placenta accreta

Objective: To compare peripartum outcomes of uterus preserving procedures to caesarean hysterectomy in women with placenta accreta spectrum (PAS), and to identify risk factors associated with adverse maternal outcomes. Design: Retrospective study (ClinicalTrials.gov identifier: NCT04384510) Setting:11 tertiary centres from 9 countries Population or Sample: women with of PAS who were managed in participating centres between January 1st, 2010 and December 31st, 2019. Women who had confirmed diagnosis with PAS with adequate documentation and follow-up, were considered eligible. Main Outcome Measures: Primary outcome was massive PAS-associated perioperative blood loss (intraoperative blood loss ≥ 2500 ml, bleeding associated massive transfusion protocol, or complicated by disseminated intravascular coagulopathy). Results: Out of 797 women, 727 were eligible for the study. Five hundred ninety-two (81.43%) women were managed by uterus preserving procedures versus 135 (18.56%) who underwen...

Accurate prenatal discrimination between a simple, non-adherent uterine scar dehiscence with an underlying placenta and the severe end of the placenta accreta spectrum is problematic as the two can appear similar on prenatal imaging. This may lead to the false diagnosis of placenta accreta spectrum resulting obstetric anxiety, overtreatment and potential iatrogenic morbidity. Despite potential similarities in the etiology, the manifestation and management of these two conditions is very different. The prenatal sonographic features of seven confirmed cases of simple uterine scar dehiscence with an underlying placenta previa were examined. The common sonographic features found for scar dehiscence was a thinned myometrium (<1 mm) overlying a generally homogenous placenta and a placental bulge. There was absence of lacunae and features of hypervascularity including bridging vessels. Our findings suggest accurate discrimination between a simple scar dehiscence with the placenta underl...

Introduction: It has been suggested that women with obesity have increased risk of developing placenta accreta spectrum (PAS). It is unclear if this is independent of the increased risk of cesarean delivery seen with obesity itself. The aim of this study was to explore the association between maternal obesity and PAS, particularly severe PAS (percreta). Material and methods: This is a cohort study based on cases recorded in the International Society for Placenta Accreta Spectrum (IS-PAS) database between April 2008 and May 2019. Multivariable logistic regression was used to explore the effect of maternal obesity on severity of PAS; this model was adjusted for other known risk factors including previous cesarean deliveries, maternal age, and placenta previa. The estimated rate of obesity in a hypothetical cohort with similar characteristics (previous | 51

The worldwide incidence of placenta accreta spectrum (PAS) is rapidly increasing, following the trend of rising cesarean delivery. PAS is an heterogeneous condition associated with a high maternal morbidity and mortality rate, presenting unique challenges in its diagnosis and management. So far, the rarity of this condition, together with the absence of high quality evidence and the lack of a standardized approach in reporting PAS cases for the ultrasound, clinical, and pathologic diagnosis, represented the main challenges for a deep understanding of this condition. The study of the available management strategies of PAS has been hampered by the heterogeneity of the available epidemiological data on this condition. The aim of this review is to provide a critical view of the current available evidence on the screening, the diagnosis, and the management options for PAS disorders, with a special focus on the challenges we foresee for the near future.

To test an objective ultrasound marker for diagnosing the presence and severity of abnormally invasive placenta. Women at risk of abnormally invasive placenta underwent a three-dimensional power Doppler ultrasound scan. The volumes were examined offline by a blinded observer. The largest area of confluent three-dimensional power Doppler signal (Area of Confluence [A con ], cm 2 ) at the uteroplacental interface was measured and compared in women subsequently diagnosed with abnormally invasive placenta and women in a control group who did not have abnormally invasive placenta. Receiver operating characteristic curves were plotted for prediction of abnormally invasive placenta and abnormally invasive placenta requiring cesarean hysterectomy. Ninety-three women were recruited. Results were available for 89. Abnormally invasive placenta was clinically diagnosed in 42 women;36 required hysterectomy and had abnormally invasive placenta confirmed histopathologically. Median and interquartile range for

In cases of placenta accreta spectrum, a precise antenatal diagnosis of the suspected degree of invasion is essential for the planning of individual management strategies at delivery. The aim of this work was to evaluate the respective performances of ultrasonography and magnetic resonance imaging for the antenatal assessment of the severity of placenta accreta spectrum disorders included in the database. The secondary objective was to identify descriptors related to the severity of placenta accreta spectrum disorders. All the cases included in the database for which antenatal imaging data were available were analyzed. The rates of occurrence of each ultrasound This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

Objective: Determining the depth of villous invasiveness before delivery is pivotal in planning individual management of placenta accreta (PA). We have evaluate the value of the various ultrasound signs described in the literature for the diagnosis of PA and in the assessment of the depth of villous invasiveness. We undertook a PubMed and MEDLINE search of the relevant studies published between the first prenatal ultrasound description of PA in 1982 and 30 March 2016 using key words "placenta accreta", "placenta increta", "placenta percreta", "abnormally invasive placenta", "morbidly adherent placenta" and "placenta adhesive disorder" as related to "sonography", "ultrasound diagnosis", "prenatal diagnosis", "greyscale imaging", three-dimensional (3D) ultrasound and "colour Doppler imaging". All articles which correlated prenatal ultrasound imaging with pregnancy outcome. Eighty-three studies, including 30 cases reports describing 38 cases of PA and 53 series describing 1078 cases were analysed. PA was subdivided in placenta creta (PC) to describe superficially adherent placentation and placenta increta (PI) and percreta (PP) to describe invasive placentation. Results: Out of 53 study series, 23 did not provide data on the depth of villous myometrial invasion on ultrasound imaging or at delivery. Detailed correlations between ultrasound findings and PA grading were found in 72 cases. A loss of clear zone (62.1%) and the presence of bridging vessels (71.4%) were the most common ultrasound signs found in cases of PC. In PI, a loss of clear zone (84.6%) and subplacental hypervascularity (60%) were the most common ultrasound signs whereas, placental lacunae (82.4%) and subplacental hypervascularity (54.5%) were the most common ultrasound signs in PP. No ultrasound sign or a combination of ultrasound signs were specific of the depth of accreta placentation. The wide heterogeneity in terminology used to describe the grades of accreta placentation and differences in study design limits the evaluation of the accuracy of ultrasound imaging in the screening and diagnosis of PA. This review emphasizes the need for further prospective studies using a standardised evidencebased approach including a systematic correlation between ultrasound signs of PA and detailed clinical and pathologic examinations at delivery.

The incidence of placenta accreta spectrum (PAS) is increasing, but it is still a rare pregnancy complication. If undiagnosed, PAS can cause serious maternal morbidity and even mortality at delivery. Ultrasound (US) is an excellent imaging modality for the diagnosis of PAS, but it must be used correctly and there is little training in placental imaging available. The aim of this paper is to review US screening for PAS and provide practical advice on its use for antenatal diagnosis.

Uterine scar dehiscence with underlying placenta is often misdiagnosed as placenta accreta spectrum both prenatally and intraoperatively due to the absence of myometrial tissue in the area. Misdiagnosis generates obstetric anxiety and results in overtreatment which carries a risk of iatrogenic injury. We present a case of the antenatal diagnosis of uterine dehiscence in a 36-year-old woman with a history of two caesarean deliveries and a low-lying placenta. We further describe the sonographic features useful for differentiating this condition from placenta accreta spectrum in instances where the placenta lies under an area of full thickness uterine scar dehiscence.

IntroductionIt has been suggested that women with obesity have increased risk of developing placenta accreta spectrum (PAS). It is unclear if this is independent of the increased risk of cesarean delivery seen with obesity itself. The aim of this study was to explore the association between maternal obesity and PAS, particularly severe PAS (percreta).Material and methodsThis is a cohort study based on cases recorded in the International Society for Placenta Accreta Spectrum (IS‐PAS) database between April 2008 and May 2019. Multivariable logistic regression was used to explore the effect of maternal obesity on severity of PAS; this model was adjusted for other known risk factors including previous cesarean deliveries, maternal age, and placenta previa. The estimated rate of obesity in a hypothetical cohort with similar characteristics (previous cesarean delivery and same parity) was calculated and compared with the observed rate of obesity in the women of the PAS cohort (one sample ...

Almost 10 years ago, clinicians at multiple locations all over Europe observed an increased number of antenatally undiagnosed cases of placenta accreta spectrum (PAS) resulting in significant morbidity and the occasional maternal death. Even with an improvement in antenatal imaging, the management of severe PAS remains challenging. One solution to improve understanding in rare but potentially lethal conditions is international collaboration. Consequently, a European working group was formed, which over the next few years grew into an international society, the IS-PAS. The collective goals are to develop a large shared database of cases, generate highquality research into all aspects of PAS, and improve education of both healthcare professionals and patients. The first results of this collaboration are presented within this supplement.

IntroductionPlacenta accreta spectrum (PAS) carries a high burden of adverse maternal outcomes, especially significant blood loss, which can be life‐threatening. Different management strategies have been proposed but the association of clinical risk factors and surgical management options during cesarean delivery with high blood loss is not clear.Material and methodsIn this international multicenter study, 338 women with PAS undergoing cesarean delivery were included. Fourteen European and one non‐European center (USA) provided cases treated retrospectively between 2008 and 2014 and prospectively from 2014 to 2019. Peripartum blood loss was estimated visually and/or by weighing and measuring of volume. Participants were grouped based on blood loss above or below the 75th percentile (>3500 ml) and the 90th percentile (>5500 ml).ResultsPlacenta percreta was found in 58% of cases. Median blood loss was 2000 ml (range: 150‐20 000 ml). Unplanned hysterectomy was associated with an ...

Introduction: Placenta accreta spectrum (PAS) is a condition often resulting in severe maternal morbidity. Scheduled delivery by an experienced team has been shown to improve maternal outcomes; however, the benefits must be weighed against the risk of iatrogenic prematurity. The aim of this study is to investigate the rates of emergency delivery seen for antenatally suspected PAS and compare the resulting outcomes in the 15 referral centers of the International Society for PAS (IS-PAS). The women included were divided into two groups according to whether they had a planned or an emergency cesarean delivery. Delivery was defined as "planned" when performed at a time and date to suit the team. All the remaining cases were classified as "emergency". Maternal characteristics and neonatal outcomes were compared between the two groups according to gestation at delivery. In all, 356 women were included. Of these, 239 (67%) underwent a planned delivery and 117 (33%) an emergency delivery. Vaginal bleeding was the indication for emergency delivery in 41 of the 117 women (41%). There were no significant differences in terms of blood loss, transfusion rates or major maternal morbidity between planned and emergency deliveries. However, the rate of maternal intensive therapy unit admission was increased with emergency delivery (45% vs 33%, P = .02). Antepartum hemorrhage was the only independent predictor of emergency delivery (aOR: 4.3, 95% confidence interval 2.4-7.7). Emergency delivery due to vaginal bleeding was more frequent with

The worldwide incidence of placenta accreta spectrum (PAS) is rapidly increasing, following the trend of rising cesarean delivery. PAS is an heterogeneous condition associated with a high maternal morbidity and mortality rate, presenting unique challenges in its diagnosis and management. So far, the rarity of this condition, together with the absence of high quality evidence and the lack of a standardized approach in reporting PAS cases for the ultrasound, clinical, and pathologic diagnosis, represented the main challenges for a deep understanding of this condition. The study of the available management strategies of PAS has been hampered by the heterogeneity of the available epidemiological data on this condition. The aim of this review is to provide a critical view of the current available evidence on the screening, the diagnosis, and the management options for PAS disorders, with a special focus on the challenges we foresee for the near future.

IntroductionManagement options for women with placenta accreta spectrum (PAS) comprise termination of pregnancy before the viable gestational age, leaving the placenta in situ for subsequent reabsorption of the placenta or delayed hysterectomy, manual removal of placenta after vaginal delivery or during cesarean section, focal resection of the affected uterine wall, and peripartum hysterectomy. The aim of this observational study was to describe actual clinical management and outcomes in PAS in a large international cohort.Material and methodsData from women in 15 referral centers of the International Society of PAS (IS‐PAS) were analyzed and correlated with the clinical classification of the IS‐PAS: From Grade 1 (no PAS) to Grade 6 (invasion into pelvic organs other than the bladder). PAS was usually diagnosed antenatally and the operators performing ultrasound rated the likelihood of PAS on a Likert scale of 1 to 10.ResultsIn total, 442 women were registered in the database. No ma...

ObjectiveTo estimate the prevalence and incidence of placenta previa complicated by placenta accreta spectrum (PAS) and to examine the different criteria being used for the diagnosis.DesignSystematic review and meta-analysis.Data sourcesPubMed, Google Scholar, ClinicalTrials.gov and MEDLINE were searched between August 1982 and September 2018.Eligibility criteriaStudies reporting on placenta previa complicated by PAS diagnosed in a defined obstetric population.Data extraction and synthesisTwo independent reviewers performed the data extraction using a predefined protocol and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies, with difference agreed by consensus. The primary outcomes were overall prevalence of placenta previa, incidence of PAS according to the type of placenta previa and the reported clinical outcomes, including the number of peripartum hysterectomies and direct maternal mortality. The secondary outcomes included the criteria used fo...

The incidence of placenta accreta spectrum (PAS) is increasing, but it is still a rare pregnancy complication. If undiagnosed, PAS can cause serious maternal morbidity and even mortality at delivery. Ultrasound (US) is an excellent imaging modality for the diagnosis of PAS, but it must be used correctly and there is little training in placental imaging available. The aim of this paper is to review US screening for PAS and provide practical advice on its use for antenatal diagnosis.

Placenta accreta spectrum is impacting maternal health outcomes globally and its prevalence is likely to increase. Maternal outcomes depend on identification of the condition before or during delivery and, in particular, on the differential diagnosis between its adherent and invasive forms. However, accurate estimation of its prevalence and outcome is currently problematic because of the varying use of clinical criteria to define it at birth and the lack of detailed pathologic examination in most series. Adherence to this new International Federation of Gynecology and Obstetrics (FIGO) classification should improve future systematic reviews and meta‐analyses and provide more accurate epidemiologic data which are essential to develop new management strategies.

ABSTRACTObjectivesTo evaluate fetal growth in pregnancies complicated by placenta previa with or without placenta accreta spectrum (PAS) disorder, compared with in pregnancies with a low‐lying placenta.MethodsThis was a multicenter retrospective cohort study of singleton pregnancies complicated by placenta previa with or without PAS disorder, for which maternal characteristics, ultrasound‐estimated fetal weight and birth weight were available. Four maternal–fetal medicine units participated in data collection of diagnosis, treatment and outcome. The control group comprised singleton pregnancies with a low‐lying placenta (0.5–2 cm from the internal os). The diagnosis of PAS and depth of invasion were confirmed at delivery using both a predefined clinical grading score and histopathological examination. For comparison of pregnancy characteristics and fetal growth parameters, the study groups were matched for smoking status, ethnic origin, fetal sex and gestational age at delivery.Resu...

Refer women with any ultrasound features suggestive of placenta accreta spectrum to a specialist unit with imaging expertise. [New 2018] B RCOG Green-top Guideline No. 27a e6 of e48 ª 2018 Royal College of Obstetricians and Gynaecologists P RCOG Green-top Guideline No. 27a e7 of e48 ª 2018 Royal College of Obstetricians and Gynaecologists D RCOG Green-top Guideline No. 27a e8 of e48 ª 2018 Royal College of Obstetricians and Gynaecologists P In case of unsuspected placenta accreta spectrum diagnosed after the birth of the baby, the placenta should be left in situ and an emergency hysterectomy performed. [New 2018] D 1. The purpose of this guideline is to describe the diagnostic modalities and review the evidence-based approach to the clinical management of pregnancies complicated by placenta praevia and placenta accreta. This guideline was developed in accordance with standard methodology for producing Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guidelines. The Cochrane Library (including the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects [DARE]), EMBASE, Trip, MEDLINE and PubMed (electronic databases) were searched for relevant randomised controlled trials (RCT), systematic reviews and meta-analyses. The search was restricted to articles published between May 2009 and July 2016 (the search for the previous guideline was up to May 2009). A top-up literature search was performed in March 2018. The databases were searched using the relevant Medical Subject Headings (MeSH) terms, including all subheadings, and this was combined with a keyword search. Search words included 'placenta praevia', 'low lying placenta', 'placenta accreta', 'placenta increta' 'placenta percreta', 'abnormally adherent placenta' and 'abnormally invasive placenta'. The search was restricted to humans and the English language. The National Library for Health and the National Guideline Clearinghouse were also searched for relevant guidelines and reviews. Where possible, recommendations are based on available evidence. In the absence of published evidence, these have been annotated as 'good practice points'. Further information about the assessment of evidence and the grading of recommendations may be found in Appendix 1. Antenatal diagnosis and care of women with placenta praevia or a low-lying placenta What are the risk factors for women with placenta praevia or a low-lying placenta? Caesarean delivery is associated with an increased risk of placenta praevia in subsequent pregnancies. This risk rises as the number of prior caesarean sections increases. [New 2018] B ART and maternal smoking increase the risk of placenta praevia. [New 2018] B RCOG Green-top Guideline No. 27a e11 of e48 ª 2018 Royal College of Obstetricians and Gynaecologists

A retained placenta after vaginal delivery where manual removal of placenta fails is a clinical challenge. We present six cases that illustrate the heterogeneity of the condition and discuss the etiology and terminology as well as the clinical management. Members of the European Working group on Abnormally Invasive Placenta (EW-AIP) were invited to report all recent cases of retained placenta that were not antenatally suspected to be abnormally adherent or invasive, but could not be removed manually despite several attempts. The six cases from Denmark, The Netherlands and the UK provide examples of various treatment strategies such as ultrasound-guided vaginal removal, removal of the placenta through a hysterotomy and just leaving the placenta in situ. The placentas were all retained, but it was only possible to diagnose abnormal invasion in the one case, which had a histopathological diagnosis of increta. Based on these cases we present a flow chart to aid clinical management for f...

The placenta accreta spectrum (PAS) is a complex obstetric complication associated with a high maternal morbidity. It is a relatively new disorder of placentation, and is the consequence of damage to the endometrium-myometrial interface of the uterine wall. When first described 80 years ago, it mainly occurred after manual removal of the placenta, uterine curettage or endometritis. Superficial damage leads primarily to an abnormally adherent placenta, and is diagnosed as the complete or partial absence of the decidua on histology. Today, the main cause of PAS is uterine surgery and, in particular, the uterine scar secondary to a caesarean delivery. In the absence of endometrial re-epithelialization of the scar area the trophoblast and villous tissue can invade deeply within the myometrium, including its circulation, and reach the surrounding pelvic organs. The cellular changes in the trophoblast observed in PAS are probably secondary to the unusual myometrial environment in which it develops, and not to a primary defect of trophoblast biology leading to excessive invasion of the myometrium. PAS was separated by pathologists into three categories: placenta creta (PC) when the villi simply adhere to the myometrium, placenta increta (PI) when the villi invade the myometrium, and placenta percreta (PP) where the villi invade the full thickness of the myometrium. Several prenatal ultrasound signs of PAS have been reported over the last 35 years, principally the disappearance of the normal uteroplacental interface (clear zone), extreme thinning of the underlying myometrium and vascular changes within the placenta (lacunae) and placental bed (hypervascularity). The pathophysiological basis of these signs is due to permanent damage of the uterine wall as far as the serosa, with placental tissue reaching the deep uterine circulation. Adherent and invasive placentation may co-exist in the same placental bed and evolve with advancing gestation. This may explain why no single, or set combination of, ultrasound sign(s) has been found to be specific for the depth of abnormal placentation, and accurate for the differential diagnosis between adherent and invasive placentation. Correlation of pathological and clinical findings with the prenatal imaging is essential to improve screening, diagnosis and management of PAS, and standardised protocols need to be developed.

Determining the depth of villous invasiveness before delivery is pivotal in planning individual management of placenta accreta (PA). We have evaluate the value of the various ultrasound signs described in the literature for the diagnosis of PA and in the assessment of the depth of villous invasiveness. We undertook a PubMed and MEDLINE search of the relevant studies published between the first prenatal ultrasound description of PA in 1982 and 30 March 2016 using key words "placenta accreta", "placenta increta", "placenta percreta", "abnormally invasive placenta", "morbidly adherent placenta" and "placenta adhesive disorder" as related to "sonography", "ultrasound diagnosis", "prenatal diagnosis", "grey-scale imaging", three-dimensional (3D) ultrasound and "colour Doppler imaging". All articles which correlated prenatal ultrasound imaging with pregnancy outcome. Eighty-three ...

The purpose of the study was to evaluate the role of ultrasound (US) and magnetic resonance imaging (MRI) in the diagnostics and management of abnormal placentation in women with placenta previa and to compare the morbidity associated with that to placenta previa alone. The study includes 100 pregnant women with placenta previa with and without abnormal placentation. The results of MRI and US in abnormal placentation were compared with post-operative data. The patients' files were reviewed for assessment of operative and post-operative morbidity. The results of our statistical analysis were compared with data from the literature. US and MRI showed no significant difference in sensitivity and specificity in diagnosing abnormal placentation (97-100% and 94-100%, respectively). MRI was more sensitive than US for the detection of myometrial invasion and the type of abnormal placentation (73.5% and 47%, respectively). The difference between pre- and post-operative hemoglobin values a...

Objective: To study the effect of music on pain perception in women scheduled for elective cesarean section (CS) Search Strategy: We used the following keywords ("music" or "music therapy" and any of the following: cesarean section OR cesarean delivery OR CS OR cesarean OR Caesarean OR "post-op*) Selection Criteria: We included all studies satisfying the following criteria: (1) Population: pregnant women scheduled for cesarean section. (2) Intervention: the addition of any type of music to routine care compared with routine care alone. (3) Study design: randomized controlled trials (RCTs). We excluded the following: (1) non-randomized trials, (2) in vitro and animal studies, (3) studies in languages other than English, and (4) studies whose data were unreliable for extraction and analysis. independently performed using a standardized form. In case of discrepancies, a consensus was reached after the involvement of the senior investigator. Then, data were extracted from assessed articles and entered RevMan software for meta-analysis. Main Results: Pooled data significantly favored the music group over the non-music one in terms of pain and anxiety scores (p<0.001). Heart rate, systolic and diastolic blood pressure did not differ significantly between both groups. Music can be used during, before, and after cesarean section to reduce associated pain and anxiety.

Background: Placenta accreta spectrum (PAS) disorders encompass a heterogeneous group of anomalies characterized by abnormal adhesion or invasion of the trophoblastic tissue into the myometrium. Advances in prenatal imaging techniques and improved knowledge of the natural history of these anomalies have led to an increase in the prenatal detection rate of PAS disorders. Prenatal diagnosis of a PAS disorder is fundamental as it has been shown to reduce the burden of maternal morbidity by allowing preplanned treatment in centers with high expertise in surgical management of this condition. TVS is often recommended to identify the cervical canal, internal os, and the relationship between the leading placental edge and the internal os; it can also be used for a focused evaluation of the lower uterine wall and the bladder interface Histopathology is now widely considered as the gold standard modality recommended to confirm clinical diagnosis of PAS. The aim of our study was to compare be...

Placenta accreta spectrum disorder is a pregnancy-related disorder responsible for important post-partum morbimortality, associated with intractable or massive hemorrhage, leading to uterine loss in up to 64% of women. Despite international recommendations advocating planned preterm cesarean hysterectomy for the management of these patients, uterus preservation management is being continuously reported with the implementation of minimally invasive bleeding reduction strategies, such as prophylactic balloon-assisted occlusion. We present the case of a 40-year-old pregnant woman with a previous cesarean, diagnosed with placenta previa and suspected placenta accreta on magnetic resonance after having second-trimester vaginal bleeding. A peri-operative multidisciplinary panel was involved, in collaboration with the interventional radiologist, and the c-section was scheduled for 36 weeks of gestation. The prophylactic balloon-assisted occlusion was successfully performed, minimizing the blood loss and allowing a uteruspreserving approach.

Objectives-To evaluate cervical length measurements in women with placenta accreta compared to women with a nonadherent low-lying placenta or placenta previa and evaluate this relationship in terms of vaginal bleeding, preterm labor, and preterm birth. Methods-We conducted a retrospective cohort study between 1997 and 2011 of gravidas with more than 1 prior cesarean delivery who had a transvaginal ultrasound examination between 24 and 34 weeks for a low-lying placenta or placenta previa. Cervical length was measured from archived images in accordance with national guidelines by a single investigator, who was blinded to outcomes and ultrasound reports. The diagnosis of placental accreta was based on histologic confirmation. For study purposes, preterm birth was defined as less than 36 weeks, and cervical lengths of 3 cm or less were considered short. Standard statistical analyses were used. Results-A total of 125 patients met inclusion criteria. The cohort was divided into patients with (n 5 43 [34%]) and without (n 5 82 [66%]) placenta accreta and stratified by gestational age at the ultrasound examinations. Women with placenta accreta had shorter cervical length measurements during their 32-to 34-week ultrasound examinations (mean 6 SD, 3.23 6 0.98 versus 3.95 6 1.0 cm; P < .01) and were more likely to have a short cervix of 3 cm or less (P 5 .001). However, these findings did not correlate with the degree of invasion (P 5 .3), or higher rates of vaginal bleeding and preterm labor (P 5 .19) resulting in preterm birth before 36 weeks (P 5 .64). Conclusions-Women with placenta accreta had shorter cervical lengths at 32 to 34 weeks than women with a nonadherent low-lying placenta or placenta previa, but this finding did not correlate with a higher risk of vaginal bleeding or preterm labor resulting in preterm birth before 36 weeks.

Objective: To describe a novel technique for clinical characterization of corneal biomechanics using non-invasive dynamic imaging. Methods: Corneal deformation response during non contact tonometry (NCT) is monitored by ultra-high-speed (UHS) photography. The Oculus Corvis ST (Scheimpflug Technology; Wetzlar, Germany) has a UHS Scheimpflug camera, taking over 4,300 frames per second and of a single 8mm horizontal slit, for monitoring corneal deformation response to NCT. The metered collimated air pulse or puff has a symmetrical configuration and fixed maximal internal pump pressure of 25 kPa. The bidirectional movement of the cornea in response to the air puff is monitored. Results: Measurement time is 30ms, with 140 frames acquired. Advanced algorithms for edge detection of the front and back corneal contours are applied for every frame. IOP is calculated based on the first applanation moment. Deformation amplitude (DA) is determined as the highest displacement of the apex in the highest concavity (HC) moment. Applanation length (AL) and corneal velocity (CVel) are recorded during ingoing and outgoing phases. Conclusion: Corneal deformation can be monitored during non contact tonometry. The parameters generated provide clinical in vivo characterization of corneal biomechanical properties in two dimensions, which is relevant for different applications in Ophthalmology.

Objectives-To evaluate cervical length measurements in women with placenta accreta compared to women with a nonadherent low-lying placenta or placenta previa and evaluate this relationship in terms of vaginal bleeding, preterm labor, and preterm birth. Methods-We conducted a retrospective cohort study between 1997 and 2011 of gravidas with more than 1 prior cesarean delivery who had a transvaginal ultrasound examination between 24 and 34 weeks for a low-lying placenta or placenta previa. Cervical length was measured from archived images in accordance with national guidelines by a single investigator, who was blinded to outcomes and ultrasound reports. The diagnosis of placental accreta was based on histologic confirmation. For study purposes, preterm birth was defined as less than 36 weeks, and cervical lengths of 3 cm or less were considered short. Standard statistical analyses were used. Results-A total of 125 patients met inclusion criteria. The cohort was divided into patients with (n 5 43 [34%]) and without (n 5 82 [66%]) placenta accreta and stratified by gestational age at the ultrasound examinations. Women with placenta accreta had shorter cervical length measurements during their 32-to 34-week ultrasound examinations (mean 6 SD, 3.23 6 0.98 versus 3.95 6 1.0 cm; P < .01) and were more likely to have a short cervix of 3 cm or less (P 5 .001). However, these findings did not correlate with the degree of invasion (P 5 .3), or higher rates of vaginal bleeding and preterm labor (P 5 .19) resulting in preterm birth before 36 weeks (P 5 .64). Conclusions-Women with placenta accreta had shorter cervical lengths at 32 to 34 weeks than women with a nonadherent low-lying placenta or placenta previa, but this finding did not correlate with a higher risk of vaginal bleeding or preterm labor resulting in preterm birth before 36 weeks.

The purpose of this study was to evaluate the association between first-trimester sonographic findings and morbidly adherent placenta at delivery. We conducted a retrospective review of all first-trimester sonographic examinations from pregnancies that underwent third-trimester sonography for placenta previa or low-lying placenta between September 1997 and October 2011. Only women with a prior cesarean delivery were included. Transabdominal and transvaginal images from these first-trimester studies were reviewed for the following sonographic parameters: distance from the inferior border of the gestational sac to the external cervical os, location of the decidua basalis, presence of anechoic areas, uterine-bladder interface irregularity, and smallest anterior myometrial thickness. Morbidly adherent placentation was confirmed on histologic examination of hysterectomy specimens. Statistical methods included univariate and multivariate analyses. Thirty-nine patients met inclusion criter...

5 patients had acute Caesarean section. Mean Apgar values were 7.9/8.8/9.4, mean pH was 7.25. Fetomaternal survival was 100%. Final diagnosis was placenta accreta for 10 (26.3%) and in-or percreta for 28 (73.7%) patients. The degree of invasiveness did not progress in 3rd trimester, no significant difference between presence or severity of the assessed US signs was found (p > 0.16 for all). The estimated AIP probability during 2nd and 3rd trimester correlated highly with the final diagnosis (r 0.72 and 0.8, p<0.0002 for both). Conclusions: Placental invasiveness does not progress significantly over the course of the 3rd trimester. Irrespective of time US diagnosis significantly correlates with the final diagnosis (r > 0.7, p< 0.0002). Bleeding or preterm labour might make earlier delivery necessary, but the majority (87%) of our patients delivered on chosen schedule (>34 week of gestation). Therefore the recommended delivery in week 34-37 seems feasible, thus avoiding unnecessary neonatal morbidity. The natural development of low-lying placentas diagnosed in the second trimester

Background: Fibroids are the most common benign tumours in women of childbearing age. 40-80% of women are affected, and the incidence is rising. The prevalence in pregnancy is 1.6-4%. Large fibroids in pregnancy are not common. While controversy exists on the safety of caesarean myomectomies (CM), new evidence is shifting this debate. Case presentation: We present a 37-year-old woman who successfully underwent a caesarean myomectomy at term. The procedure was performed due to the benefits of this procedure. Conclusion: Caesarean myomectomy in carefully selected patients has been associated with good outcomes and reduces the need for a second surgery. This is, however, not a routine procedure and can be associated with serious complications. Due to the paucity of data and lack of consensus on management, a case-by-case basis is recommended.

Placental invasion anomalies are divided into three according to invasion of uterine wall as placenta accreta, increta and percreta. In placenta percreta, the most severe but the least common form, the placenta invades the full thickness of the uterine wall and also it can attach to adjacent organs in the abdomen like the bladder and rectum. It is a potentially life treating condition. There is no recommended management strategy for placenta percreta. We herein report two cases managed differently and discuss the management options in the light of the literature.

Background: Placenta accreta spectrum (PAS) is an entity where abnormal trophoblastic invasion of placenta occurs into myometrium of uterine wall either partially or totally. Maternal and perinatal morbidity and mortality is increased in PAS due to severe hemorrhage, requirement of blood transfusion and need for peripartum hysterectomy. Objective: To find out risk factors and fetomaternal outcome after multidisciplinary team approach in cases of placenta accreta spectrum. Material and methods: All case records were obtained from medical record section and carefully analyzed to find out risk factors and primary and secondary outcome measures. Results: Maximum patients were in age group of 30-34 years (48.83%) and were third gravida (39.53%). 34.88 % cases had history of previous 2 LSCS (lower segment caesarian section) and in 67.44% it was associated with placenta previa. 67.44% had postpartum haemorrhage (PPH) with 48.83% unbooked cases. 41.18% cases went into hemorrhagic shock with 34.38 % falling into unbooked category. 69.76% had intensive care unit (ICU) admission due to various indications out of which 83.33% were unbooked and 16.67% were booked. 69.44% baby of unregistered pregnancy went to neonatal intensive care unit (NICU) in comparison to 30.56% of registered cases. Conclusion: Placenta accreta spectrum is associated with adverse maternal and perinatal outcome. Prenatal diagnosis and multidisciplinary team management can improve prognosis of both fetal and maternal outcome.