Determinants of emergency Cesarean delivery in pregnancies complicated by placenta previa with or without placenta accreta spectrum disorder: analysis of ADoPAD cohort.

To investigate the rate and outcome of emergency Cesarean delivery (CD) in women with placenta previa with or without placenta accreta spectrum disorders (PAS) and to elucidate the diagnostic accuracy of ultrasound in predicting emergency CD. This was a secondary analysis of a multicenter prospective study involving 16 referral hospitals in Italy (ADoPAD study). Inclusion criteria were women with placenta previa minor (< 20 mm from the internal cervical os) or placenta previa major (covering the os), aged ≥ 18 years, who underwent transabdominal and transvaginal ultrasound assessment at ≥ 26 + 0 weeks of gestation. The primary outcome was the occurrence of emergency CD, defined as the need for immediate surgical intervention performed for emergency maternal or fetal indication, including active labor, cumulative maternal bleeding > 500 mL, severe and persistent vaginal bleeding such that maternal hemodynamic stability could not be achieved or maintained, or category-III fetal heart rate tracing unresponsive to resuscitative measures. The primary outcome was reported separately in the population of women with placenta previa and no PAS confirmed after birth and in those with PAS. The secondary aim was to report on the strength of association and to test the diagnostic accuracy of ultrasound in predicting emergency CD. Univariate, multivariate and diagnostic accuracy analyses were used to analyze the data. A total of 450 women, including 97 women with placenta previa and PAS and 353 with placenta previa only, were analyzed. In women with placenta previa and PAS, emergency CD was required in 20.6% (95% CI, 14-30%), and 60.0% (12/20) delivered before 34 weeks of gestation. The mean gestational age at delivery was 32.3 ± 2.7 weeks in women undergoing emergency CD and 34.9 ± 1.8 weeks in those undergoing elective CD (P < 0.001). Women undergoing emergency CD had a higher median estimated blood loss (2500 (interquartile range (IQR), 1350-4500) vs 1100 (IQR, 625-2500) mL; P = 0.012), mean units of blood transfused (7.3 ± 8.8 vs 2.5 ± 3.4; P = 0.02) and more frequent placement of a mechanical balloon (50.0% vs 16.9%; P = 0.002) compared with those undergoing elective CD. On univariate analysis, the presence of interrupted retroplacental space, interrupted bladder line and placental lacunae was more common in women not experiencing emergency CD. No comprehensive multivariate analysis could be performed in this subgroup of women. Ultrasound signs of PAS, including presence of interrupted retroplacental space, interrupted bladder line and placental lacunae, were not predictive of emergency CD. In women with placenta previa but no PAS, emergency CD was required in 31.2% (95% CI, 26.6-36.2%), and 32.7% (36/110) delivered before 34 weeks of gestation. The mean gestational age at delivery was lower in women undergoing emergency CD compared with those undergoing elective CD (34.2 ± 2.9 vs 36.7 ± 1.6 weeks; P < 0.001). Pregnancies complicated by emergency CD were associated with a lower birth weight (2330 ± 620 vs 2800 ± 480 g; P < 0.001) and had a higher risk of need for blood transfusion (22.7% vs 10.7%; P = 0.003) compared with those who underwent elective CD. On multivariate analysis, only placental thickness (odds ratio (OR), 1.02 (95% CI, 1.00-1.03); P = 0.046) and cervical length < 25 mm (OR, 3.89 (95% CI, 1.33-11.33); P = 0.01) were associated with emergency CD. However, a short cervical length showed low diagnostic accuracy for predicting emergency CD in these women. Emergency CD occurred in about 20% of women with placenta previa and PAS and 30% of those with placenta previa only and was associated with worse maternal outcome compared with elective intervention. Prenatal ultrasound is not predictive of the risk of emergency CD in women with these disorders. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

ADoPAD (Antenatal Diagnosis of Placental Attachment Disorders) Study Group 《-》

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 ... -  《-》

Association between Number of Prior Cesareans and Early Preterm Delivery in Women with Abnormal Placentation.

Delivery timing at 34 to 36 weeks is nationally recommended for pregnancies complicated by placenta accreta spectrum (PAS). However, it has recently been suggested that those with ≥2 prior cesarean deliveries (CD) and PAS should be delivered earlier than 34 weeks because of a higher risk of unscheduled delivery and complications. We sought to evaluate whether the number of prior CD in women with PAS is associated with early preterm delivery (PTD) (<34 weeks). We also evaluated the same relationship in women with placenta previa alone (without PAS). This is a secondary analysis of a multicenter and observational study that included women with prior CD (maternal-fetal medicine unit cesarean registry). Women with a diagnosis of PAS (regardless of placenta previa) were included for our primary analysis, and women with known placenta previa (without a component of PAS) were independently analyzed in a second analysis. Two groups of patients from the registry were studied: patients with PAS (regardless of placenta previa) and patients with placenta previa without PAS. The exposure of interest was the number of prior CD: ≥2 CD compared with <2 CD. The primary outcome was PTD <34 weeks. Secondary outcomes included preterm labor requiring hospitalization or tocolysis, transfusion of blood products, composites of maternal and neonatal morbidities, and NICU admission. Outcomes by prior CD number groups were compared in both cohorts. Backward selection was used to identify parsimonious logistic regression models. There were 194 women with PAS, 97 (50%) of whom had <2 prior CD and 97 (50%) of whom had ≥2 prior CD. The rate of PTD <34 weeks in women with ≥2 prior CD compared with <2 in the setting of PAS was 23.7 versus 29.9%, p = 0.27; preterm labor requiring hospitalization was 24.7 versus 13.5%; p = 0.05. The rates of plasma transfusion were increased with ≥2 prior CD (29.9 vs. 17.5%, p = 0.04), but there were no differences in transfusion of other products or in composite maternal or neonatal morbidities. After multivariable adjustments, having ≥2 CDs was not associated with PTD <34 weeks in women with PAS (adjusted odds ratio (aOR): 0.73, 95% confidence interval [CI]: 0.39-13.8) despite an association with preterm labor requiring hospitalization (aOR: 2.69; 95% CI: 1.15-6.32). In our second analysis, there were 687 women with placenta previa, 633 (92%) with <2 prior CD, and 54 (8%) with ≥2 prior CD. The rate of PTD <34 weeks with ≥2 CD in the setting of placenta previa was not significantly increased (27.8 vs. 22.1%, aOR: 1.49; 95% CI: 0.77-2.90, p = 0.08); the maternal composite outcome (aOR: 4.85; 95% CI: 2.43-9.67) and transfusion of blood products (aOR: 6.41; 95% CI: 2.30-17.82) were noted to be higher in the group with ≥2 prior CD. Women with PAS who have had ≥2 prior CD as compared with women with <2 prior CD did not appear to have a higher risk of complications leading to delivery prior to 34 weeks. As such, considering the associated morbidity with early preterm birth, we would not recommend scheduled delivery prior to 34 weeks in this population. · We do not recommend delivery prior to 34 weeks of gestational age in PAS.. · PTD was not significantly increased in PAS with ≥2 CDs.. · PTD < 34 weeks of gestational age was not increased in placenta previa with ≥2 prior CDs..

Oben A ，Ausbeck EB ，Gazi MN ，Subramaniam A ，Harper LM ，Szychowski JM ，Tita AT ... -  《-》

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 ... -  《-》

Intracervical lakes as sonographic marker of placenta accreta spectrum disorder in patients with placenta previa or low-lying placenta.

To evaluate the diagnostic accuracy of a new ultrasound sign, intracervical lakes (ICL), in predicting the presence of placenta accreta spectrum (PAS) disorder and delivery outcome in patients with placenta previa or low-lying placenta. This was a retrospective multicenter study of women with placenta previa or low-lying placenta at ≥ 26 weeks' gestation, who were referred to three Italian tertiary units from January 2015 to September 2018. The presence of ICL, defined as tortuous anechoic spaces within the cervix which appeared to be hypervascular on color Doppler, was evaluated on ultrasound images obtained at the time of referral. The primary aim was to explore the diagnostic accuracy of ICL in detecting the presence and depth of PAS disorder. The secondary aim was to explore the accuracy of this sign in predicting total estimated blood loss, antepartum bleeding, major postpartum hemorrhage at the time of Cesarean section and need for Cesarean hysterectomy. The diagnostic accuracy of ICL in combination with typical sonographic signs of PAS disorder, was assessed by computing summary estimates of sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios and diagnostic odds ratios (DOR). A total of 332 women with placenta previa or low-lying placenta were included in the analysis, with a median maternal age of 33.0 (interquartile range, 29.0-37.0) years. ICL were noted in 15.1% of patients. On logistic regression analysis, the presence of ICL was associated independently with major postpartum hemorrhage (odds ratio (OR), 3.3 (95% CI, 1.6-6.5); P < 0.001), Cesarean hysterectomy (OR, 7.0 (95% CI, 2.1-23.9); P < 0.001) and placenta percreta (OR, 2.8 (95% CI, 1.3-5.8); P ≤ 0.01), but not with the presence of any PAS disorder (OR, 1.6 (95% CI, 0.7-3.5); P = 0.2). Compared with the group of patients without ultrasound signs of PAS disorder, the presence of at least one typical sonographic sign of PAS disorder in combination with ICL had a DOR of 217.2 (95% CI, 27.7-1703.4; P < 0.001) for placenta percreta and of 687.4 (95% CI, 121.4-3893.0; P < 0.001) for Cesarean hysterectomy. ICL may represent a marker of deep villus invasion in women with suspected PAS disorder on antenatal sonography and anticipate the occurrence of severe maternal morbidity. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

di Pasquo E ，Ghi T ，Calì G ，D'Antonio F ，Fratelli N ，Forlani F ，Prefumo F ，Kaihura CT ，Volpe N ，Dall'Asta A ，Frusca T ... -  《-》