Objective To determine which interventions for managing placenta accreta were associated with reduced maternal morbidity.Design Retrospective cohort study.Setting Two tertiary care teaching hospitals in Utah.Population All identified cases of placenta accreta from 1996 to 2008.Methods Cases of placenta accreta were identified using standard ICD-9 codes for placenta accreta, placenta praevia, and caesarean hysterectomy. Medical records were then abstracted for maternal medical history, hospital course, and maternal and neonatal outcomes. Maternal and neonatal complications were compared according to antenatal suspicion of accreta, indications for delivery, preoperative preparation, attempts at placental removal before hysterectomy, and hypogastric artery ligation.Main outcome measures Early morbidity (prolonged maternal intensive care unit admission, large volume of blood transfusion, coagulopathy, ureteral injury, or early re-operation) and late morbidity (intra-abdominal infection, hospital re-admission, or need for delayed re-operation).Results Seventy-six cases of placenta accreta were identified. When accreta was suspected, scheduled caesarean hysterectomy without attempting placental removal was associated with a significantly reduced rate of early morbidity compared with cases in which placental removal was attempted (67 versus 36%, P = 0.038). Women with preoperative bilateral ureteric stents had a lower incidence of early morbidity compared with women without stents (18 versus 55%, P = 0.018). Hypogastric artery ligation did not reduce maternal morbidity.Conclusions Scheduled caesarean hysterectomy with preoperative ureteric stent placement and avoiding attempted placental removal are associated with reduced maternal morbidity in women with suspected placenta accreta.

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Rickets (rachitic pelvis) was a common cause of death in childbirth in industrialized nations at the turn of the 20th century and associated with a steep rise in cesarean section rates. The addition of vitamin D to milk caused the virtual disappearance of rickets, but recent reports suggest that vitamin D deficiency is now widespread in industrialized nations. In 2 previous studies, a high incidence of vitamin D deficiency was found in pregnant and lactating women. Another study reported that 50% of mothers and 65% of newborns infants were severely vitamin D deficient (25-hydroxyvitamin D [25(OH)D: Ͻ30 nmol/L]) at the time of birth despite drinking vitamin D fortified milk and taking a prenatal vitamin D supplement. It is possible that deficiency of this vitamin may play a role in the nearly 50% increase in primary cesarean sections in the last decade.This study investigated the association between serum concentrations of maternal vitamin D (serum 25(OH)D) at birth and the frequency of primary cesarean section among 253 women enrolled at an urban teaching hospital. Demographic and medical data were obtained from maternal medical records. Maternal serum 25(OH)D was measured within 72 hours of delivery. Serum 25(OH)D was a proxy for vitamin D status. Maternal vitamin D deficiency was defined as serum 25(OH)D less than 37.5 nmol/L (15 ng/mL). Multivariable logistic regression analysis was used to adjust the data for several variables, including race, age, education level, insurance status, and alcohol use.Of the 253 study subjects, 43 (17%) had a primary cesarean section. The frequency of cesarean section and levels of serum 25(OH)D had an inverse association. In unadjusted analysis, more than twice as many women with serum 25(OH)D less than 37.5 nmol/L had a primary cesarean section compared to those with 25(OH)D 37.5 nmol/L or greater (P ϭ 0.012). Multivariate logistic regression analysis showed that a primary cesarean section in women with vitamin D deficiency was nearly 4 times more likely compared to women without deficiency (adjusted OR, 3.84; 95% CI, 1.71-8.62).These findings show a clear association between vitamin D deficiency and increased likelihood of primary cesarean section and suggest the need for a randomized trial to determine whether additional vitamin supplementation could reduce the cesarean section rate. EDITORIAL COMMENT(The abstracted article of Merewood et al was simply too provocative to pass up. Without statistical adjustment, women with vitamin D concentrations of Ͻ37.5 nmol/L (i.e., deficiency as defined by the Centers for Disease Control and Prevention) were twice as likely to undergo primary cesarean as women with higher vitamin D concentrations, 28% versus 14%. With adjustment for potential confounders, they were almost 4 times as likely! The authors enthusiastically conclude that "A randomized clinical trial is now needed to determine whether adequate vitamin D supplementation during pregnancy to raise blood levels of 25(OH)D above at least 37.5 nmol/L can reduce the cesarean section ...

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease, which, despite the advances in immunosuppressive medical therapies, remains potentially fatal in some patients, especially in treatment-refractory patients. This study found that transplantation of umbilical cord mesenchymal stem cells (UC-MSCs) has the same therapeutic effect as transplantation of bone marrow mesenchymal stem cells (BM-MSCs), which has been reported to be efficient in treating SLE-related symptoms in MRL/lpr mice. Multi-treatment (at the 18th, 19th, and 20th weeks of age) of 1 × 10(6) UC-MSCs was able to decrease the levels of 24-h proteinuria, serum creatinine, and anti-double-stranded DNA (dsDNA) antibody, and the extent of renal injury such as crescent formation in MRL/lpr mice. A lower, but still significant, reduction in these parameters was also observed in mice receiving a single dose of UC-MSCs (at the 18th week). UC-MSCs treatment also inhibited expression of monocyte chemotactic protein-1 (MCP-1) and high-mobility group box 1 (HMGB-1) expression in a similar fashion. UC-MSCs labeled with carboxyfluorescein diacetate succinimidyl ester (CFSE) were found in the lungs and kidneys 1 week post infusion. In addition, after 11 weeks post UC-MSCs infusion, human cells were found in kidney of UC-MSCs-treated mice. These findings indicated that UC-MSCs transplantation might be a potentially promising approach in the treatment of lupus nephritis, possibly by inhibiting MCP-1 and HMGB-1 production.

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