Ilan E. Timor-Tritsch1, Francesco D’Antonio2, Giuseppe Calỉ3, Josė Palacios-Jaraquemada4, Jessica Meyer1 Ana Monteagudo5

Early first trimester transvaginal ultrasound is feasible and indicated in pregnancies after a

previous cesarean delivery: should it be mandated?

1. NYU School of Medicine, Department of Obstetrics and Gynecology, New York, NY,

2. Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway; Department of Obstetrics and Gynaecology,

3. Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy.

4. Centre for Medical Education and Clinical Research (CEMIC), University Hospital, Buenos Aires, Argentina.

5. Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY

Objectives:

•To convince Ob/Gyn providers and our professional organizations by demonstrating the benefits of early 5-7 (?8) weeks US screening of pregnant patients with a history of previous cesarean delivery (CD).

•To demonstate that US recognizable markers of CSP are present in the 1st trimester and that if they go on may become 2nd and 3rd trimester cases of PAS

•To add screening for CSP to the already successful 1st

trimester screening practicesCali G, Forlani F, Foti F, et al. Diagnostic accuracy of first-trimester ultrasound in detecting abnormally invasive placenta in high-risk women with placenta previa. Ultrasound Obstet Gynecol 2018;52:258-64

Methods:

•By searching the literature we identified over 60 published articles describing devastating complications following misdiagnosed and/or undiagnosed low implanted placentae and their chorionic sac developing into scar pregnancies and subsequently second and third trimester PAS.

• In addition, we detected over 10 publications attesting to the successful direct or indirect identification of CSP as a precursor and surrogate marker for invasive placentation preventing significant complications.

Why is it important to think about, recognize and screen

for early CSP?

Reason #1

• Failure to identify a CSP (+/- PAS) can have catastrophic consequences later in pregnancy.

•Missed diagnoses of CSP may lead to complications

•Relevant articles from 1978-2016 shown in the Table

*Timor‐Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol 2012; 207: 14– 29.

**Li Y, Xiang Y, Wan X, Feng F, Ren T. Clinical study on 39 cases with caesarean scar pregnancy with sonographic mass. ZhonghuaFu Chan Ke Za Zhi 2014; 49: 10– 13.

Summary of published literature on undiagnosed and diagnosed Cesarean scar pregnancies (CSPs) with significant complications

D&C!!

BLEEDING

Laparotomy

TAH

P

A

S

Corollary to Reason #1

• Even appropriate treatments are not complication free

The issue of retained products of conception

• Treatments that do not remove the gestational sac, the placenta & the embryo/fetus create RPOCs with similar clinical features

• The result: slower drop of hCG & regression of the products, spotting, slight bleeding, need for blood tests and US

• TRUE!!: patient support, avoiding GA D&C are rewards

Case reports with CSP with EMV (AVM/pseudoaneurysm) treated with UAE

. Mou Y, Xu Y Hu Y, Jiang T

Giant uterine artery pseudoaneurysm after a missed miscarriage termination in a cesarean scar pregnancy. BMC Womens Health. 2014 Jul 29;14:89

D&C

MTX

EMV/AVM

U A E

Minimally invasive treatments of CSPs with significant complications

EMV/AVM

U

A

E

MedICal

Balloon

MTX

Reason #2•Advances in imaging techniques, medical genetics and

clinical biology enabled 1st trimester screening for various adverse outcomes, such as:

•Aneuploidy (Stoll K, Norton ME. Optimizing use of existing prenatal genetic tests: Screening and

diagnostic testing for aneuploidy. Semin Perinatol 2018; 42: 296– 302. & others)

• Pre‐eclampsia (Akolekar R, Syngelaki A, Sarquis R, Zvanca M, Nicolaides KH. Prediction of early,

intermediate and late pre‐eclampsia from maternal factors, biophysical and biochemical markers at 11–

13 weeks. Prenat Diagn 2011; 31: 66– 74. & others)

•Preterm birth ( Society for Maternal‐Fetal Medicine (SMFM). McIntosh J, Feltovich H, Berghella V,

Manuck T. The role of routine cervical length screening in selected high‐ and low‐risk women for preterm birth prevention. Am J Obstet Gynecol 2016; 215: B2– 7. & others)

• Early detection of anomalies by US (Bronstein M; and others)

Reason #3Of why is it important to think about, recognize and screen for early CSP?

•Because we are confident that CSP can be recognized and diagnosed by its US markers and understand that CSP is a 1st trimester PAS, which in turn can lead to early interventions

The above arguments are based upon the fact that there are recognizable US markers of CSP/PAS in the 1st trimester at 5-8 weeks:

Low, anterior sac, placenta previa, lacunae, bladder line distortion

Calì G, Timor-Tritsch IE, Palacios-Jaraquemada J, Monteaugudo A, Forlani F, Minneci , Foti F1, Buca D, Familiari A, Scambia G, Liberati M4

D'Antonio F Changes in US indicators of abnormally invasive placenta during pregnancy. Int J Gynaecol Obstet. 2018 140(3):319-325.

The main and most common US sign associated with PAS in the early 1st

trimester of pregnancy (6-9weeks) are present in 100% of PAS

B

B

X

Retroverted uterusLow, anterior sac Lacunae

Altered bladder line No clear space Increased vascularity

Results:•Our study clearly pointed towards the fact that CD

significantly impacts future pregnancies, including an increased risk for both short- and long-term complications, such as uterine rupture, intra-abdominal hemorrhage, invasive placenta, gravid hysterectomy, and even maternal mortality.

• In addition, our results indicate that early, accurate clinical and sonographic evaluation of a 1st trimester pregnancy after a previous CD can lead to evidence-based counseling, and if needed, pathology-indicated, individualized pregnancy management

Conclusions:•US is effective detecting 1st trimester CSP and presumed PAS by the its proven and published early 1st trimester markers.

•CSP can be used as an early surrogate marker for invasive placentation

•An early screening scan, potentially combined with other proven 1st trimester markers of chromosomal anomalies, preeclampsia and others should be seriously considered and supported by our professional governing bodies

Conclusion• We argue: if the said above is correct……..then why shouldn’t an

early screening method be used for CSP and PAS, conditions that are potentially life threatening?

• Given the grave potential for morbidity and even mortality in these patients, early 1st trimester (i.e. 5 to 7 weeks) sonogram of pregnant patients with history of cesarean is an addition to routine prenatal care that can (and should) be easily implemented (if not mandated).

• It can be added to the other established 1st trimester screenings

• Such a shift in the timing of initiating care is prudent and clinically advantageous not only for maximizing the management options available to patients, but also for optimizing their outcomes.

Early recognition of CSP starts with Patient and Physician education:

When discharging patients from the hospital after a C/D make sure to tell

her to present to the Ob/Gyn the day after the first positive pregnancy test for an US scan between 5-7 weeks.

IT SHOULD BECOME MANDATORY!?