Prospective evaluation of impact of post-Cesarean section uterine scarring in perinatal diagnosis of placenta accreta spectrum disorder

A M Hussein, R A Elbarmelgy, R M Elbarmelgy, M M Thabet, E Jauniaux, A M Hussein, R A Elbarmelgy, R M Elbarmelgy, M M Thabet, E Jauniaux

Abstract

Objective: Standardized ultrasound imaging and pathology protocols have recently been developed for the perinatal diagnosis of placenta accreta spectrum (PAS) disorders. The aim of this study was to evaluate prospectively the effectiveness of these standardized protocols in the prenatal diagnosis and postnatal examination of women presenting with a low-lying placenta or placenta previa and a history of multiple Cesarean deliveries (CDs).

Methods: This was a prospective cohort study of 84 consecutive women with a history of two or more prior CDs presenting with a singleton pregnancy and low-lying placenta/placenta previa at 32-37 weeks' gestation, who were referred for perinatal care and management between 15 January 2019 and 15 December 2020. All women were investigated using the standardized description of ultrasound signs of PAS proposed by the European Working Group on abnormally invasive placenta. In all cases, the ultrasound features were compared with intraoperative and histopathological findings. Areas of abnormal placental attachment were identified during the immediate postoperative gross examination and sampled for histological examination. The data of a subgroup of 32 women diagnosed antenatally as non-PAS who had complete placental separation at birth were compared with those of 39 cases diagnosed antenatally as having PAS disorder that was confirmed by histopathology at delivery.

Results: Of the 84 women included in the study, 42 (50.0%) were diagnosed prenatally as PAS and the remaining 42 (50.0%) as non-PAS on ultrasound examination. Intraoperatively, 66 (78.6%) women presented with a large or extended area of dehiscence and 52 (61.9%) with a dense tangled bed of vessels or multiple vessels running laterally and craniocaudally in the uterine serosa. A loss of clear zone was recorded on grayscale ultrasound imaging in all 84 cases, while there was no case with bladder-wall interruption or with a focal exophytic mass. Myometrial thinning (< 1 mm) in at least one area of the anterior uterine wall was found in 41 (97.6%) of the 42 cases diagnosed as non-PAS on ultrasound and 37 (88.1%) of the 42 diagnosed antenatally as PAS. Histological samples were available for all 48 hysterectomy specimens with abnormal placental attachment and for the three cases managed conservatively with focal myometrial resection and uterine reconstruction. Villous tissue was found directly attached to the superficial myometrium (placenta creta) in six of these cases and both creta villous tissue and deeply implanted villous tissue within the uterine wall (placenta increta) were found in the remaining 45 cases. There was no evidence of percreta placentation on histology in any of the PAS cases. Comparison of the main antenatal ultrasound signs and perioperative macroscopic findings between the two subgroups correctly diagnosed antenatally (32 non-PAS and 39 PAS) showed no significant difference with respect to the distribution of myometrial thinning and the presence of a placental bulge on ultrasound and of anterior uterine wall dehiscence intraoperatively. Compared with the non-PAS subgroup, the PAS subgroup showed significantly higher placental lacunae grade (P < 0.001) and more often hypervascularity of the uterovesical/subplacental area (P < 0.001), presence of bridging vessels (P = 0.027) and presence of lacunae feeder vessels (P < 0.001) on ultrasound examination, and increased vascularization of the anterior uterine wall intraoperatively (P < 0.001).

Conclusions: Remodeling of the lower uterine segment following CD scarring leads to structural abnormalities of the uterine contour on both ultrasound examination and intraoperatively, independently of the presence of accreta villous tissue on microscopic examination. These anatomical changes are often reported as diagnostic of placenta percreta, including cases with no histological evidence of PAS. Guided histological examination could improve the overall diagnosis of PAS and is essential to obtain evidence-based epidemiologic data. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Keywords: Cesarean section; placenta increta; placenta percreta; placenta previa accreta; ultrasound imaging; uterine dehiscence.

© 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Figures

Figure 1
Figure 1
Schematic representation (a) and sonographic (b,c) and intraoperative (d) images from a case of non‐accreta placenta previa at 36 weeks' gestation. (a) Diagram showing a large area of dehiscence between the lower uterine segment and the bladder. (b) Longitudinal transabdominal view of the lower uterine segment, showing placenta previa and myometrial thinning of the uterobladder interface (arrow). (c) Color Doppler mapping showing normal uteroplacental vasculature. (d) Intraoperative image, showing an extended area of uterine dehiscence occupying the entire lower uterine segment anterior wall (); underneath, most of the placenta is visible. AC, amniotic cavity; Cx, cervix; M, myometrium; P, placenta.
Figure 2
Figure 2
Schematic representation (a) and sonographic (b,c) and intraoperative (d) images from a case of placenta previa increta at 34 weeks' gestation. (a) Diagram showing accreta villous tissue deeply implanted into the scar of a prior lower segment Cesarean section. (b) Longitudinal transabdominal view of the lower uterine segment, showing placenta previa with large lacunae (L). (c) Color Doppler image showing large feeder vessels (arrow). (d) Intraoperative image, showing an area of focal uterine dehiscence of the lower uterine segment anterior wall () and dense tangled bed of vessels and multiple vessels running craniocaudally and laterally in the anterior perimetrium. Note an area of adhesion involving the bladder (arrow). AC, amniotic cavity; Cx, cervix; M, myometrium; P, placenta.
Figure 3
Figure 3
Intraoperative images of a case of non‐accreta placenta previa at 36 weeks' gestation, showing: (a) the anterior uterine wall with a large area of dehiscence covered by dilated vessels before hysterotomy; and (b) view after transverse lower segment hysterotomy and reconstruction of the lower uterine segment.
Figure 4
Figure 4
Flowchart showing antenatal diagnosis on ultrasound (US) and histopathological diagnosis and management in 84 women with anterior low‐lying placenta or placenta previa and a history of two or more Cesarean deliveries, included in the study. PAS, placenta accreta spectrum.

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