Creating a Multidisciplinary Placenta Accreta Program

The study aimed to demonstrate the efficacy and safety of an innovative hemostatic technique in managing Placenta Previa and Accreta Spectrum by S. Rao Spiral Suturing (SRSS) of a lower uterine segment. In this retrospective study conducted at Department of Obstetrics & Gynecology Unit-II of Nishtar Medical University, Multan between December 2018 to January 2021, one hundred and thirty consenting patients' clinical records were reviewed with major degree placenta previa/placenta accrete spectrum, either operated electively or presented in an emergency, with or without a history of previous cesarean section. The enrolled patients underwent SRSS, procedure's efficacy and safety were measured by the number of obstetrical hysterectomies, the time required for the procedure, estimated blood loss, blood transfusion volume, need for any other hemostatic technique, bladder trauma, pelvic infection, scar site hematoma or abscess, sepsis, duration of hospital stay and maternal mortality. Out of 130 patients, 17(12.6%) had Placenta Accreta, 86(66.3%) Increta, and 27(21%) Percreta. The Placenta location was anterior dominant in 102(78.4%) cases and posterior in 17(8.4%). Of the patients who underwent surgery, only two required obstetrical hysterectomy due to uncontrolled bleeding. The procedure took three to five minutes in 127 patients and five to seven minutes in three patients. Regarding intraoperative blood transfusion, 54.6% of patients were transfused 1000-2000 ml blood, and 5.38% required > 3000 ml. No blood transfusion was required postoperatively in any patient. Postpartum hemorrhage, infection, fever, and sepsis were not observed in any patient postoperatively. None of the patients suffered bladder injury. All patients were discharged as per routine. SRSS is an innovative, safe, effective, and simple suturing technique for patients with Placenta Previa and Accreta spectrum.

Caesarean section combined with temporary aortic balloon occlusion followed by uterine artery embolisation for the management of placenta accreta

Placenta accreta spectrum (PAS) is characterized by abnormal placental invasion due to incomplete or complete loss of decidua. PAS subtypes are classified based on the depth of invasion: placenta accreta, increta, and percreta. Placenta percreta is the most severe form of placenta accreta and is characterized by invasion of the placenta through the entire myometrium reaching up to the uterine serosa. The increasing rate of placenta accrete because of increased rate of cesarean delivery. Urological complications are relatively rare in placenta accreta spectrum (PAS), but can be severe. Treatment planning must always involve a multidisciplinary team. Placenta percreta is a very high-risk obstetric condition associated with morbidity and mortality. A 32-year-old woman referred from Maternal Fetal Medicine Polyclinic with G4P2A1L2 37-38 weeks of term pregnancy + total placenta previa suspected percreta PAS 2 grade 3B S2 + once previous CS, and a CCS hysterectomy was planned. PAS with bladder involvement was significantly correlated with massive surgical blood loss. Prenatally, the disorder was predicted with high specificity by the combination of loss of chemical shift artifacts in the steady-state free precession sequence and abnormal vascularization at the uterovesical interface on USG (Ultrasonography)

The rising rate of caesarean delivery has led to a dramatic increase in the incidence of placenta accreta and its variants. In the USA, placenta accreta is now estimated to occur in approximately 3 per 1000 deliveries. The entity is associated with substantial maternal morbidity and mortality, with some estimates suggesting a maternal mortality rate of up to 6–7% (Belfort et al. Am J Obstet Gynecol 2010;203:430–9). The morbidity associated with morbidly adherent placenta is due almost entirely to haemorrhage-associated complications. The bleeding that accompanies placenta accreta can be profound—hard to predict preoperatively and difficult to control intraoperatively. The central tenet of the surgical management of placenta accreta is to make every effort to minimise bleeding. This involves leaving the placenta in situ during hysterectomy, planning the hysterotomy site to avoid the placental bed, and minimising the disruption of the uterine tissue overlying the placenta during the dissection. Despite these efforts, avoiding placental disruption is often challenging in women with significant placental invasion. In an attempt to minimise bleeding at the time of hysterectomy for placenta accreta, the author presents a case series of women who underwent retrograde caesarean hysterectomy. In essence, the retroperitoneum is opened, the anterior division of the internal iliac artery is ligated, and the utero-ovarian ligament is divided. [Correction added on 22 January 2016, after first online publication: ‘infundibulopelvic ligament’ has been changed to ‘utero-ovarian ligament’ in the preceding sentence.] The posterior fornix is then exposed and opened. After identification of the ureters, the dissection is carried around the cervix and eventually to the vesicouterine space, at which time the bladder is mobilised from the uterus. The technique mimics an en bloc resection of a pelvic malignancy. In the case series, the authors describe 11 women who underwent the operation and tolerated the procedure well without major morbidity. The author's work is an important consideration to help limit blood loss at the time of hysterectomy. Other operative interventions such as uterine artery embolisation and placement of vascular balloon occlusion catheters have also been suggested, and there is great interest in conservative management of placenta accreta in which the placenta is left in situ (Perez-Delboy et al. BJOG 2014;121:163–9). However, to date, prospective trials are largely lacking and when to use each of these management strategies is based in large part on expert opinion. Perhaps the most important point that this series raises is the complexity of the management of women with placenta accreta. In essence, every case is somewhat different and often requires complex decision-making in the absence of high-quality data. Therefore, any novel surgical approach that may reduce the blood loss and the need for transfusion in women with placenta accreta adds an important component to our surgical armamentarium. Previous work has shown that women cared for at high-volume hospitals and referral centres have better outcomes (Eller et al. Obstet Gynecol 2011;117:331–7). From a policy perspective, efforts have now focused on developing guidelines and recommendations for referral of women with placenta accreta to centres of excellence in an attempt to reduce maternal morbidity (Silver et al. Am J Obstet Gynecol 2015;212:561–8). Given that the incidence of placenta accreta is likely to continue to rise, efforts such as these to optimise outcomes for women and further studies to help guide best management are urgently needed. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Disorders of placental implantation comprise a spectrum ranging from the mildest form, placenta accreta, which involves myometrial invasion, to the most severe form, placenta percreta, in which tissue invades through the uterine serosa and can involve adjacent organs. Placenta increta, with deep myometrial invasion, is an intermediate state. Any of these disorders can lead to profuse bleeding, which often occurs at the time of delivery. Accurate antepartum diagnosis can prompt an alternative surgical approach. This study is a retrospective review of the findings of magnetic resonance imaging (MRI) in four patients, three with a history of cesarean delivery and one with three prior myomectomies. All four women presented with antepartum spotting or frank vaginal bleeding. Magnetic resonance imaging was performed at 33 to 36 weeks’ gestation, and the findings were reviewed by two radiologists, who examined T2-weighted images recorded in the sagittal, axial, and coronal planes. Two women had findings of placenta percreta with previa. One each presented with placenta accreta and previa and with placenta accreta with a fundal placenta (at the site of previous myomectomies). In all instances, the MRI findings agreed completely with the surgical and pathological findings. In placenta accreta, the myometrium was focally thinned and indistinct near the placenta, but there was a lower-signal-intensity component subjacent to the abnormality. In placenta percreta, the uterine wall was focally obliterated in the area of abnormality and traversed by tissue that was isointense to and confluent with the intrauterine placenta. In one of these cases, placental tissue was seen abutting on the bladder wall, and superficial invasion of the detrusor muscle was confirmed pathologically. All four women underwent total hysterectomy. Blood loss in three cases was estimated at 800 to 1000 ml. Magnetic resonance imaging is an accurate means of assessing abnormalities of placental implantation, displaying soft tissue contrast far better than ultrasonography. Antepartum MRI may prevent morbidity and even death in women who have had previous uterine surgery when the results of ultrasonography are inconclusive. The method is especially helpful when an abnormality is present at a posterior or fundal site that is not very accessible to examination with a high-frequency transducer. Magn Reson Imaging 1999;17:965–971

Massive bleeding during caesarean section (CS) is a lifethreatening complication of placenta praevia. Placenta accreta, anterior placentation, history of previous CS, and advanced maternal age, predicted massive bleeding (Hasegawa et al. 2009), which we have also demonstrated and described in a domestic journal in the Japanese language (Watanabe et al. 2002). We also had the clinical impression that, excluding placenta accreta, patients who had not experienced warning bleeding during pregnancy bled more during/after CS than those who had. We therefore reanalysed previous data. During a 10-year period (January 1991–December 2000), we performed 124 CS due to placenta praevia. Excluding five patients with multiple pregnancies and five patients with placenta accreta (with all having to undergo hysterectomy), we analysed 114 singleton pregnant women with placenta praevia. Warning bleeding was defined as painless bleeding which did not lead to emergency CS. The amount of blood loss during/after CS was defined as the sum of blood loss during CS and the 2-h post-surgical period, excluding blood loss before CS. Of 114 cases, 63 experienced warning bleeding, and the remaining 51 did not. Patients with and without warning bleeding, bled 1,276+ 688 ml (mean+ standard deviation: range: 289–3,257) and 1,563+ 790 ml (377–4,950) during/after CS, respectively, with statistical significance (p ¼ 0.02, unpaired t-test). Our clinical impression therefore proved to be correct; patients without warning bleeding bled significantly more than those with. The following may account for the mechanism of this observation. Even excluding placenta accreta, placental attachment to the decidua may differ among patients. Some placenta may be attached more tightly and thus may be difficult to separate during pregnancy, reducing the chance of warning bleeding. Tight attachment and thus a ‘difficult to separate’ condition may also occur during CS, and thus may prohibit physiological placental separation, leading to more bleeding. Ultrasound and magnetic resonance imaging have enhanced the possibility of predicting placenta accreta, and thus the possibility of massive bleeding accompanied with this condition. Some ultrasound findings, i.e. spongy-like findings in the cervix, have been reported to predict massive bleeding during CS, regardless of whether placenta accreta is present (Hasegawa et al. 2009). Here, we provide one simple, but clinically important, rule of thumb; in patients without discernible placenta accreta, a lack in warning bleeding may be an ominous sign of greater bleeding. To our knowledge, this has hitherto never been described. ‘Warning’ bleeding may warn of the presence of placenta previa, but may not warn of more bleeding during/after CS. Thus, it seems, ‘no bleeding before, more bleeding later’. We must admit that wide ranges of blood loss during/after CS were observed in patients both with and without warning bleeding. We also admit that the study population here was not large. We must await further study to confirm this, and if so, its mechanism.

Uterine Artery Embolization following Cesarean Delivery but prior to Hysterectomy in the Management of Patients with Invasive Placenta

IntroductionThis report describes the challenges of treating a pregnant woman who had a rare case of critical placenta accreta with concurrent Cromer system anti-Tc(a) and anti-Kidd A alloantibodies. No previous case of such alloimmunization in a patient with placenta accreta has been reported.Case presentationA 28-year-old African woman with anti-Cromer Tc(a) antibodies, anti-Kidd A antibodies and placenta accreta was admitted to the obstetric emergency department at our university hospital with persistent vaginal bleeding. Her rare Cromer blood group system antibodies had been diagnosed 1 month earlier; no compatible blood had been found despite a worldwide search. We performed a cesarean section after placement of Fogarty balloons in her uterine arteries with preoperative endovascular interventional radiology. Other therapeutic interventions included preoperative iron administration to raise hemoglobin and the scheduled predeposit of autologous blood. Intraoperative therapeutic management was aimed at preventing coagulopathy and massive bleeding. With the use of alternative medical techniques determined during perioperative planning, her intraoperative blood loss was only 1000mL, despite the placenta accreta. She was discharged from the hospital 4 days after cesarean section.ConclusionsTo the best of our knowledge, this is the first report of an alloimmunized patient with two different alloantibodies and concurrent high risk of bleeding because of placenta accreta. The close collaboration among obstetricians, anesthesiologists, interventional radiologists, blood bank pathologists and intensive care doctors prevented serious consequences in this patient. The exceptional feature of this case is the patient’s double risk: the placenta accreta and the inability to transfuse compatible blood. These two extreme situations challenged the multidisciplinary medical team.

Objectives: The objective of the study was to evaluate differences in post partum bleeding, transfusion requirement and length of hospital stay in women with focal vs. diffuse placenta accreta. The same parameters were compared in women undergoing balloon occlusion vs. no occlusion of the iliac arteries at Caesarean delivery for accreta. Methods: Prospective observational study of women with suspected focal or diffuse placenta accreta on routine sonography. Follow up scans were performed as required. Surgical and histologic correlation was performed after Caesarean delivery. Independent groups t-tests and non-parametric Mann-Whitney U were used in the statistical analysis. Results: 25 women were diagnosed on ultrasound with placenta accreta, 9 with focal accreta and 16 with diffuse involvement. On average, women in the diffuse group exhibited significantly greater blood loss (P < 0.001) than the focal group and had a higher transfusion requirement (P = 0.12). There was no significant difference in hospital stay between the groups. 12 women underwent balloon iliac occlusion at Caesarean delivery, 2 of whom had focal accreta diagnosed prenatally and 10 had diffuse accreta. There were no significant differences in blood loss, transfusion requirement or length of hospital stay between the balloon vs. no-balloon occlusion groups. Conclusions: Prenatal diagnosis of extent of placenta accreta is clinically important and should guide management around delivery. Although the numbers in this study are small, no significant differences in blood loss or transfusion requirement were observable between the balloon occlusion vs. no occlusion group. Further studies are required to assess whether this is a worthwhile and cost-effective intervention in management of placenta accreta.

Introduction: Pregnancies with gynecologic complications, such as ovarian cysts, uterine myomas, and placenta accreta, may increase the risk to both mother and fetus. Ovarian cysts, although often benign, can cause complications such as torsion. Uterine myomas are found in 10-20% of pregnancies and have the potential to cause bleeding, premature birth, or fetal position disruption. Placenta accreta, common in patients with a history of caesarean section, requires early diagnosis to prevent massive bleeding. Management involves routine ultrasonography, conservative therapy, and surgery when necessary. A multidisciplinary approach to patient education is essential. This case report aims to assess a pregnancy with Gynecologic complications accompanied by placenta accreta. Case Report: A 39-year-old woman, GIII P2002, 8-9 weeks pregnant with a history of two SCs, presented with complaints of abdominal pain and bleeding. Examination revealed pregnancy in the SC scar niche and uterine myoma. Diagnosis included Cesarean Scar Pregnancy (CSP), uterine myoma, and iatrogenic buli rupture. The patient underwent One Step Conservative Surgery (OSCS) for CSP and myomectomy, and postoperative medical therapy. Discussion: This condition involves high risks, including severe bleeding, uterine rupture, and organ injury such as the bladder. Treatment includes antenatal screening with ultrasound and MRI, conservative surgery, and a multidisciplinary approach to prevent complications. Postoperatively, intensive care, psychological support, and patient education are required for optimal recovery. Conclusion: Pregnancies with a history of SC, uterine myoma, ovarian cyst, and placenta accreta require early diagnosis, surgical planning, and a multidisciplinary approach. Prevention through contraception and psychological support can improve pregnancy outcomes and reduce the risk of complications.

Anesthetic management of placenta accreta in a low-resource setting: a case series

Early first-trimester transvaginal ultrasound is indicated in pregnancy after previous Cesarean delivery: should it be mandatory?

Application of abdominal aortic balloon occlusion followed by uterine artery embolization for the treatment of pernicious placenta previa complicated with placenta accreta during cesarean section

Prophylactic balloon occlusion of internal iliac arteries in women with placenta accreta: Literature review and analysis

Objective: to describe a new method of organ-preserving surgery for combined placenta previa and placenta accreta into the uterine scar after a previous cesarean section – the CLAP method. Materials and methods. During 2015–2020, 29 women with placenta praevia and placenta accreta vera into the uterine scar after a previous cesarean section were operated. 15 women (control group) gave birth using the traditional method – cesarean section followed by hysterectomy; in 14 pregnant women (main group) the new method CLAP was used. CLAP consists of the following stages: stage I – C – cesarean section; stage II – L – ligation of internal iliac arteries; stage III – A – adherent placenta's area excision; stage IV – P – pressure, applied to the lower uterine segment, during which the technique of COLUS was performed. Patients were operated at 34–35 weeks of pregnancy after fetal respiratory distress syndrome prophylactics with a course of betamethasone.Results. Statistically significant difference in the age of patients (p = 0.968), status and weight of newborns (p = 0.058) was not found. But significant statistical difference was found in the amount of maternal blood loss during surgical delivery. In the control group, where pregnant women underwent hysterectomy, it was 3652 ± 293 ml, and in the main group, where delivery was performed using the new CLAP technique, blood loss was 2253 ± 153 ml (p &lt;0.001). All patients were discharged in satisfactory condition on the 8th–10th day. Conclusions. CLAP procedure is an effective alternative to previously used organ-preserving operations. It helps to avoid hysterectomy and does not require special equipment during a cesarean section. The CLAP technique has proven to be an effective way to prevent and cease blood loss, as well as to preserve reproductive function of woman.