State of the art management - oaawebcast.info · Morbidly adherent (invasive) placenta Placenta Creta 1 in 2500 deliveries (1667-67,000)* Pathological diagnosis Absence decidua basalis

OAA 2014

Abnormally invasive placenta

State of the art management

S RobsonProfessor of Fetal Medicine

Newcastle University

Placenta Creta

Problems with interpreting literature

• Histological definition clinical definition

• Rarely distinguish between different types of creta- Management / risk of percreta >> increta >> accreta

• Reports typically focus on prenatal diagnosis (PD)

or operative management (influenced by PD)- Few prospective series of prenatally detected cases

• Case series (rarely multicentre)

• No (never will be) RCTs of management

• Very few ‘experts’


Histological Classification

• Accreta Direct attachment of EVT to myometrium

• Increta EVT invasion into myometrium

• Percreta EVT invasion to serosa and/or adjacent

structures

X40

CK/PAS

X40

CK/PAS

Morbidly adherent (invasive) placenta

Placenta Creta

1 in 2500 deliveries (1667-67,000)*

Pathological diagnosis

Absence decidua basalis between placental villi and myometrium

* 1 in 30,000 deliveries in 1960

Clinical diagnosis

No placental separation after 20 min. (despite active management III stage)

Partially or totally adherent placenta

1 in 1000 deliveries (533-2564*)

Eshkoli et al. 2013*

NE & NC SCN

Referrals to Newcastle for placenta creta

screening/surgery

N

Abnormally invasive placenta in UK;

UKOSS

• 134 confirmed cases (1.7/10,0000 maternities)

• 65% accreta, 5% increta, 29% percreta

• Suspected prenatally in 66 (50%) - 42% by US + MRI, 48% by US, 9% MRI

- More likely to have planned CS, no attempt at placental removal

Fitzpatrick

et al. 2014

- No difference in EBL [~3 L], need for transfusion or hysterectomy

No attempt to

remove placenta

27 (41%)

Hysterectomy

16 (59%)

No hysterectomy

11 (41%)

>24 h PN - 3 (19%)

Attempt to

Remove placenta

39 (59%)

Hysterectomy

27 (69%)

>24 h PN -- 0

No hysterectomy

12 (31%)

Suspected antenatally (n=66 [50%])

Placenta creta

Risk Factors

• Caesarean section

• Placenta praevia*

• Uterine currettage(repeated / post delivery)

• Uterine surgery

• Endometrial ablation

• Endometritis

• Advanced age

• IVF

0

2

4

6

8

10

Incid

en

ce %

0

10

20

30

40

50

60

70

0 1 2 3 4+No.

CS

Clark et al 1985

Creta

Praevia

70% of cases

Placenta creta

Risk Factors

Caesarean

delivery

Placenta

praevia

No placenta

praevia

First 3.3 0.03

Second 11 0.2

Third 40 0.1

Fourth 61 0.8

Fifth 67 0.8

≥ Sixth 67 4.7

Silver et al. 2006.


Diagnosis

• Clinical suspicion

• 2D US, colour Doppler (± 3D Doppler)

• pMRI

• At delivery


Purpose of prenatal diagnosis

Avoid False Negative

Undiagnosed major invasion at CS

Risk of major

morbidity/mortality

from haemorrhage

Avoid False Positive

Unnecessary caesrean hysterectomy

Risk of major

surgical

morbidity/mortality


Purpose of prenatal diagnosis

Avoid False Negative Avoid False Positive

Correct diagnosis

(Degree / extent of invasion)

Plan appropriate surgery

Minimise risk of morbidity/mortality

Preserve fertility (where appropriate)


Ultrasound features

• Lacunae (Gray scale + Colour Doppler)

• Loss of retroplacental hypo-echoic zone(Gray scale)

• Abnormalities of uterus-bladder inferface(Gray scale + Colour Doppler)

• Abnormal placental vascularization

(3D Power Doppler)

Abnormally invasive placenta: US Features

Lacunae

• Large (> 1cm), Irregular shape

• Vascular (turbulent flow > 15 cm/sec)• Visible from 12-14 wk

• Overall Se 77.4%, Sp 95%(D’Antonio et al. 2013)


Lacunae

• Large (> 1cm), Irregular shape

• Vascular (turbulent flow > 15 cm/sec)• Visible from 12-14 wk

• Overall Se 77.4%, Sp 95%(D’Antonio et al. 2013)


Lacunae

AIP Grade 0None

Grade 11-3 small

Grade 24-6 larger,

more irregular

Grade 3*> 6 large,

irregular

None 22 6 - -

Accreta 3 4 1 -

Increta - - 5 4

Percreta - - 5 1

Total 25 10 11 5

• Grade predicts degree of invasion

51 women with placenta praevia + previous CS

*Finberg & Williams 1992Yang et al. 2006


Lacunae

• Grade predicts degree of invasion

51 women with placenta praevia + previous CS

*Finberg & Williams 1992Yang et al. 2006

Se (%) Sp (%) PPV (%) NPV (%)

Any AIP when lacunae

≥ Grade 1

86.9 78.6 76.9 88.0

In-/per-creta when

lacunae ≥ Grade 2

100 97.2 93.8 100


Loss of retroplacental hypoechoic zone

• Reflects loss of basal decidua & retroplacental vascular

bed

• Overall Se 66.5%, Sp 95.8% (D’Antonio et al. 2013)


Abnormalities of uterus/bladder interface

• Reflects invasion of placenta through bladder

mucosa and/or neovascularization at placenta/bladder

interface

• Overall Se 50%, Sp 99.75% (D’Antonio et al. 2013)


Placental MRI

• 1.5-T superconducting systems

• T1- and T2-weighted sequences. - Single-shot fast spin-echo T2-weighted sequences (HASTE)

- True fast imaging with steady-state precession (FISP)

• Acquisition of sequences in all 3 planes - Sagittal – invasion topography (S1 vs S2)

- Coronal / axial – degree/extent of invasion

• Imaging time typically < 30 min.

• Diffusion-weighting

• Gadolinium-based contrast enhancement - Delineation of the myometrium-placenta interface


Placental MRI features

• Heterogeneous signal intensity- Large, tortuous disorganized placental vessels

- High signal on FISP indicative of vascular flow

- Se 78.6%, Sp 87.7% (Bhide et al. 2014)

• Interruption of myometrium- Thinning & disruption inner layer of

myometrium

- Difficult to identify without enhancement

- Se 92.0%, Sp 75.6% (Bhide et al. 2014)

• Dark intraplacental bands (T2)

- ? Secondary to fibrin deposition

- Number /size of bands degree of AIP.

- Se 87.9%, Sp 71.9% (Bhide et al. 2014)

Sagittal

Coronal


Placental MRI features

*BL

*

E

*BL

PL

*

**

*

Coronal Sagittal

• Parametrial and bladder Invasion

Axial

Extensive vascularity at the placenta/bladder interface (without

intervening myometrium) is diagnostic of placenta percreta

Morbid adherent placenta

MRI vs US diagnosis: SR & meta-analysis

4 studies where both tests carried out on same population &

radiologist blinded to final results

Bhide et al.

2014

Se 92.9 (82.4-97.3) %

Sp 93.5 (82.2-97.8) %

LR+ 14.2 (4.92-41.1)

LR - 0.08 (0.03-0.20)

Se 87.8 (74.4-99.6) %

Sp 96.3 (76.7-94.4)) %

LR+ 24.0 (2.81-205.0)

LR - 0.13 (0.03-0.27)

No difference

in Se (p=0.24)

or Sp (p=0.91)

Placenta Creta

Accuracy of prenatal diagnosis

Warshak et al

2006

Esakoff et al.

2011

Cali et al.

2013*

Chalubinski et

al. 2013

Newcastle

453 (9)

108 (23)

187 (22)

232 (14)

125 (16)

77.0

88.5

89.5

100

91.4

94.5

75.0

91.0

100

96.1

100

95.9

90.6

91.4

65.0

100

68.0

100

80.0

85.2

62.5

98.0

82.3

97.6

100

98.4

94.5

95.0

Author Screened Se Sp PPV NPV

(% with creta) (%)

MRI

Placenta Creta

Accuracy of prenatal diagnosis

Warshak et al

2006

Esakoff et al.

2011

Cali et al.

2013*

Chalubinski et

al. 2013

Newcastle

453 (9)

108 (23)

187 (22)

232 (14)

94 (16)

77.0

89.5

100

91.4

94.5

91.0

96.1

100

95.9

90.6

65.0

68.0

100

80.0

85.2

98.0

97.6

100

98.4

94.5

Author Screened Se Sp PPV NPV

(% with creta) (%)Number Without creta Creta

Criteria (n=146) (n=41)

Five

Four

Three

Two

One

None

0

0

0

0

49

97

8*

8+8*

12

5

0

0

Three 2D & two 3D criteria

8* Percreta

Abnormally invasive placenta:

Ultrasound diagnosis

US Features

None

Exclude AIP

False negative rate

<2%

No pMRI

One / Two

Possible AIP

pMRI- Confirm diagnosis

- Degree/topography

of invasion

Three

AIP - in/per-creta

pMRI- Bladder invasion

- Parametrial invasion


Management

Previous CS +

Low lying (anterior) placenta

US (< 28 wk)

Previous myomectomy

Previous endometrial ablation

pMRI

MDT

FM specialist

Urogynaecologist

Radiologist (IR)

Anaesthetist

Consent to surgical plan

(by 30 wk)

Type (in/percreta vs accreta)

GA at delivery

Regional/general anaesthetic

IIA / aortic balloon catheters

Ureteric stenting

Incision (skin/uterus)

Placental removal

Hysterectomy

Placental resection

Cell salvage / blood products

Placenta creta

Surgical anatomy – Uterine Blood Supply

1. Ovarian arteries (10%)[Aorta]

2. Uterine arteries (90%)[Internal iliac artery]

3. Cervical arteries[67% from UA, 23% VAs]

4. Vaginal arteries

Upper

Middle

Lower [Internal Pudendal Artery]

[Internal Iliac Artery, Lower Vesical Artery

Uterine artery]

Palacios

Jaraquemada

et al 2007

Placenta creta

Surgical anatomy – 2 vascular areas

S1

Post myomectomy

S2

Post CS

Placenta creta – Surgical Management

Prenatal diagnosis - High risk in/per creta

Not suitable for conservative approach

In/per creta

confirmedR

Hysterotomy / cord ligation

Placenta left in-situ

Proximal vascular control

- Endovascular occlusion

Ligation NFV [VUS, PVS, CUS]

Hysterectomy

S2 - In- or per-creta

S1 - Area > 50% axial circumferenceNo desire for future pregnancyMultiple prior CS

Age > 40 years

Consent (for resective procedure)

CS by 35 wk (Midline incision)

GA, Cell salvage + blood products

Urogynaecologist ureteric stents

Aortic or Int. Iliac balloon catheters



Wish to preserve fertility

Consent (for conservative or resective procedure)



(Uro) Gynaecologist in theatre

In/per creta

confirmedC



[Uterine artery embolization]

[Methotrexate]

3 mo

9 mo

Advise about infection / haemorrhage

Follow up [4, 8, 12 .......wk]

Hb, Fibrinogen, CRP, US [ MRI]

Spontaneous expulsion

Reabsorption

Placental removal

Hysterectomy

Case series of ‘Conserving’ CS in MAP

Courbiere et al. 2003 R N 13 84%

Kayem et al. 2004 R N 20 85%

Timmermans et al. 20071 R N 60 80%

Sentilhes et al. 20102 R N 167 78%

Amsalem et al. 2011 R Y 10 60%

1Review of 48 (case) reports2Review of experience from 25 French centres

Author Design Comparison N Uterine

with CH preservation

Difficulties in interpretation

• Prenatal diagnosis (planned vs. emergency)

• Conservation (complete vs. partial)

• Selection

Management of Placenta creta – ‘Conservative options

Expertise/training

Exclusions

Dissection / risk UT damage

2º Haemorrhage

Infection/Sepsis

Coagulopathy/Thromosis

Failure → Hysterectomy

Recurrent AIP

In-situ placenta

-

+

-

+++

++

++

++

+++

10-20%

30% / 10%

10%

28-40%

30%

1º PPH → CH (18%)

Sentilhes et al. 2010, Amsalem et al JOGC 2011



Wish to preserve fertility

Consent (for conservative or resective procedure)



(Uro) Gynaecologist in theatre

In/per creta

confirmedC



[Uterine artery embolization]

[Methotrexate]

Advise about infection / haemorrhage

Follow up [4, 8, 12 .......wk]

Hb, Fibrinogen, CRP, US [ MRI]

Spontaneous expulsion

Reabsorption

One-step conservative surgery(if invaded area <50% axial uterine circumference)

C

AIP – Surgical Management

‘Conservative’ surgery

1. Disconnection of vesico- & colpo-

uterine anastomotic systems

2. T/V hysterotomy

3. Ligation of uterine arteries

4. Resection of invaded tissue and

entire placenta in one piece

One-stop (complete) resectionPalacios Jaraquemada 2004, 2012





2. T/V hysterotomy









2. T/V hysterotomy





‘Triple-P’ procedureChandraharan et al. 2012

1. Perioperative placental localization

– T/V Hysterotomy (above placenta)

2. Pelvic devasularization (IIA occlusion)

3. Placental non-separation with

myometrial excision

Management of AIP - ‘Conservative’ options

Expertise/training

1º Failure → Hysterectomy

Risk UT damage

2º Haemorrhage

Infection/Sepsis

Coagulopathy/Thromosis

2º Failure → Hysterectomy

Recurrent AIP

Palacios Jaraquemada et al. 2004, 2012

+++

++

++

+

+

+

+

+

One-stop

Conservative

?5%

?0%

3%

6%

?0%

2%

Aortic occlusion 40%

Additional haemostasis 43%

S1 (n=46) 4%

S2 (n=22) 72%

AIP - Surgical Management

Prenatal diagnosis - Low risk in/per creta

CS by 38 wk (Pfannenstiel incision)

Regional anaesthesia

Cell salvage (+ red cells available)

[Gynaecologist available]

Signs of in/per creta

Transverse LS incision ( through placenta)

Removal of placenta

No

Standard medical / surgical

management PPH

YesHysterotomy (away from placental site)

Cord ligated

Conservative

procedure

Secondary

resective procedure

Primary

resective procedure

IR / surgical

expertise available

High risk in/per creta

Emergency delivery < 35 wk


Learning Outcomes

• Key risk factors for AIP are uterine scar AND placental

implantation over the scar - the more scars the higher the risk

• US is valuable technique to screen for AIP but definitive

diagnosis requires expert pUS and usually pMRI

• Purpose of diagnosis is to minimise morbidity by appropriately

conducted surgical delivery by an experienced team.

All obstetricians need to know how to manage unexpected AIP

•Conservative (resective) surgery feasible in a minority of

carefully selected cases but with definitive diagnosis of AIP,

primary CH is treatment of choice

• Strong case for all suspected cases to be managed by a

regional specialised team

Documents

State of the art management - oaawebcast.info · Morbidly adherent (invasive) placenta Placenta Creta 1 in 2500 deliveries (1667-67,000)* Pathological diagnosis Absence decidua basalis