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Kennedy A, Debbink M, Griffith A, Kaiser J, Woodward P. Cesarean Scar Ectopic Pregnancy: A Do-Not-Miss Diagnosis. Radiographics 2024; 44:e230199. [PMID: 38843098 DOI: 10.1148/rg.230199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
The rate of cesarean section (CS) for delivery has increased internationally, reaching 50% in some countries. Abnormal implantation of a new pregnancy at the site of the prior hysterotomy is an important complication because of the risks of hemorrhage, uterine rupture, and progression to placenta accreta spectrum (PAS), a condition with high morbidity with potential for catastrophic obstetric hemorrhage, maternal and fetal mortality, and loss of fertility. Cesarean scar ectopic pregnancy (CSEP) is the recommended term to describe these pregnancies, which are recognized on the basis of the sac implantation site, growth pattern, and associated abnormal perfusion. The true incidence of CSEP is unknown because the condition is likely underdiagnosed and underreported. The 2022 Society for Maternal-Fetal Medicine consult series notes that severe maternal morbidity and mortality are linked to difficulty in making the diagnosis of CSEP. The authors review the signs of CSEP at imaging, some pitfalls that may lead to delayed or missed diagnosis, and the consequences thereof. CSEPs must be differentiated from low implantation of a normal pregnancy, cervical ectopic pregnancy, and evolving pregnancy loss. Early recognition allows prompt and safe treatment that is usually surgical. Early treatment results in decreased health care costs, a shorter hospital stay, preservation of fertility, and prevention of iatrogenic preterm delivery, which is typical in cases that progress to PAS. Hysterectomy has serious negative psychologic consequences for patients of childbearing age; early diagnosis and prompt treatment of CSEP can prevent this often-ignored complication. ©RSNA, 2024 Supplemental material is available for this article.
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Affiliation(s)
- Anne Kennedy
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
| | - Michelle Debbink
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
| | - April Griffith
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
| | - Jennifer Kaiser
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
| | - Paula Woodward
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
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Herrera CL, Do QN, Xi Y, Spong CY, Twickler DM. Prospective first-trimester transvaginal 3-dimensional power Doppler and hysterectomy association in placenta accreta spectrum. Am J Obstet Gynecol 2024; 231:e31-e33. [PMID: 38437892 PMCID: PMC11194145 DOI: 10.1016/j.ajog.2024.02.310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/28/2024] [Accepted: 02/28/2024] [Indexed: 03/06/2024]
Affiliation(s)
- Christina L Herrera
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9032; Parkland Health, Dallas, TX.
| | - Quyen N Do
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Yin Xi
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Catherine Y Spong
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern Medical Center, Dallas, TX; Parkland Health, Dallas, TX
| | - Diane M Twickler
- Department of Obstetrics and Gynecology and Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX; Parkland Health, Dallas, TX
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Spong CY, Yule CS, Fleming ET, Lafferty AK, McIntire DD, Twickler DM. The Cesarean Scar of Pregnancy: Ultrasound Findings and Expectant Management Outcomes. Am J Perinatol 2024; 41:e1445-e1450. [PMID: 36809793 PMCID: PMC11132851 DOI: 10.1055/a-2040-1458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 01/26/2023] [Indexed: 02/23/2023]
Abstract
OBJECTIVE The nomenclature has evolved from low implantation to cesarean scar pregnancy (CSP) and criteria are recommended for identification and management. Management guidelines include pregnancy termination due to life-threatening complications. This article applies ultrasound (US) parameters recommended by the Society for Maternal Fetal Medicine (SMFM) in women who were expectantly managed. STUDY DESIGN Pregnancies were identified between March 1, 2013 and December 31, 2020. Inclusion criteria were women with CSP or low implantation identified on US. Studies were reviewed for niche, smallest myometrial thickness (SMT), and location of basalis blinded to clinical data. Clinical outcomes, pregnancy outcome, need for intervention, hysterectomy, transfusion, pathologic findings, and morbidities were obtained by chart review. RESULTS Of 101 pregnancies with low implantation, 43 met the SMFM criteria at < 10 weeks and 28 at 10 to 14 weeks. At < 10 weeks, SMFM criteria identified 45out of 76 women; of these 13 required hysterectomy; there were 6 who required hysterectomy but did not meet the SMFM criteria. At 10 to < 14 weeks, SMFM criteria identified 28 out of 42 women; of these 15 required hysterectomy. US parameters yielded significant differences in women requiring hysterectomy, at < 10 weeks and 10 to < 14 weeks' gestational age epochs, but the sensitivity, specificity, positive (PPV), and negative predictive values (NPV) of these US parameters have limitations in identifying invasion to determine management. Of the 101 pregnancies, 46 (46%) failed < 20 weeks, 16 (35%) required medical/surgical management including 6 hysterectomies, and 30 (65%) required no intervention. There were 55 pregnancies (55%) that progressed beyond 20 weeks. Of these, 16 required hysterectomy (29%) while 39 (71%) did not. In the overall cohort of 101, 22 (21.8%) required hysterectomy and an additional16 (15.8%) required some type of intervention, while 66.7% required no intervention. CONCLUSION SMFM US criteria for CSP have limitations for discerning clinical management due to lack of discriminatory threshold. KEY POINTS · The SMFM US criteria for CSP at <10 or <14 weeks have limitations for clinical management.. · The sensitivity and specificity of the ultrasound findings limit the utility for management. · The SMT of <1 mm is more discriminating than <3 mm for hysterectomy..
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Affiliation(s)
- Catherine Y. Spong
- Departments of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
- Parkland Health, Dallas, Texas
| | - Casey S. Yule
- Departments of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
- Parkland Health, Dallas, Texas
| | - Elaine T. Fleming
- Departments of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
- Parkland Health, Dallas, Texas
| | - Ashlyn K. Lafferty
- Departments of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Donald D. McIntire
- Departments of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Diane M. Twickler
- Departments of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
- Departments of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
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Dar P, Doulaveris G. First-trimester screening for placenta accreta spectrum. Am J Obstet Gynecol MFM 2024; 6:101329. [PMID: 38447672 DOI: 10.1016/j.ajogmf.2024.101329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/02/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
In recent years, there has been a significant rise in cases of placenta accreta spectrum, a group of life-threatening placental disorders that can arise during childbirth. Early detection plays a crucial role in facilitating meticulous delivery planning, ultimately leading to a reduction in mortality and morbidity rates and improved overall outcomes. Although third-trimester ultrasound has traditionally been the primary method for prenatal screening for placenta accreta spectrum, it often falls short in identifying cases or diagnosis is too late for optimal delivery planning. Emerging evidence has highlighted the option of early detection of placenta accreta spectrum indicators during the first trimester of pregnancy. This comprehensive review delves into our current knowledge of sonographic assessment of the uterine cervicoisthmic complex in the first trimester, examining the location and appearance of cesarean scars and exploring first-trimester screening strategies, ultimately paving the way for improved maternal and neonatal outcomes.
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Affiliation(s)
- Pe'er Dar
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine (Drs Dar and Doulaveris), Bronx, NY.
| | - Georgios Doulaveris
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine (Drs Dar and Doulaveris), Bronx, NY
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Lin F, Chen Z, Tao H, Ren X, Ma P, Lash GE, Shuai H, Li P. Sonographic Findings of Vascular Signals for Retained Products of Conception in Women Following First-Trimester Termination of Pregnancy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102266. [PMID: 37940040 DOI: 10.1016/j.jogc.2023.102266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVES To evaluate the occurrence of retained products of conception (RPOC) after termination of pregnancy in the first trimester and to assess the vascular signals with transvaginal ultrasonography (TVUS) examination in the detection of retained products. METHODS A retrospective cohort study was performed using TVUS examination in patients following termination of pregnancy. In cases of RPOC, 3 scales of vascular signal were identified: type 1, no or small amount, spot flow signals; type 2, medium amount, strip-like flow signals; type 3, rich amount, circumferential-like flow signals. The correlation between vascular signals and placenta accreta spectrum (PAS) staging was proposed by sonography and histopathology findings. RESULTS The 3 vascular patterns were differently distributed within non-RPOC as well as RPOC patients with and without PAS: type 1 vascular signal detection rates of non-RPOC and RPOC were 97.8% (262/268) and 28.1% (18/64), respectively. Of 64 cases of RPOC, 48.4% (31/64) of the patients had type 2 vascular signals. Vascular signals were enhanced in RPOC with PAS patients whose diagnosis was confirmed by histopathology. CONCLUSIONS The vascularity (amount of flow), vascular pattern (spot, strip- or circumferential-like flow), and the flow penetrating myometrium were significant findings for distinguishing concomitant RPOC with and without PAS. Additionally, RPOC may contribute to PAS progression, or PAS and RPOC in coordination strengthen the observed vascular signals.
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Affiliation(s)
- Fangfang Lin
- Department of Ultrasound, Jinan University First Affiliated Hospital, Guangzhou, China
| | - Zongbing Chen
- Department of Pathology, Jinan University School of Medicine, Guangzhou, China; Department of Gynecology and Obstetrics, Jinan University First Affiliated Hospital, Guangzhou, China
| | - Huan Tao
- Department of Gynecology and Obstetrics, Jinan University First Affiliated Hospital, Guangzhou, China
| | - Xinyi Ren
- Department of Pathology, Jinan University School of Medicine, Guangzhou, China
| | - Peiyan Ma
- Department of Ultrasound, Jinan University First Affiliated Hospital, Guangzhou, China
| | - Gendie E Lash
- Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Hanlin Shuai
- Department of Gynecology and Obstetrics, Jinan University First Affiliated Hospital, Guangzhou, China.
| | - Ping Li
- Department of Pathology, Jinan University School of Medicine, Guangzhou, China.
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Araujo Júnior E, Caldas JVJ, Sun SY, Castro PT, Passos JP, Werner H. Placenta acrreta spectrum-first trimester, 2D and 3D ultrasound, and magnetic resonance imaging findings. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024; 52:321-330. [PMID: 38126224 DOI: 10.1002/jcu.23627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/23/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The term placenta accreta spectrum (PAS) is commonly used to describe abnormal trophoblastic invasion of the myometrium, serosa, or organs adjacent to the uterus. It is of great obstetric importance because of its high morbidity, risk of hemorrhage, admission to the intensive care unit, risk of hysterectomy, and high risk of iatrogenic pelvic lesions and even death. These risks are minimized when prenatal diagnosis is performed. Prenatal diagnosis of PAS is based on imaging findings suggestive of abnormal and pathologically adherent placentation, including placental lacunae (intraplacental sonolucent spaces), disruption of the bladder-uterine serosa interface, turbulent flow on color Doppler, and bridging vessels. OBJECTIVE In this article, we review the major prenatal imaging features of PAS using diagnostic modalities (first trimester, two-dimensional ultrasound, three-dimensional ultrasound, and magnetic resonance imaging) for the diagnosis of PAS.
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Affiliation(s)
- Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
- Discipline of Woman Health, Municipal University of São Caetano do Sul (USCS), São Caetano do Sul, SP, Brazil
| | - João Victor Jacomele Caldas
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Sue Yasaki Sun
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Pedro Teixeira Castro
- Department of Fetal Medicine, Biodesign Laboratory DASA/PUC, Rio de Janeiro-RJ, Brazil
| | - Jurandir Piassi Passos
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Heron Werner
- Department of Fetal Medicine, Biodesign Laboratory DASA/PUC, Rio de Janeiro-RJ, Brazil
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Cheng XL, Cao XY, Wang XQ, Lin HL, Fang JC, Wang L. Diagnosing early scar pregnancy in the lower uterine segment after cesarean section by intracavitary ultrasound. World J Clin Cases 2022; 10:547-553. [PMID: 35097080 PMCID: PMC8771384 DOI: 10.12998/wjcc.v10.i2.547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/14/2021] [Accepted: 11/28/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Early scar pregnancy (CSP) in the lower uterine segment after cesarean section is a type of ectopic pregnancy that can cause major complications if left untreated. Transabdominal ultrasound is a common procedure but is influenced by external factors. Thus, intracavitary ultrasound may have better diagnostic efficiency for CSP.
AIM To assess the value of intracavitary ultrasound for diagnosing CSP in the lower uterine segment after cesarean section.
METHODS Patients diagnosed with CSP in our hospital from October 2019 to April 2021 were recruited. Transabdominal and intracavitary ultrasound examinations were performed to compare the diagnostic differences for CSP and its types.
RESULTS Sixty-three patients were diagnosed during the study period. The diagnostic accuracy for CSP was higher in intracavitary ultrasound (96.83%) than in transabdominal ultrasound (84.13%) (P < 0.05). The missed diagnosis and misdiagnosis rates did not differ among the ultrasound types (intra: 0.00% and 3.17%; trans: 4.76% and 11.11%, respectively; P > 0.05). For the diagnostic rates for the CSP types, the rates for gestational sac (100.00% vs 90.48%), heterogeneous mass (93.75% vs 75.00%), and part of the uterine cavity (80.00% vs 60.00%) were higher in intracavitary ultrasound than in transabdominal ultrasound, but the difference was not statistically significant (P > 0.05). For gestational sac CSP patients, intracavitary ultrasound showed that the gestational sac was located in the lower uterine segment scar with abundant peripheral blood flow; the distance between the gestational sac and the serosal layer was 2.42 ± 0.50 cm. Intracavitary ultrasound for heterogeneous mass CSP patients indicated that the mass mainly occurred in the lower anterior uterine wall, protruding into the bladder, and was surrounded by abundant internal and peripheral blood flow; the distance between the mass and serosal layer was 1.79 ± 0.30 cm. For CSP type partly located in the uterine cavity, the gestational sac was partly located in the lower uterine cavity and partly in the scar with abundant internal and peripheral blood flow; the distance between the gestational sac and the serosal layer was 2.29 ± 0.28 cm.
CONCLUSION Intracavitary ultrasound had a higher diagnostic accuracy and application value for diagnosing CSP than transabdominal ultrasound, with reduced risk of missed diagnoses and misdiagnosis, thereby preventing delayed treatment.
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Affiliation(s)
- Xiao-Ling Cheng
- Department of Ultrasonography, Women and Children Health Institute Futian Shenzhen, Shenzhen 518026, Guangdong Province, China
| | - Xiao-Yan Cao
- Department of Ultrasonography, Women and Children Health Institute Futian Shenzhen, Shenzhen 518026, Guangdong Province, China
| | - Xiao-Qian Wang
- Department of Ultrasonography, Women and Children Health Institute Futian Shenzhen, Shenzhen 518026, Guangdong Province, China
| | - Heng-Li Lin
- Department of Ultrasonography, Women and Children Health Institute Futian Shenzhen, Shenzhen 518026, Guangdong Province, China
| | - Jin-Chuan Fang
- Department of Ultrasonography, Women and Children Health Institute Futian Shenzhen, Shenzhen 518026, Guangdong Province, China
| | - Lin Wang
- Department of Ultrasonography, Women and Children Health Institute Futian Shenzhen, Shenzhen 518026, Guangdong Province, China
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