Search Results (95)

Background: Placenta accreta spectrum (PAS) refers to the abnormal placental implantation into the uterine wall, and its incidence is rising in parallel with increasing cesarean deliveries and myomectomies. PAS carries high maternal risks, including hemorrhage, shock, and death. Management involves either a hysterectomy or conservative approaches to preserve fertility that come with higher risks of maternal morbidity and mortality. Radiofrequency ablation (RFA) is a well-established modality for treating soft tissue tumors, but its use for PAS is not well studied. Case: We report a case of successful postpartum treatment of placenta accreta with transcervical radiofrequency ablation, which preserved uterine integrity and resolved significant bleeding without postoperative complications. Conclusions: Transcervical RFA may offer a safe and minimally invasive treatment for placenta accreta that conserves the uterus and may maintain reproductive capacity. Full article

This narrative review presents an updated overview of the etiology, pathophysiology, diagnostic approaches, and management strategies for Placenta Accreta Spectrum (PAS), with emphasis on clinical implications and current gaps in evidence. PAS is associated with substantial maternal morbidity and mortality, with reported maternal mortality rates approaching 7%. Affected patients often experience prolonged hospitalization, repeated surgical interventions, and long-term psychological and emotional consequences. The development of PAS is primarily attributed to impaired decidualization in areas of uterine scarring, resulting in abnormal adherence or invasion of chorionic villi into the myometrium. Optimal outcomes in high-risk pregnancies depend on early antenatal identification using characteristic pathological and imaging findings. Current evidence supports planned cesarean hysterectomy as the safest and most definitive treatment for most patients, whereas conservative and uterus-preserving approaches should be reserved for carefully selected cases managed in specialized centers. Further progress in PAS management requires standardized diagnostic criteria, prospective evaluation of conservative strategies, and improved access to multidisciplinary expertise. Full article

Background: Placenta accreta spectrum (PAS) is a serious obstetric condition characterized by abnormal placental adherence to the uterus that can lead to major maternal morbidity. While hysterectomy has traditionally been the standard management, uterus-preserving approaches are increasingly used to preserve fertility. The risk of recurrent PAS in subsequent pregnancies and the overall fertility outcomes following conservative management remain unclear. Objective: We aimed to estimate the recurrence risk of PAS in subsequent pregnancies after conservative management and to assess fertility outcomes, including pregnancy and live-birth rates. Methods: This systematic review and meta-analysis followed PRISMA guidelines. A comprehensive literature search was performed across multiple databases to identify studies reporting subsequent pregnancies after conservative PAS management. Data extraction and quality assessment were independently conducted. Pooled recurrence and pregnancy success rates were calculated using random-effects meta-analysis. Results: Eleven studies met the inclusion criteria, involving 2642 patients who underwent conservative PAS management. The pooled recurrence risk of PAS in subsequent pregnancies was 20.9% (95% CI: 12.2–29.6). Successful pregnancy rates following conservative treatment were 69.7% (95% CI: 49.9–89.5). Conclusions: While conservative PAS management poses a risk of recurrence, it remains a viable fertility-preserving option, with high subsequent pregnancy success rates. These findings support informed clinical decision-making, though further prospective studies are needed to optimize management strategies and patient outcomes. Full article

Background/Objectives: Placenta accreta spectrum (PAS) is associated with substantial maternal and perinatal morbidity and may lead to respiratory distress in newborns. However, limited evidence exists regarding predictors of respiratory compromise (RC) in neonates born to pregnancies complicated by PAS. Methods: This retrospective cohort study included neonates born to pregnancies complicated by PAS between 1 January 2014 and 31 December 2024. Independent predictors of RC were identified using logistic regression, and a weighted scoring model was developed. Model performance and internal validity were assessed using area under the receiver operating characteristic curve, calibration plots, and bootstrap re-sampling. Results: Among 237 neonates born to PAS-complicated pregnancies, 112 (47.3%) experienced RC. Six independent predictors were identified and assigned weighted points: maternal vaginal bleeding within 24 h before delivery (2 points); placenta type—accreta (reference), increta (1 point), and percreta (2 points); absence of antenatal corticosteroid use (1 point); gestational age—29–31 weeks (5 points) and 32–36 weeks (3 points); birth weight < 2500 g (2 points); and male sex (2 points). At a score threshold of 7, the model demonstrated good discrimination, with an area under the receiver operating characteristic curve of 0.75, sensitivity of 67.6%, and specificity of 72.9%. Conclusions: A predictive score > 7 provides fair discrimination for identifying RC in neonates born to pregnancies complicated by PAS and may assist clinicians in identifying high-risk infants who require closer monitoring and early respiratory support. Full article

Complex or difficult cesareans are associated with significant short- and long-term complications. The complication rate increases with the increasing number of cesareans, and the incidence of cesarean section is increasing. To accurately identify women at high risk of surgical difficulty during a cesarean, ultrasound, in addition to clinical assessment, can be used to evaluate many risk factors, including placenta previa, placenta accreta spectrum (PAS) disorders, fibroids, severe pelvic adhesions, and membranous fetal vessels. The role of preoperative ultrasound is to identify ultrasonographic signs of anatomic changes that may affect the risk of intraoperative complications in subsequent cesarean sections. It is important to look for maternal problems as well as fetal problems. Ultrasound is a well-established practice in obstetrical care as it is easily available, accessible, easy to perform, and well accepted by women. However, there are few studies on the role of preoperative ultrasound in the management of complex or difficult cesareans beyond the risk assessment of PAS. Currently, preoperative ultrasound is mostly performed in selected cases only, with the exception in some settings. The aim of this review article is to discuss the benefits and the use of ultrasound assessment before different types of complex or difficult cesareans. Whether ultrasound assessment should be performed before all cesarean sections will also be discussed. Full article

Cesarean scar pregnancy (CSP) carries a high risk of severe hemorrhage and potential loss of fertility. This narrative review summarizes current evidence on uterine artery embolization (UAE) using absorbable gelatin sponge (GS), focusing on GS preparation, procedural approaches, and reported outcomes. PubMed/MEDLINE, Scopus, and Google Scholar were searched from January 2015 to 31 December 2024 for peer-reviewed studies reporting UAE with GS for CSP (GS alone or combined with intra-arterial methotrexate and/or adjunct particles). Fifty studies (N = 3139) were included. Technical success was 3133/3139 (~99.8%) and clinical success was 2975/3139 (~94.8%), with most cohorts reporting high clinical control. Severe complications were infrequently reported (typically ~2–4% in most series). Menstrual function, when assessed, generally recovered within ~1–2 months. Subsequent pregnancy outcomes were inconsistently reported and follow-up durations were heterogeneous, predominantly in retrospective designs. Overall, UAE with GS appears effective for hemostasis in CSP and may reduce escalation to hysterectomy in appropriately selected patients. Standardized reporting of GS preparation and outcomes, as well as prospective multicenter registries/studies, are needed to refine best practices. Full article

Objective: This study evaluated the association of the uric acid/albumin ratio (UAR) and platelet indices—mean platelet volume (MPV), platelet distribution width (PDW), and platelet large cell ratio (P-LCR)—in predicting hypervascularization in placenta accreta spectrum (PAS) and compared clinical and perinatal characteristics among PAS, placenta previa, and healthy pregnancies. Methods: This retrospective study included 229 pregnant women managed and delivered at a tertiary hospital (PAS, n = 76; previa, n = 77; healthy controls, n = 76) between January 2023 and January 2025. Hypervascularization was staged using the ultrasonographic PAS scoring system: PAS0 (placenta previa without hypervascularization), PAS1 (abnormal placental findings without hypervascularization), PAS2 (uterovesical hypervascularization), and PAS3 (extensive vascularity to the parametrial area). The final diagnosis and severity of PAS were confirmed intraoperatively according to the FIGO clinical classification criteria. Platelet indices and UAR were obtained from preoperative blood tests. Results: Compared with placenta previa (PAS0) and control groups, PAS1–3 cases had higher gravidity, parity, previous cesarean history, postpartum hemorrhage, hysterectomy, and transfusion rates (all p < 0.001). In the high hypervascularization subgroup (PAS2–3, n = 38), MPV (median 10.3 fL) and PDW (11.6%) were significantly lower than in low/absent hypervascularization cases (PAS0–1) (p = 0.001, p = 0.001, respectively). UAR showed no significant difference (p = 0.891). Conclusions: Lower MPV and PDW were associated with hypervascularization in PAS and may serve as non-invasive adjunctive markers for risk stratification. Their predictive performance was modest, and UAR had no diagnostic value, likely due to physiological changes in pregnancy. Further prospective, multicenter research is needed to validate these findings. Full article

Background: Severe (FIGO grade 3b & c) placenta accreta spectrum (PAS) is potentially a life-threatening condition due to catastrophic haemorrhage at delivery. Consequently, interventional radiology (IR) techniques are often employed to prevent massive blood loss, but this is not always readily available, is costly, and can cause significant morbidity, including distal limb ischaemia due to thrombus formation. We believe that internal iliac ligation under direct vision is a safe option to control bleeding. We sought to evaluate the short- and long-term outcomes relating to this technique compared to IR. Methods: This is a mixed-methods cohort study of women with severe PAS who underwent hysterectomy with either surgical devascularisation, as part of the Soleymani and Collins (SAC) technique, or IR insertion of internal iliac balloon catheters, in a UK tertiary referral centre for PAS between 2011 and 2022. Only women with intraoperative diagnosis of very severe PAS (FIGO stage 3b & c) were included in this study. Results: Of the 22 women invited to participate in the long-term component of the study, 59% agreed. Women in the surgical devascularisation group experienced no adverse short or late sequelae related to internal iliac arterial ligation. Pelvic devascularisation (11 patients, 41%) demonstrated a reduction in median estimated blood loss, 1600 millilitres vs. 2500 millilitres in the IR balloon catheter group (p = 0.04). Conclusions: We have demonstrated that the SAC technique for surgical devascularisation is a safe method for achieving haemorrhage control during caesarean hysterectomy for severe PAS. It also appears to be at least as effective at haemorrhage control as IR balloon occlusion of the internal iliac vessels. Full article

Placenta Accreta Spectrum (PAS) disorders, including placenta accreta, increta, and percreta, are serious obstetric conditions characterized by abnormal placental adherence to the uterine wall. With increasing incidence, PAS poses significant risks, primarily through massive hemorrhage during or after delivery, often necessitating hysterectomy. Key risk factors include prior cesarean sections, uterine surgery, and placenta previa diagnosis. In this review, we will examine the pathophysiology of PAS, with a focus on the mechanisms underlying abnormal trophoblast invasion and defective decidualization. We will highlight the role of uterine scarring, extracellular matrix remodeling, dysregulated signaling pathways, and immune and vascular alterations in disrupting the maternal-fetal interface, ultimately predisposing to morbid placentation and delivery complications. We will also discuss the life-threatening complications of PAS, such as shock and multi-organ failure, which require urgent multidisciplinary intensive care, as well as the optimization of management through preoperative planning and intraoperative blood loss control to reduce maternal morbidity and mortality. Full article

Background and Objective: Placenta Accreta Spectrum (PAS) encompasses a continuum of abnormal placentation conditions associated with significant maternal and fetal morbidity. Management of PAS requires coordinated cesarean hysterectomy. Associated morbidities include blood transfusion, coagulopathy, and intensive care unit (ICU) admission. Accurate prediction of ICU admission allows for enhanced multidisciplinary management, coordination of care and utilization of resources. Scoring systems exist in other surgical specialties that can predict the likelihood of ICU admission, but these have not been applied to an obstetric population. The SAS is a 10-point scale that has been validated for the prediction of ICU-level care requirements within 72 h post-operatively in numerous surgical specialties. The purpose of this study was to apply the Surgical APGAR Score (SAS, version 9) to patients undergoing management of PAS to determine if it can predict ICU admission in this population. Materials and Methods: This is a case–control study. We retrospectively analyzed 127 cases of pathology-confirmed PAS patients who underwent cesarean hysterectomy in singleton, non-anomalous, viable pregnancies. Our primary outcome was ICU admission. In addition, secondary outcomes included antepartum characteristics, operative time, intraoperative events as well as post-operative complications and total postoperative length of stay. SAS was assigned by extracting estimated blood loss (EBL), and the lowest mean intraoperative heartrate (HR and mean arterial pressure (MAP) from intraoperative documentation. Categorical and continuous factors were summarized using frequencies and percentages or means ± SD or median and range as appropriate. Pearson’s chi-square, Fisher’s exact tests, and Mann–Whitney U and t-tests were applied when appropriate. Logistical regression to assess the impact of SAS on ICU admission was performed. p-values < 0.05 were considered significant for two-tailed analysis. Statistical analysis was performed using Graphpad software (version 9). Results: Fifty-eight patients (45%) were admitted post-operatively to the ICU, while 69 patients (55%) were admitted for routine care to the post-anesthesia care unit. Baseline demographics were similar between groups. Forty-four patients (52%) admitted to the ICU had a SAS score < 4. SAS < 4 was associated with greater blood loss (3000 vs. 2500 mL, p = 0.03) and longer operative time (198 vs. 175 min, p = 0.03). Logistic regression analysis of SAS score and ICU admission revealed a low predictive value (OR 2.28, AUC = 0.599). Conclusions: The SAS system is a poor tool for the prediction of ICU admission in patients with PAS undergoing cesarean hysterectomy. A risk calculator that accounts for the unique physiologic changes in pregnancy and high risk for pregnancy is needed. Full article

Objective: We aimed to evaluate the prognostic value of the hemoglobin, albumin, lymphocyte, and platelet (HALP) score in placenta accreta spectrum (PAS) surgeries and its perioperative dynamics as a marker of surgical and neonatal outcomes. Methods: This retrospective cohort included 100 patients with histopathologically confirmed PAS who underwent cesarean hysterectomy (2016–2025). The HALP was calculated within 24 h before delivery and reassessed at 6 and 24 h after delivery. Demographic, surgical, and neonatal variables were recorded. The primary outcome was the association between preoperative HALP and surgical morbidity; the secondary outcomes were perioperative HALP changes and neonatal correlations. ROC analysis identified cutoff values; multivariable regression was used to determine predictors of HALP variability. Internal validity was assessed via bootstrap resampling (1000 and 5000 iterations). Results: Preoperative HALP was significantly greater in patients with complications (24.14 vs. 22.58; p = 0.023). ROC analysis yielded a cutoff of 29.23, with 53.2% sensitivity and 82.0% specificity (AUC: 0.602, 95% CI: 0.51–0.69;). HALP showed a biphasic perioperative pattern, increasing at 6 h and then decreasing at 24 h (p < 0.001). Elevated HALP was independently associated with earlier gestational age at diagnosis, lower birthweight, and reduced Apgar scores. Bootstrap analyses revealed a stable AUC (~0.60) and consistent cutoff estimates across resamples. Conclusions: Higher HALP scores, which are typically markers of favorable nutritional status, are paradoxically linked to increased maternal morbidity and adverse neonatal outcomes in patients with PAS. HALP may, therefore, reflect placental invasiveness rather than maternal reserve. Its low cost and dynamic behavior highlight its potential utility in preoperative risk stratification for high-risk obstetrics. Full article

Background/Objectives: Myomectomy is the preferred treatment for women with uterine fibroids who desire to preserve their fertility. This study aimed to compare perinatal outcomes between Mexican women with and without a history of myomectomy, matched in a 1:2 ratio based on maternal age and parity. Methods: A retrospective cohort study was conducted involving women with and without a history of myomectomy who received prenatal care and delivered at a tertiary care hospital in Mexico City. Women with comorbidities such as pregestational diabetes, chronic hypertension, autoimmune diseases, nephropathy, cardiomyopathy, and cancer were excluded from the study. Group 1 consisted of women with a history of myomectomy, and Group 2 included matched women without such a history. The following perinatal outcomes were evaluated: miscarriage, preterm birth, cesarean section, obstetric hemorrhage, placenta previa, surgical adhesions, and obstetric hysterectomy. Adjusted relative risk (aRR) with 95% confidence intervals (CI) was calculated. Results: A total of 122 women were analyzed in group 1, and 244 in group 2. The risk of obstetric hemorrhage aRR 7.5 (95% CI 3.9–11.9), surgical adhesions aRR 11.8 (5.3–20.7), and placenta accreta aRR 15.3 (1.3–111) were significantly higher in Group 1 compared to Group 2. Other outcomes, including miscarriage, preterm birth, cesarean section, placenta previa, and obstetric hysterectomy, were similar between groups. Conclusions: Mexican pregnant women with a history of myomectomy have a higher risk of obstetric hemorrhage, surgical adhesions, and placenta accreta compared to those without such a history. Full article

Damage control surgery (DCS) is a staged surgical strategy for rapid control of life-threatening bleeding, followed by physiological stabilization and delayed definitive repair. Abdomino-pelvic packing (APP)—placing compressive material within the pelvis and/or abdomen to tamponade bleeding—is a cornerstone of DCS as a temporizing measure to achieve hemostasis and stabilization in critically unstable patients. This narrative review synthesizes current evidence on DCS with a focus on APP—a technique historically developed in trauma and orthopedic surgery for exsanguinating pelvic bleeding but adaptable to gynecologic and obstetric emergencies. We outline the historical evolution, physiological basis, and stepwise protocol of DCS, adapted to specialty-specific conditions such as postpartum hemorrhage, placenta accreta spectrum, uterine rupture, and hepatic rupture in HELLP syndrome, as well as oncologic surgeries (debulking, exenteration, lymphadenectomy) and benign procedures (trocar-entry injuries in laparoscopy, presacral bleeding in sacrocolpopexy, and retroperitoneal hemorrhage in deep-infiltrating endometriosis). Modern adjuncts—including early tranexamic acid, topical hemostatic agents, and multidisciplinary coordination—have transformed packing from a last-resort maneuver into an integrated component of staged hemorrhage control. In OB/GYN, APP allows for successful hemostasis in 75–90% of cases, with significantly lower mortality rates than trauma surgery. In conclusion, APP as a potentially life-saving maneuver within DCS requires integration into standardized, institution-wide hemorrhage protocols in OB/GYN. Training, simulation, and guideline adoption are critical, particularly in resource-limited settings where advanced interventions for catastrophic bleeding are inaccessible. Full article

Background/Objectives: Placenta accreta spectrum (PAS) is an obstetric condition with placental adherence to the underling myometrium characterized by significant surgical morbidity at time of delivery. PAS delivery is most commonly performed by cesarean hysterectomy. The most common morbidities associated with PAS cesarean hysterectomy are blood transfusion, intensive care unit admission and urinary tract injuries. This requires interdisciplinary team management including obstetricians and urologists. Our objective was to identify pre- and intra-operative risk factors for urologic injury in this high-risk condition. Methods: A retrospective cohort study was performed at a single tertiary center with the Center for the Management of Placenta Accreta Spectrum disorders from 2012 to 2022. Urologic injuries were considered as injury to either the bladder or ureters. Furthermore, bladder injuries were subdivided into those inherent to the procedure (intentional cystotomy) and those considered unplanned complications (incidental cystotomy). Inclusion criteria required complete antenatal documentation for assessment, and these were accessed by electronic medical records. Multivariate analysis was performed for significant variables on univariate analysis. Results: During the 11-year study period, 146 cases of PAS were managed by our team. Of these, 39 (26.7%) were complicated by urologic injury. Intentional cystotomies were performed in 28.2% (11/39) of cases. There were 28 (28/39, 71.8%) incidental cystotomies and 5 (5/39, 12.8%) ureteral injuries were encountered. Of note, all 5 patients with ureteral injuries also had cystotomies. Upon univariate analysis, anterior placentation (OR 2.96 [1.94, 4.67], p = 0.04), percreta by antenatal ultrasound (OR 2.59 [1.13, 5.9], p = 0.02) and >2 pre-delivery vaginal bleeding episodes (OR 4.27 [1.54, 12.16], p = 0.005) were associated with urologic injury. Multivariate analysis revealed the independent significance of these variables. Of note, the presence of zero, one, two, and all three risk factors were associated with urologic injury rates of 11.1%, 22.5%, 41.9%, and 71.4%, respectively. Conclusions: Urologic injury during cesarean hysterectomy occurs in almost one-third of cases. Pre-operative risk factors may be used to identify those at greater risk for this surgical complication. Determining patient risk allows for the use of resources such as formal urology consultation, surgical planning, and intraoperative assistance, as well as detailed patient counseling. Full article

Background/Objectives: Adenomyosis is increasingly being identified in women of childbearing age as a cause of infertility and adverse pregnancy outcomes. As hysterectomies are not suitable for fertile women, conservative surgical management has become a promising solution. We aimed to synthesize current evidence on conservative uterus-sparing surgical techniques for adenomyosis, focusing on implications for infertility treatment and pregnancy outcomes. Methods: A search of PubMed, Google Scholar, and Europe PMC from 2022 to July 2025 was conducted using combinations of the words “adenomyosis,” “fertility,” “infertility,” “pregnancy outcomes,” “adenomyomectomy,” and “uterine-sparing surgery.” Sixteen high-relevance studies were chosen that included reproductive-aged women who had conservative surgery for adenomyosis. Results: Excisional techniques such as adenomyomectomy yield pregnancy rates of >50% and live birth rates of up to 70% in focal disease, with less success in diffuse disease. Non-excisional approaches—high-intensity focused ultrasound (HIFU), radiofrequency ablation (RFA), and uterine artery embolization (UAE)—yield equivalent pregnancy (40–53%) and live birth (35–74%) rates in selected patients, with fewer surgical complications. Adjunctive hormonal therapy, particularly GnRH agonists, appears to improve outcomes. Risks include placenta accreta spectrum disorders and uterine rupture (≤6%), especially in diffuse adenomyosis. The type of lesion, location, and junctional zone thickness are strong predictors of fertility outcomes. Conclusions: Conservative surgery can augment fertility in appropriately chosen women with adenomyosis, with removal being the preferred treatment for focal disease and non-removal techniques offering encouraging alternatives in mild or intracorporeal disease. The addition of adjunct hormonal therapy and standardized patient selection criteria will optimize results. The lack of European professional society guidelines underscores the need for harmonized protocols in order to standardize the diagnosis, surgery, and reporting of results. Full article