Ultrasound Obstet Gynecol 2006; 28: 178182

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/uog.2797

Sonographic findings of placental lacunae and the prediction

of adherent placenta in women with placenta previa totalis
and prior Cesarean section
J. I. YANG, Y. K. LIM, H. S. KIM, K. H. CHANG, J. P. LEE, and H. S. RYU
Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea

K E Y W O R D S: adherent placenta; intraplacental lacuna; placenta previa totalis

ABSTRACT number of massive transfusions and intensive care unit

Objective To investigate the value of transvaginal
sonographic findings of intraplacental lacunae for
predicting adherent placenta and clinical outcome in
patients with placenta previa totalis and a history of
Cesarean section.
Methods Fifty-one patients with placenta previa totalis
diagnosed by transvaginal sonography and with a history
of Cesarean section who delivered at our hospital
were included in the study. The sonographic findings
of intraplacental lacunae were classified into one of
four grades. Pathological analysis of the placenta was
performed for all patients who delivered, and in
cases of hysterectomy, examination of the uterus was
also performed. The placental findings and obstetric
complications, including massive transfusion, intensive
care unit admission and Cesarean hysterectomy, were
compared with the grade of lacuna.
Results Lacunae were classified as Grade 1+ in 10 cases,
Grade 2+ in 11 cases, Grade 3+ in five cases and as
Grade 0 (i.e. lacunae were absent) in the remaining 25
cases. When lacunae of Grade 1+ were considered, the
sensitivity, specificity, positive predictive value and nega-
tive predictive value of diagnosing adherent placenta were
86.9%, 78.6%, 76.9% and 88.0%, respectively. When
lacunae of Grade 2+ were considered, the sensitivity,
specificity, positive predictive value and negative predic-
tive value of diagnosing placenta increta or percreta were
100%, 97.2%, 93.8% and 100%, respectively. Hysterec-
tomy was performed in 18 cases, among whom two cases
showed Grade 1+ lacunae, 11 cases showed Grade 2+
lacunae, and five cases showed Grade 3+ lacunae. No
hysterectomy was performed in any case in which lacu-
nae were absent. Compared to those without lacunae, the
admissions and cases of disseminated intravascular coag-
ulopathy and Cesarean hysterectomy were significantly
greater in those with lacunae (P < 0.0001).
Conclusion Transvaginal sonographic findings of intra-
placental lacunae in patients with placenta previa totalis
and a history of Cesarean section are useful in the
prediction of adherent placenta and may have a role
in the prediction of clinical outcome. Copyright 2006
ISUOG. Published by John Wiley & Sons, Ltd.
INTRODUCTION
Adherent placenta, including placenta accreta and its
variants placenta increta and percreta, occurs as a
result of placental villi penetrating the myometrium
through a defect in the decidua basalis. It is a major
cause of obstetric hemorrhage and is thus associated
with increased maternal morbidity and mortality. Early
diagnosis can improve the perinatal prognosis by enabling
preparations for a possible obstetric emergency to be made
and avoiding obstetric complications such as Cesarean
hysterectomy and massive transfusion1 . However, in most
cases adherent placenta is diagnosed at the time of delivery
when total removal of the placenta from the uterus fails
and hemorrhage occurs.
The sonographic characteristics of adherent placenta
include loss of the normal hypoechoic retroplacental
myometrial zone, thinning or disruption of the hyper-
echogenic uterine serosabladder wall interface, and
presence of focal exophytic masses and intraplacental
lacunae2 . Of these, the presence of intraplacental lacu-
nae was the first criterion to be associated with placenta
accreta and it was reported that the larger and more

Correspondence to: Dr J. I. Yang, Department of Obstetrics & Gynecology, Ajou University School of Medicine, San-5, Wonchon-dong,
Yongtong-ku, Kyunggi-do, Suwon, Korea 442-749 (e-mail: yangji@ajou.ac.kr)
Accepted: 3 April 2006

Copyright 2006 ISUOG. Published by John Wiley & Sons, Ltd. ORIGINAL PAPER
Intraplacental lacunae in placenta previa totalis with prior Cesarean section
irregular the intraplacental lacunae became, the higher the
frequency of placenta accreta3 . Comstock et al. reported
that ultrasound examination during the second and third
trimesters provides the most reliable data to be used in
diagnosing placenta accreta4 .
The aim of this study was to investigate the value
of intraplacental lacunae observed on transvaginal
sonography for predicting the prognosis in patients with
a history of Cesarean section and with placenta previa
totalis, which are risk factors for placenta accreta.
METHODS
The study population consisted of 51 women with a
history of previous Cesarean section who were diagnosed
with placenta previa totalis and delivered between January
1996 and February 2004. Ultrasound examinations were
performed throughout the second and third trimesters
of pregnancy, and placenta previa totalis was defined
as the placenta covering the entire endocervix at
the time of delivery. Transvaginal sonography (ATL-
UM9, Ultramark 9, Advanced Technology Laboratories,
Bothell, WA, USA and ALOKA SSD 5500, Corometrics
Ultrasound Medical Systems, Wallingford, CT, USA) was
performed to assess the presence and extent of lacunae
within the placenta and classify them into four grades
from Grade 0 to Grade 3 according to Finbergs criteria2 .
Figure 1 Grading of intraplacental lacunae by transvaginal sonography: Grade 0 (a), Grade 1 (b), Grade 2 (c) and Grade 3 (d).
Copyright 2006 ISUOG. Published by John Wiley & Sons, Ltd.
179
Intraplacental lacunae were graded as: Grade 0 when
none was seen (Figure 1a), Grade 1+ when one to three
generally small lacunae were present (Figure 1b), Grade
2+ when four to six larger or more irregular lacunae
were present (Figure 1c), and Grade 3+ when there were
many throughout the placenta, some appearing large and
irregular in shape (Figure 1d). The examinations were
performed by two examiners (J. I. Y. and H. S. K.), whose
consensus opinion was finally recorded.
Adherent placenta was determined following surgery
and pathological analysis of the placenta, and in the
cases of Cesarean hysterectomy uterine pathology was
also examined. Pathological diagnosis of the uterus was
classified according to the depth of myometrial invasion
as placenta accreta, placenta increta, or placenta percreta.
In cases in which the placenta was difficult to detach from
the uterus or in which a part of the placenta remained
attached, if massive bleeding occurred on the placental
site after its removal, a diagnosis of placenta accreta was
made based on the operators opinion5 .
Obstetric complications, including frequency of massive
transfusion of more than four pints of packed red blood
cells, need for admission into intensive care unit, presence
of disseminated intravascular coagulopathy and Cesarean
hysterectomy, were recorded. Pathological findings and
obstetric complications were analyzed according to the
presence and absence of intraplacental lacunae.
Ultrasound Obstet Gynecol 2006; 28: 178182.
180 Yang et al.

Students t-test, the Chi-square test and multiple
regression analysis were performed using the SPSS
statistical package (version 11.5, SPSS Inc, Chicago, IL,
USA).
RESULTS
Patient characteristics are shown in Table 1. The presence
of lacunae within the placental parenchyma was noted
in 26 cases and none was seen in 25 cases. The placenta
was located anteriorly in all but one case in which it was
posterior. One prior Cesarean section had been performed
in 46 cases (90.2%), two in four cases (7.8%) and
there was one case (2.0%) in which three prior Cesarean
sections had been performed. When the cases with lacunae
were compared with those in which no lacunae were
seen, gravidity, parity and number of previous Cesarean
sections were significantly higher in those with lacunae.
Maternal age, gestational age at delivery, number of
dilatation and evacuations and neonatal body weight were
not significantly different between the groups (Table 1).
The distribution of lacunae by grade among the cases is
shown in Table 2. More serious variants of adherent
placenta (increta and percreta) were associated with
Grade 2 and 3 placental lacunae (Table 2).
In the cases with Grade 1+ lacunae (i.e. when
at least one lacuna was present within the placental
parenchyma) the sensitivity, specificity, positive predictive
value and negative predictive value for the diagnosis
of adherent placenta were 86.9%, 78.6%, 76.9% and
88.0%, respectively. In the cases with Grade 2+
lacunae, the sensitivity, specificity, positive predictive
value and negative predictive values for diagnosing
placenta increta or percreta were 100%, 97.2%, 93.8%
and 100%, respectively (Table 3).
Obstetric complications were more frequent in cases
in which lacunae were present (Table 4). Cesarean
hysterectomy was performed in 18 cases, and all of
these cases showed intraplacental lacunae on transvaginal
sonography; two cases showed Grade 1+ lacunae, 11
cases showed Grade 2+ lacunae and five cases showed
Grade 3+ lacunae. Of the cases where no lacunae were
seen, none underwent hysterectomy.
Maternal death occurred in one case, and this patient
had two previous Cesarean deliveries and showed Grade
2+ lacunae on transvaginal sonography. Emergency
Cesarean hysterectomy was performed owing to massive
bleeding, but a thromboembolism blocked the right
ventricle during the surgery and led to the patients death.
Surgicopathological findings in this case revealed placenta
increta.

Table 1 Clinical characteristics according to lacunae (mean SD)

Table 3 Diagnostic accuracy of adherent placenta according to
lacunae
Lacunae
Sensitivity Specificity PPV NPV
Characteristic Absent (n = 25) Present (n = 26) P
(%) (%) (%) (%)

Maternal age (years) 31.6 4.2 32.7 4.6 NS

Diagnosis of adherent 86.9 78.6 76.9 88.0
Gestational age at 36.0 3.8 36.5 1.8 NS
placenta when
delivery (weeks)
lacunae were
Gravidity 3.4 1.1 4.3 1.4 0.020
Grade 1
Parity 1.1 0.3 1.5 0.6 0.025
Diagnosis of increta, or 100 97.2 93.8 100
Number of previous 1.2 1.1 1.8 1.3 NS
percreta when
dilatation and
lacunae were
curretage
Grade 2
Number of previous 1.0 0.2 1.4 0.6 0.006
Cesarean sections
Neonatal body weight 2831 657 3087 522 NS NPV, negative predictive value; PPV, positive predictive value.
(g)

NS, not significant; P determined by Students t-test and Chi-square Table 4 Obstetric complications according to lacunae
test.
Lacunae

Table 2 Distribution of adherent placenta according to lacunar Absent Present

grade (n = 25) (n = 26) P

Grading Transfusion (pints) 2.30 2.99 23.37 18.14 < 0.0001

Massive transfusion 6 (24.0%) 23 (88.5%) < 0.0001
Adherent Grade 0 Grade 1 Grade 2 Grade 3 ( 4 pints of PRBC)
placenta (n = 25) (n = 10) (n = 11) ( n = 5) DIC 6 (23.1%) < 0.0001
ICU admission 12 (46.2%) < 0.0001
None 22 6 Cesarean hysterectomy 18 (69.2%) < 0.0001
Accreta 3 4 1
Increta 5 4 DIC, disseminated intravascular coagulopathy; ICU, intensive care
Percreta 5 1 unit; PRBC, packed red blood cells. Analysis by multiple regression
Total 25 10 11 5 analysis (variables: gravidity, parity, Cesarean section, curettage,
anterior placenta).

Copyright 2006 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2006; 28: 178182.
Intraplacental lacunae in placenta previa totalis with prior Cesarean section
DISCUSSION
Adherent placenta rarely occurs, but it is a major cause
of obstetric bleeding. It can also cause uterine perforation
and infection and is thus clinically very important.
Adherent placenta can occur in the lower uterus, in the
scar from a previous Cesarean delivery, and at the site of
dilatation and curettage, where the decidua basalis may
be defective. The incidence of adherent placenta has been
reported as 1 in 2500 deliveries by Read et al.6 while
Gielchinsky et al.5 reported a rate of 0.9%. Its incidence,
along with that of placenta previa, has increased with
increasing incidence of Cesarean delivery1 .
The diagnosis of adherent placenta is usually made
on delivery of the placenta, but predicting it prenatally
with the use of ultrasonography is becoming increasingly
common. The conventional sonographic criteria for
adherent placenta include absence of normal hypoechoic
retroplacental myometrial zone, thinning or disruption
of the hyperechogenic uterine serosabladder interface,
the presence of focal mass-like elevations or extensions
of placental tissue beyond the uterine serosa, and
the presence of intraplacental lacunae. Using these
sonographic criteria, Finberg and Williams2 achieved
a 77.8% positive predictive value and 93.3% negative
predictive value, and Guy et al. reported a 62.5% positive
predictive value for adherent placenta7 .
Intraplacental lacunae are vascular lakes of various
sizes and shapes seen within placental parenchyma. They
were first reported by Kerr de Mendonca3 in 1988,
and Hoffmann-Tretin et al.8 and Finberg and Williams2
subsequently used this as a criterion for the diagnosis of
adherent placenta. Their exact mechanism of development
is unknown, but the large amount of blood flow and high
flow rate of adherent placenta9 , as well as inappropriate
placental implantation10 are reported to cause mechanical
disruption of the placenta. Finberg and Williams classified
these lacunae according to the number, size and shape
into four grades, and reported that the higher the lacunar
grade, the higher the frequency of adherent placenta2 .
Recently Comstock et al. reported that of the four criteria
for diagnosing placenta accreta using ultrasonographic
examination during the second and third trimesters, that
of intraplacental lacunae was found to be the most reliable
one, with 93% sensitivity and 93% positive predictive
value4,11 . Furthermore, they reported that intraplacental
lacunae were first observed at about the 15th gestational
week, thus they serve as useful indicators for the early
diagnosis of placenta accreta at around 1520 weeks
gestation, with a sensitivity of 79% and positive predictive
value of 92%. The data from the present study showed
similar results with respect to the accuracy of predicting
adherent placenta using the presence of intraplacental
lacunae as the diagnostic criterion. There were three false-
negative cases but the outcome was good in each case
with no complications at delivery.
Since intraplacental lacunae are associated with
adherent placenta, they may be used to predict obstetric
complications. In our study the cases with intraplacental
Copyright 2006 ISUOG. Published by John Wiley & Sons, Ltd.
181
lacunae presented with a significantly higher rate of
clinical complication, especially related to the need for
massive transfusion, admission to the intensive care unit
and Cesarean hysterectomy.
The use of color Doppler imaging can improve the
accuracy of diagnosis of adherent placenta since the depth
of invasion of the placenta into the uterine myometrium
or serosa can be more accurately determined, especially
in cases where the placenta is located anteriorly10 13 .
Magnetic resonance imaging (MRI) can also be used
in the diagnosis14,15 and is particularly helpful when
the placenta is located posteriorly14 . Chou et al. used
the following criteria for diagnosing adherent placenta:
diffuse or focal lacunar flow, hypervascularity of the
bladderuterine serosa interface, prominent subplacental
venous complex and loss of subplacental Doppler vascular
signals. They reported a sensitivity of 82.4%, specificity
of 96.8%, a positive predictive value of 87.5% and
a negative predictive value of 95.3%16 . Other useful
indicators on color Doppler imaging include low velocity,
non-pulsatile flow or low-resistance pulsatile intervillous
flow velocity17,18 . Lerner et al. stated that since the
existence of flow within the lacunae alone shows 100%
sensitivity and 83% positive predictive value in diagnosing
placenta accreta, color Doppler imaging results can be
added to the pre-existing data on intraplacental lacunae
to improve the rate of diagnosis12 .
Color Doppler examinations were carried out at the
time of the present study but as both lacunae with
turbulent flow and lacunae without flow simultane-
ously appeared within the same placenta, we decided
to confine our analysis to the grayscale ultrasound
findings. However, since intraplacental lacunae tend to
have a bleeding characteristic which stems from their
developmental mechanism, the comparison of adher-
ent placenta and obstetric complications between lacu-
nae with turbulent flow and those without flow is
considered to be helpful in predicting the clinical out-
come.
In summary, intraplacental lacunae in patients with
placenta previa totalis and with a prior Cesarean section
can be useful in predicting adherent placenta, and the
presence of Grade 2+ lacunae is strongly associated with
variants of placenta accreta such as placenta increta and
percreta. Furthermore, in cases where lacunae are seen,
the incidence of maternal complications such as massive
transfusion, admission to the intensive care unit and
Cesarean hysterectomy related to massive intraoperative
bleeding increases significantly. Thus, the existence of
intraplacental lacunae in patients with placenta previa
totalis with prior Cesarean section can be useful in
determining the patients clinical outcome, as well as
in counseling the patient, and in preparing her for
surgery.
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