Placenta Accreta Spectrum · • 71% of placenta accreta cases require a hysterectomy • 25% of patients with placenta accreta lose >5 liters of blood • Mortality rate of cesarean

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


JofUltrasoundinMed2003;22:19

GestationalSacLocation


8weeks


8weeks


13weeks


CesareanScarPregnancy

• 58casesforhistologicreview(37CSPand21EAP)• 2pathologistsreviewedslides• Lookingformyometrialinvasionw/ointerveningdecidua• Identicalhistopathologicalfeatures(kappa=0.93)

UltrasoundObstetGynecol2014;43:383–395


PostTreatmentwithMTXintoSac(10days)


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




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


BJOG2014;121:171–182


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


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


bladder


BJOG2014;121:171–182


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




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


• MassivebloodlossandHypovolemicshock:-Starttransfusionearlyandstayaheadofbleeding -Rapidrestorationofeffectiveintravascularvolume -Cellsaver -AvoidstateofDIC -Avoidacidosis -FactorVII&Tranexamicacid


• Recommenda1:1ratioofPRBCtoFFP

• Hypothermia–Providewarmcoveringforpatient(bearHug)–Warmirrigationsaline


• Electrolyteabnormalities–Majorriskforarrhythmias–Checkregularlyandcorrectintraoperatively(K)


• Stagedsurgicalapproach(interventionradiology)

• Considerconservativemanagementformassivepercreta–couldbelifesavingifunprepared


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


•Transesophagealechonotesrightheartfailure•Normalelectrolytes•PatientgoesintoDICwithsignificantpelvicoozing


•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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Documents

Placenta Accreta Spectrum · • 71% of placenta accreta cases require a hysterectomy • 25% of patients with placenta accreta lose >5 liters of blood • Mortality rate of cesarean