简介：AbstractObjective:To evaluate the efficacy and safety of a modified cesarean hysterectomy (MCH) procedure in controlling hemorrhage in patients with placenta previa complicated with placenta percreta.Methods:A retrospective analysis was conducted on 23 patients with placenta previa complicated with placenta percreta from January 2016 to December 2018 in the Union Hospital. The patients’ age ranged from 24 to 41 years, and had gestational durations of 32-38 weeks. Nine of them underwent MCH and 14 underwent conventional cesarean hysterectomy (CCH). In the MCH group, the bladder was not mobilized, deliberately. The uterus was excised horizontally above the tourniquet level. Placental tissue around the cervical os was cleaned thoroughly, and hemostatic suturing was performed under direct vision. In the CCH group, the uterus was removed gradually after programmed hemostasis and dissection of adhesions of the vesicouterine peritoneal fold and mobilization of the bladder.Results:There were no significant differences in general conditions between the two groups. The blood loss was significantly less in the MCH group (P < 0.05). The operation time was also decreased dramatically and hospital stay (in days) was shorter than in the CCH group (P < 0.05). There were no bladder or ureter injuries in the MCH group, compared with three cases in the CCH group. There were no statistically significant differences in neonatal birth weight, Apgar score, or intensive care unit admittance rates between the two groups (P > 0.05).Conclusion:This MCH procedure reduced blood loss, avoided bladder injury, and had no long-term complications. It is a safe, rapid, and effective way to control fatal hemorrhage during surgery for women with placenta previa complicated with placenta percreta.

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简介：AbstractPlacenta accreta spectrum is a complication of pregnancy, which poses a great risk on maternal health. Historically, hysterectomy was the modality of treatment of such condition, but an approach towards a more conservative management has been in the light recently. This includes several methods with varying rates of success and complications. Expectant management is effective in up to 78%-80% of the cases. The extirpative method is associated with a high risk of postpartum hemorrhage. The success of the one-step conservative procedure depends on the degree of placental invasion, and the triple-P procedure appears to be successful but requires and interdisciplinary approach. Adjuvant treatment options can be tailored according to individual cases, and these include methotrexate injection, uterine devascularization and hysteroscopic resection of retained placental tissues. Follow up after conservative management is crucial to detect complications early, and it can be done by ultrasound, Doppler examination, and trending β human chorionic gonadotropin levels. Conservative management of placenta accreta spectrum can preserve future fertility but should only be done in hospitals with enough experience as it carries a high risk of maternal complications. In the future, more research should be directed to achieve clear guidelines regarding this topic.

简介：AbstractBackground:Massive bleeding is the main concern for the management of placenta percreta (PP). Intra-abdominal aortic balloon occlusion (IABO) is one method for pelvic devascularization, but the efficacy of IABO is uncertain. This study aims to investigate the outcomes of IABO in PP patients.Methods:We retrospectively reviewed the clinical data of PP cases from six tertiary centers in China between January 2011 and December 2015. PP cases with/without the use of IABO were analyzed. Propensity score matching analysis was performed to reduce the effect of selection bias. Postpartum hemorrhage (PPH) and the rate of hysterectomy, as well as neonatal outcomes, were analyzed.Results:One hundred and thirty-two matched pairs of patients were included in the final analysis. Compared with the control group, maternal outcomes, including PPH (68.9% vs. 87.9%, χ2= 13.984, P < 0.001), hysterectomy (8.3% vs. 65.2%, χ2= 91.672, P < 0.001), and repeated surgery (1.5% vs. 12.1%, χ2 = 11.686, P= 0.001) were significantly reduced in the IABO group. For neonatal outcomes, Apgar scores at 1 minute (8.67 ± 1.79 vs. 8.53 ± 1.68, t=-0.638, P= 0.947) and 5 minutes (9.43 ± 1.55 vs. 9.53 ± 1.26, t = 0.566, P = 0.293) were not significantly different between the two groups.Conclusions:IABO can significantly reduce blood loss, hysterectomies, and repeated surgeries. This procedure has not shown harmful effects on neonatal outcomes.

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简介：AbstractPlacenta percreta with bladder bleeding can occur during gestation or postpartum, posing a great threat to both mother and fetus. But it is rare and lacks standard management strategies. We reported four cases suffering from bladder bleeding caused by placenta percreta even with hemorrhagic shock admitted between January 1st, 2011 and December 31th, 2020 in The First Affiliated Hospital of Zhengzhou University. Clinical information, including age, gravidity and parity, ultrasound and magnetic resonance imaging manifestations, onset gestational age, bladder bleeding volume, clinical manifestations under bleeding, diagnosis, hemostatic methods, hospital stay, treatment cost, and prognosis, are presented. Two cases had bladder bleeding during the second trimester, respectively on the 22+3 and 23+5 weeks. Pregnancy was terminated timely. The other two cases had bladder bleeding on the 2nd day post near-term cesarean section when activity. All the four cases achieved successful hemostasis following angiography and concomitant embolization for iliac vessels, and one of them received electrocoagulation hemostasis under cystoscopy, but failed. They all had favorable clinical outcomes and had no long-term complications. The neonatal outcome in the two cases that bladder hemorrhage occurred after near-term c-section was good. The newborns did not survive in two cases in which bladder hemorrhage occurred at the second trimester of pregnancy. Timely termination of pregnancy is recommended when such a condition develops during gestation. Diagnosis of bladder bleeding is relatively easy, for it is characterized by fast speed and large volume, with concomitant distension of the lower abdomen, blood discharge from the urethral orifice, or the indwelling catheter. Interventional embolization is an effective means to treat bladder bleeding caused by placenta percreta, while electrocoagulation hemostasis under cystoscopy must be applied with great caution. For the pregnant women with a high risk of placenta percreta, timely and accurate diagnosis should be achieved during the gestational age, and bladder bleeding should be concerned when placenta penetrates through the anterior wall of uterus.

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简介：AbstractPlacenta accreta spectrum (PAS) disorders are severe obstetric complications and can cause life-threatening hemorrhage, hysterectomy, or even death. PAS disorders in one of dichorionic diamniotic twins are rare to be seen in clinical practice and lack of standard management strategies. We reported a case of retained placenta creta after selective fetal reduction in one of dichorionic diamniotic twins. A 32-year-old woman with a history of cesarean section was diagnosed with placenta increta in one of dichorionic diamniotic twins at 16 weeks of gestation. After discussion, the couple required to be hospitalized for selective fetal reduction. She received selective termination by ultrasound-guided single fetal intracardiac injection of potassium chloride. The follow-up prenatal ultrasound examinations detected the placenta of the reduced fetus did not stop invade the myometrium of the uterus but developed from placenta increta to placenta percreta. The patient was diagnosed with placental percreta by prenatal ultrasound signs and surgical findings. The patient underwent scheduled cesarean delivery at 34+5 gestational weeks. The outcome of maternal and fetal was satisfactory for our elaborate operation and optimal management. PAS disorders are severe obstetric complications with an increasing incidence. Combined with twin pregnancy makes PAS disorders more intractable. We should learn that selective fetal reduction probably cannot solve it thoroughly. Intensive and standard management is essential to promote maternal and fetal outcomes.

简介：AbstractPosterior placenta accreta spectrum (PAS) disorders are infrequent but potentially associated with significant maternal mortality and morbidity, especially if not diagnosed prenatally. Analysis of published literature is problematic since most experiences included only a few cases. Knowledge of the risk factors associated with posterior PAS is crucial to identifying mothers at higher risk and ask for high sensitivity studies. Ultrasound has poor diagnostic accuracy in detecting posterior PAS, while magnetic resonance imaging better delineates the posterior uterine wall. In comparison, prenatal imaging’s diagnostic performance in detecting posterior PAS is significantly lower than anterior placenta invasion. Management of posterior PAS depends on several factors, including maternal hemodynamic status, available resources, clinical presentation, and invasion severity. For accreta or increta cases, a compression suture is habitually enough to perform hemostasis. Nevertheless, organ involvement habitually requires a multidisciplinary team with the assistant of a general or coloproctology surgeon. The present article aims to update the risk factors, prenatal diagnosis, and surgical management of pregnancies complicated by posterior PAS.

简介：AbstractObjective:To explore the risk factors and pregnancy outcomes in women with a history of cesarean section complicated by placenta accreta (PA).Methods:This case-control study included clinical data from singleton mothers with a history of cesarean section in 11 public tertiary hospitals in seven provinces of China between January 2017 and December 2017. According to the intraoperative findings after delivery, the study population was divided into PA and non-PA groups. We compared the pregnancy outcomes between the two groups, used multivariate logistic regression to analyze the risk factors for placental accreta.Results:For this study we included 11,074 pregnant women with a history of cesarean section; and of these, 869 cases were in the PA group and 10,205 cases were in the non-PA group. Compared with the non-PA group, the probability of postpartum hemorrhage (236/10,205, 2.31% vs. 283/869, 32.57%), severe postpartum hemorrhage (89/10,205, 0.87% vs. 186/869, 21.75%), diffuse intravascular coagulation (3/10,205, 0.03% vs. 4/869, 0.46%), puerperal infection (33/10,205, 0.32% vs. 12/869, 1.38%), intraoperative bladder injury (1/10,205, 0.01% vs. 16/869, 1.84%), hysterectomy (130/10,205, 1.27% vs. 59/869, 6.79%), and blood transfusion (328/10,205,3.21 % vs. 231/869,26.58%) was significantly increased in the PA group (P < 0.05). At the same time, the neonatal birth weight (3250.00 (2950.00-3520.00) g vs. 2920.00 (2530.00-3250.00) g), the probability of neonatal comorbidities (245/10,205, 2.40% vs. 61/869, 7.02%), and the rate of neonatal intensive care unit admission (817/10,205, 8.01% vs. 210/869, 24.17%) also increased significantly (P < 0.05). Weight (odds ratio (OR)= 1.03, 95% confidence interval (CI): 1.01-1.05)), parity (OR= 1.18, 95%CI: 1.03-1.34), number of miscarriages (OR= 1.31, 95%CI: 1.17-1.47), number of previous cesarean sections (OR= 2.57, 95%CI: 2.02-3.26), history of premature rupture of membrane (OR= 1.61, 95%CI: 1.32-1.96), previous cesarean-section transverse incisions (OR= 1.38, 95%CI: 1.12-1.69), history of placenta previa (OR= 2.44,95%CI: 1.50-3.96), and the combination of prenatal hemorrhage (OR= 9.95,95%CI: 8.42-11.75) and placenta previa (OR= 91.74, 95%CI: 74.11-113.56) were all independent risk factors for PA.Conclusion:There was an increased risk of adverse outcomes in pregnancies complicated by PA in women with a history of cesarean section, and this required close clinical attention. Weight before pregnancy, parity, number of miscarriages, number of previous cesarean sections, history of premature rupture of membranes, past transverse incisions in cesarean sections, a history of placenta previa, prenatal hemorrhage, and placenta previa were independent risk factors for pregnancies complicated with PA in women with a history of cesarean section. These independent risk factors showed a high value in predicting the risk for placentab accreta in pregnancies of women with a history of cesarean section.

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简介：AbstractObjective:To detect the expression of caspase-3, baculoviral inhibitor of apoptosis repeat containing 5 (BIRC-5), vascular endothelial growth factor (VEGF), hypoxia-inducible factor (HIF), and the concentration of resistin protein in placental of patients with gestational diabetes mellitus (GDM) and normal pregnant women, and to explore its correlation with the pathogenesis of GDM and its significance.Methods:This study includes 30 pregnant women who chose cesarean section at Tongji Hospital of Tongji Medical College during May 2013 to February 2014: 15 GDM patients and 15 normal glucose tolerance patients, 26-36 years old. The expression of caspase-3, VEGF, HIF, and BIRC-5 in placenta of 15 patients with GDM (GDM group) and 15 normal late pregnancy (control group) was detected by real-time fluorescence quantitative polymerase chain reaction. The concentration of resistin protein in the placenta was detected by enzyme-linked immunosorbent assay.Results:Compared with the control group, the expression of caspase-3, HIF, VEGF, resistin in placenta of GDM group increased significantly (P < 0.05); the expression of BIRC-5 in placenta of GDM group decreased significantly (P < 0.05).Conclusion:The expression of caspase-3, BIRC-5, VEGF, HIF, and resistin in placenta of GDM patients and normal pregnant women are significantly different, which may be involved in the pathogenesis of GDM disease.

简介：Humanplacenta-derivedmononuclearcells(MNC)wereisolatedbyaPercolldensitygradientandculturedinmesenchymalstemcell(MSC)maintenancemedium.Thehomogenouslayerofadherentcellsexhibitedatypicalfibroblastlikemorphology,alargeexpansivepotential,andcellcyclecharacteristicsincludingasubsetofquiescentcells.Invitrodifferentiationassaysshowedthetripotentialdifferentiationcapacityofthesecellstowardadipogenic,osteogenicandchondrogeniclineages.FlowcytometryanalysesandimmunocytochemistrystainshowedthatplacentalMSCwasahomogeneouscellpopulationdevoidofhematopoieticcells,whichuniformlyexpressedCD29,CD44,CD73,CD105,CD166,laminin,fibronectinandvimentinwhilebeingnegativeforexpressionofCD31,CD34,CD45andα-smoothmuscleactin.Mostimportantly,immuno-phenotypicanalysesdemonstratedthatthesecellsexpressedclassImajorhistocompatibilitycomplex(MHC-Ⅰ),buttheydidnotexpressMHC-Ⅱmolecules.Additionallythesecellscouldsuppressumbilicalcordblood(UCB)lymphocytesproliferationinducedbycellularornonspecificmitogenicstimuli.Thisstronglyimpliesthattheymayhavepotentialapplicationinallografttransplantation.SinceplacentaandUCBarehomogeneous,theMSCderivedfromhumanplacentacanbetransplantedcombinedwithhematopoieticstemcells(HSC)fromUCBtoreducethepotentialgraft-versus-hostdisease(GVHD)inrecipients.

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简介：AbstractBackground:Cell salvage has recently been recommended for obstetric use in cases with a high risk of massive hemorrhage during cesarean section (CS). However, limited data are available to support the use of one suction device to collect lost blood. This study aimed to investigate the volume of red blood cells (RBCs) salvaged and the components of amniotic fluid (AF) in blood salvaged by one suction device or two devices during CS in patients with placenta previa and/or accrete.Methods:Thirty patients with placenta previa and/or accrete undergoing elective CS in the Women’s Hospital of Zhejiang University School of Medicine were recruited for the present study from November 1, 2017 to December 1, 2018. The patients were randomly assigned to one of the two groups according to an Excel-generated random number sheet: Group 1 (n = 15), in which only one suction device was used to aspirate all blood and AF, and Group 2 (n = 15), in which a second suction device was mainly used to aspirate AF before the delivery of the placenta. Three samples of blood per patient (pre-wash, post-wash, and post-filtration) were collected to measure AF components. The salvaged RBC volumes were recorded. Continuous data of pre-wash, post-wash, and postfiltration samples were analyzed by using one-way analysis of variance with Tukey’s test for multiple comparisons, or Kruskal-Wallis test with Dunn test for multiple comparisons. Comparisons of continuous data between Group 1 and Group 2 were conducted using Student’s t test or Mann-Whitney U test.Results:The salvaged RBC volume was significantly higher in Group 1 than that in Group 2 (401.6 ± 77.2 mL vs. 330.1 ± 53.3 mL, t = 4.175, P < 0.001). In both groups, squamous cells, lamellar bodies, and fat were significantly reduced by washing (all P<0.001) and squamous cells were further reduced by filtering (P < 0.001). Squamous cells were found in six post-filtration samples (three from each group). Lamellar bodies and fat were completely removed by filtering. Insulin-like growth factor binding protein 1, alphafetoprotein, albumin, lactate dehydrogenase, and potassium were significantly reduced post-wash (all P < 0.05), with no further significant reduction after filtration in either group (all P > 0.05). The mean percentage of fetal RBCs post-filtration was (1.8 ± 0.8)% with a range of 1.0% to 3.5% and (1.9 ± 0.9)% with a range of 0.7% to 4.0% in Groups 1 and 2, respectively, showing no significant difference between the two groups (U= 188.5, P = 0.651).Conclusion:Cell salvage performed by one suction device could result in higher volume of salvaged RBCs and can be used safely for CS in patients with placenta previa and/or accrete when massive hemorrhage occurs.

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