Placenta accreta spectrum disorder is a varied and increasingly common complication of pregnancy, so ob/gyns need a firm grasp of risk factors and ultrasound signs. A multidisciplinary panel of specialists from the UCSF Fetal Treatment Center explains how they handle patients to maximize outcomes, with a case-based review that illuminates their steps to evaluation and treatment.
My name is Erin Matsuda. I'm the patient care director and service line director for the Fetal Treatment Center here at UCSF. Uh, we are here to remind you that our doors are open and we are here to partner with you and your patients during these challenging times. Our facilities are allowing one support person to come with your patient to labor and delivery in some of our clinic locations and just want to let you know that we are here and we are ready. This is actually the 3rd webinar that the Fetal Treatment Center has hosted in the last couple of months, and we are taking a bit of a divergence here. Um, in honor of it being National Accreta Awareness Month, we'll be sharing with you a case-based presentation on placenta accreta spectrum disorder. At the end of this, we'll have some time for questions and answers, so you'll see a function box, um, where you can go and type in your questions and we'll be monitoring them. Some questions may be answered within the text chat, some may be answered live, and we'll definitely make sure we get to all of your questions at the end. At this time, I'd like to turn it over to Doctor Juan Gonzalez. He's an associate professor for the Department of OBGYN here at UCSF. He's the medical director of our labor and delivery program, and he is also the MFM Fellowship Program director. Thank you, Doctor Gonzalez. Uh, thank you very much, Karen, and welcome to everybody that has joined us today. So I wanna introduce our, um, panel. Um, next slide, please. Um, so, we have Doctor Jha, who's an assistant professor of radiology, um, and has expertise in, in placentation and, um, imaging in this area. Doctor Rabin, um, our pathologist who has helped us throughout the development of the MAPS program and the accreta program, Doctor Lee. Porter, who's the director um of the division of Ultrasound and Radiy and has expertise in MRI imaging of the placenta, and Doctor Li Mei Chen, who is the director of the division of GYN oncology and um one of our esteemed surgeons that helps us through these very complicated cases. Also on the call today is Molly Killian, who is, you'll hear from her at the end. Um, she is our, um, maternal fetal medicine, uh perinatal nurse who helps us coordinate, um, the care for all these patients that join us, uh, here at UCSF. Um, so next slide. So, these are the objectives of we, what we hope to discuss today. Um, we wanna talk about the pathophysiology of accreta spectrum disorder. Um, this is actually the preferred term, um, that has been endorsed. Um, we now refer to them as the accreta spectrum. Um, we have, uh, imaging modalities to review both ultrasound and MRI and features of the diagnosis. And we also wanna review, um, surgical management and planning for the care of these complex cases. Next. This is kind of the logo that we developed, and the name of our um practice is Multidisciplinary Approach to the placenta Service, also short maps. Next. So, I think um this flow diagram illustrates kind of um the nature of how we receive these consults. Um, we are open to referrals. Um, and then the first step is usually with imaging, um, both MRI and ultrasound, as we'll hear later, um, followed by all patients receiving a maternal fetal medicine consultation. To decide, um, to review the risks, and some mothers decide not to continue the pregnancy, and in those cases, we have excellent services to provide that support with our family planning colleagues. And then, um, if the patient does decide to continue, then we will have a maps huddle, um, and that is where we will review the details of timing of delivery, other potential consult services that might be needed, and longitudinal planning and logistics. Uh, next slide. In that first huddle, you can see um all the boxes uh illustrating how extensive the, the team is. It includes radiology, OB anesthesia, GYN oncology, interventional radiology, MFM, OB, and nursing, which are critical to the coordination of the care of these patients. And then the patient usually, uh, will return back, um. Home and be followed very closely. And then as we approach the timing of delivery, we usually will have a maps huddle number 2, where we'll finalize a checklist, operative planning, review labs, and kind of um go through all the details of, of the actual surgical intervention. After we um deliver and the patient is safely discharged, we usually will have another huddle to debrief on opportunities. Um, to improve and to learn as much as we can from the cases. And in addition, every quarter, we have meetings, um, where we review all the cases and, um, discuss them among our group. Next. This cartoon just illustrates the most recent statistics um in the spectrum of accreta, increta, and procreta, but the majority, 82% of them are accreta, which is usually secondary to some disruption in the desidual, um, uh, formation where the placenta abnormally implants the myometrium, but you can appreciate the spectrum. Um, as the most severe cases with Parita, which tend to be the minority, and the most recent estimates suggests only 6% of cases are in the Parita spectrum. Next. Unfortunately, in the last 4 decades, there has been a significant increase in the cases of placenta accreta spectrum. This is thought to mirror the increase in cesarean deliveries, and the most recent estimates suggests that as many as 1 in every 272 deliveries could be complicated with placenta accreta spectrum. Next. When we talk about the risk factors, we always focus on cesarean section, but there are other risk factors that we cannot forget. Um, those include myomectomy, um, endometrial damage, if there's a history of Asherman's, um, endometrial ablations, history of uterine artery embolizations. And any patient that has um a placenta previa, we want to make sure that we're doing a thorough evaluation to rule out or rule in the possibility of having a placenta accreta. Next. This table is very important, um, as it illustrates the risk as the number of cesarean deliveries increase in the patient's history, um, the, the risk of having an accreta will increase. Especially if you have the presence of a placenta previa. So you could see if you have only one placenta previa, you have one C-section in the setting of a placenta previa, the risk is uh 3.3% of the cases will be an accreta, but if you've had a history of four C-sections and have a previa, it really jumps up to 61%. And so that we have to be mindful to elicit a very detailed history. Next. Um, this resource, um, was published in 2018, and we will email this to the participants. It was published, um, by the American College of Obstetrics and Gynecology in collaboration with the Society for Maternal Fetal Medicine, and it goes into the details of management. It is a well-written document and it goes through all the evidence on how to manage these cases, and we're um happy to share this um through email. Next. As I mentioned earlier, the success um for the management of these cases, um, is a team approach, and we need all the disciplines working together, um, and you can see MFM, radiology, obstetric anesthesia, IR, interventional radiology, and pathology. Next, And it is um been demonstrated in multiple studies that patients that do deliver in a center that have experience with placenta accreta, um, do have better outcomes and end up, are less likely to require large blood um volume transfusions, require less likely to require re-operation within 7 days after the delivery. Um, and also other complications are less likely in the setting of delivery in an experience center. Next. Um, MFM consultation after the imaging that is obtained is key in order to be able to review options for the patient, including the possibility of termination if it's early on, and also to go through the potential um complications that the patient might encounter and to be able to plan, um, moving forward. Next. Um, and then, um, we collaborate closely with our family planning colleagues for those mothers that do decide, um, not to continue, um, the pregnancy to assure that they can have, uh, a safe termination. Next. This is our checklist that we have developed here at UCSF and these are the instrument that we use um in our huddles, and we will have this available to you on the slides and for future reference. Next. Timing of delivery is always um an area of a lot of interest, um, and the guidelines do recommend that delivery should occur between 34 to 36 weeks, and the reason it should not occur past 36 weeks is that in studies, in the setting of accreta, It's been shown that over, if you wait past 36 weeks, there's an over 50% risk that um the patient can hemorrhage and then you're doing the delivery in a very urgent fashion, which is exactly what we want to avoid to assure the best outcome for the patient. Um, in these cases, when we deliver between 34 to 36 weeks, amniocentesis for fetal lung maturity is not indicated as um we have a compelling reason to proceed with late preterm delivery. Um, and obviously some of this, um, will be depending on the patient's history. Um, if there's evidence of rupture of membranes, the fetal growth is taken into account, evidence of preeclampsia in the mother, that will also, um, color the timing of delivery. Next. And it is important for patients delivering in this window of time to consider um uh late uh preterm administration of betamethasone as there is a paper in the New England Journal of Medicine that was published showing benefit um for steroids between 34 and 37 weeks. So, for all our cases that are delivering in that window, we are sure that they have received antenatal cortical steroids for the benefit of fetal lung maturity. Next. Decision to hospitalize, um, some of our mothers do spend some time with us in the antepartum ward, um, has to do more with have they had any bleeding from the previa, do they have other complications, and how far are they, um, from, um, our campus. So if they live locally in San Francisco, we're less likely um to admit them to the hospital, but if they're very far away, um then that might inform our decision to admit. Also, individual preferences are taken into account. Obviously, the patient is part of that decision-making process. And as I mentioned earlier, the history of bleeding. Next, um, it is very important to, um, again, as in the document from the American College of OBGYN and the Society for Internal Fetal Medicine emphasize this, that these mothers should deliver in a maternal care facility, facility that is a level 3 or 4. Next So throughout today, we're gonna be reviewing a case of um this mother um that came to us. We'll be looking at her imaging, her surgical intervention, and then subsequently her pathology. Um, she was a 34-year-old G3P1 who, um, uh, was presented to us around late in the third trimester, 35 weeks and 6 days with a history of two prior cesarean sections, and she had a placenta previa. Um, and imaging in the outside facility was very concerning for placenta preta spectrum. Um, so then subsequently, she, um, was referred to us, um. Uh, for evaluation. Her past medical history was significant for microcytic anemia, secondary to beta thalassemia minor. She had the history of two prior cesarean sections. The first C-section was in 2012 in Mexico at 36 and 5 in the setting of preterm labor. Um, she delivered a male neonate, um, that was, uh. Diagnosed with Down syndrome, birth weight was 4 pounds 6 ounces, and unfortunately, that neonate died at 1 year of life from pulmonary complications. In 2016, she had an elective repeat cesarean section at 39 weeks and delivered a male neonate um with a birth weight of 9 pounds 1 ounce. Next, And now I'll pass on um the presentation to Doctor Ya and Doctor Porter for imaging. Thank you very much. Thank you, Juan, for describing our maps workflow and introducing the case. Every time a patient with suspicion for placenta accreta spectrum disorder is referred to UCSF, we start with an ultrasound evaluation. This ultrasound evaluation is performed first by a stenographer. While they're doing the evaluation, they would make a note of all possible risk factors, including the number of cesarean sections and prior uterine surgeries or instrumentation. We highly recommend that we screen for placenta accreta at the first given chance. For example, if you see a patient who has had a C-section before and you're evaluating them for nuchal translucency, this is an opportune time to make an early diagnosis of this disorder. Also, after the sonographers have finished scanning, our radiologists who are experienced in evaluating such high-risk patients go and perform a dedicated evaluation. Next. There are several reported signs of placenta accreta spectrum on ultrasound. Most commonly, you would encounter a placenta previa in your practice, which may have placental lagoons. There may be associated myometrial thinning. The placenta may bulge and may have the so-called snowman appearance to the uterus, and there may be abnormal vascularity. In essence, if your imaging is suspicious and the patient has risk factors, if you identify any of these imaging factor, uh, any imaging signs, I refer them to a center of excellence capable of handling such high-risk patients. Next. When this patient came to us, we started a dedicated evaluation. We checked the placenta location, found the placenta previa. In a different patient, we would also evaluate for vasa previa and make sure it's not present or present. We noted innumerable irregular lacoons, noted myometrial thinning and abnormal vascularity, all findings suspicious for placenta accreta spectrum disorder. Next. As you can see in this video, when we do this evaluation, the entire placenta is evaluated. When we are evaluating the placenta, we are looking not only for gross changes in the entire placental bed, we also look for areas of bursting involvement. As in this scenario as shown in the image on the left, there was an area where we did not visualize any visible myometrium, and we identified this as the area of worst involvement. Next. In patients who have placenta previa, we also perform a dedicated endovaginal exam, as we did for this patient. This was very helpful in identifying bladder cirrhosal involvement. As seen on the ultrasound images, we do not see any normal appearing myometrium. Intervening between the bladder as well as the placenta, along with abnormal vascularity located in this interface. This is suggestive of full thickness myometrial involvement, and uh we also evaluate for other findings of parametrial and cervix involvement. If you see findings such as these demonstrated on the slide, then when you do a cystoscopy, you may identify these prominent vessels and during cystoscopy in the bladder wall as shown in the cystoscopy image. Again, if the placenta has any posterior component, and for further planning, we send this patient to have an MRI. The beauty of doing this at UCSF is that many of our operators are specialized in both ultrasound and MRI evaluation of placentareta spectrum disorder, allowing for a complementary role. And with that, I'm going to uh ask Doctor Porter to present the MRI portion of our evaluation. Thank you. Thank you. So let's talk a little bit about MRI. As uh Doctor John mentioned, um, MRI should not be evaluated in isolation. It's um always complementary to ultrasound. And as we know, ultrasound has very good overall sensitivity and specificity, and that helps us if the ultrasound is negative, there is usually really no need to proceed with an MRI. But when do we then use the MRI's? When, let's say the ultrasound findings are equivocal or there's quite extensive disease and, you know, especially these very mild invasive cases when you need to have a very careful stepwise approach to uh surgical planning. And so, uh, MRI can provide us a better picture of the overall appearance, the extent of disease, the precise topography, and, um, how much of the uterus and adjacent structures are involved. Is it superior versus inferior lower uterine segment? Is there potentially Perometrial invasion or other um areas of invasion which can potentially alter surgical approach and require, for instance, urethral stenting or vascular clamping and a lot of times also um preoperative um embolization. Next please. And MRI has shown better, um, has been better to assess for the depth of invasion. And the extent of invasiveness. Because really the, the most important question is, is the disease myoinvasive or only myoadherent? Because the surgical approach would be completely different because as you know, we would try to remove the placenta and preserve the uterus if it's only myoadherent, but most of the cases of myoinvasive disease, uh, the patient will proceed with a um hysterectomy, cesarean hysterectomy. As has been mentioned before, there are recent FIGO guidelines which is published in 2018, which talked about a lot about the diagnosis and the management and as well then about the imaging um appearances. An ultrasound, of course, is a key modality, uh, to diagnose and follow those patients. An MRI was noted to be not essential but maybe useful and uh why it was stated as such is because MRI might not be available at all centers, as well as it really needs expertise by the reader. So, uh, as what we have learned is, obviously, if you, the more expert the readers, The, uh, that improved the accuracy of these reads and uh, so that's what we have really learned over the past 4 or 5 years that our centers where we very carefully, uh, follow the patient's presentation, the ultrasound findings, the MRI, as well as the careful correlation with surgical findings, as well as some, um, um, imaging findings and pathology. Um, one of the very important things which has applied to this topic of placenta, uh, accreta, uh, spectrum disorder is that there has to be standardized reporting and, um, we will hear more about it in our, uh, pathology section, but similar issues are with the imaging and several international radiological, um, societies have talked about standardizing the MRI findings, the descriptors, and the reporting. Next slide, please. And one of these, um, uh, sort of, uh, uh, these guidelines, um, which we came together with the European Society as well as the American Society of Abdominal Radiology was actually spearheaded by Doctor Jia at UCSF and, uh, during this study, we found out that there are 7 signs really which are quite helpful to Um, are, are sensitive and specific, uh, for diagnosing placenta accreta spectrum disorder, and this would be placental bulge, dark interplantal, uh, lines, loss of retroplacental dark zone, myometer of thinning, bladder wall interruption, focal exophytic masses, and abnormal vascularization in placental bed. Next slide, please. So a lot of times the question comes up, what is the ideal timing of MRI? Ideally, it should really be performed between 28 to 32 weeks. And um if ultrasound findings are suspicious, then it's best to wait until 24 weeks before getting the MRI. However, it all really depends on the clinical scenario. If, uh, if gravity hysterectomy is considered, then obviously we can do the MRI at any time point, uh, whatever the, um, the clinical scenario determines. Sometimes you also do the MRI later than 32 weeks when the patients present late and um it is still quite helpful for surgical planning. The one caveat is that uh the limitation of the MRI becomes greater and greater. After 35 weeks because the myometrium at this time is the thinnest and it's very difficult to determine whether is, is the, the true, true thinning of the myometrium or actually invasion of the placenta. Next please. So this was our patient, um, and we have these uh 3 planes sagittal, coronal, and axial, and if you look at the placenta, it was previa, and this is one of the illustrations where this patient actually had all different signs, uh, pretty much all the signs on MRI as well as ultrasound. So it was one of those, uh, somewhat easy cases when you, and it is recommended that when you see one side, like you cannot really rely on one side. But if you notice one, you look for others and you either find them or you don't. So we confirmed that there was placenta accreta spectrum disorder. We looked for the deepest areas of invasion. We made sure there was no invasion into the bladder, assessed the areas of urethral vesicle junction and ureters, and then we presented this case um for the surgical team at the multidisciplinary conference along with the ultrasound. Next, please. And one of the, um, as we talked about how important it is to determine whether it's myo-invasive versus myoadherent, we have found with our experience, which has also been reported in literature, that the placental bulge. Sign is predictive of myometrial invasion and um so most of the time when you just have myo adherent disease, you would not have this bulging of the placenta as was seen in this case with our patient. Hi I'm Li Mei Chen. Thank you very much for uh inviting me to participate. I'm one of the surgeons who is part of our MAPS team, and as Doctor Gonzalez mentioned, um, the surgical considerations for management relate to our findings that we have based on imaging. So if it looks like an adherent placenta where the uterus may be preserved or a straightforward hysterectomy may be performed. Our OBGYN colleagues would potentially manage those cases. In the case where there's a more invasive placenta, concern for more hemorrhage, bladder involvement, potentially, um, the oncology team is also part of our MAP service. So, I think stressing the idea of surgical management in a team fashion is really critical. Um, Doctor Potter showed us some very nice images of MRI imaging. And while it may not be as essential for the diagnosis, for our surgical considerations, again, looking at the location of the placenta, thinking about whether there is effacement of the cervix, uh, whether there's normal anatomy really helps us to be able to anticipate and visualize what we're gonna see in the operating room. The delivery coordination is important. As someone who is a consultant and on-call, um, if we can plan and schedule a case like this in the operating room at a 7:30, 8 o'clock in the morning start, um, clearly, that's favored over a Patient who delivers and starts hemorrhaging after their C-section anytime, any day, and also for our anesthesia colleagues, getting things set up, prepared, having cells saver availability, for example, uh, is important in the coordination. Uh, next slide, please. Uh, I mentioned the multidisciplinary care team and Doctor Gonzalez mentioned this as well. This has been studied at various centers of excellence, looking at comparisons between sites, looking at historical controls. Um, the factors that we think really are patient-centered are the matter of can we do a scheduled case. As opposed to an emergent case, and it really is to be able to bring all the members of the team together. Blood loss and transfusion are pretty standard metrics to measure, but the multidisciplinary teams typically can decrease that, whether it's through planning, embolization, timing, cell saver, all of those things matter. We obviously have ICU resources, but if your patient is more stable and not as emergent or urgent, there's less time spent in the ICU, which ultimately allows more time for the postpartum woman to be able to participate in her postnatal care, uh, go see her infant, not have to get stuck in the ICU, and overall, have a shorter length of stay. It's just sad. So, in preoperative considerations, um, traditionally, if we think that the placenta is invasive, we're going to be thinking along the lines of making plans for a hysterectomy. Um, we would plan ahead of time so that if a patient is an outpatient, sometimes we are informed that there is a potential patient, and then we may huddle before the patient comes into the hospital. If the patient has bleeding, they frequently are admitted for this evaluation. And then, Molly, who's on this webinar, also calls us together for an assembled huddle. And then we talk about kind of a treatment strategy, a treatment plan. Uh, steroids are used for fetal lung maturity. We do use MRI for our planning, and many places will use ultrasound, but as a surgeon, I truly value the findings on the MRI to help to think about what we would anticipate seeing at the time of delivery. Um, interventional radiology is a big part of our team. Uh, and if the patient is stable, we would anticipate after delivery of the infant, uh, embolization of the uterus before proceeding with hysterectomy. Again, that is not a strong recommendation from the international consensus, but it is something I'll show you that we have done, um, and has helped improve our outcomes. Um, so our huddle typically includes the OB team, the MFM team, nursing from both obstetrics as well as the main operating room as our cases are done there as post on labor delivery, IR, and then if needed, a guy knock, and the delivery is scheduled between 34 to 36 weeks. Next slide, please. So, in managing this patient who came to us at a relatively advanced gestation, she was already 35 weeks when she came to UCSF. We huddled quickly after she arrived and made a plan for delivery at 36 weeks. This is a picture of our hybrid OR which looks busy, um, and indeed is. We have our sonography. Equipment available. We have a cell saver in the background. We have several anesthesiologists who have their lines and monitors and blood products set up. Um, the typical anesthetic plan is a regional anesthetic converted to general, although obviously there are exceptions based on the patient and the urgency of the situation. Uh, we place patients in a lithotomy position and if possible, place a three-way Foley catheter. Uh, this allows us to backfill the bladder, and some of our providers, uh, prefer to place ureteral stents, and some of our providers use the imaging to help guide whether or not stents should be placed to identify the uteurerus both higher up in the pelvis as well as down low by the pertrium. You'll notice on the huddle, um, checklist that we talk about what type of skin incision and uterine incision the patients have, but we would consider a vertical skin incision to be able to allow for exposure if the anticipated procedure is hysterectomy. The hybrid room is called a hybrid because in the background, you'll also see our fluoroscopy equipment. Um, and what we found To be able to move a patient from an operating room bed to an IR bed in a matter of just a few moments saves us a lot of time, a lot of traveling, um, uh, and from a safety standpoint, decreases the risk of patients having an acute bleed that we have to move patients for and also helps with ster sterility and, uh, infection control. It's like. Intraoperatively, once we get in, we talk about what do we see and the clinical grading of placenta accreta spectrum is done at the time of C-section by a clinical evaluation. So the grade one is you were suspecting of placenta adherence, but the The placenta separates so there's not really adherence of the placenta and that goes in subsequent radiations to the level of adherence invasion into the wall of the uterus, um, that we can see a bulge, um, that the placenta has to be removed manually or that we see the placenta invade all the way through. Uh, as Doctor Gonzalez showed us with the cartoon of the percentages, the majority of the cases that we see that have an invasive placenta are at the grade 3 level. We will see a bulge. Uh, we will anticipate that there is involvement of the placenta into the myometrium. Um, we don't work on pulling on the placenta. We don't try and remove it. Uh, the goal would be is that we believe the placenta to be invasive, that we would remove it intact with our hysterectomy specimen. Let's just slide please. So here's an image of our patient who was at 36 weeks. Um, you can see the bladder flap in the left-hand side, in the lower left-hand corner, and you can see the bulge. The bulge frequently looks purple. Uh, the bulge is where the bladder flap is. You can see the Vascularity, um, and depending on what we know from the MRI, this can be a placenta that's sort of wrapping around or we can see much more of the placenta actually growing into, uh, and involving the uterine cirrhosa. At this point in the case, once we've opened the abdomen and identified the uterus, we create enough exposure so that our sonographers come into the OR and actually can do a scan, uh, to both identify the placenta, help identify the thickness of the placenta, the thinning of the myometrium, and most importantly, anticipating for the delivery, looking for the edge of the placenta, uh, to make a hysterotomy at the appropriate location. We have a little clip of the next slide, um, that Doctor Porter will walk us through. So this is an image or this video is taken in the operating room where the um radiologist actually joins the team and uh we identify the location of the placenta, the edge of the placenta, and we mark it, uh, so the insist. would not be made through the placenta, which would decrease the potential blood loss. Also, if we have a good window, we also evaluate to make uh what we can see right on the surface of the uterus, the invasiveness of the placenta. Next slide, please. And this is actually one of those ultrasound images of the intraoperative um ultrasound when you could see, uh, this is a sagittal view superiorly to the right of the screen. You could see normal myometrium and normal appearance of the placenta and then gradually you could see how the myometrium where the arrows are, is really uh uh quite thin and that's where the uh myoinvasive process of the placenta is starting. And um sometimes we have a great window, sometimes we, we don't see that well, so the purpose really for the radiologist in the OR is to show where is the edge of the placenta, not to go through this uh during the cesarean hysterectomy. Next slide, please. The hysterotomy on the uterus can sometimes be at the fundus, but we've had them sometimes even be at the posterior aspect of the uterus, depending on how much of the placenta is anterior is involved, and obviously we don't wanna cut through it. After the infant is delivered, uh, the uterus is closed relatively quickly. Um, and if feasible, we are in our hybrid room and our interventional radiologists are available for potential uterine artery embolization. Um, Doctor Cohe published our experience on uterine artery embolization after cesarean delivery and before hysterectomy. This was a retrospective review, so the indicator for UAE on the 24 controls was somewhat variable, but there were 7 patients with invasive placentas. Compared to 17 of the controls who had invasive placentas. Um, and when we looked at embolizing these patients, uh, versus not embolizing them before the time of hysterectomy, the embolization did result in less blood loss, less transfusion, and less ICU stay. Again, in the consensus guidelines, uh, UAE is not strongly recommended, and there are some adverse events that have been described in the literature, but in our experience, it's been relatively safe. In the lower left-hand corner, you can see the blush of the uterus and the placenta from the angiogram. So the radiologist will do a groin puncture and start with an aortogram and look to see where the perfusion is of the placenta and the uterus. And then they'll Slowly work through each branch and each vessel of the anterior division, uh, of the uterine vessels until in the right-hand side, you can see that all of those vessels are gone and that is a successful embolization of a uterus with an invasive placenta. Next slide. So, this is the image of our patient, 36 weeks who just delivered. And we Had our interventional radiology colleagues perform the study and in this particular case, you can see the robustness of the vessels, particularly on the patient's left-hand side. Um, they ended up taking about 2 to 3 hours, uh, to complete this embolization. Um, they used Omnic for their contrast with fluoroscopy and they used a gel foam slurry to be. Able to individually uh embolize the vessels. This is a uh a um substance that lasts for a couple of weeks, so it's not a coil, it's not something metal, it's not something permanent, um, and all we need is to be able to decrease the blood flow so that when we're doing the hysterectomy, we have less vascularity and can proceed with removing the uterus, uh, with decreased blood loss. Next slide, please. So, after we've done the delivery of the infant, the embolization, we bring the patient back to proceed with hysterectomy. We'll use our retractor. At this point, we'll initiate use of the cell saver. So, we don't use it at the time of the delivery. But when We're doing a hysterectomy, we will use the self-saver. Um, we talk about preparing for possible urgent hemorrhage, meaning that we have had patients that we try and move to the IR bed and then they start to bleed. We do have to bring them back and proceed with hysterectomy quickly. Um, my commentary about these invasive placentas, uh, on hysterectomy postpartum is you can see how much of the lower uterine segment and cervix is really taken up by the placenta. The blue arrow is the hysterotomy. We can see where the uterine incision was closed. You can see the bladder reflection a little bit below that, and then over half of the uterus is made up of the placenta that's invasive through the lower uterine segment. The yellow arrow points to an area where the bladder was adherent to the uterus. And we are very careful in our bladder dissection, but ultimately, we know from the MRI, um, that sometimes there can be significant thinning. And in our dissection, sometimes it is appropriate to create an intentional cystotomy. Where we make an incision into the bladder to be able to delineate the extent of where everything is stuck. Um, you can see in the lower uterine segment and the cervix that there actually is more normal anatomy there. So sometimes just getting packed below that patch of adherent bladder helps to facilitate our dissection and our hysterectomy. On the white arrow, you can see where there's more placental bulging. And this is an area where the placenta is particularly invasive. And this sometimes is an area where we're doing our pertrial dissection, um, and really trying to not enter those placental caalidins helps again to decrease bleeding. We communicate with the OR team to let them know what's going on. If we get into hemorrhage, we obviously want our anesthesia colleagues to be aware. Um, and then when we remove the specimen, we'll communicate the findings, uh, to our pathology colleagues. This particular specimen is not the patient that we're discussing. But an example of particular findings that if we tell the pathologist about them, it helps to identify where there may be anatomic considerations. If we got into the placenta, that doesn't really count as a procreta and so those are also important to identify as far as specimen disruptions. Next slide please. A couple of other comments to make would be that if there is an occult identification of a possible accreta case, you know, just helping the obstetrician, you know, kind of take a deep breath and get set up. Um, meaning that if you make a uterine incision and you see a placental bulge, Um, perhaps there is an invasive placenta that wasn't identified. Setting up the OR team, um, talking to anesthesia, getting blood set up, really, you're in control until that uterine incision is made. And even if the infant needs to be delivered, you can close the hysterotomy. And if the placenta is really Invasive, um, those patients can sometimes be transferred to tertiary care facilities. If you have a partial accreta or partial separation, um, that's not necessarily possible, but there have been cases described of this and transfers that have been, uh, transfer requests that have been made on the behalf of an invasive placenta that remains in place. I think my last comments um from a surgical management standpoint would be in the cases of postpartum hemorrhage. Um, potentially postpartum hemorrhage is related to an adherent placenta and potentially retained products of conception are related to placenta that might be adherent. And so, really communicating with pathology, thinking about these cases clinically because maybe these are part of an occult PAS spectrum. So finally, this is the uterus of our case we're discussing today. Um, and after we remove the uterus, we give it back to our radiologist. Um, we have the fortune of being able to do a debrief to corroborate our findings, to really talk about what did we see, and you can actually get a really good look at the uterus and the placenta again one more time before it goes to the pathology lab. Next slide. So this is an example where we are actually taking the uterus um into the saline bath and uh once it's been removed and then do an ultrasound uh to see how, what we can see at the, this time and we've learned or with our, this is something what we've started to do recently and we've actually learned that you can see it quite well even though that now the uterus is decompressed and the um A amniotic fluid is out, but even as you can see on this slide, you can still see the areas of normal myometrium and then the bulge and invasion into the myometrium of the placenta anteriorly which is outlined with the red line. And doing this has really um is helping us to learn more about the process and get better and be more accurate in our diagnosis. Next slide. So we're carefully looking all around. We're trying to correlate with the findings, what we suspected in um the in vivo ultrasound. Of course, and also what the areas which we thought it was the thinnest on the MRI as well as the areas which potentially could have been uh sort of uh the, the areas interrupted during the surg uh surgery and so it wasn't really a trooper creed. But it was a um surgical interruption of the cirrhosa. And then it's really key to communicate the intraoperative findings to the clinical team as well as the pathologist who is um a significant and very important member of this team. Next slide. So my name is uh Joe Rabin. I am a pathologist uh specializing in uh gynecologic pathology, and I'm part of the MAPS uh team. Um, for all of the uh significant advances that have been made recently in the radiologic detection and, uh, surgical management for PASD, uh, the world of pathology, uh, really has to catch up. Um. In the process of becoming part of this team, I think it's important to realize that the current protocols for pathologic evaluation of hysterectomy, um, there actually is no specific protocol for PASD. And then in terms of reporting the diagnosis, uh, we have a three-tier system of placenta accreta, increta, and percreta. That's basically where the field is today. The problem with this is that that level of information is not as granular as it could be in order to provide feedback to the radiologists and the clinicians so that a very detailed correlation can be made for the purposes of quality improvement. And so, For the last couple of years in our institution, we have developed um some novel strategies to bring the pathologic evaluation of these specimens more in line with the advances in radiology and management. And so to summarize, we have a three-part strategy that you see here. Um, first, instead of just looking at the pathologic features in isolation, we have learned that it is essential to have an integrated approach where we understand the radiologic and intraoperative findings. Uh, second, we have developed a specific strategy for dissection of these hysterectomy specimens. Um, and third, we use a reporting, uh, approach that, uh, accounts for both the recent 2018 FICO clinical grade, as well as a, uh, just recently published proposal for pathologic grading that I will discuss, uh, shortly. Next, In terms of integrating radiologic and intraoperative information into the pathologic interpretation, um, there are several pieces of data that we feel are essential to be communicated from the clinical team to the pathologists. First is orientation of the specimen. Uh, and understanding the the radiologist's impression of where the most extensive component of disease is. Um, we have found that it's important to understand exactly where the hysterotomy was placed because, um, it may not always be, um, uh, so clear-cut anteriorly, and so we want to know exactly how to orient the specimen so that we can provide a good correlation of our findings, um, with the radiologic findings. Um, as Dr. Chen mentioned, it's very important to understand the natural state of the uterine cirrhosa when the surgeon enters the abdomen. Um, Was it intact? Because it is very easy for artifactual mechanical disruption of the uterine cirrhosa to occur during the actual procedure itself, and that would lend to a potential overdiagnosis of procreta. And then also, as Dr. Chen mentioned, there are going to be situations in which bloc resection of a portion of the bladder wall is necessary. This can be very difficult to recognize on visual inspection of the surface of the hysterectomy by the pathologist. And so having that piece of information. Um, as well as orientation to exactly where that small piece, um, of tissue may be is critical. Um, this will help us to evaluate as to whether there is any formal, um, invasion into that bladder wall. And then finally, uh, I think it's useful to let the pathologist know if embolization was performed, if coils were used. This is more of a safety issue as we are, um, dissecting the specimen. Next slide. Um, so, step two is, um, our specific protocol for, um, dissecting the hysterectomy specimens. Um, I think, uh, we are probably one of the few places that does this. Um, uh, the standard of care currently is simply to bivalve the uterus as one would do for a standard benign hysterectomy or hysterectomy for cancer staging. Um, if that is done, it becomes very difficult to then orient those tissue slices in a way that is meaningful for the radiologist to go back and correlate. And so, um, the technique that we use is we leave the uterus intact and we perform serial parallel slices every 2 to 3 centimeters in the axial plane. Um, and then we lay the slices out, as you see in the right-hand side, uh, in anatomic order, and then we take a photograph of these slices, um, which is then part of the, um, the debriefing, um, where the radiologist can then make a direct one on one correlation between these axial slices and the axial slices from their, um, imaging. Next slice, or next slide. This is the case um that we're discussing today. Um, the hysterectomy specimen um has intact cirrhosa, but, um, it, it's easy to see that a pathologist may misinterpret some of the uh uh uh adherent tissue here as potentially disruption. Um, it's also, uh, Helpful, as I mentioned, to know whether some of that adherent blood clot may actually represent part of the urinary bladder wall, but in this case, there was no bladder that was removed. We then see the axial slices laid out with the cervix in the upper left, and then the lower uterine segment all the way to the top of the fundus, and what you can see is that the placental disc has replaced the wall of the Uh, myometrium, predominantly in the lower anterior uterine segment, especially where the green arrows are. And so this is indicative of a very, um, quote, invasive type of PAS disorder. Next slide. Um, so if we look at one slice in particular and focus at the area where the red box is indicating, you can see that the serosa is intact, but, but barely. Um, and so the histologic correlate, this is the glass slide image on the right of that area, shows that indeed the serosa is intact. There is a thin layer of myometrium, albeit very thin. Um, and you can see that the, um, chorionic villi of the placental disc extend all the way up almost to that, um, serosa. Next slide. So as I mentioned, um, we have found that it is more useful for um feedback to the radiologist to provide more granular information than the simple accreta, increta percreta uh three-tier system. Um, in 2018, the FICO, um, Uh, clinical guidelines proposed a clinical grading scale, um, which is a more clinically relevant way of assessing the extent of disease. And in 2020, actually just this summer, um, an international expert panel of pathologists put together, um, guidelines for classification and reporting that were an attempt to harmonize the pathologic language with the clinical language proposed by 2018. Potter and I were part of this panel. Uh, next slide. And um just to uh show again the grading scale from the clinical standpoint that Doctor Chen showed, um, our case that we're presenting today is a clinical grade 3A. Next slide. This is a diagram from that 2020 expert panel recommendation showing the different pathologic grading scales that have been proposed. And so for this particular case, because of the extent of invasion of the myometrial wall, um, this case is a pathologic grade 3A. Next slide. Um, and so again, these would be the images that um would be um given to the radiologist for the um post um treatment uh debriefing. Um, for this particular case, the actual pathologic report, um, final diagnosis is placenta accreta spectrum disorder, pathologic grade 3A. Next slide. Great. Thank you, everybody. Um, so, I'm in conclusion with this case, um, we ended up delivering, she delivered on hospital day number 2, so we mobilized our team very quickly at 36 weeks, um, She underwent the cesarean hysterectomy with bilateral salpingectomy, um, had the IR embolization procedure, um, in the setting of the placenta accreta spectrum disorder. Um, the case was done under general anesthesia. Total EBL was only 1.6 L, um, speaking to the advent of utilizing IR embolization. Um, she got 2 L of fluid, 3 units of packed RBCs, and 500 cc's of Cell saver. Um, great urine output during the case, delivered a female neonate. Apgar's 2 and 7 with a birth weight of 6 pounds, 12 ounces. Um, on postoperative day number 0, she went to the ICU. On postoperative day number 1, she was transferred to the postpartum ward and was discharged home on hospital day number 6, post-op day number 4. So I think um this case really speaks to um the excellent team effort, um, and, and the outside referring physicians recognizing the severity of the abnormalplanation. Thank you. And next Thank you all. Thank you, Eric. Thank you very much. Thank you. I wanna turn it over to Molly, and, um, Molly, if you could share with the our lovely participants, uh, anything about referring and also fields if there are any questions for the group. Thank you, Molly. That was a great presentation. Thank you, everyone. Um, so I wanted to just review how you refer a patient to our MAPS program, and the first way is if it's an urgent referral, for example, you have an inpatient who you want to send directly to us as an inpatient as well, um, you would call our access center and the phone number is there at 415-353-1611. That's the same phone number for any patient to be transported into or for any referral to be made or Consult questions that gets you in touch with the MFM who's on call to answer those questions or initiate the referral process. If it's a non-urgent referral, there is that long URL there that takes you to the page that gives you, uh, a referral form, uh, and instructions on how to fax that referral form with any prenatal records to our outpatient clinic and our high-risk coordinator, Sohini Vaga, whose, uh, name and email and phone number is. Below. She will then initiate those referral processes, get any insurance authorization as needed. I reach out to the patient and we do an intake phone call where I verify history, go through prenatal records, find out any other pertinent information, and then, um, the clinical picture, and at that point, we get the patient scheduled for the radiology scans and an MFM consult, and then meet together as a group to make a plan on next steps.
