Integration of first-trimester assessment in the ultrasound staging of placenta accreta spectrum disorders.

OBJECTIVE: To explore the role of early first trimester ultrasound at 5-7 postmenstrual weeks of gestation in predicting sonographic staging of placenta accreta spectrum (PAS) and to elucidate whether integrating first trimester assessment with ultrasound staging of PAS can predict surgical outcome in women at risk for PAS. METHODS: Secondary analysis of prospectively collected data of women who had at least one previous caesarean delivery (CD) or uterine surgery and placenta previa for whom early (5-7 weeks of gestation) ultrasound images could be retrieved. The relationship between gestational sac position and prior CD scar was assessed using classifications by Cali et al. (cross-over COS), Kaelin Agten et al. ("on the scar" vs "in the niche" implantation) and Timor-Tritsch et al. ("above the line" vs "below the line" implantation) by two different examiners blinded to the final diagnosis and clinical outcome. Primary aim of the study was to explore the strength of association and predictive accuracy of first trimester ultrasound in predicting PAS stage. Secondary aim was to elucidate whether integration of first trimester ultrasound with PAS staging can predict surgical outcome. Logistic regression and area under the curve analyses were used to analyse the data. RESULTS: One hundred and eighty-seven women were included. Of these ,79.6% (95% CI 67.1-88.2) had COS1, 94.4% (95% CI 84.9-98.1) "in the niche" and 92.6% (95% CI 82.4-97.1) "below the line" implantation confirmed to be affected by PAS3 in the third trimester of pregnancy. On multivariate logistic regression analysis, COS1 (OR: 7.9 (95% CI 4.0-15.5; p<0.001), "in the niche" (OR: 29.1, 95% CI 8.1-104; p<0.001) and "below the line" (OR: 38.1, 95% CI 12.1-121; p<0.001) implantations, however, neither parity (p= 0.4), nor the number of prior CDs (p= 0.5) were independently associated with PAS3. When translating these figures in a diagnostic model, either COS1 (AUC: 0.94, 95% CI 0.91-0.97), or implantation "in the niche" (AUC: 0.92, 95% CI 0.89-0.96) or "below the line" (AUC: 0.92, 95% CI 0.88-0.96) had a high predictive accuracy for PAS3. Adverse surgical outcome was more common in women with COS1 (p<0.001), implantation "in the niche" (p<0.001) and "below the line" (p<0.001) then those without them.) On multivariate logistic regression analysis, ultrasound diagnosis of PAS3 (OR: 4.3, 95% CI 2.1-17.3), COS1 (OR: 7.9, 95% CI 4.0-15.5; p<0.001), "in the niche" (OR: 29.1, 95% CI 8.1-104; p<0.001) and "below the line" (OR: 7.9, 95% CI 4.0-15.5; p<0.001) implantations were independently associated with adverse surgical outcome. When combining the three imaging methods, we identified, an area we call "high-risk-for-PAS Triangle" which may enable an easy visual perception and application of the three methods to prognosticate the risk for CSP and PAS, although it requires validation in further large prospective studies. CONCLUSION: Early first trimester sonographic assessment of pregnancies after CDs can reliably predict ultrasound staging of possible PAS. Integrating first with second and third trimester ultrasound can stratify surgical risk of women affected by PAS. This article is protected by copyright. All rights reserved

Risk factors for peripartum hysterectomy among women with postpartum haemorrhage: analysis of data from the WOMAN trial.

BACKGROUND: Peripartum hysterectomy can cause significant morbidity and mortality. Most studies of peripartum hysterectomy are from high income countries. This cohort study examined risk factors for peripartum hysterectomy using data from Africa, Asia, Europe and the Americas. METHODS: We used data from the World Maternal Antifibrinolytic (WOMAN) trial carried out in 193 hospitals in 21 countries. Peripartum hysterectomy was defined as hysterectomy within 6 weeks of delivery as a complication of postpartum haemorrhage. Univariable and multivariable random effects logistic regression models were used to analyse risk factors. A hierarchical conceptual framework guided our multivariable analysis. RESULTS: Five percent of women had a hysterectomy (1020/20,017). Haemorrhage from placenta praevia/accreta carried a higher risk of hysterectomy (17%) than surgical trauma/tears (5%) and uterine atony (3%). The adjusted odds ratio (AOR) for hysterectomy in women with placenta praevia/accreta was 3.2 (95% CI: 2.7-3.8), compared to uterine atony. The risk of hysterectomy increased with maternal age. Caesarean section was associated with fourfold higher odds of hysterectomy than vaginal delivery (AOR 4.3, 95% CI: 3.6-5.0). Mothers in Asia had a higher hysterectomy incidence (7%) than mothers in Africa (5%) (AOR: 1.2, 95% CI: 0.9-1.7). CONCLUSIONS: Placenta praevia/accreta is associated with a higher risk of peripartum hysterectomy. Other risk factors for hysterectomy are advanced maternal age, caesarean section and giving birth in Asia

Prenatal identification of invasive placentation using magnetic resonance imaging: Systematic review and meta-analysis

Objective To assess systematically the performance of prenatal magnetic resonance imaging (MRI) in diagnosing the presence, degree and topography of disorders of invasive placentation and to explore the role of the different MRI signs in predicting these disorders. The diagnostic accuracy of ultrasound and MRI in the detection of invasive placentation was also compared. Methods MEDLINE, EMBASE, CINAHL and The Cochrane Library, including The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and The Cochrane Central Register of Controlled Trials, were searched electronically utilizing combinations of the relevant medical subject heading terms, keywords and word variants for 'invasive placentation' and 'magnetic resonance imaging'. Only prospective studies reporting a diagnosis of invasive placentation at the time of MRI and retrospective studies in which the radiologist was blinded to the final results were included in the analysis. The MRI signs explored were: uterine bulging, heterogeneous signal intensity, dark intraplacental bands on T2 weighted sequences, focal interruption of the myometrium and tenting of the bladder. Summary estimates of sensitivity, specificity, positive and negative likelihood ratios (LR+, LR-) and diagnostic odds ratio (DOR) were based, depending on the number of studies, upon DerSimonian-Laird random-effect or hierarchical summary receiver-operating characteristics models. Results A total of 18 studies involving 1010 pregnancies at risk for invasive placentation were included. The overall diagnostic accuracy of MRI in detecting the presence of invasive placentation was: sensitivity, 94.4% (95% CI, 86.0-97.9%); specificity, 84.0% (95% CI, 76.0-89.8%); LR+, 5.91 (95% CI, 3.73-9.39); LR-, 0.07 (95% CI, 0.02-0.18); DOR, 89.0 (95% CI, 22.8-348.1). MRI had a high predictive accuracy in assessing both the depth and topography of placental invasion. All five MRI signs showed good predictive accuracy in the diagnosis of disorders of invasive placentation. There was no difference in either the sensitivity (P = 0.24) or the specificity (P = 0.91) between ultrasound and MRI for the detection of invasive placentation. Conclusions Prenatal MRI is highly accurate in diagnosing disorders of invasive placentation. Ultrasound and MRI have comparable predictive accuracy. Large population-based studies are needed in order to assess whether ultrasound can predict the depth and topography of placental invasion as reliably as can MRI. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd

Diagnostic accuracy of ultrasound in detecting the severity of abnormally invasive placentation: a systematic review and meta-analysis.

INTRODUCTION: Our objective was to elucidate the overall diagnostic accuracy of ultrasound in detecting the severity of abnormally invasive placentation (AIP). MATERIAL AND METHODS: Medline, Embase, CINAHL and The Cochrane databases were searched. The ultrasound signs explored were: loss of hypoechoic (clear) zone in the placental-uterine interface, placental lacunae, bladder wall interruption, myometrial thinning, focal exophitic mass, placental lacunar flow, sub-placental vascularity, and uterovescical hypervascularity. RESULTS: Twenty studies (3209 pregnancies) were included. Ultrasound had an overall good diagnostic accuracy in identifying the depth of placental invasion with a sensitivity of 90.6%, 93.0%, 89.5% and 81.2% for placenta accreta, increta, accreta/increta and percreta respectively; the corresponding figures for specificity were 97.1%, 98.4%, 94.7%, 98.9%. Placental lacunae had a sensitivity of 74.8%, 88.6% and 76.3% for the detection of placenta accreta, increta and percreta respectively. Sensitivity and specificity of loss of the clear zone in identifying placenta accreta were 74.9% and 92.0%, while the corresponding figures for placenta increta and percreta were 91.6% and 76.9% and 88.1% and 71.1%. Lacunar flow had a sensitivity of 81.2%, 84.3% and 45.2% for the detection of placenta accreta, increta and percreta respectively; the corresponding figures for specificity were 84.0%, 79.7% and 75.3%. Sensitivity of uterovescical hypervascularity was low for the detection of placenta accreta (12.3%) while it was high for placenta increta (94.4%) and percreta (86.2%); the corresponding figures for specificity were 90.8%, 88.0% and 88.2% respectively. CONCLUSIONS: Ultrasound has an overall good diagnostic accuracy in recognizing the depth and the topography of placental invasion

Urological complications in women undergoing surgery for placenta accreta spectrum disorders: systematic review and meta-analysis

OBJECTIVE: To report the occurrence of urologic complications in women undergoing surgery for placenta accreta spectrum (PAS) disorders. METHODS: Medline, Embase and Cochrane databases were searched electronically up to 1st of November 2022. Studies reporting cohort on surgical management and outcome of PAS. Two independent reviewers performed the data extraction using a predefined protocol and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies, with difference agreed by consensus. The primary outcome was the overall occurrence of urologic complications in women undergoing surgery for PAS. Secondary outcomes were overall cystotomy, intentional cystotomy, unintentional cystotomy, ureteral damage, ureteral fistula, vesicovaginal fistula. All these outcomes were explored in the overall population of patients undergoing hysterectomy for PAS disorders. In addition, we performed sub-group analyses according to the severity of PAS at histopathology (placenta accreta/increta and percreta), type of intervention (planned vs emergency), ureteral stent placing and number of cases per year. Random-effect meta-analyses of proportions were used to analyze the data. RESULTS: Sixty-two studies were included. Urologic complications occurred in 15.29% (95% CI, 13.0-17.2) of cases. Cystotomy complicated 13.02% (95% CI, 9.2-17.3) of surgical operations. Intentional cystotomy was required in 5.58% (95% CI, 2.7-9.3) of cases while damage to the bladder occurred in 7.40% (95% CI, 4.3-11.2) of cases. Urologic complications occurred in 19.36% (95% CI, 16.3-22.7) of cases undergoing hysterectomy and 12.22% (95% CI, 7.5-17.8) of those having conservative treatment. In the sub-group analyses, urologic complications occurred in 9.42% (95% CI, 5.4-14.4) of women with placenta accreta-increta and 38.52% (95% CI, 21.6-57.0) of those described as placenta percreta and were mainly represented by cystotomy (5.53% (95% CI, 0.6-15.1) in women with placenta accreta increta and 21.97% (95% CI, 15.4-45.5) in the placenta percreta subgroup). Urologic complications occurred in 15.44% (95% CI, 8.1-24.6) during planned procedures and in 24.61% (95% CI, 13.0-38.5) during emergency intervention. The incidence of urologic complications was similar to that reported in the primary analysis in studies reporting >10 cases per year. CONCLUSIONS: Patients undergoing surgery for PAS disorders are at high-risk of urologic complications, mainly cystotomy. The incidence of these complications is higher in patients described as having a placenta percreta at birth and in case of emergency surgical intervention. The high heterogeneity highlights the need to use standardized protocols for the diagnosis of PAS to identify prenatal imaging signs associated with a risk of urologic morbidity at delivery. This article is protected by copyright. All rights reserved

Urological complications in women undergoing surgery for placenta accreta spectrum disorders: systematic review and meta-analysis.

OBJECTIVE: To report the occurrence of urologic complications in women undergoing surgery for placenta accreta spectrum (PAS) disorders. METHODS: Medline, Embase and Cochrane databases were searched electronically up to 1st of November 2022. Studies reporting cohort on surgical management and outcome of PAS. Two independent reviewers performed the data extraction using a predefined protocol and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies, with difference agreed by consensus. The primary outcome was the overall occurrence of urologic complications in women undergoing surgery for PAS. Secondary outcomes were overall cystotomy, intentional cystotomy, unintentional cystotomy, ureteral damage, ureteral fistula, vesicovaginal fistula. All these outcomes were explored in the overall population of patients undergoing hysterectomy for PAS disorders. In addition, we performed sub-group analyses according to the severity of PAS at histopathology (placenta accreta/increta and percreta), type of intervention (planned vs emergency), ureteral stent placing and number of cases per year. Random-effect meta-analyses of proportions were used to analyze the data. RESULTS: Sixty-two studies were included. Urologic complications occurred in 15.29% (95% CI, 13.0-17.2) of cases. Cystotomy complicated 13.02% (95% CI, 9.2-17.3) of surgical operations. Intentional cystotomy was required in 5.58% (95% CI, 2.7-9.3) of cases while damage to the bladder occurred in 7.40% (95% CI, 4.3-11.2) of cases. Urologic complications occurred in 19.36% (95% CI, 16.3-22.7) of cases undergoing hysterectomy and 12.22% (95% CI, 7.5-17.8) of those having conservative treatment. In the sub-group analyses, urologic complications occurred in 9.42% (95% CI, 5.4-14.4) of women with placenta accreta-increta and 38.52% (95% CI, 21.6-57.0) of those described as placenta percreta and were mainly represented by cystotomy (5.53% (95% CI, 0.6-15.1) in women with placenta accreta increta and 21.97% (95% CI, 15.4-45.5) in the placenta percreta subgroup). Urologic complications occurred in 15.44% (95% CI, 8.1-24.6) during planned procedures and in 24.61% (95% CI, 13.0-38.5) during emergency intervention. The incidence of urologic complications was similar to that reported in the primary analysis in studies reporting >10 cases per year. CONCLUSIONS: Patients undergoing surgery for PAS disorders are at high-risk of urologic complications, mainly cystotomy. The incidence of these complications is higher in patients described as having a placenta percreta at birth and in case of emergency surgical intervention. The high heterogeneity highlights the need to use standardized protocols for the diagnosis of PAS to identify prenatal imaging signs associated with a risk of urologic morbidity at delivery. This article is protected by copyright. All rights reserved