[Maternal morbidity and mortality associated with conservative management for placenta morbidly adherent (accreta) diagnosed during pregnancy. Report of 15 cases].

High risk of morbidly adherent placenta increased during past years. Their management is controversial. Cesarean hysterectomy, considered the gold standard treatment by American Society, is associated with high risk of maternal morbimortality. Conservative management has been sought to reduce maternal morbidity associated with caesarean hysterectomy while maintaining fertility. It consists of leaving the placenta in place but long-term monitoring. Our main objective was to determine advantage/disadvantage of conservative management on patient with an antenatal diagnosis of placenta accreta, increta or percreta. This retrospective study included all patients with an antenatal diagnosis of placenta accreta, increta or percreta between 2007 and 2014. Conservative treatment was systematically attempted according to our protocol. The primary outcome was defined as uterine conservation and the secondary outcome as maternal morbimortality defined as any medical or surgical condition occurring after childbirth. Fifteen patients (0.07 % of all living childbirths) were included. Conservative management was successful in 80 % of patients. There was no case of maternal death. Severe post-partum hemorrhage occurred in 4 patients (33.3 %) requiring uterine arteries embolization in one patient and hysterectomy in the 3 others. They underwent immediate blood transfusion of 13.5±4.5 average of red blood cell units. No severe septic condition occurred but 4 patients suffered from endometritis, 2.6±0.5 months after birth requiring intravenous antibiotics treatment in conventional hospitalization. Mean duration for spontaneous abortion of the placenta was 23.0±7.2 weeks. Three spontaneous pregnancies occurred in 2 patients after 19±16.9 months. Conservative management seems encouraging but is associated with a non-insignificant risk of secondary complication requiring long-term monitoring in conciliant patients.

Daney de Marcillac F ，Lecointre L ，Guillaume A ，Sananes N ，Fritz G ，Viville B ，Boudier E ，Nisand I ，Gaudineau A ，Langer B ，Akladios CY ... -  《-》

Placenta percreta is associated with more frequent severe maternal morbidity than placenta accreta.

Abnormally invasive placentation is the leading cause of obstetric hysterectomy and can cause poor to disastrous maternal outcomes. Most previous studies of peripartum management and maternal morbidity have included variable proportions of severe and less severe cases. The aim of this study was to compare maternal morbidity from placenta percreta and accreta. This retrospective study at a referral center in Paris includes all women with abnormally invasive placentation from 2003 through 2017. Placenta percreta and accreta were diagnosed histologically or clinically. When placenta percreta was suspected before birth, a conservative approach leaving the placenta in situ was proposed because of the intraoperative risk of cesarean delivery. When placenta accreta was suspected, parents were offered a choice of a conservative approach or an attempt to remove the placenta, to be followed in case of failure by hysterectomy. Maternal outcomes were compared between women with placenta percreta and those with placenta accreta/increta. The primary outcome measure was a composite criterion of severe acute maternal morbidity including at least 1 of the following: hysterectomy during cesarean delivery, delayed hysterectomy, transfusion of ≥10 U of packed red blood cells, septic shock, acute kidney injury, cardiovascular failure, maternal transfer to intensive care, or death. Of the 156 women included, 51 had placenta percreta and 105 placenta accreta. Abnormally invasive placentation was suspected antenatally nearly 4 times more frequently in the percreta than the accreta group (96.1% [49/51] vs 25.7% [27/105], P < .01). Among the 76 women with antenatally suspected abnormally invasive placentation (48.7%), the rate of antenatal decisions for conservative management was higher in the percreta than the accreta group (100% [49/49] vs 40.7% [11/27], P < .01). The composite maternal morbidity rate was significantly higher in the percreta than the accreta group (86.3% [44/51] vs 28/105 [26.7%], P < .001). A secondary analysis restricted to women with an abnormally invasive placentation diameter >6 cm showed similar results (86.0% [43/50) vs 48.7% [19/38), P < .01). The rate of hysterectomy during cesareans was significantly higher in the percreta than the accreta group (52.9% [27/51] vs 20.9% [22/105], P < .01) as was the total hysterectomy rate (43/51 [84.3%] vs 23.8% [25/105], P < .01). Severe maternal morbidity is much more frequent in women with placenta percreta than with placenta accreta, despite multidisciplinary planning, management in a referral center, and better antenatal suspicion.

Marcellin L ，Delorme P ，Bonnet MP ，Grange G ，Kayem G ，Tsatsaris V ，Goffinet F ... -  《-》

Maternal outcome after conservative management of abnormally invasive placenta.

The purpose of this study was to describe our preliminary experience of the efficacy and safety of a conservative strategy for abnormally invasive placenta. A retrospective review of eight pregnant women with abnormally invasive placenta (one with placenta previa accrete, three with placenta previa increta, and four with previa percreta) was performed. The diagnosis was made by prenatal ultrasonography, and was confirmed by operative and histopathological findings. Patients who desired future fertility or who had extensive diseases were selected as candidates after panel meeting. Conservative management after obtaining informed consent was defined by a primary cesarean delivery before 35 weeks of gestation with the abnormally adherent placenta left in situ, partially or totally. The primary outcome was successful uterine preservation. The secondary outcome was severe maternal morbidity including sepsis, coagulopathy, immediate or delayed hemorrhage bladder injury, and fistula. Among the eight patients, the mean age was 34 ± 3 years (range, 30-40 years). All women had risk factors, such as placental previa, previous cesarean delivery and/or dilation & curettage, for abnormally invasive placenta. Seven women underwent planned cesarean delivery at the mean gestation age of 34 weeks (range, 31-37 weeks). One woman received hysterotomy at 18 weeks. In our series, the uterus was preserved in only two cases (25%), one who received hysterotomy at a relatively young gestational age and another who had mild disease. Mean maternal blood loss during primary cesarean delivery was 528 ± 499 ml (range, 100 ml-1,500 ml). Severe maternal morbidity was recorded in seven out of eight patients (87.5%). In this small series, we observed a low successful uterine preservation rate and a high maternal complication rate. We recommend that primary cesarean hysterectomy should be used as the treatment of choice for mild to severe abnormally invasive placenta. Conservative management should be reserved for women with a strong fertility desire and women with extensive disease that precludes primary hysterectomy due to surgical difficulty.

Su HW ，Yi YC ，Tseng JJ ，Chen WC ，Chen YF ，Kung HF ，Chou MM ... -  《-》

Retrospective cohort study of prophylactic intraoperative uterine artery embolization for abnormally invasive placenta.

To evaluate the safety and efficacy of prophylactic intraoperative uterine artery embolization (UAE) during cesarean delivery as conservative treatment for patients with abnormally invasive placenta. A retrospective cohort study enrolled patients surgically diagnosed with abnormally invasive placenta who underwent cesarean delivery at the First Affiliated Hospital of Nanjing Medical University, Nanjing, China, between February 1, 2012, and February 28, 2015. Postpartum estimated blood loss, blood transfusions, hysterectomy, and adverse events were compared between patients who underwent cesarean delivery only (control group) and those who underwent concurrent prophylactic intraoperative UAE (UAE group). There were 45 patients included in the study; 26 and 19 in the UAE and control groups, respectively. Among patients who did not undergo hysterectomy owing to placenta accreta, the mean estimated blood loss was lower among patients in the UAE group (P=0.005); however, among patients who did undergo hysterectomy for placenta increta or percreta, no difference in mean estimated blood loss was observed (P=0.973). There were no differences in the hysterectomy rate (P=0.639) or incidence of requiring massive blood transfusion (P=0.050) between the groups. Only one patient in the UAE group experienced uterine necrosis. Prophylactic intraoperative UAE was relatively safe and effective for reducing postpartum hemorrhage among patients with placenta accreta. The potential benefits could be lower among patients with placenta increta or percreta.

Pan Y ，Zhou X ，Yang Z ，Cui S ，De W ，Sun L ... -  《-》

Outcomes following a clinical algorithm allowing for delayed hysterectomy in the management of severe placenta accreta spectrum.

The incidence of placenta accreta spectrum is rising. Management is most commonly with cesarean hysterectomy. These deliveries often are complicated by massive hemorrhage, urinary tract injury, and admission to the intensive care unit. Up to 60% of patients require transfusion of ≥4 units of packed red blood cells. There is also a significant risk of death of up to 7%. The purpose of this study was to assess the outcomes of patients with antenatal diagnosis of placenta percreta that was managed with delayed hysterectomy as compared with those patients who underwent immediate cesarean hysterectomy. We performed a retrospective study of all patients with an antepartum diagnosis of placenta percreta at our large academic institution from January 1, 2012, to May 30, 2018. Patients were treated according to standard clinical practice that included scheduled cesarean delivery at 34-35 weeks gestation and intraoperative multidisciplinary decision-making regarding immediate vs delayed hysterectomy. In cases of delayed hysterectomy, the hysterotomy for cesarean birth used a fetal surgery technique to minimize blood loss, with a plan for hysterectomy 4-6 weeks after delivery. We collected data regarding demographics, maternal comorbidities, time to interval hysterectomy, blood loss, need for transfusion, occurrence of urinary tract injury and other maternal complications, and maternal and fetal mortality rates. Descriptive statistics were performed, and Wilcoxon rank-sum and chi-square tests were used as appropriate. We identified 49 patients with an antepartum diagnosis of placenta percreta who were treated at Vanderbilt University Medical Center during the specified period. Of these patients, 34 were confirmed to have severe placenta accreta spectrum, defined as increta or percreta at the time of delivery. Delayed hysterectomy was performed in 14 patients: 9 as scheduled and 5 before the scheduled date. Immediate cesarean hysterectomy was completed in 20 patients: 16 because of intraoperative assessment of resectability and 4 because of preoperative or intraoperative bleeding. The median (interquartile range) estimated blood loss at delayed hysterectomy of 750 mL (650-1450 mL) and the sum total for delivery and delayed hysterectomy of 1300 mL (70 -2150 mL) were significantly lower than the estimated blood loss at immediate hysterectomy of 3000 mL (2375-4250 mL; P<.01 and P=.037, respectively). The median (interquartile range) units of packed red blood cells that were transfused at delayed hysterectomy was 0 (0-2 units), which was significantly lower than units transfused at immediate cesarean hysterectomy (4 units [2-8.25 units]; P<.01). Nine of 20 patients (45%) required transfusion of ≥4 units of red blood cells at immediate cesarean hysterectomy, whereas only 2 of 14 patients (14.2%) required transfusion of ≥4 units of red blood cells at the time of delayed hysterectomy (P=.016). There was 1 maternal death in each group, which were incidences of 7% and 5% in the delayed and immediate hysterectomy patients, respectively. Delayed hysterectomy may represent a strategy for minimizing the degree of hemorrhage and need for massive blood transfusion in patients with an antenatal diagnosis of placenta percreta by allowing time for uterine blood flow to decrease and for the placenta to regress from surrounding structures.

Zuckerwise LC ，Craig AM ，Newton JM ，Zhao S ，Bennett KA ，Crispens MA ... -  《-》