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Walker S, Grant S, O'Brien S, Weale N, Crofts J, Vieten-Kay D, Pereira K, Elhodaiby M. Caesarean scar pregnancy presenting at 17 weeks with a journey involving an exploratory laparotomy, continuing pregnancy and delivery at 34 weeks: A case report. Case Rep Womens Health 2024; 42:e00626. [PMID: 38911044 PMCID: PMC11192978 DOI: 10.1016/j.crwh.2024.e00626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 06/25/2024] Open
Abstract
Caesarean scar pregnancy (CSP) occurs when the gestational sac implants in the region of a scar from a previous caesarean delivery. CSP can lead to life-threatening complications, including severe haemorrhage, uterine rupture, placenta accreta spectrum (PAS) and hysterectomy. A 40-year-old woman with one previous caesarean was referred to the specialist centre at 17+1 weeks of gestation with concerns about CSP. At 19 weeks, she was admitted with abdominal pain. Due to raised body habitus, accurate ultrasound assessment was challenging, necessitating reliance on magnetic resonance imaging (MRI). The patient desired to continue the pregnancy, but due to pain and concerns about uterine rupture she consented to a laparotomy to potentially terminate the pregnancy. Findings during the laparotomy were reassuring, leading to the decision not to terminate the pregnancy. The patient remained hospitalised until delivery by caesarean-hysterectomy at 33+6 weeks. Histopathology confirmed the PAS diagnosis. This case highlights the importance of achieving early diagnosis and obtaining clear sonographic findings. It emphasises the pitfalls of relying on MRI due to its tendency to over-diagnose severity. It emphasises the urgency for improved training in this domain. Early sonographic diagnosis allows safer performance of termination of pregnancy. It also provides women who continue with the pregnancy useful prognostic signs to facilitate decisions on the optimal gestation for delivery. Determining optimal conservative management for CSP remains an ongoing challenge. This case emphasises the importance of multidisciplinary discussion, comprehensive patient counselling and involving patients in their care planning, to create an individualised and adaptable treatment plan.
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Affiliation(s)
- Sarah Walker
- Placenta Accreta Spectrum Clinical Fellow, Department of Obstetrics & Gynaecology, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - Simon Grant
- Consultant Obstetrician, Department of Obstetrics & Gynaecology, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - Stephen O'Brien
- Consultant Obstetrician, Department of Obstetrics & Gynaecology, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - Nicola Weale
- Consultant Anaesthetist, Department of Obstetrics & Gynaecology, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - Joanna Crofts
- Consultant Obstetrician, Department of Obstetrics & Gynaecology, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - Daniela Vieten-Kay
- Consultant Neonatologist, Department of Obstetrics & Gynaecology, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - Karen Pereira
- Midwife, Department of Obstetrics & Gynaecology, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - Mohamed Elhodaiby
- Acting Consultant Gynaecologist North Bristol NHS Trust, Department of Obstetrics & Gynaecology, North Bristol NHS Trust, Bristol, BS10 5NB, UK
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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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Kashiwagi H, Mariya T, Umemoto M, Ogawa S, Hirohashi Y, Fujibe Y, Kubo T, Someya M, Baba T, Ishioka S, Torigoe T, Saito T. Pregnancy-specific beta-1-glycoprotein 6 is a potential novel diagnostic biomarker of placenta accreta spectrum. Med Mol Morphol 2024; 57:35-44. [PMID: 37831187 DOI: 10.1007/s00795-023-00371-y] [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: 02/11/2023] [Accepted: 09/20/2023] [Indexed: 10/14/2023]
Abstract
Early diagnosis is essential for the safer perinatal management of placenta accreta spectrum (PAS). We used transcriptome analysis to investigate diagnostic maternal serum biomarkers and the mechanisms of PAS development. We analyzed eight formalin-fixed paraffin-embedded placental specimens from two placenta increta and three placenta percreta cases who underwent cesarean hysterectomy at Sapporo Medical University Hospital between 2013 and 2019. Invaded placental regions were isolated from the uterine myometrium and RNA was extracted. The transcriptome difference between normal placenta and PAS was analyzed by microarray analysis. The PAS group showed markedly decreased expression of placenta-specific genes such as LGALS13 and the pregnancy-specific beta-1-glycoprotein (PSG) family. Term enrichment analysis revealed changes in genes related to cellular protein catabolic process, female pregnancy, autophagy, and metabolism of lipids. From the highly dysregulated genes in the PAS group, we investigated the expression of PSG family members, which are secreted into the intervillous space and can be detected in maternal serum from the early stage of pregnancy. The gene expression level of PSG6 in particular was progressively decreased from placenta increta to percreta. The PSG family, especially PSG6, is a potential biomarker for PAS diagnosis.
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Affiliation(s)
- Hazuki Kashiwagi
- Department of Obstetrics and Gynecology, Sapporo Medical University School of Medicine, South 1 West 17, Chuo-ku, Sapporo, 060-8556, Japan
| | - Tasuku Mariya
- Department of Obstetrics and Gynecology, Sapporo Medical University School of Medicine, South 1 West 17, Chuo-ku, Sapporo, 060-8556, Japan.
| | - Mina Umemoto
- Department of Obstetrics and Gynecology, Sapporo Medical University School of Medicine, South 1 West 17, Chuo-ku, Sapporo, 060-8556, Japan
| | - Shiori Ogawa
- Department of Obstetrics and Gynecology, Sapporo Medical University School of Medicine, South 1 West 17, Chuo-ku, Sapporo, 060-8556, Japan
| | - Yoshihiko Hirohashi
- Department of Pathology 1st, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yuya Fujibe
- Department of Obstetrics and Gynecology, Sapporo Medical University School of Medicine, South 1 West 17, Chuo-ku, Sapporo, 060-8556, Japan
| | - Terufumi Kubo
- Department of Pathology 1st, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Masayuki Someya
- Department of Obstetrics and Gynecology, Sapporo Medical University School of Medicine, South 1 West 17, Chuo-ku, Sapporo, 060-8556, Japan
| | - Tsuyoshi Baba
- Department of Obstetrics and Gynecology, Sapporo Medical University School of Medicine, South 1 West 17, Chuo-ku, Sapporo, 060-8556, Japan
| | - Shinichi Ishioka
- Department of Obstetrics and Gynecology, Sapporo Medical University School of Medicine, South 1 West 17, Chuo-ku, Sapporo, 060-8556, Japan
| | - Toshihiko Torigoe
- Department of Pathology 1st, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Tsuyoshi Saito
- Department of Obstetrics and Gynecology, Sapporo Medical University School of Medicine, South 1 West 17, Chuo-ku, Sapporo, 060-8556, Japan
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Do QN, Herrera CL, Rosenthal EA, Xi Y, Uddin N, Lewis MA, Fei B, Spong CY, Twickler DM. Magnetic resonance imaging improves diagnosis of placenta accreta spectrum requiring hysterectomy compared to ultrasound. Am J Obstet Gynecol MFM 2024; 6:101280. [PMID: 38216054 PMCID: PMC11070455 DOI: 10.1016/j.ajogmf.2024.101280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/22/2023] [Accepted: 01/03/2024] [Indexed: 01/14/2024]
Abstract
BACKGROUND Magnetic resonance imaging has been used increasingly as an adjunct for ultrasound imaging for placenta accreta spectrum assessment and preoperative surgical planning, but its value has not been established yet. The ultrasound-based placenta accreta index is a well-validated standardized approach for placenta accreta spectrum evaluation. Placenta accreta spectrum-magnetic resonance imaging markers have been outlined in a joint guideline from the Society of Abdominal Radiology and the European Society of Urogenital Radiology. OBJECTIVE This study aimed to compare placenta accreta spectrum-magnetic resonance imaging parameters with the ultrasound-based placenta accreta index in pregnancies at high risk for placenta accreta spectrum and to assess the additional diagnostic value of magnetic resonance imaging for placenta accreta spectrum that requires a cesarean hysterectomy. STUDY DESIGN This was a single-center, retrospective study of pregnant patients who underwent magnetic resonance imaging, in addition to ultrasonography, because of suspected placenta accreta spectrum. The ultrasound-based placenta accreta index and placenta accreta spectrum-magnetic resonance imaging parameters were obtained. Student's t test and Fisher's exact test were used to compare the groups in terms of the primary outcome (hysterectomy vs no hysterectomy). The diagnostic performance of magnetic resonance imaging and the ultrasound-based placenta accreta index was assessed using multivariable logistic regressions, receiver operating characteristics curves, the DeLong test, McNemar test, and the relative predictive value test. RESULTS A total of 82 patients were included in the study, 41 of whom required a hysterectomy. All patients who underwent a hysterectomy met the International Federation of Gynecology and Obstetrics clinical evidence of placenta accreta spectrum at the time of delivery. Multiple parameters of the ultrasound-based placenta accreta index and placenta accreta spectrum-magnetic resonance imaging were able to predict hysterectomy, and the parameter of greatest dimension of invasion by magnetic resonance imaging was the best quantitative predictor. At 96% sensitivity for hysterectomy, the cutoff values were 3.5 for the ultrasound-based placenta accreta index and 2.5 cm for the greatest dimension of invasion by magnetic resonance imaging. Using this sensitivity, the parameter of greatest dimension of invasion measured by magnetic resonance imaging had higher specificity (P=.0016) and a higher positive predictive value (P=.0018) than the ultrasound-based placenta accreta index, indicating an improved diagnostic threshold. CONCLUSION In a suspected high-risk group for placenta accreta spectrum, magnetic resonance imaging identified more patients who will not need a hysterectomy than when using the ultrasound-based placenta accrete index only. Magnetic resonance imaging has the potential to aid patient counseling, surgical planning, and delivery timing, including preterm delivery decisions for patients with placenta accreta spectrum requiring hysterectomy.
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Affiliation(s)
- Quyen N Do
- Research Division, Department of Radiology, University of Texas (UT) Southwestern Medical Center, Dallas, TX (Drs Do, Xi, Lewis, Fei, and Twickler)
| | - Christina L Herrera
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, UT Southwestern Medical Center, Dallas, TX (Drs Herrera, Rosenthal, Spong, and Twickler); Parkland Health and Hospital System, Dallas, TX (Drs Herrera, Rosenthal, Spong, and Twickler)
| | - Elise A Rosenthal
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, UT Southwestern Medical Center, Dallas, TX (Drs Herrera, Rosenthal, Spong, and Twickler); Parkland Health and Hospital System, Dallas, TX (Drs Herrera, Rosenthal, Spong, and Twickler)
| | - Yin Xi
- Research Division, Department of Radiology, University of Texas (UT) Southwestern Medical Center, Dallas, TX (Drs Do, Xi, Lewis, Fei, and Twickler)
| | - Naseem Uddin
- Department of Pathology, UT Southwestern Medical Center, Dallas, TX (Dr Uddin)
| | - Matthew A Lewis
- Research Division, Department of Radiology, University of Texas (UT) Southwestern Medical Center, Dallas, TX (Drs Do, Xi, Lewis, Fei, and Twickler)
| | - Baowei Fei
- Research Division, Department of Radiology, University of Texas (UT) Southwestern Medical Center, Dallas, TX (Drs Do, Xi, Lewis, Fei, and Twickler); Department of Bioengineering, The University of Texas at Dallas, Richardson, TX (Dr Fei); Center for Imaging and Surgical Innovation, The University of Texas at Dallas, TX (Dr Fei)
| | - Catherine Y Spong
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, UT Southwestern Medical Center, Dallas, TX (Drs Herrera, Rosenthal, Spong, and Twickler); Parkland Health and Hospital System, Dallas, TX (Drs Herrera, Rosenthal, Spong, and Twickler)
| | - Diane M Twickler
- Research Division, Department of Radiology, University of Texas (UT) Southwestern Medical Center, Dallas, TX (Drs Do, Xi, Lewis, Fei, and Twickler); Parkland Health and Hospital System, Dallas, TX (Drs Herrera, Rosenthal, Spong, and Twickler).
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Wang H, Wang Y, Zhang H, Yin X, Wang C, Lu Y, Song Y, Zhu H, Yang G. A Deep Learning Pipeline Using Prior Knowledge for Automatic Evaluation of Placenta Accreta Spectrum Disorders With MRI. J Magn Reson Imaging 2024; 59:483-493. [PMID: 37177832 DOI: 10.1002/jmri.28770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND The diagnosis of prenatal placenta accreta spectrum (PAS) with magnetic resonance imaging (MRI) is highly dependent on radiologists' experience. A deep learning (DL) method using the prior knowledge that PAS-related signs are generally found along the utero-placental borderline (UPB) may help radiologists, especially those with less experience, to mitigate this issue. PURPOSE To develop a DL tool for antenatal diagnosis of PAS using T2-weighted MR images. STUDY TYPE Retrospective. SUBJECTS Five hundred and forty pregnant women with clinically suspected PAS disorders from two institutions, divided into training (409), internal test (103), and external test (28) datasets. FIELD STRENGTH/SEQUENCE Sagittal T2-weighted fast spin echo sequence at 1.5 T and 3 T. ASSESSMENT An nnU-Net was trained for placenta segmentation. The UPB straightening approach was used to extract the utero-placental boundary region. The UPB image was then fed into DenseNet-PAS for PAS diagnosis. DenseNet-PP learnt placental position information to improve the PAS diagnosis performance. Three radiologists with 8, 10, and 12 years of experience independently evaluated the images. Two radiologists marked the placenta tissue. Histopathological findings were the reference standard. STATISTICAL TESTS Area under the curve (AUC) was used to evaluate the classification. Dice coefficient evaluated the segmentation between radiologists and the model performance. The Mann-Whitney U-test or the chi-squared test assessed the significance of differences. Decision curve analysis was used to determine clinical effectiveness. DeLong's test was used to compare AUCs. RESULTS Of the 540 patients, 170 had PAS disorders confirmed by histopathology. The DL model using UPB images and placental position yielded the highest AUC of 0.860 and 0.897 in internal test and external test cohorts, respectively, significantly exceeding the performance of three radiologists (internal test AUC, 0.737-0.770). DATA CONCLUSION By extracting the UPB image, this fully automatic DL pipeline achieved high accuracy and may assist radiologists in PAS diagnosis using MRI. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Haijie Wang
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, Shanghai, China
| | - Yida Wang
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, Shanghai, China
| | - He Zhang
- Department of Radiology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Xuan Yin
- Department of Radiology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Chenglong Wang
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, Shanghai, China
| | - Yuanyuan Lu
- Department of Radiology, Shanghai First Maternity and Infant Health Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yang Song
- MR Scientific Marketing, Siemens Healthineers China, Shanghai, China
| | - Hao Zhu
- Department of Obstetrics, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Guang Yang
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, Shanghai, China
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Sherer DM, Thompson M, Field A, Granderson F, Dalloul M. Extensive fundal placenta accreta spectrum (PAS) in a nulliparous patient with an unscarred uterus and systemic lupus erythematosus (SLE) necessitating cesarean hysterectomy at delivery. Radiol Case Rep 2023; 18:4057-4061. [PMID: 37701359 PMCID: PMC10493878 DOI: 10.1016/j.radcr.2023.08.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/21/2023] [Accepted: 08/09/2023] [Indexed: 09/14/2023] Open
Abstract
Placenta accreta spectrum (PAS) defined by various degrees of abnormally invasive placentation is strongly associated with severe maternal morbidity and maternal mortality, mainly reflecting maternal hemorrhage. Predisposing factors for this condition include: multiparity, placenta previa, previous uterine surgeries (previous curettage, cesarean delivery, and myomectomy), smoking and previous PAS. Prenatal sonographic findings associated with PAS include the presence of placenta previa, loss of the hypoechoic retroplacental sonolucency, myometrial thinning, interruption of the irregularity of the bladder wall, excessive vascularity of the uterovesical plane, placental lacunae, increased placental vascularity, bridging vessels with vascularity extending from the placental bed across the uterine wall into the bladder or other pelvic organs. PAS is very rare among nulliparous patients, especially those without previous uterine surgery. We describe an unusual case of PAS in a nulliparous patient with an unscarred uterus and systemic lupus erythematosus in whom a fundal placenta with PAS and thinned and areas of absent myometrium suspected at midtrimester sonography, sustained uterine atony and severe hemorrhage at delivery, necessitated massive blood transfusion and subtotal hysterectomy. Both mother and infant did well. Pathology confirmed PAS and marked uterine thinning. Although PAS most commonly is associated with placenta previa and the presence of previous cesarean delivery, this case emphasizes the need for alertness of at times subtle prenatal sonographic findings of PAS irrespective of placental location even among nulliparous patients, especially those with systemic lupus erythematosus.
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Affiliation(s)
- David M. Sherer
- The Division of Maternal Fetal Medicine, The Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, 450 Clarkson Ave, Box 24 Brooklyn, New York, NY, USA
| | - Marae Thompson
- The Division of Maternal Fetal Medicine, The Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, 450 Clarkson Ave, Box 24 Brooklyn, New York, NY, USA
| | - Alessia Field
- The Division of Maternal Fetal Medicine, The Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, 450 Clarkson Ave, Box 24 Brooklyn, New York, NY, USA
| | - Freeda Granderson
- The Division of Maternal Fetal Medicine, The Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, 450 Clarkson Ave, Box 24 Brooklyn, New York, NY, USA
| | - Mudar Dalloul
- The Division of Maternal Fetal Medicine, The Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Health Sciences University, 450 Clarkson Ave, Box 24 Brooklyn, New York, NY, USA
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Zhou L, Zhao X, Xu D, Pang S, Mao X, Feng S, Yue Y. Placental Area in the Lower Uterine Segment, Cervical Length, and Clinical Outcome in Pregnancies With Complete Placenta Previa. J Magn Reson Imaging 2023; 58:1047-1054. [PMID: 36847772 DOI: 10.1002/jmri.28617] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/14/2023] [Accepted: 01/17/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Complete placenta previa is associated with a higher percentage of adverse clinical outcomes and magnetic resonance imaging (MRI) is widely used in the preoperative examination of patients with placenta previa. PURPOSE To evaluate the effectiveness of the placental area in the lower uterine segment and cervical length in identifying the adverse maternal-fetal outcomes in women with complete placenta previa. STUDY TYPE Retrospective. POPULATION A total of 141 pregnant women (median age, 32; age range, 24-40 years) with complete placenta previa were examined by MRI to evaluate the uteroplacental condition. FIELD STRENGTH/SEQUENCE A 3 T with T1 -weighted imaging (T1 WI), T2 -weighted imaging (T2 WI), and half-Fourier acquisition single-shot turbo spin echo (HASTE) sequence. ASSESSMENT The association of the placental area in the lower uterine segment and cervical length measured using MRI with the risk of massive intraoperative hemorrhage (MIH) and maternal-fetal perinatal outcomes were determined. The adverse neonatal outcomes (preterm delivery, respiratory distress syndrome [RDS], admission to neonatal intensive care unit [NICU]) were analyzed in different groups. STATISTICAL TESTS The t-test, Mann-Whitney U test, Chi-square, Fisher's exact test, and receiver operating characteristic (ROC) curve were used, and a P < 0.05 indicated a statistically significant difference. RESULTS The mean operation time, intraoperative blood loss, and intraoperative blood transfusing were significantly higher in patients with large placental area and short cervix than in patients with the small placental area and long cervix, respectively. The incidence of adverse neonatal outcomes was significantly higher in the large placenta area group and short cervix group than in the small placenta group area and long cervix group, respectively, such as preterm delivery, RDS, and NICU. By combining placental area with cervical length sensitivity and specificity increased to 93% and 92%, respectively, for the identification of MIH > 2000 mL with area under the receiver operating curve (AUC) 0.941. DATA CONCLUSION Large placental area and short cervical length may be associated with a high risk of MIH and adverse maternal-fetal perinatal outcomes in patients with complete placenta previa. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY STAGE 2.
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Affiliation(s)
- Liping Zhou
- Department of Obstetrics and Gynecology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Xuepiao Zhao
- Department of Obstetrics and Gynecology, The Affiliated SuQian first people's Hospital of Nanjing Medical University, SuQian, Jiangsu, China
| | - Duo Xu
- Department of Obstetrics and Gynecology, Affiliated Shenzhen Maternity & Child Healthcare Hospital, Southern Medical University, Shenzhen, Guangdong, China
| | - Suhua Pang
- Department of Obstetrics and Gynecology, The Affiliated SuQian first people's Hospital of Nanjing Medical University, SuQian, Jiangsu, China
| | - Xiuzhen Mao
- Department of Obstetrics and Gynecology, The Affiliated SuQian first people's Hospital of Nanjing Medical University, SuQian, Jiangsu, China
| | - Shixiang Feng
- Department of Obstetrics and Gynecology, The Affiliated SuQian first people's Hospital of Nanjing Medical University, SuQian, Jiangsu, China
| | - Yongfei Yue
- Department of Obstetrics and Gynecology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
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Cheng C, Ramsey PS, Byrne JJ, Katabathina VS, Ireland KE, Munoz JL. Factors Limiting Magnetic Resonance Imaging Diagnosis of Placenta Accreta Spectrum. Am J Perinatol 2023; 40:1398-1405. [PMID: 37225128 DOI: 10.1055/a-2099-4542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Placenta accreta spectrum (PAS) disorders are characterized by an abnormal adherence of the placenta to the uterine myometrium. Magnetic resonance imaging (MRI) is an important adjunct in antenatal diagnosis. We sought to determine if there are patient and MRI characteristics that limit the accuracy of PAS diagnosis and degree of invasion. STUDY DESIGN We conducted a retrospective cohort analysis of patients who were evaluated for PAS by MRI from January 2007 to December 2020. Patient characteristics evaluated included number of prior cesarean deliveries, history of dilation and curettage (D&C) or dilation and evacuation (D&E), short interval pregnancy less than 18 months, and delivery body mass index (BMI). All patients were followed until delivery and MRI diagnosis was compared with final histopathology. RESULTS Of the 353 patients with suspected PAS, 152 (43%) underwent MRI evaluation and were included in the final analysis. In patients who underwent MRI evaluation, 105 (69%) had confirmed PAS on pathology. Patient characteristics were similar between groups and not associated with accuracy of MRI diagnosis. MRI was accurate in diagnosing PAS and the associated degree of invasion in 83 (55%) patients. Accuracy was associated with lacunae (8 vs. 0%, p = 0.02), abnormal bladder interface (25 vs. 6%, p = 0.002), and T1 hyperintensity (13 vs. 1%, p = 0.002). Of the 69 (45%) patients in whom MRI was inaccurate, overdiagnosis was seen in 44 (64%) patients and underdiagnosis in 25 (36%) patients. Overdiagnosis was significantly associated with dark T2 bands (45 vs. 22%, p = 0.005). Underdiagnosis was associated with earlier gestational age at MRI (28 vs. 30 weeks, p = 0.049) and lateral placentation (16 vs. 2.4%, p = 0.025). CONCLUSION Patient factors did not change MRI accuracy of PAS diagnosis. MRI is associated with a significant overdiagnosis of PAS when dark T2 bands are present, and underdiagnose PAS when performed earlier in gestation or when lateral placentation is present. KEY POINTS · Patient factors are not associated with MRI accuracy of PAS diagnosis.. · MRI overdiagnoses PAS invasion when there are dark T2 bands.. · MRI underdiagnoses PAS invasion when performed earlier in gestation.. · Underdiagnosis of PAS is associated with lateral placentation..
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Affiliation(s)
- CeCe Cheng
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, Texas
| | - Patrick S Ramsey
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, Texas
| | - John J Byrne
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, Texas
| | - Venkata S Katabathina
- Department of Radiology, University of Texas Health Science Center at San Antonio, Texas
| | - Kayla E Ireland
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Methodist Hospital San Antonio, Texas
| | - Jessian L Munoz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
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Bartels HC, O'Doherty J, Wolsztynski E, Brophy DP, MacDermott R, Atallah D, Saliba S, Young C, Downey P, Donnelly J, Geoghegan T, Brennan DJ, Curran KM. Radiomics-based prediction of FIGO grade for placenta accreta spectrum. Eur Radiol Exp 2023; 7:54. [PMID: 37726591 PMCID: PMC10509122 DOI: 10.1186/s41747-023-00369-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/26/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Placenta accreta spectrum (PAS) is a rare, life-threatening complication of pregnancy. Predicting PAS severity is critical to individualise care planning for the birth. We aim to explore whether radiomic analysis of T2-weighted magnetic resonance imaging (MRI) can predict severe cases by distinguishing between histopathological subtypes antenatally. METHODS This was a bi-centre retrospective analysis of a prospective cohort study conducted between 2018 and 2022. Women who underwent MRI during pregnancy and had histological confirmation of PAS were included. Radiomic features were extracted from T2-weighted images. Univariate regression and multivariate analyses were performed to build predictive models to differentiate between non-invasive (International Federation of Gynecology and Obstetrics [FIGO] grade 1 or 2) and invasive (FIGO grade 3) PAS using R software. Prediction performance was assessed based on several metrics including sensitivity, specificity, accuracy and area under the curve (AUC) at receiver operating characteristic analysis. RESULTS Forty-one women met the inclusion criteria. At univariate analysis, 0.64 sensitivity (95% confidence interval [CI] 0.0-1.00), specificity 0.93 (0.38-1.0), 0.58 accuracy (0.37-0.78) and 0.77 AUC (0.56-.097) was achieved for predicting severe FIGO grade 3 PAS. Using a multivariate approach, a support vector machine model yielded 0.30 sensitivity (95% CI 0.18-1.0]), 0.74 specificity (0.38-1.00), 0.58 accuracy (0.40-0.82), and 0.53 AUC (0.40-0.85). CONCLUSION Our results demonstrate a predictive potential of this machine learning pipeline for classifying severe PAS cases. RELEVANCE STATEMENT This study demonstrates the potential use of radiomics from MR images to identify severe cases of placenta accreta spectrum antenatally. KEY POINTS • Identifying severe cases of placenta accreta spectrum from imaging is challenging. • We present a methodological approach for radiomics-based prediction of placenta accreta. • We report certain radiomic features are able to predict severe PAS subtypes. • Identifying severe PAS subtypes ensures safe and individualised care planning for birth.
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Affiliation(s)
- Helena C Bartels
- Department of UCD Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Holles Street, Dublin 2, Ireland.
| | - Jim O'Doherty
- Siemens Medical Solutions, Malvern, PA, USA
- Department of Radiology & Radiological Science, Medical University of South Carolina, Charleston, SC, USA
- Radiography & Diagnostic Imaging, University College Dublin, Dublin, Ireland
| | - Eric Wolsztynski
- Statistics Department, University College Cork, Cork, Ireland
- Insight Centre for Data Analytics, Dublin, Ireland
| | - David P Brophy
- Department of Radiology, St. Vincent's University Hospital, Dublin, Ireland
| | - Roisin MacDermott
- Department of Radiology, St. Vincent's University Hospital, Dublin, Ireland
| | - David Atallah
- Department of Gynecology and Obstetrics, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Souha Saliba
- Department of Radiology: Fetal and Placental Imaging, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
| | - Constance Young
- Department of Histopathology, National Maternity Hospital, Dublin, Ireland
| | - Paul Downey
- Department of Histopathology, National Maternity Hospital, Dublin, Ireland
| | - Jennifer Donnelly
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland
| | - Tony Geoghegan
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Donal J Brennan
- Department of UCD Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Holles Street, Dublin 2, Ireland
- University College Dublin Gynaecological Oncology Group (UCD-GOG), Mater Misericordiae University Hospital and St Vincent's University Hospital, Dublin, Ireland
- Systems Biology Ireland, School of Medicine, University College Dublin, Dublin, Ireland
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10
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Singh S, Carusi DA, Wang P, Reitman-Ivashkov E, Landau R, Fields KG, Weiniger CF, Farber MK. External Validation of a Multivariable Prediction Model for Placenta Accreta Spectrum. Anesth Analg 2023; 137:537-547. [PMID: 36206114 DOI: 10.1213/ane.0000000000006222] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Placenta accreta spectrum (PAS) is a disorder of abnormal placentation associated with severe postpartum hemorrhage, maternal morbidity, and mortality. Predelivery prediction of this condition is important to determine appropriate delivery location and multidisciplinary planning for operative management. This study aimed to validate a prediction model for PAS developed by Weiniger et al in 2 cohorts who delivered at 2 different United States tertiary centers. METHODS Cohort A (Brigham and Women's Hospital; N = 253) included patients with risk factors (prior cesarean delivery and placenta previa) and/or ultrasound features of PAS presenting to a tertiary-care hospital. Cohort B (Columbia University Irving Medical Center; N = 99) consisted of patients referred to a tertiary-care hospital specifically because of ultrasound features of PAS. Using the outcome variable of surgical and/or pathological diagnosis of PAS, discrimination (via c-statistic), calibration (via intercept, slope, and flexible calibration curve), and clinical usefulness (via decision curve analysis) were determined. RESULTS The model c-statistics in cohorts A and B were 0.728 (95% confidence interval [CI], 0.662-0.794) and 0.866 (95% CI, 0.754-0.977) signifying acceptable and excellent discrimination, respectively. The calibration intercept (0.537 [95% CI, 0.154-0.980] for cohort A and 3.001 [95% CI, 1.899- 4.335] for B), slopes (0.342 [95% CI, 0.170-0.532] for cohort A and 0.604 [95% CI, -0.166 to 1.221] for B), and flexible calibration curves in each cohort indicated that the model underestimated true PAS risks on average and that there was evidence of overfitting in both validation cohorts. The use of the model compared to a treat-all strategy by decision curve analysis showed a greater net benefit of the model at a threshold probability of >0.25 in cohort A. However, no net benefit of the model over the treat-all strategy was seen in cohort B at any threshold probability. CONCLUSIONS The performance of the Weiniger model is variable based on the case-mix of the population with regard to PAS clinical risk factors and ultrasound features, highlighting the importance of spectrum bias when applying this PAS prediction model to distinct populations. The model showed benefit for predicting PAS in populations with substantial case-mix heterogeneity at threshold probability of >25%.
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Affiliation(s)
- Shubhangi Singh
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital-Harvard Medical School, Boston, Massachusetts
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Daniela A Carusi
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital-Harvard Medical School, Boston, Massachusetts
| | - Penny Wang
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital-Harvard Medical School, Boston, Massachusetts
| | - Elena Reitman-Ivashkov
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Ruth Landau
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Kara G Fields
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital-Harvard Medical School, Boston, Massachusetts
| | - Carolyn F Weiniger
- Division of Anaesthesia, Critical Care and Pain, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michaela K Farber
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital-Harvard Medical School, Boston, Massachusetts
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11
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Pan W, Chen J, Zou Y, Yang K, Liu Q, Sun M, Li D, Zhang P, Yue S, Huang Y, Wang Z. Uterus-preserving surgical management of placenta accreta spectrum disorder: a large retrospective study. BMC Pregnancy Childbirth 2023; 23:615. [PMID: 37633887 PMCID: PMC10464453 DOI: 10.1186/s12884-023-05923-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 08/14/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND The two-child policy implemented in China resulted in a surge of high-risk pregnancies among advanced maternal aged women and presented a window of opportunity to identify a large number of placenta accreta spectrum (PAS) cases, which often invoke severe blood loss and hysterectomy. We thus had an opportunity to evaluate the surgical outcomes of a unique conservative PAS management strategy for uterus preservation, and the impacts of magnetic resonance imaging (MRI) in PAS surgical planning. METHODS Cross-sectional study, comparing the outcomes of a new uterine artery ligation combined with clover suturing technique (UAL + CST) with the existing conservative surgical approaches in a maternal public hospital with an annual birth of more than 20,000 neonates among all placenta previa cases suspecting of PAS between January 1, 2015 and December 31, 2018. RESULTS From a total of 89,397 live births, we identified 210 PAS cases from 400 singleton pregnancies with placenta previa. Aside from 2 self-requested natural births (low-lying placenta), all PAS cases had safe cesarean deliveries without any total hysterectomy. Compared with the existing approaches, the evaluated UAL + CST had a significant reduction in intraoperative blood loss (β=-312 ml, P < .001), RBC transfusion (β=-1.08 unit, P = .001), but required more surgery time (β = 16.43 min, P = .01). MRI-measured placenta thickness, when above 50 mm, can increase blood loss (β = 315 ml, P = .01), RBC transfusion (β = 1.28 unit, P = .01), surgery time (β = 48.84 min, P < .001) and hospital stay (β = 2.58 day, P < .001). A majority of percreta patients resumed normal menstrual cycle within 12 months with normal menstrual fluid volume, without abnormal urination or defecation. CONCLUSIONS A conservative surgical management approach of UAL + CST for PAS is safe and effective with a low complication rate. MRI might be useful for planning PAS surgery. CLINICAL TRIAL REGISTRATION NUMBER ChiCTR2000035202.
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Affiliation(s)
- Wenxia Pan
- Department of Obstetrics, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Juan Chen
- Department of Obstetrics, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Yinrui Zou
- Havy International (Shanghai) Ltd, Building 25, No.1665, Kongjiang Road, Yangpu District, Shanghai, 200092, China
| | - Kun Yang
- Department of Obstetrics, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Qingfeng Liu
- Department of Obstetrics, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Meiying Sun
- Department of Obstetrics, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Dan Li
- Department of Radiology, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Ping Zhang
- Department of Ultrasound, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Shixia Yue
- Department of Nursery, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China
| | - Yuqiang Huang
- Department of Pediatric Cardiology, Linyi Maternal and Child Healthcare Hospital, NO.1, South Qinghe Road, Luozhuang District, Linyi City, 276016, Shandong Province, China.
| | - Zhaoxi Wang
- Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Kirstein 3, 02215, Boston, MA, USA
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12
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Einerson BD, Gilner JB, Zuckerwise LC. Placenta Accreta Spectrum. Obstet Gynecol 2023; 142:31-50. [PMID: 37290094 PMCID: PMC10491415 DOI: 10.1097/aog.0000000000005229] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/08/2023] [Indexed: 06/10/2023]
Abstract
Placenta accreta spectrum (PAS) is one of the most dangerous conditions in pregnancy and is increasing in frequency. The risk of life-threatening bleeding is present throughout pregnancy but is particularly high at the time of delivery. Although the exact cause is unknown, the result is clear: Severe PAS distorts the uterus and surrounding anatomy and transforms the pelvis into an extremely high-flow vascular state. Screening for risk factors and assessing placental location by antenatal ultrasonography are essential for timely diagnosis. Further evaluation and confirmation of PAS are best performed in referral centers with expertise in antenatal imaging and surgical management of PAS. In the United States, cesarean hysterectomy with the placenta left in situ after delivery of the fetus is the most common treatment for PAS, but even in experienced referral centers, this treatment is often morbid, resulting in prolonged surgery, intraoperative injury to the urinary tract, blood transfusion, and admission to the intensive care unit. Postsurgical complications include high rates of posttraumatic stress disorder, pelvic pain, decreased quality of life, and depression. Team-based, patient-centered, evidence-based care from diagnosis to full recovery is needed to optimally manage this potentially deadly disorder. In a field that has relied mainly on expert opinion, more research is needed to explore alternative treatments and adjunctive surgical approaches to reduce blood loss and postoperative complications.
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Affiliation(s)
- Brett D Einerson
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, Utah; Duke University, Durham, North Carolina; and Vanderbilt University Medical Center, Nashville, Tennessee
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13
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Khandelwal M, Shipp TD, Zelop CM, Abuhamad AZ, Afshar Y, Einerson BD, Fox KA, Huisman TAGM, Lyell DJ, Perni U, Platt LD, Shainker SA. Imaging the Uterus in Placenta Accreta Spectrum Disorder. Am J Perinatol 2023; 40:1013-1025. [PMID: 37336220 DOI: 10.1055/s-0043-1761914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Antenatal diagnosis of placenta accreta spectrum (PAS) improves maternal and neonatal outcomes by allowing for multidisciplinary planning and preparedness. Ultrasound is the primary imaging tool. Simplification and standardization of placental evaluation and reporting terminology allows improved communication and understanding between teams. Prior to 10 weeks of gestation, gestational sac position and least myometrial thickness surrounding the gestational sac help PAS diagnosis very early in pregnancy. Late first-, second-, and third-trimester evaluation includes comprehensive evaluation of the placenta, transabdominal and transvaginal with partially full maternal urinary bladder, and by color Doppler. Subsequently, the sonologist should indicate whether the evaluation was optimal or suboptimal; the level of suspicion as low, moderate, or high; and the extent as focal, global, or extending beyond the uterus. Other complementary imaging modalities such as 3D-power Doppler ultrasound, magnetic resonance imaging (MRI), and vascular topography mapping strive to improve antenatal placental evaluation but remain investigational at present. KEY POINTS: · Antenatal imaging, primarily using ultrasound with partially full maternal urinary bladder, is an essential means of evaluation of those at risk for PAS.. · Simplification and standardization of placental evaluation and reporting will allow improved communication between the multidisciplinary teams.. · Gestational sac location prior to 10 weeks of gestation and four markers after that (placental lacunae and echostructure, myometrial thinning, hypoechoic zone with or without bulging between placenta and myometrium, and increased flow on color Doppler)..
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Affiliation(s)
- Meena Khandelwal
- Department of Obstetrics and Gynecology, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Thomas D Shipp
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Carolyn M Zelop
- Department of Obstetrics and Gynecology, Valley Medical Group, Paramus, New Jersey and Clinical Professor of Obstetrics and Gynecology, Ne NYU Grossman School of Medicine, New York
| | - Alfred Z Abuhamad
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
| | - Yalda Afshar
- Department of Obstetrics and Gynecology, University of California, Los Angeles, California
| | - Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Karin A Fox
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Thierry A G M Huisman
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houstan, Texas
| | - Deirdre J Lyell
- Department of Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, California
| | - Uma Perni
- Subspecialty Care for Women's Health, Cleveland Clinic, Beachwood, Ohio
| | - Lawrence D Platt
- Center for Fetal Medicine & Women's Ultrasound and the David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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14
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Abstract
Placenta accreta spectrum is a group of disorders involving abnormal trophoblastic invasion to the deep layers of endometrium and myometrium. Placenta accrete spectrum is one of the major causes of severe maternal morbidity, with increasing incidence in the past decade mainly secondary to an increase in cesarean deliveries. Severity varies depending on the depth of invasion, with the most severe form, known as percreta, invading uterine serosa or surrounding pelvic organs. Diagnosis is usually achieved by ultrasound, and MRI is sometimes used to assess invasion. Management usually involves a hysterectomy at the time of delivery. Other strategies include delayed hysterectomy or expectant management.
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Affiliation(s)
- Mahmoud Abdelwahab
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
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15
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Wu X, Yang H, Yu X, Zeng J, Qiao J, Qi H, Xu H. The prenatal diagnostic indicators of placenta accreta spectrum disorders. Heliyon 2023; 9:e16241. [PMID: 37234657 PMCID: PMC10208845 DOI: 10.1016/j.heliyon.2023.e16241] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 04/29/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Placenta accreta spectrum (PAS) disorders refers to a heterogeneous group of anomalies distinguished by abnormal adhesion or invasion of chorionic villi through the myometrium and uterine serosa. PAS frequently results in life-threatening complications, including postpartum hemorrhage and hysterotomy. The incidence of PAS has increased recently as a result of rising cesarean section rates. Consequently, prenatal screening for PAS is essential. Despite the need to increase specificity, ultrasound is still considered a primary adjunct. Given the dangers and adverse effects of PAS, it is necessary to identify pertinent markers and validate indicators to improve prenatal diagnosis. This article summarizes the predictors regarding biomarkers, ultrasound indicators, and magnetic resonance imaging (MRI) features. In addition, we discuss the effectiveness of joint diagnosis and the most recent research on PAS. In particular, we focus on (a) posterior placental implantation and (b) accreta after in vitro fertilization-embryo transfer, both of which have low diagnostic rates. At last, we graphically display the prenatal diagnostic indicators and each diagnostic performance.
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Affiliation(s)
- Xiafei Wu
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Huan Yang
- Department of Obstetrics, Chongqing University Three Gorges Hospital, Chongqing 404100, China
| | - Xinyang Yu
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Jing Zeng
- Stomatological Hospital of Chongqing Medical University, Chongqing 401147, China
| | - Juan Qiao
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Hongbo Qi
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Women and Children's Hospital of Chongqing Medical University, Chongqing 401147, China
| | - Hongbing Xu
- Department of Obstetrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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16
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Ferumoxytol-enhanced MR demonstration of changes to internal placental structure in placenta accreta spectrum: Preliminary findings. Placenta 2023; 134:1-8. [PMID: 36807998 DOI: 10.1016/j.placenta.2023.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/04/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023]
Abstract
INTRODUCTION The goal of this pilot study is to determine if ferumoxytol-enhanced MR might provide a new approach to the diagnosis of placenta accreta spectrum (PAS), and if so, to identify signs of PAS. METHODS Ten pregnant women were referred for MRI evaluation for PAS. MR studies consisted of pre-contrast SSFSE, SSFP, DWI, and ferumoxytol-enhanced sequences. Post-contrast images were rendered as MIP and MinIP images to separately display the maternal and fetal circulations respectively. Two readers examined the images for architectural changes to placentone (fetal cotyledon) that might distinguish PAS cases from normal. Attention was given to the size and morphology of the placentone, villous tree, and vascularity. In addition, the images were examined for evidence of fibrin/fibrinoid, intervillous thrombus, basal and chorionic plate bulges. Interobserver agreement was characterized with kappa coefficients and levels of confidence for feature identification was recorded on a 10-point scale. RESULTS At delivery, there were five normal placentas and five with PAS (one accreta, two increta, two percreta). The ten changes of placental architecture in PAS included: focal/regional expansion of placentone(s); lateral displacement and compression of the villous tree; disruption of a regular pattern of normal placentones; bulging of the basal plate; bulging of the chorionic plate; transplacental stem villi; linear/nodular bands at basal plate; non-tapering villous branches; intervillous hemorrhage; and dilated subplacental vessels. All these changes were more common in PAS; the first five achieved statistical significance in this small sample. The interobserver agreement and confidence for the identification of these features was good to excellent except for dilated subplacental vessels. DISCUSSION Ferumoxytol-enhanced MR imaging appears to depict derangements of the internal architecture of placentas with PAS, thereby suggesting a promising new strategy to diagnose PAS.
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DI Girolamo R, Buca D, Galliani C, D'Amico A, CALì G, Lucidi A, Giannini C, Chiarelli F, Liberati M, D'Antonio F. Systematic review and meta-analysis on placenta accreta spectrum disorders in twin pregnancies: risk factors, detection rate and histopathology. Minerva Obstet Gynecol 2023; 75:55-61. [PMID: 34328297 DOI: 10.23736/s2724-606x.21.04886-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The occurrence of PAS has been recently associated with the presence of twin pregnancy. Aim of this review is to report the risk factors, histopathological correlation, diagnostic accuracy of prenatal ultrasound and clinical outcome of twin pregnancies complicated by placenta accreta spectrum (PAS) disorders. EVIDENCE ACQUISITION PubMed, Embase, Cinahl, Clinical Trial.Gov and Google Scholar databases were searched. Inclusion criteria were studies on twin pregnancies complicated by PAS. The outcomes explored were risk factors for PAS (including placenta previa, prior uterine surgery or assisted reproductive technology, ART), histopathology (placenta accreta and increta/percreta), detection rate of prenatal ultrasound and clinical outcome, including need for blood transfusion, hysterectomy, emergency or scheduled Cesarean delivery (CD), and maternal death. Random effect meta-analyses of proportions were sued to combine the data. EVIDENCE SYNTHESIS Two studies considering 103 pregnancies were included in this systematic review: 41.86% (95% CI 27.0-57.9) of twin pregnancies complicated by PAS disorders had a prior CD, 28.22% (95% CI 13.4-46.0) presented placenta previa and 58.14% (95% CI 42.1-73.0) of twin pregnancies were conceived by ART. 74.49% (95% CI 41.6-96.5) of PAS in twin pregnancies were placenta accreta, while 25.51% (95% CI 3.5-58.4) were placenta increta or percreta. Prenatal diagnosis of PAS in twin pregnancies was accomplished only in 27.91% (95% CI 15.3-43.7) of cases. Finally, only one study consistently reported the clinical outcome of PAS in twins. 31.67% (95% CI 20.3-45.0) of women required blood transfusion, 26.67% (95% CI 16.1-39.7) had hysterectomy, while there was no case of maternal death. 44.19% of women had an emergency CD. CONCLUSIONS There is still limited evidence on the clinical course of PAS disorders in twin pregnancies. Placenta previa, prior uterine surgery (mainly CD), and ART are the most commonly risk factors for PAS disorders in twins. Prenatal diagnosis of PAS in twins is lower compared to what reported in singleton. Finally, about 30% of women with a twin pregnancy complicated by PAS required blood transfusion and hysterectomy.
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Affiliation(s)
- Raffaella DI Girolamo
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Danilo Buca
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Carmen Galliani
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Alice D'Amico
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Giuseppe CALì
- Department of Obstetrics and Gynecology, Ospedali Riuniti, Palermo, Italy
| | - Alessandro Lucidi
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Cosimo Giannini
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | | | - Marco Liberati
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Francesco D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy -
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Ultrasonographic Prediction of Placental Invasion in Placenta Previa by Placenta Accreta Index. J Clin Med 2023; 12:jcm12031090. [PMID: 36769741 PMCID: PMC9918036 DOI: 10.3390/jcm12031090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/27/2023] [Accepted: 01/29/2023] [Indexed: 02/03/2023] Open
Abstract
This study aimed to investigate the diagnostic accuracy of the placenta accreta index (PAI) for predicting placenta accreta spectrum (PAS) in women with placenta previa. We analyzed 33 pregnancies with placenta previa at Keio University Hospital. The PAI was assessed in the early third trimester, and PAS was diagnosed histologically or clinically defined as retained placenta after manual removal attempts. The PAI and incidence of PAS were analyzed. Ten women (30%) were diagnosed with PAS and had higher volumes of perioperative bleeding (p = 0.016), higher rate of requiring uterine artery embolization (p = 0.005), and peripartum hysterectomy (p = 0.0002) than women without PAS. A PAI > 2 was the most useful cut-off point for predicting PAS and was more sensitive than prediction values using traditional evaluation (history of cesarean section and placental location). Post-hoc analysis revealed a higher rate of previous history of cesarean delivery (30% vs. 4.4%, p = 0.038), severe placental lacunae (≥grade2) (70% vs. 8.7%, p = 0.0003), thin myometrial thickness (90% vs. 22%, p = 0.0003), anterior placenta (100% vs. 30%, p = 0.0002), and presence of bridging vessels (30% vs. 0%, p = 0.0059) in PAS women. PAI could help predict the outcomes of women with placenta previa with and without a history of cesarean delivery to reduce PAS-induced perinatal complications.
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Rodriguez M, Smith EL, Silva LM, Gultekin-Elbir EE, Tetla R, Genc MR. The effect of abnormal placentation on maternal serum fetal fraction of cell-free DNA. J Perinat Med 2023; 51:97-101. [PMID: 36383690 DOI: 10.1515/jpm-2022-0420] [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: 08/28/2022] [Accepted: 10/28/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Abnormal placentation may affect the maternal serum fraction of cell-free fetal DNA (fetal fraction) determined as part of non-invasive prenatal screening (NIPS). This study aimed to assess whether the fetal fraction can predict placenta accreta spectrum (PAS) with or without placenta previa (PP). We also investigated the impact of trophoblastic invasion depth on the fetal fraction. METHODS This is a retrospective case-control study of pregnant women with and without abnormal placentation carrying a singleton and having undergone NIPS prior to 20 weeks of gestation. The eligible subjects were selected from a cohort managed at our institution for PAS suspected antenatally. We compared women with normal placentation (controls) to PAS, PP, or PAS + PP cases. Data were abstracted from electronic medical records, and PAS was confirmed histologically. RESULTS Of the 146 patients in our cohort, 8 controls, 10 PP, 6 PAS, and 7 PAS + PP cases were eligible for the study. Among the groups, there were no significant differences in baseline demographic and clinical characteristics except the median number of prior uterine surgeries. Also, the groups did not significantly differ in their median fetal fraction. The fetal fraction did not discriminate any group when stratified according to the depth of placental invasion, i.e., no PAS, abnormally adherent, and abnormally invasive placenta. CONCLUSIONS The maternal serum fraction of cell-free fetal DNA measured before 20 weeks of gestation is not predictive of PAS with or without concurrent PP or the depth of trophoblastic invasion.
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Affiliation(s)
- Marcella Rodriguez
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Erica L Smith
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Lauren M Silva
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Elif Esra Gultekin-Elbir
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Ryan Tetla
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Mehmet Rifat Genc
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL, USA
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Baumann HE, Pawlik LKA, Hoesli I, Schoetzau A, Schoenberger H, Butenschoen A, Monod C, Manegold-Brauer G. Accuracy of ultrasound for the detection of placenta accreta spectrum in a universal screening population. Int J Gynaecol Obstet 2022; 161:920-926. [PMID: 36436922 DOI: 10.1002/ijgo.14595] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/09/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The current study aimed to determine the sensitivity and specificity of ultrasound for the diagnosis of placenta accreta spectrum (PAS) in a universal screening population and assesses the added value of magnetic resonance imaging (MRI). METHODS This retrospective analysis evaluated 5219 patients with singleton pregnancies who had a standardized ultrasound (US) examination in our unit and delivered at our institution between 2014 and 2019. RESULTS A total of 181 (3.5%) of 5219 (100%) patients had a suspicion or diagnosis of PAS with US. The accuracy of US in detecting placenta increta/percreta showed a sensitivity of 100%, specificity of 99.9%, positive predictive value of 82.4%, and a negative predictive value of 100%. The diagnosis of all forms of PAS showed a sensitivity of 25.8%, specificity of 99.8%, positive predictive value of 80.8%, and a negative predictive value of 97.7%. MRI was concordant with US in 11 of 14 (78.5%) cases of severe forms of PAS and in three of 15 (20.0%) cases with placenta accreta. CONCLUSION A standardized US evaluation can be applied in a universal screening setting for the diagnosis of severe forms of PAS. MRI is a complementary examination in severe forms of PAS but seems of limited value to discriminate placenta accreta from placenta increta/percreta.
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Affiliation(s)
- Hanna Elise Baumann
- Department of Gynecologic and Prenatal Ultrasound, University of Basel, Women's Hospital, Basel, Switzerland
| | | | - Irene Hoesli
- Department of Obstetrics and Prenatal Medicine, University of Basel, Women's Hospital, Basel, Switzerland
| | | | - Heidrun Schoenberger
- Department of Gynecologic and Prenatal Ultrasound, University of Basel, Women's Hospital, Basel, Switzerland
| | - Annkathrin Butenschoen
- Department of Gynecologic and Prenatal Ultrasound, University of Basel, Women's Hospital, Basel, Switzerland
| | - Cécile Monod
- Department of Gynecologic and Prenatal Ultrasound, University of Basel, Women's Hospital, Basel, Switzerland.,Department of Obstetrics and Prenatal Medicine, University of Basel, Women's Hospital, Basel, Switzerland
| | - Gwendolin Manegold-Brauer
- Department of Gynecologic and Prenatal Ultrasound, University of Basel, Women's Hospital, Basel, Switzerland
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Abstract
The incidence of placenta accreta spectrum (PAS) is increasing and is now about 3 per 1000 deliveries, largely due to the rising cesarean section rate. Ultrasound is the preferred method for diagnosis of PAS. Ultrasound markers include multiple vascular lacunae, loss of the hypoechoic retroplacental zone, abnormalities of the uterine serosa-bladder interface, retroplacental myometrial thickness less than 1 mm, increased placental vascularity, and observation of bridging vessels linking the placenta and bladder. Patients with PAS should be managed by experienced multidisciplinary teams. Hysterectomy is the accepted management of PAS and conservative or expectant management of PAS should be considered investigational.
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Pain F, Dohan A, Grange G, Marcellin L, Uzan‐Augui J, Goffinet F, Soyer P, Tsatsaris V. Percreta score to differentiate between placenta accreta and placenta percreta with ultrasound and MR imaging. Acta Obstet Gynecol Scand 2022; 101:1135-1145. [PMID: 35822244 PMCID: PMC9812204 DOI: 10.1111/aogs.14420] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/05/2022] [Accepted: 06/18/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The objective of this study was to assess the performance of ultrasound and magnetic resonance imaging (MRI) features in helping to classify the type of placenta accreta spectrum (PAS; accreta/increta vs percreta), alone or combined in a predictive score. MATERIAL AND METHODS We conducted a retrospective study in 82 pregnant women with PAS who underwent ultrasound and MRI examination of the pelvis before delivery (from an initial cohort of 185 women with PAS). We estimated the sensitivity, specificity and accuracy of MRI and ultrasound in the diagnosis of the type of PAS. We analyzed cesarean and imaging features using univariable logistic regression analysis. We constructed a nomogram to predict the risk of placenta percreta and validated it with bootstrap resampling, then used receiver operating characteristic curves to assess the performance of the model in distinguishing between placenta percreta and placenta accreta/increta. RESULTS Among the 82 patients, 29 (35%) had placenta accreta/increta and 53 (65%) had placenta percreta. The best features to discriminate between placenta accreta/increta and placenta percreta with ultrasound were increased vascularization at the uterine serosa-bladder wall interface (odds ratio [OR] 7.93; 95% confidence interval [CI] 2.78-24.99; p < 0.01) and the number of lacunae without a hyperechogenic halo (OR 1.36; 95% CI 1.14-1.67; p = 0.012). Concerning MRI markers, heterogeneous placenta (OR 12.89; 95% CI 3.05-89.16; p = 0.002), dark intraplacental bands (OR 12.89; 95% CI 3.05-89.16; p = 0.002) and bladder wall interruption (OR 15.89; 95% CI 4.78-73.33; p < 0.001) had a higher OR in discriminating placenta accreta/increta from placenta percreta. The nomogram yielded areas under the curve of 0.841 (95% CI 0.754-0.927) and 0.856 (95% CI 0.767-0.945), after bootstrap resampling, for the accurate prediction of placenta percreta. CONCLUSIONS The nomogram we developed to predict the risk of placenta percreta among patients with PAS had good discriminative capabilities. This performance and its impact on maternal morbidity should be confirmed by future prospective studies.
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Affiliation(s)
- Flore‐Anne Pain
- Department of Gynecology & Obstetrics, FHU PREMACochin HospitalParisFrance
| | - Anthony Dohan
- Faculty of MedicineUniversité Paris CentreParisFrance,Department of RadiologyCochin HospitalParisFrance
| | - Gilles Grange
- Department of Gynecology & Obstetrics, FHU PREMACochin HospitalParisFrance
| | - Louis Marcellin
- Department of Gynecology & Obstetrics, FHU PREMACochin HospitalParisFrance,Faculty of MedicineUniversité Paris CentreParisFrance
| | | | - François Goffinet
- Department of Gynecology & Obstetrics, FHU PREMACochin HospitalParisFrance,Faculty of MedicineUniversité Paris CentreParisFrance
| | - Philippe Soyer
- Faculty of MedicineUniversité Paris CentreParisFrance,Department of RadiologyCochin HospitalParisFrance
| | - Vassilis Tsatsaris
- Department of Gynecology & Obstetrics, FHU PREMACochin HospitalParisFrance,Faculty of MedicineUniversité Paris CentreParisFrance
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Reeder CF, Sylvester-Armstrong KR, Silva LM, Wert EM, Smulian JC, Genc MR. Outcomes of pregnancies at high-risk for placenta accreta spectrum following negative diagnostic imaging. J Perinat Med 2022; 50:595-600. [PMID: 35218171 DOI: 10.1515/jpm-2021-0591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/07/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To assess the pretest and negative post-test probability for placenta accreta spectrum (PAS) in a group of patients with high-risk clinical factors. METHODS We included patients with suspected and/or confirmed PAS at our institution over 8 years. Sonography performed by maternal-fetal medicine specialists, and selected patients underwent MRI. Imaging was considered positive if either sonography or MRI suggested PAS. Histopathology was the gold standard for diagnosis of PAS. We assessed the pretest and negative imaging-test probability, and resources required. RESULTS We identified 82 high-risk patients with the following: (1) a history of ≥1 cesarean section and/or intrauterine gynecologic procedure and placenta previa in the index pregnancy; (2) a history of >3 cesarean deliveries and/or gynecologic procedures regardless of placental location; (3) prior PAS disorder, or retained placenta requiring manual extraction and/or curettage, complicated by postpartum hemorrhage; and (4) suspected cesarean section scar pregnancy. Histopathology confirmed PAS in 52 patients, with pretest probability of 63%. Imaging correctly identified 44/50 cases with PAS, and excluded this condition in 24/30 cases. Thus, the positive and negative post-test probability for PAS following negative imaging was 88 and 20%, respectively. Of the six patients with false-negative imaging, all had either surgical complications or required care beyond that for routine cesarean section. CONCLUSIONS Although diagnostic imaging is sensitive, the negative posttest probability remains high in women with high pretest probability for PAS. Therefore, women at high risk for PAS should be managed in experienced centers by a multidisciplinary team even if imaging is negative.
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Affiliation(s)
- Callie F Reeder
- University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Lauren M Silva
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Erika M Wert
- University of Florida College of Medicine, Gainesville, FL, USA
| | - John C Smulian
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Mehmet R Genc
- University of Florida College of Medicine, Gainesville, FL, USA
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Alzoubi O, Maaita W, Madain Z, Alzoubi M, Sweis JJG, Arar AR, Sweis NWG. Association between placenta accreta spectrum and third-trimester serum levels of vascular endothelial growth factor, placental growth factor, and soluble Fms-like tyrosine kinase-1: A meta-analysis. J Obstet Gynaecol Res 2022; 48:2363-2376. [PMID: 35726123 DOI: 10.1111/jog.15330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/10/2022] [Accepted: 06/01/2022] [Indexed: 12/01/2022]
Abstract
AIM Antenatal suspicion of placenta accreta spectrum (PAS) currently relies on ultrasonographic findings, color doppler, and MRI, which have rendered it operator and expertise-dependent. No serum markers for PAS have been integrated into clinical practice yet. The aim of this meta-analysis was to identify potential serum markers for PAS by investigating third-trimester serum levels of vascular endothelial growth factor (VEFG), placental growth factor (PIGF), and soluble Fms-like tyrosine kinase-1 (sFlt-1) among PAS-cases and controls. METHODS PubMed, Scopus, EBSCO, Web of Science, and CNKI databases were systematically searched for relevant articles. Random-effects model was applied to calculate the overall standardized mean difference (SMD) for each marker. Subgroup analysis and meta-regression were performed to assess for potential covariates. RESULTS Eight studies involving 366 PAS-cases and 518 controls were included. Third trimester sFlt-1 levels were significantly lower in PAS-cases when compared to controls (SMD = -7.76, 95%CI = -10.42 to -5.10). This was, to a certain extent, consistent among studies though they differed in their extent of significance. Levels of VEGF (SMD = 1.59, 95%CI = -0.07 to 3.25) and PlGF (SMD = -0.49, 95%CI = -1.66 to 0.67) were not significantly different between PAS cases and controls, in which studies demonstrated conflicting results. CONCLUSIONS Third trimester sFlt-1 levels may be useful to predict PAS. Nonetheless, further studies are recommended to better understand conflicting results before adopting either VEGF or PlGF.
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Affiliation(s)
- Osama Alzoubi
- School of Medicine, The University of Jordan, Amman, Jordan
| | - Ward Maaita
- School of Medicine, The University of Jordan, Amman, Jordan
| | - Zaid Madain
- School of Medicine, The University of Jordan, Amman, Jordan
| | | | | | - Ahmad R Arar
- School of Medicine, The University of Jordan, Amman, Jordan
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Prenatal diagnosis and management of placenta accreta in a Moroccan high-level maternity. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Cavalli C, Maggi C, Gambarini S, Fichera A, Santoro A, Grazioli L, Prefumo F, Odicino FE, Fratelli N. Ultrasound and magnetic resonance imaging in the diagnosis of clinically significant placenta accreta spectrum disorders. J Perinat Med 2022; 50:277-285. [PMID: 34854274 DOI: 10.1515/jpm-2021-0334] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 11/14/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES We aimed to assess the performance of ultrasound (US) and magnetic resonance imaging (MRI) signs for antenatal detection of placenta accreta spectrum (PAS) disorders in women with placenta previa (placental edge ≤2 cm from the internal uterine orifice, ≥260/7 weeks' gestation) with and without a history of previous Caesarean section. METHODS Single center prospective observational study. US suspicion of PAS was raised in the presence of obliteration of the hypoechoic space between uterus and placenta, interruption of the hyperechoic uterine-bladder interface and/or turbulent placental lacunae on color Doppler. All MRI studies were blindly evaluated by a single operator. PAS was defined as clinically significant when histopathological diagnosis was associated with at least one of: intrauterine balloon placement, compressive uterine sutures, peripartum hysterectomy, uterine or hypogastric artery ligature, uterine artery embolization. RESULTS A total of 39 women were included: 7/39 had clinically significant PAS. There were 6/18 cases of PAS with anterior placenta: hypoechoic space interruption and placental lacunae were the most sensitive sonographic signs (83%), while abnormal hyperechoic interface was the most specific (83%). On MRI, focal myometrial interruption and T2 intraplacental dark bands showed the best sensitivity (83%), bladder tenting had the best specificity (100%). 1/21 women with posterior placenta had PAS. There was substantial agreement between US and MRI in patients with anterior placenta (κ=0.78). CONCLUSIONS US and MRI agreement in antenatal diagnosis of clinically significant PAS was maximal in high-risk women. Placental lacunae on ultrasound scan and T2 intraplacental hypointense bands on MRI should trigger the suspicion of PAS.
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Affiliation(s)
- Cecilia Cavalli
- Department of Clinical and Experimental Sciences, Division of Obstetrics and Gynecology, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Claudia Maggi
- Department of Clinical and Experimental Sciences, Division of Obstetrics and Gynecology, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Sebastiana Gambarini
- Department of Diagnostic Imaging, First Service of Radiology, ASST Spedali Civili, Brescia, Italy
| | - Anna Fichera
- Department of Clinical and Experimental Sciences, Division of Obstetrics and Gynecology, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Amerigo Santoro
- Department of Pathology, ASST Spedali Civili, Brescia, Italy
| | - Luigi Grazioli
- Department of Diagnostic Imaging, First Service of Radiology, ASST Spedali Civili, Brescia, Italy
| | - Federico Prefumo
- Department of Clinical and Experimental Sciences, Division of Obstetrics and Gynecology, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Franco E Odicino
- Department of Clinical and Experimental Sciences, Division of Obstetrics and Gynecology, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Nicola Fratelli
- Department of Clinical and Experimental Sciences, Division of Obstetrics and Gynecology, ASST Spedali Civili, University of Brescia, Brescia, Italy
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Hong S, Le Y, Lio KU, Zhang T, Zhang Y, Zhang N. Performance comparison of ultrasonography and magnetic resonance imaging in their diagnostic accuracy of placenta accreta spectrum disorders: a systematic review and meta-analysis. Insights Imaging 2022; 13:50. [PMID: 35316430 PMCID: PMC8940971 DOI: 10.1186/s13244-022-01192-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 02/23/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Accurate prenatal diagnosis of placenta accrete spectrum disorder (PAS) remains a challenge, and the reported diagnostic value of ultrasonography (US) and magnetic resonance imaging (MRI) varies widely. This study aims to systematically evaluate the diagnostic accuracy of US as compared with MRI in the detection of PAS within the identical patient population. METHODS Medline, EMBASE, Google scholar and Cochrane library were searched. Pooled sensitivity, specificity, diagnostic odds ratio (DOR) and the area under the summary receiver operating characteristic (SROC) curve were calculated. Subgroup analysis was also performed to elucidate the heterogeneity of results. RESULTS A total of 18 articles comprising 861 pregnancies were included in the study. The overall diagnostic accuracy of US for identification of PAS was as follows: sensitivity [0.90 (0.86-0.93)], specificity [0.83 (0.79-0.86)], DOR [39.5 (19.6-79.7)]. The overall diagnostic accuracy of MRI for identification of PAS was as follows: sensitivity [0.89 (0.85-0.92)], specificity [0.87 (0.83-0.89)], DOR [37.4 (17.0-82.3)]. The pooled sensitivity (p = 0.808) and specificity (p = 0.413) between US and MRI are not significantly different. SROC analysis revealed that there was no statistical difference (p = 0.552) in US and MRI for the overall predictive accuracy of PAS. Furthermore, in the subgroup analysis of between retrospective and prospective studies, between earlier and most recent studies, there was no statistical difference (p > 0.05) in diagnostic accuracy of US and MRI for the detection of PAS. CONCLUSIONS Both ultrasonography (US) and magnetic resonance imaging (MRI) showed comparable accuracy in the prenatal diagnosis of placenta accrete spectrum disorder (PAS). Routine employment of MRI with relatively high expense in the prenatal identification of PAS should not be recommended.
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Affiliation(s)
- Shibin Hong
- Department of Obstetrics and Gynecology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Pudong New District, Shanghai, 200127, China.,Shanghai Key Laboratory of Gynecologic Oncology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Shanghai, 200127, China
| | - Yiping Le
- Department of Obstetrics and Gynecology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Pudong New District, Shanghai, 200127, China
| | - Ka U Lio
- Department of Medicine, Temple University Hospital, Lewis Katz School of Medicine at Temple University, 3401 N Broad St, Philadelphia, PA, 19140, USA
| | - Ting Zhang
- Department of Obstetrics and Gynecology, Hainan Women and Children's Medical Center, Changbin Road, Haikou City, 570312, Hainan Province, China
| | - Yu Zhang
- Department of Obstetrics and Gynecology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Pudong New District, Shanghai, 200127, China. .,Shanghai Key Laboratory of Gynecologic Oncology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Shanghai, 200127, China.
| | - Ning Zhang
- Department of Obstetrics and Gynecology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Pudong New District, Shanghai, 200127, China. .,Shanghai Key Laboratory of Gynecologic Oncology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, 160 Pujian Road, Shanghai, 200127, China.
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Ghezzi CLA, Silva CK, Casagrande AS, Westphalen SS, Salazar CC, Vettorazzi J. Diagnostic performance of radiologists with different levels of experience in the interpretation of MRI of the placenta accreta spectrum disorder. Br J Radiol 2021; 94:20210827. [PMID: 34538067 PMCID: PMC8631015 DOI: 10.1259/bjr.20210827] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/23/2021] [Accepted: 09/07/2021] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES There have been no investigations on the association between previous abdominopelvic MRI experience without placental MRI experience and diagnostic accuracy of placenta accreta spectrum (PAS). To evaluate the diagnostic performance of radiologists with different experience levels in interpreting PAS-related MRI findings. METHODS This retrospective study included 60 women who underwent MRI for placental assessment between 2016 and 2020. MR images were reviewed by four radiologists who were blinded to the clinical outcomes and had different experience levels in interpreting PAS-related MRI findings. The radiologists' diagnostic performance was evaluated according to the pathologic and surgical outcomes. Simple κ statistics were calculated to determine agreement among the radiologists. RESULTS Of 60 women, 46 were diagnosed with PAS. The maternal age mean ± SD was 33.0 years ± 5.0 for the PAS absent group and 36.0 ± 4.3 for the PAS present group (p = 0.013). Overall, the most experienced radiologist had the highest sensitivity (100%, 95% confidence interval (CI): 92.3-100%) and NPV (100%, 95% CI: 63.1-100%) in PAS diagnoses. However, the PPV and specificity were independent of experience. The most experienced radiologist had the highest diagnostic accuracy in PAS (90%, 95% CI: 79.5-96.2%) and placenta percreta (95%, 95% CI: 86.1-99.0%). There was a strong association between definitive PAS diagnoses and the highest experience level. The κ values for the interobserver agreement regarding PAS diagnoses were 0.67 for the most experienced radiologist (p < 0.001) and 0.38, 0.40, and 0.43 for the other radiologists (p = 0.001) and regarding placenta percreta diagnoses were 0.87 for the senior radiologist (p < 0.001) and 0.63, 0.57, and 0.62 for the other radiologists (p < 0.001). CONCLUSION Previous experience in interpreting PAS-related MRI findings plays a significant role in accurately interpreting such imaging findings. Previous abdominopelvic MRI experience without specific placental MRI experience did not improve diagnostic performance. ADVANCES IN KNOWLEDGE We believe that our study makes a significant contribution to the literature and that this paper will be of interest to the readership of your journal because to the best of our knowledge, this study is the first in which the correlation between previous experience in abdominopelvic MRI with no specific experience in PAS-related MRI and diagnostic accuracy of radiologists has been explored. Our results could aid in setting up specialized multidisciplinary teams to assist women with PAS disorders.
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Affiliation(s)
| | - Cristiano Kohler Silva
- Department of Radiology, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
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Abstract
Placenta accreta spectrum (PAS) refers to the range of pathologic adherence of the placenta to the uterine myometrium, including the placenta accreta, increta, and percreta. The incidence of PAS is rising primarily because of an increase in related risk factors, such as the rate of cesarean deliveries and pregnancies resulting from assisted reproductive technology. The maternal risks associated with PAS are significant, including hemorrhage, hysterectomy, and death. Fetal and neonatal risks are primarily the result of premature delivery. Antenatal diagnosis via ultrasonography and magnetic resonance imaging remains imperfect. Management of PAS varies, however, and there is a clear improvement in maternal outcomes with an antenatal diagnosis compared with unexpected diagnosis at the time of delivery. Studies that evaluate the balance between maternal and fetal/neonatal risks of expectant management versus preterm delivery have found that planned delivery between 34 and 35 weeks' gestation optimizes outcomes. Multidisciplinary PAS care teams have become the norm and recommended approach to management, given the complexity of caring for this obstetrical condition. Although significant advances have been made over the years, large knowledge gaps remain in understanding the pathophysiology, diagnosis, and clinical management.
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Affiliation(s)
- Bridget M Donovan
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA.,Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Scott A Shainker
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA.,Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA
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Alves ÁLL, Silva LBD, Costa FDS, Rezende GDC. Management of placenta accreta spectrum. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:713-723. [PMID: 34670307 PMCID: PMC10183858 DOI: 10.1055/s-0041-1736371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
| | | | - Fabrício da Silva Costa
- Maternal Fetal Medicine Unit, Gold Coast University Hospital and School of Medicine, Griffith University, Gold Coast, Queensland, Australia
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Matthews KC, Fields JC, Chasen ST. Suspected Placenta Accreta: Using Imaging to Stratify Risk of Morbidity. Am J Perinatol 2021; 38:1308-1312. [PMID: 32512608 DOI: 10.1055/s-0040-1712948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE This study was aimed to compare clinical outcomes and use of interventions in women with suspected accreta based on the degree of antenatal suspicion. STUDY DESIGN This was a retrospective cohort study of women with suspected accreta from 2007 to 2019. Included patients had one or more imaging studies suggestive of accreta. Cases were classified as "lower risk" if imaging showed possible signs of accreta including mild or superficial myometrial infiltration, an abnormal uterine contour, an abnormal uteroplacental interface, or loss of the retroplacental hypoechoic zone and "higher risk" if there was clear evidence of more than superficial myometrial infiltration, placental tissue extruding beyond the uterine serosa, bridging vessel(s), or placental lacunae with high velocity and/or turbulent flow. The primary study outcome was a composite maternal morbidity including cesarean hysterectomy, transfusion of blood or blood products, unintentional cystotomy, or intensive care unit (ICU) admission. Chi-square, Fisher's exact test, and Mann-Whitney U-test were used for analysis. RESULTS A total of 78 women had a suspected accreta on imaging, 36 with "lower risk" features and 42 with "higher risk" features. There were no differences in baseline maternal demographics. Women in the "higher risk" group were more likely to have a placenta previa (p < 0.01) and preoperative consultation with gynecologic oncology (p = 0.04). There was a significant difference in composite maternal morbidity between patients with "lower risk" and "higher risk" features of accreta on imaging (50 vs. 92.9%, p < 0.01). Median gestational age at planned and actual delivery were earlier in the "higher risk" group (36.6 vs. 34.9 weeks, p < 0.01; 36.0 vs. 34.7 weeks, p < 0.01). CONCLUSION Stratification of women with suspected accreta based on imaging corresponded to rates of maternal morbidity and operative complications, and appears to have been used clinically in selecting timing of delivery and interventions. KEY POINTS · Increased morbidity with high risk accreta imaging.. · Interventions correlate with accreta imaging risk.. · Imaging can be used to stratify accreta cases..
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Affiliation(s)
- Kathy C Matthews
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, New York Presbyterian-Weill Cornell Medical Center, New York, New York
| | - Jessica C Fields
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, New York Presbyterian-Weill Cornell Medical Center, New York, New York
| | - Stephen T Chasen
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, New York Presbyterian-Weill Cornell Medical Center, New York, New York
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Afshar Y, Dong J, Zhao P, Li L, Wang S, Zhang RY, Zhang C, Yin O, Han CS, Einerson BD, Gonzalez TL, Zhang H, Zhou A, Yang Z, Chou SJ, Sun N, Cheng J, Zhu H, Wang J, Zhang TX, Lee YT, Wang JJ, Teng PC, Yang P, Qi D, Zhao M, Sim MS, Zhe R, Goldstein JD, Williams J, Wang X, Zhang Q, Platt LD, Zou C, Pisarska MD, Tseng HR, Zhu Y. Circulating trophoblast cell clusters for early detection of placenta accreta spectrum disorders. Nat Commun 2021; 12:4408. [PMID: 34344888 PMCID: PMC8333096 DOI: 10.1038/s41467-021-24627-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 06/21/2021] [Indexed: 11/21/2022] Open
Abstract
Placenta accreta spectrum (PAS) is a high-risk obstetrical condition associated with significant morbidity and mortality. Current clinical screening modalities for PAS are not always conclusive. Here, we report a nanostructure-embedded microchip that efficiently enriches both single and clustered circulating trophoblasts (cTBs) from maternal blood for detecting PAS. We discover a uniquely high prevalence of cTB-clusters in PAS and subsequently optimize the device to preserve the intactness of these clusters. Our feasibility study on the enumeration of cTBs and cTB-clusters from 168 pregnant women demonstrates excellent diagnostic performance for distinguishing PAS from non-PAS. A logistic regression model is constructed using a training cohort and then cross-validated and tested using an independent cohort. The combined cTB assay achieves an Area Under ROC Curve of 0.942 (throughout gestation) and 0.924 (early gestation) for distinguishing PAS from non-PAS. Our assay holds the potential to improve current diagnostic modalities for the early detection of PAS.
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Affiliation(s)
- Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jiantong Dong
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
- Beijing National Laboratory for Molecular Sciences, MOE Key Laboratory of Bioorganic Chemistry and Molecular Engineering, College of Chemistry and Molecular Engineering, Peking University, Beijing, China
| | - Pan Zhao
- Clinical Medical Research Center, The First Affiliated Hospital of Southern University of Science and Technology, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Lei Li
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Shan Wang
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Ryan Y Zhang
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ceng Zhang
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ophelia Yin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Christina S Han
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Center for Fetal Medicine and Women's Ultrasound, Los Angeles, CA, USA
| | - Brett D Einerson
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - Tania L Gonzalez
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Huirong Zhang
- Clinical Medical Research Center, The First Affiliated Hospital of Southern University of Science and Technology, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Anqi Zhou
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Zhuo Yang
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Shih-Jie Chou
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Na Sun
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ju Cheng
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Henan Zhu
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jing Wang
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Tiffany X Zhang
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Yi-Te Lee
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jasmine J Wang
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Pai-Chi Teng
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Peng Yang
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Dongping Qi
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Meiping Zhao
- Beijing National Laboratory for Molecular Sciences, MOE Key Laboratory of Bioorganic Chemistry and Molecular Engineering, College of Chemistry and Molecular Engineering, Peking University, Beijing, China
| | - Myung-Shin Sim
- Departments of Computational Medicine & Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ruilian Zhe
- Clinical Medical Research Center, The First Affiliated Hospital of Southern University of Science and Technology, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Jeffrey D Goldstein
- Department of Pathology and Laboratory Medicine, Ronald Reagan Medical Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - John Williams
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Xietong Wang
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Qingying Zhang
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Obstetrics, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Lawrence D Platt
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Center for Fetal Medicine and Women's Ultrasound, Los Angeles, CA, USA
| | - Chang Zou
- Clinical Medical Research Center, The First Affiliated Hospital of Southern University of Science and Technology, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, Guangdong, China.
| | - Margareta D Pisarska
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Hsian-Rong Tseng
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA.
| | - Yazhen Zhu
- California NanoSystems Institute, Crump Institute for Molecular Imaging, Department of Molecular and Medical Pharmacology, University of California, Los Angeles, Los Angeles, CA, USA.
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Pregnancy-Related Hysterectomy for Peripartum Hemorrhage: A Literature Narrative Review of the Diagnosis, Management, and Techniques. BIOMED RESEARCH INTERNATIONAL 2021; 2021:9958073. [PMID: 34307683 PMCID: PMC8282389 DOI: 10.1155/2021/9958073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/21/2021] [Indexed: 12/14/2022]
Abstract
Postpartum hemorrhage is a life-threatening situation, in which hysterectomy can be performed to prevent maternal death. However, it is associated with high rates of maternal morbidity and mortality and permanent infertility. The incidence of pregnancy-related hysterectomy varies across countries, but its main indications are the following: uterine atony and placenta spectrum (PAS) disorders. PAS disorder prevalence is rising during the last years, mainly due to the increased number of cesarean sections. As a result, obstetricians should be aware of the difficulties of this emergent condition and improve its accurate antenatal diagnosis rates, as well as its modern management strategies. Of course, special skills are required during a pregnancy-related hysterectomy, so these patients should be referred to centers of excellence in antenatal care, where a multidisciplinary team approach is followed. This study is a narrative review of the literature of the last 5 years (PubMed, Cochrane) regarding postpartum hemorrhage to offer obstetricians up-to-date knowledge on this pregnancy-related life-threatening issue. However, there is a lack of available high-quality data, because most published papers are retrospective case series or observational cohorts.
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Einerson BD, Rodriguez CE, Silver RM, Donnelly MA, Kennedy AM, Woodward PJ. Accuracy and Interobserver Reliability of Magnetic Resonance Imaging for Placenta Accreta Spectrum Disorders. Am J Perinatol 2021; 38:960-967. [PMID: 31986538 DOI: 10.1055/s-0040-1701196] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study aims to define the accuracy, predictive value, and interobserver reliability of magnetic resonance imaging (MRI) in the diagnosis of placenta accreta spectrum (PAS) disorders. STUDY DESIGN Two experienced radiologists independently interpreted the MRI studies of patients with possible PAS from two referral centers. Radiologists were blinded to sonographic and clinical information. We calculated diagnostic testing characteristics and kappa statistics of interobserver reliability for MRI findings of PAS. RESULTS Sixty-eight MRI cases were evaluated. Confirmed PAS and severe PAS were present in 44 (65%) and 20 (29%) cases. For the diagnosis of any PAS, MRI had a sensitivity 66%, specificity 71%, positive predictive value (PPV) 81%, negative predictive value (NPV) 53%, and accuracy 68%. For the diagnosis of severe PAS (percreta), MRI had a sensitivity 85%, specificity 79%, PPV 63%, NPV 93%, and accuracy 81%. The accuracy of individual signs of PAS was lower (44-65%). Interobserver agreement was almost perfect for previa; substantial for myometrial interruptions, PAS, severe PAS, and placental bulging/balling; and moderate to slight for other signs of PAS. CONCLUSION Although the interobserver reliability of MRI for a diagnosis of PAS is substantial, the accuracy and predictive value are modest and lower than previously reported.
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Affiliation(s)
- Brett D Einerson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah.,Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| | - Christina E Rodriguez
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
| | - Robert M Silver
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah.,Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| | - Meghan A Donnelly
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
| | - Anne M Kennedy
- Department of Radiology, University of Utah Health, Salt Lake City, Utah
| | - Paula J Woodward
- Department of Radiology, University of Utah Health, Salt Lake City, Utah
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Romeo V, Verde F, Sarno L, Migliorini S, Petretta M, Mainenti PP, D'Armiento M, Guida M, Brunetti A, Maurea S. Prediction of placenta accreta spectrum in patients with placenta previa using clinical risk factors, ultrasound and magnetic resonance imaging findings. Radiol Med 2021; 126:1216-1225. [PMID: 34156592 DOI: 10.1007/s11547-021-01348-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 03/15/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To predict placental accreta spectrum (PAS) in patients with placenta previa (PP) evaluating clinical risk factors (CRF), ultrasound (US) and magnetic resonance imaging (MRI) findings. METHODS Seventy patients with PP were retrospectively selected. CRF were retrieved from medical records. US and MRI images were evaluated to detect imaging signs suggestive of PAS. Univariable analysis was performed to identify CRF, US and MRI signs associated with PAS considering histology as standard of reference. Receiver operating characteristic curve (ROC) analysis was performed, and the area under the curve (AUC) was calculated. Multivariable analysis was also performed. RESULTS At univariable analysis, the number of previous cesarean section, smoking, loss of the retroplacental clear space, myometrial thinning < 1 mm, placental lacunae, intraplacental dark bands (IDB), focal interruption of myometrial border (FIMB) and abnormal vascularity were statistically significant. The AUC in predicting PAS progressively increased using CRF, US and MRI signs (0.69, 0.79 and 0.94, respectively; p < 0.05); the accuracy of MRI alone was similar to that obtained combining CRF, US and MRI variables (AUC = 0.97) and was significantly higher (p < 0.05) than that combining CRF and US (AUC = 0.83). Multivariable analysis showed that only IDB (p = 0.012) and FIMB (p = 0.029) were independently associated with PAS. CONCLUSIONS MRI is the best modality to predict PAS in patients with PP independently from CRF and/or US finding. It is reasonable to propose the combined assessment of CRF and US as the first diagnostic level to predict PAS, sparing MRI for selected cases in which US findings are uncertain for PAS.
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Affiliation(s)
- Valeria Romeo
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80123, Naples, Italy
| | - Francesco Verde
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80123, Naples, Italy.
| | - Laura Sarno
- Department of Neuroscience, Reproductive and Dentistry Sciences, University of Naples "Federico II", Naples, Italy
| | - Sonia Migliorini
- Department of Neuroscience, Reproductive and Dentistry Sciences, University of Naples "Federico II", Naples, Italy
| | - Mario Petretta
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy
| | - Pier Paolo Mainenti
- Institute of Biostructures and Bioimaging of the National Council of Research (CNR), Naples, Italy
| | - Maria D'Armiento
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80123, Naples, Italy
| | - Maurizio Guida
- Department of Neuroscience, Reproductive and Dentistry Sciences, University of Naples "Federico II", Naples, Italy
| | - Arturo Brunetti
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80123, Naples, Italy
| | - Simone Maurea
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Via S. Pansini, 5, 80123, Naples, Italy
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Young AMP, Uribe K, Shaddeau AK. Protrusion of placental tissue through the cervical os as an unusual presentation of placenta accreta: A case report. Case Rep Womens Health 2021; 31:e00334. [PMID: 34189059 PMCID: PMC8220340 DOI: 10.1016/j.crwh.2021.e00334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Abnormal placentation commonly occurs in women with a history of uterine surgery or placenta previa. Placenta accreta spectrum can occur in the setting of lesser-known risk factors and anatomical locations. Case A 41-year-old woman (G6P4014) at 18 weeks of gestation without major risk factors was diagnosed with a placenta accreta after presenting for desired termination of pregnancy. On examination, placental tissue was found to be protruding through the cervical os and this was confirmed by magnetic resonance imaging (MRI). Management included pregnancy termination with intracardiac potassium chloride injection, uterine artery embolization, and a total abdominal hysterectomy. Conclusion Protruding cervical tissue should raise suspicion for placenta accreta. Appropriate evaluation and surgical planning should be performed to ensure a safe delivery. Placenta accreta can occur in a patient without traditional risk factors. Placenta acreeta should be considered when protruding cervical tissue is suspected or identified during pregnancy The role of advanced maternal age in abnormal placentation should be further characterized. Institutions should utilize a standard screening protocol for abnormal placentation including indications for MRI. A multidisciplinary approach is critical to optimize maternal safety.
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Affiliation(s)
| | - Katelyn Uribe
- Johns Hopkins Department of Gynecology and Obstetrics, Baltimore, MD, United States of America
| | - Angela K Shaddeau
- Johns Hopkins Department of Gynecology and Obstetrics, Baltimore, MD, United States of America
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Nelson LW, Richardson D, Chavan NR, Kapoor H, Stanley ZD, Gulati V, Winfrey OK, Khurana A. Correlation of placental MR imaging signs and pathologic diagnosis of placenta accreta spectrum: Retrospective single center case series. Eur J Obstet Gynecol Reprod Biol 2021; 262:239-247. [PMID: 34091159 DOI: 10.1016/j.ejogrb.2021.05.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/10/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Alongside initial screening obstetric US, use of placental MRI has been increasing in the last few decades to aid with antenatal diagnosis and delivery planning in Placenta Accreta Spectrum (PAS). The aim of this study was to determine if the MRI pathophysiological sign subcategories described in the current literature can predict the severity of pathologic diagnosis. METHODS Institutional imaging records were reviewed for placental MRIs performed for suspicion of PAS in the last decade. Electronic health records were searched for patient history and pathology. The 59 MRI studies were reviewed using the 11 MRI signs described by the SAR and ESUR joint consensus statement. Further breakdown of the signs was divided by underlying pathophysiologic subcategories including gross morphologic, interface and tissue architecture signs. RESULTS Pathologic diagnosis yielded 34 cases: accreta 4/34, incerta 14/34, percreta 10/34 and normal 6/34. Of the accreta cases all of them demonstrated at least two interface and half of the cases had tissue architecture signs, 13/14 increta cases demonstrated interface signs and 12/14 demonstrated tissue architecture signs, 9/10 percreta cases had two interface and at least six demonstrated three tissue architecture signs. Statistical analysis showed significant difference between pathologic diagnosis and the number of positive interface signs with p = 0.02. DISCUSSION Interface signs were the most objective and sensitive MRI subcategory. Statistical analysis determined there was a significant difference between PAS diagnosis and number of interface signs present. This subcategory has the most overlap with classic US signs which are traditionally used before MRI referral.
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Affiliation(s)
- Leslie W Nelson
- Department of Radiology, University of Kentucky, 800 Rose St, HX 316, Lexington, KY, USA
| | - Darington Richardson
- University of Kentucky College of Medicine, 800 Rose St, MN 150, Lexington, KY, USA
| | - Niraj R Chavan
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Kentucky College of Medicine, 800 Rose St, Lexington, KY, USA
| | - Harit Kapoor
- Department of Radiology, University of Kentucky, 800 Rose St, HX 316, Lexington, KY, USA
| | - Zachary D Stanley
- Department of Obstetrics and Gynecology, University of Kentucky College of Medicine, 800 Rose St, Lexington, KY, USA
| | - Vaibhav Gulati
- Department of Radiology, Imaging Associates at National Heart Institute, New Delhi, India
| | - Olivia K Winfrey
- Department of Obstetrics and Gynecology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, USA
| | - Aman Khurana
- Department of Radiology, University of Kentucky, 800 Rose St, HX 316, Lexington, KY, USA.
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Role of Ultrasound and MRI in Diagnosis of Severe Placenta Accreta Spectrum Disorder: An Intraindividual Assessment With Emphasis on Placental Bulge. AJR Am J Roentgenol 2021; 217:1377-1388. [PMID: 34037411 DOI: 10.2214/ajr.21.25581] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: The placental bulge sign (focal area of myometrial-placental bulging beyond the normal uterine contour) on ultrasound (US) or MRI is postulated to represent deeper venous invasion in placental accreta spectrum (PAS) disorder and may represent severe PAS. Objective: To evaluate the diagnostic performance and interobserver agreement of US and MRI features for diagnosis of severe PAS, with an emphasis on the placental bulge sign. Method: This retrospective study included 62 pregnant women (mean age 33.2±5.5 years) with clinically suspected PAS who underwent both US and MRI. Five independent reviewers (two maternal-fetal medicine specialists for US; three abdominal radiologists for MRI) independently reviewed images for the given modality, blinded to the final diagnosis, and recorded presence of a range of findings (nine on US, eight on MRI) including placental bulge. Intraoperative and pathologic findings were used to separate patients into those with and without severe PAS, based on International Federation of Gynaecology and Obstetrics classification. Diagnostic performance of US and MRI findings for severe PAS were evaluated; multivariable logistic regression was performed; and interobserver agreement was assessed. Results: A total of 58.1% (36/62) of patients had severe PAS. On US, the finding with highest accuracy for severe PAS was placental bulge (85.5%), which was associated with sensitivity of 91.7% and specificity of 76.9%. On MRI, the finding with highest accuracy was also placental bulge (90.3%), which was associated with sensitivity of 94.4% and specificity of 84.6%. At multivariable regression, placental bulge was an independent predictor of severe PAS for US [odds ratio (OR)=8.94; p=.02] and MRI (OR=45.67; p=.003). Interobserver agreement analysis demonstrated kappa for placental bulge of 0.48 for MRI and 0.40 for US. Given wide 95% CIs, differences among features for a given modality as well as differences between modalities were not statistically significant. Conclusion: The findings suggest strong performance of placental bulge in diagnosing severe PAS on both US and MRI, with potentially relatively stronger performance on MRI. Nonetheless, interobserver agreement remains suboptimal on both modalities. Clinical impact: Accurate prenatal diagnosis of severe PAS by imaging could help guide maternal counseling and selection between hysterectomy and uterine-preserving surgery.
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40
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Morel O, van Beekhuizen HJ, Braun T, Collins S, Pateisky P, Calda P, Henrich W, Al Naimi A, Norgaardt LN, Chalubinski KM, Sentilhes L, Tutschek B, Schwickert A, Stefanovic V, Bertholdt C. Performance of antenatal imaging to predict placenta accreta spectrum degree of severity. Acta Obstet Gynecol Scand 2021; 100 Suppl 1:21-28. [PMID: 33811333 PMCID: PMC8252006 DOI: 10.1111/aogs.14112] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/26/2021] [Accepted: 02/02/2021] [Indexed: 12/03/2022]
Abstract
Introduction In cases of placenta accreta spectrum, a precise antenatal diagnosis of the suspected degree of invasion is essential for the planning of individual management strategies at delivery. The aim of this work was to evaluate the respective performances of ultrasonography and magnetic resonance imaging for the antenatal assessment of the severity of placenta accreta spectrum disorders included in the database. The secondary objective was to identify descriptors related to the severity of placenta accreta spectrum disorders. Material and methods All the cases included in the database for which antenatal imaging data were available were analyzed. The rates of occurrence of each ultrasound and magnetic resonance imaging descriptor were reported and compared between the Group “Accreta‐Increta” (FIGO grades 1 & 2) and the Group “Percreta” (FIGO grade 3). Results Antenatal imaging data were available for 347 women (347/442, 78.5%), of which 105 were included in the Group “Accreta – Increta” (105/347, 30.2%) and 213 (213/347, 61.4%) in the Group “Percreta”. Magnetic resonance imaging was performed in addition to ultrasound in 135 women (135/347, 38.9%). After adjustment for all ultrasound descriptors in multivariate analysis, only the presence of a bladder wall interruption was associated with a significant higher risk of percreta (Odds ratio 3.23, Confidence interval 1.33–7.79). No magnetic resonance imaging sign was significantly correlated with the degree of severity. Conclusions The performance of ultrasound and magnetic resonance imaging to discriminate mild from severe placenta accreta spectrum disorders is very poor. To date, the benefit of additional magnetic resonance imaging has not been demonstrated.
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Affiliation(s)
- Olivier Morel
- Women's Division, Nancy Regional University Hospital (CHRU), Université de Lorraine, and Diagnosis and International Adaptive Imaging (IAD), Inserm, Université de Lorraine, Nancy, France
| | | | - Thorsten Braun
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Department of Obstetrics, Berlin Institute of Health, Berlin, Germany
| | - Sally Collins
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK and the Fetal Medicine Unit, John Radcliffe Hospital, Oxford, UK
| | - Petra Pateisky
- Division of Obstetrics and Feto-Maternal Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Pavel Calda
- Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Wolfgang Henrich
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ammar Al Naimi
- Department of Obstetrics and Gynecology, Buergerhospital - Dr. Senckenberg Foundation, Frankfurt, Germany.,Department of Obstetrics and Gynecology, University Hospital of the Goethe University of Frankfurt, Frankfurt, Germany
| | - Lone Nikoline Norgaardt
- Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kinga M Chalubinski
- Division of Obstetrics and Feto-Maternal Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Loic Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France
| | - Boris Tutschek
- Praenatal-Zuerich and Medical Faculty Heinrich Heine University, Duesseldorf, Germany
| | - Alexander Schwickert
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Vedran Stefanovic
- Department of Obstetrics and Gynecology, Fetomaternal Medical Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Charline Bertholdt
- Women's Division, Nancy Regional University Hospital (CHRU), Université de Lorraine, and Diagnosis and International Adaptive Imaging (IAD), Inserm, Université de Lorraine, Nancy, France
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41
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Rekawek P, Liu L, Pan S, Overbey J, Wagner B. The clinical utility of magnetic resonance imaging as an adjunct to ultrasound in the diagnosis of placenta accreta spectrum disorders. J Matern Fetal Neonatal Med 2021; 35:6008-6012. [PMID: 33771092 DOI: 10.1080/14767058.2021.1903861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To determine if the use of magnetic resonance imaging (MRI) changes the diagnosis of placenta accreta spectrum (PAS) made on prenatal ultrasound (US) leading to an improvement in clinical outcomes. METHODS This was a retrospective chart review of all patients with evidence of PAS on US from 2012 to 2018 in one tertiary care medical center with subsequent use of MRI of the uterus to confirm diagnosis. The type of PAS classified by imaging was compared between US and MRI, with a final diagnosis made using histology. Outcomes that were analyzed included the following: 1) MRI correctly changed diagnosis, 2) MRI incorrectly downgraded diagnosis, 3) MRI incorrectly upgraded diagnosis, and 4) MRI did not change diagnosis. A T-test and Chi-squared test were performed to compare the clinical outcomes of patients with an upgraded diagnosis by MRI to those whose diagnosis was downgraded or stayed the same. RESULTS Forty-one patients received an MRI to validate the diagnosis of PAS after ultrasound and are included in the analysis. MRI changed the diagnosis in 36.6% (15/41) patients, correctly changing the diagnosis in 22% (9/41) and incorrectly upgrading the diagnosis in 14.6% (6/41). Patients whose diagnosis was upgraded by MRI (either correctly or incorrectly) were more likely to deliver earlier compared to those who were either downgraded or had no change in their diagnosis [33. 2 ± 3. 5 weeks vs 35. 2 ± 2. 9 weeks, p = 0.05]. Patients who were upgraded were more likely to have interventional radiology and/or urology involvement at the time of delivery [91.7% (11/12) vs 25. 9% (7/27), p = 0.001]. There were no complications from these procedures. CONCLUSION The use of MRI incorrectly changed the diagnosis as much as it correctly changed the diagnosis of PAS after US. MRI should not be used routinely as a clinical adjunct to ultrasound in the diagnosis of placenta accreta spectrum.
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Affiliation(s)
- Patricia Rekawek
- Department of Obstetrics, Gynecology and Reproductive Science, NYU Langone Hospital - Long Island, New York University Long Island School of Medicine, Mineola, NY, USA
| | - Lilly Liu
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stephanie Pan
- Department of Biostatistics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jessica Overbey
- Department of Biostatistics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brian Wagner
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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42
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Einerson BD, Weiniger CF. Placenta accreta spectrum disorder: updates on anesthetic and surgical management strategies. Int J Obstet Anesth 2021; 46:102975. [PMID: 33784573 DOI: 10.1016/j.ijoa.2021.102975] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 01/31/2021] [Accepted: 02/24/2021] [Indexed: 12/15/2022]
Abstract
Placenta accreta spectrum (PAS) is a leading contributor to major obstetric hemorrhage and severe maternal morbidity in the developed world. In the United States, PAS has become the most common cause of peripartum hysterectomy. Over the last 40 years, clinicians have also witnessed a dramatic increase in the incidence of PAS. In the 1950s, the incidence of PAS was reported to be 0.03 per 1000 pregnancies. Recent epidemiological studies estimate that the PAS incidence is between 0.79 and 3.11 in 1000 pregnancies. As a consequence, obstetric anesthesiologists are increasingly likely to be called upon to manage women with suspected PAS for delivery. Given the increasing incidence and the morbidity burden associated with PAS, anesthesiologists play a vital role in optimizing maternal outcomes for women with PAS. This review will provide up-to-date information on nomenclature, pathophysiology, risk factors, antenatal detection, systemic preparations (includes timing of delivery, location of surgery, pre-operative evaluation and patient positioning), surgical and anesthetic approach, intra-operative management, invasive radiology and postoperative plans.
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Affiliation(s)
- B D Einerson
- University of Utah Health Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Salt Lake City, Utah, USA.
| | - C F Weiniger
- Division of Anesthesia, Critical Care and Pain, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
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43
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El-Haieg DO, Madkour NM, Basha MAA, Ahmad RA, Sadek SM, Ibrahim SA, Sibai H, Mahdy ER, Abd Elhady RR, Mohamed EM, Khamis MEM, Azmy TM. An Ultrasound Scoring Model for the Prediction of Intrapartum Morbidly Adherent Placenta and Maternal Morbidity: A Cross-Sectional Study. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2021; 42:e1-e8. [PMID: 31261435 DOI: 10.1055/a-0891-0772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To design an ultrasound scoring model for the prediction of the intrapartum morbidly adherent placenta (MAP) and maternal morbidity. PATIENTS AND METHODS 114 females with singleton pregnancies ≥ 28 weeks of gestation referred for suspicion of MAP were included. All patients underwent examination by two-dimensional ultrasound with the color Doppler setting. Five signs were evaluated: the retroplacental echolucent space, placental lacunae, the hyperechoic uterine-bladder interface, retroplacental myometrium thickness, and subplacental, uterine serosa-bladder wall, intraplacental and bladder wall vascularity. We designed a score ranging from 0-8.5 points, including the five signs according to their odds ratios and evaluated its prediction for MAP and maternal morbidity. RESULTS Using multivariate logistic regression, all ultrasound signs were significant dependent predictors for both MAP and maternal morbidity (myometrium thickness < 1 mm followed by lacunae ≥ 4 and lost retroplacental echolucent space). The only independent predictors for MAP were myometrium thickness < 1 mm and lacunae ≥ 4, while myometrium thickness < 1 mm and lost retroplacental echolucent space were predictive for maternal morbidity. The score showed a perfect agreement with MAP and a good one for maternal morbidity. CONCLUSION Application of the score we designed can improve the ultrasound diagnosis of MAP and the maternal outcome.
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Affiliation(s)
- Dahlia O El-Haieg
- Obstetrics & Gynecology, Zagazig-University-Faculty of Human Medicine, Zagazig, Egypt
| | - Nadia M Madkour
- Obstetrics & Gynecology, Zagazig-University-Faculty of Human Medicine, Zagazig, Egypt
| | | | - Reda A Ahmad
- Obstetrics & Gynecology, Zagazig-University-Faculty of Human Medicine, Zagazig, Egypt
| | - Somayya M Sadek
- Obstetrics & Gynecology, Zagazig-University-Faculty of Human Medicine, Zagazig, Egypt
| | - Safaa A Ibrahim
- Obstetrics & Gynecology, Zagazig-University-Faculty of Human Medicine, Zagazig, Egypt
| | - Hoda Sibai
- Obstetrics & Gynecology, Zagazig-University-Faculty of Human Medicine, Zagazig, Egypt
| | - Entesar R Mahdy
- Obstetrics & Gynecology, Zagazig-University-Faculty of Human Medicine, Zagazig, Egypt
| | - Rasha R Abd Elhady
- Obstetrics & Gynecology, Zagazig-University-Faculty of Human Medicine, Zagazig, Egypt
| | | | - Mai E M Khamis
- Radiology, Zagazig-University-Faculty of Human Medicine, Zagazig, Egypt
| | - Taghreed M Azmy
- Radiology, Zagazig-University-Faculty of Human Medicine, Zagazig, Egypt
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44
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Dighe M. Intraplacental Fetal Vessels: An Additional Sign for Placenta Accreta Spectrum. Radiology 2020; 298:413-414. [PMID: 33236960 DOI: 10.1148/radiol.2020204118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Manjiri Dighe
- From the Department of Radiology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195
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45
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Barzilay E, Brandt B, Gilboa Y, Kassif E, Achiron R, Raviv-Zilka L, Katorza E. Comparative analysis of ultrasound and MRI in the diagnosis of placenta accreta spectrum. J Matern Fetal Neonatal Med 2020; 35:4056-4059. [PMID: 33179565 DOI: 10.1080/14767058.2020.1846699] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Placenta accreta spectrum constitutes one of the most complicated challenges in modern obstetrics. Given the conflicting data regarding the added value of MRI in the diagnosis of invasive placentation, we aim to assess individual and combined ability of multiple sonographic and MRI signs to diagnose placenta accreta spectrum in suspected cases. METHODS We assessed 28 cases of suspected placenta accreta spectrum in the third trimester. All cases underwent ultrasound assessment as well as MRI scan. Diagnosis was confirmed during surgery. The value of sonographic and MRI signs in the detection of placenta accreta spectrum was assessed. RESULTS A total of 23 cases were diagnosed with placenta accreta spectrum during cesarean delivery. Overall, ultrasound was found to be more sensitive and specific compared to MRI (sensitivity of 0.96 and specificity of 0.6 in ultrasound vs. sensitivity of 0.83 and specificity of 0.4 in MRI). However, the use of a post-hoc structured model improved MRI performance to a similar level of ultrasound (sensitivity of 0.96 and specificity of 0.6). CONCLUSIONS Ultrasound is superior to MRI in the detection of placenta accreta spectrum. However, MRI performance can be greatly improved by the use of a structured scoring system.
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Affiliation(s)
- Eran Barzilay
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Department of Obstetrics and Gynecology, Samson Assuta Ashdod Hospital, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Benny Brandt
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Yinon Gilboa
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Eran Kassif
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Reuven Achiron
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Lisa Raviv-Zilka
- Department of Diagnostic Radiology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Eldad Katorza
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
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46
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Morlando M, Collins S. Placenta Accreta Spectrum Disorders: Challenges, Risks, and Management Strategies. Int J Womens Health 2020; 12:1033-1045. [PMID: 33204176 PMCID: PMC7667500 DOI: 10.2147/ijwh.s224191] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 09/26/2020] [Indexed: 12/26/2022] Open
Abstract
The worldwide incidence of placenta accreta spectrum (PAS) is rapidly increasing, following the trend of rising cesarean delivery. PAS is an heterogeneous condition associated with a high maternal morbidity and mortality rate, presenting unique challenges in its diagnosis and management. So far, the rarity of this condition, together with the absence of high quality evidence and the lack of a standardized approach in reporting PAS cases for the ultrasound, clinical, and pathologic diagnosis, represented the main challenges for a deep understanding of this condition. The study of the available management strategies of PAS has been hampered by the heterogeneity of the available epidemiological data on this condition. The aim of this review is to provide a critical view of the current available evidence on the screening, the diagnosis, and the management options for PAS disorders, with a special focus on the challenges we foresee for the near future.
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Affiliation(s)
- Maddalena Morlando
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Sally Collins
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Fetal Medicine Unit, John Radcliffe Hospital, Oxford, UK
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47
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Abstract
Postpartum hemorrhage is a leading cause of severe maternal morbidity and mortality worldwide and the United States. While the rates of maternal mortality attributable to hemorrhage are declining, severe maternal morbidity continues to be a growing problem. Efforts in recent years to more appropriately identify patients at risk, define significant hemorrhage, quantify blood loss, and standardize approaches to care in pregnancy and postpartum have led to an increasing preventability of PPH. We aim to review the most current recommendation for the prevention and effective management of obstetric hemorrhage.
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Affiliation(s)
- Veronica Gonzalez-Brown
- Division Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Patrick Schneider
- Division Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH, USA.
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Ishibashi H, Miyamoto M, Shinmoto H, Soga S, Matsuura H, Kakimoto S, Iwahashi H, Sakamoto T, Hada T, Suzuki R, Takano M. The use of magnetic resonance imaging to predict placenta previa with placenta accreta spectrum. Acta Obstet Gynecol Scand 2020; 99:1657-1665. [PMID: 32542670 DOI: 10.1111/aogs.13937] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/28/2020] [Accepted: 06/01/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Massive hemorrhage due to placenta previa with placenta accreta spectrum is associated with high maternal mortality and morbidity. Therefore, accurate prediction of placenta previa with placenta accreta spectrum is essential; magnetic resonance imaging (MRI) is a useful tool for this purpose. This study investigated novel predictors of anterior and posterior placenta previa with placenta accreta spectrum using MRI. MATERIAL AND METHODS This was a retrospective study at a tertiary obstetrics hospital in Japan. The singleton patients with placenta previa who were scanned with MRI prenatally and had a cesarean section at our institution between 2007 and 2018 were included. The prediction of anterior and posterior placenta previa with placenta accreta spectrum was evaluated using four MRI findings: heterogeneous signals in the placenta, dark T2-weighted intraplacental bands, myometrial thinning or interruption, and focal uterine bulging. The prediction of posterior placenta previa with placenta accreta spectrum was performed using the quantification of cervical varicosities, which were defined as the ratio of the distance between the minimum distance from the most dorsal cervical varicosities (a) to the deciduous and amniotic placenta (b) on a sagittal image. RESULTS Among 202 patients, 14 (6.9%) patients were pathologically diagnosed as having placenta accreta spectrum. Further, 38 (18.8%) patients had anterior placenta previa and 164 (81.2%) patients had posterior placenta previa. When anterior placenta previa with placenta accreta spectrum was predicted using at least one of the four MRI findings, the sensitivity and specificity of the anterior placenta previa with placenta accreta spectrum were 87.5% and 86.7%, respectively. In contrast, the sensitivity and specificity of posterior placenta previa with placenta accreta spectrum were 42.9% and 96.2%, respectively. But when the A/B ratio was set at 0.20, the sensitivity and specificity of the prediction for posterior placenta previa with placenta accreta spectrum using cervical varicosities were 100.0% and 89.2%, respectively. CONCLUSIONS The findings of MRI to predict the anterior placenta previa with placenta accreta spectrum were different from posterior placenta previa. The cervical varicosities may be useful in predicting posterior placenta previa with placenta accreta spectrum.
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Affiliation(s)
- Hiroki Ishibashi
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Morikazu Miyamoto
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Hiroshi Shinmoto
- Department of Radiology, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Shigeyoshi Soga
- Department of Radiology, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Hiroko Matsuura
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Soichiro Kakimoto
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Hideki Iwahashi
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Takahiro Sakamoto
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Taira Hada
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Rie Suzuki
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Masashi Takano
- Department of Obstetrics and Gynecology, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
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Placenta Accreta Spectrum: Correlation of MRI Parameters With Pathologic and Surgical Outcomes of High-Risk Pregnancies. AJR Am J Roentgenol 2020; 214:1417-1423. [DOI: 10.2214/ajr.19.21705] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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50
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Berhan Y, Urgie T. A Literature Review of Placenta Accreta Spectrum Disorder: The Place of Expectant Management in Ethiopian Setup. Ethiop J Health Sci 2020; 30:277-292. [PMID: 32165818 PMCID: PMC7060376 DOI: 10.4314/ejhs.v30i2.16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 11/22/2019] [Indexed: 11/17/2022] Open
Abstract
In the last three to four decades, the increasing caesarean delivery rate has contributed to several fold increment in the incidence of placenta accreta spectrum disorders globally. Placenta accreta spectrum with its subtypes (accreta, increta and percreta) is one of the devastating obstetric complications. As a result, it is the commonest indication for peripartum hysterectomy and common cause of severe maternal morbidity. However, in recent years, there is a growing interest in and practice of expectant management either to minimize emergency hysterectomy related maternal complications or to preserve the fertility potential of a woman with an intact uterus. A large body of observational research findings has demonstrated the success rate of expectant management in many of well selected cases. Similarly, the experience on delayed hysterectomy was encouraging in order to have less hemorrhage. For the best success of placenta accreta spectrum management, multidisciplinary team approach, antenatal diagnosis and managing such cases in a hospital with center of excellence has been strongly recommended. This literature review provides a robust synthesis of up-to-date knowledge and practice on the challenges and successes of placenta accreta spectrum disorders management. The currently practiced management options in the high and middle income countries are also summarized under seven categories. Therefore, the purpose of this review was to shed light on the applicability of the PAS disorder management modalities in our setup.
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Affiliation(s)
- Yifru Berhan
- St. Paul's Hospital Millennium Medical College Ethiopia, Addis Ababa
| | - Tadesse Urgie
- St. Paul's Hospital Millennium Medical College Ethiopia, Addis Ababa
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