PlacentalAbnormalities:UltrasoundDiagnosis&Management
AlfredAbuhamad,MD.EasternVirginiaMedicalSchool
Disclosures
Nothingtodisclose
PlacentaAccretaSpectrum
• USfindingsinFirstTrimester• USfindingsinSecond&ThirdTrimesters• RecentLiterature-controversy• OptimizingyourUSDiagnosis• Management
WhyareweConcerned?• Risingincidence:1/2500to1/533pregnancies• 40-60%ofcasesarediagnosedintrapartumwithlittlepreoperativeplanning
• 71%ofplacentaaccretacasesrequireahysterectomy• 25%ofpatientswithplacentaaccretalose>5litersofblood
• Mortalityrateofcesareanhysterectomy1.6%butashighas10%withplacentapercreta
NICHD2009-Milleretal1997
Terminology
• Placentaaccreta:75%• Placentaincreta:18%• Placentapercreta:7%
AmJObstetGynecol1997;177:210-214
PlacentaAccretaSpectrumMorbidlyAdherentPlacenta
RiskFactors
AbuhamadA-UltrasoundinObstetricsandGynecology:APracticalApproach
RiskFactors
ClinPerinatol2011;38:285-296 ObstetGynecol2006;107:1226-32
CesareanSection/PlacentaPrevia
SonographicFindings
FirstTrimester
UltrasoundObstetGynecol2016;47:271–275
IntJGynecolObstet2018;140:274-280
AdaptedtheEuropeanConsensusGroupClassification
SMFMTaskForce
Boston,December2018
•SMFM•ACOG•AIUM•ISUOG•ACR•SRU•ARDMS
•StandardizedefinitionsofPASultrasoundmarkers•StandardizeultrasoundapproachtopregnanciessuspectedofPAS
SMFMTaskForce
Boston,December2018
FirstTrimester
bladder
GS
FirstTrimester
LowerUterineSegmentImplantation
•Databaseof90,435births•Placentaaccretain20•Firsttrimesterscanin7/20•Sacinlowersegmentin6/7
JofUltrasoundinMed2003;22:19
GestationalSacLocation
LowerUterineSegmentImplantation
JofUltrasoundinMed2003;22:19
GestationalSacLocation
LowerUterineSegmentImplantation
8weeks
LowerUterineSegmentImplantation
8weeks
LowerUterineSegmentImplantation
13weeks
LowerUterineSegmentImplantation
CesareanScarPregnancy
• 58casesforhistologicreview(37CSPand21EAP)• 2pathologistsreviewedslides• Lookingformyometrialinvasionw/ointerveningdecidua• Identicalhistopathologicalfeatures(kappa=0.93)
UltrasoundObstetGynecol2014;43:383–395
CesareanScarPregnancy
PostTreatmentwithMTXintoSac(10days)
CesareanScarPregnancy
Journal Ultrasound Medicine, August 2018
SonographicFindings
Second&ThirdTrimester
SMFMTaskForce
Boston,December2018
Multiplevascularlacunaewithinplacenta
JUltrasoundMed1992;11(7):333-343
•Firsttoclassifyriskbasedon#lacunae•NotethatallstudypopulationhadpriorCSandPlacentaprevia
SonographicFindingsMultiplevascularlacunaewithinplacenta(#Lacunae)
G0=0lacunaeG1=1-3lacunaeG2=4-6lacunaeG3=>6lacunae
UltrasoundObstetGynecol2006;28:178-182-JUM1992:11;333-343
Multiplevascularlacunaehaveveryhighpredictivepowerinassociationwithaplacentaprevia
PersonalObservation
Multiplevascularlacunaewithinplacenta
Multiplevascularlacunaewithinplacenta
Multiplevascularlacunaewithinplacenta
PathogenesisofPlacentalLacunae
Radiology1997;205:773-6–JUltrasoundMed1999;18:853-6–AJOG1990;163:723-727AmJObstetGynecol2004;190:1135-40–Radiographics2008;28:1905-16
Placentaltissuealterationsresultingfromlong-termexposuretopulsatilebloodflow
Lacunae–BloodFlowGrayScale
Lacunae–BloodFlowGrayScale&Color
Lacunae–BloodFlowGrayScale
Lacunae–BloodFlowColorDoppler
LacunaeinPlacentaAccretaSpectrum
BJOG2014;121:171–182
SMFMTaskForce
Boston,December2018
Normalhypoechoicretroplacentalzone
Normalhypoechoicretroplacentalzone
*
**
Lossofhypoechoicretroplacentalzone
Lossofhypoechoicretroplacentalzone
BJOG2014;121:171–182
Lossofhypoechoicretroplacentalzone
ObstetGynecol2004;104:527-30-ObstetGynecolSurv1998;53:509-17ObstetGynecol2004;190:1135-1140–JUltrasoundMed1992;11:333-343–Radiology1980;134:475-478–RCOG;2005:26.Green-topGuidelineNo.27.2011:26
•Falsepositiverateof21%orhigher•Shouldnotbeusedalone•Angledependent,canbeabsentinnormalanteriorplacentas
Lossofhypoechoicretroplacentalzone
XWhatdefinesanaccreta
Abnormalityoftheuterineserosa-bladderinterface
UltrasoundObstetGynecol2005;26:89-96–ObstetGynecol2006;108:573-81
-Interruptionofline-Thickeningofline-Irregularityofline-IncreasedvascularityoncolorDoppler
SonographicFindings
NormalUterineSerosa-BladderInterface
Bladder
Bladder
NormalUterineSerosa-BladderInterface
AbnormalUterineSerosa-BladderInterface
bladder
AbnormalUterineSerosa-BladderInterface
bladder
AbnormalUterineSerosa-BladderInterface
BJOG2014;121:171–182
AbnormalUterineSerosa-BladderInterface
SMFMTaskForce
Boston,December2018
CourtesyofDr.Belfort
NewMarker:PlacentalThickness
PlacentalThickness
UOGDecember2018
HowaboutColorDoppler&PAS?
• StrikingcolorDoppler• Bridgingvessels• Increasedretroplacentalflow
ColorDoppler&PAS
HowAccuratearePASUltrasoundMarkerswhenEvaluatedinaBlindedFashion?
- 55patientswithaccretaand56controls(previa)- De-identifiedUSstudies- Reviewedby6investigators,blindedtoDx
AmJObstetGynecol2014;211:177
- Placentallacunae(OR1.4–95%CI,1.3-1.6)- Lossofretroplacentalspace(OR2.2–95%CI,1.6-3.0)- Irregularbladderwall(OR1.3–95%CI,1.0-1.6)- ColorDopplerabnormalities(OR1.3–95%CI,1.1-1.4)
AmJObstetGynecol2014;211:177
WhySuchDisparity?• Lackofstandardizationofdefinitions• FIGO-SMFM
• Needforoptimizationofultrasoundexamination• SMFM
• Needformoreprospectivestudiestounderstandtheindependentvalueofeachmarker
HowCommonarePASUltrasoundMarkersinLow-RiskPregnancies?
Prospective, longitudinal cohort studyMay 2016 February 2017
Study Population
History of prior c-section
Second trimester scan (18-24 wks)
Third trimester scan (28-34
wks)
No history of prior c-section
Second trimester scan (18-24 wks)
Third trimester scan (28-34
wks)
Inclusion criteria: >18 years of age, singleton gestation presenting before gestational age of 24w, no known fetal anomalies or genetic conditions
AmericanJournalPerinatol-Dec2018
AmericanJournalPerinatol-Dec2018
AmericanJournalPerinatol-Dec2018
AmericanJournalPerinatol-Dec2018
UnderstandRelevanceofa-PrioriRisk
NoPrevia Previa
• Alwaysusethetransvaginalapproach• Evaluateplacentainrealtime&Magnify• AlwaysaddcolorDopplerinlowvelocity• Carefullyassessthelowersegment/cervicalarea(lookforcervicalinvasion)
• Developaprotocol• Stratifyriskforbleeding(High-Intermediate-Low)
HowtoOptimizeUltrasoundImaginginPAS?
HighRiskforBleeding
LowRiskforBleeding
IntermediateRiskforBleeding
PlacentaAccretaSpectrum:OptimizingtheOutcome
ComplicationsofPAS• Damagetolocalorgans• Postoperativebleeding• Amnioticfluidembolism• Consumptivecoagulopathy• Transfusion-relatedcomplications• Acuterespiratorydistresssyndrome• Postoperativethromboembolism• Infectiousmorbidities• Multi-systemorganfailure• Maternaldeath
AmJObstetGynecol1996;175:1632-8–HawaiMedJ2002;61:66-9–AmJObstetGynecol2010;203(5)430-439
ComplicationsofCesareanHysterectomy(NICHD2009)
Complication N=186 %
PRBC 156 83.9
FFP 59 31.7
Cryoprecipitate 22 11.8
Platelets 28 15.1
Postopfever 21 11.3
Ileus 10 5.4
Exlap 7 3.8
Maternaldeath 3 1.6
Bowelinjury 2 1.1
DVT 1 05
Ureteralinjury 6 3
Cystotomy 18 10
StepstoOptimizeOutcomeinPAS
UltrasoundObstetGynecol.2016;47:271–275.
IntJGynecolObstet2018;140:274–280
• LearnofPASsonographicmarkers• ReviewEuropean,FIGO&SMFMstandardization• Understandlimitations• Commoninlow-riskpopulation• Standardizeapproachtoultrasound(Protocol)
1-ImproveyourAntenatalDiagnosis
2-StandardizeyourAntenatalPreparation
• Createaprotocolandachecklist• Providepatientcounseling• Performfollow-upultrasounds• ConsideraPASclinic
2-StandardizeyourAntenatalPreparation• Assembleskilledmultidisciplinaryteam• Bestpelvicsurgeons• Skillednursingteams• Experiencedanesthesiology• Interventionradiology• Urology• Bloodbank(massivetransfusion)• SkilledORteam• Criticalcare
MultidisciplinaryCareTeam
ObstetGynecol2011;117:331
ObstetGynecol2011;117:331–AJOG1996;175:1632-1638
PlannedDelivery•AssociatedwithshorterORtimes•Lowerfrequencyoftransfusions•LowerICUadmission
•LargenumberofpatientswithPASreporthemorrhageafter35weeks
3-PlanCesareanDeliveryat34-37Weeks
4-OptimizeSurgicalApproach
• Considermidlineskinincision• Ultrasoundmappingofplacentalimplantationsiteintraoperatively
• Classicaluterineincisionaboveplacenta• Cesareanhysterectomywithplacentaleftinsitu
• Uterinestapler(ifdecisionforhysterectomy)• Abdominalretractors:Bookwalterretractor• Appropriatesizeclamps:Mastersonclamps• Ligasureimpactcoagulator• Bipolarcauteryforceps• Appropriatesutures• Cellsaversuction
4-OptimizeSurgicalApproach
• MassivebloodlossandHypovolemicshock:-Starttransfusionearlyandstayaheadofbleeding -Rapidrestorationofeffectiveintravascularvolume -Cellsaver -AvoidstateofDIC -Avoidacidosis -FactorVII&Tranexamicacid
4-OptimizeSurgicalApproach
• Recommenda1:1ratioofPRBCtoFFP
• Hypothermia–Providewarmcoveringforpatient(bearHug)–Warmirrigationsaline
4-OptimizeSurgicalApproach
• Electrolyteabnormalities–Majorriskforarrhythmias–Checkregularlyandcorrectintraoperatively(K)
4-OptimizeSurgicalApproach
• Stagedsurgicalapproach(interventionradiology)
• Considerconservativemanagementformassivepercreta–couldbelifesavingifunprepared
4-OptimizeSurgicalApproach
StagedSurgicalApproach
AmJObstetGynecol2010;202:38.e1-9.
StagedSurgicalApproach
AmJObstetGynecol2010;202:38.e1-9.
ConservativeTreatmentPlacentaleftinsitu
Total cases 167
Successful conservative management 131 (78%)
Spontaneous placental resorption 87 (75%)
Severe maternal morbidity 10 (6%)
ObstetGynecol2010Mar;115(3):526
• ICUadmissionswithcriticalcare• Monitorbleedinginfirst24hours• Monitorelectrolytesandlungfunction• Roleforinterventionradiologyifstable
5-OptimizePostoperativeCare
Placenta Accreta Spectrum Case Presentation:
How Complicated Can It Gets!
Patient History
•31yearold•G2P1001•OnepriorCSforfailuretoprogress•PrenatalcarewithMaternal-FetalMedicine•Historyofkidneystones•Prenatalcarestartedinfirsttrimester
12 Weeks
12 Weeks
23 Weeks
Patient referred to our PAS Clinic
- Counseling- Anesthesiaconsult- Interventionradiologyconsult- Coordinationforcesareanhysterectomy
27 Weeks
12 Weeks
Patient History
•PresentedtoLabor&Deliveryunitwithabdominalpain&earlylaborat33weeksofgestation
•Decisiontoproceedwithcesareandelivery•Discussedconservativemanagement•Preparationforpossiblehysterectomy
Stonefoundinleftureter
Intraop Findings•Followingdeliveryofbaby,heavybleedingwasnotedfromthecervix
•Conservativemanagementwasnotanoption
•Plantoproceedwithhysterectomy•Activatedmassivetransfusionprotocol
Intraop Findings
•Followingdeliveryofbaby–•DropinBP•Maternaltachycardia
Attributedtobleeding
Intraoperative Findings
• Intraop,patientnotedtogointomassivepulmonaryedemaandrightheartfailure
•MassiveamountofpleuralfluidpouringfromETTube
Intraoperative Findings
•Transesophagealechonotesrightheartfailure•Normalelectrolytes•PatientgoesintoDICwithsignificantpelvicoozing
Intraoperative Findings
•SuspectedDiagnosis:•TRALI(Transfusionrelatedacutelunginjury)or•AmnioticFluidEmbolism(BPdropimmediatelyafterdeliveryofbaby)
Intraoperative Management
•Bluetowelclosure•Packabdomen•Keepfasciaopen•Placedrains(vacuum)•Coverwithplasticadhesive
GivenSeverityofLundDiseaseandRightHeartFailure
OnlyOptiontoConsiderisECMO
Intraoperative Management•ECMO(extra-corporealmembraneoxygenation)
Postoperative care•CardiacICUadmission•ECMOfor48hours•BacktoORforabdomenclosurein48hours•Nephrostomyforleftrenaldrainage•Lithotripsyday4forureteralstone•Hospitaldischargeday7postop•Nephrostomytuberemoved2weekslater
Patient’sconsentobtained
4weekspostoperative
TakeHomeMessage• KnowthematernalriskfactorsforPAS• KnowthesignificanceandlimitationsofUltrasoundmarkersinPAS
• Beconservative,whenindoubt-callaccreta• Considerdeliveryat34-37weeksforaccreta• Multidisciplinaryapproachtocare• Aggressivetransfusion&resuscitation• Plan–Plan–Plan
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