Predicting Placenta Accreta Spectrum: Validation of the Placenta Accreta Index.

OBJECTIVES: The placenta accreta spectrum (PAS) incidence has risen substantially over the past century, paralleling a rise in cesarean delivery (CD) rates. Prenatal diagnosis of PAS improves maternal outcomes. The Placenta Accreta Index (PAI) is a standardized approach to prenatal diagnosis of PAS incorporating clinical risk and ultrasound (US) findings suggestive of placental invasion. We sought to validate the PAI for prediction of PAS in pregnancies with prior CD. METHODS: This work was a retrospective cohort study of pregnancies with 1 or more prior CDs that received a US diagnosis of placenta previa or low-lying placenta in the third trimester. Images of third-trimester US with a complete placental evaluation were read by 2 blinded physicians, and the PAI was applied. Surgical outcomes and pathologic findings were reviewed. Placenta accreta spectrum was diagnosed if clinical evidence of invasion was seen at time of delivery or if any placental invasion was identified histologically. International Federation of Gynecology and Obstetrics criteria were used. RESULTS: A total of 194 women met inclusion criteria. Cesarean hysterectomy was performed in 92 (47%), CD in 97 (50%), and vaginal delivery in 5 (3%). Of those who underwent hysterectomy, PAS was histologically confirmed in 79 (85%) pregnancies. Of the remaining 13 who underwent hysterectomy, all met International Federation of Gynecology and Obstetrics grade 1 clinical criteria for PAS. With a threshold of greater than 4, the PAI has a sensitivity of 87%, specificity of 77%, positive predictive value of 72%, and negative predictive value of 90% for PAS diagnosis. CONCLUSIONS: Contemporaneous application of the PAI, a standardized approach to US diagnosis, is useful in the prenatal prediction of PAS.

Prospective First-Trimester Ultrasound Imaging of Low Implantation and Placenta Accreta Spectrum.

OBJECTIVES: To prospectively evaluate low implantation of the gestational sac and other first-trimester ultrasound (US) parameters for prediction of placenta accreta spectrum (PAS). METHODS: Women with a diagnosis of low implantation on clinically indicated first-trimester US underwent a transvaginal US examination at 10 to 13 weeks' gestation to assess the trophoblast location, anechoic areas, bridging vessels, and smallest myometrial thickness (SMT). The placental location was evaluated in the second trimester, and serial US examinations were performed in cases of low placentation. Placenta accreta spectrum was based on clinical findings and confirmed by histologic results. RESULTS: Of 68 women, 40 (59%) had prior cesarean delivery (CD). Hysterectomy was performed in 8, all with prior CD. Of these, 7 (88%) had US suspicion of PAS. In 16 with prior CD and basalis overlying the internal os, 9 (56%) had second-trimester placenta previa, and 7 of 9 (78%) underwent hysterectomy with pathologic confirmation of PAS. Of 28 without prior CD, there were no cases of persistent low placentation in the third trimester regardless of the trophoblast location. Ultrasound parameters associated with PAS were a smaller distance from the inferior trophoblastic border to the external os, disruption of the bladder-serosal interface, bridging vessels, anechoic areas, and the SMT. In women with prior CD, use of the SMT in the sagittal plane yielded an area under the receiver operating characteristic curve of 0.96 (95% confidence interval, 0.91-1.00). CONCLUSIONS: First-trimester low implantation increases the risk of persistent placenta previa and PAS in women with prior CD. All parameters were associated with PAS, the most predictive being the SMT.

Cervical Length in Patients at Risk for Placenta Accreta.

OBJECTIVES: To evaluate cervical length measurements in women with placenta accreta compared to women with a nonadherent low-lying placenta or placenta previa and evaluate this relationship in terms of vaginal bleeding, preterm labor, and preterm birth. METHODS: We conducted a retrospective cohort study between 1997 and 2011 of gravidas with more than 1 prior cesarean delivery who had a transvaginal ultrasound examination between 24 and 34 weeks for a low-lying placenta or placenta previa. Cervical length was measured from archived images in accordance with national guidelines by a single investigator, who was blinded to outcomes and ultrasound reports. The diagnosis of placental accreta was based on histologic confirmation. For study purposes, preterm birth was defined as less than 36 weeks, and cervical lengths of 3 cm or less were considered short. Standard statistical analyses were used. RESULTS: A total of 125 patients met inclusion criteria. The cohort was divided into patients with (n = 43 [34%]) and without (n = 82 [66%]) placenta accreta and stratified by gestational age at the ultrasound examinations. Women with placenta accreta had shorter cervical length measurements during their 32- to 34-week ultrasound examinations (mean ± SD, 3.23 ± 0.98 versus 3.95 ± 1.0 cm; P < .01) and were more likely to have a short cervix of 3 cm or less (P = .001). However, these findings did not correlate with the degree of invasion (P = .3), or higher rates of vaginal bleeding and preterm labor (P = .19) resulting in preterm birth before 36 weeks (P = .64). CONCLUSIONS: Women with placenta accreta had shorter cervical lengths at 32 to 34 weeks than women with a nonadherent low-lying placenta or placenta previa, but this finding did not correlate with a higher risk of vaginal bleeding or preterm labor resulting in preterm birth before 36 weeks.

Comparison of saline infusion sonography (SIS) versus SIS-guided endometrial sampling in the diagnosis of endometrial pathology.

PURPOSE: To compare saline infusion sonography (SIS) to tissue obtained from SIS-guided endometrial sampling (SISES) to determine sensitivity and specificity for benign and malignant conditions of the endometrium. METHODS: Added value of SISES after SIS was evaluated over 5 years. SIS and SISES techniques have been previously described. Women with abnormal uterine bleeding and endometrial findings underwent SIS. Criteria for SISES included atypical polypoid mass, focal irregularity or global endometrial thickening, nondiagnostic SIS, discordance between SIS and endometrial biopsy, or request from the primary team. Final surgical pathology was compared with SIS and SISES. RESULTS: One-hundred twenty-three SIS patients had SISES. SIS alone had a sensitivity of 100%, specificity of 42%, positive predictive value of 16%, and negative predictive value of 100%. A total of 120 patients had final clinical or surgical outcomes. Specificity was greatly improved with addition of SISES (95.5%, p < 0.001). Combination of SIS with SISES detected all 12 premalignant and malignant endometrial lesions. Three cases had small foci of hyperplasia (n = 2) or atypia (n = 1) in polyps on final surgical pathology, which were not prospectively identified on SISES. CONCLUSIONS: SISES significantly improves the specificity in the diagnosis of endometrial lesions. False-negative findings of SISES in polyps in postmenopausal women with bleeding suggest the need for surgical removal in this setting. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:416-422, 2016.

Sonographic Findings of Morbidly Adherent Placenta in the First Trimester.

OBJECTIVES: The purpose of this study was to evaluate the association between first-trimester sonographic findings and morbidly adherent placenta at delivery. METHODS: We conducted a retrospective review of all first-trimester sonographic examinations from pregnancies that underwent third-trimester sonography for placenta previa or low-lying placenta between September 1997 and October 2011. Only women with a prior cesarean delivery were included. Transabdominal and transvaginal images from these first-trimester studies were reviewed for the following sonographic parameters: distance from the inferior border of the gestational sac to the external cervical os, location of the decidua basalis, presence of anechoic areas, uterine-bladder interface irregularity, and smallest anterior myometrial thickness. Morbidly adherent placentation was confirmed on histologic examination of hysterectomy specimens. Statistical methods included univariate and multivariate analyses. RESULTS: Thirty-nine patients met inclusion criteria, of whom 14 (36%) had confirmed placental invasion. The number of prior cesarean deliveries was significantly associated with placental invasion (P < .0001). The only first-trimester sonographic finding associated with invasion was the smallest anterior myometrial thickness measured in the sagittal plane (P < .02). Multivariate analysis based on these two variables yielded an area under the receiver operating characteristic curve of 0.94 (95% confidence interval, 0.87-1.00) and significantly improved the prediction of placental invasion compared to using the number of prior cesarean deliveries alone. CONCLUSIONS: In women with persistent placenta previa or low-lying placenta and prior cesarean delivery, the smallest anterior myometrial thickness on first-trimester sonography significantly improved detection of morbidly adherent placenta.

Placenta accreta and vaginal bleeding according to gestational age at delivery.

OBJECTIVE: To evaluate the incidence of vaginal bleeding in women with placenta accreta according to gestational age at delivery. METHODS: This is a retrospective cohort study of women with prior cesarean delivery and persistent placenta previa delivered at our institution between December 1997 and December 2011. Diagnosis of invasion was based on hysterectomy performed for an abnormally adherent placenta with histologic confirmation. Suspicion for invasion was based on the impression of the attending physician at the time of ultrasonography. Records were reviewed to identify indication for delivery and estimated blood loss. Statistical analyses were performed using Student's t test, χ2 test, and Mantel-Haenszel and Jonckheere-Terpstra tests for trend. RESULTS: Of 216 women with prior cesarean delivery and persistent previa, 65 (30%) required cesarean hysterectomy and had histologic confirmation of invasion. Urgent delivery for bleeding was performed in 20% of these pregnancies (13/65). Delivery for bleeding decreased significantly with advancing gestation (P=.001). In our series, 71% with accreta were delivered at 36 weeks of gestation or greater with delivery for bleeding in five (11%), and estimated blood loss was not increased in these pregnancies. Of 79 women with ultrasonographic suspicion for accreta, the incidence of vaginal bleeding prompting urgent delivery also decreased with advancing gestation (P<.001). CONCLUSION: Likelihood of vaginal bleeding necessitating delivery declined with advancing gestation in pregnancies with placenta accreta as did blood loss. Most were delivered at 36 weeks of gestation or greater, nearly 90% in the absence of bleeding complications. Thus, although preterm delivery is an important consideration when placenta accreta is suspected, our findings support individualizing delivery planning.

Ultrasound predictors of placental invasion: the Placenta Accreta Index.

OBJECTIVE: We sought to apply a standardized evaluation of ultrasound parameters for the prediction of placental invasion in a high-risk population. STUDY DESIGN: This was a retrospective review of gravidas with ≥1 prior cesarean delivery who received an ultrasound diagnosis of placenta previa or low-lying placenta in the third trimester at our institution from 1997 through 2011. Sonographic images were reviewed by an investigator blinded to pregnancy outcome and sonography reports. Parameters assessed included loss of retroplacental clear zone, irregularity and width of uterine-bladder interface, smallest myometrial thickness, presence of lacunar spaces, and bridging vessels. Diagnosis of placental invasion was based on histologic confirmation. Statistical analyses were performed using linear logistic regression and multiparametric analyses to generate a predictive equation evaluated using a receiver operating characteristic curve. RESULTS: Of 184 gravidas who met inclusion criteria, 54 (29%) had invasion confirmed on hysterectomy specimen. All sonographic parameters were associated with placental invasion (P < .001). Constructing a receiver operating characteristic curve, the combination of smallest sagittal myometrial thickness, lacunae, and bridging vessels, in addition to number of cesarean deliveries and placental location, yielded an area under the curve of 0.87 (95% confidence interval, 0.80-0.95). Using logistic regression, a predictive equation was generated, termed the "Placenta Accreta Index." Each parameter was weighted to create a 9-point scale in which a score of 0-9 provided a probability of invasion that ranged from 2-96%, respectively. CONCLUSION: Assignment of the Placenta Accreta Index may be helpful in predicting individual patient risk for morbidly adherent placenta.

Prediction of polycystic ovarian syndrome based on ultrasound findings and clinical parameters.

OBJECTIVE: To determine the accuracy of sonographic-diagnosed polycystic ovaries and clinical parameters in predicting polycystic ovarian syndrome. METHODS: Medical records and ultrasounds of 151 women with sonographically diagnosed polycystic ovaries were reviewed. Sonographic criteria for polycystic ovaries were based on 2003 Rotterdam European Society of Human Reproduction and Embryology/American Society for Reproductive Medicine guidelines: at least one ovary with 12 or more follicles measuring 2-9 mm and/or increased ovarian volume >10 cm(3) . Clinical variables of age, gravidity, ethnicity, body mass index, and sonographic indication were collected. One hundred thirty-five patients had final outcomes (presence/absence of polycystic ovarian syndrome). Polycystic ovarian syndrome was diagnosed if a patient had at least one other of the following two criteria: oligo/chronic anovulation and/or clinical/biochemical hyperandrogenism. A logistic regression model was constructed using stepwise selection to identify variables significantly associated with polycystic ovarian syndrome (p < .05). The validity of the model was assessed using receiver operating characteristics and Hosmer-Lemeshow χ(2) analyses. RESULTS: One hundred twenty-eight patients met official sonographic criteria for polycystic ovaries and 115 (89.8%) had polycystic ovarian syndrome (p = .009). Lower gravidity, abnormal bleeding, and body mass index >33 were significant in predicting polycystic ovarian syndrome (receiver operating characteristics curve, c = 0.86). Pain decreased the likelihood of polycystic ovarian syndrome. CONCLUSIONS: Polycystic ovaries on ultrasound were sensitive in predicting polycystic ovarian syndrome. Ultrasound, combined with clinical parameters, can be used to generate a predictive index for polycystic ovarian syndrome.

Biometric sonographic findings of abnormally adherent trophoblastic implantations on cesarean delivery scars.

OBJECTIVES: The purpose of this study was to review first-trimester transvaginal sonograms of patients with cervicoisthmic implantations and prior cesarean deliveries to determine whether sonographic biometric measurements can distinguish between abnormally adherent trophoblastic implantations and normally implanted pregnancies. METHODS: Our database was reviewed from October 2006 through December 2011 for patients with first-trimester sonographic diagnoses of cervicoisthmic implantations and previous cesarean deliveries. Biometric measurements of the smallest distance from the anterior trophoblastic border to the uterine serosa were performed on transvaginal sagittal images of the uterus. Outcomes were classified into 5 categories: cesarean scar pregnancy, placental invasion (accreta/increta/percreta), previa without invasion, spontaneous abortion, and delivered intrauterine pregnancy. Statistical methods included analysis of variance with the Tukey range test and Student t test. RESULTS: Of 77 studies, outcome data were available for 56 patients. The mean gestational age was 8.8 weeks (minimum, 2.0 weeks; maximum, 14.9 weeks). The anterior trophoblastic border distances from the uterine serosa were significantly smaller in cesarean scar pregnancies (mean, 1.6 mm; SD, 0.6 mm) and placental invasion pregnancies (mean, 2.2 mm; SD, 1.0 mm) than the normally implanted groups (mean, 7.9 mm, SD, 3.3 mm; P < .0001). CONCLUSIONS: Smaller trophoblastic border distances to the anterior uterine serosa are seen in abnormally adherent trophoblastic implantations, and these distances distinguish them from other pregnancy outcomes.

Does the type of intrauterine device affect conspicuity on 2D and 3D ultrasound?

OBJECTIVE: The objective of our study was to assess the conspicuity and position evaluation of intrauterine devices (IUDs) on 2D ultrasound and 3D ultrasound in nongravid patients. MATERIALS AND METHODS: Review of the ultrasound database for the period from July 2008 through June 2009 was performed for identification of patients with IUDs, of the type and position of the IUD, and of the patient's presenting symptoms. The conspicuity of the IUD on 2D sagittal and transverse planes and 3D coronal views was scored according to a 7-point scale. Data analysis was performed using the Student t test and the Pearson chi-square test. RESULTS: Of the 269 patients with IUDs who had undergone ultrasound during the study period, 180 patients had a copper IUD; 59, a levonorgestrel-releasing device; and three, a Lippes loop. Twenty-seven IUDs were excluded because they were not seen on ultrasound (n = 15) or the type of IUD was not identifiable (n = 12). Of the 239 IUDs identified, the conspicuity score for copper IUDs (mean score, 5.3 [SD, 1.4]) differed significantly from that for levonorgestrel-releasing IUDs (mean, 3.1 [1.0]) on 2D ultrasound (p < 0.001). The difference in the conspicuity score for copper IUDs (mean, 6.6 [0.95]) versus that for levonorgestrel-releasing devices (mean, 6.2 [0.92]) on 3D ultrasound was marginally significant (p = 0.05). One hundred seventy-six IUDs (74%) were properly positioned within the endometrial cavity and 60 (25%) were malpositioned; proper positioning of three IUDs (1%) could not be confirmed. The indications for sonographic evaluation were pain (111/239, 46%), missing strings (91/239, 38%), and bleeding (34/239, 14%). Of the patients who presented with bleeding, the IUD was malpositioned in 13 (38%). CONCLUSION: The levonorgestrel-releasing IUD is significantly less conspicuous than the copper IUD on 2D imaging. Three-dimensional ultrasound enhances the conspicuity of both types of IUD.

Intrauterine devices in early pregnancy: findings on ultrasound and clinical outcomes.

OBJECTIVE: The objective of this study was to describe ultrasound findings, clinical symptoms, and outcomes of first-trimester pregnancies with intrauterine devices (IUDs). STUDY DESIGN: This was a retrospective review of 42 women with history of IUD placement and positive serum human chorionic gonadotropin in the first trimester. RESULTS: There were 31 intrauterine pregnancies (IUPs), 3 ectopic pregnancies, and 8 pregnancies of unknown location. Of 36 IUDs visualized, 15 were normally positioned and 21 malpositioned. Of 31 IUPs, 8 IUDs were within the endometrium, 17 were malpositioned, and 6 were not seen. Indications included bleeding (14 of 31), pain (12 of 31), and missing strings (5 of 31); 11 had no symptoms. Of 26 IUPs with known pregnancy outcomes, 20 were term deliveries and 6 had failed pregnancies of 20 weeks or less. CONCLUSION: More than half of IUDs identified in the first trimester were malpositioned. IUP was 3 times as likely with a malpositioned or missing IUD. Three quarters of the IUPs with known outcomes had term deliveries. Symptoms were not predictive of IUD malposition.

Ultrasound and assessment of ovarian cancer risk.

OBJECTIVE: The purpose of this article is to review the ultrasound characteristics of ovarian and adnexal masses and to discuss the prediction of the likelihood of ovarian cancer based on these characteristics and clinical parameters. CONCLUSION: Ultrasound characteristics can be used to diagnose the classic-appearing nonneoplastic entities, benign neoplasms and malignancies. In cases in which the appearance of an ovarian mass is not classic, assignment of relative risk of malignancy using a multiparametric model is appropriate and beneficial for patient management.

Saline-infusion sonography endometrial sampling compared with endometrial biopsy in diagnosing endometrial pathology.

OBJECTIVE: To evaluate prospectively whether saline-infusion sonography endometrial sampling will improve diagnosis of benign and malignant endometrial disease compared with blind endometrial biopsy in perimenopausal and postmenopausal women with abnormal uterine bleeding. METHODS: After initial assessments and endometrial biopsies, women aged 40 or older with abnormal uterine bleeding were referred for transvaginal ultrasonography. Patients with abnormal endometrial evaluations were offered sonohysterography and invited to enter the saline-infusion sonography endometrial sampling study. Saline-infusion sonography endometrial sampling was performed at the end of sonohysterography using an endometrial sampling curette at the sight of the endometrial abnormality or at a representative site in the endometrial cavity if the cavity was normal. Histopathologic diagnoses of blind endometrial biopsy and saline-infusion sonography endometrial sampling were compared with final outcomes. Kappa values for the two sampling techniques were calculated for diagnostic accuracy. RESULTS: A total of 88 saline-infusion sonography endometrial samples were obtained; final outcomes were attained in 80 cases. When comparing saline-infusion sonography endometrial sampling with final outcomes, saline-infusion sonography endometrial sampling provided a diagnosis 89% of the time (95% confidence interval [CI] 82-95%) compared with endometrial biopsy at 52% (95% CI 42-62%). Forty-five patients with endometrial biopsies had final outcomes. When comparing endometrial biopsy with final outcomes, endometrial biopsy underestimated the incidence of pathology, especially when focal lesions and malignancy were present. This difference was statistically significant (P<.005). CONCLUSION: Saline-infusion sonography endometrial sampling is superior to endometrial biopsy in diagnosing endometrial pathology in perimenopausal and postmenopausal women with abnormal uterine bleeding. LEVEL OF EVIDENCE: II.

First-trimester diagnosis of cesarean scar ectopic pregnancy.

Once considered extremely rare, implantation of a pregnancy within the scar of a previous cesarean section is becoming more common. In fact, its incidence is now higher than that of cervical ectopic pregnancies. We identified 5 cases of ectopic pregnancy implanted in a prior cesarean section scar at our institution since 2004. We outline the criteria for the first-trimester sonographic diagnosis of cesarean scar ectopic pregnancy, including a new sign of lower uterine segment ballooning, which has previously not been reported. Clinicians must have a heightened awareness of this serious and potentially fatal pregnancy complication.

Acquiring laparoscopic skill proficiency: does orientation matter?

OBJECTIVE: This study was undertaken to determine whether side-on laparoscopic operating orientation alters time-to-skill mastery compared with head-on orientation. STUDY DESIGN: One hundred thirty-one medical students were randomly assigned by operating axis (camera position to operating field) and completed 10 attempts at each of 5 previously validated laparoscopic skills stations. Time-to-completion was recorded for each attempt, generating an orientation and skill station learning curve. Statistical analysis was performed by using repeated measures analysis of variance and linear, polynomial, and logarithmic models with 95% CIs. RESULTS: Sixty-eight students were randomly assigned to head-on orientation and 63 to side-on orientation. Comparing median time-to-completion by station, head-on attempts were faster than side-on attempts for every station. Comparing learning curves by orientation, side-on learning curves were steeper than head-on learning curves for every station, except one. Asymptotes were reached in both strata by the tenth attempt. CONCLUSION: Greater initial disorientation is seen with side-on orientation compared with head-on orientation. This can be overcome with practice.

Resident attrition: is gender a factor?

OBJECTIVE: This study was undertaken to identify the causes of resident attrition from obstetrics and gynecology on the basis of gender. STUDY DESIGN: Two sequential questionnaires were sent to the 246 obstetrics and gynecology residency programs in the United States in March 2001 and May 2002. The programs were asked for the number of residents who left from 1997 to 2001, the postgraduate years, and genders of those residents, the reasons for leaving, and program demographics. Statistical analysis was performed with chi 2 and odds ratio calculations. RESULTS: The rate of attrition was 3% over 4 years. Female residents were 2.5 to 5 times as likely as male residents to leave because of family issues, specifically for reasons related to spouses ( P =.002). Female residents were one quarter as likely to leave to change specialty (P =.002), whereas this was the principal reason of more than half of the male residents who left. CONCLUSION: Important gender differences do exist in the reasons for attrition from obstetrics and gynecology residency programs.