3D

and DOPPLER in
DIAGNOSIS of AIP

THE “A”CCRETA TEAM SURABAYA

Agussul, Rozi, Ninta, Gala, Erza, Aldi, Budi, Erna,
Bangun, Adit, HOS, Erry, Nadir, Marsi, Dikman, Hariadi
 OUTLINE
ULTRASOUND DIAGNOSIS
-  Grey scale
-  Color Doppler
-  3D color Doppler
-  VCT
 ULTRASONOGRAPHY
OPTIMIZATION EXAMINATION in MAP :
Ø  Sufficient bladder volume
Ø  Adjust focal zone(s) to the region of interest
Ø  On TAS, magnify placenta & scan in its entirety
Ø  On TVS, reduce sector width, but ensure
posterior bladder wall is in view
Ø  Add color Doppler in low velocity scales & low
filters
Ø  Save images &/or clips of placenta
Diagnostic approach: ULTRASONOGRAPHY

Sensitivity 91%; Specificity 97% D’Antonio, 2013

 MARKERS of PLACENTA ACCRETA
Ø  Multiple vascular lacunae
Ø  Loss of the normal hypoechoic retroplac
zone
Ø  Abnormal uterine serosa-bladder
interface
Ø  Thinning retroplacental myometrium
Ø  Bulging of LUS
Ø  Increased plac vascularity on color
Doppler
Berkley & Abuhamad, in Silver Placental Accreta Syndrome, 2017
 Loss of Retroplacental Clear Zone

2D N
Ultrasound
Colins, et al, 2016

Abnormal Placenta Lacunae Myometrial Thickness

N
N

N
 Placental Buldge

2D
Ultrasound
Colins, et al, 2016

Bladder Wall Interuption Focal Exophytic Mass

N N
Placenta Accreta
Index (PAI)

ACCURACY : 72% RSDS, 2017

 COLOR DOPPLER
Diffuse or focal lacunar flow pattern
Vascular lakes with :
- High velocity turbulent flow (PSV>15cm/s)
- Low resistance waveform
Hypervascularity uterine-bladder interface
(bridging vessels)
Marked dilated vessels over peripheral
subplac region
Chou, 2000; Comstock,2005
 Uterovesical hypervascular
Bridging vessel Lacunar feeding vessel

Subplacental hypervascular

Doppler
Ultrasound
 Vascular lakes with :
- High velocity turbulent flow (PSV>15cm/s)
- Low reistence waveform
 Vascular lakes with :
- High velocity turbulent flow (PSV>15cm/s)
- Low reistence waveform
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LACUNAE : Gray Scale vs Color Doppler
Focal Plasenta Inkreta (35 wks)
Hipervascular uteroplacenta :
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Color Flow Doppler vs Power Doppler *
*

Color Flow Doppler Power Doppler

 3D POWER DOPPLER
2 VIEWS (maternal pelvis) :
-  SAGITAL AXIS (lateral view)
-  Intra-plac vasculature
-  Serosa-bladder complex
-  90o ROTATION LATERAL VIEWS (basal view)
-  Serosa-bladder interface
PLACENTA ACCRETA :
Abundant neovasc ut-plac region
PLACENTA PREVIA :
not abundant
 PLACENTA PREVIA
BASAL VIEW :
Vessel in uterine serosa – bladder border
LATERAL VIEW :
cotyledon (fetal villous) circulation
intervillous (maternal) circulation
à parallel to each other, perpendicular
to decidual plate
Cotyledon & intervillous circ à separate
Cotyledon circ à longer & more apparent
 Cotyl circulation : longer & more apparent
than intervillous

PLACENTA PREVIA NON ACCRETA

BASAL VIEW : vessels in uterine serosa-bladder border :
discrete Shih, 2009
 PLACENTA ACCRETA
AT LEAST 1 OF THE FOLLOWING :
LATERAL VIEW :
- intraplacental hypervascularization
- inseparable cotyl & intervillous circ
- tortuous vasc with “chaotic branching”
à vessel : irregular, tortuous, varrying
calibres, complex vessels ~ malignancies
BASAL VIEW :
- numerous coherent vessels In serosa-
bladder interface
 PLACENTA ACCRETA

LATERAL VIEW : extreme hypervasc, chaotic branching. Cotyl & intervillous circ : cannot
discriminated
BASAL VESSEL : numerous dilated & coherent vessels à huge vasc complex in plac base
Shih, 2009
 PLACENTA ACCRETA

35 wks : intervillous circ & abnormal lacunae merged à large

aneurysm
BASAL VIEW : numerous dilated vessels fused & extended to the
whole plac base
Shih, 2009
Durante op : numerous engorged & coherent vessel
over the uterine serosa à placenta percreta
 BLEEDING OF PLACENTA ACCRETA SPECTRUM

Accreta: placenta attach to

myometrium
Increta: placenta penetrate
to myometrium
Percreta: placenta invade to
the serosa of uterine, or
surrounding organs
(Resnik & Silver, 2018)

This classification is relative to the surgical procedure

diificulities (ex: accreta with massive bleeding, or percreta
but focal invasion) (Jaraquemada, 2012).
 Classification : Anatomi – pelvic vascularization

From angiographic examination :

Interconnecting between pelvic
vascularization

S1 Upper pedicle Uterine Artery 100% from Iliac Internal Artery

Middle pedicle Cervical Artery 67% from Uterine Artery
23% from Vaginal artery
10% lower Vesical artery
S2A Lower pedicle Upper vaginal artery
à 18% from Uterine Artery
Middle vaginal artery
à 11% from Iliac Internal Artery
Lower vaginal artery
S2B à 71% from Pudendal Internal 75% as as descending branch
artery 25% as ascending branch
Sectional diameter Uterine artery : 1,81 mm
Internal illiac artery ligation à does not result in complete blockage of blood supply
Main vaginal artery : 1,88 mm
Palacios-Jaraquemada JM, et al. A Comprehensive Textbook of Postpartum Haemorrhage 2012, 2nd
edition. Dumfriesshire, Scotland: Sapiens Publishing; p.19.
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 Volume CT Rendering 3D Doppler
Some cases AIP had massive collateral
vascularity
Usually vascularity involvement only can
seen during surgery and sometime it can
make complication like massive blood loss
The Aim for this study : to predict the
uteroplacental vascularity
Volume CT Rendering 3D Doppler
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 PLACENTAL MAPPING *
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Placental Topography
Placental diffuse or focal S1/S2 uterine segment
Invasion

Placental invasion to other organ Vascular Mapping

THANK
YOU

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