early diagnostic Placenta accreta.Aswin.pptx

How to diagnosed early diagnostic Placenta accreta and scar pregnancy

1. Program Studi Obstetri Ginekologi Peminatan Kedokteran Fetomaternal Program SubSpesialis FK Unand Aswin Boy Early Diagnostic Screening for Placenta Accreta American Journal of Obstetrics & Gynecology MFM, .https://doi.org/10.1016/j.ajogmf.2024

2. I. Introducing Program Studi Obstetri Ginekologi Peminatan Kedokteran Fetomaternal Program SubSpesialis FK Unand PAS typically occurs when a trophoblast abnormally adheres to a uterine defect, most often a previous cesarean scar, leading to progressive invasion of the uterine scar niche and related morbidity. Early prenatal diagnosis of PAS is crucial; it enables detailed planning for delivery, which involves transferring patient care to a PAS-specialized tertiary facility, scheduling delivery, typically before 37 weeks, and developing a thorough pre-surgical strategy. Currently, screening for PAS is predominantly conducted by ultrasound during the third trimester and, to a lesser extent, the second trimester The effectiveness and advantage of MRI over ultrasound in this context remain subjects of debate PAS biasanya terjadi ketika trofoblas melekat secara tidak normal pada defek uterus, paling sering pada bekas luka sesar sebelumnya , yang menyebabkan invasi progresif pada bekas luka uterus dan morbiditas terkait . Diagnosis dini PAS pada masa prenatal sangat penting ; hal ini memungkinkan perencanaan persalinan yang terperinci , yang melibatkan pemindahan perawatan pasien ke fasilitas tersier khusus PAS, menjadwalkan persalinan , biasanya sebelum 37 minggu , dan mengembangkan strategi pra-bedah yang menyeluruh . Saat ini , skrining PAS sebagian besar dilakukan dengan USG pada trimester ketiga dan, pada tingkat lebih rendah , pada trimester kedua Efektivitas dan keunggulan MRI dibandingkan USG dalam konteks ini masih menjadi bahan perdebatan

3. I. Introducing.. Program Studi Obstetri Ginekologi Peminatan Kedokteran Fetomaternal Program SubSpesialis FK Unand Mounting evidence suggests that sonographic indicators of PAS can be detectable as early as the first trimester Cesarean scar pregnancy (CSP) has been recognized as a precursor to PAS, underscoring the early initiation of abnormal placental adherence to the uterine scar Two primary screening approaches have emerged: one focuses on screening for CSP early in the first trimester, between 5-8 weeks, and the other screens for PAS between 11-14 weeks, with the routine nuchal translucency scan Banyak bukti menunjukkan bahwa indikator sonografi PAS dapat dideteksi sejak trimester pertama Kehamilan bekas luka sesar (CSP) telah diakui sebagai pendahulu PAS, yang menggarisbawahi permulaan awal perlekatan plasenta yang abnormal pada bekas luka rahim . Dua pendekatan skrining utama telah muncul : yang pertama berfokus pada skrining CSP pada awal trimester pertama , antara minggu ke 5-8, dan skrining PAS pada minggu ke 11-14, dengan pemindaian tembus nukal rutin.

4. 2. First-trimester assessment of the cervico-isthmical complex Program Studi Obstetri Ginekologi Peminatan Kedokteran Fetomaternal Program SubSpesialis FK Unand An in-depth understanding of the utero-cervical anatomy and the cervico-isthmical complex (CIC) as visualized on transvaginal sonography (TVS) earlier in pregnancy, is paramount to the proper evaluation of placentation in the setting of a prior cesarean delivery, as well as to an early diagnosis of a scar pregnancy and associated risk of PAS The CIC is a sonographically virtual structure, comprising the cervix and the uterine isthmus, the lowest part of the uterine corpus that evolves into the lower uterine segment as the pregnancy advances (figure 1) The cervical canal can be identified as a thin, usually echoic line surrounded by hypoechoic cervical mucosa The internal os is identified at the end of the cervical canal and in most cases is seen perpendicular to the lower end of the bladder Pemahaman mendalam tentang anatomi utero- serviks dan cervico-isthmical complex (CIC) seperti yang divisualisasikan pada sonografi transvaginal (TVS) pada awal kehamilan , sangat penting untuk evaluasi plasentasi yang tepat pada kondisi bekas persalinan sesar , seperti serta diagnosis dini kehamilan bekas luka dan risiko PAS yang terkait CIC adalah struktur virtual secara sonografis , yang terdiri dari serviks dan isthmus uterus, bagian terendah dari korpus uterus yang berkembang menjadi segmen bawah rahim seiring dengan perkembangan kehamilan . Saluran serviks dapat diidentifikasi sebagai garis tipis biasanya ekoik yang dikelilingi oleh mukosa serviks hipoekoik Os internal diidentifikasi di ujung saluran serviks dan dalam banyak kasus terlihat tegak lurus dengan ujung bawah kandung kemih

5. Figure 1. The cervicoisthmical complex (CIC) is a transient sonographic structure that is seen in most cases of early pregnancy ultrasounds. It encompasses both the isthmus, the lowest part of the uterine body which later transforms into the lower uterine segment, and the cervix. The cervical canal is discerned as a thin echoic line enveloped by a hypoechoic layer, representing the cervical mucosa. Notably, the internal os is located at the internal canal's end (small arrow), typically seen perpendicular to the bladder's lower end. The isthmical portion of the CIC is situated between the internal os and the gestational sac. The cesarean scar here can be seen within the CIC (large arrow).

6. The isthmical segment of the CIC begins at the internal os at one end and ends at the gestational sac at the other. One notable marker is the lack of the hypoechoic glandular tissue that is seen around the cervical canal As pregnancy progresses, the isthmical myometrium becomes thinner, allowing the gestational sac to occupy the space between its walls, and eventually be in direct contact with the internal cervical os In addition to the significant implication of the CIC in the assessment of the actual length of the cervical canal it is crucial to the identification of a cesarean scar, as cesarean hysterotomies are expected to be done at the low uterine segment Segmen isthmical dari CIC dimulai pada ostium interna pada salah satu ujung dan berakhir pada kantung kehamilan pada ujung yang lain. Salah satu penanda penting adalah kurangnya jaringan kelenjar hipoekoik yang terlihat di sekitar saluran serviks Ketika kehamilan berlanjut , miometrium isthmical menjadi lebih tipis, memungkinkan kantung kehamilan menempati ruang di antara dinding-dindingnya , dan akhirnya berkontak langsung dengan ostium serviks bagian dalam . Selain implikasi signifikan dari CIC dalam penilaian panjang aktual saluran serviks , hal ini juga penting untuk mengidentifikasi bekas luka sesar , karena histerotomi sesar diharapkan dilakukan pada segmen bawah rahim .

7. Figure 2. A cervicoisthmical complex that persists in the second trimester of the pregnancy. The isthmus or low uterine segment (LUS) can be identified separately from the cervix. Similar to the first trimester, the circular echogenic structures in the LUS are helpful in differentiating the isthmus from the cervical canal. Gambar 2 . Kompleks cervicoisthmical yang menetap pada trimester kedua kehamilan . Tanah genting atau segmen bawah rahim (LUS) dapat diidentifikasi secara terpisah dari leher rahim . Mirip dengan trimester pertama , struktur ekogenik melingkar pada LUS sangat membantu dalam membedakan isthmus dari saluran serviks

8. Figure 3 . The cesarean scar as seen in the early first trimester in a normal pregnancy (Figure 3A). By using transvaginal ultrasonography, the scar (arrows) can be seen within the cervicoisthmical complex (CIC) and therefore hidden from the gestational sac and placenta (Figure 3B). In Figure 3C the cesarean scar is identified outside the CIC, exposed to the gestational sac in this case. The internal cervical os can be identified by the curved arrow in Figures 3B and 3C. A B C

9. Most of the scars are identified in the isthmical section of the CIC close to the internal cervical os , just under the lower edge of the bladder wall. We speculate that hysterotomies that were done after dissecting down the bladder flap on a developed, thin, low uterine segment, result in a scar seen in the CIC hysterotomies that were done without dissecting down the bladder or when the low uterine segment is thick and cannot be clearly identified, as seen in preterm deliveries, may result in higher scars outside the CIC In cases with more than one prior cesarean section, a combination of scar locations, in and outside the CIC, can be seen that may suggest a more cephalad hysterotomy in repeat surgeries scar niches can appear different in width, and while the reason behind these differences is unclear, a wider niche may be related to inadequate scar healing Sebagian besar bekas luka teridentifikasi di bagian isthmical dari CIC dekat dengan ostium serviks internal, tepat di bawah tepi bawah dinding kandung kemih . Kami berspekulasi bahwa histerotomi yang dilakukan setelah membedah penutup kandung kemih pada segmen uterus yang berkembang , tipis, dan rendah , menghasilkan bekas luka yang terlihat pada CIC. histerotomi yang dilakukan tanpa membedah kandung kemih atau ketika segmen bawah rahim tebal dan tidak dapat diidentifikasi dengan jelas , seperti yang terlihat pada kelahiran prematur , dapat menyebabkan bekas luka yang lebih tinggi di luar CIC Pada kasus dengan lebih dari satu operasi caesar sebelumnya , kombinasi lokasi bekas luka , di dalam dan di luar CIC, dapat terlihat yang mungkin menunjukkan histerotomi yang lebih cephalad pada operasi berulang . Lebar ceruk bekas luka bisa berbeda-beda , dan meskipun alasan di balik perbedaan ini tidak jelas , ceruk yang lebih luas mungkin terkait dengan penyembuhan bekas luka yang tidak memadai

10. 3. Sonographic assessment of low placentation and diagnosis of a cesarean scar pregnancy Program Studi Obstetri Ginekologi Peminatan Kedokteran Fetomaternal Program SubSpesialis FK Unand In the setting of a prior cesarean scar, the pathogenesis of CSP involves the implantation of a blastocyst in the niche of the cesarean scar in the low uterine segment This abnormal trophoblastic attachment leads to abnormal angiogenesis and vascular remodeling that in turn leads to progressive uterine scar dehiscence The diagnosis of CSP can therefore be made by a systematic examination of the CIC by transvaginal ultrasound in the first trimester, optimally at 5-7 weeks Transvaginal ultrasound is the preferred diagnostic modality in the first trimester due to the optimal image resolution and the good agreement between sonographers. The position of the gestational sac relative to the scar niche and the uterine cavity is the most important parameter in the early diagnosis of CSP In a recent Delphi consensus, most ultrasound experts agreed that a CSP can be defined as a pregnancy in which either the largest portion of a low implanted gestational sac is outside the uterine cavity, is embedded in the myometrium, or crosses the serosal line herniating anteriorly towards the bladder Pada bekas luka operasi caesar sebelumnya , patogenesis CSP melibatkan implantasi blastokista di ceruk bekas luka operasi caesar di segmen bawah rahim . Perlekatan trofoblas yang abnormal ini menyebabkan angiogenesis abnormal dan remodeling vaskular yang selanjutnya menyebabkan dehiscence bekas luka uterus yang progresif . Oleh karena itu , diagnosis CSP dapat ditegakkan dengan pemeriksaan sistematis CIC dengan USG transvaginal pada trimester pertama , optimal pada 5-7 minggu . USG transvaginal adalah modalitas diagnostik pilihan pada trimester pertama karena resolusi gambar yang optimal dan kesepakatan yang baik antara ahli sonografi . Posisi kantung kehamilan relatif terhadap ceruk bekas luka dan rongga rahim merupakan parameter terpenting dalam diagnosis dini CSP Dalam konsensus Delphi baru-baru ini , sebagian besar ahli USG sepakat bahwa CSP dapat didefinisikan sebagai kehamilan dimana sebagian besar kantung kehamilan yang tertanam di bagian bawah berada di luar rongga rahim , tertanam di dalam miometrium , atau melintasi garis serosal yang herniasi ke anterior. menuju kandung kemih

11. Figure 4. A cesarean scar pregnancy, in which the gestational sac is implanted in the niche of the previous cesarean scar, as seen in the early first trimester (Figure 4A). Transvaginal ultrasound (Figure 4B) reveals low implantation of the gestational sac (asterisk), inside the niche of the cesarean scar (arrows). The gestational sac is seen above the endometrial line and towards the anterior uterine wall (crossover sign, COS-1). In Figure 4C, examination of a cesarean scar pregnancy by application of Color Doppler in the early first trimester reveals hypervascularity surrounding the gestational sac, mostly in the fundal side of the scar niche. A B C

12. On the other hand, a pregnancy that is implanted below the cesarean scar niche but not penetrating it, is not considered a CSP and should be described as a low-implanted pregnancy caution should also be exercised to distinguish a CSP from a cervical ectopic pregnancy, where the gestational sac's blood supply originates directly from the cervical canal This is also true for differentiating a CSP from an ongoing spontaneous miscarriage, which is characterized by a gestational sac present in the cervical canal without a detectable blood supply Di sisi lain, kehamilan yang tertanam di bawah ceruk bekas luka sesar tetapi tidak menembusnya , tidak dianggap sebagai CSP dan harus digambarkan sebagai kehamilan dengan implan rendah . kehati-hatian juga harus dilakukan untuk membedakan CSP dari kehamilan ektopik serviks , dimana suplai darah kantung kehamilan berasal langsung dari saluran serviks . Hal ini juga berlaku untuk membedakan CSP dari keguguran spontan yang sedang berlangsung , yang ditandai dengan adanya kantung kehamilan di saluran serviks tanpa suplai darah yang terdeteksi .

13. 4. First-trimester screening strategies for PAS Program Studi Obstetri Ginekologi Peminatan Kedokteran Fetomaternal Program SubSpesialis FK Unand Pregnancies that progress to develop PAS in the second and third trimesters, demonstrate sonographic features during the early first trimester that are comparable to those observed in cases of CSP (Table 1) The histopathological features of CSP and PAS are indistinguishable, suggesting that they may be distinct stages in the same disease continuum with the CSP being a precursor of PAS In a recent systematic review and meta-analysis evaluating the outcome in patients with CSP managed expectantly, 74.8% of patients had a surgical or pathological diagnosis of PAS at delivery, with 69.7% of them diagnosed with placenta percreta . Screening for PAS in the early first trimester at less than 8 gestational weeks should aim at diagnosis of CSP, and an initial finding of a gestational sac that is located low and anteriorly with close proximity to the cesarean scar should warrant further investigation with transvaginal and transabdominal ultrasound. Kehamilan yang berkembang menjadi PAS pada trimester kedua dan ketiga , menunjukkan gambaran sonografi pada awal trimester pertama yang sebanding dengan yang diamati pada kasus CSP ( Tabel 1) Gambaran histopatologis CSP dan PAS tidak dapat dibedakan , menunjukkan bahwa keduanya mungkin merupakan tahapan yang berbeda dalam rangkaian penyakit yang sama dengan CSP sebagai prekursor PAS. Dalam tinjauan sistematis dan meta- analisis baru-baru ini yang mengevaluasi hasil pada pasien dengan CSP yang ditangani dengan harapan , 74,8% pasien memiliki diagnosis bedah atau patologis PAS saat melahirkan , dengan 69,7% di antaranya didiagnosis dengan plasenta perkreta . Skrining PAS pada awal trimester pertama pada usia kehamilan kurang dari 8 minggu harus bertujuan untuk mendiagnosis CSP, dan temuan awal kantung kehamilan yang terletak di bagian bawah dan anterior yang dekat dengan bekas luka sesar harus memerlukan penyelidikan lebih lanjut dengan pemeriksaan transvaginal dan transabdominal. USG. 4.1 Screening for PAS in the early first-trimester (5-8 weeks)

14. Given the potential variability in the positioning of the gestational sac relative to the scar niche (including the different positions of the gestational seen between Figures 4A and 5A), the researchers of this cohort also have proposed the "crossover sign" (COS) as a tool to more accurately determine the sac's location early in the first trimester. The COS is defined as the gestational sac position relative to an imaginary line connecting the internal cervical os and the uterine fundus A gestational sac that is above and towards the anterior uterine wall near the cesarean scar, was considered as a positive COS and was found to be helpful in stratifying patients at increased risk for intraoperative or postoperative complications A finding of a CSP growing “in the niche” was significantly associated with PAS at delivery with most cases being on the severe end of the spectrum (increta or percreta ) requiring hysterectomy at delivery Other sonographic markers to detect CSP in the early first trimester have also been described including a thin or absent myometrial layer under the gestational sac (between the sac and the bladder), presence of placenta lacunae, and increased or chaotic vascularity surrounding the gestational sac

15. Figure 5. A low implanted pregnancy, in which the gestational sac can be seen under the previous cesarean scar but not penetrating the scar niche (Figure 5A). Figure 5B depicts a low implanted gestational sac (asterisk) that is implanted below the cesarean scar (arrows) but not penetrating. This is not considered a CSP and should be described as a low-implanted pregnancy A B

16. 4.2 Screening for PAS in late first-trimester (11-14 weeks) Routine ultrasound between 11 and 14 weeks is advocated by both national and international guidelines to screen for chromosomal anomalies and structural malformations. The early first trimester, a standardized screening protocol for PAS has not been established. By 11 to 14 weeks, the gestational sac enlarges considerably, occupying the entirety of the uterine cavity towards its fundus, complicating the assessment of the initial implantation site Consequently, during this period, only 28% of patients with PAS could have a low gestational sac implantation identified USG rutin antara minggu ke-11 dan ke-14 dianjurkan oleh pedoman nasional dan internasional untuk menyaring anomali kromosom dan malformasi struktural . P ada awal trimester pertama , protokol skrining standar untuk PAS belum ditetapkan . Pada minggu ke 11 hingga 14, kantung kehamilan membesar secara signifikan , menempati seluruh rongga rahim hingga ke arah fundus, sehingga mempersulit penilaian lokasi implantasi awal . Akibatnya , selama periode ini , hanya 28% pasien PAS yang dapat teridentifikasi memiliki implantasi kantung kehamilan rendah

17. 4.2 Screening for PAS in late first-trimester (11-14 weeks)….. Stirnemann et al were the first to assess the feasibility of first trimester screening for PAS Groups : graded as “no suspicion” for PAS if the placenta was not next to the scar; “intermediate suspicion” if the placenta was next or on the scar but not inside the niche (Figures 6A and 6B) “high suspicion” if the placenta was inside the scar niche (Figures 7A and 7B) Using this grading system, we identified at least three out of four cases of PAS and found that placenta implanting inside the scar niche had a high positive predictive value for PAS Stirnemann et al adalah orang pertama yang menilai kelayakan skrining PAS pada trimester pertama Grup : dinilai “ tidak ada kecurigaan ” untuk PAS jika plasenta tidak berada di dekat bekas luka ; “ kecurigaan menengah ” jika plasenta berada di sebelah atau pada bekas luka tetapi tidak berada di dalam ceruk (Gambar 6A dan 6B) “ kecurigaan tinggi ” jika plasenta berada di dalam ceruk bekas luka (Gambar 7A dan 7B) Dengan menggunakan sistem penilaian ini , kami mengidentifikasi setidaknya tiga dari empat kasus PAS dan menemukan bahwa implantasi plasenta di dalam ceruk bekas luka memiliki nilai prediksi positif yang tinggi untuk PAS.

18. A B Figure 6. The relationship between the placenta and the cesarean scar in the cervicoisthmical complex, as examined in the late first trimester at 11-14 weeks in “intermediate suspicion” cases (Figure 6A; illustration, Figure 6B; sonographic image). The placenta can be seen overlying an exposed scar (arrows) but not penetrating the scar niche.

19. Figure 7. The relationship between the placenta and the cesarean scar in the cervicoisthmical complex, as examined in the late first trimester at 11-14 weeks in “high suspicion” cases (Figure 7A; illustration and Figure 7B; sonographic image). The placenta appears to penetrate inside the cesarean scar niche (arrows), completely replacing the anterior portion of the isthmus. A B

20. Other sonographic markers that have traditionally been associated with PAS in the second and third trimester, such as the presence of placental lacunae, myometrial thinning, loss of retroplacental clear zone, uterine-bladder interface abnormalities, and uterovesical hypervascularity have also been examined in the late first-trimester and have In a prospective study by Yule et al, color Doppler mapping during the late first trimester revealed a significant increase in color Doppler pixel area at the bladder-uterine serosal interface in patients who were subsequently diagnosed with PAS demonstrating the significant neovascularization occurring with the abnormal placentationbeen variably associated with PAS Penanda sonografi lain yang secara tradisional dikaitkan dengan PAS pada trimester kedua dan ketiga , seperti adanya lakuna plasenta , penipisan miometrium , hilangnya zona bening retroplasenta , kelainan antarmuka antara rahim dan kandung kemih , dan hipervaskularisasi uterovesikal juga telah diperiksa pada trimester akhir . trimester pertama dan sudah Dalam studi prospektif yang dilakukan oleh Yule dkk , pemetaan Doppler warna pada akhir trimester pertama menunjukkan peningkatan yang signifikan pada area piksel Doppler warna pada antarmuka serosal kandung kemih-rahim pada pasien yang kemudian didiagnosis dengan PAS yang menunjukkan neovaskularisasi signifikan yang terjadi dengan plasentasi abnormal. bervariasi terkait dengan PAS

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