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're here to remind you that our doors are open and we're here to partner with you and your patients during these challenging times, our facilities air, 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're here and we are ready. This is actually the third webinar that the futile treatment Center has hosted in the last couple of months, and we're taking a bit of a divergent here. Um, in honor of it being national Credo Awareness Month will be sharing with you a case based presentation on placenta accrete, a spectrum disorder. At the end of this will have some time for question. The answer. 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 all of your questions at the end. At this time, I'd like to turn it over to Dr Juan Gonzalez. He is 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 MFF Fellowship program Director. Thank you, Doctor Gonzalez. Thank you very much, Erin. And welcome to everybody that has joined us today. So I wanna introduce our panel. Um, next slide, please. Mhm eso We have Dr John who's an assistant professor of radiology on Daz expertise in presentation and image ing in this area. Dr. Robin, our pathologist who has helped us throughout the development of the Max program and the Accredo program. Dr. Lena Porter, who is the director doctor of the Division of Ultrasound and Radiology and has Expertise and Emory Imaging of the Placenta and Dr Li Mei Chen, who is the director of the Division of G Y n oncology and 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. She is our maternal fetal medicine. Peri Natal nurse who helps us coordinate the care for all these patients that join us here at UCSF. Eso next slide. Mhm. So these are the objectives of what we hope to discuss today. We wanna talk about the path of physiology, of a creed, a spectrum disorder. Um, this is actually the preferred term that has been endorsed. We now refer to them as the creed A spectrum. Um, we have imaging modalities to review both ultrasound and Emory 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 this flow diagram illustrates kind of the nature of how we received these. Consul Tom, we are open to referrals on den. The first step is usually with image ing both memory 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 others 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 the patient does decide to continue. Then we will have a maps huddle. Andi. That is where we will review the details of timing of delivery, other potential consults, services that might be needed and longitudinal plan 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, G Y n oncology, interventional radiology, M, F, M, O, B and nursing, which are critical thio 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 Ah, maps Huddle number two, where we'll finalize a checklist operative planning, review labs and kind of go through all the details of the actual surgical intervention. After we deliver and the patients safely discharge, 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 him among our group Next. This cartoon just illustrates the most recent statistics, Um, in the spectrum of acri tha in Creed A in proc rita. But the majority 82% of them are creed A, which is usually secondary to some disruption in the decisional um uh, formation where the placenta abnormally implants to the Miami trim. But you can appreciate the spectrum a za most severe cases with credo, which tend to be the minority. And the most recent estimates suggest only 6% of cases are in the Secreta spectrum next. Unfortunately, in the last four decades, there has been a significant increase in the cases of placenta treat a spectrum. This eyes start to mirror the increase in Caesarian 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 Caesarian section. But there are other risk factors that we cannot forget. Um, those include myomectomy on Dmitri all damage. If there's a history of Astra Mons on Dmitri Elaborations history of uterine artery embolization and any patient that has, um ah, 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. Uh, next. This table is very important, as it illustrates the risk as the number of caesarian deliveries increase in the patient's history. Um, then 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 was published in 2018 and we will email this to the participants. It was published by the American College of Obstetrics and Gynecology and Collaboration with the Society from 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 I'm happy to share this through email next. As I mentioned earlier, the success for the management of these cases, um, is a team approach, and we need all the disciplines working together on Do you could CMF m radiology of civic 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 experienced with placenta accrete uh 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 air less likely in the setting of delivery and and experience center. Next um, EM FM consultation after the image ing 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 complications that the patient might encounter and to be able to plan moving forward next, Um, and then we collaborate closely with our family planning colleagues for those mothers that do decide not to continue the pregnancy to assure that they can have, ah, 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 a new area of a lot of interest bond. 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 a CREA has been showing 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. Toe assure the best outcome for the patient. Um, in these cases, when we deliver between 34 to 36 weeks and you know, statistics for fetal lung maturity is not indicated as we have a compelling reason to proceed with late preterm delivery. Um and obviously some of this will be depending on the patient's history. Um, if there's evidence of rupture of membranes, the fetal growth has 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 method. Sona. There is a paper in the New England Journal of Medicine that was published showing benefit, um, for steroids between 34 37. So for all our cases that are delivering in that window were sure that they have received antenatal cortical steroids for the benefit of fetal along maturity. Next decision to hospitalize. Um, some of our mothers do spend some time with us in the ante. Partum ward has to do more with. Have they had any bleeding from the Previa? Do they have other complications? And how far are they from our campus? So they live locally in San Francisco. We're less likely, um, toe 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 toe again. As and the document from the American College of O, B, G, Y n and the society from into Internal Fuel 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 that came to us. We'll be looking at her image ing her surgical intervention and then subsequently her pathology. 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 to Syrian sections. And she had ah, placenta previa. Andi image ing in the outside facility was very concerning for placenta create a spectrum eso. Then subsequently she was referred to us, um, for evaluation. Her past medical history was significant for micro civic anemia. Secondary debate, a fallacy. Me a 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 off preterm labor, um, she delivered a male neon it that was diagnosed with down syndrome. Birthday was £4.6 ounces, and unfortunately, that Nanny died at one year of life from pulmonary complications. In 2016 she had an elective repeat cesarean section at 39 weeks and delivered Ah, male Naomi with the birth weight of £9.1 ounce, it's next. And now I'll pass on the presentation to Dr Yeah and Dr Porter for image. 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 U. C S F. 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 off all possible risk factors, including the number of his alien sections and prior uterine surgeries or instrumentation. We highly recommend that we screen for placenta creator 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 new coal translucency, this is an opportune time to make an early diagnosis off this disorder. Also, after the Sinaga furs 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 off placenta. Create a spectrum on ultrasound. Most commonly, you would encounter a placenta previa in your practice, which may have placental Lipkins, there may be associated my material. Cleaning 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 image ing is suspicious and the patient has risk factors, if you identify any of these image in factor in any emerging science that offer them to a center of excellence capable of handling such high risk patients next. Yeah, when this patient came to us, we started a dedicated evaluation. We checked the placental location, found a 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 racoons, noted my mutual pinning on abnormal vascular charity. All findings suspicious for placenta accrete 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 that the center we are looking not only for gross changes in the entire percentile bed. We also look for areas of course involvement. As in this scenario, as shown in the image on the left, there was an area where we did not visualize any visible myo Metreon, and we identified this as the area off worst involvement. Next, mhm in patients who have present a previa. We also perform a dedicated and a vaginal exam, as we did for this patient. This was very helpful in identifying bladder Ciro's all involvement. As seen on the ultrasound images, we do not see any normal appearing Miami atrium intervening between the bladder as well. A sleepless center along with abnormal vascular ality located in this interface. This is suggestive off full techniques. Miami It'll involvement, and we also evaluate for other findings of Parametric and service involvement. If you see findings such as these demonstrated on the slide, then when you do, it's just a Skopje you may identify these permanent vessels and during sista Skopje in the bladder wall, as shown in thesis Tosca Me image again. If the placenta has any bust, your component and for further planning with center stations to have an emery. The beauty of doing this that UCSF is that many of our operators are specialized in both ultrasound and Marie evaluation off the Santa Rita Spectrum disorder, allowing for a complementary role. And with that, I'm going thio. Ask Dr Porter to present the Emory portion off our evaluation. Thank you, thank you. So let's talk a little bit about the Marie. As Dr John mentioned, Emery should not be evaluated in isolation. It's always complimentary toe 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 Marie. But when do we then use them? Arise when let's say the ultrasound findings are equivocal or there is quite extensive disease and you know, especially this very mild invasive cases when you need to have a very careful stepwise approach, the surgical planning and so Emery can provide us a better picture of the overall appearance, the extent of disease, precise topography and how much of the U. S. And adjacent structures are involved. Is it superior versus inferior lower uterine segment? Is there potentially para mutual invasion or other areas of invasion, which can potentially alter surgical approach and require, for instance, your actual stenting or vascular clamping? And a lot of times also a preoperative embolization. Next, please. And the more 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 myo invasive or only myo 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 oh adherent on most of the cases of my invasive disease, the patient will proceed with a 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 image ING appearances annulled just and, of course, it's a key a modality to diagnose and follow those patients. And memory was noted to be not essential, but maybe useful. And why it was stated as such is because memory might not be available at all centers as well as it really needs expertise by the reader. So as what we have learned this, obviously if you the more expert, the readers, they improved the accuracy off these weeds s. 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 Emery as well as then careful correlation with surgical findings as well as some, um, um, image ING findings and pathology, one of the very important things which has applied to this topic of placenta treat a spectrum disorders 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 Emory findings, the descriptors and the reporting next life, please, and one of these, um, sort of thes guidelines which we came together with the European Society as well as the American Society of Abdominal Radiology, was actually spearheaded by Dr Jonah at UCSF. And during this study, we found out that there are seven signs really, which are quite helpful to are sensitive and specific for diagnosing placenta. Create a spectrum disorder, and this would be placental bulge. Dark inter placental lines, loss of retro presentable dark zone, my a meter of thinning bladder wall interruption, vocal exotic masses and abnormal rescue ization in placental bed. Next slide, please. So a lot of times the question comes up. What is the ideal timing of Emory? Ideally, it should really be before between 28 to 32 weeks. And if ultrasound findings are suspicious, then it's best to wait until 24 weeks before getting the memory. However, it all really depends on the clinical scenario. If, uh, if Gravity's directed me is considered, then obviously we can do the Emory at any time point. Whatever the clinical scenario determines, sometimes you also do them 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 Miami atrium at this time is the thinnest, and it's very difficult to determine whether is the truth thinning of the Maya Mottram or actually in based invasion off the placenta. Next, please. So this was our patient, Um, and we have these three planes satchel, criminal 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 memory as well as ultrasound. So it was one of those some more easy cases when you and it is recommended that when you see one side like you cannot really rely on one sign. 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 fears of invasion. We make sure there is no invasion into the bladder. Assess the areas of your visible junction and your orders. And then we presented this case 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 it is to determine whether it's my oh invasive versus myo adherent we have found with our experience, which is also been reported in literature, that the placental bulge sign is predictive of my own mutual invasion. And so most of the time, when you just have mild adherent disease, you would not have this bulging off the placenta, as was seen in this case with our patient. Next, I am leaving Ken, thank you very much for inviting me to participate. I'm one of the surgeons who is part of our maps team. And as Doctor Gonzales mentioned, 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 his direct me maybe performed R o B G Y N colleagues would potentially manage those cases in the case where there is a more invasive placenta concern for more hemorrhage bladder involvement. Potentially theology 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 from very nice images of memory image ing. 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 face mint 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 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 self saver availability, for example, eyes important in the coordination, uh, next slide, please. 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. The factors that we think really are patient centered are the matter of can we do a schedule cases 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. I see you re sources, but if you're patient is more stable and not as emergent or urgent. There's less time spent in the I C U, 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 I. C. U 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. We would plan ahead of time so that if a patient is an outpatient, sometimes were 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 were used for fetal lung maturity. We do use memory for our planning, and many places will use ultrasound. But as a surgeon, truly value the findings on the Emory 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. On if the patient is stable, we would anticipate, after delivery of the infant embolization of the uterus before proceeding with his direct me again. That is not a strong recommendation from the international consensus, but it is something I'll show you that we have done. Andi has helped improve our outcomes. S. O R huddle typically includes the O B team AM FM team nursing from both obstetrics as well as the main operating room. As our cases are done there as post from labor delivery, I r. And then, if needed, a guy knock on the delivery is scheduled between 34 to 36 weeks. It's like please. So in managing this patient who came to us at a relatively advanced gestation. She was already 35 weeks when she came to U. C s F. 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. 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 leth autumn e position and, if possible, place a three way Foley catheter. This allows us to backfill the bladder, and some of our providers of prefer to place your general stents. And some of our providers use the image ing 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 direct me, the hybrid room is called a hybrid because in the background you will also see our fluoroscope e equipment on. Do 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 Onda, from a safety standpoint, decreases the risk of patients having an acute bleed that we have to move patients for and also helps with sterility and infection control. It's like inter operatively. Once we get in, we talk about what do we see? And the clinical grading off a create a spectrum is done at the time of C section by a clinical evaluation so they raid. One is you are suspecting up Lucinda adherence, but the placenta separates so there's not really adherence of the placenta, and that goes in subsequent gradations to the level of adherence invasion into the wall of the uterus that we can see a bulge that the placenta has to be removed manually, or that we see the placenta invades all the way through a doctor. Gonzalez showed us with the cartoon of the percentages. The majority of the cases that we see that haven't invasive placenta are a the grade three level. We will see a bulge. We will anticipate that there is involvement of the placenta into the Miami tree. Um, 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. It's cycles. 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. The bulge is where the bladder flap is. You can see the vascular arat e on depending on what we know from the memory. This can be a placenta that sort of wrapping around, or we can see much more of the placenta actually growing into. In involving the utterance, Derosa At this point in the case. Once we have 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 helped 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 history Autumn E at the appropriate location, we have a little clip with the next slide 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 mark it s o. The incision 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 what we can see right on the surface of the university invasiveness off the center. Next life, please. And this is actually one of those ultrasound images off the inter operative ultrasound. When you could see this is a satchel view securely to the right of the screen. You could see normal Miami atrium and normal appearance of the placenta. And then gradually, you could see how the Miami atrium, where the arrows are, is really, uh, quite thin. And that's where the my oh invasive process off the placenta is starting. And sometimes we have a great windows. Sometimes 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 Syrian hysterectomy. Next life, please. Okay, History rata me on the uterus can sometimes be at the fund nous, 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 want to cut through it after the infant is delivered. Three uterus disclosed 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 his direct me. This was a retrospective review. So that indicate 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. Andi. When we looked at immobilizing 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 is not strongly recommended. And there are some adverse events that have been described in the literature, but in our experience has 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 aorta graham, and look to see where the profusion is of the placenta and the uterus, and then they'll 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 center next time. 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 patients left hand side. Um, they ended up taking about 2 to 3 hours to complete this embolization, Um, they used Romney picked for their contrast with Fluoroscope E, and they used a gel foam slurry to be able to individually m belies the vessels. This is a a a substance that last for a couple weeks. So it's not a coil. It's not something metal. It's not something permanent. Andi. All we need is to be able to decrease the blood flow so that when we're doing the hysterectomy, we have less vascular ity and can proceed with removing the uterus with decreased blood loss. Excite, please. So, after we've done the delivery of the infant, the embolization, we bring the patient back to proceed with this direct me. We'll use our retractor at this point, will 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. 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 this directly. Quickly. Um, my commentary about these invasive placentas 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 botany. 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 memory, um, that sometimes there can be significant thinning, and in our dissection, sometimes it is appropriate to create an intentional Sasana 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 packed below that patch of inherent bladder helps to facilitate our dissection. In our hysterectomy on the White Arrow, you can see where there is 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 para mutual dissection on drily trying toe not enter those placental cattle. Eden'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 on Ben 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 pathologist 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 faras specimen disruptions. It's like this a couple of other comments to make would be that if there is an occult identification of a possible a created case just helping the obstetrician, you 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 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 Khatemi. And if the placenta is really invasive, um, those patients can sometimes be transferred to tertiary care facilities. If you have a partial creator of partial separation, 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 P A s spectrum Mhm. So finally, this is the uterus of our case we're discussing today, Andi. After we remove the uterus, we give it back to our radiologists. 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 leg. 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, uh, to see how what we can see at this time and we have learned, or with our This is something that we've started thio do recently, and we've actually learned that you can see it quite well even though that now the uterus is decompressed in the amniotic fluid is out. But even as you can see on this slide, you could still see the areas of normal Miami tree, Um and then the bulge and invasion into the Miami team of the placenta interior, 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. Looks like And so we carefully looking all around we're trying to correlate with the findings What we suspected in three the in vivo ultrasound, of course. And also what? The areas which we thought of us, the thinnest on the Marie as well as the areas which potentially could have bean, uh, sort of the areas interrupted during the surgery surgery. And so it wasn't really a trooper creator, but it was a surgical interruption off the sea, Rosa. 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 off this team next life. No. 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 inthe e radiologic detection and, uh, surgical management for P A S T 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 on. Then, In terms of reporting the diagnosis, we have, ah, three tier system of placenta. Ah, create in create a 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 the clinicians so that a very detailed, um, correlation can be made for the purposes of quality improvement. And so, over the last couple years in our institution, we have developed some novel strategies to bring the pathologic evaluation of these specimens mawr 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. Uh, 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 FICO 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's several pieces of data that we feel are essential to be communicated from the clinical team to the pathologist First, this orientation of the specimen on understanding the radio lot, the radiologist impression of where the most extensive component of diseases we have found that it's important to understand exactly where the history Artemis was placed because, um, it may not always the, um eso clear cut interior early. And so we want to know exactly how to orient the specimen 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 Saros A. When the surgeon enters the abdomen, 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 PRA creates up Onda then also, Dr Chen mentioned, there are going to be situations in which on bloc resection of a portion of the bladder wall is necessary. This could be very difficult to recognize on visual inspection of the surface of the hysterectomy by the pathologist. And so having that piece of information a zwelling orientation to exactly where that small piece a 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, I think it's useful toe. Let the pathologist know if embolization was performed if coils were used. This is more of a safety issue, as we are on the second in the specimen. Next slide. Eso Step two is our specific protocol for, um dissecting the hysterectomy specimens. I think we're 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 has direct me or has directed me 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 to 3 centimeters in the axial plane on Ben. We lay the slices out as you see in the right hand side, uh, in an atomic order. And then we take a photograph of the slices, which is then part of the debriefing where the radiologist can then make a direct one on one correlation between these axial slices and the axial slices. From there, um, imaging next slice our next slide. This is the case 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. 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 fund ISS. And what you can see is that the placental disk has replaced the ball of the, uh, my Metreon, 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 and eso 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 Corlett, this is the glass slight image on the right of that area shows that indeed the SYRIZA is intact. There is a thin layer of Miami tree, um, albeit very thin. Um, and you can see that the chorionic villus placental this extend all the way up almost to that, um, so 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 up, create A and create a per create a three tier system. Um, in 2018 the Figo, um, clinical guidelines proposed a clinical grading scale, which is, um, or 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 classifications and reporting that were an attempt to harmonize the pathologic language with the clinical language proposed by 2018. Dr. Porter and I were part of this panel. Uh, next slide and, um, just toe show again. The grading scale. From the clinical standpoint that Dr Chen showed 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 Maya mutual 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 debriefing for this particular case. The actual pathologic report. Final diagnosis is placenta accrete a spectrum disorder Pathologic grade three A next slide talk. Great. Thank you, everybody. Eso I'm in conclusion with this case. We ended up delivered. She delivered on hospital day number two. So we mobilized 13 very quickly at 36 weeks. Um, she underwent the cesarean hysterectomy with bilateral self injected me had the i r. Embolization procedure. Um, in the setting of the placenta, create a spectrum disorder. The case was done under general anesthesia. Totally. Bl was only 1.6 leaders speaking to the advent of utilizing ir embolization. Um, she got two liters of fluid, three units of packed RBC s and 500 cc's of self saber. Um, great urine output during the case delivered a female neonatal at bars two and seven with the birth weight of £6.12 ounces. I'm postoperative day number zero. She went to the E u on postoperative 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 this case really speaks to the the excellent team effort, um, and end the outside referring physicians, recognizing the severity of the abnormal plastination. Thank you a 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 er 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 s o. 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 in patient as well. Um, you would call our access center and the phone numbers. Therefore, 153531611 That's the same phone number for any patient to be transported into or for any referral to be made or consulate 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 you are all there That takes you to the page. That gives you a referral form on instructions on how to fax that referral form with any prenatal records to our outpatient clinic and are high risk coordinator. So he Nevada, 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.