Maternal Outcome After Conservative Treatment of Placenta Accreta

Abstract

P erinatal asphyxia, a major cause of neonatal and childhood death and morbidity (eg, hypoxic ischemic encephalopathy, seizures, intraventricular hemorrhage, cerebral palsy, and delayed development), is predicted by fetal acidosis measured by umbilical cord pH at birth. The cord pH (about <7.00) and base deficit (about Z12 mmol/L) levels commonly used to judge risk, were derived by consensus, and the longterm implications of a low arterial cord pH are uncertain. Despite this, cord pH values are commonly used as an outcome measure in obstetric clinical trials, are a benchmark for judging obstetricians' clinical performance, and are used to support medicolegal claims of harm due to intrapartum events that might lead to long-term child disability. The authors of this systematic review and meta-analysis evaluated more closely the association between umbilical cord pH readings at birth and short-term and long-term childhood outcomes.Data were obtained from Medline, Embase, the Cochrane Library (2008 issue 8), and Medion, without language restrictions. Reference lists of selected articles were recorded, follow-up contact with authors was performed and review articles, the SIGLE, Web of Science, the national research register, and medical conferences register were all examined. Eligible studies were those (cohort, case-controlled, review) in which cord pH at birth was compared with any neonatal or long-term outcome. Criteria for inclusion also included a study population of >5 subjects in whom cord blood was obtained at birth, performance of an index test (cord blood examined for arterial or venous pH or base excess); a recording of outcomes (any measure of compromise of neonatal or childhood well-being); and inclusion of a study design that allowed generation of a 2 Â 2 table to compute estimates of associations between test results and outcomes. The primary outcome measures were neonatal mortality, an author created composite of neonatal morbidity, and cerebral palsy.A total of 51 primary articles (with 481,753 infants) were found, with widely variable design, quality, outcome definition, and results. Meta-analyses carried out within predefined groups from 43 studies showed that low arterial cord pH was significantly associated with neonatal mortality [odds ratio (OR), 16.9; 95% confidence interval (CI), 9.7-29.5]; hypoxic ischemic encephalopathy (OR, 13.8; 95% CI, 6.6-28.9); intraventricular hemorrhage or periventricular leukomalacia (OR, 2.9; 95% CI, 2.1-4.1); and cerebral palsy (OR, 2.3; 95% CI, 1.3-4.2). Longterm (1 to 8 y) adverse outcomes found in 15 studies included cerebral palsy, unspecified neurologic abnormalities, intelligent quotient (IQ) deficits, and developmental problems.

Leaving the placenta in situ versus conservative and radical surgery in the treatment of placenta accreta spectrum disorders

“…This shortcoming is common among all studies reporting these cases. 4,17,20 In conclusion, leaving the placenta in situ in cases of PAS disorder could be the management approach of choice not only for patients who want to retain their uterus and fertility, but also for patients with invasive placenta who are at increased risk of surgical morbidity.…”

“…The basic principle of the approach is to avoid the placenta while performing uterine incision and manipulating the uterus after the delivery of the neonate. In one of the largest retrospective series including 167 cases, Sentilhes et al17 reported that 78.4% of women retained their uteruses. However, 21.6% of women underwent primary or delayed hysterectomy, and ten patients experienced serious morbidity such as sepsis, vesico-uterine fistula, and uterine necrosis.…”

Surgical management of placenta accreta: to leave or remove the placenta?

“…11,13,70 Conservative management of placenta accreta Conservative, uterine-sparing approaches for the management of placenta accreta have been described to both reduce the morbidity of peripartum hysterectomy as well as allow for future fertility in selected women. 30,[74][75][76][77][78][79] For women with placenta accreta managed conservatively, the uterus is closed after delivery and the placenta is left in situ. A number of different approaches including uterine artery embolisation, methotrexate therapy, haemostatic sutures, pelvic devascularisation, and balloon tamponade have been described, with varying rates of success.…”

“…75 One large series reported a success rate of 78%, with a rate of maternal morbidity of 6%. 77 In that study, which included 167 women from 25 hospitals in France, 78% retained their uterus, just 18 women required a hysterectomy within 24 hours of delivery because of haemorrhage, and 18 women underwent hysterectomy within 3 months of delivery because of complications. Ten women experienced severe morbidity, including sepsis, vesicouterine fistula, and/or uterine necrosis.…”

“…The mean time to conception was 17.3 months after treatment; however, there was a 28.6% recurrence of placenta accreta. 77…”