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

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

Intramuscular 17α-hydroxyprogesterone caproate to decrease preterm delivery in women with placenta praevia: a randomised controlled trial.

We tested the hypothesis that 17α-hydroxyprogesterone caproate (17α-OHP-C) may decrease preterm delivery (PTD) in women with placenta praevia. This was a randomised controlled trial included 114 women with placenta praevia (between 24 and 28 weeks). They were randomly assigned to group I (17α-OHP-C) who received weekly injection of 17α-OHP-C (250 mg/IM) till completing 37 weeks' gestation or group II (Non 17α-OHP-C). The percentage of placenta praevia patients went into PTD in the 17α-OHP-C group was significantly less in comparison to the PTD in the Non 17α-OHP-C group (∼37% vs. 63.5%, p = .004). Furthermore, the mean gestational age was significantly longer (36.7 ± 0.7 vs. 34.9 ± 1.2 weeks, p < .000), the mean number of bleeding attacks was significantly less and the mean birth weight was significantly higher (2841 ± 159 vs. 2561 ± 168 g, p < .000). In conclusion, maintenance tocolysis with intramuscular 17α-OHP-C in placenta praevia women appears beneficial in decreasing the number of bleeding attacks, the percentage of PTD and the neonatal ICU admission.IMPACT STATEMENTWhat is already known on this subject? Over the last two decades, a large number of studies indicated that placenta praevia is a major risk factor for preterm labour and prematurity with its neonatal complications. Increasing caesarean section rates had proportionally increased the incidence of placenta praevia.What do the results of this study add? Up to now, the effective and safe tocolytic agent among these patients is not established. The results of this study (prospective, randomised and controlled with calculated sample size) added a considerable support for hydroxyprogesterone caproate as an effective, safe and cheap tocolytic agent with excellent patient compliance.What are the implications of these findings for clinical practice and/or further research? Our findings may prompt researchers to conduct a large multicentre study to evaluate the prophylactic use of hydroxyprogesterone caproate to decrease preterm labour due to placenta praevia.

Maintenance nifedipine therapy for preterm symptomatic placenta previa: A randomized, multicenter, double-blind, placebo-controlled trial.

OBJECTIVE: To assess the impact of maintenance nifedipine therapy on pregnancy duration in women with preterm placenta previa bleeding. METHODS: PPADAL was a randomized, double-blind, placebo-controlled trial conducted between 05/2008 and 05/2012 in five French hospitals. The trial included 109 women, aged ≥ 18 years, with at least one episode of placenta previa bleeding, intact membranes and no other pregnancy complication, at gestational age 24 to 34 weeks and after 48 hours of complete acute tocolysis. Women were randomly allocated to receive either 20 mg of slow-release nifedipine three times daily (n = 54) or placebo (n = 55) until 36 + 6 weeks of gestation. The primary outcome for the trial was length of pregnancy measured in days after enrolment. Main secondary outcomes were rates of recurrent bleeding, cesarean delivery due to hemorrhage, blood transfusion, maternal side effects, gestational age at delivery and adverse perinatal outcomes (perinatal death, chronic lung disease, neonatal sepsis, intraventricular hemorrhage > grade 2, perventricular leukomalacia > grade 1, or necrotizing enterocolitis). Analysis was by intention to treat. RESULTS: Mean (SD) prolongation of pregnancy was not different between the nifedipine (n = 54) and the placebo (n = 55) group; 42.5 days ± 23.8 versus 44.2 days ± 24.5, p = 0.70. Cesarean due to hemorrhage performed before 37 weeks occurred more frequently in the nifedipine group in comparison with the placebo group (RR, 1.66; 95% confidence interval, 1.05-2.72). Adverse perinatal outcomes were comparable between groups; 3.8% for nifedipine versus 5.5% for placebo (relative risk, 0.52; 95% confidence interval 0.10-2.61). No maternal mortality or perinatal death occurred. CONCLUSION: Maintenance oral nifedipine neither prolongs duration of pregnancy nor improves maternal or perinatal outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT00620724.

Topical application of recombinant activated factor VII during cesarean delivery for placenta previa.

BACKGROUND: During cesarean delivery in patients with placenta previa, hemorrhaging after removal of the placenta is often challenging. In this condition, the extraordinarily high concentration of tissue factor at the placenta site may constitute a principle of treatment as it activates coagulation very effectively. The presumption, however, is that tissue factor is bound to activated factor VII. OBJECTIVE: We hypothesized that topical application of recombinant activated factor VII at the placenta site reduces bleeding without affecting intravascular coagulation. STUDY DESIGN: We included 5 cases with planned cesarean delivery for placenta previa. After removal of the placenta, the surgeon applied a swab soaked in recombinant activated factor VII containing saline (1 mg in 246 mL) to the placenta site for 2 minutes; this treatment was repeated once if the bleeding did not decrease sufficiently. We documented the treatment on video recordings and measured blood loss. Furthermore, we determined hemoglobin concentration, platelet count, international normalized ratio, activated partial thrombin time, fibrinogen (functional), factor VII:clot, and thrombin generation in peripheral blood prior to and 15 minutes after removal of the placenta. We also tested these blood coagulation variables in 5 women with cesarean delivery planned for other reasons. Mann-Whitney test was used for unpaired data. RESULTS: In all 5 cases, the uterotomy was closed under practically dry conditions and the median blood loss was 490 (range 300-800) mL. There were no adverse effects of recombinant activated factor VII and we did not measure factor VII to enter the circulation. Neither did we observe changes in thrombin generation, fibrinogen, activated partial thrombin time, international normalized ratio, and platelet count in the peripheral circulation (all P values >.20). CONCLUSION: This study indicates that in patients with placenta previa, topical recombinant activated factor VII may diminish bleeding from the placenta site without initiation of systemic coagulation.

Mifepristone combined with ethacridine lactate for the second-trimester pregnancy termination in women with placenta previa and/or prior cesarean deliveries.

PURPOSE: This study was aimed to evaluate the safety and efficacy of the second-trimester medical abortions using mifepristone and ethacridine lactate in women with placenta previa and/or prior cesarean deliveries. METHODS: The patients who underwent a second-trimester pregnancy termination from January 2009 to December 2015 were retrospectively analyzed. The eligible patients were assigned to four groups based on placentation and cesarean history. The abortion interval (AI), blood loss, hospital stays, incidence of curettage, and transfusion were reviewed. RESULTS: Two women underwent cesarean sections for placenta increta. Finally, 443 patients were enrolled in this study, including 92 with placenta previa, 153 with prior cesarean deliveries, 36 with the both factors, and 236 with normal placentation and no cesarean delivery history. All the included cases had a successful vaginal delivery. There was no significant difference in AI, hospital stay, rate of hemorrhage, and transfusion among the four groups. Patients with prior cesarean section had higher blood loss than the normal group (P = 0.0017), as well as patients with both placenta previa and prior cesarean (P = 0.0018). However, there was no obvious blood loss in patients with placenta previa when compared with normal placetal patients (P = 0.23). No uterine rupture occurred in all patients. CONCLUSIONS: Mifepristone combined with ethacridine lactate is safe and effective for patients with low placentation or/and prior cesarean in the second-trimester pregnancy termination.

How do we manage blood product support in the massively hemorrhaging obstetric patient?

Obstetric hemorrhage remains a leading cause of maternal mortality with more than 140,000 deaths annually worldwide. Abnormal placentation has increased to become the most common diagnosis requiring massive blood transfusion in obstetrics, with uterine atony a close second. At our institution, as well as nationwide, there has been a steady increase in pregnancies complicated by abnormal placentation, including accreta, increta, and percreta. Providers at our facility created the New England Center for Placental Disorders in May 2015 to address these complex patients. The incidence of accreta has actually increased 10-fold over the past 50 years, becoming the most common reason for cesarean hysterectomy in highly industrialized countries. The most common risk factor for accreta is repeat cesarean sections, particularly those with associated placenta previa. Contemporary cesarean section rates have risen, with more than 1.2 million women having had a cesarean section in the United States in 2014. We present a case vignette of a multiparous woman presenting with heavy vaginal bleeding at 30 weeks' gestation with imaging concerning for placenta accreta and possible percreta. We describe our approach to the management of these complicated patients.

[Treatment of placenta percreta requires a multidisciplinary approach]. / Behandling af placenta percreta kræver involvering af flere specialer.

Placenta percreta is a rare life-threatening obstetrical condition, often resulting in severe haemorrhage and hysterectomy. The incidence seems to be increasing, probably secondary to the increase in caesarean section rates. We present a protocol for an elective multidisciplinary approach with proactive management to reduce haemorrhage and allow appropriate surgery, which imply a low maternal and fetal morbidity as well as maintained fertility.

Tractocile as maintenance treatment in selected cases of threatened preterm labor

El parto prematuro es una de las causas más importantes de mortalidad y morbilidad neonatal. Su manejo sigue siendo uno de los problemas sin solucionar dentro de la obstetricia moderna ya que no se ha conseguido disminuir su incidencia. Actualmente, el tratamiento tocolítico en las amenazas de parto prematuro se mantiene durante 48h con la finalidad de tener tiempo suficiente para inducir farmacológicamente la maduración pulmonar. Sin embargo, lo ideal sería prolongar la gestación hasta conseguir un recién nacido sano y a término. Exponemos los casos de 3 pacientes con amenaza de parto prematuro en las que se mantuvo el tratamiento con tractocile entre 9 y 38 días, hasta alcanzar las 32 semanas. Ninguna presentó efectos secundarios. Las gestaciones se consiguieron prolongar entre 11,7 y 8 semanas (AU)

Preterm delivery is one of the main causes of perinatal morbidity and mortality. The management of this entity is an unresolved issue in modern obstetrics, since its incidence has not decreased.Currently, tocolytic treatment in acute episodes of preterm labor is maintained for 48h to induce lung maturation pharmacologically. However, the ideal situation is to prolong pregnancy until a healthy, term neonate can be delivered.We report the cases of three patients with threatened preterm labor in which tractocile treatment was maintained for between 9 and 38 days until 32-week pregnancies were achieved. There were no adverse effects. The pregnancies were prolonged for 11, 8 and 7 weeks (AU)

When should women with placenta previa be delivered? A decision analysis.

OBJECTIVE: To determine the optimal gestational age of delivery for women with placenta previa by accounting for both neonatal and maternal outcomes. STUDY DESIGN: A decision-analytic model was designed comparing total maternal and neonatal quality-adjusted life years for delivery of women with previa at gestational ages from 34 to 38 weeks. At each week, we allowed for four different delivery strategies: (1) immediate delivery, without amniocentesis or steroids; (2) delivery 48 hours after steroid administration (without amniocentesis); (3) amniocentesis with delivery if fetal lung maturity (FLM) positive or retesting in one week if FLM negative; (4) amniocentesis with delivery if FLM testing is positive or administration of steroids if FLM negative. RESULTS: Delivery at 36 weeks, 48 hours after steroids, for women with previa optimizes maternal and neonatal outcomes. In sensitivity analyses, these results were robust to a wide range of variation in input assumptions. If it is assumed that steroids offer no neonatal benefit at this gestational age, outright delivery at 36 weeks' gestation is the best strategy. CONCLUSION: Steroid administration at 35 weeks and 5 days followed by delivery at 36 weeks for women with placenta previa optimizes maternal and neonatal outcomes.

[Placenta previa percreta with bladder involvement managed conservatively--case report]. / Zachowawcze postepowanie w placenta previa percreta przerastajacym sciany pecherza moczowego--opis przypadku.

Placenta percreta is potentially a life-threatening condition. Pelvic organ invasion of the placenta carries high mortality and morbidity to the mother and fetus. We present a 33 year old gravida 3, para 2-0-0 female with placenta previa, percreta with bladder invasion. Placental invasion caused a giant vesicouterine fistula. The pregnant woman was managed conservatively until 33 weeks gestation, at which time she underwent a classical cesarean section. Postoperatively the patient was treated with methotrexate. Immediately postpartum the placenta was left in situ and successfully removed transvaginally after 11 weeks postpartum.

Late postpartum hemorrhage after hemostatic square suturing technique: a case report.

BACKGROUND: Hemostatic square suturing is a useful technique for postpartum hemorrhage, but some complications may occasionally occur. CASE: A 36-year-old pregnant woman with placenta previa and percreta at 35 weeks' gestation complicated with massive vaginal bleeding. An emergency cesarean section was performed, and placenta previa with percreta and uterine atony were noted. A hemostatic square suture was placed to compress the uterus and stopped the hemorrhage successfully. The estimated blood loss was approximately 2,200 mL. Thirty-seven days after operation, massive vaginal bleeding developed and the ultrasonography showed a 6.84 x 5.71-cm complex intrauterine mass. The patient was treated with intravenous oxytocin, rectal misoprostol, and blood transfusion. The beta-human chorionic gonadotropin levels returned to normal level on day 70 postoperatively, and ultrasonography revealed no obvious intrauterine mass. CONCLUSION: Late postpartum hemorrhage may result from the use of hemostatic square suture technique.

Tocolytic therapy in conservative management of symptomatic placenta previa.

OBJECTIVES: To study the effect of ritodrine therapy on maternal and perinatal outcome in cases of symptomatic placenta previa being managed conservatively. METHODS: A prospective, randomized controlled clinical trial was made of a total of 60 women whose pregnancies ranged from 28 through 34 menstrual weeks who were randomly allocated to the two study groups using Tippet's random number table. Of these women, 30 were included in the study group where tocolysis with ritodrine was given whereas the other 30 in the control group did not receive tocolysis. Prolongation of pregnancy and birth weight of the newborn were evaluated. The unpaired t-test and chi-square test were used for statistical analysis. RESULTS: Use of tocolysis in symptomatic placenta previa was associated with significant prolongation of pregnancy (25.33 vs. 14.47 days, P<0.05) and difference in birth weight (2270 g vs. 1950 g, P<0.05). There was no observed statistical difference between the two groups with regard to number of episodes of hemorrhage after admission, total amount of blood loss during stay in hospital, number of blood transfusions and maternal complications due to tocolysis in the study group. CONCLUSIONS: The present prospective study suggests that ritodrine hydrochloride in patients with symptomatic placenta previa tends to prolong the pregnancy and result in an increase in birth weight of the babies without causing any adverse effect on the mother and fetus.

[The use of the vasoconstrictor hemostatic Remestyp in surgical obstetrics]. / Prilozhenie na vazokonstriktorniia khemostatik Remestyp v operativnoto akusherstvo.

Terlipressin (Remestyp) or N-a-triglycyl-(8-lysme) vasopressin after parenteral application and slow enzymatic cleavage releases synthetic analog of vasopressin-8-lysine-vasopressin. It is potent myometrial stimulator in pregnant and non-pregnant uterus and at the same time decreases myometrial and endometrial blood flow. Remestyp has synergistic effect with oxytocin and/or methergin. Our experience shows good effect of Remestyp in the complex treatment of cases with hypotonic uterus, placenta praevia or adherence during and after abdominal or vaginal birth. Injection of Remestyp around the fibroids during cesarean section significantly decrease the blood lost and make the myomectomy safer. We observe decrease of oozing at the incision of the skin and stopping initial subfascial hematoma.

[Expectant treatment of placenta previa with ritodrine].

OBJECTIVE: To investigate the effectiveness of the expectant treatment in placenta previa with adrenergic agonist ritodrine. METHODS: 50 women with placenta previa of preterm labor were randomly assigned into two groups. 26 patients treated with magnesium sulfate were served as control group. 24 patients were enrolled in the study group, receiving ritodrine 100 mg in 5% glucose 500 ml intravenous. The drip speed was started at 8 drips per minute routinely, then adjusted according to the treatment response, and oral ritodrine was used after vaginal bleeding and uterine contraction disappeared 12 hours. If contraction reappeared, the i.v. infusion would be restarted. RESULTS: The study group prolonged the gestational period to an average of 28.24 days and increased the birth weight of newborn to an average of 2,913.68 g (P < 0.05). CONCLUSION: Ritodrine is highly effective and safe for expectant treatment of placenta previa.

The effect of tocolytic use in the management of symptomatic placenta previa.

OBJECTIVE: The null hypothesis is that tocolysis has no effect on pregnancy prolongation in the aggressive expectant management of symptomatic preterm placenta previa. STUDY DESIGN: One hundred twelve preterm pregnancies with confirmed placenta previa and an initial episode of acute vaginal bleeding were selected for this retrospective analysis. Exclusion criteria included gestational age > or = 35 weeks, delivery within 24 hours of admission, prior treatment for bleeding or preterm labor, and contraindications to tocolytic use. Tocolysis was prescribed, at the discretion of the treating clinical staff, in selected pregnancies with significant uterine contractions after admission of the patient. The majority of treated patients (85%) received intravenous magnesium sulfate and/or oral or subcutaneous beta-sympathomimetics within 24 hours of admission. Most patients remained hospitalized until delivery under this aggressive expectant management protocol. Both treated and untreated control study groups were similar at inclusion with regard to parity, gestational age, contraction frequency, and degree of initial bleeding. Outcome variables for each treatment group were obtained from final chart review. Continuous and categoric variables were compared with Student t test or chi 2 analysis-Fisher's exact test, respectively. RESULTS: The clinical use of tocolysis in symptomatic placenta previa was associated with a clinically significant delay of preterm delivery. Significant improvement in clinical parameters such as interval from admission to delivery (39.2 vs 26.9 days, p < 0.02) and birth weight (2520 vs 2124 gm, p < 0.03) was observed in the tocolysis group. There was no observed statistical difference between the two treatment groups with regard to incidence of recurrent bleeding, interval from admission to first recurrent bleeding, and need for transfusion. There was a trend for patients with multiple bleeding episodes to have been receiving tocolytic therapy (p < 0.10). A trend for requiring a postpartum transfusion was also noted in the tocolysis group (p < 0.09). Treated pregnancies receiving long-term maintenance tocolysis with oral or subcutaneous terbutaline exhibited a greater degree of pregnancy prolongation than those treated with short-term intravenous magnesium alone (43.7 vs 15.3 days, p < 0.02). CONCLUSIONS: This retrospective analysis suggests that tocolytic intervention in cases of symptomatic preterm previa may be associated with clinically significant prolongation of pregnancy and increased birth weight. Tocolytic therapy in these cases does not appear to have an impact on frequency or severity of recurrent vaginal bleeding. Further prospective analysis may delineate the role of tocolysis in the aggressive expectant management of symptomatic placenta previa.

Magnesium sulfate tocolysis in selected patients with symptomatic placenta previa.

Tocolysis can be used to arrest contractions in selected patients with placenta previa if the maternal condition is stable. Over a 5-year period, 41 patients with symptomatic placenta previa were treated, of whom 18 were given magnesium sulfate therapy for tocolysis. The mean prolongation of gestation was 18.5 days, and tocolysis was successful in 17 of 18 cases. Since betamimetic drugs used for tocolysis may mask or blunt maternal cardiovascular responses to volume depletion, magnesium sulfate is a better choice to inhibit contractions in patients with symptomatic placenta previa whose bleeding is mild or moderate.

Prolonged use of tocolytic agents in the expectant management of placenta previa.

The effects of the prolonged use (greater than seven days) of tocolytic agents, along with other established procedures of conservative, expectant management, were studied in 45 patients with either total or marginal-partial placenta previa. Our regimen prolonged pregnancy for seven days or more in 81.2% of total placenta previas and 91.7% of marginal-partial ones. Antepartum hospitalization and shortened neonatal length of stay resulted in a total saving of $18,175 per case. The prolonged use of tocolytic agents, in addition to expectant management, in patients with placenta previa increased the length of pregnancy, decreased neonatal morbidity and was cost effective.