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Abnormal Invasive Placenta Question: Discuss about the Abnormal invasive placenta.     Answer: Abnormal invasive placenta is clinically defined as a condition where “a placenta that cannot be removed spontaneously or manually, without causing severe bleeding” (Rajora and Singh 2017). It is a trophoblastic attachment with the myometrium without the presence of intervening decidua and involves conditions like the placenta accreta, placenta increta and placenta percreta. When the trophoblast remains attached to the myometrium it is called placenta accreta, when the trophoblast invades the myometrium it is called placenta increta and when the trophoblast invades beyond the myometrium, serosa, bladder and intestines, it is called placenta percreta (Fitzpatrick et al. 2014; Thurn et al. 2016). The primary complication associated with abnormal invasive placenta is a life threatening peripartum hemorrhage, which in turn can lead to disseminated intravascular coagulation, hysterectomy, multiorgan failure, respiratory distress and can also cause death. It also increases the risk associated with pre-term birth (Fan et al. 2017). This is the most common form of placental invasion and occurs in 1 in 7,000 pregnancies. Depending upon location the maternal mortality rate is up to 7%. The presence of previous caesarean sections and anterior placenta previa raises the possibility of development of placenta accreta (Cooper 2012). Accurate diagnosis of such a life threatening medical condition is highly important as it gives rise to significant hemorrhage during the post delivery period, which in turn results in maternal as well as fetal mortality and morbidity (Spari? et al. 2014). One of the techniques used for the diagnosis of abnormal invasive placenta is the ultrasound technique. It has a sensitivity of 89.5%, has a positive predictive value of 68% and a 98% negative predictive value in the case of diagnosis of placenta accreta (Berkley and Abuhamad 2013). Ultrasonography helps in the detection of placenta accreta by identifying features like the loss of retroplacental hypoechoic zone or its marked thinning, interruptions between the bladder and uterine serosa in the hyperechoic border, detection of a mass like tissue having echogenicity similar to the echogenicity of a placenta and also helps in visualizing prominent lakes or vessels within the myometrium or the placenta. The highest sensitivity in the detection of placenta accreta is the visualization of lacunae (Shawky, AbouBieh and Masood 2016).   Research has previously been done on the use of ultrasound markers in the detection of abnormal invasive placenta. Power doppler ultrasound scans have been carried out to determine the area of confluence or Acon at the uteroplacental interface, which indicated that the area of confluence was higher in the case of abnormal invasive placenta than a normal placenta (Collins et al. 2015). However, the studies have revealed the variability of the performance of the markers for diagnosis of abnormal invasive placenta. However, the limitations of the studies lay in the small sample size, variability in the inclusion criteria, retrospective design and the diagnosis of the abnormal invasive placenta. Other limitations include the patient’s body habitus, posterior location of the placenta and the ultrasound operator skills (Collins et al. 2016). Based on the background cited, my area of research will be to undertake studies with the help of the power Doppler ultrasound in order to effectively differentiate between the placenta accreta, placenta increta and placenta percreta at their early stages, so that timely interventions can be applied with the aim to reduce maternal and fetal mortality and morbidity. The study would consider assessment of the abnormal invasive placenta with the help of placental vascular sonobiopsy (PVS) by 3D power Doppler ultrasound. Sonobiopsy is a valid alternative for evaluation of the placental vascular tree for convenient visualization of the entire placenta. VOCAL imaging analysis program would be advantageous in this regard. The study is to consider at least 50 pregnant women admitted to different healthcare units for delivery recruited randomly. Pregnancies with an entirely visualized anterior placenta are to be included in the study (Sato et al., 2016). The research would cover a span of minimum three months for a thorough analysis. Reports are to be prepared after suitable data analysis with software application.   Reference List Berkley, E.M. and Abuhamad, A.Z., 2013. Prenatal Diagnosis of Placenta Accreta. Journal of ultrasound in medicine, 32(8), pp.1345-1350. Collins, S.L., Ashcroft, A., Braun, T., Calda, P., Langhoff?Roos, J., Morel, O., Stefanovic, V., Tutschek, B. and Chantraine, F., 2016. Proposal for standardized ultrasound descriptors of abnormally invasive placenta (AIP). Ultrasound in Obstetrics & Gynecology, 47(3), pp.271-275. Collins, S.L., Stevenson, G.N., Al-Khan, A., Illsley, N.P., Impey, L., Pappas, L. and Zamudio, S., 2015. Three-dimensional power Doppler ultrasonography for diagnosing abnormally invasive placenta and quantifying the risk. Obstetrics & Gynecology, 126(3), pp.645-653. Cooper, A.C., 2012. The Rate of Placenta Accreta and Previous Exposure to Uterine Surgery. Fan, D., Li, S., Wu, S., Wang, W., Ye, S., Xia, Q., Liu, L., Feng, J., Wu, S., Guo, X. and Liu, Z., 2017. Prevalence of abnormally invasive placenta among deliveries in mainland China: A PRISMA-compliant Systematic Review and Meta-analysis. Medicine, 96(16). Fitzpatrick, K.E., Sellers, S., Spark, P., Kurinczuk, J.J., Brocklehurst, P. and Knight, M., 2014. The management and outcomes of placenta accreta, increta, and percreta in the UK: a population?based descriptive study. BJOG: An International Journal of Obstetrics & Gynaecology, 121(1), pp.62-71. Rajora, P. and Singh, A., 2017. Abnormally invasive placenta: an overview of diagnosis and management options. International Journal of Reproduction, Contraception, Obstetrics and Gynecology, 6(11), pp.5013-5017 Sato, M., Noguchi, J., Mashima, M., Tanaka, H. and Hata, T., 2016. 3D power Doppler ultrasound assessment of placental perfusion during uterine contraction in labor. Placenta, 45, pp.32-36. Shawky, M., AbouBieh, E. and Masood, A., 2016. Gray scale and Doppler ultrasound in placenta accreta: Optimization of ultrasound signs. The Egyptian Journal of Radiology and Nuclear Medicine, 47(3), pp.1111-1115. Spari?, R., Mirkovi?, L., Ravili?, U. and Janji?, T., 2014. Obstetric complications of placenta previa percreta. Vojnosanitetski pregled, 71(12), pp.1163-1166. Thurn, L., Lindqvist, P.G., Jakobsson, M., Colmorn, L.B., Klungsoyr, K., Bjarnadóttir, R.I., Tapper, A.M., Børdahl, P.E., Gottvall, K., Petersen, K.B. and Krebs, L., 2016. Abnormally invasive placenta—prevalence, risk factors and antenatal suspicion: results from a large population?based pregnancy cohort study in the Nordic countries. BJOG: An International Journal of Obstetrics & Gynaecology, 123(8), pp.1348-1355.

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