Ultrasonographic Diagnosis of Placenta Accreta Spectrum (PAS) Disorder: Ideation of an Ultrasonographic Score and Correlation with Surgical and Neonatal Outcomes
Abstract
:1. Introduction
2. Materials and Methods
2.1. Conception of the Ultrasound Score
- Placental lacunae were graded with reference to Finberg’s study [20] for their number, the site (near or far from the myometrium), the shape (irregular, linear or round), the borders (echogenic or non-echogenic i.e., distinct or indistinct), and Doppler study (diffuse or focal turbulent or non-turbulent flow) as follows: score 0: absent; score 1: present in a number of 2–3, generally round and small, mean diameter 2 cm; score 2: present in number of 4–6, generally irregular, mean diameter 4 cm with turbulent blood flow or tributary vessels;
- Retro placental space (Clear zone). Score 0: present; score 1: irregular; score 2: absent.
- Retro placental myometrial thickness (millimeter). Score 0: myometrium >1 mm; score 1: myometrium <1 mm; score 2: myometrium not measurable (disappeared).
- The bladder wall (hyperechoic uterine serosa-to-bladder interface). Score 0: line clear and complete; score 1: line vague or irregular; score 2: line lost.
- Focal exophytic mass and/or placental bulge. Score 0 and score 1: absent; score 2: present.
- Increased peri-uterine vascularity between uterus and urinary bladder. Score 0: normal flow; score1: increased flow, presence of numerous vases, tortuous; score 2: multidirectional flow or presence of bridge vessels.
- Subplacental hypervascularity. Score 0: normal flow; score 1: increased flow; score 2: bridge vessels with perpendicular course
- Diffuse or focal turbulent flow in the lacunae. Score 0: absent; score 1: focal; score 2: diffused with tributary vessels (>15 cm/sec)
- Position of the placenta. Score 1: low lying; score 2: previa
- The previous history of CS. Score 0: 1 previous CS; score 1: 2 previous CS; score 2: ≥3 previous CS.
2.2. Ultrasonographic Assessment
2.3. Clincal and Histopathologic Definition of Placental Invasion
3. Results
Surgical Outcomes
4. Discussion
5. Conclusions
Author Contributions
Funding
Conflicts of Interest
References
- Silver, R.M.; Branch, D.W. Placenta accreta spectrum. N. Engl. J. Med. 2018, 378, 1529–1536. [Google Scholar] [CrossRef] [PubMed]
- Gilboa, Y.; Spira, M.; Mazaki-Tovi, S.; Schiff, E.; Sivan, E.; Achiron, R. A novel sonographic scoring system for antenatal risk assessment of obstetric complications in suspected morbidly adherent placenta. J. Ultrasound Med. 2015, 34, 561–567. [Google Scholar] [CrossRef] [PubMed]
- Morgan, E.A.; Sidebottom, A.; Vacquier, M.; Wunderlich, W.; Loichinger, M. The effect of placental location in cases of placenta accreta spectrum. Am. J. Obstet. Gynecol. 2019, 221, 357. [Google Scholar] [CrossRef] [PubMed]
- Cahill, A.G.; Beigi, R.; Heine, R.P.; Silver, R.M.; Wax, J.R. Placenta Accreta Spectrum. Am. J. Obstet. Gynecol. 2018, 219, B2–B16. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Jauniaux, E.; Collins, S.; Burton, G.J. Placenta accreta spectrum: Pathophysiology and evidence-based anatomy for prenatal ultrasound imaging. Am. J. Obstet. Gynecol. 2018, 218, 75–87. [Google Scholar] [CrossRef] [PubMed]
- Jauniaux, E.; Bhide, A.; Kennedy, A.; Woodward, P.; Hubinont, C.; Collins, S. FIGO consensus guidelines on placenta accreta spectrum disorders: Prenatal diagnosis and screening. Int. J. Gynecol. Obstet. 2018, 140, 274–280. [Google Scholar] [CrossRef]
- Jauniaux, E.; Bhide, A. Prenatal ultrasound diagnosis and outcome of placenta previa accreta after cesarean delivery: A systematic review and meta-analysis. Am. J. Obstet. Gynecol. 2017, 217, 27–36. [Google Scholar] [CrossRef] [Green Version]
- Jauniaux, E.; Grønbeck, L.; Bunce, C.; Langhoff-Roos, J.; Collins, S.L. Epidemiology of placenta previa accreta: A systematic review and meta-analysis. BMJ Open 2019, 9, 1–9. [Google Scholar] [CrossRef] [Green Version]
- Chalubinski, K.M.; Pils, S.; Klein, K.; Seemann, R.; Speiser, P.; Langer, M.; Ott, J. Prenatal sonography can predict degree of placental invasion. Ultrasound Obstet. Gynecol. 2013, 42, 518–524. [Google Scholar] [CrossRef]
- Rac, M.W.F.; Dashe, J.S.; Wells, C.E.; Moschos, E.; McIntire, D.D.; Twickler, D.M. Ultrasound predictors of placental invasion: The Placenta Accreta Index. Am. J. Obstet. Gynecol. 2015, 212, 343. [Google Scholar] [CrossRef]
- Tovbin, J.; Melcer, Y.; Shor, S.; Pekar-Zlotin, M.; Mendlovic, S.; Svirsky, R.; Maymon, R. Prediction of morbidly adherent placenta using a scoring system. Ultrasound Obstet. Gynecol. 2016, 48, 504–510. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Chong, Y.; Zhang, A.; Wang, Y.; Chen, Y.; Zhao, Y. An ultrasonic scoring system to predict the prognosis of placenta accreta a prospective cohort study. Medicine 2018, 97, 1–9. [Google Scholar] [CrossRef] [PubMed]
- Marsoosi, V.; Ghotbizadeh, F.; Hashemi, N.; Molaei, B. Development of a scoring system for prediction of placenta accreta and determine the accuracy of its results. J. Matern. Neonatal Med. 2018, 7058. [Google Scholar] [CrossRef] [PubMed]
- Tanimura, K.; Morizane, M.; Deguchi, M.; Ebina, Y.; Tanaka, U.; Ueno, Y.; Kitajima, K.; Maeda, T.; Sugimura, K.; Yamada, H. A novel scoring system for predicting adherent placenta in women with placenta previa. Placenta 2018, 64, 27–33. [Google Scholar] [CrossRef] [Green Version]
- Bostancı, E.; Kılıccı, C.; Özkaya, E.; Yayla, C.A.; Darici, E.; Berkel, G.; Eroglu, M.; Kocakusak, C.K. Ultrasound predictors of candidates for segmental resection in pregnants with placenta accreta. J. Matern. Neonatal Med. 2020, 33, 1004–1007. [Google Scholar] [CrossRef]
- Cali, G.; Forlani, F.; Lees, C.; Timor-Tritsch, I.; Palacios-Jaraquermada, J.; DallÁsta, A.; Bhide, A.; Flacco, M.E.; Manzoli, L.; Labate, F.; et al. Prenatal ultrasound staging system for placenta accreta spectrum disorders. Ultrasound Obstet. Gynecol. 2019, 53, 752–760. [Google Scholar] [CrossRef]
- Luo, L.; Sun, Q.; Ying, D.; Wu, X.; Yan, P.; Yang, Y.; Chen, Z. Scoring system for the prediction of the severity of placenta accrete spectrum in women with placenta previa: A prospective observational study. Arch. Gynecol. Obstet. 2019, 300, 783–791. [Google Scholar] [CrossRef]
- Zhu, L.; Xie, L. Value of ultrasound scoring system for assessing risk of pernicious placenta previa with accreta spectrum disorders and poor pregnancy outcomes. J. Med. Ultrason. 2019, 46, 481–487. [Google Scholar] [CrossRef]
- Collins, S.L.; Ashcroft, A.; Braun, T.; Calda, P.; Langhoff-Roos, J.; Morel, O.; Stefanovic, V.; Tutschek, B.; Chantraine, F.; EW-AIP. Proposal for standardized ultrasound descriptors of abnormally invasive placenta (AIP). Ultrasound Obstet. Gynecol. 2016, 47, 271–275. [Google Scholar] [CrossRef] [Green Version]
- Finberg, H.J.; Williams, J.W. Placenta accreta: Prospective sonographic diagnosis in patients with placenta previa and prior cesarean section. J. Ultrasound Med. 1992, 11, 333–343. [Google Scholar] [CrossRef]
- Jauniaux, E.; Ayres-de-Campos, D.; Langhoff-Roos, J.; Fox, K.A.; Collins, S.; FIGO. Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO classifications for the clinical diagnosis of placenta accreta spectrum disorders. Int. J. Gynaecol. Obstet. 2019, 146, 20–24. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Jauniaux, E.; Bunce, C.; Grønbeck, L.; Langhoff-Roos, J. Prevalence and main outcomes of placenta accreta spectrum: Systematic review and meta-analysis. Am. J. Obstet. Gynecol. 2019, 221, 208–218. [Google Scholar] [CrossRef] [PubMed]
- Yang, J.I.; Lim, Y.K.; Kim, H.S.; Chang, K.H.; Lee, J.P.; Ryu, H.S. Sonographic findings of placental lacunae and the prediction of adherent placenta in women with placenta previa totalis and prior Cesarean section. Ultrasound Obstet. Gynecol. 2006, 28, 178–182. [Google Scholar] [CrossRef] [PubMed]
Ultrasound and Clinical Signs | Score = 0 | Score = 1 | Score = 2 |
---|---|---|---|
Placental lacunae | Not seen | 2–3, regular ≤2 cm | 4–6, irregular, 4 cm |
Hypoechoic retroplacental space ("clear zone") | Present | Irregular | Absent |
Myometrial thinning | Myometrium > 1 mm | Myometrium < 1 mm | Absent |
Hyperechoic uterus–bladder interface (bladder line) | Line clear and complete | Line vague or irregular | Line lost |
Focal exophytic mass and/or placental bulge | Absent | - | Present |
Utero-vescical hypervascularity | Absent | Increased | Multidirectional flow with bridging vessels |
Prior Caesarean section | 1 | 2 | ≥3 |
Placental relationship with internal cervical os | - | Low-lying | Previa |
Subplacental hypervascularity | Normal | Increased with numerous vases, tortuous | Bridging vessels with perpendicular course |
Diffuse or focal turbulent flow in the lacunae | Absent | Focal turbulent flow | Diffuse turbulent flow with feeding vessels |
Characterics and Risk Factors | Normal Placenta | Placenta Accreta | Placenta Increta | Placenta Percreta | p Value |
---|---|---|---|---|---|
Group 0 | Group 1 | Group 2 | Group 3 | ||
Number of patients | 109 | 19 | 6 | 4 | |
Age (years) mean age ± SD | 38 (±5.4) | 39 (±5.18) | 40 (±6.9) | 35 (±5.25) | <0.357 a |
Previous CS 0 (1) | 99 (90.8%) | 3 (15.8%) | 1 (16.7%) | 0 (0%) | <0.001 a |
Previous CS 1 (2) | 6 (5.5%) | 12 (63.2%) | 3 (50%) | 1 (25%) | <0.001 a |
Previous CS 2 (≥3) | 4 (3.7%) | 4 (21.1%) | 2 (33.3%) | 3 (75%) | <0.001 a |
Placenta Previa | 40 (36.7%) | 11 (58%) | 4 (66.7%) | 4 (100%) | <0.001 b |
Low-lying Placenta | 69 (63.3%) | 8 (42%) | 2 (33.3%) | 0 (0%) | <0.001 b |
Previous curettage | 26 (72.2%) | 6 (16.7%) | 2 (5.6%) | 2 (5.6%) | < 0.587 b |
Ultrasound and Clinical Markers | Group 0 Without PAS n 109 (79%) | Group 1 PA n 19 (13.7%) | Group 2 PI n 6 (4,3%) | Group 3 PP n 4(3,0%) | p Value |
---|---|---|---|---|---|
Placental lacunae | |||||
0 | 109 (100%) | 0 | 0 | 0 | 0.001 |
1 | 19 (100%) | 0 | 0 | 0.001 | |
2 | 0 | 0 | 6 (100%) | 4 (100%) | 0.001 |
Hypoechoic retroplacental space ("clear zone") | |||||
0 | 109 (100%) | 0 | 0 | 0 | 0.001 |
1 | 0 | 5 (26.3 %) | 0 | 0 | 0.001 |
2 | 0 | 14 (73.7%) | 6 (100%) | 4 (100%) | 0.001 |
Myometrial thickness | |||||
0 | 106 (97.2%) | 0 | 0 | 0 | 0.001 |
1 | 3 (2.8%) | 12 (63.2%) | 0 | 0 | 0.001 |
2 | 0 | 7 (36.8%) | 6 (100%) | 4 (100%) | 0.001 |
Bladder line | |||||
0 | 109% (100%) | 19 (100%) | 1 (17%) | 0 | 0.001 |
1 | 0 | 0 | 5 (83%) | 0 | 0.001 |
2 | 0 | 0 | 0 | 4 (100%) | 0.001 |
Focal exophytic mass or placental bulging | |||||
0 | 109 (100%) | 19 (100%) | 6 (100%) | 1 (25%) | 0.001 |
2 | 0 | 0 | 0 | 3 (75%) | 0.001 |
Vascularity at the uterus–bladder interface | |||||
0 | 109 (100%) | 19(100%) | 3 (50%) | 0 | 0.001 |
1 | 0 | 0 | 3 (50%) | 0 | 0.001 |
2 | 0 | 0 | 0 | 4 (100%) | 0.001 |
Subplacental hypervascularity | |||||
0 | 109 (100%) | 0 | 0 | 0 | 0.001 |
1 | 0 | 11 (57.9%) | 0 | 0 | 0.001 |
2 | 0 | 8 (42.1%) | 6 (100%) | 4 (100%) | 0.001 |
Diffuse or focal turbulent flow in the lacunae | |||||
0 | 109 (100%) | 0 | 0 | 0 | 0.001 |
1 | 0 | 9 (47.4%) | 2 (33.3%) | 0 | 0.001 |
2 | 0 | 10 (52.6%) | 4 (66.7%) | 4 (100%) | 0.001 |
The previous history of caesarean section | |||||
0 | 99 (90.8%) | 3 (15.8%) | 1 (16.7%) | 0 (0%) | 0.001 |
1 | 6 (5.5%) | 12 (63.2%) | 3 (50%) | 1 (25%) | 0.001 |
2 | 4 (3.7%) | 4 (21.1%) | 2 (33.3%) | 3 (75%) | 0.001 |
Placental relationship with internal cervical os | |||||
1 | 69 (63.3%) | 8 (42.0%) | 2 (33.3%) | 0 (0%) | 0.001 |
2 | 40 (36.7%) | 11 (58.0%) | 4 (66.7%) | 4 (100%) | 0.001 |
Placental Localization | Group 0 Without PAS n 109 | Group 1 PA n 19 | Group 2 PI n 6 | Group 3 PP n 4 |
---|---|---|---|---|
Anterior placenta | 104 | 15 | 6 | 3 |
Posterior placenta | 5 | 4 | 0 | 1 |
Outcomes | Without PAS | PAS | p Value | ||||||
---|---|---|---|---|---|---|---|---|---|
Group 0, without PAS, Score ≤5 | n | Group 1, P. Accreta, Score >5–<12.5 | n | Group 2, P. Increta, Score >12.5–≤15.5 | n | Group 3, P. Percreta, Score >15.5 –≤20 | n | ||
Length of hospital stay (day) ± SD | 4 ± 2.3 | 109 | 6 ± 4.5 | 19 | 8.5 ± 5.6 | 6 | 9.5 ± 3.9 | 4 | <0.001 |
Duration of surgery (min) ± SD | 60 ± 16.6 | 109 | 100 ± 36.3 | 19 | 126.5 ± 21.4 | 6 | 170 ± 84.2 | 4 | <0.001 |
Admission to intensive care unit | 0.90% | 1 | 5.30% | 1 | 0% | 0 | 75% | 3 | <0.001 |
Transfusion ≥ 4 PRBC | 3.60% | 4 | 68.40% | 13 | 33.30% | 2 | 75% | 3 | <0.001 |
Transfusion of Plasma | 1.83% | 2 | 47.30% | 9 | 33.30% | 2 | 75% | 3 | <0.001 |
Interventional radiology request | - | - | - | - | - | - | - | - | - |
Re-laparotomy | 0% | 0 | 10.50% | 2 | 0% | 0 | 0% | 0 | <0.001 |
Hysterectomy: | - | - | - | - | - | - | - | <0.001 | |
Subtotal | 0% | 0 | 21.00% | 4 | 33.30% | 2 | - | - | |
Total | 0.90% | 1 | 52.60% | 10 | 66.70% | 4 | 100% | 4 | |
DIC | 0.90% | 1 | 10.50% | 2 | 0% | 0 | 75% | 3 | <0.064 |
Bladder lesion | 0% | 0 | 5.30% | 1 | 0% | 0 | 75% | 3 | <0.001 |
Ureteral lesion | 0% | 0 | 0% | 0 | 0% | 0 | 50% | 2 | <0.001 |
Urgency Caesarean section | 24.80% | 27 | 52.60% | 10 | 33.30% | 2 | 75% | 3 | <0.001 |
Balloon tamponade Bakri | 12.80% | 14 | 36.80% | 7 | 0% | 0 | 0% | 0 | <0.008 |
General anesthesia | 0.90% | 1 | 10.50% | 2 | 0% | 0 | 50% | 2 | <0.009 |
Apgar score 5 min (minim/max) | 9 (7–10) | 109 | 9 (7–10) | 19 | 8 (7–10) | 6 | 7 (7–8) | 4 | <0.013 |
Gestational age at delivery ± SD | 36 ± 2.5 | 109 | 34 ± 2.9 | 19 | 33 ± 1.89 | 6 | 32.5 ± 2.63 | 4 | <0.001 |
Birth weight (gr) | 2680 | 109 | 2160 | 19 | 1980 | 6 | 1870 | 4 | <0.001 |
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Del Negro, V.; Aleksa, N.; Galli, C.; Ciminello, E.; Derme, M.; Vena, F.; Muzii, L.; Piccioni, M.G. Ultrasonographic Diagnosis of Placenta Accreta Spectrum (PAS) Disorder: Ideation of an Ultrasonographic Score and Correlation with Surgical and Neonatal Outcomes. Diagnostics 2021, 11, 23. https://doi.org/10.3390/diagnostics11010023
Del Negro V, Aleksa N, Galli C, Ciminello E, Derme M, Vena F, Muzii L, Piccioni MG. Ultrasonographic Diagnosis of Placenta Accreta Spectrum (PAS) Disorder: Ideation of an Ultrasonographic Score and Correlation with Surgical and Neonatal Outcomes. Diagnostics. 2021; 11(1):23. https://doi.org/10.3390/diagnostics11010023
Chicago/Turabian StyleDel Negro, Valentina, Natalia Aleksa, Cecilia Galli, Enrico Ciminello, Martina Derme, Flaminia Vena, Ludovico Muzii, and Maria Grazia Piccioni. 2021. "Ultrasonographic Diagnosis of Placenta Accreta Spectrum (PAS) Disorder: Ideation of an Ultrasonographic Score and Correlation with Surgical and Neonatal Outcomes" Diagnostics 11, no. 1: 23. https://doi.org/10.3390/diagnostics11010023
APA StyleDel Negro, V., Aleksa, N., Galli, C., Ciminello, E., Derme, M., Vena, F., Muzii, L., & Piccioni, M. G. (2021). Ultrasonographic Diagnosis of Placenta Accreta Spectrum (PAS) Disorder: Ideation of an Ultrasonographic Score and Correlation with Surgical and Neonatal Outcomes. Diagnostics, 11(1), 23. https://doi.org/10.3390/diagnostics11010023