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Objectives

O bstetric hemorrhage is the cause of 10% of maternal deaths in the United States, and occurs in more than 600,000 women a year. One of the most common causes of obstetric hemorrhage is abnormal placentation. Past cesarean deliveries directly increase the risk of placenta accreta. Peripartum hysterectomy is often the treatment for placenta accreta but is associated with morbidity and requires large quantities of blood products in a small time span. The goal of this study was to establish predictors of massive blood loss in patients with placenta accreta who went on to hysterectomy. The authors identified the factors associated with large-volume blood component transfusion to create referral recommendations for women with abnormal placentation.The authors did a retrospective study of women with pathologically confirmed placenta accreta (including placenta increta and percreta) who delivered between 2000 and 2010. Preoperative, intraoperative, and postoperative factors of each delivery were reviewed and imaging results were gathered. The authors considered loss of the endometrial-myometrial interface, invasion in to the myometrium or surrounding tissues or the presence of lacunar spaces within the placenta to be verification of abnormal placentation. Estimated blood loss (EBL) was taken from operative reports, and the number of units of packed red blood cells (PRBCs) given during surgery was determined. The primary endpoints of the study were massive blood loss, defined as Z5000 mL, and large-volume PRBC transfusion, defined as Z10 units of red cells. Multivariable logistic regression models were used to study predictors of the primary endpoints with a statistically significant probability value of <0.05.Seventy-seven patients met the criteria. At the time of delivery, 68 women (88.3%) had a hysterectomy, 44 women (57.1%) were Z35 years old, and 19 women (24.7%) were Z37 weeks pregnant. Thirty-nine women (50.6%) chose elective delivery; 72.7% of the patients had a placenta previa. Fifty-two women (67.5%) had placenta accreta and 25 women (32.5%) had placenta increta or percreta.The median EBL was 3000 mL; it was r2500 mL in 31 patients (40.3%). Sixty (60) women (77.9%) had an EBL of r5000 mL. Ten women (13.0%) experienced blood loss of more than 10,000 mL. The mean transfusion requirement was 5 units of PRBCs; 34 women (44.2%) needed <5 units, 52 women (67.5%) needed <10 units, and 60 women (77.9%) needed <15 units. Twelve patients (15.6%) received Z20 units, and 6 patients (7.8%) needed Z30 units of PRBCs. Among women diagnosed antenatally with abnormal placentation, 41.7%, had an EBL of Z5000 mL compared with 12% who were not diagnosed antenatally (P = 0.01). Patients treated more recently had a higher chance of heavy bleeding; 41.9% of women who delivered between 2006 and 2010 had an EBL of Z5000 mL versus only 17.7% of women who delivered between 2000 and 2005 (P = 0.02). Massive blood loss occurred in 26.9% of patients with placenta accreta and in 40.0% of patients with placenta increta or placenta percreta (P...

Antenatal bleeding is associated with an increased risk of emergent delivery. Emergent delivery in a tertiary care facility with immediate access to blood bank and ICU capabilities does not appear to be associated with an increased risk of adverse maternal outcomes. Consequently, some patients may be candidates for delivery later than 34 weeks of gestation.

Intracytoplasmic sperm injection (ICSI) is currently widely used despite concern regarding pregnancy complications and outcome, specifically congenital malformations. The aim of this study was to compare the obstetric and neonatal outcome of pregnancies conceived by IVF and ICSI. Long-term follow-up was achieved through questionnaires sent to women who conceived after IVF/ICSI treatment. Information was obtained regarding 219 pregnancies (322 children) conceived after ICSI and 145 pregnancies (201 children) conceived after IVF. There were no significant differences between the ICSI and regular IVF pregnancies in regard to the couple's characteristics and the obstetric complications. The mean +/- SD birth weight of the singletons conceived after ICSI was similar to that of singletons conceived after IVF: 3001 +/- 703 versus 3059 +/- 643 g respectively. In both groups there was a high incidence of multiple pregnancies, Caesarean sections, prematurity and low birth weights. The incidence of congenital malformations following IVF or ICSI pregnancies was similar, 6.3 and 7.7% respectively, but was increased compared with the general Israeli population. In summary, concern remains regarding the incidence of congenital malformations after IVF and the long-term outcome of ICSI pregnancies. However, the present results are reassuring with regard to the obstetric and neonatal outcome of pregnancies conceived by ICSI compared with those achieved by IVF.