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Placenta accreta spectrum: value of placental bulge as a sign of myometrial invasion on MR imaging

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Abstract

Purpose

To evaluate correlation of “placental bulge sign” with myometrial invasion in placenta accreta spectrum (PAS) disorders. Placental bulge is defined as deviation of external uterine contour from expected plane caused by abnormal outward bulge of placental tissue.

Materials and methods

In this IRB-approved, retrospective study, all patients undergoing MRI for PAS disorders between March 2014 and 2018 were included. Patients who delivered elsewhere were excluded. Imaging was reviewed by 2 independent readers. Surgical pathology from Cesarean hysterectomy or pathology of the delivered placenta was used as reference standard. Fisher’s exact and kappa tests were used for statistical analysis.

Results

Sixty-one patients underwent MRI for PAS disorders. Two excluded patients delivered elsewhere. Placental bulge was present in 32 of 34 cases with myometrial invasion [True positive 32/34 = 94% (95% CI 0.80–0.99)]. Placental bulge was absent in 24 of 25 cases of normal placenta or placenta accreta without myometrial invasion [True negative = 24/25, 96% (95% CI 80–99.8%)]. Positive and negative predictive values were 97% and 96%, respectively. Placental bulge in conjunction with other findings of PAS disorder was 100% indicative of myometrial invasion (p < 0.01). Kappa value of 0.87 signified excellent inter-reader concordance. In 1 false positive, placenta itself was normal but the bulge was present. Surgical pathology revealed markedly thinned, fibrotic myometrium without accreta. One false-negative case was imaged at 16 weeks and may have been imaged too early.

Conclusions

Placental bulge in conjunction with other findings of invasive placenta is 100% predictive of myometrial invasion. Using the bulge alone without other signs can lead to false-positive results.

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Authors and Affiliations

  1. Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Ave., Box 0628, San Francisco, CA, 94131, USA

    Priyanka Jha, Ruth B. Goldstein, Stefanie Weinstein, Tara A. Morgan, Dorothy Shum, Michael A. Ohliger & Liina Poder

  2. Department of Pathology, University of California San Francisco, San Francisco, USA

    Joseph Rabban

  3. Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, USA

    Lee-may Chen

  4. Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, USA

    Nancy Hills

Authors
  1. Priyanka Jha
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  2. Joseph Rabban
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  3. Lee-may Chen
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  4. Ruth B. Goldstein
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  5. Stefanie Weinstein
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  6. Tara A. Morgan
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  7. Dorothy Shum
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  10. Liina Poder
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Correspondence to Priyanka Jha.

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Jha, P., Rabban, J., Chen, Lm. et al. Placenta accreta spectrum: value of placental bulge as a sign of myometrial invasion on MR imaging. Abdom Radiol 44, 2572–2581 (2019). https://doi.org/10.1007/s00261-019-02008-0

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