Ultrasound in diagnosis of placental invasion Special Fetal Care Unit Ain Shams University Hospital Presentation1.pptx, radiological imaging of female infertility. The placenta at term weighs ~470 g and measures ~22 cm in diameter with a thickness of 2.0-2.5 cm 3 . The placenta normally lies along the anterior or posterior wall of the uterus and may extend to the lateral wall with increasing gestational age 1. The cardinal findings of PAS on US include placental lacunae, loss of retroplacental clear space, reduction of myometrial thickness, and an irregular bladder wall with . The various signs used on ultrasound to diagnose PA are placental lacunae, loss of hypoechoic retroplacental zone, abnormal bladder-uterus interface and abnormalities on colour Doppler imaging such as hypervascularisation within the placenta and in the subplacental zone. Therefore, PAPP-A levels increase with time of pregnancy. to assess the placenta, MRI appearance of normal placenta, and imaging findings that sug- . 3D volumes were obtained and processed, either on the ultrasound monitor or using the 4D View software application (GE Medical Systems). The pathophysiology of lacunae are unknown, but they appear as hypoechoic foci that represent abnormal clusters of . So far, the rarity of this condition, together . Ultrasound assessments found in 90% of the cases enlarged, bulky, and thickened placentas associated with multiple large anechoic and avascular areas. Address correspondence to . Lerner JP, Deane S, Timor . Presentation1, radiological imaging of placenta accreta. Placental lakes can be seen within the placenta or on the fetal surface of the placenta bulging into the amniotic cavity. . Study design. Study design: Target ultrasonography for diagnosis of placental lake was performed in the 2nd trimester of pregnancy and followed up in the 3rd trimester. BTFE, balanced turbo field-echo.

Placental Lake (PL) Enlarged intervillous vascular spaces Contain maternal blood May have fluid/fluid level Variable size Transient nature Change size and shape with time Can completely resolve Location Within placenta without appreciable border Subchorionic towards fetal surface Occasional PL are normal Late second trimester Third trimester (Color versin of the figure available online.) Placental Lacunae: First described by Finberg and Williams in 1992, placental lacunae have been the most predictive US finding for PA. Bladder wall . Placental lakes were defined as homogenous sonolucent avillous lesions greater than 2 cm 2 . The scanning protocol is demonstrated in Table 1. It can also cause uterine perforation and infection and is thus clinically very important. The imaging characteristics of the normal placenta and the spectrum of placental pathologic conditions are reviewed, with emphasis on the role of various imaging modalities. There are several risk factors for placenta accreta spectrum. Sixty singleton pregnant women with persistent placenta praevia (after 28 weeks' gestation) were prospectively enrolled in this study.. Comprehensive maternal history and findings obtained by antenatal ultrasound, including placental location, presence of lacunae, lack of a clear zone, abnormal color Doppler indices were reviewed, and their effect on the severity of maternal . Six out of eight false positive cases all demonstrated low- lying placenta or previa with greater than five lacunae, focal placental bulging and myometrial thinning and focally abnormal vascularity. PAS is an heterogeneous condition associated with a high maternal morbidity and mortality rate, presenting unique challenges in its diagnosis and management. vijayalakshmi pillai Advertisement Similar to Imaging of placenta (20) Sites of implantation of embryo Saudamini Sharma with abnormal placental lacunae (asterisk, A) and bridging vessels (open arrow, B) at site of bulge. Initial examination 5-7 Weeks - placenta is a diffusely echogenic ring. placental clear space), presence of lacunae (vas-cular spaces with turbulent flow), interruption Some have reported that the higher the number of lacunae, the higher the risk of placenta accreta. 8 and Finberg and Williams 2 subsequently used this as a criterion for the diagnosis of adherent placenta. Placenta bulges into upper bladder surface (2 ). Grade 1. . Intraplacental lacunae in placenta previa totalis with prior Cesarean section 181 DISCUSSION Adherent placenta rarely occurs, but it is a major cause of obstetric bleeding. There is little mixing of maternal and foetal blood, and for most purposes .

It does not normally exceed 4 cm in the second trimester or 6 cm in the third trimester. The worldwide incidence of placenta accreta spectrum (PAS) is rapidly increasing, following the trend of rising cesarean delivery. Abdellah Nazeer Morbidly Adherent Placenta (for APAN39) Body CT for Emergency Physicians Rathachai Kaewlai Morbidly adherent Placenta; conservative management. Conclusion. The sonographic findings of intraplacental lacunae were classified into one of four grades. In recent years, there has been increased interest in magnetic resonance (MR) imaging for the evaluation of PA, since it can provide information on depth of invasion and more clearly depict posterior placentas. The most sensitive sign is the presence of multiple placental lacunae . The ultrasonographic features suggestive of placenta accreta include multiple irregular placental lacunae with a "moth-eaten" or "Swiss cheese" appearance of . 205, no. visualization of lacunae has the highest sensitivity in the diagnosis of placenta accreta, allowing the identification in 78%-93% of cases after 15 weeks gestation, with a specificity of 78.6% 2 When a placenta accreta occurs on the posterior or lateral walls of the uterus, it may be difficult to detect by ultrasound. This primarily affects the extent of calcifications. As a general rule, the placental thickness in millimeters roughly approximates the gestational age in weeks. Multiple placental lacunae are due to high blood pressure from the radial and arcuate arteries entering the intervillous spaces of the myometrium. MRI The most common is a previous cesarean delivery, with the incidence of placenta accreta spectrum increasing with the number of prior cesarean deliveries 1 8 9.In a systematic review, the rate of placenta accreta spectrum increased from 0.3% in women with one previous cesarean delivery to 6.74% for women with five or . Interventional radiology offers a minimally invasive, fertility-preserving alternative to conventional surgical treatment.27Either regional or general anesthesia is acceptable depending on the anticipated risk of massive hemorrhage . Transabdominal ultrasound images of 31-year-old woman showing placental lacunae are the most sensitive sonographic finding of placenta accreta. Placental grading (Grannum classification) refers to an ultrasound grading system of the placenta based on its maturity. MRI In an acute setting, the following signal changes are seen: Using phased-array pelvic coil patients were scanned in the supine position.

The main imaging findings in abnormally adherent placenta are: Loss of the "clear zone" or irregularity of the hypoechoic plane in the myometrium underneath the placental bed. Although the cause of placental lacunae is unknown, many authors have found them to be predictive of placenta accrete (12-15). . 3, pp. The American College of Radiology guidance advocated the safety of MRI practices but stated that intravenous gadolinium should be avoided during pregnancy and should be used . Placental lacunae and abnormal color Doppler imaging patterns are the most helpful US markers for PA. In the setting of postpartum hemorrhage, however, distinguishing RPOC from bleeding related to normal postpartum lochia or . These include increased myometrial thickness, presence of placental lacunae, loss of the clear space between the placenta and myometrium, and anomalies of the interface of the bladder and myometrium . Mid 2 nd trimester -early 3 rd trimester (~18-29 wks) Subtle indentations of chorionic plate. Abstract. The pathologic diagnosis of RPOC is made based on the presence of chorionic villi, which indicates persistent placental or trophoblastic tissue. Adherent placenta can occur in the lower uterus, in the Radiographic features CT In the acute setting, lacunar infarcts appear as ill-defined hypodensities. Lacunae are reported to be the single most predictive sonographic marker, with a sensitivity of 79% at 15 to 20 weeks' gestation and 93% at 15 to 40 weeks' gestation. Visualization of lacunae had the highest sensitivity (79%) in the 15-20-week range and a sensitivity of 93% in the 15-40-week gestational age time frame. Placenta lacunae and lack of a clear zone were observed in 31.4 and 9.7% of cases with and without placenta previa [odds ratio (OR) 4.2]. Normal placenta in a 25-year-old at 13 weeks gestation referred for abdominopelvic MRI. However, only 88% of cases of PA are associated with placenta previa. The placenta was inspected for areas of vascularity by color Doppler, particularly within the lower uterine segment. Risk Factors. 1 Department of Radiology, University of Washington School of Medicine, Box 357115, 1959 NE Pacific St, Seattle, WA 98195. .

Spectral Doppler waveforms were . from publication: The sonographic appearance and obstetric management of placenta accreta | Placenta . B, Diedrichsen L, Frei K, Saar B, Tutschek B, et al. These features may help to distinguish a placental lakes from a thrombus. By 8-13 Weeks - focal chorionic thickening and determination of placental site, umbilical cord inserts in center of the chorionic frondosum. Placenta accreta spectrum: the pattern and character of intraplacental blood flow by color and spectral Doppler 21,24-27 Myometrium . Fig. 13.3. This hormone promotes placental growth and function through the facilitation of the insulin-like growth factor (IGF). Radiology 2010;257:810-819.

(A) penetration of the placental tissue through the myometrium which results interrupted (white arrowhead) and intraplacental nodular black band (white empty arrow) which correspond in B) to an hyperintense T1 spot (white arrow) representing a focus of haemorrhage typical of abnormal placentation. Slow swirling blood flow (larger arrow) may be seen within the spaces, and the shape of the spaces tends to change with uterine contractions. Coronal ( a) and axial ( b) T2-weighted MR images demonstrate a late first trimester intrauterine pregnancy. 773-776, 1997. Pathological analysis of the placenta was performed for all patients who delivered, and in cases of hysterectomy, examination of the uterus was also performed. Grade 2. Lack of a clear zone was observed in 5.7 and 0.9% of cases with and without placenta previa (OR 7.0). Purpose To characterize intraplacental blood flow patterns in placenta accreta spectrum (PAS) with color and spectral Doppler imaging. Transabdominal 3D power Doppler was used to map the vascularization of the intraplacental and uterine serosa-bladder interface. Typically, the placenta is discoid in shape. Finding placental lakes during a second trimester ultrasound scan is not associated with any uteroplacental complication or with an adverse pregnancy outcome. The placenta signifies the "second" or "embryonic" period of pregnancy (after the implantation period) and describes the establishment of a fully functional placenta.

Ultrasound of Placental Abnormalities Guy Steinberg, MD March 5, 2011. Conclusions: 1.

"Placenta accreta: evaluation with color Doppler US, power Doppler US, and MR imaging," Radiology, vol. The typical ultrasound signs of abnormally adherent and invasive placenta are the loss of the hypoechoic retroplacental zone, numerous large or irregular lacunae connected to a feeding vessel, hyper-vascularization patterns within the placenta and between the placental basal plate or subplacental zone and underlying structures (myometrium . The placenta was assessed for: more precise placental location, the type of previa and to demonstrate the presence of placental invasion radiological signs even if initial US evaluation was negative. 1 All authors: Body Imaging Section, Radiology Department, University of Washington Medical Center, 1959 NE Pacific St, Box 357115, Seattle, WA 98195-7115. . PAPP-A is a hormone produced by the fetus and the placenta in pregnancy. Close modal. 1Associate Professor of Radiology, 2,3Assistant Professor Radiology, 4Postgraduate Trainee Radiology, (Holy Family Hospital, Rawalpindi) . With a 180 rotation process, we visualized the sagittal and coronal sections. The placenta accreta index, developed by Rac et al., combines the number of cesarean deliveries, placental location, and ultrasound markers such as reduced myometrial thickness, intraplacental lacunae, and bridging vessels in order to predict PAS disorders with an area under the receiver operating characteristic (ROC) curve of 0.87 [ 22, 23 ]. Retained products of conception (RPOC) are a common and treatable complication after delivery or termination of pregnancy. 17,18 In this study, a case of type III with the exogenous type of GS at a gestational age of 8 weeks and 4 days showed the above-mentioned ultrasound manifestations of placental implantation, and . Placenta accreta and its variants can lead to significant morbidity and mortality as a result of postpartum . Specific features of IP (Figure 3) evaluated to formulate MRI diagnosis were: uterine bulging, placental signal heterogeneity, dark intraplacental bands, hyperintense placental lacunae, interruption of the myometrium and of inner myometrial layer, placental implant on previous CS uterine scar and tenting of the bladder. A finding of placenta previa should elicit a detailed evaluation for PA, including color Doppler imaging and a transvaginal examination. Chronic lesions appear as hypodense foci (similar to CSF). Placental lacunae are the most sensitive sign for placenta accreta diagnosis after 15 weeks' gestation and consist on vascular structures within the placenta that extend into the myometrium, giving the placenta an appearance of "Swiss cheese" [3]. It is a nine-point score based on the combination of three sonographic parameters (abnormal placental lacunae, reduced myometrial thickness, and bridging vessels) in a high-risk population of pregnant women in the third trimester (i.e. In some countries, the use of placental grading has fallen out of obstetric practice due to a weak correlation with adverse perinatal outcome 5. Placenta lacunae is the most sensitive US finding for accreta Loss of interface between placenta and myometrium, lacunae and bulging vessels into the myometrium can detect 80% of women with accreta MRI aids by demonstrating: increased intra-placental vascularity, fibrin bands of dark T2-bright T1 signal, uterine Methods Thirty-two patients at risk for PAS underwent ultrasound imaging with both color and spectral Doppler. Intraplacental lacunae are vascular lakes of various sizes and shapes seen within placental parenchyma. Radiology 1980; 134: 475-478. Smooth chorionic plate without indentations. Computed tomography (CT) has a limited role in evaluation of placental abnormalities because of the ionizing radiation exposure and the relatively limited assessment of the placenta; however, CT can provide important information in specific circumstances, particularly evaluation of trauma and staging of choriocarcinoma. The placenta is often overlooked in the routine evaluation of a normal gestation, receiving attention only when an abnormality is detected. Note: Image courtesy of the Department of Diagnostic Radiology, Queen Mary Hospital, Hong Kong. Small, diffuse calcifications (hyperechoic) randomly dispersed in placenta. 12 First trimester diagnosis of placenta increta in CS scar 13 OBSTETRIC MR CLINICAL VIGNETTE History: Complete placenta previa. The retroplacental "clear" space normally measures less than 1 to 2 cm and, as the name suggests, appears hypoechoic. Diffusion-weighted MR imaging of the placenta in fetuses with placental insufficiency. Late 3 rd trimester (~30 wks to delivery) Larger indentations along chorionic plate.


Placenta previa with placental lacunae, myometrial . 1Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. R/o implantation on fibroid and succinturiate lobes. women with previous CS and anterior low-lying placenta or PP). 2. The placenta is an apposition of foetal and parental tissue for the purposes of physiological exchange. Presence of numerous lacunae including some that are large and irregular often containing turbulent flow. Abdellah Nazeer Mri of placenta accreta spectrum hazem youssef placenta-140315062308-phpapp01.pdf MuhamadAznorAqwaAzma Uterine malformations Susmita Halder Abnormal placental lacunae. CONCLUSION: To our knowledge, our study is the. The most useful findings on placenta accreta/percreta in MRI included: uterine bulging, heterogeneous signal intensity within the placenta, dark intraplacental bands on T2-WI, focal defects in the myometrial wall, tenting of the bladder, direct visualization of invasion of pelvic structures by placental tissue. Note heterogeneous placenta with lacunae (1 ). Pathologically, they are small holes of encephalomalacia and are traversed by a cobweb-like mesh of fibrous strands.


and interventional radiology. View larger version (368K) A mass-like area in the anterior uterine wall ( arrow) resolves on later imaging consistent with a focal myometrial contraction. Objective: The aim of our study was to establish whether there is a correlation between the size of placental lakes and adverse pregnancy outcome. Download Figure They were first reported by Kerr de Mendonca 3 in 1988, and Hoffmann-Tretin et al. Placental (venous) lakes refer to a phenomenon of formation of hypoechoic cystic spaces centrally within the placenta.