Re: Developing Accreta

From: art fougner, md (evsono@pipeline.com)
Tue Aug 25 10:52:35 1998

Jim,

i've found that the learning curve factor plays a significant role in predictive values of diagnostic studies. here are some references which may be useful regarding the noninvasive dx of accreta.

Radiology 1997 Dec;205(3):773-776

Placenta accreta: evaluation with color Doppler US, power Doppler US, and MR imaging.

Levine D, Hulka CA, Ludmir J, Li W, Edelman RR

Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.

PURPOSE: To determine the value of transabdominal ultrasound (US), transvaginal US, color Doppler US, power Doppler US, and magnetic resonance (MR) imaging in the diagnosis of placenta accreta. MATERIALS AND METHODS: Nineteen patients in the third trimester of pregnancy who were at risk for placenta accreta underwent color Doppler and power Doppler US; 18 patients also underwent MR imaging. Images were interpreted prospectively for signs of accreta by two reviewers. The reviewers' confidence in their diagnosis was graded on a five-point scale. RESULTS: Outcomes at delivery were as follows: normal placenta (n = 11), hysterectomy owing to uncontrollable bleeding (n = 1), and placenta accreta (n = 7). Five cases of lower-uterine-segment placenta accreta were diagnosed with a high level of confidence with vaginal and power Doppler US. In one patient with a posterior placenta who had previously undergone myomectomy, MR imaging enabled the diagnosis of placenta accreta, which was not well depicted at US. CONCLUSION: In patients with a history of uterine scars, vaginal US with power Doppler US performed well in the evaluation of lower-uterine-segment placenta accreta. MR imaging depicts posterior placenta accreta.

PMID: 9393534, UI: 98055252

Am J Obstet Gynecol 1997 Jul;177(1):210-214

Clinical risk factors for placenta previa-placenta accreta.

Miller DA, Chollet JA, Goodwin TM

Department of Obstetrics and Gynecology, Los Angeles County/University of Southern California Women's and Children's Hospital, Los Angeles 90033, USA.

OBJECTIVE: Our purpose was to define the clinical risk factors associated with placenta previa-placenta accreta. STUDY DESIGN: Hospital records were reviewed of all cases of placenta accreta confirmed histologically between January 1985 and December 1994. Additionally, we reviewed the records of all women with placenta previa and all those undergoing cesarean hysterectomy during the same period. Multiple logistic regression analysis was used to identify independent clinical risk factors for placenta accreta. RESULTS: Among 155,670 deliveries, 62 (1/2510) were complicated by histologically confirmed placenta accreta. Placenta accreta occurred in 55 of 590 (9.3%) women with placenta previa and in 7 of 155,080 (1/22,154) without placenta previa (relative risk 2065, 95% confidence interval 944 to 4516, p < 0.0001). Among women with placenta previa, advanced maternal age (> or = 35 years) and previous cesarean delivery were independent risk factors for placenta accreta. Placenta accreta was present in 36 of 124 (29%) cases in which the placenta was implanted over the uterine scar and in 4 of 62 (6.5%) cases in which it was not (relative risk 4.5, 95% confidence interval 1.68 to 12.07). Among women with placenta previa, the risk of placenta accreta ranged from 2% in women < 35 years old with no previous cesarean deliveries to almost 39% in women with two or more previous cesarean deliveries and an anterior or central placenta previa. CONCLUSION: Placenta accreta occurs in approximately 1 of 2500 deliveries. Among women with placenta previa, the incidence is nearly 10%. In this high-risk group advanced maternal age and previous cesarean section are independent risk factors.

PMID: 9240608, UI: 97382604

patient's tend to do better once folks consider the possibility.

Art

At Tue, 25 Aug 1998, James S Smeltzer MD wrote: >
>Art,
>
>The last one the MRI also suggested accreta & at section, with much
>elaborate preparation, a thin LUS had the placenta removed easily. The
>cystoscopy idea is a good one & over the last fifteen years I have had two
>with negative cystos, true negatives, so this and the flame-like lakes from
>base to surface of placenta with generous flow are the best findings in my
>hands.
>
>The MRI may be better able to sort out the layers, but I still do not
>regard placenta accreta as diagnosable or excludable with a high level of
>confidence (I have always thought it should be, but it aint).
>
>Jim Smeltzer MD gaperina@mindspring.com (:^]>
>
>At 07:38 AM 8/24/1998 -0500, you wrote:
>>Jim,
>>
>>look at it this way - the U/S is a screen. if you feel that the images
>>suggest a high risk for percreta or even increta for that matter, why
>>not get a targeted MRI? additionally, if bladder involvement is
>>suspected, then a cysto would shed more light i suspect. fortunately,
>>these cases are usually few and far between but it does pay to have some
>>additional diagnostic modalities for the tough cases. btw in our case
>>posted awhile back, the patient's OB punted to the hospital which quite
>>predictably took over all aspects of the case. sad to say, i have no
>>more input and can't even obtain follow-up images. i will post the
>>outcome, however.
>>
>>Art
>>
>>At Mon, 24 Aug 1998, James S Smeltzer MD wrote:
>>>
>>>At 02:44 PM 8/22/1998 -0500, you wrote:
>>>> Did not come thru but q was detectability of percreta.
>>>
>>>Hi Martin,
>>>
>>>In my 15 years of prenatal diagnosis I have been singularly unimpressed
>>>with my and my peers' ability to perform this simple task.
>>>
>>>A patient scanned at a leading sonography center came into our ER DOA
>>>because of a percreta which was not detected or detectable by a 16 week
>>>scan done there. I have thought I had percreta on multiple occasions to
>>>find that I did not.
>>>
>>>Others have been through the same thing.
>>>
>>>I had an increta which was extensive that was manifested by a second stage
>>>arrest in a 20 week miscarriage, and by numerous flame-like lakes in the
>>>placenta (Base to surface & ramified). I did not recognize that as a
>>>manifestation at the time. This patient died of this cause after delivery.
>>> I have subsequently seen this four times & three had accreta, two lost
>>>uterus, two preterm & one normal outcome.
>>>
>>>This is humbling, as I approach every problem of pregnancy as diagnosable
>>>by US until proven otherwise. Why do you ask? Jim Smeltzer MD
>>>(perinatal@perinatal.net)
>>
>>--
>>art fougner, md
>>SonoScan/Genetic Sciences
>>forest hills, ny
>>evsono@pipeline.com
>>

--
art fougner, md
SonoScan/Genetic Sciences
forest hills, ny
evsono@pipeline.com



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