Abstract：
BACKGROUND: Placenta accreta spectrum (PAS) disorders are associated with a high risk of maternal morbidity, especially when surgery is performed in emergency conditions. In this context we aimed to report on the incidence of emergency cesarean section (CS) in patients with a high probability of placenta accreta spectrum (PAS) disorders on prenatal imaging and to compare the maternal and neonatal outcomes of patients requiring compared to those not requiring an emergency CS.
METHODS: Medline, Embase, Cochrane and Clinicaltrial.gov databases were searched.
METHODS: Case-control studies reporting the outcome of pregnancies with high probability of PAS on prenatal imaging confirmed at birth delivered by unplanned emergency CS for maternal or fetal indications compared to those who had a planned elective CS. The outcomes observed were the occurrence of emergency CS, incidence of placenta accreta and increta/percreta, preterm birth < 34 weeks of gestation and indications for emergency delivery. We analyzed and compared the outcomes of patients with emergency CS with those with elective including: estimated blood loss (EBL) (ml), number of packed red blood cells (PRBC) units transfused and blood products transfused, transfusion of more than 4 units of PRBC ureteral, bladder or bowel injury, disseminated intra-vascular coagulation (DIC), re-laparotomy after the primary surgery, maternal infection or fever, wound infection, vesicouterine or vesicovaginal fistula, admission to neonatal intensive care unit, maternal death, composite neonatal morbidity, admission to NICU, fetal or neonatal loss, Apgar score < 7 at 5 minutes, neonatal birthweight.
METHODS: Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale for case-control and cohort studies Random-effect meta-analyses of proportions, risk and mean differences were used to combine the data.
RESULTS: Eleven studies with 1290 pregnancies complicated by PAS were included in the systematic review. Emergency CS was reported in 36.2% (95% CI 28.1-44.9) pregnancies with PAS at birth, of which 80.3% (95% CI 36.5-100) occurred before 34 weeks of gestation. The main indication for emergency CS was antepartum bleeding which complicated 61.8% (95% CI 32.1-87.4) of the cases. Emergent CS had a higher EBL during surgery (pooled MD 595 ml, 95% CI 116.1-1073.9, p< 0.001), PRBC (pooled MD 2.3 units, 95% CI 0.99-3.6, p< 0.001) and blood products (pooled MD 3.0, 95% CI 1.1-4.9, p= 0.002) transfused compared to scheduled CS. Patients with emergency CS had a higher risk of requiring transfusion of more than 4 units of PRBC (OR: 3. 8, 95% CI 1.7-4.9; p= 0.002) bladder injury (OR: 2.1, 95% CI 1.1-4.00; p= 0.003), DIC (OR 6.1, 95% CI 3.1-13.1; p<0.001) and admission to ICU (OR 2.1, 95% CI 1. 4-3.3; p<0.001). Newborns delivered in emergency had a higher risk of adverse composite neonatal outcome (OR 2.6, 95% CI 1.4-4.7; p= 0.019), admission to NICU (OR: 2.5, 95% CI 1.1-5.6; p= 0.029), Apgar score <7 at 5 minutes (OR 2.7, 95% CI 1.5-4. 9; p= 0.002) and fetal or neonatal loss (OR: 8.2, 95% CI 2.5-27.4; p<0.001.
CONCLUSIONS: Emergency CD complicates about 35% of pregnancies affected by PAS disorders and is associated with a higher risk of adverse maternal and neonatal outcome. Large prospective studies are needed to evaluate the clinical and imaging signs that can identify those patients with a high probability of PAS at birth, at risk of requiring an emergency CS, intrapartum hemorrhage and peri-partum hysterectomy.
METHODS: Medline, Embase, Cochrane and Clinicaltrial.gov databases were searched.
METHODS: Case-control studies reporting the outcome of pregnancies with high probability of PAS on prenatal imaging confirmed at birth delivered by unplanned emergency CS for maternal or fetal indications compared to those who had a planned elective CS. The outcomes observed were the occurrence of emergency CS, incidence of placenta accreta and increta/percreta, preterm birth < 34 weeks of gestation and indications for emergency delivery. We analyzed and compared the outcomes of patients with emergency CS with those with elective including: estimated blood loss (EBL) (ml), number of packed red blood cells (PRBC) units transfused and blood products transfused, transfusion of more than 4 units of PRBC ureteral, bladder or bowel injury, disseminated intra-vascular coagulation (DIC), re-laparotomy after the primary surgery, maternal infection or fever, wound infection, vesicouterine or vesicovaginal fistula, admission to neonatal intensive care unit, maternal death, composite neonatal morbidity, admission to NICU, fetal or neonatal loss, Apgar score < 7 at 5 minutes, neonatal birthweight.
METHODS: Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale for case-control and cohort studies Random-effect meta-analyses of proportions, risk and mean differences were used to combine the data.
RESULTS: Eleven studies with 1290 pregnancies complicated by PAS were included in the systematic review. Emergency CS was reported in 36.2% (95% CI 28.1-44.9) pregnancies with PAS at birth, of which 80.3% (95% CI 36.5-100) occurred before 34 weeks of gestation. The main indication for emergency CS was antepartum bleeding which complicated 61.8% (95% CI 32.1-87.4) of the cases. Emergent CS had a higher EBL during surgery (pooled MD 595 ml, 95% CI 116.1-1073.9, p< 0.001), PRBC (pooled MD 2.3 units, 95% CI 0.99-3.6, p< 0.001) and blood products (pooled MD 3.0, 95% CI 1.1-4.9, p= 0.002) transfused compared to scheduled CS. Patients with emergency CS had a higher risk of requiring transfusion of more than 4 units of PRBC (OR: 3. 8, 95% CI 1.7-4.9; p= 0.002) bladder injury (OR: 2.1, 95% CI 1.1-4.00; p= 0.003), DIC (OR 6.1, 95% CI 3.1-13.1; p<0.001) and admission to ICU (OR 2.1, 95% CI 1. 4-3.3; p<0.001). Newborns delivered in emergency had a higher risk of adverse composite neonatal outcome (OR 2.6, 95% CI 1.4-4.7; p= 0.019), admission to NICU (OR: 2.5, 95% CI 1.1-5.6; p= 0.029), Apgar score <7 at 5 minutes (OR 2.7, 95% CI 1.5-4. 9; p= 0.002) and fetal or neonatal loss (OR: 8.2, 95% CI 2.5-27.4; p<0.001.
CONCLUSIONS: Emergency CD complicates about 35% of pregnancies affected by PAS disorders and is associated with a higher risk of adverse maternal and neonatal outcome. Large prospective studies are needed to evaluate the clinical and imaging signs that can identify those patients with a high probability of PAS at birth, at risk of requiring an emergency CS, intrapartum hemorrhage and peri-partum hysterectomy.
摘要：
背景：胎盘植入谱（PAS）疾病与产妇发病的高风险相关，尤其是在紧急情况下进行手术时。在这种情况下，我们旨在报告在产前影像学检查中胎盘植入谱（PAS）障碍的高概率患者的紧急剖宫产（CS）发生率，并比较需要与不需要的患者相比的产妇和新生儿结局。紧急CS。
方法：Medline，Embase,搜索了Cochrane和Clinicaltrial.gov数据库。
方法：病例对照研究报告，与那些有计划的选择性CS的孕妇相比，在通过计划外的紧急CS分娩时，产前影像学检查证实有高概率的妊娠结局，用于产妇或胎儿的指征。观察到的结果是急诊CS的发生，胎盘植入和植入/穿孔的发生率，早产<34孕周和紧急分娩的指征。我们分析并比较了急诊CS患者与选择性CS患者的结局，包括：估计失血量（EBL）（ml），输血的红细胞（PRBC）单位和输血的血液制品的数量，输注超过4个单位的PRBC输尿管，膀胱或肠损伤，播散性血管内凝血（DIC），初次手术后再次剖腹手术，产妇感染或发烧，伤口感染,膀胱膀胱或膀胱阴道瘘，入住新生儿重症监护室，产妇死亡,新生儿复合发病率，入住NICU,胎儿或新生儿丢失，阿普加5分钟得分<7，新生儿出生体重。
方法：采用病例对照和队列研究的Newcastle-Ottawa量表对纳入研究进行质量评估随机效应meta分析，风险和平均差异用于合并数据.
结果：11项研究纳入了1290例妊娠合并PAS的研究。在出生时PAS的36.2％（95％CI28.1-44.9）妊娠中报告了紧急CS，其中80.3%(95%CI36.5-100)发生在妊娠34周之前。急诊CS的主要指征是产前出血，其中61.8％（95％CI32.1-87.4）的病例并发。急诊CS在手术期间有较高的EBL(合并MD595毫升，95%CI116.1-1073.9，p<0.001），PRBC（合并MD2.3单位，95％CI0.99-3.6，p<0.001）和血液制品（合并MD3.0，95％CI1.1-4.9，p=0.002）与计划CS相比输血。急诊CS患者需要输血超过4单位PRBC的风险较高（OR：3。8，95％CI1.7-4.9；p=0.002）膀胱损伤（OR：2.1，95％CI1.1-4.00；p=0.003），DIC（OR6.1，95%CI3.1-13.1；p<0.001）和入住ICU（OR2.1，95%CI1。4-3.3；p<0.001）。急诊分娩的新生儿出现不良复合新生儿结局的风险较高(OR2.6,95%CI1.4-4.7;p=0.019),入院NICU（OR：2.5，95%CI1.1-5.6；p=0.029），5分钟时Apgar评分<7（OR2.7，95%CI1.5-4。9；p=0.002）和胎儿或新生儿丢失（OR：8.2，95％CI2.5-27.4；p<0.001。
结论：急诊CD会使约35％的受PAS疾病影响的妊娠复杂化，并与更高的母婴不良结局风险相关。需要大量的前瞻性研究来评估临床和影像学征象，以识别出生时发生PAS的可能性很高的患者。有需要紧急CS的风险，产时出血和围产期子宫切除术。
方法：Medline，Embase,搜索了Cochrane和Clinicaltrial.gov数据库。
方法：病例对照研究报告，与那些有计划的选择性CS的孕妇相比，在通过计划外的紧急CS分娩时，产前影像学检查证实有高概率的妊娠结局，用于产妇或胎儿的指征。观察到的结果是急诊CS的发生，胎盘植入和植入/穿孔的发生率，早产<34孕周和紧急分娩的指征。我们分析并比较了急诊CS患者与选择性CS患者的结局，包括：估计失血量（EBL）（ml），输血的红细胞（PRBC）单位和输血的血液制品的数量，输注超过4个单位的PRBC输尿管，膀胱或肠损伤，播散性血管内凝血（DIC），初次手术后再次剖腹手术，产妇感染或发烧，伤口感染,膀胱膀胱或膀胱阴道瘘，入住新生儿重症监护室，产妇死亡,新生儿复合发病率，入住NICU,胎儿或新生儿丢失，阿普加5分钟得分<7，新生儿出生体重。
方法：采用病例对照和队列研究的Newcastle-Ottawa量表对纳入研究进行质量评估随机效应meta分析，风险和平均差异用于合并数据.
结果：11项研究纳入了1290例妊娠合并PAS的研究。在出生时PAS的36.2％（95％CI28.1-44.9）妊娠中报告了紧急CS，其中80.3%(95%CI36.5-100)发生在妊娠34周之前。急诊CS的主要指征是产前出血，其中61.8％（95％CI32.1-87.4）的病例并发。急诊CS在手术期间有较高的EBL(合并MD595毫升，95%CI116.1-1073.9，p<0.001），PRBC（合并MD2.3单位，95％CI0.99-3.6，p<0.001）和血液制品（合并MD3.0，95％CI1.1-4.9，p=0.002）与计划CS相比输血。急诊CS患者需要输血超过4单位PRBC的风险较高（OR：3。8，95％CI1.7-4.9；p=0.002）膀胱损伤（OR：2.1，95％CI1.1-4.00；p=0.003），DIC（OR6.1，95%CI3.1-13.1；p<0.001）和入住ICU（OR2.1，95%CI1。4-3.3；p<0.001）。急诊分娩的新生儿出现不良复合新生儿结局的风险较高(OR2.6,95%CI1.4-4.7;p=0.019),入院NICU（OR：2.5，95%CI1.1-5.6；p=0.029），5分钟时Apgar评分<7（OR2.7，95%CI1.5-4。9；p=0.002）和胎儿或新生儿丢失（OR：8.2，95％CI2.5-27.4；p<0.001。
结论：急诊CD会使约35％的受PAS疾病影响的妊娠复杂化，并与更高的母婴不良结局风险相关。需要大量的前瞻性研究来评估临床和影像学征象，以识别出生时发生PAS的可能性很高的患者。有需要紧急CS的风险，产时出血和围产期子宫切除术。
