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

To report on the occurrence of urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders (PAS). MEDLINE, EMBASE and the Cochrane databases were searched electronically up to 1 November 2022. Studies reporting on the urological outcome of women undergoing Cesarean section for PAS were included. Two independent reviewers performed data extraction using a predefined protocol and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies, with disagreements resolved by consensus.The primary outcome was the overall occurrence of urological complications. Secondary outcomes were the occurrence of any cystotomy, intentional cystotomy, unintentional cystotomy, ureteral damage, ureteral fistula and vesicovaginal fistula. All outcomes were explored in the overall population of women undergoing surgery for PAS. In addition, we performed subgroup analyses according to the type of surgery (Cesarean hysterectomy, or conservative surgery or management), severity of PAS at histopathology (placenta accreta/increta and placenta percreta), type of intervention (planned vs emergency) and number of cases per year. Random-effects meta-analyses of proportions were used to analyze the data. There were 62 studies included in the systematic review and 56 were included in the meta-analysis. Urological complications occurred in 15.2% (95% CI, 12.9-17.7%) of cases. Cystotomy complicated 13.5% (95% CI, 9.7-17.9%) of surgical operations. Intentional cystotomy was required in 7.7% (95% CI, 6.5-9.1%) of cases, while unintentional cystotomy occurred in 7.2% (95% CI, 6.0-8.5%) of cases. Urological complications occurred in 19.4% (95% CI, 16.3-22.7%) of cases undergoing hysterectomy and 12.2% (95% CI, 7.5-17.8%) of those undergoing conservative treatment. In the subgroup analyses, urological complications occurred in 9.4% (95% CI, 5.4-14.4%) of women with placenta accreta/increta and 38.5% (95% CI, 21.6-57.0%) of those described as having placenta percreta, and included mainly cystotomy (5.5% (95% CI, 0.6-15.1%) and 22.0% (95% CI, 5.4-45.5%), respectively). Urological complications occurred in 15.4% (95% CI, 8.1-24.6%) of cases undergoing a planned procedure and 24.6% (95% CI, 13.0-38.5%) of those undergoing an emergency intervention. In subanalysis of studies reporting on ≥ 12 cases per year, the incidence of urological complication was similar to that reported in the primary analysis. Women undergoing surgery for PAS are at high risk of urological complication, mainly cystotomy. The incidence of these complications was particularly high in women described as having placenta percreta at birth and in those undergoing emergency surgical intervention. The high heterogeneity between the included studies highlights the need for a standardized protocol for the diagnosis of PAS to identify prenatal imaging signs associated with the increased risk of urological morbidity at delivery. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Lucidi A ，Jauniaux E ，Hussein AM ，Coutinho CM ，Tinari S ，Khalil A ，Shamshirsaz A ，Palacios-Jaraquemada JM ，D'Antonio F ... -  《-》

Emergency delivery in pregnancies at high probability of placenta accreta spectrum on prenatal imaging: a systematic review and meta-analysis.

Placenta accreta spectrum disorders are associated with a high risk of maternal morbidity, particularly when surgery is performed under emergency conditions. This study aimed to investigate the incidence of emergency cesarean delivery in patients with a high probability of placenta accreta spectrum disorders on prenatal imaging and to compare the maternal and neonatal outcomes between patients requiring emergency cesarean delivery and those not requiring emergency cesarean delivery. MEDLINE, Embase, Cochrane, and ClinicalTrials.gov databases were searched. This study included case-control studies reporting the outcomes of pregnancies with a high probability of placenta accreta spectrum on prenatal imaging confirmed at birth delivered via unplanned emergency cesarean delivery vs those delivered via planned elective cesarean delivery for maternal or fetal indications. The outcomes observed were the occurrence of emergency cesarean delivery; incidence of placenta accreta and placenta increta/placenta percreta; preterm birth at <34 weeks of gestation; and indications for emergency delivery. This study analyzed and compared the outcomes between patients who underwent emergency cesarean delivery and those who underwent elective cesarean delivery, including estimated blood loss; number of packed red blood cell units transfused and blood products transfused; transfusion of more than 4 units of packed red blood cell; ureteral, bladder, or bowel injury; disseminated intravascular coagulation; relaparotomy after the primary surgery; maternal infection or fever; wound infection; vesicouterine or vesicovaginal fistula; admission to the neonatal intensive care unit; maternal death; composite neonatal morbidity; fetal or neonatal loss; Apgar score of <7 at 5 minutes; and neonatal birthweight. Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale for case-control and cohort studies. Random-effect meta-analyses of proportions, risks, and mean differences were used to combine the data. A total of 11 studies with 1290 pregnancies complicated by placenta accreta spectrum were included in the systematic review. Emergency cesarean delivery was reported in 36.2% of pregnancies (95% confidence interval, 28.1-44.9) with placenta accreta spectrum at birth, of which 80.3% of cases (95% confidence interval, 36.5-100.0) occurred before 34 weeks of gestation. The main indication for emergency cesarean delivery was antepartum bleeding, which complicated 61.8% of the cases (95% confidence interval, 32.1-87.4). Patients who underwent emergent cesarean delivery had higher estimated blood loss during surgery (pooled mean difference, 595 mL; 95% confidence interval, 116.10-1073.90; P<.001), higher number of packed red blood cells transfused (pooled mean difference, 2.3 units; 95% confidence interval, 0.99-3.60; P<.001), and higher number of blood products transfused (pooled mean difference, 3.0; 95% confidence interval, 1.10-4.90; P=.002) than patients who underwent scheduled cesarean delivery. Patients who underwent emergency cesarean delivery had a higher risk of requiring transfusion of more than 4 units of packed red blood cell (odds ratio, 3.8; 95% confidence interval, 1.7-4.9; P=.002), bladder injury (odds ratio, 2.1; 95% confidence interval, 1.1-4.0; P=.003), disseminated intravascular coagulation (odds ratio, 6.1; 95% confidence interval, 3.1-13.1; P<.001), and admission to the intensive care unit (odds ratio, 2.1; 95% confidence interval, 1.4-3.3; P<.001). Newborns delivered via emergency cesarean delivery had a higher risk of adverse composite neonatal outcomes (odds ratio, 2.6; 95% confidence interval, 1.4-4.7; P=.019), admission to the neonatal intensive care unit (odds ratio, 2.5; 95% confidence interval, 1.1-5.6; P=.029), Apgar score of <7 at 5 minutes (odds ratio, 2.7; 95% confidence interval, 1.5-4.9; P=.002), and fetal or neonatal loss (odds ratio, 8.2; 95% confidence interval, 2.5-27.4; P<.001). Emergency cesarean delivery complicates approximately 35% of pregnancies affected by placenta accreta spectrum disorders and is associated with a higher risk of adverse maternal and neonatal outcomes. Large prospective studies are needed to evaluate the clinical and imaging signs that can identify patients with a high probability of placenta accreta spectrum at birth, patients at risk of requiring emergency cesarean delivery or peripartum hysterectomy, and patients at high risk of experiencing intrapartum hemorrhage.

Lucidi A ，Janiaux E ，Hussein AM ，Nieto-Calvache A ，Khalil A ，D'Amico A ，Rizzo G ，D'Antonio F ... -  《-》

Maternal outcomes of conservative management and cesarean hysterectomy for placenta accreta spectrum disorders: a systematic review and meta-analysis.

Cesarean hysterectomy as a traditional therapeutic maneuver for placenta accreta spectrum (PAS) has been associated with serious morbidity, conservative management has been used in many institutions to treat women with PAS. This systematic review aims to compare maternal outcomes according to conservative management or cesarean hysterectomy in women with placenta accreta spectrum disorders. A systematic literature search was performed in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, and four Chinese databases (Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Chinese Wanfang database and VIP database) to May 2024. Included studies were to be retrospective or prospective in design and compare and report relevant maternal outcomes according to conservative management (the placenta left partially or totally in situ) or cesarean hysterectomy in women with PAS. A risk ratio (RR) with 95% confidence interval (95% CI) was calculated for categorical outcomes and weighted mean difference (WMD) with 95% CI for continuous outcomes. The Newcastle-Ottawa Quality Assessment Scale was used to assess the observational studies. All analyses were performed using STATA version 18.0. Eight studies were included in the meta-analysis. Compared with cesarean hysterectomy, PAS women undergoing conservative management showed lower estimated blood loss [WMD - 1623.83; 95% CI: -2337.87, -909.79], required fewer units of packed red blood cells [WMD - 2.37; 95% CI: -3.70, -1.04] and units of fresh frozen plasma transfused [WMD - 0.40; 95% CI: -0.62, -0.19], needed a shorter mean operating time [WMD - 73.69; 95% CI: -90.52, -56.86], and presented decreased risks of bladder injury [RR 0.24; 95% CI: 0.11, 0.50], ICU admission [RR 0.24; 95% CI: 0.11, 0.52] and coagulopathy [RR 0.20; 95% CI: 0.06, 0.74], but increased risk for endometritis [RR 10.91; 95% CI: 1.36, 87.59] and readmission [RR 8.99; 95% CI: 4.00, 12.21]. The incidence of primary or delayed hysterectomy rate was 25% (95% CI: 19-32, I2 = 40.88%) and the use of uterine arterial embolization rate was 78% (95% CI: 65-87, I2 = 48.79%) in conservative management. Conservative management could be an effective alternative to cesarean hysterectomy when women with PAS desire to preserve the uterus and are informed about the limitations of conservative management. CRD42023484578.

Pan S ，Han M ，Zhai T ，Han Y ，Lu Y ，Huang S ，Zuo Q ，Jiang Z ，Ge Z ... -  《BMC Pregnancy and Childbirth》

Trends, characteristics, and outcomes of placenta accreta spectrum: a national study in the United States.

Although an infrequent occurrence, the placenta can adhere abnormally to the gravid uterus leading to significantly high maternal morbidity and mortality during cesarean delivery. Contemporary national statistics related to a morbidly adherent placenta, referred to as placenta accreta spectrum, are needed. This study aimed to examine national trends, characteristics, and perioperative outcomes of women who underwent cesarean delivery for placenta accreta spectrum in the United States. This is a population-based retrospective, observational study querying the National Inpatient Sample. The study cohort included women who underwent cesarean delivery from October 2015 to December 2017 and had a diagnosis of placenta accreta spectrum. The main outcome measures were patient characteristics and surgical outcomes related to placenta accreta spectrum assessed by the generalized estimating equation on multivariable analysis. The temporal trend of placenta accreta spectrum was also assessed by linear segmented regression with log transformation. Of 2,727,477 cases who underwent cesarean delivery during the study period, 8030 (0.29%) had the diagnosis of placenta accreta spectrum. Placenta accreta was the most common diagnosis (n=6205, 0.23%), followed by percreta (n=1060, 0.04%) and increta (n=765, 0.03%). The number of placenta accreta spectrum cases increased by 2.1% every quarter year from 0.27% to 0.32% (P=.004). On multivariable analysis, (1) patient demographics (older age, tobacco use, recent diagnosis, higher comorbidity, and use of assisted reproductive technology), (2) pregnancy characteristics (placenta previa, previous cesarean delivery, breech presentation, and grand multiparity), and (3) hospital factors (urban teaching center and large bed capacity hospital) represented the independent characteristics related to placenta accreta spectrum (all, P<.05). The median gestational age at cesarean delivery was 36 weeks for placenta accreta and 34 weeks for both placenta increta and percreta vs 39 weeks for non-placenta accreta spectrum cases (P<.001). On multivariable analysis, cesarean delivery complicated by placenta accreta spectrum was associated with increased risk of any surgical morbidities (78.3% vs 10.6%), Centers for Disease Control and Prevention-defined severe maternal morbidity (60.3% vs 3.1%), hemorrhage (54.1% vs 3.9%), coagulopathy (5.3% vs 0.3%), shock (5.0% vs 0.1%), urinary tract injury (8.3% vs 0.2%), and death (0.25% vs 0.01%) compared with cesarean delivery without placenta accreta spectrum. When further analyzed by subtype, cesarean delivery for placenta increta and percreta was associated with higher likelihood of hysterectomy (0.4% for non-placenta accreta spectrum, 45.8% for accreta, 82.4% for increta, 78.3% for percreta; P<.001) and urinary tract injury (0.2% for non-placenta accreta spectrum, 5.2% for accreta, 11.8% for increta, 24.5% for percreta; P<.001). Moreover, women in the placenta increta and percreta groups had markedly increased risks of surgical mortality compared with those without placenta accreta spectrum (increta, odds ratio, 19.9; and percreta, odds ratio, 32.1). Patient characteristics and outcomes differ across the placenta accreta spectrum subtypes, and women with placenta increta and percreta have considerably high surgical morbidity and mortality risks. Notably, 1 in 313 women undergoing cesarean delivery had a diagnosis of placenta accreta spectrum by the end of 2017, and the incidence seems to be higher than reported in previous studies.

Matsuzaki S ，Mandelbaum RS ，Sangara RN ，McCarthy LE ，Vestal NL ，Klar M ，Matsushima K ，Amaya R ，Ouzounian JG ，Matsuo K ... -  《-》

Third-trimester ultrasound for antenatal diagnosis of placenta accreta spectrum in women with placenta previa: results from the ADoPAD study.

To evaluate the performance of third-trimester ultrasound for the diagnosis of clinically significant placenta accreta spectrum disorder (PAS) in women with low-lying placenta or placenta previa. This was a prospective multicenter study of pregnant women aged ≥ 18 years who were diagnosed with low-lying placenta (< 20 mm from the internal cervical os) or placenta previa (covering the internal cervical os) on ultrasound at ≥ 26 + 0 weeks' gestation, between October 2014 and January 2019. Ultrasound suspicion of PAS was raised in the presence of at least one of these signs on grayscale ultrasound: (1) obliteration of the hypoechogenic space between the uterus and the placenta; (2) interruption of the hyperechogenic interface between the uterine serosa and the bladder wall; (3) abnormal placental lacunae. Histopathological examinations were performed according to a predefined protocol, with pathologists blinded to the ultrasound findings. To assess the ability of ultrasound to detect clinically significant PAS, a composite outcome comprising the need for active management at delivery and histopathological confirmation of PAS was considered the reference standard. PAS was considered to be clinically significant if, in addition to histological confirmation, at least one of these procedures was carried out after delivery: use of hemostatic intrauterine balloon, compressive uterine suture, peripartum hysterectomy, uterine/hypogastric artery ligation or uterine artery embolization. The diagnostic performance of each ultrasound sign for clinically significant PAS was evaluated in all women and in the subgroup who had at least one previous Cesarean section and anterior placenta. Post-test probability was assessed using Fagan nomograms. A total of 568 women underwent transabdominal and transvaginal ultrasound examinations during the study period. Of these, 95 delivered in local hospitals, and placental pathology according to the study protocol was therefore not available. Among the 473 women for whom placental pathology was available, clinically significant PAS was diagnosed in 99 (21%), comprising 36 cases of placenta accreta, 19 of placenta increta and 44 of placenta percreta. The median gestational age at the time of ultrasound assessment was 31.4 (interquartile range, 28.6-34.4) weeks. A normal hypoechogenic space between the uterus and the placenta reduced the post-test probability of clinically significant PAS from 21% to 5% in women with low-lying placenta or placenta previa in the third trimester of pregnancy and from 62% to 9% in the subgroup with previous Cesarean section and anterior placenta. The absence of placental lacunae reduced the post-test probability of clinically significant PAS from 21% to 9% in women with low-lying placenta or placenta previa in the third trimester of pregnancy and from 62% to 36% in the subgroup with previous Cesarean section and anterior placenta. When abnormal placental lacunae were seen on ultrasound, the post-test probability of clinically significant PAS increased from 21% to 59% in the whole cohort and from 62% to 78% in the subgroup with previous Cesarean section and anterior placenta. An interrupted hyperechogenic interface between the uterine serosa and bladder wall increased the post-test probability for clinically significant PAS from 21% to 85% in women with low-lying placenta or placenta previa and from 62% to 88% in the subgroup with previous Cesarean section and anterior placenta. When all three sonographic markers were present, the post-test probability for clinically significant PAS increased from 21% to 89% in the whole cohort and from 62% to 92% in the subgroup with previous Cesarean section and anterior placenta. Grayscale ultrasound has good diagnostic performance to identify pregnancies at low risk of PAS in a high-risk population of women with low-lying placenta or placenta previa. Ultrasound may be safely used to guide management decisions and concentrate resources on patients with higher risk of clinically significant PAS. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Fratelli N ，Prefumo F ，Maggi C ，Cavalli C ，Sciarrone A ，Garofalo A ，Viora E ，Vergani P ，Ornaghi S ，Betti M ，Vaglio Tessitore I ，Cavaliere AF ，Buongiorno S ，Vidiri A ，Fabbri E ，Ferrazzi E ，Maggi V ，Cetin I ，Frusca T ，Ghi T ，Kaihura C ，Di Pasquo E ，Stampalija T ，Belcaro C ，Quadrifoglio M ，Veneziano M ，Mecacci F ，Simeone S ，Locatelli A ，Consonni S ，Chianchiano N ，Labate F ，Cromi A ，Bertucci E ，Facchinetti F ，Fichera A ，Granata D ，D'Antonio F ，Foti F ，Avagliano L ，Bulfamante GP ，Calì G ，ADoPAD (Antenatal Diagnosis of Placental Adhesion Disorders) Working Group ... -  《-》