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Objective Antenatal diagnosis of placenta accreta spectrum (PAS) is critical to reduce maternal morbidity. While clinical outcomes of women with PAS have been extensively described, little information is available regarding the women who undergo cesarean delivery with a presumptive PAS diagnosis that is not confirmed by histopathologic examination. We sought to examine resource utilization and clinical outcomes of this group of women with a false-positive diagnosis of PAS. Study Design This is a retrospective analysis of patients with prenatally diagnosed PAS cared for between 2015 and 2020 by our multidisciplinary PAS team. Maternal outcomes were examined. Univariate analysis was performed and a multivariate model was employed to compare outcomes between women with and without histopathologically confirmed PAS. Results A total of 162 patients delivered with the preoperative diagnosis of PAS. Of these, 146 (90%) underwent hysterectomy and had histopathologic confirmation of PAS. Thirteen women did not undergo the planned hysterectomy. Three women underwent hysterectomy but pathologic examination did not confirm PAS. In comparing women with and without pathologic confirmation of PAS, the false-positive PAS group delivered later in pregnancy (34 vs. 33 weeks of gestation, p = 0.015) and had more planned surgery (88 vs. 47%, p = 0.002). There was no difference in skin incision type or hysterotomy placement for delivery. No significant difference in either the estimated blood loss or blood components transfused was noted between groups. Conclusion Careful intraoperative evaluation of women with preoperatively presumed PAS resulted in a 3/149 (2%) retrospectively unnecessary hysterectomy. Management of women with PAS in experienced centers benefits patients in terms of both resource utilization and avoidance of unnecessary maternal morbidity, understanding that our results are produced in a center of excellence for PAS. We also propose a management protocol to assist in the avoidance of unnecessary hysterectomy in women with the preoperative diagnosis of PAS. Key Points Evaluation and delivery planning of patients with suspected placenta accreta spectrum in experienced centers provides acceptable outcomes. Under specific circumstances, delivery of placenta may be attempted if placenta accreta is suspected. Patients with suspected placenta accreta rarely undergo unindicated hysterectomy. [ABSTRACT FROM AUTHOR]

Objective Placenta accreta spectrum (PAS) covers a wide spectrum of placental adherence/invasion with varied clinical significance. Histopathologic examination is considered the confirmatory gold standard, but is only obtained sometime after definitive treatment. The International Federation of Gynecology and Obstetrics (FIGO) has published a new clinical classification that can be assigned at delivery, and we aimed to investigate the association between this new FIGO classification and histopathology and also to assess its correlation with maternal outcomes. Study Design We studied a retrospective cohort of 185 patients with histopathologically proven PAS managed at our referral center between September 2012 and January 2019. Two experienced surgeons retrospectively reviewed charts and assigned the FIGO grading based on findings reported at delivery. A third experienced reviewer adjudicated to determine the classification used for final analysis. Categorical outcomes were compared with the use of chi-squared and the Fisher exact test, as appropriate. A multivariate model was designed to adjust outcomes in different FIGO groups for the involvement of a formal multidisciplinary management team. Results Among 185 patients, there were 41 (22%) placenta accreta, 44 (24%) placenta increta, and 100 (54%) placenta percreta on histopathology. The inter-rater reliability was found to be substantial with Kappa = 0.661 (p < 0.001), and 95% confidence interval (CI): 0.449–0.872. There was a significant association between all histopathology groupings and the FIGO clinical classification (p < 0.001). However, we found no association between FIGO classifications and maternal complications. Conclusion The new FIGO clinical classification is strongly associated with histopathologic findings. A better understanding of the depth and extent of invasion as afforded by the clinical classification system will help standardize reporting and future research. Key Points PAS includes a wide spectrum of placental invasion with varied clinical significance. Histopathological examination is considered the confirmatory gold standard. The new FIGO clinical classification is strongly associated with histopathologic findings. [ABSTRACT FROM AUTHOR]

Objective Massive transfusion protocols are widely implemented in obstetrical practice in case of severe hemorrhage; however, different recommendations exist regarding the appropriate ratios of blood product components to be transfused. We report our extensive experience with massive component transfusion in a referral center in which the standard massive transfusion protocol is modified by ongoing clinical and laboratory evaluation. Study Design A retrospective chart review of all patients who had massive transfusion protocol activation in a level 4 referral center for obstetrical practice was performed from January 2014 to January 2020. Data collected included the etiology of obstetrical hemorrhage, number of blood products of each type transfused, crystalloid infusion, and several indices of maternal morbidity and mortality. Data are presented with descriptive statistics. Results A total of 62 patients had massive transfusion protocol activation, of which 97% received blood products. Uterine atony was found to be the most common etiology for massive hemorrhage (34%), followed by placenta accreta spectrum (32%). The mean estimated blood loss was 1,945 mL. A mean of 6.5 units of packed red blood cells, 14.8 units of fresh frozen plasma and cryoprecipitate, and 8.3 units of platelets were transfused per patient. No maternal deaths were seen. Conclusion The ratios of transfused packed red blood cell to fresh frozen plasma/cryoprecipitate and of packed red blood cell to platelet units varied significantly from the fixed initial infusion ratio called for by our massive transfusion protocol resulting in universally favorable maternal outcomes. When rapid laboratory evaluation of hematologic and clotting parameters is available, careful use of this information may facilitate safe modification of an initial fixed transfusion ratio based on etiology of the hemorrhage and individual patient response. Key Points Massive transfusion protocols in obstetrics follow fixed ratios of blood products. Actual usage of blood components is different than the standardized protocols. We recommend to modify the initial fixed transfusion ratio according to clinical response. [ABSTRACT FROM AUTHOR]

Objective The aim of the study is to evaluate whether pathologic severity of placenta accreta spectrum (PAS) is correlated with the incidence of small for gestational age (SGA) and neonatal birthweight. Study Design This was a multicenter cohort study of viable, non-anomalous, singleton gestations delivered with histology-proven PAS. Data including maternal history, neonatal birthweight, and placental pathology were collected and deidentified. Pathology was defined as accreta, increta, or percreta. The primary outcome was rate of SGA defined by birth weight less than the 10th percentile. The secondary outcomes included incidence of large for gestational age (LGA) babies as defined by birth weight greater than the 90th percentile as well as incidence of SGA and LGA in preterm and term gestations. Statistical analysis was performed using Chi-square, Kruskal–Wallis, and log-binomial regression. Increta and percreta patients were each compared with accreta patients. Results Among the cohort of 1,008 women from seven United States centers, 865 subjects were included in the analysis. The relative risk (RR) of SGA for increta and percreta did not differ from accreta after adjusting for confounders (adjusted RR = 0.63, 95% confidence interval [CI]: 0.36–1.10 for increta and aRR = 0.72, 95% CI: 0.45–1.16 for percreta). The results were stratified by placenta previa status, which did not affect results. There was no difference in incidence of LGA (p = 1.0) by PAS pathologic severity. The incidence of SGA for all PAS patients was 9.2% for those delivered preterm and 18.7% for those delivered at term (p = 0.004). The incidence of LGA for all PAS patients was 12.6% for those delivered preterm and 13.2% for those delivered at term (p = 0.8203). Conclusion There was no difference in incidence of SGA or LGA when comparing accreta to increta or percreta patients regardless of previa status. Although we cannot suggest causation, our results suggest that PAS, regardless of pathologic severity, is not associated with pathologic fetal growth in the preterm period. Key Points PAS severity is not associated with SGA in the preterm period. PAS severity is not associated with LGA. Placenta previa does not affect the incidence of SGA in women with PAS. [ABSTRACT FROM AUTHOR]