Prenatal identification of invasive placentation using ultrasound in women with placenta previa and prior cesarean delivery.

To evaluate the performance of ultrasound for antenatal identification of invasive placentation in women with placenta previa in the setting of prior cesarean delivery. This was a multicenter, retrospective, cohort study. Singleton pregnancies at risk of placenta accreta because of persistent placenta previa in the setting of prior cesarean delivery who delivered at four centers, from January 2010 to May 2020, were included in the study. For this study, pregnancies with diagnosis of accreta, increta, or percreta were considered under the umbrella term of placenta accreta. All women with placenta previa identified in the second trimester had a follow-up ultrasound at 32-34 weeks. Only those with prior cesarean delivery were considered at risk of placenta accreta. Women were considered with suspected accreta in case of suspected prenatal ultrasound. Women with suspected placenta accreta had delivery planned via cesarean hysterectomy at 34+0 - 35+6 weeks, without any attempt to remove the placenta. The primary endpoint of the study was the performance of ultrasound for antenatal identification of invasive placentation. The following ultrasound signs were evaluated: placenta lacunae; loss of clear space; increased vascularity between myometrium and placenta; intracervical lake; rail sign; uterovesical hypervascularity; increased vascularity in the inferior part of the lower uterine segment potentially extending into the parametrial region; and disruption of bladder-myometrial interface. 180 singleton pregnancies with placenta previa in the setting of prior cesarean delivery were identified. Of them, 155 (86.1%) had antenatal suspected placenta accreta based on ultrasound, having at least one sign of invasive placentation. Of the 155 suspected cases, 99 had confirmed placenta accreta at the time of delivery. Among the 99 cases of confirmed placenta accreta, all of them had at least one sign of invasive placentation at ultrasound. Among the 81 cases with placenta previa, prior cesarean delivery, without placenta accreta, 25/81 (30.9%) had ultrasound scan negative for sign of invasive placentation, and 56/81 (69.1%) had at least one sign of invasive placentation). In particular, 12/81 (14.8%) had placenta lacunae, 16/81 (19.8%) had loss of clear space, 20/81 (24.7%) had increased vascularity between myometrium and placenta, 9/81 (11.1%) had intracervical lake, 14/81 (17.3%) had rail sign, 14 (17.3%) had uterovesical hypervascularity, 5/81 (6.2%) had increased vascularity in the inferior part of the lower uterine segment potentially extending into the parametrial region, 8/81 (9.9%) had disruption of bladder-myometrial interface. In the group of women with confirmed placenta accreta, the most common sign recorded was the disruption of bladder-myometrial interface, being recorded in 88/99 women. Disruption of bladder-myometrial interface had the highest sensitivity in detection placenta accreta. Women with disruption of bladder-myometrial interface at ultrasound had 73-fold increase in the risk of placenta accreta compared to those who did not. Prenatal ultrasound has an excellent diagnostic accuracy in identifying invasive placentation in women with placenta previa and prior cesarean delivery.

Califano G ，Saccone G ，Maria Maruotti G ，Bartolini G ，Quaresima P ，Morelli M ，Venturella R ，Votino C ，Morlando M ，Sarno L ，Miceli M ，Mazzulla R ，Collà Ruvolo C ，Nazzaro G ，Locci M ，Guida M ，Berghella V ，Bifulco G ... -  《-》

Evaluation of preoperative ultrasound signs associated with bladder injury during complex Cesarean delivery: case-control study.

Hussein AM ，Thabet MM ，Elbarmelgy RA ，Elbarmelgy RM ，Jauniaux E ... -  《-》

Exploring pathophysiological insights to improve diagnostic utility of ultrasound markers for distinguishing placenta accreta spectrum from uterine-scar dehiscence.

Accurate differentiation between placenta accreta spectrum (PAS) and uterine-scar dehiscence with underlying non-adherent placenta is often challenging, even for PAS experts, both prenatally and intraoperatively. We investigated the use of standardized two-dimensional grayscale ultrasound and Doppler imaging markers in differentiating between these closely related, yet distinct, conditions. This was a retrospective cohort study conducted in two centers with specialized PAS services. All consecutive women with at least one previous Cesarean delivery and a current pregnancy with a low-lying placenta or placenta previa, for whom detailed prenatal ultrasound, management and outcome information was available for review by the research team, were included. PAS was diagnosed clinically by the abnormal adherence of the placenta to the uterus. The PAS cases were classified using the International Federation of Gynecology and Obstetrics clinical classification. Grade 1 was considered low-grade PAS while Grades 2 and 3 were classified as high-grade PAS. The ultrasound markers were categorized according to their underlying pathophysiology, including lower uterine segment (LUS) remodeling, uteroplacental vascular remodeling and serosal hypervascularity. The combined ultrasound features were analyzed among the PAS and non-PAS subgroups using the chi-square test or Fisher's exact test, and univariable and multivariable logistic regression analysis. Additionally, receiver-operating-characteristics (ROC) curves were used to evaluate the diagnostic accuracy of the combined ultrasound features in differentiating between high-grade PAS and uterine-scar dehiscence. Out of the 150 cases retrieved, six cases were excluded for not meeting the eligibility criteria. The included 144 cases comprised 89 cases of PAS, 23 cases of uterine-scar dehiscence and 32 cases of uncomplicated low-lying placenta or placenta previa. Among the PAS cases, there were 16 cases of low-grade PAS and 73 of high-grade PAS. Combined signs of LUS remodeling were present in most cases of uterine-scar dehiscence (20/23 (87.0%)) and high-grade PAS (67/73 (91.8%)) (P = 0.444), while these signs were absent in cases of low-grade PAS (0/16) and uncomplicated low-lying placenta or placenta previa (0/32). A subgroup analysis of cases with all LUS remodeling features present revealed that the combined signs of serosal hypervascularity (adjusted odds ratio (aOR), 41.2 (95% CI, 7.5-225.3)) and uteroplacental vascular remodeling (aOR, 116.0 (95% CI, 15.3-878.3)) were significantly associated with high-grade PAS. Diagnostic accuracy testing within this subgroup revealed an area under the ROC curve (AUC) of 0.90 (95% CI, 0.81-0.99), sensitivity of 89.6% (95% CI, 79.7-95.7%) and specificity of 90.0% (95% CI, 68.3-98.8%) for the diagnosis of high-grade PAS when all signs of uteroplacental vascular remodeling were present. If both signs of serosal hypervascularity were present, the AUC was 0.84 (95% CI, 0.74-0.95) with a sensitivity of 83.6% (95% CI, 72.5-91.5%) and specificity of 85.0% (95% CI, 62.1-96.8%) for the diagnosis of high-grade PAS. The combined ultrasound markers of LUS remodeling are common in both high-grade PAS and uterine-scar dehiscence, while the combined features of abnormal vascularity (uteroplacental vascular remodeling and serosal hypervascularity) are specific to high-grade PAS. Understanding these pathophysiological differences would enhance the diagnostic accuracy of ultrasound in distinguishing between these two conditions. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Adu-Bredu T ，Aryananda RA ，Mathewlynn S ，Collins SL ... -  《-》

Up-front dissection of the uterovesical space or "bladder-first approach" reduces hemorrhage and bladder injury during hysterectomy for placenta accreta spectrum: reconfirmed in 78 more cases in a prospective single-center study.

Cesarean hysterectomy for placenta accreta spectrum disorder may be associated with severe hemorrhage because of placental invasion of the myometrium and the uterovesical space or parametrium. It leads to serious complications, such as massive hemorrhage requiring massive transfusion, coagulopathy, bladder and ureteric injuries, need for intensive care unit admission and prolonged hospital stay. To reduce the complications of cesarean hysterectomy for placenta accreta spectrum disorder, ongoing efforts are being made to develop different surgical approaches. In previous 12 cases upfront dissection of uterovesical space (bladder-first approach) before delivery of the neonate was observed to reduce hemorrhage arising from extensive neovascularization in this area and bladder injury. This study aimed to assess the efficacy of the bladder-first approach in a large sample to reduce the complications of cesarean hysterectomy for placenta accreta spectrum disorder. This study presented data of 78 women (2017-2022) who underwent cesarean hysterectomy for placenta accreta spectrum disorder using the "bladder-first approach" from a tertiary care institute in Chandigarh, India. In this surgical approach, dissection of the uterovesical fold from the lower uterine segment to the cervix was performed before making the uterine incision for delivery. During this dissection, vascular areas were isolated and coagulated with bipolar electrosurgery or ligated with silk suture and then divided. The 78 women with placenta accreta spectrum disorder underwent cesarean hysterectomy under general anesthesia. The mean gestational age was 35.0±2.5 weeks (range, 25.4-38.0), the mean blood loss was 1.56±1.06 L (range, 0.40-5.00 L), and the mean number of blood transfusions was 2.08±2.10 units (range, 0.00-9.00). Bladder injury occurred in 3 of 78 women (3.8%), and intensive care unit admission (for ≤24 hours) was needed by 3 of 78 women (3.8%). Histology was available in 73 of 78 women (19 with placenta percreta, 23 with placenta increta, and 31 with placenta accreta). There were 3 of 78 antenatal stillbirths. Of note, 75 women had live-born neonates, including 2 pairs of twins. The Apgar score of ≤7 at 5 minutes was seen in 6 of 77 neonates, and 20 of 77 neonates required neonatal intensive care unit care. There was 1 neonatal death on day 3 of life because of extreme prematurity and sepsis. In addition, 74 women went home with neonates, including 2 pairs of twins. Our data support that up-front dissection of the uterovesical space or "bladder-first approach" reduces hemorrhage and bladder injury during cesarean hysterectomy in placenta accreta spectrum disorder, with no adverse effect on neonatal outcome. Achieving peripheral vascular control of the neovascularized uterovesical area before achieving control of the central vascular supply (uterine arteries) reduced intraoperative hemorrhage. This approach requires no additional resource and can be implemented easily in developing countries.

Saha PK ，Bagga R ，Singla R ，Arora A ，Jain V ，Suri V ，Jain K ，Kumar P ，Gupta N ，Jain A ，Singh T ，Mavuduru RS ... -  《-》

Bladder involvement in placenta accreta spectrum disorders: 2D US combined with the 3D crystal Vue and MRI comparative analysis.

Placental accreta spectrum (PAS) disorder with bladder involvement is found to be associated with severe maternal and neonatal morbidity.When planning surgery or other treatments, a diagnosis and assessment of the invasiveness of placenta accreta spectrum disorder with bladder involvement are crucial.The detection of the depth of villi invasion can be accomplished with both MRI and US.The advent of three-dimensional Crystal Vue provides details additional information for scanning abnorma issue. Our goal was to compare and assess the diagnostic accuracy of 2D US combined with the 3D Crystal Vue and MRI in case of placenta accreta spectrum (PAS) involving the bladder. 111 pregnancy patients between May 2019 and November 2023 at the First Affiliated Hospital of Anhui Medical University whether or not they had placenta previa were included in the study if they were diagnosed of having placenta increta (PI) or placenta percreta (PP).Both US and MRI were used to evaluate the pregnant women.Total 53 pregnant women were ultimately included in our analysis.53 patients were split into groups with and without bladder involvement. They underwent 2D US,3D Crystal Vue, and MRI.The visual features of every subject were noted. Next, we analyzed the fundamental information, associated medical history, pregnancy outcomes, and different US and MRI signals between the two groups. To determine the potential contributing factors of PAS complicated with bladder involvement, a univariate analysis was performed. A multivariable logistic regression analysis was performed to identify US and MRI findings predictive of bladder involvement in placenta accreta spectrum. Multiple logistic regression analysis found that the bridging vessels (OR, 31.76,95% CI, 1.64-614.31,p = 0.022) and the tramline sign "fully" obliterated on Crystal Vue feature (OR, 68.92;95%CI,6.76-702.35,p < 0.001) were independently associated with an increased likelihood of bladder involvement. These findings when combined allowed for the prediction of bladder involvement with an 88.2% sensitivity, a 94.4% specificity, and an AUC of 0.933 (95% CI,0.829-0.983, p = 0.001). The results of the MRI logistic regression analysis were as follows: the three independent risk factors for bladder involvement were: Placental bulge (OR,57.99,95%CI,3.89-835.80,p = 0.003),Bladder wall interruption (OR,11.93, 95%CI, 1.60-88.85, p = 0.016), and Bladder vessel sign (OR, 9.75,95%CI, 1.43-66.21, p = 0.020).The joint diagnosis showed a sensitivity of 94.1% and specificity of 83.3%.The area under the curve was 0.942(95%CI,0.841-0.988). Regarding projected bladder involvement, there were no statistically significant differences between MRI and 2D integrated 3D Crystal Vue imaging. Both 2D coupled 3D Crystal Vue imaging and MRI are highly effective for predicting bladder invasion.Ultrasound is preferred over MRI because it is more convenient and more affordable.Among them, the tramline sign "fully" obliterated on 3D Crystal Vue was a new and reliable US sign for detecting bladder involvement.

Shuai X ，Gao C ，Zhang H ，Zhang T ，Li H ，Yan Y ，Yao W ，Liu Y ，Zhang C ... -  《BMC Pregnancy and Childbirth》