%0 Journal Article
%T Emergency delivery in pregnancies at high probability of placenta accreta spectrum on prenatal imaging: a systematic review and meta-analysis.
%A Lucidi A
%A Janiaux E
%A Hussein AM
%A Nieto A
%A Khalil A
%A D'Amico A
%A Rizzo G
%A D'Antonio F
%J Am J Obstet Gynecol MFM
%V 0
%N 0
%D 2024 Jul 26
%M 39069207
%F 8.679
%R 10.1016/j.ajogmf.2024.101432
%X <B>BACKGROUND: </B>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.<BR><B>METHODS: </B>Medline, Embase, Cochrane and Clinicaltrial.gov databases were searched.<BR><B>METHODS: </B>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.<BR><B>METHODS: </B>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.<BR><B>RESULTS: </B>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.<BR><B>CONCLUSIONS: </B>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.