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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Norwitz ER, Park JS. Overview of the etiology and evaluation of vaginal bleeding in pregnant women.  Available at: https://www.uptodate.com/contents/overview-of-the-etiology-and-evaluation-of-vaginal-bleeding-in-pregnant-women. Review/Other-Dx N/A To review the etiology and evaluation of vaginal bleeding in pregnant women. N/A 4
2. Society for Maternal-Fetal Medicine (SMFM). Electronic address: pubs@smfm.org, Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine (SMFM) Consult Series #44: Management of bleeding in the late preterm period. Am J Obstet Gynecol. 218(1):B2-B8, 2018 01. Review/Other-Dx N/A To provide guidance on management of late preterm (34 0/7- 36 6/7 weeks of gestation) vaginal bleeding. The following are Society for Maternal-Fetal Medicine recommendations: (1) we recommend delivery at 36e37 6/7 weeks of gestation for stable women withplacenta previa without bleeding or other obstetric complications (GRADE 1B); (2) we do not recommend routine cervical length screening for women with placenta previa in the late preterm period due to a lack of data on an appropriate management strategy (GRADE 2C); (3) we recommend delivery between 34 and 37 weeks of gestation for stable women with placenta accreta (GRADE 1B); (4) we recommend delivery between 34 and 37 weeks of gestation for stable women with vasa previa (GRADE 1B); (5) we recommend that in women with active hemorrhage in the late preterm period, delivery should not be delayed for the purpose of administering antenatal corticosteroids (GRADE 1B); (6) we recommend that fetal lung maturity testing should not be used to guide management in the latepreterm period when an indication for delivery is present (GRADE 1B); and (7) we recommend that antenatal corticosteroids should be administered to women who are eligible and are managed expectantly if delivery is likely within 7 days, the gestational age is between 34 0/7 and 36 6/7 weeks of gestation, and antenatal corticosteroids have not previously been administered (GRADE 1A). 4
3. Yang J, Hartmann KE, Savitz DA, et al. Vaginal bleeding during pregnancy and preterm birth. Am J Epidemiol. 2004; 160(2):118-125. Observational-Dx 2,829 pregnant women To investigate the relation between self-reported vaginal bleeding during pregnancy and preterm birth in a prospective cohort. The overall association between vaginal bleeding and preterm birth was modest (RR 1.3, 95% CI: 1.1, 1.6). Bleeding in the first trimester only was associated with earlier preterm birth (=34 weeks' gestation) (RR 1.6, 95% CI: 1.1, 2.4) and preterm birth due to preterm premature rupture of the membranes (RR 1.9, 95% CI: 1.1, 3.3). Bleeding in both trimesters was associated with preterm birth due to preterm labor (RR 3.6, 95% CI: 1.9, 6.8). Bleeding of multiple episodes, on multiple days, and with more total blood loss was associated with an approximate twofold increased risk of earlier preterm birth, preterm premature rupture of the membranes, and preterm labor. In contrast, bleeding in the second trimester only, of a single episode, on a single day, and with less total blood loss was not associated with any category of preterm birth. Vaginal bleeding was not associated with preterm birth among African Americans (RR 1.2, 95% CI: 0.9, 1.7). 4
4. Vahanian SA, Vintzileos AM. Placental implantation abnormalities: a modern approach. [Review]. Curr Opin Obstet Gynecol. 28(6):477-484, 2016 Dec. Review/Other-Tx N/A To review modern approach to placental implantation abnormalities Risk factors include prior uterine surgery/myometrial scarring and the presence of placenta previa with or without prior cesarean delivery. Newly identified risk factors include previous prelabor cesarean delivery and previous postpartum hemorrhage. PIAs contribute substantially to preterm birth with prematurity rates ranging from 38 to 82%. Diagnosis is typically made by ultrasound in the second or third trimester; transvaginal ultrasound and color Doppler are useful in evaluating for placental invasion, placental edge thickness, presence of fetal vessels, and cervical length. Suggestive MRI features include increased vascularity, dark T2 bands, uterine bulging, thin or indistinct myometrium, and loss of dark T2 interface. An important first-trimester finding is the implantation of the gestational sac into prior hysterotomy scar (cesarean scar pregnancy). Recommendations for delivery are universally preterm and based on expert opinion. Proposed management strategies are outlined depending on cervical length, distance between internal cervical os and placenta, and placental edge thickness. 4
5. Oyelese Y, Ananth CV. Placental abruption. Obstet Gynecol. 2006; 108(4):1005-1016. Review/Other-Dx N/A Review risk factors, diagnosis and management of placental abruption. Prediction or prevention of most placental abruption cases is impossible. But, in some cases, maternal and infant outcomes can be optimized through attention to the risks and benefits of conservative management, ongoing evaluation of fetal and maternal well-being, and through expeditious delivery. 4
6. Nkwabong E, Tiomela Goula G. Placenta abruption surface and perinatal outcome. J Matern Fetal Neonatal Med. 30(12):1456-1459, 2017 Jun. Observational-Dx 47 cases To identify the relationship between the placenta abruption (PA) surface and the perinatal outcome. PA occurred in 47 women (1.3%). Mean gestational age was 36.0 weeks. PA percentages varied between 5% and 60%. Detachment =45% was always associated with stillbirth and was significantly observed in central PA (p<0.0002), while separation of 25-44% was associated with various degrees of neonatal asphyxia. Compared to marginal separation of the placenta, central separation was significantly associated with stillbirth (77.8% versus 10.5%, p<0.0002) and perinatal death (88.9% versus 13.1%, p<0.0001). 3
7. Reddy UM, Abuhamad AZ, Levine D, Saade GR, Fetal Imaging Workshop Invited Participants. Fetal imaging: executive summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging workshop. Obstet Gynecol. 123(5):1070-82, 2014 May. Review/Other-Dx N/A To provide an executive summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society forPediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop No results stated in abstract 4
8. Silver RM.. Abnormal Placentation: Placenta Previa, Vasa Previa, and Placenta Accreta. [Review]. Obstet Gynecol. 126(3):654-68, 2015 Sep. Review/Other-Dx N/A To emphasize an evidence-based approach to the clinical management of pregnancies placental disorders such as placenta previa, placenta accreta, and vasa previa as well as highlights important knowledge gaps. No results stated in abstract 4
9. Baumfeld Y, Gutvirtz G, Shoham I, Sheiner E. Fetal heart rate patterns of pregnancies with vasa previa and velamentous cord insertion. Arch Gynecol Obstet. 293(2):361-7, 2016 Feb. Observational-Dx 184 pregnancies with VCI and 37 pregnancies To investigate the fetal heart rate (FHR) patterns in pregnancies complicated with vasa previa and velamentous cord insertion (VCI). During the study period, there were 184 pregnancies with VCI and 37 pregnancies with vasa previa, undetected during pregnancy. FHR patterns of the VCI group included more cases of abnormal baseline (7 vs. 2 %, p < 0.05), out of which 7 % were fetal tachycardia (vs. 2 %) and 4 % were bradycardia (vs. 1 %). There were also more cases of abnormal baseline and abnormal variability (7 vs. 2 % and 32 vs. 22 %, respectively, p < 0.05) in the VCI group. FHR categories also differed between the velamentous cord insertion pregnancies and subsequent ones. VCI pregnancies had more category 2 patterns, not statistically significant (64 vs. 55 %, p = 0.11). FHR patterns of the vasa previa group included more cases of abnormal baseline (27 vs. 7 %, p < 0.05), out of which 18 % were tachycardia and 9 % were bradycardia. Decelerations were recorded in a total of 61 % of the vasa previa cases (61 vs. 31 %, p = 0.02), most of which were variable decelerations (48 vs. 17 %). Vasa previa pregnancies had more category 2 patterns (64 vs. 52 %). 3
10. Society of Maternal-Fetal (SMFM) Publications Committee, Sinkey RG, Odibo AO, Dashe JS. #37: Diagnosis and management of vasa previa. Am J Obstet Gynecol. 213(5):615-9, 2015 Nov. Review/Other-Dx N/A To review the management and diagnosis of vasa previa No results stated in abstract 4
11. American College of Radiology. ACR Appropriateness Criteria®: Suspected Placenta Accreta Spectrum Disorder. Available at: https://acsearch.acr.org/docs/3102403/Narrative/. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. No abstract available. 4
12. Leerentveld RA, Gilberts EC, Arnold MJ, Wladimiroff JW. Accuracy and safety of transvaginal sonographic placental localization. Obstet Gynecol. 1990; 76(5 Pt 1):759-762. Observational-Dx 100 patients To evaluate the accuracy and safety of TVS placental localization. The diagnosis was confirmed at cesarean delivery in all cases of placenta previa found by US before delivery, resulting in a 93.3% predictive value of a positive test. The predictive value of a negative test was 97.6%; in 2 patients a low-insertion placenta diagnosed by US was found to be a placenta previa at delivery. The sensitivity and specificity of the technique were 87.5% and 98.8%, respectively. Although in some instances TVS was performed during vaginal hemorrhage, aggravation of bleeding was never observed. TVS localization of the placenta proved to be an accurate and safe diagnostic procedure. 3
13. Oppenheimer LW, Farine D, Ritchie JW, Lewinsky RM, Telford J, Fairbanks LA. What is a low-lying placenta? Am J Obstet Gynecol. 1991; 165(4 Pt 1):1036-1038. Observational-Dx 127 patients Analysis of the use of TVS in placental previa. No patient with a placental edge >2 cm from the internal cervical os required cesarean section for the indication of placenta previa, whereas 7/8 patients with a distance of =2 cm underwent cesarean section because of bleeding characteristic of a placenta previa. These preliminary results suggest that TVS measurement may indicate the optimal delivery route and make the traditional classification of placenta previa obsolete. 4
14. Timor-Tritsch IE, Monteagudo A. Diagnosis of placenta previa by transvaginal sonography. Ann Med. 1993; 25(3):279-283. Review/Other-Dx N/A Review on diagnosis of placenta previa by TVS. TVS should be the principal diagnostic modality used in the work-up of an obstetric patient with vaginal bleeding. 4
15. American College of Radiology. ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Patients with Ionizing Radiation. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Pregnant_Patients.pdf. Review/Other-Dx N/A To assist practitioners in providing appropriate radiologic care for pregnant or potentially pregnant adolescents and women by describing specific training, skills and techniques. No abstract available. 4
16. Hertzberg BS, Bowie JD, Carroll BA, Kliewer MA, Weber TM. Diagnosis of placenta previa during the third trimester: role of transperineal sonography. AJR. 1992; 159(1):83-87. Observational-Dx 164 patients Role of transperineal sonography in the diagnosis of placenta previa during the third trimester. Transperineal sonography successfully visualized the internal surface of the cervix in all patients, allowing determination of the presence or absence of placenta previa. Transperineal sonography complements TAS for detection of placenta previa. 4
17. Vintzileos AM, Ananth CV, Smulian JC. Using ultrasound in the clinical management of placental implantation abnormalities. [Review]. Am J Obstet Gynecol. 213(4 Suppl):S70-7, 2015 Oct. Review/Other-Dx N/A To propose literature-supported guidelines to the current opinion-based management of asymptomatic patients with placental implantation abnormalities based on relevant and specific ultrasound findings such as cervical length, distance between the internal cervical os and placenta, and placental edge thickness. No results stated in abstract. 4
18. American College of Radiology. ACR Appropriateness Criteria®: Assessment of Gravid Cervix. Available at: https://acsearch.acr.org/docs/69464/Narrative/. Accessed September, 12, 2019. Review/Other-Dx NA Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. No abstract available. 4
19. Carlan SJ, Richmond LB, O'Brien WF. Randomized trial of endovaginal ultrasound in preterm premature rupture of membranes. Obstet Gynecol. 1997;89(3):458-461. Experimental-Dx 47 patients assigned to no-probe and 45 patients assigned to probe group Randomized study to assess the effect of weekly endovaginal US on the incidence of maternal infection and the time from rupture to delivery in women with preterm premature rupture of membranes. The latency period, defined as days from rupture to delivery, was 9.8 and 11.7 days for the no-probe and probe groups, respectively (95% CI, -5.9, 2.1). There were no significant differences in the incidence of chorioamnionitis (28% and 20%), endometritis (6% and 9%), or neonatal infection (17% and 20%). The mean latency period in women who went into spontaneous labor and whose initial cervical length was 3.0 cm or less was 9.4 days, compared with 11.0 days if the cervix exceeded 3.0 cm, a nonsignificant difference. There were three neonatal deaths, all in the probe group and none directly related to infection. Endovaginal US in patients whose pregnancies are complicated by preterm premature rupture of membranes does not appear to increase the incidence of maternal infection. 1
20. Timor-Tritsch IE, Monteagudo A, Rebarber A, Goldstein SR, Tsymbal T. Transrectal scanning: an alternative when transvaginal scanning is not feasible. Ultrasound Obstet Gynecol. 21(5):473-9, 2003 May. Review/Other-Dx 42 patients To investigate the applicability of transrectal scanning (TRS) for cases in which transvaginal sonography (TVS) is impossible. All scans were completed without significant patient discomfort or complaints. TRS was clearly superior to TAS in 31 cases. In nine cases TAS furnished some clinical information but TRS yielded better images. Only in one such case was TAS similar in quality to TRS. In four obese patients TAS did not reveal sufficient pelvic anatomy to generate a clinical diagnosis, whereas TRS revealed two sets of normal ovaries and two patients with ovarian cysts. In the two cases with vaginal agenesis TRS revealed the diagnosis of Rokitansky-Küster syndrome. In three of the four patients with ruptured membranes the cervix could be measured precisely. 4
21. Wachsberg RH.. Transrectal ultrasonography for problem solving after transvaginal ultrasonography of the female internal reproductive tract. J Ultrasound Med. 22(12):1349-56, 2003 Dec. Review/Other-Dx 10 cases To report the value of transrectal ultrasonography of the female internal reproductive tract as a complementary problem-solving technique after transvaginal ultrasonography in selected patients. Transrectal ultrasonography was helpful in 2 scenarios: (1) women with a retroverted uterus in whom the endometrial stripe was virtually parallel to the ultrasound beam and thus could not be properly measured on transvaginal ultrasonography, and (2) women in whom normal or pathologic adnexal findings were distant from the vagina or obscured by intervening structures during transvaginal ultrasonography but were near the rectum or not obscured during transrectal ultrasonography. In 1 case, transrectal ultrasonography yielded a diagnosis of ectopic pregnancy that was missed prospectively on transvaginal ultrasonography because pain severely limited the examiner's ability to manipulate the transvaginal ultrasound transducer. 4
22. Nomiyama M, Toyota Y, Kawano H. Antenatal diagnosis of velamentous umbilical cord insertion and vasa previa with color Doppler imaging. Ultrasound Obstet Gynecol. 1998; 12(6):426-429 Observational-Dx 587 patients To determine whether cord insertion can be consistently visualized and whether velamentous cord insertion and vasa previa can be consistently identified with color Doppler imaging during routine sonography in the mid-trimester. Cord insertion was visualized by color Doppler imaging in 99.8% (586/587) of the fetuses in our study. The mean time required for examination was 20 s and, in 95% of the cases, cord insertion was visualized within 1 min. The sonographic identification of velamentous cord insertion had a sensitivity of 100% (5/5), a specificity of 99.8% (580/581), a PPV of 83% (5/6) and a NPV of 100% (580/580). In our study, vasa previa was diagnosed at 18 gestational weeks in two cases and, in one of the cases, vasa previa was confirmed at delivery. 4
23. D'Antonio F, Bhide A. Ultrasound in placental disorders. [Review]. Best Pract Res Clin Obstet Gynaecol. 28(3):429-42, 2014 Apr. Review/Other-Dx N/A To provide an up-to-date review of prenatal diagnosis of placental disorders with ultrasound. No results stated in abstract 4
24. Quant HS, Friedman AM, Wang E, Parry S, Schwartz N. Transabdominal ultrasonography as a screening test for second-trimester placenta previa. Obstet Gynecol. 123(3):628-33, 2014 Mar. Observational-Dx One thousand two hundred fourteen women To determine the test characteristics of transabdominal ultrasonography as a screening test for second-trimester placenta previa. One thousand two hundred fourteen women were included in the analysis. A transabdominal placenta-cervix distance cutoff of 4.2 cm was 93.3% sensitive and 76.7% specific for detection of previa with a 99.8% negative predictive value at a screen-positive rate of 25.0%. A cutoff of 2.8 cm was 86.7% sensitive and 90.5% specific with a 99.6% negative predictive value at a screen-positive rate of 11.4%. Only 9.8% (four of 41) of previas and low-lying placentas persisted through delivery. 3
25. Taipale P, Hiilesmaa V, Ylostalo P. Transvaginal ultrasonography at 18-23 weeks in predicting placenta previa at delivery. Ultrasound Obstet Gynecol. 1998; 12(6):422-425. Observational-Dx 3,696 patients To determine if TVS at 18-23 weeks’ gestation is useful in predicting placenta previa at delivery. Performed TVS and routine TAS in non-selected pregnant women with singleton fetuses and measured the distance from the placental edge to the internal cervical os. In 57/3,696 patients (1.5%), the placental edge extended to or over the internal cervical os. In 27 patients (0.7%), the placenta extended =15 mm over the internal cervical os; in these cases the PPV of placenta previa at delivery was 19% (95% CI, 6%-38%) with 100% (95% CI, 48%-100%) sensitivity. With =25 mm used as the cut-off point, 10 cases (0.3%) were screen-positive and the PPV for previa at delivery was 40% (95% CI, 12%-74%) and sensitivity was 80% (95% CI, 28%-100%). The frequency of placenta previa at delivery in this population was 5/3,696 (0.14%, 95% CI, 0.04%-0.31%). 3
26. Becker RH, Vonk R, Mende BC, Ragosch V, Entezami M. The relevance of placental location at 20-23 gestational weeks for prediction of placenta previa at delivery: evaluation of 8650 cases. Ultrasound Obstet Gynecol. 2001; 17(6):496-501. Observational-Dx 8,650 patients Prospective study using TAS and TVS to determine the correlation between placental position at 20-23 weeks and incidence of birth complications caused by placental position. At 20-23 weeks, combining TAS and TVS location of placental position is effective in predicting placenta previa at delivery. 4
27. Morales-Rosello J, Khalil A, Akhoundova F, et al. Fetal cerebral and umbilical Doppler in pregnancies complicated by late-onset placental abruption. J Matern Fetal Neonatal Med. 30(11):1320-1324, 2017 Jun. Observational-Dx 1325 Doppler examinations To evaluate whether changes in the cerebroplacental Doppler and birth weight (BW) suggestive of chronic fetal hypoxemia, precede the development of late-onset placental abruption (PA) after 32 weeks. Pregnancies complicated by late-onset PA (n=31) presented lower MCA PI (p=0.015) and were smaller (p<0.001) than those who did not (n=1294). Logistic regression analysis indicated that cerebral vasodilation was more important than umbilical flow in the explanation of PA (MCA PI OR=0.106, p=0.014 and UA PI OR 1.901, p=0.32). In addition, the influence of BW exerted was residual (BW centile OR=0.989, p=0.15). 3
28. Glantz C, Purnell L. Clinical utility of sonography in the diagnosis and treatment of placental abruption. J Ultrasound Med. 2002; 21(8):837-840. Observational-Dx 149 patients To determine the sensitivity, specificity, positive and predictive values of sonography for detection of placental abruption and to determine whether sonographic results correlate with management or outcome. Sensitivity: 24%, Specificity: 96%, PPV: 88%, and NPV: 53%. 4
29. Uharcek P, Brestansky A, Ravinger J, Manova A, Zajacova M. Sonographic assessment of lower uterine segment thickness at term in women with previous cesarean delivery. Arch Gynecol Obstet. 292(3):609-12, 2015 Sep. Observational-Dx Three hundred and thirty-six women To establish the validity of abdominal sonographic evaluation of lower uterine segment (LUS) thickness in full-term pregnancies with a single previous cesarean section, and to assess the usefulness of measuring LUS thickness in predicting the risk of uterine dehiscence. In our present study, 2.5 mm was considered the critical cut-off value of the LUS thickness. This critical cut-off value was derived from the ROC curve with sensitivity, specificity, PPV, and NPV of 90.9, 84, 71.4, and 95.5 %, respectively (using transabdominal ultrasound). The linear regression model analysis revealed that full LUS thickness of <2.5 mm was the only factor to be correlated with translucent lower uterine segment (C3) (8.8 vs. 0 %; P = 0.02). 3
30. Ramaeker DM, Simhan HN. Sonographic cervical length, vaginal bleeding, and the risk of preterm birth. Am J Obstet Gynecol. 2012; 206(3):224 e221-224. Observational-Dx 2,988 women with singleton gestations To evaluate the contributions of vaginal bleeding and cervical length to the risk of preterm birth. There was a significant second-order relation between cervical length and preterm birth (P<.001, P=.005). Women with vaginal bleeding were at higher risk of preterm birth (OR, 1.5; 95% CI, 1.3-2.0). There was a significant interaction between cervical length and vaginal bleeding (P=.015). After accounting for cervical length and interaction, the adjusted OR for vaginal bleeding and preterm birth was 4.8 (95% CI, 1.89-12.4; P=.001). 3
31. Hasegawa J, Kawabata I, Takeda Y, et al. Improving the Accuracy of Diagnosing Placenta Previa on Transvaginal Ultrasound by Distinguishing between the Uterine Isthmus and Cervix: A Prospective Multicenter Observational Study. Fetal Diagn Ther. 41(2):145-151, 2017. Observational-Dx 53 patients To clarify whether distinguishing between the uterine isthmus and cervix can improve the accuracy of diagnosing placenta previa at term. We screened 9,341 patients, and 53 (0.6%) met the inclusion criteria. Nineteen cases with an open isthmus and 34 with a closed isthmus were followed. The accuracy for diagnosing placenta previa or a low-lying placenta at term was 94.7% in the open isthmus group and 26.5% in the closed isthmus group (p < 0.001). Elective or emergency Cesarean section was required in 100% of cases in the open isthmus group and 20.6% in the closed isthmus group (p < 0.001). 3
32. Goto M, Hasegawa J, Arakaki T, et al. Placenta previa with early opening of the uterine isthmus is associated with high risk of bleeding during pregnancy, and massive haemorrhage during caesarean delivery. Eur J Obstet Gynecol Reprod Biol. 201:7-11, 2016 Jun. Observational-Dx Forty-four cases of EO-previa and 55 cases of LO-previa To demonstrate the relationship between the timing of opening of the uterine isthmus and bleeding during pregnancy and caesarean section in patients with placenta previa. Forty-four cases of EO-previa and 55 cases of LO-previa were analysed. Complete placenta previa at delivery was observed more frequently in the EO-previa group than in the LO-previa group (88.6% vs 47.3%, p < 0.001). An emergency caesarean section due to active bleeding was performed more frequently in the EO-previa group (48%) than in the LO-previa group (25%) (p = 0.021). The frequency of massive haemorrage (>2500 ml) during caesarean section was higher in the EO- previa group than in the LO-previa group (25% vs 9%, p = 0.033). 3
33. Gouhar GK, Sadek SM, Siam S, Ahmad RA. Role of transperineal sonography in diagnosis of placenta previa/accreta: A prospective study. The Egyptian Journal of Radiology and Nuclear Medicine 2012;43:637-45. Observational-Dx 134 patients To evaluate the role of transperineal ultrasound (TPS) in the detection of morphological and vascular manifestations of placenta previa (PP)/accreta and to compare it with transabdominal sonography (TAS) and transvaginal sonography (TVS), with the clinical outcomes as the reference standards. One hundred and three patients had PP, the sensitivity, specificity, and accuracy in diagnosing PP were 97.1%, 75% and 94% for TPS, 94.2%, 75% and 91.5% for TAS, and 98.1%, 93.8% and 97.4% for TVS respectively. PP accreta was present in 39 patients. The sensitivity, specificity, and accuracy in diagnosing PP accreta were 89.7%, 100% and 96% for TPS, 87%, 95% and 92.2% for TAS, and 94.9%, 100% and 98% for TVS respectively. 4
34. Ruiter L, Kok N, Limpens J, et al. Systematic review of accuracy of ultrasound in the diagnosis of vasa previa. [Review]. Ultrasound Obstet Gynecol. 45(5):516-22, 2015 May. Review/Other-Dx 8 articles To assess the accuracy of ultrasound in the prenatal diagnosis of vasa previa. The literature search revealed 583 articles, of which two prospective and six retrospective cohort studies were eligible for inclusion in the qualitative analysis. Allstudies documented methods suitable for the prenatal diagnosis of vasa previa. Four out of the eight studies used transvaginal ultrasound (TVS) for primary evaluation, while the remaining four studies used transabdominal ultrasound and performed a subsequent TVS when vasa previa was suspected. The QUADAS-2 tool reflected poor methodology in six of the eight included studies, and prenatal detection rates varied from 53% (10/19) to 100% (total of 442 633 patients, including 138 cases of vasa previa). In the two prospective studies (n=33 795, including 11 cases of vasa previa), transvaginal color Doppler performed during the second trimester detected all cases of vasa previa (sensitivity, 100%) with a specificity of 99.0–99.8%. 4
35. Oppenheimer L. Diagnosis and management of placenta previa. J Obstet Gynaecol Can. 2007; 29(3):261-273. Review/Other-Dx 127 patients Analysis of the use of TVS in placental previa. TVS measurement may indicate the optimal delivery route and make the traditional classification of placenta previa obsolete. 4
36. Kapoor S, Thomas JT, Petersen SG, Gardener GJ. Is the third trimester repeat ultrasound scan for placental localisation needed if the placenta is low lying but clear of the os at the mid-trimester morphology scan?. Aust N Z J Obstet Gynaecol. 54(5):428-32, 2014 Oct. Observational-Dx One hundred and eighty-one women 1. To determine the rate of placenta praevia, vasa praevia and cord prolapse in the third trimester in women with a low-lying placenta (not overlapping the internal cervical os) at the mid-trimester morphology scan.2. To perform a meta-analysis, in addition, to investigate the effect of the placenta to os distance at the mid-trimester scan on the rate of placenta praevia at term. One hundred and eighty-one women with a low-lying placenta not overlapping the os at mid-trimester scan were identified. The composite outcome was documented in 20 (11.0%) women, including placenta praevia in 15 (8.3%). Based on multivariate analysis, multiparity, distance from os < 10 mm and antenatal bleeding were independently associated with the composite outcome. Meta-analysis demonstrated significant reduction in rate of placenta praevia for every 10-mm increase in placenta-os distance at mid-trimester. 3
37. Olive EC, Roberts CL, Nassar N, Algert CS. Test characteristics of placental location screening by transabdominal ultrasound at 18-20 weeks. Ultrasound Obstet Gynecol. 2006; 28(7):944-949. Experimental-Dx 54 women; 168 randomly selected controls Case control study of 54 women with placenta previa at time of delivery and 168 randomly selected controls to determine the test characteristics of a second-trimester transabdominal fetal anomaly scan in screening for placenta previa. Different second-trimester placenta os measurements for case control and randomly selected controls. False positives among the much larger population of women without placenta previa. Second-trimester transabdominal fetal anomaly scan is a useful screening test for placenta previa. 3
38. Dashe JS, McIntire DD, Ramus RM, Santos-Ramos R, Twickler DM. Persistence of placenta previa according to gestational age at ultrasound detection. Obstet Gynecol. 2002; 99(5 Pt 1):692-697. Observational-Dx 714 patients Retrospective cohort study to evaluate gestational age at US detection of placenta previa as a predictor of previa persistence and to estimate the effects of previa type, parity, and prior cesarean delivery on previa persistence. Previa was detected during 940 US examinations in 714 pregnancies. Concluded that gestational age at US detection of placenta previa may be used to predict likelihood of previa persistence. 4
39. Ananth CV, Demissie K, Smulian JC, Vintzileos AM. Placenta previa in singleton and twin births in the United States, 1989 through 1998: a comparison of risk factor profiles and associated conditions. Am J Obstet Gynecol. 2003; 188(1):275-281. Observational-Dx 37,956,020 singleton births 961,578 twin births To compare risk factor profiles for placenta previa between singleton and twin live births. The rate of placenta previa was 40% higher among twin births (3.9 per 1,000 live births, n=3,793 births) than among singleton births (2.8 per 1,000 live births, n=104,754 births). Comparison of risk factors for placenta previa between the singleton and twin births revealed fairly similar risk factor profiles. Compared with primigravid women <20 years old, the risk for placenta previa increased by advancing age and by increasing number of pregnancies among both singleton and twin births. The number of cigarettes smoked per day also showed a dose-response trend for placenta previa risk in the two groups. 4
40. Faiz AS, Ananth CV. Etiology and risk factors for placenta previa: an overview and meta-analysis of observational studies. J Matern Fetal Neonatal Med. 2003; 13(3):175-190. Meta-analysis 58 studies Systematic review of the etiology and risk factors for placenta previa. The results showed that the overall prevalence rate of placenta previa was 4.0 per 1000 births, with the rate being higher among cohort studies (4.6 per 1000 births), USA-based studies (4.5 per 1000 births) and hospital-based studies (4.4 per 1000 births) than among case-control studies (3.5 per 1000 births), foreign-based studies (3.7 per 1000 births) and population-based studies (3.7 per 1000 births), respectively. Advancing maternal age, multiparity, previous Cesarean delivery and abortion, smoking and cocaine use during pregnancy, and male fetuses all conferred increased risk for placenta previa. Strong heterogeneity in the associations between risk factors and placenta previa were noted by study design, accuracy in the diagnosis of placenta previa and population-based versus hospital-based studies. Future etiological studies on placenta previa must, at the very least, adjust for potentially confounding effects of maternal age, parity, prior Cesarean delivery and abortions. M
41. Gilliam M, Rosenberg D, Davis F. The likelihood of placenta previa with greater number of cesarean deliveries and higher parity. Obstet Gynecol. 2002; 99(6):976-980. Experimental-Dx 316 multiparous women; 2,051 controls To examine the relationship between prior cesarean delivery and placenta previa. Women with a prior cesarean delivery were more likely to have a placenta previa than those without (OR 1.59, 95% CI: 1.21, 2.08). The likelihood of placenta previa increased as both parity and number of cesarean deliveries increased. Thus, the adjusted OR for a primiparous woman with one cesarean delivery was 1.28 (95% CI: 0.82, 1.99). For a woman who has four or more deliveries with only a single cesarean delivery, the OR increases to 1.72 (95% CI: 1.12, 2.64). This trend continues with greater parity and a greater number of cesarean deliveries such that the likelihood of placenta previa for a woman with parity greater than four and greater than four cesarean deliveries was OR 8.76 (95% CI: 1.58, 48.53). 3
42. Heller HT, Mullen KM, Gordon RW, Reiss RE, Benson CB. Outcomes of pregnancies with a low-lying placenta diagnosed on second-trimester sonography. J Ultrasound Med. 33(4):691-6, 2014 Apr. Review/Other-Tx 1240 patients To determine how often a low-lying placenta, defined as a placenta ending within 2 cm of the internal cervical os but not covering it, diagnosed sonographically in the second trimester resolves before delivery. In total, 1220 of 1240 low-lying placentas (98.4%) that had sonographic follow up resolved to no previa before delivery; 89.9% of placentas cleared the cervix by 32 weeks, and 95.9% cleared by 36 weeks. Twenty patients (1.6%) had persistent sonographic placenta previa or a low-lying placenta at or near term, including 5 complete previas, 7 marginal previas, 5 low-lying placentas, and 3 vasa previas; all had cesarean deliveries. 4
43. Shin JE, Shin JC, Lee Y, Kim SJ. Serial Change in Cervical Length for the Prediction of Emergency Cesarean Section in Placenta Previa. PLoS ONE. 11(2):e0149036, 2016. Observational-Dx 93 women To evaluate whether serial change in cervical length (CL) over time can be a predictor for emergency cesarean section (CS) in patients with placenta previa. A total of 93 women were evaluated; 31 had emergency CS due to massive vaginal bleeding. CL tended to decrease with advancing gestational age in each group. Until 29–31 weeks, CL showed no significant differences between the two groups, but after that, CL in the emergency CS group decreased abruptly, even though CL in the elective CS group continued to gradually decrease. On multivariate analysis to determine risk factors, only admissions for bleeding (odds ratio, 34.710; 95% CI, 5.239–229.973) and change in CL (odds ratio, 3.522; 95% CI, 1.210–10.253) were significantly associated with emergency CS. Analysis of the receiver operating characteristic curve showed that change in CL could be the predictor of emergency CS (area under the curve 0.734, p < 0.001), with optimal cutoff for predicting emergency cesarean delivery of 6.0 mm. 3
44. Sekiguchi A, Nakai A, Okuda N, Inde Y, Takeshita T. Consecutive cervical length measurements as a predictor of preterm cesarean section in complete placenta previa. J Clin Ultrasound. 43(1):17-22, 2015 Jan. Observational-Dx Seventy-one women To evaluate whether consecutive cervical length measurements can predict preterm cesarean section in women with complete placenta previa. Cervical length gradually decreased with advancing gestational age. After 26 weeks’ gestation, this decrease was significantly more rapid in the pretermcesarean section group. Cervical length before cesarean section in the preterm cesarean section group was significantly shorter than that in the controlgroup. Just before cesarean section, 71.4% of the preterm cesarean section group presented with cervical lengths of <=35 mm, whereas only 34.9% of thecontrol group had cervical lengths of <=35 mm (odds ratio 4.67, 95% confidence interval 1.66–13.10, p=0.006). 3
45. Rebarber A, Dolin C, Fox NS, Klauser CK, Saltzman DH, Roman AS. Natural history of vasa previa across gestation using a screening protocol. J Ultrasound Med. 33(1):141-7, 2014 Jan. Review/Other-Dx 27,573 patients To estimate the prevalence and persistence rate of vasa previa in at-risk pregnancies using a standardized screening protocol. A total of 27,573 patients were referred to our unit for fetal anatomic surveys over the study period. Thirty-one cases of vasa previa were identified, for an incidenceof 1.1 per 1000 pregnancies. Twenty-nine cases had full records available for analysis. Five patients (17.2%) had migration and resolution of the vasa previa. When the diagnosis was made during the second trimester (<26 weeks), there was a 23.8% resolution rate (5 of 21); when the diagnosis was made in the third trimester, none resolved (0 of 8 cases). Of the 24 pregnancies (5 twin gestations and 19 singleton gestations) with persistent vasa previa, there was 100% perinatal survival and a median length of gestation of 35 weeks (range, 27 weeks 5 days–36 weeks 5 days). No known missed cases were identified over the study period. 4
46. Swank ML, Garite TJ, Maurel K, et al. Vasa previa: diagnosis and management. Am J Obstet Gynecol. 215(2):223.e1-6, 2016 Aug. Review/Other-Dx 68 pregnancies To investigate the diagnostic and management strategies for this potentially catastrophic entity and to describe further maternal and placental risk factors that may aid in the establishment of a screening protocol for vasa previa. Sixty-eight pregnancies were identified that included the diagnosis of vasa previa or “possible vasa previa” either in the ultrasound record or in the hospital record at the time of delivery. Four cases (5.8%) appeared to resolve on repeat ultrasound examination. Fifteen of the 64 cases that were suspected of having vasa previa could not be verified or were not documented at delivery. Of the remaining 49 cases, where vasa previa was documented, 47 cases (96%) were diagnosed by ultrasound scanning antenatally. Known risk factors for vasa previa were present in 41 of 47 cases (87%). Of the 49 cases, 41 were delivered by planned cesarean delivery at a mean gestational age of 34.7 weeks, and 8 cases required emergent cesarean delivery at a mean gestational age of 34.6 weeks (range, 32.4-36.0 weeks gestation). Seven of these emergent cesarean deliveries had been diagnosed previously; 1 case had not. All of the emergent cesarean deliveries were for vaginal bleeding; 1 case was also for a concerning fetal heart rate, but only 1 of the known cases had a documented ruptured fetal vessel. None of these cases were found to have cervical shortening before the onset of bleeding. One of the undiagnosed cases resulted in a ruptured fetal vessel and a baby with no heart beat at birth who survived but had periventricular leukomalacia at 1 month of age with mild white-matter atrophy. Of the remaining neonates in this group, there were no deaths and no major complications beyond mild respiratory distress syndrome in 9 cases. There were no other major neonatal complications, which included no cases of periventricular leukomalacia, neonatal sepsis, necrotizing enterocolitis, or any grade of intraventricular hemorrhage in the confirmed cases of vasa previa. 4
47. American College of Radiology. ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI). Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/mr-fetal.pdf Review/Other-Dx N/A To promote safe and optimal performance of fetal magnetic resonance imaging (MRI). No abstract available. 4
48. American College of Radiology. ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical Ultrasound. Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/us-ob.pdf Review/Other-Dx N/A To promote the safe and effective use of diagnostic and therapeutic radiology by describing the key elements of standard ultrasound examinations in the first, second, and third trimesters of pregnancy. No abstract available. 4
49. American College of Radiology. Manual on Contrast Media. Available at: https://www.acr.org/Clinical-Resources/Contrast-Manual. Review/Other-Dx N/A To assist radiologists in recognizing and managing risks associated with the use of contrast media. No abstract available. 4
50. Expert Panel on MR Safety, Kanal E, Barkovich AJ, et al. ACR guidance document on MR safe practices: 2013. J Magn Reson Imaging. 37(3):501-30, 2013 Mar. Review/Other-Dx N/A To help guide MR practitioners regarding MR safety issues and provide a basis for them to develop and implement their own MR policies and practices. No abstract available. 4
51. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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