Ultrasound Obstet Gynecol. 2024 Feb;63(2):243-250. doi: 10.1002/uog.27465.
To investigate the rate and outcome of emergency Cesarean delivery (CD) in women with placenta previa with or without placenta accreta spectrum disorders (PAS) and to elucidate the diagnostic accuracy of ultrasound in predicting emergency CD.
This was a secondary analysis of a multicenter prospective study involving 16 referral hospitals in Italy (ADoPAD study). Inclusion criteria were women with placenta previa minor (< 20 mm from the internal cervical os) or placenta previa major (covering the os), aged ≥ 18 years, who underwent transabdominal and transvaginal ultrasound assessment at ≥ 26 + 0 weeks of gestation. The primary outcome was the occurrence of emergency CD, defined as the need for immediate surgical intervention performed for emergency maternal or fetal indication, including active labor, cumulative maternal bleeding > 500 mL, severe and persistent vaginal bleeding such that maternal hemodynamic stability could not be achieved or maintained, or category-III fetal heart rate tracing unresponsive to resuscitative measures. The primary outcome was reported separately in the population of women with placenta previa and no PAS confirmed after birth and in those with PAS. The secondary aim was to report on the strength of association and to test the diagnostic accuracy of ultrasound in predicting emergency CD. Univariate, multivariate and diagnostic accuracy analyses were used to analyze the data.
A total of 450 women, including 97 women with placenta previa and PAS and 353 with placenta previa only, were analyzed. In women with placenta previa and PAS, emergency CD was required in 20.6% (95% CI, 14-30%), and 60.0% (12/20) delivered before 34 weeks of gestation. The mean gestational age at delivery was 32.3 ± 2.7 weeks in women undergoing emergency CD and 34.9 ± 1.8 weeks in those undergoing elective CD (P < 0.001). Women undergoing emergency CD had a higher median estimated blood loss (2500 (interquartile range (IQR), 1350-4500) vs 1100 (IQR, 625-2500) mL; P = 0.012), mean units of blood transfused (7.3 ± 8.8 vs 2.5 ± 3.4; P = 0.02) and more frequent placement of a mechanical balloon (50.0% vs 16.9%; P = 0.002) compared with those undergoing elective CD. On univariate analysis, the presence of interrupted retroplacental space, interrupted bladder line and placental lacunae was more common in women not experiencing emergency CD. No comprehensive multivariate analysis could be performed in this subgroup of women. Ultrasound signs of PAS, including presence of interrupted retroplacental space, interrupted bladder line and placental lacunae, were not predictive of emergency CD. In women with placenta previa but no PAS, emergency CD was required in 31.2% (95% CI, 26.6-36.2%), and 32.7% (36/110) delivered before 34 weeks of gestation. The mean gestational age at delivery was lower in women undergoing emergency CD compared with those undergoing elective CD (34.2 ± 2.9 vs 36.7 ± 1.6 weeks; P < 0.001). Pregnancies complicated by emergency CD were associated with a lower birth weight (2330 ± 620 vs 2800 ± 480 g; P < 0.001) and had a higher risk of need for blood transfusion (22.7% vs 10.7%; P = 0.003) compared with those who underwent elective CD. On multivariate analysis, only placental thickness (odds ratio (OR), 1.02 (95% CI, 1.00-1.03); P = 0.046) and cervical length < 25 mm (OR, 3.89 (95% CI, 1.33-11.33); P = 0.01) were associated with emergency CD. However, a short cervical length showed low diagnostic accuracy for predicting emergency CD in these women.
Emergency CD occurred in about 20% of women with placenta previa and PAS and 30% of those with placenta previa only and was associated with worse maternal outcome compared with elective intervention. Prenatal ultrasound is not predictive of the risk of emergency CD in women with these disorders. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
研究有无胎盘植入谱系疾病（PAS）的前置胎盘孕妇行急诊剖宫产（CD）的发生率和结局，并阐明超声预测急诊 CD 的诊断准确性。
这是一项多中心前瞻性研究的二次分析，涉及意大利 16 家转诊医院（ADoPAD 研究）。纳入标准为：年龄≥18 岁，胎盘前置（胎盘下缘距宫颈内口＜20mm 或＞20mm），在≥26+0 孕周时行经腹和经阴道超声评估。主要结局为急诊 CD 的发生，定义为因紧急母婴或胎儿指征需要立即进行手术干预，包括活跃的产程、累计母体出血量＞500ml、严重持续阴道出血导致母体血流动力学无法维持或保持、或胎儿心率 III 类图形对复苏措施无反应。主要结局分别在分娩后证实有 PAS 的前置胎盘孕妇和无 PAS 的前置胎盘孕妇人群中进行报告，并报告超声预测急诊 CD 的关联强度和诊断准确性。采用单变量、多变量和诊断准确性分析来分析数据。
共分析了 450 名孕妇，其中 97 名孕妇有 PAS 的前置胎盘，353 名孕妇仅有前置胎盘。在有 PAS 的前置胎盘孕妇中，需要行急诊 CD 的比例为 20.6%（95%CI，14-30%），60.0%（12/20）在 34 孕周前分娩。行急诊 CD 的孕妇中位分娩孕周为 32.3±2.7 周，而行择期 CD 的孕妇为 34.9±1.8 周（P＜0.001）。行急诊 CD 的孕妇中位估计出血量更高（2500（四分位距 1350-4500）vs 1100（625-2500）ml；P=0.012），中位输血量更多（7.3±8.8 vs 2.5±3.4；P=0.02），更常放置机械球囊（50.0% vs 16.9%；P=0.002），与行择期 CD 的孕妇相比。在单变量分析中，无急诊 CD 的孕妇中，胎盘后间隙中断、膀胱线中断和胎盘陷窝更常见。在这些孕妇亚组中，无法进行全面的多变量分析。PAS 的超声征象，包括胎盘后间隙中断、膀胱线中断和胎盘陷窝，不能预测急诊 CD。在无 PAS 的前置胎盘孕妇中，需要行急诊 CD 的比例为 31.2%（95%CI，26.6-36.2%），32.7%（36/110）在 34 孕周前分娩。行急诊 CD 的孕妇中位分娩孕周低于行择期 CD 的孕妇（34.2±2.9 vs 36.7±1.6 周；P＜0.001）。与择期 CD 相比，行急诊 CD 的妊娠与较低的出生体重（2330±620 vs 2800±480 g；P＜0.001）和更高的输血需求风险相关（22.7% vs 10.7%；P=0.003）。多变量分析显示，仅胎盘厚度（比值比（OR），1.02（95%CI，1.00-1.03）；P=0.046）和宫颈长度＜25mm（OR，3.89（95%CI，1.33-11.33）；P=0.01）与急诊 CD 相关。然而，对于这些女性，宫颈长度较短对预测急诊 CD 的诊断准确性较低。
有 PAS 的前置胎盘孕妇和仅有前置胎盘孕妇行急诊 CD 的比例分别约为 20%和 30%，与择期干预相比，其母婴结局较差。产前超声不能预测这些疾病孕妇发生急诊 CD 的风险。© 2023 年国际妇产科超声学会。
