The relationship between cervical length and area measurements evaluated by MRI and the amount of hemorrhage in PAS cases.

BACKGROUND: Placenta accreta spectrum often leads to massive hemorrhage and even maternal shock and death. This study aims to identify whether cervical length and cervical area measured by magnetic resonance imaging correlate with massive hemorrhage in patients with placenta accreta spectrum. METHODS: The study was conducted at our hospital, and 158 placenta previa patients with placenta accreta spectrum underwent preoperative magnetic resonance imaging examination were included. The cervical length and cervical area were measured and evaluated their ability to identify massive hemorrhage in patients with placenta accreta spectrum. RESULTS: The cervical length and area in patients with massive hemorrhage were both significantly smaller than those in patients without massive hemorrhage. The results of multivariate analysis show that cervical length and cervical area were significantly associated with massive hemorrhage. In all patients, a negative linear was found between cervical length and amount of blood loss (r =-0.613), and between cervical area and amount of blood loss (r =-0.629). Combined with cervical length and cervical area, the sensitivity, specificity, and the area under the curve for the predictive massive hemorrhage were 88.618%, 90.209%, and 0.890, respectively. CONCLUSION: The cervical length and area might be used to recognize massive hemorrhage in placenta previa patients with placenta accreta spectrum.

Placental Site Trophoblastic Tumour Mimicking Placenta Previa.

ABSTRACT: We present a 42-year-old Nigerian woman who had three previous caesarean sections and is being managed conservatively for placenta previa. She underwent a caesarean hysterectomy on account of uncontrollable bleeding, and histopathology revealed a placental site trophoblastic tumour.

Obstetric blood transfusion in placenta previa patients with prenatal anemia: a retrospective study.

BACKGROUND: The appropriate use of obstetric blood transfusion is crucial for patients with placenta previa and prenatal anemia. This retrospective study aims to explore the correlation between prenatal anemia and blood transfusion-related parameters in this population. METHODS: We retrieved the medical records of consecutive participants who were diagnosed with placenta previa and underwent cesarean section in our hospital. We compared the baseline demographics and clinical characteristics of patients with and without anemia. The correlation between prenatal anemia and obstetric blood transfusion-related parameters was evaluated using multivariate regression analysis. RESULTS: A total of 749 patients were enrolled, with a mean prenatal hemoglobin level of 10.87 ± 1.37 g/dL. Among them, 54.87% (391/749) were diagnosed with anemia. The rate of obstetric blood transfusion was significantly higher in the anemia group (79.54%) compared to the normal group (44.41%). The median allogeneic red blood cell transfusion volume in the anemia group was 4.00 U (IQR 2.00-6.00), while in the normal group, it was 0.00 U (IQR 0.00-4.00). The prenatal hemoglobin levels had a non-linear relationship with intraoperative allogeneic blood transfusion rate, massive blood transfusion rate, red blood cell transfusion units, and fresh plasma transfusion volume in patients with placenta previa, with a threshold of 12 g/dL. CONCLUSIONS: Our findings suggest that prenatal anemia is associated with a higher rate of blood transfusion-related parameters in women with placenta previa when the hemoglobin level is < 12 g/dL. These results highlight the importance of promoting prenatal care in placenta previa patients with a high requirement for blood transfusion.

Outcomes of cesarean delivery in placenta accreta: conservative delivery vs. cesarean hysterectomy.

OBJECTIVES: To compare delivery outcomes of pregnancies diagnosed with placenta-accreta-syndrome (PAS) who underwent conservative treatment to patients who underwent cesarean hysterectomy. METHODS: A retrospective study of all women diagnosed with PAS treated in one tertiary medical center between 03/2011 and 11/2020 was performed. Comparison was made between conservative management during cesarean delivery and cesarean hysterectomy. Conservative management included leaving uterus in situ with/without placenta and with/without myometrial resection. RESULTS: A total of 249 pregnancies (0.25 % of all deliveries) were diagnosed with PAS, 208 underwent conservative cesarean delivery and 41 had cesarean hysterectomy, 31 of them were unplanned (75.6 %). The median number of previous cesarean deliveries was significantly higher in the cesarean hysterectomy group. There was no difference in the duration from the last cesarean delivery, the presence of placenta previa, pre-operative hemoglobin or platelets levels between the pregnancies with conservative management and the cesarean hysterectomy. Significantly more pregnancies with sonographic suspicion of placenta percreta and bladder invasion had cesarean hysterectomy. Cesarean hysterectomy was significantly associated with earlier delivery, with bleeding and required significantly more blood products. There was no statistically significant difference in the rate of relaparotomy following cesarean delivery or the rate of infections. Multivariable-regression-analysis revealed a significant odds ratio of 3.38 of blood loss of >3,000 mL following cesarean hysterectomy. CONCLUSIONS: Conservative management in delivery of PAS pregnancies is associated with less bleeding complications during surgery compared to cesarean hysterectomy.

Peripartum hysterectomy clinical characteristics and outcomes- a hospital based retrospective audit study.

INTRODUCTION: The study aims to evaluate and report on the clinical characteristics, incidence, risk factors and associated complications of emergency and planned peripartum hysterectomy in a single training and research tertiary health care centre in Malaysia. MATERIALS AND METHODS: We conducted a 6-year retrospective cross-sectional study from the 1st January 2016 until 31st December 2021. Clinical, demographic characteristics, perioperative parameters, operative indications, blood loss, maternal/neonatal outcomes and complications were analysed. Patients were subdivided, analysed and studied in two subgroups- emergency hysterectomy (EH) and planned hysterectomy (PH). RESULTS: There were 65 cases of peripartum hysterectomy out of total 100,567 deliveries, with a prevalence rate of 0.06%. Overall, the majority of patients were multiparous (96.9%), having previous caesarean scar (73.8%) or diagnosed with placenta praevia (75.4%). More than half of the total patients (61.5%) have both previous caesarean scar and concomitant placenta praevia. EH was carried out in 39(60%) patients while 26(40%) patients underwent PH. The only indication for surgery in the PH group (100%) was abnormal placentation while the most common indication for surgery in the EH group (53.8%) was postpartum haemorrhage related to abnormal placentation. Patients who underwent EH were more likely to have massive blood loss (p=0.001), require ICU admissions (p=0.001), have DIVC cycles transfused (mean [SD] regime: 1.35 [0.95] vs 0.54 [0.99]; p=0.002), have lower postoperative haemoglobin level (mean [standard deviation, SD] haemoglobin: 9.23g/l [SD1.8] vs. 10.8 g/l [SD1.86]; p=0.001) and have higher difference between pre/post operative haemoglobin level (mean [SD] haemoglobin difference: 1.78g/l [SD6.34] vs 0.32g/l [SD1.7]; p=0.008) compared to patients with PH. Red blood cell transfusion, operating time, length of stay, weight of babies and Apgar score between two groups showed no significant differences. A significant reduction of blood loss between the first and the second half duration of the study (mean [SD] blood loss: 6978 ml [SD 4999.45] vs. 4100ml [SD2569.48]; p=0.004) was also observed. In the emergency group, 'non-placental cause' EH required significantly more red blood cell transfusion than 'placental cause' (p<0.05) while in the PH group, no significant difference was observed between the occlusive internal iliac artery 'balloon' and 'no balloon' subgroup in terms of operating time, total blood loss or blood transfusion. Overall complications showed more cases of post operative fever and relaparotomy in the EH group (18.4% vs. 7.6%) while urinary tract injuries including injuries to bladder and ureter occurred only in the PH group (9.4% vs. 0%). CONCLUSION: The majority of peripartum hysterectomy cases are due to placenta accreta spectrum disorders. Planned peripartum hysterectomies have a lower morbidity rate compared to emergency hysterectomies. Therefore, early identification of placenta accreta spectrum disorders and timely planning for elective procedures are crucial to minimise the need for emergency surgery.

Surgical approach could be a major factor in placenta previa outcome: A comparative retrospective study.

Placenta previa is associated with high morbidity and mortality rates due to major hemorrhage during surgery. Thus, a standard surgical approach with a low risk of morbidity is required. This study aimed to propose surgical steps for placenta previa with scarred uterus. All deliveries at the Al-Karak governmental hospital between January 2019 and January 2022 were retrospectively reviewed. Placenta previa cases were divided into 2 groups according to management. Group A was managed by incising the uterus at the level of the fundus to avoid disrupting the placenta, whereas group B was managed by opening the lower uterine segment and delivering the baby through the placenta after the incision. A total of 26 cases with placenta previa were included in this study. Group A (n = 12) was managed by avoiding the placenta and group B (n = 14) was managed by opening through the placenta. No differences were noted between the 2 groups regarding demographics. Patients who underwent the suggested surgical approach (Group A) had less blood loss (median = 775 cc), whereas Group B (median = 1700 cc) (P = .001) had significantly higher blood loss. The duration of hospital stay was significantly shorter in Group A (median = 2 days) than in Group B (median = 6 days) (P = .000). Incising the upper uterine segment to avoid the placenta may lead to better outcomes in terms of blood loss and its consequences.

Ultrasound discrimination between placenta accreta spectrum and urinary bladder varices.

Distinguishing between urinary bladder varices and retroplacental neovascularization in placenta accreta spectrum in high-risk patients with placental previa is a diagnostic challenge since they have similar appearances on prenatal ultrasound. Placenta accreta spectrum is associated with massive obstetric haemorrhage while the presence of urinary bladder varices in pregnancy poses a lower surgical risk. Since the clinical implications and management approach for both conditions are entirely different, false positive diagnoses have iatrogenic consequences. In this article, we share our experiences in differentiating these two phenomena on prenatal ultrasound supported by ultrasound and intraoperative images.

Tourniquet, Uterine Inversion, and Placental dissection （TURIP） procedure as a novel hemostatic technique to preserve fertility for placenta accreta spectrum disorders without placenta previa.

The number of cases of placenta accreta spectrum disorder has been increasing with the increase in in vitro fertilization and cesarean deliveries. In addition, placenta accreta spectrum without placenta previa is difficult to diagnose before delivery and sometimes requires a hysterectomy because of heavy bleeding. We have devised a uterus-preserving technique (referred to as the tourniquet, uterine inversion, and placental dissection procedure) for such cases. First, the bleeding is stopped by the tourniquet method, the uterus is relaxed with nitroglycerin, and the uterus is inverted to expose the adhesion site. After that, the placenta is detached by sharp dissection under direct visualization, and the detached areas are sutured, and then the tourniquet and internal rotation are released. This technique does not require advanced skills. Thus, a surgeon could avoid performing a hysterectomy and have a greater chance of uterus preservation when encountering massive hemorrhage caused by unpredictable placenta accreta spectrum without placenta previa in either cesarean deliveries or vaginal deliveries.

A multimodal deep learning model for predicting severe hemorrhage in placenta previa.

Placenta previa causes life-threatening bleeding and accurate prediction of severe hemorrhage leads to risk stratification and optimum allocation of interventions. We aimed to use a multimodal deep learning model to predict severe hemorrhage. Using MRI T2-weighted image of the placenta and tabular data consisting of patient demographics and preoperative blood examination data, a multimodal deep learning model was constructed to predict cases of intraoperative blood loss > 2000 ml. We evaluated the prediction performance of the model by comparing it with that of two machine learning methods using only tabular data and MRI images, as well as with that of two human expert obstetricians. Among the enrolled 48 patients, 26 (54.2%) lost > 2000 ml of blood and 22 (45.8%) lost < 2000 ml of blood. Multimodal deep learning model showed the best accuracy of 0.68 and AUC of 0.74, whereas the machine learning model using tabular data and MRI images had a class accuracy of 0.61 and 0.53, respectively. The human experts had median accuracies of 0.61. Multimodal deep learning models could integrate the two types of information and predict severe hemorrhage cases. The model might assist human expert in the prediction of intraoperative hemorrhage in the case of placenta previa.

Current state of interventional procedures to treat pernicious placenta previa accompanied by placenta accreta spectrum: A review.

Pernicious placenta previa (PPP) accompanied by placenta accreta spectrum (PAS) is a life-threatening placental implantation that causes a variety of complications, including antepartum hemorrhage, postpartum hemorrhage, hemorrhagic shock, preterm birth, and neonatal asphyxia. Along with continuous improvements in medical technology, interventional procedures have been widely used to prevent intraoperative hemorrhage associated with PPP. The commonly used interventional procedures include abdominal aorta clamping, prophylactic balloon occlusion of the internal or common iliac arteries, and uterine artery embolization. The above-mentioned interventional procedures have their respective advantages and disadvantages. The best procedure for different situations continues to be debated considering the complex pattern of blood supply to the uterus in patients with PPP. The specific choice of interventional procedure depends on the clinical situation of the patient with PPP. For grade III PAS, the need for uterine artery embolization is assessed based on blood loss and preoperative hemostatic effect following abdominal aorta clamping. Repair or hysterectomy may be performed following uterine artery embolization if there is a hybrid operating room for grade III PAS patients with extensive sub-serosal penetration of the uterus and repair difficulty. For grade II PAS (shallow placental implantation), prophylactic balloon occlusion may not be necessary before surgery. Uterine artery embolization can be performed in case of postoperative hemorrhage.

Uterus-preserving surgical management of placenta accreta spectrum disorder: a large retrospective study.

BACKGROUND: The two-child policy implemented in China resulted in a surge of high-risk pregnancies among advanced maternal aged women and presented a window of opportunity to identify a large number of placenta accreta spectrum (PAS) cases, which often invoke severe blood loss and hysterectomy. We thus had an opportunity to evaluate the surgical outcomes of a unique conservative PAS management strategy for uterus preservation, and the impacts of magnetic resonance imaging (MRI) in PAS surgical planning. METHODS: Cross-sectional study, comparing the outcomes of a new uterine artery ligation combined with clover suturing technique (UAL + CST) with the existing conservative surgical approaches in a maternal public hospital with an annual birth of more than 20,000 neonates among all placenta previa cases suspecting of PAS between January 1, 2015 and December 31, 2018. RESULTS: From a total of 89,397 live births, we identified 210 PAS cases from 400 singleton pregnancies with placenta previa. Aside from 2 self-requested natural births (low-lying placenta), all PAS cases had safe cesarean deliveries without any total hysterectomy. Compared with the existing approaches, the evaluated UAL + CST had a significant reduction in intraoperative blood loss (ß=-312 ml, P < .001), RBC transfusion (ß=-1.08 unit, P = .001), but required more surgery time (ß = 16.43 min, P = .01). MRI-measured placenta thickness, when above 50 mm, can increase blood loss (ß = 315 ml, P = .01), RBC transfusion (ß = 1.28 unit, P = .01), surgery time (ß = 48.84 min, P < .001) and hospital stay (ß = 2.58 day, P < .001). A majority of percreta patients resumed normal menstrual cycle within 12 months with normal menstrual fluid volume, without abnormal urination or defecation. CONCLUSIONS: A conservative surgical management approach of UAL + CST for PAS is safe and effective with a low complication rate. MRI might be useful for planning PAS surgery. CLINICAL TRIAL REGISTRATION NUMBER: ChiCTR2000035202.

Utility of the angle between the cervical canal and the anatomical conjugate line for predicting pouch of Douglas obliteration in patients with posterior placenta previa.

AIM: Pouch of Douglas obliteration, which prevents exteriorization of the uterus, increases surgical morbidity in patients with placenta previa. We aimed to identify magnetic resonance imaging features that can predict pouch of Douglas obliteration preoperatively. METHODS: We retrospectively assessed 39 women with posterior placenta previa who underwent magnetic resonance imaging for the preoperative assessment of placenta accreta spectrum. We defined the angle formed by the anatomical conjugate line (based on pelvimetry) and the cervical canal as the cervical inclination angle, which was measured on sagittal T2-weighted magnetic resonance imaging. Subsequently, we analyzed the correlation between the cervical inclination angle and pouch of Douglas obliteration. RESULTS: The median maternal age was 34 years (range, 22-44 years) and 26 (66.7%) women delivered at term. The median cervical inclination angle was 98° (range, 71-128). Pouch of Douglas obliteration was confirmed in six patients (15.4%). The cut-off value of the cervical inclination angle for the prediction of pouch of Douglas obliteration was 102° with a sensitivity of 66.7%, specificity of 78.8%, positive predictive value of 36.4%, and negative predictive value of 92.9% (area under the curve, 0.83). CONCLUSIONS: Measuring the cervical inclination angle may help in ruling out an obliteration of the pouch of Douglas. It may also be useful in the operative management of women with posterior placenta previa. However, caution should be exercised when generalizing the results of this study because of the small sample size, which makes the results prone to bias.

Placenta previa percreta with surrounding organ involvement: a proposal for management.

Placenta accreta spectrum encompasses cases where the placenta is morbidly adherent to the myometrium. Placenta percreta, the most severe form of placenta accreta spectrum (grade 3E), occurs when the placenta invades through the myometrium and possibly into surrounding structures next to the uterine corpus. Maternal morbidity of placenta percreta is high, including severe maternal morbidity in 82.1% and mortality in 1.4% in the recent nationwide U.S. statistics. Although cesarean hysterectomy is commonly performed for patients with placenta accreta spectrum, conservative management is becoming more popular because of reduced morbidity in select cases. Treatment of grade 3E disease involving the urinary bladder, uterine cervix, or parametria is surgically complicated due to the location of the invasive placenta deep in the maternal pelvis. Cesarean hysterectomy in this setting has the potential for catastrophic hemorrhage and significant damage to surrounding organs. We propose a step-by-step schema to evaluate cases of grade 3E disease and determine whether immediate hysterectomy or conservative management, including planned delayed hysterectomy, is the most appropriate treatment option. The approach includes evaluation in the antenatal period with ultrasound and magnetic resonance imaging to determine suspicion for placenta previa percreta with surrounding organ involvement, planned cesarean delivery with a multidisciplinary team including experienced pelvic surgeons such as a gynecologic oncologist, intra-operative assessment including gross surgical field exposure and examination, cystoscopy, and consideration of careful intra-operative transvaginal ultrasound to determine the extent of placental invasion into surrounding organs. This evaluation helps decide the safety of primary cesarean hysterectomy. If safely resectable, additional considerations include intra-operative use of uterine artery embolization combined with tranexamic acid injection in cases at high risk for pelvic hemorrhage and ureteral stent placement. Availability of resuscitative endovascular balloon occlusion of the aorta is ideal. If safe resection is concerned, conservative management including planned delayed hysterectomy at around 4 weeks from cesarean delivery in stable patients is recommended.

Timing of intra-abdominal aortic balloon occlusion for prevention of hemorrhage in patients with placenta previa and placenta accreta spectrum.

OBJECTIVE: Placenta accreta spectrum (PAS) has been linked to severe negative maternal-fetal pregnancy outcomes, including a high risk of maternal death. The goal of this study was to determine whether an abdominal aortic balloon block performed before fetal birth lowered intraoperative bleeding and the risk of severe bleeding, as opposed to a block performed after fetal birth. METHODS: In this retrospective cohort study, patients who underwent pre-delivery or post-delivery inflation were compared for intraoperative hemorrhage, transfusion rate, hysterectomy rate, intensive care unit (ICU) hospitalization, and newborn indices. To ensure the robustness of our findings, we applied multivariate logistic regression, propensity score analysis, and an inverse probability-weighting model. RESULTS: This study included 168 patients who underwent balloon occlusion (62 pre-delivery, 106 post-delivery). The overall probability of major bleeding was 56.5% (95/168), and the pre-delivery and post-delivery probabilities for major bleeding were 64.5% (40/62) and 51.9% (55/106) (P = 0.112), respectively. In the multivariable-adjusted model, post-delivery inflation was associated with a 33% numerically higher probability of massive bleeding (odds ratio 1.33, 95% confidence interval 0.54-3.25, P = 0.535). However, the difference was not statistically significant. CONCLUSION: According to our findings, pre-delivery inflation did not significantly reduce the risk or amount of severe bleeding.