Morlando, Maddalena (2018) Abnormal invasive placenta: epidemiology, diagnosis, management, fetal and maternal implications. [Tesi di dottorato]

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Abstract

Abnormal invasive placentation (AIP) is a potentially life-threatening complication of pregnancy characterized by an abnormal adherence of the placenta to the uterine wall. Its clinical consequence is failure of placental separation leading to massive postpartum haemorrhage with a significant increase in maternal morbidity and mortality. The reported incidence of abnormal placentation is highly variable, ranging from 1:93 000 to 1:111 pregnancies. A deficit in the uterine wall thickness due to a scarred uterus or an abnormal placentation site in the lower segment is a major risk factor. An increasing incidence of AIP has been demonstrated to be related to higher rates of cesarean section (CS). Therefore, populations with a high CS rate, such as in southern Italy, are expected to have an increased incidence of AIP. While obstetricians agree that a planned delivery with a multidisciplinary team is the best management option to optimize maternal outcomes, there is little evidence to guide the timing of delivery for previa-accreta patients. Choosing the timing of delivery is critical in terms of limiting both maternal and neonatal risk. Several studies have suggested the benefits of planned delivery in the reduction of maternal morbidity. An early delivery can be beneficial as it allows to arrange a multidisciplinary team and to avoid an emergency delivery because of bleeding or labour. However, a scheduled delivery often means delivery of a premature infant, and all the risks related to iatrogenic prematurity must be taken into account. Placenta previa and AIP represent the second most common cause for indicated preterm delivery, accounting for 5.6-8.7% of iatrogenic preterm deliveries. Preterm delivery before 37 weeks represents a major burden worldwide, with 15 million preterm births per year. Preterm birth is associated with many specific acute complications of immaturity. In almost all high- and middle-income countries, preterm birth is the leading cause of child deaths. In addition to its contribution to mortality, preterm birth can have lifelong effects on neurodevelopment, with increased risks of cerebral palsy, impaired learning, and mental disorders. Of 15 million (12.3–18.2 million) preterm births per year, 13.0 million (12.7–14.3 million) are estimated to survive the neonatal period. Among them, 0.9 million (uncertainty range: 0.8–1.1 millions) of these survivors will suffer long-term neurodevelopmental impairment with 345,000 moderately or severely affected. Preterm brain injury results from developmental vulnerability given that the brain weighs only 65% of its full-term weight at 34 weeks and glial cell migration continues to 36 weeks. Gyral and sulcal development is still incomplete late preterm. The cortical volume in the late preterm infant is only 53% of the term volume, with approximately half the volume to be obtained in the last 6 weeks before 40 weeks. Brain insults in the late preterm brain can also alter the trajectory of specific programs in neuronal and glial development, as they do in the very premature brain, thereby contributing to the neurological disabilities of the survivors. Ideally we would deliver patients with AIP at the gestational age at which lowest morbidity for the mother coincides with lowest morbidity for the infant. As the second leading cause of iatrogenic prematurity, during this PhD programme research has been focused on the epidemiology, diagnosis, and management of AIP, trying to provide more evidence to restrict the earliest planned AIP deliveries to situations with demonstrated benefit.

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