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 Aaron Matsuda, I'm the patient care director and service line director for the fetal treatment center here at UCSF. 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 and some of our clinic locations and just want to let you know that we are here and we are ready. This is actually the third webinar that the fatal treatment center has hosted in the last couple of months and we are taking a bit of a divergent here um in honor of it being nationally created awareness month, we'll be sharing with you a case based presentation on placenta and create a 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, so maybe 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 Dr Juan Gonzalez. He's an associate professor for the Department of O B G Y N. Here at UCSF. He's the Medical director of our labor and delivery program and he is also the AM FM fellowship program director. Thank you Dr Gonzalez. Thank you very much Karen and welcome to everybody that has joined us today. So I want to introduce our panel um next slide please. Um So we have dr john who's an assistant professor of radiology um and has expertise in presentation and um imaging in this area. Dr raben, our pathologist who has helped us throughout the development of the maps program in the program. Dr Lee Porter, who is the director of the division of ultrasound and radiology and has expertise in M. R. I. Imaging of the placenta and Dr li mei Chen, who is the director of the division of G. Y. N. Oncology and um one of our esteemed surgeons that helps us to these very complicated cases. Also on the call today is molly Killian, who is your hero from her at the end. Um She is our maternal fetal medicine perinatal nurse who helps us coordinate the care for all these patients that join us here at UCSF. Um So next slide so these are the objectives of we what we hope to discuss today. Um We want to talk about the path of physiology of a creed. A spectrum disorder. Um This is actually the preferred term um that has been endorsed. Um We now refer to them as the creed A spectrum. Um We have imaging modalities to review both ultrasound and M. R. I. And features of the diagnosis and we also want to 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 practices. 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 M. R. I. And older sound 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 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 consults services that might be needed and longitudinal planning and logistics. Next slide in that first huddle you can see all the boxes illustrating how extensive the team is. It includes radiology, obi anesthesia, gy in oncology, interventional radiology, M. F. M. O. B. And nursing which are critical to the coordination of the care of these patients. And then the patient usually 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 two where we'll finalize a checklist operative planning review labs and kind of go through all the details of of the actual surgical intervention after we do 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 where we review all the cases and discuss them among our group. Next This cartoon just illustrates the most recent statistics um in the spectrum of a cree to increase to. But the majority, 82% of them are created which is usually secondary to some disruption in the decide dual um uh formation where the placenta abnormally implants implants to the Miami trim. But you can appreciate the spectrum Um as the most severe cases with credo which tend to be the minority. And the most recent estimates suggest only 6% of cases are in the creed. A spectrum next. Unfortunately in the last four decades there has been a significant intra increase in the cases of Placenta spectrum. This is thought to mirror the increase in Cesarean deliveries. And the most recent estimates suggest that as many as one in every 272 deliveries could be complicated with placenta accrete a 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, There's a history of ash Germans um endometrial ablation history of uterine artery embolization 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 accrete to next. This table is very important as it illustrates the risk as the number of cesarean deliveries increase in the patient's history. Um the risk of having an acquittal will increase especially if you have the presence of a placenta previa. So you could see if you have only one placenta previa. We have one C section in the setting of a placenta previa. The risk is 3.3% of the cases will be in a creed. A but if you 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 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 goes through all the evidence on how to manage these cases and we're 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 em FM radiology of cedric anesthesia. Ir interventional radiology and pathology Next. And it is um being demonstrated in multiple studies that patients that do deliver in a center that have experienced with placenta accrete to um do have better outcomes and end up are less likely to require large blood volume transfusions, require less likely to require re operation within seven days after the delivery. Um And also other complications are less likely in the setting of delivery. And an experience center next um M. F. M. Consultation after the imaging it 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 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 the pregnancy to assure that they can have a safe termination. Next this is our checklist that we have developed here at U. C. S. F. 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 34-36 weeks and the reason it should not occur past 36 weeks is that in studies in the setting of the credo to It's been shown that over if you wait past 36 weeks there's a over 50% risk that 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 34-36 weeks and synthesis 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 pre eclampsia and 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 late preterm administration of beta medicine 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 ante partum 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 from um our campus? So they live locally in san Francisco were less likely to admit him 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 Next. Um It is very important to um again as and the document from the American college of O. B. G. Y. N. And the Society for maternal fetal medicine emphasize this that these mothers should deliver in a maternal care facility facility that is a level three or four. Next. So throughout today we're gonna be reviewing a case of this mother um that came to us, we'll be looking at her imaging her her surgical intervention and then subsequently her pathology. Um She was a 34 year old G. Three P. One who uh was presented to us around late in the third trimester, 35 weeks and six 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 Korea spectrum. Um So then subsequently she um was referred to us um for evaluation. Her past medical history was significant for microscopic 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 5. In the setting of preterm labor. Um She delivered a male neo Nate. Um that was die diagnosed with down syndrome. Birth weight was £4.06 ounces and unfortunately that neon A died at one year of life from pulmonary complications. In 2016 she had an elective repeat cesarean section at 39 weeks and delivered a male neonatal um with a birth weight of £9.01 ounces. Next. And now I'll pass on the presentation to dr yeah and dr 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 create a 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 accrete to 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 nuclear translucency. This is an opportune time to make an early diagnosis of this disorder. Also after the stenographers 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. Create a spectrum on ultrasound. Most commonly you would encounter a placenta previa in your practice which may have placental like coons. There may be associated maya material thinning the placenta may bulge and may have the so called snowman appearance to the uterus and there may be abnormal vascular charity. In essence, if your imaging is suspicious and the patient has risk factors. If you identify any of these imaging factor in imaging signs that offer 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 placental location, found the placenta previa in a different patient. We would also evaluate for Visa previa and make sure it's not present or present. We noted innumerable, irregular cocoons, noted my mitral thinning and abnormal vascular charity. All findings suspicious for placenta create a 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 mihama tree. Um and we identified this as the area of worst involvement. Next in patients who have presented previa, we also perform a dedicated endo vaginal exam as we did for this patient. This was very helpful in identifying bladder Ciro cell involvement as seen on the ultrasound images. We do not see any normal appearing Miami atrium intervening between the bladder as well as the placenta along with abnormal vascular charity located in this interface. This is suggestive of full thickness Miami atrial involvement. And we also evaluate for other findings of parametric and cervix involvement. If you see findings such as these demonstrated on the slide, then when you do assist, ask api you may identify these prominent vessels and during this task api in the bladder wall as shown in the image. Again if the placenta has an atmosphere component and for further planning we send the station to have an M. R. I. The beauty of doing this at UCSF is that many of our operators are specialized in both ultrasound and M. R. I. Evaluation of the center create a spectrum disorder allowing for a complementary role. And with that I'm going to ask dr Porter to present the M. R. I. Portion of our evaluation. Thank you. Thank you. So let's talk a little bit about M. R. I. As dr john mentioned M. R. I should not be evaluated in isolation. It's um always complimentary 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 M. R. I. 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 surgical planning. And so M. R. I can provide us a better picture of the overall appearance, the extent of disease precise topography and how much of the uterus and adjacent structures are involved. Is it superior versus inferior? Lower uterine segment? Is there potentially para material invasion or other areas of invasion which can potentially alter surgical approach and require, for instance your actual standing or vascular clamping and a lot of times also preoperative embolization next please. And M. R. Has shown better has been better to assess for the depth of invasion and the extent of invasiveness. Because really the most important question is is the disease my own invasive or only my own adherent 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 my own adherent and most of the cases of my own invasive disease. The patient will proceed with a hysterectomy, cesarean hysterectomy As has been mentioned before. There are recent Fico guidelines which is published in 2018 which talked about a lot about the diagnosis and the management and as well then about the imaging appearances and an ultrasound of course is a key modality to diagnose and follow those patients. An M. R. I. Was noted to be not essential but may be useful and why it was stated as such is because M. R. I. Might not be available at all centers as well as it really needs expertise by the readers. So as what we have learned is obviously if the more expert the readers, they improved the accuracy of these reeds. And so that's what we have really learned over past the four or five years that our centers where we very carefully follow the patient's presentation, the ultrasound findings, the M. R. I. 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 treat a spectrum disorder is that there has to be standardized reporting and we will hear more about it in our pathology section. But similar issues are with the imaging and several international radiological societies have talked about standardizing the M. R. I. Findings, the descriptors and the reporting next slide please. And one of these um uh sort of uh these guidelines which we came together with the european society as well as the american society of abdominal radiology was actually spearheaded by dr jah at UCSF. And during this study we found out that there are seven signs really which are quite helpful too. Um Are sensitive and specific for diagnosing placenta. Accrete a spectrum disorder. And this would be placental bulge dark inter placental lines, loss of retro presentable dark zone, maya meter of thinning bladder wall, interruption, focal, exotic masses and abnormal vascular ization in placental bed. Next slide please. So a lot of times the question comes up, what is the ideal timing of M. R. I. ideally it should really be be formed between 28-32 weeks. And if ultrasound findings are suspicious then it's best wait until 24 weeks before getting the M. R. I. However it all really depends on the clinical scenario. If uh if gravity hysterectomy is considered then obviously we can do the M. R. I. At any time point. Whatever the clinical scenario determines. Sometimes you also do the M. R. I. later than 32 weeks when the patients present late and it is still quite helpful for surgical planning. The one caveat is that the limitation of them are becomes a greater and greater after 35 weeks because the mama tree. Um at this time is the thinnest and it's very difficult to determine whether is the true true thinning of the Miami atrium or actually invasive invasion of the placenta. Next please. So this was our patient. Um And we have these three planes, satchel corona and axial and if you look at the placenta previa and this is one of the illustrations where this patient actually had all different signs, pretty much all the signs on M. R. I. As well as ultrasound. So it was one of those uh some 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 create a spectrum disorder. We look for the deepest areas of invasion. We made sure there was no invasion into the bladder, assess the areas of your physical junction and your orders. And then we presented this case um for the surgical team at the multi disciplinary conference along with the ultrasound next please. And one of the as we talked about how important Denise to determine whether it's my oh invasive versus my own adherent we have found with our experience which is also been reported in literature that the placental bulge sign is predictive of my ah material invasion. And so most of the time when you just have my own adherent disease, you would not have this bulging of the placenta as was seen in this case with our patient. Hi, I'm thank you very much for inviting me to participate. I'm one of the surgeons who is part of our maps team. And as Dr 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 straightforward hysterectomy may be performed. R O B G Y N. Colleagues would potentially manage those cases in the case where there's a more invasive placenta concern for more hemorrhage, bladder involvement. Potentially 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. DR Porter 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 a basement of the cervix, whether there's normal anatomy really helps us to be able to anticipate and visualize what we're going to 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 38 o'clock in the morning. Start. Clearly, that's favored over a a patient who delivers and starts hemorrhaging after their C section any time any day and also for anesthesia, colleagues getting things set up prepared, having cell saver available Milady, for example, is important in the coordination looks like this. I mentioned, the multidisciplinary care team and Dr Gonzalez mentioned this as well. This has been studied at various centers of Excellence, looking at comparisons between sites, looking at historical controls. 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 you're 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 women to be able to participate in her post natal care, go see her infant not have to get stuck in the ICU and overall have a shorter length of stay. So in preoperative considerations 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. Steroids are used for fetal lung maturity. We do use M. R. I. For our planning and many places will use ultrasound. But as a surgeon I truly value the findings on the M. R. I. 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 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 O. B. Team M. FM. Team nursing from both obstetrics as well as the main operating room as our cases are done there as opposed to on labor delivery. Ir and then if needed and the delivery is scheduled between 34 to 36 weeks. 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 O. R. 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. We place patients in a lathe to me position and if possible place a three way fully catheter. This allows us to backfill the bladder. And some of our providers prefer to place your general stents. And some of our providers use the imaging to help guide whether or not stents should be placed to identify the jurors both higher up in the pelvis as well as down low by the parametric. Um You'll notice on the huddle 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 is direct me. The hybrid room is called a hybrid because in the background you will also see our flora safi equipment. Um And what we found to be able to move a patient from an operating room bed to an IR bed in the matter of just a few moments, saves us a lot of time. A lot of traveling um from a safety standpoint decreases the risk of patients having an acute lead that we have to move patients for and also helps with sterile sterility and infection control. Inter operatively. Once we get in we talk about what do we see and the clinical grading of a create a spectrum is done at the time of C. Section by a clinical evaluation. So the grade one is you are suspecting a adherence of the the placenta separates. So there's not really adherence of the placenta and that goes in subsequent relations to the level of adherence invasion into the wall of the uterus. That we can see the bulge um that the placenta has to be removed manually. Or that we see the placenta invade all the way through. As dr 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 three level. We will see a bulge. We will anticipate that there is involvement of the placenta into the Miami atrium. We don't work on pulling on the placenta. We don't try and remove it. The goal would be if that we believe the placenta to be invasive. That we would remove it intact with our hysterectomy specimen. Next slide. So here's an image of our patient who is 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. The bulge is where the bladder flap is. You can see the vascular charity. Um And depending on what we know from the M. R. I. 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 cirrhosis at this point in the case. Once we've opened the abdomen and identified the uterus we create enough exposure so that our sonography furs come into the O. R. And actually can do a scan to both identify the placenta. Help identify the thickness of the placenta, the thinning of the Miami trim and most importantly anticipating for the delivery. Looking for the edge of the placenta to make a hysterectomy at the appropriate location. We have a little clip of the next slide um That dr porter will walk us through. So this is an image or this video is taken in the operating room where the radiologist actually joins the team and we identify the location of the placenta. The edge of the placenta and we market So the inside 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 me 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 inter operative ultrasound When you can see this is a saddle view securely to the right of the screen. You can see normal Miami atrium and normal appearance of the placenta. And then gradually you can see how the Miami atrium where the arrows are is really uh quite thin. And that's where the maya invasive process of the placenta is starting. And sometimes we have a great window. Sometimes we we don't see that well. So the purpose really for the radiologist you know our is to show where is the edge of the placenta. Not to go through this during the cesarean hysterectomy. Next slide please history to me on the uterus can sometimes be at the fungus but we've had them sometimes even be at the posterior aspect of the uterus depending on how much of the placenta in is anterior is involved. And obviously we don't want to 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 Dr cho he published our experience on uterine artery embolization after cesarean delivery. And before hysterectomy this was a retrospective review. So the indicator for U. A. E. On the 24 controls was somewhat variable but there were seven patients with invasive placentas Compared to 17 of the controls who had invasive placentas. Um and when we looked at symbolizing these patients versus not symbolizing them before the time of hysterectomy. The embolization did result in less blood loss, less transfusion. Unless I see you stay again in the consensus guidelines of U. A. E. 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 A. Or a gram and look to see where the perfusion is of the placenta and the uterus and then they'll say slowly work through each branch and each vessel of the anterior division 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 life. 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 2-3 hours to complete this embolization. Um they used to pick for their contrast with flora skopje and they used a telephone slurry to be a individually m belies the vessels. This is a a a substance that last 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 vascular charity and can proceed with removing the uterus 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 the hysterectomy we will use the self hate saver. Um We talk about preparing for possible urgent hemorrhage meaning that we have had patients that we try and move to the I. R. 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 history economy. 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 M. R. I. Um that sometimes there can be significant thinning and in our dissection. Sometimes it is appropriate to create an intentional system to me where we make an incision into the bladder to be able to delineate the extent of where everything is stuck. You can see in the lower uterine segment and the cervix that there actually is more normal anatomy there. So sometimes just getting 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 parametric dissection um and really trying to not enter those placental cattle Eaton's helps again to decrease bleeding. We communicate with the O. R. 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 will communicate the findings 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 pathologists about them, it helps to identify where there may be an atomic considerations if we got into the placenta that doesn't really count as a perk rita. And so those are also important to identify as far as specimen disruptions looks like. Please the couple of other comments to make would be that if there is an occult identification of a possible create a case. You know just helping the obstetrician, you know kind of take a deep breath and get set up, 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 O. R. 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 history to me and if the placenta is really in invasive um those patients can sometimes be transferred to tertiary care facilities if you have a partial creator of partial separation. Um that's not necessarily possible but there have been cases described of this and transfers that have been transfer requests that have been made on the behalf of an invasive placenta that remains in place. I think my last comments 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 retain 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 PS 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 radiologists 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 time. So this is an example where we are actually taking the US um into the sailing bath and once it's been removed and then do an ultrasound to see how what we can see at this time. And we have learned over with our this is something that we've started to do recently and we've actually learned that you can see it quite well even though now the uterus is decompressed and the the fluid is out. But even as you can see on this slide you can still see the areas of normal Miami tree um and then the bulge and invasion into the Miami team of the the center anterior which is outlined with the red line and doing this has really is helping us to learn more about the process and get better and be more accurate in our diagnosis slide. So we 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 was the thinnest on the M. R. I. As well as the areas which potentially could have been uh sort of the area's interrupted during the surgery surgery. And so it wasn't really a trooper chris but it was a surgical interruption of the cirrhosis and then it's really key to communicate the inter operative findings to the clinical team as well as a pathologist who is a significant and very important member of this team. Next slide. So my name is joe Robin. I am a pathologist specializing in gynecologic pathology and I'm part of the maps team. Um for all of the uh significant advances that have been made recently in the radiologic detection and uh surgical management for P. A. S. The uh the world of pathology 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 uh specific protocol for PSD uh And then in terms of reporting the diagnosis, we have a three tier system of placenta. Accrete to increase to and perk rita, that's basically where the field is today. The problem with this is that that level of information um is not as granular as it could be in order to provide feedback to the radiologists and clinicians so that a very detailed um correlation can be made for the purposes of quality improvement. And so over the last couple of years in our institution we have developed 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 inter operative findings. Second, we have developed a specific strategy for dissection of these hysterectomy specimens. Um and third we use a reporting approach that accounts for both the recent 2018 Figo clinical grade as well as a just recently published proposal for pathologic grading that I will discuss shortly next uh in terms of integrating radiologic and inter operative information into the pathologic uh interpretation. Um There are several pieces of data that we feel are essential to be communicated from the clinical team to the pathologist. First is orientation of the specimen uh and understanding the radio, the radiologists impression of where the most extensive component of diseases. Um We have found that it's important to understand exactly where the hysterectomy was placed because um it may not always be um so clear cut interior early and so we want to know exactly how to orient the specimens so that we can provide a good correlation of our findings with the radiologic findings. Um As dr Chen mentioned, it's very important to understand the natural state of the uterine Ciro's a when the surgeon enters the abdomen. Um Was it intact? Because it is very easy for art if actual mechanical disruption of the uterine. So rosa to occur during the actual procedure itself and that would lend to a potential over diagnosis of park rita. Um And then also as dr Chen mentioned, there are going to be situations in which on block 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 have that piece of information um as well as orientation to exactly where that small piece um of tissue maybe 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 pathologists know if embolization was performed. If coils were used. This is more of a safety issue as we are dissecting the specimen next slide. Um So step two is our specific protocol for um dissecting the hysterectomy specimens. Um I think we are probably one of the few places that does this. Um 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 uh 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 2-3 cm in the axial plane. Um And then we lay the slices out as you see in the right hand side in an atomic order. And then we take a photograph of the slices which is then part of the debriefing um where the radiologist can then make a direct one on one correlation between these axial slices and the axle slices from there. Um imaging next slice or next slide. This is the case um that we're discussing today. Um The hysterectomy specimen um has inTACS rosa but um it's easy to see that a pathologist may misinterpret some of the uh adherent tissue here is 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 um there was no bladder that was removed. Um We then see the axial slices laid out with the cervix in the upper left um and then the lower uterine segment all the way to the top of the fungus. And what you can see is that the placental disk has replaced the wall of the uh Miami atrium 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 PS disorder. Next slide. Um So if we look at one slice um in particular and focus at the area where the red boxes indicating you can see that the syriza is intact but but barely. Um and so the histological correlate this is the glass slide image on the right of that area shows that indeed the syriza is intact. There is a thin layer of geometry um albeit very thin. Um and you can see that the chorionic villus at the placental disk extend all the way up almost to that. Um See rosa 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 upgrade to and create a perk rita three tier system. Um In 2018 the Figo um Clinical guidelines proposed a clinical grading scale which is a more clinically relevant way of assessing the extent of disease. And in 2020, actually just the 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. UU Porter and I were part of this panel uh next slide. And um just to show again the grading scale from the clinical standpoint that dr Chen showed um our case that we're presenting today is a clinical grade three, a 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 Miami atrial wall. Um This case is a pathologic grade three A next slide. Um And so again these would be the images that would be given to the radiologist for the post treatment the briefing um For this particular case the actual pathologic report, final diagnosis is placenta. Accrete a spectrum disorder pathologic grade three. A next slide. Great thank you everybody. Um So I'm in conclusion with this case. Um We ended up delivered, she delivered on hospital day number two. So we mobilized her team very quickly at 36 weeks. Um She underwent necessary in hysterectomy with bilateral self inject a me. Um Had the IR embolization procedure um In the setting of the placenta spectrum disorder. The case was done under general anesthesia totally bl was only 1.6 leaders. Um speaking to the advent of utilizing IR embolization. Um She got two liters of fluid, three units of packed RbC. S. And 500 CCs of cell saver. Um Great urine output During the case delivered a female neonatal guards two and seven with a birth weight of £6.02 ounces. Um On post operative day number zero she went to the I. C. U. On post operative day number one she was transferred to the postpartum ward and was discharged home on hospital day number six. Post op day number four. So I think um this case really speaks to the the excellent team effort. Um And and the outside referring physicians recognizing the severity of the abnormal presentation. Thank you. And next thank you all. Thank you. Thank you. Thank you. I want to turn it over to molly and molly if you could share with the our lovely participants uh anything about referring and also feels 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 in patient who you want to send directly to us as an inpatient as well. Um You would call our access center and the phone numbers there at 4153531611. That's the same phone number for any patient to be transported into or for any referral to be made or call consult questions. That gets you in touch with the M. F. M. Who's on call to answer those questions or initiate the referral process. If it's a non urgent referral, there is that long U. R. L. There that takes you to the page that gives you a referral form and instructions on how to facts that referral form with any prenatal records to our outpatient clinic and our high risk coordinator. So he vega whose 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 the clinical picture. And at that point we get the patients scheduled for the radiology scans and an M. F. M. Consult and then meet together as a group to make a plan on next steps.