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Placenta Accreta Syndrome
Robert Silver, Robert Silver
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eBook - ePub
Placenta Accreta Syndrome
Robert Silver, Robert Silver
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Placenta accreta comprises a spectrum of disorders where all or part of the placenta becomes attached to the muscular wall of the uterus, which can result in life-threatening hemorrhage at the time of delivery. Previous surgical procedures (including cesarean delivery) and placenta previa are important risk factors, and the incidence is dramatically increasing. This important practical guide to how clinicians should diagnose and manage placenta accreta will be an invaluable reference for all obstetricians and maternal-fetal specialists.
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1
Placenta Accreta: Epidemiology and Risk Factors
Daniela Carusi
CONTENTS
Definition
Incidence
Mortality
Risk Factors
Placenta Previa
Prior Cesarean Section
Maternal Age
Other Uterine Surgery
Past Obstetric History
Current Pregnancy Factors
Abnormal Endometrium
In Vitro Fertilization
Conclusions
References
Placenta accreta represents one of the most morbid conditions in modern obstetrics, with high rates of hemorrhage, hysterectomy, and intensive care unit admission.1 By most accounts, placenta accreta appears to be on the rise,2–4 paralleling the rise in cesarean section rate as a major risk factor. In fact, the true incidence of placenta accreta is difficult to determine, owing to marked variation in the definition of accreta and heterogeneity in the populations studied. This chapter interprets available data on incidence, mortality, and risk factors for placenta accreta.
Definition
Placenta accreta is strictly defined as direct attachment of the placental trophoblast to the uterine myometrium, with no normal intervening decidua or basalis layer.5 Cases with partial or complete invasion of trophoblast through the uterine wall are called increta and percreta, respectively, though all three categories are collectively identified as “accreta” in the epidemiologic literature. The definition has been further categorized based on the amount of placenta involved, with a “total” accreta involving the entire placenta, while “partial” or “focal” accretas involve individual cotyledons or areas within a cotyledon, respectively.6
The first published review of accreta focused on clinical rather than pathologic diagnosis, specifying “undue adherence of the placenta” to the uterine wall.5 More recently, the term “morbidly adherent placenta” has been used to define accreta clinically, though exact diagnostic criteria still vary from study to study. Most researchers using a clinical definition identify “difficult,” or “piecemeal” removal of the placenta,7–10 sometimes specifying an antecedent prolonged third stage of labor following a vaginal delivery.11 Some also specify placental bed hemorrhage after a difficult removal,3,8,9 though not all authors require a morbidity factor in the diagnosis. Others have allowed a very broad clinical definition, including any postpartum curettage for retained products of conception.7
Concerns over diagnostic specificity have led some authors to require histologic confirmation, excluding cases that were suspected clinically but lacked pathologic evidence.12,13 However, reliable pathologic results may not be available when the uterus is conserved, or when multicenter or national-level data are collected.14–16 Some have conversely emphasized a clinical definition, arguing that adherence and morbidity are the most relevant features of accreta.6 In fact, some studies have shown that microscopic findings of accreta have a clinical correlation only 11%–33% of the time, suggesting that isolated histologic criteria may also be nonspecific.17,18 To date, no universal, strict definition exists for data collection purposes.
Incidence
Accreta incidence estimates will be influenced both by the definition used and the specific population of patients studied. Table 1.1 details various estimates according to these factors. When using either a clinical or pathologic diagnosis, regardless of previa status or mode of delivery, general incidence ranges from 1/533 to 1/731 deliveries.9,13,14
TABLE 1.1
Studies Reporting Accreta Incidence
Study and Years Investigated | Accreta Incidence | Patient Source | Definition | Notes |
---|---|---|---|---|
Hospital-Level Data Collection | ||||
Clark et al.19: 1977–1983 | All deliveries: 1/3372 Previas only: 1/10 | Single teaching hospital, United States | Not given | Accreta diagnosed only with previa |
Miller et al.12: 1985–1994 | All deliveries: 1/2510 Previas only: 1/11 Prior CS only: 1/396 | Single teaching hospital, United States | All histologically confirmed | Accretas diagnosed either with previa or with hysterectomy |
Zaki et al.20: 1990–1996 | All deliveries: 1/1922 Previas only: 1/9 | Single hospital, Saudi Arabia | Clinical | Accreta diagnosed only with previa |
Gielchinsky et al.7: 1990–2000 | All deliveries: 1/111 Previas only: 1/10 | Single hospital, Israel | Clinical or histologic | Used broad clinical criteria, including ultrasound findings of RPOC requiring curettage |
Wu et al.9: 1982–2002 | All deliveries: 1/533 | Single teaching hospital, United States | Clinical or histologic | Excluded women with fbroids; gravida 1 patients excluded from risk factor analysis |
Silver et al.10: 1999–2002 | Unlabored CS only: 1/211 Primary unlabored CS only: 1/333 | 19 academic centers, United States | Clinical or histologic | Evaluated unlabored CSs only |
Usta et al.8: 1983–2003 | Previas only: 1/16 | Single teaching hospital, Lebanon | Clinical or histologic | Included cases of previa only |
Morlando et al.3: 1976–2008 | All deliveries: 1976–1978: 1/833 2006–2008: 1/322 | Single teaching hospital, Italy | Clinical or histologic | Rising CS rate over time period: 17%–64% |
Esh-Broder et al.13: 2004–2009 | All deliveries: 1/599 | Single teaching hospital, Israel | Clinical and histologic | Searched all pathology reports |
Eshkoli et al.21: 1988–2011 | Singleton CS only: 1/250 | Single tertiary center, Israel | Clinical | Included singleton cesarean deliveries only |
Bailit et al.14: 2008–2011 | All deliveries: 1/731 | 25 hospitals (22/25 teaching hospitals), United States | Clinical | Evaluated a random sample of deliveries during the time period |
National-Level Data Collection | ||||
Upson et al.16: 2005–2010 | All deliveries: 1/1136 2005: 1/1266 2010: 1/943 | National discharge data, Ireland | Discharge coding | ICD-10 codes for MAP and some form of accreta |
Mehrabadi et al.22: 2009–2010 | All deliveries: 1/694 | National coding, Canadian Institute for Health Information | Canadian Health System ICD coding | Used unique codes for accreta |
Fitzpatrick et al.23: 2010–2011 | All deliveries: 1/5882 No prior CS: 1/33,000 Previa and prior CS: 1/20 | National,... |