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Introduction Material and Methods Results Conclusions Uterus transplantation (UTx) is a treatment for absolute uterine factor infertility. The results of pregnancies of this complex infertility treatment should be established. The aim of the study was to systematically review maternal and neonatal outcomes in the pregnancies of women who have undergone UTx.The population of this review were women that have undergone UTx and delivered child(ren). Cesarean delivery after UTx were planned to be compared with studies reporting maternal mortality/morbidity and perinatal mortality/morbidity after delivery by elective cesarean section without UTx. Systematic literature searches were performed utilizing Medline, Embase, the Cochrane Library, Cinahl, PsycInfo, Web of Science, and clinicaltrials.gov for studies written in English language and published between January 1, 2010, and November 08, 2023. No study design limitation was applied. If no comparative studies were identified, we planned to report the outcomes from the case reports and case series. Included studies were assessed for risk of bias using a checklist for case series. The study protocol was registered with the International Platform of Registered Systematic Review and Meta‐analysis Protocols (registration number: INPLASY202310052).Twenty‐four articles were identified, containing data on 40 unique live births. Multiple publications including same cases were identified and clearly indicated. No comparative studies were identified. The certainty of evidence was very low, as all studies were either case reports (n = 15) or case series (n = 9). All deliveries were by cesarean section and 47.5% of them resulted in emergency cesarean sections. Out of the 21 elective cesarean sections, 52.4% were performed before 37 weeks' gestation. Historical comparison to population data on pregnancies delivered by cesarean section found a markedly increased risk for both the mother and child following cesarean section for UTx. Risks for placenta previa and preterm birth were notably high after UTx; however, some of the later may reflect the results of provider‐initiated births.The maternal and perinatal outcomes of 40 live births post‐UTx indicate that these pregnancies may be at high risk of maternal and perinatal complications. Aiming to delay elective cesarean section beyond 37 weeks' gestation could potentially reduce some of these risks. Registration of maternal and perinatal outcomes after UTx through quality registries are essential and obstetrical care guidelines for these women should be established. [ABSTRACT FROM AUTHOR]

Introduction Material and Methods Results Conclusions The European Working Group for Abnormally Invasive Placenta proposed a checklist of ultrasound features for the antenatal detection of placenta accreta spectrum (PAS). This study aims to assess the performance of the checklist in identifying histopathologically confirmed PAS cases in a cohort with a high pre‐test probability of PAS, and identify if particular features are associated with PAS.This is a prospective multi‐site cohort study conducted between 2018 and 2023. Consecutive patients who underwent ultrasound assessment for suspicion of PAS were included, and the sonographic checklist was completed at the time of ultrasound. Cases were defined as PAS where they had intraoperative findings as described by the International Federation of Gynecology and Obstetrics (FIGO) grading, and histopathological findings for hysterectomy and myometrial resection cases. All non‐PAS cases in this study had placenta previa and at least one prior cesarean delivery.Seventy‐eight participants met inclusion criteria, of whom 63 (80.7%) were diagnosed with PAS. Cesarean hysterectomy was performed in 49 cases (62.8%). Overall, third‐trimester ultrasound performed at a median gestational age of 32 weeks (IQR 30–34 weeks) had a sensitivity of 0.84 (95% CI 0.73 to 0.92) and specificity of 0.73 (95% CI 0.45 to 0.92) for detecting PAS, with a positive and negative likelihood ratio of 3.15 (95% CI 1.35 to 7.35) and 0.22 (95% CI 0.11 to 0.41), respectively. Features most associated with PAS were abnormal placental lacunae (Odds Ratio [OR] 5.40 [95% CI 1.61 to 18.03] and myometrial thinning OR 6.87 [95% CI 1.93 to 24.4]). While many of the ultrasound features seen in PAS were also present in cases of placenta previa with prior Cesarean section, the median (IQR) number of features present in PAS cases was significantly higher than in the non‐PAS placenta previa group (six features [3–8] vs. two features [0–3] p = 0.001). No case of non‐PAS placenta previa had more than five features present.The use of a standardized sonographic checklist had a high sensitivity and good specificity for the detection of PAS in this prospective cohort of well‐classified PAS cases. [ABSTRACT FROM AUTHOR]

Introduction Material and Methods Results Conclusions Placenta accreta spectrum disorders (PAS) lead to major complications in pregnancy. While the maternal morbidity associated with PAS is well known, there is less information regarding neonatal morbidity in this setting.The aim of this study is to describe the neonatal outcomes (fetal malformations, neonatal morbidity, twin births, stillbirth, and neonatal death), using an international multicenter database of PAS cases.This was a prospective, multicenter cohort study based on prospectively collected cases, using the international multicenter database of the International Society for PAS, carried out between January 2020 and June 2022 by 23 centers with experience in PAS care. All PAS cases were included, regardless of whether singleton or multiple pregnancies and were managed in each center according to their own protocols. Data were collected via chart review. Local Ethical Committee approval and Data Use Agreements were obtained according to local policies.There were 315 pregnancies eligible for inclusion, with 12 twin pregnancies, comprising 329 fetuses/newborns; 2 cases were excluded due to inconsistency of data regarding fetal abnormalities. For the calculation of neonatal morbidity and mortality, all elective pregnancy terminations were excluded, hence 311 pregnancies with 323 newborns were analyzed. In our cohort, 3 neonates (0.93%) were stillborn; of the 320 newborns delivered, there were 10 cases (3.13%) of neonatal death. The prevalence of major congenital malformations was 4.64% (15/323 newborns), most commonly, cardiovascular, central nervous system, and gastrointestinal tract malformations. The overall prevalence of major neonatal morbidity in pregnancies complicated by PAS was 47/311 (15.1%). There were no stillbirths, neonatal deaths, or fetal malformations in reported twin gestations.Although some outcomes may be too rare to detect within our cohort and data should be interpreted with caution, our observational data supports reassuring neonatal outcomes for women with PAS. [ABSTRACT FROM AUTHOR]

Introduction: This study examined obstetric outcomes in patients diagnosed with uterine adenomyosis. Material and methods: This historical cohort study queried the Healthcare Cost and Utilization Project's National Inpatient Sample. The study population was all hospital deliveries in women aged 15–54 years between January 2016 and December 2019. The exposure was a diagnosis of uterine adenomyosis. The main outcome measures were obstetric characteristics, including placenta previa, placenta accreta spectrum, and placental abruption. Secondary outcomes were delivery complications including severe maternal morbidity. Analytic steps to assess these outcomes included (i) a 1‐to‐N propensity score matching to mitigate and balance prepregnancy confounders to assess obstetric characteristics, followed by (ii) an adjusting model with preselected pregnancy and delivery factors to assess maternal morbidity. Sensitivity analyses were also performed with restricted cohorts to account for prior uterine scar, uterine myoma, and extra‐uterine endometriosis. Results: After propensity score matching, 5430 patients with adenomyosis were compared to 21 720 patients without adenomyosis. Adenomyosis was associated with an increased odds of placenta accreta spectrum (adjusted‐odds ratio [aOR] 3.07, 95% confidence interval [CI] 2.01–4.70), placenta abruption (aOR 3.21, 95% CI: 2.60–3.98), and placenta previa (aOR 5.08, 95% CI: 4.25–6.06). Delivery at <32 weeks of gestation (aOR 1.48, 95% CI: 1.24–1.77) and cesarean delivery (aOR 7.72, 95% CI: 7.04–8.47) were both increased in women with adenomyosis. Patients in the adenomyosis group were more likely to experience severe maternal morbidity at delivery compared to those in the nonadenomyosis group (aOR 1.86, 95% CI: 1.59–2.16). Results remained robust in the aforementioned several sensitivity analyses. Conclusions: This national‐level analysis suggests that a diagnosis of uterine adenomyosis is associated with an increased risk of placental pathology (placenta accreta spectrum, placenta abruption, and placental previa) and adverse maternal outcomes at delivery. [ABSTRACT FROM AUTHOR]

Introduction: Placental abruption is a serious complication, especially when accompanied by intrauterine fetal death. The optimal delivery route for placental abruption with intrauterine fetal death for reducing maternal complications is still unclear. In this study we aimed to compare the maternal outcomes between cesarean delivery and vaginal delivery in women with placental abruption with intrauterine fetal death. Material and methods: Using the Japan Society of Obstetrics and Gynecology nationwide perinatal registry database, we identified pregnant women with placental abruption with intrauterine fetal death between 2013 and 2019. The following women were excluded: those with multiple pregnancies, placenta previa, placenta accreta spectrum, amniotic fluid embolism, or whose delivery route was missing data. The association between delivery routes (cesarean delivery and vaginal delivery) and the maternal outcome was examined using a linear regression model with inverse probability weighting. The primary outcome was the amount of bleeding during delivery. Missing data were imputed using multiple imputation. Results: The number of women with placental abruption with intrauterine fetal death was 1218/1601932 (0.076%). Of 1134 women analyzed, 608 (53.6%) underwent cesarean delivery. Bleeding during delivery (median [interquartile range]) was 1650.00 (950.00-2450.00) (mL) and 1171.00 (500.00-2196.50) (mL) in cesarean and vaginal delivery, respectively. Bleeding during delivery (mL) was significantly greater in cesarean delivery than in vaginal delivery (regression coefficient, 1086.39; 95% confidence interval, 130.96-2041.81; p = 0.026). Maternal death and uterine rupture occurred in four (0.4%) and five (0.4%) women, respectively. The four maternal deaths were noted in the vaginal delivery group. Conclusions: Bleeding during delivery was significantly greater in cesarean delivery than that in vaginal delivery in women with placental abruption with intrauterine fetal death. However, severe complications, including maternal death and uterine rupture, occurred in vaginal delivery-related cases. The management of women with placental abruption with intrauterine fetal death should be cautious regardless of the delivery route. [ABSTRACT FROM AUTHOR]

Introduction: Alcohol consumption during pregnancy is related to severe birth complications such as low birthweight, preterm birth and birth defects. During the last decade, the Alcohol Use Disorders Identification Test (AUDIT) has been used as a screening tool in Swedish maternal healthcare units to identify hazardous, pre‐pregnancy alcohol use. However, evaluation of the screening with AUDIT, as well as adverse maternal or neonatal outcomes, has not been assessed at a national level. Material and methods: This was a population‐based cohort study of 530 458 births from 2013 to 2018 using demographic, reproductive and maternal health data from the Swedish Pregnancy Register. Self‐reported alcohol consumption in the year before pregnancy, measured as AUDIT scores, was categorized into moderate (6–13 points) and high‐risk (14–40 points) consumption, with low‐risk (0–5 points) consumption as the reference group. Associations with pregnancy‐ and birth outcomes were explored with logistic regressions using generalized estimating equation models, adjusting for maternal and socioeconomic characteristics. Estimates are presented as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Results: High‐risk and moderate pre‐pregnancy alcohol consumption was associated with preeclampsia, preterm birth and birth of an infant small for gestational age (SGA), but these associations were nonsignificant after adjustments. Prior moderate‐risk (aOR 1.29, 95% CI 1.17–1.42) and high‐risk consumption (aOR 1.62, 95% CI 1.17–2.25) increased the likelihood of intrapartum and neonatal infections. Conclusions: Apart from identifying hazardous alcohol consumption prior to pregnancy and the offer of counseling, screening with the AUDIT in early pregnancy indicates a high risk of inflammatory‐/placenta‐mediated pregnancy and birth outcomes. For most outcomes, AUDIT was not an independent contributor when adjusting for confounding factors. Hazardous alcohol use prior to pregnancy was independently linked to intrapartum and neonatal infections; conditions associated with morbidity and long‐term sequalae. These associations may be explained by alcohol‐induced changes in the maternal or fetal immune system in early pregnancy or persistent alcohol intake during pregnancy, or may depend on unidentified confounding factors. [ABSTRACT FROM AUTHOR]

Introduction: A peripartum hysterectomy is typically performed as a lifesaving procedure in obstetrics to manage severe postpartum hemorrhage. Severe hemorrhages that lead to peripartum hysterectomies are mainly caused by uterine atony and placenta accreta spectrum disorders. In this study, we aimed to estimate the incidence, risk factors, causes and management of severe postpartum hemorrhage resulting in peripartum hysterectomies, and to describe the complications of the hysterectomies. Material and methods: Eligible women had given birth at gestational week 23+0 or later and had a postpartum hemorrhage ≥1500 mL or a blood transfusion, due to postpartum hemorrhage, at Oslo University Hospital, Norway, between 2008 and 2017. Among the eligible women, this study included those who underwent a hysterectomy within the first 42 days after delivery. The Norwegian Medical Birth Registry provided the reference group. We used Poisson regression to estimate adjusted incidence rate ratios with 95% confidence intervals to identify clinical factors associated with peripartum hysterectomy. Results: The incidence of hysterectomies with severe postpartum hemorrhage was 0.44/1000 deliveries (42/96313). Among the women with severe postpartum hemorrhage, 1.6% ended up with a hysterectomy (42/2621). Maternal age ≥40, previous cesarean section, multiple pregnancy and placenta previa were associated with a significantly higher risk of hysterectomy. Placenta accreta spectrum disorders were the most frequent cause of hemorrhage that resulted in a hysterectomy (52%, 22/42) and contributed to most of the complications following the hysterectomy (11/15 women with complications). Conclusions: The rate of peripartum hysterectomies at Oslo University Hospital was low, but was higher than previously reported from Norway. Risk factors included high maternal age, previous cesarean section, multiple pregnancy and placenta previa, well known risk factors for placenta accreta spectrum disorders and severe postpartum hemorrhage. Placenta accreta spectrum disorders were the largest contributor to hysterectomies and complications. [ABSTRACT FROM AUTHOR]

We developed a V-shaped uterine suture (VUS), which is a new non-compression penetrating suture technique covering the internal uterine ostium, to control lower uterine bleeding during cesarean section for PP. In comparison with previous reports, the estimated blood loss with VUS was less than with vertical compression sutures for PP.[[1], [3]] The characteristics of VUS compared with a parallel vertical compression suture are summarized below. V-shaped uterine suture (VUS): A new non-compression penetrating suture technique to control lower uterine bleeding during cesarean section for placenta previa. [Extracted from the article]

Introduction: The presence of vasa previa carries a high risk for severe fetal morbidity and mortality due to fetal bleeding caused by injury to unprotected fetal vessels when rupture of membranes occurs. Previously, it has been shown that prenatal diagnosis significantly improves the outcome. However, systematic screening for vasa previa is not generally performed and clinical studies demonstrating the performance of systematic screening for vasa previa in routine clinical practice are rare. The objective of this study was to assess the performance of systematic screening for vasa previa by determining placental cord insertion at the 20‐week anomaly scan. Material and methods: This is a retrospective study of 6038 pregnant women between 18+0 and 24+0 gestational weeks who were prospectively screened for vasa previa by depiction of the site of placental cord insertion at the 20‐week anomaly scan. Pregnancies with marginal or velamentous cord insertion underwent vaginal sonography for examination for vasa previa. In cases with succenturiate or bilobed placentas, the bridging vessels were depicted, and vaginal sonography was performed if necessary. Results: There were 21 cases of vasa previa and all were diagnosed prenatally. In 18 cases, the cord insertion was marginal or velamentous. The remaining three cases had placental anomalies, which necessitated a detailed examination. All pregnancies with vasa previa were delivered at a mean of 35.2 (SD 1.8) gestational weeks by cesarean section. Among pregnancies affected by vasa previa, all fetuses survived. The median birthweight was 2390 g (range 1200–2990 g) and the mean umbilical artery pH 7.34 (SD 0.04). The median 5‐min APGAR score was nine (range 7–10). None of the fetuses or neonates died or required blood transfusions. In all pregnancies of the whole cohort which were complicated by fetal or neonatal demise and in neonates with a 5‐min APGAR score ≤5 and/or an umbilical artery pH ≤7.10, fetal blood loss was excluded as a cause of the poor obstetric outcome. Conclusions: Screening for vasa previa is feasible and efficient, taking into account the site of placental cord insertion in pregnancies not affected by placenta previa and bilobed and succenturiate placenta. [ABSTRACT FROM AUTHOR]

Introduction: Placenta previa with placenta accreta spectrum (PAS) is a life-threatening disease that results in massive hemorrhage. The clinical and histologic criteria of PAS were adopted according to the International Federation of Gynaecology and Obstetrics (FIGO) classification. We aimed to investigate whether FIGO criteria and topography were associated with maternal complications in patients with placenta previa.Material and Methods: Patients with placenta previa who underwent cesarean section at our institution between January 2003 and December 2019 were identified. First, they were divided based on FIGO classification, as follows: Group A, with clinical criteria; Group B, with histologic criteria; and Group C: without clinical or histologic criteria. Next, cases with PAS were classified according to the topographic invasion area, as follows: type 1, upper posterior bladder; type 2, lower posterior bladder; type 3, parametrium; type 4, posterior lower uterine segment. Predictive factors for massive hemorrhage were retrospectively analyzed.Results: Among the 350 patients, 24 (6.9%) were classified as Group A, 16 (4.6%) as Group B and 310 (88.5%) as Group C. Regarding maternal history and hemostatic procedures, there were no significant factors other than hysterectomy (p < .01) in Groups A and B. The volume of blood loss in both Groups A and B was greater than in Group C (p < .01). The rates of uterine artery embolization and blood transfusion were higher in Groups A and B than in Group C (p < .01). In addition, there were no significant factors other than hysterectomy between Groups A and B. In the multivariate analysis for massive hemorrhage, Group A (odds ratio: 2.73, p = .04) and Group B (odds ratio: 12.69, p < .01) were identified as independent predictive factors. In addition, massive hemorrhage was closely related to the lower posterior bladder and parametrial invasion in both Groups A and B.Conclusions: Both clinical and histologic criteria for PAS in the FIGO classification were associated with massive hemorrhage. Diagnosing clinical PAS using the FIGO classification, additional hemostatic procedures might be necessary according to the topographic invasion area. [ABSTRACT FROM AUTHOR]

Introduction: In cases of placenta accreta spectrum, a precise antenatal diagnosis of the suspected degree of invasion is essential for the planning of individual management strategies at delivery. The aim of this work was to evaluate the respective performances of ultrasonography and magnetic resonance imaging for the antenatal assessment of the severity of placenta accreta spectrum disorders included in the database. The secondary objective was to identify descriptors related to the severity of placenta accreta spectrum disorders.Material and Methods: All the cases included in the database for which antenatal imaging data were available were analyzed. The rates of occurrence of each ultrasound and magnetic resonance imaging descriptor were reported and compared between the Group "Accreta-Increta" (FIGO grades 1 & 2) and the Group "Percreta" (FIGO grade 3).Results: Antenatal imaging data were available for 347 women (347/442, 78.5%), of which 105 were included in the Group "Accreta - Increta" (105/347, 30.2%) and 213 (213/347, 61.4%) in the Group "Percreta". Magnetic resonance imaging was performed in addition to ultrasound in 135 women (135/347, 38.9%). After adjustment for all ultrasound descriptors in multivariate analysis, only the presence of a bladder wall interruption was associated with a significant higher risk of percreta (Odds ratio 3.23, Confidence interval 1.33-7.79). No magnetic resonance imaging sign was significantly correlated with the degree of severity.Conclusions: The performance of ultrasound and magnetic resonance imaging to discriminate mild from severe placenta accreta spectrum disorders is very poor. To date, the benefit of additional magnetic resonance imaging has not been demonstrated. [ABSTRACT FROM AUTHOR]

Introduction: Management options for women with placenta accreta spectrum (PAS) comprise termination of pregnancy before the viable gestational age, leaving the placenta in situ for subsequent reabsorption of the placenta or delayed hysterectomy, manual removal of placenta after vaginal delivery or during cesarean section, focal resection of the affected uterine wall, and peripartum hysterectomy. The aim of this observational study was to describe actual clinical management and outcomes in PAS in a large international cohort.Material and Methods: Data from women in 15 referral centers of the International Society of PAS (IS-PAS) were analyzed and correlated with the clinical classification of the IS-PAS: From Grade 1 (no PAS) to Grade 6 (invasion into pelvic organs other than the bladder). PAS was usually diagnosed antenatally and the operators performing ultrasound rated the likelihood of PAS on a Likert scale of 1 to 10.Results: In total, 442 women were registered in the database. No maternal deaths occurred. Mean blood loss was 2600 mL (range 150-20 000 mL). Placenta previa was present in 375 (84.8%) women and there was a history of a previous cesarean in 329 (74.4%) women. The PAS likelihood score was strongly correlated with the PAS grade (P < .001). The mode of delivery in the majority of women (n = 252, 57.0%) was cesarean hysterectomy, with a repeat laparotomy in 20 (7.9%) due to complications. In 48 women (10.8%), the placenta was intentionally left in situ, of those, 20 (41.7%) had a delayed hysterectomy. In 26 women (5.9%), focal resection was performed. Termination of pregnancy was performed in 9 (2.0%), of whom 5 had fetal abnormalities. The placenta could be removed in 90 women (20.4%) at cesarean, and in 17 (3.9%) after vaginal delivery indicating mild or no PAS. In 34 women (7.7%) with an antenatal diagnosis of PAS, the placenta spontaneously separated (false positives). We found lower blood loss (P < .002) in 2018-2019 compared with 2009-2017, suggesting a positive learning curve.Conclusions: In referral centers, the most common management for severe PAS was cesarean hysterectomy, followed by leaving the placenta in situ and focal resection. Prenatal diagnosis correlated with clinical PAS grade. No maternal deaths occurred. [ABSTRACT FROM AUTHOR]

Introduction: It has been suggested that women with obesity have increased risk of developing placenta accreta spectrum (PAS). It is unclear if this is independent of the increased risk of cesarean delivery seen with obesity itself. The aim of this study was to explore the association between maternal obesity and PAS, particularly severe PAS (percreta).Material and Methods: This is a cohort study based on cases recorded in the International Society for Placenta Accreta Spectrum (IS-PAS) database between April 2008 and May 2019. Multivariable logistic regression was used to explore the effect of maternal obesity on severity of PAS; this model was adjusted for other known risk factors including previous cesarean deliveries, maternal age, and placenta previa. The estimated rate of obesity in a hypothetical cohort with similar characteristics (previous cesarean delivery and same parity) was calculated and compared with the observed rate of obesity in the women of the PAS cohort (one sample test of proportions).Results: Of the 386 included women with PAS, 227 (58.8%) had severe disease (percreta). In univariable analysis, maternal obesity initially appeared to be associated with increased odds of developing the most severe type of PAS, percreta (odds ratio [OR] 1.87; 95% CI 1.14-3.09); however, this association was lost after adjustment for other risk factors including previous cesarean delivery (OR 1.44; 95% CI 0.85-2.44). There was no difference in the observed rate of obesity and the rate estimated based on the risk of cesarean delivery from obesity alone (31.3% vs 36.8%, respectively; P = .07).Conclusions: Obesity does not seem to be an independent risk factor for PAS or severity for PAS. These findings are relevant for clinicians to provide accurate counseling to women with obesity regarding increased risks related to pregnancy. [ABSTRACT FROM AUTHOR]

Introduction: Endometrial ablation encapsulates a range of procedures undertaken to destroy the endometrial lining of the uterus as a treatment for heavy menstrual bleeding in women who no longer wish to bear children. Pregnancy following ablation, while unlikely, can occur and may carry higher rates of complications. The aim of this study was to identify factors associated with post-endometrial ablation pregnancy and to describe pregnancy and birth outcomes for post-endometrial ablation pregnancies.Material and Methods: This population-based data linkage study included all female residents of New South Wales, Australia, aged 15-50 years with a hospital admission between July 2001 to June 2014 who birthed between July 2001 and June 2015. Cox proportional hazard regression was used to estimate associations between women's characteristics and post-endometrial ablation pregnancy of at least 20 weeks' gestation. Descriptive statistics were used to characterize pregnancy and birth outcomes.Results: Of 18 559 women with an endometrial ablation, 575 (3.1%) had a post-ablation pregnancy of at least 20 weeks' gestation. Nulliparity (adjusted hazard ratio [aHR] 12.2, 95% confidence interval [CI] 9.1-16.2), older age (35-39 years: aHR 0.39, 95% CI 0.29-0.51; 40-44 years: aHR 0.06, 95% CI 0.04-0.11), marital status (single: aHR 0.67, 95% CI 0.55-0.83; widowed/divorced/separated: aHR 0.58, 95% CI 0.36-0.94) and a diagnosis of heavy menstrual bleeding (aHR 0.09, 95% CI 0.07-0.13) were associated with post-ablation pregnancy. There were high rates of cesarean delivery (43%), preterm birth (13%), twin or higher order pregnancies (9%) and stillbirth (13.3/1000 births) among these post-ablation pregnancies.Conclusions: Nulliparity at the time of endometrial ablation is associated with increased risk of post-ablation pregnancy, highlighting the importance of careful discussion and consideration of treatment options for heavy menstrual bleeding. [ABSTRACT FROM AUTHOR]

Introduction: Massive hemorrhage due to placenta previa with placenta accreta spectrum is associated with high maternal mortality and morbidity. Therefore, accurate prediction of placenta previa with placenta accreta spectrum is essential; magnetic resonance imaging (MRI) is a useful tool for this purpose. This study investigated novel predictors of anterior and posterior placenta previa with placenta accreta spectrum using MRI. Material and methods: This was a retrospective study at a tertiary obstetrics hospital in Japan. The singleton patients with placenta previa who were scanned with MRI prenatally and had a cesarean section at our institution between 2007 and 2018 were included. The prediction of anterior and posterior placenta previa with placenta accreta spectrum was evaluated using four MRI findings: heterogeneous signals in the placenta, dark T2‐weighted intraplacental bands, myometrial thinning or interruption, and focal uterine bulging. The prediction of posterior placenta previa with placenta accreta spectrum was performed using the quantification of cervical varicosities, which were defined as the ratio of the distance between the minimum distance from the most dorsal cervical varicosities (a) to the deciduous and amniotic placenta (b) on a sagittal image. Results: Among 202 patients, 14 (6.9%) patients were pathologically diagnosed as having placenta accreta spectrum. Further, 38 (18.8%) patients had anterior placenta previa and 164 (81.2%) patients had posterior placenta previa. When anterior placenta previa with placenta accreta spectrum was predicted using at least one of the four MRI findings, the sensitivity and specificity of the anterior placenta previa with placenta accreta spectrum were 87.5% and 86.7%, respectively. In contrast, the sensitivity and specificity of posterior placenta previa with placenta accreta spectrum were 42.9% and 96.2%, respectively. But when the A/B ratio was set at 0.20, the sensitivity and specificity of the prediction for posterior placenta previa with placenta accreta spectrum using cervical varicosities were 100.0% and 89.2%, respectively. Conclusions: The findings of MRI to predict the anterior placenta previa with placenta accreta spectrum were different from posterior placenta previa. The cervical varicosities may be useful in predicting posterior placenta previa with placenta accreta spectrum. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study is to compare immediate and long-term obstetrical outcomes of patients who underwent cesarean delivery with and without uterine artery embolization (UAE) for the management of placenta accreta spectrum disorder.Material and Methods: A retrospective case control study including all pregnant women admitted to a single tertiary medical center between December 2001 and May 2018 with a diagnosis of placenta accreta spectrum disorder, who underwent cesarean delivery with and without UAE. Groups were compared for maternal characteristics, operative management, postoperative complication rate and long-term outcomes. Follow up on future obstetrical outcomes was conducted via telephone questionnaire. Non-parametric statistics were used.Results: During the study period, 272 women met the inclusion criteria: 64 (23.53%) and 208 (76.47%) underwent preservative cesarean section with and without UAE, respectively. UAE procedure was associated with a longer operative time (82.5 [68-110] vs 50.5 [39-77] minutes; P = .001), and higher blood loss (2000 (1500-3000) vs 1000 (600-2000) mL; P = .001). Hysterectomy rate was comparable between the groups (9 [14%] vs 35 [16.82%]; P = .88); however, multivariate logistic regression analysis found UAE to be an independent factor associated with lower hysterectomy rate (P = .02). Postoperative complications were more frequent in the UAE group. Follow up was achieved in 29 (59.18%) and 72 (51.79%) of the women with and without UAE, respectively (P = .36). No differences were found in rate of abortions, pregnancy and deliveries between the groups.Conclusions: Cesarean delivery using UAE in placenta accreta spectrum disorder is associated with a higher rate of operative and postoperative complications. Nevertheless, in cases of severe adherence of the placenta, embolization reduces the need for hysterectomy, allowing future fertility. [ABSTRACT FROM AUTHOR]

Introduction: Peripartum hysterectomy is a surgical procedure performed for severe obstetric complications such as major obstetric hemorrhage. The prevalence of peripartum hysterectomy in high-resource settings is relatively low. Hence, international comparisons and studying indications and associations with mode of birth rely on the use of national obstetric survey data. Objectives were to calculate the prevalence and indications of peripartum hysterectomy and its association with national cesarean section rates and mode of birth in nine European countries.Material and Methods: We performed a descriptive, multinational, population-based study among women who underwent peripartum hysterectomy. Data were collected from national or multiregional databases from nine countries participating in the International Network of Obstetric Survey Systems. We included hysterectomies performed from 22 gestational weeks up to 48 hours postpartum for obstetric hemorrhage, as this was the most restrictive, overlapping case definition between all countries. Main outcomes were prevalence and indications of peripartum hysterectomy. Additionally, we compared prevalence of peripartum hysterectomy between women giving birth vaginally and by cesarean section, and between women giving birth with and without previous cesarean section. Finally, we calculated correlation between prevalence of peripartum hysterectomy and national cesarean section rates, as well as national rates of women giving birth after a previous cesarean section.Results: A total of 1302 peripartum hysterectomies were performed in 2 498 013 births, leading to a prevalence of 5.2 per 10 000 births ranging from 2.6 in Denmark to 10.7 in Italy. Main indications were uterine atony (35.3%) and abnormally invasive placenta (34.8%). Relative risk of hysterectomy after cesarean section compared with vaginal birth was 9.1 (95% CI 8.0-10.4). Relative risk for hysterectomy for birth after previous cesarean section compared with birth without previous cesarean section was 10.6 (95% CI 9.4-12.1). A strong correlation was observed between national cesarean section rate and prevalence of peripartum hysterectomy (ρ = 0.67, P < .05).Conclusions: Prevalence of peripartum hysterectomy may vary considerably between high-income countries. Uterine atony and abnormally invasive placenta are the commonest indications for hysterectomy. Birth by cesarean section and birth after previous cesarean section are associated with nine-fold increased risk of peripartum hysterectomy. [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]

In cases other than PAS, if a patient is informed that some planned surgeries may cause high morbidities and even mortality, they may choose "no surgery" and opt for alternative treatments. Women having experienced life-threatening perinatal events are considered at high risk of later psychological disorders, especially post-traumatic stress disorder (PTSD). Considering that there is no choice but to receive PAS surgery, and PAS surgery sometimes is accompanied by severe morbidities and even mortality, detailed information may not improve, or even worsen, the patient's psychological condition. [Extracted from the article]

For the children, fetal and neonatal risks were also higher in twins than in singletons, and included congenital anomalies, preterm birth, low birthweight, admission to neonatal intensive care unit, perinatal mortality, and stillbirth.[2] Moreover, the transfer of multiple embryos increases the risk of major congenital anomalies, small for gestational age, low birth weight, and preterm birth in singleton births.[3] To date, studies with longer follow up have been lacking. Although the mode of conception was not investigated, assisted reproductive technology treatments were involved in 24.1% of twin pregnancies vs 1.7% of singleton pregnancies. Twin pregnancies have a higher maternal and perinatal morbidity, when compared with singleton pregnancies. [Extracted from the article]

Introduction: We aimed to determine predictive factors for severe hypocalcemia in women with placenta accreta spectrum.Material and Methods: Study of 123 women with histology-proven placenta accreta spectrum with cesarean hysterectomy between 2011 and 2017. Two groups were selected: Cases: critically low ("panic value") serum total calcium (≤7 mg/dL) and Controls: normal serum total calcium (≥8.5 mg/dL). Regression and receiver operating characteristic (ROC) analyses were performed to evaluate the potential associations.Results: There were 13 women with critically low (cases) and 18 with normal calcium (controls). Baseline characteristics were not statistically different. The median estimated blood loss, units of red blood cells (RBCs) transfused and volume of crystalloid transfused, were higher in the low calcium group. Six out of 13 (46.2%) cases had received ≥4 units of RBCs during surgery vs 2 of 18 (11.1%) controls (P = 0.04). ROC analysis showed that estimated blood loss, units of RBCs transfused, and crystalloid transfused were associated with severe hypocalcemia and univariate regression analysis confirmed that estimated blood loss ≥1500 mL, RBC transfusion ≥4 units, and crystalloid transfused ≥4L were associated with severe hypocalcemia.Conclusions: Intraoperative transfusion of ≥4 units RBCs is predictive of the development of severe hypocalcemia in placenta accreta spectrum patients experiencing active bleeding. Empiric replacement of 1 g CaCL2 is recommended for every 4 U RBC transfused. [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]

GLO:23B/01jan23:aogs14484-fig-0001.jpg PHOTO (COLOR): 1 Schematic presentation of the opening the bladder technique or sandwich excision in patients with placenta percreta with bladder invasion. a: Engorged vessels are usually present at the vesicouterine plica and around the bladder top. In either hysterectomy or uterus-preserving surgery, extensive bladder separation injures the engorged vessels, causing marked bleeding (Figure 1a).[[3]] Thus, without attempting to extensively separate the bladder, the bladder wall should be cut (intentional cystotomy; "opening the bladder") (Figure 1b).[[1], [4]] In hysterectomy, the invaded bladder wall should be cut without uterine-wall-resection. In anterior PAS, the placenta usually exists in the uterus-bladder interface-space, and vessels at the vesicouterine plica and around the bladder top are engorged: its extreme end is observed in placenta percreta with bladder invasion. [Extracted from the article]

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]

We appreciate the comments by Nieto-Calvache and Aryananda regarding the proposal for the surgical classification of placenta accreta spectrum disorders (PASD), which may be useful to triage the necessity of endovascular intervention.1 To identify patients who may benefit from arterial occlusion at cesarean hysterectomy for PASD, Nieto-Calvache and colleagues previously proposed a PASD topographic classification and surgical staging by the following two-step approach: (a) antenatal evaluation of the ultrasonographic or magnetic resonance imaging findings, and (b) intraoperative evaluation of parametrial and vesico-uterine space.2 As lower placental implantation and invasion into the parametrium and/or bladder pose distinct technical surgical challenges, this two-step evaluation may predict the surgical difficulty of cesarean hysterectomy.3 We agree that this system can be useful to evaluate the severity of PASD to triage the necessity for endo-arterial occlusion. In fact, Nieto-Calvache et al. successfully decreased the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) without increasing intraoperative blood loss using this two-step evaluation.2 Based on these findings, the authors considered the use of REBOA only in severe PASD cases but not for mild cases to avoid the adverse events related to REBOA. Minimizing surgical blood loss at cesarean hysterectomy for placenta previa with evidence of placenta increta or placenta percreta: the state of play in 2020. [Extracted from the article]

The study also highlighted the association of PAS with the need for transfusion.9 It is noteworthy that all of the cases meeting clinical criteria, and the majority of those meeting histologic criteria, were cases of FIGO PAS grade 1. In this issue of I AOGS i , Ishibachi et al. report on whether FIGO PAS grading was predictive of clinical outcomes in a cohort of women with placenta previa. Placenta accreta spectrum (PAS), a condition of deeply adherent placental villi into the myometrium (and sometimes beyond) has seen a dramatic increase in clinical prevalence (as well as academic inquiry) in recent years. [Extracted from the article]

Cesarean section in women with placenta previa is associated with the risk of heavy bleeding. We describe a new method where local hemostasis is obtained by applying a hemostatic fleece directly onto the lower uterine segment. During a 2-year period women undergoing cesarean section due to placenta previa were treated with this hemostatic fleece if they had ongoing bleeding during the surgical procedure despite routine treatment. Data were obtained retrospectively from the hospital records. Fifteen patients were treated by 15 different surgeons. No patients required reoperation. Three patients required blood transfusion due to anemia. No patients were readmitted to the hospital due to endometritis. We conclude that the application of a hemostatic fleece directly onto the bleeding surfaces in patients with post-cesarean bleeding due to placenta previa is technically unproblematic. The results suggest that this procedure should be considered in case of bleeding after delivery in women with placenta previa. [ABSTRACT FROM AUTHOR]

Background: : Placental abruption, placenta previa, and preeclampsia are serious pregnancy complications with an increased risk of perinatal death. Smoking during pregnancy is associated with increased risk of abruption and placenta previa, and it reduces the risk of preeclampsia. We examined the association between mothers' smoking habits during pregnancy, taking the sex of the offspring into consideration, and the risk and prognosis of placental abruption, placenta previa, and preeclampsiaMethods: : We conducted the study in the County of North Jutland, Denmark. Using the 10-digit personal identification number given to every Danish citizen at birth, we linked data from the Danish Medical Birth Registry, including information on mother and child, to data from the Pharmaco-Epidemiological Prescription Database with data on all reimbursed prescriptions to use selected drugs as a proxy measure for some maternal diseases, and data from the Regional Hospital Discharge Registry, including the discharge diagnoses. Among 47,932 singleton births we included only births for which we had information about the mothers' smoking habits, leaving 46,313 births for analysis.Results: : Smoking was associated with the risk of placental abruption (OR=1.99 (95% CI 1.72-2.30)) and placenta previa (OR=1.88 (95% CI 1.15-3.07)). Smoking was inversely associated with the risk of preeclampsia (OR=0.55 (95% CI 0.48-0.62)). After stratification for the sex of the offspring the risk estimate of smoking as risk factor for placenta previa decreased for male fetuses (OR=1.63 (95% CI 0.75-3.51)) and increased for female fetuses (OR=4.82 (95% CI 1.69-13.75)).Conclusion: : Female fetuses are more vulnerable than male to the negative effect of maternal smoking on placenta previa. [ABSTRACT FROM AUTHOR]

Objective. To evaluate secular trends in the occurrence of placenta previa and whether placenta previa is associated with the outcome of previous pregnancies, cesarean section, and sociodemographic factors. Design. A cohort study based on the Medical Birth Registry of Norway. Placenta previa in the second pregnancy was investigated for associations with outcomes in the first pregnancy and sociodemographic factors. Results. In birth orders 1 and 2 the occurrence of placenta previa was 1.2 and 2.2 per 1000, respectively, with no secular trend. The occurrence increased with maternal age and was lowest in women aged 20–29 years. The recurrence rate was 23 per 1000 (adjusted odds ratio (OR) of recurrence=9.7). In women with prior delivery at ≤25 gestational weeks the risk of placenta previa was 6.7 per 1000 (adjusted OR=3.0). In women with prior placental abruption the risk was 5.8 per 1000 (OR=2.6). In women with prior perinatal death the risk was 4.4 per 1000 (adjusted OR=1.8). No independent relationship emerged with socio-economic factors, previous birthweight, and a history of pregnancy induced hypertension. Cesarean section was associated with subsequent development of placenta previa (adjusted OR=1.3). Conclusions. We found no secular trends in the occurrence of placenta previa. Placenta previa is associated with previously described risk factors for placental abruption. The increased risk of placenta previa subsequent to placental abruption supports the theory of a shared etiologic factor. However, placenta previa and placental abruption do not share a common etiology in relation to a history of pregnancy induced hypertension, fetal growth retardation, and socio-economic factors. [ABSTRACT FROM AUTHOR]

Examines the changes of placental bed biopsy in placenta previa. Prevalence of trophoblastic giant cell migration on myometrium; Complication of placenta previa; Assessment on histopathological changes.

As explained in the Material and methods, the serum calcium level was measured before, during, and after placenta accreta spectrum (PAS) surgery. 1 Levin G, Rottenstreich A. Bleeding during surgery for placenta accreta spectrum - empiric replacement of calcium is doubtful. [Extracted from the article]

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]

Presents the case of an unexpected fundal hiatus discovered in unscarred uterus at emergency cesarean section in a twin pregnancy without labor. Suggestion of a chronic event with the expulsion of the second twin through the defect at a later date; Death of fetuses in utero.

The article discusses the relationship between the transplacental approach and fetal or neonatal anemia among pregnant women with placenta previa (PP). Topics discussed include the requirements that need to be satisfied for a transplacental approach to be used, the perinatal and neonatal outcomes for PP with and without the use of the transplacental approach and the assertion that the transplacental approach can be used in cases wherein the chances of an abnormally invasive placenta are low.

We thank Dr. Matsubara and colleagues(1) for commenting on our study, "Patient selection for later delivery timing with suspected previa-accreta."(2) We particularly appreciate the emphasis on individualized patient care, and that access (or lack thereof) to a tertiary center with experience in managing abnormally invasive placenta (AIP) is of paramount importance when considering delivery timing. This article is protected by copyright. All rights reserved. [ABSTRACT FROM AUTHOR]

The article examines whether abdominal or vaginal route is better when inserting the catheter during cesarean section for placenta previa. It describes some practical measures that the author usually use during cesarean section for placenta previa. It also illustrates how the abdominal approach is better than the vaginal approach.

A letter to the editor is presented in response to the article "Male Fetal Sex Is Associated With Earlier Onset of Placental Abruption," by M. Tikkanen, M. Metsaranta, M. Gissler, V. Hiilesmaa, O. Ylikorkala, J. Paavonen et al in a 2010 issue of the journal.

Comments on M. Ogawa and colleagues' case report about a method of transfundal vertical incision for placenta previa percreta in a woman with two previous cesarean deliveries. Diagnosis of placenta previa percreta; Reduction of bleeding and morbidity of placenta percreta; Etiology of placenta percreta; Treatment methods.

A response by Shigeki Matsubara to a letter to the editor about their article "Important Surgical Measures and Techniques at Cesarean Hysterectomy for Placenta Previa Accreta" in the 2013 issue is presented.

A letter to the editor is presented in response to the article "Important Surgical Measures and Techniques at Cesarean Hysterectomy for Placenta Previa Accreta" by S. Matsubara and colleagues in the 2013 issue.

A letter to the editor is presented about a case of aortic dissection in a Marfan syndrome patient with total placenta previa.