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Placenta Accreta Is Associated With IVF Pregnancies: A Retrospective Chart Review
Placenta Accreta Is Associated With IVF Pregnancies: A Retrospective Chart Review
DOI: 10.1111/j.1471-0528.2011.02976.x
www.bjog.org
Introduction
Placenta accreta (PA) is a potentially catastrophic obstetric
complication. Whether the placenta is completely or focally
adherent to the myometrium, PA is associated with massive
postpartum haemorrhage, and has become one of the most
common indications for emergent peripartum hysterectomy.13 PA develops when the placental implantation is
abnormal: the decidua basalis that normally separates the
anchoring placental villi and the myometrium is missing.
More invasive types include placenta increta and placenta
percreta, in which the placenta extends to and through the
uterine myometrium, respectively. The exact pathogenesis
is unknown. Possible hypotheses include: (1) a mechanical
factor, i.e. primary deficiency of the decidua caused by
local trauma to the uterine wall; (2) a biological factor, i.e.
abnormal maternal response to trophoblast invasion; and
(3) a combination of both processes.
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2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG
Statistical analysis
Methods
During the 5 years between January 2004 and February
2009, there were 25 193 deliveries in Hadassah Mt Scopus,
Jerusalem, Israel, a university-affiliated tertiary care centre
in the north of Jerusalem. Seven hundred and fiftytwo deliveries (3%) were of IVF-achieved pregnancies.
According to our departmental protocols, whenever there
is a clinical suspicion of PA in vaginal or caesarean delivery, the placenta is sent for pathological examination. This
included cases that were clinically suspected as PA. Cases
were defined as clinically suspected PA if significant difficulty was encountered in placental separation, requiring
manual lysis of the placenta or uterine revision, and in caesarean sections, cases with heavy bleeding from the placental bed requiring haemostatic sutures. The histopathology
sas v9.2 (SAS Institute Inc., Cary, NC, USA) was used for
statistical analysis. The exact Wilcoxon test was applied to
continuous variables, and Fishers exact test was applied
to categorical variables. All tests were two-tailed. Results
were considered statistically significant when P 0.05.
Results
During the study period there were 42 cases of clinically
suspected PA that were confirmed histologically: 30 SP and
12 IVF. The SP group included two women that each had
two pregnancies with PA during the study period. Nine
of the patients in the IVF group were treated in our IVF
unit, and we were able to retrieve detailed data including
treatment indication, protocols and early pregnancy
hormonal support from the hospital files. Three women
2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology 2011 RCOG
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Esh-Broder et al.
Deliveries
Spontaneous pregnancy
IVF
Total
deliveries
Placenta
accreta (%)
25 193
24 441
752
42 (0.17)
30 (0.12)
12 (1.60)
Table 2. Demographic parameters, obstetric and gynaecological history, and index pregnancy and delivery details in the study groups
Demographic parameters
Age (years, mean 2SE)
Ethnic origin (%)
Non-Jewish
Jewish
Obstetric and gynaecological history
Parity (%)
0
14
>5
Previous uterine surgery (%)
Caesarean section
0
1
>1
Other
Miscarriages
Curettage
Previous placenta accreta
Index pregnancy and delivery details
Pregnancy (%)
Single
Multiple
Maternal complications
Fetal complications
Placenta pathology visualized by ultrasound (%)
Placenta praevia (complete, partial or marginal)
Suspected placenta accreta
Gestational age (weeks), mean 2 SE
Mode of delivery (%)
Vaginal
Caesarean section
Caesarean section + hysterectomy
Fetal weight (g), mean 2 SE)
Spontaneous pregnancy
n = 30
IVF
n = 12
33.57 1.31
37.83 5.47
0.4096
4 (13)
26 (87)
1 (8)
11 (92)
1.0000
5 (17)
23 (77)
2 (6)
9 (75)
3 (25)
0
0.0007
25
3
2
0
13
10
2
(83)
(10)
(7)
(43)
(33)
(7)
29 (97)
1 (3)
Hypertension n = 1
11
1
0
1
7
5
0
(92)
(8)
(8)
(58)
(42)
9 (75)
3 (25)
Hypertension n = 1;
gestational diabetes n = 2
IUGR* n = 1
1.0000
0.4994
0.7260
1.0000
0.0634
4 (13)
1 (3)
38.03 1.36
2 (17)
0
37.58 1.64
1.0000
1.0000
0.2729
25 (84)
1 (3)
4 (13)
3151.97 282.16
5 (42)
7 (58)
0
2712.83 335.22
0.0003
0.0301
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1
2
3
4
5
6
7
8
9
10
11
12
Age
IVF indication
Induction
protocol
Endometrial
thickness (cm/days
before b-hCG)
30
43
44
31
49
35
35
40
28
31
59
29
Tubal factor
Unexplained
Male factor
Unexplained
Age
Unexplained
Male factor
Unexplained
Unexplained
Anovulatory after failed COH
Age
Short-antagonist
Long
OD
Long
OD
Short-antagonist
Frozen
Long
Frozen
Frozen
OD
0.65/2
1.1/1
0.7/8*
1.0/2
0.79/8*
0.73/0
0.87/4*
1.3/1
0.78/8*
Fertilisation
Embryo
transfer
Early
pregnancy
support
IVF
ICSI
ICSI
IVF + ICSI
ICSI
ICSI
ICSI
IVF + ICSI
IVF
Day
Day
Day
Day
Day
Day
Day
Day
Day
E
E
E
E
E
E
E
E
E
5
3
3
3
3
3
3
3
5
+
+
+
+
+
+
+
+
+
P
P
P
P
P
P
P
P
P
b-hCG, b subunit of human chorionic gonadotrophin; E + P, estrogen plus progesterone; ICSI, intracytoplasmic sperm injection; OD, ovum donor.
*Number of days before embryo transfer.
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Disclosure of interest
None.
Contribution to authorship
EE-B coordinated the study, assisted in chart review, and
prepared the article. IA examined placentas and participated in article preparation, NA-B assisted in chart review,
YB assisted in chart review, and reviewed and commented
on the manuscript draft, DHC coordinated the study and
prepared the manuscript.
Funding
None.
Acknowledgement
None. j
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