Surgery for Uterine Preservation in Placenta Accreta Spectrum: A Retrospective Cohort Study

2021 ◽  
Author(s):  
Yi-Lei Li ◽  
Tao Li ◽  
Wen Peng ◽  
Xiang-Bin Liu ◽  
Hong-Mei Wang
Keyword(s):  
Blood Loss ◽  
Placenta Accreta ◽  
Psychological Trauma ◽  
Uterine Preservation ◽  
Cesarean Scar ◽  
Estimated Blood Loss ◽  
Placenta Accreta Spectrum ◽  
Placental Invasion ◽  
Cervical Involvement ◽  
Surgery Duration

Abstract Background: Owing to high risks of maternal morbidity, surgical complications, and loss of fertility, including psychological trauma caused by cesarean hysterectomy, innovative approaches for uterine preservation have been investigated. This study aimed to determine the efficacy of a novel eight-step surgical protocol for uterine preservation in placenta accreta spectrum (PAS) overlying the previous cesarean scar.Methods: We retrospectively studied consecutive patients with PAS overlying the cesarean scar, who were treated between December 2015 and October 2019 using the protocol. The depth and extension of placental invasion and severity of pelvic adhesion were assessed intraoperatively. Information regarding the gestational week at surgery, surgery duration, estimated blood loss (EBL), bladder injury, and post-procedural recovery was retrieved from the hospital database. Multiple linear regression was used to analyze factors influencing surgical blood loss. EBL was compared between the perioperative aortic balloon and non-balloon groups in severe cases using t-tests.Results: Overall, 115 patients with PAS were included. The mean EBL and surgery duration were 1666.1±1379.0 mL and 2.2±0.8 h, respectively. The uterus was successfully preserved in all patients with one surgery. Incidences of placenta accreta, increta, and percreta were 40 (35.8%), 46 (40.0%), and 29 (25.2%) cases, respectively. Extensive placental invasion and cervical involvement were observed in 41.7% and 28.7% of patients, respectively. EBL was significantly correlated with the extent of placental invasion, cervical involvement, and pelvic adhesion. No difference was seen in EBL between the balloon and non-balloon groups among the 44 patients with severe PAS.Conclusion: The eight-step protocol is effective for uterine preservation in PAS overlying the cesarean scar. EBL is affected by the extent of placental invasion, cervical involvement, and severity of pelvic adhesion. Perioperative aortic balloon should be used conservatively.

Improved management of placenta accreta spectrum disorders: experience from a single institution

2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Kendra Sylvester-Armstrong ◽  
Callie Reeder ◽  
Kathryn Patrick ◽  
Mehmet R. Genc
Keyword(s):  
Blood Loss ◽  
Maternal Morbidity ◽  
Placenta Accreta ◽  
Blood Products ◽  
Packed Red Blood Cells ◽  
Logistic Analysis ◽  
Improved Outcomes ◽  
Estimated Blood Loss ◽  
Placenta Accreta Spectrum ◽  
T1 And T2

Abstract Objectives To assess the applicability of a standardized multidisciplinary protocol for managing placenta accreta spectrum (PAS) disorders and its impact on the outcomes. Methods We compared patients with PAS manage by a standardized multidisciplinary protocol (T2) to historic controls managed on a case-by-case basis by individual physicians between (T1). The primary outcome is composite maternal morbidity. Secondary outcomes were the rates of surgical complications, estimated blood loss, number of blood products transfused, intensive care unit admissions, ventilator use, and birth weight. Multivariate logistic analysis was used to identify independent predictors of composite maternal morbidity. Results During T1 and T2, we managed 39 and 36 patients with confirmed PAS, respectively. During T2, the protocol could be implemented in 21 cases (58%). Compared to T1, patients managed during T2 had 70% less composite maternal morbidity (95% CI: 0.11–0.82) and lower blood loss (median, 2,000 vs. 1,100 mL, p=0.008). Also, they were 68% less likely to require transfusion of blood products (95% CI: 0.12–0.81; p=0.01), including fewer units of packed red blood cells (median, 2 vs. 0, p=0.02). Management following the protocol was the only independent factor associated with lower composite maternal morbidity (OR: 0.22; 95% CI: 0.05–0.95; p=0.04). Selected maternal and neonatal outcomes were not different among 12 and 15 patients with suspected but unconfirmed PAS disorders managed during T1 and T2, respectively. Conclusions Most patients can be managed under a standardized multidisciplinary protocol for PAS disorders, leading to improved outcomes.

scholarly journals Placenta Accreta Spectrum Disorders and Cesarean Scar Pregnancy Screening: Are we Asking the Right Questions?

2021 ◽  
Vol 43 (05) ◽  
pp. 347-350
Author(s):  
Conrado Milani Coutinho ◽  
Laure Noel ◽  
Veronica Giorgione ◽  
Lígia Conceição Assef Marçal ◽  
Amar Bhide ◽  
...  
Keyword(s):  
Placenta Accreta ◽  
Cesarean Scar Pregnancy ◽  
Cesarean Scar ◽  
Placenta Accreta Spectrum ◽  
Spectrum Disorders ◽  
The Right

Clinical outcomes of a false positive antenatal diagnosis of placenta accreta spectrum

2021 ◽  
Author(s):  
Bahram Salmanian ◽  
Amir A. Shamshirsaz ◽  
Karin Fox ◽  
nazlisadat meshinchi asl ◽  
Hadi Erfani ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Resource Utilization ◽  
False Positive ◽  
Maternal Morbidity ◽  
Placenta Accreta ◽  
Antenatal Diagnosis ◽  
Estimated Blood Loss ◽  
Management Protocol ◽  
Significant Difference ◽  
Placenta Accreta Spectrum

Objective: Antenatal diagnosis of placenta accreta spectrum (PAS) is critical to reduce maternal morbidity. While clinical outcomes of women with PAS have been extensively described, little information is available regarding the women who undergo cesarean delivery with a presumptive PAS diagnosis which is not confirmed by histopathologic examination. We sought to examine resource utilization and clinical outcomes of this group of women with a false-positive diagnosis of PAS. Study design: Retrospective analysis of patients with prenatally diagnosed PAS cared for between 2015 and 2020 by our multidisciplinary PAS team. Maternal outcomes were examined. Univariate analysis was performed and a multivariate model was employed to compare outcomes between women with and without histopathologically confirmed PAS. Results: A total of 162 patients delivered with the pre-operative diagnosis of PAS. Of these, 146 (90%) underwent hysterectomy and had histopathologic confirmation of PAS. Thirteen women did not undergo the planned hysterectomy. Three women underwent hysterectomy but pathologic examination did not confirm PAS. In comparing women with and without pathologic confirmation of PAS, the false positive PAS group delivered later in pregnancy (34 vs. 33 weeks of gestation, P=0.015) and had more planned surgery (88% vs. 47%, P = 0.002). There was no difference in skin incision type or hysterotomy placement for delivery. No significant difference in either the estimated blood loss or blood components transfused was noted between groups. Conclusion: Careful intraoperative evaluation of women with pre-operatively presumed PAS resulted in a 3/149 (2%) retrospectively unnecessary hysterectomy. Management of women with PAS in experienced centers benefits patients both in terms of resource utilization and avoidance of unnecessary maternal morbidity, understanding that our results are produced in a center of excellence for PAS. We also propose a management protocol to assist in the avoidance of unnecessary hysterectomy in women with the pre-operative diagnosis of PAS.

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

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.

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

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.

Surgical advances in the management of placenta accreta spectrum: establishing new expectations for operative blood loss

2020 ◽  
pp. 1-10
Author(s):  
Liviu Cojocaru ◽  
Allison Lankford ◽  
Jessica Galey ◽  
Shobana Bharadwaj ◽  
Bhavani S. Kodali ◽  
...  
Keyword(s):  
Blood Loss ◽  
Placenta Accreta ◽  
Operative Blood Loss ◽  
Placenta Accreta Spectrum

The role of ultrasound in prediction of intra-operative blood loss in cases of placenta accreta spectrum disorders

2020 ◽  
Vol 302 (5) ◽  
pp. 1143-1150
Author(s):  
Ahmed M. Hussein ◽  
Mohamed Momtaz ◽  
Ahmad Elsheikhah ◽  
Ahmed Abdelbar ◽  
Ahmed Kamel
Keyword(s):  
Blood Loss ◽  
Placenta Accreta ◽  
Operative Blood Loss ◽  
Placenta Accreta Spectrum ◽  
Spectrum Disorders

scholarly journals A new scoring system for placement of abdominal aortic balloon in Placenta accreta spectrum patients with placenta previa: A retrospective cohort study

2021 ◽  
Author(s):  
Fusen Huang ◽  
Jingjie Wang ◽  
Qiuju Xiong ◽  
Wenjian Wang ◽  
Yi Xu ◽  
...  
Keyword(s):  
Blood Transfusion ◽  
Blood Loss ◽  
Scoring System ◽  
Placenta Accreta ◽  
Placenta Previa ◽  
Operation Time ◽  
Balloon Occlusion ◽  
Abdominal Aortic ◽  
Placenta Accreta Spectrum ◽  
New Scoring

Abstract Background In recent years, abdominal aortic balloon occlusion is considered an effective method for placenta accreta spectrum patients with placenta previa. However, not all patients in this category require abdominal aortic balloon placement. This study aims to investigate whether the new scoring system is effective for the placement of the abdominal aortic balloon in Placenta accreta spectrum (PAS)patients with placenta previa. Methods PAS patients with placenta previa diagnosed by color Doppler ultrasound were included, and divided into three groups according to their scores graded by a new scoring system (grade Ⅰ group ≤ 5 points, 6 points ≤ grade Ⅱ group ≤ 9 points, grade Ⅲ group ≥ 10 points). Patients with grade Ⅲ were placed with an abdominal aortic balloon unless their families and patients strongly refused. Those with grade I were not placed with an abdominal aortic balloon. Those with grade II generally were not placed with an abdominal aortic balloon unless their families and patients strongly request. Indicators were analyzed, including postpartum hemorrhage, transfusion requirements, operation time, and the ability to preserve the uterus and fertility. Results Estimated blood loss, the number of intraoperative transfused patients, postoperative days were different among the three groups. In group 2 (grade II), there was no significant difference in other observation indexes༈intraoperative blood loss 629 ± 214 vs 758 ± 749, P = 0.488, packed red blood cells47 ± 194 vs 154 ± 445, P = 0.488, admission to ICU 0/7 vs 3/71, P = 1.000, total hysterectomies 0/7 vs 2/71, P = 1.000༉(except for the operation time81.4 ± 19.5 vs 61.7 ± 30.6, P = 0.013) between the abdominal aortic balloon and non-abdominal aortic balloon groups. In group 3 (grade III), significant differences were found in intraoperative blood loss (950 ± 390 vs 2238 ± 1052, P༜0.001), packed red blood cells(213 ± 311 vs 662 ± 528, P༜0.001), postoperative blood transfusion volume(105 ± 181 vs 300 ± 321, P = 0.008), operation time(90.0 ± 25.9 vs 115.9 ± 45.3, P = 0.013), the proportion of people who need blood transfusion(14 in the IABO vs 11 in the NIABO, P = 0.002) and the total Hysterectomies (0 in the IABO vs 2 in the NIABO, P = 0.011) between the abdominal aortic balloon and non-abdominal aortic balloon groups. Conclusion With the new scoring system, not all patients with PAS and placenta previa need a preventive temporary balloon occlusion of the subrenal abdominal aorta. We recommend placing an abdominal aortic balloon in patients with grade III, for it can control intraoperative bleeding and reduce intraoperative blood transfusion, and reduce the risk of hysterectomy. For patients with grade I and II, abdominal aortic balloon placement is not recommended.

scholarly journals Efficacy of Precesarean Infrarenal Abdominal Aorta Balloon Occlusion Among Women With Pernicious Placenta Previa and Placenta Accreta: A Retrospective Cohort Analysis

2021 ◽  
Author(s):  
Xuemin Wei ◽  
Yan Chen ◽  
Weiwei Cheng
Keyword(s):  
Blood Loss ◽  
Abdominal Aorta ◽  
Placenta Accreta ◽  
Placenta Previa ◽  
Balloon Occlusion ◽  
Neonatal Outcomes ◽  
Control Group ◽  
Study Group ◽  
Estimated Blood Loss ◽  
Infrarenal Abdominal Aorta

Abstract Purpose To evaluate the efficacy and safety of prophylactic balloon occlusion of the infrarenal abdominal aorta among women with pernicious placenta previa and placenta accreta.Methods This retrospective study included 110 patients with pernicious placenta previa and placenta accreta. The control group consisted of 55 patients who underwent cesarean section alone, and the study group included 55 patients who underwent precesarean prophylactic balloon occlusion of the infrarenal abdominal aorta. In addition, both of the groups were further divided according to FIGO clinical grading standards. Prevention of hysterectomy was the primary outcome evaluated. The secondary outcomes included operative duration, estimated blood loss, blood transfusion, intensive care unit admission, total hospital stay (days), and puerperal morbidity, and these data were compared between the two groups. Additionally, the neonatal outcomes were compared.Results There were no significant differences in maternal and neonatal outcomes in the PAS 2 and PAS 3 groups (P > 0.05). However, in the PAS 4 and PAS 5 groups, the amount of bleeding in the study group was significantly less than that in the control group (3533.3 ± 2391.4 vs 4293.6 ± 1235.4, P < 0.05), and the total hysterectomy rate was also lower (7.8% vs 13.2%, P < 0.05).Conclusion Precesarean infrarenal abdominal aortic balloon occlusion is an effective and safe option for treating pernicious placenta previa and placenta accreta and can effectively reduce the risk of hysterectomy and intraoperative blood loss in women with PAS grade 4-5.

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