Division of Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY.
Am J Obstet Gynecol MFM. 2020 Nov;2(4):100183. doi: 10.1016/j.ajogmf.2020.100183. Epub 2020 Jul 19.
There is a growing body of evidence that sonographic signs of placenta accreta spectrum can be observed in the first trimester of pregnancy. The most significant marker is placental location next to or in the scar niche in women with a prior cesarean delivery.
This study aimed to assess the performance of transvaginal ultrasound in the early prediction of placenta accreta spectrum in women with a prior cesarean delivery.
This was a retrospective cohort of women with a history of cesarean delivery who had transvaginal ultrasound at 11 to 14 weeks' gestation between September 2016 and May 2018. Ultrasound reports were reviewed and graded for suspicion of placenta accreta spectrum as follows: Grade 0 (no suspicion) if the placenta is not next to the scar; Grade 1 (intermediate suspicion) if the placenta is next or on the scar; Grade 2 (high suspicion) if the placenta was inside the scar niche. In addition, all images were reviewed and graded by trained specialists blinded to the outcome. The primary outcome was a histologic diagnosis of placenta accreta spectrum. Sensitivity, specificity, positive predictive value, and negative predictive value of first-trimester transvaginal ultrasound to detect placenta accreta spectrum were assessed.
In this study, 467 patients were included, and 8 (1.7%) had placenta accreta spectrum at delivery. Using the original report, 442 patients (94.6%) were Grade 0, 20 (4.3%) Grade 1, and 5 (1.1%) Grade 2. The revised grading had 456 patients (97.6%) with Grade 0, 5 (1.1%) with Grade 1, and 6 (1.3%) with Grade 2. Patients with Grade 2 yielded a sensitivity of 62.5% (95% confidence interval, 24.5-91.5), specificity of 100% (95% confidence interval, 99.2-100.0), positive predictive value of 100% (95% confidence interval, 97.0-100.0), and negative predictive value of 99.4% (95% confidence interval, 98.4-99.7). Any sonographic suspicion of placenta accreta spectrum (Grade 1 or Grade 2) had a sensitivity of 75% (95% confidence interval, 34.9-96.8), specificity of 95.9% (95% confidence interval, 93.6-97.5), positive predictive value of 24% (95% confidence interval, 14.8-36.4), and negative predictive value of 99.6% (95% confidence interval, 98.5-99.9). The blinded image review yielded a better specificity (99.1% vs 95.9%; P=.001) and a positive predictive value (63.6% vs 24%; P=.02) with similar sensitivity (87.5% vs 75%; P=.52) and negative predictive value (99.8% vs 99.6%; P=.55).
Transvaginal ultrasound between 11 and 14 weeks' gestation in women a with prior cesarean delivery can identify at least 3 of 4 cases of placenta accreta spectrum. A finding of placental implantation within the scar niche has high positive predictive value for placenta accreta spectrum. Prospective studies are needed to assess routine screening for placenta accreta spectrum at 11 to 14 weeks' gestation in women with a prior cesarean delivery.
越来越多的证据表明，胎盘植入谱系的超声征象可在妊娠早期观察到。对于有剖宫产史的妇女，最显著的标志物是胎盘位于先前剖宫产切口处或切口附近。
本研究旨在评估经阴道超声在预测有剖宫产史的妇女胎盘植入谱系中的作用。
这是一项回顾性队列研究，纳入了 2016 年 9 月至 2018 年 5 月期间在 11 至 14 周经阴道超声检查的有剖宫产史的妇女。回顾超声报告并对胎盘植入谱系的可疑程度进行分级：如果胎盘不在疤痕旁，则为 0 级（无可疑）；如果胎盘紧邻或位于疤痕上，则为 1 级（中度可疑）；如果胎盘位于疤痕窝内，则为 2 级（高度可疑）。此外，所有图像均由经过培训的专家进行盲法评估。主要结局为胎盘植入谱系的组织学诊断。评估了经阴道超声检查在妊娠早期检测胎盘植入谱系的敏感性、特异性、阳性预测值和阴性预测值。
本研究纳入了 467 例患者，8 例（1.7%）在分娩时被诊断为胎盘植入谱系。根据原始报告，442 例患者（94.6%）为 0 级，20 例（4.3%）为 1 级，5 例（1.1%）为 2 级。修订后的分级为 456 例患者（97.6%）为 0 级，5 例（1.1%）为 1 级，6 例（1.3%）为 2 级。2 级患者的敏感性为 62.5%（95%置信区间，24.5-91.5），特异性为 100%（95%置信区间，99.2-100.0），阳性预测值为 100%（95%置信区间，97.0-100.0），阴性预测值为 99.4%（95%置信区间，98.4-99.7）。任何超声可疑胎盘植入谱系（1 级或 2 级）的敏感性为 75%（95%置信区间，34.9-96.8），特异性为 95.9%（95%置信区间，93.6-97.5），阳性预测值为 24%（95%置信区间，14.8-36.4），阴性预测值为 99.6%（95%置信区间，98.5-99.9）。盲法图像评估的特异性（99.1% vs 95.9%；P=.001）和阳性预测值（63.6% vs 24%；P=.02）更好，而敏感性（87.5% vs 75%；P=.52）和阴性预测值（99.8% vs 99.6%；P=.55）相似。
在有剖宫产史的妇女中，妊娠 11 至 14 周经阴道超声检查可以识别至少 4 例胎盘植入谱系中的 3 例。胎盘位于疤痕窝内的发现对胎盘植入谱系具有较高的阳性预测值。需要前瞻性研究来评估在有剖宫产史的妇女中，在妊娠 11 至 14 周进行常规筛查胎盘植入谱系的效果。
