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.

Risk Factors for Urological Complications Associated with Caesarean Section—A Case-Control Study

Background and Objectives: Acute urologic complications, including bladder and/or ureteric injury, are rare but known events occurring at the time of caesarean section (CS). Delayed or inadequate management is associated with increased morbidity and poor long-term outcomes. We conducted this study to identify the risk factors for urologic injuries at CS in order to inform obstetricians and patients of the risks and allow management planning to mitigate these risks. Materials and Methods: We reviewed all cases of urological injuries that occurred at CS surgeries in a tertiary university centre over a period of four years, from January 2016 to December 2019. To assess the risk factors of urologic injuries, a case-control study of women undergoing caesarean delivery was designed, matched 1:3 to randomly selected women who had an uncomplicated CS. Electronic medical records and operative reports were reviewed for socio-demographic and clinical information. Descriptive and univariate analyses were used to characterize the study population and identify the risk factors for urologic complications. Results: There were 36 patients with urologic complications out of 14,340 CS patients, with an incidence of 0.25%. The patients in the case group were older, had a lower gestational age at time of delivery and their newborns had a lower birth weight. Prior CS was more prevalent among the study group (88.2 vs. 66.7%), as was the incidence of placenta accreta and central praevia. In comparison with the control group, the intraoperative blood loss was higher in the case group, although there was no difference among the two groups regarding the type of surgery (emergency vs. elective), uterine rupture, or other obstetrical indications for CS. Prior CS and caesarean hysterectomy were risk factors for urologic injuries at CS. Conclusions: The major risk factor for urological injuries at the time of CS surgery is prior CS. Among patients with previous CS, those who undergo caesarean hysterectomy for placenta previa central and placenta accreta are at higher risk of surgical haemostasis and complex urologic injuries involving the bladder and the ureters.

Incidence of Emergency Peripartum Hysterectomy in a Tertiary Obstetrics Unit in Romania

Background and Objectives: Emergency peripartum hysterectomy (EPH) is a life-saving surgical procedure performed when medical and surgical conservative measures fail to control postpartum hemorrhage. The objective of this study was to estimate the incidence of EPH and to determine the factors leading to this procedure and the maternal outcomes. Materials and Methods: A retrospective cohort study with all cases of EPH performed at Filantropia Clinical Hospital in Bucharest between January 2012 and May 2021. Results: There were 36 EPH, from a total of 36,099 births recorded. The overall incidence of EPH was 0.99 per 1000 deliveries, most cases being related to placenta accreta spectrum disorder and uterine atony. Conclusions: Peripartum hysterectomy is associated with an important maternal morbidity rate and severe complications. Efforts should be made to reduce the number of unnecessary cesarean deliveries.

Effectiveness of ultrasound screening for placenta accreta spectrum using standard ultrasound criteria in a secondary care setting

Objectives: Ultrasound detection of placenta accreta spectrum (PAS) among women at risk is a key goal to reduce obstetric morbidity, but there is scarce information of its performance in real clinical settings. We report the effectiveness of a standardized ultrasound protocol to detect PAS in women with placenta previa in a secondary-level hospital. Methods: A retrospective analysis, including a cohort of 126 women with persistent placenta previa among 27,975 pregnancies between 2008 and 2020. All 126 women underwent standardized transabdominal and transvaginal ultrasound assessing 5 criteria: 1) loss of hypoechoic retroplacental zone and/or myometrial thinning <1 mm; 2) lacunar images with flow >15 cm/sec; 3) thick and bulging placenta; 4) thinning or interruption of the uterine-bladder serous interface; and 5) placental or uterovesical hypervascularity. The presence of at least one criterion was considered a high-risk for PAS. Diagnosis of PAS was confirmed during caesarean section and by histopathological analysis. Results: Among 126 women with placenta previa, 11 (8.7%) cases of PAS were diagnosed, of which 10 were detected prenatally by ultrasound. This resulted in a sensitivity of 90,9%, a specificity of 98,3%, a positive predictive value (PPV) of 83,3%, and negative predictive value (NPV) of 99,1%. Histopathological assessment showed six placenta increta (54.5%), four percreta (36.4%) and one accreta (9.1%). All 10 cases of invasive placenta presented more than three ultrasound criteria. Conclusions: Standardized ultrasound screening protocol in women at risk due to placenta previa in the third trimester was highly effective in detecting PAS in a secondary-level hospital setting.

Case Report: Anaesthetic Management of Placenta Percreta

Background: The placenta is a complicated organ and is partially understood. It is the essential part for physiological changes leading to a successful pregnancy. Placenta percreta is the most severe and least common form of placenta accreta in which villi penetrate the entire myometrial thickness and reach or traverse the serosa to encroach adjacent organs. Patients with placenta percreta are at a greater risk of life-threatening perioperative bleeding as well as massive and deadly thromboembolic events. Case report: Our patient was a 34-year-old gravida 5female who underwent elective cesarean section at 37 weeks of gestation with a diagnosis of placenta accreta or percreta. Intraoperative findings showed placenta percreta with bladder wall involvement. Hence, hysterectomy was done. Anticipated intraoperative haemorrhage and hemodynamic instability were managed properly. Discussion: Placenta percreta is the most serious among abnormal placentation, sometimes leading to catastrophic blood loss and very high maternal mortality and morbidity up to 10%. The most important risk factor in placenta percreta is placenta previa (low lying placenta) after cesarean delivery. Our patient met all these risk factors. Prenatal diagnosis of an invasive placenta is paramount for reducing maternal morbidity and mortality by implementing a multidisciplinary approach. Keywords: haemorrhage, placenta percreta, hysterectomy, high-risk pregnancy.