Cesarean hysterectomy in pregnancies complicated with placenta previa accreta: a retrospective hospital-based study.

BACKGROUND: Placenta previa accreta (PPA) is a severe obstetric condition that can cause massive postpartum hemorrhage and transfusion. Cesarean hysterectomy is necessary in some severe cases of PPA to stop the life-threatening bleeding, but cesarean hysterectomy can be associated with significant surgical blood loss and major complications. The current study is conducted to investigate the potential risk factors of excessive blood loss during cesarean hysterectomy in women with PPA. METHODS: This is a retrospective study including singleton pregnancies after 28 weeks of gestation in women with placenta previa and pathologically confirmed placenta accreta spectrum who received hysterectomy during cesarean sections. A total of 199 women from January 2012 to August 2023 were included in this study and were divided into Group 1 (estimated surgical blood loss (EBL) ≤ 3500 mL, n = 103) and Group 2 (EBL > 3500 mL, n = 96). The primary outcome was defined as an EBL over 3500 mL. Baseline characteristics and surgical outcomes were compared between the two groups. A multivariate logistic regression model was applied to find potential risk factors of the primary outcome. RESULTS: Massive surgical blood loss was prevalent in our study group, with a median EBL of 3500 mL. The multivariate logistic analysis showed that emergency surgery (OR 2.18, 95% CI 1.08-4.41, p = 0.029), cervical invasion of the placenta (OR 2.70, 95% CI 1.43-5.10, p = 0.002), and intraoperative bladder injury (OR 5.18, 95% CI 2.02-13.28, p = 0.001) were all associated with the primary outcome. Bilateral internal iliac arteries balloon occlusion (OR 0.57, 95% CI 0.34-0.97) and abdominal aortic balloon occlusion (OR 0.33, 95% CI 0.19-0.56) were negatively associated with the primary outcome. CONCLUSIONS: Emergency surgery, cervical invasion of the placenta, and intraoperative bladder injury were potential risk factors for additional EBL during cesarean hysterectomy in women with PPA. Future prospective studies are needed to confirm the effect of intra-arterial balloon occlusion in cesarean hysterectomy of PPA.

Prenatal detection of placenta accreta spectrum using a sonographic checklist.

INTRODUCTION: The European Working Group for Abnormally Invasive Placenta proposed a checklist of ultrasound features for the antenatal detection of placenta accreta spectrum (PAS). This study aims to assess the performance of the checklist in identifying histopathologically confirmed PAS cases in a cohort with a high pre-test probability of PAS, and identify if particular features are associated with PAS. MATERIAL AND METHODS: This is a prospective multi-site cohort study conducted between 2018 and 2023. Consecutive patients who underwent ultrasound assessment for suspicion of PAS were included, and the sonographic checklist was completed at the time of ultrasound. Cases were defined as PAS where they had intraoperative findings as described by the International Federation of Gynecology and Obstetrics (FIGO) grading, and histopathological findings for hysterectomy and myometrial resection cases. All non-PAS cases in this study had placenta previa and at least one prior cesarean delivery. RESULTS: Seventy-eight participants met inclusion criteria, of whom 63 (80.7%) were diagnosed with PAS. Cesarean hysterectomy was performed in 49 cases (62.8%). Overall, third-trimester ultrasound performed at a median gestational age of 32 weeks (IQR 30-34 weeks) had a sensitivity of 0.84 (95% CI 0.73 to 0.92) and specificity of 0.73 (95% CI 0.45 to 0.92) for detecting PAS, with a positive and negative likelihood ratio of 3.15 (95% CI 1.35 to 7.35) and 0.22 (95% CI 0.11 to 0.41), respectively. Features most associated with PAS were abnormal placental lacunae (Odds Ratio [OR] 5.40 [95% CI 1.61 to 18.03] and myometrial thinning OR 6.87 [95% CI 1.93 to 24.4]). While many of the ultrasound features seen in PAS were also present in cases of placenta previa with prior Cesarean section, the median (IQR) number of features present in PAS cases was significantly higher than in the non-PAS placenta previa group (six features [3-8] vs. two features [0-3] p = 0.001). No case of non-PAS placenta previa had more than five features present. CONCLUSIONS: The use of a standardized sonographic checklist had a high sensitivity and good specificity for the detection of PAS in this prospective cohort of well-classified PAS cases.

Risk factor stratification for urgent and non-urgent transfusion in patients giving birth.

BACKGROUND: A common approach to attempt to reduce maternal morbidity from hemorrhage is to recognize patients at increased risk, and to make advance preparations for possible blood transfusion in these patients. Preparation may consist of a hold clot, type and screen, or crossmatch. Most hospitals, including ours, have pathways or guidelines that lay out which of these preparations should be made at the time a patient is admitted to labor and delivery. These are often based on risk factors for hemorrhage, but don't take into account the probability that transfusion will be needed. The cost effectiveness of performing a type and screen or routine crossmatch on patients admitted for delivery has been questioned. Several studies have shown that the chance of transfusions in individuals giving birth is very low. In terms of the need for routine blood preparation, the need for urgent transfusion is most relevant. This has not been included in studies of transfusion rates. OBJECTIVES: The purpose of this study was to quantify the relative importance of risk factors present on admission for needing a blood transfusion and to develop a formula to define each individual's risk. This could then be used to decide an appropriate level of initial blood preparation for patients at different risk levels. STUDY DESIGN: Risk factors for hemorrhage and the level of transfusion preparation were extracted from the medical records of a cohort of 89,881 patients delivering in an 18-hospital health care system over 40 months. We tabulated the number who required at least one RBC transfusion and the number needing an urgent transfusion- defined as receiving blood during labor or within 4 hours after delivery. Odds ratios for requiring a transfusion were calculated for each risk factor. We then calculated the probability of needing a transfusion for each patient based on their risk factor profile. RESULTS: 643 patients had any transfusion during their hospitalization (0.72 % of deliveries), and 311 had an urgent transfusion (0.35% of deliveries). The calculated probability of needing a transfusion was less than 1% in 87.8% of patients and was greater than 5% in 1.2% of patients. The chance of needing a transfusion was highest for placenta accreta spectrum, admission Hgb <8.0, and placenta previa. A second tier of risk factors included abruption, bleeding with no specific diagnosis, and Hgb between 8.0 and 10.0. CONCLUSION: In our cohort, very few patients received a transfusion. Applying a formula derived from patient- specific risk factors, we found that almost all patients have a very low probability of needing a transfusion, especially an urgent transfusion. Based on these results, we suggest that a hold clot be used except for the highest risk patients or in settings with barriers to procuring blood in the rare case of urgent transfusion need. Making this change would greatly reduce hospital blood bank charges.

Placental T2-weighted MRI-based radiomics-clinical nomogram to predict postpartum hemorrhage of placenta previa.

BACKGROUND: Placenta previa is an obstetric complication related to severe maternal morbidity and mortality. Magnetic resonance imaging (MRI) can be used for the preoperative evaluation of postpartum hemorrhage. PURPOSE: To investigate the value of MRI-based radiomics analysis in predicting postpartum hemorrhage among pregnant women with placenta previa. MATERIAL AND METHODS: Preoperative T2-weighted MRI and related clinical data of 371 patients were retrospectively collected, and these patients were randomly allocated into two subsets: the training dataset (n = 260) and the validation dataset (n = 111). The logistic regression (LR) classifier was used for the development of the radiomics model and the calculation of the radiomics score (Radscore). RESULTS: A total of eight radiomics features and five clinical features were selected for model development. The area under the receiver operating characteristic curve (AUC) of the radiomics model in the training and validation datasets were 0.929 (95% confidence interval [CI] = 0.891-0.957) and 0.914 (95% CI = 0.846-0.959), respectively. Combined with clinical factors, nomograms demonstrated improved diagnostic efficacy, with an AUC of 0.968 (95% CI = 0.939-0.986) in the training dataset and 0.947 (95% CI = 0.888-0.981) in the validation dataset. CONCLUSION: The MRI-based model has certain value in predicting postpartum hemorrhage in pregnant women with placenta previa.

Low placenta at the mid trimester anomaly scan-A cause for concern?

OBJECTIVE: This study was aimed to assess the predictive validity of internal os distance (IOD) in mid-trimester scan for the prediction of third-trimester low-positioned placenta, and to define a cut-off of IOD at which third-trimester low-positioned placenta could be identified, see the association of placental site (anterior/posterior), previous history of cesarean section with abnormal location of placenta in third trimester and see the maternal and neonatal outcomes. METHODS: It was a prospective cohort study of women with low-positioned placenta (IOD < 20 mm) at mid-trimester anomaly scan followed up in third trimester till birth. Relative risks for a low-positioned placenta in the third-trimester were calculated for women with posterior versus anterior, low-lying placenta versus placenta previa and positive versus negative history of cesarean section. Multilevel likelihood ratios and corresponding ROC curves for different ranges of IOD were calculated. RESULTS: Women with posterior placenta had a high risk of low positioned placenta compared to anterior placenta (9.28% vs. 0.74%); RR 1.45, similarly women with placenta previa had high risk compared to low lying placenta (68.57% vs. 1.69%); RR 6.51, so did the women with previous cesarean section (9.41% vs. 5.87%); RR 1.47. CONCLUSIONS: 93.42% placenta which were low positioned in mid trimester were normally situated in third trimester. The cut-off for IOD in anterior placenta was -40 mm and in posterior placenta was 14.3 mm. IOD measurement and interpretation seems promising.

First and Second Trimester Aneuploidy Screening Biomarkers and Risk Assessment of Placenta Previa and Accreta: A Systematic Review and Meta-Analysis.

OBJECTIVES: This study evaluates differences in first and second trimester maternal serum biomarkers for aneuploidy screening among women with placenta accreta spectrum disorders (PAS), placenta previa, and those with normal placentation. METHODS: A systematic review of five major databases up to April 2023 was conducted. Included were comparative studies analyzing mean biomarker levels in multiples of the median (MoM) among pregnant women with PAS, placenta previa, and uncomplicated pregnancies. RESULTS: Analysis of 8 retrospective studies involving 1886 participants showed significant variances in biomarker levels. In the first trimester, pregnancy associated plasma protein-A levels were notably higher in the PAS group compared to the placenta previa group (731 patients, mean difference (MD) 0.48 MoM, 95% CI 0.23 to 0.73, P = .0001). Also, ß-human chorionic gonadotropin levels were elevated in the placenta previa group compared to those with normal attachment (362 patients, MD 0.27 MoM, 95% CI 0.17 to 0.38, P < .00001). In the second trimester, alpha fetoprotein and human chorionic gonadotropin levels were significantly increased in PAS patients compared to the placenta previa and normal groups, indicating potential markers for PAS. CONCLUSIONS: Significant differences in early pregnancy biomarker levels among women with PAS, placenta previa, and normal placentation were identified. These findings suggest potential for early screening, but further large-scale studies are essential for validation. This study underscores the need for improved screening methods for placental disorders, potentially aiding in early diagnosis and management strategies.

Risk Factors of Velamentous Cord Insertion in Singleton Pregnancies-A Systematic Review and Meta-Analysis.

Objective: This meta-analysis aims to quantitatively summarize current data on various potential risk factors of velamentous cord insertion (VCI). A better understanding of these risk factors could enhance prenatal identification both in settings with routine screening and in those where universal screening for cord insertion anomalies is not yet recommended. Methods: A systematic search was conducted in MEDLINE, Cochrane Library, and Scopus from their inception until 7 February 2024. Eligible studies included observational studies of singleton pregnancies with VCI, identified either prenatally or postnatally, compared with pregnancies with central or eccentric cord insertion. Analyses were performed using DerSimonian and Laird random-effects models, with outcomes reported as risk ratios (RR) or mean differences with 95% confidence intervals (CI). Results: In total, 14 cohort and 4 case-control studies were included, reporting on 952,163 singleton pregnancies. Based on the cohort studies, the overall prevalence of VCI among singleton pregnancies was calculated to be 1.54%. The risk of VCI was significantly higher among pregnancies conceived using assisted reproductive technology (RR, 2.32; 95% CI: 1.77-3.05), nulliparous women (RR, 1.21; 95% CI: 1.15-1.28), women who smoked (RR, 1.14; 95% CI: 1.08-1.19), and pregnancies diagnosed with placenta previa (RR, 3.60; 95% CI: 3.04-4.28). Conclusions: This meta-analysis identified assisted reproductive technology, nulliparity, smoking, and placenta previa as significant risk factors of VCI among singleton pregnancies. These findings could inform screening policies in settings where universal screening for cord insertion is not routinely performed, suggesting a targeted approach for women with these specific risk factors.

Uterine isthmic tourniquet left in situ as a new approach for placenta previa-accreta surgery: a comparative study.

OBJECTIVES: Placenta previa-accreta spectrum disorders are a cause of obstetric hemorrhage that can lead to maternal fetal mortality and morbidity. We aimed to describe the use of a uterine isthmic tourniquet left in situ as a new uterus-preserving approach for patients with placenta previa-accreta. METHODS: In this retrospective comparative study, the patients who underwent surgery for placenta previa between 2017 and 2024 at our tertiary hospital were reviewed. Primary outcome of the study is to evaluate feasibility of uterine isthmic tourniquet left in situ for uterine preserving by preventing postpartum hemorrhage for patients with placenta previa-accreta. As a secondary outcome, group 1 (n=28) patients who were managed with uterine isthmic tourniquet left in place were compared with patients in group 2 (n=32) who were managed with only bilateral uterine artery ligation. RESULTS: This new approach uterine isthmic tourniquet technique prevented postpartum hemorrhage with a rate of 100 percent in group 1 patients, while uterine artery ligation prevented postpartum hemorrhage with a rate of 75 % in group 2. Postoperative additional interventions (relaparotomy hysterectomy, balloon tamponade application, uterine or vaginal packing) were performed for eight patients in group 2 (25 %) but not in group 1 (0 %) (p=0.015). The haemoglobin levels before caesarean section were similar in both groups (p=0.235), while the postoperative haemoglobin levels were lower in group 2 (9.69 ± 1.37 vs. 8.15 ± 1.32) (p=0.004). Erythrocyte suspension was given to two patients in group 1 and 12 patients in group 2 (2/28 7 % vs. 12/32 37 %, p=0.018). CONCLUSIONS: The uterine isthmic tourniquet left in situ technique is a safe, simple and effective for preventing postpartum hemorrhage and preserving uterus during placenta previa accreta surgery as superior to uterine artery ligation alone.

Trophectoderm grade is associated with the risk of placenta previa in frozen-thawed single-blastocyst transfer cycles.

STUDY QUESTION: Do obstetric and perinatal complications vary according to different blastocyst developmental parameters after frozen-thawed single-blastocyst transfer (SBT) cycles? SUMMARY ANSWER: Pregnancies following the transfer of a blastocyst with a grade C trophectoderm (TE) were associated with an increased risk of placenta previa compared to those with a blastocyst of grade A TE. WHAT IS KNOWN ALREADY: Existing studies investigating the effect of blastocyst morphology grades on birth outcomes have mostly focused on fetal growth and have produced conflicting results, while the risk of obstetric complications has rarely been reported. Additionally, growing evidence has suggested that the appearance of TE cells could serve as the most important parameter for predicting implantation and live birth. Given that the TE ultimately develops into the placenta, it is plausible that this independent predictor may also impact placentation. STUDY DESIGN, SIZE, DURATION: This retrospective cohort study at a tertiary-care academic medical center included 6018 singleton deliveries after frozen-thawed SBT cycles between January 2017 and December 2021. PARTICIPANTS/MATERIALS, SETTING, METHODS: Singleton pregnancies were grouped into two groups according to blastocyst developmental stage (Days 5 and 6), four groups according to embryo expansion (Stages 3, 4, 5, and 6), three groups according to inner cell mass (ICM) quality (A, B, and C), and three groups according to TE quality (A, B, and C). The main outcomes included pregnancy-induced hypertension, preeclampsia, gestational diabetes mellitus, preterm premature rupture of membrane, placenta previa, placental abruption, placenta accreta, postpartum hemorrhage, preterm birth, low birth weight, small for gestational age, and birth defects. Multivariate logistic regressions were performed to evaluate the effect of blastocyst developmental stage, embryo expansion stage, ICM grade, and TE grade on measured outcomes adjusting for potential confounders. MAIN RESULTS AND THE ROLE OF CHANCE: No association was found between blastocyst developmental stage and obstetric or perinatal outcomes both before and after adjusting for potential confounders, and similar results were found with regard to embryo expansion stage and ICM grade. Meanwhile, the incidence of placenta previa derived from a blastocyst with TE of grade C was higher compared with those derived from a blastocyst with TE of grade A (1.7%, 2.4%, and 4.0% for A, B, and C, respectively, P = 0.001 for all comparisons). After adjusting for potential covariates, TE grade C blastocysts had 2.81 times the likelihood of resulting in placenta previa compared to TE grade A blastocysts (adjusted odds ratio 2.81, 95% CI 1.11-7.09). No statistically significant differences were detected between any other measured outcomes and TE grades both before or after adjustment. LIMITATIONS, REASONS FOR CAUTION: The study is limited by its retrospective, single-center design. Additionally, although the sample size was relatively large for the study group, the sample size for certain subgroups was relatively small and lacked adequate power, particularly the ICM grade C group. Therefore, these results should be interpreted with caution. WIDER IMPLICATIONS OF THE FINDINGS: The study extends our knowledge of the potential downstream effect of TE grade on placental abnormalities. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by the National Key Research and Development Program of China (2023YFC2705500, 2023YFC2705501, 2023YFC2705505, 2019YFA0802604); National Natural Science Foundation of China (82130046, 82320108009, 82371660, 32300710); Shanghai leading talent program, Innovative research team of high-level local universities in Shanghai (SHSMU-ZLCX20210201, SHSMU-ZLCX20210200, SHSMU-ZLCX20180401), Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital Clinical Research Innovation Cultivation Fund Program (RJPY-DZX-003), Science and Technology Commission of Shanghai Municipality (23Y11901400), Shanghai's Top Priority Research Center Construction Project (2023ZZ02002), and Three-Year Action Plan for Strengthening the Construction of the Public Health System in Shanghai (GWVI-11.1-36). The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Nomogram based on clinical characteristics and ultrasound indicators for predicting severe postpartum hemorrhage in patients with anterior placenta previa combined with previous cesarean section: a retrospective case-control study.

BACKGROUND: Placental accreta spectrum disorders (PAS) are a high-risk group for severe postpartum hemorrhage (SPPH), with the incidence of PAS increasing annually. Given that cesarean section and anterior placenta previa are the primary risk factors for PAS, therefore, our study aims to investigate the predictive value of clinical characteristics and ultrasound indicators for SPPH in patients with anterior placenta previa combined with previous cesarean section, providing a theoretical basis for early prediction of SPPH. METHODS: A total of 450 patients with anterior placenta previa combined with previous cesarean section were retrospectively analyzed at Shengjing Hospital affiliated with China Medical University between January 2018 and March 2022. Clinical data and ultrasound indicators were collected. Patients were categorized into SPPH (blood loss >2000mL, 182 cases) and non-SPPH (blood loss ≤ 2000mL, 268 cases) groups based on the blood loss within 24 h postpartum. The population was randomly divided into training and validation cohorts at a 7:3 ratio. LASSO and multifactorial logistic regression analyses were utilized to identify independent risk factors for SPPH. Accordingly, a nomogram prediction model was constructed, the predictive performance was assessed using receiver operating characteristic (ROC) curves, calibration curves and decision curve analysis (DCA). RESULTS: Among the 450 patients, 182 experienced SPPH (incidence rate, 40.44%). Preoperative systemic immune-inflammatory index, preoperative D-dimer level, preoperative placenta accreta spectrum ultrasound scoring system (PASUSS) score, and one-step-conservative surgery were identified as independent risk factors for SPPH in patients with anterior placenta previa combined with previous cesarean section. A nomogram was constructed based on these factors. The areas under the ROC curves for the training and validation cohorts were 0.844 (95%CI: 0.801-0.888) and 0.863 (95%CI: 0.803-0.923), respectively. Calibration curves and DCA indicated that this nomogram demonstrated good predictive accuracy. CONCLUSIONS: This nomogram presents an effective and convenient prediction model for identifying SPPH in patients with anterior placenta previa combined with previous cesarean section. It can guide surgical planning and improve prognosis.

A prediction model based on MRI and ultrasound to predict the risk of PAS in patient with placenta previa.

INTRODUCTION: To investigate the risk factors affecting patients with placenta previa (PP) and to construct an effective prediction model for the severity of PAS in PP. METHODS: A total of 240 pregnant women with PP were enrolled in this study. An MRI+Ultrasound-based model was developed to classify patients into placental implantation and non-placental implantation groups. Multivariate nomograms were created based on imaging features. The model was evaluated using Receiver Operating Characteristic (ROC) curve analysis. The predictive accuracy of the nomogram was assessed through calibration plots and decision curve analysis. RESULTS: The MRI+Ultrasound-based prediction model demonstrated favorable discrimination between the placental implantation and non-placental implantation groups. The calibration curve exhibited agreement between the estimated and actual probability of placental implantation. Additionally, decision curve analysis indicated a high clinical benefit across a wide range of probability thresholds. The Area under the ROC curve (AUC) was 0.911 (95 % CI: 0.76-0.947), with a sensitivity of 88.40 % and specificity of 88.10 %. CONCLUSION: The MRI+Ultrasound-based prediction model could be a valuable tool for preoperative prediction of the percentage of implantation. Our study enables obstetricians to conduct more adequate preoperative evaluations.

Diagnostic accuracy of magnetic resonance imaging to predict peripartum hysterectomy and neonatal mortality in total placenta previa: A retrospective cohort study.

OBJECTIVES: To assess the reliability of placental magnetic resonance imaging measurements in predicting peripartum hysterectomy and neonatal outcomes in patients with total placenta previa. STUDY DESIGN: This retrospective cohort study, conducted at a single tertiary center, identified 372 pregnant women diagnosed with placenta previa. 277 singleton pregnancies that met the inclusion criteria and were diagnosed with total placenta previa in the third trimester were divided into two groups according to whether a placental MRI was performed. Two radiologists analyzed the MRI findings of 150 pregnant women with total placenta previa. Measurements were conducted for the placental volume of the upper and lower uterine sectors, cervical canal length, and cervical canal dilatation. A comparison was made between the surgical progression of these pregnant women and 127 pregnant women with total placenta previa who did not undergo an MRI. After pathological examination, 122 (63.2%) of 193 pregnant women diagnosed with placenta accreta spectrum underwent peripartum total abdominal hysterectomy. The results were compared using logistic regression analysis. RESULTS: Reduced placental volume in the upper uterine segment and increased volume in the lower uterine segment significantly correlated with a higher probability of peripartum hysterectomy (cut-off: ≤343.4 and ≥ 403.4 cm3; OR: 0.993, 95 % CI: 0.990-0.995 and OR: 1.007, 95 % CI: 1.005-1.009, respectively). Shortened cervical canal length and increased dilatation raise the risk of peripartum hysterectomy (cut-off: ≤34, ≥11 mm; OR: 0.82, 95 % CI: 0.77 - 0.88 and OR: 1.7, 95 % CI: 1.4 - 2.1, respectively). The risk of neonatal death is 32 times higher in those < 34 weeks than in those 34 weeks or higher (95 % CI: 4.2-250, p = 0.001). CONCLUSIONS: Placental MRI significantly contributes to predicting peripartum total abdominal hysterectomy and neonatal mortality in patients with total placenta previa associated with placenta accreta spectrum.

The Importance of Multidisciplinary Management for Placenta Increta: A Case Report.

This case involves a 34-year-old pregnant woman, gravida 6 para 5, with a gestational age of 32 weeks plus one day. After imaging studies, doctors suspected that she had an abnormal placentation and referred her to a secondary hospital for further management. Surgeons there performed a successful elective cesarean section and a total abdominal hysterectomy with a multidisciplinary approach in mind.

Association between endometriosis and perinatal complications: a case-control study.

BACKGROUND: Recently, a history of endometriosis has been reported to be associated with several perinatal complications. However, it is unknown whether pre-pregnancy treatment for endometriosis reduces perinatal complications. In this study, we aimed to clarify the association between endometriosis and perinatal complications and investigate whether there is a significant difference in the incidence of placenta previa depending on the degree of surgical completion of endometriosis before pregnancy. METHODS: This case-control study included 2781 deliveries at the Hirosaki University Hospital between January 2008 and December 2019. The deliveries were divided into a case group with a history of endometriosis (n = 133) and a control group without endometriosis (n = 2648). Perinatal outcomes and complications were compared between the case and control groups using a t-test and Fisher's exact test. Multiple logistic regression models were used to identify the risk factors for placenta previa. Additionally, we examined whether the degree of surgical completion of endometriosis before pregnancy was associated with the risk of placenta previa. RESULTS: Patients with a history of endometriosis had a significantly higher risk of placenta previa (crude odds ratio, 2.66; 95% confidence interval, 1.37‒4.83). Multiple logistic regression analysis showed that a history of endometriosis was a significant risk factor for placenta previa (adjusted odds ratio, 2.30; 95% confidence interval, 1.22‒4.32). In addition, among patients with revised American Society for Reproductive Medicine stage III-IV endometriosis, the incidence of placenta previa was significantly lower in patients who underwent complete surgery (3/51 patients, 5.9%) than in those who did not (3/9 patients, 33.3%) (p = 0.038). CONCLUSIONS: A history of endometriosis is an independent risk factor for placenta previa. Given the limitations of this study, further research is needed to determine the impact of endometriosis surgery on perinatal complications.

Endometriosis and risk of adverse pregnancy outcomes: a retrospective multicenter cohort study.

OBJECTIVE: To investigate first, the association between endometriosis and preterm birth; second, the associations between endometriosis and preeclampsia, placenta previa, postpartum hemorrhage, stillbirth, and small-for-gestational-age infants (assessed by birthweight); and third, the risk of these adverse pregnancy outcomes with and without the use of medically assisted reproduction. DESIGN: Multicenter retrospective cohort study. SETTING: A total of 103 French maternity units. PATIENTS: Deliveries by 368,935 women (377,338 infants) from 1999 through 2016. EXPOSURE: Endometriosis, defined as a single disease entity (endometriosis and/or ademyosis) MAIN OUTCOMES MEASURES: The main outcome was the preterm birth rate (both <37 and <33 weeks). The secondary outcomes were rates of preeclampsia, placenta previa, postpartum hemorrhage, stillbirth, and small-for-gestational-age neonates. RESULTS: Women in the endometriosis group had more frequent histories of infertility before the included pregnancy (34.7 vs. 5.0%), more hospitalizations during the pregnancy (27.4 vs. 19.8%), and more planned cesarean sections (14.0 vs. 8.7); they more often were nulliparous (51.7 vs. 43.4%). The prevalence of preterm birth at <37 weeks was 11.1% in the endometriosis group and 7.7% in the unexposed group, and for <33 weeks, it was 3.1% and 2.2%, respectively. The adjusted relative risk for confounding factors was higher in the endometriosis than the unexposed group for preterm delivery <37 weeks (1.40, 95% confidence interval, 1.18-1.67) or <33 weeks (1.53, 95% confidence interval, 1.08-2.16). For the secondary outcomes, the adjusted risk ratios for preeclampsia, placenta previa, postpartum hemorrhage, and small-for-gestational-age status of <10th and <5th percentiles were higher in the endometriosis group. The adjusted risk ratios for stillbirth and small-for-gestational-age status of <3rd percentile did not differ between the two groups, and those after stratification by medically assisted reproduction for preterm birth at <37 and <33 weeks did not differ statistically significantly between them, for the secondary outcomes, only the risk of placenta previa was higher in the medically assisted reproduction and non-medically assisted reproduction subgroups. CONCLUSION: Pregnant women with endometriosis had higher risks of preterm birth and other poor pregnancy outcomes than women without endometriosis.

Fetomaternal Outcome in Antepartum Hemorrhage After 34 Weeks of Gestation.

BACKGROUND: Antepartum hemorrhage is defined as any bleeding from or into the genital tract during pregnancy, after the period of viability until delivery of the fetus. APH complicates 2-5% of pregnancies and is a primary cause of perinatal and maternal mortality globally. Aim of this study is to evaluate maternal and perinatal outcome in patients with APH at a tertiary care hospital. METHODS: The present study was a cross sectional study conducted in Obstetrics and Gynaecology department of Paropakar Maternity and Women's Hospital, during a period of 5 months from December 2022 to April 2023. 50 cases of APH were enrolled with gestational age ≥ 34 weeks of gestation. RESULTS: Incidence of APH after 34 weeks of gestation was 0.51%. The most common type of APH was abruption placenta (44%) followed by placenta previa (32%) and undetermined (24%). The age range of 26 to 30 years old accounted for the highest number of APH patients i.e., 21(42%). In placenta previa, 75% and in abruption placenta 63.64% were multigravida. APH was presented mostly between 37-40 weeks. Around 26% of the patients had anemia at the time of admission. Most common mode of delivery was cesarean section (82%). Most common maternal complications were PPH (40%), blood transfusion (28%), DIC (4%), cesarean hysterectomy (4%). Low birth weight and preterm were the most common causes of fetal complications. Maternal mortality was 2% and perinatal mortality was 18% overall. CONCLUSIONS: APH is primary cause of maternal and perinatal morbidity and mortality. In our study, an abruption placenta was the most frequent cause of APH. Cesarean section was the most commonly used mode of delivery. PPH with blood transfusion was the most prevalent maternal complication, while fetal complications included low birth weight and preterm..

Placenta Accreta Spectrum in Normal Situated Placenta and Unscarred Uterus.

Placenta accreta, one of the morbidly adherent placenta components and currently known as placenta accreta spectrum (PAS), is a condition characterized by abnormal adherence of the placenta to the uterine wall. This can lead to significant blood loss and may lead to high morbidity and mortality rates for the mother. It is a failure of placenta separation during the third stage of labor, which is thought to be high prevalence in those with previous cesarean delivery, especially with the presence of placenta previa. However, PAS is possible in cases of a normally-situated placenta without previous cesarean delivery. We reported an interesting case of a 41-year-old woman, gravida 8 para 7, admitted to the labor room for augmentation of labor, who needed emergency lower segment cesarean section. The incidental finding of PAS was made intraoperatively and was complicated with a hysterectomy. PAS in a normally situated placenta (upper segment) in a virgin abdomen that has been discovered during emergency lower segment cesarean section could cause a nightmare to the obstetrician as it leads to massive postpartum hemorrhage, ureteric injury, and high maternal morbidity and mortality.

Antepartum hemorrhage due to placenta previa with autologous transfusion: A case report.

INTRODUCTION AND IMPORTANCE: Bleeding during pregnancy or during childbirth can cause significant morbidity and mortality for the mother and baby, this can be overcome by performing a caesarean section (C-section) and blood transfusions. Although blood transfusions can save lives, there is a risk such as transfusion reactions, transmission of infection, and anaphylaxis. Giving autologous blood transfusion can reduce the risk of these events. This case report aims to investigate the advantages of autologous blood transfusion in managing the patient's hemodynamic status compared to homologous blood transfusion. CASE PRESENTATION: A 21-year-old female (G2P1A0) with antepartum hemorrhage (APH) due to placenta previa underwent emergency C-section with intrauterine device installation and hysterectomy. The patient received an autologous transfusion to improving the hematocrits and hemoglobin within 30 min. Autologous transfusion provided routine postoperative hemodynamics, electrolytes, and blood stability. However, it could not completely replace homologous transfusion. CLINICAL DISCUSSION: Autologous transfusion reduces transfusion response, infection risk, and immunosuppression. Consequently, it reduces the need for allogenic blood supplies and enables safer transfusion for people with rare blood types and various auto-antibodies. CONCLUSION: Autologous transfusions may provide better outcomes in C-section surgery for APH patients due to placenta previa. Thus, we recommend the use of autologous over homologous transfusion. Further research is required to compare them to a large population.

Innovative hemostasis technique for cesarean section in placenta previa: A retrospective study.

OBJECTIVE: To evaluate hemostatic efficacy, complications, and subsequent pregnancy outcomes in women with placenta previa who underwent combined vertical compression sutures in the lower uterine segment and intrauterine balloon tamponade (Hot-Dog method) to achieve hemostasis after cesarean section. METHODS: We retrospectively reviewed data for 117 women with singleton pregnancy diagnosed with placenta previa who underwent cesarean section between 29 and 38 weeks' gestation. Treatments were as follows: (1) conventional-intravenous oxytocin administration after placental detachment and suturing of bleeding points at the detachment site as needed (conventional group) (n = 47). (2) Intrauterine balloon tamponade alone (balloon group) (n = 41). (3) Vertical compression sutures + intrauterine balloon tamponade (Hot-Dog group) (n = 29). RESULTS: The placenta accreta spectrum prevalence was significantly higher in the balloon and Hot-Dog groups versus the conventional group. The prevalence of anteriorly located placenta was significantly higher in the Hot-Dog versus balloon groups. Intraoperative and total blood loss were significantly higher in the Hot-Dog versus conventional groups. Postoperative blood loss was significantly lower in the Hot-Dog versus balloon groups. Fewer additional procedures for managing postoperative hemorrhage were required in the Hot-Dog versus conventional and balloon groups. The number of subsequent pregnancies in the conventional, balloon, and Hot-Dog groups was 11 (23.4%), 8 (19.5%), and 4 (13.8%), respectively; all resulted in live births at term without serious obstetric complications. CONCLUSION: The Hot-Dog method is a straightforward and safe hemostasis technique for placenta previa that preserves fertility and controls severe bleeding.

Evaluation of maternal serum protein biomarkers in the prenatal evaluation of placenta accreta spectrum: A systematic scoping review.

INTRODUCTION: Placenta accreta spectrum (PAS) is an increasingly commonly reported condition due to the continuous increase in the rate of cesarean deliveries (CD) worldwide; however, the prenatal screening for pregnant patients at risk of PAS at birth remains limited, in particular when imaging expertise is not available. MATERIAL AND METHODS: Two major electronic databases (MEDLINE and Embase) were searched electronically for articles published in English between October 1992 and January 2023 using combinations of the relevant medical subject heading terms and keywords. Two independent reviewers selected observational studies that provided data on one or more measurement of maternal blood-specific biomarker(s) during pregnancies with PAS at birth. PRISMA Extension for Scoping Review (PRISMA-ScR) was used to extract data and report results. RESULTS: Of the 441 reviewed articles, 29 met the inclusion criteria reporting on 34 different biomarkers. 14 studies were retrospective and 15 prospective overall including 18 251 participants. Six studies had a cohort design and the remaining a case-control design. Wide clinical heterogeneity was found in the included studies. In eight studies, the samples were obtained in the first trimester; in five, the samples were collected on hospital admission for delivery; and in the rest, the samples were collected during the second and/or third trimester. CONCLUSIONS: Measurements of serum biomarkers, some of which have been or are still used in screening for other pregnancy complications, could contribute to the prenatal evaluation of patients at risk of PAS at delivery; however, important evidence gaps were identified for suitable cutoffs for most biomarkers, variability of gestational age at sampling and the potential overlap of the marker values with other placental-related complications of pregnancy.