Placenta accreta spectrum: Risk factors, diagnosis and management with special reference to the Triple P procedure.

Abnormal invasion of placenta or placenta accreta spectrum disorders refer to the penetration of the trophoblastic tissue through the decidua basalis into the underlying uterine myometrium, the uterine serosa or even beyond, extending to pelvic organs. It is classified depending on the degree of invasion into placenta accreta (invasion 50% of the myometrium) and percreta (invading the serosa and adjacent pelvic organs). Clinical diagnosis is made intra-operatively; however, the confirmative diagnosis can only be made after a histopathological examination. The incidence of abnormal invasion of placenta has increased worldwide, mostly as a consequence of the rise in caesarean section rates, from 1 in 2500 pregnancies to 1 in 500 pregnancies. The importance of the disease is due to the increased maternal and foetal morbidity and mortality. Foetal implications are mainly due to iatrogenic prematurity, while maternal implications are mostly the increased risk of obstetric haemorrhage and surgical complications. The average blood loss is 3000-5000 mL, and up to 90% of the patients require a blood transfusion. An accurate and timely antenatal diagnosis is essential to improve outcomes. The traditional management of abnormal invasion of placenta has been a peripartum hysterectomy; however, the increased incidence and the short- and long-term consequences of a radical approach have led to the development of more conservative techniques, such as the intentional retention of the placenta, partial myometrial excision and the 'Triple P procedure'. Irrespective of the surgical technique of choice, women with a high suspicion or confirmed abnormally invasive placenta should be managed in a specialist centre with surgical expertise with a multi-disciplinary team who is experienced in managing these complex cases with an immediate availability of blood products, interventional radiology service, an intensive care unit and a neonatal intensive care unit to optimize the outcomes

Morbid adherence of the placenta: lack of specificity should remind us that ultrasound is a screening tool.

Excellent performance has been reported with prenatal diagnosis of abnormal placental invasion using ultrasound. We describe a case which illustrates the validity of ultrasound features of abnormally invasive placentation in women without previous caesarean delivery. CASE: Ms. CB, a 27 year-old G3 P1+1 was seen in her pregnancy at 36 weeks of gestation. Her first pregnancy was uncomplicated and she gave vaginal birth to a normally grown baby at term. Before the current pregnancy, she suffered a miscarriage in the first trimester, and underwent surgical evacuation. She suffered prolonged vaginal blood loss for which she was investigated, and a diagnosis of A-V malformation (AVM) was made on the basis of the ultrasound findings (Figure 1). She conceived spontaneously before intervention

Intrapartum cardiotocography patterns observed in suspected clinical and subclinical chorioamnionitis in term fetuses.

AIM: To evaluate the cardiotocography (CTG) features observed in suspected intrapartum chorioamnionitis in term fetuses according to the recently suggested criteria for the pathophysiological interpretation of the fetal heart rate and their correlation with perinatal outcomes. METHODS: Retrospective analysis of nonconsecutive CTG traces. 'CTG chorioamnionitis' was diagnosed either based on a persistent rise in the baseline for the given gestation or on a persistent increase in the baseline fetal heart rate during labor >10% without preceding CTG signs of hypoxia and in the absence of maternal pyrexia. Perinatal outcomes were compared among cases with no sign of chorioamnionitis, in those with only CTG features suspicious for chorioamnionitis and in those who developed clinical chorioamnionitis. RESULTS: Two thousand one hundred and five CTG traces were analyzed. Of these, 356 fulfilled the criteria for "CTG chorioamnionitis". Higher rates of Apgar <7 at 1 and 5 min (21.6% vs 9.0% and 9.8% vs 2.0%, respectively, P < 0.01 for both) and lower umbilical artery pH (7.14 ± 0.11 vs 7.19 ± 0.11, P < 0.01) and an over fivefold higher rate of neonatal intensive care unit admission (16.6% vs 2.9%, P < 0.01) were noted in the 'CTG chorioamnionitis' group. Differences in the incidence of abnormal CTG patterns were noted between cases who eventually had clinical evidence of chorioamnionitis (89/356) and those showing CTG features suspicious for chorioamnionitis in the absence of clinical evidence of chorioamnionitis (267/356). CONCLUSION: Intrapartum CTG features of suspected chorioamnionitis are associated with adverse perinatal outcomes

Lower uterine segment placental thickness in women with abnormally invasive placenta.

Introduction Ultrasound signs of abnormal placental invasion are subjective in nature. We tested the hypothesis that placental thickness in the lower uterine segment is increased when there is abnormally invasive placenta (AIP) in women with a low‐lying placenta. Material and methods Retrospective analysis of data of placental thickness in women with ultrasound evidence of major placenta previa or a low‐lying anterior placenta was done. The diagnosis of AIP was confirmed both intraoperatively and on histopathology for those managed by partial myometrial excision with uterine conservation or by hysterectomy. Results In all, 131 records were available for analysis after exclusion of 33 cases due to unsuitable images and eight cases without pregnancy outcomes. The diagnosis of AIP was confirmed in 28 (21.4%) of the 131 cases. The lower segment placental thickness was significantly higher in women with AIP (median = 50.3 mm, IQR: 42.7‐64.3) than in those with normal placentation (median = 30.9 mm, IQR: 22.9‐42.2, P < 0.001). Logistic regression analysis showed that previous cesarean section and placental thickness on ultrasound were independent predictors for AIP. Conclusions Lower uterine segment placental thickness is increased in women with AIP compared with those with noninvasive placentation. This association constitutes a pragmatic objective sign and may be of clinical value in improving prenatal detection of AIP in women with placental implantation in the lower uterine segment. Prospective studies are necessary to ascertain lower segment placental thickness as a predictor for AIP

Effectiveness of contingent screening for placenta accreta spectrum disorders based on persistent low‐lying placenta and previous uterine surgery

Objectives Maternal mortality related to placenta accreta spectrum (PAS) disorders remains substantial when diagnosed unexpectedly at delivery. The aim of this study was to evaluate the effectiveness of a routine contingent ultrasound screening program for PAS. Methods This was a retrospective study of data obtained between 2009 and 2019, involving two groups: a screening cohort of unselected women attending for routine mid‐trimester ultrasound assessment and a diagnostic cohort consisting of women referred to the PAS diagnostic service with a suspected diagnosis of PAS. In the screening cohort, women with a low‐lying placenta at the mid‐trimester assessment were followed up in the third trimester, and those with a persistent low‐lying placenta (i.e. placenta previa) and previous uterine surgery were referred to the PAS diagnostic service. Ultrasound assessment by the PAS diagnostic service consisted of two‐dimensional grayscale and color Doppler ultrasonography, and women with a diagnosis of PAS were usually managed with conservative myometrial resection. The final diagnosis of PAS was based on a combination of intraoperative clinical findings and histopathological examination of the surgical specimen. Results In total, 57 179 women underwent routine mid‐trimester fetal anatomy assessment, of whom 220 (0.4%) had a third‐trimester diagnosis of placenta previa. Seventy‐five of these women were referred to the PAS diagnostic service because of a history of uterine surgery, and 21 of 22 cases of PAS were diagnosed correctly (sensitivity, 95.45% (95% CI, 77.16–99.88%) and specificity, 100% (95% CI, 99.07–100%)). Univariate analysis demonstrated that parity ≥ 2 (odds ratio (OR), 35.50 (95% CI, 6.90–649.00)), two or more previous Cesarean sections (OR, 94.20 (95% CI, 22.00–656.00)) and placenta previa (OR, 20.50 (95% CI, 4.22–369.00)) were the strongest risk factors for PAS. In the diagnostic cohort, there were 173 referrals, with one false‐positive and three false‐negative diagnoses, resulting in a sensitivity of 96.63% (95% CI, 90.46–99.30%) and a specificity of 98.81% (95% CI, 93.54–99.97%). Conclusions A contingent screening strategy for PAS is both feasible and effective in a routine healthcare setting. When linked to a PAS diagnostic and surgical management service, adoption of such a screening strategy has the potential to reduce the maternal morbidity and mortality associated with this condition. However, larger prospective studies are necessary before implementing this screening strategy into routine clinical practice

Comparing the effect of CTG+STan with CTG alone on emergency Cesarean section rate : STan Australian Randomized controlled Trial (START)

The authors would like to thank the women and their babies for participating. We would like to thank all the staff at the WCH, in particular Priya Umampathysivam, Denise Cheetham and Cecilia Heitmann for their assistance in recruitment of participants for START. We would also like to thank the members of the DSMC, Diogo Ayres-de-Campos, Scott Morris and Katherine Lee, for their oversight of START and the Clinical Information Service (CIS) team at the WCH for the comparative hospital dataPeer reviewedPublisher PD

Comparing the effect of STan (cardiotocographic electronic fetal monitoring (CTG) plus analysis of the ST segment of the fetal electrocardiogram) with CTG alone on emergency caesarean section rates: study protocol for the STan Australian Randomised controlled Trial (START).

BACKGROUND: Cardiotocography is almost ubiquitous in its use in intrapartum care. Although it has been demonstrated that there is some benefit from continuous intrapartum fetal monitoring using cardiotocography, there is also an increased risk of caesarean section which is accompanied by short-term and long-term risks to the mother and child. There is considerable potential to reduce unnecessary operative delivery with up to a 60% false positive diagnosis of fetal distress using cardiotocography alone. ST analysis of the fetal electrocardiogram is a promising adjunct to cardiotocography alone, and permits detection of metabolic acidosis of the fetus, potentially reducing false positive diagnosis of fetal distress. METHODS: This study will be a single-centre, parallel-group, randomised controlled trial, conducted over 3 years. The primary hypothesis will be that the proportion of women with an emergency caesarean section on ST analysis will not equal that for women on cardiotocography monitoring alone. Participants will be recruited at the Women's and Children's Hospital, a high-risk specialty facility with approximately 5000 deliveries per annum. A total of 1818 women will be randomised to the treatment or conventional arm with an allocation ratio of 1:1, stratified by parity. The primary outcome is emergency caesarean section (yes/no). Statistical analysis will follow standard methods for randomised trials and will be performed on an intention-to-treat basis. Secondary maternal and neonatal outcomes will also be analysed. Additional study outcomes include psychosocial outcomes, patient preferences and cost-effectiveness. DISCUSSION: Approximately 20% of Australian babies are delivered by emergency caesarean section. This will be the first Australian trial to examine ST analysis of the fetal electrocardiogram as an adjunct to cardiotocography as a potential method for reducing this proportion. The trial will be among the first to comprehensively examine ST analysis, taking into account the impact on psychosocial well-being as well as cost-effectiveness. This research will provide Australian evidence for clinical practice and guideline development as well as for policy-makers and consumers to make informed, evidence-based choices about care in labour. TRIAL REGISTRATION: ANZCTR, ACTRN1261800006268 . Registered on 19 January 2018

Placental thickness in the lower uterine segment and invasive placentation: Will the promise live up?

We thank Takahashi and Matsubara for the interest in our article in which it was demonstrated that the placental thickness in the lower uterine segment is increased in women with abnormally invasive, compared to those with normal placentation. Takahashi & Matsubara argue that measurement of the placental thickness can be difficult in cases of central placenta previa. To support their argument, they show MRI images of central placenta previa. This article is protected by copyright. All rights reserved

The DESiGN trial (DEtection of Small for Gestational age Neonate), evaluating the effect of the Growth Assessment Protocol (GAP): study protocol for a randomised controlled trial.

BACKGROUND: Stillbirth rates in the United Kingdom (UK) are amongst the highest of all developed nations. The association between small-for-gestational-age (SGA) foetuses and stillbirth is well established, and observational studies suggest that improved antenatal detection of SGA babies may halve the stillbirth rate. The Growth Assessment Protocol (GAP) describes a complex intervention that includes risk assessment for SGA and screening using customised fundal-height growth charts. Increased detection of SGA from the use of GAP has been implicated in the reduction of stillbirth rates by 22%, in observational studies of UK regions where GAP uptake was high. This study will be the first randomised controlled trial examining the clinical efficacy, health economics and implementation of the GAP programme in the antenatal detection of SGA. METHODS/DESIGN: In this randomised controlled trial, clusters comprising a maternity unit (or National Health Service Trust) were randomised to either implementation of the GAP programme, or standard care. The primary outcome is the rate of antenatal ultrasound detection of SGA in infants found to be SGA at birth by both population and customised standards, as this is recognised as being the group with highest risk for perinatal morbidity and mortality. Secondary outcomes include antenatal detection of SGA by population centiles, antenatal detection of SGA by customised centiles, short-term maternal and neonatal outcomes, resource use and economic consequences, and a process evaluation of GAP implementation. Qualitative interviews will be performed to assess facilitators and barriers to implementation of GAP. DISCUSSION: This study will be the first to provide data and outcomes from a randomised controlled trial investigating the potential difference between the GAP programme compared to standard care for antenatal ultrasound detection of SGA infants. Accurate information on the performance and service provision requirements of the GAP protocol has the potential to inform national policy decisions on methods to reduce the rate of stillbirth. TRIAL REGISTRATION: Primary registry and trial identifying number: ISRCTN 67698474 . Registered on 2 November 2016