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      Clinical risk factors for placenta previa–placenta accreta

      , ,
      American Journal of Obstetrics and Gynecology
      Elsevier BV

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          Abstract

          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 < 0.0001). Among women with placenta previa, advanced maternal age (> 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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          PLACENTA ACCRETA, 1945–1969

          H. Fox (1972)
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            Stepwise uterine devascularization: a novel technique for management of uncontrolled postpartum hemorrhage with preservation of the uterus.

            The objective of this study was to test the efficacy of a novel stepwise technique of uterine devascularization for management of uncontrollable postpartum hemorrhage. Stepwise uterine devascularization was performed for 103 patients to control intractable postpartum hemorrhage not responding to classic management. This technique entails five successive steps, so if bleeding is not controlled by one step the next step is taken until bleeding stops. The steps were (1) unilateral uterine vessel ligation, (2) bilateral uterine vessel ligation, (3) low uterine vessel ligation, (4) unilateral ovarian vessel ligation and (5) bilateral ovarian vessel ligation. The procedure was effective in all cases (100%), and hysterectomy was not needed in any case. No complications occurred, and the survival rate was 100%. Among the patients followed up normal menstruation and pregnancy occurred. Stepwise uterine devascularization is an effective and safe alternative to hysterectomy for management of uncontrollable postpartum hemorrhage.
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              Emergency peripartum hysterectomy.

              By means of hospital-based data over 9 years we sought to evaluate the clinical indications and incidence of emergency peripartum hysterectomy by demographic characteristics and reproductive history. From the obstetric records of all deliveries at Brigham and Women's Hospital between Oct. 1, 1983, and July 31, 1991, we identified all women undergoing emergency peripartum hysterectomy, calculated crude and adjusted incidence rates, conducted statistical tests of linear trends and heterogeneity, and observed the clinical indications preceding the onset of this procedure. There were 117 cases of peripartum gravid hysterectomy identified during this period, for an overall annual incidence of 1.55 per 1000 deliveries. The rate increased with increasing parity and was significantly influenced by placenta previa and a history of cesarean section. The incidence by parity increased from one in 143 deliveries in nulliparous women with placenta previa to one in four deliveries in multiparous women with four or more deliveries with placenta previa. Likewise, the incidence increased from one in 143 deliveries in women with one prior live birth and a prior cesarean section to one in 14 deliveries in multiparous women with four or more deliveries with a history of a prior cesarean section. Both these trends were highly significant (p < 0.001). Abnormal adherent placentation was the most common cause preceding gravid hysterectomy (64%, p < 0.001), with uterine atony accounting for 21%. Although no maternal deaths occurred, maternal morbidity remained high, including postoperative infection in 58 (50%), intraoperative urologic injury in 10 patients (9%), and need for transfusion in 102 patients (87%). The data identify abnormal adherent placentation as the primary cause for gravid hysterectomy. The data also illustrate how the incidence of emergency peripartum hysterectomy increases significantly with increasing parity, especially when influenced by a current placenta previa or a prior cesarean section. Maternal morbidity remained high although no maternal deaths occurred.
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                Author and article information

                Journal
                American Journal of Obstetrics and Gynecology
                American Journal of Obstetrics and Gynecology
                Elsevier BV
                00029378
                July 1997
                July 1997
                : 177
                : 1
                : 210-214
                Article
                10.1016/S0002-9378(97)70463-0
                9240608
                89d1eb4b-ed36-44ca-ae4a-187ef304bd73
                © 1997

                https://www.elsevier.com/tdm/userlicense/1.0/

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