Morbidly adherent placenta

Evaluation of maternal serum VEGF, TNF-alpha, IL-4, and IL-10 levels in differentiating placenta accreta spectrum from isolated placenta previa

OBJECTIVE

Our study aimed to differentiate patients with placenta accreta spectrum (PAS) from those with placenta previa (PP) using maternal serum levels of vascular endothelial growth factor (VEGF), tumor necrosis factor-alpha (TNF-alpha), interleukin-4 (IL-4), and IL-10.

METHODS

The case group consisted of 77 patients with placenta previa, and the control group consisted of 90 non-previa pregnant women. Of the pregnant women in the case group, 40 were diagnosed with PAS in addition to placenta previa and 37 had placenta previa with no invasion. The maternal serum VEGF, TNF-alpha, IL-4, and IL-10 levels were compared between the case and control groups. Then the success of these markers in differentiating between PP and PAS was evaluated.

RESULTS

We found the VEGF, TNF-alpha, and IL-4 levels to be higher and the IL-10 level to be lower in the case group compared to the control group (p < 0.001). We observed a statistically significantly lower IL-10 level in the patients with PAS than those with PP (p = 0.029). In the receiver operating characteristic analysis, the optimal cut-off of IL-10 in the detection of PAS was 0.42 ng/mL). In multivariate analysis, the risk of PAS was significant for IL-10 (odds ratio (OR) 0.45, 95 % confidence interval (CI) 0.25-0.79, p = 0.006) and previous cesarean section (OR 2.50, 95 % Cl 1.34-4.66, p = 0.004). The model's diagnostic sensitivity and specificity, including previous cesarean section, preoperative hemoglobin (Hb), TNF-alpha, and IL-10 were 75 % and 72.9 %, respectively.

CONCLUSION

The study showed that the IL-10 level was lower in patients with PAS than in those with PP. A statistical model combining risk factors including previous cesarean section, preoperative Hb, TNF-alpha, and IL-10 may improve clinical diagnosis of PAS in placenta previa cases. Cytokines may be used as additional biomarkers to the clinical risk factors in the diagnosis of PAS.

Comparison of serum levels of cell adhesion molecules (E-selectin, P-selectin, ICAM-1, VCAM-1, LRG-1) in placental invasion and adhesion anomalies with patients with vaginal delivery and former cesarean

OBJECTIVE

It is aimed to be a technique that can be used for diagnosis and to prevent maternal deaths in cases where the serum levels of cell adhesion molecules are different in patients with abnormal placentation compared to healthy pregnant women.

MATERIALS AND METHODS

Patients between March 2020 and September 2021 were included in the study. While 56 patients, out of 153 cases formed the placental adhesion and/or localization anomaly group, 55 cases without placental adhesion anomaly (placental invasion anomaly and/or previa pathology) constituted the cesarean section group and 42 cases constituted the vaginal birth control group. Demographic characteristics and histories of 153 patients were questioned. I-CAM-1, V-CAM-1, E-Selectin, P-Selectin, LRG-1 levels were studied. The parameters measured by the ELISA method were studied in the Thermo Fisher Scientific Multiscan Go (Finland) device at the Hatay Mustafa Kemal University Medical Faculty Medical Biochemistry USA ELISA Laboratory. Wholehouse and One Way Anova analysis methods were used to compare the results.

RESULTS

There were significant differences in E-Selectin, P-Selectin, ICAM-1 and LRG-1 values between the groups (p < 0.05). There was a significant difference between the vaginal birth (VB) and previa/percreata (PP) groups in terms of E-Selectin (p = 0.038). In terms of P-Selectin, there was a significant difference between the C/S and previa/percreata (PP) groups (p < 001). P-Selectin was higher in the previa/percreata (PP) group. There was a significant difference between the Vaginally birth (VB), C/S group (p = 0.041) and the vaginal birth (VB), previa/percreata (PP) group (p = 0.013) in terms of ICAM-1, but there was no significant difference between the C/S and previa/percreata (PP) groups. In terms of LRG-1, there was a significant difference between all 3 groups (p < 0.05).

DISCUSSION

A recent study investigated the potential modulatory effects of trans-resveratrol (RSV), arginase and endothelial dysfunction biomarkers in patients with PE. Another reflection of endothelial dysfunction in PE is increased endothelial activation biomarkers such as intercellular adhesion molecule-1 (ICAM-1), von Willebrand factor (vWF), and Caspase-3 (CASP-3). The study, regarding vWF expression, the preeclampsia (PE) group showed higher levels compared to endothelial cells incubated with healty pregnant (HP) plasma [Bueno-Pereira et al 2022 Antioxidants 2111]. From this and similar studies, the hypothesis that the role of cell adhesion molecules in endothelial damage may be the underlying cause of invasion and location anomalies emerges. This hypothesis is the starting point of our study.

CONCLUSIONS

In our study, all adhesion molecules except V-CAM-1 were found to be significantly higher in the previa/percreata (PP) group. E-Selectin and LRG-1 adhesion molecules were found to be significantly higher even in C/S patients compared to normal delivery. As a result; these adhesion molecules can be studied as a marker in previa/percreata (PP) patients.

Clinical Outcomes of a False-Positive Antenatal Diagnosis of Placenta Accreta Spectrum

OBJECTIVE

 Antenatal diagnosis of placenta accreta spectrum (PAS) is critical to reduce maternal morbidity. While clinical outcomes of women with PAS have been extensively described, little information is available regarding the women who undergo cesarean delivery with a presumptive PAS diagnosis that is not confirmed by histopathologic examination. We sought to examine resource utilization and clinical outcomes of this group of women with a false-positive diagnosis of PAS.

STUDY DESIGN

 This is a retrospective analysis of patients with prenatally diagnosed PAS cared for between 2015 and 2020 by our multidisciplinary PAS team. Maternal outcomes were examined. Univariate analysis was performed and a multivariate model was employed to compare outcomes between women with and without histopathologically confirmed PAS.

RESULTS

 A total of 162 patients delivered with the preoperative diagnosis of PAS. Of these, 146 (90%) underwent hysterectomy and had histopathologic confirmation of PAS. Thirteen women did not undergo the planned hysterectomy. Three women underwent hysterectomy but pathologic examination did not confirm PAS. In comparing women with and without pathologic confirmation of PAS, the false-positive PAS group delivered later in pregnancy (34 vs. 33 weeks of gestation, p = 0.015) and had more planned surgery (88 vs. 47%, p = 0.002). There was no difference in skin incision type or hysterotomy placement for delivery. No significant difference in either the estimated blood loss or blood components transfused was noted between groups.

CONCLUSION

 Careful intraoperative evaluation of women with preoperatively presumed PAS resulted in a 3/149 (2%) retrospectively unnecessary hysterectomy. Management of women with PAS in experienced centers benefits patients in terms of both resource utilization and avoidance of unnecessary maternal morbidity, understanding that our results are produced in a center of excellence for PAS. We also propose a management protocol to assist in the avoidance of unnecessary hysterectomy in women with the preoperative diagnosis of PAS.

KEY POINTS

· Evaluation and delivery planning of patients with suspected placenta accreta spectrum in experienced centers provides acceptable outcomes.. · Under specific circumstances, delivery of placenta may be attempted if placenta accreta is suspected.. · Patients with suspected placenta accreta rarely undergo unindicated hysterectomy..

External Validation of a Multivariable Prediction Model for Placenta Accreta Spectrum

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%.

Ferumoxytol-enhanced MR demonstration of changes to internal placental structure in placenta accreta spectrum: Preliminary findings

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.

Placenta accreta spectrum: the pattern and character of intraplacental blood flow by color and spectral Doppler

PURPOSE

To characterize intraplacental blood flow patterns in placenta accreta spectrum (PAS) with color and spectral Doppler imaging.

METHODS

Thirty-two patients at risk for PAS underwent ultrasound imaging with both color and spectral Doppler. The placenta was inspected for areas of vascularity by color Doppler, particularly within the lower uterine segment. Spectral Doppler waveforms were obtained from these vessels and categorized as either intraplacental or subplacental (myometrial), venous or arterial, fetal or maternal (based on heart rate). Arterial waveforms were measured for heart rate, peak systolic velocity, end diastolic velocity, and resistive index. Statistical comparisons were made between cases with and without PAS using Fisher exact tests (categorical variables) and Mann-Whitney U tests (numerical indices). Interobserver agreement was characterized with kappa coefficients.

RESULTS

At delivery, there were 19 cases with PAS and 13 without PAS. On ultrasound studies, clustered intraplacental vascularity was found in the lower uterine segment in 66% of cases (95% of PAS cases and 23% cases without PAS; p < 0.0001). Maternal arterial waveforms were found within the vascular cluster in 84% of PAS cases and 15% of cases without PAS (p < 0.0001). A traversing fetal artery was found within the vascular cluster in 56% of cases (84% PAS cases and 15% cases without PAS; p = 0.001). Venous waveforms were found in 84% of PAS cases and 15% of cases without PAS. Interobserver agreement was good to excellent.

CONCLUSION

Intraplacental blood flow pattern in PAS is characterized by an intraplacental vascular cluster containing low-resistance maternal arterial flow and transplacental fetal arteries.

The Society for Pediatric Pathology Task Force grading system for placenta accreta spectrum and its correlation with clinical outcomes

BACKGROUND

The terminology and diagnostic criteria presently used by pathologists to report placenta accreta spectrum is inconsistent and does not reflect current knowledge of the pathogenesis of this disease.

OBJECTIVE

In 2020, the perinatal subcommittee of the Society for Pediatric Pathology Placenta Accreta Task Force proposed a new pathologic grading system for placenta accreta spectrum. We sought to correlate the clinical outcomes with the classification into each group in the new placenta accreta spectrum grading system.

STUDY DESIGN

The pathology reports of patients with histopathologic confirmation of placenta accreta spectrum were reviewed in 2 academic referral centers by placental pathologists. Pathologic grading was assigned based on the new grading system according to which placenta accreta spectrum is categorized into 5 groups depending on the depth of invasion, from grade p1 with no invasion into the uterine wall to grade p3E with invasion beyond the uterine wall to the adjacent organs. Patient characteristics and clinical outcomes were compared among these groups. A univariate analysis was performed, and a multivariate linear or binomial regression was employed when needed.

RESULTS

A total of 683 patients with placenta accreta spectrum were identified. Of those, 407 were included for histology review. There were 92 patients (23%) categorized into the grade p1 group, 74 (18%) in the grade p2 group, 84 (20%) in the grade p3A group, 121 (30%) in the grade p3D group, and 36 (9%) in the grade p3E group. There was a significant association between the pathology grading and the number of red blood cells transfused (β=1.14; 95% confidence interval, 0.48-1.79) and the postoperative complications including the rate of readmission (risk ratio, 1.93; 95% confidence interval, 1.26-2.94) and bladder injury (risk ratio, 1.81; 95% confidence interval, 1.23-2.68) after adjustment for antenatal diagnosis and other variables. The pathology grading was not associated with the estimated blood loss (P=.072).

CONCLUSION

The new pathology grading system accurately reflects maternal outcomes and complications of placenta accreta spectrum. We encourage the utilization of this new pathologic grading system because it is designed to omit discrepancies in placenta accreta spectrum reporting and to standardize communication.

Characterization of cord blood CD3+ TCRVα7.2+ CD161high T and innate lymphoid cells in the pregnancies with gestational diabetes, morbidly adherent placenta, and pregnancy hypertension diseases

PROBLEM

Although pregnant women with gestational diabetes (GD), morbidly adherent placenta (MAP), and pregnancy hypertension (pHT) diseases lead to intrauterine growth restriction (IUGR), little is known about their effect on mucosal-associated invariant T (MAIT) and innate lymphoid cells (ILC) in the umbilical cord. This study aimed to quantify and characterize MAIT cells and ILCs in the cord blood of pregnant women with GD, MAP, and pHT diseases.

METHOD OF STUDY

Cord blood mononuclear cells (CBMCs) were isolated by Ficoll-Paque gradient. CD3⁺ TCRVα7.2⁺ CD161^high cells and ILC subsets were quantified by flow cytometry. CBMCs were stimulated with PMA/Ionomycin and Golgi Plug for 4 h and stained for IFN-γ, TNF-α, and granzyme B. The stained cells were analyzed on FACS ARIA III.

RESULTS

Compared with healthy pregnancies, in the cord blood of the pHT group, elevated number of lymphocytes was observed. Moreover, the absolute number of IFN-γ producing CD4⁺ or CD4^- subsets of CD3⁺ TCRVα7.2⁺ CD161^high cells as well as those producing granzyme B were significantly elevated in the pHT group compared to healthy controls suggesting increased MAIT cell activity in the pHT cord blood. Similarly, in the MAP group, the absolute number of total CD3⁺ TCRVα7.2⁺ CD161^high cells, but not individual CD4⁺ or negative subsets, were significantly increased compared with healthy controls' cord blood. Absolute numbers of total CD3⁺ TCRVα7.2⁺ CD161^high cells and their subsets were comparable in the cord blood of the GD group compared with healthy controls. Finally, the absolute number of total ILCs and ILC3 subset were significantly elevated in only pHT cord blood compared with healthy controls. Our data also reveal that IFN-γ⁺ or granzyme B⁺ cell numbers negatively correlated with fetal birth weight.

CONCLUSIONS

CD3⁺ TCRVα7.2⁺ CD161^high cells and ILCs show unique expansion and activity in the cord blood of pregnant women with distinct diseases causing IUGR and may play roles in fetal growth restriction.

Validation of a scoring system for prediction of obstetric complications in placenta accreta spectrum disorders

BACKGROUND

Placenta accreta spectrum (PAS) refers to a spectrum of conditions characterized by the abnormal adherence of the placenta to the implantation site and has been a challenge due to the risk of postpartum hemorrhage, peripartum hysterectomy and maternal mortality. Despite of sonographic findings, no consensus on the prenatal evaluation of PAS has been established yet. We are aiming to establish a scoring system to increase the accuracy of prediction of PAS severity, especially to differentiate placenta percreta and placenta increta.

METHODS

We conducted a retrospective study and collected 2,219 cases of placenta increta and placenta percreta obtained from 20 tertiary care centers in China. Demographic information, clinical characteristics, and sonographic findings were collected. Logistic regression analysis was used to determine the risk factors and sonographic features that were significantly associated with a clinical diagnosis of placenta percreta. The formula and subsequent scoring system were generated. This scoring system was then verified in 67 cases of placenta increta or placenta percreta in Peking University First Hospital from 2016 to 2017. Diagnosis of placental invasion was confirmed by surgical findings or histopathologic results. The scoring system was evaluated using a receiver operating characteristic (ROC) curve.

RESULTS

The scoring system combined maternal risk factors and ultrasound features and was then verified in 67 cases. According to ROC curve, the area under the curve (AUC) of our scoring system for prenatal diagnosis of placenta percreta is 0.96 (95%CI, 0.91-1.00, p < .001), for severe postpartum hemorrhage (≥1500 ml) is 0.76 (95%CI, 0.62-0.91, p = .005), for hysterectomy is 0.98 (95%CI, 0.93-1.000, p = .023).

CONCLUSIONS

Our scoring system combining maternal risk factors and ultrasound features can improve the predictive accuracy of placenta percreta and obstetric outcomes (severe hemorrhage and hysterectomy).

Classification and reporting guidelines for the pathology diagnosis of placenta accreta spectrum (PAS) disorders: recommendations from an expert panel

The terminology and diagnostic criteria presently used by pathologists to report invasive placentation is inconsistent and does not reflect current knowledge of the pathogenesis of the disease or the needs of the clinical care team. A consensus panel was convened to recommend terminology and reporting elements unified across the spectrum of PAS specimens (i.e., delivered placenta, total or partial hysterectomy with or without extrauterine tissues, curetting for retained products of conception). The proposed nomenclature under the umbrella diagnosis of placenta accreta spectrum (PAS) replaces the traditional categorical terminology (placenta accreta, increta, percreta) with a descriptive grading system that parallels the guidelines endorsed by the International Federation of Gynaecology and Obstetrics (FIGO). In addition, the nomenclature for hysterectomy specimens is separated from that for delivered placentas. The goal for each element in the system of nomenclature was to provide diagnostic criteria and guidelines for expected use in clinical practice.

Prospective First-Trimester Ultrasound Imaging of Low Implantation and Placenta Accreta Spectrum

OBJECTIVES

To prospectively evaluate low implantation of the gestational sac and other first-trimester ultrasound (US) parameters for prediction of placenta accreta spectrum (PAS).

METHODS

Women with a diagnosis of low implantation on clinically indicated first-trimester US underwent a transvaginal US examination at 10 to 13 weeks' gestation to assess the trophoblast location, anechoic areas, bridging vessels, and smallest myometrial thickness (SMT). The placental location was evaluated in the second trimester, and serial US examinations were performed in cases of low placentation. Placenta accreta spectrum was based on clinical findings and confirmed by histologic results.

RESULTS

Of 68 women, 40 (59%) had prior cesarean delivery (CD). Hysterectomy was performed in 8, all with prior CD. Of these, 7 (88%) had US suspicion of PAS. In 16 with prior CD and basalis overlying the internal os, 9 (56%) had second-trimester placenta previa, and 7 of 9 (78%) underwent hysterectomy with pathologic confirmation of PAS. Of 28 without prior CD, there were no cases of persistent low placentation in the third trimester regardless of the trophoblast location. Ultrasound parameters associated with PAS were a smaller distance from the inferior trophoblastic border to the external os, disruption of the bladder-serosal interface, bridging vessels, anechoic areas, and the SMT. In women with prior CD, use of the SMT in the sagittal plane yielded an area under the receiver operating characteristic curve of 0.96 (95% confidence interval, 0.91-1.00).

CONCLUSIONS

First-trimester low implantation increases the risk of persistent placenta previa and PAS in women with prior CD. All parameters were associated with PAS, the most predictive being the SMT.

Antenatal diagnosis of placenta accreta spectrum (PAS) disorders

Antenatal diagnosis of placenta accreta spectrum (PAS) disorders allows planned management by a multidisciplinary team in a tertiary center, and thus can reduce hemorrhagic morbidity, compared with intrapartum diagnosis. Previous Cesarean section and placenta previa are the two most common risk factors. Prenatal ultrasound is a promising diagnostic tool for PAS in the second or third trimester. Recent evidence shows sonographic markers of PAS can be present in the first trimester. Prenatal ultrasound may help predict the depth and topography of placental invasion which are the major determinants of maternal morbidity. The presence of increased vascularity in the inferior part of the lower uterine segment and the parametrial region is associated with a more severe disorder according to a newly proposed staging system. In this chapter, we will discuss how to improve the prediction of PAS, the depth, and topography of placental invasion.

A national update on rates of postpartum haemorrhage and related interventions

BACKGROUND

Postpartum haemorrhage (PPH) is still a leading cause of maternal morbidity in the US. We aimed to reassess national trends in severe and non-severe PPH using recent data.

MATERIAL AND METHODS

We performed a cross-sectional study using the 2001-2012 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Delivery-related hospitalisations with PPH were identified using the International Classification of Diseases (9th revision). Rates were calculated per 1,000 delivery hospitalisations. All statistical analyses accounted for the complex sampling design of the data source.

RESULTS

Rates of non-severe PPH did not change significantly from 2001-2002 to 2011-2012 (25.5 and 24.2 per 1,000; p=0.058). The rates of PPH requiring blood transfusions for caesarean deliveries more than doubled in this time period from 2.0 to 4.8 (p<0.001). The overall rate of PPH with a procedure other than blood transfusion has risen from 0.9 to 1.9. Specifically, rates of hysterectomy (0.5 to 0.7; p<0.001), embolisation (0.3 to 0.5; p<0.001), and uterine tamponade use (0.09 to 0.69; p<0.001) increased over the time period.

DISCUSSION

Population-based surveillance data show an increasing rate of only severe PPH in the US. Rates of medical/surgical intervention including hysterectomy, embolisation and uterine tamponade use are also rising.

ACR Appropriateness Criteria® Placenta Accreta Spectrum Disorder

Placenta accreta spectrum disorder (PASD) is the current terminology recommended by the International Federation of Obstetrics and Gynecology (FIGO) and should replace terms such as abnormally adherent/invasive placenta or morbidly adherent placenta. PASD refers to a variety of potential clinical complications, which may result from abnormal placental implantation. More specifically, placenta accreta refers to a defect in the decidua basalis where the chorionic villi adhere directly to the myometrium with trophoblastic invasion. Accurate antenatal diagnosis is needed to plan for an appropriate delivery strategy at an experienced center in order to reduce maternal and potential fetal morbidity and mortality. Obtaining radiologic and clinical data when PASD is first suspected can play a significant role in formulating an appropriate delivery strategy. Depending on the clinical risk factors and initial imaging findings, transabdominal ultrasound of the pregnant uterus with duplex Doppler and transvaginal ultrasound as needed are the most appropriate imaging procedures. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

A comprehensive severity score for the morbidly adherent placenta: combining ultrasound and magnetic resonance imaging

BACKGROUND

Ultrasound (US) is the first-line imaging modality to assess the morbidly adherent placenta, but sensitivity and specificity are lacking.

OBJECTIVE

This investigation aims to improve diagnostic accuracy with a comprehensive score using clinical history, US, and magnetic resonance imaging (MRI).

MATERIALS AND METHODS

We conducted a retrospective cohort study of pregnant women who received both transvaginal US and MRI with suspicion for morbidly adherent placenta between 2009 and 2016. US was scored with the following metrics: (i) previa, (ii) hypervascularity, (iii) loss of retroplacental clear space and (iv) lacunae. MRI was evaluated for (i) intraparenchymal vessels, (ii) abnormally dilated vessels, (iii) fibrin deposition, (iv) placental bulge and (v) bladder dome irregularity. Bayesian analysis was used to estimate the probability of morbidly adherent placenta for a given score. Diagnostic testing parameters were calculated.

RESULTS

Among the 41 women with concerning imaging, histologically identified disease was confirmed in 16. The probability of morbidly adherent placenta increased with the score. At the highest US score, the probability of disease was 63.7%. With the highest MRI score, the probability of adherent placentation was 90.5%. Combining the US and MRI findings had a sensitivity of 56% and a specificity of 92%.

CONCLUSION

A combined scoring system using MRI and US may accurately identify patients at risk for morbidity associated with morbidly adherent placenta.

Right external iliac artery thrombus following the use of resuscitative endovascular balloon occlusion of the aorta for placenta accreta

A 33-year-old female, 32 weeks and 1 day gestation, with known placenta accreta who presented to the emergency department with 2 h of severe abdominal pain, nausea and vomiting. She became hypotensive and underwent emergency cesarean section. Emergency general surgery was consulted for placement of a resuscitative endovascular balloon for aortic occlusion (REBOA). After successful delivery, the balloon was inflated in zone 3 and systolic blood pressure rose from 70 to 170 mmHg. The patient underwent hysterectomy for ongoing hemorrhage. The patient was taken to the surgical intensive care unit. The patient was noted to have pulses following removal of the sheath. Arterial brachial indices and arterial duplex was performed 48 h after sheath removal. The patient was found to have complete occlusion of the right external iliac artery. Vascular surgery was consulted and cut-down performed with thrombus removal via fogarty catheter. The patient was discharged 2 days later without further complication.

Ultrasound predictors of candidates for segmental resection in pregnants with placenta accreta

Objective: We aimed to assess the predictive values of individual sonographic findings of abnormal placentation to determine the candidates for segmental resectionStudy design: This was a retrospective review of 43 pregnancies with at least one prior cesarean delivery who received an ultrasound diagnosis of placenta previa or low-lying placenta with suspected abnormal placentation in the third trimester at our institution from 2015 through 2017. Sonographic images were reviewed by an investigator blinded to pregnancy outcome. Sonographic parameters were assessed including loss of retroplacental clear zone, irregularity and width of uterine-bladder interface, smallest myometrial thickness, presence of lacunar spaces, and bridging vessels. Diagnosis of placental invasion was based on histologic confirmation. Parameters were analyzed to predict candidates for conservative approach.Results: There were 27 cases with cesarean hysterectomy where as conservative approach was successful in 16 of the cases. Numbers of transfusions of packed red blood cells (2.6 vs. 1.7), fresh frozen plasma (2.3 vs. 0.9) and mean smallest retroplacental myometrial thickness (1.3 vs. 2.1 mm) were significantly different between the two groups (p < .05). Smallest retroplacental myometrial thickness was a significant predictor for the cases appropriate for successful conservative approach (Area Under Curve, AUC =0.911, p < .001), optimal cut off value was obtained at 1.6 mm with 94% sensitivity and 85% specificity.Conclusions: Our data showed that among some sonographic findings of abnormal placentation, smallest myometrial thickness was a significant predictor to determine candidates for conservative approach.

Infectious complications in morbidly adherent placenta treated with leaving placenta in situ: a cohort series and suggested approach. J Matern Fetal Neonatal Med 2018;32:3520-3525. [PMID: 29671364 DOI: 10.1080/14767058.2018.1465918]

Background: The aim of this study is to assess the clinical and microbiological features of infections in patients with morbidly adherent placenta (MAP) treated by leaving placenta in situ (LPIS). Materials and methods: Retrospective analysis of MAP cases who were treated by LPIS between 2 May 2010 and 15 March 2017. The inclusion criteria were gestational age at or above 24 weeks, prenatal diagnosis, elective operation, and complete data. Results: Nineteen MAP cases were treated by LPIS during the study period. The mean ± SD duration for total placental resorbtion was 145 ± 47 days. Three patients were readmitted to the hospital because of fever (3/19). A total of 65 culture samples were taken from the patients during their follow- up periods. In four cases (4/12) cervical cultures showed positive growth [Escherichia coli (2), Klebsiella pneumoniae (1), mixed culture with Enterococcus spp. and E. coli (1)]. Fifteen (15/26) urine samples were sterile, three were polymicrobial. In eight cases, urine culture revealed E. coli growth (one E. coli and Enterococcus spp.). Three out of 16 (3/16) surgical incision samples revealed growth of E. coli. No bacterial growth was detected in blood cultures. Susceptibility results of Gram-negatives indicate that the resistance rates of beta-lactam antibiotics are high (14/20, 70%). No secondary surgical intervention occurred during the study period due to infection. Conclusions: Majority of postpartum cervical discharge, fever, and increased CRP levels do not represent morbid infections and/or sepsis. With early detection, and implementation of antibiotherapy (combination of an aminoglycoside and clindamycin), they can be easily controlled and secondary surgical interventions can be prevented.

Maternal and neonatal outcomes of placenta increta and percreta from a multicenter study in China

OBJECTIVE

The objective of this study is to identify the maternal and neonatal outcomes in women with placenta increta or placenta percreta in China.

MATERIALS AND METHODS

We retrospectively analyzed 2219 cases from 20 tertiary care centers in China between January 2011 and December 2015. All cases were diagnosed of placenta increta or placenta percreta, based on either intraoperative findings or histopathological findings.

RESULTS

The incidence of placenta increta and placenta percreta progressively increased from 0.18% in 2011 to 0.78% in 2015. Compared with the placenta increta, placenta percreta was strongly related to serious adverse outcomes: postpartum hemorrhage (65.9% versus 38.6%, p = .003), blood transfusion (86.2% versus 46.5%, p < .001), hysterectomy (43.3% versus 11.2%, p < .001), preterm birth (65.7% versus 49.9%, p < .001), and the need for neonatal intensive care unit (NICU) admission (54.5% versus 36.7%, p < .001).

CONCLUSION

The incidence of placenta increta and placenta percreta is likely to increase in China. The depth of placenta implantation is associated with the severity of outcomes. Placenta percreta tends to have worse maternal and neonatal outcomes.

Use of Bladder Filling to Prevent Urinary System Complications in the Management of Placenta Percreta: a Randomized Prospective Study

Introduction

The aim of our study was to evaluate the effect of filling the bladder on peripartum genitourinary injuries (especially bladder complications) in women with placenta percreta and to compare patient characteristics.

Material and Methods

Our prospective cohort study consisted of pregnant women with placenta percreta who underwent planned cesarean hysterectomy at the Department of Obstetrics and Gynecology of Gaziantep University Hospital between January 2015 and July 2016. Bladders were filled with 300 ml saline solution to determine surgical borders better and enable dissection of the lower uterine segment without excessive bleeding or unintended injury.

Results

A total of 66 women were included in the study: 32 women whose bladders were filled during surgery (filled-bladder group) and 34 women whose bladders were not filled (not filled-bladder group). Comparisons of demographic and obstetrical data, surgical parameters, the need for transfusion, and bladder injury rates revealed no significant differences between the two groups. We did not observe any beneficial effect of filling the bladder on preventing urinary complications compared with the women whose bladders were not filled (p = 0.339).

Conclusions

Filling the bladder with saline solution and mobilization of the bladder from the lower uterine segment did not have a statistically significant beneficial effect on preventing complications of the genitourinary system. But although the beneficial effects were not significant, shorter operation times, shorter postoperative hospital stays, and fewer bladder injuries were noted in patients whose bladders were filled.

Placental Pathologic Associations With Morbidly Adherent Placenta: Potential Insights Into Pathogenesis

Background The pathology that underlies morbidly adherent placenta (MAP) is poorly understood. The objective of this study was to describe the placental pathology, especially implantation site pathology, associated with MAP. Methods This was a single institution, retrospective case-control study design examining placentas of patients who delivered between January 2008 and September 2013. MAP cases were defined by the need for clinical intervention at delivery beyond spontaneous placental delivery or simple manual extraction of the placenta. Controls consisted of patients with placentas sent for examination due to a history of maternal malignancy with no clinical suspicion of accreta. Placental pathologic findings of maternal vascular underperfusion (MVU), acute inflammation, chronic inflammation, fetal vascular obstruction, and hemorrhage were recorded and compared using bivariable and multivariable analyses. Results Three categories of pathologic changes were seen more commonly in MAP placentas (N = 101) than control placentas (N = 110): chronic basal inflammation, villous changes of MVU, and retromembranous and subchorionic/intervillous hemorrhage. In multivariable analyses adjusted for confounders, basal chronic villitis (aOR 5.6, 1.73-18.18), plasma cell deciduitis (aOR 2.63, 1.08-6.39), increased syncytial knots (aOR 3.92, 1.57-9.75), villous agglutination (aOR 24.85, 2.78-221.75), increased perivillous fibrin (aOR 5.08, 1.49-17.34), and the presence of subchorionic/intervillous thrombi (aOR 4.01, 1.63-9.86) remained associated with MAP. Conclusions MAP is highly associated with evidence of intraparenchymal placental hemorrhage, villous changes of MVU, and a lymphoplasmacytic infiltrate at the implantation site. The contribution of this basal chronic inflammatory infiltrate to MAP requires further investigation.

Can 3-dimensional power Doppler indices improve the prenatal diagnosis of a potentially morbidly adherent placenta in patients with placenta previa?

BACKGROUND

Traditionally, 2-dimensional ultrasound parameters have been used for the diagnosis of a suspected morbidly adherent placenta previa. More objective techniques have not been well studied yet.

OBJECTIVE

The objective of the study was to determine the ability of prenatal 3-dimensional power Doppler analysis of flow and vascular indices to predict the morbidly adherent placenta objectively.

STUDY DESIGN

A prospective cohort study was performed in women between 28 and 32 gestational weeks with known placenta previa. Patients underwent a two-dimensional gray-scale ultrasound that determined management decisions. 3-Dimensional power Doppler volumes were obtained during the same examination and vascular, flow, and vascular flow indices were calculated after manual tracing of the viewed placenta in the sweep; data were blinded to obstetricians. Morbidly adherent placenta was confirmed by histology. Severe morbidly adherent placenta was defined as increta/percreta on histology, blood loss >2000 mL, and >2 units of PRBC transfused. Sensitivities, specificities, predictive values, and likelihood ratios were calculated. Student t and χ² tests, logistic regression, receiver-operating characteristic curves, and intra- and interrater agreements using Kappa statistics were performed.

RESULTS

The following results were found: (1) 50 women were studied: 23 had morbidly adherent placenta, of which 12 (52.2%) were severe morbidly adherent placenta; (2) 2-dimensional parameters diagnosed morbidly adherent placenta with a sensitivity of 82.6% (95% confidence interval, 60.4-94.2), a specificity of 88.9% (95% confidence interval, 69.7-97.1), a positive predictive value of 86.3% (95% confidence interval, 64.0-96.4), a negative predictive value of 85.7% (95% confidence interval, 66.4-95.3), a positive likelihood ratio of 7.4 (95% confidence interval, 2.5-21.9), and a negative likelihood ratio of 0.2 (95% confidence interval, 0.08-0.48); (3) mean values of the vascular index (32.8 ± 7.4) and the vascular flow index (14.2 ± 3.8) were higher in morbidly adherent placenta (P < .001); (4) area under the receiver-operating characteristic curve for the vascular and vascular flow indices were 0.99 and 0.97, respectively; (5) the vascular index ≥21 predicted morbidly adherent placenta with a sensitivity and a specificity of 95% (95% confidence interval, 88.2-96.9) and 91%, respectively (95% confidence interval, 87.5-92.4), 92% positive predictive value (95% confidence interval, 85.5-94.3), 90% negative predictive value (95% confidence interval, 79.9-95.3), positive likelihood ratio of 10.55 (95% confidence interval, 7.06-12.75), and negative likelihood ratio of 0.05 (95% confidence interval, 0.03-0.13); and (6) for the severe morbidly adherent placenta, 2-dimensional ultrasound had a sensitivity of 33.3% (95% confidence interval, 11.3-64.6), a specificity of 81.8% (95% confidence interval, 47.8-96.8), a positive predictive value of 66.7% (95% confidence interval, 24.1-94.1), a negative predictive value of 52.9% (95% confidence interval, 28.5-76.1), a positive likelihood ratio of 1.83 (95% confidence interval, 0.41-8.11), and a negative likelihood ratio of 0.81 (95% confidence interval, 0.52-1.26). A vascular index ≥31 predicted the diagnosis of a severe morbidly adherent placenta with a 100% sensitivity (95% confidence interval, 72-100), a 90% specificity (95% confidence interval, 81.7-93.8), an 88% positive predictive value (95% confidence interval, 55.0-91.3), a 100% negative predictive value (95% confidence interval, 90.9-100), a positive likelihood ratio of 10.0 (95% confidence interval, 3.93-16.13), and a negative likelihood ratio of 0 (95% confidence interval, 0-0.34). Intrarater and interrater agreements were 94% (P < .001) and 93% (P < .001), respectively.

CONCLUSION

The vascular index accurately predicts the morbidly adherent placenta in patients with placenta previa. In addition, 3-dimensional power Doppler vascular and vascular flow indices were more predictive of severe cases of morbidly adherent placenta compared with 2-dimensional ultrasound. This objective technique may limit the variations in diagnosing morbidly adherent placenta because of the subjectivity of 2-dimensional ultrasound interpretations.

Aortic balloon occlusion for controlling intraoperative hemorrhage in patients with placenta previa increta/percreta

BACKGROUND/AIMS

To investigate whether abdominal aortic balloon occlusion (ABO) effectively reduces intraoperative hemorrhage in patents with placenta previa increta/increta.

METHODS

Forty-three women were diagnosed as placenta previa increta/percreta by ultrasound and MRI. These patients' assessments were taken by their chief physician, and they were under necessity of previous cesarean section as confirmed by the committee of experts during consultation. There was no significant difference in disease risk rating between them in whole process. Although our department provided a more appropriate method, 10 of 43 patients chose intraoperative aortic balloon occlusion (IABO). Other 33 patients who refused that suggestion were considered as control group. Fully informed consents were obtained from all patients in this study group. The intraoperative blood loss, blood transfusion, rate of hysterectomy and complications of mothers and fetus of IABO group and control group were analyzed.

RESULTS

The median intraoperative blood loss was 1000 ml in the IABO group compared with 2000 ml in the control group (p < 0.05). The median volume of transfused red blood cells was 1100 ml in the IABO group compared with 2000 ml in the control group (p < 0.05). 33.3% (11/33) patients in the control group had hemorrhagic shock, and one of them suffered from cardiac arrest intraoperatively because of severe bleeding. However, none of these serious events occurred in the IABO group (p < 0.05). The hysterectomy rate was 70% (7/10) in the IABO group and 63.3% (21/33) in the control group (p > 0.05). No IABO-related complications were observed in the mother and fetus.

CONCLUSION

IABO is an effective and safe method to control intraoperative blood loss and blood transfusion in patients with placenta previa increta/percreta.

Buttock Necrosis after Uterine Artery Embolization for Delayed Hysterectomy in Placenta Percreta

Background. Morbidly adherent placenta (MAP) is increasing in incidence and is commonly associated with maternal hemorrhage and cesarean hysterectomy. Uterine artery embolization (UAE) may be utilized in the conservative management of placenta percreta to potentially reduce blood loss. The incidence of complications from UAE in the conservative management of placenta percreta is poorly described. To our knowledge, we present the first reported case of buttock necrosis in this setting. Case. A 39-year-old gravida nine para two with placenta percreta who underwent conservative management with UAE complicated by right buttock necrosis. Conclusion. While UAE may potentially decrease blood loss, it is not without risk. More studies must be performed in order to quantify those risks and determine the clinical utility of UAE.

Prediction of morbidly adherent placenta using a scoring system

OBJECTIVE

To evaluate the accuracy of an ultrasound-based scoring system for diagnosing morbidly adherent placenta (MAP).

METHODS

This study included pregnant women referred to our ultrasound unit during 2013-2015 because of suspected MAP on a previous ultrasound examination or because they had at least one previous Cesarean delivery. All women were assessed using a scoring system based on the following: number and size of placental lacunae; obliteration of the demarcation between the uterus and placenta; placental location; color Doppler signals within placental lacunae; hypervascularity of the placenta-bladder and/or uteroplacental interface zone; and number of previous Cesarean deliveries. Each criterion was assigned 0, 1 or 2 points and the sum of points yielded the final score. Patients were classified into low, moderate or high probability for MAP based on the final score. The presence of MAP was determined by the surgeon at delivery and clinical descriptions were documented in the electronic patient file. Pathological diagnoses were available only in cases that underwent hysterectomy.

RESULTS

In total, 258 pregnant women were included in the study, of whom 23 (8.9%) were diagnosed with MAP. There was a statistically significant difference in the prevalence of MAP when women were grouped according to the scoring system, with 0.9%, 29.4% and 84.2% in the low, moderate and high probability groups, respectively (P < 0.0001). All sonographic criteria of the scoring system were significantly associated with MAP (P < 0.0001). Receiver-operating characteristics (ROC) curves for prediction of MAP using the number of placental lacunae and obliteration of the uteroplacental demarcation yielded an area under the ROC curve of 0.94 (95% CI, 0.86-1.00).

CONCLUSIONS

Our proposed scoring system is highly predictive of MAP in patients at risk. This allows an adequate multidisciplinary team approach for the planning and timing of delivery in such cases. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

A Marked Increase in Obstetric Hysterectomy for Placenta Accreta

Background:

Obstetric hysterectomy (OH) as a lifesaving measure to manage uncontrolled uterine hemorrhage appears to be increasing recently. The objective of this study was to determine the etiology and changing trends of OH and to identify those at particular risk of OH to enhance the early involvement of multidisciplinary intensive care.

Methods:

A retrospective study was carried out in patients who had OH in China-Japan Friendship Hospital from 2004 to 2014. Maternal characteristics, preoperative evaluation, operative reports, and prenatal outcomes were studied in detail.

Results:

There were 19 cases of OH among a total of 18,838 deliveries. Comparing the study periods between 2004–2010 and 2011–2014, OH increased from 0.8/1000 (10/12,890) to 1.5/1000 (9/5948). Indications for OH have changed significantly during this study period with uterine atony decreasing from 50.0% (5/10) to 11.1% (1/9) (P < 0.05), and placenta accreta as the indication for OH has increased significantly from 20.0% (2/10) to 77.8% (7/9) (P < 0.05). Ultrasonography and magnetic resonance imaging (MRI) have been used to make an exact antepartum diagnosis of placenta accreta. A multidisciplinary management led to improved outcomes for patients with placenta accreta.

Conclusion:

As the multiple cesarean delivery rates have risen, there has been a dramatic increase in OH for placenta accreta. An advance antenatal diagnosis of ultrasonography, and MRI, and a multidisciplinary teamwork can maximize patients’ safety and outcome.

Sonographic Findings of Morbidly Adherent Placenta in the First Trimester

OBJECTIVES

The purpose of this study was to evaluate the association between first-trimester sonographic findings and morbidly adherent placenta at delivery.

METHODS

We conducted a retrospective review of all first-trimester sonographic examinations from pregnancies that underwent third-trimester sonography for placenta previa or low-lying placenta between September 1997 and October 2011. Only women with a prior cesarean delivery were included. Transabdominal and transvaginal images from these first-trimester studies were reviewed for the following sonographic parameters: distance from the inferior border of the gestational sac to the external cervical os, location of the decidua basalis, presence of anechoic areas, uterine-bladder interface irregularity, and smallest anterior myometrial thickness. Morbidly adherent placentation was confirmed on histologic examination of hysterectomy specimens. Statistical methods included univariate and multivariate analyses.

RESULTS

Thirty-nine patients met inclusion criteria, of whom 14 (36%) had confirmed placental invasion. The number of prior cesarean deliveries was significantly associated with placental invasion (P < .0001). The only first-trimester sonographic finding associated with invasion was the smallest anterior myometrial thickness measured in the sagittal plane (P < .02). Multivariate analysis based on these two variables yielded an area under the receiver operating characteristic curve of 0.94 (95% confidence interval, 0.87-1.00) and significantly improved the prediction of placental invasion compared to using the number of prior cesarean deliveries alone.

CONCLUSIONS

In women with persistent placenta previa or low-lying placenta and prior cesarean delivery, the smallest anterior myometrial thickness on first-trimester sonography significantly improved detection of morbidly adherent placenta.

Placental transcriptome in development and pathology: expression, function, and methods of analysis

The placenta is the essential organ of mammalian pregnancy and errors in its development and function are associated with a wide range of human pathologies of pregnancy. Genome sequencing has led to methods for investigation of the transcriptome (all expressed RNA species) using microarrays and next-generation sequencing, and implementation of these techniques has identified many novel species of RNA including: micro-RNA, long noncoding RNA, and circular RNA. These species can physically interact with both each other and regulatory proteins to modify gene expression and messenger RNA to protein translation. Transcriptome analysis is actively used to investigate placental development and dysfunction in pathologies ranging from preeclampsia and fetal growth restriction to preterm labor. Genome-wide gene expression analysis is also being applied to identify prognostic and diagnostic biomarkers of these disorders. In this comprehensive review we summarize transcriptome biology, methods of isolation and analysis, application to placental development and pathology, and use in diagnostic analysis in maternal blood. Key information for analysis methods is organized into quick reference tables where current analysis techniques and tools are cited and compared. We have created this review as a practical guide and starting reference for those interested in beginning an investigation into the transcriptome of the placenta.

Accuracy of three-dimensional multislice view Doppler in diagnosis of morbid adherent placenta

OBJECTIVE

To detect the accuracy of the three-dimensional multislice view (3D MSV) Doppler in the diagnosis of morbid adherent placenta (MAP).

MATERIAL AND METHODS

Fifty pregnant women at ≥28 weeks gestation with suspected MAP were included in this prospective study. Two dimensional (2D) trans-abdominal gray-scale ultrasound scan was performed for the subjects to confirm the gestational age, placental location, and findings suggestive of MAP, followed by the 3D power Doppler and then the 3D MSV Doppler to confirm the diagnosis of MAP. Intraoperative findings and histopathology results of removed uteri in cases managed by emergency hysterectomy were compared with preoperative sonographic findings to detect the accuracy of the 3D MSV Doppler in the diagnosis of MAP.

RESULTS

The 3D MSV Doppler increased the accuracy and predictive values of the diagnostic criteria of MAP compared with the 3D power Doppler. The sensitivity and negative predictive value (NPV) (79.6% and 82.2%, respectively) of crowded vessels over the peripheral sub-placental zone to detect difficult placental separation and considerable intraoperative blood loss in cases of MAP using the 3D power Doppler was increased to 82.6% and 84%, respectively, using the 3D MSV Doppler. In addition, the sensitivity, specificity, and positive predictive value (PPV) (90.9%, 68.8%, and 47%, respectively) of the disruption of the uterine serosa-bladder interface for the detection of emergency hysterectomy in cases of MAP using the 3D power Doppler was increased to 100%, 71.8%, and 50%, respectively, using the 3D MSV Doppler.

CONCLUSION

The 3D MSV Doppler is a useful adjunctive tool to the 3D power Doppler or color Doppler to refine the diagnosis of MAP.

The invasive phenotype of placenta accreta extravillous trophoblasts associates with loss of E-cadherin

INTRODUCTION

Epithelial-to-mesenchymal transition (EMT) is a process of molecular and phenotypic epithelial cell alteration promoting invasiveness. Loss of E-cadherin (E-CAD), a transmembrane protein involved in cell adhesion, is a marker of EMT. Proteolysis into N- and C-terminus fragments by ADAM10 and presenilin-1 (PSEN-1) generates soluble (sE-CAD) and transcriptionally active forms. We studied the protein expression patterns of E-CAD in the serum and placenta of women with histologically-confirmed over-invasive placentation.

METHODS

The patterns of expression and levels of sE-CAD were analyzed by Western blot, immunoassay, and immunoprecipitation. Tissue immunostaining for E-CAD, cytokeratin-7 (epithelial marker), vimentin (mesenchymal marker), ADAM10, PSEN-1 and β-catenin expression were investigated in parallel.

RESULTS

N-terminus cleaved 80 kDa sE-CAD fragments were present in serum of pregnant women with gestational age regulation of the circulatory levels. Women with advanced trophoblast invasion did not display circulatory levels of sE-CAD different from those of women with normal placentation. Histologically, extravillous trophoblasts (EVT) closer to the placental-myometrial interface demonstrated less E-CAD staining than those found deeper in the myometrium. These cells expressed both vimentin and cytokeratin, an additional feature of EMT. EVT of placentas with advanced invasion displayed intracellular E-CAD C-terminus immunoreactivity predominating over that of the extracellular N-terminus, a pattern consistent with preferential PSEN-1 processing.

DISCUSSION

Local processing of E-CAD may be an important molecular mechanism controlling the invasive phenotype of accreta EVT.

Ultrasound predictors of placental invasion: the Placenta Accreta Index

OBJECTIVE

We sought to apply a standardized evaluation of ultrasound parameters for the prediction of placental invasion in a high-risk population.

STUDY DESIGN

This was a retrospective review of gravidas with ≥1 prior cesarean delivery who received an ultrasound diagnosis of placenta previa or low-lying placenta in the third trimester at our institution from 1997 through 2011. Sonographic images were reviewed by an investigator blinded to pregnancy outcome and sonography reports. Parameters assessed included loss of retroplacental clear zone, irregularity and width of uterine-bladder interface, smallest myometrial thickness, presence of lacunar spaces, and bridging vessels. Diagnosis of placental invasion was based on histologic confirmation. Statistical analyses were performed using linear logistic regression and multiparametric analyses to generate a predictive equation evaluated using a receiver operating characteristic curve.

RESULTS

Of 184 gravidas who met inclusion criteria, 54 (29%) had invasion confirmed on hysterectomy specimen. All sonographic parameters were associated with placental invasion (P < .001). Constructing a receiver operating characteristic curve, the combination of smallest sagittal myometrial thickness, lacunae, and bridging vessels, in addition to number of cesarean deliveries and placental location, yielded an area under the curve of 0.87 (95% confidence interval, 0.80-0.95). Using logistic regression, a predictive equation was generated, termed the "Placenta Accreta Index." Each parameter was weighted to create a 9-point scale in which a score of 0-9 provided a probability of invasion that ranged from 2-96%, respectively.

CONCLUSION

Assignment of the Placenta Accreta Index may be helpful in predicting individual patient risk for morbidly adherent placenta.

Obstetric anesthesia: not just for cesareans and labor

The scope of obstetric anesthesia practice ranges far beyond the delivery of care to women for vaginal and cesarean deliveries. Increasingly, obstetric anesthesiologists are involved in the management of anesthetics for new procedures and for new indications. Anesthesia is frequently needed for maternal procedures, as well as fetal procedures, and at varying times in the intrapartum period. Maternal-specific procedures include cerclage, external cephalic version (ECV), postpartum bilateral tubal ligation (BTL), and dilation and evacuation (D and E). Fetus-specific procedures include fetoscopic laser photocoagulation and ex-utero intrapartum treatment (EXIT). This review will not include discussion of the anesthetic management of non-obstetric surgery during pregnancy, such as appendectomy or cholecystectomy.