Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy.
Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy.
Eur J Obstet Gynecol Reprod Biol. 2024 Nov;302:97-103. doi: 10.1016/j.ejogrb.2024.08.035. Epub 2024 Aug 28.
To evaluate the performance of ultrasound for antenatal identification of invasive placentation in women with placenta previa in the setting of prior cesarean delivery.
This was a multicenter, retrospective, cohort study. Singleton pregnancies at risk of placenta accreta because of persistent placenta previa in the setting of prior cesarean delivery who delivered at four centers, from January 2010 to May 2020, were included in the study. For this study, pregnancies with diagnosis of accreta, increta, or percreta were considered under the umbrella term of placenta accreta. All women with placenta previa identified in the second trimester had a follow-up ultrasound at 32-34 weeks. Only those with prior cesarean delivery were considered at risk of placenta accreta. Women were considered with suspected accreta in case of suspected prenatal ultrasound. Women with suspected placenta accreta had delivery planned via cesarean hysterectomy at 34+0 - 35+6 weeks, without any attempt to remove the placenta. The primary endpoint of the study was the performance of ultrasound for antenatal identification of invasive placentation. The following ultrasound signs were evaluated: placenta lacunae; loss of clear space; increased vascularity between myometrium and placenta; intracervical lake; rail sign; uterovesical hypervascularity; increased vascularity in the inferior part of the lower uterine segment potentially extending into the parametrial region; and disruption of bladder-myometrial interface.
180 singleton pregnancies with placenta previa in the setting of prior cesarean delivery were identified. Of them, 155 (86.1%) had antenatal suspected placenta accreta based on ultrasound, having at least one sign of invasive placentation. Of the 155 suspected cases, 99 had confirmed placenta accreta at the time of delivery. Among the 99 cases of confirmed placenta accreta, all of them had at least one sign of invasive placentation at ultrasound. Among the 81 cases with placenta previa, prior cesarean delivery, without placenta accreta, 25/81 (30.9%) had ultrasound scan negative for sign of invasive placentation, and 56/81 (69.1%) had at least one sign of invasive placentation). In particular, 12/81 (14.8%) had placenta lacunae, 16/81 (19.8%) had loss of clear space, 20/81 (24.7%) had increased vascularity between myometrium and placenta, 9/81 (11.1%) had intracervical lake, 14/81 (17.3%) had rail sign, 14 (17.3%) had uterovesical hypervascularity, 5/81 (6.2%) had increased vascularity in the inferior part of the lower uterine segment potentially extending into the parametrial region, 8/81 (9.9%) had disruption of bladder-myometrial interface. In the group of women with confirmed placenta accreta, the most common sign recorded was the disruption of bladder-myometrial interface, being recorded in 88/99 women. Disruption of bladder-myometrial interface had the highest sensitivity in detection placenta accreta. Women with disruption of bladder-myometrial interface at ultrasound had 73-fold increase in the risk of placenta accreta compared to those who did not.
Prenatal ultrasound has an excellent diagnostic accuracy in identifying invasive placentation in women with placenta previa and prior cesarean delivery.
评估超声在有剖宫产史的前置胎盘孕妇中的产前侵袭性胎盘的表现。
这是一项多中心、回顾性队列研究。2010 年 1 月至 2020 年 5 月，在四家中心因持续前置胎盘且有剖宫产史而有胎盘植入风险的单胎妊娠，纳入本研究。在本研究中，诊断为粘连、植入或穿透性胎盘的妊娠被认为属于胎盘植入的范畴。所有在妊娠中期发现前置胎盘的孕妇在 32-34 周时都进行了后续超声检查。只有那些有剖宫产史的孕妇才被认为有胎盘植入的风险。如果产前超声检查怀疑有胎盘植入，则认为孕妇有疑似胎盘植入。有疑似胎盘植入的孕妇计划在 34+0-35+6 周时通过剖宫产行子宫切除术分娩，不试图取出胎盘。本研究的主要终点是超声对产前诊断侵袭性胎盘的表现。评估了以下超声征象：胎盘腔隙；清晰间隙缺失；子宫肌层与胎盘之间的血管增多；宫颈湖；铁轨征；子宫-膀胱高血管性；子宫下段下部的血管增多，可能延伸至子宫旁区；膀胱-子宫肌层界面中断。
确定了 180 例有剖宫产史的前置胎盘的单胎妊娠。其中，155 例（86.1%）根据超声检查有产前疑似胎盘植入，有至少一个侵袭性胎盘的征象。在 155 例疑似病例中，99 例在分娩时确诊为胎盘植入。在 99 例确诊的胎盘植入病例中，所有病例在超声检查中均有至少一个侵袭性胎盘的征象。在 81 例有前置胎盘、有剖宫产史而无胎盘植入的病例中，25/81（30.9%）的超声检查对侵袭性胎盘的征象为阴性，56/81（69.1%）有至少一个侵袭性胎盘的征象。特别是，12/81（14.8%）有胎盘腔隙，16/81（19.8%）有清晰间隙缺失，20/81（24.7%）有子宫肌层与胎盘之间的血管增多，9/81（11.1%）有宫颈湖，14/81（17.3%）有铁轨征，14（17.3%）有子宫-膀胱高血管性，5/81（6.2%）有子宫下段下部的血管增多，可能延伸至子宫旁区，8/81（9.9%）有膀胱-子宫肌层界面中断。在确诊胎盘植入的妇女中，最常见的征象是膀胱-子宫肌层界面中断，88/99 例妇女记录到该征象。膀胱-子宫肌层界面中断对胎盘植入的检测具有最高的敏感性。在超声检查中有膀胱-子宫肌层界面中断的妇女发生胎盘植入的风险增加了 73 倍。
产前超声对有剖宫产史的前置胎盘孕妇的侵袭性胎盘具有极好的诊断准确性。
