Vasa previa in singleton pregnancies: diagnosis and clinical management based on an international expert consensus.

BACKGROUND: There are limited data to guide the diagnosis and management of vasa previa. Currently, what is known is largely based on case reports or series and cohort studies. OBJECTIVE: This study aimed to systematically collect and classify expert opinions and achieve consensus on the diagnosis and clinical management of vasa previa using focus group discussions and a Delphi technique. STUDY DESIGN: A 4-round focus group discussion and a 3-round Delphi survey of an international panel of experts on vasa previa were conducted. Experts were selected on the basis of their publication record on vasa previa. First, we convened a focus group discussion panel of 20 experts and agreed on which issues were unresolved in the diagnosis and management of vasa previa. A 3-round anonymous electronic survey was then sent to the full expert panel. Survey questions were presented on the diagnosis and management of vasa previa, which the experts were asked to rate on a 5-point Likert scale (from "strongly disagree"=1 to "strongly agree"=5). Consensus was defined as a median score of 5. Following responses to each round, any statements that had median scores of ≤3 were deemed to have had no consensus and were excluded. Statements with a median score of 4 were revised and re-presented to the experts in the next round. Consensus and nonconsensus statements were then aggregated. RESULTS: A total of 68 international experts were invited to participate in the study, of which 57 participated. Experts were from 13 countries on 5 continents and have contributed to >80% of published cohort studies on vasa previa, as well as national and international society guidelines. Completion rates were 84%, 93%, and 91% for the first, second, and third rounds, respectively, and 71% completed all 3 rounds. The panel reached a consensus on 26 statements regarding the diagnosis and key points of management of vasa previa, including the following: (1) although there is no agreement on the distance between the fetal vessels and the cervical internal os to define vasa previa, the definition should not be limited to a 2-cm distance; (2) all pregnancies should be screened for vasa previa with routine examination for placental cord insertion and a color Doppler sweep of the region over the cervix at the second-trimester anatomy scan; (3) when a low-lying placenta or placenta previa is found in the second trimester, a transvaginal ultrasound with Doppler should be performed at approximately 32 weeks to rule out vasa previa; (4) outpatient management of asymptomatic patients without risk factors for preterm birth is reasonable; (5) asymptomatic patients with vasa previa should be delivered by scheduled cesarean delivery between 35 and 37 weeks of gestation; and (6) there was no agreement on routine hospitalization, avoidance of intercourse, or use of 3-dimensional ultrasound for diagnosis of vasa previa. CONCLUSION: Through focus group discussion and a Delphi process, an international expert panel reached consensus on the definition, screening, clinical management, and timing of delivery in vasa previa, which could inform the development of new clinical guidelines.

Risk Profiling In Vitro Fertilization Pregnancies that Develop Placenta Accreta Spectrum.

OBJECTIVE: The objective of this study is to assess whether, among a cohort of placenta accreta spectrum (PAS) patients, antenatal suspicion of PAS was less likely in in vitro fertilization (IVF) compared with non-IVF patients. In addition, we aimed to assess whether IVF patients exhibited similar risk factors for PAS compared with non-IVF patients. STUDY DESIGN: This is an international multicenter retrospective study of patients with pathologically confirmed PAS (accreta, increta, percreta) between 1998 and 2021. PAS patients were identified through a central international PAS database. Antenatal and pathological criteria are specific to each institution. Pregnancies that resulted from IVF were compared with non-IVF pregnancies. Comparisons were made using a chi-square or Fisher's exact test for categorical variables and Wilcoxon rank-sum test for continuous variables. RESULTS: Of the 692 pregnancies included, 44 were in the IVF group and 648 were in the non-IVF group. The IVF group was less likely to have had a prior cesarean delivery (70.5 vs. 91%, p < 0.01) but a similar prevalence of placenta previa (63.6 vs. 68.1%, p = 0.12) compared with the non-IVF group. The IVF group was also less likely to have either a prior cesarean delivery or placenta previa than the non-IVF group (79.5 vs. 95.4%, p < 0.01). Antenatal detection of PAS was less common in the IVF group compared with the non-IVF group (40.9 vs. 60.5%, p < 0.01, respectively), even when adjusted for maternal age, prior cesarean delivery, prior uterine surgery, placenta previa and site (risk ratio: 0.70, 95% confidence interval: 0.62-0.81). The IVF group had less severe pathological disease compared with the non-IVF group (p = 0.02). CONCLUSION: Pregnant people with PAS who underwent IVF are less likely to have an antenatal suspicion compared with non-IVF patients. This finding may be explained by the lower incidence of prior cesarean deliveries and/or placenta previa as well as less severe forms of PAS. KEY POINTS: · IVF group is less likely to have antenatal PAS suspicion.. · IVF group is less likely to have had prior cesarean delivery.. · Risk profile for PAS differs in IVF pregnancies..

Placenta accreta spectrum care infrastructure: an evidence-based review of needed resources supporting placenta accreta spectrum care.

The incidence of placenta accreta spectrum, the deeply adherent placenta with associated increased risk of maternal morbidity and mortality, has seen a significant rise in recent years. Therefore, there has been a rise in clinical and research focus on this complex diagnosis. There is international consensus that a multidisciplinary coordinated approach optimizes outcomes. The composition of the team will vary from center to center; however, central themes of complex surgical experts, specialists in prenatal diagnosis, critical care specialists, neonatology specialists, obstetrics anesthesiology specialists, blood bank specialists, and dedicated mental health experts are universal throughout. Regionalization of care is a growing trend for complex medical needs, but the location of care alone is just a starting point. The goal of this article is to provide an evidence-based framework for the crucial infrastructure needed to address the unique antepartum, delivery, and postpartum needs of the patient with placenta accreta spectrum. Rather than a clinical checklist, we describe the personnel, clinical unit characteristics, and breadth of contributing clinical roles that make up a team. Screening protocols, diagnostic imaging, surgical and potential need for critical care, and trauma-informed interaction are the basis for comprehensive care. The vision from the author group is that this publication provides a semblance of infrastructure standardization as a means to ensure proper preparation and readiness.

Delivery outcomes in the subsequent pregnancy following the conservative management of placenta accreta spectrum disorder: a systematic review and meta-analysis.

OBJECTIVE: Cesarean hysterectomy is generally presumed to decrease maternal morbidity and mortality secondary to placenta accreta spectrum disorder. Recently, uterine-sparing techniques have been introduced in conservative management of placenta accreta spectrum disorder to preserve fertility and potentially reduce surgical complications. However, despite patients often expressing the intention for future conception, few data are available regarding the subsequent pregnancy outcomes after conservative management of placenta accreta spectrum disorder. Thus, we aimed to perform a systematic review and meta-analysis to assess these outcomes. DATA SOURCES: PubMed, Scopus, and Web of Science databases were searched from inception to September 2022. STUDY ELIGIBILITY CRITERIA: We included all studies, with the exception of case studies, that reported the first subsequent pregnancy outcomes in individuals with a history of placenta accreta spectrum disorder who underwent any type of conservative management. METHODS: The R programming language with the "meta" package was used. The random-effects model and inverse variance method were used to pool the proportion of pregnancy outcomes. RESULTS: We identified 5 studies involving 1458 participants that were eligible for quantitative synthesis. The type of conservative management included placenta left in situ (n=1) and resection surgery (n=1), and was not reported in 3 studies. The rate of placenta accreta spectrum disorder recurrence in the subsequent pregnancy was 11.8% (95% confidence interval, 1.1-60.3; I2=86.4%), and 1.9% (95% confidence interval, 0.0-34.1; I2=82.4%) of participants underwent cesarean hysterectomy. Postpartum hemorrhage occurred in 10.3% (95% confidence interval, 0.3-81.4; I2=96.7%). A composite adverse maternal outcome was reported in 22.7% of participants (95% confidence interval, 0.0-99.4; I2=56.3%). CONCLUSION: Favorable pregnancy outcome is possible following successful conservation of the uterus in a placenta accreta spectrum disorder pregnancy. Approximately 1 out of 4 subsequent pregnancies following conservative management of placenta accreta spectrum disorder had considerable adverse maternal outcomes. Given such high incidence of adverse outcomes and morbidity, patient and provider preparation is vital when managing this population.

Knowledge Gaps in Placenta Accreta Spectrum.

Since its first description early in the 20th Century, placenta accreta and its variants have changed substantially in incidence, risk factor profile, clinical presentation, diagnosis and management. While systematic use of diagnostic tools and a multidisciplinary team care approach has begun to improve patient outcomes, the condition's pathophysiology, epidemiology, and best practices for diagnosis and management remain poorly understood. The use of large databases with broadly accepted terminology and diagnostic criteria should accelerate research in this area. Future work should focus on non-traditional phenotypes, such as those without placenta previa-preventive strategies, and long term medical and emotional support for patients facing this diagnosis. KEY POINTS: · Placenta accreta spectrum research may be improved with standardized terminology and use of large databases.. · Placenta accreta prediction should move beyond ultrasound with the addition of biomarkers, and needs to extend to those without traditional risk factors.. · Future research should identify practices that can prevent future accreta development..

Surgical Techniques for the Management of Placenta Accreta Spectrum.

The surgical management of placenta accreta spectrum (PAS) is often challenging. There are a variety of techniques and management options described in the literature ranging from uterine sparing to cesarean hysterectomy. Following the inaugural meeting of the Pan-American Society for Placenta Accreta Spectrum a multidisciplinary group collaborated to describe collective recommendations for the surgical management of PAS. In this manuscript, we outline individual components of the procedure and provide suggested direction at key points of a cesarean hysterectomy in the setting of PAS. KEY POINTS: · The surgical management of PAS requires careful planning and expertise.. · Multidisciplinary team care for pregnancies complicated by PAS can decrease morbidity and mortality.. · Careful surgical techniques can minimize risk of significant hemorrhage by avoiding pitfalls..

Imaging the Uterus in Placenta Accreta Spectrum Disorder.

Antenatal diagnosis of placenta accreta spectrum (PAS) improves maternal and neonatal outcomes by allowing for multidisciplinary planning and preparedness. Ultrasound is the primary imaging tool. Simplification and standardization of placental evaluation and reporting terminology allows improved communication and understanding between teams. Prior to 10 weeks of gestation, gestational sac position and least myometrial thickness surrounding the gestational sac help PAS diagnosis very early in pregnancy. Late first-, second-, and third-trimester evaluation includes comprehensive evaluation of the placenta, transabdominal and transvaginal with partially full maternal urinary bladder, and by color Doppler. Subsequently, the sonologist should indicate whether the evaluation was optimal or suboptimal; the level of suspicion as low, moderate, or high; and the extent as focal, global, or extending beyond the uterus. Other complementary imaging modalities such as 3D-power Doppler ultrasound, magnetic resonance imaging (MRI), and vascular topography mapping strive to improve antenatal placental evaluation but remain investigational at present. KEY POINTS: · Antenatal imaging, primarily using ultrasound with partially full maternal urinary bladder, is an essential means of evaluation of those at risk for PAS.. · Simplification and standardization of placental evaluation and reporting will allow improved communication between the multidisciplinary teams.. · Gestational sac location prior to 10 weeks of gestation and four markers after that (placental lacunae and echostructure, myometrial thinning, hypoechoic zone with or without bulging between placenta and myometrium, and increased flow on color Doppler)..

General Management Considerations for Placenta Accreta Spectrum.

The ideal management of a patient with placenta accreta spectrum (PAS) includes close antepartum management culminating in a planned and coordinated delivery by an experienced multidisciplinary PAS team. Coordinated team management has been shown to optimize outcomes for mother and infant. This section provides a consensus overview from the Pan-American Society for the Placenta Accreta Spectrum regarding general management of PAS.

Basal Plate Myofibers and the Risk of Placenta Accreta Spectrum in the Subsequent Pregnancy: A Large Single-Center Cohort.

OBJECTIVE: We aimed to evaluate whether there is a significant association between a placental pathology diagnosis basal plate myofibers (BPMF) in an index pregnancy with placenta accreta spectrum (PAS) in the subsequent pregnancy. STUDY DESIGN: We conducted a retrospective nested cohort study of all cases with a histopathological finding of BPMF between August 2012 and March 2020 at a single tertiary referral center. Data were collected for all subjects (cases and controls) with at least two consecutive pregnancies (the initial index pregnancy and at least one subsequent pregnancy) accompanied by a concomitant record of histopathological study of the placenta at our center. The primary outcome was pathologically confirmed PAS in the subsequent pregnancy. Data are presented as percentage or median, interquartile range accordingly. RESULTS: A total of n = 1,344 participants were included, of which n = 119 (index cases) carried a contemporaneous histopathological diagnosis of BPMF during the index pregnancy and n = 1,225 did not (index controls). Among the index cases, patients with BPMF were older (31.0 [20, 42] vs. 29.0 [15, 43], p < 0.001), more likely to have undergone in vitro fertilization (IVF) for conception (10.9 vs. 3.8%, p = 0.001) and were of a more advanced gestational age at delivery (39.0 [25, 41] vs. 38.0 [20, 42], p = 0.006). In the subsequent pregnancy, the rate of PAS was significantly higher among the BPMF index cases (6.7 vs. 1.1%, p < 0.001). After adjusting for maternal age and IVF, a histopathological diagnosis of BPMF in an index pregnancy was shown to be a significant risk factor for PAS in the subsequent gestation (hazard ratio: 5.67 [95% confidence interval: 2.28, 14.06], p < 0.001). CONCLUSION: Our findings support that a histopathological diagnosis of BPMF is an independent risk factor for PAS in the subsequent pregnancy. KEY POINTS: · BPMF may indicate morbid adherence of placenta.. · Patients with BPMF were older and more likely to have undergone IVF for conception.. · The BPMF in the current pregnancy is an independent risk factor for PAS in the subsequent pregnancy..

Emergency department burden of hyperemesis gravidarum in the United States from 2006 to 2014.

BACKGROUND: Hyperemesis gravidarum is the most severe form of nausea and vomiting of pregnancy, potentially affecting both maternal and pregnancy health. Hyperemesis gravidarum often results in emergency department visits, although the exact frequency and costs associated with these visits have not been well studied. OBJECTIVE: This study aimed to analyze the trends in hyperemesis gravidarum emergency department visits, inpatient admissions, and the associated costs between 2006 and 2014. STUDY DESIGN: Patients were identified from the 2006 and 2014 Nationwide Emergency Department Sample database files using International Classification of Diseases, Ninth Revision diagnosis codes. Patients with a primary diagnosis of hyperemesis gravidarum, nausea and vomiting of pregnancy, and all nondelivery pregnancy-related diagnoses (all antepartum visits) were identified. All groups were analyzed; trends in demographics, number of emergency department visits, and visit costs were compared. Costs were inflation-adjusted to 2021 US dollars. RESULTS: Emergency department visits for hyperemesis gravidarum increased by 28% from 2006 to 2014; however, the proportion of those who were subsequently admitted to the hospital decreased. The average cost of an emergency department visit for hyperemesis gravidarum increased by 65% ($2156 to $3549), as opposed to an increase of 60% for all antepartum visits ($2218 to $3543). The aggregate cost for all hyperemesis gravidarum visits increased by 110% ($383,681,346 to $806,696,513) from 2006 to 2014, which was similar to the increase observed for all antepartum emergency department visits. CONCLUSION: From 2006 to 2014, emergency department visits for hyperemesis gravidarum increased by 28%, with associated costs increasing by 110%, whereas the number of admissions from the emergency department for hyperemesis gravidarum decreased by 42%.

The Association between Placenta Accreta Spectrum Severity and Incidence of Small for Gestational Age Neonates.

OBJECTIVE: The aim of the study is to evaluate whether pathologic severity of placenta accreta spectrum (PAS) is correlated with the incidence of small for gestational age (SGA) and neonatal birthweight. STUDY DESIGN: This was a multicenter cohort study of viable, non-anomalous, singleton gestations delivered with histology-proven PAS. Data including maternal history, neonatal birthweight, and placental pathology were collected and deidentified. Pathology was defined as accreta, increta, or percreta. The primary outcome was rate of SGA defined by birth weight less than the 10th percentile. The secondary outcomes included incidence of large for gestational age (LGA) babies as defined by birth weight greater than the 90th percentile as well as incidence of SGA and LGA in preterm and term gestations. Statistical analysis was performed using Chi-square, Kruskal-Wallis, and log-binomial regression. Increta and percreta patients were each compared with accreta patients. RESULTS: Among the cohort of 1,008 women from seven United States centers, 865 subjects were included in the analysis. The relative risk (RR) of SGA for increta and percreta did not differ from accreta after adjusting for confounders (adjusted RR = 0.63, 95% confidence interval [CI]: 0.36-1.10 for increta and aRR = 0.72, 95% CI: 0.45-1.16 for percreta). The results were stratified by placenta previa status, which did not affect results. There was no difference in incidence of LGA (p = 1.0) by PAS pathologic severity. The incidence of SGA for all PAS patients was 9.2% for those delivered preterm and 18.7% for those delivered at term (p = 0.004). The incidence of LGA for all PAS patients was 12.6% for those delivered preterm and 13.2% for those delivered at term (p = 0.8203). CONCLUSION: There was no difference in incidence of SGA or LGA when comparing accreta to increta or percreta patients regardless of previa status. Although we cannot suggest causation, our results suggest that PAS, regardless of pathologic severity, is not associated with pathologic fetal growth in the preterm period. KEY POINTS: · PAS severity is not associated with SGA in the preterm period.. · PAS severity is not associated with LGA.. · Placenta previa does not affect the incidence of SGA in women with PAS..

Clinical Correlates of Placenta Accreta Spectrum Disorder Depending on the Presence or Absence of Placenta Previa: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate whether there are differences in risk factors and maternal outcomes of pregnancies complicated by placenta accreta spectrum depending on the presence or absence of placenta previa. DATA SOURCES: We performed a systematic search in Medline, EMBASE, ClinicalTrials.gov , and Web of Science from inception through April 25, 2022, without language or date restrictions. Search strategy included the key words "placenta accreta," "placenta increta," "placenta percreta," "adherent placenta," "invasive placenta," "abnormal placent*," "placenta previa," and "marginal placent*." METHODS OF STUDY SELECTION: Of the 1,122 articles screened, seven studies were included in the final review. Studies were included if they compared the risk factors and maternal outcomes of pregnancies complicated by placenta accreta spectrum depending on the presence or absence of placenta previa. TABULATION, INTEGRATION, AND RESULTS: A random-effects model was used to pool the mean differences or odds ratios (OR) and the corresponding 95% CIs using RevMan software. A total of 3,342 pregnancies complicated by placenta accreta spectrum were included in the meta-analysis (2,365 without previa and 977 with previa). Pregnancies complicated by placenta accreta spectrum without previa were more likely to have been conceived by in vitro fertilization (IVF) (OR 3.11, 95% CI 1.93-5.02, P <.001, I 2 =52.0%) and to be associated with prior dilation and curettage (D&C) (OR 1.60, 95% CI 1.15-2.22, P =.005, I 2 =0.0%) and myomectomy (OR 2.47, 95% CI 1.31-4.66, P =.005, I 2 =0.0%), but they were less likely to be associated with prior cesarean delivery (OR 0.15, 95% CI 0.06-0.37, P <.001, I 2 =87.0%). Placenta accreta spectrum without previa was less likely to be diagnosed antenatally (OR 0.07, 95% CI 0.04-0.11, P <.001, I 2 =38.0%). Also, women with pregnancies without previa had lower rates of red blood cell transfusion, intensive care unit admission, risk of hysterectomy, unscheduled delivery, and intraoperative bowel or bladder injuries. CONCLUSION: Pregnancies complicated by placenta accreta spectrum without previa had a more prominent association with IVF and prior D&C and myomectomy but were much less likely to be associated with prior cesarean delivery. Further, placenta accreta spectrum without previa was less likely to be diagnosed antenatally, although it had better maternal outcomes as compared with placenta accreta spectrum with previa. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022307637.

Timing of delivery for placenta accreta spectrum: the Pan-American Society for the Placenta Accreta Spectrum experience.

BACKGROUND: The Society for Maternal-Fetal Medicine recommends cesarean delivery with potential hysterectomy scheduled in the late preterm period between 34 0/7 and 35 6/7 weeks of gestation for prenatally suspected placenta accreta spectrum. OBJECTIVES: We aimed to investigate clinical compliance with the recommended delivery timing window for placenta accreta spectrum and its impact on maternal and neonatal outcomes. STUDY DESIGN: We performed a retrospective multicenter review of data from referral centers within the Pan-American Society for Placenta Accreta Spectrum. Patients with placenta accreta spectrum with both antenatal diagnosis and confirmed histopathologic findings were included. We investigated adherence to the Society for Maternal-Fetal Medicine-recommended gestational age window for delivery, and compliance was further stratified by scheduled and unscheduled delivery. We compared the outcomes for patients with scheduled delivery within vs immediately 2 weeks outside the recommended window. RESULTS: Among 744 patients with a prenatal diagnosis of placenta accreta spectrum and placental histopathologic confirmation, 488 (66%) had scheduled delivery. Among all prenatally diagnosed placenta accreta spectrum patients, 252 (39%) delivered within the recommended window of 34 0/7 and 35 6/7 weeks gestation. For the subgroup of patients who underwent scheduled delivery (n=426), 209 (49%) had delivery in this window, 120 (28%) delivered before 34 weeks, and 97 (23%) delivered at or later than 36 weeks. In the patients with scheduled delivery, 27% of placenta accreta spectrum patients with accreta delivered in the 2 weeks immediately after the recommended window (36 0/7-37 6/7 weeks), and 22% of placenta accreta spectrum pregnancies with increta/percreta delivered in the 2 weeks immediately before the recommended delivery (32 0/7-33 6/7 weeks). The maternal outcomes among those who delivered within the recommended range vs those delivering 2 weeks before and after the recommended range were similar, regardless of placenta accreta spectrum severity. CONCLUSION: Less than half of placenta accreta spectrum patients had scheduled delivery within the recommended gestational age of 34 0/7 to 35 6/7 weeks. The reasons for deviation from recommendations and the risks and benefits of individualized timing of delivery on the basis of risk factors and predicted outcomes warrant further investigation.

Patient Perception of Care, Outcomes, and Consequences from Placenta Accreta Spectrum: A Survey-Based Study.

OBJECTIVE: Placenta accreta spectrum (PAS) is an obstetric diagnosis that carries significant risks. However, little is known about patient perceptions of care. This study was conducted to describe the patient experience, reported outcomes, and assess geographical variation in PAS care in the United States. STUDY DESIGN: Partnering with a PAS patient advocacy organization, we conducted an online survey of PAS patients. Perceptions of care and outcomes, and geographic variation were described. RESULTS: We received 108 responses (69% response rate); 103 respondents delivered in the United States. Demographic characteristics were similar across each region. Most (67%) reported at least one prior cesarean delivery and 53% reported placenta previa in the PAS pregnancy. Over half (63%) reported an antenatal suspicion of PAS and 66% of those respondents reported changing their delivery hospital as a result of their antenatal diagnosis. Though not statistically significant, both showed variability across regions (both p ≥0.60). Seventy-five percent of respondents with antenatal diagnosis reported their pregnancy was managed by a dedicated PAS care team, which did not differ by region (p = 0.80). A majority of respondents (75%) felt their PAS care team was prepared for their delivery; this too did not vary across regions (p = 0.97). Many respondents reported at least one physical (63%) or mental health (17%) adverse outcome as a result of their PAS pregnancy. CONCLUSION: As reported by prior PAS patients, perception of care and outcomes are overall favorable. There are long-term physical and mental adverse consequences reported. Geographical variation is mixed, however, national guidelines are predominately followed. KEY POINTS: · Patient perceptions of care and outcomes are overall positive and favorable.. · Long lasting physical and mental health consequence from PAS pregnancies are commonly seen.. · Multidisciplinary care is widely adopted for PAS pregnancies..

COVID-19 in the Critically Ill Pregnant Patient.

Pregnant women are at increased risk for severe coronavirus disease 2019 (COVID-19) and COVID-19-related complications. Their increased risk in conjuncture with the normal physiologic changes in pregnancy poses unique challenges for the management of the critically ill pregnant patient. This article will review the initial management of pregnant patients who develop acute hypoxic respiratory failure and subsequent treatment of those that deteriorate to acute respiratory distress syndrome and require advanced therapies. Moreover, fetal monitoring and timing of delivery will be reviewed.

Timing of birth and adverse pregnancy outcomes in cases of prenatally diagnosed vasa previa: a systematic review and meta-analysis.

OBJECTIVE: The ideal time for birth in pregnancies diagnosed with vasa previa remains unclear. We conducted a systematic review aiming to identify the gestational age at delivery that best balances the risks for prematurity with that of pregnancy prolongation in cases with prenatally diagnosed vasa previa. DATA SOURCES: Ovid MEDLINE, PubMed, CINAHL, Embase, Scopus, and Web of Science were searched from inception to January 2022. STUDY ELIGIBILITY CRITERIA: The intervention analyzed was delivery at various gestational ages in pregnancies prenatally diagnosed with vasa previa. Cohort studies, case series, and case reports were included in the qualitative synthesis. When summary figures could not be obtained directly from the studies for the quantitative synthesis, authors were contacted and asked to provide a breakdown of perinatal outcomes by gestational age at birth. METHODS: Study appraisal was completed using the National Institutes of Health quality assessment tool for the respective study types. Statistical analysis was performed using a random-effects meta-analysis of proportions. RESULTS: The search identified 3435 studies of which 1264 were duplicates. After screening 2171 titles and abstracts, 140 studies proceeded to the full-text screen. A total of 37 studies were included for analysis, 14 of which were included in a quantitative synthesis. Among 490 neonates, there were 2 perinatal deaths (0.4%), both of which were neonatal deaths before 32 weeks' gestation. In general, the rate of neonatal complications decreased steadily from <32 weeks' gestation (4.6% rate of perinatal death, 91.2% respiratory distress, 11.4% 5-minute Apgar score <7, 23.3% neonatal blood transfusion, 100% neonatal intensive care unit admission, and 100% low birthweight) to 36 weeks' gestation (0% perinatal death, 5.3% respiratory distress, 0% 5-minute Apgar score <7, 2.9% neonatal blood transfusion, 29.2% neonatal intensive care unit admission, and 30.9% low birthweight). Complications then increased slightly at 37 weeks' gestation before decreasing again at 38 weeks' gestation. CONCLUSION: Prolonging pregnancies until 36 weeks' gestation seems to be safe and beneficial in otherwise uncomplicated pregnancies with antenatally diagnosed vasa previa.

The Society for Pediatric Pathology Task Force grading system for placenta accreta spectrum and its correlation with clinical outcomes.

BACKGROUND: The terminology and diagnostic criteria presently used by pathologists to report placenta accreta spectrum is inconsistent and does not reflect current knowledge of the pathogenesis of this disease. OBJECTIVE: In 2020, the perinatal subcommittee of the Society for Pediatric Pathology Placenta Accreta Task Force proposed a new pathologic grading system for placenta accreta spectrum. We sought to correlate the clinical outcomes with the classification into each group in the new placenta accreta spectrum grading system. STUDY DESIGN: The pathology reports of patients with histopathologic confirmation of placenta accreta spectrum were reviewed in 2 academic referral centers by placental pathologists. Pathologic grading was assigned based on the new grading system according to which placenta accreta spectrum is categorized into 5 groups depending on the depth of invasion, from grade p1 with no invasion into the uterine wall to grade p3E with invasion beyond the uterine wall to the adjacent organs. Patient characteristics and clinical outcomes were compared among these groups. A univariate analysis was performed, and a multivariate linear or binomial regression was employed when needed. RESULTS: A total of 683 patients with placenta accreta spectrum were identified. Of those, 407 were included for histology review. There were 92 patients (23%) categorized into the grade p1 group, 74 (18%) in the grade p2 group, 84 (20%) in the grade p3A group, 121 (30%) in the grade p3D group, and 36 (9%) in the grade p3E group. There was a significant association between the pathology grading and the number of red blood cells transfused (ß=1.14; 95% confidence interval, 0.48-1.79) and the postoperative complications including the rate of readmission (risk ratio, 1.93; 95% confidence interval, 1.26-2.94) and bladder injury (risk ratio, 1.81; 95% confidence interval, 1.23-2.68) after adjustment for antenatal diagnosis and other variables. The pathology grading was not associated with the estimated blood loss (P=.072). CONCLUSION: The new pathology grading system accurately reflects maternal outcomes and complications of placenta accreta spectrum. We encourage the utilization of this new pathologic grading system because it is designed to omit discrepancies in placenta accreta spectrum reporting and to standardize communication.