Differential expression of angiopoietin-1, angiopoietin-2, and Tie receptors in placentas from pregnancies complicated by placenta accreta.

OBJECTIVE: The purpose of this study was to investigate the differential expression of angiopoietin-1, angiopoietin-2, and Tie receptors (Tie-1 and Tie-2) in placentas from pregnancies complicated by placenta accreta. STUDY DESIGN: Paraffin sections of 46 placental specimens with (cases) and 46 without (controls) placenta accreta were studied immunohistochemically for the expression of Tie receptors and angiopoietin-2 in trophoblast populations. Protein levels of Tie receptors and angiopoietins were also examined by Western blot analysis and/or enzyme-linked immunosorbent assay. Controls were matched for gestational age in this case-control study. RESULTS: In both second and third trimesters, the percentage of intermediate/strong immunoreactivity of Tie-2 in the syncytiotrophoblast was significantly lower in cases than controls (P = .015 and .025, respectively). However, Tie-2 expression in the cytotrophoblastic and extravillous trophoblastic cells and Tie-1 in all trophoblast subpopulations were not significantly different between cases and controls (P > .05). The majority of Tie-2 expression, as demonstrated by Western blots, was consistent with the trends of immunohistochemical findings in the syncytiotrophoblast. Enzyme-linked immunosorbent assay in the placental lysates showed that women with placenta accreta demonstrated significantly higher angiopoietin-2 and lower Tie-2 concentrations than did women with normal pregnancies (P = .026 and .003, respectively). Placental angiopoietin-1 levels did not have any significance (P > .05). Also, angiopoietin-2 immunoreactivity in the syncytiotrophoblast was compatible with the finding demonstrated by enzyme-linked immunosorbent assay (P = .005 and .012, respectively). CONCLUSION: These observations suggest that the participation of up-regulated angiopoietin-2 and down-regulated Tie-2 in the placental tissues may indicate a role for these angiogenic factors in the development of placenta accreta.

Diagnosis of an interstitial pregnancy with 4-dimensional volume contrast imaging.

OBJECTIVE: The purpose of this study was to investigate the use of a new ultrasound technique, termed 4-dimensional volume contrast imaging in coronal-plane to facilitate the early detection of interstitial pregnancy. STUDY DESIGN: A case of interstitial pregnancy was diagnosed accurately at 6 weeks of gestation with 4-dimensional transvaginal volume contrast imaging in coronal plane technology. A scan of the uterus revealed that the eccentric gestational sac was located in the right uterotubal junctional area, lying 1 cm outside the most upper lateral edge of the uterine cavity with thick endometrial echoes. RESULTS: After the appropriate counseling, the patient was treated with an ultrasonographically guided intracardiac injection of 2.5 mEq of potassium chloride followed by aspiration of the gestational sac. A transvaginal scan immediately after the procedure demonstrated a collapsed empty gestational sac. Three months after the conservative treatment, the serum beta-human chorionic gonadotropin level fell to 1.17 mIU/mL, and normal echotexture of the uterus was noted. CONCLUSION: Four-dimensional volume contrast imaging in coronal-plane technology provides scan planes that are not accessible by conventional 2-dimensional scanning, with enhanced tissue contrast resolution in region of interest. This new ultrasound technique has the potential to provide more accurate, inexpensive and less variable virtual reality image-guided interventional options through more realistic interaction with the virtualized in utero condition, particularly when 2-dimensional transvaginal scan fails to differentiate between interstitial, angular, and cornual pregnancies.

Expression of epidermal growth factor receptor and c-erbB-2 oncoprotein in trophoblast populations of placenta accreta.

OBJECTIVE: The purpose of this study was to investigate the expression of epidermal growth factor receptor and c-erbB-2 oncoprotein in trophoblast populations of placenta accreta. STUDY DESIGN: Paraffin sections of 43 placental specimens with (cases) and 43 without (controls) placenta accreta were studied immunohistochemically for epidermal growth factor receptor and c-erbB-2 expression in the syncytiotrophoblast, villous cytotrophoblast, and extravillous cytotrophoblast. Epidermal growth factor receptor and c-erbB-2 protein levels were also performed by Western blot analysis. Controls were matched for gestational age in this case-control study. RESULTS: The percentage of strong/intermediate immunoreactivity of epidermal growth factor receptor in the syncytiotrophoblast was significantly higher in cases (98%) than controls (79%; odds ratio,11.1; 95% CI, 1.3-92.0; P = .03), although strong/intermediate immunoreactivity of c-erbB-2 in the syncytiotrophoblast was significantly lower in cases (35%) than controls (81%; odds ratio, 0.1; 95% CI, 0.1-0.3; P < .001). Epidermal growth factor receptor and c-erbB-2 expression in the villous and extravillous cytotrophoblastic cells were not significantly different between controls and cases ( P > .05). Most immunoreactive bands on Western blots were consistent with the trends of immunohistochemical findings. CONCLUSION: The development of placenta accreta is related closely to the differential expression of epidermal growth factor receptor and c-erbB-2 in the syncytiotrophoblast.

Cesarean scar pregnancy: quantitative assessment of uterine neovascularization with 3-dimensional color power Doppler imaging and successful treatment with uterine artery embolization.

OBJECTIVE: The purpose of this study was to investigate the use of a 3-dimensional virtual organ computer-aided analysis imaging system for the monitoring of the quantification of changes of uterine neovascularization before and after successful treatment with uterine artery embolization in cesarean scar pregnancy. STUDY DESIGN: A case of cesarean scar pregnancy that was associated with extensive uterine neovascularization was diagnosed at 8 weeks of gestation with the 3-dimensional virtual organ computer-aided analysis imaging system. After appropriate counseling, a bilateral uterine arteries embolization procedure was performed with nonresorbable microspheres by interventional radiologists. RESULTS: The gestational cystic mass at the site of previous cesarean scar completely disappeared at the follow-up examination 3 months later. CONCLUSION: A 3-dimensional virtual organ computer-aided analysis imaging system can be used for the monitoring of the quantification of changes of uterine neovascularization before and after successful treatment with uterine artery embolization in cesarean scar pregnancy.

Internal iliac artery embolization before hysterectomy for placenta accreta.

Six patients with early sonographic diagnosis of invasive placenta previa increta/percreta before fetal viability were offered hysterectomy to terminate the pregnancy with prophylactic internal iliac artery embolization (IIAE). The mean gestational age at treatment was 19.7 weeks (range, 14-23). Among these six patients undergoing hysterectomy, the mean estimated blood loss was 1,767 mL +/- 1,213 (range, 300-3000), and the mean transfusion requirements were 4.33 U +/- 4.08. With this limited experience, we are encouraged by the apparent reduction in operative blood loss and fewer transfusion requirements after the use of prophylactic IIAE compared with historical controls. These preliminary findings are based on a small number of patients, and therefore further investigation is needed to determine the effectiveness of this procedure.