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Invasive placenta previa: Placental bulge with distorted uterine outline and uterine serosal hypervascularity at 1.5T MRI – useful features for differentiating placenta percreta from placenta accreta

European Radiology volume 28, pages 708–717 (2018)Cite this article

Abstract

Objectives

To characterise MRI features of invasive placenta previa and to identify specific features for differentiating placenta percreta (PP) from placenta accreta (PA).

Methods

Forty-five women with PP and 93 women with PA who underwent 1.5T placental MRI were included. Two radiologists independently evaluated the MRI features of invasive placenta previa, including our novel type of placental bulge (i.e. placental bulge type-II, characterized by placental bulge with distorted uterine outline). Pearson’s chi-squared or Fisher’s two-sided exact test was performed to compare the MRI features between PP and PA. Logistic stepwise regression analysis and the area under the receiver operating characteristic curve (AUC) were performed to select the optimal features for differentiating PP from PA.

Results

Significant differences were found in nine MRI features between women with PP and those with PA (P <0.05). Placental bulge type-II and uterine serosal hypervascularity were independently associated with PP (odds ratio = 48.618, P < 0.001; odds ratio = 4.165, P = 0.018 respectively), and the combination of the two MRI features to distinguish PP from PA yielded an AUC of 0.92 for its predictive performance.

Conclusion

Placental bulge type-II and uterine serosal hypervascularity are useful MRI features for differentiating PP from PA.

Key Points

• Placental bulge type-II demonstrated the strongest independent association with PP.

• Uterine serosal hypervascularity is a useful feature for differentiating PP from PA.

• MRI features associated with abnormal vessels increase the risk of massive haemorrhage.

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Abbreviations

AIP:

Abnormal invasive placenta

AUC:

Area under the receiver operating characteristic curve

MRI:

Magnetic resonance imaging

NPV:

Negative predictive value

PA:

Placenta accreta

PP:

Placenta percreta

PPV:

Positive predictive value

ROC:

Receiver operating characteristic curve

T2-Haste:

T2-weighted half-Fourier single-shot turbo spin echo

T2-True FISP:

T2-weighted true fast imaging with steady-state precession

References

  1. Belfort MA, S. c. f. M.-F. M. Publications Committee (2010) Placenta accreta. Am J Obstet Gynecol 203:430–439

    Article  PubMed  Google Scholar 

  2. Clark SL, Koonings PP, Phelan JP (1985) Placenta previa/accreta and prior cesarean section. Obstet Gynecol 66:89–92

    CAS  PubMed  Google Scholar 

  3. Wu S, Kocherginsky M, Hibbard JU (2005) Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol 192:1458–1461

    Article  PubMed  Google Scholar 

  4. Silver RM, Barbour KD (2015) Placenta accreta spectrum: accreta, increta, and percreta. Obstet Gynecol Clin North Am 42:381–402

    Article  PubMed  Google Scholar 

  5. Cunningham FG WJ (2010) Obstetrical hemorrhage. William’s obstetrics, 23rd edn. McGraw-Hill, New York, pp 776–780

    Google Scholar 

  6. Eller AG, Porter TF, Soisson P, Silver RM (2009) Optimal management strategies for placenta accreta. BJOG 116:648–654

    CAS  Article  PubMed  Google Scholar 

  7. Warshak CR, Ramos GA, Eskander R et al (2010) Effect of predelivery diagnosis in 99 consecutive cases of placenta accreta. Obstet Gynecol 115:65–69

    Article  PubMed  Google Scholar 

  8. Palacios Jaraquemada JM, Bruno CH (2005) Magnetic resonance imaging in 300 cases of placenta accreta: surgical correlation of new findings. Acta Obstet Gynecol Scand 84:716–724

    Article  PubMed  Google Scholar 

  9. Bour L, Place V, Bendavid S et al (2014) Suspected invasive placenta: evaluation with magnetic resonance imaging. Eur Radiol 24:3150–3160

    Article  PubMed  Google Scholar 

  10. Derman AY, Nikac V, Haberman S, Zelenko N, Opsha O, Flyer M (2011) MRI of placenta accreta: a new imaging perspective. AJR Am J Roentgenol 197:1514–1521

    Article  PubMed  Google Scholar 

  11. Kim JA, Narra VR (2004) Magnetic resonance imaging with true fast imaging with steady-state precession and half-Fourier acquisition single-shot turbo spin-echo sequences in cases of suspected placenta accreta. Acta Radiol 45:692–698

    CAS  Article  PubMed  Google Scholar 

  12. Lax A, Prince MR, Mennitt KW, Schwebach JR, Budorick NE (2007) The value of specific MRI features in the evaluation of suspected placental invasion. Magn Reson Imaging 25:87–93

    Article  PubMed  Google Scholar 

  13. Maldjian C, Adam R, Pelosi M, Pelosi M 3rd, Rudelli RD, Maldjian J (1999) MRI appearance of placenta percreta and placenta accreta. Magn Reson Imaging 17:965–971

    CAS  Article  PubMed  Google Scholar 

  14. Srisajjakul S, Prapaisilp P, Bangchokdee S (2014) MRI of placental adhesive disorder. Br J Radiol 87:20140294

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  15. D'Antonio F, Iacovella C, Palacios-Jaraquemada J, Bruno CH, Manzoli L, Bhide A (2014) Prenatal identification of invasive placentation using magnetic resonance imaging: systematic review and meta-analysis. Ultrasound Obstet Gynecol 44:8–16

    Article  PubMed  Google Scholar 

  16. Meng X, Xie L, Song W (2013) Comparing the diagnostic value of ultrasound and magnetic resonance imaging for placenta accreta: a systematic review and meta-analysis. Ultrasound Med Biol 39:1958–1965

    Article  PubMed  Google Scholar 

  17. Masselli G, Brunelli R, Casciani E et al (2008) Magnetic resonance imaging in the evaluation of placental adhesive disorders: correlation with color Doppler ultrasound. Eur Radiol 18:1292–1299

    Article  PubMed  Google Scholar 

  18. Warshak CR, Eskander R, Hull AD et al (2006) Accuracy of ultrasonography and magnetic resonance imaging in the diagnosis of placenta accreta. Obstet Gynecol 108:573–581

    Article  PubMed  Google Scholar 

  19. Leyendecker JR, DuBose M, Hosseinzadeh K et al (2012) MRI of pregnancy-related issues: abnormal placentation. AJR Am J Roentgenol 198:311–320

    Article  PubMed  Google Scholar 

  20. Baughman WC, Corteville JE, Shah RR (2008) Placenta accreta: spectrum of US and MR imaging findings. Radiographics 28:1905–1916

    Article  PubMed  Google Scholar 

  21. Millischer AE, Salomon LJ, Porcher R, et al. (2016) Magnetic resonance imaging for abnormally invasive placenta: the added value of intravenous gadolinium injection. BJOG

  22. Blaicher W, Brugger PC, Mittermayer C et al (2006) Magnetic resonance imaging of the normal placenta. Eur J Radiol 57:256–260

    Article  PubMed  Google Scholar 

  23. Rahaim NS, Whitby EH (2015) The MRI features of placental adhesion disorder and their diagnostic significance: systematic review. Clin Radiol 70:917–925

    CAS  Article  PubMed  Google Scholar 

  24. Cuthbert F, Teixidor Vinas M, Whitby E (2016) The MRI features of placental adhesion disorder–a pictorial review. Br J Radiol 89:20160284

    Article  PubMed  PubMed Central  Google Scholar 

  25. Thiravit S, Lapatikarn S, Muangsomboon K, Suvannarerg V, Thiravit P, Korpraphong P (2016) MRI of placenta percreta: differentiation from other entities of placental adhesive disorder. Radiol Med

  26. Kilcoyne A, Shenoy-Bhangle AS, Roberts DJ, Sisodia RC, Gervais DA, Lee SI (2016) MRI of placenta accreta, placenta increta, and placenta percreta: pearls and pitfalls. AJR Am J Roentgenol 20:1–8

    Google Scholar 

  27. Cali G, Giambanco L, Puccio G, Forlani F (2013) Morbidly adherent placenta: evaluation of ultrasound diagnostic criteria and differentiation of placenta accreta from percreta. Ultrasound Obstet Gynecol 41:406–412

    CAS  Article  PubMed  Google Scholar 

  28. Jauniaux E, Collins SL, Jurkovic D, Burton GJ (2016) Accreta placentation: a systematic review of prenatal ultrasound imaging and grading of villous invasiveness. Am J Obstet Gynecol

  29. Rac MW, Dashe JS, Wells CE, Moschos E, McIntire DD, Twickler DM (2015) Ultrasound predictors of placental invasion: the Placenta Accreta Index. Am J Obstet Gynecol 212:343 e341–347

    Google Scholar 

  30. Chantraine F, Blacher S, Berndt S et al (2012) Abnormal vascular architecture at the placental-maternal interface in placenta increta. Am J Obstet Gynecol 207:188 e181–189

    Article  Google Scholar 

  31. Alamo L, Anaye A, Rey J et al (2013) Detection of suspected placental invasion by MRI: do the results depend on observer' experience? Eur J Radiol 82:e51–e57

    Article  PubMed  Google Scholar 

  32. Levine D, Hulka CA, Ludmir J, Li W, Edelman RR (1997) Placenta accreta: evaluation with color Doppler US, power Doppler US, and MR imaging. Radiology 205:773–776

    CAS  Article  PubMed  Google Scholar 

  33. Palacios Jaraquemada JM, Bruno C (2000) Gadolinium-enhanced MR imaging in the differential diagnosis of placenta accreta and placenta percreta. Radiology 216:610–611

    CAS  Article  PubMed  Google Scholar 

  34. Tanaka YO, Sohda S, Shigemitsu S, Niitsu M, Itai Y (2001) High temporal resolution dynamic contrast MRI in a high risk group for placenta accreta. Magn Reson Imaging 19:635–642

    CAS  Article  PubMed  Google Scholar 

  35. Ray JG, Vermeulen MJ, Bharatha A et al (2016) Association between MRI exposure during pregnancy and fetal and childhood outcomes. JAMA 316:952–961

    Article  PubMed  Google Scholar 

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Author information

Affiliations

  1. Department of MR, Shandong Medical Imaging Research Institute, Shandong University, 324, Jingwu Road, Jinan, Shandong, 250021, People’s Republic of China

    Xin Chen, Xinjuan Zhang, Shanshan Wang, Honglu Shi, Fei Gao & Guangbin Wang

  2. Department of Obstetrics, Jinan Maternity and Child Care Hospital, 2 Jianguoxiaojingsan Road, Jinan, 250001, People’s Republic of China

    Ruiqin Shan

  3. Department of Radiology, Qilu Hospital of Shandong University, 107, Wenhua Xi Road, Jinan, Shandong, 250012, People’s Republic of China

    Lianxin Zhao

  4. Department of Radiation Oncology, Qilu Hospital of Shandong University, 107, Wenhua Xi Road, Jinan, Shandong, 250012, People’s Republic of China

    Qingxu Song

  5. Department of Obstetrics and Gynaecology, Shandong Provincial Hospital Affiliated to Shandong University, 107, Wenhua Xi Road, Jinan, Shandong, 250012, People’s Republic of China

    Changting Zuo

  6. Siemens Healthcare, MR Collaborations NE Asia, Beijing, 100000, People’s Republic of China

    Tianyi Qian

  7. Division of Diagnostic Imaging and Radiology, Children’s National Health System, Washington, DC, 20010, USA

    Catherine Limperopoulos

  8. Department of Radiology, George Washington University School of Medicine, Washington, DC, 20052, USA

    Catherine Limperopoulos

Authors
  1. Xin Chen
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  2. Ruiqin Shan
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  3. Lianxin Zhao
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  4. Qingxu Song
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  5. Changting Zuo
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  6. Xinjuan Zhang
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  7. Shanshan Wang
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  8. Honglu Shi
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  9. Fei Gao
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  10. Tianyi Qian
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  11. Guangbin Wang
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  12. Catherine Limperopoulos
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Corresponding author

Correspondence to Guangbin Wang.

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Guarantor

The scientific guarantor of this publication is Guangbin Wang.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Funding

This work was supported by the National Natural Science Foundation of China under Grant No. 81371534, 81171380.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Ethical approval

Institutional Review Board approval was obtained.

Informed consent

Written informed consent was waived in this retrospective study.

Methodology

• retrospective

• comparative study 

• performed at one institution

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Cite this article

Chen, X., Shan, R., Zhao, L. et al. Invasive placenta previa: Placental bulge with distorted uterine outline and uterine serosal hypervascularity at 1.5T MRI – useful features for differentiating placenta percreta from placenta accreta. Eur Radiol 28, 708–717 (2018). https://doi.org/10.1007/s00330-017-4980-z

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  • DOI: https://doi.org/10.1007/s00330-017-4980-z

Keywords

  • Placenta percreta
  • Placenta increta
  • Placenta accreta
  • Magnetic resonance imaging
  • Prenatal diagnosis