Abstract：
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.
This study aimed to evaluate the role of transvaginal sonography in the third trimester of pregnancy in predicting outcomes in patients with a high probability of placenta accreta spectrum at birth.
This was a retrospective analysis of prospectively collected data of patients presenting with a singleton pregnancy and a history of at least 1 previous cesarean delivery and patients diagnosed prenatally with an anterior low-lying placenta or placenta previa delivered electively after 32 weeks of gestation. All patients had a least 1 detailed ultrasound examination, including transabdominal and transvaginal scans, within 2 weeks before delivery. Of note, 2 experienced operators, blinded to the clinical data, were asked to make a judgment 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 cotyledons could not be digitally separated from the uterine wall at delivery or during the gross examination of the hysterectomy or partial myometrial resection specimens.
A total of 111 patients were included in the study. Abnormal placental tissue attachment was found in 76 patients (68.5%) at birth, and histologic examination confirmed superficial villous attachment (creta) and deep villous attachment (increta) in 11 and 65 cases, respectively. Of note, 72 patients (64.9%) had a peripartum hysterectomy, including 13 cases with no evidence of placenta accreta spectrum at birth because of 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=.002) between transabdominal and transvaginal ultrasound examinations, but both ultrasound techniques had similar likelihood scores in identifying accreta placentation that was confirmed at birth. On transabdominal scan, only a high lacuna score was significantly associated (P=.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=.003), changes in the cervix structure (P=.01), cervix increased vascularity (P=.001), and the presence of placental lacunae (P=.005). The odds ratio for peripartum hysterectomy were 5.01 (95% confidence interval, 1.25-20.1) for a very thin (<1-mm) distal lower uterine segment and 5.62 (95% confidence interval, 1.41-22.5) for a lacuna score of 3+.
Transvaginal ultrasound examination contributes to both prenatal management and the prediction of surgical outcomes in patients with a history of previous cesarean delivery with and without ultrasound signs suggestive of placenta accreta spectrum. 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.
This study aimed to evaluate the role of transvaginal sonography in the third trimester of pregnancy in predicting outcomes in patients with a high probability of placenta accreta spectrum at birth.
This was a retrospective analysis of prospectively collected data of patients presenting with a singleton pregnancy and a history of at least 1 previous cesarean delivery and patients diagnosed prenatally with an anterior low-lying placenta or placenta previa delivered electively after 32 weeks of gestation. All patients had a least 1 detailed ultrasound examination, including transabdominal and transvaginal scans, within 2 weeks before delivery. Of note, 2 experienced operators, blinded to the clinical data, were asked to make a judgment 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 cotyledons could not be digitally separated from the uterine wall at delivery or during the gross examination of the hysterectomy or partial myometrial resection specimens.
A total of 111 patients were included in the study. Abnormal placental tissue attachment was found in 76 patients (68.5%) at birth, and histologic examination confirmed superficial villous attachment (creta) and deep villous attachment (increta) in 11 and 65 cases, respectively. Of note, 72 patients (64.9%) had a peripartum hysterectomy, including 13 cases with no evidence of placenta accreta spectrum at birth because of 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=.002) between transabdominal and transvaginal ultrasound examinations, but both ultrasound techniques had similar likelihood scores in identifying accreta placentation that was confirmed at birth. On transabdominal scan, only a high lacuna score was significantly associated (P=.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=.003), changes in the cervix structure (P=.01), cervix increased vascularity (P=.001), and the presence of placental lacunae (P=.005). The odds ratio for peripartum hysterectomy were 5.01 (95% confidence interval, 1.25-20.1) for a very thin (<1-mm) distal lower uterine segment and 5.62 (95% confidence interval, 1.41-22.5) for a lacuna score of 3+.
Transvaginal ultrasound examination contributes to both prenatal management and the prediction of surgical outcomes in patients with a history of previous cesarean delivery with and without ultrasound signs suggestive of placenta accreta spectrum. 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.
摘要：
背景：经阴道超声成像已成为产前评估子宫下段和子宫颈解剖结构的重要工具，但关于经阴道超声在处理出生时胎盘植入频谱高危患者中的作用的数据有限。
目的：本研究的目的是评估妊娠晚期经阴道超声检查在预测出生时胎盘植入谱概率高的患者结局中的作用。
方法：这是一项前瞻性收集的单胎妊娠患者资料的回顾性分析，至少有一次既往剖宫产史,并在产前诊断为前低位/前置胎盘,32周后择期分娩.所有患者在分娩前两周内进行了至少一次详细的超声检查，包括经腹和经阴道扫描。两位经验丰富的操作员，在不了解临床数据的情况下,我们要求对胎盘植入谱的可能性进行判断:胎盘植入谱的可能性低或高,并预测主要手术结局(保守性与围产期子宫切除术).当一个或多个胎盘子叶在分娩时或在子宫切除术或部分子宫肌层切除术标本的大体检查期间不能与子宫壁数字分离时，就可以确认植入胎盘的诊断。
结果：本研究共纳入111例患者。出生时胎盘组织附着异常76例（68.5％），组织学检查证实浅层绒毛附着（creta）和深层绒毛附着（intrta）11例和65例，分别。72例（64.9％）患者进行了围产期子宫切除术，其中13例由于未能重建子宫下段和/或出血过多而在出生时没有PAS的证据。经腹和经阴道超声检查的胎盘位置分布存在显着差异（X2=12.66；p=0.002），但两种超声技术在识别出生时确认的植入胎盘方面具有相似的可能性得分。经腹扫描,只有较高的腔隙评分与子宫切除术的机会增加显著相关(p=0.02)，而在经阴道扫描中发现子宫切除术的需要与子宫下段远端部分的厚度显著相关(p=0.003)，子宫颈结构的变化（p=0.01），子宫颈血管增加（p=0.001），和胎盘腔隙的存在（p=0.005）。对于非常薄（<1mm）的远端子宫下段，围产期子宫切除术的比值比为5.01（95CI1.25;20.1），以及5.62（95CI1.41;22.5）3+腔隙评分。
结论：经阴道超声检查有助于有或没有提示PAS超声征象的CD病史患者的产前管理和手术结果预测。经阴道超声检查子宫下段和子宫颈应纳入临床方案，以术前评估有复杂剖宫产风险的患者，在影像学上有或没有提示PAS的迹象。
目的：本研究的目的是评估妊娠晚期经阴道超声检查在预测出生时胎盘植入谱概率高的患者结局中的作用。
方法：这是一项前瞻性收集的单胎妊娠患者资料的回顾性分析，至少有一次既往剖宫产史,并在产前诊断为前低位/前置胎盘,32周后择期分娩.所有患者在分娩前两周内进行了至少一次详细的超声检查，包括经腹和经阴道扫描。两位经验丰富的操作员，在不了解临床数据的情况下,我们要求对胎盘植入谱的可能性进行判断:胎盘植入谱的可能性低或高,并预测主要手术结局(保守性与围产期子宫切除术).当一个或多个胎盘子叶在分娩时或在子宫切除术或部分子宫肌层切除术标本的大体检查期间不能与子宫壁数字分离时，就可以确认植入胎盘的诊断。
结果：本研究共纳入111例患者。出生时胎盘组织附着异常76例（68.5％），组织学检查证实浅层绒毛附着（creta）和深层绒毛附着（intrta）11例和65例，分别。72例（64.9％）患者进行了围产期子宫切除术，其中13例由于未能重建子宫下段和/或出血过多而在出生时没有PAS的证据。经腹和经阴道超声检查的胎盘位置分布存在显着差异（X2=12.66；p=0.002），但两种超声技术在识别出生时确认的植入胎盘方面具有相似的可能性得分。经腹扫描,只有较高的腔隙评分与子宫切除术的机会增加显著相关(p=0.02)，而在经阴道扫描中发现子宫切除术的需要与子宫下段远端部分的厚度显著相关(p=0.003)，子宫颈结构的变化（p=0.01），子宫颈血管增加（p=0.001），和胎盘腔隙的存在（p=0.005）。对于非常薄（<1mm）的远端子宫下段，围产期子宫切除术的比值比为5.01（95CI1.25;20.1），以及5.62（95CI1.41;22.5）3+腔隙评分。
结论：经阴道超声检查有助于有或没有提示PAS超声征象的CD病史患者的产前管理和手术结果预测。经阴道超声检查子宫下段和子宫颈应纳入临床方案，以术前评估有复杂剖宫产风险的患者，在影像学上有或没有提示PAS的迹象。
