Pregnancy after Endometrial Ablation is rare but associated with high maternal and neonatal morbidity

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Women undergoing Endometrial ablation should be informed that pregnancy is possible after the procedure and is associated with significant maternal and neonatal morbidity. She should be advised to use contraception after the procedure says the results of a systematic review published 27 September 2017 in British Journal of Obstetrics and Gynecology (BJOG).

This is the first systematic review published on this topic despite years of use of endometrial ablation for Abnormal Uterine Bleeding (AUB).  After a new technology is introduced, it takes years to come to know about unintended consequences and pregnancy is a late complication of EA.

This review by Kohn et al. reports 274 cases of pregnancy after endometrial ablation in median 1.5 years after the procedure (range 3 weeks – 13 years). The mean age of women was 37.5 ± 5(range 26-50 years). About 80-90% had not used any form of contraception, but the remaining does use some form of contraception.

1 in 4 pregnant women were amenorrhoeic after ablation.

About 4 out of every 5 pregnancies ended into miscarriage, ectopic or termination. Those who continued either had preterm labor, preterm premature rupture of membranes (PROM), morbidly adherent placenta, cesarean, cesarean hysterectomy and rupture of uterus. There was also higher incidence of neonatal complications like IUGR, prematurity, IUD or early neonatal demise.

Methods of doing Endometrial Ablation
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It was also seen that first generations ablation devices were more commonly used in clinical practice and have higher rates of less completely ablated endometrium, with lower rates of post-ablation amenorrhea and concomitant higher risk for subsequent pregnancy.

Physicians should explain in detail the risk of post-ablation pregnancy, using reliable contraception even if they are amenorrhoeic or perimenopausal.

In an accompanying commentary, Sharp HT focuses that physicians should think of alternative ways to treat AUB like levonorgestrel-containing intrauterine devices or delay ablation until completion of childbearing. If women still desire pregnancy after ablation, surrogacy or adoption can be a valid alternative.

Full text review

Commentary 

Ultrasound is sufficient for prenatal diagnosis of placenta previa accreta: a systematic review and meta-analysis

Ultrasound is highly sensitive and specific in diagnosing placenta previa accreta, after previous cesarean section when performed by skilled sonologist reports the results of a systematic review and meta-analysis by Jauniaux and Bhide published in July issue of Obstetrics and Gynecology.

Placenta accreta is a potential life-threatening condition and requires multidiscipline involvement for successful management and reducing maternal and neonatal morbidity and mortality. Because of increasing incidence of cesarean sections, the incidence of morbidly adherent placenta is on rise.

The incidence of placenta previa accreta was 4.1% in women with 1 prior cesarean and 13.3% in women with ≥2 previous cesarean deliveries.

Prenatal diagnosis of placenta accreta allows for sufficient time and planning by involving the concerned discipline to be prepared in advance.

The researchers included data from 14 cohort studies with 3889 pregnancies presenting with placenta previa or low-lying placenta and 1 or more prior cesarean deliveries in the quantitative analysis.

There were 328 (8.4%) cases of placenta previa accreta, 90% (298 cases) of which were diagnosed with ultrasound.

Two hundred and eight patients underwent cesarean hysterectomy out of 232 cases (89.7%)

The odds of diagnosing placenta accreta were higher in prospective studies (odds ratios = 228.5) as compared to retrospective studies (odds ratio=80.8). Sonography was more accurate in diagnosing placenta accreta as the depth of villous invasion increased.

The authors stressed the need of developing screening protocols for better management of this increasingly common and life threatening obstetric complication.

Placental Accreta Index (PAI) was recently proposed to predict individual risk for morbidly adherent placenta using 2-D and color Doppler sonographic exam. It includes 5 parameters: 2 or > cesarean delivery, lacunae, myometrial thickness, anterior placenta previa and bridging vessels.

Each parameter was weighted to create a 9-point scale in which a score of 0-9 provided a probability of invasion that ranged from 2–96%, respectively. The probability of invasion increases with increasing PAI score, such that a score of 9 confers a 96% chance of histologic placental invasion.

But, the score needs further validation before it can be used as a standardized method in prediction of placenta accreta, but it definitely improved the  antenatal detection.