Placenta accreta spectrum (PAS) disorder poses significant risks to maternal health, given the complexities of screening, diagnosis, and management. To address these challenges, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) hosted a workshop on June 10–11, 2024, bringing together expert health care professionals, researchers, stakeholders, and patient advocates to identify knowledge gaps, with an overarching goal of informing future research and best practices for PAS. Key discussions revolved around the resources and infrastructure needed to advance screening, diagnosis, and clinical management of PAS, alongside ways to enhance collaboration across disciplines. Participants considered strategies to optimize existing research resources and explored opportunities to strengthen partnerships between the NICHD and key stakeholders to achieve mutual objectives. The workshop—attended by representatives from the Society for Maternal-Fetal Medicine, the American College of Obstetricians and Gynecologists, the Pan-American Society for the Placenta Accreta Spectrum, the National Accreta Foundation, the American Institute of Ultrasound in Medicine, and the Society of Gynecologic Oncology—aimed to foster consensus on essential PAS topics and to identify clinical and research priorities in all phases of PAS care. Additionally, a critical focus of the workshop was to enhance understanding of patient experiences and needs, recognizing that patient perspectives are essential for informing future research and improving outcomes.

Placenta accreta spectrum (PAS) disorder poses significant risks to maternal health, given the complexities of screening, diagnosis, and management. To address these challenges, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) hosted a workshop on June 10-11, 2024, bringing together expert health care professionals, researchers, stakeholders, and patient advocates to identify knowledge gaps, with an overarching goal of informing future research and best practices for PAS. Key discussions revolved around the resources and infrastructure needed to advance screening, diagnosis, and clinical management of PAS, alongside ways to enhance collaboration across disciplines. Participants considered strategies to optimize existing research resources and explored opportunities to strengthen partnerships between the NICHD and key stakeholders to achieve mutual objectives. The workshop-attended by representatives from the Society for Maternal-Fetal Medicine, the American College of Obstetricians and Gynecologists, the Pan-American Society for the Placenta Accreta Spectrum, the National Accreta Foundation, the American Institute of Ultrasound in Medicine, and the Society of Gynecologic Oncology-aimed to foster consensus on essential PAS topics and to identify clinical and research priorities in all phases of PAS care. Additionally, a critical focus of the workshop was to enhance understanding of patient experiences and needs, recognizing that patient perspectives are essential for informing future research and improving outcomes.

In patients with a prior cesarean delivery, some propose the risk of placenta accreta spectrum (PAS) is influenced by uterine factors such as cesarean scar defect size, remaining myometrial scar thickness, and defective decidua.1,2 We sought to evaluate PAS risk factors associated with prior surgical procedures and wound healing to optimize triage and counseling in pregnancies at the highest risk for PAS, specifically in patients with placenta previa and prior cesarean delivery.

Antenatal diagnosis of placenta accreta spectrum (PAS) improves maternal and neonatal outcomes by allowing for multidisciplinary planning and preparedness. Ultrasound is the primary imaging tool. Simplification and standardization of placental evaluation and reporting terminology allows improved communication and understanding between teams. Prior to 10 weeks of gestation, gestational sac position and least myometrial thickness surrounding the gestational sac help PAS diagnosis very early in pregnancy. Late first-, second-, and third-trimester evaluation includes comprehensive evaluation of the placenta, transabdominal and transvaginal with partially full maternal urinary bladder, and by color Doppler. Subsequently, the sonologist should indicate whether the evaluation was optimal or suboptimal; the level of suspicion as low, moderate, or high; and the extent as focal, global, or extending beyond the uterus. Other complementary imaging modalities such as 3D-power Doppler ultrasound, magnetic resonance imaging (MRI), and vascular topography mapping strive to improve antenatal placental evaluation but remain investigational at present. KEY POINTS: · Antenatal imaging, primarily using ultrasound with partially full maternal urinary bladder, is an essential means of evaluation of those at risk for PAS.. · Simplification and standardization of placental evaluation and reporting will allow improved communication between the multidisciplinary teams.. · Gestational sac location prior to 10 weeks of gestation and four markers after that (placental lacunae and echostructure, myometrial thinning, hypoechoic zone with or without bulging between placenta and myometrium, and increased flow on color Doppler)..

In Brief Hysterotomy extension at cesarean delivery is associated with uterine rupture in a subsequent pregnancy.

INTRODUCTION: To determine if prior Cesarean surgical characteristics that may compromise healing are associated with an increased risk of subsequent uterine rupture. METHODS: Retrospective case-control study matching women with uterine rupture to randomly selected controls (1:3) based on number of prior Cesarean deliveries (CD) and labor at the time of current CD. A multivariable logistic regression was performed focusing on hemorrhage and surgical procedures at prior CD, including all factors that differentiated the groups plus maternal age. RESULTS: 60 women with uterine rupture were matched to 180 controls. Case patients were more often white (P=.005) and had a higher rate of prior pelvic surgeries (P=.002). With regards to the prior CD, case patients had increased rates of classical incisions (P=.0006), labor (P=.001), and endometritis (P=.01). Case subjects had higher rates of prior postpartum hemorrhage (PPH) (9% vs. 3%, P=.04), and more prior hysterotomy extension (23% vs 6%, P=.0009), but did not differ in the rates of prior compression suture, arterial ligation, or uterine artery embolization (5% composite rate for each group). In multivariable regression analysis, prior uterine extension remained significantly associated with rupture (aOR 2.05, 95% CI 1.48–5.69), while PPH (aOR 1.31, 95% CI 0.15–4.20) was not. CONCLUSION: A prior history of hysterotomy extension is associated with an increased risk of subsequent uterine rupture. This may reflect vascular disruption or diminished integrity of the lower uterine segment. Prior surgical details should be reviewed in counseling patients in future pregnancies.

Preterm birth remains the leading cause of perinatal morbidity and mortality. Although the greatest risk factor for preterm birth is a history of prior preterm birth, a short cervical length (≤25 mm) before 24 weeks' gestational age is also associated with increased risk of spontaneous preterm delivery. As such, cervical length assessment has become of particular interest in predicting those patients at risk for preterm birth. Other clinical scenarios (eg, preterm labor, induction of labor, and active labor) may arise, in which assessment of the cervix may be of interest. Ultrasound is the mainstay imaging modality for assessing the gravid cervix, with transvaginal ultrasound recommended in patients at high risk for preterm birth or suspected preterm labor. Transperineal ultrasound is an alternate approach in those cases where transvaginal ultrasound in contraindicated. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Vaginal bleeding can occur throughout pregnancy with varied etiologies. Although history and physical examination can identify many etiologies, imaging, in particular ultrasound (US), is the backbone of current medical practice. US pregnant uterus transabdominal, US pregnant uterus transvaginal, and US duplex Doppler velocimetry are usually appropriate for the evaluation of women with painless vaginal bleeding, those with painful vaginal bleeding, and also for those with second or third trimester vaginal bleeding with suspicion of or known placenta previa, low-lying placenta, or vasa previa. US cervix transperineal may be appropriate for those with painless or painful vaginal bleeding but is usually not appropriate for second or third trimester vaginal bleeding with suspicion of or known placenta previa, low-lying placenta, or vasa previa. Because the outcome of pregnancies is unequivocally related to the specific etiology of the vaginal bleeding, knowledge of imaging results directly informs patient management to optimize the outcome for mother and fetus. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Placenta accreta spectrum disorder (PASD) is the current terminology recommended by the International Federation of Obstetrics and Gynecology (FIGO) and should replace terms such as abnormally adherent/invasive placenta or morbidly adherent placenta. PASD refers to a variety of potential clinical complications, which may result from abnormal placental implantation. More specifically, placenta accreta refers to a defect in the decidua basalis where the chorionic villi adhere directly to the myometrium with trophoblastic invasion. Accurate antenatal diagnosis is needed to plan for an appropriate delivery strategy at an experienced center in order to reduce maternal and potential fetal morbidity and mortality. Obtaining radiologic and clinical data when PASD is first suspected can play a significant role in formulating an appropriate delivery strategy. Depending on the clinical risk factors and initial imaging findings, transabdominal ultrasound of the pregnant uterus with duplex Doppler and transvaginal ultrasound as needed are the most appropriate imaging procedures. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Fetal growth restriction, or an estimated fetal weight of less than the 10th percentile, is associated with adverse perinatal outcome. Optimizing management for obtaining the most favorable outcome for mother and fetus is largely based on detailed ultrasound findings. Identifying and performing those ultrasound procedures that are most associated with adverse outcome is necessary for proper patient management. Transabdominal ultrasound is the mainstay of initial management and assessment of fetal growth. For those fetuses that are identified as small for gestational age, assessment of fetal well-being with biophysical profile and Doppler velocimetry provide vital information for differentiating those fetuses that may be compromised and may require delivery and those that are well compensated. Delivery of the pregnancy is primarily based upon the gestational age of the pregnancy and the ultrasound findings. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

There are approximately 9.1 pelvic surgeries performed for every histologically confirmed adnexal malignancy in the United States, compared to 2.3 surgeries per malignancy (in oncology centers) and 5.9 surgeries per malignancy (in other centers) in Europe. An important prognostic factor in the long-term survival in patients with ovarian malignancy is the initial management by a gynecological oncologist. With high accuracy of imaging for adnexal mass characterization and consequent appropriate triage to subspecialty referral, the better use of gynecologic oncology can improve treatment outcomes. Ultrasound, including transabdominal, transvaginal, and duplex ultrasound, combined with MRI with contrast can diagnose adnexal masses as benign with specific features (ie, functional masses, dermoid, endometrioma, fibroma, pedunculated fibroid, hydrosalpinx, peritoneal inclusion cyst, Tarlov cyst), malignant, or indeterminate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Objectives The influence of placental morphologic characteristics on pregnancy outcomes is poorly understood. Our objective was to evaluate the relationship of the distance of the placental cord insertion from the placental edge (PCI-D) with associated placental characteristics as well as birth outcomes. Methods We performed a retrospective cohort study of nulliparous women with singleton gestations undergoing obstetric ultrasound examinations between 14 and 23 weeks' gestation with a cervical length of greater than 3.0 cm who delivered between 24 and 42 weeks. A 3-dimensional volume of the placenta was evaluated. The PCI-D was obtained with Virtual Organ computer-aided analysis software (GE Healthcare, Milwaukee, WI). Generalized linear regression and generalized additive models were fitted to explore the associations between the PCI-D in relation to demographic and clinical characteristics. Results A total of 216 pregnancies were included in the analysis. The PCI-D did not correlate with maternal age, gestational age at delivery, mode of delivery, or 5-minute Apgar score. Although not statistically significant, the birth weight z score (P = .09) was associated with a longer PCI-D, and gravidity was associated with a shorter PCI-D (P = .10). A low-lying placenta or placenta previa was associated with a longer PCI-D (P = .03). Conclusions The PCI-D is associated with a low placental position in the second trimester. These data are helpful for understanding placental development. The PCI-D may be associated with pregnancy-related factors such as birth weight and multigravidity. More research is required to evaluate the effects of pregnancy-related factors on the PCI-D and the effect of the PCI-D on pregnancy outcomes.

for and of The of of any and of circumstances in an individual

In the management of epithelial ovarian cancers, imaging is used for cancer detection and staging, both before and after initial treatment. The decision of whether to pursue initial cytoreductive surgery for ovarian cancer depends in part on accurate staging. Contrast-enhanced CT of the abdomen and pelvis (and chest where indicated) is the current imaging modality of choice for the initial staging evaluation of ovarian cancer. Fluorine-18-2-fluoro-2-deoxy-d-glucose PET/CT and MRI may be appropriate for problem-solving purposes, particularly when lesions are present on CT but considered indeterminate. In patients who achieve remission, clinical suspicion for relapse after treatment prompts imaging evaluation for recurrence. Contrast-enhanced CT is the modality of choice to assess the extent of recurrent disease, and fluorine-18-2-fluoro-2-deoxy-d-glucose PET/CT is also usually appropriate, as small metastatic foci may be identified. If imaging or clinical examination confirms a recurrence, the extent of disease and timing of disease recurrence then determines the choice of treatments, including surgery, chemotherapy, and radiation therapy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Procedure Appropriateness Category Relative Radiation Level CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢ CT chest abdomen pelvis with IV contrast Usually Appropriate ☢☢☢☢ FDG-PET/CT skull base to mid-thigh May Be Appropriate ☢☢☢☢ MRI abdomen and pelvis without and with IV contrast May Be Appropriate O CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢ CT chest abdomen pelvis without IV contrast May Be Appropriate ☢☢☢☢ MRI abdomen and pelvis without IV contrast May Be Appropriate O CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢ CT chest abdomen pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢ US abdomen and pelvis transabdominal Usually Not Appropriate O US pelvis transvaginal Usually Not Appropriate O X-ray contrast enema Usually Not Appropriate ☢☢☢ Radiography intravenous urography Usually Not Appropriate ☢☢☢

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.

Vaginal bleeding is not uncommon in the first trimester of pregnancy. The majority of such patients will have a normal intrauterine pregnancy (IUP), a nonviable IUP, or an ectopic pregnancy. Ultrasound (US) is the primary imaging modality in evaluation of these patients. US, along with clinical observations and serum human chorionic gonadotropin levels, can usually distinguish these causes. Although it is important to diagnose ectopic pregnancies and nonviable IUPs, one should also guard against injury to normal pregnancies due to inappropriate treatment with methotrexate or surgical intervention. Less common causes of first trimester vaginal bleeding include gestational trophoblastic disease and arteriovenous malformations. Pulsed methods of Doppler US should generally be avoided in the first trimester when there is a normal, or a potentially normal, IUP. Once a normal IUP has been excluded, Doppler US may be useful when other diagnoses such as retained products of conception or arteriovenous malformations are suspected. MRI may occasionally be helpful as a problem-solving tool. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The influence of placental morphology on pregnancy outcomes is poorly understood. The objective of this study was to evaluate the relationship of the distance of the placental cord insertion from the placental edge with other placental characteristics as well as birth outcomes. We performed a retrospective cohort study of nulliparous women undergoing obstetric ultrasound between 14 and 23 weeks with a cervical length greater than 3.0 cm who delivered between 24 and 42 weeks gestation. A 3D volume of the placenta was evaluated. The distance from the placental cord insertion to the placental edge (PCI-D) was obtained using VOCAL software. Demographic, ultrasound and pregnancy outcome information were abstracted. Generalised linear regression and generalised additive models were fitted to explore the associations between PCI-D in relation to demographic and clinical characteristics. 216 pregnancies were included in the analysis. PCI-D did not correlate with maternal age, gestational age at delivery, mode of delivery or 5-minute Apgar score. While not statistically significant, both multigravidity and birth weight Z-score were associated with shorter PCI-D (p=0.08, adjusted model). Low-lying placenta or placenta previa was associated with greater PCI-D (p=0.03). The distance of the placental cord insertion from the placental edge is associated with placental position. This data is vital for understanding placental development. PCI-D may be associated with pregnancy factors such as birthweight and multigravidity in nulliparous women. More research is needed to evaluate the effects of pregnancy-related factors on PCI-D and the effect of PCI-D on pregnancy outcomes. EP17.04: Table 1. Association of PCI-D with maternal characteristics and delivery outcomes