Ultrasound and magnetic resonance imaging in the diagnosis of clinically significant placenta accreta spectrum disorders

Assessment of serum levels and placental bed tissue expression of IGF-1, bFGF, and PLGF in patients with placenta previa complicated with placenta accreta spectrum disorders

OBJECTIVE

This study aims to detect the serum levels of IGF-1, bFGF, and PLGF and their expressions in placental bed tissues of patients with placenta previa complicated with PAS disorders.

METHODS

This case and control study included 40 multiparous pregnant women with complete placenta previa between 34 weeks and 38 weeks of gestation and they were divided into two groups: 25 patients with PAS (case group) and 15 patients without PAS (control group). The venous blood samples were collected 2 h before the cesarean section, and the placental bed tissues were taken intraoperatively at the placental implantation site and then were histologically examined to evaluate the gravity of the myometrial invasion of the placenta. According to FIGO PAS increasing grading, the 25 patients were also divided into three groups: PAS grade I group, PAS grade II group, and PAS grade III group. The concentrations of IGF-1, bFGF, and PLGF in serum were measured using ELISA, and the mean ratio of the relative mRNA expression of each biomarker in placental bed tissues was calculated using qRT-PCR. The staining intensity and the positive cells were quantitatively measured and expressed as means by using Image J software for IHC analysis.

RESULTS

IGF-1 had low serum levels and high placental bed expression in placenta previa patients with PAS disorders compared to those without PAS (all p < 0.0001). PLGF had high serum levels (p = 0.0200) and high placental bed expression (p < 0.0001) in placenta previa patients with PAS disorders compared to those without PAS. IGF-1 serum levels decreased up to PAS grade II (means were 24.3 ± 4.03, 21.98 ± 3.29, and 22.03 ± 7.31, respectively for PAS grade I, PAS grade II, PAS grade III groups, p = 0.0006). PLGF serum levels increased up to PAS grade II (means were 12.96 ± 2.74, 14.97 ± 2.56, and 14.89 ± 2.14, respectively for the three groups, p = 0.0392). However, IGF-1 and PLGF mRNA placental bed expression increased up to PAS grade III. The relative expression of mRNA means for the three groups was 3.194 ± 1.40, 3.509 ± 0.63, and 3.872 ± 0.70, respectively for IGF-1; and 2.784 ± 1.14, 2.810 ± 0.71, and 2.869 ± 0.48, respectively for PLGF (all p < 0.0001). Their IHC (immunohistochemical) staining also had increasing trends, but p > 0.05. bFGF was not significantly expressed in placenta previa with PAS disorders in most of the analysis sections (p > 0.05).

CONCLUSIONS

Low serum levels and high expression in placental bed tissues of IGF-1, or high serum levels and high expression in placental bed tissues of PLGF, may differentiate placenta previa patients with FIGO PAS grade I and PAS grade II from those without PAS disorders. However, they could not significantly predict the degree of placental invasiveness in FIGO PAS grades II and III.

Placenta accreta outcomes and risk factors in a referral hospital in north of Iran: A case control study

Background

Placenta accreta syndrome (PAS) may led to heavy blood loss and maternal death. Here we analyzed the main risk factors of PAS+ pregnancies and its complications in a referral hospital in the north of Iran.

Methods

In a case control study, all pregnant women with PAS referred to our department during 2016 till 2021 were enrolled and divided in two groups case (PAS+) and control (PAS-) based on preoperative imaging, intraoperative findings, and pathological reports. The sociodemographic features and neonatal-maternal outcomes also were recorded.

Results

The most frequent reason for cesarean (C/S) was repeated C/S (62.9%, 56/89). A significant difference showed up in the time lag between previous C/S and the present delivery (p < 0.001) which shows that when the time distance is longer, the risk of PAS rises (OR: 1.01 [95% CI: 1.003-1.017]). Also, a positive history of prior abortion and elective type of previous C/S were related to PAS+ pregnancies. Our other finding showed that PAS+ pregnancies will end in lower gestational age and have a longer duration of operation and hospitalization, heavy blood transfusion, and hysterectomy. Also, PAS+ pregnancies were not related to poor neonatal outcomes.

Conclusions

It seems that, in addition to repeated C/S as a strong risk factor, previous abortion is a forgotten key which leads to incomplete evacuation or damage the endometrial-myometrial layers.

Outcomes of cesarean delivery in placenta accreta: conservative delivery vs. cesarean hysterectomy

OBJECTIVES

To compare delivery outcomes of pregnancies diagnosed with placenta-accreta-syndrome (PAS) who underwent conservative treatment to patients who underwent cesarean hysterectomy.

METHODS

A retrospective study of all women diagnosed with PAS treated in one tertiary medical center between 03/2011 and 11/2020 was performed. Comparison was made between conservative management during cesarean delivery and cesarean hysterectomy. Conservative management included leaving uterus in situ with/without placenta and with/without myometrial resection.

RESULTS

A total of 249 pregnancies (0.25 % of all deliveries) were diagnosed with PAS, 208 underwent conservative cesarean delivery and 41 had cesarean hysterectomy, 31 of them were unplanned (75.6 %). The median number of previous cesarean deliveries was significantly higher in the cesarean hysterectomy group. There was no difference in the duration from the last cesarean delivery, the presence of placenta previa, pre-operative hemoglobin or platelets levels between the pregnancies with conservative management and the cesarean hysterectomy. Significantly more pregnancies with sonographic suspicion of placenta percreta and bladder invasion had cesarean hysterectomy. Cesarean hysterectomy was significantly associated with earlier delivery, with bleeding and required significantly more blood products. There was no statistically significant difference in the rate of relaparotomy following cesarean delivery or the rate of infections. Multivariable-regression-analysis revealed a significant odds ratio of 3.38 of blood loss of >3,000 mL following cesarean hysterectomy.

CONCLUSIONS

Conservative management in delivery of PAS pregnancies is associated with less bleeding complications during surgery compared to cesarean hysterectomy.

An update of diagnostic efficacy of ultrasound and magnetic resonance imaging in the diagnosis of clinically significant placenta accreta spectrum disorders

PURPOSE OF REVIEW

Systematic screening and diagnosis of placenta accreta spectrum disorder (PAS) either by ultrasound or magnetic resonance imaging (MRI) would allow referral of high-risk women to specialized multidisciplinary teams. We aimed to report recent findings regarding the diagnostic accuracy of ultrasound and magnetic resonance imaging in the diagnosis of PAS.

RECENT FINDINGS

Recent evidence from the literature shows that both ultrasound and MRI are good tests to identify PAS in high-risk populations. Ultrasound can also be used safely to guide management decisions, concentrating greater resources in patients with the higher risk of clinically significant PAS requiring complex peripartum management. Moreover, there are increasing data showing that routine contingent screening for PAS disorders based on the finding of a placenta implanted low in the uterine cavity and previous uterine surgery is effective in a public healthcare setting. A contingent screening strategy for PAS is feasible if placental location is routinely assessed during routine scans, and may even start from the first trimester of pregnancy.

SUMMARY

Ultrasound is an effective tool to screen pregnancies at high risk of PAS. In such pregnancies, ultrasound and MRI are effective imaging modalities for guiding management.