Role of Abdominal Aortic Balloon Placement in Planned Conservative Management of Placenta Previa With Placenta Increta or Percreta

Background: We investigated the role of balloon placement in the abdominal aorta (BPAA) in planned conservative management of placenta previa with placenta increta or percreta and the effects of BPAA on perinatal adverse maternal events.Methods: This retrospective case-control study included women with placenta previa (increta or percreta), who underwent pregnancy termination at the Qilu Hospital of Shandong University between January 2016 and June 2019. Patients were categorized into the BPAA and non-BPAA groups based on the BPAA placement before delivery. The Chi-square and non-parametric rank-sum tests were used for the intergroup comparison of patient characteristics. The propensity score matching algorithm was used to minimize the intergroup differences in clinical characteristics. Logistic regression analysis was used to identify the factors associated with a high risk of adverse pregnancy outcomes. The area under the receiver operating characteristic curve [area under the curve (AUC)] was used to evaluate the classification of the selected high-risk factors.Results: The study included 260 patients, and 104 patients were identified after propensity score matching. In the post-matched cohort, intraoperative blood loss was significantly lower in the BPAA than in the non-BPAA group (median 1,000 vs. 2,250 ml, P < 0.001). Intraoperative B-Lynch suture was performed in fewer patients in the BPAA (15.4 vs. 34.6%, P = 0.024) than in the non-BPAA group. The packed red blood cell (PRBC) transfusion rate was lower in the BPAA group (median 4 vs. 8 units, P < 0.001). Overall, 46 (45.1%) patients developed adverse maternal events; however, the rate of adverse maternal events was lower in the BPAA group (19.6 vs. 80.4%, P < 0.001). No ligation of the ascending branch of the uterine artery (P = 0.034), no BPAA (P < 0.001), intraplacental vascular lacunae (P = 0.046), and cervical hypervascularity (P = 0.001) were associated with a high risk of adverse perinatal maternal events. The AUC of the high-risk factors was 0.89 in the post-matched and 0.76 in the pre-matched cohorts.Conclusion: Planned conservative management using BPAA significantly minimized the intraoperative blood loss, the need for a B-Lynch suture, and PRBC transfusion in patients with severe placenta accreta spectrum and placenta previa.

Parallel Loop Binding Compression Suture, a Modified Procedure for Pernicious Placenta Previa Complicated With Placenta Increta

Objective: To evaluate the efficacy and safety of parallel loop binding compression suture of the lower uterus during cesarean section in pernicious placenta previa complicated with placenta increta.Methods: This retrospective study was performed in patients with pernicious placenta previa complicated with placenta increta or percreta between November 2014 and December 2020 at the Qilu Hospital of Shandong University. Patients underwent parallel loop binding compression suture surgery were defined as study group, and patients underwent traditional surgery with figure-of-eight sutures as the main hemostatic method were defined as control group. Postpartum hemorrhage was evaluated as the primary outcome. The secondary outcomes included age, gestational weeks, operative time, fetal childbirth time, prevention of hysterectomy, blood transfusion, duration of postoperative catheterization, duration of antibiotic treatment, and postoperative hospitalization (days). Additionally, neonatal outcomes were evaluated.Results: A total of 124 patients were enrolled in the study, including 38 patients receiving parallel loop binding compression suture surgery in the study group, and 86 patients in the control group. With parallel loop binding compression suture, the average operation time was significantly reduced (109.0 ± 33.5 vs. 134.4 ± 54.2 min, p = 0.00), and the volume of blood lost were also decreased (2152.6 ± 1169.4 vs. 2960.5 ± 1963.6 ml, p = 0.02), which correspondingly reduced RBC transfusion (7.2 ± 3.5 vs. 10.3 ± 8.7 units, p = 0.03) and FFP transfusion (552.6 ± 350.3 vs. 968.0 ± 799.8 ml, p = 0.00). The fetal childbirth time was extended (14.1 ± 5.6 vs. 11.0 ± 8.0 min, p = 0.03), however, there was no increase in NICU admission rates (36.9 vs. 34.9%, p = 0.83). Except for one premature infant (32 weeks) death in the control group, all infants at our hospital were safely discharged after treatment.Conclusion: Parallel loop binding compression suture is an effective, swift, practical, and safe method to reduce postpartum bleeding in women with pernicious placenta previa, complicated with placenta increta. Besides, it has no adverse effects on newborns.

Diagnosis pitfall of interstitial pregnancy: a case report of a term pregnancy with abnormal placentation

Background Interstitial Pregnancy (IP) is a lethal condition due to high risk of sudden onset massive hemorrhage. Such conditions are managed as soon as diagnosed almost in the first trimester. There are a few case reports of IP conditions terminated after the second trimester. Herein, we introduce a term interstitial pregnancy complicated by abnormal placentation. Case presentation In this case report, we introduce a 32-year-old lady, primigravida, with an undiagnosed IP that was in her 38 weeks of gestational with placenta increta. She developed with perforated IP presenting with acute abdomen and internal bleeding at 26 weeks of gestational age. However, with a misdiagnosis impression, she got stable in operation room. Then, the pregnancy continued till 36 weeks of gestational age that was misdiagnosed with cervical cancer in prenatal work-ups. Finally, during elective cesarean section at 38 weeks, an IP with placenta increta (placenta evading from the serosa to the myometrium of the uterus) was observed. The baby was healthy with no obvious anomaly or morbidity. Conclusions Physicians should be aware to detect IP in all trimesters and pay attention to the coexisting complications such as placenta accreta to manage them more accurately.

АНОМАЛЬНА ПЛАЦЕНТАЦІЯ У ВАГІТНИХ ІЗ РУБЦЕМ НА МАТЦІ

Мета дослідження – оцінка частоти аномальної плацентації у вагітних із рубцем на матці. Матеріали та методи. Дослідження виконано на базі Одеського обласного перинатального центру впродовж 2016–2020 рр. Обстежено 435 жінок із рубцем на матці, в тому числі 118 (27,1 %) – із двома та більше рубцями. Середній вік обстежених склав (33,3±1,2) року. Аналізували частоту виявлення аномалій плацентації на пренатальному етапі. Всім пацієнткам під час вагітності у термін 20 тижнів було проведено трансвагінальне ультразвукове дослідження за допомогою сканера експертного класу Accuvix V20 Prestige (Samsung Medison, Республіка Корея). Додатково проводили доплерометричне дослідження кровотоку по маткових артеріях. Статистичний аналіз проводили з використанням програмного забезпечення Statistica 13.0 (TIBCO, США). Результати дослідження та їх обговорення. У всіх обстежених вагітних із часу виконання оперативного втручання минуло більше 2 років. Рубець після консервативної міомектомії (КМЕ) був у 109 (25,1 %) жінок. Середній термін після виконання КМ Е склав (2,7±0,2) року. Найбільш часто реєструвалися фундальні (28, або 25,7 %) та корпоральні (73, або 66,9 %) розрізи. Частим явищем були аномалії прикріплення плаценти – у 70,3 %, причому в структурі ураження переважало низьке розташування плаценти – 163 випадки, або 53,3 %. Рlacenta accrete зареєстрована у 131, або 42,8 %. Казуїстикою були випадки placenta increta (2,6 %) т??а placenta previa (1,3 %). При оцінці частоти ускладнень у жінок із рубцем на матці встановлено, що у першому триместрі вагітності загроза переривання вагітності виникала у 20,4 % вагітних, ранній гестоз – у 50,3 %, анемія вагітних – у 64,1 %. Затримку росту плода реєстрували у 69,6 % вагітних. У третьому триместрі прояви дисфункції плаценти реєстрували у 72,1 %, прееклампсії – у 66,8 %, анемії вагітних – у 73,6 %. За літературними даними, поширеність аналогічних ускладнень у жінок без носійства рубця є втричі меншою. У 103 (25,9 %) жінок вдавалися до оперативного розродження, в решти пологи відбулися per via naturales. Висновки. Найчастішою причиною утворення рубця на матці є КР (74,9 %). Рубець після консервативної міомектомії був у 109 (25,1 %) жінок. Середній термін після виконання КМЕ склав (2,7±0,2) року. На відміну від жінок після КР, у яких розріз завжди локалізувався у нижньому сегменті матки, у пацієнток із рубцем на матці після КМЕ його локалізація відповідала первинній локалізації видаленого міоматозного вузла. Найбільш часто реєстрували фундальні (28, або 25,7 %) та корпоральні (73, або 66,9 %) розрізи. Частим явищем були аномалії прикріплення плаценти – у 70,3 % жінок, причому в структурі ураження переважало низьке розташування плаценти – 163 (53,3 %). Рlacenta accrete зареєстрована у 42,8 % вагітних, placenta increta – у 2,6 % та placenta previa – у 1,3 %.

Placenta increta presenting with threatened miscarriage during the first trimester in rhesus-negative mother: a case report

Background Placenta accreta is known to be associated with significant maternal morbidity and mortality—primarily due to intractable bleeding during abortion or delivery at any level of gestation. The complications could be reduced if placenta accreta is suspected in a patient with a history of previous cesarean delivery and the gestational sac/placenta is located at the lower part of the uterus. Then, a proper management plan can be instituted, and complications can be reduced. The diagnosis of placenta accreta in the first trimester of pregnancy is considered uncommon. Case presentation A 34-year-old Malay, gravida 4, para 3, rhesus-negative woman was referred from a private hospital at 13 weeks owing to accreta suspicion for further management. She has a history of three previous lower-segment cesarean sections. She also had per vaginal bleeding in the early first trimester, which is considered to indicate threatened miscarriage. Transabdominal ultrasound revealed features consistent with placenta accreta spectrum. She was counseled for open laparotomy and hysterectomy because of potential major complication if she continued with the pregnancy. Histopathological examination revealed placenta increta. Conclusion A high index of suspicion of placenta previa accreta must be in practice in a patient with a history of previous cesarean deliveries and low-lying placenta upon ultrasound examination during early gestation.