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Placenta accreta spectrum disorder varies from minimally adherent placenta to deeply invasive placenta. Placenta percreta is a rare cause for uterine rupture and the incidence of morbidly adherent placenta is on the rise due to increase in the rates of caesarean section. We report a case of a 32-year-old, G2P1L1 who presented to us at 27 weeks in a state of haemodynamic shock with intrauterine fetal death. She had a history of prior caesarean section complicated by postpartum haemorrhage requiring B-Lynch suturing. With an initial diagnosis of caesarean scar rupture, she underwent an emergency laparotomy. Intraoperatively, the caesarean scar was found to be intact and uterine fundal rupture with placental protrusion identified. She underwent caesarean hysterectomy and was discharged in a stable condition. The histopathology report confirmed the diagnosis of placenta percreta.

Uterine scar dehiscence with underlying placenta is often misdiagnosed as placenta accreta spectrum both prenatally and intraoperatively due to the absence of myometrial tissue in the area. Misdiagnosis generates obstetric anxiety and results in overtreatment which carries a risk of iatrogenic injury. We present a case of the antenatal diagnosis of uterine dehiscence in a 36-year-old woman with a history of two caesarean deliveries and a low-lying placenta. We further describe the sonographic features useful for differentiating this condition from placenta accreta spectrum in instances where the placenta lies under an area of full thickness uterine scar dehiscence.

Placenta accreta spectrum (PAS) disorders is the abnormal invasion of the placenta to the myometrium.[1][1] One of the risk factors of PAS is a previous caesarean section.[2][2] Only few studies described caesarean hysterectomy in patients with PAS with images. We report a case of a caesarean

Aim: To determine the diagnostic accuracy and epidemiology of placenta accreta spectrum (PAS) in patients of placenta previa. Design: Systematic review. Methods: PubMed, Google Scholar, ClinicalTrials.gov and MEDLINE were searched between January1992 and December 2020. Studies on placenta previa complicated by PAS diagnosed in a defined obstetric population. This research was carried out using standard methods and protocols and keeping in view Newcastle-Ottawa scale for observation and assessment of case study along with the difference approved by consensus. The overall diagnostic accuracy of ultrasonographic findings is the main outcome of this study, whereas the prevalence of placenta accreta in patients of placenta previa and its incidence among different countries all over the world is also described. Results: In this review study, about 300 articles were evaluated. More over about 15 prospective and 14 retrospective case studies incorporated for assessment having complication with placenta previa and PAS. According to the meta-analysis, a significant (p

Placenta Accreta Spectrum (PAS) disorders have become a major iatrogenic obstetric complication worldwide. Data on the accuracy of ultrasound examination diagnosis are limited by incomplete confirmation and variability in the description of the different grades of PAS at delivery. The aim of this study was to compare our prenatal routine sonographic screening and diagnostic scoring system with a standardized clinical grading system at birth in patient at risk of PAS.This is a retrospective cohort study of 607 pregnant patients with at least one prior cesarean delivery between December 2013 and December 2018. All patients were assessed for PAS using our institutional prenatal sonographic scoring system and the corresponding ultrasound findings were compared with those of a standardized clinical intra-operative macroscopic grading system of the degree of accreta placentation at vaginal birth or laparotomy.PAS was diagnosed clinically at birth in 50 (8.2%) cases, 17 of which were confirmed by histopathology. A low (score ≤ 5), medium (score 6-7), high (score ≥ 8) probability for PAS was reported in 502, 61 and 44 cases, respectively. The probability score increased significantly (Both ends of the spectrum of accreta placentation remain difficult to diagnose antenatal and clinically at birth, in particular when no histopathologic confirmation is available. There is a need to develop ultrasound accuracy score systems that can differentiate between the different grades of PAS and which are validated by standardized clinical and pathology protocols.

OBJECTIVE To examine the association between hospital surgical volume of caesarean hysterectomy and surgical morbidity in women with placenta accreta spectrum (PAS). DESIGN Population-based retrospective cohort study. SETTING National Inpatient Sample, January 2016 to December 2018. POPULATION Six thousand and ten women with PAS who underwent caesarean hysterectomy in 738 centres. METHODS (1) Comprehensive modelling for relative hospital surgical volume cut-point selection, (2) multinomial regression analysis for characterising hospital surgical volume, and (3) binary logistic regression analysis to examine the volume-outcome relationship. MAIN OUTCOME MEASURES Surgical morbidity (haemorrhage, coagulopathy, shock, urinary tract injury, and death). RESULTS The majority of centres had five surgeries over the 3-year period (468 centres, 63.4%) and were grouped as the low-volume group. Surgical morbidity decreased after a relative hospital surgical volume of 25 cases (24 centres, 3.3%) was reached, grouped as the high-volume group. The remaining centres were grouped as the mid-volume group (246 centres, 33.3%). In multivariable analysis, women in the high-volume group were more likely to be Black, have lower median household income, medical comorbidity, previous caesarean delivery, placenta praevia or placenta percreta, and to have undergone surgeries at large urban teaching hospitals compared with those in the low-volume group (all, P

Objective The training of groups responsible for managing patients with placenta accreta spectrum (PAS) is complex because of the lack of hospitals with a high flow of patients and absence of formal educational programs. We report the results of a virtual training program (VTP) that implement one-step conservative surgery (OSCS). Methods A prospective observation study of OSCS VTP between three expert groups and PAS reference hospitals without experience in OSCS was performed. Accessible or cost-efficient web meeting platforms were used to implement the VTP components: baseline observation of the participant's prior knowledge; instructions about essential PAS surgery topics; base selection and joint planning of surgery; expert group "telepresence" during surgery and postoperative debriefing. Results OSCS was performed successfully at 6 hospitals. All patients had increta/percreta with a median intraoperative bleeding of 1300 mL (IQR 825-2325) and surgical time of 184 minutes (IQR 113-240). All groups considered the VTP very useful (n=33, 97%) or useful (n=1, 3%), they would use it again (definitely: n=27, 81.8%; or probably: n=6, 18.2%), and they would recommend it to other colleagues. Conclusion Tele education and telepresence during PAS surgery facilitates the implementation of OSCS in selected cases.

Pregnancies complicated by the placenta praevia are associated with an increased risk of massive obstetric bleeding and high rates of hysterectomy which are often caused by the placenta accreta.This was a cohort study carried out between 2014 and 2020 in 532 women with abnormal placental localization and attachment. The placental attachment spectrum (PAS) disorder diagnosis was confirmed during the surgery and by the histology results in 164/532 participants. Depending on the surgical approach during the Cesarean delivery, patients were divided into three groups. In Group 1 (PAS was observed in 30.8% of the placenta praevia cases, and in 93.3% was associated with the presence of a uterine scar. Women with the placenta praevia and PAS had a significantly higher number of past deliveries (

Objective Prior cesarean delivery is a well-known risk factor for placenta accreta spectrum disorders. While primary cesarean section is unavoidable in some patients, in others it may not be clearly indicated. The aim of the study is to determine the proportion of patients with placenta accreta spectrum who had a potentially preventable primary cesarean section and to identify factors associated with preventable placenta accreta spectrum. Study Design This was a single-center retrospective cohort study of women with pathology-confirmed placenta accreta spectrum from 2007 to 2019. Primary cesarean sections were categorized as potentially preventable or unpreventable based on practice consistent with the American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine “Safe Prevention of the Primary Cesarean Delivery” recommendations. Fisher's exact test and Mann-Whitney U-test were used for comparison with p Results Seventy-two patients had pathology-confirmed placenta accreta spectrum over the course of the study period, 15 (20.8%) of whom required a cesarean hysterectomy at the time of primary cesarean section. Fifty-seven patients had placenta accreta spectrum in a pregnancy following their primary cesarean section. Of these, 29 (50.9%) were considered potentially preventable. Most were performed without clear medical indication (37.9%) or for fetal malpresentation without attempted external cephalic version (37.9%). The remainder were due to arrest of labor not meeting criteria (17.2%) and abnormal or indeterminate fetal heart patterns with documented recovery (6.9%). Of the 11 patients without clear medical indication for primary cesarean section, eight (72.7%) were patient-choice cesarean sections and three (27.3%) were for suspected fetal macrosomia with estimated fetal weights not meeting criteria for cesarean delivery. There was no difference in the incidence of potentially preventable primary cesarean sections before and after the ACOG-SMFM “Safe Prevention of the Primary Cesarean Delivery” publication (48.8 vs. 57.1%, p = 0.59). Privately insured patients were more likely to have a potentially preventable primary cesarean section than those with Medicaid (62.5 vs. 23.5%, p = 0.008) and were more likely to have a primary cesarean section without clear medical indication (81.8 vs. 18.2%, p = 0.004). Conclusion Many patients with placenta accreta spectrum had a potentially preventable primary cesarean section. Most were performed without clear medical indication or for malpresentation without attempted external cephalic version, suggesting that at least a subset of placenta accreta spectrum cases may be preventable. This was particularly true for privately insured patients. These findings call for continued investigation of potentially preventable primary cesarean sections with initiatives to address concerns at the patient, provider, and hospital level. Key Points

Objective To validate the use of placenta accreta risk-antepartum (PAR-A) score as a predictive tool of clinical outcomes of placenta accreta spectrum (PAS). Methods This is a prospective study, conducted in six PAS specialized centers in six different countries. The study was conducted between October 1, 2020 and March 31, 2021. Women who were provisionally diagnosed with PAS during pregnancy were considered eligible. A machine-learning-based PAR-A score was calculated. Diagnostic performance of the PAR-A score was evaluated using a receiver operating characteristic curve, for perioperative massive blood loss and admission to intensive care unit (ClinicalTrials.gov identifier NCT04525001). Results Of 97 eligible women, 86 were included. PAS-associated massive blood loss occurred in 10 patients (11.63%). Median PAR-A scores of massive blood loss in the current cohort were 8.9 (interquartile range 6.9-14.1). In predicting massive blood loss, the area under the curve of PAR-A scores was 0.85 (95% confidence interval [CI] 0.74-0.95), which was not significantly different from the original cohort (P = 0.2). PAR-A score prediction of intensive care unit admission was slightly higher compared with the original cohort (0.88, 95% CI 0.81-0.95; P = 0.06). Conclusion PAR-A score is a novel scoring system of PAS outcomes, which showed external validity based on current data.

To describe the performance of ultrasound in detecting placenta accreta spectrum (PAS) in patients with history of prior myomectomy.A retrospective cohort study of patients who were referred for so...

Aims To evaluate the estimated fetal radiation dose during prophylactic internal iliac arterial occlusion in patients with abnormal placenta and to estimate the risk of radiation induced cancer in child age. Methods Prophylactic occlusion of the internal iliac arteries during Caesarean section was performed in 42 patients with placenta praevia and/or placenta accreta spectrum. Fogarty embolectomy catheters were used for prophylactic occlusion of the internal iliac arteries. All procedures were performed in the hybrid operating room using Philips Allura Xper FD 20 X-ray system. Low dose X-ray fluoroscopy (7.5 frames per second) was used. The CODE (Conceptus dose estimation) Software was used to estimate the fetal dose and the risk of radiation induced carcinoma. Results Fluoroscopy times required for insertion of Fogarty catheters were 0.5-4.2 min (mean: 1.7 min, median: 1.5 min). The estimated radiation dose to the fetus was 0.26-3.36 mGy (mean: 1.49 mGy, median: 1.25 mGy). The risk of radiation induced cancer in child age was 0.01-0.04% (mean 0.02%, median 0.01%). One patient developed thrombosis of a common femoral artery. Conclusion Prophylactic occlusion of the internal iliac arteries is a simple and safe procedure with minimal risk of complications and with a very low estimated radiation dose to the fetus.

A 35-year-old woman G5P2 was referred to the gynecologic oncology service for evaluation and management of a large cornual mass on MRI. She was otherwise healthy with no previous surgery or comorbidities. She had two uncomplicated vaginal deliveries and two previous miscarriages. Four months prior

Objective In order to create a comprehensive scoring system based on maternal characteristics and ultrasonographic features for predicting placenta accreta spectrum (PAS). Materials and methods This was a retrospective review of pregnant women who underwent routine ultrasound examination in the third trimester of pregnancy from January 2014 to November 2018 were used as a training set to establish the scoring system for PAS prediction while those who underwent examination from January 2019 to December 2019 served as a validation set.. Maternal characteristics including maternal age, parity, previous vaginal deliveries, previous curettage, previous cesarean section (CS), history of hypertension and diabetes mellitus, prenatal body mass index (BMI) were recorded. Ultrasonographic features including abnormal placental lacunae, subplacental hypervascularity, myometrial thinning, placental bulge, bladder wall interruption, location of placenta, placenta previa (yes or not) were recorded. Multivariate analysis was applied to analyze independent risk factors and assess the predictive power of selected parameters predicting PAS. Receiver operating characteristics (ROC) curve was used to evaluate the diagnosis power. Results Parity, previous curettage and CS were independent risk factors. The best comprehensive scoring system was established as follow: the number of abnormal lacunae ≥3, 2 points; lacuna maximum dimension ≥2 cm, 5 points; subplacental hypervascularity (rich), 1 point; subplacental hypervascularity (extremely rich and disordered), 3 points; bladder wall interruption, 9 points; placental bulge, 9 points; placenta previa, 8 points; anterior placenta, 1 point; previous CS ≥ 1, 1 point; parity ≥ 4, 3 point; previous abortions ≥ 2, 1 point. The area under the ROC curve of the scoring system diagnosing PAS was 0.925. Sensitivity and specificity were 83.3% and 85.7%, respectively. Cross-validation for our model showed that sensitivity, specificity, positive predictive value and negative predictive value of the model in diagnosis of PAS were 82.6%, 81.8%, 82.6% and 81.8%, respectively. Diagnosis of 37 cases were consistent with the “gold standard”, and the coincidence rate was 82.2% (37/45). Conclusion The comprehensive scoring system established in this study can effectively diagnose PAS.

The National Specialty Commission in Obstetric Emergency and the National Specialty Commission on Ultrasonography in Gynecology of the Brazilian Federation of Gynecology and Obstetrics Associations (FEBRASGO) endorses to this document. The content production is based on scientific studies on a thematic proposal and the findings presented contribute to clinical practice.

Placenta accreta spectrum (PAS) refers to the range of pathologic adherence of the placenta to the uterine myometrium, including the placenta accreta, increta, and percreta. The incidence of PAS is rising primarily because of an increase in related risk factors, such as the rate of cesarean deliveries and pregnancies resulting from assisted reproductive technology. The maternal risks associated with PAS are significant, including hemorrhage, hysterectomy, and death. Fetal and neonatal risks are primarily the result of premature delivery. Antenatal diagnosis via ultrasonography and magnetic resonance imaging remains imperfect. Management of PAS varies, however, and there is a clear improvement in maternal outcomes with an antenatal diagnosis compared with unexpected diagnosis at the time of delivery. Studies that evaluate the balance between maternal and fetal/neonatal risks of expectant management versus preterm delivery have found that planned delivery between 34 and 35 weeks’ gestation optimizes outcomes. Multidisciplinary PAS care teams have become the norm and recommended approach to management, given the complexity of caring for this obstetrical condition. Although significant advances have been made over the years, large knowledge gaps remain in understanding the pathophysiology, diagnosis, and clinical management.

Placenta accreta spectrum (PAS) refers to the spectrum of diagnoses involving abnormally and morbidly adherent trophoblastic tissue to the gravid uterus. These disorders are associated with significant maternal morbidity and mortality. While race/ethnicity is known to impact pregnancy outcomes, racial disparities have not been previously examined in women with PAS. The objective of current study was to compare patient characteristics and perioperative outcomes of women with PAS who underwent cesarean delivery across race/ethnicity. This is a comparative study that retrospectively queried the National Inpatient Sample, a hospital-based inpatient database in the USA. The study cohort was women diagnosed with PAS who underwent cesarean delivery from 10/2015 to 12/2018. The exposure group was race/ethnicity. Main outcomes were (i) patient/pregnancy characteristics and (ii) surgical morbidity for cesarean delivery, assessed in multivariable analysis. A total of 10,535 women comprised the study cohort (White n = 5,230 [49.6%], Black n = 2,045 [19.4%], Hispanic n = 2,540 [24.1%], and Asian n = 720 [6.8%]). Patient demographics, pregnancy characteristics, and hospital factors for the non-White groups significantly differed compared to the White group. Older age, obesity, diabetes, placenta previa, percreta, non-elective surgery, lower median household income, and Medicaid particularly represented the non-White groups. When perioperative outcomes were compared, non-White women were more likely to have any measured complications, hemorrhage/transfusion, and shock/coagulopathy compared to White women. Various sensitivity analyses redemonstrated the main cohort results. In conclusion, this study suggests that there were significant disparities in patient characteristics and outcomes of women with PAS across race/ethnicity.

Objective While evidence-based guidelines exist for placenta accreta spectrum (PAS) diagnosis and management, there is a paucity of data on PAS practice patterns worldwide. The objective of this study was to describe global geographic variations in the diagnosis and management of PAS. Methods An international cross-sectional study was conducted among PAS experts practicing at medical institutions in member states of the United Nations. Survey questions focused on diagnostic evaluation and management strategies for PAS. Results A total of 136 centers participated. Participating centers represented each of the United Nations' designated regions. Of those, 88% reported practicing in a medium or high volume center. First trimester PAS screen was reported in 26.1% of centers. Respondents consistently implement guideline-supported care practices, including utilization of ultrasound as the primary diagnostic modality (100%) and implementation of multidisciplinary care teams (85.8%). Less than 10% of respondents reported routinely managing PAS without hysterectomy; these centers were predominantly located in Europe and Africa. Antepartum management and availability of mental health support for PAS patients varied widely. Conclusion Worldwide, there is a strong adherence to PAS care guidelines; however, regional variations do exist. Comparing variations in care to outcomes will provide insight into the clinically significant practice variability.

The consequence of each cesarean section is the uterine scar formation. In some patients, uterine scar after cesarean section heals incompletely and as a result, the uterine niche is formed. Most of the small niches are asymptomatic, but the large cesarean scar niches in nonpregnant women may cause a cesarean scar syndrome, which manifest itself as abnormal uterine bleeding, dysmenorrhea and secondary infertility. Among pregnant women, the presence of large niches may be associated with potentially life-threatening consequences, such as cesarean scar dehiscence and uterine rupture, placenta accreta spectrum disorders, placenta previa, cesarean scar pregnancy. Due to the possibility of dangerous consequences related to the occurrence of a uterine niche, in recent years many studies have focused on the term of cesarean scar niche, its risk factors, diagnostic methods and treatment options. Uterine niche can be examined using two- or three-dimensional transvaginal ultrasonography, as well as two- and three-dimensional sonohysterography, hysterosalpingography, hysteroscopy or magnetic resonance imaging. However, neither of the above diagnostic method is considered as the "gold standard". There are no unambiguous guidelines on some aspect concerning the diagnosis of cesarean scar niche. The aim of this study is to analyze and describe the diagnostic methods of cesarean section niche.

Placenta Accreta Spectrum (PAS) represents a series of placental disorders with an estimated incidence of 1:1000. Delivery and subsequent cesarean hysterectomy for PAS is associated with significant maternal morbidity and mortality. Neuraxial anesthesia may be utilized initially with subsequent conversion to general anesthesia after delivery of the fetus as an alternative to initiating with general anesthesia.We performed a case-control study and analyzed 85 cases of pathology-confirmed PAS patients who underwent a cesarean hysterectomy in singleton, non-anomalous, viable pregnancies. All patients were delivered at our institution's established Placenta Accreta Program from 2005 to 2020.Fifty-two (61%) patients underwent general anesthesia and 33 (39%) patients underwent neuraxial anesthesia (collectively spinal, epidural, and combined spinal-epidural) converted to general anesthesia after cesarean delivery. Baseline demographics between groups were similar. Pre-operative ASA airway assessment of III/IV was equivalent between groups (94 and 82%,Taken together, our data show neuraxial conversion to general anesthesia has equivalent intra-operative parameters with improved post-operative outcomes when compared to general anesthesia alone in the case of cesarean hysterectomy for Placenta Accreta Spectrum disorders.

INTRODUCTION This study examined national-level trends, characteristics, and perioperative outcomes of women who had intra-arterial balloon occlusion at cesarean hysterectomy for placenta accreta spectrum (PAS). MATERIAL AND METHODS This was a population-based retrospective observational study that queried the National Inpatient Sample from October 2015 to December 2018. Study population was women who underwent hysterectomy at cesarean delivery for PAS (n = 6440 in 806 centers). Exposure allocation was the use of intra-arterial balloon occlusion. Main outcome measures were (a) characteristics associated with intra-arterial balloon occlusion use, and (b) perioperative outcome including hemorrhage, blood transfusion, coagulopathy, shock, urinary tract injury, intra-arterial balloon occlusion-related complication (arterial injury, arterial thrombosis, and lower extremities ischemia), and death, assessed in multivariable analysis. RESULTS Intra-arterial balloon occlusion was used in 420 (6.5%) women in 64 (7.9%) centers. Utilization of intra-arterial balloon occlusion during cesarean hysterectomy for placenta accreta decreased significantly over time (from 6.3% to 3.1%, p

Placenta accreta spectrum (PAS) encompasses a range of disorders of placental trophoblastic tissue that is morbidly adherent to the underlying gravid uterus. Women with PAS commonly undergo surgical treatment with hysterectomy at cesarean delivery that is associated with significant surgical morbidity and mortality. Increased vascularity due to gestational change and the abnormally enlarged lower uterine segment due to the location of placenta make the surgery complex and morbid. Here, we propose a simple 2-hand technique that can be used to improve surgical outcomes of cesarean hysterectomy for PAS. Unlike the ordinary hysterectomy where the transection of the cardinal ligament is started at the isthmus below the low uterine segment, the proposed 2-hand technique allows transection of the cardinal ligament at the level of the lower uterine segment below the placental bed. This minimizes blood loss that may be associated with serial transection of cardinal ligament which occurs when it is transected at or above the placenta level. This surgical approach starts with demarcation of 3 anatomical landmarks [rectum (posterior aspect), ureters (lateral aspect), and bladder (anterior aspect)] in postero-anterior progression. Complete de-serosalization of posterior low uterine segment allows lateralization of the ureter and enables the uterus to be mobilized antero-caudally where the surgeon’s hand can reach below the placental bed. After the bladder flap creation to the level of endopelvic fascia, the surgeon’s two hands are placed antero-posteriorly at low uterine segment below the placental bed. The fingertips of both hands meet at the cardinal ligament below placenta at the level of the upper cervix. At this point the two hands are gently moved upwards, carrying the placenta-containing low uterine segment. This step enables creation of a safe anatomical distance from surrounding structures and isolation of the cardinal ligament where surgical clamp can be applied to transect the cardinal ligament.

Aplasia cutis congenita (ACC) is a congenital disorder characterized by the absence of epidermis, dermis, and sometimes subcutaneous tissue and bone. There are nine types of ACC based on the number and location of the lesions as well as the presence or absence of associated deformities, with type I ACC being the most common. Type V affects the trunk with a characteristic pattern resembling the “H” letter of the alphabet, generally accompanied by fetus papyraceus (death of one of the twin fetuses) or placental infarction. Type V ACC without fetus papyraceus and placental infarction is a rare case. We reported a case of type V ACC in a 3-day-old baby girl, with clinical manifestation of extensive ulcers on the scalp, back, buttocks, and both lower extremities, in an “H”-shaped pattern, with history of placenta accreta, but no fetus papyraceus or placental infarction was found. The patient received dialkyl carbamoyl chloride hydrophobic swab with hydrogel (Sorbact® gel dressing-BSN Medical) and hydrocolloid wound dressing with good response, as indicated by the wounds becoming dried up, leaving an atrophic scar. Complete epithelialization was achieved in 72 days. The cause of type V ACC remains not completely understood. The diagnosis of ACC can be established based on clinical manifestations. Further examination is required if extracutaneous involvement is suspected. Early identification of the etiology of the lesions and appropriate investigation and treatment, including conservative wound management, are needed so that aplastic lesions can heal successfully, although cosmetic repair may be required at a later stage.

Posterior placenta accreta spectrum (PAS) disorders are infrequent but potentially associated with significant maternal mortality and morbidity, especially if not diagnosed prenatally. Analysis of published literature is problematic since most experiences included only a few cases. Knowledge of the risk factors associated with posterior PAS is crucial to identifying mothers at higher risk and ask for high sensitivity studies. Ultrasound has poor diagnostic accuracy in detecting posterior PAS, while magnetic resonance imaging better delineates the posterior uterine wall. In comparison, prenatal imaging's diagnostic performance in detecting posterior PAS is significantly lower than anterior placenta invasion. Management of posterior PAS depends on several factors, including maternal hemodynamic status, available resources, clinical presentation, and invasion severity. For accreta or increta cases, a compression suture is habitually enough to perform hemostasis. Nevertheless, organ involvement habitually requires a multidisciplinary team with the assistant of a general or coloproctology surgeon. The present article aims to update the risk factors, prenatal diagnosis, and surgical management of pregnancies complicated by posterior PAS.

Placenta accreta spectrum is a complication of pregnancy, which poses a great risk on maternal health. Historically, hysterectomy was the modality of treatment of such condition, but an approach towards a more conservative management has been in the light recently. This includes several methods with varying rates of success and complications. Expectant management is effective in up to 78%–80% of the cases. The extirpative method is associated with a high risk of postpartum hemorrhage. The success of the one-step conservative procedure depends on the degree of placental invasion, and the triple-P procedure appears to be successful but requires and interdisciplinary approach. Adjuvant treatment options can be tailored according to individual cases, and these include methotrexate injection, uterine devascularization and hysteroscopic resection of retained placental tissues. Follow up after conservative management is crucial to detect complications early, and it can be done by ultrasound, Doppler examination, and trending β human chorionic gonadotropin levels. Conservative management of placenta accreta spectrum can preserve future fertility but should only be done in hospitals with enough experience as it carries a high risk of maternal complications. In the future, more research should be directed to achieve clear guidelines regarding this topic.

Background: The worldwide incidence of placenta accreta (PA) is rapidly rising, following the trend of increasing cesarean delivery. Antenatal diagnosis is highly desirable because outcomes are optimized when delivery occurs at a level III or IV maternal care facility before the onset of labor and with avoidance of placental disruption. The primary diagnostic modality for antenatal diagnosis is obstetric color Doppler ultrasonography (CDUS). Magnetic Resonance Imaging (MRI), although widely employed, has yet to clearly demonstrate a significant improvement in management, but it is expensive and requires expertise that is rarely available in most low-income countries and many medium income countries. Objective: To evaluate and compare the accuracy of CDUS and MRI in the diagnosis of PA and to define the most relevant specific features that may predict placental invasion. Patients and methods: A case control study was conducted at AL- Azhar University Hospitals during the interval between November 2017 and November 2020, total set of 50 patients in the third trimester of pregnancy with diagnosis of placenta accreta and at least one previous caesarean section (CS). Patients were equally divided into 2 groups; Group I: Control group diagnosed as PA by CDUS. Group II: Study group diagnosed as placenta accreta by CDUS and subjected to MRI. With inclusion and exclusion criteria, all included women was subjected to; history taking, physical examination, obstetric CDUS and MRI scan was added for Group II only to pick up features suggestive of PA. Results: The sensitivity and specificity of CDUS were 100% and 72%, whereas the sensitivity and specificity of MRI were 76% and 52%, respectively, in their ability to diagnose PA. The highest sensitivity of individual CDUS and MRI markers in predicting PA were obliteration of the retroplacental clear space (63.6%) and focal interruption in the myometrial wall (73.7%), respectively. Conclusion: Ultrasound imaging is the mainstay of screening for placenta accreta. MRI appears to be complementary to ultrasonography, especially when there are few ultrasound signs or if there is a suspicion for invasion into surrounding organs.

BACKGROUND Most maternal deaths related to postpartum hemorrhage are preventable. In most cases, placenta accreta spectrum is the principal cause of severe postpartum hemorrhage; however, there are few studies about maternal deaths, probably because of the legal implications of “problems” in the management of patients who have died. OBJECTIVE This study aimed to identify the problems or “delays” in the care of patients who die because of placenta accreta spectrum in Latin America. STUDY DESIGN A retrospective, descriptive, observational multicentric study in Latin American hospitals was conducted. The care of patients who died from placenta accreta spectrum was investigated under a “delay” study model that included delays related to patients, institutions, and healthcare providers. Centers of excellence standards of care were taken into account, and 2 analysis moments were included: an initial analysis for each local care group in the place where maternal death occurred and another analysis that included the main researcher. All information were collected through a predesigned survey and discussed by telephone. RESULTS Overall, 52 patients in 10 Latin American countries were included, with options for improvement identified in all cases. The most prevalent type of delay was associated with health providers (98% of cases), followed by health institutions (96% of cases) and patients (63% of cases). Each hospital's analysis group defined maternal death as avoidable in all cases and determined that the interventions needed to improve the outcome would present low, moderate, and high difficulties in 28.8%, 48.1%, and 34.8% of cases, respectively. CONCLUSION All maternal deaths related to placenta accreta spectrum were potentially preventable, and 76.9% of cases were avoidable by low to moderate complexity interventions.

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.

Objective:to describe a new method of organ-preserving surgery for combined placenta previa and placenta accreta into the uterine scar after a previous cesarean section – the CLAP method. Materials and methods.During 2015–2020, 29 women with placenta praevia and placenta accreta vera into the uterine scar after a previous cesarean section were operated. 15 women (control group) gave birth using the traditional method – cesarean section followed by hysterectomy; in 14 pregnant women (main group) the new method CLAP was used. CLAP consists of the following stages: stage I – C – cesarean section; stage II – L – ligation of internal iliac arteries; stage III – A – adherent placenta's area excision; stage IV – P – pressure, applied to the lower uterine segment, during which the technique of COLUS was performed. Patients were operated at 34–35 weeks of pregnancy after fetal respiratory distress syndrome prophylactics with a course of betamethasone. Results.Statistically significant difference in the age of patients (p = 0.968), status and weight of newborns (p = 0.058) was not found. But significant statistical difference was found in the amount of maternal blood loss during surgical delivery. In the control group, where pregnant women underwent hysterectomy, it was 3652 ± 293 ml, and in the main group, where delivery was performed using the new CLAP technique, blood loss was 2253 ± 153 ml (p Conclusions.CLAP procedure is an effective alternative to previously used organ-preserving operations. It helps to avoid hysterectomy and does not require special equipment during a cesarean section. The CLAP technique has proven to be an effective way to prevent and cease blood loss, as well as to preserve reproductive function of woman.

This study aimed to assess the maternal features, Vascular Endothelial Growth Factor (VEGF) and Placenta Growth Factor (PLGF) in the Placenta Accreta Spectrum (PAS); then, to determine a predictive value of VEGF and PLGF in the PAS. This prospective case-control study was conducted on 90 pregnant women including 45 PAS, and 45 Normal Placenta (NP). Maternal age, gravidity, C/S, and serum levels of VEGF and PLGF were assessed between NP and PAS, and among NP and PAS sub-groups, including Placenta Accreta (PA), Placenta Increta (PI), and Placenta Percreta (PP). The Multi-gravidity, previous C/S, maternal age, and serum level of PLGF were significantly higher in the PAS group compared to the NP group OR = 42, 8.1, 1.17, and 1.002 (p-value .05). The same differences were seen among NP with PA, PI, and PP sub-groups (p-value .05 for VEGF). Placenta Previa was uniformly distributed across the PAS sub-groups (p-value >.05), also the VEGF and PLGF serum levels did not differ between PAS with Previa and PAS without Previa groups (p-value >.05). A valid cut-off point for PLGF was reported at 63.55. A predictive value of PLGF for the PAS patients is presented enjoying high accuracy and generalisability for the study population.Impact statementWhat is already known on this subject? The Placenta Accreta Spectrum (PAS), in which the placenta grows too deep in the uterine wall, is responsible for maternal-foetal morbidity and mortality worldwide; so, the antenatal diagnosis of PAS is an important key to improve maternal-foetal health. Normal placental implantation requires a fine balance among the levels of angiogenic and anti-angiogenic factors, such as the Placenta Growth Factor (PLGF), the Vascular Endothelial Growth Factor (VEGF), and soluble Fms-like tyrosine kinase-1. However, there is still controversy regarding The PLGF and VEGF level changes in PAS patients.What do the results of this study add? Despite traditional measuring the levels of PLGF and VEGF from the placenta at the time of delivery; in this study including 90 participants (28-34 weeks of gestation) the maternal serum levels of PLGF and VEGF were measured in advance (temporality causation), resulted in presenting a more valid cut-off point for PLGF in PAS group. In addition, the serum level of PLGF was significantly higher in the PAS and PAS sub-groups compared to the Normal Placenta group. Also, the Previa status of PAS patients did not affect the VEGF and PLGF serum levels.What are the implications of these findings for clinical practice and/or further research? PLGF cut-off point derived from the maternal serum level could predict PAS validly and, if used as a screening test in an earlier pregnancy, the maternal-foetal morbidity and mortality would decrease.

Objective To describe a stepwise surgical approach for conservative management of placenta previa accreta to preserve the uterus and to evaluate the efficacy and safety of this approach in controlling postpartum hemorrhage including intrapartum hemorrhage. Methods A prospective case series study conducted on 62 pregnant women with one or more cesarean deliveries diagnosed with placenta previa accreta between January 2018 and June 2019 at Ain Shams University Maternity Hospital. All participants underwent a conservative stepwise surgical approach through Pfannenstiel skin incision with fetal delivery through a uterine incision just above the upper border of the placenta, followed by bilateral uterine artery ligation with myometrial excision of the remaining adherent placenta and cervico-isthmic sutures by MMG (the main surgeon) and MS. Results Among 62 women, the surgical approach was successful in controlling postpartum hemorrhage and preserving the uterus in 50 (80.64%) participants. Three women (4.83%) had urinary bladder injuries, all were managed intraoperatively during the cesarean section. Five women (8%) had postpartum pyrexia and five women (8%) had postpartum endometritis, all were managed conservatively with broad-spectrum antibiotics. Conclusion The stepwise surgical approach can be applied to the conservative management of placenta previa accreta to avoid unnecessary cesarean hysterectomy.

Background The uterus shows tremendous increase in size during pregnancy to nurture the fetus within it. It may show a spectrum of physiological changes or pathological lesions that may affect the pregnancy favorably or adversely. The main purpose of our study was to analyze the physiological changes in the uterus during pregnancy and the postpartum period, thereby gaining deeper knowledge. Materials and Methods We studied a total of 152 uterine specimens obtained from obstetric hysterectomies and maternal autopsies for the presence or absence of normal physiological changes. As a control group, an equal number of surgical uterine specimens received for abnormal uterine bleeding were studied. Results Decidual change was observed from 6 weeks of gestation to 16 days postpartum. It was partially deficient to absent in four cases of placenta accreta. Myometrial hypertrophy was seen in 150 cases (98.68%) from 8 weeks of gestation till 30 days postpartum period. Vascular remodeling was partially deficient to absent in eight cases of pregnancy-induced hypertension. Preischemia of myometrial fibers was an unexpected finding noticed from 20 weeks of gestation to 16 days postpartum in 131 cases (86.18%). Cervical wall hemorrhages were seen in 84.84% cases of vaginal delivery and in only 17.64% cases of lower segment cesarean section. Conclusion Ours is the first study to describe the duration of the routine physiological uterine changes during pregnancy. The relationship between cervical wall hemorrhages and vaginal delivery as well as between myometrial preischemia and gestational age, both being normal physiologic findings, was found to be statistically significant.

Antenatal diagnosis of placenta accreta spectrum (PAS) can ensure multidisciplinary management at center of excellence which can reduce maternal and fetal complications. This can be established by a scoring system which provides a standardized criterion for the diagnosis and management. The objective of our study was to assess the placenta accreta index (PAI) and its individual parameters for diagnosis of PAS in high-risk patients. A prospective study was conducted on 71 pregnant women with placenta previa and previous cesarean section. After informed consent, history was taken and ultrasonography was used to calculate the PAI for each patient. Definitive diagnosis was made clinically during cesarean section or by histopathology for those requiring hysterectomy. The data were evaluated using the latest version of Statistical Package for the Social Sciences software. All ultrasound parameters of placenta accreta index were statistically significant for predicting PAS (p value

Objective:Placenta accreta spectrum (PAS), which occurs in ~1/500 deliveries, represents the disorders that arise due to adherent placenta, which may infiltrate adjacent organs, including the urinary tract. Recently, its incidence rate has increased because of increasing rate of cesarean deliveries worldwide.Materials and Methods:Case records of all institutional deliveries that took place at a single, tertiary care hospital within two years were reviewed to identify all patients with PAS. The case records of patients who required urological referral were studied.Results:In total, 80 patients were diagnosed with PAS. Ten patients (12.5%) required urological referral for urinary tract involvement. All (100%) patients showed bladder involvement. Two patients (2.5%) required ureteric reimplantation. One patient (1.2%) required bilateral ureterostomies as an urgent temporizing measure because the bladder was extensively infiltrated. All patients were discharged in a stable condition. There were no long-term urological complications observed in patients who followed up (90%).Conclusion:PAS is a condition with high mortality and morbidity rates and increasing incidence. The findings of this study correlate well with international series on PAS. A multidisciplinary management team is necessary to manage the myriad complications that may arise from PAS.

Introduction: Placenta accreta spectrum (PAS) is a life-threating obstetric complication, and prenatal prediction of PAS can decrease maternal morbidity and mortality. The aim of this prospective cohort study was to determine the clinical factors associated with PAS. Methods: Pregnant women who delivered at a university hospital were enrolled. Clinical data were collected from medical records, and logistic regression analyses were performed to determine which clinical factors were associated with PAS. Results: Eighty-seven (2.1%) of the 4146 pregnant women experienced PAS. Multivariable analyses revealed that a prior history of cesarean section (CS) (OR 3.3; 95% CI 1.9-5.7; p < 0.01), dilation and curettage (D&C) (OR 2.8; 95% CI 1.7-4.6; p < 0.01), hysteroscopic surgery (OR 5.7; 95% CI 2.3-14.4; p < 0.01), uterine artery embolization (UAE) (OR 44.1; 95% CI 13.8-141.0; p < 0.01), current pregnancy via assisted reproductive technology (ART) (OR 4.1; 95% CI 2.4-7.1; p < 0.01), and the presence of placenta previa in the current pregnancy (OR 13.1; 95% CI 7.9-21.8; p < 0.01) were independently associated with the occurrence of PAS. Conclusion: Pregnant women who have a prior history of CS, D&C, hysteroscopic surgery, UAE, current pregnancy via ART, and the presence of placenta previa in the current pregnancy are high risk for PAS.

Background: Maternal and neonatal morbidity and mor-tality are associated with abnormal placentation and obstetric hemorrhage. To reduce morbidity and mortality in morbidly adherent placentas, a high index of suspicion, early antenatal diagnosis, adequate patient counselling, scheduled surgery at a well-equipped institution, and anticipation of high volume blood transfusion are the essential steps. Aim of Study: The aim of this study was to reach the best way of management of abnormal adherent placentathrough evaluation of conservative and radical management of cases ofplacenta accreta over last three years in Mansoura University Hospital. Patients and Methods: A retrospective observational study conducted in Obstetrics and Gynecology Dept. of Mansoura University Hospital. We reviewed the medical records of 250 women who diagnosed as invasive placenta from the beginning of (2017) to the end of (2019). The main aim to reach the best way of management of abnormal adherent placenta through evaluation of conservative and radical management of cases of placenta accreta over last three years in Mansoura University. Results: There was statistically significant higher median volume blood loss, packed RBCs units, fresh frozen plasma and platelet units with radical management than with conserv-ative management. Regarding maternal complications, bladder injury, ureteric injury, major vessel injury, wound infection, coagulopathy, re-admission and ICU admission were higher incidence among cases in radical group than cases with conservative management. Grade 3 was present among cases with radical management only (30.5%) while grade 1 was higher among cases with conservative management 96.9%. Conclusion: According to our study, conservative man-agement in G1 (placenta accreta) is the recommended man-agement option, well-planned cesarean hysterectomy in G3 (placenta percreta) is the only management option. While G2 (placenta increta) can be managed either radically or conserv-atively according to bleeding degree and bleeding control.

Background; the term morbid adherent placenta suggests a nontypical placental implantation of the into the uterine barrier and was utilized to express placental accreta, percreta, and increta. Placental accreta (PA) is a placental where the placenta villi stick on straightly to the myometrium. Aim and objectives; this work aim to evaluate the specificity, sensitivity, and diagnosis accurateness of ultrasound (US) in placental accretes diagnosing in the 2nd and 3rd trimesters of gestation. Patient and methods; This was a prospective research that was performed at obstetrics and gynecology departments of both El Hussein and Kafr El-Sheikh Hospitals during the period between January 2020 till July 2020 aiming for evaluating the accurateness of US in the placenta accreta diagnosing Result; The US sensitivity was (100 %), specificity was (85 %), NPV was (100% ) and PPV was (90.9%) with accuracy of (94%) in placental accreta diagnosing. Conclusion; Ultrasonography has satisfactory sensitivity for placental accreta diagnosing; but specificity doesn’t seem to be good as concluded in other reports. US still the most sensitive and frequently utilized scanning modality for the placental accreta diagnosing as it is precise, cheap, and noninvasive and save time. This modality has excellent popularity as it is extensively accessible, patients friendly, and comparatively cheap.

Background Placenta accreta is known to be associated with significant maternal morbidity and mortality—primarily due to intractable bleeding during abortion or delivery at any level of gestation. The complications could be reduced if placenta accreta is suspected in a patient with a history of previous cesarean delivery and the gestational sac/placenta is located at the lower part of the uterus. Then, a proper management plan can be instituted, and complications can be reduced. The diagnosis of placenta accreta in the first trimester of pregnancy is considered uncommon. Case presentation A 34-year-old Malay, gravida 4, para 3, rhesus-negative woman was referred from a private hospital at 13 weeks owing to accreta suspicion for further management. She has a history of three previous lower-segment cesarean sections. She also had per vaginal bleeding in the early first trimester, which is considered to indicate threatened miscarriage. Transabdominal ultrasound revealed features consistent with placenta accreta spectrum. She was counseled for open laparotomy and hysterectomy because of potential major complication if she continued with the pregnancy. Histopathological examination revealed placenta increta. Conclusion A high index of suspicion of placenta previa accreta must be in practice in a patient with a history of previous cesarean deliveries and low-lying placenta upon ultrasound examination during early gestation.

Дослідження виконані у 82 вагітних і породіль при кесаревому розтині з приводу передлежання плаценти з вростанням на 37–38 тижні. Органозберігаюча операція була виконана за такою методикою: лапаротомія за Джоель Кохен, донний кесарів розтин з залишенням плаценти, перев’язка трьох пар магістральних маткових судин і внутрішніх клубових артерій з обох сторін (поетапна деваскуляризація матки) з подальшим видаленням стінки матки (метропластика) при вростанні плаценти. Операції виконані в умовах спінальної анестезії (Сан) 0,5 % гіпербаричним розчином бупівакаїну. Інфузійна програма будувалася відповідно до рекомендацій з обмежувальної інфузії. Преінфузію проводили збалансованим кристалоїдом Реосорбілакт (10–15 мл/кг) з подальшим введенням на етапах операції збалансованого кристалоїду і компонентів крові за необхідності. Оцінювали гемодинаміку, КОР та електроліти крові. Оцінку крововтрати проводили гравіметричним способом. Дослідження показали, що Сан і Реосорбілакт у програмі малооб’ємної інфузійної терапії зберігають доставку кисню на фізіологічному рівні, стабілізують гемодинамічний профіль і КОР. При вростанні плаценти використання сучасних технологій в анестезіології реаніматології та акушерстві, з мультидисциплінарним підходом, дозволяють реалізувати органозберігаючу тактику у цієї категорії жінок, Исследования выполнены у 82 беременных и родильниц при кесаревом сечении по поводу предлежания плаценты с врастанием в 37–38 нед. Органосохраняющая операция была выполнена по следующей методике: лапаротомия по Джоэль Кохену, донное кесарево сечение с оставлением плаценты, перевязка трех пар магистральных маточных сосудов и внутренних подвздошных артерий с обеих сторон (поэтапная деваскуляризация матки) с последующим иссечением стенки матки (метропластика) при врастании плаценты. Операции выполнены в условиях спинальной анестезии (САн) 0,5 % гипербарическим раствором бупивакаина. Инфузионная программа строилась согласно рекомендациям по ограничительной инфузии. Преинфузию проводили сбалансированным кристаллоидом Реосорбилакт (10–15 мл/кг) с последующим введением на этапах операции сбалансированного кристаллоида и компонентов крови при необходимости. Оценивали гемодинамику, КЩC и электролиты крови. Оценку кровопотери проводили гравиметрическим способом. Исследования показали, что САн и Реосорбилакт в программе малообъемной инфузионной терапии сохраняют уровень доставки кислорода на физиологическом уровне, стабилизируют гемодинамический профиль и КЩС. При врастании плаценты использование современных технологий в анестезиологии-реаниматологии и акушерстве, с мультидисциплинарным подходом, позволяют реализовать органосохраняющую тактику у данной категории женщин

OBJECTIVE To examine the detection rate of placenta previa and placenta accreta spectrum (PAS) by routine mid-pregnancy obstetric ultrasound and to estimate risk factors and prevalence within this cohort. METHODS This was an observational cohort study with prospectively collected data. Women attending routine mid-pregnancy obstetric ultrasound at the Sahlgrenska University Hospital with a suspected cup-shaped placenta (cohort 1, n = 339) and women diagnosed with placenta previa or PAS (cohort 2, n = 227) were analyzed according to detection rate, risk factors, and prevalence. RESULTS The detection rates of placenta previa and PAS were 49% (98) and 25% (14), respectively. However, 216 (99%) women with placenta previa were diagnosed prenatally, as were 14 (50%) women with PAS. In vitro fertilization was identified as the strongest independent risk factor for placenta previa (odds ratio 6.96; 95% confidence interval 4.77-10.16, P

Background Following the discovery that fetal DNA originates from the trophoblastic cells of the placenta, the contribution of the cell-free DNA test in placenta-related obstetric complications has begun to be investigated. Compared to uncomplicated pregnancies, higher fetal fractions were detected in placenta accreta spectrum and placenta previa, which are among placenta-related obstetric complications. However, this data applies only to advanced gestational weeks. Aim To investigate the possible predictive value of fetal fraction in cell-free DNA tests in pregnancies with placenta previa and placenta accreta spectrum in early gestational ages. Materials and Methods This study was conducted in women who were screened via cell-free DNA tests for common aneuploidies in the first and second trimester and subsequently diagnosed with placenta previa or placenta accreta spectrum. After the diagnosis was confirmed with a C-section, fetal fractions were retrospectively compared to a control group with a history of an uncomplicated C-section who were also previously screened by cell-free DNA test. Results The median and interquartile range (IQR) of fetal fractions for placenta previa (n=19), placenta accreta spectrum (n=7), and control groups (n=85) were 8.1 (6–10), 6.8 (6.7–10.7), and 7.1 (4.7–9.65), respectively. No statistically significant difference was observed among the three groups in terms of fetal fractions (p=0.587). Conclusions According to our data, we did not observe any relationship between placental invasion abnormalities vs. control group or placenta previa vs. control group using the fetal fractions of the cell-free DNA test. Furthermore, we could not confirm a predictive role and/or any additional clinical contribution. We believe that future studies focusing on placental mRNA might be more helpful than cell-free fetal DNA testing.

The magnetic resonance imaging (MRI) image processing capabilities were investigated based on the improved particle swarm optimization (IPSO) algorithm, and the clinical application analysis of MRI images in the diagnosis of placenta accreta (PA) was evaluated in this study. The MRI uterine images were detected on the basis of IPSO. Besides, the clinical data of 89 patients with PA were selected and collected, who were diagnosed by clinical cesarean section surgery and pathological comprehensive diagnosis in hospital from January 2018 to July 2020. Then, all of them underwent the ultrasound (US) and MRI examinations, and the differences of sensitivity, specificity, and accuracy between MRI and US under IPSO in the diagnosis of PA were compared, as well as the differences in the diagnosis of adhesive, implantable, and penetrated PA. The results showed that the difference in detection between IPSO-based MRI images and US images was not statistically substantial ( p > 0.05 ), but the number of initial detections was higher than the number of US examination. MRI examination had higher sensitivity and specificity in the diagnosis of PA during pregnancy, especially for implantable PA, compared with US examination ( p < 0.05 ). In conclusion, MRI images based on the improved particle swarm optimization algorithm showed a good application effect in the diagnosis of placental implantation diseases, which was worthy of further promotion in clinical practice.

This study aimed to review the obstetric complications during subsequent pregnancies after uterine artery embolization (UAE) for postpartum hemorrhage (PPH) by exploring the relationship between prior UAE and obstetric complications through a meta-analysis. We conducted a systematic literature review through March 31, 2021, using PubMed, Scopus, and the Cochrane Central Register of Controlled Trials in compliance with the PRISMA guidelines and determined the effect of prior UAE for PPH on the rate of placenta accreta spectrum (PAS), PPH, placenta previa, hysterectomy, fetal growth restriction (FGR), and preterm birth (PTB). Twenty-three retrospective studies (2003–2021) met the inclusion criteria. They included 483 pregnancies with prior UAE and 320,703 pregnancies without prior UAE. The cumulative results of all women with prior UAE indicated that the rates of obstetric complications PAS, hysterectomy, and PPH were 16.3% (34/208), 6.5% (28/432), and 24.0% (115/480), respectively. According to the patient background-matched analysis based on the presence of prior PPH, women with prior UAE were associated with higher rates of PAS (odds ratio [OR] 20.82; 95% confidence interval [CI] 3.27–132.41) and PPH (OR 5.32, 95% CI 1.40–20.16) but not with higher rates of hysterectomy (OR 8.93, 95% CI 0.43–187.06), placenta previa (OR 2.31, 95% CI 0.35–15.22), FGR (OR 7.22, 95% CI 0.28–188.69), or PTB (OR 3.00, 95% CI 0.74–12.14), compared with those who did not undergo prior UAE. Prior UAE for PPH may be a significant risk factor for PAS and PPH during subsequent pregnancies. Therefore, at the time of delivery, clinicians should be more attentive to PAS and PPH when women have undergone prior UAE. Since the number of women included in the patient background-matched study was limited, further investigations are warranted to confirm the results of this study.

Background: Placenta accreta spectrum is a term which describes abnormal invasion of the placenta into the uterine myometrium. The first line in diagnosis is ultrasonography and magnetic resonance imaging may complement the diagnosis. Aim: The aim of the work is to assess the accuracy of shear wave elastography in predication of placental invasion in women with placental previa.Materials and Methods: This is a prospective cohort study which was conducted in Ain Shams University on 50 women with a diagnosis of anterior placenta previa and history of previous cesarean section who were pregnant at 32 weeks or more and were planned for delivery by elective cesarean section. They were subjected to ultrasonography and elastography study and the diagnosis of placenta accreta spectrum was confirmed/ excluded intraoperatively.Results: Placental separation was normal in 36% of cases, delayed in 46 % of cases, partial in 6% of cases only whereas non separation occurred in 12% of cases. elastrgraphy had a sensitivity of 73.7%, specificity of 90.3%, positive predicting value of 82.4% and negative predictive value of 84.8% in diagnosing cases with abnormal placental invasion while sensitivity, specificity positive and negative predictive value of ultrasonography in diagnosing abnormal placental invasion was 89.5%, 96.8%, 94.4% and 93.8% respectively.Conclusion: Elastography is sensitive and specific but inferior to ultrasonography in evaluating women with suspected placenta accreta spectrum but it may be useful in diagnosis of focal invasion.

To separately perform visual and texture analyses of the axial, coronal, and sagittal planes of T2-weighted images and identify the optimal method for differentiating between the normal placenta and placenta accreta spectrum (PAS). Eighty consecutive patients (normal group, n = 50; PAS group, n = 30) underwent preoperative MRI. A scoring system (0–2) was used to evaluate the degree of abnormality observed in visual analysis (bulging, abnormal vascularity, T2 dark band, placental heterogeneity). The axial, coronal, and sagittal planes were manually segmented separately to obtain texture features, and seven combinations were obtained: axial; coronal; sagittal; axial and coronal; axial and sagittal; coronal and sagittal; and axial, coronal, and sagittal. Feature selection using the least absolute shrinkage and selection operator method and model construction using a support vector machine algorithm with k-fold cross-validation were performed. AUC was used to evaluate diagnostic performance. The AUC of visual analysis was 0.75. The model ‘coronal and sagittal’ had the highest AUC (0.98) amongst the seven combinations. The fivefold cross-validation for the model ‘coronal and sagittal’ showed AUCs of 0.85 and 0.97 in training and validation sets, respectively. The AUC of the model ‘coronal and sagittal’ for all subjects was significantly higher than that of visual analysis (0.98 vs. 0.75; p

OBJECTIVE To develop a predictive tool to accurately screen women at high risk of severe postpartum hemorrhage (SPPH) undergoing vaginal delivery. METHODS We analyzed 28 150 mothers who underwent vaginal delivery after 28 weeks of pregnancy in the Third Affiliated Hospital of Guangzhou Medical University from January 2015 to August 2019. Two-thirds of the cohort were randomly allocated to a training set (n = 18 766) and the rest to a validation set (n = 9384). In the training set, we built a radiomic nomogram based on multivariate logistic analysis, and calibration and C-index were evaluated. The performance of the validated nomogram was then tested in the validation cohort. RESULTS Independent risk factors for SPPH in women undergoing vaginal delivery were previous cesarean section, history of PPH, in vitro fertilization, anemia, intrauterine death, prolonged labor, low-lying placenta, placental abruption, placenta accreta spectrum, and macrosomia. Good calibration was observed for the probability of SPPH in the validation cohort, and the C-index of the nomogram for the prediction of SPPH was 0.861 (95% confidence interval 0.820-0.902). CONCLUSION This model would be a useful tool to accurately screen for women at high-risk of SPPH undergoing vaginal delivery. It would be expected to be an effective tool to guide clinical practice and further reduce maternal mortality.