| Background The high rate of cesarean delivery and recent changes in fertility policies have increased the rate of recurrent pregnancies in scarred uteruses,which will lead to an increased incidence of placenta accrete spectrum(PAS).Currently,there are no standardized clinical management criteria for PAS worldwide,and in 2018,the International Federation of Gynecology and Obstetrics(FIGO)published consensus guidelines for placenta accrete disease stating that it is crucial to evaluate epidemiological data and outcomes in the context of clear diagnostic criteria,which will provide an accurate theoretical basis for subsequent studies.The results of previous retrospective studies on placental implantation suggest that prenatal diagnostic imaging and clinical data at delivery,as well as histopathological reports,play a very important role in future improvements in screening,diagnosis,and management of implantable placental spectrum disorders.Objective This study was conducted to collect clinical characteristics,high-risk factors,perioperative-related risks and maternal and child outcomes in patients with PAS,and to summarize key influencing factors according to pregnancy outcomes,with the aim of establishing a preliminary predictive model for adverse perioperative outcomes in PAS,to better guide prognosis and to facilitate stratified management of patients for individualized treatment strategies.Methods The data of 277 patients who attended or were referred to Qilu Hospital of Shandong University from January 2017 to December 2021 and were finally diagnosed with PAS were collected as the study population,and all patients were divided into three groups according to the different pregnancy endpoints: cesarean section group;midterm pregnancy induction group;and postpartum placenta retention group.There were 236 cases in the cesarean section group,29 cases in the midterm induction of labor group,and 12 cases in the postpartum retained placenta group.The study focused on the cesarean section group,which was divided into the penetrating PAS group,the implantation PAS group,and the adherent PAS group according to the PAS typology,and statistical analysis was performed to compare the differences between the three clinical typologies of PAS in terms of general clinical characteristics,typical ultrasound signs,perioperative characteristics,and neonatal outcome.The data obtained were categorized into preoperative clinical characteristics and intraoperative clinical characteristics and analyzed using the c2 test for univariate analysis and Logistic regression analysis for multivariate analysis to identify the predictors associated with adverse pregnancy outcomes and to perform a predictive model for adverse perioperative pregnancy outcomes in PAS.The prediction model was developed and evaluated.The midterm pregnancy induction group mainly consisted of the cesarean extraction group,whose general clinical characteristics,typical ultrasound signs,and perioperative-related characteristics were analyzed and compared with the cesarean delivery group accordingly,and the differential characteristics of the two groups were obtained by statistical processing.The clinical data of the postpartum retained placenta group were comprehensively analyzed and summarized,and their clinical characteristics were summarized and extracted for analysis.Results1.There were significant differences in the general clinical characteristics of the penetrating placenta implantation group,implantable placenta implantation group and adherent placenta implantation group in terms of vaginal bleeding symptoms(P=0.001)and preoperative anemia(p<0.001),and in the perioperative characteristics in terms of length of surgery(p<0.001),intraoperative application of tourniquet(p=0.026),abdominal aortic balloon implantation(p<0.001),hysterectomy(p=0.009),implantation area(P<0.001),implantation depth(p<0.001)? implantation site(p<0.001)5 severe postpartum hemorrhage(p<0.001)? massive blood transfusion(p<0.001)5 preoperative uterine rupture(p=0.027),urinary tract injury(p<0.001),ICU(p=0.053),and prolonged postpartum hospital stay(p<0.001)were significantly different.There were no statistically significant differences in neonatal outcomes between the three groups.2.There were significant differences in intraoperative blood transfusion,abdominal aortic balloon implantation,ligation of superior uterine artery branches,and severe postpartum hemorrhage between the cesarean section group and the cesarean delivery group among the midterm pregnancy induction groups,with the intraoperative hemorrhage and the proportion of severe postpartum hemorrhage occurring in the cesarean section group being higher than those in the cesarean delivery group.3.In the postpartum placenta retention group,50.0% of the patients with scarred uterus,about 66.7% of the patients had a history of other uterine operations,he median treatment interval was about 26.50(3.25? 45.25)days,and 50.0% of the patients were treated with oral mifepristone.The main complications of treatment interval were vaginal bleeding,accounting for 50.00%.The surgical approach was mostly laparoscopic combined with hysteroscopic surgery,and the implantation sites were mostly at the fundus and horn of the uterus.4.Model 1 for predicting massive intraoperative transfusion consisted of 6 independent predictors of preoperative(delivery,posterior placental hypoechoic zone,placental basal flow signal)combined with intraoperative(duration of surgery,implantation depth,ligation of superior uterine artery branch),and model 2 for predicting massive intraoperative transfusion consisted of 4 independent predictors of preoperative(advanced age,bladder line,placental basal flow signal,cervical blood sinus).The differences in predictive value were statistically significant,with model 1 having a higher predictive value than model 2 and better discrimination and calibration.The prediction of severe postpartum hemorrhage model 3consisted of 9 independent predictors of preoperative(gestation,placental basal flow signal)combined with intraoperative(gestational week of surgery,duration of surgery,lower uterine bulge,implantation depth,implantation site,abdominal aortic balloon,and ligation of superior uterine artery),and the test suggested that the model had good discrimination and calibration.The model predicting prolonged postpartum hospital stay4 consisted of 3 independent predictors of preoperative(GDM)combined with intraoperative(hysterectomy,grade of intraoperative bleeding),and the test suggested that the model was well differentiated and well calibrated.Conclusions1.The highest percentage of severe anemia occurred in the penetrating PAS group,and the main significant differences in ultrasonographic diagnostic features between the penetrating PAS,implanting PAS,and adherent PAS groups were the posterior placental hypoechoic zone,bladder line,placental trap,and basal placental blood flow signal.2.The penetrating PAS group was higher than the implanted PAS and adherent PAS groups in terms of massive blood transfusion,bladder injury,prolonged postpartum hospital stay,implantation area,and implantation depth,and higher than the implanted PAS group in terms of hysterectomy and preoperative uterine rupture.There was no statistical difference in neonatal outcome between the three groups.3.The intraoperative hemorrhage and the proportion of severe postpartum hemorrhage occurred in the cesarean extraction group were higher than those in the cesarean delivery group.4.The number of births,posterior placental hypoechoic zone,placental basal flow signal,length of surgery,implantation depth,and superior uterine artery branch ligation were the six independent predictors of massive intraoperative transfusion during cesarean delivery for PAS;the number of pregnancies,placental basal flow signal,gestational week of surgery,length of surgery,lower uterine distension,implantation depth,implantation site,abdominal aortic balloon,and superior uterine artery branch ligation were the predictors of 9 independent predictors of severe postpartum hemorrhage occurring during cesarean delivery;GDM,hysterectomy,and intraoperative bleeding grade were 3 independent predictors of prolonged postpartum hospital stay after cesarean delivery for PAS. |
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