University of Santo Tomas

Department of Obstetrics and Gynecology

Section of Obstetrics

Journal Report:
Bleeding in the 2nd Half of
Pregnancy
Clinical Clerk Vicente I. Martires III
February 21, 2019
OBJECTIVE:
• To analyze the ability of gray-scale 2D Ultrasound VS. 3D Power
Doppler vascular and flow indices to objectively predict Morbidly
Adherent Placenta (MAP).
 Introduction
• Morbidly Adherent Placenta (MAP)
• Used to describe abnormal implantation of the placental villi into the uterine
wall
• Further classified as accreta, increta, or perceta.
• Risk factors include: Hx of Cesarian Delivery, Hx of Placenta Previa
• Can result in major maternal morbidities (life threatening hemorrhage, intra-
operative organ injuries)
• Important to detect antenatally with high reliability to allow proper
preparation for delivery
Diagnostics: MAP by 2-D Ultrasound
• Diagnosis of MAP has traditionally been suspected on 2D Ultrasound
• Presence of hypoechoic areas in the body of the placenta
(Placental Lacunae)
• Loss of the normal hypoechoic myometrium adjacent to the base
of the placenta (Loss of
Sonolucency)
• Absent or disrupted hyperechoic line separating the uterus from
the urinary bladder (Abnormal Uterine
Serosae Bladder Line)
Diagnostics: MAP by Other Methods
• Color Doppler
• Subjective
• Published descriptions of what the supposed findings are
predictive of MAP, are not specific
• Color Doppler of vascular patterns in the placenta and MRI may
also be helpful in the diagnosis.

• Diagnosis of MAP remains as a subjective diagnosis per the

interpretation of the observer
 CLINICAL QUESTION
• Can 3-dimensional power Doppler indices improve the prenatal
diagnosis of a potentially morbidly adherent placenta in patients with
placenta previa?
P: Women between 28 and 32 gestational weeks with
known placenta previa
I : 3-dimensional power Doppler indices
O: vascular index accurately predicts the morbidly
adherent placenta in patients with placenta previa.
M: Prospective Cohort
 STUDY DESIGN
• Prospective Cohort
• University of Texas Health Science Center at Houston, TX
• Between October 2014 and December 2015
 METHODOLOGY
Inclusion Criteria
• Women who were referred to the ultrasound for the evaluation of placenta
previa and morbidly adherent placenta between 28 weeks and 32 weeks

Exclusion Criteria

• Fetal Anomalies
• Multiple Gestations
2-D Ultrasound Diagnostic Criteria
Uniform diagnostic criteria were to make the diagnosis of suspected
MAP

1. Placental lacunae
2. Loss of sonolucency
3. Abnormal uterine serosabladder interface.
3D Power Doppler
GE Voluson E8 RAB4-8 transducer probe with the following standardized settings:
- Smooth, 4/5
- FRQ, low
- Quality, high
- Density, 6
- Enhance, 16
- Balance, GO150
- Filter, 2
- Pulse repetition frequency, 0.9 kHz
- Power, 100%
- Gain, e5.4
- Wall motion filter, low2.
3D Power Doppler
• Vascularization Index (VI)
• Flow Index (FI)
• Vascular Flow Index (VFI)

• Data were blinded to the maternal-fetal medicine specialist

interpreting the 2D Ultrasound findings
• 2D findings were also blinded to the provider
 VALIDITY
• Was there an independent comparison with a reference standard? YES
• Was the reference standard done regardless of the result of the diagnostic
test being evaluated? YES
• Did the patient sample include an appropriate spectrum of patients to
whom the test will be used? YES
• The demographs of the the study fits those of our patients and representative
population
RESULTS
 Applicability
• Will the reproducibility of the test and its interpretation be
satisfactory in my setting?
• Availability
• Cost effectiveness
• Are the result applicable to my patient?
• Yes, it would highly be applicable to our patients with placenta previa
• Will the result change my management?
• No but the result will allow proper preparation for delivery in an appropriate unit, equipped to
handle potentially complicated surgery
 CONCLUSION
• The study found a significant increase of VI in MAP cases.
• Strongly suggests that the use of the 3D Doppler VI can accurately
predict the diagnosis of MAP which notes increased vascularity