Temporary cross-clamping of the infrarenal abdominal aorta during cesarean hysterectomy to control operative blood loss in placenta previa increta/percreta

Objective To evaluate the efficacy and safety of temporary cross-clamping of the infrarenal abdominal aorta for controlling operative blood loss during cesarean hysterectomy in severe invasive placentation. Case Report A 35-year-old woman with a significant risk factor of four previous cesarean sections and placenta previa was referred to Taichung Veterans General Hospital with suspected abnormal placentation at 37 weeks of gestation. Obstetric ultrasonography and magnetic resonance imaging showed a bulky inhomogeneous placenta with extensive uterine serosa-bladder interface hypervascularity and suspicious focal bladder invasion. Cesarean hysterectomy was performed with the use of temporary cross-clamping of the infrarenal abdominal aorta. The duration of aortic cross-clamping was 1 hour, and the estimated blood loss was 2,000 mL. The patient was discharged home on postoperative day 11 with no postoperative sequelae. Conclusion With this limited experience, we are encouraged by the apparent reduction in operative blood loss after the use of temporary cross-clamping of the infrarenal abdominal aorta during cesarean hysterectomy. Further investigation is needed to determine the efficacy and safety of this procedure. Key Words: aortic cross-clamping; blood loss; cesarean hysterectomy; placenta percreta Correspondence to: Dr Min-Min Chou, Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, 160, Section 3, Taichungkang Road, Taichung, Taiwan Copyright © 2010 Taiwan Association of Obstetric & Gynecology. Published by Elsevier B.V. All rights reserve

Outcome of cesarean scar pregnancy according to gestational age at diagnosis: A systematic review and meta-analysis

Objective: The association between the most severe types of placenta accreta spectrum disorders and caesarean scar pregnancy (CSP) poses the question of whether early diagnosis may impact the clinical outcome of these anomalies. The aim of this study is to report the outcome of cesarean scar pregnancy (CSP) diagnosed in the early (≤9 weeks) versus late (>9 weeks) first trimester of pregnancy. Study design: Medline, Embase and Clinicaltrail.gov databases were searched. Studies including cases of CSP with an early (≤9 weeks of gestation) compared to a late (>9 weeks) first trimester diagnosis of CSP, followed by immediate treatment, were included in this systematic review. The primary outcome was a composite measure of severe maternal morbidity including either severe first trimester bleeding, need for blood transfusion, uterine rupture or emergency hysterectomy. The secondary outcomes were the individual components of the primary outcome. Random-effect meta-analyses were used to combine data. Results: Thirty-six studies (724 women with CSP) were included. Overall, composite adverse outcome complicated 5.9 % (95 % CI 3.5−9.0) of CSP diagnosed ≤9 weeks and 32.4 % (95 % CI 15.7−51.8) of those diagnosed >9 weeks. Massive hemorrhage occurred in 4.3 % (95 % CI 2.3−7.0) of women with early and in 28.0 % (95 % CI 14.1−44.5) of those with late first trimester diagnosis of CSP, while the corresponding figures for the need for blood transfusion were 1.5 % (95 % CI 0.6−2.8) and 15.8 % (95 % CI 5.5−30.2) respectively. Uterine rupture occurred in 2.5 % (95 % CI 1.2−4.1) of women with a prenatal diagnosis of CSP ≤ 9 weeks and in 7.5 % (95 % CI 2.5−14.9) of those with CSP > 9 weeks, while an emergency intervention involving hysterectomy was required in 3.7 % (95 % CI 2.2−5.4) and 16.3 % (95 % CI5.9−30.6) respectively. When computing the risk, early diagnosis of CSP was associated with a significantly lower risk of composite adverse outcome, (OR: 0.14; 95 % CI 0.1−0.4 p < 0.001). Conclusions: Early first trimester diagnosis of CSP is associated with a significantly lower risk of maternal complications, thus supporting a policy of universal screening for these anomalies in women with a prior cesarean delivery although the cost-effectiveness of such policy should be tested in future studies

Geographic variation in management of patients with placenta accreta spectrum : an international survey of experts (GPASS)

OBJECTIVE : To describe global geographic variations in the diagnosis and management of placenta accreta spectrum (PAS). METHODS : An international cross-sectional study was conducted among PAS experts practicing at medical institutions in member states of the United Nations. Survey questions focused on diagnostic evaluation and management strategies for PAS. RESULTS : A total of 134 centers participated. Participating centers represented each of the United Nations' designated regions. Of those, 118 (88%) reported practicing in a medium-volume or high-volume center. First-trimester PAS screen was reported in 35 (26.1%) centers. Respondents consistently implement guideline-supported care practices, including utilization of ultrasound as the primary diagnostic modality (134, 100%) and implementation of multidisciplinary care teams (115, 85.8%). Less than 10% of respondents reported routinely managing PAS without hysterectomy; these centers were predominantly located in Europe and Africa. Antepartum management and availability of mental health support for PAS patients varied widely. CONCLUSION : Worldwide, there is a strong adherence to PAS care guidelines; however, regional variations do exist. Comparing variations in care to outcomes will provide insight into the clinically significant practice variability. SYNOPSIS : This international study sought to determine the geographic variations in diagnosis and management of placenta accreta spectrum worldwide.http://www.wileyonlinelibrary.com/journal/ijgo2022-10-05hj2022Obstetrics and Gynaecolog