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Grand Rounds

Does Prenatal Diagnosis of Placenta Accreta Help Reduce Adverse Perinatal Outcomes?

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BACKGROUND AND PURPOSE: 

  • Abnormally invasive placenta is increasing due to increased cesarean section rates 
    • Placenta accreta: Chorionic villi adherent to the myometrium 
    • Placenta increta: Chorionic villi invade myometrium  
    • Placenta percreta: Chorionic villi invade through the myometrium, serosa and possibly surrounding organs and structures  
  • Buca et al. (Ultrasound in Obstetrics & Gynecology, 2018) sought to determine the impact of prenatal diagnosis for abnormally invasive placenta on outcomes

METHODS: 

  • Systematic review and meta-analysis  
    • Database search of studies measuring impact of prenatal diagnosis on surgical outcome for abnormally invasive placenta cases 
    • Compared prenatal to intrapartum abnormally invasive placenta diagnosis  
    • Prenatal diagnosis based on ultrasound, with MRI as needed  
  • Outcomes  
    • Gestational age at birth | Amount of blood loss (L) | Units of RBCs, platelets and FFP transfused | Length of stay in hospital and ICU | Urinary tract injury and infection

RESULTS: 

  • Thirteen studies were included 
  • Hysterectomy rate was not significantly different between groups   
    • Prenatal abnormally invasive placenta diagnosis: 83.7%  
    • Intrapartum abnormally invasive placenta diagnosis: 75.1% (P = 0.07).  
  • Interventional radiology was performed more often when abnormally invasive placenta was diagnosed prenatally 
    • Prenatal abnormally invasive placenta diagnosis: 53.5%  
    • Intrapartum abnormally invasive placenta diagnosis: 16.0%  
  • Compared to those with an intrapartum diagnosis, women with a prenatal diagnosis of abnormally invasive placenta  
    • Lost less blood loss during surgery 
      • Mean difference (MD) −0.87; 95% CI, −1.5 to −0.23 (P=0.008) 
    • Required fewer transfused units of 
      • RBCs: MD −1.45; 95% CI, −2.9 to −0.04 (P=0.04) 
      • FFP: MD −1.73; 95% CI, −3.3 to −0.2 (P=0.03) 
    • Delivered earlier 
      • MD -1.33 weeks; 95% CI, −2.23 to −0.43 (0.004) 
  • There was no difference in risk of admission to an ICU, length of hospital stay or ICU stay  
  • Prenatal diagnosis of abnormally invasive placenta was associated with a higher risk of urinary‐tract injury (odds ratio, 2.5; 95% CI, 1.3–4.6), due to the higher prevalence of placenta percreta in this group  
    • Could include planned surgical approach, not necessarily unintentional error

CONCLUSION: 

  • Authors recognize study limitations including small number of included studies, some with less rigorous design (e.g. retrospective, non-randomized) 
    • Limited data could result in the study being underpowered for less common outcomes  
  • Percreta over-represented in the prenatal diagnosis group, leading to potential bias
  • Prenatal diagnosis of abnormally invasive placenta leads to fewer complications during and following delivery  
    • Allows for delivery at expert centers  
    • Larger studies required to determine best management approach

Learn More – Primary Sources: 

Influence of prenatal diagnosis of abnormally invasive placenta on maternal outcome: systematic review and meta‐analysis

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Related ObG Topics:

Latest SMFM Guidelines: Third Trimester Bleeding Between 34w0d and 36w6d Gestation
Does MRI Help or Hurt When Making a Diagnosis of Placenta Accreta?
Placenta Accreta Spectrum Disorder: Definitions and Management
How Effective is Ultrasound in Diagnosing Placenta Accreta?
Ultrasound for Previa Accreta in Women with Prior C-Section

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