High risk of massive hemorrhage and hysterectomy in patients with placenta previa accreta presenting with macroscopic hematuria.

Abstract

Macroscopic hematuria is a rare but potentially serious perinatal complication. This study aimed to evaluate the relationship between maternal gross hematuria, prenatal ultrasound findings, perinatal outcomes, and histopathologic findings at birth. Of note, 3 major electronic databases were searched for articles published between inception and July 2024 using combinations of relevant subject heading terms. Only observational studies that provided data on prenatal macroscopic hematuria in pregnancies complicated with placenta accreta spectrum at birth were included. Of note, 2 independent reviewers selected studies and extracted data using a predesigned protocol registered on the International Prospective Register of Systematic Reviews (registration number: CRD42024528300). Of the 135 articles reviewed, 17 met our inclusion criteria, describing 18 cases complicated by antenatal macroscopic hematuria. Gestational ages at the first episode of gross hematuria and at delivery ranged from 15 to 30 and 15 and 38 weeks, respectively. Moreover, 12 of 17 patients (70.6%) had an obstetrical history of ≥2 previous cesarean deliveries. Data on prenatal imaging was available in 15 cases and described as placenta percreta with invasion of the bladder. All authors reported on the management, describing cesarean hysterectomy as the main management strategy in 17 cases (94.4%). Massive intraoperative hemorrhage and transfusion were reported by all authors who performed a hysterectomy and provided detailed intraoperative description. There were 2 maternal deaths due to hemorrhagic complications. In 11 cases (61.1%), a partial cystectomy was performed during hysterectomy. In addition, of 175 cases from our prospective database, this study included the data of 3 patients (1.7%) with macroscopic hematuria at 33 to 34 weeks of gestation. All patients who underwent ultrasound examination presented with a major placenta previa, abnormalities of the uterine contour, and abnormalities of uteroplacental and intraplacental circulations. The patients' intraoperative estimated blood loss was >1.5 L requiring a primary hysterectomy for hemostasis, massive transfusion, and postoperative admission to the intensive care unit. Patients with prenatal macroscopic hematuria are at high risk of major peripartum hemorrhagic complications and require emergency preterm delivery and hysterectomy. This information should be integrated into the surgical management plan and patient preoperative counseling.