Correlation of An Ultrasonic Scoring System and Intraoperative Blood Loss in Placenta Accreta Spectrum Disorders: A Retrospective Cohort Study

Objective This study aims to investigate the correlation of an ultrasonic scoring system with intraoperative blood loss(IBL) in placenta accreta spectrum(PAS) disorders.Methods A retrospective cohort study was conducted between January 2015 and November 2019.Clinical data for patients with PAS have been obtained from medical records. Generalized additive models were used to explore the nonlinear relationships between ultrasonic scores and IBL. Logistic regressions were used to determine the differences in the risk of IBL ≥ 1,500 m L among groups with different ultrasonic scores.Results A total of 332 patients participated in the analysis. Generalized additive models showed a significant positive correlation between score and blood loss. The amount of IBL was increased due to the rise in the ultrasonic score. All cases were divided into three groups according to the scores(low score group: ≤ 6 points, n = 147;median score group: 7-9 points, n = 126;and high score group: ≥ 10 points, n = 59). Compared with the low score group, the high score group showed a higher risk of IBL≥ 1,500 m L [odds ratio, 15.09;95% confidence interval(3.85, 59.19);P ≤ 0.001] after a multivariable adjustment.Conclusions The risk of blood loss equal to or greater than 1,500 m L increases further when ultrasonic score greater than or equal to 10 points, the preparation for transfusion and referral mechanism should be considered.

Application of Abdominal Aortic Balloon Occlusion Combined with Tourniquet in Pregnant Women with Severe Placenta Accreta Spectrum

Objective Abdominal aortic balloon occlusion(AABO)is a vascular intervention method that has been widely used in the treatment of severe placenta accreta spectrum(PAS).The aim of this study was to investigate the benefits,potential risks,and characteristics of AABO combined with tourniquet binding of the lower uterine segment(LUS)in treatment of pregnant women with PAS.Methods In this study,64 pregnant women with PAS scores greater than 5 were enrolled as research subjects and divided into two groups.Group A(n=34)underwent normal operative procedures including tourniquet binding of the LUS.Group B(n=30)underwent AABO combined with tourniquet binding of the LUS.General clinical characteristics,ultrasonography PAS score,intraoperative blood loss(IBL),blood loss within 24 h after surgery(24-h BL),postoperative complications,and neonatal data of the two groups were retrospectively reviewed.The influencing factors of IBL for the two groups were analyzed.Results The amounts of IBL,24-h BL,total input red blood cell,and the incidence of disseminated intravascular coagulation were significantly lower in group B than in group A(P<0.05),and this difference was even more significant in the subgroup of placenta percreta(PAS scores≥10).Further multivariate linear analysis showed that the combined therapy of AABO and tourniquet could independently predict lower IBL than normal operative procedures did(P=0.001).Conclusion AABO combined with tourniquet binding of the LUS could improve the outcomes of pregnant women with severe PAS and reduce serious peripartum complications of AABO.

A Seven-Step Approach to Control Severe Hemorrhage in Cesarean Delivery with the Placenta Accreta Spectrum Disorders Avoiding Hysterectomy

Objectives: To describe a novel procedure to treat hemorrhage of placenta accreta spectrum disorders (PAS) or cesarean-scar pregnancy (CSP). Methods: This was a retrospective study of women under cesarean delivery with PAS or placenta previa. Patients’ information was acquired from hospital records. A novel procedure of surgery is developed with seven major steps, including avoiding placenta incised, elevating upward the uterine, clamping the uterine arteries with sponge forceps, removing the placenta, opening the vesicouterine space and suture techniques. Results: A total of 38 patients were reviewed. Twenty-one patients diagnosed with placenta accrete syndrome and 3 patients with CSP were underwent surgery with the novel procedure of surgery and all severe hemorrhage was controlled without hysterectomy. There were 2 women with bladder injuries needing primary repair. Fourteen patients with placenta previa underwent cesarean delivery and there was no intraoperative complication of the total 14 patients. Conclusion: The seven-step approach is more secure and effective to control severe hemorrhage without other invasive procedures in cesarean delivery with PAS. It is technically easier to maintain and improve surgical skills.

Fazari’s Sign in Ultrasound Scan of Morbid Adherent Placenta/Placenta Accreta Spectrum (MAP/PAS) and Fazari’s Triad during (MAP/PAS) Surgery

Morbid Adherent Placenta (MAP)/Placenta Accreta Spectrum (PAS) is a serious diagnosis which has a risk of complications. Ultrasound scan helps in early diagnosis and has great value in further confirmation and follow up. Observed new clinical sign and associated clinical triad are discussed here.

Matrix Metalloproteinase-9 in the Etiopathogenesis of Placenta Accreta Spectrum:A Literature Review

The recent increase in placenta accreta spectrum has been correlated with a rise in the rate of cesarean sections.A recent study provides evidence that hampered wound healing results in cesarean scar defects that lead to a failure in the normal process of decidualization and deeper adherence of trophoblasts.Matrix metalloproteinase(MMP)is crucial in every step of wound healing as it alters the wound matrix,facilitating cell migration,as well as tissue remodeling.MMP-9 expression is higher in placental and decidual tissue in cases of placenta accreta.Based on these findings,assessment of MMP-9 expression can shed new light on the etiopathology of placenta accreta spectrum disorder and can be a potential diagnostic marker.

Posterior Placenta Accreta Spectrum Disorders:Risk Factors,Diagnostic Accuracy,and Surgical Management

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.

腹主动脉球囊阻断术与改良后子宫血管阻断术在胎盘植入性疾病患者再次剖宫产中的应用比较

目的研究预置腹主动脉球囊阻断术与改良后子宫血管阻断术在前置胎盘伴胎盘植入性疾病再次剖宫产中的应用效果。方法选取2016年4月至2022年12月在合肥市妇幼保健院行再次剖宫产手术治疗的前置胎盘伴胎盘植入性疾病的瘢痕子宫患者97例。术前行腹主动脉球囊阻断术48例为对照组,术中行改良后子宫血管阻断术49例为观察组。观察比较两组患者术中、术后情况。结果观察组的术后行双侧子宫动脉栓塞术数、人均住院费用均小于对照组,差异均有统计学意义(P<0.05);两组的术中平均出血量、输注红细胞悬液量、子宫切除率、膀胱破裂率差异无统计学意义(P>0.05)。结论两种手术方式在完全性前置胎盘伴胎盘植入患者的再次剖宫产手术治疗中均能有效减少术中出血,而使用改良后子宫血管阻断术,未出现血管介入手术并发症,无需X线暴露,母儿安全性高,同时降低了住院费用,具有临床推广潜力。

子宫动脉结扎联合腹主动脉球囊阻断术在胎盘植入性疾病剖宫产术中的应用

目的 :探讨子宫动脉结扎联合腹主动脉球囊阻断术在胎盘植入性疾病(placenta accreta spectrum disorders,PAS)剖宫产术中的有效性和有安全性。方法 :将83例PAS剖宫产产妇随机分为观察组(n=42)和对照组(n=41)。对照组给予腹主动脉球囊阻断剖宫产术,观察组给予子宫动脉结扎联合腹主动脉球囊阻断剖宫产术。比较2组手术相关指标和并发症。结果 :观察组手术时间长于对照组,术中出血量、术后24 h总出血量少于对照组,术后血红蛋白差值小于对照组(均P <0.05),并发症发生率低于对照组(4.76%vs 19.51%,χ^(2)=4.260,P=0.028)。结论 :子宫动脉结扎联合腹主动脉球囊阻断术有助于降低PAS剖宫产产妇术中及术后出血量,减少产后出血等并发症的发生。

子宫动脉血流联合多参数对胎盘植入性疾病的诊断价值研究

目的探讨子宫动脉血流联合多参数在胎盘植入性疾病诊断中的应用价值。方法本研究为回顾性队列研究,选取2017年1月—2021年12月就诊于首都医科大学附属北京妇产医院且诊断为前置胎盘的孕妇为研究对象。通过医院电子病历系统获取孕妇的一般资料、既往史、产检信息[子宫动脉搏动指数(pulsatility index,PI)和胎盘超声征象等]、手术信息。根据手术结果将其分为胎盘植入组与非植入组。分析子宫动脉PI值联合剖宫产史及超声征象诊断胎盘植入性疾病的价值。结果共纳入符合标准的前置胎盘孕妇80例,其中植入组34例,非植入组46例。与非植入组相比,植入组孕妇的年龄(P=0.017)、剖宫产史(P<0.001)均显著升高,子宫动脉平均PI值显著降低(P=0.006),胎盘后低回声带局部中断或消失(P<0.001)、胎盘后丰富血流(P<0.001)、子宫-膀胱交界线中断/消失/不规则(P=0.003)等超声征象均具有显著性差异;子宫动脉PI值、剖宫产史、超声征象三者联合诊断胎盘植入性疾病的ROC曲线下面积为0.96(95%CI:0.93~0.99),灵敏度为97.06%(95%CI:91%~100%),特异度为65.22%(95%CI:51%~79%)。结论子宫动脉血流PI值联合多参数预测胎盘植入性疾病的灵敏度较高,有助于早期发现胎盘植入性疾病并及早进行干预。

基于磁共振T2WI影像组学模型对胎盘植入性疾病进行产前诊断及分型

目的探讨基于磁共振T2WI的影像组学模型在产前预测胎盘植入性疾病(placenta accreta spectrum disorders,PAS)及其亚型的应用价值。材料与方法回顾性分析了2018年1月至2023年1月在北京妇产医院住院分娩的193例单胎妊娠孕妇数据,其中PAS 134例,非PAS 59例,所有患者根据同一分型的总数按2∶1的比例随机划分为训练集和测试集。在T2WI序列图像提取影像组学特征,Pearson相关系数和最小绝对收缩和选择算子(least absolute shrinkage and selection operator,LASSO)回归用于特征筛选,基于筛选后的特征构建PAS预测模型。然后,计算便于临床应用的影像组学评分评估PAS分型,使用单因素分析与多因素分析进一步分析其他潜在的临床危险因素,包括年龄、孕周、此前孕次、此前产次、此前剖宫产次数、胎盘问题(前置胎盘)和既往子宫手术史,选择临床主要风险因素建立基于影像组学评分和临床特征的临床-影像组学模型并绘制诺莫图。通过受试者工作特征(receiver operating characteristic,ROC)曲线下面积(area under the curve,AUC)评估模型的预测性能,采用DeLong检验比较模型间的预测效能,校准曲线用于评估预测模型的校准程度,决策曲线用于评估预测模型临床价值。结果在T2WI序列图像上提取了806个影像组学特征,经过Pearson相关分析后保留147个影像组学特征,经LASSO回归处理后筛选出10个影像组学特征,基于影像组学特征构建影像组学模型。影像组学模型的训练集AUC值为0.933(95%CI:0.888~0.978),准确率为88.37%,敏感度为88.78%,特异度为87.10%,阳性预测值(positive predictive value,PPV)为95.60%,阴性预测值(negative predictive value,NPV)为71.05%;测试集AUC值为0.914(95%CI:0.835~0.993),准确率为89.06%,敏感度为90.91%,特异度为85.00%,PPV为90.00%,NPV为80.95%。校准曲线和决策曲线表明模型具有较高性能和潜在临床应用价值。影像组学评分对穿透性胎盘植入具有较强的识别能力,训练集和测试集准确率分别为82.95%、89.06%,敏感度和NPV在训练集和测试集都达到了100.00%,特异度分别为81.35%、88.33%。同时,本研究成功构建了临床-影像组学模型并绘制诺莫图用于可视化预测患者的PAS,训练集中临床-影像组学模型的AUC值为0.969(95%CI:0.946~0.993),测试集中AUC值为0.976(95%CI:0.947~1.000)。DeLong检验测试结果表明两模型性能存在显著性差异(P<0.05),临床-影像组学模型具有更好的性能表现。结论基于临床特征及影像组学评分构建的临床-影像组学模型预测效能较好,可作为产前预测是否存在PAS的方法。且影像组学评分对PAS亚型具有较好的鉴别能力,尤其是对于穿透性胎盘植入。

双绒毛膜双胎之一胎盘植入性疾病临床及超声征象分析(附7例报道)

目的探讨双绒毛膜双胎之一胎盘植入性疾病(placenta accreta spectrum,PAS)的高危因素及产前超声征象。方法回顾性选取2013年1月至2023年4月首都医科大学附属北京妇产医院双绒毛膜双胎之一PAS患者7例,总结患者临床资料及超声声像图特点。结果7例患者年龄31~52岁,中位年龄37岁,均合并3种及以上高危因素。4例产前经超声诊断PAS,存在胎盘植入的典型征象,3例产前超声漏诊,均无剖宫产手术史;4例双活胎,经剖宫产分娩,3例双胎之一胚胎停育;2例术中出血量为8000 ml及3500 ml,行全子宫切除术,余5例保留子宫。结论双绒毛膜双胎妊娠孕妇合并前置胎盘、剖宫产史、高龄及体外受精-胚胎移植等高危因素时,发生PAS的风险增高。规范产前超声检查可提高双绒毛膜双胎之一PAS早期检出率,改善妊娠结局。

基于MRI征象及临床因素的评分系统预测胎盘植入性疾病的价值

目的:探讨基于MRI征象及临床因素的评分系统预测胎盘植入性疾病(PAS)的应用价值。方法:回顾性分析132例孕妇的临床及MRI资料,其中非PAS组80例,PAS组52例(其中黏连型胎盘植入(PA)亚组25例、植入型胎盘植入(PI)/穿透型胎盘植入(PP)亚组27例)。采用5分评分法对MRI征象及临床因素进行评分。统计分析各参数的组间差异性以及与PAS的相关性,采用ROC曲线分析各个相关参数对PAS的诊断效能。利用二元Logistics回归分析构建MRI+临床诊断模型,并运用ROC曲线分析该模型的诊断效能。结果:两位医师对MRI征象评分的一致性极好(ICC>0.9,P<0.05)。孕次评分、产次评分、子宫手术史评分、胎盘位置评分、11个征象总分及7个共识征象总分在非PAS组与PAS组间差异具有统计学意义并均与PAS呈正相关性(P<0.05),其中7个共识征象总分相关性最高(r=0.635)。孕次评分、产次评分、子宫手术史评分、胎盘位置评分、11个征象总分及7个共识征象总分预测PAS的ROC曲线下面积(AUC)分别为0.625、0.684、0.778、0.741、0.868、0.875(P<0.05)。ROC曲线分析结果显示,MRI+临床诊断模型预测PAS组与非PAS组、非PAS组与PA亚组、PA亚组与PI/PP亚组的AUC分别为0.892、0.795、0.871(P<0.05)。结论:基于MRI及临床相关因素的评分系统可以较准确地预测PAS及其植入深度,具有较高的应用价值。

基于超声征象和临床高危因素的风险模型预测凶险性前置胎盘术中严重出血的临床价值

目的基于超声征象和临床高危因素构建风险模型,探讨其预测凶险性前置胎盘患者术中严重出血的临床价值。方法选取凶险性前置胎盘患者80例,根据术中出血量分为轻型出血组(出血量<1000 ml)27例和重型出血组(出血量≥1000 ml)53例,比较两组超声征象、临床高危因素的差异。采用二元Logistic回归分析筛选预测凶险性前置胎盘患者术中严重出血的独立危险因素并构建风险模型;绘制受试者工作特征曲线分析其预测凶险性前置胎盘患者术中严重出血的诊断效能。结果轻型出血组中,无胎盘植入性疾病12例(44.44%),胎盘粘连13例(48.15%),胎盘植入2例(7.41%);重型出血组中,胎盘粘连11例(20.76%),胎盘植入24例(45.28%),胎盘穿透18例(33.96%)。共7例行子宫切除术,均为重型出血组患者。轻型出血组与重型出血组剖宫产次数、胎盘后间隙、胎盘陷窝、子宫膀胱交界面血流、膀胱线及宫颈受累情况比较,差异均有统计学意义(均P<0.05)。二元Logistic回归分析显示,剖宫产次数和子宫膀胱交界面血流均为预测凶险性前置胎盘患者术中严重出血的独立危险因素(OR=10.560、15.831,均P<0.05);由此构建的风险模型预测凶险性前置胎盘患者术中严重出血的曲线下面积为0.805,其与子宫膀胱交界面血流的曲线下面积(0.768)均高于剖宫产次数的曲线下面积(0.632),差异均有统计学意义(均P<0.05)。结论基于剖宫产次数和子宫膀胱交界面血流构建的风险模型在预测凶险性前置胎盘患者术中严重出血中有较好的临床价值。

GNA13在侵入性胎盘植入性疾病中的表达及临床价值

目的:探讨鸟嘌呤核苷酸结合蛋白α亚基13(GNA13)在侵入性胎盘植入性疾病(PAS)妊娠晚期外周血和胎盘中的表达及意义。方法:采用病例对照的研究方法,选择2021年9月至2023年6月在广西医科大学第一附属医院产科住院剖宫产并经临床和病理诊断为PAS的32例患者作为研究对象(PAS组),以分娩孕周、胎盘位置、剖宫产史及是否合并内科疾病为条件,匹配同期非PAS剖宫产孕妇32例作为对照组。应用酶联免疫吸附试验(ELISA)检测孕妇血清GNA13水平,免疫组化(IHC)和蛋白免疫印迹法(western blotting)检测胎盘GNA13的表达。受试者工作特征曲线(ROC)分析GNA13的诊断效能。结果:PAS组外周血中GNA13表达水平显著高于对照组(P<0.05)。ROC曲线下面积(AUC)为0.734(95%CI:0.593~0.876),血GNA13辨别PAS的最佳阈值为201.53 ng/mL,灵敏度为96%,特异度为52%。GNA13定位于胎盘绒毛滋养层细胞。PAS组胎盘GNA13表达显著低于对照组(P<0.05)。结论:GNA13具有成为侵入性PAS的产前预测指标的潜力。PAS滋养细胞侵袭、迁移能力增强可能与GNA13低表达有关。

PAS产前超声分级系统及子宫动脉超声参数在凶险性前置胎盘患者术前评估中的价值

目的评估胎盘植入性疾病(PAS)产前超声分级系统及子宫动脉超声参数在凶险性前置胎盘患者术前评估中的用价值。方法选取2020年2月—2022年11月三亚市妇幼保健院收治的92例凶险性前置胎盘患者作为研究对象,根据PAS产前超声分级将患者分为≤PAS-4组(1~4级)和>PAS-4组(5、6级),其中≤PAS-4组患者52例,>PAS-4组患者40例。比较两组患者一般临床资料、超声指标特征,采用多因素一般Logistic回归模型分析其在凶险性前置胎盘患者术前评估中的应用价值。结果≤PAS-4组既往剖宫产次数少于>PAS-4组,完全性凶险型比例低于>PAS-4组,血流搏动指数(PI)、血液流动阻力(RI)高于>PAS-4组(P<0.05)。≤PAS-4组子宫膀胱间高度血管化、胎盘后高度血管化、局部组织外生、胎盘陷窝支流血管、胎盘增厚、宫颈膨大、胎盘后间隙消失比例低于>PAS-4组(P<0.05)。多因素一般Logistic回归分析结果显示:PI高[O^R=0.961(95%CI:0.848,0.983)]、RI高[O^R=0.867(95%CI:0.839,0.923)]、既往剖宫产次数多[O^R=4.568(95%CI:2.012,7.609)]均是凶险性前置胎盘患者PAS产前超声分级>4级的影响因素(P<0.05)。联合预测凶险性前置胎盘患者PAS产前超声分级>4级的曲线下面积最高,为0.929(95%CI:0.881,0.977),其次为既往剖宫产次数;RI敏感性最高,为0.910(95%CI:0.711,0.953),其次为PI;联合预测特异性最高,为0.956(95%CI:0.727,0.975),其次为既往剖宫产次数。结论PI、RI、既往剖宫产次数指标在术前对凶险性前置胎盘PAS 4级以上患者有较好的预测价值,为术前制订手术方案提供了可靠的依据,可降低此类患者的手术并发症风险。

MRI征象预测胎盘植入患者不良妊娠结局的临床价值

随着胎盘植入谱系疾病发生率的上升,胎盘植入的产前诊断以及如何精确判断疾病凶险程度、完善手术方案等问题需要解决。因此,如何更好的使用影像学方法预测胎盘植入患者不良妊娠结局,是值得深入研究的一个问题。本文就MRI征象对各类不良妊娠结局预测的临床价值进行综述。

胎盘植入性疾病的相关影响因素分析及预测

目的研究胎盘植入性疾病(placenta accreta spectrum,PAS)的相关影响因素。方法选取2013年1月1日至2022年10月31日于杭州市西溪医院分娩的154例PAS的孕妇作为观察组,选取同期154例非PAS的孕妇作为对照组。通过单因素及多因素Logistic回归模型分析PAS的相关影响因素。绘制受试者操作特征曲线(receiver operating characteristic curve,ROC曲线)了解模型的区分度。结果多因素Logistic回归分析结果显示孕妇的年龄、孕次、人工流产史、孕早期保胎史、剖宫产手术史、辅助生殖、前置胎盘是影响PAS的独立危险因素(P<0.05)。胎盘植入发生的联合预测模型的ROC曲线下面积为0.726(95%CI:0.670~0.783)。结论独立危险因素联合预测PAS的发生具有一定的临床指导意义。加强孕前、孕期检查,及早发现和筛查有高危因素的孕妇并尽早干预,对于减少PAS的发生及母婴并发症具有重要意义。

Distinct Placenta Increta and Percreta in the Setting of Dichorionic Diamniotic Twin Gestation: A Unique Histological Finding

Multiple gestations have been reported as a risk factor for placenta accreta spectrum (PAS) but the evidence is limited. Previous reports showed that PAS degrees (creta, increta, percreta) were similar in multiple gestation placentas. To our knowledge, there have been no reports of PAS in dichorionic placentas with different degrees of invasion. Here, we report dichorionic diamniotic placentas with two different degrees of invasion, one increta and another percreta.

Blood Consumption in Placental Abnormalities

Introduction: Hemorrhage is one of the most common causes of maternal morbidity and mortality. This study was conducted to investigate how much abnormal placentation can affect blood bank capacity and to measure the burden on the blood bank caused by excessive use of blood and blood products. Methodology: This is a retrospective study conducted at King Saud Medical City Maternity Hospital in Riyadh, Kingdom of Saudi Arabia, from January 2019-September 2020. It includes 170 cases diagnosed with abnormal placentation (low-lying placenta or placenta previa, accreta, increta, or percreta). The primary purpose was to measure consumption of blood and blood products in cases of placental abnormalities and to investigate how much this affects blood bank capacity. A secondary aim was to report rates of admission to the ICU and maternal mortality. Results: This study included 170 women with placental abnormalities. Placental previa had occurred in 96 cases, followed by placenta accreta in 46 cases, placenta increta in 13 cases, placenta percreta in 8 cases, and low-lying placenta in 7 cases. Most patients (93) were treated with a Bakri balloon to prevent hemorrhage, but 38 patients had a hysterectomy. The average estimation of blood loss was 2210 ml, with no maternal mortality. An average of 3.39 units of packed red blood cells (PRBC) with a maximum of 20 units, 2.12 units of fresh frozen plasma (FFP) with a maximum of 20 units, and 0.7 units of packed platelets (PP) with maximum of 12 units consumed per patient. Eighty-seven patients (51.2%) were admitted to the ICU and 83 others (48.8%) were admitted to the high dependency unit. Conclusion:<span style="font-family: "> Blood and blood product volumes had a linear relationship with the severity of placental abnormalities and estimated blood loss. Therefore, blood bank services should be available to save mothers’ life.

Placenta Percreta with Bladder Invasion:Delayed Bladder Bleeding After Hysterectomy

Placenta percreta is a rare condition,which can lead to significant morbidity and potentially,mortality.This paper discusses two cases of complete placenta previa with placenta percreta invading the urinary bladder.Both patients underwent caesarean hysterectomy and experienced delayed bladder bleeding postoperatively.