The Jellyfish Sign: A New Sonographic Cervical Marker to Predict Maternal Morbidity in Abnormally Invasive Placenta Previa

Abstract

Purpose To investigate the value of a new cervical sonographic sign, called the jellyfish sign (JS), for predicting the risk of maternal morbidity in cases of abnormally invasive placenta (AIP) previa totalis.

Materials and Methods Retrospective evaluation of transvaginal (TV) and transabdominal (TA) scans performed in all singleton pregnancies with placenta previa totalis. JS, i. e. the absence of the normal linear demarcation between the placenta previa and the cervix, was evaluated by TV scans. The presence/severity of AIP and outcomes of maternal morbidity were related to this sign.

Results JS was noted in 8/39 (20.5 %) patients. The two analyzed groups, i. e. with and without JS, were similar. The specificity of JS in AIP diagnosis, histological findings of accreta/increta/percreta, need for caesarean hysterectomy or blood loss > 2000 ml ranges between 92 % and 96.2 %, with the PPV and NPV ranging between 71.4 % and 85.7 % and 61.3 % and 80.6 %, respectively. The JS group had a significant increase in blood loss (ml) (p = 0.003), transfusions (%) (p = 0.016), red blood cells (p = 0.002) and plasma (p = 0.002), admission to an postoperative intensive care unit (ICU) (%) (p = 0.002), hospitalization length (p < 0.001) and the need of cesarean hysterectomy (%) (p < 0.001). JS was independently correlated to cesarean hysterectomy (OR 25.6; 95 % CI 2.0:322.3, p = 0.012) and blood loss > 2000 ml (OR 16.6; 95 % CI 1.5:180.1, p = 0.021) also in a logistic regression model.

Conclusion JS is useful in predicting the increase in maternal morbidity: massive transfusion, admission to the ICU and cesarean hysterectomy related to intraoperative bleeding in patients with a previa AIP.

Zusammenfassung

Ziel Beurteilung eines neuen sonografischen zervikalen Markers, dem sogenannten Jellyfish-Sign (JS), zur Prognose des Risikos der mütterlichen Morbidität bei ungewöhnlich invasiver Plazenta (AIP) previa totalis. Materialien und Methoden: Retrospektive Auswertung der transvaginalen (TV) und transabdominalen (TA) Scans in allen Einlingsschwangerschaften mit placenta previa totalis. JS, also die Abwesenheit der deutlichen Abgrenzung zwischen der Plazenta previa und dem Gebärmutterhals, wurde mittels TV-Scans ausgewertet. Das Vorkommen / die Schwere der AIP und die Häufigkeit der mütterlichen Morbidität standen mit dem JS in Relation.

Ergebnisse JS wurde bei 8/39 (20,5 %) der Patienten festgestellt. Die beiden analysierten Gruppen, das heißt mit und ohne JS, waren ähnlich. Die Spezifität von JS zur AIP-Diagnose, bei histologischen Befunden von accreta / increta / percreta, zur Notwendigkeit für Kaiserschnitt oder bei Blutverlust > 2000ml lag zwischen 92 % und 96,2 %, mit dem PPV und NPV zwischen 71,4 % und 85,7 % und 61,3 % und 80,6 %. Die JS-Gruppe hatte einen deutlich höheren Blutverlust (ml) (p = 0,003), benötigte mehr Transfusionen (%) (p = 0,016) sowie rote Blutzellen (p = 0,002) und Plasma (p = 0,002), höhere Aufnahmerate in einer postoperativen Intensivstation (ICU) (%) (p = 0,002), Hospitalisierungslänge (p < 0,001) und die Notwendigkeit eines Kaiserschnitts (%) (p < 0,001). JS korrelierte unabhängig zu Kaiserschnitt- (OR 25,6; 95 % CI 2,0: 322,3, p = 0,012) und Blutverlust > 2000 ml (OR 16,6, 95 % CI 1,5: 180,1, p = 0,021), auch in einem logistischen Regressionsmodell.

Schlussfolgerung Das JS ist hilfreich zur Prognose der Zunahme von mütterlicher Morbidität: höhere Transfusionraten, Aufnahme in ein ICU und Kaiserschnitt stehen im Zusammenhang mit intraoperativer Blutungen bei Patienten mit einer Previa AIP.

Key Words

placenta accreta - morbidly adherent placenta - ultrasound - cervix - maternal morbidity

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