Uterine sutures at prior caesarean section and placenta accreta in subsequent pregnancy: a case–control study

Abstract

Objective To clarify the effects of uterine myometrial suture techniques at prior caesarean section on the incidence of pathologically diagnosed placenta accreta in placenta praevia with prior caesarean section (PPPC).Design Case-control study.Setting Eleven tertiary referral hospitals in central Japan.Population A total of 98 cases of placenta praevia, a history of one or more prior caesarean sections, and a history of uterine transverse incision and usage of only absorbable thread for myometrial sutures at the prior caesarean section. Exclusions were a history of myomectomy or Strassmann's operation.Methods Cases were grouped into a pathologically diagnosed placenta accreta group (38 cases) and a no accreta group (60 cases). Clinical characteristics including uterine suture methods at prior caesarean section were compared (single-layer versus double-layer closure; continuous versus interrupted sutures in the inner myometrial layer).Main outcome measure The incidence of placenta accreta.Results No difference was found comparing single-layer with double-layer closure in the incidence of placenta accreta (37.1 versus 39.7%, P = 0.805); however, a significant difference was found comparing continuous with interrupted sutures (58.1 versus 29.9%, P = 0.008). Multivariable logistic regression analysis with stepwise selection for the eight factors meeting the criterion of P < 0.10 in univariate analysis was used, and four independent factors were selected, as follows: gravidity ≥ 3 (adjusted odds ratio, aOR, 3.4, 95% confidence interval, 95% CI, 0.99-11.6, P = 0.050); total praevia (versus non-total, aOR 18.4, 95% CI 3.2-107.0, P = 0.001); anterior/centre placenta (versus posterior, aOR 16.4, 95% CI 3.7-72.2, P < 0.001); and continuous sutures (versus interrupted, aOR 6.0, 95% CI 1.4-25.2, P = 0.015).Conclusions In this limited study, a history of continuous sutures on the inner side of the uterine wall showed potential to influence the development of placenta accreta in PPPC patients.

Interpregnancy interval and abnormally invasive placentation

“…10 The conclusion was that there was no significant difference in interpregnancy interval and risk of AIP; however, these women were not matched by location of placenta and it is therefore difficult to interpret these results. 10 Another study by Wax et al, which was underpowered, sought to determine cesarean to conception interval and the effect on development of abnormally adherent placenta. 11 They concluded that cesarean to conception mean intervals are shorter in women with abnormally adherent placentas (35 months) vs controls (48 months); however, this was not statistically significant.…”

Surgical techniques at caesarean might modify placenta accreta risk

“…2 The explanation by Sumigama et al that 'it is the incomplete healing and insufficiency of the endometrium that may allow villous invasion, and once myometrium has been invaded, further invasion cannot be prevented' seems unsound. 1 The endometrium does not heal end-to-end or form a bond (over a period of up to 12 months?). 1 Moreover, the trophoblastic invasion of myometrium occurs in all pregnancies, not just with placenta accreta.…”

“…1 The endometrium does not heal end-to-end or form a bond (over a period of up to 12 months?). 1 Moreover, the trophoblastic invasion of myometrium occurs in all pregnancies, not just with placenta accreta. Nonetheless, their article does focus our attention to thinking about the effect of the surgical techniques of uterine incision closure on the subsequent scar integrity.…”

Possible Association between Cathepsin V and the Development of Placenta Accreta Spectrum Disorders

“…Several risk factors are established such as previous uterine surgery, placenta previa, multiparity, advanced maternal age, previous endometritis, and so on [3][4][5]. When one previous cesarean section was complicated with placenta previa, the incidence rate of placenta accreta was reported to be 11-37%, showing further increases with an increased number of prior cesarean deliveries (over 60% in previa with 3 or more prior cesarean deliveries) [6][7][8][9].…”