Comparison of effect of CTG + STan with CTG alone on emergency Cesarean section rate: STan Australian Randomized controlled Trial (START).

OBJECTIVE: To investigate whether use of ST analysis of the fetal electrocardiogram (STan) as an adjunct to continuous cardiotocography (CTG) reduces the rate of emergency Cesarean section (EmCS) compared with CTG alone. METHODS: This was a randomized controlled trial of patients with a singleton fetus in cephalic presentation at ≥ 36 weeks' gestation, requiring continuous electronic fetal monitoring during labor at a tertiary maternity hospital in Adelaide, Australia, between January 2018 and July 2021. Participants were randomized to undergo CTG + STan or CTG alone. The calculated sample size was 1818 participants. The primary outcome was EmCS. Secondary outcomes included metabolic acidosis, a composite adverse perinatal outcome, and other maternal and neonatal morbidity and safety outcomes. RESULTS: The present study enrolled 970 women, of whom 967 were included in the primary analysis. EmCS occurred in 107/482 (22.2%) deliveries in the CTG + STan arm and in 107/485 (22.1%) in the CTG arm (adjusted relative risk, 1.02 (95% CI, 0.81-1.27); P = 0.89). There was no difference in the rate of adverse maternal or neonatal outcomes between arms. CONCLUSIONS: The addition of STan as an adjunct to continuous CTG did not reduce the EmCS rate. The smaller-than-anticipated sample size meant that this study was underpowered to detect absolute differences of ≤ 5% and, therefore, this negative finding could be due to a Type-2 error. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Effectiveness of contingent screening for placenta accreta spectrum disorders based on persistent low-lying placenta and previous uterine surgery.

OBJECTIVES: Maternal mortality related to placenta accreta spectrum (PAS) disorders remains substantial when diagnosed unexpectedly at delivery. The aim of this study was to evaluate the effectiveness of a routine contingent ultrasound screening program for PAS. METHODS: This was a retrospective study of data obtained between 2009 and 2019, involving two groups: a screening cohort of unselected women attending for routine mid-trimester ultrasound assessment and a diagnostic cohort consisting of women referred to the PAS diagnostic service with a suspected diagnosis of PAS. In the screening cohort, women with a low-lying placenta at the mid-trimester assessment were followed up in the third trimester, and those with a persistent low-lying placenta (i.e. placenta previa) and previous uterine surgery were referred to the PAS diagnostic service. Ultrasound assessment by the PAS diagnostic service consisted of two-dimensional grayscale and color Doppler ultrasonography, and women with a diagnosis of PAS were usually managed with conservative myometrial resection. The final diagnosis of PAS was based on a combination of intraoperative clinical findings and histopathological examination of the surgical specimen. RESULTS: In total, 57 179 women underwent routine mid-trimester fetal anatomy assessment, of whom 220 (0.4%) had a third-trimester diagnosis of placenta previa. Seventy-five of these women were referred to the PAS diagnostic service because of a history of uterine surgery, and 21 of 22 cases of PAS were diagnosed correctly (sensitivity, 95.45% (95% CI, 77.16-99.88%) and specificity, 100% (95% CI, 99.07-100%)). Univariate analysis demonstrated that parity ≥ 2 (odds ratio (OR), 35.50 (95% CI, 6.90-649.00)), two or more previous Cesarean sections (OR, 94.20 (95% CI, 22.00-656.00)) and placenta previa (OR, 20.50 (95% CI, 4.22-369.00)) were the strongest risk factors for PAS. In the diagnostic cohort, there were 173 referrals, with one false-positive and three false-negative diagnoses, resulting in a sensitivity of 96.63% (95% CI, 90.46-99.30%) and a specificity of 98.81% (95% CI, 93.54-99.97%). CONCLUSIONS: A contingent screening strategy for PAS is both feasible and effective in a routine healthcare setting. When linked to a PAS diagnostic and surgical management service, adoption of such a screening strategy has the potential to reduce the maternal morbidity and mortality associated with this condition. However, larger prospective studies are necessary before implementing this screening strategy into routine clinical practice. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Eficacia de la detección contingente para los trastornos del espectro de la placenta acreta a partir de la placenta baja persistente y en la cirugía uterina previa OBJETIVOS: La mortalidad materna relacionada con los trastornos de la gama espectral de la placenta acreta (EPA) sigue siendo considerable cuando se diagnostica de forma inesperada en el momento del parto. El objetivo de este estudio fue evaluar la efectividad de un programa rutinario de detección contingente mediante ecografía para el EPA. MÉTODOS: Este fue un estudio retrospectivo de datos obtenidos entre 2009 y 2019, en el que participaron dos grupos: una cohorte de detección de mujeres no seleccionadas que acudieron a la evaluación ecográfica rutinaria de mitad de trimestre y una cohorte de diagnóstico, integrada por mujeres remitidas al servicio de diagnóstico del EPA con un presunto diagnóstico del EPA. En la cohorte de detección, a las mujeres con una placenta baja en la evaluación de mitad de trimestre se les hizo un seguimiento en el tercer trimestre, y a aquellas con una placenta baja persistente (es decir, placenta previa) que habían tenido cirugía uterina previa se las remitió al servicio de diagnóstico del EPA. La evaluación ecográfica por el servicio de diagnóstico del EPA consistió en una ecografía Doppler bidimensional en escala de grises y en color, y a las mujeres con diagnóstico del EPA se las trató habitualmente con una resección conservadora del miometrio. El diagnóstico final del EPA se basó en una combinación de indicadores clínicos intraoperatorios y el examen histopatológico de la muestra quirúrgica. RESULTADOS: En total, 57179 mujeres se sometieron a una evaluación rutinaria de la anatomía fetal a mitad del trimestre, de las cuales a 220 (0,4%) se les diagnosticó con placenta previa en el tercer trimestre. Setenta y cinco de estas mujeres fueron remitidas al servicio de diagnóstico del EPA, debido a su historial de cirugía uterina, y 21 de los 22 casos de EPA fueron diagnosticados correctamente (sensibilidad, 95,45% (IC 95%, 77,16-99,88%) y especificidad, 100% (IC 95%, 99,07-100%)). El análisis univariante demostró que la paridad ≥2 (razón de momios (RM), 35,50 (IC 95%, 6,90-649,00)), dos o más cesáreas previas (RM, 94,20 (IC 95%, 22,00-656,00)) y la placenta previa (RM, 20,50 (IC 95%, 4,22-369,00)) fueron los factores de riesgo más fuertes para el EPA. En la cohorte de diagnóstico, se remitió a 173 mujeres, entre las cuáles hubo un diagnóstico de falso-positivo y tres diagnósticos de falsos-negativos, lo que dio como resultado una sensibilidad del 96,63% (IC 95%, 90,46-99,30%) y una especificidad del 98,81% (IC 95%, 93,54-99,97%). CONCLUSIONES: La adopción de una estrategia de detección contingente para el EPA es tanto factible como eficaz en un entorno de atención sanitaria rutinaria. Cuando se asocia a un servicio de diagnóstico y gestión quirúrgica del EPA, la adopción de esa estrategia de detección podría reducir la morbilidad y la mortalidad maternas asociadas a esta afección. Sin embargo, se necesitan estudios prospectivos más amplios antes de aplicar esta estrategia de detección en la práctica clínica habitual. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Endometriosis in adolescence: Early manifestation of the traditional disease or a unique variant?

Little is known about Endometriosis in Adolescents and its prevalence is yet to be estimated. Traditional Endometriosis seems to be, by far, quite different with this unique variant when it comes to clinical presentation, management and course of the disease. Further research needs to be conducted in order to classify these two, phenomenically similar, diseases. Adolescents with a history of dysmenorrhea and chronic pelvic pain (CPP) imply findings suggestive of endometriosis. The severity of the disease is variable, from superficial endometriosis to deep endometriotic lesions or even ovarian endometriomas. The course of the disease also suggests the necessity of a more personalized approach since among adolescents, endometriosis could resolve or even aggravate with no particular pathophysiological pattern. Some studies suggest that appropriate treatment should be based on the understanding of the pathophysiologic mechanisms. Long term course of the disease, as well as, a high recurrence rate pose a difficulty to scientists, deciding conservative over operative surgery. Some believe that early operation on superficial forms of endometriosis could potentially prevent deep endometriotic lesions in the long-run. Others find medication such as, combined oral contraceptive pills (COCPs), progestins, levonorgestrel intrauterine device or gonadotrophin releasing hormone analogues (GnRHa), more appropriate for this age group. Last but not least, operation with post-operative hormonal treatment remains the most common treatment approach. Nevertheless, our limited understanding of the disease, as well as, particular factors needed to be taken into consideration, for instance, bone formation in this age group, underline the necessity of further studies, needed to be appointed, in order to determine the best diagnostic and therapeutic approach.

Comparing the effect of STan (cardiotocographic electronic fetal monitoring (CTG) plus analysis of the ST segment of the fetal electrocardiogram) with CTG alone on emergency caesarean section rates: study protocol for the STan Australian Randomised controlled Trial (START).

BACKGROUND: Cardiotocography is almost ubiquitous in its use in intrapartum care. Although it has been demonstrated that there is some benefit from continuous intrapartum fetal monitoring using cardiotocography, there is also an increased risk of caesarean section which is accompanied by short-term and long-term risks to the mother and child. There is considerable potential to reduce unnecessary operative delivery with up to a 60% false positive diagnosis of fetal distress using cardiotocography alone. ST analysis of the fetal electrocardiogram is a promising adjunct to cardiotocography alone, and permits detection of metabolic acidosis of the fetus, potentially reducing false positive diagnosis of fetal distress. METHODS: This study will be a single-centre, parallel-group, randomised controlled trial, conducted over 3 years. The primary hypothesis will be that the proportion of women with an emergency caesarean section on ST analysis will not equal that for women on cardiotocography monitoring alone. Participants will be recruited at the Women's and Children's Hospital, a high-risk specialty facility with approximately 5000 deliveries per annum. A total of 1818 women will be randomised to the treatment or conventional arm with an allocation ratio of 1:1, stratified by parity. The primary outcome is emergency caesarean section (yes/no). Statistical analysis will follow standard methods for randomised trials and will be performed on an intention-to-treat basis. Secondary maternal and neonatal outcomes will also be analysed. Additional study outcomes include psychosocial outcomes, patient preferences and cost-effectiveness. DISCUSSION: Approximately 20% of Australian babies are delivered by emergency caesarean section. This will be the first Australian trial to examine ST analysis of the fetal electrocardiogram as an adjunct to cardiotocography as a potential method for reducing this proportion. The trial will be among the first to comprehensively examine ST analysis, taking into account the impact on psychosocial well-being as well as cost-effectiveness. This research will provide Australian evidence for clinical practice and guideline development as well as for policy-makers and consumers to make informed, evidence-based choices about care in labour. TRIAL REGISTRATION: ANZCTR, ACTRN1261800006268 . Registered on 19 January 2018.

Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure.

OBJECTIVES: To evaluate patient outcomes and need for further interventions in women with a morbidly adherent placenta (MAP), before and after introduction of the Triple-P procedure involving placental non-separation, myometrial excision and reconstruction of the uterine wall. METHODS: Between December 2007 and February 2014, 30 patients with MAP were treated at our center. In 2007, we instituted a policy of bilateral prophylactic occlusion balloon catheter placement in both internal iliac arteries followed by Cesarean section with non-placental separation and preservation of the uterus. In 2010, the surgical technique was modified and the Triple-P procedure introduced. As a result, 19 women in our study received the Triple-P protocol (study group) and 11 did not (control group). The quantity of blood replacement products, estimated blood loss, and necessity for uterine arterial embolization and/or hysterectomy were recorded retrospectively and compared between the two groups. RESULTS: Placenta percreta was confirmed in six (54.5%) patients in the control group and 13 (68.4%) in the study group. Estimated mean blood loss during the procedure was lower in the study group than in the control group (1.70 L vs 2.17 L, respectively), but the difference was not statistically significant (P = 0.445). The risks of postpartum hemorrhage (PPH) and hysterectomy were statistically significantly lower in the study group (PPH, 54.5% vs 15.8%; P = 0.035; hysterectomy, 27.3% vs 0.0%; P = 0.045). As a consequence, there was a significant decrease in duration of inpatient stay in the study group (P = 0.044). CONCLUSION: Introduction of the Triple-P procedure conveyed a significantly reduced rate of hysterectomy, PPH and duration of hospital stay in patients with MAP. .

The role of interventional radiology in reducing haemorrhage and hysterectomy following caesarean section for morbidly adherent placenta.

AIM: To report experience of prophylactic occlusion balloon catheters (POBCs) in both internal iliac arteries before caesarean section, with or without embolization, to preserve the uterus and reduce haemorrhage. METHODS AND MATERIALS: Twenty-seven women diagnosed with morbidly adherent placenta (MAP) and with suspected placenta percreta underwent POBC placement before caesarean section. The balloons were inflated immediately after delivery of the baby. The patients' case notes were reviewed retrospectively for histological grading of MAP, blood loss, transfusion, requirement of uterine artery embolization (UAE), or hysterectomy, radiation dose, and infant or maternal morbidity and mortality. RESULTS: MAP was confirmed histologically as percreta in 17, accreta in eight, and increta in two women. Mean blood loss was 1.92 l (range 0.5-12 l). Postpartum haemorrhage (PPH) occurred in nine patients. Eight were referred for UAE, which was successful in six. Immediate peri-partum hysterectomy was performed in one patient. Three women in total required hysterectomy, two after recurrent haemorrhage after UAE. No foetal morbidity or mortality occurred. No maternal mortality occurred. There was one case of iliac artery thrombosis, which resolved with conservative therapy. CONCLUSION: POBC, with or without UAE, contributes to reduction of blood loss and preservation of the uterus in women with MAP.

Conservative approach to the management of morbidly adherent placentae.

OBJECTIVE: To determine the effect of conservative management of morbidly adherent placentae on maternal morbidity and mortality and to review management options METHODS: All case notes of patients with placenta accreta and percreta between June 2008 and August 2010 were studied retrospectively. RESULTS: Eight placentae percretae and 4 placentae accretae were identified out of a total of 11,358 deliveries.All 12 patients underwent caesarean section. Placentae percretae were intentionally left in situ. Interventional radiology was used in these cases. There was one emergency hysterectomy for massive obstetric haemorrhage,one case of disseminated intravascular coagulation,one case of early sepsis and 3 cases of delayed sepsis.Average blood loss was 2490 ml with the mean volume transfused being 1425 ml. The mean hospital stay was 7 days and 2 patients were admitted to intensive care. One patient was readmitted with sepsis complicated by a utero-cutaneous fistula (complete placenta praevia).Another patient required re-embolisation 5 months post delivery for persistent haemorrhage. No ureteric or bladder injuries occurred. CONCLUSIONS: Conservative management of placenta percreta is an alternative to caesarean hysterectomy. It is associated with lower maternal morbidity rates.However, monitoring for sepsis and secondary postpartum haemorrhage is essential. Rare complications such as utero-cutanus fistulae may occur.

Transcatheter pelvic arterial embolisation for control of obstetric and gynaecological haemorrhage.

We present a 5-year experience of pelvic arterial embolisation at two centres in the UK, and emphasise the role of interventional radiology in the treatment of obstetric and gynaecological haemorrhage. A total of 31 women underwent pelvic embolization:19 patients had complete medical records, and of these, two women had antepartum haemorrhage, 12 women had primary postpartum haemorrhage (PPH), four women had secondary PPH and one woman had a haemorrhage following termination of pregnancy (TOP). The source of the haemorrhage was only identified in four women (21.1%). All patients underwent selective embolisation of the uterine artery or anterior divisional branch of the internal iliac artery with successful haemorrhage control in 17 patients (89.4%) and no immediate complications. Haemorrhage continued despite embolisation in two patients; both proceeded to surgery. Selective pelvic embolisation is a safe and effective treatment for acute obstetric or gynaecological haemorrhage and should be part of the management algorithm for PPH.