Urological Involvement in the Multidisciplinary Management of Placenta Accreta Spectrum in a Centralised, High-Volume Centre: A Retrospective Analysis

Objectives Placenta accreta spectrum (PAS) significantly increases the complexity of childbirth and frequently involves urologic organs. Multidisciplinary team (MDT) care is paramount to ensure optimal outcomes. We aimed to evaluate urologic interventions in patients with PAS at a centralised, tertiary referral centre. Methods An analysis of a prospectively collected data set, consisting of all women presenting with PAS at our institution between November 2013 and June 2019. Patients who required urological intervention were identified, and perioperative details were retrieved. Results Forty-two cases of PAS were identified. The mean maternal age was 35 years, and mean gestational age at delivery was 34 weeks. Thirty-seven cases were managed electively, with 5 cases managed conservatively (no hysterectomy) and 5 requiring emergency management. Fifteen patients (36%) had suspected bladder invasion on MRI. A total of 36 patients (86%) had ureteric catheters inserted, 14 (33%) required bladder repair, and 2 had ureteric injuries (5%). Conclusions PAS frequently requires urological intervention to prevent and repair injury to the urinary bladder and ureter. PAS is a rare condition that is best managed in an MDT setting in a centralised, tertiary, high-volume centre with access to a variety of medical and surgical sub-specialities.

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Intraoperative blood volume loss according to gestational age at delivery among pregnant women with placenta accreta spectrum (PAS): an 11-year experience in Songklanagarind Hospital

Journal of Obstetrics and Gynaecology ◽

10.1080/01443615.2021.1910638 ◽

2021 ◽

pp. 1-6

Author(s):

Nuttaporn Maison ◽

Athithan Rattanaburi ◽

Ninlapa Pruksanusak ◽

Rakchai Buhachat ◽

Sathana Tocharoenvanich ◽

...

Keyword(s):

Pregnant Women ◽

Blood Volume ◽

Gestational Age ◽

Placenta Accreta ◽

Volume Loss ◽

Gestational Age At Delivery ◽

Placenta Accreta Spectrum

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Evaluation of the Tramline Sign in the Prediction of Placenta Accreta Spectrum and Perioperative Outcomes in Anterior Placenta Previa

Ultraschall in der Medizin - European Journal of Ultrasound ◽

10.1055/a-1309-1665 ◽

2021 ◽

Author(s):

Andrea Dall’Asta ◽

Francesco Forlani ◽

Harsha Shah ◽

Gowrishankar Paramasivam ◽

Joseph Yazbek ◽

...

Keyword(s):

Placenta Accreta ◽

Placenta Previa ◽

3D Ultrasound ◽

Perioperative Outcomes ◽

Pathology Report ◽

Full Bladder ◽

Estimated Blood Loss ◽

Gestational Age At Delivery ◽

Placenta Accreta Spectrum

Abstract Purpose To evaluate perioperative outcomes and the prognostic role of the tramline sign in a cohort of women with anterior placenta previa. Materials and Methods Retrospective analysis of 3D ultrasound volumes from women with anterior placenta previa who underwent ultrasound examination beyond 32 weeks. 3D and 3D color volumes were obtained from a sagittal section of the uterus bisecting a partially full bladder and processed using Crystal Vue and Crystal Vue Flow rendering to look for the “tramline sign”. “Partial obliteration” was defined as a loss of some or part of the uterine-serosal interface and “full obliteration” as when both interfaces were interrupted. Postnatal ascertainment of placenta accreta spectrum (PAS) was confirmed by findings recorded intraoperatively or on a pathology report. Results 65 cases were included. The tramline sign was “partially” (17) or “fully” (19) obliterated in 36 cases (55.4 %), and present in 29 (44.6 %). Obliteration was associated with earlier gestational age at delivery (35 + 1 (26 + 3–38 + 3) vs. 36 + 4 (25 + 3–38 + 0) weeks, p = 0.005), greater estimated blood loss (800 (400–11 000) vs. 600 (300–2100) mls, p = 0.003), longer operative time (155 (60–240) vs. 54 (25–80) minutes, p < 0.001), higher rate of hysterectomy (97.2 % vs. 0.0 %, p < 0.001), longer postoperative admission (7 (3–19) vs. 3 (1–5) days, p < 0.001) and a 100 % rate of postnatal diagnosis of PAS. The finding of an “obliterated” tramline sign identified all women that required hysterectomy and all cases of PAS. Conclusion A “partially or fully obliterated” tramline sign is strongly associated with indicators of operative complexity, the postnatal confirmation of PAS, and the need for peripartum hysterectomy.

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Outcomes in emergency versus elective cases of placenta accreta spectrum disorder managed by caesarean-hysterectomy within a dedicated multidisciplinary care team: retrospective cohort study.

10.22541/au.163253036.69537467/v1 ◽

2021 ◽

Author(s):

Homero Flores Mendoza ◽

Anjana Chandran ◽

Carlos Hernandez-Nieto ◽

Ally Murji ◽

Lisa Allen ◽

...

Keyword(s):

Cohort Study ◽

Gestational Age ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Placenta Accreta ◽

Perinatal Outcomes ◽

Elective Delivery ◽

Gestational Age At Delivery ◽

Placenta Accreta Spectrum ◽

Caesarean Hysterectomy

Objective: Compare maternal and perinatal outcomes between emergency and elective caesarean-hysterectomy for placenta accreta spectrum (PAS) disorders managed by a multidisciplinary team. Design and setting: Single-centre retrospective cohort study Population: 125 cases of antenatally suspected and pathologically confirmed PAS disorder. Methods: Maternal and perinatal outcomes were analyzed. Multivariate logistic regression was used to test associations, adjusting for potential confounders. Survival curves exploring risk factors for emergency delivery were sought. Main Outcome Measures: Maternal outcomes including hemorrhagic morbidity, operative complications. Perinatal outcomes included gestational age at delivery, birthweight, Apgar scores and perinatal death. Results: 25 (20%) and 100 (80%) patients had emergency and elective delivery, respectively. Emergency delivery had a higher estimated blood loss (median IQR 2772 [2256.75] vs. 1561.19 [1152.95], p<0.001), with a higher rate of coagulopathy (40 vs. 6%; p<0.001) and bladder injury (44 vs. 13%; p<0.001). Emergency delivery was associated with increased rates of blood transfusion (aOR 4.9, CI95% 1.3-17.5, p=0.01), coagulopathy (aOR 16.4, CI95% 2.6-101.4, p=0.002) and urinary tract injury (aOR 6.96, CI95% 1.5-30.7, p=0.01). Gestational age at delivery was lower in the emergency group (mean SD 35.19 [2.77] vs. 31.55 [4.75], p=0.001), no difference in perinatal mortality was found (aOR 0.01, CI95% <0.001-17.5, p=0.53). A sonographically short cervix and/or history of APH had an increased cumulative risk of emergency delivery with advancing gestational age. Conclusions: Patients with PAS disorders managed in a tertiary centre by a multidisciplinary team requiring emergency delivery have increased maternal morbidity and poorer perinatal outcomes than those with elective delivery.

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Effects of Placenta Location in Pregnancy Outcomes of Placenta Accreta Spectrum (PAS); A Retrospective Cohort Study

Journal of Family & Reproductive Health ◽

10.18502/jfrh.v15i4.7888 ◽

2021 ◽

Author(s):

Shokoh Abotorabi ◽

Solmaz Chamanara ◽

Sonia Oveisi ◽

Maryam Rafiei ◽

Leila Amini

Keyword(s):

Risk Factors ◽

Cohort Study ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Placenta Accreta ◽

Placenta Previa ◽

Chi Square ◽

Gestational Age At Delivery ◽

History Of ◽

Placenta Accreta Spectrum

Objective: Placenta Accreta Spectrum (PAS) affects approximately one in a thousand deliveries. Very few studies evaluated PAS risk factors based on their location. In this study, we have investigated the effects of placenta location on placental adhesion-related complications, its risk factors, and outcomes. Materials and methods: We performed a retrospective cohort study of pathology-confirmed cases of PAS from patients with peripartum hysterectomy, at a large educational hospital in Qazvin, Iran, from 2009 to 2019. Placenta location was found by ultrasound reports and intraoperative evaluation. We measured demographic features, basic characteristics, maternal and neonatal outcomes based on placental location including anterior, posterior, and lateral in Placenta Accreta Spectrum. Chi-square, t-test, and one-way ANOVA were used to examine the relation of complications, risk factors, and outcomes in PAS. Results: A review of 70 cases showed the distribution of placenta location as follows: 57% anterior, 27% posterior, and 16% lateral. The mean gestational age at delivery was 35 (33-39) weeks. In 78.6% (n=55) of the patients, an association with placenta previa and in 94/2% (n=66) of cases a history of cesarean section was found, however, it was not significantly correlated with placenta location (p=0.082). We found that surgery duration was significantly longer in patients with lateral PAS (155±38, vs 129.35±33.8 and 133.15±31.5 for anterior and posterior placenta respectively, p=0.09). Patients with lateral PAS also bled more than the remaining two groups (2836 ml for lateral PAS vs 2002 and 1847 for anterior and posterior placenta respectively, p=0.022). Moreover, women with a history of uterine surgery were more likely to have posterior PAS compared to those with anterior and lateral PAS (p=0.035). Conclusion: Differences in complications, risk factors, and outcomes of PAS based on placenta location may lead to improved diagnosis and decreased morbidity in women.

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When a rare condition creates a scientific society: The history of the International Society for Placenta Accreta Spectrum (IS‐PAS)

Acta Obstetricia Et Gynecologica Scandinavica ◽

10.1111/aogs.14077 ◽

2021 ◽

Vol 100 (S1) ◽

pp. 3-6

Author(s):

Frederic Chantraine ◽

Vedran Stefanovic ◽

Thorsten Braun ◽

Pavel Calda ◽

Pasquale Martinelli ◽

...

Keyword(s):

International Society ◽

Placenta Accreta ◽

Rare Condition ◽

Scientific Society ◽

History Of ◽

Placenta Accreta Spectrum

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Up-regulated cytotrophoblast DOCK4 contributes to over-invasion in placenta accreta spectrum

Proceedings of the National Academy of Sciences ◽

10.1073/pnas.1920776117 ◽

2020 ◽

Vol 117 (27) ◽

pp. 15852-15861

Author(s):

Leah McNally ◽

Yan Zhou ◽

Joshua F. Robinson ◽

Guangfeng Zhao ◽

Lee-may Chen ◽

...

Keyword(s):

Messenger Rna ◽

Placenta Accreta ◽

Expression Patterns ◽

Rare Condition ◽

Global Gene Expression ◽

Nucleotide Exchange ◽

Altered Expression ◽

Guanine Nucleotide Exchange ◽

Nucleotide Exchange Factor ◽

Placenta Accreta Spectrum

In humans, a subset of placental cytotrophoblasts (CTBs) invades the uterus and its vasculature, anchoring the pregnancy and ensuring adequate blood flow to the fetus. Appropriate depth is critical. Shallow invasion increases the risk of pregnancy complications, e.g., severe preeclampsia. Overly deep invasion, the hallmark of placenta accreta spectrum (PAS), increases the risk of preterm delivery, hemorrhage, and death. Previously a rare condition, the incidence of PAS has increased to 1:731 pregnancies, likely due to the rise in uterine surgeries (e.g., Cesarean sections). CTBs track along scars deep into the myometrium and beyond. Here we compared the global gene expression patterns of CTBs from PAS cases to gestational age-matched control cells that invaded to the normal depth from preterm birth (PTB) deliveries. The messenger RNA (mRNA) encoding the guanine nucleotide exchange factor,DOCK4, mutations of which promote cancer cell invasion and angiogenesis, was the most highly up-regulated molecule in PAS samples. Overexpression ofDOCK4increased CTB invasiveness, consistent with the PAS phenotype. Also, this analysis identified other genes with significantly altered expression in this disorder, potential biomarkers. These data suggest that CTBs from PAS cases up-regulate a cancer-like proinvasion mechanism, suggesting molecular as well as phenotypic similarities in the two pathologies.

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