Placenta accreta spectrum (PAS) disorders, comprising placenta accreta, increta, and percreta, are associated with serious maternal morbidity and mortality in both the developed and the developing ...world. The incidence of PAS has increased in the recent years, and the rising rates of cesarean section rate, placenta accreta in previous pregnancies, and other uterine surgeries including myomectomies and repeated endometrial curettage are implicated in its etiopathogenesis. The absolute risk of PAS increases with the number of previous cesarean sections. The PAS remains undiagnosed in one-half to two-thirds of cases, thus increasing maternal morbidity and mortality. Understanding etiopathogenesis and risk factors of this condition allows early diagnosis and planning of delivery, and thereby would help improve maternal and fetal outcomes.
•Iatrogenic damage to decidua basalis results in trophoblastic invasion into the myometrium resulting in PAS.•Increasing cesarean section and uterine surgery rates are implicated in the etiopathogenesis of PAS.•Pros and cons of performing elective uterine procedures should take into account its effects on future pregnancy.
The use of continuous intrapartum electronic fetal heart rate monitoring (EFM) using a cardiotocograph (CTG) was developed to enable obstetricians and midwives to analyse the changes of fetal heart ...rate during labour so as to institute timely intervention to avoid intrapartum hypoxic–ischaemic injury. Although CTG was initially developed as a screening tool to predict fetal hypoxia, its positive predictive value for intrapartum fetal hypoxia is approximately only 30%. Even though different international classifications have been developed with the aim of defining combinations of features that help predict intrapartum fetal hypoxia, the false-positive rate of the CTG is high (60%). Moreover, there has not been a demonstrable improvement in the rate of cerebral palsy or perinatal deaths since the introduction of CTG into clinical practice approximately 45 years ago. However, there has been a significant increase in intrapartum caesarean section and operative vaginal delivery rates. Unfortunately, existing guidelines employ the visual interpretation of CTG based on ‘pattern recognition’, which is fraught with inter- and intra-observer variability. Therefore, clinicians need to understand the physiology behind fetal heart rate changes and to respond to them accordingly, instead of purely relying on guidelines for management. It is very likely that such a ‘physiology-based’ approach would reduce unnecessary operative interventions and improve perinatal outcomes whilst reducing the need for ‘additional tests’ of fetal well-being.
Abnormal invasion of placenta or placenta accreta spectrum disorders refer to the penetration of the trophoblastic tissue through the decidua basalis into the underlying uterine myometrium, the ...uterine serosa or even beyond, extending to pelvic organs. It is classified depending on the degree of invasion into placenta accreta (invasion <50% of the myometrium), increta (invasion >50% of the myometrium) and percreta (invading the serosa and adjacent pelvic organs). Clinical diagnosis is made intra-operatively; however, the confirmative diagnosis can only be made after a histopathological examination. The incidence of abnormal invasion of placenta has increased worldwide, mostly as a consequence of the rise in caesarean section rates, from 1 in 2500 pregnancies to 1 in 500 pregnancies. The importance of the disease is due to the increased maternal and foetal morbidity and mortality. Foetal implications are mainly due to iatrogenic prematurity, while maternal implications are mostly the increased risk of obstetric haemorrhage and surgical complications. The average blood loss is 3000–5000 mL, and up to 90% of the patients require a blood transfusion. An accurate and timely antenatal diagnosis is essential to improve outcomes. The traditional management of abnormal invasion of placenta has been a peripartum hysterectomy; however, the increased incidence and the short- and long-term consequences of a radical approach have led to the development of more conservative techniques, such as the intentional retention of the placenta, partial myometrial excision and the ‘Triple P procedure’. Irrespective of the surgical technique of choice, women with a high suspicion or confirmed abnormally invasive placenta should be managed in a specialist centre with surgical expertise with a multi-disciplinary team who is experienced in managing these complex cases with an immediate availability of blood products, interventional radiology service, an intensive care unit and a neonatal intensive care unit to optimize the outcomes.
Abstract The reported maternal mortality for morbidly adherent placenta ranges from 7% to 10% worldwide. Current treatment modalities for this potentially life-threatening condition include radical ...approaches such as elective peripartum hysterectomy with or without bowel/bladder resection or ureteric re-implantation (for placenta percreta infiltrating these organs), and conservative measures such as compression sutures with balloon tamponade and the placenta remaining in situ. However, both conservative and radical measures are associated with significant maternal morbidity and mortality. The present article describes the Triple-P procedure—which involves p erioperative placental localization and delivery of the fetus via transverse uterine incision above the upper border of the placenta; p elvic devascularization; and p lacental non-separation with myometrial excision and reconstruction of the uterine wall—as a safe and effective alternative to conservative management or peripartum hysterectomy.
Aim
To evaluate the cardiotocography (CTG) features observed in suspected intrapartum chorioamnionitis in term fetuses according to the recently suggested criteria for the pathophysiological ...interpretation of the fetal heart rate and their correlation with perinatal outcomes.
Methods
Retrospective analysis of nonconsecutive CTG traces. ‘CTG chorioamnionitis’ was diagnosed either based on a persistent rise in the baseline for the given gestation or on a persistent increase in the baseline fetal heart rate during labor >10% without preceding CTG signs of hypoxia and in the absence of maternal pyrexia. Perinatal outcomes were compared among cases with no sign of chorioamnionitis, in those with only CTG features suspicious for chorioamnionitis and in those who developed clinical chorioamnionitis.
Results
Two thousand one hundred and five CTG traces were analyzed. Of these, 356 fulfilled the criteria for “CTG chorioamnionitis”. Higher rates of Apgar <7 at 1 and 5 min (21.6% vs 9.0% and 9.8% vs 2.0%, respectively, P < 0.01 for both) and lower umbilical artery pH (7.14 ± 0.11 vs 7.19 ± 0.11, P < 0.01) and an over fivefold higher rate of neonatal intensive care unit admission (16.6% vs 2.9%, P < 0.01) were noted in the ‘CTG chorioamnionitis’ group. Differences in the incidence of abnormal CTG patterns were noted between cases who eventually had clinical evidence of chorioamnionitis (89/356) and those showing CTG features suspicious for chorioamnionitis in the absence of clinical evidence of chorioamnionitis (267/356).
Conclusion
Intrapartum CTG features of suspected chorioamnionitis are associated with adverse perinatal outcomes.
Fetal scalp blood sampling (FBS) was developed as a complementary test to a Pinard's stethoscope in 1962 by Erich Saling, 6 years before the introduction of the cardiotocograph (CTG) into clinical ...practice. Unfortunately, no randomised controlled trials were performed to determine its presumed efficacy in improving perinatal outcomes or reducing operative interventions during labour. The normal values currently used were obtained by sampling only 77 fetuses and therefore, they are not scientifically valid. Not only the area of the scalp sampled is least vascular, and so has been shown to be useless in determining fetal oxygenation (O'Connor et al. Lancet 1979:314;8149), results are also affected by caput and moulding. Due to centralisation of the blood during hypoxic stress, from a physiological point of view, it is nonsensical to sample a peripheral tissue (scalp). As in adults, only an arterial blood sample and not a capillary blood sample should be taken to estimate the pH. Contamination with the alkaline amniotic fluid or meconium (bile acids) can alter the results leading to false reassurance or unnecessary interventions, respectively. In addition, significant differences were observed from two scalp blood samples taken from the same fetus at the same time (O'Brien et al. Eur J Obstet Gynecol Reprod Biol 2013;167:142–5).
Intrapartum fetal scalp blood sampling (FBS) (pH or lactate) has not been shown to reduce emergency cesarean sections or operative vaginal births or improve long-term perinatal outcomes. In contrast, ...it is associated with rare but potentially very serious complications such as leakage of cerebro-spinal fluid (CSF) and perinatal hemorrhagic shock. Therefore, it does not fulfill the "First Do No Harm" principle and its use during labor should be critically re-evaluated.
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