Matsuzaki Shinya, Rau Alesandra R, Mandelbaum Rachel S, Tavakoli Amin, Mazza Genevieve R, Ouzounian Joseph G, Matsuo Koji
Department of Gynecology, Osaka International Cancer Institute, Osaka, Japan (Dr Matsuzaki).
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA (Ms Rau and Drs Tavakoli, Mazza, and Matsuo); Keck School of Medicine, University of Southern California, Los Angeles, CA (Ms Rau).
Am J Obstet Gynecol MFM. 2023 Oct;5(10):101115. doi: 10.1016/j.ajogmf.2023.101115. Epub 2023 Aug 3.
Previous cesarean delivery is a risk factor for developing placenta accreta spectrum in a subsequent pregnancy and patients with antenatally suspected placenta accreta spectrum frequently undergo planned cesarean hysterectomy. There is a paucity of data regarding unsuspected placenta accreta spectrum among patients undergoing trial of labor after cesarean delivery for attempted vaginal birth after cesarean delivery.
This study aimed to investigate the incidence, characteristics, and delivery outcomes of patients with placenta accreta spectrum diagnosed at the time of vaginal birth after cesarean delivery.
The Healthcare Cost and Utilization Project's National Inpatient Sample was retrospectively queried to examine 184,415 patients with a history of low transverse cesarean delivery who had vaginal delivery in the current index hospital admission between 2017 and 2020. Those with placenta previa, previous vertical cesarean delivery, other uterine scars, and uterine rupture were excluded. This study identified placenta accreta spectrum cases using the World Health Organization International Classification of Disease, Tenth Revision, codes of O43.2. Coprimary outcomes were (1) the incidence rate of placenta accreta spectrum at vaginal birth after cesarean delivery; (2) clinical and pregnancy characteristics related to placenta accreta spectrum, assessed with multivariable binary logistic regression model; and (3) delivery outcomes associated with placenta accreta spectrum by fitting propensity score adjustment. The secondary outcome was to conduct a systematic literature review using 3 public search engines (PubMed, Cochrane, and Scopus). Data on incidence rate and maternal morbidity related to placenta accreta spectrum at vaginal birth after cesarean delivery were evaluated.
The incidence rate of placenta accreta spectrum at vaginal birth after cesarean delivery was 8.1 per 10,000 deliveries. Most placenta accreta spectrum cases were placenta accreta (83.3%). In a multivariable analysis, older maternal age, tobacco use, preeclampsia, multifetal pregnancy, fetal anomaly, preterm premature rupture of membrane, chorioamnionitis, low-lying placenta, and preterm delivery were associated with an increased risk of placenta accreta spectrum (all, P<.05). Of these factors, low-lying placenta had the largest odds for placenta accreta spectrum (526.3 vs 7.3 per 10,000 deliveries; adjusted odds ratio, 35.02; 95% confidence interval, 18.19-67.42). Patients in the placenta accreta spectrum group were more likely to have postpartum hemorrhage (80.0% vs 5.5%), blood product transfusion (23.3% vs 1.0%), shock or coagulopathy (20.0% vs 0.2%), and hysterectomy (43.3% vs <0.1%) than those without placenta accreta spectrum (all, P<.001). In a systematic literature review, a total of 212 studies were screened, and none of these studies examined the incidence and morbidity of placenta accreta spectrum at vaginal birth after cesarean delivery.
This nationwide assessment suggests that although placenta accreta spectrum with vaginal birth after cesarean delivery is uncommon (1 of 1229 cases), the diagnosis of placenta accreta spectrum at vaginal birth after cesarean delivery is associated with significant maternal morbidity. In addition, the data suggest that low-lying placenta in the setting of previous low transverse cesarean delivery warrants careful evaluation for possible placenta accreta spectrum before a trial of labor.
既往剖宫产是后续妊娠发生胎盘植入谱系疾病的危险因素，产前怀疑胎盘植入谱系疾病的患者常接受计划性剖宫产子宫切除术。对于剖宫产术后试产以尝试经阴道分娩的患者，关于未被怀疑的胎盘植入谱系疾病的数据较少。
本研究旨在调查剖宫产术后经阴道分娩时诊断为胎盘植入谱系疾病的患者的发病率、特征及分娩结局。
对医疗成本与利用项目的全国住院患者样本进行回顾性查询，以检查2017年至2020年期间在当前索引医院住院时有低位横切口剖宫产史且经阴道分娩的184,415例患者。排除前置胎盘、既往纵切口剖宫产、其他子宫瘢痕及子宫破裂的患者。本研究使用世界卫生组织国际疾病分类第十版O43.2编码识别胎盘植入谱系疾病病例。共同主要结局为：（1）剖宫产术后经阴道分娩时胎盘植入谱系疾病的发病率；（2）通过多变量二元逻辑回归模型评估与胎盘植入谱系疾病相关的临床及妊娠特征；（3）通过拟合倾向评分调整来评估与胎盘植入谱系疾病相关的分娩结局。次要结局是使用3个公共搜索引擎（PubMed、Cochrane和Scopus）进行系统的文献综述。评估剖宫产术后经阴道分娩时与胎盘植入谱系疾病相关的发病率及孕产妇发病率数据。
剖宫产术后经阴道分娩时胎盘植入谱系疾病的发病率为每10000例分娩中有8.1例。大多数胎盘植入谱系疾病病例为胎盘粘连（83.3%）。在多变量分析中，产妇年龄较大、吸烟、子痫前期、多胎妊娠、胎儿畸形、胎膜早破、绒毛膜羊膜炎、前置胎盘及早产与胎盘植入谱系疾病风险增加相关（均P<0.05）。在这些因素中，前置胎盘发生胎盘植入谱系疾病的几率最高（每10000例分娩中526.3例vs 7.3例；调整优势比为35.02；95%置信区间为18.19 - 67.42）。与无胎盘植入谱系疾病的患者相比，胎盘植入谱系疾病组患者更易发生产后出血（80.0% vs 5.5%）、输血（23.3% vs 1.0%）、休克或凝血功能障碍（20.0% vs 0.2%）及子宫切除术（43.3% vs <0.1%）（均P<0.001）。在系统的文献综述中，共筛选出212项研究，这些研究均未考察剖宫产术后经阴道分娩时胎盘植入谱系疾病的发病率及发病率。
这项全国性评估表明，尽管剖宫产术后经阴道分娩时胎盘植入谱系疾病并不常见（1229例中有1例），但剖宫产术后经阴道分娩时胎盘植入谱系疾病的诊断与显著的孕产妇发病率相关。此外，数据表明，既往低位横切口剖宫产的情况下前置胎盘需要在试产前行仔细评估以排除可能的胎盘植入谱系疾病。
