Placenta Accreta: A Review of Current Advances in Prenatal Diagnosis

Role of acoustic radiation force impulse elastography of placenta in the diagnosis of pre-eclampsia

BACKGROUND

Placental dysfunction is one of the main causes of preeclampsia and hypertensive disorders of pregnancy.

MATERIAL AND METHODS

This is a prospective comparative study done on 30 pregnant women with pre-eclampsia and another 30 pregnant women as controls. In all these subjects the elasticity of the placenta was measured.

RESULTS

The results obtained showed that there was a significant difference in SWV values between the two groups (p value = 0.001). The mean SWV value of normal pregnant women was 0.99 m/ second as opposed to 1.99 m/second in pre-eclamptic pregnant women.

CONCLUSION

Sonoelastography is a promising noninvasive tool in the detection of preeclampsia with high diagnostic accuracy. The SWV values measured at the central zones of the placenta with a cut-off value of 1.325 m/s identify the presence of pre-eclampsia with high sensitivity and specificity.

Urinary tract injuries during surgery for placenta accreta spectrum disorders

OBJECTIVE

The main purpose of this study was to report the incidence of lower urinary tract injuries (UTI) during cesarean section (CS) hysterectomy in cases of Placenta Accreta Spectrum (PAS) disorders. Study design Retrospective analysis including all women with a prenatal diagnosis of PAS between January 2010 and December 2020. A dedicated multidisciplinary team was involved to define a tailored management for each patient. All relevant demographic parameters, risk factors, degree of placental adhesion, type of surgery, complications and operative outcomes were reported.

RESULTS

One hundred and fifty-six singleton gestations with a prenatal diagnosis PAS were included in the analysis. 32.7% of cases were classified as PAS 1 (grade 1-3a FIGO classification), 20.5% as PAS 2 (grade 3b FIGO classification) and 46.8% as PAS 3 (grade 3c FIGO classification). A CS hysterectomy was performed in all cases. Surgical complication occurred in seventeen cases (0% in PAS 1, 12.5% in PAS 2 cases and in 17.8% in PAS 3). The incidence of UTI in our series was 7.6% in all women with PAS, including 8 cases of bladder and 12 of ureteral lesion, and 13.7 % in those with PAS 3 only.

CONCLUSION

Despite advances in prenatal diagnosis and management, surgical complications, mainly those involving the urinary system, still occur in a significant proportion of women undergoing surgery for PAS. The findings from this study highlight the need for a multidisciplinary management of women with PAS in centers with high expertise in prenatal diagnosis and surgical management of these conditions.

RU-Net: An improved U-Net placenta segmentation network based on ResNet

BACKGROUND

In recent years, with the increase of late puerperium, cesarean section and induced abortion, the incidence of placenta accreta has been on the rise. It has become one of the common clinical diseases in obstetrics and gynecology. In clinical practice, accurate segmentation of placental tissue is the basis for identifying placental accreta and assessing the degree of accreta. By analyzing the placenta and its surrounding tissues and organs, it is expected to realize automatic computer segmentation of placental adhesion, implantation, and penetration and help clinicians in prenatal planning and preparation.

METHODOLOGY

We propose an improved U-Net framework: RU-Net. The direct mapping structure of ResNet was added to the original contraction path and expansion path of U-Net. The feature information of the image was restored to a greater extent through the residual structure to improve the segmentation accuracy of the image.

RESULTS

Through testing on the collected placenta dataset, it is found that our proposed RU-Net network achieves 0.9547 and 1.32% on the Dice coefficient and RVD index, respectively. We also compared with the segmentation frameworks of other papers, and the comparison results show that our RU-Net network has better performance and can accurately segment the placenta.

CONCLUSION

Our proposed RU-Net network addresses issues such as network degradation of the original U-Net network. Good segmentation results have been achieved on the placenta dataset, which will be of great significance for pregnant women's prenatal planning and preparation in the future.

Comparison of T2-weighted and diffusion-weighted imaging for the diagnosis of placenta accreta spectrum abnormality

Background

Diffusion-weighted imaging (DWI) is feasible in prenatal imaging, and it exhibits better contrast between the placenta and the myometrium compared to T2-weighted (T2W) images.

Purpose

To compare magnetic resonance imaging (MRI) features of placenta accreta on T2W and DW imaging.

Material and Methods

In this retrospective study, 42 pregnant patients who underwent prenatal MRI were included. MRI was performed on a Siemens 1.5-T scanner. T2W and DWI sequences in the axial, sagittal, and/or coronal planes were compiled for review. Two radiologists independently interpreted T2W and DW images for placenta accreta. T2W and DWI scores were calculated based on the presence of features and graded as low, intermediate, and high risk. The association between imaging features and placental invasion on pathology was calculated using chi-square tests. Sensitivity, specificity, and positive and negative predictive values (NPV) were compared between T2W and DWI interpretations. Inter-reader agreement between the two radiologists for T2W and DWI scores was calculated using Cohen's kappa coefficient.

Results

Out of 42 pregnant patients, 10 were pathologically/surgically proven to have placenta accreta. There were no significant differences between T2W and DWI interpretations. Considering a cutoff >6 as positive, the T2W score had higher sensitivity (90% vs. 80%) and NPV (96.9% vs. 94.1%) than the DWI score. The specificity and positive predictive value were 100% for both scores. The inter-reader agreement of T2W score was higher (k = 0.943 vs. 0.882).

Conclusion

T2W and DWI are comparable in diagnosing placenta accreta spectrum. T2W sequences have higher sensitivity, NPV, and inter-reader agreement than DWI.

Utility of diffusion-weighted MR imaging in the diagnosis of placenta accreta spectrum abnormality

PURPOSE

The aim of this study was to evaluate the utility of added DWI sequences as an adjunct to traditional MR imaging in the evaluation of abnormal placentation in patients with suspicion for placenta accreta spectrum abnormality or morbidly adherent placenta (MAP).

MATERIALS AND METHODS

The study was approved by local ethics committee. The subjects included pregnant women with prenatal MRI performed between July 2013 to July 2015. All imaging was performed on a Philips 1.5T MR scanner using pelvic phased-array coil. Only T2-weighted and diffusion-weighted imaging (DWI) series were compiled for review. Two randomized imaging sets were created: set 1 included T2-weighted series only (T2W); set 2 included T2W with DWI series together (T2W + DWI). Three radiologists, blinded to history and pathology, reviewed the imaging, with 2 weeks of time between the two image sets. Sensitivity, specificity, and overall accuracy for MAP were calculated and compared between T2W only and T2W + DWI reads. Associations between imaging findings and invasion on pathology were tested using the Chi-squared test. Confidence scores, inter-reader agreement, and systematic differences were documented.

RESULTS

A total of 17 pregnant women were included in the study. 8 cases were pathologically diagnosed with MAP. There were no significant differences in the diagnostic accuracy between T2W and T2W + DWI in the diagnosis of MAP in terms of overall accuracy (62.7% for T2W vs. 68.6% for T2W + DWI, p = 0.68), sensitivity (70.8% for T2W vs. 95.8% for T2W + DWI, p = 0.12), and specificity (55.6% for T2W vs. 44.4% for T2W + DWI, p = 0.49). There was no significant difference in the diagnostic confidence between the review of T2W images alone and the T2W + DWI review (mean 7.3 ± 1.8 for T2W vs. 7.5 ± 1.8 for T2W + DWI, p = 0.37).

CONCLUSION

With the current imaging technique, addition of DWI sequence to the traditional T2W images cannot be shown to significantly increase the accuracy or reader confidence for diagnosis of placenta accreta spectrum abnormality. However, DWI does improve identification of abnormalities in the placental-myometrial interface.

Striking Multiple Primary Tumors that underwent Whipple Procedure due to Periampullary Carcinoma: An Analysis of 21 Cases

Introduction

The term multiple primary tumor (MPT) is used to describe cases where two or more primary tumors show no histopathological similarities in between. Multiple primary tumor cases have begun to increase in recent years as a result of the increase in life expectancy because of the increase in life standards and progress in diagnostic methods. In this study, MPT cases with periampullary tumors that underwent Whipple procedure were discussed in the light of literature data.

Materials and methods

The patient files of 223 cases with periampullary tumors that underwent Whipple procedure in our hospital during the last 6 years were examined retrospectively. More than one primary tumor was detected in 21 patients.

Results

Periampullary carcinomas were detected as a second primary tumor in 18 patients. First primary tumor was periampullary carcinoma in 3 patients that underwent Whipple procedure. After the Whipple procedure, 5 patients died due to early complications in the first 30 days and 6 patients died due to metastases and additional problems that developed during follow-up.

Discussion

The incidence of MPT has been reported as 0.7 to 14.5% in the literature. Most of them are multiple primary case presentations. In patient management, it is recommended that each tumor should be evaluated independently of its own characteristics, and treatment and follow-up should be planned accordingly.

Conclusion

The MPT cases are increasing. The possibility of MPT as well as metastasis should be kept in mind during the evaluation of tumor foci seen during diagnosis and follow-up of patients. The characteristics of each tumor, survival, and prognosis should be evaluated separately and the most appropriate treatment should be offered to the patient. It is recommended that synchronic primary tumors which are considered to be surgically resectable without metastasis should be removed in the same session.How to cite this article: Dilek ON, Ozsay O, Karaisli S, Gür EÖ, Er A, Haciyanli SG, Kar H, Dilek FH. Striking Multiple Primary Tumors that underwent Whipple Procedure due to Periampullary Carcinoma: An Analysis of 21 Cases. Euroasian J Hepato-Gastroenterol 2018;8(1):1-5.

The Incidence and Predictive Factors in the Development of Acute Hepatitis in Patients with Leukemia

Introduction

Liver involvement is common in hematological malignancies, but the incidence and pattern of liver injury vary among the different types. The aims of our study were to determine the incidence and clinical course of acute hepatitis and the important factors for its development in patients with leukemia after chemotherapy.

Materials and methods

All patients with the diagnosis of leukemia who were treated at the Department of Hematology between January 2008 and January 2013 were included in the study. A detailed medical history, clinical and laboratory findings, treatment modalities, complications, and clinical course were recorded retrospectively.

Results

A total of 124 patients (64 females) with the diagnosis of leukemia were included in the study. The mean age was 45.2 years (16-89 years) and mean follow-up time was 29.7 months (0.25-192 months). A total of 43 (34.6%) patients had acute hepatitis after chemotherapy. Pattern of liver injury was hepatocellular in 31 patients, cholestasis in 2, and mix in 10 patients. Age (p = 0.001), hepatitis B surface antigen (HBsAg, p = 0.007), acute leukemia (p < 0.001), positive blood culture (p = 0.004), the amount of transfused red blood cell (p = 0.001), and amount of transfused platelets (p = 0.002) were significantly different under univariate analysis between the acute hepatitis group and the nonacute hepatitis group. Under multivariate analysis, only acute lymphoblastic leukemia (ALL) was identified as independent predictive factor for development of acute hepatitis after starting chemotherapy.

Conclusion

Acute and self-limited hepatitis develops in the substantial proportion of patients with leukemia. The most important factor for development of acute hepatitis is the type of leukemia.

How to cite this article: Kaya M, Akdogan R, Uçmak F, Ayyildiz MO, Karakus A, Kaplan MA. The Incidence and Predictive Factors in the Development of Acute Hepatitis in Patients with Leukemia. Euroasian J Hepato-Gastroenterol 2018;8(1):31-37.

Cross-validation Studies of a Novel Low-cost Hepatitis B Virus Quantitative Polymerase Chain Reaction System

Aim

This research focused on the results of the cross-validation program related with the performance of a Cuban novel low-cost real-time quantitative polymerase chain reaction (qPCR) assay for hepatitis B virus (HBV) quantification developed by the Therapeutic Vaccine against Hepatitis B Department, Vaccines Division, Center for Genetic Engineering and Biotechnology (CIGB), Havana, Cuba.

Materials and methods

Dilution series with the plasmid standard at concentrations of 900,000 to 0.09 copies/reaction (c/r) were made for each PCR instrument. The mean cycles threshold (Ct) values and PCR efficiency were compared among the cyclers. Hepatitis B virus-positive serum samples were used for the calculation of reproducibility of the HBV assay. Biotecon Diagnostics (BCD) also ordered the oligo sequences from a second supplier and compared the PCR performance to those provided from the CIGB.

Results

All PCR cyclers were able to detect concentrations up to 0.09 c/r. However, below the concentration of 9 c/r, the variation of results increased within and between the cyclers. The PCR efficiency showed satisfying results. The overall coefficient of variation (CV) cycler values were 1.29 and 0.91% for M6 and M19 respectively. No significance was observed between the different primer suppliers.

Conclusion

The HBV assay was performed with a good concordance between the five real-time instruments from different suppliers. The HBV assay was also performed with a high reproducibility for samples with a high and a low viral load. The HBV assay is robust against different primer suppliers.

How to cite this article: Aguiar J, Silva JA, García G, Guillén G, Aguilar JC. Cross-validation Studies of a Novel Low-cost Hepatitis B Virus Quantitative Polymerase Chain Reaction System. Euroasian J Hepato-Gastroenterol 2018;8(1):38-41.

Endovascular Interventions for the Morbidly Adherent Placenta

Morbidly adherent placentas are a spectrum of abnormalities ranging from placental invasion of the myometrium to invasion past the myometrium and muscular layers into adjacent structures. This entity is becoming more prevalent recently with increased number of cesarean deliveries. Given the high risk of morbidity and mortality, this was traditionally treated with pre-term planned cesarean hysterectomy. However, recently, uterine preservation techniques have been implemented for those women wishing to preserve future fertility or their uterus. Early identification is crucial as studies have shown better outcomes for women treated at tertiary care facilities by a dedicated multidisciplinary team. Interventional radiologists are frequently included in the care of these patients as there are several different endovascular techniques which can be implemented to decrease morbidity in these patients both in conjunction with cesarean hysterectomy and in the setting of uterine preservation. This article will review the spectrum of morbidly adherent placentas, imaging, as well as the surgical and endovascular interventions implemented in the care of these complex patients.

Primary Gastric Lymphoma: Clinicopathological Profile

Introduction

Gastrointestinal tract (GIT) is the most common site of involvement of extranodal non-Hodgkin’s lymphoma (NHL). There is regional variation in anatomical distribution of extranodal NHL, stomach being the most common site followed by small intestine. Primary gastric lymphoma (PGL) predominantly involves the antrum and corpus of the stomach. It arises from mucosa-associated lymphoid tissue (MALT) and is of B-cell lineage and often associated with Helicobacter pylori infection. Primary gastric lymphoma often presents with nonspecific symptoms. The present study was undertaken to ascertain the clinicopathological characteristics of PGL at a tertiary care center in South India.

Materials and methods

It is a retrospective study from 2006 to 2016. Patient’s data were obtained from institutional medical records. The histopathology slides were reviewed. The relevant immunohistochemistry (IHC) markers done were leukocyte common antigen (LCA), CD3, CD20, CD79a, CD10, Bcl-2, Bcl-6, CD5, Cyclin D1, CD138, and Ki-67. Correlating with the immunoprofile, further subtyping was done.

Results

A total of 405 patients of NHL were seen during the study period, out of which 43 patients were PGL. There were 32 males and 11 females, with M:F of 2.9:1. The mean age at diagnosis was 58 years. Abdominal pain and new-onset dyspepsia were the commonly observed presenting symptoms. The common site of involvement was antrum (20). Diffuse large B-cell lymphoma (DLBCL) was the most common histological subtype. Helicobacter pylori infection was seen in 18 (41%) patients. Majority of the patients were in stages II and III.

Conclusion

In our study, the initial presentation of PGL was with nonspecific symptoms like abdominal pain and new-onset dyspepsia. High degree of suspicion of such symptoms and biopsy of all suspicious lesions is essential for early detection. Diffuse large B-cell lymphoma was the most common histological subtype seen in our study.

How to cite this article: Malipatel R, Patil M, Rout P, Correa M, Devarbhavi H. Primary Gastric Lymphoma: Clinicopathological Profile. Euroasian J Hepato-Gastroenterol 2018;8(1):6-10.

Nature of Host Immunity during Hepatitis B Virus Infection and designing Immune Therapy

Hepatitis B virus (HBV) infections represent one of the major public health problems in global context. More than 2 billion people in the world have been infected with this virus at some point of time in their life and millions are chronically infected, indicating that chronic HBV-infected subjects remain as a living source of HBV transmission. The public health impact of this is tremendous. Considerable numbers of chronic HBV-infected individuals would eventually develop progressive liver diseases and their complications like hepatic failure, liver cirrhosis (LC), and hepatocellular carcinoma (HCC). Epidemiological studies have suggested that about 0.6 to 1.2 million people die annually from HBV-related liver diseases. These figures about death due to HBV and sufferings from HBV-related diseases indicate a notion of medical emergencies about HBV. In addition to these, the impact of HBV on health care delivery system moves beyond these numbers of HBV-related patients and HB-related deaths. This is because significant insights have already been developed about epidemiology, virology, and pathogenesis of HBV. Also, an effective and widely used preventive vaccine is available against HBV. In addition to these, antiviral drugs against HBV have been developed from early 1980s and several such drugs are now available commercially in the open market around the worldwide. Unfortunately, the ongoing therapeutic regimens could not stand the test of time and new insights about HBV pathogenesis are required for the development of new, novel, and evidence-based therapies for chronic HBV infections.

How to cite this article: Akbar SMF, Al-Mahtab M, Khan SI. Nature of Host Immunity during Hepatitis B Virus Infection and designing Immune Therapy. Euroasian J Hepato-Gastroenterol 2018;8(1):42-46.

Diagnostic and Prognostic Role of Serum Interleukin-6 in Malignant Transformation of Liver Cirrhosis

Aim

Alpha-fetoprotein (AFP) is still the most commonly used and the single most recommended marker in the diagnosis of hepatocellular carcinoma (HCC). Interleukin (IL)-6 is a circular cytokine and its role on carcinogenesis in various hematological and solid tumors is clearly documented. A combination of serum IL-6 and AFP may provide beneficial information regarding early diagnosis of HCC. In this study, the effect of plasma IL-6 level in the diagnosis of HCC was investigated.

Materials and methods

A total of 130 patients with liver cirrhosis, together with 30 control cases were enrolled in the trial. A diagnosis of HCC was present in 75 patients (57.6%) in the liver cirrhosis group. Blood samples were obtained from the enrolled study and control cases. Alpha-fetoprotein was quantified by chemiluminescent method. Plasma IL-6 levels of samples obtained at -80°C were quantified by human IL-6 BMS213/2 BMS213/2TEN kit.

Results

The HCC patients were older than the patients in the cirrhosis group (p = 0.016). On comparison of the HCC patients with the control group, AFP (p < 0.001) and IL-6 (p < 0.001) were significantly higher among the HCC patients. Comparison of HCC patients with liver cirrhosis cases with no diagnosis of HCC revealed significantly high AFP (p < 0.001) and IL-6 levels (p < 0.001) in HCC group. Cutoff value for IL-6 was calculated as 5.73 (pg/mL). No difference was detected in AFP (p = 0.600) and IL-6 (0.344) in all three subgroups. A total of 17 patients died during a mean follow-up period of 32.9 months. No correlation was found between mean AFP values and IL-6 values and survival rates.

Conclusion

Plasma IL-6 level was found to be significant in the diagnosis of HCC. Alpha-fetoprotein and IL-6 provided no advantage in terms of early diagnosis of HCC and no correlation was observed between these markers and survival.

How to cite this article: Yakut M, Özkan H, Karakaya MF, Erdal H. Diagnostic and Prognostic Role of Serum Interleukin-6 in Malignant Transformation of Liver Cirrhosis. Euroasian J Hepato-Gastroenterol 2018;8(1):23-30.

Intake of Bifidobacterium longum and Fructo-oligosaccharides prevents Colorectal Carcinogenesis

INTRODUCTION

We aimed to investigate the effects of intake of yogurt containing Bifidobacterium longum (BB536-y) and fructo-oligosaccharides (FOS) in preventing colorectal carcinogenesis in healthy subjects, and the preventive effects of short-chain fatty acids (SCFA), whose production was enhanced by the intake of BB536-y and FOS, in human colon cancer cell lines.

MATERIALS AND METHODS

The subjects were 27 healthy persons who were divided into a group taking yogurt containing BB536 (BB536-y group; n = 14) and a group taking yogurt containing BB536 and FOS (BB536-y with FOS group; n = 13) once a day for 5 weeks. The feces were sampled before and after the intake to analyze the amount of SCFA in the feces and the profile of intestinal flora, such as putrefactive bacteria and Bacteroides fragilis enterotoxin (ETBF). Subsequently, human colon cancer cell lines (DLD-1 cells, WirDr cells) were cultured in the presence of SCFA (butyric acid, isobutyric acid, acetic acid) in order to evaluate the cell growth-inhibitory activity of SCFA (WST-8 assay) by calculating the IC50 value from the dose-response curve.

RESULTS

Intake of BB536-y increased the total amount of SCFA in the feces and significantly suppressed the detection rate of ETBF and growth of putrefactive bacteria. Intake of BB536-y with FOS was associated with a higher Bifidobacterium detection rate than that of BB536-y alone. The contents of butyric acid, isobutyric acid, and acetic acid, namely, of SCFA, were also decreased. Analysis of the results of culture of DLD-1 cells and WirDr cells in the presence of butyric acid, isobutyric acid, and acetic acid revealed that each of the substances showed significant cell growth-inhibitory activity, with the activity being the highest for butyric acid, followed by that for isobutyric acid and acetic acid.

CONCLUSION

These findings suggest that intake of both BB536-y and BB536-y with FOS prevents colorectal carcinogenesis.How to cite this article: Ohara T, Suzutani T. Intake of Bifidobacterium longum and Fructo-oligosaccharides prevents Colorectal Carcinogenesis. Euroasian J Hepato-Gastroenterol 2018;8(1):11-17.

Screening of Esophageal Varices by Noninvasive Means in Chronic Liver Disease

Introduction

Noninvasive assessment of esophageal varices (EV) decreases the medical and financial burden related to screening and helps in the management of patients with chronic liver diseases (CLDs). In this study, our aim was to assess the utility of the platelet count/spleen diameter index for the noninvasive evaluation of EV.

Materials and methods

In this cross-sectional observational study, a total of 100 CLD patients underwent screening endoscopy for EV in Medicine and Gastroenterology Department, Sylhet MAG Osmani Medical College Hospital, Sylhet, Bangladesh. Platelet count/spleen diameter ratio was assessed in all patients and its diagnostic implication was calculated.

Results

Upper gastrointestinal endoscopy revealed that 45 (45.0%) patients had medium EV followed by 27 (27.0%) that had small EV and 19 (19.0%) patients had large EV. Receiver operator characteristic (ROC) curve was constructed using platelet count/spleen index, which gave a cut-off value of >905. The validity of platelet count/spleen index evaluation of CLD was: Sensitivity 92.3%, specificity 66.7%, accuracy 90.0%, positive predictive value (PPV) and negative predictive value (NPV) were 96.6 and 46.2% respectively. True positive was 84 cases, false positive 3 cases, false negative 7 cases, and true negative 6 cases. If we consider cut-off value as 909 in the evaluation of EV in CLD, then true positive was 85 cases, false positive 3 cases, false negative 6 cases, and true negative 6 cases. From this, by calculation, sensitivity was 93.4%, specificity 66.7%, accuracy 91%, PPV 96.6%, and NPV 50%.

Conclusion

The platelet count/spleen index may be proposed to be a safe and reliable mean of screening of EV in CLD patients; however, case-control study would be required to validate this.

How to cite this article: Hossain E, Ahammed F, Saha SK, Foez SA, Rahim MA, Noor-e-Alam SM, Abdullah AS. Screening of Esophageal Varices by Noninvasive Means in Chronic Liver Disease. Euroasian J Hepato-Gastroenterol 2018;8(1):18-22.

Slic-Seg: A minimally interactive segmentation of the placenta from sparse and motion-corrupted fetal MRI in multiple views

Segmentation of the placenta from fetal MRI is challenging due to sparse acquisition, inter-slice motion, and the widely varying position and shape of the placenta between pregnant women. We propose a minimally interactive framework that combines multiple volumes acquired in different views to obtain accurate segmentation of the placenta. In the first phase, a minimally interactive slice-by-slice propagation method called Slic-Seg is used to obtain an initial segmentation from a single motion-corrupted sparse volume image. It combines high-level features, online Random Forests and Conditional Random Fields, and only needs user interactions in a single slice. In the second phase, to take advantage of the complementary resolution in multiple volumes acquired in different views, we further propose a probability-based 4D Graph Cuts method to refine the initial segmentations using inter-slice and inter-image consistency. We used our minimally interactive framework to examine the placentas of 16 mid-gestation patients from MRI acquired in axial and sagittal views respectively. The results show the proposed method has 1) a good performance even in cases where sparse scribbles provided by the user lead to poor results with the competitive propagation approaches; 2) a good interactivity with low intra- and inter-operator variability; 3) higher accuracy than state-of-the-art interactive segmentation methods; and 4) an improved accuracy due to the co-segmentation based refinement, which outperforms single volume or intensity-based Graph Cuts.

Abnormal placentation: the role of MRI in diagnosis and therapeutic planning

AIM

To evaluate the role of magnetic resonance imaging (MRI) for diagnosis and therapeutic planning in patients with abnormal placentation (AP).

MATERIALS AND METHODS

Overall, 168 consecutive patients with suspected placenta previa and AP were referred for MRI before caesarean section (CS). The ability of MRI to properly detect and assess abnormal placentation was correlated with findings at CS, which were considered the reference standard diagnostic tool. For each patient, MRI was used to determine whether the AP was suitable for complete/incomplete delivery, hysterectomy, or conservative treatment. Treatment planning with MRI was prospectively compared with the actual treatment that had been carried out in each patient decided at CS.

RESULTS

Placenta previa was detected at MRI in 63 patients and AP in 105 patients; 16 patients had false-positive MRI findings, and three had false-negative findings. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of MRI compared to findings at CS were 88.9% (149 of 168), 96.7% (89 of 92), 78.9% (60 of 76), 84.8% (89 of 105), and 95.2% (60 of 63), respectively. Treatment planning could be correctly made on the basis of MRI with accuracy, sensitivity, specificity, PPV, and NPV of 97%, 100%, 92.6%, 95.2%, and 100%, respectively.

CONCLUSIONS

MRI offers high diagnostic accuracy in the detection of AP, and it may be helpful in the detailed planning of treatment.

MRI of Placenta Accreta, Placenta Increta, and Placenta Percreta: Pearls and Pitfalls

OBJECTIVE

The purpose of this article is to provide a primer for radiologists performing MRI for suspected placenta accreta, illustrating normal and abnormal findings and diagnostic pitfalls. Appropriate examination indications and recommendations for optimizing image acquisition and interpretation are summarized.

CONCLUSION

MRI increases the accuracy of the workup of high-risk patients and aids in multidisciplinary delivery planning to improve maternal outcome. Reader accuracy and confidence require adherence to examination performance, image interpretation criteria, and awareness of common pitfalls.

Preservation of fertility and subsequent childbirth after methotrexate treatment of placenta percreta: a case report

Introduction

Placenta percreta is associated with maternal morbidity and mortality. A hysterectomy is often needed to control the bleeding in such cases. However, it has been advocated that placenta percreta be managed conservatively to avoid massive pelvic bleeding and to preserve the patient’s fertility. Here, we present a case of placenta percreta diagnosed by magnetic resonance imaging, and treated with systemic administration of methotrexate.

Case presentation

A 27-year-old nulliparous Japanese woman at 39 gestational weeks had an uncomplicated vaginal delivery of a 3244-g infant. However, her placenta was not delivered, and we could not remove it manually. Contrast-enhanced magnetic resonance imaging indicated deep myometrial invasion by placental tissue and the whole placenta was strongly enhanced. Seven days post-partum, her serum human chorionic gonadotropin level was 12,656IU/L. Our patient hoped to preserve her uterus for a future pregnancy. She therefore received 13 courses of methotrexate (50mg/week, intravenous injection). Her serum human chorionic gonadotropin level was undetectable 97 days after the first methotrexate injection. At 117 days post-partum, she had a labor-like pain every three minutes and delivered the placenta. Our patient regained normal menses and at follow-up remained in good health. Two years later, she delivered a healthy daughter.

Conclusion

We should try to detect placenta percreta in high-risk patients by any means. For low-risk patients, we should give a diagnosis swiftly and control any intrauterine infection and massive bleeding.

Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure

OBJECTIVES

To evaluate patient outcomes and need for further interventions in women with a morbidly adherent placenta (MAP), before and after introduction of the Triple-P procedure involving placental non-separation, myometrial excision and reconstruction of the uterine wall.

METHODS

Between December 2007 and February 2014, 30 patients with MAP were treated at our center. In 2007, we instituted a policy of bilateral prophylactic occlusion balloon catheter placement in both internal iliac arteries followed by Cesarean section with non-placental separation and preservation of the uterus. In 2010, the surgical technique was modified and the Triple-P procedure introduced. As a result, 19 women in our study received the Triple-P protocol (study group) and 11 did not (control group). The quantity of blood replacement products, estimated blood loss, and necessity for uterine arterial embolization and/or hysterectomy were recorded retrospectively and compared between the two groups.

RESULTS

Placenta percreta was confirmed in six (54.5%) patients in the control group and 13 (68.4%) in the study group. Estimated mean blood loss during the procedure was lower in the study group than in the control group (1.70 L vs 2.17 L, respectively), but the difference was not statistically significant (P = 0.445). The risks of postpartum hemorrhage (PPH) and hysterectomy were statistically significantly lower in the study group (PPH, 54.5% vs 15.8%; P = 0.035; hysterectomy, 27.3% vs 0.0%; P = 0.045). As a consequence, there was a significant decrease in duration of inpatient stay in the study group (P = 0.044).

CONCLUSION

Introduction of the Triple-P procedure conveyed a significantly reduced rate of hysterectomy, PPH and duration of hospital stay in patients with MAP. .

Sonography of placental abnormalities: a pictorial review

Often overlooked during routine ultrasound evaluation of a normal pregnancy, the placenta forms the biologic interface between the mother and fetus and is critical to fetal growth and development. Malformations in development, positioning, and vascularity can have profound implications for both maternal and fetal well-being. As such, a judicious inspection of the placenta is warranted as an integral part of every screening or emergent prenatal ultrasound. Herein, we present a pictorial review of a variety of placental pathologic conditions including abnormalities in positioning, adherence, vascularity, and hemorrhage as well as potential peri-placental masses and gestational trophoblastic disease, all of which are readily encountered in a busy emergency radiology practice.

The importance of a late first trimester placental sonogram in patients at risk of abnormal placentation

Background. Placenta accreta is a potentially life-threatening obstetrical condition and is responsible for many emergency Caesarean hysterectomies. Early prenatal diagnosis may help minimize maternal morbidity and mortality. This report highlights risk factors, early diagnostic findings and complications associated with placenta accreta, and the role of first trimester sonography in diagnosis. Case. A 38-year-old pregnant woman, G2P1L1 with history of one previous Caesarean section, presented with vaginal bleeding at 13 weeks' gestation. Ultrasound examination was highly suspicious of placenta previa with accreta. During an earlier 12-week scan for nuchal translucency measurement, the placenta was suboptimally visualized. She was counselled regarding potential maternal and fetal complications as well as management options. At 33 weeks' gestation Caesarean hysterectomy was performed due to vaginal bleeding. Conclusion. Early ultrasound screening in high-risk patients may be advantageous in order to identify placenta accreta and conduct appropriate patient counseling regarding risks and management options.

Adenomyosis in pregnancy mimicking morbidly adherent placenta

The objective of this study was to illustrate a false-positive diagnosis of adherent placenta due to underlying adenomyosis. A 34-year-old woman was diagnosed for placenta previa totalis with adherent placenta at 33 weeks, based on the findings of loss of clear space or distinguishing outline separating the placenta and uterine wall, presence of intraplacental lacunae and densely atypical vessels in the lesion. Caesarean hysterectomy was performed at 35 weeks. Pathological findings revealed placenta previa totalis with adenomyosis beneath the placenta at the lower segment, with no adherent placenta. In conclusion, this report underlines the importance of possible false-positive test of prenatal ultrasound and MRI findings of adherent placenta caused by underlying adenomyosis which could obliterate the outline distinguishing the placenta and myometrium and atypical vessels secondary to decidualisation and hypervascularity from pregnancy. This case may probably encourage physician to beware of false-positive test of adherent placenta due to adenomyosis.

Manual removal of the placenta after vaginal delivery: an unsolved problem in obstetrics

The third stage of labor is associated with considerable maternal morbidity and mortality. The major complication is postpartum hemorrhage (PPH), which is the leading cause of maternal morbidity and mortality worldwide. Whereas in the event of PPH due to atony of the uterus there exist numerous treatment guidelines; for the management of retained placenta the general consensus is more difficult to establish. Active management of the third stage of labour is generally accepted as standard of care as already its duration is contributing to the risk of PPH. Despite scant evidence it is commonly advised that if the placenta has not been expelled 30 minutes after delivery, manual removal of the placenta should be carried out under anaesthesia. Pathologic adhesion of the placenta in the low risk situation usually is diagnosed at the time of delivery; therefore a pre- or intrapartum screening opportunity for placenta accreta would be desirable. But diagnosis of abnormalities of placentation other than placenta previa remains a challenge. Nevertheless the use of ultrasound and doppler sonography might be helpful in the third stage of labor. An improvement might be the implementation of standardized operating procedures for retained placenta which could contribute to a reduction of maternal morbidity.

Maternal and fetal outcomes in placenta accreta after institution of team-managed care

INTRODUCTION

Placenta accreta significantly contributes to maternal morbidity and mortality. We evaluated whether planned delivery and experienced, team-managed surgical intervention results in improved outcomes. We also examined whether risk factors differed for accreta, increta, and percreta and evaluated whether excess lower segment uterine vascularity correlates with disease severity.

METHODS

We retrospectively analyzed patients before versus after institution of a management protocol. Of the 58 044 deliveries over 10 years, there were 67 women whose pregnancies were histopathologically confirmed as placenta accreta, increta, or percreta (1/866). Clinical outcome measures were estimated blood loss (EBL), packed red blood cells (pRBCs) transfused, maternal and fetal complications, intensive care unit admission, and length of stay.

RESULTS

There were no maternal or infant deaths. In the managed cohort, EBL was reduced by 48% (P < .001), intraoperative pRBCs transfused by 40% (P < .01), total transfused pRBCs per case by 50% (P < .01), and surgical intensive care unit admissions by >50% (P < .01). Assessment of maternal risk factors by diagnosis revealed marked differences between accreta versus increta and percreta. Clinically assessed excess vascularity of the lower uterine segment correlated with disease severity. The incidence of neonatal complications was similar in both cohorts.

CONCLUSIONS

Targeted delivery at 34 weeks and team-managed diagnosis, treatment, and care of patients with placenta accreta were associated with improved maternal, but not neonatal outcomes.

Prenatal sonography can predict degree of placental invasion

OBJECTIVE

To evaluate whether the maximum degree of placental invasion (placenta accreta, increta or percreta) can be predicted with ultrasound imaging, using criteria developed in our department.

METHODS

This was a retrospective study of all 232 patients at risk for placental invasion who were part of a routine screening program for placental invasion from January 2001 to January 2011. The whole placenta was scanned in a systematic manner using both gray-scale ultrasound and color-flow mapping. Sonographic findings were compared with the clinical outcome during and after delivery and the histomorphological examination of the placenta.

RESULTS

Placental invasion was suspected by ultrasound in 40 (17.2%) patients and was clinically/histopathologically confirmed in a total of 35 (15.1%) patients. The sensitivity, specificity and positive and negative predictive values of ultrasound for placental invasion were 91.4% (95% CI, 77.6-97.0%), 95.9% (95% CI, 92.2-97.9%), 80.0% (95% CI, 65.2-89.5%) and 98.4% (95% CI, 95.5-99.5%), respectively. No case of placenta increta (n = 7) or percreta (n = 17) was diagnosed as showing normal placentation or placenta accreta on ultrasound, giving an overall accuracy for the differentiation between normal placentation/placenta accreta and placenta increta/percreta of 100%.

CONCLUSION

Our data suggest that prediction of the degree of placental invasion is possible using prenatal ultrasound, with high overall accuracy.

Morbidly adherent placenta: evaluation of ultrasound diagnostic criteria and differentiation of placenta accreta from percreta

OBJECTIVES

To evaluate the diagnostic accuracy of two-dimensional (2D) gray-scale and color Doppler and three-dimensional (3D) power Doppler sonographic criteria for morbidly adherent placenta (MAP), and to identify criteria to help distinguish placenta accreta from placenta percreta.

METHODS

We enrolled 187 patients with placenta previa and history of uterine surgery and performed transabdominal and transvaginal ultrasound examination for early detection of MAP. With 2D gray-scale transabdominal and transvaginal ultrasonography, we investigated loss/irregularity of the echolucent area between the uterus and the placenta ('clear space'), thinning or interruption of the hyperechoic interface between the uterine serosa and the bladder wall and the presence of turbulent placental lacunae with high-velocity flow (>15 cm/s). Using transabdominal 3D power Doppler, we evaluated the hypervascularity of the uterine serosa-bladder wall interface and irregular intraplacental vascularization. Ultrasound findings were reviewed against the final diagnosis made during Cesarean section (CS).

RESULTS

MAP was detected on CS in 41 patients. All of them had an anterior placenta previa (34 major and seven minor) and had undergone at least one previous CS. The evaluated sonographic criteria showed good diagnostic performance; in MAP patients at least two out of five criteria were detected, with at most one of the criteria present in patients without MAP. Loss/irregularity of clear space used as a single criterion was responsible for the most false positives, demonstrating a low positive predictive value. Irregular intraplacental vascularization with tortuous confluent vessels affecting the entire width of the placenta, and hypervascularity of the entire uterine serosa-bladder wall interface, were only detected, on 3D power Doppler, in cases of placenta percreta.

CONCLUSIONS

The reviewed ultrasound criteria may be useful for the prenatal diagnosis of MAP and to differentiate between placenta accreta and placenta percreta; 3D power Doppler techniques were an important aid in the diagnosis.

Transcatheter arterial embolisation for the management of obstetric haemorrhage associated with placental abnormality in 40 cases

OBJECTIVE

To evaluate pelvic artery embolisation (PAE) in the emergency management of intractable postpartum haemorrhage (PPH) associated with placenta accreta (PA).

METHODS

Forty such patients (PAE for PPH/PA) were retrospectively reviewed. Medical records were reviewed regarding the delivery and PAE procedure. Follow-up gynaecological outcomes after PAE were obtained by telephone interviews.

RESULTS

Technical success was achieved in all women (100 %). The initial clinical success rate was 82.5 % (33/40). Three patients with PA underwent hysterectomy after PAE failed to stop the bleeding within 24 h after the embolisation. The other three patients underwent re-embolisation (two patients underwent re-embolisation on the next day and one patient had undergone re-embolisation 6 h after the first embolisation), and bleeding had stopped eventually. The clinical success rate was 92.5 %. There were four cases of immediate complications, such as, pelvic pain, nausea and urticaria. There were three late minor complications, temporary menopause, but no late major complications. After the procedure, 35 patients resumed normal menstruation, including two uncomplicated pregnancies. One patient expired owing to disseminated intravascular coagulopathy and intracerebral haemorrhage, despite successful embolisation.

CONCLUSION

PAE can be performed safely and effectively for patients with PPH and PA and can preserve the uterus in many patients.

Placenta Accreta and Percreta

The incidence of abnormally adherent placenta (accreta/percreta) has increased 10-fold in the past 50 years, predominantly due to the increased use of cesarean section delivery. The causes, clinical correlates, and pathology of these conditions are discussed in this article.

Roles of microRNA-34a in the pathogenesis of placenta accreta

AIM

MicroRNA-34a (miR-34a) is associated with invasion and metastasis of various cancers. The trophoblastic cells of placenta accreta invade into the myometrium in a similar way to the invasion of cancers. We studied the roles of miR-34a in the pathogenesis of placenta accreta.

METHODS

The human choriocarcinoma cell line JAR was used for in vitro experiments as a model of trophoblasts, and placental tissues from the operative specimen of patients with or without placenta accreta were used for experiments in vivo. Morpholino antisense oligomer against miR-34a (miR-34a Morpho/AS) was added to JAR, and the expression of miR-34a and plasminogen activator inhibitor-1 (PAI-1) was determined by real time PCR. The effects of antisense, interleukin (IL)-6 and IL-8 in the process of invasion were studied with an invasion assay. Expression of miR-34a in vivo was studied with the use of fluorescent in situ hybridization (FISH).

RESULTS

Expression of miR-34a was inhibited by 65% with the administration of antisense, and a slight increase in miR-34a expression was observed with the addition of IL-6 and IL-8. PAI-1 expression decreased with the addition of IL-6 and IL-8, and increased with the administration of antisense. There was an increase in invasive capacity through the inhibition of miR-34a expression. Strong FISH expression of miR-34a was observed in trophoblast cells of non-placenta accreta, and a clear decrease in miR-34a expression was observed in those of placenta accreta.

CONCLUSIONS

Expression of miR-34a was downregulated in placenta accreta. In vitro experiments also showed that the invasive potential of JAR increased by suppressing miR-34a, probably through the expression of PAI-1.

Epidemiology, etiology, diagnosis, and management of placenta accreta

Placenta accreta is a severe pregnancy complication and is currently the most common indication for peripartum hysterectomy. It is becoming an increasingly common complication mainly due to the increasing rate of cesarean delivery. Main risk factor for placenta accreta is a previous cesarean delivery particularly when accompanied with a coexisting placenta previa. Antenatal diagnosis seems to be a key factor in optimizing maternal outcome. Diagnosis can be achieved by ultrasound in the majority of cases. Women with placenta accreta are usually delivered by a cesarean section. In order to avoid an emergency cesarean and to minimize complications of prematurity it is acceptable to schedule cesarean at 34 to 35 weeks. A multidisciplinary team approach and delivery at a center with adequate resources, including those for massive transfusion are both essential to reduce neonatal and maternal morbidity and mortality. The optimal management after delivery of the neonate is vague since randomized controlled trials and large cohort studies are lacking. Cesarean hysterectomy is probably the preferable treatment. In carefully selected cases, when fertility is desired, conservative management may be considered with caution. The current review discusses the epidemiology, predisposing factors, pathogenesis, diagnostic methods, clinical implications and management options of this condition.

Placenta and Transvaginal Sonography

In recent years, transvaginal evaluation of the placenta has completely changed the way obstetricians need to perceive and assess a low-lying placenta. Additionally, the number of negative ultrasound examinations in morbid placental adherence has reduced. This article presents the evidence on the safety and accuracy of transvaginal placental evaluation and goes on to discuss the manner in which transvaginal findings should alter clinical protocols to optimize maternal and fetal outcomes. It also answers a very pertinent clinical question: How low is low?

How to cite this article

Khurana A. Placenta and Transvaginal Sonography. Donald School J Ultrasound Obstet Gynecol 2012;6(4):391-397.

Ultrasound of fetal cardiac anomalies

OBJECTIVE

Fetal cardiac anomalies are common, with half of them being lethal or requiring complex surgeries. Early detection of these anomalies enables early referral to tertiary care centers with adequate expertise. A routine antenatal ultrasound performed between 18 and 22 weeks enables detection of most of these malformations. Further comprehensive evaluation can be performed with a dedicated fetal echocardiography, particularly in high-risk pregnancies and in cases with extracardiac anomalies.

CONCLUSION

Doppler imaging is used in the evaluation of vascular and valvular lesions. Three-dimensional imaging enables reconstruction of multiple complex planes from a single transverse acquisition. Four-dimensional imaging enables cine looping of images in multiple planes, enabling estimation of cardiac motion and function. This review illustrates the various sonographic techniques for evaluation of fetal hearts and the imaging appearance of various fetal cardiac anomalies.

Assessing the role of magnetic resonance imaging in the management of gravid patients at risk for placenta accreta

RATIONALE AND OBJECTIVES

The role of magnetic resonance imaging (MRI) in the diagnosis of placenta accreta remains uncertain. The purpose of this study was to evaluate the incremental benefit of MRI after ultrasound (US) for a large cohort of gravid patients at risk for a placenta accreta.

MATERIALS AND METHODS

A retrospective review of outcomes in women with risk factors for a placenta accreta between November 1995 and February 2008 was performed. Inclusion criteria were high-risk women with abnormal placenta implantation on US or operative diagnosis of placenta accreta, with or without a prenatal MRI. Delivery mode, diagnosis, and transfusion requirements were compared.

RESULTS

Ranging in age from 19 to 43 years, with zero to five prior cesarean sections, 139 women met inclusion criteria. The MRI was performed in 28.7% (40/139). US, MRI, and operative diagnoses were highly correlated (P < .001). Women who underwent both US and MRI were more likely to deliver by cesarean hysterectomy (P < .001). When the cohort is stratified by outcome diagnosis (normal, previa, accreta), no difference in delivery mode is found; regardless of whether subjects were imaged by US alone or US and MRI. Transfusion requirements were highest in the US and MRI group (mean of 3.9 units vs. 0.9 units in the US only group, P < .001).

CONCLUSION

This study fails to demonstrate that the incremental use of MRI for placenta accreta changes delivery mode in stratified analysis. Patients who underwent both US and MRI were most likely to have a cesarean hysterectomy delivery, and required more blood products, suggesting that undergoing tests may be indicative of an abnormal and at risk patient population.

Cell-free fetal nucleic acids as prenatal biomarkers

INTRODUCTION

Cell-free fetal nucleic acids in maternal plasma or serum have become important tools in the pursuance of new methods for non-invasive prenatal diagnosis, such as the determination of fetal blood groups and fetal gender. During these pioneering explorations, elevations in the concentration of these new-found biological analytes were noted in several pregnancy-related disorders, including preterm labor, pre-eclampsia and malimplantation. As these elevations appeared to occur before onset of clinical symptoms, it was proposed that such analyses might assist in screening for at-risk pregnancies. A major problem with these early studies is that they relied on the quantitation of Y-chromosome-specific gene sequences, and as such could be applied only in those cases where the fetus was male. Recent developments that might permit gender-independent analysis include epigenetic markers, as well as the analysis of cell-free placentally derived mRNA species.

AREAS COVERED

This article focuses specifically on prognostic markers, which enable at-risk pregnancies to be identified, allowing the modification of pregnancy management and in turn improvement of pregnancy outcome. The authors also provide their opinion on the progress and future challenges that lie ahead.

EXPERT OPINION

Accurate quantification of fetal nucleic acids and the specificity of these elevations for particular disorders remain controversial issues. Regarding the multifactorial etiology of some pregnancy disorders, the use of fetal nucleic acids as prenatal markers is restricted to well-defined high-risk groups.

Prediction of placenta accreta by ultrasonography and color Doppler imaging

OBJECTIVE

To determine the accuracy of ultrasound and color flow Doppler to diagnose placenta accreta.

METHODS

Respectively, ultrasound images consistent with signs of placenta accreta (concomitant previa, numerous vascular lacunae, absent lower uterine segment between bladder-placenta, turbulent or complicated blood flow at the uteroplacental interface) were correlated with findings at the time of surgery and pathologic examination.

RESULTS

Over 64 months, 12 cases with suspected placenta accreta by ultrasound were studied. The median gestational age at first diagnosis was 25 weeks and 92% had a previa while all had at least one previous cesarean delivery. At surgery, 83% (10/12) had an adherent placenta requiring hysterectomy (eight accreta, one increta, and one percreta). There were two false positives (one complete previa, one low-lying placenta with vasa previa). Nine of 12 women (75%) required blood transfusions due to a mean hematocrit nadir of 22.7 ± 4.6%. The mean number of packed red blood cell units transfused was 4.9 ± 4.7 units (range 2-17 units).

CONCLUSION

Sonography coupled with color-flow Doppler appears helpful in allowing antenatal diagnosis of accreta.

Fertility and obstetric outcome after conservative management of placenta accreta

OBJECTIVE

To determine the fertility and obstetric outcomes after conservative management of placenta accreta.

METHODS

A retrospective observational cohort study of all identified cases of placenta accreta from 1993 to 2007 in 2 tertiary university hospitals in France. For patients treated conservatively, maternal and fetal morbidity, reproductive function, fertility, and subsequent pregnancies were recorded.

RESULTS

During the study period, 46 patients were treated by conservative management; 6 patients underwent a secondary hysterectomy. Of the remaining 40 patients, 35 were followed up for a median of 65 months (range 18-156 months). Patients resumed their menstrual cycles after a median of 130 days (range 48-176 days). Menses were irregular in 11 patients (31%), but none had amenorrhea. Twelve of the 14 patients desiring another pregnancy achieved a total of 15 pregnancies; 2 patients had recurrent placenta accreta. Five spontaneous abortions and 1 termination of pregnancy occurred during the first trimester. The median term at delivery was 37 weeks (range, 35-40 weeks). Four patients delivered prematurely.

CONCLUSION

Conservative management of placenta accreta can preserve fertility, although the risk of recurrent placenta accreta appears to be high.