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      Nonremoval of an abnormally invasive placenta at cesarean section with postoperative uterine artery embolization

      , , , ,
      Acta Obstetricia et Gynecologica Scandinavica
      Wiley-Blackwell

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          Abnormal placentation: twenty-year analysis.

          This study was undertaken to determine whether the rate of abnormal placentation is increasing in conjunction with the cesarean rate and to evaluate incidence, risk factors, and outcomes. Cases from 1982-2002 were identified by histopathologic or strong clinical criteria. Risk factors were assessed in a matched case-control study, and analyzed using conditional logistic regression models. There were 64,359 deliveries, with cesarean rates increasing from 12.5% (1982) to 23.5% (2002). The overall incidence of placenta accreta was 1 in 533. Significant risk factors for placenta accreta in our final analysis included advancing maternal age (odds ratio [OR] 1.13, 95% CI 1.089-1.194, P < .0001), 2 or more cesarean deliveries (OR 8.6, 95% CI 3.536-21.078, P < .0001), and previa (OR 51.4, 95% CI: 10.646-248.390, P < .0001). The rate of placenta accreta increased in conjunction with cesarean deliveries; the most important risk factors were previous cesarean delivery, previa, and advanced maternal age.
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            Clinical risk factors for placenta previa-placenta accreta.

            Our purpose was to define the clinical risk factors associated with placenta previa-placenta accreta. Hospital records were reviewed of all cases of placenta accreta confirmed histologically between January 1985 and December 1994. Additionally, we reviewed the records of all women with placenta previa and all those undergoing cesarean hysterectomy during the same period. Multiple logistic regression analysis was used to identify independent clinical risk factors for placenta accreta. Among 155,670 deliveries, 62 (1/2510) were complicated by histologically confirmed placenta accreta. Placenta accreta occurred in 55 of 590 (9.3%) women with placenta previa and in 7 of 155,080 (1/22,154) without placenta previa (relative risk 2065, 95% confidence interval 944 to 4516, p or = 35 years) and previous cesarean delivery were independent risk factors for placenta accreta. Placenta accreta was present in 36 of 124 (29%) cases in which the placenta was implanted over the uterine scar and in 4 of 62 (6.5%) cases in which it was not (relative risk 4.5, 95% confidence interval 1.68 to 12.07). Among women with placenta previa, the risk of placenta accreta ranged from 2% in women < 35 years old with no previous cesarean deliveries to almost 39% in women with two or more previous cesarean deliveries and an anterior or central placenta previa. Placenta accreta occurs in approximately 1 of 2500 deliveries. Among women with placenta previa, the incidence is nearly 10%. In this high-risk group advanced maternal age and previous cesarean section are independent risk factors.
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              The management of placenta percreta: conservative and operative strategies.

              Our purpose was to assess preferences for the management of placenta percreta and identify aspects of care related to an improved outcome. Both an analysis of a questionnaire issued to members of the Society of Perinatal Obstetricians and a retrospective study at our institution were used to obtain case histories of women with placenta percreta during a recent 3-year period. Fifty-five of the 109 cases (50%) reported by members of the Society of Perinatal Obstetricians were suspected ante partum. Complications associated with this disorder included uterine rupture (3 cases), transfusion of > 10 units (44 cases, 40%), ureteral ligation or fistula formation (5 cases each, 5%), infection (31 cases, 28%), perinatal death (10 cases, 9%), and maternal death (8 cases, 7%). Management options included surgical removal of the uterus and involved tissues (101 cases, 93%) and conservative treatment with the placenta left in situ after delivery (8 cases, 7%). More members of the Society of Perinatal Obstetricians responding to our survey opted for conservative management if adjacent tissues were involved (69% with extension into the bladder or gastrointestinal tract) compared with 31% when the percreta was confined to the uterus, p < 0.001. Conservative therapy was also associated with less blood loss in reported cases (median units red blood cells transfused, 0 vs 7, p = 0.003). Two of the three cases of placenta percreta at our institution were identified ante partum. The third case represents the first reported with antepartum identification of percreta followed by deliberate conservative treatment. With greater involvement of surrounding tissues, conservative treatment was preferred in hemodynamically stable patients. If surgical excision of the placenta is attempted or necessary, physicians experienced in pelvic dissection must be involved because of the frequency of maternal morbidity and mortality.
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                Author and article information

                Journal
                Acta Obstetricia et Gynecologica Scandinavica
                Acta Obstet Gynecol Scand
                Wiley-Blackwell
                00016349
                November 2013
                November 07 2013
                : 92
                : 11
                : 1250-1255
                Article
                10.1111/aogs.12230
                23937444
                6ea9e602-1183-4444-8839-beeefd11b456
                © 2013

                http://doi.wiley.com/10.1002/tdm_license_1.1

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