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ORIGINAL ARTICLE  
Year : 2021  |  Volume : 64  |  Issue : 2  |  Page : 288-293
The effect of different diagnostic timings and types of placenta accreta on the pregnancy outcome


1 Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
2 Department of Obstetrics and Gynecology, The Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian, China
3 Department of Pathology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, China

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Date of Submission12-Feb-2020
Date of Decision07-Apr-2020
Date of Acceptance18-May-2020
Date of Web Publication9-Apr-2021
 

   Abstract 


Objectives: To explore the effects of maternal and fetal outcomes after different diagnostic timings of placenta accreta and its types. Methods: We retrospectively collected the clinical information of 1178 pregnant women with placenta accreta in Fujian Maternity and Children Health Hospital from January 2012 to January 2017. According to the different diagnostic timings of placenta accreta, they were divided into groups of prenatal diagnosis and postpartum diagnosis; and according to the types of placenta accreta, they were divided into groups of accreta group, increta group, and percreta group. Results: 1. Women with antenatal diagnosis more often had placenta previa and history of previous cesarean section. 2. Women with antenatal diagnosis had a higher rate in blood loss and blood transfusion. 3. The rate of blood loss, blood transfusion, infection,disseminated intravascular coagulation (DIC), secondary laparotomy, hysterectomy had statistically significant differences (P < 0.05) in different types of placenta accreta. The deeper of placenta accreta, the higher the incidence of complications. Conclusion: It is important to pay attention for risk factors of the placenta accreta, then improve prenatal diagnostic rate of the placenta accreta and its types, which can forecast the severity of illness to improve maternal and fetal outcomes.

Keywords: Antenatal diagnosis, placenta accreta, types of placenta accreta

How to cite this article:
Xu R, Cai L, Xu S, Yan J. The effect of different diagnostic timings and types of placenta accreta on the pregnancy outcome. Indian J Pathol Microbiol 2021;64:288-93

How to cite this URL:
Xu R, Cai L, Xu S, Yan J. The effect of different diagnostic timings and types of placenta accreta on the pregnancy outcome. Indian J Pathol Microbiol [serial online] 2021 [cited 2021 May 16];64:288-93. Available from: https://www.ijpmonline.org/text.asp?2021/64/2/288/313299




Placenta accreta is an abnormally deep attachment of the placenta, through the endometrium and into the myometrium. Distinguishable by the depth of the nurse cells into the myometrium, it can fall into adhesive placenta, implanted placenta, and penetrating placenta. Over the scores of years, its incidence had been on the increase. According to Serena Wu et al., the incidence has reached 1/533.[1] Because placenta accreta is dangerous and leading to postpartum hemorrhage, shock, uterine perforation, secondary infection and even death, it is gradually becoming a huge challenge for obstetrics.[2] Studies have shown that prenatal prediction of placenta accreta and assessment of its type can be followed by countermeasures to improve women and child outcomes.[3] In this paper, we retrospectively analyzed the clinical data of maternal placenta accreta to explore the effect of diagnostic timing and type of placenta accreta on the pregnancy outcome.


   Materials and Mehtods Top


Subjects

A total of 1178 patients hospitalized at the Fujian Women and Children Health Hospital from January 2012 to January 2017 and diagnosed with placenta accreta were selected. The total number of childbirth for the same period was 74,282. The clinical data were true and complete. The subjects were divided into the prenatal diagnosis group and the postnatal diagnosis group according to the diagnostic timing. The subjects were divided into the adhesive placenta group, the implanted placenta group, and the penetrating placenta group according to the type of placenta accreta.

Diagnosis criteria for placenta accrete

Prenatal diagnosis: (1) Color Doppler ultrasound showed placenta accreta signs: normal structural disorder of the placenta, diffuse or focal placental parenchymal lacunar blood flow, thinned or disappeared hypoechoic area after placenta, abundant blood vessels at the uterine serosa-vesicular junction. (2) NMR imaging showed placenta accreta signs: uterine bulged to the bladder, the un-even signal intensity in the placenta, T2 weighted images in the placenta, and the abnormal placental blood supply. Postpartum diagnosis found: (1) The placenta could not be peeled off by itself during vaginal delivery. When the placenta was peeled off by artificial hand, the placenta was found to be closely connected with the uterine wall and difficult to separate; (2) the placenta was found to penetrate the muscular layer or surrounding organs during surgery; (3) postoperative pathology suggested the presence of villi tissue in the myometrium.[4]


   Methods Top


A retrospective study was conducted to design a placenta accreta clinical data case questionnaire. General patient information and clinical data were collected, including admission, length of hospital stay, hospitalization costs, gestational age of delivery, mode of delivery, pregnancy complications, complications, and hospitalized ICU rate and neonatal Apgar score, neonatal birth weight, NICU rate, etc., The effects of diagnostic timing and implant type of placenta accreta on maternal and perinatal infants were investigated. The differences in gestational age, mode of delivery, postpartum hemorrhage, blood transfusion, DIC incidence, secondary laparotomy, hysterectomy, organ damage, intrauterine infection, neonatal birth weight, fetal distress, neonatal asphyxia, small for gestational age (SGA) and other aspects were compared.

Statistical processing

Using SPSS18.0 software, we compared the measurement data by t-test or one-way analysis of variance. The comparison of count data was performed by χ2 test. Confounding factors were corrected using logistic regression analysis. P < 0.05 was considered statistically significant.


   Results Top


Incidence of placenta accreta and its types

The overall incidence of placenta accreta was 1.59% (1178/74282). Among the composition ratios of various types of placenta accreta, the incidences of adhesive placenta, implanted placenta, and penetrating placenta were 86.33% (1017/1178), 12.65% (149/1178), and 1.02% (12/1178), respectively [Figure 1]. There were 60 cases of prenatal diagnosis, with the prenatal diagnosis rate being 5.10%. To be specific, the prenatal diagnosis rates for each type were: for adhesive placenta, 1.57% (16/1017), for implanted placenta, 24.83% (37/149), and for penetrating placenta, 58.33% (7/12). The prenatal diagnosis rate of placenta in the past five years had generally increased, mainly represented by implanted placenta and penetrating placenta. The prenatal diagnosis rate of adhesive placenta had no obvious change [Figure 2].
Figure 1: The proportion of occurrences of each placenta accreta type

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Figure 2: The curve of changes in prenatal diagnosis rate of different placenta accreta types in our hospital over the past 5 years

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General data and clinical characteristics of placenta accreta patients in different diagnostic timing groups

Among the placenta accreta patients, the prenatal diagnosis group was greater than the postnatal diagnosis group in pregnancy number, birth number and hysterotomy number, with the difference being statistically significant (P<0.05) [Table 1]. The differences of Gestational Diabetes Mellitus (GDM), premature rupture of membranes(PROM), placenta previa and scar surface between the prenatal diagnosis group and the postnatal diagnosis group were statistically significant (P<0.05) [Table 2]. Multivariate logistic regression analysis of statistically significant influencing factors showed that scar uterus and placenta previa were independent risk factors for placenta accreta prenatal diagnosis. At the same time, the interaction analysis showed that the scar uterus, placenta previa and placenta accreta type were correlated (P<0.05), and were interacting with each other [Table 3].
Table 1: General data and clinical characteristics of placenta accreta patients in different diagnostic timing groups (x±s)

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Table 2: Clinical features of placenta accreta patients in different diagnostic timing groups

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Table 3: Logistic regression analysis of the influencing factors of prenatal diagnosis placenta accreta

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Placenta accreta patient's delivery timing

In the prenatal diagnosis group, the correlation between gestational age and postpartum hemorrhage critical line (total bleeding volume ≥ 1500 mL after delivery) was found in patients with placenta accreta. The results showed that there was a correlation between gestational age and postpartum hemorrhage critical line (P < 0.05). The ROC curve was used to evaluate the value of the postpartum hemorrhage critical line and to guide the timing of delivery, as shown in [Figure 1]. When the gestational time was 35 weeks, the sensitivity was 86.10%, the specificity was 50.00%, and the area under the curve (AUC) was 0.63 [Figure 3].
Figure 3: Prediction of ROC curve of postpartum hemorrhage critical line during delivery and gestational age

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Comparison of delivery methods and perinatal outcomes of placenta accreta patients in different diagnostic timing groups

Placenta accreta patients in most of the prenatal diagnosis group chose cesarean section to terminate the pregnancy. The postpartum hemorrhage rate, blood transfusion rate, and hysterectomy rate of patients with placenta accreta were compared between different delivery method groups. The results showed that the postpartum hemorrhage rate, blood transfusion rate, and hysterectomy rate in the vaginal delivery group were lower than those in the cesarean section group, having differential statistical significance (P < 0.05). In vaginal delivery of patients with implanted placenta, more than 50% experienced postpartum hemorrhage, and more than 70% were admitted to the ICU. There was a case of penetrating placenta in vaginal delivery. A hysterectomy was performed after refractory postpartum hemorrhage, and the patient was found to have placenta accreta during surgery.

Comparison of complications in different diagnostic timing groups of placenta accreta patients

The placenta accrete patients in the prenatal diagnosis group had more risk of postpartum hemorrhage and blood transfusion, while the placenta previa and accreta type were risk factors for postpartum hemorrhage (P < 0.001, P < 0.001). Compared with those without placenta previa, patients with combined placenta previa had 2.1-fold more risk of postpartum hemorrhage and 4.7-fold more risk of transfusion. The more severe the accreta type, the greater the risk of post-production bleeding and transfusion (P < 0.001). In different diagnostic timing groups, there were no significant differences in the dysfunction of organ function (bladder ureteral injury), intrauterine infection rate, DIC incidence, secondary laparotomy rate, and hysterectomy rate in placenta accreta patients (P > 0.05). However, the differences in postpartum hemorrhage rate, blood transfusion rate, intrauterine infection rate, DIC incidence rate, secondary laparotomy rate, and hysterectomy rate were statistically significant in different accreta type groups (P < 0.05). The more severe the accreta type, the higher the risk of the above complications in the patients [Table 4].
Table 4: Prognostic comparison of different diagnostic timings and types of placenta accreta patients (corrected logistic regression analysis)

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There were 60 patients with placenta accreta in the prenatal diagnosis group. Seven patients of them underwent preoperative uterine artery embolization for postpartum hemorrhage. There were 53 patients in the nonintervention group without experiencing prenatal intervention. The average postpartum hemorrhage volumes of the intervention group and the nonintervention group were 1274.00 mL and 3093.36 mL, respectively; the average inputs of red blood cells were 4.0 u and 8.4 u, respectively; the average input volumes of fresh frozen plasma were 240.00 mL and 627.45 mL, respectively. It was shown that the amount of postpartum hemorrhage and blood transfusion in the intervention group was significantly less than that in the nonintervention group. A stratified analysis of different types of placenta accreta was performed. The results showed that prenatal intervention in the penetrating placenta group significantly reduced postpartum hemorrhage and blood transfusion, with the difference being statistically significant (P < 0.05). The differences of postpartum hemorrhage rate, transfusion rate, intrauterine infection rate, DIC incidence rate, secondary laparotomy rate, and hysterectomy rate in patients with placenta accreta were statistically significant (P < 0.05). The more severe the accreta type, the higher the risk of these complications [see [Table 4]].

Comparison of perinatal outcomes in placenta accreta patients of different diagnostic timing groups

There were no significant differences in neonatal birth weight, fetal distress rate, neonatal asphyxia rate, and small for gestational age between different diagnostic timing groups (P > 0.05), whereas the difference in Neonatal Intensive Care Unit (NICU) rate was statistically significant (P < 0.05). Comparison showed that the differences of neonatal birth weight, neonatal asphyxia rate, and NICU rate between different accreta type groups were statistically significant (P < 0.05). Pairwise comparisons between different accrete type groups showed that there was a statistically significant difference of neonatal body mass, neonatal asphyxia rate, and NICU rate between the adhesive placenta group and the implanted placenta group (P < 0.05).


   Discussions Top


The gold standard for placenta accreta is a pathological diagnosis, but patients with placenta accreta do not have the opportunity to undergo histopathological diagnosis. Incomplete placenta specimen for testing, and uterine myometrium damage in the uterus specimen and other reasons may cause wrong diagnosis of placenta accreta and wrong assessment of the placenta accreta type. So the incidence of placental implantation would be vastly underestimated if the diagnostic criterion was used. This study used clinical comprehensive diagnostic criteria to calculate the incidence of placenta accreta in our hospital for nearly 5 years, which was 1.59%. The prenatal diagnosis rate was 5.10%, but the prenatal diagnosis rate of placenta accreta was generally on the rise. In particular, the prenatal diagnosis rate of the penetrating placenta group and the implanted placenta group increased significantly. In recent years, the imaging technique has been continuously improved in the prenatal diagnosis of placenta accreta. Especially for patients with high risk factors of placenta accreta, MRI can be used for further identification when ultrasound examination of accreta type cannot ascertain the condition. However, prenatal MRI is still limited in its ability to diagnose adhesive placenta. Jiang et al. believed that the reason may be that the prenatal uterine wall is thin.[5] MRI does not currently recognize the chorion and decidua basalis of the placenta; thus, it is difficult to distinguish whether it infiltrates into the surface of the myometrium. Therefore, the prenatal diagnosis rate of the adhesive placenta is significantly lower than that of the implanted placenta and the penetrating placenta. Naturally, the prenatal diagnosis of adhesive placenta is more inclined to rely on clinical risk factors for prenatal identification. The results of this study show that scar uterus and placenta previa are independent risk factors for prenatal diagnosis. On this basis, we also found that the scar uterus and placenta previa are correlated with the type of placenta accreta. In other words, patients with scar uterus and placenta previa have a higher risk of accreta depth than those patients with simple scar uterus and simple placenta previa have. Studies have shown that multiple maternal history and intrauterine operation history are not an independent risk factor for placenta accreta, but these high-risk patients are often prone to suffer adhesive placenta.[6] Scar uterus and placenta predisposed patients are prone to suffer implanted placenta and penetrating placenta. Therefore, prenatal imaging examinations for those patients with a history of combined scar uterus and placenta previa, often need to be made cautious in order to improve the prenatal diagnosis rate of placenta accreta in such population. At the same time, for the population prenatally identified with placenta accreta, we should predict the type of placenta accreta as per imaging and clinical risk factors to assess the severity of the disease.

When it comes to the choice of timing for placenta accreta patients, how to balance the pros and cons between maternal complications and perinatal morbidity/mortality to find the optimal childbirth time is worth our exploration. There are currently no randomized controlled studies of optimal childbirth time in patients with placenta accreta. Robinson and Grobman found that the optimal childbirth time for placenta accreta patients was 34 weeks, which reduced neonatal morbidity and mortality, but this increased the risk of bleeding.[7] Bowman et al. showed that patients with placenta accreta had a gestational time greater than 36 weeks and the risk of bleeding increased.[8] It is, therefore, recommended that the timing of childbirth be between 34 and 36 weeks. In the analysis of patients with placenta accreta in the prenatal diagnosis group, there was a correlation between the gestational age of delivery and the critical line of postpartum hemorrhage. As the gestational age increase, the risk of critical line of bleeding after production increases. The optimal critical value for predicting postpartum hemorrhage critical line in the ROC curve was 35 weeks. When the gestational age is greater than 35 weeks, the risk of postpartum hemorrhage critical line will increase significantly. However, the area under this ROC curve is less than 0.7, suggesting that the diagnostic accuracy is not high. The main reason is the shortage of sample size, which is to be further confirmed by increasing the sample size in the future. Most studies suggest that gestational age, if greater than 34 weeks, can reduce the incidence and mortality of newborns. Therefore, this study considers balancing the advantages and disadvantages between premature delivery and the incidence of postpartum hemorrhage critical line. Patients with placenta accreta are advised to terminate their pregnancy between 34 and 35 weeks.

Most patients with placenta accreta terminate their pregnancy with cesarean section. Compared with emergency cesarean section, full preoperative preparation for planned delivery is undoubtedly beneficial to the prognosis of the mother and child. Studies have shown that the management of the placenta accreta population by the multidisciplinary health care team can reduce complications in patients prenatally undiagnosed with placenta accreta by more than 50%, and reduce 80% prenatal complications or above in patients diagnosed with placenta accreta. For example, with regard to perinatal hysterectomy,[9] Al-Khan et al. reported that planned hysterectomy compared with emergency hysterectomy could reduce the probabilities of bleeding, blood transfusion and ICU occupancy.[10] This study found that although vaginal delivery can reduce postpartum hemorrhage rate and blood transfusion rate, placenta accreta is found during vaginal delivery, making it difficult to remove placenta and refractory postpartum hemorrhage. In that case, emergency cesarean section or emergency hysterectomy is required. In this study, multivariate regression analysis finds that placenta accreta type is associated with hysterectomy rate. The more severe the accreta type, the increased risk of hysterectomy. The postpartum hemorrhage rate, blood transfusion rate, vesicoureteral injury, DIC incidence, and uterine infection rate are also related to the type of placenta accreta. The more severe the accreta type, the higher the incidence of complications. Therefore, prenatal identification of placenta accreta and its type and weighing the advantages and disadvantages of delivery methods are of great significance to better perinatal outcome of patients with placenta accreta.

There is no evidence-based medical proof regarding whether placenta accreta affects perinatal development. 34450 cases of childbirth were found to show statistically significant difference of premature birth and small-for-gestational age (SGA) infant between combined pregnancy and placenta accreta group and the non-placenta accrete group, infant, thinking that pregnancy combined with placenta accreta resulted in an increased risk of perinatal adverse outcomes.[11] In this study, patients with placenta accreta had a NICU rate of 39.0% in the prenatal diagnosis group, which was significantly higher than that in the postnatal diagnosis group. The main cause is premature birth. In the different types of placenta accreta, the newborn weight of the implanted placenta group was significantly less than that of the adhesive placenta group; the neonatal asphyxia rate and NICU rate are higher than in the adhesive placenta group. Therefore, for prenatal diagnosis of placenta accreta patients, the fetal growth should be closely monitored during pregnancy, and the pregnancy should be terminated in a timely manner; if a medical institution has no facilities or conditions for premature infants, a timely transfer to the better-equipped medical institution for diagnosis is recommended.


   Conclusion Top


Placenta accreta is one of severe complications of obstetric, a serious threat to maternal and child health. But, now a single diagnostic method to predict placenta accreta and placenta accreta type has its limitation. It will be a good suggestion to combine the clinical risk factors to color Doppler and MRI to improve the prenatal diagnostic rate of placenta accreta and placenta accreta type, which will be of great significance to decide delivery timing, have an individualized treatment plan such as vascular intervention treatment, and improve the prognosis of pregnant women and perinatal children.

Ethics and Consent statement

The study protocol was approved by the hospital ethics committee (FuJian Provincial Maternity and Children's Hospital) in Fuzhou, China, and conducted from January 2012 to January 2017. As the case was analyzed retrospectively, there was no informed consent from the patients.

Financial support and sponsorship

Fujian 2014 key clinical specialty construction project: Fujian health and medical policy letter (2015)593.

Fujian Medical Innovation Subject (2017-CX-11)

Fujian Science and Technology Project (2018Y0005).

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: Twenty-year analysis. Am J Obstet Gynecol 2005;192:1458-61.  Back to cited text no. 1
    
2.
Eshkoli T, Weintraub AY, Sergienko R, Sheiner E. Placenta accreta: Risk factors, perinatal outcomes, and consequences for subsequent births. Am J Obstet Gynecol 2013;208:219 e1-7.  Back to cited text no. 2
    
3.
Shamshirsaz AA, Fox KA, Salmanian B, Diaz-Arrastia CR, Lee W, Baker BW, et al. Maternal morbidity in patients with morbidly adherent placenta treated with and without a standardized multidisciplinary approach. Am J Obstet Gynecol 2015;212:218 e1-9.  Back to cited text no. 3
    
4.
Chinese Medical Association Perinatal Medicine Branch, Obstetrics Team of Obstetrics and Gynecology Branch, Chinese Medical Association. Placenta accreta diagnosis and treatment guidelines (2015). Chinese J Perinat Med 2015;7:481-5.  Back to cited text no. 4
    
5.
Jiang KM, Li ST, Zhong X, Dong TF. Prenatal MRI manifestation and pathological basis of placenta accreta. Chinese J Med Imag Tech 2013;296:1002-5.  Back to cited text no. 5
    
6.
Chen YS, Zhao YY. Analysis of clinical risk factors affecting the prevalence of placenta accreta. J Pract Obstet Gynecol 2015;31:916-9.  Back to cited text no. 6
    
7.
Robinson BK, Grobman WA. Effectiveness of timing strategies for delivery of individuals with placenta previa and accrete. Obstet Gynecol 2010;116:835-42.  Back to cited text no. 7
    
8.
Bowman ZS, Manuck TA, Eller AG. Risk factors for unscheduled delivery inpatients with placenta accrete. Am J Obstet Gynecol 2014;210:241.e1-6.  Back to cited text no. 8
    
9.
Eller AG, Bennett MA, Sharshiner M, Masheter C, Soisson AP, Dodson M, et al. Maternal morbidity in cases of placenta accreta managed by a multidisciplinary care team compared with standard obstetric care. Obstet Gynecol 2011;117:331-7.  Back to cited text no. 9
    
10.
Al-Khan A, Gupta V, Illsley NP. Maternal and fetal outcomes in placenta accrete after institution of team-managed care. Reprod Sci 2014;21:761-71.  Back to cited text no. 10
    
11.
Gielchinsky Y, Mankuta D, Rojansky N, Laufer N, Gielchinsky I, Ezra Y. Perinatal outcome of pregnancies complicated by placenta accreta. Obstet Gynecol 2004;104:527-30.  Back to cited text no. 11
    

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Correspondence Address:
Jianying Yan
Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, No. 18, Daoshan Road, Gulou District, 350001 - Fuzhou, Fujian
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_60_20

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