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Am J Perinatol 2023; 40(13): 1398-1405
DOI: 10.1055/a-2099-4542
SMFM Fellowship Series Article

Factors Limiting Magnetic Resonance Imaging Diagnosis of Placenta Accreta Spectrum

CeCe Cheng 
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, Texas
,
Patrick S. Ramsey
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, Texas
,
John J. Byrne
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, Texas
,
Venkata S. Katabathina
2   Department of Radiology, University of Texas Health Science Center at San Antonio, Texas
,
Kayla E. Ireland
3   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Methodist Hospital San Antonio, Texas
,
Jessian L. Munoz 
4   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
› Author Affiliations Funding None.
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Abstract

Objective Placenta accreta spectrum (PAS) disorders are characterized by an abnormal adherence of the placenta to the uterine myometrium. Magnetic resonance imaging (MRI) is an important adjunct in antenatal diagnosis. We sought to determine if there are patient and MRI characteristics that limit the accuracy of PAS diagnosis and degree of invasion.

Study Design We conducted a retrospective cohort analysis of patients who were evaluated for PAS by MRI from January 2007 to December 2020. Patient characteristics evaluated included number of prior cesarean deliveries, history of dilation and curettage (D&C) or dilation and evacuation (D&E), short interval pregnancy less than 18 months, and delivery body mass index (BMI). All patients were followed until delivery and MRI diagnosis was compared with final histopathology.

Results Of the 353 patients with suspected PAS, 152 (43%) underwent MRI evaluation and were included in the final analysis. In patients who underwent MRI evaluation, 105 (69%) had confirmed PAS on pathology. Patient characteristics were similar between groups and not associated with accuracy of MRI diagnosis. MRI was accurate in diagnosing PAS and the associated degree of invasion in 83 (55%) patients. Accuracy was associated with lacunae (8 vs. 0%, p = 0.02), abnormal bladder interface (25 vs. 6%, p = 0.002), and T1 hyperintensity (13 vs. 1%, p = 0.002). Of the 69 (45%) patients in whom MRI was inaccurate, overdiagnosis was seen in 44 (64%) patients and underdiagnosis in 25 (36%) patients. Overdiagnosis was significantly associated with dark T2 bands (45 vs. 22%, p = 0.005). Underdiagnosis was associated with earlier gestational age at MRI (28 vs. 30 weeks, p = 0.049) and lateral placentation (16 vs. 2.4%, p = 0.025).

Conclusion Patient factors did not change MRI accuracy of PAS diagnosis. MRI is associated with a significant overdiagnosis of PAS when dark T2 bands are present, and underdiagnose PAS when performed earlier in gestation or when lateral placentation is present.

Key Points

  • Patient factors are not associated with MRI accuracy of PAS diagnosis.

  • MRI overdiagnoses PAS invasion when there are dark T2 bands.

  • MRI underdiagnoses PAS invasion when performed earlier in gestation.

  • Underdiagnosis of PAS is associated with lateral placentation.

Keywords

magnetic resonance imaging - placenta accreta spectrum - abnormally invasive placenta - ultrasonography - diagnosis - accuracy - limitations

Note

These findings of this study were presented at the Society for Maternal-Fetal Medicine's 42nd Annual Pregnancy Meeting, Virtual, January 31–February 5, 2022.




Publication History

Received: 02 November 2022

Accepted: 22 May 2023

Accepted Manuscript online:
24 May 2023

Article published online:
26 June 2023

© 2023. Thieme. All rights reserved.

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  • References

  • 1 Silver RM, Branch DW. Placenta accreta spectrum. N Engl J Med 2018; 378 (16) 1529-1536
    CrossrefPubMedGoogle Scholar
  • 2 Jauniaux E, Moffett A, Burton GJ. Placental implantation disorders. Obstet Gynecol Clin North Am 2020; 47 (01) 117-132
    CrossrefPubMedGoogle Scholar
  • 3 ACOG. Placenta accreta spectrum. Obstetric care consensus. Obstet Gynecol 2018; 132: 16
    PubMedGoogle Scholar
  • 4 Silver RM, Fox KA, Barton JR. et al. Center of excellence for placenta accreta. Am J Obstet Gynecol 2015; 212 (05) 561-568
    CrossrefPubMedGoogle Scholar
  • 5 ACOG. Levels of maternal care. Obstetric care consensus. Obstet Gynecol 2019; 134: 14
    PubMedGoogle Scholar
  • 6 Jauniaux E, Alfirevic Z, Bhide AG. et al; Royal College of Obstetricians and Gynaecologists. Placenta praevia and placenta accreta: diagnosis and management: green-top guideline no. 27a. BJOG 2019; 126 (01) e1-e48
    PubMedGoogle Scholar
  • 7 D'Antonio F, Iacovella C, Palacios-Jaraquemada J, Bruno CH, Manzoli L, Bhide A. Prenatal identification of invasive placentation using magnetic resonance imaging: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2014; 44 (01) 8-16
    CrossrefPubMedGoogle Scholar
  • 8 Einerson BD, Rodriguez CE, Kennedy AM, Woodward PJ, Donnelly MA, Silver RM. Magnetic resonance imaging is often misleading when used as an adjunct to ultrasound in the management of placenta accreta spectrum disorders. Am J Obstet Gynecol 2018; 218 (06) 618.e1-618.e7
    CrossrefPubMedGoogle Scholar
  • 9 Jauniaux E, Bhide A, Kennedy A, Woodward P, Hubinont C, Collins S. FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO consensus guidelines on placenta accreta spectrum disorders: prenatal diagnosis and screening. Int J Gynaecol Obstet 2018; 140 (03) 274-280
    CrossrefPubMedGoogle Scholar
  • 10 Rahaim NS, Whitby EH. The MRI features of placental adhesion disorder and their diagnostic significance: systematic review. Clin Radiol 2015; 70 (09) 917-925
    CrossrefPubMedGoogle Scholar
  • 11 Einerson BD, Rodriguez CE, Silver RM, Donnelly MA, Kennedy AM, Woodward PJ. Accuracy and interobserver reliability of magnetic resonance imaging for placenta accreta spectrum disorders. Am J Perinatol 2021; 38 (09) 960-967
    Article in Thieme ConnectPubMedGoogle Scholar
  • 12 Jauniaux E, Collins S, Burton GJ. Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging. Am J Obstet Gynecol 2018; 218 (01) 75-87
    CrossrefPubMedGoogle Scholar
  • 13 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42 (02) 377-381
    CrossrefPubMedGoogle Scholar
  • 14 Rac MW, Dashe JS, Wells CE, Moschos E, McIntire DD, Twickler DM. Ultrasound predictors of placental invasion: the placenta accreta index. Am J Obstet Gynecol 2015; 212 (03) 343.e1-343.e7
    CrossrefPubMedGoogle Scholar
  • 15 Shetty MK, Dryden DK. Morbidly adherent placenta: ultrasound assessment and supplemental role of magnetic resonance imaging. Semin Ultrasound CT MR 2015; 36 (04) 324-331
    CrossrefPubMedGoogle Scholar
  • 16 Collins SL, Ashcroft A, Braun T. et al; European Working Group on Abnormally Invasive Placenta (EW-AIP). Proposal for standardized ultrasound descriptors of abnormally invasive placenta (AIP). Ultrasound Obstet Gynecol 2016; 47 (03) 271-275
    CrossrefPubMedGoogle Scholar
  • 17 Tovbin J, Melcer Y, Shor S. et al. Prediction of morbidly adherent placenta using a scoring system. Ultrasound Obstet Gynecol 2016; 48 (04) 504-510
    CrossrefPubMedGoogle Scholar
  • 18 Gilboa Y, Spira M, Sivan E, Schiff E, Achiron R. OP33.11: a new scoring system for the diagnosis of placenta accreta by ultrasound. Ultrasound Obstet Gynecol 2012; 40: 157-157
    CrossrefPubMedGoogle Scholar
  • 19 Zheng W, Zhang H, Ma J. et al. Validation of a scoring system for prediction of obstetric complications in placenta accreta spectrum disorders. J Matern Fetal Neonatal Med 2021; 35 (21) 4149-4155
    CrossrefPubMedGoogle Scholar
  • 20 Kapoor H, Hanaoka M, Dawkins A, Khurana A. Review of MRI imaging for placenta accreta spectrum: pathophysiologic insights, imaging signs, and recent developments. Placenta 2021; 104: 31-39
    CrossrefPubMedGoogle Scholar
  • 21 Jha P, Pōder L, Bourgioti C. et al. Society of Abdominal Radiology (SAR) and European Society of Urogenital Radiology (ESUR) joint consensus statement for MR imaging of placenta accreta spectrum disorders. Eur Radiol 2020; 30 (05) 2604-2615
    CrossrefPubMedGoogle Scholar
  • 22 Clark HR, Ng TW, Khan A. et al. Placenta accreta spectrum: correlation of MRI parameters with pathologic and surgical outcomes of high-risk pregnancies. AJR Am J Roentgenol 2020; 214 (06) 1417-1423
    CrossrefPubMedGoogle Scholar
  • 23 Haba RM, Pristavu AI, Cobzeanu ML. et al. Predicting placenta accreta spectrum disorders in a cohort of pregnant patients in the north-east region of Romania: diagnostic accuracy of ultrasound and magnetic resonance imaging. Diagnostics (Basel) 2022; 12 (09) 12
    PubMedGoogle Scholar
  • 24 Pain FA, Dohan A, Grange G. et al. Percreta score to differentiate between placenta accreta and placenta percreta with ultrasound and MR imaging. Acta Obstet Gynecol Scand 2022; 101 (10) 1135-1145
    CrossrefPubMedGoogle Scholar
  • 25 Shamshirsaz AA, Fox KA, Erfani H, Belfort MA. The role of centers of excellence with multidisciplinary teams in the management of abnormal invasive placenta. Clin Obstet Gynecol 2018; 61 (04) 841-850
    CrossrefPubMedGoogle Scholar
  • 26 Jauniaux E, Ayres-de-Campos D, Langhoff-Roos J, Fox KA, Collins S. FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO classification for the clinical diagnosis of placenta accreta spectrum disorders. Int J Gynaecol Obstet 2019; 146 (01) 20-24
    CrossrefPubMedGoogle Scholar
  • 27 Erfani H, Fox KA, Clark SL. et al. Maternal outcomes in unexpected placenta accreta spectrum disorders: single-center experience with a multidisciplinary team. Am J Obstet Gynecol 2019; 221 (04) 337.e1-337.e5
    CrossrefPubMedGoogle Scholar
  • 28 Bowman ZS, Eller AG, Kennedy AM. et al. Accuracy of ultrasound for the prediction of placenta accreta. Am J Obstet Gynecol 2014; 211 (02) 177.e1-177.e7
    CrossrefPubMedGoogle Scholar
  • 29 Collins SL, Alemdar B, van Beekhuizen HJ. et al; International Society for Abnormally Invasive Placenta (IS-AIP). 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 (06) 511-526
    CrossrefPubMedGoogle Scholar