Association Between Pre-delivery Coagulation Indicators and Invasive Placenta Accreta Spectrum

Objectives To analyze the association between pre-operational coagulation indicators and the severity of placenta accreta spectrum (PAS), as well as blood loss volume during operation. Methods Hospitalized patients of the obstetric department in a major hospital from 2018 to 2020 who were clinically and/or pathologically diagnosed with invasive PAS were included. Univariate and multivariate logistic regression and Poisson regression models were used to quantify the association between each of the 6 coagulation indicators and PAS severity (measured by FIGO grade) as well as maternal outcomes. Results Ninety-five patients (46 FIGO grade 2 and 49 FIGO grade 3) were included. Higher PT [adjusted OR (aOR): 5.54; 95% CI, 1.80 to 17.07] and FDP (aOR: 1.19; 95% CI, 1.01–1.42) levels were associated with an increased risk of FIGO grade 3 after adjusting for covariates. D-dimer [incidence rate ratio (IRR): 1.19; 95% CI, 1.05 to 1.35)] and FDP (IRR: 1.03; 95% CI, 1.01–1.04) levels were significantly associated with higher blood loss volume after adjusting for covariates. Conclusion Preoperative coagulation indicators, especially PT, D-dimer and FDP, are associated with disease severity and blood loss volume during operation of invasive PAS. The underlying mechanism for the coagulation profile of PAS patients warrants further analysis. Synopsis Preoperative coagulation indicators, especially PT, D-dimer and FDP, are associated with disease severity and blood loss volume during operation among invasive placenta accreta spectrum patients.

The Role of Bilateral Internal Iliac Artery Ligation in Minimizing Blood Loss Prior to Cesarean Hysterectomy Patients with Abnormally Invasive Placenta

Background Abnormally invasive placenta (AIP) is a term that describes cases in which there is complete or partial failure of separation of the placenta from the uterine wall following delivery of the fetus. Objective to detect the role of bilateral internal iliac artery ligation in minimizing blood loss, prior to performing Cesarean Hysterectomy in cases with confirmed preoperative or intraoperative diagnosis of Abnormally invasive placenta. Patients and Methods The study was carried out at Ain shams university maternity hospital in 2019. Women were recruited from the labor ward who underwent CS Hysterectomy. The total number of pregnant women enrolled in the study was 95 women. Approval from the Medical Ethics Committee were obtained. Results Our study showed that internal iliac artery ligation in CS hysterectomy cases for AIP has non significant lower blood loss than cases who did not underwent internal iliac artery ligation. In stead, it had increased the operative time. In comparison of 45 patients underwent internal iliac artery ligation and 45 without ligation blood loss was non significantly lower in the group who underwent ligation with mean 1933 ml blood loss in comparison with 2117 ml in the group who did not. Conclusion Bilateral internal iliac artery ligation, in cases of AIP undergoing caesarean hysterectomy, is not recommended for routine practice to minimize blood loss intraoperatively.

Placenta percreta presenting as uterine rupture following previous B-Lynch suture

Placenta accreta spectrum disorder varies from minimally adherent placenta to deeply invasive placenta. Placenta percreta is a rare cause for uterine rupture and the incidence of morbidly adherent placenta is on the rise due to increase in the rates of caesarean section. We report a case of a 32-year-old, G2P1L1 who presented to us at 27 weeks in a state of haemodynamic shock with intrauterine fetal death. She had a history of prior caesarean section complicated by postpartum haemorrhage requiring B-Lynch suturing. With an initial diagnosis of caesarean scar rupture, she underwent an emergency laparotomy. Intraoperatively, the caesarean scar was found to be intact and uterine fundal rupture with placental protrusion identified. She underwent caesarean hysterectomy and was discharged in a stable condition. The histopathology report confirmed the diagnosis of placenta percreta.

Stepwise Treatment for Abnormally Invasive Placenta with Placenta Previa

Placenta accreta spectrum (PAS) disorder often causes a large amount of intraoperative bleeding in a short period which makes maternal circulation unstable and threatens life. As a countermeasure, two-stage surgery combined with selective uterine arterial embolization (UAE), named “stepwise treatment” was introduced in 2003. At a cesarean section (CS), only the baby is delivered and the placenta is left in situ. The transcatheter angiographic UAE is performed on the operation day, followed by the total hysterectomy on 5 to 7 days after CS. The difficulty in the operative procedures for hysterectomy and the amount of bleeding can be reduced by the added effect of the blood flow interruption by UAE and the uterine involution. Although there are not many indication cases, this is the prudent operation that should be considered for the most severe PAS case such as total placenta increta/percreta with placenta previa.In this article, the practical procedures and tips of stepwise treatment are described.

Cesarean Hysterectomy in Abnormally Invasive Placenta: The Role of Prenatal Diagnosis

An abnormally invasive placenta (AIP) is a placenta that cannot be removed spontaneously or manually without causing severe bleeding. It is a dangerous condition associated with a high rate of maternal and perinatal morbidity and mortality due to the high rate of massive bleeding and visceral injuries. The standardized ultrasound diagnostic criteria have helped improve its early diagnosis, which is essential to plan coordinated actions to reduce associated morbimortality. We present a case report in which ultrasound diagnosis played a decisive role, enabling the coordination of a multidisciplinary team and improving the immediate care of both mother and newborn. Cesarean hysterectomy was performed with minimal blood loss and a good postsurgical recovery.

Patient blood management» strategy in pregnant women with the risk of massive obstetric bleeding

The objective: a determination of the effectiveness of anemia treatment with intravenous iron (III) hydroxide sucrose complex in pregnant women with pathological placentation, as the first stage of “patient blood management” before delivery.Materials and methods. Among 86 pregnant women with placental pathology, 58 (70.7 %) had anemia. Severe anemia with a hemoglobin level <70 g/l was in 13 (22.4 %), moderate anemia with a hemoglobin level <90 g/l — in 19 (32.8 %). The first group included 18 (31.1 %) pregnant women with placenta previa with periodic blood loss during pregnancy. The second group consisted of 40 (68.9 %) pregnant women with invasive placenta. The gestation period in all women was 33+6 weeks. Anemia was treated by intravenous administering iron (III) hydroxide sucrose complex 3 times a week (5-7 injections).Results. The main factor that led to pathological placentation was the scar on the uterus. In pregnant women in the second group with invasive placenta, the scar on the uterus was in 38 (95 %) women. Severe anemia was present in 2 (11.1 %) pregnant women with placenta previa that was in 2.4 times less than in pregnant women with invasive placenta — 11 (27.5 %). Moderate anemia was present in 4 (22.2 %) women in the first group and in 15 (37.5 %) in the second group.In pregnant women with severe anemia, after 5–7 injections of the drug iron (III) hydroxide sucrose complex the level of hemoglobin increased significantly by 30 g/l, the number of erythrocytes increased to 2.8×1012/l, serum iron – in 2 times, the level of ferritin – to 19.6 μg/l and transferrin content decreased. For pregnant women with moderate anemia, 3–5 injections of the drug were sufficient to normalize the indicators. Normalization of blood parameters allowed to reduce the risk of bleeding, the number of blood transfusions and improve treatment outcomes.Conclusions. Timely diagnosis of the iron deficiency anemia in pregnant women with placental pathology is an important means of preventing massive blood loss and reducing the number of blood transfusions, as the first stage of the strategy “patient blood management”.Intravenous iron (III) sucrose complex hydroxide has demonstrated a high clinical efficacy in the treatment of iron deficiency anemia in pregnant women with placental pathology and can be recommended for widespread use in practical medicine.