Objective: To compare peripartum outcomes of uterus preserving procedures to caesarean hysterectomy in women with placenta accreta spectrum (PAS), and to identify risk factors associated with adverse maternal outcomes. Design: Retrospective study (ClinicalTrials.gov identifier: NCT04384510) Setting:11 tertiary centres from 9 countries Population or Sample: women with of PAS who were managed in participating centres between January 1st, 2010 and December 31st, 2019. Women who had confirmed diagnosis with PAS with adequate documentation and follow-up, were considered eligible. Main Outcome Measures: Primary outcome was massive PAS-associated perioperative blood loss (intraoperative blood loss ≥ 2500 ml, bleeding associated massive transfusion protocol, or complicated by disseminated intravascular coagulopathy). Results: Out of 797 women, 727 were eligible for the study. Five hundred ninety-two (81.43%) women were managed by uterus preserving procedures versus 135 (18.56%) who underwent caesarean hysterectomy. After adjustment for significant or close-to-significance variables, type of management was not associated with higher risk of massive blood loss (aOR 1.71, 95% CI 0.78 - 3.81). Other factors that were significantly associated with higher risk of massive PAS-associated blood loss included body mass index, preoperative haemoglobin, centrally located placenta, diffuse placental invasion, parametrial invasion, and intrauterine foetal death. Conclusions: In the presence of sufficient experience, uterus preserving procedures may not be associated with higher risk of massive blood loss compared to caesarean hysterectomy. Funding: none

Objective: To establish a prediction model of clinical outcomes in women with placenta accreta spectrum (PAS) Design: Retrospective cohort study Setting: International multicenter study (PAS-ID); 11 centers from 9 countries Population: Women who were diagnosed with PAS and were managed in recruiting centers between January 1st, 2010 and December 31st, 2019. Methods: Data were collected using a standardized sheet, which included baseline information, medical and obstetric history, diagnosis, disease characteristics, management, and outcomes. Analysis of association between these variables and primary outcome was first conducted using conventional logistic regression. Data were reanalyzed using machine learning (ML) models, and 2 models were created to predict outcomes using antepartum and perioperative features. Main Outcome Measures: Massive PAS-associated perioperative blood loss (intraoperative blood loss ≥ 2500 ml, triggering massive transfusion protocol, or complicated by disseminated intravascular coagulopathy). Other outcomes include prolonged hospitalization > 7 days and admission to intensive care unit (ICU). Results: 727 women with PAS were included. Area under curve (AUC) for ML antepartum prediction model was 0.84, 0.81, and 0.82 for massive blood loss, prolonged hospitalization, and admission to ICU, respectively. Significant contributors to this model were parity, placental site, method of diagnosis and antepartum hemoglobin. Combing baseline and perioperative variables, ML model performed at 0.86, 0.90, and 0.86 for study outcomes, respectively. This model was most contributed by ethnicity, pelvic invasion, and uterine incision. Conclusions: ML models may be used to calculate individualized risk of morbidity in women with PAS, which may assist to outline management plan in priori

Background: Standard management of ovarian cancer is surgical debulking and adjuvant chemotherapy. The role of systematic lymphadenectomy, as a part of debulking, has been controversial. Objective: To assess prognostic value of systematic lymphadenectomy in women with ovarian cancer based on stage, control group and type of chemotherapy Search strategy: A literature search was conducted on SCOPUS, PUBMED, COCHRANE, MEDLINE, and WEB OF SCIENCE databases. Selection criteria: All comparative studies that assess outcomes of systematic lymphadenectomy in patients with ovarian cancer were eligible. Data Collection and Analysis: overall survival was analyzed by pooling log hazard ratio (HR) and standard error of multivariable Cox regression models. MOGGE Meta-analysis Matrix is a novel illustration tool that was used to demonstrate multiple subgroup analyses of included studies. Main results: Twenty-two studies were eligible. Systematic lymphadenectomy was associated with better overall survival, that was close to significance, compared to control group (HR 0.93, 95%CI 0.86-1.00). Among women treated with adjuvant chemotherapy, overall survival improved in women with stage IIB-IV who underwent systematic lymphadenectomy (HR 0.91, 95%CI 0.84-0.99) and was most significant among patients with III to IV (HR 0.85, 95%CI 0.73-0.99). Systematic lymphadenectomy did not improve survival in women who received neoadjuvant chemotherapy (HR 0.97, 95%CI 0.73-1.29). Systematic lymphadenectomy was associated with improved progress-free survival compared to control group (HR 0.88, 95%CI 0.79-0.99). Conclusion: Data from clinical trials do not support role of systematic lymphadenectomy in advanced ovarian cancer. However, further studies may be warranted to assess substage-specific survival outcomes in women with advanced stages.

Background: High intensity focused ultrasound (HIFU) is a non-invasive procedure that has been recently studied in management of placenta accreta spectrum (PAS). Objective: To appraise efficacy and safety of HIFU in management of PAS and to highlight restrictions of transitioning uterus-preserving studies to clinical practice. Search Strategy: A search on Scopus, Cochrane, PubMed and Web of Science was conducted from date of database inception to January 31st, 2020. Selection Criteria: Studies on use of HIFU in management of PAS were eligible. Review articles, conference papers, animal studies, and case reports were excluded. Data Collection and Analysis: A standardized data collection sheet was used to abstract data from eligible studies. CON-PAS registry was used to include studies on other conservative modalities of management of PAS. Results: Out of 30 studies, four were eligible (399 patients). Average residual placental volume was 61.74 cm3 (6.01-339). Treatment was successful in all patients. Normal menstruation recovered after 48.8 days (15-150). Average time for normalization of β-HCG was 16.5 (1-82) days. No major complications were encountered. Sixty-one studies were retrieved from CON-PAS registry; uterine artery embolization (23 studies), Prophylactic balloon placement (15), compression sutures (10), leaving placenta in situ (7), and uterine wall excision (6) were successful in 83.7% 92.9% 87.9%, 85.2%, and 79.3% of patients, respectively. Conclusions: HIFU yields promising success and safety profile in management of PAS in certain clinical situations. A global research strategy is recommended to incorporate conservative approaches in selected patients within a comprehensive protocol to manage PAS.