Jauniaux, Eric; Hussein, Ahmed M; Thabet, Mohamed M; Elbarmelgy, Rana M; Elbarmelgy, Rasha A; Jurkovic, Davor; (2023) The role of transvaginal ultrasound in the third-trimester evaluation of patients at high-risk of placenta accreta spectrum at birth. American Journal of Obstetrics and Gynecology , 229 (4) 445.e1-445.e11. 10.1016/j.ajog.2023.05.004.

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Abstract

BACKGROUND: Transvaginal ultrasound imaging has become an essential tool in the prenatal evaluation of the lower uterine segment and anatomy of the cervix but there are only limited data on the role of transvaginal ultrasound in the management of patients at high risk of placenta accreta spectrum at birth. OBJECTIVES: The aim of this study was to evaluate the role of transvaginal sonography in the third trimester in predicting outcomes in patients with a high probability of placenta accreta spectrum at birth. STUDY DESIGN: This was a retrospective analysis of prospectively collected data of patients presenting with a singleton pregnancy, a history of at least one prior cesarean delivery and diagnosed prenatally with an anterior low-lying/placenta previa delivered electively after 32 weeks. All patients had a least one detailed ultrasound examination including transabdominal and transvaginal scans within two weeks prior to delivery. Two experienced operators, blinded to the clinical data were asked to make a judgement on the likelihood of placenta accreta spectrum as a binary: low or high-probability of placenta accreta spectrum and to predict the main surgical outcome (conservative vs peripartum hysterectomy). The diagnosis of accreta placentation was confirmed when one or more placental cotyledon(s) could not be digitally separated from the uterine wall at delivery or during the gross examination of the hysterectomy or partial myometrial resection specimens. RESULTS: A total of 111 patients were included in the study. Abnormal placental tissue attachment was found in 76 (68.5%) patients at birth and histologic examination confirmed superficial villous attachment (creta) and deep villous attachment (increta) in 11 and 65 cases, respectively. Seventy-two (64.9%) patients had a peripartum hysterectomy including 13 cases with no evidence of PAS at birth due to failure to reconstruct the lower uterine segment and/or excessive bleeding. There was a significant difference in the distribution of placental location (X2 = 12.66; p= 0.002) between transabdominal and transvaginal ultrasound examination but both ultrasound techniques had similar likelihood score in identifying accreta placentation that was confirmed at birth. On transabdominal scan, only a high lacuna score was significantly associated (p= 0.02) with an increased chance of hysterectomy whereas on transvaginal scan significant associations were found between the need for hysterectomy and the thickness of the distal part of the lower uterine segment (p= 0.003), changes in the cervix structure (p= 0.01), cervix increased vascularity (p= 0.001), and the presence of placental lacunae (p= 0.005). The odds ratio for peripartum hysterectomy were 5.01 (95%CI 1.25;20.1) for a very thin (< 1mm) distal lower uterine segment and 5.62 (95%CI 1.41;22.5) 3+ lacuna score. CONCLUSION: Transvaginal ultrasound examination contribute to both prenatal management and to prediction of surgical outcomes in patients with a history of prior CD with and without ultrasound signs suggestive of PAS. Transvaginal ultrasound examination of the lower uterine segment and cervix should be included in clinical protocols for the preoperative evaluation of patients at risk of complex cesarean delivery, with or without signs suggesting PAS on imaging.

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