Total Placenta Previa Associated With the Placenta Accreta Spectrum.
Condition: Maternal; Procedure
MeSH terms: Placenta Previa
Study type: Interventional

Summary: 
      To assess the reliability of placental magnetic resonance imaging measurements in predicting
      peripartum hysterectomy and neonatal outcomes in patients with total placenta previa.
    

Detailed description: 
      Study design and patients This study analyzed the outcomes of a cohort of 372 pregnant women
      diagnosed with PP over five years, from November 2017 to June 2023. The patient population
      for the study included women between the ages of 17 and 42 who were in their third trimester
      of pregnancy (27th to 37th weeks of gestation) and had received a t-PP diagnosis via color
      Doppler ultrasonography (cd-USG) and/or p-MRI. The resulting cohort compared a final sample
      population of 277 singleton pregnant women with t-PP, which comprised 150 pregnant women who
      underwent antenatal p-MRI examinations in the third trimester and 127 pregnant women who did
      not undergo a p-MRI.

      Standards of reference The study covered all singleton pregnancies in which t-PP extended to
      both the anterior and posterior uterine walls, resulting in complete coverage of the internal
      cervical os by the placenta. Transvaginal and transabdominal USG were planned between 32 and
      34 weeks for all patients who were followed up in our clinic due to t-PP and were scheduled
      to be delivered. The gestational ages of the participants were determined using the last
      menstrual date and crown-rump length (CRL) measurements from a first-trimester ultrasound.
      Two perinatologists with at least ten years of experience examined each patient's cd-USG for
      signs of PAS. Ultrasonographic signs identified included placental lacunae, placenta previa
      involving the cervix, loss of the clear zone, and bladder wall interruption.

      Two radiologists with at least ten years of experience, independently of each other,
      evaluated p-MRI scans of pregnant women diagnosed with t-PP without prior knowledge of the
      original reports.

      Definitive diagnosis and pathological reporting Pathological reports and approvals were
      granted according to a rigorous protocol involving at least two pathologists, each with a
      minimum of seven years of professional expertise in their field.

      p-MRI image interpretations The assessment focused on analyzing the different positions of
      the atypical placenta in the lower uterine segment, including the anterior, posterior,
      anterolateral, and posterolateral locations. Precise measurements were taken to calculate the
      placental volume in the S1 and S2 sectors, cervical canal length, and cervical canal
      dilatation. Based on sagittal p-MRI scans, the placental invasion was classified into two
      main areas. Implementing a plane perpendicular to the upper bladder's axis facilitated the
      boundary of these sectors. The term S1 refers to the upper uterine segment that forms the
      part of the uterus that contacts the bladder's posterior wall. Likewise, the lower uterine
      segment, identified as S2, was formed in the lower posterior wall of the bladder.
      Radiologists conducted a sector-wise (S1 and S2) examination of the invasion topography,
      which allowed them to identify specific invasion locations, including parametrial and
      cervical involvement and bladder interruption.

      Multidisciplinary team The operations of patients who gave birth due to PAS were performed by
      the same multidisciplinary team, which included perinatologists, gynecological and obstetric
      surgeons, gynecological oncologists, urologists, neonatologists, cardiovascular surgeons,
      anesthesiology and reanimation specialists, interventional radiologists, and allied health
      personnel with ten years of experience.

      Scheduled surgery and preoperative preparations All participants in our study underwent
      cesarean births during the third trimester of pregnancy. Except for urgent situations, all
      scheduled preterm cesarean deliveries and p-TAH procedures were conducted during the
      gestational period of 34+0 to 36+6 weeks. Among the patients admitted to our clinic due to
      t-PP, surgical intervention was performed before the planned delivery date in cases of
      uterine contraction, the onset of vaginal bleeding, or unexpected medical indications for the
      mother and fetus.

      Statistical Method and Power Analysis G*Power V. 3.1.9.6 estimated sample size. All p-MRI
      values of patients with and without PAS were compared in the reference study, and the
      difference was substantial. Using 95% confidence (1-α), 95% test power (1-β), d=0.8 effect
      size, and the two-way hypothesis, the study contained 84 cases, with a minimum of 42 in each
      group. The study included 155 cesarean sections and 122 TAH cases; post hoc analysis revealed
      a power of 99.9%. 16 Data were analyzed using IBM SPSS V23. ROC analysis determined the
      surgical procedure variable cut-off values. Univariate and multivariate binary logistic
      regression analyses examined independent surgical risk factors. Backward-Wald method was used
      for multivariate binary logistic regression. The analysis findings present mean ± standard
      deviation, median (minimum-maximum), and frequency (percentage) for quantitative and
      categorical variables. Intraclass correlation coefficients and Kappa (k) tests were conducted
      to assess intra- and inter-observer agreement reliability. The significance level was set at
      p<0.05.
    

Intervention name(s): Peripartum total abdominal hysterectomy (p-TAH); Cesarean Section (C/S); Neonatal mortality
Intervention type(s): Procedure; Procedure; Other
Intervention description(s): Peripartum total abdominal hysterectomy (cesarean hysterectomy) refers to a surgical procedure in which a woman undergoes both a cesarean section (C-section) and a hysterectomy simultaneously.
Placenta Accreta, Increta, or Percreta: These are conditions where the placenta attaches too deeply to the uterine wall. In cases of severe attachment, it may be difficult to remove the placenta without causing excessive bleeding, and a hysterectomy may be required.
Cesarean hysterectomy is a major surgical procedure involving significant medical expertise and coordination among healthcare professionals, including obstetricians and surgeons. The decision to perform a cesarean hysterectomy is usually made in emergency situations to address life-threatening complications.; A cesarean section (C/S) involves making an incision in the abdominal wall and uterus to deliver a baby when a vaginal delivery is not feasible or safe.
Total placenta previa refers to a condition where the placenta completely covers the opening of the cervix in the uterus. This condition can pose significant risks during pregnancy and childbirth, and it often necessitates a planned cesarean section (C/S) for delivery.; Neonatal mortality refers to the death of a newborn within the first 28 days of life. This period is divided into early neonatal mortality, which covers the first seven days of life, and late neonatal mortality, which extends from the eighth to the 28th day. Neonatal mortality is a critical measure of the health and well-being of infants and is often used to assess a population's overall health and healthcare systems.
To reduce neonatal mortality, efforts are made to improve maternal healthcare, access to prenatal care, skilled attendance during childbirth, and the availability of neonatal healthcare services. Tracking and addressing factors contributing to neonatal mortality are crucial for improving the chances of survival of newborns and overall health outcomes.
Other intervention name(s): Cesarean hysterectomy; C-section
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: 277 singleton pregnancies that met the inclusion criteria and were diagnosed with total placenta previa (t-PP) in the third trimester were divided into two groups according to whether a placental-MRI (p-MRI) was performed. Nevertheless, we explored whether pregnant women diagnosed with total placenta previa (t-PP), with or without a placental-MRI (p-MRI), needed to undergo peripartum-total abdominal hysterectomy (p-TAH) during cesarean section (C/S) due to the placenta accreta spectrum (PAS).
Masking: Single (Outcomes Assessor)
Primary purpose: Diagnostic
Keywords: magnetic resonance imaging; obstetric labor complications; placenta percreta; placenta previa; pregnancy complications