Center of excellence for placenta accreta.

Abnormal Placentation: Placenta Previa, Vasa Previa, and Placenta Accreta.

https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/1471-0528.15306

Placenta Praevia and Placenta Accreta: Diagnosis and Management: Green-top Guideline No. 27a.

Objective
The accuracy of prospective sonographic prenatal detection of invasive placentation is unclear. The objective of this study was to conduct a systematic review and meta-analysis to assess the performance of ultrasound in at-risk women for prenatal identification of invasive placentation.

Methods
MEDLINE, EMBASE, The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE) and The Cochrane Central Register of Controlled Trials (CENTRAL) were searched using the search terms ‘placenta accreta’, ‘placenta increta’, ‘placenta percreta’, ‘ultrasound’, ‘magnetic resonance imaging (MRI)’, ‘invasive placenta’ and ‘infiltrative placenta’. Two authors independently abstracted data from the articles. Sensitivity, specificity, positive and negative likelihood ratios (LR+ and LR–), the diagnostic odds ratio (DOR) and their 95% CIs for each study were calculated. Forest plots and summary receiver–operating characteristics curves were produced. Between-study heterogeneity was explored both graphically and statistically. The MOOSE (meta-analysis of observational studies in epidemiology) guidelines were followed.

Results
Twenty-three studies involving 3707 pregnancies at risk for invasive placentation were included. The overall performance of ultrasound for the antenatal detection of invasive placentation was as follows: sensitivity, 90.72 (95% CI, 87.2–93.6)%; specificity, 96.94 (95% CI, 96.3–97.5)%; LR+, 11.01 (95% CI, 6.1–20.0); LR–, 0.16 (95% CI, 0.11–0.23); and DOR, 98.59 (95% CI, 48.8–199.0). Among the different ultrasound signs, color Doppler had the best predictive accuracy (sensitivity, 90.74 (95% CI, 85.2–94.7)%; specificity, 87.68 (95% CI, 84.6–90.4)%; LR+, 7.77 (95% CI, 3.3–18.4); LR–, 0.17 (95% CI, 0.10–0.29); and DOR, 69.02 (95% CI, 22.8–208.9)).

Conclusions
Ultrasound has a high accuracy for prenatal diagnosis of disorders of invasive placentation in high-risk women. The use of color Doppler improves the test performance. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1002/uog.13194

Prenatal identification of invasive placentation using ultrasound: systematic review and meta-analysis.

Placenta Accreta Spectrum.

Objectives
To evaluate the diagnostic accuracy of two-dimensional (2D) gray-scale and color Doppler and three-dimensional (3D) power Doppler sonographic criteria for morbidly adherent placenta (MAP), and to identify criteria to help distinguish placenta accreta from placenta percreta.

Methods
We enrolled 187 patients with placenta previa and history of uterine surgery and performed transabdominal and transvaginal ultrasound examination for early detection of MAP. With 2D gray-scale transabdominal and transvaginal ultrasonography, we investigated loss/irregularity of the echolucent area between the uterus and the placenta (‘clear space’), thinning or interruption of the hyperechoic interface between the uterine serosa and the bladder wall and the presence of turbulent placental lacunae with high-velocity flow (>15 cm/s). Using transabdominal 3D power Doppler, we evaluated the hypervascularity of the uterine serosa–bladder wall interface and irregular intraplacental vascularization. Ultrasound findings were reviewed against the final diagnosis made during Cesarean section (CS).

Results
MAP was detected on CS in 41 patients. All of them had an anterior placenta previa (34 major and seven minor) and had undergone at least one previous CS. The evaluated sonographic criteria showed good diagnostic performance; in MAP patients at least two out of five criteria were detected, with at most one of the criteria present in patients without MAP. Loss/irregularity of clear space used as a single criterion was responsible for the most false positives, demonstrating a low positive predictive value. Irregular intraplacental vascularization with tortuous confluent vessels affecting the entire width of the placenta, and hypervascularity of the entire uterine serosa–bladder wall interface, were only detected, on 3D power Doppler, in cases of placenta percreta.

Conclusions
The reviewed ultrasound criteria may be useful for the prenatal diagnosis of MAP and to differentiate between placenta accreta and placenta percreta; 3D power Doppler techniques were an important aid in the diagnosis. Copyright © 2013 ISUOG. Published by John Wiley & Sons, Ltd.

https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1002/uog.12385

Morbidly adherent placenta: evaluation of ultrasound diagnostic criteria and differentiation of placenta accreta from percreta.

Objective To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP). Methods An electronic search of MEDLINE, EMBASE and ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for 'Cesarean scar pregnancy' and 'outcome'. Reference lists of relevant articles and reviews were hand-searched for additional reports. Observed outcomes included: severe first-trimester vaginal bleeding; clinical symptoms (abdominal pain, vaginal bleeding) requiring treatment; uncomplicated miscarriage; complicated miscarriage requiring intervention; first- or second-trimester uterine rupture or hysterectomy; third-trimester bleeding, uterine rupture or hysterectomy; maternal death; incidence of abnormally invasive placenta (AIP); prevalence of placenta percreta; ultrasound signs suggestive of AIP; and live birth. Meta-analyses of proportions using a random-effects model were used to combine data. Cases were stratified based on the presence or absence of embryonic/fetal heart activity at the time of diagnosis. Results A total of 17 studies (69 cases of CSP managed expectantly, 52 with and 17 without embryonic/fetal heart beat) were included. In women with CSP and embryonic/fetal heart activity, 13.0% (95% CI, 3.8-26.7%) experienced an uncomplicated miscarriage, while 20.0% (95% CI, 7.1-37.4%) required medical intervention. Uterine rupture during the first or second trimester of pregnancy occurred in 9.9% (95% CI, 2.9-20.4%) of cases, while hysterectomy was required in 15.2% (95% CI, 3.6-32.8%) of all cases. Forty (76.9% (95% CI, 65.4-86.5%)) women progressed to the third trimester of pregnancy, of whom 39.2% (95% CI, 15.4-66.2%) experienced severe bleeding. Finally, 74.8% (95% CI, 52.0-92.1%) had a surgical or pathological diagnosis of AIP at delivery and around two-thirds (69.7% (95% CI, 42.8-90.1%)) of them had placenta percreta. In women with CSP but no embryonic/fetal cardiac activity, an uncomplicated miscarriage occurred in 69.1% (95% CI, 47.4-87.1%) of cases, while surgical or medical intervention during or immediately after miscarriage was required in 30.9% (95% CI, 12.9-52.6%). Uterine rupture during the first trimester of pregnancy occurred in 13.4% (95% CI, 2.7-30.3%) of cases, but hysterectomy was not required in any case. Conclusions CSP with positive embryonic/fetal heart activity managed expectantly is associated with a high burden of maternal morbidity including severe hemorrhage, early uterine rupture, hysterectomy and severe AIP. Despite this, a significant proportion of pregnancies complicated by CSP may progress to, or close to, term, thus questioning whether termination of pregnancy should be the only therapeutic option offered to these women. Expectant management of CSP with no cardiac activity may be a reasonable option in view of the low likelihood of maternal complications requiring intervention, although close surveillance is advisable to avoid adverse maternal outcome. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1002/uog.17568

Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta-analysis

http://www.engel-hajdasz.pl/wp-content/uploads/2015/02/laser_co2.pdf

Vulvo-vaginal atrophy: A new treatment modality using thermo-ablative fractional CO2 laser

Objective To ascertain the impact of prenatal diagnosis on surgical outcome of women affected by abnormally invasive placenta (AIP). Methods MEDLINE, EMBASE, CINAHL and Cochrane databases were searched. Observed outcomes included: gestational age at birth (weeks), amount of blood loss (L), units of red blood cells (RBC), platelets (PLT) and fresh frozen plasma (FFP) transfused, length of stay in hospital and the intensive care unit (ICU) (days), urinary tract injury and infection. Only studies reporting the occurrence of any of the explored outcomes in women with a prenatal compared with an intrapartum diagnosis of AIP were considered eligible for inclusion. Random-effect head-to-head meta-analyses were used to analyze the data. Results Thirteen studies were included. Women with a prenatal diagnosis of AIP had less blood loss during surgery (mean difference (MD), -0.87; 95% CI, -1.5 to -0.23), had fewer units of RBC (MD, -1.45; 95% CI, -2.9 to -0.04) and FFP (MD, -1.73; 95% CI, -3.3 to -0.2) transfused, and delivered earlier (MD, 1.33 weeks; 95% CI, -2.23 to -0.43) compared with those with an intrapartum diagnosis. The risk of admission to an ICU and length of in-hospital and in-ICU stay were not different between the groups. Prenatal diagnosis of AIP was associated with a higher risk of urinary-tract injury (odds ratio, 2.5; 95% CI, 1.3-4.6), mainly due to the higher prevalence of placenta percreta in the group with AIP diagnosed prenatally. Conclusion Prenatal diagnosis of AIP is associated with reduced hemorrhagic morbidity compared with cases in which such anomalies are detected at delivery. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

F. Forlani

Papers

Morbidly adherent placenta: evaluation of ultrasound diagnostic criteria and differentiation of placenta accreta from percreta.

Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta-analysis

Vulvo-vaginal atrophy: A new treatment modality using thermo-ablative fractional CO2 laser

Influence of prenatal diagnosis of abnormally invasive placenta on maternal outcome: systematic review and meta-analysis.

Prophylactic use of intravascular balloon catheters in women with placenta accreta, increta and percreta