Download PDF
CC BY 4.0 · Rev Bras Ginecol Obstet 2023; 45(06): 297-302
DOI: 10.1055/s-0043-1770917
Editorial

Placenta Accreta Spectrum Disorders: Current Recommendations from the Perspective of Antenatal Imaging

Conrado Milani Coutinho 
1   Departament of Ginecology and Obstetrics, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
,
Alexia Viegas Georg 
1   Departament of Ginecology and Obstetrics, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
,
Ligia Conceição Assef Marçal 
1   Departament of Ginecology and Obstetrics, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
,
Albaro José Nieto-Calvache 
2   Clínica de Espectro de Acretismo Placentario, Hospital Universitario Fundación Valle del Lili, Cali, Colombia
3   Universidad ICESI, Cali, Colombia
,
Theophilus Adu-Bredu 
4   Obstetrics and Gynecology Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana
,
Francesco D'Antonio 
5   Center for Fetal Care and High Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
,
José Miguel Palacios-Jaraquemada 
6   CEMIC University Hospital and School of Medicine, Universidad de Buenos Aires, Argentina
› Author Affiliations
› Further Information
   Permissions and Reprints

The Burden of a Previous Uterine Scar

Cesarean section (CS) is the most commonly performed surgical procedure in the United States (more than a million surgeries per year) and one of the most frequently performed procedures worldwide.[1] Although CS is a potentially life-saving procedure when correctly indicated, its worldwide use has steadily increased over the last decades (currently 21.1% globally, ranging from 5% in sub-Saharan Africa to 42.8% in Latin America and the Caribbean). Moreover, it will continue increasing worldwide (2030 projection: 28.5% globally, ranging from 7.1% in sub-Saharan Africa to 63.4% in Eastern Asia).[2] Dominican Republic, Brazil, Cyprus, Egypt and Turkey are the worldwide leaders, with CS rates ranging from 58.1% to 50.8%, respectively, which points to a worrying trend towards overmedicalization of childbirth and overuse of CS.[2] Other surgical procedures such as dilation, curettage, myomectomy, and surgical hysteroscopy are less frequent than CS. Still, due to the trend towards more advanced maternal age, the number of pregnant women previously submitted to these procedures also tends to increase. These data point to a growing number of pregnancies in surgically manipulated uteruses.

Pregnant women with previous uterine scars are at risk for increased morbimortality. Complications such as placenta previa, spontaneous uterine rupture, uterine dehiscence (with or without placental intrusion), cesarean scar pregnancy (CSP) and placenta accreta spectrum disorders (PAS) are associated with potentially life-threatening uterine bleeding, extra-uterine lesions and preterm delivery ([Figure 1]).[3]

Zoom Image
Fig. 1 The broader spectrum of potential complications in pregnancies with prior uterine scars. On first and second lines, the respective ultrasound and surgical appearances of the following potential pregnancy abnormalities: A- myometrial dehiscence without overlying placenta; B- myometrial dehiscence with partial placental intrusion; C- myometrial dehiscence with complete placental intrusion; D- cesarean scar pregnancy; E- placenta accreta spectrum. Apart from case A, placenta previa is present on all other cases. On the lower line, potential perinatal adverse outcomes: major uterine bleeding, uterine rupture, unintentional bladder lesion, and neonatal complications of prematurity.

A previous CS increases up to 60% the risk for placenta previa at delivery (approximate incidence: 0.3-2%), with a dose-response pattern based on the number of previous surgeries.[4] The incidence of uterine rupture was estimated as being 5.1 per 10,000 in scarred and 0.8 per 10,000 in unscarred uteruses, with 72% occurring during spontaneous labor.[5] A retrospective cohort of 169,356 pregnancies in a high-risk tertiary hospital reported 0.1% cases of uterine disruption - 83% dehiscence and 17% complete uterine ruptures - the latter significantly more associated with adverse perinatal outcomes. All these pregnancies had previous CS, mainly by low transverse incisions (60%).[6] CSP was estimated to range from 1:1,800 to 1:2,216 pregnancies, 52% in women with only one previous CS.[7] A systematic review and meta-analysis reported that the median prevalence of placenta previa with PAS was 0.07%, with an incidence of PAS in women with placenta previa of 11.1%. More than 90% of PAS cases occurred in women with a previous CS and low-lying/placenta previa.[8] Based on its mounting incidence and potential impact on maternal-fetal mortality, current strategies for mitigating the risks of CSP/PAS must be discussed.



Publication History

Article published online:
21 July 2023

© 2023. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Thieme Revinter Publicações Ltda.
Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil