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Ultraschall Med 2022; 43(06): e118-e124
DOI: 10.1055/a-1309-1665
Original Article

Evaluation of the Tramline Sign in the Prediction of Placenta Accreta Spectrum and Perioperative Outcomes in Anterior Placenta Previa

Bewertung des Tramline-Zeichens zur Vorhersage einer Placenta-accreta-spectrum-Störung und des perioperativen Outcomes bei anteriorer Placenta praevia
Andrea Dall’Asta 
1   Queen Charlottes and Chelsea Hospital, Imperial College Hleathcare NHS Trust, London, United Kingdom
2   Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, United Kingdom
3   Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
,
Francesco Forlani
4   Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
,
Harsha Shah
1   Queen Charlottes and Chelsea Hospital, Imperial College Hleathcare NHS Trust, London, United Kingdom
2   Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, United Kingdom
,
Gowrishankar Paramasivam
1   Queen Charlottes and Chelsea Hospital, Imperial College Hleathcare NHS Trust, London, United Kingdom
,
Joseph Yazbek
5   Department of Gynaecologic Oncology, Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
,
Tom Bourne
2   Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, United Kingdom
6   Department of Development and Regeneration, KU Leuven, Leuven, Belgium
,
Giuseppe Calì
4   Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
7   Department of Obstetrics and Gynaecology, Azienda Ospedaliera Villa Sofia Cervello, Palermo, Italy
,
Christoph Lees 
1   Queen Charlottes and Chelsea Hospital, Imperial College Hleathcare NHS Trust, London, United Kingdom
2   Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, United Kingdom
6   Department of Development and Regeneration, KU Leuven, Leuven, Belgium
› Author AffiliationsSupported by: CCL is supported by the UK National Institute for Health Research Biomedical Research Centre (BRC) based at Imperial College Healthcare National Health Service Trust and Imperial College
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Abstract

Purpose To evaluate perioperative outcomes and the prognostic role of the tramline sign in a cohort of women with anterior placenta previa.

Materials and Methods Retrospective analysis of 3D ultrasound volumes from women with anterior placenta previa who underwent ultrasound examination beyond 32 weeks. 3D and 3D color volumes were obtained from a sagittal section of the uterus bisecting a partially full bladder and processed using Crystal Vue and Crystal Vue Flow rendering to look for the “tramline sign”. “Partial obliteration” was defined as a loss of some or part of the uterine-serosal interface and “full obliteration” as when both interfaces were interrupted. Postnatal ascertainment of placenta accreta spectrum (PAS) was confirmed by findings recorded intraoperatively or on a pathology report.

Results 65 cases were included. The tramline sign was “partially” (17) or “fully” (19) obliterated in 36 cases (55.4 %), and present in 29 (44.6 %). Obliteration was associated with earlier gestational age at delivery (35 + 1 (26 + 3–38 + 3) vs. 36 + 4 (25 + 3–38 + 0) weeks, p = 0.005), greater estimated blood loss (800 (400–11 000) vs. 600 (300–2100) mls, p = 0.003), longer operative time (155 (60–240) vs. 54 (25–80) minutes, p < 0.001), higher rate of hysterectomy (97.2 % vs. 0.0 %, p < 0.001), longer postoperative admission (7 (3–19) vs. 3 (1–5) days, p < 0.001) and a 100 % rate of postnatal diagnosis of PAS. The finding of an “obliterated” tramline sign identified all women that required hysterectomy and all cases of PAS.

Conclusion A “partially or fully obliterated” tramline sign is strongly associated with indicators of operative complexity, the postnatal confirmation of PAS, and the need for peripartum hysterectomy.

Zusammenfassung

Ziel Beurteilung der perioperativen Outcomes und der prognostischen Rolle des sogenannten Tramline-Zeichens in einer Kohorte von Frauen mit anteriorer Placenta praevia.

Material und Methoden Retrospektive Analyse der 3D-Ultraschallvolumina von Frauen mit anteriorer Placenta praevia, bei denen nach der 32. Woche eine Ultraschalluntersuchung durchgeführt wurde. 3D- und 3D-Farbvolumina wurden aus einem sagittalen Abschnitt des Uterus gewonnen, der die teilweise gefüllte Blase halbierte und mit Crystal Vue und Crystal Vue FlowTM Rendering bearbeitet wurde, um nach dem „Tramline-Zeichen“ zu suchen. Eine „partielle Auslöschung“ wurde definiert als ein Verlust einiger Stellen oder eines Teils der Uterus-Serosa-Grenzfläche, und „vollständige Auslöschung“, wenn beide Grenzflächen unterbrochen waren. Die postnatale Diagnose einer Placenta-accreta-spectrum (PAS)-Störung wurde durch Befunde bestätigt, die intraoperativ oder in einem Pathologiebericht festgehalten wurden.

Ergebnisse 65 Fälle wurden eingeschlossen. Das Tramline-Zeichen war in 36 Fällen (55,4 %) „teilweise“ (17) oder „vollständig“ (19) ausgelöscht und in 29 (44,6 %) vorhanden. Die Auslöschung war assoziiert mit einer früheren Schwangerschaftswoche bei Entbindung (35 + 1 (26 + 3–38 + 3) vs. 36 + 4 (25 + 3–38 + 0); p = 0,005), einem höheren geschätzten Blutverlust (800 (400–11 000) vs. 600 (300–2100) ml; p = 0,003), einer längeren Operationszeit (155 (60–240) vs. 54 (25–80) Minuten; p < 0,001), einer höheren Hysterektomierate (97,2 % vs. 0,0 %; p < 0,001), einem längeren postoperativen Aufenthalt (7 (3–19) vs. 3 (1–5) Tage; p < 0,001) und einer 100 %igen Rate der postnatalen Diagnose der PAS. Der Befund eines „ausgelöschten“ Tramline-Zeichens identifizierte alle Frauen, bei denen eine Hysterektomie erforderlich war, sowie alle Fälle von PAS.

Schlussfolgerung Ein „teilweise oder vollständig ausgelöschtes“ Tramline-Zeichen ist stark mit Indikatoren für die operative Komplexität, mit der postnatalen Diagnose einer PAS und der Notwendigkeit einer peripartalen Hysterektomie assoziiert.

Key words

abnormally invasive placenta - morbidly adherent placenta - 3D ultrasound - Crystal Vue - cesarean hysterectomy

Supplement



Publication History

Received: 07 July 2020

Accepted: 23 October 2020

Article published online:
08 February 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 D’Antonio F, Bhide A. Ultrasound in placental disorders. Best Pract Res Clin Obstet Gynaecol 2014; 28: 429-442
    CrossrefPubMedGoogle Scholar
  • 2 Cali G, Forlani F, Lees C. et al Prenatal ultrasound staging system for placenta accreta spectrum disorders. Ultrasound Obstet Gynecol 2019; DOI: 10.1002/uog.20246. . [Epub ahead of print]
    CrossrefPubMedGoogle Scholar
  • 3 Committee on Obstetric Practice. Committee opinion no. 529: placenta accreta. Obstet Gynecol 2012; 120: 207-211
    CrossrefPubMedGoogle Scholar
  • 4 Jauniaux E, Ayres-de-Campos D. FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO consensus guidelines on placenta accreta spectrum disorders: Introduction. Int J Gynaecol Obstet 2018; 140: 261-264
    CrossrefPubMedGoogle Scholar
  • 5 Downes KL, Hinkle SN, Sjaarda LA. et al Previous prelabor or intrapartum cesarean delivery and risk of placenta previa. Am J Obstet Gynecol 2015; 212: 669.e1–e6 . doi: 10.1016/j.ajog.2015.01.004. Epub 2015 Jan 7. PMID: 25576818; PMCID: PMC4416991
    CrossrefPubMedGoogle Scholar
  • 6 Tikkanen M, Paavonen J, Loukovaara M. et al. Antenatal diagnosis of placenta accreta leads to reduced blood loss. Acta Obstet Gynecol Scand 2011; 90: 1140-1146
    CrossrefPubMedGoogle Scholar
  • 7 Jauniaux E, Bunce C, Grønbeck L. et al. Prevalence and main outcomes of placenta accreta spectrum: a systematic review and meta-analysis. Am J Obstet Gynecol 2019; 221: 208-218
    CrossrefPubMedGoogle Scholar
  • 8 Jauniaux E, Collins SL, Jurkovic D. et al. Accreta placentation: a systematic review of prenatal ultrasound imaging and grading of villous invasiveness. Am J Obstet Gynecol 2016; 215: 712-721
    CrossrefPubMedGoogle Scholar
  • 9 Berkley EM, Abuhamad AZ. Prenatal diagnosis of placenta accreta: is sonography all we need?. J Ultrasound Med 2013; 32: 1345-1350
    CrossrefPubMedGoogle Scholar
  • 10 Collins SL, Alemdar B, van Beekhuizen HJ. et al. Evidence-based guidelines for the management of abnormally invasive placenta: recommendations from the International Society for Abnormally Invasive Placenta. Am J Obstet Gynecol 2019; 220: 511-526
    Google Scholar
  • 11 Cali G, Forlani F, Timor-Trisch I. et al. Diagnostic accuracy on ultrasound in detecting the depth of invasion in women at risk of abnormally invasive placenta: A prospective longitudinal study. Acta Obstet Gynecol Scand 2018; 97: 1219-1227
    Google Scholar
  • 12 D’Antonio F, Iacovella C, Bhide A. Prenatal identification of invasive placentation using ultrasound: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2013; 42: 509-517
    CrossrefPubMedGoogle Scholar
  • 13 Calì G, Forlani F. Three-dimensional sonographic virtual cystoscopy in a case of placenta percreta. Ultrasound Obstet Gynecol 2014; 43: 481-482
    CrossrefPubMedGoogle Scholar
  • 14 Shih JC, Palacios Jaraquemada JM, Su YN. et al. Role of three-dimensional power Doppler in the antenatal diagnosis of placenta accreta: comparison with gray-scale and color Doppler techniques. Ultrasound Obstet Gynecol 2009; 33: 193-203
    CrossrefPubMedGoogle Scholar
  • 15 Di Pasquo E, Ghi T, Calì G. et al Intracervical lakes as a sonographic marker of placenta accreta spectrum (PAS) in patients with previa and low-lying placenta. Ultrasound Obstet Gynecol 2020; 55: 460-466 . doi:10.1002/uog.21866. Epub 2020 Mar 6. PMID: 31503353
    CrossrefPubMedGoogle Scholar
  • 16 Dall’Asta A, Paramasivam G, Lees CC. Crystal Vue technique for imaging fetal spine and ribs. Ultrasound Obstet Gynecol 2016; 47: 383-384
    CrossrefPubMedGoogle Scholar
  • 17 Dall’Asta A, Paramasivam G, Lees CC. Qualitative evaluation of Crystal Vue rendering technology in assessment of fetal lip and palate. Ultrasound Obstet Gynecol 2017; 49: 549-552
    CrossrefPubMedGoogle Scholar
  • 18 Dall’Asta A, Shah H, Masini G. et al. Evaluation of tramline sign for prenatal diagnosis of abnormally invasive placenta using three-dimensional ultrasound and Crystal Vue rendering technology. Ultrasound Obstet Gynecol 2018; 52: 403-404
    CrossrefPubMedGoogle Scholar
  • 19 von Elm E, Altman DG, Egger M. et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. Int J Surg 2014; 12: 1495-1499
    CrossrefPubMedGoogle Scholar
  • 20 Jauniaux E, Collins S, Burton GJ. Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging. Am J Obstet Gynecol 2018; 218: 75-87
    CrossrefPubMedGoogle Scholar
  • 21 Melcer Y, Jauniaux E, Maymon S. et al. Impact of targeted scanning protocols on perinatal outcomes in pregnancies at risk of placenta accreta spectrum or vasa previa. Am J Obstet Gynecol 2018; 218: 443.e1-443.e8
    CrossrefPubMedGoogle Scholar
  • 22 Chou MM, Ho ES, Lee YH. Prenatal diagnosis of placenta previa accreta by transabdominal color Doppler ultrasound. Ultrasound Obstet Gynecol 2000; 15: 28-35
    CrossrefPubMedGoogle Scholar
  • 23 Wong HS, Cheung YK, Williams E. Antenatal ultrasound assessment of placental/myometrial involvement in morbidly adherent placenta. Aust N Z J Obstet Gynaecol 2012; 52: 67-72
    CrossrefPubMedGoogle Scholar
  • 24 Lax A, Prince MR, Mennitt KW. et al. The value of specific MRI features in the evaluation of suspected placental invasion. Magn Reson Imaging 2007; 25: 87-93
    CrossrefPubMedGoogle Scholar
  • 25 Royal College of Obstetricians and Gynecologists. Placenta praevia, placenta praevia accreta and vasa praevia: diagnosis and management. Green Top Guideline No 27. London: RCOG; 2011
    PubMedGoogle Scholar
  • 26 Silver RM, Branch DW. Placenta Accreta Spectrum. N Engl J Med 2018; 378: 1529-1536
    CrossrefPubMedGoogle Scholar
  • 27 Cal M, Ayres-de-Campos D, Jauniaux E. International survey of practices used in the diagnosis and management of placenta accreta spectrum disorders. Int J Gynaecol Obstet 2018; 140: 307-311
    CrossrefPubMedGoogle Scholar
  • 28 Jauniaux E, Bhide A, Kennedy A. et al. FIGO consensus guidelines on placenta accreta spectrum disorders: Prenatal diagnosis and screening. Int J Gynaecol Obstet 2018; 140: 274-280
    Google Scholar
  • 29 Weiniger CF, Einav S, Deutsch L. et al. Outcomes of prospectively-collected consecutive cases of antenatal-suspected placenta accreta. Int J Obstet Anesth 2013; 22: 273-279
    Google Scholar
  • 30 Rac MW, Dashe JS, Wells CE. et al. Ultrasound predictors of placental invasion: The Placenta Accreta Index. Am J Obstet Gynecol 2015; 212: 343.e341–e347
    PubMedGoogle Scholar