Search

We describe a novel surgical technique in 31 women with histopathologically confirmed placenta accreta spectrum (PAS) disorders managed by a multidisciplinary team using a prophylactic infrarenal abdominal aortic cross-clamping technique during caesarean hysterectomy. We conclude that this new surgical procedure is a relatively safe technique to potentially control operative blood loss. Our work may stimulate others to develop protocols assessing this innovative technique to improve the surgical outcome of PAS disorders., (© 2020 John Wiley & Sons Ltd.)

Placenta accreta is a pregnancy complication characterized by the presence of life-threatening uteroplacental neovascularization. The factors involving its development are unknown. Vascular endothelial growth factor (VEGF), placenta growth factor (PlGF) and their receptors (VEGFR) have important roles in vascular remodeling. We have investigated the differential expression of these proteins in placentae from placenta accreta (cases) and normal placentation (controls). Immunohistochemically, the expression of VEGFR-2 in the syncytiotrophoblast was significantly lower in cases than in controls during both the second and third trimesters (P = 0.005 and 0.002, respectively). However, VEGFR-2 expression in the cytotrophoblastic and extravillous trophoblastic cells and VEGFR-1, -3 and Ki-67 in the trophoblast populations were not significantly different between controls and cases (P > 0.05). Ki-67 immunostaining also showed that endothelial cells of the larger vessels were stained weaker in normal placenta than in placenta accreta. The majority of VEGFR-2 expression, as demonstrated by Western blot or reverse transcription polymerase chain reaction, was consistent with the immunohistochemical findings in the syncytiotrophoblast. Furthermore, enzyme-linked immunosorbent assay in the placental lysates showed that the women with placenta accreta demonstrated significantly higher VEGF (P = 0.001) and lower soluble VEGFR-2 (P = 0.015) concentrations than did women with normal pregnancy. PlGF and soluble VEGFR-1 levels did not show any significance in study groups (P > 0.05). These observations suggest that the participation of up-regulated VEGF and down-regulated VEGFR-2 (both membrane-bound and soluble forms) may be associated with the development of placenta accreta.

Objective: The aim of this study was to evaluate the efficacy of transabdominal color Doppler ultrasound in diagnosing placenta previa accreta., Design: Eighty patients with persistent placenta previa underwent transabdominal B-mode and color Doppler ultrasound evaluation in the second and third trimesters because they had a high risk of placenta accreta. Color Doppler imaging criteria used included diffuse intraparenchymal placental lacunar flow; focal intraparenchymal placental lacunar flow; bladder-uterine serosa interphase hypervascularity; prominent subplacental venous complex; and loss of subplacental Doppler vascular signals. The color Doppler images were interpreted prospectively for signs of placenta previa accreta according to the exhibited color Doppler sonographic features., Results: Sixteen of the 80 patients exhibited characteristic color Doppler imaging patterns highly specific for placenta accreta according to the preceding criteria, and 14 of these had histopathological proof of placenta accreta. Two patients had false-positive color Doppler imaging evidence mistaken for interphase hypervascularity caused by bladder varices. Thirteen patients underwent hysterectomy in the group suspicious for accreta. Of the 64 patients with negative color Doppler imaging results, three had placenta accreta, while two required cesarean hysterectomy; the remaining patient underwent uterine artery ligation for bleeding from the lower uterine segment. The sensitivity of color Doppler imaging in the diagnosis of placenta previa accreta was 82.4% (14/17) and the specificity was 96.8% (61/63). The positive and negative predictive values were 87.5% (14/16) and 95.3% (61/64), respectively., Conclusions: Variable vascular morphological patterns of placenta previa accreta were exhibited and categorized by transabdominal color Doppler sonography in the antenatal period. The identification of these specific vascular patterns had a positive impact on the peripartum clinical management of the affected patients.

A case of placenta previa accreta was diagnosed at 28 weeks' gestation with use of power amplitude ultrasonic angiography, which showed an unusually intense blood flow within the placental sonolucent spaces and hypervascularity within the placental and surrounding tissues. High-velocity (> or = 15 cm/sec) turbulent venous-type flow was detected within the placental blood lakes, and prominent low-impedance (resistance index 0.24) arterial blood flow was detected within the uterine serosa-posterior bladder wall boundary zone. An uneventful cesarean hysterectomy was performed at 32 weeks' gestation, and histopathologic examination revealed placenta previa increta.

We describe a novel surgical technique in 31 women with histopathologically confirmed placenta accreta spectrum (PAS) disorders managed by a multidisciplinary team using a prophylactic infrarenal abdominal aortic cross‐clamping technique during caesarean hysterectomy. We conclude that this new surgical procedure is a relatively safe technique to potentially control operative blood loss. Our work may stimulate others to develop protocols assessing this innovative technique to improve the surgical outcome of PAS disorders. [ABSTRACT FROM AUTHOR]

Among several surgical techniques for the aforementioned conditions, the first strategy is a primary caesarean hysterectomy and partial cystectomy for scenario 1 and an extended hysterectomy with radical parametrectomy procedure for scenario 2. Authors' response Re: Some concerns regarding aortic cross-clamping in caesarean hysterectomy for placenta accreta spectrum (Re: Vascular control by infrarenal aortic cross-clamping in placenta accreta spectrum disorders: description of technique; something old, something new & something borrowed) I Sir, i We thank Matsubara and Fox for their insightful comments1,2 on our article.3 We agree with their point that the infrarenal aortic cross-clamping technique for placenta accreta spectrum (PAS) disorder ideally should be evaluated by well-designed, high-quality, prospective randomised controlled studies. [Extracted from the article]

Balloon occlusion of the infrarenal abdominal aorta theoretically provides the same level of pelvic perfusion blockage as our approach.3 A major disadvantage of this procedure is that the catheter must be placed before commencing the surgery,3 which may not be possible if a prenatal diagnosis of PAS disorder has not been made. I Sir, i We thank Nieto-Calvache et al. for their insightful comments1 on our article.2 We agree with their point that the choice of vascular control techniques should be determined by the topography and severity of placenta accreta spectrum (PAS) disorders. Authors' reply re: Vascular control by infrarenal aortic cross-clamping in placenta accreta spectrum disorders: description of technique. [Extracted from the article]