1.
Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta‐analysis
Calì, G.; Timor‐Tritsch, I. E.; Palacios‐Jaraquemada, J. ...
Ultrasound in obstetrics & gynecology,
February 2018, Volume:
51, Issue:
2
Journal Article
ABSTRACT
Objective
To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP).
Methods
An electronic search of MEDLINE, EMBASE and
ClinicalTrials.gov ...
databases was performed utilizing combinations of relevant medical subject headings for ‘Cesarean scar pregnancy’ and ‘outcome’. Reference lists of relevant articles and reviews were hand‐searched for additional reports. Observed outcomes included: severe first‐trimester vaginal bleeding; clinical symptoms (abdominal pain, vaginal bleeding) requiring treatment; uncomplicated miscarriage; complicated miscarriage requiring intervention; first‐ or second‐trimester uterine rupture or hysterectomy; third‐trimester bleeding, uterine rupture or hysterectomy; maternal death; incidence of abnormally invasive placenta (AIP); prevalence of placenta percreta; ultrasound signs suggestive of AIP; and live birth. Meta‐analyses of proportions using a random‐effects model were used to combine data. Cases were stratified based on the presence or absence of embryonic/fetal heart activity at the time of diagnosis.
Results
A total of 17 studies (69 cases of CSP managed expectantly, 52 with and 17 without embryonic/fetal heart beat) were included. In women with CSP and embryonic/fetal heart activity, 13.0% (95% CI, 3.8–26.7%) experienced an uncomplicated miscarriage, while 20.0% (95% CI, 7.1–37.4%) required medical intervention. Uterine rupture during the first or second trimester of pregnancy occurred in 9.9% (95% CI, 2.9–20.4%) of cases, while hysterectomy was required in 15.2% (95% CI, 3.6–32.8%) of all cases. Forty (76.9% (95% CI, 65.4–86.5%)) women progressed to the third trimester of pregnancy, of whom 39.2% (95% CI, 15.4–66.2%) experienced severe bleeding. Finally, 74.8% (95% CI, 52.0–92.1%) had a surgical or pathological diagnosis of AIP at delivery and around two‐thirds (69.7% (95% CI, 42.8–90.1%)) of them had placenta percreta. In women with CSP but no embryonic/fetal cardiac activity, an uncomplicated miscarriage occurred in 69.1% (95% CI, 47.4–87.1%) of cases, while surgical or medical intervention during or immediately after miscarriage was required in 30.9% (95% CI, 12.9–52.6%). Uterine rupture during the first trimester of pregnancy occurred in 13.4% (95% CI, 2.7–30.3%) of cases, but hysterectomy was not required in any case.
Conclusions
CSP with positive embryonic/fetal heart activity managed expectantly is associated with a high burden of maternal morbidity including severe hemorrhage, early uterine rupture, hysterectomy and severe AIP. Despite this, a significant proportion of pregnancies complicated by CSP may progress to, or close to, term, thus questioning whether termination of pregnancy should be the only therapeutic option offered to these women. Expectant management of CSP with no cardiac activity may be a reasonable option in view of the low likelihood of maternal complications requiring intervention, although close surveillance is advisable to avoid adverse maternal outcome. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
Resumen
Resultado del embarazo sobre cicatriz de cesárea tratado de forma expectante: revisión sistemática y metaanálisis
Objetivo
Investigar el resultado en mujeres tratadas de forma expectante después del diagnóstico de embarazo sobre cicatriz de cesárea (CSP, por sus siglas en inglés).
Métodos
Se realizó una búsqueda electrónica en las bases de datos MEDLINE, EMBASE y ClinicalTrials.gov utilizando combinaciones de encabezados de temas médicos relevantes para ‘embarazo sobre cicatriz de cesárea’ y ‘resultado’. Para encontrar más informes se realizó una búsqueda manual en la bibliografía de cada artículo. Los resultados observados incluyeron: hemorragia vaginal grave en el primer trimestre; síntomas clínicos (dolor abdominal, hemorragia vaginal) que requirieron tratamiento; aborto sin complicaciones; aborto con complicaciones que requirieron intervención; ruptura uterina o histerectomía en el primer o segundo trimestre; hemorragia, ruptura uterina o histerectomía en el tercer trimestre; muerte materna; prevalencia de placenta invasiva (AIP, por sus siglas en inglés); prevalencia de placenta percreta; indicios de ultrasonido que sugieren AIP; y nacimiento vivo. Para combinar los datos se utilizó un metaanálisis de proporciones con un modelo de efectos aleatorios. Los casos se estratificaron en función de la presencia o ausencia de actividad cardíaca del embrión o del feto en el momento del diagnóstico.
Resultados
Se incluyeron un total de 17 estudios (69 casos de CSP tratados de forma expectante, 52 con presencia de latido del embrión/feto y 17 con ausencia de este). En mujeres con CSP y actividad cardíaca del embrión/feto, el 13,0% (IC 95%, 3,8–26,7%) experimentaron un aborto espontáneo sin complicaciones, mientras que el 20,0% (IC 95%, 7,1‐37,4%) requirieron intervención médica. La rotura uterina durante el primer o segundo trimestre del embarazo ocurrió en un 9,9% (IC 95%, 2,9–20,4%) de los casos, mientras que en un 15,2% (IC 95%, 3,6–32,8%) de todos los casos se requirió histerectomía. Cuarenta mujeres (76,9% (95% CI, 65,4–86,5%)) llegaron al tercer trimestre del embarazo, de las cuales el 39,2% (IC 95%, 15,4–66,2%) experimentaron una hemorragia severa. Finalmente, el 74,8% (IC 95%, 52,0–92,1%) recibió un diagnóstico quirúrgico o patológico de AIP en el momento del parto y alrededor de dos tercios (69,7% (IC 95%, 42,8–90,1%)) tenían placenta percreta. En mujeres con CSP pero sin actividad cardíaca del embrión o del feto, en el 69,1% (95% CI, 47,4–87,1%) de los casos se produjo un aborto espontáneo sin complicaciones, mientras que en un 30,9% se requirió intervención quirúrgica o médica durante o inmediatamente después del aborto (95% CI, 12,9–52,6%). La rotura uterina durante el primer trimestre del embarazo ocurrió en un 13,4% (IC 95%, 2.7–30.3%) de los casos, pero en ningún caso se requirió histerectomía.
Conclusiones
La CSP con actividad cardíaca positiva del embrión o del feto tratada de forma expectante se asocia con una alta carga de morbilidad materna que incluye hemorragia grave, ruptura uterina temprana, histerectomía y AIP grave. A pesar de esto, una proporción significativa de embarazos complicados por CSP pueden llegar a término, o cerca de este, lo que cuestiona si la terminación del embarazo debería ser la única opción terapéutica ofrecida a estas mujeres. El tratamiento de forma expectante de la CSP sin actividad cardíaca puede ser una opción razonable, en vista de la baja probabilidad de complicaciones maternas que requieren intervención, aunque se recomienda una intensa vigilancia para evitar resultados maternos adversos.
摘要
剖宫产瘢痕妊娠期待治疗的结局:系统综述和meta分析
目的
探讨诊断为剖宫产瘢痕妊娠(Cesarean scar pregnancy,CSP)妇女经期待治疗后的结局。
方法
在MEDLINE、EMBASE和ClinicalTrials.gov数据库中进行“Cesarean scar pregnancy”和“outcome”相关医学主题词组合检索。手式检索相关文章及综述中的参考文献以发现其他研究。纳入的观察结局包括:严重的孕早期阴道出血;需治疗的临床症状(腹痛、阴道出血);单纯流产;需要干预的合并并发症的流产;孕早中期子宫破裂或子宫切除术;孕晚期出血、子宫破裂或子宫切除术;孕产妇死亡;异常侵入性胎盘 (abnormally invasive placenta,AIP)发生率;胎盘植入发生率;提示AIP的超声征象;活产。采用随机效应模型进行比例的meta分析以整合数据。基于诊断时是否存在胎芽或胎心活动对于病例进行分层。
结果
共计纳入17 项研究(69例接受期待治疗的CSP,52例有胎芽或胎心搏动,17例无)。在有胎芽或胎心活动的CSP妇女中,13.0%(95% CI,3.8%~26.7%)患者出现单纯流产,而20.0%(95% CI,7.1%~37.4%)患者需要药物干预。在孕早中期子宫破裂发生率为9.9%(95% CI,2.9%~20.4%),而15.2%(95% CI,3.6%~32.8%)患者需要行子宫切除术。40例进入孕晚期的妇女76.9%(95% CI,65.4%~86.5%),其中39.2%(95% CI,15.4%~66.2%)发生严重出血。最后,74.8%(95% CI,52.0%~92.1%)在分娩时手术或病理诊断AIP,约三分之二69.7%(95% CI,42.8%~90.1%)患者发生胎盘植入。在无胎芽或胎心活动的CSP妇女中,单纯流产发生率为69.1%(95% CI,47.4%~87.1%),而其中30.9%(95% CI,12.9%~52.6%)流产时或流产后立即需要手术或药物干预。孕早期子宫破裂发生率为13.4%(95% CI,2.7%~30.3%),而无病例需行子宫切除术。
结论
有胎芽或胎心活动的CSP妇女接受期待治疗与更高的孕产妇死亡率相关,包括严重出血、早期子宫破裂、子宫切除术以及严重AIP。尽管如此,仍有相当大比例的合并CSP的妊娠妇女几近分娩,因此质疑中断妊娠是否为此类妇女的唯一治疗选择。尽管建议对于无胎心活动的CSP妇女进行密切监测以避免孕产妇的不良结局,但鉴于需要干预的孕产妇并发症可能性较低,故接受期待治疗仍为此类妇女的理想选择。
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Quenching of Exciton Recombination in Strained Two-Dimensional Monochalcogenides
Esteve-Paredes, J J; Pakdel, Sahar; Palacios, J J
Physical review letters,
2019-Aug-16, Volume:
123, Issue:
7
Journal Article
We predict that long-lived excitons with very large binding energies can also exist in a single or few layers of monochalcogenides such as GaSe. Our theoretical study shows that excitons confined by ...
a radial local strain field are unable to recombine despite electrons and holes coexisting in space. The localized single-particle states are calculated in the envelope function approximation based on a three-band k·p Hamiltonian obtained from density-functional-theory calculations. The binding energy and the decay rate of the exciton ground state are computed after including correlations in the basis of electron-hole pairs. The interplay between the localized strain and the caldera-type valence band characteristic of few-layered monochalcogenides creates localized electron and hole states with very different quantum numbers which hinders the recombination even for singlet excitons.
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7.
First‐trimester detection of abnormally invasive placenta in high‐risk women: systematic review and meta‐analysis
D'Antonio, F.; Timor‐Tritsch, I. E.; Palacios‐Jaraquemada, J. ...
Ultrasound in obstetrics & gynecology,
February 2018, Volume:
51, Issue:
2
Journal Article
ABSTRACT
Objectives
The primary aim of this systematic review was to ascertain whether ultrasound signs suggestive of abnormally invasive placenta (AIP) are present in the first trimester of ...
pregnancy. Secondary aims were to ascertain the strength of association and the predictive accuracy of such signs in detecting AIP in the first trimester.
Methods
An electronic search of MEDLINE, EMBASE, CINAHL and Cochrane databases (2000–2016) was performed. Only studies reporting on first‐trimester diagnosis of AIP that was subsequently confirmed in the third trimester either during operative delivery or by pathological examination were included. Meta‐analysis of proportions, random‐effects meta‐analysis and hierarchical summary receiver–operating characteristics curve analysis were used to analyze the data.
Results
Seven studies, involving 551 pregnancies at high risk of AIP, were included. At least one ultrasound sign suggestive of AIP was detected in 91.4% (95% CI, 85.8–95.7%) of cases with confirmed AIP. The most common ultrasound feature in the first trimester of pregnancy was low implantation of the gestational sac close to a previous uterine scar, which was observed in 82.4% (95% CI, 46.6–99.8%) of cases. Anechoic spaces within the placental mass (lacunae) were observed in 46.0% (95% CI, 10.9–83.7%) and a reduced myometrial thickness in 66.8% (95% CI, 45.2–85.2%) of cases affected by AIP. Pregnancies with a low implantation of the gestational sac had a significantly higher risk of AIP (odds ratio, 19.6 (95% CI, 6.7–57.3)), with a sensitivity and specificity of 44.4% (95% CI, 21.5–69.2%) and 93.4% (95% CI, 90.5–95.7%), respectively.
Conclusions
Ultrasound signs of AIP can be present during the first trimester of pregnancy, even before 11 weeks' gestation. Low anterior implantation of the placenta/gestational sac close to or within the scar was the most commonly seen early ultrasound sign suggestive of AIP, although its individual predictive accuracy was not high. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Prenatal identification of invasive placentation using magnetic resonance imaging: systematic review and meta‐analysis
D'Antonio, F.; Iacovella, C.; Palacios‐Jaraquemada, J. ...
Ultrasound in obstetrics & gynecology,
July 2014, Volume:
44, Issue:
1
Journal Article
ABSTRACT
Objective
To assess systematically the performance of prenatal magnetic resonance imaging (MRI) in diagnosing the presence, degree and topography of disorders of invasive placentation and to ...
explore the role of the different MRI signs in predicting these disorders. The diagnostic accuracy of ultrasound and MRI in the detection of invasive placentation was also compared.
Methods
MEDLINE, EMBASE, CINAHL and The Cochrane Library, including The Cochrane Database of Systematic Reviews, Database of s of Reviews of Effects and The Cochrane Central Register of Controlled Trials, were searched electronically utilizing combinations of the relevant medical subject heading terms, keywords and word variants for ‘invasive placentation’ and ‘magnetic resonance imaging’. Only prospective studies reporting a diagnosis of invasive placentation at the time of MRI and retrospective studies in which the radiologist was blinded to the final results were included in the analysis. The MRI signs explored were: uterine bulging, heterogeneous signal intensity, dark intraplacental bands on T2 weighted sequences, focal interruption of the myometrium and tenting of the bladder. Summary estimates of sensitivity, specificity, positive and negative likelihood ratios (LR+, LR–) and diagnostic odds ratio (DOR) were based, depending on the number of studies, upon DerSimonian–Laird random‐effect or hierarchical summary receiver–operating characteristics models.
Results
A total of 18 studies involving 1010 pregnancies at risk for invasive placentation were included. The overall diagnostic accuracy of MRI in detecting the presence of invasive placentation was: sensitivity, 94.4% (95% CI, 86.0–97.9%); specificity, 84.0% (95% CI, 76.0–89.8%); LR+, 5.91 (95% CI, 3.73–9.39); LR–, 0.07 (95% CI, 0.02–0.18); DOR, 89.0 (95% CI, 22.8–348.1). MRI had a high predictive accuracy in assessing both the depth and topography of placental invasion. All five MRI signs showed good predictive accuracy in the diagnosis of disorders of invasive placentation. There was no difference in either the sensitivity (P = 0.24) or the specificity (P = 0.91) between ultrasound and MRI for the detection of invasive placentation.
Conclusions
Prenatal MRI is highly accurate in diagnosing disorders of invasive placentation. Ultrasound and MRI have comparable predictive accuracy. Large population‐based studies are needed in order to assess whether ultrasound can predict the depth and topography of placental invasion as reliably as can MRI. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.
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Value of first‐trimester ultrasound in prediction of third‐trimester sonographic stage of placenta accreta spectrum disorder and surgical outcome
Calí, G.; Timor‐Tritsch, I. E.; Forlani, F. ...
Ultrasound in obstetrics & gynecology,
April 2020, Volume:
55, Issue:
4
Journal Article
ABSTRACT
Objectives
To explore whether early first‐trimester ultrasound can predict the third‐trimester sonographic stage of placenta accreta spectrum (PAS) disorder and to elucidate whether ...
combining first‐trimester ultrasound findings with the sonographic stage of PAS disorder can stratify the risk of adverse surgical outcome in women at risk for PAS disorder.
Methods
This was a retrospective analysis of prospectively collected data from women with placenta previa, and at least one previous Cesarean delivery (CD) or uterine surgery, for whom early first‐trimester (5–7 weeks' gestation) ultrasound images could be retrieved. The relationship between the position of the gestational sac and the prior CD scar was assessed using three sonographic markers for first‐trimester assessment of Cesarean scar (CS) pregnancy, reported by Calí et al. (crossover sign (COS)), Kaelin Agten et al. (implantation of the gestational sac on the scar vs in the niche of the CS) and Timor‐Tritsch et al. (position of the center of the gestational sac below vs above the midline of the uterus), by two different examiners blinded to the final diagnosis and clinical outcome. The primary aim of the study was to explore the association between first‐trimester ultrasound findings and the stage of PAS disorder on third‐trimester ultrasound. Our secondary aim was to elucidate whether the combination of first‐trimester ultrasound findings and sonographic stage of PAS disorder can predict surgical outcome. Logistic regression analysis and area under the receiver‐operating‐characteristics curve (AUC) were used to analyze the
data.
Results
One hundred and eighty‐seven women with vasa previa were included. In this cohort, 79.6% (95% CI, 67.1–88.2%) of women classified as COS‐1, 94.4% (95% CI, 84.9–98.1%) of those with gestational‐sac implantation in the niche of the prior CS and 100% (95% CI, 93.4–100%) of those with gestational sac located below the uterine midline, on first‐trimester ultrasound, were affected by the severest form of PAS disorder (PAS3) on third‐trimester ultrasound. On multivariate logistic regression analysis, COS‐1 (odds ratio (OR), 7.9 (95% CI, 4.0–15.5); P < 0.001), implantation of the gestational sac in the niche (OR, 29.1 (95% CI, 8.1–104); P < 0.001) and location of the gestational sac below the midline of the uterus (OR, 38.1 (95% CI, 12.0–121); P < 0.001) were associated independently with PAS3, whereas parity (P = 0.4) and the number of prior CDs (P = 0.5) were not. When translating these figures into diagnostic models, first‐trimester diagnosis of COS‐1 (AUC, 0.94 (95% CI, 0.91–0.97)), pregnancy implantation in the niche (AUC, 0.92 (95% CI, 0.89–0.96)) and gestational sac below the uterine midline (AUC, 0.92 (95% CI, 0.88–0.96)) had a high predictive accuracy for PAS3. There was an adverse surgical outcome in 22/187 pregnancies and it was more common in women with, compared to those without, COS‐1 (P < 0.001), gestational‐sac implantation in the niche (P < 0.001) and gestational‐sac position below the uterine midline (P < 0.001). On multivariate logistic regression analysis, third‐trimester ultrasound diagnosis of PAS3 (OR, 4.3 (95% CI, 2.1–17.3)) and first‐trimester diagnosis of COS‐1 (OR, 7.9 (95% CI, 4.0–15.5); P < 0.001), pregnancy implantation in the niche (OR, 29.1 (95% CI, 8.1–79.0); P < 0.001) and position of the sac below the uterine midline (OR, 6.6 (95% CI, 3.9–16.2); P < 0.001) were associated independently with adverse surgical outcome. When combining the sonographic coordinates of the three first‐trimester imaging markers, we identified an area we call high‐risk‐for‐PAS triangle, which may enable an easy visual perception and application of the three methods to prognosticate the risk for CS pregnancy and PAS disorder, although it requires validation in large prospective studies.
Conclusions
Early first‐trimester sonographic assessment of pregnancies with previous CD can predict reliably ultrasound stage of PAS disorder. Combination of findings on first‐trimester ultrasound with second‐ and third‐trimester ultrasound examination can stratify the surgical risk in women affected by a PAS disorder. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Risk factors, histopathology and diagnostic accuracy in posterior placenta accreta spectrum disorders: systematic review and meta‐analysis
Tinari, S.; Buca, D.; Cali, G. ...
Ultrasound in obstetrics & gynecology,
June 2021, 2021-06-00, 20210601, Volume:
57, Issue:
6
Journal Article
ABSTRACT
Objective
To elucidate the risk factors, histopathological correlations and diagnostic accuracy of prenatal imaging in pregnancies complicated by posterior placenta accreta spectrum (PAS) ...
disorders.
Methods
MEDLINE, EMBASE and CINAHL were searched for studies reporting on women with posterior PAS. Inclusion criteria were women with posterior PAS confirmed either at surgery or on histopathological analysis. The outcomes explored were risk factors for posterior PAS, histopathological correlation and the diagnostic accuracy of ultrasound and magnetic resonance imaging (MRI) in detecting posterior PAS. Random‐effects meta‐analysis of proportions was used to analyze the data.
Results
Twenty studies were included. Placenta previa was present in 92.8% (107/114; 17 studies) of pregnancies complicated by posterior PAS, while 76.1% (53/88; 11 studies) of women had had prior uterine surgery, mainly a Cesarean section (CS) or curettage and 82.5% (66/77; 10 studies) were multiparous. When considering histopathological analysis in women affected by posterior PAS, 77.5% (34/44; 11 studies) had placenta accreta, 19.5% (8/44; 11 studies) had placenta increta and 9.3% (2/44; 11 studies) had placenta percreta. Of the cases of posterior PAS disorder, 52.4% (31/63; 12 studies) were detected prenatally on ultrasound, while 46.7% (32/63; 12 studies) were diagnosed only at birth. When exploring the distribution of the classic ultrasound signs of PAS, placental lacunae were present in 39.0% (12/30; seven studies), loss of the clear zone in 41.1% (13/30; seven studies) and bladder‐wall interruption in 16.6% (4/30; seven studies) of women, while none of the included cases showed hypervascularization at the bladder‐wall interface. When assessing the role of MRI in detecting posterior PAS, 73.5% (26/32; 11 studies) of cases were detected on prenatal MRI, while 26.5% (6/32; 11 studies) were discovered only at the time of CS.
Conclusions
Placenta previa, prior uterine surgery and multiparity represent the most commonly reported risk factors for posterior PAS. Ultrasound had a very low diagnostic accuracy in detecting these disorders prenatally. © 2020 International Society of Ultrasound in Obstetrics and Gynecology
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