Andrew D. Hull

Accuracy of ultrasonography and magnetic resonance imaging in the diagnosis of placenta accreta

BACKGROUND: The incidence of placenta accreta has increased dramatically over the last three decades, in concert with the increase in the cesarean delivery rate. Optimal management requires accurate prenatal diagnosis. The purpose of this study was to determine the precision and reliability of ultrasonography and magnetic resonance imaging (MRI) in diagnosing placenta accreta. METHODS: A historical cohort study was performed with information gathered from our obstetric, radiologic, and pathology databases. Records from January 2000 to June 2005 were reviewed to identify patients with a diagnosis of placenta previa, low-lying placenta with a prior cesarean delivery, or history of a myomectomy to determine the accuracy of pelvic ultrasonography in the diagnosis of placenta accreta. The records of those considered to be suspicious for placenta accreta and subsequently referred for additional confirmation by MRI were also analyzed. The sonographic and MRI diagnoses were compared with the final pathologic or operative findings or with both. RESULTS: Of the 453 women with placenta previa, previous cesarean delivery and low-lying anterior placenta, or previous myomectomy, 39 had placenta accreta confirmed by pathological examination. Ultrasonography accurately predicted placenta accreta in 30 of 39 of women and correctly ruled out placenta accreta in 398 of 414 without placenta accreta (sensitivity 0.77, specificity 0.96). Forty-two women underwent MRI evaluation because of findings suspicious or inconclusive of placenta accreta by ultrasonography. Magnetic resonance imaging accurately predicted placenta accreta in 23 of 26 cases with placenta accreta and correctly ruled out placenta accreta in 14 of 14 (sensitivity 0.88, specificity 1.0). CONCLUSION: A two-stage protocol for evaluating women at high risk for placenta accreta, which uses ultrasonography first, and then MRI for cases with inconclusive ultrasound features, will optimize diagnostic accuracy. LEVEL OF EVIDENCE: II-3

Effects of ultrasound on maternal-fetal bonding: a comparison of two- and three-dimensional imaging

The purpose of this study was to evaluate the effect of two‐dimensional (2DUS) compared to three‐dimensional ultrasound (3DUS) imaging on the maternal‐fetal bonding process.

Placenta Accreta An Association With Fibroids and Asherman Syndrome

Objective. Placenta accreta is a life‐threatening problem that is rising in incidence in the developed world. The increased risk of placenta accreta in women with placenta previa and 1 or more prior cesarean deliveries is well established and prompts careful sonographic evaluation. Our objective was to emphasize that accreta is also identified at sites other than cesarean scars. Methods. Two cases of placenta accreta without placenta previa seen in association with uterine scarring from myomectomy and uterine fibroids are described. Results. The sonographic and magnetic resonance imaging findings of accreta are reviewed in the classic setting of prior cesarean deliveries as well as myomectomy and uterine fibroids. Conclusions. We suggest that when the placenta overlies any uterine abnormality, a careful search for invasive placentation is warranted.

Placenta accreta and postpartum hemorrhage.

Placenta accreta is the abnormal adherence of the placenta to the uterine wall. Where placenta accreta is present, the failure of the placenta to separate normally from the uterus after delivery is accompanied by severe postpartum hemorrhage. The best outcomes in placenta accreta are in prenatally diagnosed electively delivered cases. Management should take place in centers with special expertise. All obstetric units should have an obstetric hemorrhage protocol in place.

Preoperative intravascular balloon catheters and surgical outcomes in pregnancies complicated by placenta accreta: a management paradox

OBJECTIVE The objective of the study was to compare outcomes between patients who did and did not receive preoperative uterine artery balloon catheters in the setting placenta accreta. STUDY DESIGN This was a retrospective case-control study of patients with placenta accreta from 1990 to 2011. RESULTS Records from 117 patients with pathology-proven accreta were reviewed. Fifty-nine patients (50.4%) had uterine artery balloons (UABs) placed preoperatively. The mean estimated blood loss (EBL) was lower (2165 mL vs 2837 mL; P = .02) for the group that had UABs compared with the group that did not. There were more cases with an EBL greater than 2500 mL and massive transfusions of packed red blood cells (>6 units) in the group that did not have UABs. Percreta was diagnosed more often on final pathology in the group with UABs. Surgical times did not differ between the 2 groups. Two patients (3.3%) had complications related to the UABs. CONCLUSION Preoperative placement of UABs is relatively safe and is associated with a reduced EBL and fewer massive transfusions compared with a group without UABs.

Three-dimensional ultrasonographic imaging of the neonatal brain in high-risk neonates: preliminary study.

The aim of this investigation was to compare the utility of three‐dimensional ultrasonography versus two‐dimensional ultrasonography in imaging the neonatal brain. Thirty patients in the neonatal intensive care unit underwent two‐dimensional and three‐dimensional ultrasonography. The resultant two‐ and three‐dimensional images recorded on film and three‐dimensional volumes (reviewed on a workstation) were evaluated independently. Comparable numbers of normal and abnormal studies were diagnosed by each modality. Axial images were considered useful in approximately 50% of three‐dimensional cases. Image quality, overall and in the far‐field, was rated higher on two‐dimensional images. Three‐dimensional sonographic acquisition time in the neonatal intensive care unit (1.7 min+/‐0.7 standard deviation) was significantly shorter than that for two‐dimensional sonography (9.0+/‐4.5 min). The total time for evaluation on the three‐dimensional workstation (4.4+/‐1.1 min) was significantly less than that for two‐dimensional images on film (10.6+/‐4.7 min). In conclusion, three‐dimensional ultrasonography is a promising, diagnostically accurate, and efficient imaging tool for evaluation of the neonatal brain; however, visualization must improve before it can replace two‐dimensional ultrasonography.

Three-dimensional Ultrasonography and Assessment of the First-Trimester Fetus

We used transvaginal three‐dimensional ultrasonography to assess the first‐trimester fetus and compared the findings with contemporaneous two‐dimensional ultrasonographic studies. Multiplanar three‐dimensional ultrasonography provided good visualization of fetal anatomy and allowed fetal measurement and assessment of nuchal translucency thickness. Three‐dimensional ultrasonography required significantly less time to perform and to interpret than two‐dimensional ultrasonography. Three‐dimensional ultrasonography is an effective means of assessing the first‐trimester fetus and offers potential advantages over two‐dimensional ultrasonography.

Identifying Sonographic Markers for Placenta Accreta in the First Trimester

Our study attempted to identify whether sonographic markers for placenta accreta may be present as early as the first trimester. We reviewed 10 cases with pathologically proven accreta and retrospectively analyzed their first‐trimester images. The gestational ages ranged from 8 weeks 4 days to 14 weeks 2 days. Sonographic findings included anechoic placental areas (9 of 10), low implantation of the gestational sac (9 of 10), an irregular placental‐myometrial interface (9 of 10), and placenta previa (7 of 10). Nine patients had at least 1 prior cesarean delivery; 3 had additional uterine surgical procedures. One patient underwent hysteroscopic myomectomy. Our case series suggests that signs of placenta accreta may be present in the first trimester.

Can prenatal ultrasound detect the effects of in‐utero alcohol exposure? A pilot study

The aim of this pilot study was to explore possible ultrasound parameters for the early detection of alcohol‐mediated fetal somatic and central nervous system (CNS) maldevelopment. Maternal alcohol ingestion during pregnancy may lead to fetal alcohol spectrum disorders (FASD), which encompass a broad range of structural abnormalities including growth impairment, specific craniofacial features and CNS abnormalities. Early detection of fetuses at risk of FASD would support earlier interventions.

Prenatal detection of associated anomalies in fetuses diagnosed with cleft lip with or without cleft palate in utero.

The aim of this study was to determine the prenatal detection rate of associated anomalies in fetuses with a suspected cleft lip with or without cleft palate.