José M. Palacios Jaraquemada

Magnetic resonance imaging in 300 cases of placenta accreta: surgical correlation of new findings

Background.  To establish the usefulness of placental magnetic resonance in patients with a diagnosis of placenta accreta through the correlation of diagnostic images and surgical findings.

Anterior placenta percreta: surgical approach, hemostasis and uterine repair

Background.  To describe an accurate approach, hemostatic procedures and uterine repair in patients with anterior placenta percreta.

Lower uterine blood supply: extrauterine anastomotic system and its application in surgical devascularization techniques

Background. To establish the arterial components that determine lower uterine blood supply, varieties and anastomoses that result in complications during selective devascularization procedures. Methods. Thirty‐nine female cadaveric pelvises with latex repletion in pelvic arteries were used. All the material was studied through direct dissection, and dissection enlarged with a 90‐diopter magnifying glass, establishing origin, course, and anastomoses of the genital arteries. Axial calibers of the uterine and the main vaginal arteries were compared. An anatomical and a historical compilation of the uterine artery was made, with special reference to anastomotic areas in the lower sector. Results. Three main pedicles were determined in the lower uterine blood supply: a cephalic one constituted by the uterine artery, a medial one made up by the cervical artery, and a distal one formed by the vaginal arteries. Different types of anastomoses were distinguished among the upper, middle, and lower pedicles. All types of anastomoses displayed similar features and were interconnected along the isthmic‐vaginal borders, or as an intramural anastomotic network. In many cases, a transmedial interuterine anastomosis of axial caliber equivalent to the uterine artery itself could be observed. The bibliography consulted provided neither detailed descriptions of the cervical‐segmental arterial system nor of the vaginal system or its anastomoses. In two cases, images were found in books that show this anastomotic system without further explanation. Conclusion. A not very well known anastomotic system was described between uterine and vaginal arteries. This system explains some reported failures, complications, and hemodynamic changes after uterine devascularization procedures.

Standardised pro forma for ultrasound reporting in suspected abnormally invasive placenta (AIP) – an international consensus

Accurate antenatal diagnosis of an abnormally invasive placenta (AIP), allowing multidisciplinary management at the time of delivery, has been shown to improve maternal and fetal outcomes1–3. AIP can be predicted as early as in the first trimester, by identifying cases of suspected Cesarean scar pregnancy (CSP), as there is evidence that CSP in the first trimester and AIP in the second and third trimesters may represent different stages of a similar pathology4. Grayscale ultrasonography, with or without color Doppler and performed both transabdominally and transvaginally, has been used widely for antenatal screening and diagnosis of AIP. Many signs have been suggested, with reports varying as to their sensitivity and specificity5. Most of these ‘signs’ are poorly defined and, consequently, it is difficult to assess which are the most robust. To address this, the European Working Group on AIP (EW-AIP) have produced a consensus proposal to standardize the ultrasound descriptions used to define each sign, published in this issue of the Journal6. We assembled an international group of experts in the field with the specific aim of reaching an agreement regarding a standardized means of reporting ultrasound assessment of suspected AIP. If adopted by sonographers, clinicians and researchers worldwide, such a pro forma may facilitate better communication, and better evaluation of our diagnostic performance, in cases of suspected AIP. The group of international experts comprised an e-mail discussion group (n = 50) led by Jose Palacios Jaraquemada, members of the EW-AIP (n = 19) and members of the ISUOG (International Society of Ultrasound in Obstetrics and Gynecology) Clinical Standards Committee (n = 7). Each expert was asked to participate in a survey which involved completion of an online questionnaire to indicate what they believed should be included in the pro forma for reporting ultrasound assessment of suspected AIP. The online questionnaire, created using Survey Monkey, included risk factors known to be associated with AIP and all commonly reported ultrasound signs and definitions related to the diagnosis of AIP5–11. Ultrasound signs were divided into three subgroups according to modality: grayscale ultrasound, color Doppler and three-dimensional (3D) power Doppler. Each ultrasound sign in each subgroup had between one and six associated definitions reported in the published literature. To each selected demographic characteristic and ultrasound sign we assigned three options: (i) definitely include in report; (ii) include optionally in report and (iii) do not include in report. The definitions for each ultrasound sign were also assigned three options: (i) include; (ii) do not include and (iii) unsure. Participants were also asked whether clinical interpretation and relevance of the ultrasound findings should be included in the report. Options for preferred method of reporting clinical interpretation included: (i) give probability of clinically significant AIP, (ii) state whether manual removal of placenta should be attempted, and (iii) give free text description to provide guidance to the local team. There was the opportunity to provide free text comments for each section. A reminder to complete the questionnaire was sent out after 2 weeks, and we allowed 4 weeks for a response. All demographic characteristics and ultrasound signs for which >50% respondents selected ‘definitely include in report’ were incorporated into the standardized report, while those for which >50% respondents selected ‘do not include in report’ were excluded. For each ultrasound sign, the definitions for which >50% of respondents selected either ‘include’ or ‘unsure’ were kept for further evaluation. A second questionnaire was created for such items requiring further evaluation, in which respondents could specify first and second choice for definition of the ultrasound sign, and included additional suggestions from the free text comments, such as assessment for suspected parametrial involvement. For confirmation, we distributed a third and final round of the survey, with three domains, addressing: demographic and risk factors, ultrasound signs and clinical interpretation. At this round, consensus was sought from all participants that the ultrasound signs previously agreed on should be defined using the standardized descriptors proposed by the EW-AIP6. There were 42 respondents in the first round of the survey (response rate, 55%). For all of the demographic characteristics, placental location and grayscale ultrasound parameters, and for all but one color Doppler parameter, >50% of respondents chose ‘definitely include in report’. Only seven respondents thought that 3D power Doppler volumes should definitely be included and thus this criterion was excluded. All

Uterine conservation in patient with consecutive double placenta percreta

A 28 year-old patient in the 35th week of her 6th pregnancy was admitted for placenta percreta with vesical invasion (enhanced MRI). As an antecedent the patient had previously had five cesarean sections and, during her latest section, she had had placenta percreta with vesical invasion. On this occasion conservative surgery of the uterus was performed with aortic vascular control, and uterine and vesical plastic operation. The patient underwent general anesthesia and immediately after she was anesthetized a median incision was made. Then, after fundal hysterotomy, a male newborn was extracted. The baby weighed 1190 grams, Apgar was 7/10. After hemostasis, the patient was placed in Trendelenburg’s position, the uterus was luxated forward and the retroperitoneum was accessed. The abdominal aorta was approached between lumbar vertebrae 3 and 4; a double aortic loop with silk number 7 was made below the infrarenal aorta and 3.500 U I.V. Sodium Heparin was administered. Then, dieresis of the vesico-uterine space was carried out by ligation of every newly formed vessel between the two organs. Once this stage was over, uterine, ovarian and the two posterior cervical arteries were sutured. Forty-five minutes later the aortic loop was loosened and 30 units of intravenous drip oxytocin were administered. Intrauterine hemostasis was checked as well as the indemnity of uterine and vesical surfaces. In particular, the previously repaired uterine surface appeared firm, with an approximate thickness of 1 cm and full of newly formed vessels. Hemostatic stitches were made with Dexon 3.0 in small bleeding retrovesical points. The abdomen was closed in a plane with Nylon 0 monofilament. Total transfused volume in the operating theater was 2 units of fresh frozen plasma, 2 units of whole blood and 2,000 ml of crystaloids.