Third-trimester ultrasound for antenatal diagnosis of placenta accreta spectrum in women with placenta previa: results from the ADoPAD study

OBJECTIVE

To evaluate the performance of third-trimester ultrasound for the diagnosis of clinically significant placenta accreta spectrum disorder (PAS) in women with low-lying placenta or placenta previa.

METHODS

This was a prospective multicenter study of pregnant women aged ≥ 18 years who were diagnosed with low-lying placenta (< 20 mm from the internal cervical os) or placenta previa (covering the internal cervical os) on ultrasound at ≥ 26 + 0 weeks' gestation, between October 2014 and January 2019. Ultrasound suspicion of PAS was raised in the presence of at least one of these signs on grayscale ultrasound: (1) obliteration of the hypoechogenic space between the uterus and the placenta; (2) interruption of the hyperechogenic interface between the uterine serosa and the bladder wall; (3) abnormal placental lacunae. Histopathological examinations were performed according to a predefined protocol, with pathologists blinded to the ultrasound findings. To assess the ability of ultrasound to detect clinically significant PAS, a composite outcome comprising the need for active management at delivery and histopathological confirmation of PAS was considered the reference standard. PAS was considered to be clinically significant if, in addition to histological confirmation, at least one of these procedures was carried out after delivery: use of hemostatic intrauterine balloon, compressive uterine suture, peripartum hysterectomy, uterine/hypogastric artery ligation or uterine artery embolization. The diagnostic performance of each ultrasound sign for clinically significant PAS was evaluated in all women and in the subgroup who had at least one previous Cesarean section and anterior placenta. Post-test probability was assessed using Fagan nomograms.

RESULTS

A total of 568 women underwent transabdominal and transvaginal ultrasound examinations during the study period. Of these, 95 delivered in local hospitals, and placental pathology according to the study protocol was therefore not available. Among the 473 women for whom placental pathology was available, clinically significant PAS was diagnosed in 99 (21%), comprising 36 cases of placenta accreta, 19 of placenta increta and 44 of placenta percreta. The median gestational age at the time of ultrasound assessment was 31.4 (interquartile range, 28.6-34.4) weeks. A normal hypoechogenic space between the uterus and the placenta reduced the post-test probability of clinically significant PAS from 21% to 5% in women with low-lying placenta or placenta previa in the third trimester of pregnancy and from 62% to 9% in the subgroup with previous Cesarean section and anterior placenta. The absence of placental lacunae reduced the post-test probability of clinically significant PAS from 21% to 9% in women with low-lying placenta or placenta previa in the third trimester of pregnancy and from 62% to 36% in the subgroup with previous Cesarean section and anterior placenta. When abnormal placental lacunae were seen on ultrasound, the post-test probability of clinically significant PAS increased from 21% to 59% in the whole cohort and from 62% to 78% in the subgroup with previous Cesarean section and anterior placenta. An interrupted hyperechogenic interface between the uterine serosa and bladder wall increased the post-test probability for clinically significant PAS from 21% to 85% in women with low-lying placenta or placenta previa and from 62% to 88% in the subgroup with previous Cesarean section and anterior placenta. When all three sonographic markers were present, the post-test probability for clinically significant PAS increased from 21% to 89% in the whole cohort and from 62% to 92% in the subgroup with previous Cesarean section and anterior placenta.

CONCLUSIONS

Grayscale ultrasound has good diagnostic performance to identify pregnancies at low risk of PAS in a high-risk population of women with low-lying placenta or placenta previa. Ultrasound may be safely used to guide management decisions and concentrate resources on patients with higher risk of clinically significant PAS. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Material and energy recovery from Automotive Shredded Residues (ASR) via sequential gasification and combustion

Shredding is the common end-of-life treatment in Europe for dismantled car wrecks. It produces the so-called Automotive Shredded Residue (ASR), usually disposed of in landfill. This paper summarizes the outcome of a study carried out by Politecnico di Milano and LEAP with the support of Actelios SpA on the prospects of a technology based on sequential gasification and combustion of this specific waste stream. Its application to the treatment of ASR allows the recovery of large fractions of metals as non-oxidized, easily marketable secondary raw materials, the vitrification of most of the ash content and the production of power via a steam cycle. Results show that despite the unfavourable characteristics of ASR, the proposed technology can reach appealing energy performances. Three of four environmental impact indicators and the cumulative energy demand index are favourable, the main positive contributes being electricity production and metal recovery (mainly aluminium and copper). The only unfavourable indicator is the global warming index because, since most of the carbon in ASR comes from fossil sources, the carbon dioxide emissions at the stack of the thermal treatment plant are mainly non-renewable and, at the same time, the avoided biogas production from the alternative disposal route of landfilling is minor.

Alternative strategies for energy recovery from municipal solid waste Part A: Mass and energy balances

This two-part paper assesses four strategies for energy recovery from municipal solid waste (MSW) by dedicated waste-to-energy (WTE) plants generating electricity through a steam cycle. The feedstock is the residue after materials recovery (MR), assumed to be 35% by weight of the collected MSW. In strategy 1, the MR residue is fed directly to a grate combustor. In strategy 2, the MR residue is first subjected to light mechanical treatment. In strategies 3 and 4, the MR residue is converted into RDF, which is combusted in a fluidized bed combustor. To examine the relevance of scale, we considered a small waste management system (WMS) serving 200,000 people and a large WMS serving 1,200,000 people. A variation of strategy 1 shows the potential of cogeneration with district heating. The assessment is carried out by a Life Cycle Analysis where the electricity generated by the WTE plant displaces electricity generated by fossil fuel-fired steam plants. Part A focuses on mass and energy balances, while Part B focuses on emissions and costs. Results show that treating the MR residue ahead of the WTE plant reduces energy recovery. The largest energy savings are achieved by combusting the MR residue "as is" in large scale plants; with cogeneration, primary energy savings can reach 2.5% of total societal energy use.

Alternative strategies for energy recovery from municipal solid waste Part B: Emission and cost estimates

This two-part paper assesses four strategies for energy recovery from Municipal Solid Waste (MSW) by dedicated Waste-To-Energy (WTE) plants. In strategy 1, the residue of Material Recovery (MR) is fed directly to a grate combustor, while in strategy 2 the grate combustor comes downstream of light mechanical treatment. In strategies 3 and 4, the MR residue is converted into Refuse Derived Fuel (RDF), in a fluidized cumbuster bed. The results of Part A, devoted to mass and energy balances, clearly show that pre-treating the MR residue in order to increase the heating value of the feedstock fed to the WTE plant has marginal effects on the energy efficiency of the WTE plant. When considering the efficiency of the whole strategy of waste management, the energy balances show that the more thorough the pre-treatment, the smaller the amount of energy recovered per unit of MR residue. Starting from the heat/mass balances illustrated in Part A, Part B examines the environmental impacts and economics of the various strategies by means of a Life Cycle Assessment (LCA). Results show that treating the MR residues ahead of the WTE plant does not provide environmental or economic benefits. RDF production worsens almost all impact indicators because it reduces net electricity production and thus the displacement of power plant emissions; it also increases costs, because the benefits of improving the quality of the material fed to the WTE plant do not compensate the cost of such improvement.