Placenta previa with posterior extrauterine adhesion: clinical features and management practice

Abstract

Background A diagnostic sign on magnetic resonance imaging, suggestive of posterior extrauterine adhesion (PEUA), was identified in patients with placenta previa. However, the clinical features or surgical outcomes of patients with placenta previa and PEUA are unclear. Our study aimed to investigate the clinical characteristics of placenta previa with PEUA and determine whether an altered management strategy improved surgical outcomes. Methods This single institution retrospective study examined patients with placenta previa who underwent cesarean delivery between 2014 and 2019. In June 2017, we recognized that PEUA was associated with increased intraoperative bleeding; thus, we altered the management of patients with placenta previa and PEUA. To assess the relationship between changes in practice and surgical outcomes, a quasi-experimental method was used to examine the difference-in-difference before (pre group) and after (post group) the changes. Surgical management was modified as follows: (i) minimization of uterine exteriorization and adhesion detachment during cesarean delivery and (ii) use of Nelaton catheters for guiding cervical passage during Bakri balloon insertion. To account for patient characteristics, propensity score matching and multivariate regression analyses were performed. Results The study cohort (n = 141) comprised of 24 patients with placenta previa and PEUA (PEUA group) and 117 non-PEUA patients (control group). The PEUA patients were further categorized into the pre (n = 12) and post groups (n = 12) based on the changes in surgical management. Total placenta previa and posterior placentas were more likely in the PEUA group than in the control group (66.7% versus 42.7% [P = 0.04] and 95.8% versus 63.2% [P < 0.01], respectively). After propensity score matching (n = 72), intraoperative blood loss was significantly higher in the PEUA group (n = 24) than in the control group (n = 48) (1515 mL versus 870 mL, P < 0.01). Multivariate regression analysis revealed that PEUA was a significant risk factor for intraoperative bleeding before changes were implemented in practice (t = 2.46, P = 0.02). Intraoperative blood loss in the post group was successfully reduced, as opposed to in the pre group (1180 mL versus 1827 mL, P = 0.04). Conclusions PEUA was associated with total placenta previa, posterior placenta, and increased intraoperative bleeding in patients with placenta previa. Our altered management could reduce the intraoperative blood loss.

Placenta Previa Complicated with Endometriosis: Contemporary Clinical Management, Molecular Mechanisms, and Future Research Opportunities

“…In this systematic literature search, we identified one study that reported the surgical morbidity of PP patients with endometriosis [ 56 ]. This study included 24 women with PP who had posterior extrauterine adhesion.…”

“…This retrospective study also examined the characteristics of PP complicated with endometriosis and found that endometriosis was correlated with a higher rate of total PP (66.7% vs. 42.7%, p = 0.04), posterior placenta (95.8% versus 63.2%, p < 0.01), longer cervical length (56.1 mm versus 36.1 mm, p < 0.01), and increased intraoperative bleeding (1.515 mL versus 870 mL, p < 0.01) compared to those without endometriosis [ 56 ]. These findings suggest that PP complicated with endometriosis appears to be a high risk factor for postpartum hemorrhage; however, the underlying cause of increased intraoperative bleeding remains unclear.…”

“…We identified one study that compared and examined the surgical outcomes between PP patients with and without endometriosis [ 56 ]. This study suggested that PP complicated with endometriosis appears to be a high risk factor for postpartum hemorrhage; however, the reason for increased intraoperative bleeding remains unclear.…”

“…Nevertheless, placement of the IUBT for PP complicated with endometriosis is difficult since the balloon catheter is twisted by the long, narrow cervix with strong retroflexion of the uterus [ 56 ]. Therefore, the exteriorization of the uterus is required to fix the strong retroflexion, which induces further bleeding from the uterine posterior wall due to inevitable detachment of the pelvic adhesion.…”

“…Therefore, the exteriorization of the uterus is required to fix the strong retroflexion, which induces further bleeding from the uterine posterior wall due to inevitable detachment of the pelvic adhesion. Due to these factors, it is exceptionally challenging to insert the intrauterine balloon transabdominally through a uterine incision or transvaginally without performing uterine exteriorization [ 56 ].…”