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Introduction: Placental syndrome is an umbrella term encompassing the clinical phenotypes of preeclampsia and fetal growth restriction, and is associated with high maternal and neonatal morbidity. In women with placental syndrome, histologicl examination of the uteroplacental unit commonly demonstrates pathological lesions, such as decidual vasculopathy. Decidual vasculopathy are pathological changes in the spiral arteries, which are associated with adverse outcome in preeclampsia and long‐term maternal cardiovascular health. The relation between placental syndrome phenotypes and placental pathology has been previously demonstrated; however, the role of uteroplacental Doppler measurements as a link between placental syndrome phenotypes and the underlying placental pathology is still unclear. We hypothesized that decidual vasculopathy is associated with abnormal uteroplacental Doppler profiles and ultrasound placental parameters, independent of clinical phenotype. Material and Methods: We performed a retrospective analysis of data from a prospective cohort of pregnancies with placental syndrome, as well as cases without hypertensive disease or fetal growth restriction. The study group was divided into women with decidual vasculopathy on histologic analysis of placental specimen and those without the lesions. Outcome parameters included maternal and fetal Dopplers, estimated fetal weight, placental weight and thickness, placental lacunae and abnormal placental calcification. Results: Compared with the women without the lesions (n = 91), the group with decidual vasculopathy (n = 25) had a higher mean uterine artery pulsatility index (1.70 vs 0.81, p < 0.001) and uterine artery pulsatility index percentile (>p99 vs p67, p < 0.001). Decidual vasculopathy was associated with abnormal uterine artery Doppler profile (defined as pulsatility index p > 95 and/or bilateral notch) (82%) compared with women without the lesions (33%) (odds ratio [OR] 9.3, 95% CI 2.4–36.0), which remained significant after adjusting for possible confounding factors preeclampsia, tobacco use and gestational age at birth (OR 7.1, 95% CI 1.3–39.1). Decidual vasculopathy was not associated with fetal Doppler abnormalities or placental parameters and only modestly so with lower cerebroplacental ratio (p = 0.036). Conclusions: Histologic decidual vasculopathy is associated with abnormal uterine artery Doppler, independent of clinical phenotype during pregnancy. [ABSTRACT FROM AUTHOR]

Introduction: Stillbirth remains an often unpredictable and devastating pregnancy outcome, and despite thorough investigation, the number of stillbirths attributable to unexplained causes remains high. Placental examination has become increasingly important where access to perinatal autopsy is limited. We aimed to examine the causes of stillbirth in normally formed infants over 30 years and whether a declining autopsy rate has affected our ability to determine a cause for stillbirths.Material and Methods: All cases of normally formed singleton infants weighing ≥500 g that died prior to the onset of labor from 1989 to 2018 were examined. Trends for specific causes and uptake of perinatal autopsy were analyzed individually.Results: In all, 229 641 infants were delivered, with 840 stillbirths giving a rate of 3.66/1000. The rate of stillbirth declined from 4.84/1000 in 1989 to 2.51 in 2018 (P < .001). There was no difference in the rate of stillbirth between nulliparous and multiparous women (4.25 vs 3.66 per 1000, P = .026). Deaths from placental abruption fell (1.13/1000 in 1989 to 0 in 2018, P < .001) and the relative contribution of placental abruption to the incidence of stillbirth also fell, from 23.3% (7/30) in 1989 to 0.0% (0/19) in 2018 (P < .001). Stillbirth attributed to infection remained static (0.31/1000 in 1989 to 0.13 in 2018, P = .131), while a specific causal organism was found in 79.2% (42/53) of cases. Unexplained stillbirths decreased from 2.58/1000 (16/6200) in 1989 to 0.13 (1/7581) in 2018 (P < .001) despite a fall in the uptake of perinatal autopsy (96.7% [29/30] in 1989 to 36.8% (7/19) in 2018; P < .001). Placental disease emerged as a significant cause of stillbirth from 2004 onwards (89.5% [17/19] in 2018).Conclusions: The present analysis is one of the largest single-center studies on stillbirth published to date. Stillbirth rates have fallen across the study period across parity. A decrease in deaths secondary to placental abruption contributed largely to this. Infection-related deaths are static; however, in one-fifth of cases a causative organism was not found. Despite a decreasing autopsy rate, the number of unexplained stillbirths continues to fall as the importance of placental pathology is increasingly recognized. [ABSTRACT FROM AUTHOR]

Low-lying placentas, placenta previa and abnormally invasive placentas are the most frequently occurring placental abnormalities in location and anatomy. These conditions can have serious consequences for mother and fetus mainly due to excessive blood loss before, during or after delivery. The incidence of such abnormalities is increasing, but treatment options and preventive strategies are limited. Therefore, it is crucial to understand the etiology of placental abnormalities in location and anatomy. Placental formation already starts at implantation and therefore disorders during implantation may cause these abnormalities. Understanding of the normal placental structure and development is essential to comprehend the etiology of placental abnormalities in location and anatomy, to diagnose the affected women and to guide future research for treatment and preventive strategies. We reviewed the literature on the structure and development of the normal placenta and the placental development resulting in low-lying placentas, placenta previa and abnormally invasive placentas. [ABSTRACT FROM AUTHOR]

Introduction: Maternal perception of fetal movements has long been considered an indicator of fetal well-being. A sudden decrease in the number of fetal movements is suggestive of fetal compromise. We aimed to determine whether the maternal perception of reduced fetal movements (RFM) is associated with placental pathological lesions in a low-risk term population.Material and Methods: Our study was a case-control study that was performed in a single university center. Placental histopathology, maternal demographics, labor characteristics, and neonatal outcomes of term, singleton pregnancies with maternal perception of RFM during the 2 weeks prior to delivery were collected. To isolate the effect of RFM on placental pathology, we excluded cases complicated by preterm birth, hypertensive disorders, diabetes mellitus, small-for-gestational-age and congenital/genetic anomalies. We compared pregnancy outcomes and placental pathology between the RFM group and a control group matched for gestational age and mode of delivery. Placental lesions were classified according to the "Amsterdam" criteria. Composite adverse neonatal outcome was defined as one or more of the following: sepsis, transfusion, hypoglycemia, phototherapy, respiratory morbidity, cerebral morbidity, necrotizing enterocolitis and fetal/neonatal death. Multivariable regression analysis was performed to identify independent associations with adverse neonatal outcome.Results: We included patients who gave birth from January 2008 until May 2019. The study group included 203 term pregnancies with RFM during the 2 weeks prior to delivery, which was matched with 203 controls. The RFM group was characterized by a higher rate of placental weight <10th percentile (22.6% vs. 3.9%, P < .001), a higher rate of maternal vascular malperfusion lesions (30.5% vs. 18.7%, P = .007) and lesions of maternal inflammatory response (43.3% vs. 29.5%, P = .005). At delivery, the RFM group had higher rates of cesarean delivery due to non-reassuring fetal heart rate monitoring (P = .01), 5-minute Apgar score ≤7 (P = .03), neonatal intensive care unit admissions (P < .001) and composite adverse neonatal outcomes (P = .007). Using multivariable analysis, RFM (adjusted odds ratio [aOR] 1.7, 95% confidence interval [CI] 1.1-4.8), and placental maternal vascular malperfusion lesions (aOR 1.2, 95% CI 1.0-2.9) were independently associated with adverse neonatal outcome.Conclusions: After excluding important placental-related morbidities, RFM was associated with a higher rate of placental weight <10th percentile and placental maternal vascular malperfusion lesions vs. controls. This study suggests a placental involvement in the association between RFM at term and adverse pregnancy outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Late-gestation adverse pregnancy outcome is associated with reduced placental villous vascularity but rarely with a frankly abnormal umbilical artery Doppler waveform. The clinical utility of umbilical artery Doppler velocimetry in late gestation is limited by poor understanding of what aspect(s) of placental structure and function the impedance reflects. We hypothesized that placental arterial circulation impedance reflects placental vascularity and arterial function.Material and Methods: This was a secondary analysis of data from the FEMINA2 study, a study of pregnancy outcome after reduced fetal movement. Forty-three pregnancies that delivered within 7 days of ultrasound assessment were examined. Impedance was quantified by pulsatility index (PI) from umbilical, chorionic plate arteries, and intra-placental arteries. Site-specific PI was compared with villous vascularity (CD31 immunostaining) and placental arterial function (wire myography) by regression analysis (P < .01) where factor analysis suggested potential co-variance (Eigen value > 2).Results: Pulsatility index decreased with proximity to the placental microvasculature (P < .0001). Intra-placental artery PI correlated significantly with vessel number (R2  = 0.40, P = .0007). No significant relations between umbilical or chorionic plate artery PI and villous vascularity were found (P ≥ .11 and P ≥ .042). No significant co-variance was suggested between PI at any Doppler sampling site and ex vivo placental arterial function indices. Measurement reliability (intraclass correlation coefficient) was highest in the umbilical artery (PI 0.75 and 0.50 for intra- and interoperator reliability, respectively) and lowest in the intra-placental arteries (PI 0.55 and 0.41, respectively). Systematic bias in umbilical artery PI was observed between observers, but not at other Doppler sampling sites.Conclusions: More vascular placentas ex vivo are associated with reduced intra-placental artery Doppler impedance in utero. Although umbilical (but not intra-placental) artery Doppler PI is associated with adverse outcome after reduced fetal movement, this predictive ability does not appear to be through assessment of placental vascularity or chorionic plate arterial function. The inferior reliability of intra-placental artery Doppler, although similar to previously published reliability of umbilical artery Doppler, impairs its ability to detect subtle differences in placental vascularity, and must be significantly improved before it could be considered a clinically useful test. [ABSTRACT FROM AUTHOR]

Introduction: The purpose of the study was to evaluate the differences in individual histopathologic placental lesions in pregnancies complicated by early‐onset (<32 weeks at diagnosis) and late‐onset (≥32 weeks at diagnosis) fetal growth restriction (FGR). Material and methods: A cohort study of 440 singleton pregnancies complicated by FGR, diagnosed according to standard ultrasonographic criteria, followed up and delivered at the same institution between 2010 and 2016. Placental lesions were classified according to the Amsterdam Placental Workshop Consensus Criteria. Pathologic examination of placentas from 113 healthy singleton term pregnancies served as controls. Binary and multinomial logistic regression models were used to evaluate the independent association of placental lesions with the type of FGR. Results: In our cohort the prevalences of early and late FGR were 37.3% (164/440) and 62.7% (276/440), respectively. The overall rates of preeclampsia (69/164 vs 59/276, P < 0.01) and absent/reversed umbilical artery pulsatility indices (61/164 vs 14/276, P < 0.001) were higher among early FGR than late FGR. Placental characteristics from early and late FGR pregnancies differed mainly in regard to maternal vascular malperfusion scores rather than fetal scores, with preeclampsia found to be a cofactor modulating the rates and severity of associated lesions. In the binary logistic analysis, recent infarcts (OR 2.44, 95% CI 1.2‐5), distal villous hypoplasia (OR 1.8, 95% CI 1.0‐3.2), atherosis (OR 2.71, 95% CI 1.35‐5.47), persistent endovascular trophoblasts (OR 1.67, 95% CI 1.03‐2.7), and a reduced fetal/placental weight score (OR 0.27, 95% CI 0.2‐0.38) were independently associated with an increased likelihood of early FGR compared with late FGR. The sensitivity, specificity, and area under the curve of the model were 60% (95% CI 51.2‐66.2), 89.1% (95% CI 84.9‐92.3), and 0.81 (95% CI 0.77‐0.85), respectively, suggesting a fair to good predictive value. Conclusions: Individual placental lesions suggestive of increased rates of ischemia, defective remodeling of spiral arteries, peripheral hypoxia interfering with villus development, and reduced placental efficiency were significantly more common in early FGR than late FGR. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to investigate the planned place of delivery for women antenatally diagnosed with abnormally invasive placenta (AIP) in England and identify how many units regard themselves to be "specialist centers" for the management of AIP.Material and Methods: Observational study of obstetric-led units in England. An anonymous survey was sent to the delivery suite lead clinician in all 154 consultant-led units throughout England. The main outcome measures were whether each unit planned to manage AIP "in-house", the estimated number of AIP cases delivered in the previous 5 years and whether the unit considered itself a "specialist center" for AIP management.Results: In all, 114 of 154 units responded (74%): 80 (70%) manage AIP cases "in-house", 23 (29%) of these report that they regard themselves "specialist centers" for AIP. The 23 "specialist centers" managed significantly more cases than "non-specialist centers" (5.4, 95% confidence interval (CI) 4.3-7.3 vs 2.3, 95% CI 1.5-3.1 cases/unit/year; P < .001); nearly one-third of "non-specialist centers" manage less than 1 case per year. Extrapolating the reported number of cases to all 154 obstetrician-led delivery units produces an estimate of 5.2 cases per 10 000 births over the last 5 years.Conclusions: Most units plan to manage AIP "in-house" despite encountering few cases each year. Centralizing care would allow the multidisciplinary team in each "specialist center" to develop significant experience in the management of this rare condition, leading to improved outcomes for the women. [ABSTRACT FROM AUTHOR]

Introduction: The presence of a previous uterine scar is a strong risk factor for developing abnormally invasive placentation (AIP). We sought to determine whether a short interpregnancy interval predisposes to AIP. We hypothesized that a short interpregnancy interval after a previous cesarean delivery increases the risk of AIP in comparison with a longer interpregnancy interval.Material and Methods: We performed a retrospective cohort study of women with a histological diagnosis of AIP and a history of a previous cesarean section. Women were included in the control group if they had a previous cesarean section with a placenta underlying the previous uterine scar or an anterior previa. The time interval between pregnancy and AIP data was analyzed using the chi-square test and two-tailed Fisher's exact test.Results: There was no statistical difference in the interpregnancy interval between women who had AIP vs the control group. Gravidity and parity were found to be significantly higher in the women with AIP vs the controls.Conclusions: These results suggest that a short interpregnancy interval may not increase the risk of developing AIP. [ABSTRACT FROM AUTHOR]

Introduction: Ultrasound signs of abnormal placental invasion are subjective in nature. We tested the hypothesis that placental thickness in the lower uterine segment is increased when there is abnormally invasive placenta (AIP) in women with a low-lying placenta.Material and Methods: Retrospective analysis of data of placental thickness in women with ultrasound evidence of major placenta previa or a low-lying anterior placenta was done. The diagnosis of AIP was confirmed both intraoperatively and on histopathology for those managed by partial myometrial excision with uterine conservation or by hysterectomy.Results: In all, 131 records were available for analysis after exclusion of 33 cases due to unsuitable images and eight cases without pregnancy outcomes. The diagnosis of AIP was confirmed in 28 (21.4%) of the 131 cases. The lower segment placental thickness was significantly higher in women with AIP (median = 50.3 mm, IQR: 42.7-64.3) than in those with normal placentation (median = 30.9 mm, IQR: 22.9-42.2, P < 0.001). Logistic regression analysis showed that previous cesarean section and placental thickness on ultrasound were independent predictors for AIP.Conclusions: Lower uterine segment placental thickness is increased in women with AIP compared with those with noninvasive placentation. This association constitutes a pragmatic objective sign and may be of clinical value in improving prenatal detection of AIP in women with placental implantation in the lower uterine segment. Prospective studies are necessary to ascertain lower segment placental thickness as a predictor for AIP. [ABSTRACT FROM AUTHOR]

Introduction: Accurate prenatal diagnosis of abnormally invasive placenta (AIP) is fundamental because it significantly reduces maternal morbidities.Material and Methods: Medline, Embase, CINAHL and the Cochrane databases were searched. The primary aim of the present review was to elucidate the diagnostic accuracy of prenatal magnetic resonance imaging (MRI) in recognizing the severity of AIP, defined as the depth and topography of invasion. The secondary aim was to ascertain the strength of association between each MRI sign and the depth of placental invasion and to test their individual predictive accuracy in detecting such invasion. Inclusion criteria were studies on women who had prenatal MRI for ultrasound suspicion or the presence of clinical risk factors for AIP. Estimates of sensitivity, specificity, positive and negative likelihood ratios and diagnostic odds ratio were calculated using the hierarchical summary receiver characteristics curve model, and individual data random-effect logistic regression was used to calculate OR.Results: Twenty studies (1080 pregnancies undergoing MRI mainly for the ultrasound suspicion of AIP) were included. MRI showed a sensitivity of 94.4% [95% confidence interval (CI) 15.8-99.9], 100% (95% CI 75.3-100) and 86.5% (95% CI 74.2-94.4) for detection of placenta accreta, increta and percreta, respectively; the corresponding values for specificity were 98.8% (95% CI 70.7-100), 97.3% (95% CI 93.3-99.3), 96.8% (95% CI 93.5-98.7). MRI identified 100% of cases with S1 and 100% of those with S2 invasion confirmed at surgery. Among the different MRI signs, intra-placental dark bands showed the best sensitivity for the detection of placenta accreta, increta and percreta; as well as abnormal intra-placental vascularity, uterine bulging was associated with a higher risk of increta and percreta, exophitic mass and bladder tenting with placenta percreta.Conclusion: Prenatal MRI has an excellent diagnostic accuracy in identifying the depth and the topography of placental invasion. However, these findings come mainly from studies in which MRI was performed as a secondary imaging tool in women already screened for AIP on ultrasound and might not reflect its actual diagnostic performance in detecting the severity of these disorders. [ABSTRACT FROM AUTHOR]

Introduction: Current knowledge of the fetoplacental vasculature in fetal growth restriction (FGR) due to placental dysfunction focuses on the microvasculature rather than the macrovasculature. The aim of this study was to investigate the feasibility of computed tomography angiography to analyze the fetoplacental macrovasculature in normal and FGR pregnancies.Material and Methods: We included 29 placentas (22-42 weeks of gestation) from normal birthweight pregnancies and eight placentas (26-37 weeks of gestation) from FGR pregnancies (birthweight < -15% and abnormal umbilical Doppler flow). We performed postpartum placental computed tomography angiography followed by semi-automatic three-dimensional image segmentation.Results: A median of nine (range seven to eleven) vessel generations was identified. In normal birthweight placentas, gestational age was positively linearly correlated with macrovascular volume (p = 0.002), vascular surface area (p < 0.0005) and number of vessel junctions (p = 0.012), but not with vessel diameter and inter-branch length. The FGR placentas had a lower weight (p = 0.004) and smaller convex volume (p = 0.022) (smallest convex volume containing the macrovasculature); however, macrovascular volume was not significantly reduced. Hence, macrovascular density given as macrovascular outcomes per placental volume was increased in FGR placentas: macrovascular volume per convex volume (p = 0.004), vascular surface area per convex volume (p = 0.004) and number of vessel junctions per convex volume (p = 0.037).Conclusions: Evaluation of the fetoplacental macrovasculature is feasible with computed tomography angiography. In normal birthweight placentas, macrovascular volume and surface area increase as pregnancy advances by vessel branching rather than increased vessel diameter and elongation. The FGR placenta was smaller; however, the macrovascular volume was within normal range because of an increased macrovascular density. [ABSTRACT FROM AUTHOR]

Introduction: Women with a history of placenta-related pregnancy complications, such as preeclampsia, intrauterine growth restriction or preterm delivery, have an increased risk for recurrence of such complications. This recurrence is likely the result of underlying endothelial dysfunction that leads to abnormal placentation, especially in complications with an early onset. This study provides an overview of biomarkers of placental development and function in pregnancies from women with a history of placenta-related complications.Material and Methods: A systematic literature search was conducted limited to human studies and including keywords related to a history of placenta-related complications and markers of placental development and function. Two independent reviewers assessed eligibility and quality of 1553 retrieved unique articles.Results: Five articles reporting on placental development and function in women with an obstetric history of preeclampsia (n = 3), intrauterine growth restriction (n = 1) and preterm delivery (n = 2) were eligible for quality assessment. We identified associations between a history of preeclampsia and abnormal placental histological findings at term in the current pregnancy, but found contradictory results regarding presence of uterine artery notching. In women with a history of very preterm delivery (<32 weeks), one study showed associations with abnormal placental histology.Conclusion: Literature on the association between a history of placenta-related complications and placental development and function in subsequent pregnancies is scarce and studies are heterogeneous. However, literature shows that placenta-related pregnancy complications are associated with subsequent placental histology. [ABSTRACT FROM AUTHOR]

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, subplacental vascularity, and uterovesical hypervascularity.Results: Twenty studies (3209 pregnancies) were included. Ultrasound had an overall good diagnostic accuracy in identifying the depth of placental invasion with sensitivities of 90.6%, 93.0%, 89.5%, and 81.2% for placenta accreta, increta, accreta/increta, and percreta, respectively; the corresponding specificities were 97.1%, 98.4%, 94.7%, and 98.9%. Placental lacunae had sensitivities 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%, whereas the corresponding figures for placenta increta and percreta were 91.6% and 76.9%, and 88.1% and 71.1%. Lacunar flow had sensitivities 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 uterovesical hypervascularity was low for the detection of placenta accreta (12.3%) but 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. [ABSTRACT FROM AUTHOR]

Introduction: Mothers at risk of preterm birth are treated with antenatal corticosteroids, which have advantageous effects for prematurely born infants. Accelerated villous maturation in the placenta is also associated with improved perinatal outcome. The primary aim of this study was to examine the association between antenatal corticosteroids and accelerated villous maturation. The secondary aim was to study associations with other placental pathologies.Material and Methods: A retrospective cohort study including 105 women who had (n = 75) or had not (n = 30) been treated with antenatal corticosteroids. The women gave birth between 22+0 and 26+6  weeks of gestation in Stockholm County between 1 April 2004 and 31 March 2007. A pathologist blinded to all clinical data except gestational age examined the placental slides to identify pathology parameters. The outcomes were correlated with antenatal corticosteroid treatment, and confounding factors were adjusted using logistic regression.Results: Accelerated villous maturation was significantly higher in the group treated with corticosteroids (odds ratio 16, 95% CI 2.4-690, p = 0.0005). After adjustment for gestational age and preeclampsia, the difference remained significant (odds ratio 8.9, 95% CI 1.2-389, p = 0.021). No significant associations were found regarding the secondary outcome variables, after adjusting for possible confounders.Conclusions: Antenatal corticosteroid treatment before preterm birth is associated with accelerated villous maturation. This could be one of the pathways by which corticosteroids are beneficial for preterm infants. [ABSTRACT FROM AUTHOR]

Introduction: We identified patients with previa and suspected accreta who are at lowest risk of unscheduled delivery or major morbidity with planned delivery beyond 34 weeks' gestation.Material and Methods: This was a retrospective cohort study of patients who had reached 34.0 weeks' gestational age with a suspected previa-accreta. We evaluated rates of unscheduled and emergent delivery based on known risk factors for premature birth. In a second analysis, we stratified patients based on level of preoperative morbidity concern and evaluated rates of major transfusion and Intensive Care Unit admission by delivery week (34 weeks, 35 weeks or 36 weeks and beyond).Results: Of 84 available patients, we classified 31 patients as low risk for unscheduled delivery and 52 as high risk. The low risk group was scheduled later (36.6 vs. 36.0 weeks; p < 0.01), but demonstrated lower rates of unscheduled delivery prior to 36 weeks (3% vs. 19%, p = 0.05). Of the patients with no prior cesarean section, only one (7%) experienced massive blood loss even though 36% had unscheduled deliveries. We observed no significant increase in major transfusion or massive blood loss with advancing gestational age, likely due to selection of the most concerning patients for early, scheduled delivery.Conclusion: Patients with suspected previa-accreta and no risk factors for preterm birth are at low risk for an unscheduled delivery prior to 36 weeks. Those with no concern for percreta or increta or no prior cesarean section may also be candidates for later delivery. [ABSTRACT FROM AUTHOR]

Introduction: The objective of this study was to assess obstetrical complications and neonatal outcomes in women with endometriosis as compared with women without endometriosis.Material and Methods: National cohort including all delivering women and their newborns in Denmark 1997-2014. Data were extracted from the Danish Health Register and the Medical Birth Register. Logistic regression analysis provided odds ratios (OR) with 95% confidence intervals (CI). Sub-analyses were made for primiparous women with a singleton pregnancy and for women with endometriosis who underwent gynecological surgery before pregnancy.Results: In 19 331 deliveries, women with endometriosis had a higher risk of severe preeclampsia (OR 1.7, 95% CI 1.5-2.0), hemorrhage in pregnancy (OR 2.3, 95% CI 2.0-2.5), placental abruption (OR 2.0, 95% CI 1.7-2.3), placenta previa (OR 3.9, 95% CI 3.5-4.3), premature rupture of membranes (OR 1.7, 95% CI 1.5-1.8), and retained placenta (OR 3.1, 95% CI 1.4-6.6). The neonates had increased risks of preterm birth before 28 weeks (OR 3.1, 95% CI 2.7-3.6), being small for gestational age (OR 1.5, 95% CI 1.4-1.6), being diagnosed with congenital malformations (OR 1.3, 95% CI 1.3-1.4), and neonatal death (OR 1.8, 95% CI 1.4-2.1). Results were similar in primiparous women with a singleton pregnancy. Gynecological surgery for endometriosis before pregnancy carried a further increased risk.Conclusion: Women with endometriosis had a significantly higher risk of several complications, such as preeclampsia and placental complications in pregnancy and at delivery. The newborns had increased risk of being delivered preterm, having congenital malformations, and having a higher neonatal death rate. Pregnant women with endometriosis require increased antenatal surveillance. [ABSTRACT FROM AUTHOR]

The standard treatment for retained placenta is manual removal whatever its subtype (adherens, trapped or partial accreta). Although medical treatment should reduce the risk of anesthetic and surgical complications, they have not been found to be effective. This may be due to the contrasting uterotonic needs of the different underlying pathologies. In placenta adherens, oxytocics have been used to contract the retro-placental myometrium. However, if injected locally through the umbilical vein, they bypass the myometrium and perfuse directly into the venous system. Intravenous injection is an alternative but exacerbates a trapped placenta. Conversely, for trapped placentas, a relaxant could help by resolving cervical constriction, but would worsen the situation for placenta adherens. This confusion over medical treatment will continue unless we can find a way to diagnose the underlying pathology. This will allow us to stop treating the retained placenta as a single entity and to deliver targeted treatments. [ABSTRACT FROM AUTHOR]

Introduction: Neonatal outcomes after the maternal obstetric near-miss complications of uterine rupture, abnormally invasive placenta, and emergency peripartum hysterectomy were assessed.Material and Methods: This case-control study was conducted as part of the Nordic Obstetric Surveillance Study (NOSS). Data on 211 newborns from 197 deliveries in which an obstetric near-miss complication was involved, were collected prospectively from April 2009 to August 2011 from all Finnish delivery units via questionnaires. Missing cases were obtained from national health registers and confirmed by the clinics. Control populations consisted of all other children born during the same period of time in the Finnish Medical Birth Register (n = 147 551).Results: The number of stillbirths in this cohort was high [n = 8, 3.8% vs. 0.3% among controls, odds ratio (OR) 12.5, 95% confidence interval (CI) 6.32-24.9]. In addition, there were two neonatal deaths. The majority of cases (n = 8, 80%) were connected to uterine rupture. The risk of severe birth asphyxia diagnosis was increased compared with controls (n = 17, 8.1% vs. 0.1%, OR 137, 95% CI 82.7-226). A low umbilical artery pH (<7.05) was also observed among these neonates (28.8% vs. 1.0%, OR 28.7, 95% CI 21.5-38.2). Post-term pregnancies were relatively common among the uterine rupture cases. Adverse neonatal outcomes in the AIP and emergency peripartum hysterectomy cases were associated with preterm deliveries.Conclusions: The prospective data collected from clinicians, combined with the information gathered from national health registers, provided valuable insights into rare maternal near-miss cases. These complications also predisposed stillbirth and neonatal death. In this study, 75% of fetal losses were associated with uterine rupture. [ABSTRACT FROM AUTHOR]

Introduction: Abnormally invasive placenta is a major cause of maternal morbidity and mortality. The aim of this study was to assess the effectiveness of a standardized operative approach performed by gynecological oncologists in the surgical management of abnormally invasive placenta.Materials and Methods: We performed a retrospective analysis of all cases of morbid placental adherence managed at the Mater Mothers' Hospitals, Brisbane, Australia between January 2000 and June 2013. A standard operative approach involving extensive retro-peritoneal and bladder dissection before delivery of the fetus, was undertaken when a gynecological oncologist was present at the start of the procedure. Main outcome measures were estimated blood loss, transfusion requirements, and maternal and neonatal morbidity.Results: The study includes 98 cases of histologically confirmed abnormally invasive placenta. Median estimated blood loss for the entire cohort was 2150 mL (range 300-11 500 mL). Women were divided into three groups, (1) those who had a gynecological oncologist present at the start of the procedure (group 1; n = 43), (2) those who had a gynecological oncologist called in during the procedure (group 2; n = 23), and (3) those who had no gynecological oncologist involved (group 3; n = 32). Group 2 had a significantly higher blood loss than the other groups (p = 0.001) (median 4400 mL). Transfusion requirements were higher in groups 2 and 3 compared with group 1 (p = 0.004). Other maternal and neonatal morbidity was similar across all three groups.Conclusion: This study supports the early presence of a gynecological oncologist at delivery when abnormally invasive placenta is suspected and demonstrates that a "call if needed" approach is not acceptable for these complex cases. [ABSTRACT FROM AUTHOR]

The article discusses that prenatal diagnosis of placenta accreta spectrum (PAS) disorders still lacks clinical correlation. Topics include prenatal diagnosis stated to have been shown to reduce the burden of associated maternal morbidities by allowing a pre-planned treatment in centres with high expertise in surgical management, and there is a lack of ultrasound studies aiming at correlating prenatal diagnosis PAS disorders with surgical prognosis.

Objective To evaluate the outcome of three different modes of management of abnormally invasive placenta over a 6-year period. Design Retrospective cohort study. Setting Tertiary hospital in Hong Kong. Population In 39 757 deliveries, 25 cases of abnormally invasive placenta were identified at cesarean section. Methods Identification of cases by hospital database and review of medical records. Main outcome measures Blood loss, blood transfusion requirement, operative time, duration of hospital stay, secondary postpartum hemorrhage and endometritis. Results Six women were managed by leaving the placenta in situ and by postoperative uterine artery embolization. Ten women were managed by an extirpative approach and nine women with direct cesarean hysterectomy. The success rate of nonremoval of the placenta with uterine artery embolization was 4/6 (67%). The intraoperative blood loss, blood transfusion requirements and operation times were lowest in the group with nonremoval of the placenta, although a higher secondary complication rate and a longer hospital stay followed. Conclusion Nonremoval of an abnormally invasive placenta at cesarean section and prophylactic postoperative uterine artery embolization are an alternative to elective cesarean hysterectomy. [ABSTRACT FROM AUTHOR]

Cesarean hysterectomy is considered the reference standard treatment for placenta accreta. In young women who want the option of future pregnancy and agree to close follow-up monitoring, conservative treatment is a valid option. Several key points of both cesarean hysterectomy and conservative treatment remain debatable, such as timing of delivery, attempted removal of the placenta, use of temporal internal iliac occlusion balloon catheters, ureteral stents, prophylactic embolization, and methotrexate. In cases of placenta percreta with bladder involvement, conservative treatment may be the optimal management. Regardless of the chosen option, the woman and her partner should be warned of the high risk of maternal complications related to an abnormally invasive placenta. [ABSTRACT FROM AUTHOR]

Objective To examine maternal morbidity in primary surgical management of placenta accreta. Design Retrospective case series. Setting Quaternary perinatal referral center in Melbourne, Australia. Population Clinically suspected and histologically confirmed cases of placenta accreta, increta and percreta. Methods Women were identified from our hospital database coded for placenta accreta, increta, percreta and peripartum hysterectomy. Relevant details were sought from medical records. Main outcome measures Predefined maternal morbidities: blood loss, transfusion requirements, surgical complications, reoperation rate, duration in hospital. Predefined neonatal outcomes: gestational age at birth, birth-weight, admission to intensive ( NICU) or special care nurseries ( SCN), respiratory distress syndrome. Results Between 1999 and 2009, 33 women were diagnosised with invasive placentation. A total of 27 were confirmed histologically after hysterectomy: 12 accreta, one increta, and 14 percreta. Median blood loss was 2 L. There was a 1.8-L reduction in mean blood loss with elective vs. emergency hysterectomy ( p = 0.04). Nearly two-thirds of women required four or more units of packed red-blood-cells. Half of the women suffered from surgical complications, mostly from bladder injury. The risk of returning to theater for further surgery was 20%. Women with placenta percreta were more likely to require additional blood products ( p = 0.03), sustain renal tract injury ( p = 0.003) and require intensive care admission ( p = 0.002). Conclusions A primary surgical approach to management of placenta accreta is associated with significant maternal morbidity, even when managed in a dedicated quaternary perinatal referral center. [ABSTRACT FROM AUTHOR]

For cesarean hysterectomy with placenta previa accreta, 'universally achievable' measures are required. We propose eight measures: (i) placement of intra-iliac arterial occlusion balloon catheters; (ii) placement of ureter stents; (iii) 'holding the cervix' to identify the site to be transected; (iv) uterine fundal incision; (v) avoidance of uterotonics; (vi) 'M cross double ligation' for ligating the ovarian ligament; (vii) 'filling the bladder' to identify the bladder separation site and 'opening the bladder' for placenta previa accreta with bladder invasion; and (viii) to continue to clamp the medial side of the parametrium or the cervix or employment of the 'double edge pick-up' to ligate it. These eight measures are simple, easy, effective, and thus 'universally achievable'. [ABSTRACT FROM AUTHOR]

Background No population-based study has assessed the prevalence of placenta accreta, the predictive value of prenatal diagnostic examinations, the maternal morbidity associated with its management, or its psychological effects. Moreover, the technical resources necessary for the safest delivery of women at risk have not been clearly identified. Objectives The primary objectives are to identify individual risk factors, as well as factors associated with types of management and with the healthcare facilities for postpartum hemorrhage. Secondary objectives are to (i) determine the prevalence of placenta accreta among women at risk; (ii) assess the predictive value of ultrasound and MRI for the diagnosis of placenta accreta in this population; (iii) evaluate psychological impact and physical complications; and (iv) report maternal physical complications during the year after delivery. Design Population-based prospective observational study of pregnant women with a placenta inserted at a uterine scar. Setting A total of 182 centers in eight French regions, with 270 000 deliveries annually. Methods We expect to include 620 women at risk of placenta accreta in two years, of whom approximately 120 (20%) will have placenta accreta. Main outcome measures The primary outcome measure is severe maternal hemorrhage; secondary outcome measures are maternal morbidity and deaths, predictive value of ultrasound and MRI, and psychological evaluations at 6 and 12 months. Conclusion This study will be the first prospective population-based study to include women at risk of placenta accreta and to investigate incidence, prenatal detection, type of management, morbidity and maternal psychological consequences. [ABSTRACT FROM AUTHOR]

Objective. To analyze the effectiveness of intravenous sulprostone infusion for the treatment of retained placenta without massive primary hemorrhage among women at an university hospital over a three-year period. Design. Retrospective observational study. Setting. University teaching hospital. Population. 126 consecutive women with placental retention and intravenous sulprostone infusion as primary treatment performed from October 2007 up to December 2011. Methods. Hospital records of women who received sulprostone infusion to attempt placental expulsion were reviewed. Main outcome measures. Primary endpoints of the study were expulsion of placenta and the total amount of blood loss during delivery. Results. The placenta was successfully expelled in 39.7% of cases, whereas 60.3% of women underwent manual removal of placenta. Blood loss was significantly lower in women with successful placental expulsion than in women who had manual removal of the placenta (582 ± 431 ml vs. 1275 ± 721 ml, p < 0.0001). Sulprostone infusion did not cause adverse effects or significant postpartum morbidity. Conclusions. Intravenous sulprostone infusion is safe and reduces both blood loss and the need for manual removal of the placenta. [ABSTRACT FROM AUTHOR]

Objective. To investigate apoptosis, proliferation and Fas ligand expression of placental trophoblast in the hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome and in pre-eclampsia (PE), and to compare this with normal pregnancies. Design. Prospective study. Setting. University hospital in Croatia. Sample. Placentae from women with HELLP syndrome ( n=10), PE ( n=10) and normal pregnancies ( n=10). Methods. The HELLP syndrome was diagnosed with platelets <100×109/L, aspartate aminotransferase (AST) and alanine transaminase (ALT) >70U/L and lactic acid dehydrogenase (LDH) > 600U/L. Pre-eclampsia was diagnosed at blood pressure >140/90mmHg, with proteinuria >300mg/L/24hours. For detection of apoptosis and proliferation in villous trophoblast, antibodies M30 and Ki-67 were used. Expression of Fas ligand was assessed using immunohistochemistry and the semiquantitative HSCORE method. Main Outcome Measures. Apoptosis, proliferation and Fas ligand expression in villous trophoblast. Results. Apoptosis, proliferation and Fas ligand expression were higher in villous trophoblast in HELLP syndrome than in the PE group ( p=0.015, p=0.018 and p=0.002, respectively) and the control group ( p=0.000, p=0.012 and p=0.049, respectively). Placentae from the PE group had higher levels of apoptosis ( p=0.019), lower Fas ligand expression ( p=0.029) and no difference in proliferation ( p=0.887) compared with the control group. Conclusions. There is an increase in apoptosis, proliferation and Fas ligand expression in placentae from women with HELLP syndrome compared with placentae from PE and normal pregnancies. Our findings indicate the possibility of differential mechanisms behind HELLP syndrome and PE. [ABSTRACT FROM AUTHOR]

Objective: Placenta accreta is one of the most devastating pregnancy complications. We sought to compare outcomes between women with placenta accreta when diagnosed antenatally or intrapartum, and to define predictors of the antenatal diagnosis. Design: Retrospective case-control study. Setting: University teaching hospital. Population: Twenty-four women with placenta accreta diagnosed antenatally and 20 women discovered intrapartum. Methods: Chart review of historical and delivery-associated variables. Rates were compared between the groups. Main Outcome Measures: Placenta accreta diagnosed antenatally or intrapartum. Results: Women with antenatal diagnosis had a lower estimated blood loss of a median of 4500ml (range 100-15000ml) compared with 7800ml (range 2500-17000ml, p=0.012) and required fewer units of packed red blood cells transfused (median 7; range 0-27 compared with 13.5; range 4-31, p=0.026). Nineteen (79%) women diagnosed antenatally had balloon catheter occlusion carried out during the cesarean section. Five (21%) had the entire placenta left in situ. There was no difference in the rate of surgical complications or duration of hospitalization. The clinical diagnosis among women with antenatal diagnosis was more often placenta percreta (p=0.013). The risk factor profile of women with antenatal diagnosis of placenta accreta included higher gravidity (p=0.014) and parity (p<0.0001), history of cesarean section (p=0.004), and placenta previa in the current pregnancy (p<0.001). Conclusions: Antenatal diagnosis of placenta accreta may reduce peripartum blood loss and the need for blood transfusion. Women with antenatal diagnosis more often have placenta previa and history of previous cesarean section, and the clinical diagnosis is more often placenta percreta. [ABSTRACT FROM AUTHOR]

Objective. To assess whether premature rupture of membranes (PROM) is associated with placental abruption. Design. Population-based study. Setting. Data were extracted from the Medical Birth Registry of Norway. Population. All women with PROM (18 889 cases), including 3 077 cases of preterm premature rupture of membranes (p-PROM), among a total of 355 416 singleton births in Norway during 1999-2005 with gestational age 17-44weeks. Methods. Logistic regression was used to assess whether placental abruption was associated with PROM in preterm and term births. Main Outcome Measures. Placental abruption. Results. The occurrence of placental abruption in p-PROM was higher than in the total study population, 11.0 per 1 000 (34 of 3 077) vs. 4.2 per 1 000 (1 495 of 355 416; adjusted odds ratio 2.6, 95% confidence interval 1.8-3.7). Restricting the analyses to preterm births, the occurrence of placental abruption was less in p-PROM (11.0 per 1 000) than in births without p-PROM (36.1 per 1 000; adjusted odds ratio 0.3, 95% confidence interval 0.2-0.4). In term births, no statistically significant association was observed. Conclusions. The findings suggest that in p-PROM the risk of placental abruption is not higher than in other preterm births; rather the opposite. However, comparing the risks in p-PROM and the total gestational age range, the present study confirmed results reported in previous studies of a higher risk of placental abruption in p-PROM than in the total birth population. [ABSTRACT FROM AUTHOR]

A retrospective audit identified 10 cases of massive idiopathic subchorionic thrombohematoma. The incidence was 1:3,133. Only six of these pregnancies resulted in a livebirth and only two reached term. In eight cases there were ultrasound abnormalities, including two cases of placentomegaly both of which resulted in a pregnancy loss. There was one placental abruption. Seven of the women were nulliparous. Massive subchorionic thrombohematoma is associated with poor pregnancy outcome. Ultrasound findings of placentomegaly might be a bad prognostic sign. [ABSTRACT FROM AUTHOR]

Background. To study the risk factors of placental abruption during the index pregnancy. Methods. One hundred and ninety-eight women with placental abruption and 396 control women were identified among 46,742 women who delivered at a tertiary referral university hospital between 1997 and 2001. Clinical variables were compared between the groups. Multivariate logistic regression analysis was applied to identify independent risk factors. The clinical manifestations of placental abruption were also studied. Results. The overall incidence of placental abruption was 0.42%. The independent risk factors were maternal (adjusted OR 1.8; 95% CI 1.1, 2.9) and paternal smoking (2.2; 1.3, 3.6), use of alcohol (2.2; 1.1, 4.4), placenta previa (5.7; 1.4, 23.1), pre-eclampsia (2.7; 1.3, 5.6), and chorioamnionitis (3.3; 1.0, 10.0). Vaginal bleeding (70%), abdominal pain (51%), bloody amniotic fluid (50%), and fetal heart rate abnormalities (69%) were the most common manifestations. Neither bleeding nor pain was present in 19% of the cases. Overall, 59% had preterm labor (OR 12.9; 95% CI 8.3, 19.8), and 91% were delivered by cesarean section (34.7; 20.0, 60.1). Of the newborns, 25% were growth restricted. The perinatal mortality rate was 9.2% (OR 10.1; 95% CI 3.4, 30.1). Retroplacental blood clot was seen by ultrasound in 15% of the cases. Conclusions. Maternal alcohol consumption and smoking, and smoking by the partner turned out to be independent risk factors for placental abruption. Smoking by both partners multiplied the risk. The liberal use of ultrasound examination contributed little to the management of women with placental abruption. [ABSTRACT FROM AUTHOR]

Background. To establish the usefulness of placental magnetic resonance in patients with a diagnosis of placenta accreta through the correlation of diagnostic images and surgical findings. Methods. Three hundred patients with ultrasound signs of placenta accreta were studied. In 252 patients, magnetic resonance imaging (MRI) was performed in a closed 1.5 T-resonator, and in 48 patients, open 0.23 T-set was used. T1 and T2 slices in the three planes were performed, and placental invasion was classified in depth levels and topographic areas in relation to the posterior vesical wall. The final degree of invasion was established during surgery according to clinical and anatomical criteria. The information obtained with MRI was analyzed, thus establishing its relevance to the change in surgical technique. Results. In 286 cases, MRI provided topographic information of placental invasion, and in 90 patients, it modified invasion levels. Undiagnosed parametrium extent was determined in ii cases, and 11 other cases were reclassified as placenta previa. Changes in conduct following MRI study included: recommendation to modify surgery date at week 35, recommendation for prophylactic ureteral catheterization, recommendation for the use of intraoperative blood salvage, possibility of approach through Pfannenstiel incision, probability of segmental myometrial approach, probability of aortic clamping, need to investigate subclinical disseminated intravascular coagulation, need of posterior pelvic dissection, and the possibility of uterine conservation. Conclusions. Magnetic resonance imaging turned out to be essential to define the topography and area of placental invasion. New findings modified surgical tactic and technique, allowing a reduction in historical morbidity and a significant increase in conservative surgeries. [ABSTRACT FROM AUTHOR]

. [ABSTRACT FROM AUTHOR]

Background: To study the risk of placenta complications following an induced abortion as a function of the interpregnancy interval.Methods: This study is based on three Danish national registries; the Medical Birth Registry, the Hospital Discharge Registry, and the Induced Abortion Registry. All primigravida women from 1980 to 1982 were identified in these three registries. A total of 15,727 women who terminated the pregnancy with a first trimester induced abortion were selected to the abortion cohort, and 46,026 women who did not terminate the pregnancy with an induced abortion constituted the control cohort. By register linkage all subsequent pregnancies were identified from 1980 to 1994. Only women who had a non-terminated pregnancy following the index pregnancy were selected to the study. Placenta complications were identified using either the Hospital Discharge Registry ICD-8 codes or the Medical Birth Registry records.Results: A slightly higher risk of placenta complications following an abortion was found. Retained placenta occurred more frequently in women with one, two or more previous abortions, compared with women without any previous abortion of similar gravidity. Adjusting for maternal age and residence at time of pregnancy, the interpregnancy interval, and the number of previous miscarriages (control cohort only), the odds ratios of retained placenta in deliveries of singleton live births in women with one previous abortion was 1.17 (95%CI=1.02-1.35), and for women with two or more previous abortions it was 1.68 (95%CI=1.23-2.30), respectively, compared with the control cohort of similar gravidity. Only for women who had one abortion did the results follow the predicted pattern of a higher risk of retained placenta after a short pregnancy interval. No association with placenta previa was seen.Conclusions: The findings suggest a positive association between abortions and retained placenta in subsequent singleton live births, but the association was weak and confounding cannot be ruled out. [ABSTRACT FROM AUTHOR]

Objective. To assess the risk of small for gestational age (SGA), preterm birth, pregnancy induced hypertension (PIH), and perinatal death in the pregnancy immediate subsequent to a placental abruption (PA) in the same mother. Design. A cohort study based on the Medical Birth Registry of Norway. Results. Odds ratios of SGA in subsequent PA- and non-PA deliveries were 2.8 (absolute risk = 18.5%) and 2.0 (13.9%), respectively, compared with non-PA deliveries without a history of previous PA among siblings (7.5%) after exclusion of cases with SGA in the immediate previous birth. After exclusion of cases with spontaneous preterm birth in the immediate previous delivery, odds ratios of spontaneous preterm birth in subsequent PA- and non-PA deliveries were 17.0 (36.3%) and 2.1 (6.6%), compared with non-PA deliveries without a history of previous PA among siblings (3.2%). After exclusion of cases with PIH in the immediate previous pregnancy, odds ratios of PIH in subsequent PA- and non-PA pregnancies were 2.9 (6.3%) and 1.6 (3.4%), compared with non-PA deliveries without a history of previous PA among siblings (2.3%). After adjustment for demographic variables and obstetrical complications, the increased risks persisted. Conclusion. A pregnancy following a PA must be considered a high risk pregnancy, not only in terms of excess risk of recurrence, but also due to excess risk of SGA, preterm birth, and PIH irrespective of recurrence of PA. Consequently, all pregnancies following a pregnancy with PA should be offered close antenatal surveillance and care. [ABSTRACT FROM AUTHOR]

Sir, I read with interest the article by Granfors et al1 regarding placental location and risk of retained placenta after previous cesarean delivery. Except for the standard transverse incision in the lower segment, there are situations when the surgeon is forced to do a corporeal incision, inverted-T incision or even a fundal incision, especially in the earlier weeks of gestation. Adherent placenta is to be expected in cases of submucosal fibroids during pregnancy.4 Rates of retained placenta appear to be increasing with the age of women in the study by Granfors et al, although not significantly.1 We wonder why were these factors not taken into consideration in their data analysis?. [Extracted from the article]

We determined the effect of cord blood collection before placental expulsion on postpartum maternal blood loss in a retrospective study between a group of cord blood donors and a group of non-donors. The study was conducted in a university hospital blood bank and obstetric services and included Spanish women entered in a European study project (EUPHRATES) and who had consented to donate cord blood for public banking purposes. We measured blood volume lost during delivery by a bag collection method, as well as the need for transfusion and postpartum anemia symptoms. Deliveries at which cord blood was collected presented a significant increase in blood loss (321±273 vs. 255±237ml, p=0.02). Instrumental deliveries were associated with higher postpartum blood loss than spontaneous deliveries. Cord blood collection can increase intrapartum blood loss, especially at instrumental deliveries. Additional staff who handle the collection are required to allow the leading clinician to focus on maternal care. [ABSTRACT FROM AUTHOR]

The article presents a case report of placenta accreta without previa diagnosed before delivery succeeded in preservation of the uterus by uterine artery embolization (UAE). The case involves a 34-year-old woman was referred to a hospital at 26 weeks of gestation because of intrauterine growth restriction (IUGR) with placental abnormality. It shows how placenta accreta carries an increased risk of maternal morbidity and mortality.

Presents a case of placenta accreta diagnosed during a cesarean section and treated successfully with methotrexate (MTX) as adjuvant therapy with preservation of the uterus. Action taken to prevent a serious infection with the considerable amount of placenta tissue left in the uterus; Discussion on MTX; Reason for initiating MTX treatment.

Examines the case of a patient who was a healthy 37-year-old gravida 4, para 3, spontaneously pregnant with diamniotic, dichorionic twins, with 2 previous vaginal, uncomplicated deliveries. Result of the macroscopic examination of the placenta; Discussion on chorioangioma; How symptomatic chorioangiomas can be treated.