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Dellapiana G, Mok T, Platt LD, Silverman NS, Han CS, Esakoff TF. Sensitivity of antenatal ultrasound in diagnosing posterior placenta accreta spectrum disorders. J Perinat Med 2024; 52:288-293. [PMID: 38243911 DOI: 10.1515/jpm-2023-0491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/01/2024] [Indexed: 01/22/2024]
Abstract
OBJECTIVES Optimal management of placenta accreta spectrum (PAS) requires antenatal diagnosis. We sought to evaluate the sensitivity of ultrasound findings suggestive of PAS in detecting posterior PAS. METHODS Cohort study of patients with posterior placentation and pathology-confirmed PAS from 2011 to 2020 at a tertiary center. Patients were excluded if ultrasound images were unavailable. Ultrasounds were reviewed for presence of lacunae, hypervascularity, myometrial thinning, loss of the hypoechoic zone, bridging vessels, abnormal uterine serosa-bladder interface, placental bulge, placental extension into/beyond the myometrium, and an exophytic mass. Risk factors, postpartum outcomes, and ultrasound findings were compared by antepartum suspicion for PAS. Sensitivity was calculated for each ultrasound finding. RESULTS Thirty-three patients were included. PAS was not suspected antenatally in 70 % (23/33). Patients with unsuspected PAS were more likely to be non-Hispanic, have in vitro fertilization, no prior Cesarean deliveries, no placenta previa, and delivered later in gestation. Depth of invasion and estimated blood loss were less for unsuspected PAS, but there was no difference in hysterectomy between groups. Ultrasound findings were less frequently seen in those who were not suspected antenatally: lacunae 17.4 vs. 100 % (p<0.001), hypervascularity 8.7 vs. 80 % (p<0.001), myometrial thinning 4.4 vs. 70 % (p<0.001), and placental bridging vessels 0 vs. 60 % (p<0.001). There was poor sensitivity (0-42.4 %) for all findings. CONCLUSIONS Posterior PAS is less likely to be detected antenatally due to a lower sensitivity of typical ultrasound findings in the setting of a posterior placenta. Further studies are needed to better identify reliable markers of posterior PAS.
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Affiliation(s)
- Gabriela Dellapiana
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Thalia Mok
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Lawrence D Platt
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Center for Fetal Medicine & Women's Ultrasound, Los Angeles, CA, USA
| | - Neil S Silverman
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Center for Fetal Medicine & Women's Ultrasound, Los Angeles, CA, USA
| | - Christina S Han
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Tania F Esakoff
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Li R, Tang X, Qiu X, Wang W, Wang Q. Associations of characteristics of previous induced abortion with different grades of current placenta accreta spectrum disorders. J Matern Fetal Neonatal Med 2023; 36:2253349. [PMID: 37648652 DOI: 10.1080/14767058.2023.2253349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/19/2023] [Accepted: 08/24/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE Induced abortion could increase the risk of placenta accreta spectrum (PAS) in the next pregnancy. We aimed to explore the associations between characteristics of previous induced abortion and grades of current PAS. METHODS A retrospective case-control study was performed in eligible pregnant women with PAS between January 2014 and June 2022. Data collected included demographics, obstetric characteristics, and information on previous induced abortion. RESULTS The study included 211 pregnant women, with 51 and 160 in the invasive (placenta increta or percreta) and adherence (placenta creta) PAS groups, respectively. The risk of invasive PAS was 14.3-fold higher in patients with abnormal vaginal bleeding after abortion (odds ratio = 14.3, 95% confidence interval 5.6-36.4, p < .01) than those without abnormal vaginal bleeding and approximately 5.8-fold higher in patients with the last induced abortion ≥5 years ago than those within 5 years (odds ratio = 5.8, 95% confidence interval 2.2-15.2, p < .01). The risk of invasive PAS was 13.4-fold higher in patients with placenta attached to uterine cornu than patients with the placenta attached to uterine wall (odds ratio = 17.5, 95% confidence interval 5.5-55.5, p < .01). The number of previous induced abortions, hospital grades, and gestational age at abortion were not different between two groups. CONCLUSION In pregnant women with a history of induced abortion, abnormal vaginal bleeding after induced abortion and prolonged duration after the last induced abortion increased the risk for invasive PAS in the current pregnancy. The number of previous induced abortions and gestational age at abortion had no relation to the grades of PAS.
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Affiliation(s)
- Rui Li
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xiaoqin Tang
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xia Qiu
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Wan Wang
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Qi Wang
- Department of Obstetrics and Gynecology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
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3
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Adu-Bredu TK, Collins SL, Nieto-Calvache AJ. Ultrasound discrimination between placenta accreta spectrum and urinary bladder varices. Aust N Z J Obstet Gynaecol 2023; 63:725-727. [PMID: 37872717 DOI: 10.1111/ajo.13703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 05/01/2023] [Indexed: 10/25/2023]
Abstract
Distinguishing between urinary bladder varices and retroplacental neovascularization in placenta accreta spectrum in high-risk patients with placental previa is a diagnostic challenge since they have similar appearances on prenatal ultrasound. Placenta accreta spectrum is associated with massive obstetric haemorrhage while the presence of urinary bladder varices in pregnancy poses a lower surgical risk. Since the clinical implications and management approach for both conditions are entirely different, false positive diagnoses have iatrogenic consequences. In this article, we share our experiences in differentiating these two phenomena on prenatal ultrasound supported by ultrasound and intraoperative images.
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Affiliation(s)
| | - Sally L Collins
- Nuffield Department of Women's and Reproductive Health, University of Oxford, UK
- Fetal Medicine Unit, John Radcliffe Hospital, Oxford, UK
| | - Albaro José Nieto-Calvache
- Fundación Valle del Lili, Abnormally Invasive Placenta Clinic, Cali, Colombia
- Clinical Postgraduate Department, Universidad Icesi, Cali, Colombia
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Elharras Y, Choayb S, Lrhorfi N, Allali N, Chat L, Elhaddad S. The role of the radiologist in diagnosing placenta percreta: a case report and review of the literature. J Surg Case Rep 2023; 2023:rjad319. [PMID: 37293337 PMCID: PMC10247335 DOI: 10.1093/jscr/rjad319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/19/2023] [Indexed: 06/10/2023] Open
Abstract
Placenta percreta is the most severe and least common form of placental insertion abnormalities. The increasing frequency of C-Section deliveries has led to more of these abnormalities. Ultrasound and magnetic resonance imaging (MRI) have a key role in diagnosing these abnormal adherences since it shows best transmural extension of the placental tissue. We report a case of a woman with a previous cesarean delivery who had been diagnosed with a placenta preavia on ultrasound and a suspicion of transmural extension with her MRI later showing a placenta percreta.
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Affiliation(s)
| | - Safaa Choayb
- Pediatric Radiology Department, Children’s Hospital, University Mohammed V, Rabat, Morroco
| | - Najlae Lrhorfi
- Pediatric Radiology Department, Children’s Hospital, University Mohammed V, Rabat, Morroco
| | - Nazik Allali
- Pediatric Radiology Department, Children’s Hospital, University Mohammed V, Rabat, Morroco
| | - Latifa Chat
- Pediatric Radiology Department, Children’s Hospital, University Mohammed V, Rabat, Morroco
| | - Siham Elhaddad
- Pediatric Radiology Department, Children’s Hospital, University Mohammed V, Rabat, Morroco
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Pineles BL, Sibai BM, Sentilhes L. Is conservative management of placenta accreta spectrum disorders practical in the United States? Am J Obstet Gynecol MFM 2023; 5:100749. [PMID: 36113717 DOI: 10.1016/j.ajogmf.2022.100749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 08/31/2022] [Indexed: 10/14/2022]
Abstract
This commentary discusses the issues related to conservative management (also called leaving the placenta in situ or intentional retention of the placenta) of placenta accreta spectrum disorders. Considerations related to placenta accreta spectrum disorder management in the United States are compared with France, where conservative management is a well-accepted management option. The history of placenta accreta spectrum disorder treatment is reviewed, finding that since 1937, the most common treatment in the United States been cesarean-hysterectomy without placental removal. Although definitive studies have yet to be conducted, a growing body of evidence suggests that conservative management is able to reduce maternal morbidity, compared with cesarean-hysterectomy. International and national guidelines from several countries are examined. Comparisons between the United States and France that are addressed in the commentary include population and geography, structure of the healthcare system, physician training and acceptability, and patient acceptability. Considering the differences between the countries, conservative management is feasible in the United States. Different options for placenta accreta spectrum disorder management should be rigorously researched in multicenter international collaborations. Conservative management should be considered as an option for women with placenta accreta spectrum disorders in the United States, especially for those desiring fertility preservation.
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Affiliation(s)
- Beth L Pineles
- Department of Obstetrics, Gynecology & Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX (Drs Pineles and Sibai).
| | - Baha M Sibai
- Department of Obstetrics, Gynecology & Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX (Drs Pineles and Sibai)
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France (Dr Sentilhes)
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Bachmann C, Abele H, Hoopmann M. Placenta Previa et Percreta: A Potentially Life-Threatening Condition. Diagnostics (Basel) 2023; 13:diagnostics13030539. [PMID: 36766644 PMCID: PMC9914632 DOI: 10.3390/diagnostics13030539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
Placenta percreta occurs in about 5% of placenta accreta spectrum (PAS) and causes high maternal and fetal peripartum morbidity/mortality. A 34-year-old multiparous 4G2P (1xcesarean section (CS)) was admitted to hospital at the 34th week of gestation. Transvaginal ultrasound revealed a placenta previa totalis et percreta with a small tissue layer towards the bladder. Ultrasound was crucial for further planning. An interdisciplinary setting was established based on this life-threatening diagnosis. Due to the onset of labor one day later, a CS was performed. Intraoperatively, the suspicion was confirmed of a placenta previa et percreta with CS scar infiltration. Due to the life-threatening bleeding risk, simultaneous subtotal hysterectomy was needed. The diagnosis was confirmed histologically. The higher the number of previous CS, the higher the PASrate. Placenta percreta is the most severe form of this, characterized by placental invasion through the entirety of the myometrium and possibly into extrauterine tissues. This case demonstrates the great importance of prenatal diagnosis with the realization of dimensions of this very rare finding, especially with an increasing CS rate and other associated complications. Due to the close interdisciplinary cooperation of the prenatal diagnosticians, obstetricians, and anesthesiologists with optimal care in a specialized center, the otherwise high morbidity/mortality can be minimized.
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Aiob A, Gaziyev Z, Mikhail SM, Wolf M, Lowenstein L, Odeh M. The value of a simple sonographic screening test for placenta accreta spectrum prediction: A case-control study. Aust N Z J Obstet Gynaecol 2022; 63:228-233. [PMID: 36068725 DOI: 10.1111/ajo.13611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/21/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Placenta accreta spectrum (PAS) represents life-threatening conditions; however, early diagnosis reduces complications and mortality rates. AIMS To develop and evaluate the accuracy of a simple sonographic screening test for PAS prediction. MATERIALS AND METHODS A retrospective case-control study of 481 women with singleton pregnancies at 28 weeks or later, with a scarred uterus or placenta praevia, who underwent sonographic testing for PAS detection during 2010-2020. We compared demographic and sonographic features, and delivery outcomes between women who were and were not confirmed to have a PAS condition at delivery. We evaluated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and predictive probability for the sonographic screening model. RESULTS Among all the women with at least one sonographic sign (large lacunae or loss of clear zone), the odds ratio (OR) of PAS was 21.7 (95% CI, 16.7-70.4), among those with placenta praevia (and at least one sonographic sign), the OR was 41.9 (95% CI, 15.8-111). For the screening model (the combinations of placental location (major or minor placenta praevia) with at least one sonographic sign (large lacunae or loss of clear zone)), sensitivity, specificity, PPV, NPV and predicted probability were 94.9% (85.8-98.9%), 91.5% (88.4-93.9%), 60.9% (50.1-70.9%), 99.2% (97.7-99.8%) and 92.3%, respectively. CONCLUSIONS A combination of simple ultrasound signs for PAS screening may be highly effective for prenatal assessment and prediction of placenta accreta. This screening test can be carried out as routine pregnancy follow-up for women with risk factors for PAS.
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Affiliation(s)
- Ala Aiob
- Department of Obstetrics and Gynaecology, Galilee Medical Centre, Nahariya and Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Ziyada Gaziyev
- Department of Obstetrics and Gynaecology, Galilee Medical Centre, Nahariya, Israel
| | - Susana Mustafa Mikhail
- Department of Obstetrics and Gynaecology, Galilee Medical Centre, Nahariya and Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Maya Wolf
- Department of Obstetrics and Gynaecology, Galilee Medical Centre, Nahariya and Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Lior Lowenstein
- Department of Obstetrics and Gynaecology, Galilee Medical Centre, Nahariya and Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Marwan Odeh
- Department of Obstetrics and Gynaecology, Galilee Medical Centre, Nahariya and Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
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Matsuzaki S, Mandelbaum RS, Sangara RN, McCarthy LE, Vestal NL, Klar M, Matsushima K, Amaya R, Ouzounian JG, Matsuo K. Trends, characteristics, and outcomes of placenta accreta spectrum: a national study in the United States. Am J Obstet Gynecol 2021; 225:534.e1-534.e38. [PMID: 33894149 DOI: 10.1016/j.ajog.2021.04.233] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/17/2021] [Accepted: 04/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although an infrequent occurrence, the placenta can adhere abnormally to the gravid uterus leading to significantly high maternal morbidity and mortality during cesarean delivery. Contemporary national statistics related to a morbidly adherent placenta, referred to as placenta accreta spectrum, are needed. OBJECTIVE This study aimed to examine national trends, characteristics, and perioperative outcomes of women who underwent cesarean delivery for placenta accreta spectrum in the United States. STUDY DESIGN This is a population-based retrospective, observational study querying the National Inpatient Sample. The study cohort included women who underwent cesarean delivery from October 2015 to December 2017 and had a diagnosis of placenta accreta spectrum. The main outcome measures were patient characteristics and surgical outcomes related to placenta accreta spectrum assessed by the generalized estimating equation on multivariable analysis. The temporal trend of placenta accreta spectrum was also assessed by linear segmented regression with log transformation. RESULTS Of 2,727,477 cases who underwent cesarean delivery during the study period, 8030 (0.29%) had the diagnosis of placenta accreta spectrum. Placenta accreta was the most common diagnosis (n=6205, 0.23%), followed by percreta (n=1060, 0.04%) and increta (n=765, 0.03%). The number of placenta accreta spectrum cases increased by 2.1% every quarter year from 0.27% to 0.32% (P=.004). On multivariable analysis, (1) patient demographics (older age, tobacco use, recent diagnosis, higher comorbidity, and use of assisted reproductive technology), (2) pregnancy characteristics (placenta previa, previous cesarean delivery, breech presentation, and grand multiparity), and (3) hospital factors (urban teaching center and large bed capacity hospital) represented the independent characteristics related to placenta accreta spectrum (all, P<.05). The median gestational age at cesarean delivery was 36 weeks for placenta accreta and 34 weeks for both placenta increta and percreta vs 39 weeks for non-placenta accreta spectrum cases (P<.001). On multivariable analysis, cesarean delivery complicated by placenta accreta spectrum was associated with increased risk of any surgical morbidities (78.3% vs 10.6%), Centers for Disease Control and Prevention-defined severe maternal morbidity (60.3% vs 3.1%), hemorrhage (54.1% vs 3.9%), coagulopathy (5.3% vs 0.3%), shock (5.0% vs 0.1%), urinary tract injury (8.3% vs 0.2%), and death (0.25% vs 0.01%) compared with cesarean delivery without placenta accreta spectrum. When further analyzed by subtype, cesarean delivery for placenta increta and percreta was associated with higher likelihood of hysterectomy (0.4% for non-placenta accreta spectrum, 45.8% for accreta, 82.4% for increta, 78.3% for percreta; P<.001) and urinary tract injury (0.2% for non-placenta accreta spectrum, 5.2% for accreta, 11.8% for increta, 24.5% for percreta; P<.001). Moreover, women in the placenta increta and percreta groups had markedly increased risks of surgical mortality compared with those without placenta accreta spectrum (increta, odds ratio, 19.9; and percreta, odds ratio, 32.1). CONCLUSION Patient characteristics and outcomes differ across the placenta accreta spectrum subtypes, and women with placenta increta and percreta have considerably high surgical morbidity and mortality risks. Notably, 1 in 313 women undergoing cesarean delivery had a diagnosis of placenta accreta spectrum by the end of 2017, and the incidence seems to be higher than reported in previous studies.
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Affiliation(s)
- Shinya Matsuzaki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Rachel S Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Rauvynne N Sangara
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Lauren E McCarthy
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Nicole L Vestal
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Rodolfo Amaya
- Department of Anesthesiology, University of Southern California, Los Angeles, CA
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA.
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Gorczyca ME, Springer S, Pateisky P, Ott J, Ulm B, Chalubinski K. Comparison of Ultrasound Descriptors of Abnormally Invasive Placenta (AIP) over the Course of the Second and Third Trimester-Is an Increase Verifiable? J Clin Med 2021; 10:4960. [PMID: 34768481 DOI: 10.3390/jcm10214960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 01/09/2023] Open
Abstract
Limited data exist regarding the course of abnormally invasive placentation (AIP) (=placenta accreta spectrum (PAS)) during the 2nd and 3rd trimester, although this knowledge would be important for optimal patient care. In this retrospective single-center longitudinal cohort study, potential aggravation of AIP was evaluated in 37 patients with ultrasound (US) pictures stored on a minimum of two visits. Five raters, blinded to diagnosis and gestational age, judged the degree of AIP as recommended by the International Society for PAS. The probability of invasiveness was estimated as absent, low, intermediate, severe (0–3 points), the extent as absent, focal, diffuse (0–2 points), and the presence and appearance of each US-sign as absent, mild, severe (0–3 points). None of the 10 judged signs appeared more severe (p ≥ 0.41) with progressing pregnancy. Neither the number of positively scored US-signs (earlier scan; 6.14 ± 2.06, later scan; 5.94 ± 2.16; p = 0.28), nor the estimated probability & extent of AIP rose (3.69 ± 1.15 vs. 3.67 ± 1.22; p = 1.0). Test-retest reliability corroborated excellent agreement between visits (mean number of positive US-signs ICC (3,1) = 0.94, 95% CI 0.91–0.97; p < 0.0001). Overall, there was no clinically detectable increase in invasiveness over the course of the 2nd and 3rd trimester. This should be further evaluated in prospective studies.
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10
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Rekawek P, Liu L, Pan S, Overbey J, Wagner B. The clinical utility of magnetic resonance imaging as an adjunct to ultrasound in the diagnosis of placenta accreta spectrum disorders. J Matern Fetal Neonatal Med 2021; 35:6008-6012. [PMID: 33771092 DOI: 10.1080/14767058.2021.1903861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To determine if the use of magnetic resonance imaging (MRI) changes the diagnosis of placenta accreta spectrum (PAS) made on prenatal ultrasound (US) leading to an improvement in clinical outcomes. METHODS This was a retrospective chart review of all patients with evidence of PAS on US from 2012 to 2018 in one tertiary care medical center with subsequent use of MRI of the uterus to confirm diagnosis. The type of PAS classified by imaging was compared between US and MRI, with a final diagnosis made using histology. Outcomes that were analyzed included the following: 1) MRI correctly changed diagnosis, 2) MRI incorrectly downgraded diagnosis, 3) MRI incorrectly upgraded diagnosis, and 4) MRI did not change diagnosis. A T-test and Chi-squared test were performed to compare the clinical outcomes of patients with an upgraded diagnosis by MRI to those whose diagnosis was downgraded or stayed the same. RESULTS Forty-one patients received an MRI to validate the diagnosis of PAS after ultrasound and are included in the analysis. MRI changed the diagnosis in 36.6% (15/41) patients, correctly changing the diagnosis in 22% (9/41) and incorrectly upgrading the diagnosis in 14.6% (6/41). Patients whose diagnosis was upgraded by MRI (either correctly or incorrectly) were more likely to deliver earlier compared to those who were either downgraded or had no change in their diagnosis [33. 2 ± 3. 5 weeks vs 35. 2 ± 2. 9 weeks, p = 0.05]. Patients who were upgraded were more likely to have interventional radiology and/or urology involvement at the time of delivery [91.7% (11/12) vs 25. 9% (7/27), p = 0.001]. There were no complications from these procedures. CONCLUSION The use of MRI incorrectly changed the diagnosis as much as it correctly changed the diagnosis of PAS after US. MRI should not be used routinely as a clinical adjunct to ultrasound in the diagnosis of placenta accreta spectrum.
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Affiliation(s)
- Patricia Rekawek
- Department of Obstetrics, Gynecology and Reproductive Science, NYU Langone Hospital - Long Island, New York University Long Island School of Medicine, Mineola, NY, USA
| | - Lilly Liu
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Stephanie Pan
- Department of Biostatistics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jessica Overbey
- Department of Biostatistics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brian Wagner
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Timofeeva AV, Fedorov IS, Pirogova MM, Vasilchenko ON, Chagovets VV, Ezhova LS, Zabelina TM, Shmakov RG, Sukhikh GT. Clusterin and Its Potential Regulatory microRNAs as a Part of Secretome for the Diagnosis of Abnormally Invasive Placenta: Accreta, Increta, and Percreta Cases. Life (Basel) 2021; 11:life11040270. [PMID: 33805203 PMCID: PMC8064394 DOI: 10.3390/life11040270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/17/2021] [Accepted: 03/20/2021] [Indexed: 12/18/2022] Open
Abstract
Magnetic resonance imaging (MRI) and ultrasound methods used for the diagnosis of an abnormally invasive placenta (AIP) have a wide range of sensitivity (Se, 33–93%) and specificity (Sp, 71–100%) levels, which results in a high risk of unfavorable maternal and perinatal outcomes. The relevance of optimizing the diagnosis of AIP is beyond doubt. Given the epigenetic nature of trophoblast invasion, we aimed to quantitate microRNAs and proteins of their target genes that are potentially associated with AIP in blood plasma samples from 64 pregnant women at gestation weeks 30–34 by reverse transcription coupled with polymerase chain reaction (RT-PCR) and Western blotting, respectively. Statistically significant increases in the expression levels of hsa-miR-17-5p, hsa-miR-21-5p, hsa-miR-25-3p, hsa-miR-92a-3p, and hsa-miR-320a-3p were revealed in the groups of women with AIP (accreta, increta, percreta) relative to the group of women with scars on the uterus or to the group with placenta previa. Opposite changes in the expression level of “gene–target protein/miRNA” pairs were found for the α-subunit of the clusterin secretory form and any of the hsa-miR-21-5p, hsa-miR-25-3p, hsa-miR-92a-3p, hsa-miR-320a-3p, and hsa-miR-17-5p in all cases of AIP. The developed logistic regression models to diagnose AIP cases of various severity gave Se values of 88.8–100% and Sp values of 91.6–100% using a combination of hsa-miR-21-5p, hsa-miR-92a-3p, hsa-miR-320a-3p, or clusterin levels.
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Affiliation(s)
- Angelika V. Timofeeva
- Kulakov National Medical Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of Russia, Ac. Oparina 4, 117997 Moscow, Russia; (I.S.F.); (M.M.P.); (O.N.V.); (V.V.C.); (L.S.E.); (T.M.Z.); (R.G.S.); (G.T.S.)
- Correspondence: or ; Tel.: +7-4955314444
| | - Ivan S. Fedorov
- Kulakov National Medical Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of Russia, Ac. Oparina 4, 117997 Moscow, Russia; (I.S.F.); (M.M.P.); (O.N.V.); (V.V.C.); (L.S.E.); (T.M.Z.); (R.G.S.); (G.T.S.)
| | - Mariya M. Pirogova
- Kulakov National Medical Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of Russia, Ac. Oparina 4, 117997 Moscow, Russia; (I.S.F.); (M.M.P.); (O.N.V.); (V.V.C.); (L.S.E.); (T.M.Z.); (R.G.S.); (G.T.S.)
| | - Oksana N. Vasilchenko
- Kulakov National Medical Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of Russia, Ac. Oparina 4, 117997 Moscow, Russia; (I.S.F.); (M.M.P.); (O.N.V.); (V.V.C.); (L.S.E.); (T.M.Z.); (R.G.S.); (G.T.S.)
| | - Vitaliy V. Chagovets
- Kulakov National Medical Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of Russia, Ac. Oparina 4, 117997 Moscow, Russia; (I.S.F.); (M.M.P.); (O.N.V.); (V.V.C.); (L.S.E.); (T.M.Z.); (R.G.S.); (G.T.S.)
| | - Larisa S. Ezhova
- Kulakov National Medical Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of Russia, Ac. Oparina 4, 117997 Moscow, Russia; (I.S.F.); (M.M.P.); (O.N.V.); (V.V.C.); (L.S.E.); (T.M.Z.); (R.G.S.); (G.T.S.)
| | - Tatiana M. Zabelina
- Kulakov National Medical Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of Russia, Ac. Oparina 4, 117997 Moscow, Russia; (I.S.F.); (M.M.P.); (O.N.V.); (V.V.C.); (L.S.E.); (T.M.Z.); (R.G.S.); (G.T.S.)
| | - Roman G. Shmakov
- Kulakov National Medical Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of Russia, Ac. Oparina 4, 117997 Moscow, Russia; (I.S.F.); (M.M.P.); (O.N.V.); (V.V.C.); (L.S.E.); (T.M.Z.); (R.G.S.); (G.T.S.)
| | - Gennadiy T. Sukhikh
- Kulakov National Medical Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of Russia, Ac. Oparina 4, 117997 Moscow, Russia; (I.S.F.); (M.M.P.); (O.N.V.); (V.V.C.); (L.S.E.); (T.M.Z.); (R.G.S.); (G.T.S.)
- Department of Obstetrics, Gynecology, Perinatology and Reproductology, First Moscow State Medical University Named after I.M. Sechenov, 119991 Moscow, Russia
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Shainker SA, Coleman B, Timor-Tritsch IE, Bhide A, Bromley B, Cahill AG, Gandhi M, Hecht JL, Johnson KM, Levine D, Mastrobattista J, Philips J, Platt LD, Shamshirsaz AA, Shipp TD, Silver RM, Simpson LL, Copel JA, Abuhamad A. Special Report of the Society for Maternal-Fetal Medicine Placenta Accreta Spectrum Ultrasound Marker Task Force: Consensus on definition of markers and approach to the ultrasound examination in pregnancies at risk for placenta accreta spectrum. Am J Obstet Gynecol 2021; 224:B2-B14. [PMID: 33386103 DOI: 10.1016/j.ajog.2020.09.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Placenta accreta spectrum includes the full range of abnormal placental attachment to the uterus or other structures, encompassing placenta accreta, placenta increta, placenta percreta, morbidly adherent placenta, and invasive placentation. The incidence of placenta accreta spectrum has increased in recent years, largely driven by increasing rates of cesarean delivery. Prenatal detection of placenta accreta spectrum is primarily made by ultrasound and is important to reduce maternal morbidity associated with the condition. Despite a large body of research on various placenta accreta spectrum ultrasound markers and their screening performance, inconsistencies in the literature persist. In response to the need for standardizing the definitions of placenta accreta spectrum markers and the approach to the ultrasound examination, the Society for Maternal-Fetal Medicine convened a task force with representatives from the American Institute of Ultrasound in Medicine, the American College of Obstetricians and Gynecologists, the American College of Radiology, the International Society of Ultrasound in Obstetrics and Gynecology, the Society for Radiologists in Ultrasound, the American Registry for Diagnostic Medical Sonography, and the Gottesfeld-Hohler Memorial Ultrasound Foundation. The goals of the task force were to assess placenta accreta spectrum sonographic markers on the basis of available data and expert consensus, provide a standardized approach to the prenatal ultrasound evaluation of the uterus and placenta in pregnancies at risk of placenta accreta spectrum, and identify research gaps in the field. This manuscript provides information on the Placenta Accreta Spectrum Task Force process and findings.
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Herbert K, Buchbinder L, Seshachellam V, Lee L. Resuscitative Endovascular Balloon Occlusion of the Aorta and Concomitant Tranexamic Acid for Cesarean Hysterectomy Complicated by Common Femoral Artery Thrombosis: A Case Report. Cureus 2020; 12:e11197. [PMID: 33269128 PMCID: PMC7704019 DOI: 10.7759/cureus.11197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2020] [Indexed: 11/06/2022] Open
Abstract
With increasing cesarean delivery rates, placenta accreta spectrum (PAS) disorders are occurring more frequently and represent a significant cause of peripartum hemorrhage. Different modalities have been explored to control blood loss during cesarean hysterectomies for PAS disorders, including administration of tranexamic acid (TXA) and balloon occlusion strategies. We present a case of a cesarean hysterectomy for a placenta percreta with the use of TXA and arterial balloon occlusion complicated by a lower extremity arterial thrombus requiring emergent thrombectomy. The outcome of this case suggests using caution with concomitant use of TXA and arterial balloon occlusion.
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Affiliation(s)
- Katherine Herbert
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, USA
| | - Lindsey Buchbinder
- Department of Anesthesiology, McGovern Medical School University of Texas Health Science Center, Houston, USA
| | - Vishwas Seshachellam
- Department of Anesthesiology, McGovern Medical School University of Texas Health Science Center, Houston, USA
| | - Linden Lee
- Department of Anesthesiology, McGovern Medical School University of Texas Health Science Center, Houston, USA
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Jauniaux E, Hussein AM, Zosmer N, Elbarmelgy RM, Elbarmelgy RA, Shaikh H, Burton GJ. A new methodologic approach for clinico-pathologic correlations in invasive placenta previa accreta. Am J Obstet Gynecol 2020; 222:379.e1-379.e11. [PMID: 31730756 DOI: 10.1016/j.ajog.2019.11.1246] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/03/2019] [Accepted: 11/04/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND The development of new management strategies for women presenting with placenta accreta spectrum requires quality epidemiology data, which have so far been limited by the high variability in clinical and histopathologic data confirming the diagnosis at birth. OBJECTIVE To evaluate the role of a new methodologic approach for the correlation of clinical and pathological data for women with a history of prior cesarean delivery diagnosed prenatally with placenta previa accreta. MATERIALS AND METHODS A modified pathologic technique for gross examination of hysterectomy specimens with placenta in situ consisting of intraoperative examination, immediate postoperative examination, and guided histologic sampling was used prospectively in a cohort of 24 patients with singleton pregnancies complicated by placenta low-lying/placenta previa accreta. Maternal characteristics, detailed ultrasound findings, surgical outcomes, and histopathologic examination were compared with those of a group of 24 patients with similar clinical characteristics and in whom a standard pathologic examination method was used. RESULTS The median reporting time for obtaining the complete histopathology results including the microscopic examination was significantly shorter (7 versus 15 days; P < .001) and the median number of samples taken for histologic examination significantly lower (4 versus 14 samples; P < .001) in the study group than in the controls. The number of histologic slides showing villous invasion was significantly higher (2 versus 1 slide; P = .002), and the ratio of the number of samples taken to the numbers of slides confirming villous invasion was significantly lower (2 versus 9; P < .001) in the study group than in the controls. In all cases in the study group, intraoperative examination identified a dense tangled bed of vessels or multiple vessels running laterally and cranio-caudally in the uterine serosa above the placental insertion that were no longer visible during immediate gross postoperative examination of the hysterectomy specimens. Immediate postoperative dissection enables the differential diagnosis between focal and large increta areas, and between abnormally adherent placenta and invasive placenta accreta. CONCLUSION Valuable clinical information on the serosal vascularity, uterine dehiscence, and extension of the accreta area is added with the description of the macroscopic examination during the surgical procedure and immediate dissection of the specimen. This methodological approach is cost-effective and increases the quality of the histologic sampling. It thus provides more accurate correlations with the clinical data and more accurate epidemiologic data collection. Perinatal pathologists should be part of multidisciplinary teams involved the management placenta accreta spectrum disorders.
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di Pasquo E, Ghi T, Calì G, D'Antonio F, Fratelli N, Forlani F, Prefumo F, Kaihura CT, Volpe N, Dall'Asta A, Frusca T. Intracervical lakes as sonographic marker of placenta accreta spectrum disorder in patients with placenta previa or low-lying placenta. Ultrasound Obstet Gynecol 2020; 55:460-466. [PMID: 31503353 DOI: 10.1002/uog.21866] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 08/16/2019] [Accepted: 08/30/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of a new ultrasound sign, intracervical lakes (ICL), in predicting the presence of placenta accreta spectrum (PAS) disorder and delivery outcome in patients with placenta previa or low-lying placenta. METHODS This was a retrospective multicenter study of women with placenta previa or low-lying placenta at ≥ 26 weeks' gestation, who were referred to three Italian tertiary units from January 2015 to September 2018. The presence of ICL, defined as tortuous anechoic spaces within the cervix which appeared to be hypervascular on color Doppler, was evaluated on ultrasound images obtained at the time of referral. The primary aim was to explore the diagnostic accuracy of ICL in detecting the presence and depth of PAS disorder. The secondary aim was to explore the accuracy of this sign in predicting total estimated blood loss, antepartum bleeding, major postpartum hemorrhage at the time of Cesarean section and need for Cesarean hysterectomy. The diagnostic accuracy of ICL in combination with typical sonographic signs of PAS disorder, was assessed by computing summary estimates of sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios and diagnostic odds ratios (DOR). RESULTS A total of 332 women with placenta previa or low-lying placenta were included in the analysis, with a median maternal age of 33.0 (interquartile range, 29.0-37.0) years. ICL were noted in 15.1% of patients. On logistic regression analysis, the presence of ICL was associated independently with major postpartum hemorrhage (odds ratio (OR), 3.3 (95% CI, 1.6-6.5); P < 0.001), Cesarean hysterectomy (OR, 7.0 (95% CI, 2.1-23.9); P < 0.001) and placenta percreta (OR, 2.8 (95% CI, 1.3-5.8); P ≤ 0.01), but not with the presence of any PAS disorder (OR, 1.6 (95% CI, 0.7-3.5); P = 0.2). Compared with the group of patients without ultrasound signs of PAS disorder, the presence of at least one typical sonographic sign of PAS disorder in combination with ICL had a DOR of 217.2 (95% CI, 27.7-1703.4; P < 0.001) for placenta percreta and of 687.4 (95% CI, 121.4-3893.0; P < 0.001) for Cesarean hysterectomy. CONCLUSION ICL may represent a marker of deep villus invasion in women with suspected PAS disorder on antenatal sonography and anticipate the occurrence of severe maternal morbidity. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- E di Pasquo
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - T Ghi
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - G Calì
- Department of Obstetrics and Gynecology, Arnas Civico Hospital, Palermo, Italy
| | - F D'Antonio
- Department of Obstetrics and Gynaecology, University Hospital of Northern Norway, Tromsø, Norway
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Science, UiT, The Arctic University of Norway, Tromsø, Norway
| | - N Fratelli
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - F Forlani
- Department of Obstetrics and Gynecology, Arnas Civico Hospital, Palermo, Italy
| | - F Prefumo
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - C T Kaihura
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - N Volpe
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - A Dall'Asta
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - T Frusca
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
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Abstract
Placenta accreta spectrum disorder (PASD) is the adherence of the placenta caused by an abnormal trophoblast invasion into the myometrium. It is classified as placenta accreta, placenta increta, and placenta percreta depending on the extent of the invasion. Placenta accreta, defined as the superficial invasion of the placenta to the myometrium, accounts for 75% of PASD. Placenta increta is characterized by chorionic villi invasion deep into the myometrium. Placenta percreta involves placental invasion through the uterus and serosa and into the peritoneal cavity or surrounding viscera. Maternal morbidity and mortality can occur secondary to hemorrhage, disseminated intravascular coagulation, risks associated with blood transfusion, and pelvic and abdominal viscera injury. The standard of care in a known diagnosis of PASD is a cesarean delivery followed by hysterectomy with the placenta in situ. We report a case in which the diagnosis of focal PASD was not known antenatally but suspected after vaginal delivery. The patient subsequently underwent conservative management with uterine preservation and did not require laparotomy.
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Affiliation(s)
- Mary K Marquette
- Obstetrics and Gynecology, East Tennessee State University Quillen College of Medicine, Johnson City, USA
| | - Olga Sarkodie
- Obstetrics and Gynecology, East Tennessee State University Quillen College of Medicine, Johnson City, USA
| | - Anne T Walker
- Obstetric and Gynecology, East Tennessee State University Quillen College of Medicine, Johnson City, USA
| | - Emily Patterson
- Pathology, East Tennessee State University Quillen College of Medicine, Johnson City, USA
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Jauniaux E, Dimitrova I, Kenyon N, Mhallem M, Kametas NA, Zosmer N, Hubinont C, Nicolaides KH, Collins SL. Impact of placenta previa with placenta accreta spectrum disorder on fetal growth. Ultrasound Obstet Gynecol 2019; 54:643-649. [PMID: 30779235 PMCID: PMC6699933 DOI: 10.1002/uog.20244] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 02/08/2019] [Accepted: 02/14/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To evaluate fetal growth in pregnancies complicated by placenta previa with or without placenta accreta spectrum (PAS) disorder, compared with in pregnancies with a low-lying placenta. METHODS This was a multicenter retrospective cohort study of singleton pregnancies complicated by placenta previa with or without PAS disorder, for which maternal characteristics, ultrasound-estimated fetal weight and birth weight were available. Four maternal-fetal medicine units participated in data collection of diagnosis, treatment and outcome. The control group comprised singleton pregnancies with a low-lying placenta (0.5-2 cm from the internal os). The diagnosis of PAS and depth of invasion were confirmed at delivery using both a predefined clinical grading score and histopathological examination. For comparison of pregnancy characteristics and fetal growth parameters, the study groups were matched for smoking status, ethnic origin, fetal sex and gestational age at delivery. RESULTS The study included 82 women with placenta previa with PAS disorder, subdivided into adherent (n = 35) and invasive (n = 47) PAS subgroups, and 146 women with placenta previa without PAS disorder. There were 64 controls with a low-lying placenta. There was no significant difference in the incidence of small-for-gestational age (SGA) (birth weight ≤ 10th percentile) and large-for-gestational age (LGA) (birth weight ≥ 90th percentile) between the study groups. Median gestational age at diagnosis was significantly lower in pregnancies with placenta previa without PAS disorder than in the low-lying placenta group (P = 0.002). No significant difference was found between pregnancies complicated by placenta previa with PAS disorder and those without for any of the variables. Median estimated fetal weight percentile was significantly lower in the adherent compared with the invasive previa-PAS subgroup (P = 0.047). Actual birth weight percentile at delivery did not differ significantly between the subgroups (P = 0.804). CONCLUSIONS No difference was seen in fetal growth in pregnancies complicated by placenta previa with PAS disorder compared with those without and compared with those with a low-lying placenta. There was also no increased incidence of either SGA or LGA neonates in pregnancies with placenta previa and PAS disorder compared with those with placenta previa with spontaneous separation of the placenta at birth. Adverse neonatal outcome in pregnancies complicated by placenta previa and PAS disorder is linked to premature delivery and not to impaired fetal growth. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- Eric Jauniaux
- EGA Institute for Women’s Health, Faculty of Population Health Sciences, University College London (UCL), London, UK
| | - Ivelina Dimitrova
- The Fetal Medicine Research Institute, Kings College Hospital, Harris Birthright Research Centre, London, UK
| | - Naomi Kenyon
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, UK
| | - Mina Mhallem
- Department of Obstetrics, Saint Luc University Hospital, Université de Louvain, Brussels, Belgium
| | - Nikos A Kametas
- The Fetal Medicine Research Institute, Kings College Hospital, Harris Birthright Research Centre, London, UK
| | - Nurit Zosmer
- The Fetal Medicine Research Institute, Kings College Hospital, Harris Birthright Research Centre, London, UK
| | - Corinne Hubinont
- Department of Obstetrics, Saint Luc University Hospital, Université de Louvain, Brussels, Belgium
| | - Kypros H. Nicolaides
- The Fetal Medicine Research Institute, Kings College Hospital, Harris Birthright Research Centre, London, UK
| | - Sally L. Collins
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, UK
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Abstract
In the last 30 years, with increasing cesarean section rates, the incidence of the placenta accreta spectrum has also increased. It is estimated that by the year 2020 there will be nearly 9000 cases annually in the United States. Currently, no consensus exists regarding optimal management. Conventional treatment by cesarean-hysterectomy is challenging, with a high maternal morbidity due to massive hemorrhage, and surgical complications such as urinary tract, bowel and pelvic nerve injury, in addition to loss of fertility and its accompanying psychological trauma. Innovative approaches seek to preserve the uterus with the adherent placenta in situ, thus maintaining fertility and potentially reducing hemorrhage and adjacent organ injury. This review reports strategies for conservative treatment of such conditions, based on the current literature.
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Affiliation(s)
- Joanna Sichitiu
- Women-Mother-Child Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Zeina El-Tani
- Women-Mother-Child Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Patrice Mathevet
- Women-Mother-Child Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - David Desseauve
- Women-Mother-Child Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Slaoui A, Talib S, Nah A, Moussaoui KE, Benzina I, Zeraidi N, Baydada A, Kharbach A. Placenta accreta in the department of gynaecology and obstetrics in Rabat, Morocco: case series and review of the literature. Pan Afr Med J 2019; 33:86. [PMID: 31489064 PMCID: PMC6711691 DOI: 10.11604/pamj.2019.33.86.17700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 03/11/2019] [Indexed: 11/11/2022] Open
Abstract
Placenta accreta spectrum disorders is a rare pathology but the incidence has not stopped to increase in recent years. The purpose of our work was the analysis of the epidemiological profile of our patients, the circumstances of diagnosis, the interest of paraclinical explorations in antenatal diagnosis and the evaluation of the evolutionary profile. We hereby report a case series spread over a period of one year from 01/01/2015 to 01/01/2016 at the Gynaecology-Obstetrics department of the University Hospital Center IBN SINA of Rabat where we identified six cases of placenta accreta. We selected patients whose diagnosis was confirmed clinically and histologically. The major risk factors identified were a history of placenta previa, previous caesarean section, advanced maternal age, multiparity. 2D ultrasound and magnetic resonance imaging (MRI) allowed us to strongly suspect the presence of a placenta accreta in a pregnant woman with risk factor(s) but the diagnosis of certainty was always histological. Placenta accreta spectrum disorders were associated with a high risk of severe postpartum hemorrhage, serious comorbidities, and maternal death. Leaving the placenta in situ was an option for women who desire to preserve their fertility and agree to continuous long-term monitoring in centers with adequate expertise but a primary elective caesarean hysterectomy was the safest and most practical option. Placenta accreta spectrum disorders is an uncommon pathology that must be systematically sought in a parturient with risk factors, to avoid serious complications. In light of the latest International Federation of Gynecology and Obstetrics (FIGO) recommendations of 2018, a review of the literature and finally the experience of our center, we propose a course of action according to whether the diagnosis of the placenta is antenatal or perpartum.
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Affiliation(s)
- Aziz Slaoui
- Gynaecology-Obstetrics and Endocrinology Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco
| | - Sarah Talib
- Gynaecology-Obstetrics and Endocrinology Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco
| | - Anass Nah
- Gynaecology-Obstetrics and Endoscopy Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco
| | - Kamal El Moussaoui
- Gynaecology-Obstetrics and Endocrinology Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco
| | - Intissar Benzina
- Gynaecology-Obstetrics and Endocrinology Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco
| | - Najia Zeraidi
- Gynaecology-Obstetrics and Endoscopy Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco
| | - Aziz Baydada
- Gynaecology-Obstetrics and Endoscopy Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco
| | - Aicha Kharbach
- Gynaecology-Obstetrics and Endocrinology Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco
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Collins SL, Alemdar B, van Beekhuizen HJ, Bertholdt C, Braun T, Calda P, Delorme P, Duvekot JJ, Gronbeck L, Kayem G, Langhoff-Roos J, Marcellin L, Martinelli P, Morel O, Mhallem M, Morlando M, Noergaard LN, Nonnenmacher A, Pateisky P, Petit P, Rijken MJ, Ropacka-Lesiak M, Schlembach D, Sentilhes L, Stefanovic V, Strindfors G, Tutschek B, Vangen S, Weichert A, Weizsäcker K, Chantraine F. Evidence-based guidelines for the management of abnormally invasive placenta: recommendations from the International Society for Abnormally Invasive Placenta. Am J Obstet Gynecol 2019; 220:511-526. [PMID: 30849356 DOI: 10.1016/j.ajog.2019.02.054] [Citation(s) in RCA: 170] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/13/2019] [Accepted: 02/27/2019] [Indexed: 11/28/2022]
Abstract
The worldwide incidence of abnormally invasive placenta is rapidly rising, following the trend of increasing cesarean delivery. It is a heterogeneous condition and has a high maternal morbidity and mortality rate, presenting specific intrapartum challenges. Its rarity makes developing individual expertise difficult for the majority of clinicians. The International Society for Abnormally Invasive Placenta aims to improve clinicians' understanding and skills in managing this difficult condition. By pooling knowledge, experience, and expertise gained within a variety of different healthcare systems, the Society seeks to improve the outcomes for women with abnormally invasive placenta globally. The recommendations presented herewith were reached using a modified Delphi technique and are based on the best available evidence. The evidence base for each is presented using a formal grading system. The topics chosen address the most pertinent questions regarding intrapartum management of abnormally invasive placenta with respect to clinically relevant outcomes, including the following: definition of a center of excellence; requirement for antenatal hospitalization; antenatal optimization of hemoglobin; gestational age for delivery; antenatal corticosteroid administration; use of preoperative cystoscopy, ureteric stents, and prophylactic pelvic arterial balloon catheters; maternal position for surgery; type of skin incision; position of the uterine incision; use of interoperative ultrasound; prophylactic administration of oxytocin; optimal method for intraoperative diagnosis; use of expectant management; adjuvant therapies for expectant management; use of local surgical resection; type of hysterectomy; use of delayed hysterectomy; intraoperative measures to treat life-threatening hemorrhage; and fertility after conservative management.
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Affiliation(s)
- Sally L Collins
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK; The Fetal Medicine Unit, John Radcliffe Hospital, Oxford, UK.
| | - Bahrin Alemdar
- Department of Obstetrics and Gynecology, South General Hospital, Stockholm, Sweden
| | | | - Charline Bertholdt
- Centre Hospitalier Régional Universitaire de Nancy, Université de Lorraine, France
| | - Thorsten Braun
- Departments of Obstetrics and Division of Experimental Obstetrics, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Pavel Calda
- Department of Obstetrics and Gynecology, General Faculty Hospital, Charles University, Prague, Czech Republic
| | - Pierre Delorme
- Port-Royal Maternity Unit, Cochin Hospital, Paris-Descartes University, DHU Risk and Pregnancy, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Johannes J Duvekot
- Department of Obstetrics and Gynecology, Erasmus Medical Center Rotterdam, Rotterdam, Netherlands
| | - Lene Gronbeck
- Department of Obstetrics, Rigshospitalet, University of Copenhagen, Denmark
| | - Gilles Kayem
- Department of Obstetrics and Gynecology, Hôpital Trousseau, Assistance Publique des Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Jens Langhoff-Roos
- Department of Obstetrics, Rigshospitalet, University of Copenhagen, Denmark
| | - Louis Marcellin
- Department of Gynecology Obstetrics II and Reproductive Medicine, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, APHP; Sorbonne Paris Cité, Université Paris Descartes, Faculté de Médecine, Paris, France
| | - Pasquale Martinelli
- Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy
| | - Olivier Morel
- Centre Hospitalier Régional Universitaire de Nancy, Université de Lorraine, France
| | - Mina Mhallem
- Department of Obstetrics, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Maddalena Morlando
- Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy; Department of Women, Children and of General and Specialized Surgery, University "Luigi Vanvitelli", Naples, Italy
| | - Lone N Noergaard
- Department of Obstetrics, Rigshospitalet, University of Copenhagen, Denmark
| | - Andreas Nonnenmacher
- Departments of Obstetrics and Division of Experimental Obstetrics, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Petra Pateisky
- Department of Obstetrics and Gynecology, Division of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - Philippe Petit
- Department of Obstetrics and Gynecology, CHR Citadelle, University of Liege, Liege, Belgium
| | - Marcus J Rijken
- Vrouw & Baby, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
| | - Mariola Ropacka-Lesiak
- Department of Perinatology and Gynecology, University of Medical Sciences, Poznan, Poland
| | - Dietmar Schlembach
- Vivantes Network for Health, Clinicum Neukoelln, Clinic for Obstetric Medicine, Berlin, Germany
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - Vedran Stefanovic
- Department of Obstetrics and Gynecology, Fetomaternal Medical Center, Helsinki University Hospital and University of Helsinki, Finland
| | - Gita Strindfors
- Department of Obstetrics and Gynecology, South General Hospital, Stockholm, Sweden
| | - Boris Tutschek
- Prenatal Zurich, Zürich, Switzerland; Heinrich Heine University, Düsseldorf, Germany
| | - Siri Vangen
- Division of Obstetrics and Gynaecology, Norwegian National Advisory Unit on Women's Health, Oslo University Hospital, Rikshospitalet and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Alexander Weichert
- Departments of Obstetrics and Division of Experimental Obstetrics, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Katharina Weizsäcker
- Departments of Obstetrics and Division of Experimental Obstetrics, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Frederic Chantraine
- Department of Obstetrics and Gynecology, CHR Citadelle, University of Liege, Liege, Belgium
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Zaghal AA, Hussain HK, Berjawi GA. MRI evaluation of the placenta from normal variants to abnormalities of implantation and malignancies. J Magn Reson Imaging 2019; 50:1702-1717. [PMID: 31102327 DOI: 10.1002/jmri.26764] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/18/2019] [Accepted: 04/18/2019] [Indexed: 11/06/2022] Open
Abstract
Even though the placenta has been known for millennia, it is still considered one of the most complex and least understood human organs. Imaging of the placenta is gaining attention due to its impact on fetal and maternal outcomes. MRI plays a vital role in evaluation of inconclusive cases by ultrasonography. It enables precise mapping of placental abnormalities for proper multidisciplinary planning and management. In this article we provide a comprehensive in-depth review of the role of antenatal MR in evaluating "The Placenta." We will describe the protocols and techniques used for MRI of the placenta, review anatomy of the placenta, describe MRI features of major placental abnormalities including those related to position, depth of implantation, hemorrhage, gestational trophoblastic neoplasia, and retained products of conception and discuss the added value of MRI in the management and preoperative planning of such abnormalities. Level of Evidence: 3 Technical Efficacy Stage: 5 J. Magn. Reson. Imaging 2019;50:1702-1717.
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Affiliation(s)
- Arwa A Zaghal
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hero K Hussain
- Department of Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ghina A Berjawi
- Department of Radiology, American University of Beirut Medical Center, Beirut, Lebanon
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Mitric C, Desilets J, Balayla J, Ziegler C. Surgical Management of the Placenta Accreta Spectrum: An Institutional Experience. J Obstet Gynaecol Can 2019; 41:1551-1557. [PMID: 30948337 DOI: 10.1016/j.jogc.2019.01.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/10/2019] [Accepted: 01/10/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The incidence of placenta accreta spectrum (PAS) has risen over the past decades, primarily in response to increasing Caesarean section rates. The surgical management of PAS is associated with significant morbidity, including hemorrhage and intensive care unit (ICU) admission. This study sought to evaluate the surgical outcomes of a PAS operative approach. METHODS A single-centre retrospective chart review of all Caesarean hysterectomies for PAS by an assigned surgeon over a 16-year period was performed. Surgical outcomes were described (Canadian Task Force Classification II-2). RESULTS The described surgical approach involves a midline skin incision, high midline hysterotomy, a rapid single-layer uterine closure with no placental removal attempt, constant cephalad uterine traction, and liberal choice of subtotal hysterectomy. A total of 47 patients were included: 19 (40.4%) with placenta accreta, 14 (29.8%) with placenta increta, and 14 (29.8%) with placenta percreta. Mean estimated blood loss was 1416 ± 699 mL, and mean operative time was 112 ± 49 minutes. Overall, 16 patients (34.0%) required blood transfusion, and 4 patients (8.5%) required ICU admission. The average hospitalization was 5.2 days, with no re-admission within 30 days. The use of internal iliac balloons did not result in a difference in blood loss or operative time (P > 0.05). Patients with placenta percreta had significantly more blood loss (P = 0.02) and longer operative time (P = 0.007) compared with those with placenta accreta and increta. CONCLUSION The current surgical model for planned Caesarean hysterectomy for PAS exhibits a low complication rate. Further research is needed for developing a standardized approach to the management of PAS.
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Affiliation(s)
- Cristina Mitric
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montréal, QC
| | - Jade Desilets
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montréal, QC
| | - Jacques Balayla
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montréal, QC
| | - Cleve Ziegler
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montréal, QC.
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Martimucci K, Bilinski R, Perez AM, Kuhn T, Al-Khan A, Alvarez-Perez JR. Interpregnancy interval and abnormally invasive placentation. Acta Obstet Gynecol Scand 2018; 98:183-187. [PMID: 30288733 DOI: 10.1111/aogs.13478] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 09/30/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The presence of a previous uterine scar is a strong risk factor for developing abnormally invasive placentation (AIP). We sought to determine whether a short interpregnancy interval predisposes to AIP. We hypothesized that a short interpregnancy interval after a previous cesarean delivery increases the risk of AIP in comparison with a longer interpregnancy interval. MATERIAL AND METHODS We performed a retrospective cohort study of women with a histological diagnosis of AIP and a history of a previous cesarean section. Women were included in the control group if they had a previous cesarean section with a placenta underlying the previous uterine scar or an anterior previa. The time interval between pregnancy and AIP data was analyzed using the chi-square test and two-tailed Fisher's exact test. RESULTS There was no statistical difference in the interpregnancy interval between women who had AIP vs the control group. Gravidity and parity were found to be significantly higher in the women with AIP vs the controls. CONCLUSIONS These results suggest that a short interpregnancy interval may not increase the risk of developing AIP.
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Affiliation(s)
- Kristina Martimucci
- Department of Maternal Fetal Medicine and Surgery, Hackensack University Medical Center, Hackensack, NJ, USA.,Department of Obstetrics, Gynecology and Women's Health, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Robyn Bilinski
- Department of Maternal Fetal Medicine and Surgery, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Anisha M Perez
- Department of Maternal Fetal Medicine and Surgery, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Theresa Kuhn
- Department of Maternal Fetal Medicine and Surgery, Hackensack University Medical Center, Hackensack, NJ, USA.,Department of Obstetrics, Gynecology and Women's Health, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Abdulla Al-Khan
- Department of Maternal Fetal Medicine and Surgery, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Jesus R Alvarez-Perez
- Department of Maternal Fetal Medicine and Surgery, Hackensack University Medical Center, Hackensack, NJ, USA
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Al-Khan A, Guirguis G, Zamudio S, Alvarez M, Martimucci K, Luke D, Alvarez-Perez J. Preoperative cystoscopy could determine the severity of placenta accreta spectrum disorders: An observational study. J Obstet Gynaecol Res 2018; 45:126-132. [PMID: 30136333 DOI: 10.1111/jog.13794] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/01/2018] [Indexed: 11/28/2022]
Abstract
AIM In the surgical treatment of placenta accreta spectrum disorders, cystoscopy for prophylactic stent placement is performed to protect the ureters from potential injury. Despite its frequent use, the use of cystoscopy in assessing the severity of these disorders has not been explored. Our objective was to find out if the abnormal findings documented during cystoscopy are associated with disease severity. METHODS In this retrospective, observational cohort study (n = 56), the bladder wall was evaluated at the time of ureteral stent placement via cystoscopy in prenatally diagnosed placenta accreta spectrum cases. Three abnormal findings were commonly present in these cases: bulging of the posterior bladder wall, neovascularization and arterial pulsatility in the area of neovascularization. These findings were stratified according to severity in histologically confirmed specimens. Continuous variables were compared via two-tailed t-tests and Wilcoxon rank sum tests. Categorical data were evaluated using logistic regression analysis. RESULTS Neovascularization affected 84%, bulging 71% and pulsatility 54% of the cases. Bulging and neovascularization increased with disease severity. Pulsatility occurred exclusively in percretas. Bulging was associated with a 12-fold (OR = 11.6, 95% CI 2.94-46.33, P = 0.0005) increased likelihood of percreta and neovascularization with a 17-fold (OR = 17.06, 95% CI 2.98-97.79, P = 0.0014) increase. Neovascularization and/or the presence of bulging of the bladder have high positive predictive value for placenta increta and percreta (91.5% and 95.0%, respectively). Cystoscopy can be used to assess the severity of placenta accreta spectrum cases preoperatively, especially when placentation is over the previous uterine scar and is in proximity to the bladder wall.
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Affiliation(s)
- Abdulla Al-Khan
- Center for Abnormal Placentation, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine and Surgery, Department of Research and Department of Pathology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - George Guirguis
- Center for Abnormal Placentation, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine and Surgery, Department of Research and Department of Pathology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Stacy Zamudio
- Center for Abnormal Placentation, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine and Surgery, Department of Research and Department of Pathology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Manuel Alvarez
- Center for Abnormal Placentation, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine and Surgery, Department of Research and Department of Pathology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Kristina Martimucci
- Center for Abnormal Placentation, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine and Surgery, Department of Research and Department of Pathology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Davlyn Luke
- Center for Abnormal Placentation, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine and Surgery, Department of Research and Department of Pathology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Jesus Alvarez-Perez
- Center for Abnormal Placentation, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine and Surgery, Department of Research and Department of Pathology, Hackensack University Medical Center, Hackensack, New Jersey, USA
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Cali G, Forlani F, Timor-Trisch I, Palacios-Jaraquemada J, Foti F, Minneci G, Flacco ME, Manzoli L, Familiari A, Pagani G, Scambia G, D'Antonio F. Diagnostic accuracy of ultrasound in detecting the depth of invasion in women at risk of abnormally invasive placenta: A prospective longitudinal study. Acta Obstet Gynecol Scand 2018; 97:1219-1227. [PMID: 29797715 DOI: 10.1111/aogs.13389] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/16/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The aim of this study was to assess the diagnostic accuracy of ultrasound in detecting the depth of abnormally invasive placenta in women at risk. MATERIAL AND METHODS Prospective longitudinal study including women with placenta previa and at least one prior cesarean delivery or uterine surgery. Depth of abnormally invasive placenta was defined as the degree of trophoblastic invasion through the myometrium and was assessed with histopathological analysis. The ultrasound signs explored were: loss of clear zone, placental lacunae, bladder wall interruption, uterovesical hypervascularity, and increased vascularity in the parametrial region. RESULTS In all, 210 women were included in the analysis. When using at least one sign, ultrasound had an overall sensitivity of 100% (95% CI 96.5-100) and overall specificity of 61.9 (95% CI 51.9-71.2) for all types of abnormally invasive placenta. Using two ultrasound signs increased the diagnostic accuracy in terms of specificity (100%, 95% CI 96.5-100) but did not affect sensitivity. When stratifying the analysis according to the depth of placental invasion, using at least one sign had a sensitivity of 100% (95% CI 93.7-100) and 100% (95% CI 92.6-100) for placenta accreta/increta and percreta, respectively. Using three ultrasound signs improved the detection rate for placenta percreta with a sensitivity of 100% (95% CI 92.6-100) and a specificity of 77.2% (95% CI 69.9-83.4). CONCLUSION Ultrasound has a high diagnostic accuracy in detecting the depth of placental invasion when applied to a population with specific risk factors for anomalies such as placenta previa and prior cesarean delivery or uterine surgery.
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Affiliation(s)
- Giuseppe Cali
- Department of Obstetrics and Gynecology, Arnas Civico Hospital, Palermo, Italy
| | - Francesco Forlani
- Department of Obstetrics and Gynecology, Arnas Civico Hospital, Palermo, Italy
| | - Ilan Timor-Trisch
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, New York University SOM, New York, NY, USA
| | - José Palacios-Jaraquemada
- Center for Medical Education and Clinical Research (CEMIC), University Hospital, Buenos Aires, Argentina
| | - Francesca Foti
- Department of Obstetrics and Gynecology, Arnas Civico Hospital, Palermo, Italy
| | - Gabriella Minneci
- Department of Obstetrics and Gynecology, Arnas Civico Hospital, Palermo, Italy
| | | | - Lamberto Manzoli
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Alessandra Familiari
- Department of Obstetrics and Gynecology Catholic University of The Sacred Heart, Rome, Italy
| | - Giorgio Pagani
- Department of Obstetrics and Gynecology, Fondazione Poliambulanza, Brescia, Italy
| | - Giovanni Scambia
- Department of Obstetrics and Gynecology Catholic University of The Sacred Heart, Rome, Italy
| | - Francesco D'Antonio
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway.,Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway
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Calì G, Forlani F, Minneci G, Foti F, Di Liberto S, Familiari A, Scambia G, D'Antonio F. First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign. Ultrasound Obstet Gynecol 2018; 51:184-188. [PMID: 28233462 DOI: 10.1002/uog.17440] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 01/09/2017] [Accepted: 02/14/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Ultrasound assessment of the relationship between the ectopic gestational sac and the endometrial line (cross-over sign; COS) in Cesarean scar pregnancy (CSP) has been shown to be useful in predicting the evolution of CSP towards different types of abnormally invasive placenta (AIP). The aim of this study was to ascertain whether the COS can be used to predict surgical outcome in women with AIP. METHODS A retrospective analysis was performed of early first-trimester (6-8 weeks' gestation) ultrasound images of women with AIP managed in the third trimester of pregnancy. We hypothesized that assessment of COS may identify cases of AIP at higher risk of intra- or postsurgical morbidity. Outcomes explored were estimated blood loss during surgery, need for and amount of packed red blood cells and fresh frozen plasma units required either during or after surgery, operative time, intrasurgical complications, gestational age at birth, delivery < 34 weeks of gestation, length of hospital stay and admission to intensive care unit. Differences in the explored outcomes were assessed among women with different types of COS variant (COS-1, COS-2+ or COS-2-) as observed on first-trimester ultrasound examination. RESULTS Sixty-eight pregnancies were included in the study. Mean estimated blood loss was higher in AIP pregnancies with COS-1 than in those with COS-2+ (P = 0.039) or COS-2- (P = 0.01). Mean number of packed red blood cell units required during or after the operation was higher in women with COS-1 compared with those with COS-2+ (P = 0.001) and COS-2- (P = 0.029), while there was no difference between pregnancies with COS-2+ and those with COS-2- (P = 0.797). Mean operative time was longer in AIP pregnancies with COS-1 than in those with COS-2+ (P = 0.039) or COS-2- (P = 0.017). Finally, pregnancies with COS-1 were delivered earlier than those with COS-2+ (P = 0.0001) or COS-2- (P = 0.0001). CONCLUSION First-trimester ultrasound assessment of the relationship between the ectopic gestational sac and the endometrial line (COS) may identify women with AIP who are at higher risk of intra- or postsurgical morbidity. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G Calì
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - F Forlani
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - G Minneci
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - F Foti
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - S Di Liberto
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - A Familiari
- Department of Maternal-Fetal Medicine, Catholic University of The Sacred Heart, Rome, Italy
| | - G Scambia
- Department of Maternal-Fetal Medicine, Catholic University of The Sacred Heart, Rome, Italy
- Department of Women's and Children's Health, Catholic University of the Sacred Heart, Rome, Italy
| | - F D'Antonio
- Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
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Jauniaux E, Collins S, Burton GJ. Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging. Am J Obstet Gynecol 2018; 218:75-87. [PMID: 28599899 DOI: 10.1016/j.ajog.2017.05.067] [Citation(s) in RCA: 365] [Impact Index Per Article: 60.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 05/31/2017] [Indexed: 01/16/2023]
Abstract
Placenta accreta spectrum is a complex obstetric complication associated with high maternal morbidity. It is a relatively new disorder of placentation, and is the consequence of damage to the endometrium-myometrial interface of the uterine wall. When first described 80 years ago, it mainly occurred after manual removal of the placenta, uterine curettage, or endometritis. Superficial damage leads primarily to an abnormally adherent placenta, and is diagnosed as the complete or partial absence of the decidua on histology. Today, the main cause of placenta accreta spectrum is uterine surgery and, in particular, uterine scar secondary to cesarean delivery. In the absence of endometrial reepithelialization of the scar area the trophoblast and villous tissue can invade deeply within the myometrium, including its circulation, and reach the surrounding pelvic organs. The cellular changes in the trophoblast observed in placenta accreta spectrum are probably secondary to the unusual myometrial environment in which it develops, and not a primary defect of trophoblast biology leading to excessive invasion of the myometrium. Placenta accreta spectrum was separated by pathologists into 3 categories: placenta creta when the villi simply adhere to the myometrium, placenta increta when the villi invade the myometrium, and placenta percreta where the villi invade the full thickness of the myometrium. Several prenatal ultrasound signs of placenta accreta spectrum were reported over the last 35 years, principally the disappearance of the normal uteroplacental interface (clear zone), extreme thinning of the underlying myometrium, and vascular changes within the placenta (lacunae) and placental bed (hypervascularity). The pathophysiological basis of these signs is due to permanent damage of the uterine wall as far as the serosa, with placental tissue reaching the deep uterine circulation. Adherent and invasive placentation may coexist in the same placental bed and evolve with advancing gestation. This may explain why no single, or set combination of, ultrasound sign(s) was found to be specific for the depth of abnormal placentation, and accurate for the differential diagnosis between adherent and invasive placentation. Correlation of pathological and clinical findings with prenatal imaging is essential to improve screening, diagnosis, and management of placenta accreta spectrum, and standardized protocols need to be developed.
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Affiliation(s)
- Eric Jauniaux
- Elizabeth Garrett Anderson Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, United Kingdom.
| | - Sally Collins
- Nuffield Department of Obstetrics and Gynecology, University of Oxford, and the Fetal Medicine Unit, John Radcliffe Hospital, Oxford, United Kingdom
| | - Graham J Burton
- Center for Trophoblast Research, Department of Physiology, Development, and Neuroscience, University of Cambridge, Cambridge, United Kingdom
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Familiari A, Liberati M, Lim P, Pagani G, Cali G, Buca D, Manzoli L, Flacco ME, Scambia G, D'antonio F. Diagnostic accuracy of magnetic resonance imaging in detecting the severity of abnormal invasive placenta: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 2017; 97:507-520. [PMID: 29136274 DOI: 10.1111/aogs.13258] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 11/01/2017] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Accurate prenatal diagnosis of abnormally invasive placenta (AIP) is fundamental because it significantly reduces maternal morbidities. MATERIAL AND METHODS Medline, Embase, CINAHL and the Cochrane databases were searched. The primary aim of the present review was to elucidate the diagnostic accuracy of prenatal magnetic resonance imaging (MRI) in recognizing the severity of AIP, defined as the depth and topography of invasion. The secondary aim was to ascertain the strength of association between each MRI sign and the depth of placental invasion and to test their individual predictive accuracy in detecting such invasion. Inclusion criteria were studies on women who had prenatal MRI for ultrasound suspicion or the presence of clinical risk factors for AIP. Estimates of sensitivity, specificity, positive and negative likelihood ratios and diagnostic odds ratio were calculated using the hierarchical summary receiver characteristics curve model, and individual data random-effect logistic regression was used to calculate OR. RESULTS Twenty studies (1080 pregnancies undergoing MRI mainly for the ultrasound suspicion of AIP) were included. MRI showed a sensitivity of 94.4% [95% confidence interval (CI) 15.8-99.9], 100% (95% CI 75.3-100) and 86.5% (95% CI 74.2-94.4) for detection of placenta accreta, increta and percreta, respectively; the corresponding values for specificity were 98.8% (95% CI 70.7-100), 97.3% (95% CI 93.3-99.3), 96.8% (95% CI 93.5-98.7). MRI identified 100% of cases with S1 and 100% of those with S2 invasion confirmed at surgery. Among the different MRI signs, intra-placental dark bands showed the best sensitivity for the detection of placenta accreta, increta and percreta; as well as abnormal intra-placental vascularity, uterine bulging was associated with a higher risk of increta and percreta, exophitic mass and bladder tenting with placenta percreta. CONCLUSION Prenatal MRI has an excellent diagnostic accuracy in identifying the depth and the topography of placental invasion. However, these findings come mainly from studies in which MRI was performed as a secondary imaging tool in women already screened for AIP on ultrasound and might not reflect its actual diagnostic performance in detecting the severity of these disorders.
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Affiliation(s)
- Alessandra Familiari
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Fondazione Policlinico A. Gemelli, Rome, Italy
| | - Marco Liberati
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Philip Lim
- Department of Radiology, Abington Hospital, Abington, PA, USA
| | - Giorgio Pagani
- Department of Obstetrics and Gynecology, Fondazione Poliambulanza, Brescia, Italy
| | - Giuseppe Cali
- Department of Obstetrics and Gynecology, Arnas Civico Hospital, Palermo, Italy
| | - Danilo Buca
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Lamberto Manzoli
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | - Giovanni Scambia
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Fondazione Policlinico A. Gemelli, Rome, Italy
| | - Francesco D'antonio
- Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway.,Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
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Zeng C, Yang M, Ding Y, Yu L, Deng W, Hu Y, Gong X. Preoperative infrarenal abdominal aorta balloon catheter occlusion combined with Bakri tamponade reduced maternal morbidity of placenta increta/ percreta. Medicine (Baltimore) 2017; 96:e8114. [PMID: 28930860 PMCID: PMC5617727 DOI: 10.1097/md.0000000000008114] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Placenta increta/percreta is an increasingly common and life-threatening obstetric complication. It poses a management challenge to clinicians. The present study aimed to evaluate efficacy and safety of preoperative placement of infrarenal abdominal aorta balloon catheter (IAABC) alone or combined with Bakri tamponade for the management of cases with placenta increta/percreta. METHODS We retrospectively analyzed all cases with placenta increta/percreta at a tertiary referral teaching hospital in China between the year 2014 and 2017. Statistical analysis considered the individual subgroups: IAABC placed group and control group (without IAABC), and compared their maternal-fetal outcomes. RESULTS The study covered 86 cases with placenta increta. For cases in the IAABC placed group (n = 48), significant reductions were noted in maternal morbidity including estimated blood loss (EBL), EBL ≥ 2000 mL, blood products transfusions, postpartum hemorrhage, operative time, intensive care unit admission, and postoperative days (P < .05 for all). The overall rate of hysterectomy was much lower (4.2%vs 23.7%, P = .018), compared with those in the control group (n = 38). Furthermore, in the IAABC placed group, hysterectomy was avoided in a further 17 cases combined with Bakri tamponade. In the control group, 10 cases were successful in preserving uterus by Bakri tamponade. Four cases failed and needed reoperation (3 uterine arterial embolism, 1 hysterectomy). There were no differences in fetal outcomes between the 2 groups. Eighteen cases were diagnosed with placenta percreta. Almost all the cases (17/18) inevitably underwent caesarean hysterectomy. Only 1 case was treated with a combination of IAABC and Bakri tamponade, and successfully reserved uterus. No differences were observed in any other outcomes, except for a significant less mean operative time (P = .017) in cases with IAABC placed (n = 10), compared with those without IAABC (n = 8). Only 1 case had a femoral artery thrombosis directly related to IAABC placement and recovered after conservative treatment. There was no maternal or neonatal death in this study. CONCLUSION Prophylactic insertion of IAABC alone or combined with Bakri tamponade should be safe and effective in controlling intraoperative bleeding due to placenta increta, thus hysterectomy could be avoided. It seems to be less beneficial to women with placenta percreta. Bakri tamponade can be a good choice in the management of placenta increta/percreta before more aggressive surgeries.
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Jauniaux E, Collins SL, Jurkovic D, Burton GJ. Accreta placentation: a systematic review of prenatal ultrasound imaging and grading of villous invasiveness. Am J Obstet Gynecol 2016; 215:712-721. [PMID: 27473003 DOI: 10.1016/j.ajog.2016.07.044] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 07/02/2016] [Accepted: 07/20/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Determining the depth of villous invasiveness before delivery is pivotal in planning individual management of placenta accreta. We have evaluated the value of various ultrasound signs proposed in the international literature for the prenatal diagnosis of accreta placentation and assessment of the depth of villous invasiveness. OBJECTIVE We undertook a PubMed and MEDLINE search of the relevant studies published from the first prenatal ultrasound description of placenta accreta in 1982 through March 30, 2016, using key words "placenta accreta," "placenta increta," "placenta percreta," "abnormally invasive placenta," "morbidly adherent placenta," and "placenta adhesive disorder" as related to "sonography," "ultrasound diagnosis," "prenatal diagnosis," "gray-scale imaging," "3-dimensional ultrasound", and "color Doppler imaging." STUDY DESIGN The primary eligibility criteria were articles that correlated prenatal ultrasound imaging with pregnancy outcome. A total of 84 studies, including 31 case reports describing 38 cases of placenta accreta and 53 series describing 1078 cases were analyzed. Placenta accreta was subdivided into placenta creta to describe superficially adherent placentation and placenta increta and placenta percreta to describe invasive placentation. RESULTS Of the 53 study series, 23 did not provide data on the depth of villous myometrial invasion on ultrasound imaging or at delivery. Detailed correlations between ultrasound findings and placenta accreta grading were found in 72 cases. A loss of clear zone (62.1%) and the presence of bridging vessels (71.4%) were the most common ultrasound signs in cases of placenta creta. In placenta increta, a loss of clear zone (84.6%) and subplacental hypervascularity (60%) were the most common ultrasound signs, whereas placental lacunae (82.4%) and subplacental hypervascularity (54.5%) were the most common ultrasound signs in placenta percreta. No ultrasound sign or a combination of ultrasound signs were specific of the depth of accreta placentation. CONCLUSION The wide heterogeneity in terminology used to describe the grades of accreta placentation and differences in study design limits the evaluation of the accuracy of ultrasound imaging in the screening and diagnosis of placenta accreta. This review emphasizes the need for further prospective studies using a standardized evidence-based approach including a systematic correlation between ultrasound signs of placenta accreta and detailed clinical and pathologic examinations at delivery.
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Affiliation(s)
- Eric Jauniaux
- Department of Obstetrics and Gynecology, University College London Hospitals and University College London Institute for Women's Health, University College London, London, United Kingdom.
| | - Sally L Collins
- Nuffield Department of Obstetrics and Gynecology, University of Oxford, and the Fetal Medicine Unit, John Radcliffe Hospital, Oxford, United Kingdom
| | - Davor Jurkovic
- Department of Obstetrics and Gynecology, University College London Hospitals and University College London Institute for Women's Health, University College London, London, United Kingdom
| | - Graham J Burton
- Center for Trophoblast Research, Department of Physiology, Development, and Neuroscience, University of Cambridge, Cambridge, United Kingdom
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Balcacer P, Pahade J, Spektor M, Staib L, Copel JA, McCarthy S. Magnetic Resonance Imaging and Sonography in the Diagnosis of Placental Invasion. J Ultrasound Med 2016; 35:1445-56. [PMID: 27229131 DOI: 10.7863/ultra.15.07040] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 10/05/2015] [Indexed: 05/28/2023]
Abstract
OBJECTIVES To compare older and newer magnetic resonance imaging (MRI) criteria for placental invasion and to compare the sensitivity, specificity, and accuracy of MRI and sonography in determining the depth of placental invasion. METHODS Forty pregnant patients at high risk for morbidly adherent placenta based on prenatal sonography underwent MRI evaluations. Two reviewers, who were blinded to the original MRI and sonographic interpretations, clinical history, and obstetric/pathologic findings, reviewed the MRI examinations. The MRI and sonographic scans were analyzed for the presence and depth of invasion. The MRI scans were tabulated for the presence of dark intraplacental T2 bands, bulging of the myometrium, increased vascularity, and indistinct myometrium, loss of the dark T2 myometrial/placental interface, and a thin myometrium. The obstetric/pathologic results served as the reference standards. RESULTS Eighteen of 40 patients had a morbidly invasive placenta. The sensitivity, specificity, and accuracy of MRI and sonography were not significantly different. The accuracy rates for determining the depth of placental invasion by readers 1 and 2 were 0.65 and 0.55, respectively (P > .05). According to the Cohen κ statistic, there was a good inter-reader agreement between the MRI readers in assessing the depth of placental invasion (κ = 0.45). The features most commonly seen were dark T2 bands, bulging of the uterus, and loss of the dark T2 interface, which were all associated with the presence of placental invasion. CONCLUSIONS The diagnosis of placental invasion remains challenging on sonography and MRI, which perform similarly. The presence of 2 or more criteria adds specificity to the diagnosis of placental invasion on MRI.
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Affiliation(s)
- Patricia Balcacer
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut USA
| | - Jay Pahade
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut USA
| | - Michael Spektor
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut USA
| | - Lawrence Staib
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut USA
| | - Joshua A Copel
- Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, Connecticut USA
| | - Shirley McCarthy
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut USA
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Fox KA, Shamshirsaz AA, Carusi D, Secord AA, Lee P, Turan OM, Huls C, Abuhamad A, Simhan H, Barton J, Wright J, Silver R, Belfort MA. Conservative management of morbidly adherent placenta: expert review. Am J Obstet Gynecol 2015; 213:755-60. [PMID: 25935779 DOI: 10.1016/j.ajog.2015.04.034] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 04/24/2015] [Accepted: 04/27/2015] [Indexed: 11/16/2022]
Abstract
Over the last century, the incidence of placenta accreta, increta, and percreta, collectively referred to as morbidly adherent placenta, has risen dramatically. Planned cesarean hysterectomy at the time of cesarean delivery is the standard recommended treatment in the United States. Recently, interest in conservative management has resurged, especially in Europe. The aims of this review are the following: (1) to provide an overview of methods used for conservative management, (2) to discuss clinical implications for both clinicians and patients, and (3) to identify areas in need of further research.
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Affiliation(s)
| | | | | | | | - Paula Lee
- Duke University Medical Center, Durham, NC
| | - Ozhan M Turan
- University of Maryland School of Medicine, Baltimore, MD
| | - Christopher Huls
- Phoenix Perinatal Associates/Medivax, Banner Good Samaritan Medical Center, University of Arizona, Phoenix, AZ
| | | | - Hyagriv Simhan
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Jason Wright
- Columbia University College of Physicians and Surgeons, New York, NY
| | - Robert Silver
- University of Utah Medical School, Salt Lake City, UT
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Al-Khan A, Gupta V, Illsley NP, Mannion C, Koenig C, Bogomol A, Alvarez M, Zamudio S. Maternal and fetal outcomes in placenta accreta after institution of team-managed care. Reprod Sci 2013; 21:761-71. [PMID: 24336676 DOI: 10.1177/1933719113512528] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Abdulla Al-Khan
- 1Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Surgery, Hackensack University Medical Center, Hackensack, NJ, USA
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Pather S, Strockyj S, Richards A, Campbell N, de Vries B, Ogle R. Maternal outcome after conservative management of placenta percreta at caesarean section: a report of three cases and a review of the literature. Aust N Z J Obstet Gynaecol 2013; 54:84-7. [PMID: 24471850 DOI: 10.1111/ajo.12149] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 09/28/2013] [Indexed: 10/26/2022]
Abstract
Retaining the placenta in situ at caesarean section for placenta percreta and awaiting placental reabsorption is widely practiced; however, there is limited evidence on the efficacy and complications of this strategy. We present three cases of placenta percreta managed conservatively and note that all three women experienced significant complications. A review of the literature showed that despite initial conservative management, 40% of women subsequently require emergency hysterectomy and 42% will experience major morbidity.
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Affiliation(s)
- Selvan Pather
- The Sydney Gynaecologic Oncology Group, Sydney Cancer Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; University of Sydney, Camperdown, New South Wales, Australia
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