Abnormally invasive placenta

Vascular endothelial growth factor (VEGF)

Placental growth factor (PlGF)

Vascular endothelial growth factor receptor (Flt-1)

Soluble vascular endothelial growth factor receptor (Flt-1)

1. Esakoff TF, Sparks TN, Kaimal AJ, et al. Diagnosis and morbidity of placenta accreta. Ultrasound Obstet Gynecol. 2011;37:324-327.

2. Calì G, Giambanco L, Puccio G, Forlani F. Morbidly adherent placenta: evaluation of ultrasound diagnostic criteria and differentiation of placenta accreta from percreta. Ultrasound Obstet Gynecol. 2013;41:406-412.

3. Shih JC, Palacios Jaraquemada JM, Su YN, et al. Role of three-dimensional power Doppler in the antenatal diagnosis of placenta accreta: comparison with gray-scale and color Doppler techniques. Ultrasound Obstet Gynecol. 2009;33:193-203.

4. Belfort MA. Placenta accreta. Am J Obstet Gynecol. 2010;203:430-439.

Case 1

C

a

s

e

2

Basal View

Lateral View

A 41 year old woman G9 with 8 prior cesarean deliveries underwent an ultrasound at 18 weeks’ gestation revealing a previa and possible accreta. MFM was consulted and recommended early delivery and preparation for embolization of the hypogastric arteries. Her pregnancy was “uneventful” until admission at 38 weeks for elective cesarean delivery. Preoperatively, a catheter was positioned in the aorta in preparation for embolization of the hypogastric arteries if needed.

At time of delivery, a percreta was obvious involving the bladder.

Bleeding was significant and a supracervical hysterectomy was performed. An attempt was made to embolize the hypogastric arteries. A vaginal pack was placed and extensive gel foam was used in the pelvis. Intraoperative blood was estimated at 25 liters. She was transferred to the ICU in DIC. Her HCT was 13%. Cardiac arrest occurred later that evening.

No Accreta

Omniview

Accreta

Focal accreta-

Placenta removed and uterus left in situ

Descriptive Statistics

# of true positives

PPV = -----------------------------------------------

# of true positives + # of false positives

# of true positives

Sensitivity = -----------------------------------------------

# of true positives + # of false negatives

(The total number of affected individuals)

(The total number of abnormal tests)

# of true negatives

NPV = -----------------------------------------------

# of true negatives + # of false negatives

# of true negatives

Specificity = -----------------------------------------------

# of true negatives + # of false positives

(The total number of unaffected individuals)

(The total number of normal tests)

Dr. David Felson, Professor of Medicine Boston University School of Medicine

sph.bu.edu/otlt/MPH-Modules/EP/EP713_Screening/EP713_Screening5.html

Cell Free Fetal DNA

Additional MAP Risk Factors

Factors involved with early placental development

Pregnancies, scars, & previas, oh my!

Trophoblast invasion in early placental development

Langhans

Previous cesarean

Previa

Advanced maternal age

Multiparity

Uterine surgery

Rohr

Nitabuch

Loss of the retroplacental zone

Disruption of echogenic bladder mucosa

Lacunae

Lacunar flow with color Doppler

Basal View

Hypervascularity of serosa-bladder interface

High velocity low resistance flow

A test with a high PPV gives the clinician confidence that the uterus can be removed and have accreta confirmed by pathology.

A test with a high PPV gives the clinician confidence that the uterus should be removed to reduce morbidity and mortality associated with an abnormally invasive placenta

NPV represents the precision of diagnosis of placenta previa without accreta, relating to the confidence with which clinicians can remove the placenta and leave the uterus in situ without concerns of severe bleeding.

Lateral View

PPV

• 3D power Doppler 76%
• Gray-scale 51%
• Color Doppler 47%