Association of peripartum management and high maternal blood loss at cesarean delivery for placenta accreta spectrum (PAS): A multinational database study

Background and objectives: Placenta previa and placenta accreta spectrum are considered major causes of massive postpartum hemorrhage. Objective: To determine whether the placement of an occlusion balloon catheter in the internal iliac artery could reduce bleeding and other related complications during cesarean delivery in patients with placenta previa and placenta accreta spectrum. Materials and Methods: A retrospective analysis was conducted at two tertiary obstetric units of Lithuania. From January 2016 to November 2019 patients with placenta previa and antenatally suspected invasive placenta were included in the intervention group and underwent cesarean delivery with endovascular procedure. From January 2014 to December 2015 patients with placenta previa and suspected placenta accreta spectrum were included in the non-intervention group. The primary outcomes were reduction in intraoperative blood loss and transfusion volumes in the intervention group. Secondary outcomes were the incidence of hysterectomy and maternal complications. Results: Nineteen patients underwent cesarean delivery with preoperative endovascular procedure, and 47 women underwent elective cesarean delivery. The median intraoperative blood loss (1000 (400–4500) mL vs. 1000 (400–5000) mL; p = 0.616) and the need for red blood cell transfusion during operation (26% vs. 23%; p = 0.517) did not differ significantly between the patients groups. Seven patients in the intervention group and two patients in the non-intervention group underwent perioperative hysterectomy (p = 0.002). None of the patients had complications related to the endovascular procedure. Conclusion: The use of intermittent balloon occlusion catheter in patients with placenta pathology is a safe method but does not significantly reduce intraoperative blood loss during cesarean delivery.

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Maternal and fetal outcome in placenta accreta spectrum (PAS) associated with placenta previa: a retrospective analysis from a tertiary center

Journal of Medicine and Life ◽

10.25122/jml-2021-0134 ◽

2021 ◽

Vol 14 (3) ◽

pp. 367-375

Author(s):

◽

Valentin Nicolae Varlas ◽

Roxana Georgiana Bors ◽

...

Keyword(s):

Risk Factors ◽

Cesarean Delivery ◽

Conservative Management ◽

Placenta Accreta ◽

Placenta Previa ◽

Maternal Blood ◽

Uterine Preservation ◽

Tertiary Center ◽

Placenta Accreta Spectrum ◽

The Mean

Accreta placenta spectrum is a complex obstetrical condition of abnormal placental invasion associated with severe maternal morbidity. This study aimed to analyze our therapeutic management and counseling of the cases with placenta accreta spectrum (PAS) associated with placenta previa. We performed a retrospective study of pregnant women with PAS associated with placenta previa at the Filantropia Clinical Hospital between January 2017–April 2021. In these cases, the earlier diagnosis was realized by an ultrasonographic scan and was confirmed by histopathological findings after the surgical treatment. The conservative management was obtained in one case at <37 weeks of gestation, and the maternal outcome was uterine preservation. Among the 12 patients, the mean age was 34±3.44 years. All women had risk factors for abnormally invasive placenta, such as placenta previa or previous cesarean delivery. Most women underwent planned cesarean delivery at the mean gestational age of 36.4±0.9 weeks. In our study, the uterus was preserved in only one case (8.33%), and hysterectomy with preservation of ovaries was performed in the rest of the cases. Mean maternal blood loss during surgery was 2175±1440 ml. Severe maternal outcomes were recorded only in one case (8.33%). We identified a low uterine preservation rate and a good perinatal outcome. Conservative management should be reserved for fertility desire and extensive disease due to surgical difficulty. Early identification of the risk factors and strategic management may improve maternal and fetal outcomes.

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Maternal and neonatal outcomes in planned versus emergency cesarean delivery for placenta accreta spectrum: A multinational database study

Acta Obstetricia Et Gynecologica Scandinavica ◽

10.1111/aogs.14120 ◽

2021 ◽

Author(s):

Maddalena Morlando ◽

Alexander Schwickert ◽

Vedran Stefanovic ◽

Mina M. Gziri ◽

Petra Pateisky ◽

...

Keyword(s):

Cesarean Delivery ◽

Placenta Accreta ◽

Neonatal Outcomes ◽

Database Study ◽

Emergency Cesarean ◽

Maternal And Neonatal Outcomes ◽

Placenta Accreta Spectrum

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646 Characterizing placenta accreta spectrum in patients without prior cesarean delivery

American Journal of Obstetrics and Gynecology ◽

10.1016/j.ajog.2020.12.670 ◽

2021 ◽

Vol 224 (2) ◽

pp. S406

Author(s):

Teodora Kolarova ◽

Rebecca Simon ◽

Hayley MacKinnon ◽

Ralph N. Burns ◽

Kelsey Olerich ◽

...

Keyword(s):

Cesarean Delivery ◽

Placenta Accreta ◽

Placenta Accreta Spectrum

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Placenta accreta spectrum disorders—experience of management in a German tertiary perinatal centre

Archives of Gynecology and Obstetrics ◽

10.1007/s00404-020-05875-x ◽

2020 ◽

Author(s):

Anja Bluth ◽

Axel Schindelhauer ◽

Katharina Nitzsche ◽

Pauline Wimberger ◽

Cahit Birdir

Keyword(s):

Caesarean Section ◽

Blood Loss ◽

Placenta Accreta ◽

Caesarean Section Rate ◽

Management Strategies ◽

Management Approach ◽

Optimal Setting ◽

Placenta Accreta Spectrum ◽

Management Approaches

Abstract Purpose Placenta accreta spectrum (PAS) disorders can cause major intrapartum haemorrhage. The optimal management approach is not yet defined. We analysed available cases from a tertiary perinatal centre to compare the outcome of different individual management strategies. Methods A monocentric retrospective analysis was performed in patients with clinically confirmed diagnosis of PAS between 07/2012 and 12/2019. Electronic patient and ultrasound databases were examined for perinatal findings, peripartum morbidity including blood loss and management approaches such as (1) vaginal delivery and curettage, (2) caesarean section with placental removal versus left in situ and (3) planned, immediate or delayed hysterectomy. Results 46 cases were identified with an incidence of 2.49 per 1000 births. Median diagnosis of placenta accreta (56%), increta (39%) or percreta (4%) was made in 35 weeks of gestation. Prenatal detection rate was 33% for all cases and 78% for placenta increta. 33% showed an association with placenta praevia, 41% with previous caesarean section and 52% with previous curettage. Caesarean section rate was 65% and hysterectomy rate 39%. In 9% of the cases, the placenta primarily remained in situ. 54% of patients required blood transfusion. Blood loss did not differ between cases with versus without prenatal diagnosis (p = 0.327). In known cases, an attempt to remove the placenta did not show impact on blood loss (p = 0.417). Conclusion PAS should be managed in an optimal setting and with a well-coordinated team. Experience with different approaches should be proven in prospective multicentre studies to prepare recommendations for expected and unexpected need for management.

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The Choice of Anesthesia During Organ-Saving Operations Concerning Patients With Placenta Accreta Spectrum Disorders

Russian Sklifosovsky Journal Emergency Medical Care ◽

10.23934/2223-9022-2020-9-2-221-230 ◽

2020 ◽

Vol 9 (2) ◽

pp. 221-230

Author(s):

E. N. Plakhotina ◽

T. N. Belousova ◽

I. A. Kulikov ◽

R. V. Latyshev ◽

K. M. Pavlyutina

Keyword(s):

Blood Loss ◽

General Anesthesia ◽

Epidural Anesthesia ◽

Placenta Accreta ◽

Pain Syndrome ◽

Tissue Perfusion ◽

Optimal Method ◽

Clear Trend ◽

Placenta Accreta Spectrum ◽

Spectrum Disorders

Abstract Placenta accreta (PAS-disorders) is one of the most serious complications of pregnancy, associated with the risk of massive uterine bleeding, massive hemotransfusion and maternal mortality. Peripartum hysterectomy is a common treatment strategy for patients with placenta accreta. Currently, there is a clear trend of changing surgical tactics in favor of organ-saving operations, but there are no studies devoted to anesthesiological support of such operations.The aim of the study is to substantiate an effective and safe method of anaesthesia in organ-saving operations for placenta accreta spectrum disorders.Materia l and methods The study involved 80 patients with a diagnosis of placenta accreta spectrum disorders, confirmed intraoperatively, who underwent organ-saving operations. The patients were randomized depending on the method of anesthesia into 3 groups: general anesthesia, spinal anesthesia with planned conversion to general after fetal extraction and epidural anesthesia with planned conversion to general also after fetal extraction. The comparison of intraoperative hemodynamics, efficiency of tissue perfusion, efficiency of antinociceptive protection at the stages of surgery was performed. A comparative analysis of the volume of blood loss and blood transfusion, time of patients activation in the postoperative period, severity of pain on the first day after surgery, duration of hospital stay before discharge and comparison of the assessment of the newborn according to Apgar score at first and fifth minute after extraction.Conclusion The study shows that the optimal method of anesthesia in organ-saving operations for placenta accreta spectrum disorders is epidural anesthesia with its planned conversion to general anesthesia with an artificial lung ventilation after fetal extraction. Such an approach to anesthesia allows to maintain stable hemodynamic profile with minimal vasopressor support, sufficient heart performance, providing effective tissue perfusion and a high level of antinociceptive protection at the intraoperative stage and reduce the volume of intraoperative blood loss and hemotransfusion. In the current study there were no differences in neonatal outcomes and duration of hospitalization depending on the method of anesthesia. The advantage of epidural anesthesia with its conversion to general anesthesia was earlier activation after surgery and lower intensity of postoperative pain syndrome.

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Potentially Preventable Primary Cesarean Sections in Future Placenta Accreta Spectrum

American Journal of Perinatology ◽

10.1055/s-0041-1739493 ◽

2021 ◽

Author(s):

Kathy C. Matthews ◽

Andrew S. Quinn ◽

Stephen T. Chasen

Keyword(s):

Cesarean Section ◽

Cesarean Delivery ◽

Placenta Accreta ◽

External Cephalic Version ◽

Cesarean Sections ◽

Medical Indication ◽

Placenta Accreta Spectrum ◽

Primary Cesarean Delivery ◽

Insured Patients ◽

Privately Insured

Background Prior cesarean delivery is a well-known risk factor for placenta accreta spectrum disorders. While primary cesarean section is unavoidable in some patients, in others it may not be clearly indicated. Objective The aim of the study is to determine the proportion of patients with placenta accreta spectrum who had a potentially preventable primary cesarean section and to identify factors associated with preventable placenta accreta spectrum. Study Design This was a single-center retrospective cohort study of women with pathology-confirmed placenta accreta spectrum from 2007 to 2019. Primary cesarean sections were categorized as potentially preventable or unpreventable based on practice consistent with the American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine “Safe Prevention of the Primary Cesarean Delivery” recommendations. Fisher's exact test and Mann-Whitney U-test were used for comparison with p <0.05 considered statistically significant. Results Seventy-two patients had pathology-confirmed placenta accreta spectrum over the course of the study period, 15 (20.8%) of whom required a cesarean hysterectomy at the time of primary cesarean section. Fifty-seven patients had placenta accreta spectrum in a pregnancy following their primary cesarean section. Of these, 29 (50.9%) were considered potentially preventable. Most were performed without clear medical indication (37.9%) or for fetal malpresentation without attempted external cephalic version (37.9%). The remainder were due to arrest of labor not meeting criteria (17.2%) and abnormal or indeterminate fetal heart patterns with documented recovery (6.9%). Of the 11 patients without clear medical indication for primary cesarean section, eight (72.7%) were patient-choice cesarean sections and three (27.3%) were for suspected fetal macrosomia with estimated fetal weights not meeting criteria for cesarean delivery. There was no difference in the incidence of potentially preventable primary cesarean sections before and after the ACOG-SMFM “Safe Prevention of the Primary Cesarean Delivery” publication (48.8 vs. 57.1%, p = 0.59). Privately insured patients were more likely to have a potentially preventable primary cesarean section than those with Medicaid (62.5 vs. 23.5%, p = 0.008) and were more likely to have a primary cesarean section without clear medical indication (81.8 vs. 18.2%, p = 0.004). Conclusion Many patients with placenta accreta spectrum had a potentially preventable primary cesarean section. Most were performed without clear medical indication or for malpresentation without attempted external cephalic version, suggesting that at least a subset of placenta accreta spectrum cases may be preventable. This was particularly true for privately insured patients. These findings call for continued investigation of potentially preventable primary cesarean sections with initiatives to address concerns at the patient, provider, and hospital level. Key Points

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