Three-dimensional volume rendering ultrasound for assessing placenta accreta spectrum severity and discriminating it from simple scar dehiscence

BACKGROUND Prenatal ultrasound discrimination between placenta accreta spectrum and scar dehiscence with underlying nonadherent placenta is challenging both prenatally and intraoperatively, which often leads to overtreatment. In addition, accurate prenatal prediction of surgical difficulty and morbidity in placenta accreta spectrum is difficult, which precludes appropriate multidisciplinary planning. The advent of advanced 3-dimensional volume rendering and contrast enhancement techniques in modern ultrasound systems provides a comprehensive prenatal assessment, revealing details that are not discernible in traditional 2-dimensional imaging. OBJECTIVE This study aimed to evaluate the use of 3-dimensional volume rendering ultrasound techniques in determining the severity of placenta accreta spectrum and distinguishing between placenta accreta spectrum and scar dehiscence with underlying nonadherent placenta. STUDY DESIGN A prospective, cohort study was conducted between July 2022 and July 2023 in the fetal medicine unit of Dr Soetomo Academic General Hospital, Surabaya, Indonesia. All pregnant individuals with anterior low-lying placenta or placenta previa with a previous caesarean section who were referred with suspicion of placenta accreta spectrum were consented and screened using the standardised 2-dimensional and Doppler ultrasound imaging. Additional 3-dimensional volumes were obtained from the sagittal section of the uterus with a filled urinary bladder. These were analyzed by rotating the region of interest to be perpendicular to the uterovesical interface. The primary outcomes were the clinical and histologic severity in the cases of placenta accreta spectrum and correct diagnosis of dehiscence with nonadherent placenta underneath. The strength of association between ultrasound and clinical outcomes was determined. Multivariate logistic regression analyses and diagnostic testing of accuracy were used to analyze the data. RESULTS A total of 70 patients (56 with placenta accreta spectrum and 14 with scar dehiscence) were included in the analysis. Multivariate logistic regression of all 2-dimensional and 3-dimensional signs revealed the 3-dimensional loss of clear zone (P<.001) and the presence of bridging vessels on 2-dimensional Doppler ultrasound (P=.027) as excellent predictors in differentiating scar dehiscence and placenta accreta spectrum. The 3-dimensional loss of clear zone demonstrated a high diagnostic accuracy with an area under the curve of 0.911 (95% confidence interval, 0.819–1.002), with a sensitivity of 89.3% (95% confidence interval, 78.1–95.97%) and specificity of 92.9% (95% confidence interval, 66.1–99.8%). The presence of bridging vessels on 2-dimensional Doppler demonstrated an area under the curve of 0.848 (95% confidence interval, 0.714–0.982) with a sensitivity of 91.1% (95% confidence interval, 80.4–97.0%) and specificity of 78.6% (95% confidence interval, 49.2–95.3%). A subgroup analysis among the placenta accreta spectrum group revealed that the presence of a 3-dimensional disrupted bladder serosa with obliteration of the vesicouterine space was associated with vesicouterine adherence (P<.001)

Serial case reports: Pregnancy with Lucio’s phenomenon of leprosy in dr. Soetomo hospital, Surabaya

Leprosy is a complex disease which will affect in many aspects of the patient. In dr. Soetomo hospital, there were two cases of pregnancy with leprosy and Lucio’s phenomenon from 2014 until 2018. Both had been receiving multidrug therapy (MDT) before pregnancy but stopped due to lack of compliance. First case was resulted with term. Second case was admitted with worse condition than the first case, fetal growth restriction and ended with preterm delivery probably because the severity of the case. Lucio’s phenomenon incidence is increased in pregnancy due to immunodeficient condition. This serial case report shows that the initial diagnosis and optimum treatment of leprosy is very important especially in women of child-bearing age

Three-dimensional volume rendering ultrasound for assessing placenta accreta spectrum severity and discriminating it from simple scar dehiscence

BACKGROUND: Prenatal ultrasound discrimination between placenta accreta spectrum and scar dehiscence with underlying nonadherent placenta is challenging both prenatally and intraoperatively, which often leads to overtreatment. In addition, accurate prenatal prediction of surgical difficulty and morbidity in placenta accreta spectrum is difficult, which precludes appropriate multidisciplinary planning. The advent of advanced 3-dimensional volume rendering and contrast enhancement techniques in modern ultrasound systems provides a comprehensive prenatal assessment, revealing details that are not discernible in traditional 2-dimensional imaging.OBJECTIVE: This study aimed to evaluate the use of 3-dimensional volume rendering ultrasound techniques in determining the severity of placenta accreta spectrum and distinguishing between placenta accreta spectrum and scar dehiscence with underlying nonadherent placenta. STUDY DESIGN: A prospective, cohort study was conducted between July 2022 and July 2023 in the fetal medicine unit of Dr Soetomo Academic General Hospital, Surabaya, Indonesia. All pregnant individuals with anterior low-lying placenta or placenta previa with a previous caesarean section who were referred with suspicion of placenta accreta spectrum were consented and screened using the standardised 2-dimensional and Doppler ultrasound imaging. Additional 3-dimensional volumes were obtained from the sagittal section of the uterus with a filled urinary bladder. These were analyzed by rotating the region of interest to be perpendicular to the uterovesical interface. The primary outcomes were the clinical and histologic severity in the cases of placenta accreta spectrum and correct diagnosis of dehiscence with nonadherent placenta underneath. The strength of association between ultrasound and clinical outcomes was determined. Multivariate logistic regression analyses and diagnostic testing of accuracy were used to analyze the data.RESULTS:A total of 70 patients (56 with placenta accreta spectrum and 14 with scar dehiscence) were included in the analysis. Multivariate logistic regression of all 2-dimensional and 3-dimensional signs revealed the 3-dimensional loss of clear zone (P&lt;.001) and the presence of bridging vessels on 2-dimensional Doppler ultrasound (P=.027) as excellent predictors in differentiating scar dehiscence and placenta accreta spectrum. The 3-dimensional loss of clear zone demonstrated a high diagnostic accuracy with an area under the curve of 0.911 (95% confidence interval, 0.819–1.002), with a sensitivity of 89.3% (95% confidence interval, 78.1–95.97%) and specificity of 92.9% (95% confidence interval, 66.1–99.8%). The presence of bridging vessels on 2-dimensional Doppler demonstrated an area under the curve of 0.848 (95% confidence interval, 0.714–0.982) with a sensitivity of 91.1% (95% confidence interval, 80.4–97.0%) and specificity of 78.6% (95% confidence interval, 49.2–95.3%). A subgroup analysis among the placenta accreta spectrum group revealed that the presence of a 3-dimensional disrupted bladder serosa with obliteration of the vesicouterine space was associated with vesicouterine adherence (P&lt;.001). CONCLUSION: Three-dimensional volume rendering ultrasound is a promising tool for effective discrimination between scar dehiscence with underlying nonadherent placenta and placenta accreta spectrum. It also shows potential in predicting the clinical severity with urinary bladder involvement in cases of placenta accreta spectrum.</p

Effectiveness of Participation in Pregnancy Classes to Reduce the Incidence of Obstetric Labor Complications and Cesarean Section

Objective : to assess the effectiveness of participation in pregnancy classes to inform such a prenatal program for physicians and midwives, focusing to reduce the incidence of obstetric labor complications and cesarean section. Methods : This study was done using an analytic observational approach, using a cross-sectional study and consecutive sampling. One hundred and ninety-four participants of this study were women aged 20–35 years who gave birth between January and November 2019 in balarejo sub-district, East Java, Indonesia. The subjects were divided into two groups: participation (four times) and non-participation (less than four times) in the pregnancy classes. The analyzed outcomes are labor complications (prolonged labor, postpartum hemorrhage, postpartum fever, premature rupture of membrane), and cesarean section birth.. Results: The results of this study indicate that participants of pregnancy classes have a significantly lower probability of suffering prolonged labor (OR=0.05, 95% CI=0.01-0.23, p&lt;0.05), postpartum hemorrhage (OR=0.20, 95% CI=0.04-0.95, p&lt;0.05), and postpartum fever (OR=0.13, 95% CI=0.16-1.08, p&lt;0.05) compared with non-participants. Also, participating women have a lower chance of undergoing cesarean section (OR=0.08, 95% CI=0.03-0.21, p&lt;0.05). Conclusion : The incidence of obstetric labor complications and cesarean section can be effectively reduced by the participation of pregnant woman class

Three-dimensional volume rendering ultrasound for assessing placenta accreta spectrum severity and discriminating it from simple scar dehiscence

BACKGROUND: Prenatal ultrasound discrimination between placenta accreta spectrum and scar dehiscence with underlying nonadherent placenta is challenging both prenatally and intraoperatively, which often leads to overtreatment. In addition, accurate prenatal prediction of surgical difficulty and morbidity in placenta accreta spectrum is difficult, which precludes appropriate multidisciplinary planning. The advent of advanced 3-dimensional volume rendering and contrast enhancement techniques in modern ultrasound systems provides a comprehensive prenatal assessment, revealing details that are not discernible in traditional 2-dimensional imaging.OBJECTIVE: This study aimed to evaluate the use of 3-dimensional volume rendering ultrasound techniques in determining the severity of placenta accreta spectrum and distinguishing between placenta accreta spectrum and scar dehiscence with underlying nonadherent placenta. STUDY DESIGN: A prospective, cohort study was conducted between July 2022 and July 2023 in the fetal medicine unit of Dr Soetomo Academic General Hospital, Surabaya, Indonesia. All pregnant individuals with anterior low-lying placenta or placenta previa with a previous caesarean section who were referred with suspicion of placenta accreta spectrum were consented and screened using the standardised 2-dimensional and Doppler ultrasound imaging. Additional 3-dimensional volumes were obtained from the sagittal section of the uterus with a filled urinary bladder. These were analyzed by rotating the region of interest to be perpendicular to the uterovesical interface. The primary outcomes were the clinical and histologic severity in the cases of placenta accreta spectrum and correct diagnosis of dehiscence with nonadherent placenta underneath. The strength of association between ultrasound and clinical outcomes was determined. Multivariate logistic regression analyses and diagnostic testing of accuracy were used to analyze the data.RESULTS:A total of 70 patients (56 with placenta accreta spectrum and 14 with scar dehiscence) were included in the analysis. Multivariate logistic regression of all 2-dimensional and 3-dimensional signs revealed the 3-dimensional loss of clear zone (P&lt;.001) and the presence of bridging vessels on 2-dimensional Doppler ultrasound (P=.027) as excellent predictors in differentiating scar dehiscence and placenta accreta spectrum. The 3-dimensional loss of clear zone demonstrated a high diagnostic accuracy with an area under the curve of 0.911 (95% confidence interval, 0.819–1.002), with a sensitivity of 89.3% (95% confidence interval, 78.1–95.97%) and specificity of 92.9% (95% confidence interval, 66.1–99.8%). The presence of bridging vessels on 2-dimensional Doppler demonstrated an area under the curve of 0.848 (95% confidence interval, 0.714–0.982) with a sensitivity of 91.1% (95% confidence interval, 80.4–97.0%) and specificity of 78.6% (95% confidence interval, 49.2–95.3%). A subgroup analysis among the placenta accreta spectrum group revealed that the presence of a 3-dimensional disrupted bladder serosa with obliteration of the vesicouterine space was associated with vesicouterine adherence (P&lt;.001). CONCLUSION: Three-dimensional volume rendering ultrasound is a promising tool for effective discrimination between scar dehiscence with underlying nonadherent placenta and placenta accreta spectrum. It also shows potential in predicting the clinical severity with urinary bladder involvement in cases of placenta accreta spectrum.</p

Geographic variation in management of patients with placenta accreta spectrum : an international survey of experts (GPASS)

OBJECTIVE : To describe global geographic variations in the diagnosis and management of placenta accreta spectrum (PAS). METHODS : An international cross-sectional study was conducted among PAS experts practicing at medical institutions in member states of the United Nations. Survey questions focused on diagnostic evaluation and management strategies for PAS. RESULTS : A total of 134 centers participated. Participating centers represented each of the United Nations' designated regions. Of those, 118 (88%) reported practicing in a medium-volume or high-volume center. First-trimester PAS screen was reported in 35 (26.1%) centers. Respondents consistently implement guideline-supported care practices, including utilization of ultrasound as the primary diagnostic modality (134, 100%) and implementation of multidisciplinary care teams (115, 85.8%). Less than 10% of respondents reported routinely managing PAS without hysterectomy; these centers were predominantly located in Europe and Africa. Antepartum management and availability of mental health support for PAS patients varied widely. CONCLUSION : Worldwide, there is a strong adherence to PAS care guidelines; however, regional variations do exist. Comparing variations in care to outcomes will provide insight into the clinically significant practice variability. SYNOPSIS : This international study sought to determine the geographic variations in diagnosis and management of placenta accreta spectrum worldwide.http://www.wileyonlinelibrary.com/journal/ijgo2022-10-05hj2022Obstetrics and Gynaecolog

Are international guideline recommendations for the management of placenta accreta spectrum applicable in low- and middle-income countries?

Objective: The aim of this study was to explore how obstetricians-gynecologists in low- and middle-income countries (LMICs) can apply current international clinical practice guidelines (CPGs) for the management of placenta accreta spectrum (PAS) in limited resource settings. Methods: This was an observational, survey-based study. Clinicians with expertise in managing patients with PAS in LMICs were contacted for their evaluation of the recommendations included in four PAS clinical practice guidelines. Results: Out of the 158 clinicians contacted, we obtained responses from 65 (41.1%), representing 27 middle income countries (MICs). The results of this survey suggest that the care of PAS patients in middle income countries is very different from what is recommended by international CPGs. Participants in the survey identified that their practice was limited by insufficient availability of hospital infrastructure, low resources of local health systems and lack of trained multidisciplinary teams (MDTs) and this did not enable them to follow CPG recommendations. Two-thirds of the participants surveyed describe the absence of centers of excellence in their country. In over half of the referral hospitals with expertise in managing PAS, there are no MDTs. One-third of patients with intraoperative findings of PAS are managed by the team initially performing the surgery (without additional assistance). Conclusion: The care of patients with PAS in middle income countries frequently deviates from established CPG recommendations largely due to limitations in local resources and infrastructure. New practical guidelines and training programs designed for low resource settings are needed

Is telehealth useful in the management of placenta accreta spectrum in low-resource settings? Results of an exploratory survey

Objective The optimal management of placenta accreta spectrum (PAS) requires the participation of multidisciplinary teams that are often not locally available in low-resource settings. Telehealth has been increasingly used to manage complex obstetric conditions. Few studies have explored the use of telehealth for PAS management, and we aimed evaluate the usage of telehealth in the management of PAS patients in low-resource settings. Methods Between March and April 2023, an observational, survey-based study was conducted, and obstetricians-gynecologists with expertise in PAS management in low- and middle-income countries were contacted to share their opinion on the potential use of telehealth for the diagnosis and management of patients at high-risk of PAS at birth. Participants were identified based on their authorship of at least one published clinical study on PAS in the last 5 years and contacted by email. This is a secondary analysis of the results of that survey. Results From 158 authors contacted we obtained 65 responses from participants in 27 middle-income countries. A third of the participants reported the use of telehealth during the management obstetric emergencies (38.5%, n = 25) and PAS (36.9%, n = 24). Over 70% of those surveyed indicated that they had used “informal” telemedicine (phone call, email, or text message) during PAS management. Fifty-nine participants (90.8%) reported that recommendations given remotely by expert colleagues were useful for management of patients with PAS in their setting. Conclusion Telehealth has been successfully used for the management of PAS in middle-income countries, and our survey indicates that it could support the development of specialist care in other low resource settings