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ObjectivesIntraoperative hemorraghe and peripartum hysterectomy are the main complications in patients presenting with a low‐lying or placenta previa undergoing repeat cesarean delivery. Patients with a high probability of placenta accreta spectrum (PAS) at birth also have a higher risk of intraoperative urologic injuries and the aim of this study was to evaluate the ultrasound signs and intraoperative features associated with these injuries.MethodsThis was a retrospective case–control study of consecutive singleton pregnancies included in a prospective cohort of patients with a history of at least one prior cesarean delivery (CD) and were diagnosed prenatally with an anterior low‐lying or placenta previa at 32‐36 weeks. All patients underwent investigational preoperative transabdominal and transvaginal ultrasound examinations within 48h prior to delivery. Ultrasound anomalies of uterine contour and utero‐placental vascularity and gross anomalies of the lower uterine segment (LUS) and surrounding pelvic tissue at delivery were recorded using a standardised protocol including the evaluation of the size of anomalies of uterine contour. The diagnosis of PAS was established when one or more placental lobule(s) could not be digitally separated from the uterine wall at delivery or during the gross examination of the hysterectomy or partial myometrial resection specimens, confirmed by histopathology. Data were compared between cases complicated by intraoperative urologic injuries and three controls from the same cohort matched by parity and the number of prior cesarean deliveries using conditional logistic regression.ResultsThere were 16 (9.4%) patients with an intraoperative bladder injury out of a cohort of 170 patients managed by the same multidisciplinary team during the study period. There were no patients diagnosed with ureteric or bladder trigone damage. Fourteen patients (87.5%) with a bladder injury had histopathologic evidence of PAS at birth including 11 (68.8%) cases described on microscopic examination as placenta increta and three as placenta creta. There was a significant (p= 0.03) difference between cases and controls in the distribution of the intraoperative LUS vascularity with the higher the number of enlarged vessels the higher the odds ratio (OR) of bladder injury. The multivariable regression analysis revealed that both gestational age and LUS remodelling on transabdominal ultrasound were associated with a bladder injury. A longer gestational age was associated with a lower risk of an injury. A higher LUS remodelling grade on TAS was associated with an increased risk of bladder injury. Patients with a grade of 3 (involving > 50% of the LUS) had odds of a bladder injury that were 9 times higher than for patients with a grade of 1 (involving < 30% of the LUS).ConclusionsPreoperative ultrasound examination is useful in the evaluation of the risk of the intraoperative bladder injury in patients with a history of prior CD presenting with a low‐lying or placenta previa. The larger the remodelling of the LUS on transabdominal ultrasound the higher the risk of adverse urologic events.This article is protected by copyright. All rights reserved.
ObjectivesIntraoperative hemorraghe and peripartum hysterectomy are the main complications in patients presenting with a low‐lying or placenta previa undergoing repeat cesarean delivery. Patients with a high probability of placenta accreta spectrum (PAS) at birth also have a higher risk of intraoperative urologic injuries and the aim of this study was to evaluate the ultrasound signs and intraoperative features associated with these injuries.MethodsThis was a retrospective case–control study of consecutive singleton pregnancies included in a prospective cohort of patients with a history of at least one prior cesarean delivery (CD) and were diagnosed prenatally with an anterior low‐lying or placenta previa at 32‐36 weeks. All patients underwent investigational preoperative transabdominal and transvaginal ultrasound examinations within 48h prior to delivery. Ultrasound anomalies of uterine contour and utero‐placental vascularity and gross anomalies of the lower uterine segment (LUS) and surrounding pelvic tissue at delivery were recorded using a standardised protocol including the evaluation of the size of anomalies of uterine contour. The diagnosis of PAS was established when one or more placental lobule(s) could not be digitally separated from the uterine wall at delivery or during the gross examination of the hysterectomy or partial myometrial resection specimens, confirmed by histopathology. Data were compared between cases complicated by intraoperative urologic injuries and three controls from the same cohort matched by parity and the number of prior cesarean deliveries using conditional logistic regression.ResultsThere were 16 (9.4%) patients with an intraoperative bladder injury out of a cohort of 170 patients managed by the same multidisciplinary team during the study period. There were no patients diagnosed with ureteric or bladder trigone damage. Fourteen patients (87.5%) with a bladder injury had histopathologic evidence of PAS at birth including 11 (68.8%) cases described on microscopic examination as placenta increta and three as placenta creta. There was a significant (p= 0.03) difference between cases and controls in the distribution of the intraoperative LUS vascularity with the higher the number of enlarged vessels the higher the odds ratio (OR) of bladder injury. The multivariable regression analysis revealed that both gestational age and LUS remodelling on transabdominal ultrasound were associated with a bladder injury. A longer gestational age was associated with a lower risk of an injury. A higher LUS remodelling grade on TAS was associated with an increased risk of bladder injury. Patients with a grade of 3 (involving > 50% of the LUS) had odds of a bladder injury that were 9 times higher than for patients with a grade of 1 (involving < 30% of the LUS).ConclusionsPreoperative ultrasound examination is useful in the evaluation of the risk of the intraoperative bladder injury in patients with a history of prior CD presenting with a low‐lying or placenta previa. The larger the remodelling of the LUS on transabdominal ultrasound the higher the risk of adverse urologic events.This article is protected by copyright. All rights reserved.
IntroductionAccurate discrimination between placenta accreta spectrum (PAS) and scar dehiscence with underlying non‐adherent placenta is challenging both on prenatal ultrasound and intraoperatively. This can lead to overdiagnosis of PAS and unnecessarily aggressive management of scar dehiscence which increases the risk of morbidity. Several scoring systems have been published which combine clinical and ultrasound information to help diagnose PAS in women at high risk. This research aims to provide insights into the reliability and utility of existing accreta scoring systems in differentiating these two closely related but different conditions to contribute to improved clinical decision making and patient outcomes.Material and MethodsA literature search was performed in four electronic databases. The references of relevant articles were also assessed. The articles were then evaluated according to the predefined inclusion criteria. Primary data for testing each scoring system were obtained retrospectively from two hospitals with specialized PAS services. Each scoring system was used to evaluate the predicted outcome of each case.ResultsThe literature review yielded 15 articles. Of these, eight did not have a clearly described diagnostic criteria for accreta, hence were excluded. Of the remaining seven studies, one was excluded due to unorthodox diagnostic criteria and two were excluded as they differed from the other systems hindering comparison. Four scoring systems were therefore tested with the primary data. All the scoring systems demonstrated higher scores for high‐grade PAS compared to scar dehiscence (p < 0.001) with an excellent Area Under the receiver operator characteristic Curve ranging from 0.82 (95% CI 0.71–0.92) to 0.87 (95% CI 0.79–0.96) in differentiating between these two conditions. However, no statistically significant differences were noted between the low‐grade PAS and scar dehiscence on all scoring systems.ConclusionsMost published scoring systems have no clearly defined diagnostic criteria. Scoring systems can differentiate between scar dehiscence with underlying non‐adherent placenta from high‐grade PAS with excellent diagnostic accuracy, but not for low‐grade PAS. Hence, relying solely on these scoring systems may lead to errors in estimating the risk or extent of the condition which hinders preoperative planning.
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