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Percreta with Vascular Recruitment

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This is an MRI of the abdomen and pelvis in

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a patient presenting at 28 weeks gestation

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referred from the maternal-fetal medicine

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clinic after abnormal obstetric ultrasound

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with concern for placenta accreta spectrum.

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Again, we've placed our steady-state free

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precession images on the left and our

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turbo spin echo images on the right.

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As we scroll inferiorly, we begin to

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see the gravid uterus come into view.

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We can see T2 heterogeneous myometrium

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in its entirety surrounding the gestational sac.

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As we scroll inferiorly, the

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placenta begins to come into view.

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We can see direct abutment of the myometrium

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by the placenta here with a relatively normal

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overlying appearance of the myometrium.

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As we scroll more inferiorly, we can see that

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the bulk of the placenta is low-lying and is

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along the left lateral aspect of the uterus.

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We also begin to see classic features

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of placenta accreta spectrum.

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Large placental bands and engorged abnormal

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vasculature within the placenta at this level.

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When we try to follow the myometrium

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overlying the placenta, we can see

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that it's relatively easy to identify

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the muscular layer more superiorly.

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But as we scroll inferiorly, we begin to lose

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the uterine myometrium overlying the placenta.

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And as we near the level of the cervix and

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upper vagina, there's a mass of placental

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tissue with little to no intervening myometrium.

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Particularly inferiorly within the pelvis, as we

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have this mass of placental tissue in the region

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of the upper vagina, I'd like to point out the

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number of asymmetric and engorged blood vessels

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in the left hemipelvis that are

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extending toward the placental mass.

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We'll revisit this in a moment.

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These are coronal T2-weighted

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images of the same patient.

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Again, we can see a low-lying,

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left-sided placenta with features

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of placenta accreta spectrum.

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The placenta has an abnormal, rounded contour.

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It's thickened in multiple

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locations without smooth tapering.

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We see large aberrant placental vessels,

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placental heterogeneity, and placental bands.

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In addition to marked thinning and

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absence of the myometrium inferiorly.

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Again, within the left hemipelvis, we can

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see multiple dilated blood vessels, which

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course toward the cervix and upper vagina.

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These are the sagittal T2-weighted images

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of the abdomen and pelvis for this patient.

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We can see that like many of the patients

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with placenta accreta spectrum, this patient

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also has complete placenta previa, with the

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placenta covering the internal os of the cervix.

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The placental bands

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and aberrant placental vessels are evident

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on the turbo spin echo sequences for this

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patient and are much more apparent than they

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are on the steady state precession images.

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An important distinguishing feature when

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you're trying to determine if something

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is a placental band rather than a vessel,

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is if it's dark on both sequences, you

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can confirm that it's a placental band

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rather than an engorged blood vessel.

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If it's dark on the turbo spin

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echo sequences only, you can favor

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an engorged placental vessel.

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Now, let's revisit the axial

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images for this patient.

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I'd like to again focus on the

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blood vessels that seem to

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be recruited in the pelvis here.

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As we mentioned in the region of the cervix

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and upper vagina, this patient has a focal

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placental mass without intervening myometrium

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and extensive engorgement of the left greater

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than right pelvic sidewall vasculature.

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When we reported this case, we raised suspicion

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for placenta percreta, but in addition to

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this, we also said that there was likely

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recruitment of the cervical vaginal plexus,

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particularly on the left, and that further

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evaluation with angiography was warranted.

Report

Faculty

Erin Gomez, MD

Assistant Professor of Radiology

Johns Hopkins Hospital

Tags

Women's Health

Uterus

MRI

Gynecologic (Gyn)

Gynecologic (GYN)

Genitourinary (GU)

Body

Bladder

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