of cases undergoing a planned procedure and 24.6% (95% CI, 13.0-38.5%) of those undergoing an emergency intervention. In subanalysis of studies reporting on ≥ 12 cases per year, the incidence of urological complication was similar to that reported in the primary analysis. CONCLUSIONS: Women undergoing surgery for PAS are at high risk of urological complication, mainly cystotomy. The incidence of these complications was particularly high in women described as having placenta percreta at birth and in those undergoing emergency surgical intervention. The high heterogeneity between the included studies highlights the need for a standardized protocol for the diagnosis of PAS to identify prenatal imaging signs associated with the increased risk of urological morbidity at delivery. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

YKL-40 promotes proliferation and invasion of HTR-8/SVneo cells by activating akt/MMP9 signalling in placenta accreta spectrum disorders.

YKL-40 is a secreted glycoprotein that can promote invasion, angiogenesis and inhibit apoptosis, and was highly expressed in a variety of tumours. In this paper, we investigated the impacts of YKL-40 on proliferation and invasion in HTR-8/SVneo cells during placenta accreta spectrum disorders (PAS) development. The levels of YKL-40 protein in late-pregnant placental tissue were detected using immunohistochemistry and Western blotting, and gene expression using reverse transcription-quantitative polymerase chain reaction (RT-qPCR). The proliferation, migration, invasion and apoptosis abilities of HTR-8/SVneo cells were detected by cell counting kit-8 (CCK-8), Transwell, scratch assay, and flow cytometry, respectively. Our current results showed that YKL-40 was significantly increased in the PAS group compared to the normal control group (P < 0.01). Biological function experiments showed that YKL-40 significantly promoted the proliferation, migration and invasion of HTR-8/SVneo cells, and inhibited cell apoptosis. Knockdown of YKL-40 inhibited the activation of Akt/MMP9 signalling in trophoblast cells. These data suggested that YKL-40 might be involved in the progression of PAS, which may be attributed to the regulation of Akt/MMP9 signalling pathway.

What is already known on this subject? YKL-40 is a secretory glycoprotein that can promote invasion, angiogenesis, and inhibit apoptosis and was highly expressed in a variety of tumours. Trophoblast cells resemble tumour cells in their migration and invasion.What the results of this study add? YKL-40 expression was significantly up-regulated in PAS. CCK-8 assays showed that YKL-40 remarkably enhanced the viability of HTR-8/SVneo cells. Scratch and Transwell assays demonstrated that YKL-40 significantly promoted the migration and invasion of HTR-8/SVneo cells. Additionally, YKL-40 attenuated apoptosis in HTR-8/SVneo cells.What the implications are of these findings for clinical practice and/or further research? Akt/MMP9 was involved in the regulation of YKL-40 on trophoblast invasion, which may provide theoretical basis and new ideas for the drug blocking intervention of placenta accreta.

Differentiation of placenta percreta through MRI features and diffusion-weighted magnetic resonance imaging.

OBJECTIVES: To identify whether parameters measured from diffusion kurtosis and intravoxel incoherent motion help diagnose placenta percreta. METHODS: We retrospectively enrolled 75 patients with PAS disorders including 13 patients with placenta percreta and 40 patients without PAS disorders. Each patients underwent diffusion-weighted imaging (DWI), intravoxel incoherent motion (IVIM), and diffusion kurtosis imaging (DKI). The apparent diffusion coefficient (ADC), perfusion fraction (f), pure diffusion coefficient (D), pseudo-diffusion coefficient (D*), mean diffusion kurtosis (MK) and mean diffusion coefficient (MD) were measured by the volumetric analysis and compared. MRI features were also analyzed and compared. The receiver operating characteristic (ROC) curve and logistic regression analysis were used to evaluate the diagnostic efficiency of different diffusion parameters and MRI features for distinguishing placental percreta. RESULTS: D* was an independent risk factor from DWI for predicting placenta percreta with sensitivity of 73% and specificity of 76%. Focal exophytic mass remained as independent risk factor from MRI features for predicting placenta percreta with sensitivity of 72.7% and specificity of 88.1%. When the two risk factors were combined together, the AUC was the highest, 0.880 (95% CI 0.8-0.96). CONCLUSION: D* and focal exophytic mass were associated with placenta percreta. A combination of the 2 risk factors can be used to predict placenta percreta. CRITICAL RELEVANCE STATEMENT: A combination of D* and focal exophytic mass can be used to differentiate placenta percreta.

Conservative surgical approach towards placenta accreta spectrum disorders for uterine preservation.

OBJECTIVE: We previously described a technique for repair of the myometrial defect at repeat Caesarean section which increases residual myometrial thickness thereby potentially reducing future niche-related complications. Here we describe how this technique can be modified for use for placenta accreta spectrum disorders, in line with emerging evidence that this is more a disorder of myometrial deficiency than morbid adherence. DESIGN: The surgical performance of peripartum hysterectomy was compared with that of the modified technique in all women having repeat Caesarean delivery for placenta accreta spectrum disorder in a tertiary unit in Singapore between December 2019 and October 2021. METHODS: Modification of the original technique involved the systematic delivery of the placenta starting from its most posterior attachment after uterine exteriorization. This is followed by the identification, mobilization, and apposition of the boundaries of myometrial defects as described previously. RESULTS: Ten women had Caesarean hysterectomy and ten had Caesarean section using the modified approach. Age and gestational age at delivery were similar for the two groups. Women in the modified technique group had had fewer prior Caesarean sections and had a lower body mass index. Operating time, estimated blood loss and need for transfusion were all lower in the myometrial repair group but without statistical significance. There were no visceral injuries in the repair group but there was one bladder injury in the hysterectomy group. CONCLUSION: The modified approach provides an effective alternative to peripartum hysterectomy with favourable surgical profile and allows uterine conservation with restoration of myometrial thickness.

Efficacy of low extra-abdominal aortic block in cesarean section for placenta accreta spectrum disorders and its effect on the expression of MDA and SOD. / ä½Žä½è ¹ä¸»åŠ¨è„‰å¤–é˜»æ–­æœ¯åœ¨èƒŽç›˜æ¤å ¥æ€§ç–¾ç— å‰–å®«äº§æœ¯ä¸­çš„æ•ˆæžœåŠå¯¹MDA、SOD表达的影响.

OBJECTIVES: Placenta accreta spectrum disorders (PAS) refers to a group of abnormalities in placental adhesion and invasion, which may lead to serious complications such as intractable postpartum hemorrhage. The use of low-level extra-abdominal aortic temporary block during cesarean section may reduce intraoperative bleeding in patients with PAS, but it may also cause ischemia-reperfusion injury. In this study, we intend to investigate the efficacy of low extra-abdominal aortic block in cesarean section for placental implantation disease and its effect on malondialdehyde (MDA) level and superoxide dismutase (SOD) activity, and analyze the severity of ischemia-reperfusion injury caused by them. METHODS: Pregnant women with invasive placenta accreta spectrum disorders who delivered in the Department of Obstetrics and Gynecology of the Third Xiangya Hospital of Central South University from July 2017 to July 2021, were selected, and they were divided into 2 groups. Group A consisted of those who underwent low extra-abdominal aortic block during cesarean section (n=15) and group B consisted of those who did not undergo extra-abdominal aortic block (n=15). The intraoperative bleeding, blood transfusion, hysterectomy and complication rate, postoperative hospital stay and hospitalization expenses were compared between the 2 groups to analyze the efficacy of abdominal aortic block. The biochemical indexes related to ischemia-reperfusion, MDA content and total superoxide dismutase (T-SOD) activity, were measured at the corresponding time points in both groups. The time points of each test were: in group A, before the block of the low extra-abdominal aorta after delivery (A0), 0 h (A1, when the myometrium was started to be sutured), 0.5 h (A2), 2 h (A3), and 4 h (A4) after the open block; in group B, after delivery of the fetus (B0), 0 h (B1), 0.5 h (B2), 2 h (B3), and 4 h (B4) after the myometrium was started to be sutured. Total duration of abdominal aortic block in group A was also recorded. Both groups were observed for sings of edema, ischemia, necrosis and infection in the limbs after surgery. The severity of ischemia-reperfusion injury caused by abdominal aortic block were determined by detecting the relevant biochemical indexes at different moments of reperfusion. RESULTS: The intraoperative bleeding and blood transfusion in group A were less than those in group B, and the difference was statistically significant (P<0.05). There was no significant difference in postoperative hospital stay and hospitalization expenses between the 2 groups (P>0.05). Surgical complications: in group A, the uterus was preserved in all cases, there was 1 bladder injury and 2 pelvic infections; while in group B, there was 1 hysterectomy, 3 bladder injuries, and 3 pelvic infections. Changes in T-SOD and MDA values: compared with A0 before block, the MDA level was significantly elevated in blood at time points A1, A2, and A3, while SOD activity was significantly decreased (P<0.05), and the 2 observed indexes basically returned to A1 level (ischemic period) at 4 h after open block (A4). There was no significant difference in the changes of T-SOD and MDA in group B (P>0.05). Comparison of T-SOD and MDA levels between group A and B: the difference of the 2 indexes was not statistically significant between A0 and B0 (P>0.05), MDA level was not statistically significant between A1 and B1, T-SOD activity at A1 was lower than B1, the difference was statistically significant, at the rest of the same time point, MDA level in group A were higher than that in group B, T-SOD activity in group A were lower than that in group B, the difference was statistically significant (P<0.05). No postoperative limb edema, ischemia, necrosis, or infection occurred in both groups. CONCLUSIONS: Low-level extra-abdominal aortic block effectively reduces bleeding and transfusion during cesarean section for placenta accreta spectrum disorders, resulting in a transient MDA elevation and a decrease of SOD activity, which means causing transient ischemia-reperfusion injury without complications such as limb edema, ischemia, necrosis, and infection.

Diffusion and perfusion MRI parameters in the evaluation of placenta accreta spectrum disorders in patients with placenta previa.

OBJECTIVES: To evaluate the placental function by monoexponential, biexponential, and diffusion kurtosis MR imaging (MRI) in patients with placenta previa. METHODS: A total of 62 patients with placenta accreta spectrum (PAS) disorders and 11 patients with normal placentas were retrospectively enrolled, who underwent conventional diffusion-weighted imaging (DWI), intravoxel incoherent motion (IVIM), and diffusion kurtosis imaging (DKI). The apparent diffusion coefficient (ADC) and exponential ADC (eADC) from standard DWI, mean kurtosis (MK), and diffusion coefficient (MD) from DKI, and pure diffusion coefficient (D), pseudo-diffusion coefficient (D*), and perfusion fraction (f) from IVIM were measured and compared from the volumetric analysis. RESULTS: Comparisons between patients with PAS disorders and patients with normal placentas demonstrated that MD mean, D mean, and D* mean values in patients with PAS disorders were significantly higher than those in patients with normal placentas (p < 0.05). Comparisons between patients with accreta, increta, and percreta, and patients with normal placentas showed that the D mean was significantly higher in patients with placenta increta and percreta than in patients with normal placentas (p < 0.05). CONCLUSION: The accreta lesions in PAS disorders had deceased cellularity and increased blood movement. The alteration of placental cellularity was more prominent in placenta increta and percreta.

Epidemiology of placenta accreta spectrum disorders in Chinese pregnant women: A multicenter hospital-based study.

INTRODUCTION: Placenta accreta spectrum disorder (PASD) is a life-threatening obstetric complication. China still lacks high-quality data on the epidemiology of PASD. We intend to examine the major risk factors for PASD, explore the association of PASD with severe adverse perinatal outcomes and describe the geographical variations in China. METHODS: We used data from the China Labor and Delivery Survey, which included a total of 75,132 births from 96 hospitals in 24 provinces in China in 2015 and 2016. Each participating hospital randomly selected 6-10 weeks within a 12-month period. In the selected weeks, all births with gestational age ≥24 weeks or birth weight ≥500 g were included. We analyzed the demographic characteristics and prevalence of PASD in pregnant women. Multivariable logistic regression was used to examine the association of previous caesarean section (CS) and repeated surgical abortion with PASD. We explored the association of PASD with severe adverse perinatal outcomes, which indicated by Weighted Adverse Outcome Score (WAOS) ≥ 20. Multivariable logistic regression was used to examine the association of PASD with WAOS. We also calculated and compared the prevalence of PASD in different regions of China. RESULTS: The weighted prevalence of PASD was 2.20% (95% CI 0.76 to 4.95) in our population，and there was a substantial difference in the prevalence of PASD by geographic regions in China. Two or more previous CS (adjusted OR 2.34, 95%CI 1.41 to 3.88) and repeated surgical abortion (twice: 2.16, 1.20 to 3.92; 3 times: 4.31, 1.70 to 10.96; ≥4 times: 4.76, 3.12 to 7.26) were significant risk factors for PASD. PASD (adjusted OR 3.77, 95% CI 2.80 to 5.06) was a significant risk factor for severe adverse perinatal outcomes indicated by WAOS score. DISCUSSION: The prevalence of PASD in China appeared higher than that in other countries, and varied substantially by geographic regions. Two or more previous CS and repeated surgical abortion were major risk factors for PASD. Pregnant women with PASD had more severe adverse pregnancy outcomes. Reducing primary cesarean section and repeated surgical abortion are the key to decreasing PASD.

Placenta accreta spectrum disorders in the first trimester: a systematic review.

Placenta accreta spectrum (PAS) disorders involve an abnormality in the implantation of the placenta, being rarely diagnosed in the first trimester. To conduct a systematic review of the risk factors, clinical and imaging features, and outcomes of histopathologically confirmed cases of PAS disorders in the first trimester of pregnancy. Different databases including PubMed, MEDLINE Complete, Scopus, Web of Science, EMBASE, SciELO, LILACS, and Ovid were reviewed up to November 2018. 55 patients with a definitive histopathological diagnosis were reported. About 18 had a history of prior curettage and 47 of previous caesarean deliveries (CD). About 74.54% presented with miscarriage and ultrasound signs of caesarean scar pregnancy (CSP) were reported in 22.49%. Temporal sequence of diagnostic studies could be determined in 52 women, and, among these, PAS disorders were defined through imaging techniques in 11 (21.15%) while surgical findings unveiled them in 15 (28.84%). Nonetheless, in half of the cases, the diagnosis was concluded only on histopathological samples. PAS disorders in the first trimester of pregnancy are rarely diagnosed through imaging techniques and lead to hysterectomy in most cases. Ultrasound training to detect PAS disorders in women with risk factors is crucial for early diagnosis and prevention of adverse outcomes.

Peripartum hysterectomy due to severe postpartum hemorrhage: A hospital-based study.

INTRODUCTION: A peripartum hysterectomy is typically performed as a lifesaving procedure in obstetrics to manage severe postpartum hemorrhage. Severe hemorrhages that lead to peripartum hysterectomies are mainly caused by uterine atony and placenta accreta spectrum disorders. In this study, we aimed to estimate the incidence, risk factors, causes and management of severe postpartum hemorrhage resulting in peripartum hysterectomies, and to describe the complications of the hysterectomies. MATERIAL AND METHODS: Eligible women had given birth at gestational week 23+0 or later and had a postpartum hemorrhage ≥1500 mL or a blood transfusion, due to postpartum hemorrhage, at Oslo University Hospital, Norway, between 2008 and 2017. Among the eligible women, this study included those who underwent a hysterectomy within the first 42 days after delivery. The Norwegian Medical Birth Registry provided the reference group. We used Poisson regression to estimate adjusted incidence rate ratios with 95% confidence intervals to identify clinical factors associated with peripartum hysterectomy. RESULTS: The incidence of hysterectomies with severe postpartum hemorrhage was 0.44/1000 deliveries (42/96313). Among the women with severe postpartum hemorrhage, 1.6% ended up with a hysterectomy (42/2621). Maternal age ≥40, previous cesarean section, multiple pregnancy and placenta previa were associated with a significantly higher risk of hysterectomy. Placenta accreta spectrum disorders were the most frequent cause of hemorrhage that resulted in a hysterectomy (52%, 22/42) and contributed to most of the complications following the hysterectomy (11/15 women with complications). CONCLUSIONS: The rate of peripartum hysterectomies at Oslo University Hospital was low, but was higher than previously reported from Norway. Risk factors included high maternal age, previous cesarean section, multiple pregnancy and placenta previa, well known risk factors for placenta accreta spectrum disorders and severe postpartum hemorrhage. Placenta accreta spectrum disorders were the largest contributor to hysterectomies and complications.

Cook Cervical Ripening Balloon for placenta accreta spectrum disorders with placenta previa: a novel approach to uterus preserving.

PURPOSE: To evaluate the efficacy of intrauterine inflated Cook Cervical Ripening Balloon (ICRB) in postpartum hemorrhage (PPH) management and fertility preserving for placenta accreta spectrum disorders with placenta previa (previa PAS). METHODS: At a tertiary referral center, 74 patients suffering with previa PAS were entered into this retrospective cohort study from January, 2016 to December, 2020, and were confirmed intraoperatively that abnormal invasive placenta reaches the cervical internal ostium and the upper part of the cervical canal. In control group (n = 39), the combination of infrarenal abdominal aorta balloon occlusion (IAABO) and longitudinal parallel compression suture to lower uterine segment were performed. In study group (n = 35), in addition to the aforementioned surgical techniques, ICRB was implemented at the cervical internal ostium and the outside of the cervix simultaneously. RESULTS: Use of ICRB significantly reduced the rate of peripartum hysterectomy (2.9% vs 30.4%, p = 0.001), and associated with a reduction in surgical time and duration of IAABO (mean 172.7 min vs 206.6 min, p = 0.017; median 30 min vs 40 min, p < 0.001). Use of ICRB significantly reduced the estimated amount of blood loss (median 2500 ml vs 4000 ml, p < 0.001), amounts of packed red blood cells and fresh-frozen plasma transfusion (median 6 U vs 13.5 U, p < 0.001; median 450 ml vs 1200 ml, p < 0.001), postoperative hospital stay and the incidence of oligomenorrhea postoperatively (median 5 days vs 6 days, p = 0.009; 13.8% vs 61.1% p = 0.001). No significant difference was observed between both the groups regarding the use of cryo and PLT, injury of urinary system, relaparotomy, admission to the ICU, postpartum hematocele in uterine cavity, and postoperative complications (including incidence rate of DVT, incidence rate of femoral thrombosis, puerperal morbidity, intrauterine infection, surgical site infection, and deep tissue infection). CONCLUSION: ICRB was a simple, effective procedure for PPH management and fertility preserving in some previa PAS cases in which abnormal invasive placenta reaches the cervical internal ostium and the upper part of the cervical canal, in tandem with IAABO and compression suture.

Comparison between a prenatal sonographic scoring system and a clinical grading at delivery for Placenta Accreta Spectrum disorders.

OBJECTIVE: Placenta Accreta Spectrum (PAS) disorders have become a major iatrogenic obstetric complication worldwide. Data on the accuracy of ultrasound examination diagnosis are limited by incomplete confirmation and variability in the description of the different grades of PAS at delivery. The aim of this study was to compare our prenatal routine sonographic screening and diagnostic scoring system with a standardized clinical grading system at birth in patient at risk of PAS. STUDY DESIGN: This is a retrospective cohort study of 607 pregnant patients with at least one prior cesarean delivery between December 2013 and December 2018. All patients were assessed for PAS using our institutional prenatal sonographic scoring system and the corresponding ultrasound findings were compared with those of a standardized clinical intra-operative macroscopic grading system of the degree of accreta placentation at vaginal birth or laparotomy. RESULTS: PAS was diagnosed clinically at birth in 50 (8.2%) cases, 17 of which were confirmed by histopathology. A low (score ≤ 5), medium (score 6-7), high (score ≥ 8) probability for PAS was reported in 502, 61 and 44 cases, respectively. The probability score increased significantly (p < .001) in women ≥2 prior cesarean deliveries, with an anterior low-lying/placenta previa, with absent clear space, increased in retroplacental vascularity and with the size and numbers of lacunae. The number of cases classified clinically as grade 1 (non-PAS) and 3 (adherent PAS) was significantly (p < .001) lower in women with a high probability score whereas the rates of the other grades was significantly (p < .001) higher. The widest discrepancy between ultrasound probability score and clinical grade was found for grade 2 which, describes a partial placental adherence and grades 4 and 5 which, refer to placental percreta which describes tissue having invade trough the uterine serosa and beyond. CONCLUSIONS: Both ends of the spectrum of accreta placentation remain difficult to diagnose antenatal and clinically at birth, in particular when no histopathologic confirmation is available. There is a need to develop ultrasound accuracy score systems that can differentiate between the different grades of PAS and which are validated by standardized clinical and pathology protocols.