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IMAGING
Accuracy of ultrasound for the prediction of placenta accreta
Zachary S. Bowman, MD, PhD; Alexandra G. Eller, MD; Anne M. Kennedy, MB BCh, BAO; Douglas S. Richards, MD;
Thomas C. Winter III, MD, MA; Paula J. Woodward, MD; Robert M. Silver, MD

OBJECTIVE: Ultrasound has been reported to be greater than 90% observations. 1205/1374 (87.7% overall, 90% controls, 84.9% cases)
sensitive for the diagnosis of accreta. Prior studies may be subject to studies were given a diagnosis. There were 371 (27.0%) true posi-
bias because of single expert observers, suspicion for accreta, and tives; 81 (5.9%) false positives; 533 (38.8%) true negatives, 220
knowledge of risk factors. We aimed to assess the accuracy of ul- (16.0%) false negatives, and 169 (12.3%) with uncertain diagnosis.
trasound for the prediction of accreta. Sensitivity, specificity, positive predictive value, negative predictive
value, and accuracy were 53.5%, 88.0%, 82.1%, 64.8%, and 64.8%,
STUDY DESIGN: Patients with accreta at a single academic center were
respectively. In multivariate analysis, true positives were more likely to
matched to patients with placenta previa, but no accreta, by year of
have placental lacunae (odds ratio [OR], 1.5; 95% confidence interval
delivery. Ultrasound studies with views of the placenta were collected,
[CI], 1.4e1.6), loss of retroplacental clear space (OR, 2.4; 95% CI,
deidentified, blinded to clinical history, and placed in random sequence.
1.1e4.9), or abnormalities on color Doppler (OR, 2.1; 95% CI,
Six investigators prospectively interpreted each study for the presence
1.8e2.4).
of accreta and findings reported to be associated with its diagnosis.
Sensitivity, specificity, positive predictive, negative predictive value, and
CONCLUSION: Ultrasound for the prediction of placenta accreta may
accuracy were calculated. Characteristics of accurate findings were
not be as sensitive as previously described.
compared using univariate and multivariate analyses.
RESULTS: Six investigators examined 229 ultrasound studies from Key words: placenta accreta, prenatal diagnosis, sensitivity and
55 patients with accreta and 56 controls for 1374 independent specificity, ultrasound

Cite this article as: Bowman ZS, Eller AG, Kennedy AM, et al. Accuracy of ultrasound for the prediction of placenta accreta. Am J Obstet Gyneol 2014;211:177.e1-7.

P lacenta accreta is dened as an


abnormal adherence of placental
villi to underlying myometrium with an infection, venous thromboembolism or
incidence of cesarean delivery,1,4,8,9 pa-
tients and providers are more frequently
confronted with difcult decisions such
absence of decidua basalis. Failure to prolonged hospitalization.4-6 Accurate as whether to plan for a scheduled hys-
anticipate placenta accreta and prepare antenatal diagnosis of placenta accreta terectomy or to transfer care to a tertiary
for its appropriate management can can allow arrangements to be made for a care center. With its implications for
lead to emergency hysterectomy with planned delivery at a tertiary care center surgical morbidity and future fertility,
profuse, life-threatening hemorrhage,1,2 utilizing a multidisciplinary approach, this is not a decision taken lightly.
disseminated coagulopathy, renal fail- which has been shown to signicantly Placenta previa and history of prior
ure, acute respiratory distress, or even reduce maternal morbidity.5-7 cesarean delivery remain the most im-
death.3 Additional surgical complica- As the incidence of placenta accreta portant predictors of placenta accreta.4
tions include cystotomy, ureteral injury, increases concurrently with an increased In addition to clinical risk factors, ul-
trasound is often used antenatally as
an adjunct to clinical history to modify
From the Departments of Obstetrics and Gynecology (Drs Bowman, Eller, Richards, and Silver) and
risk estimation for placenta accreta. The
Radiology (Drs Kennedy, Winter, and Woodward), University of Utah Health Sciences Center, and the
Department of Obstetrics and Gynecology, Intermountain Healthcare (Drs Bowman, Eller, Richards, accuracy of ultrasound for the prediction
and Silver), Salt Lake City, UT. of placenta accreta is generally reported
Received Dec. 17, 2013; revised Jan. 30, 2014; accepted March 10, 2014. to be good with sensitivities ranging
The authors report no conict of interest. from 77e97%.10-15 However, prior
University of Utah Center for Clinical and Translational Sciences grant support (CTSA
studies on the accuracy of ultrasound
5UL1RR025764-02) enabled the use of Research Electronic Data Capture (REDCap) for this project. for the prediction of accreta may be
Presented, in part, in poster format at the 34th annual meeting of the Society for Maternal-Fetal subject to bias because of single expert
Medicine, New Orleans, LA, Feb. 3-8, 2014. observers, suspicion for accreta, and
Reprints not available from the authors. knowledge of risk factors. Our objective
0002-9378/free  2014 Mosby, Inc. All rights reserved.  http://dx.doi.org/10.1016/j.ajog.2014.03.029 was to assess the accuracy of ultrasound
for the prediction of placenta accreta
See related editorial, page 87 using multiple observers blinded to
clinical status.

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Six investigators consisting of 3 expe-


TABLE 1 rienced obstetric radiologists (A.M.K.,
Patient characteristics T.C.W., and P.J.W.) and 3 maternal-fetal
Characteristic Accreta (Cases) Controls P value medicine physicians (A.J.E., D.S.R., and
Maternal age, 32.4  5.2 31.3  6.9 .36a R.M.S.) prospectively reviewed and in-
y (mean  SD) terpreted each ultrasound study. All
Body mass index, kg/m2 29.0  9.4 31.9  6.9 .15a 3 radiologists are fellowship trained in
(mean  SD) abdominal imaging and have more than
Gravidity (median, range) 5 (2e18) 4 (1e14) .0047b 10 years experience in obstetric ultra-
sound, including evaluation of accreta.
Parity (median, range) 3 (1e7) 2 (0e10) .0090b Similarly, all 3 maternal-fetal medicine
Cesarean delivery (n, %) < .001c specialists are fellowship trained and
0 1 (1.8) 16 (28.6) have a minimum of 8 years of experience
in diagnosing placenta accreta (>20
1 17 (30.9) 25 (44.6)
years for 2 of the 3 physicians). In-
2 16 (29.1) 9 (16.1) vestigators were asked to score each
3 21 (38.2) 6 (10.7) imaging study for the presence of accreta
Delivery gestational age, 33.8  3.0 34.9  4.0 .12a (yes, no, or unable to determine)
wk (mean  SD) and indicate the presence or absence
Gestational age at 29.2 (25.1e32.4) 29.3 (23.9e33.6) .11b of specic ndings that have been re-
study, wk (median, ported to be associated with its diag-
interquartile range) nosis. These ndings included the
a
Students t test; b Wilcoxon-Mann-Whitney test; c Fisher exact test. following: number of lacunae,17-20 loss
Bowman. Accuracy of ultrasound for the prediction of placenta accreta. Am J Obstet Gynecol 2014. of retroplacental clear space,13,17,18,20,21
loss of visualization of the myome-
trium,20 and bladder wall irregularity.20
M ATERIALS AND M ETHODS of abnormal adherence of the placenta or
If color Doppler was used, investigators
Patients who delivered at the University evidence of gross placental invasion at the
further identied the presence or
of Utah between 2000 and 2012 with time of surgery. Patients were included
absence of the following: subplacental
documentation of a clinical or histopath- if they had ultrasound images of the
vascularity,10,11,22 vessels bridging from
ologic diagnosis of placenta accreta5,7,16 placenta available at a gestational age of
the placenta to the uterine margin,10,13,20
were identied and matched to patients greater than or equal to 16 weeks. For
gaps in myometrial blood ow,10,20 ves-
with placenta previa but no accreta by each patient, every image of the placenta
sels crossing interface disruption sites,13
year of delivery. Histopathalogic diagno- was collected, de-identied, and blinded
or turbulent lacunae.10,23 If a diagnosis
sis of accreta was conrmed by docu- to clinical history. Images from each study
was made, investigator condence for
mentation of placental invasion into the were then placed in random sequence
each imaging study was scored on a scale
myometrium, and clinical diagnosis of using the Microsoft Excel random num-
of 0 (none) to 10 (certain), and image
accreta was conrmed by documentation ber generator.
quality was scored on a scale from 1 (very
poor) to 10 (best).
Study data were collected and
TABLE 2 managed using REDCap electronic data
Diagnostic performance characteristics of ultrasound for the diagnosis capture tools hosted at the University of
of placenta accreta Utah.24 REDCap (Research Electronic
Excluding Missing/uncertain Data Capture) is a secure, web-based
missing/uncertain diagnoses assigned application designed to support data
Characteristic diagnoses as no accreta capture for research studies, providing:
Sensitivity 62.8 (58.7e66.7) 53.3 (49.5e57.1) (1) an intuitive interface for validated
Specificity 86.8 (83.9e89.4) 88.1 (85.4e90.4) data entry; (2) audit trails for tracking
data manipulation and export pro-
PPV 82.1 (78.7e85.0) 82.1 (78.8e85.4)
cedures; (3) automated export proce-
NPV 70.8 (68.5e73.0) 64.8 (62.9e66.7) dures for seamless data downloads to
Accuracy 75.0 (72.5e77.4) 65.8 (63.2e68.3) common statistical packages; and (4)
Data are % (95% confidence interval). procedures for importing data from ex-
NPV, negative predictive value; PPV, positive predictive value. ternal sources.
Bowman. Accuracy of ultrasound for the prediction of placenta accreta. Am J Obstet Gynecol 2014. Continuous variables were analyzed
with the Student t test. Categorical

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variables were analyzed by the
Wilcoxon-Mann-Whitney, c2 or Fisher FIGURE 1
exact test, where appropriate. Sensitivity, Receiver operating characteristic curve for ultrasound to accurately
specicity, positive predictive value, diagnose placenta accreta
negative predictive value, and accuracy
were calculated according to standard
denitions. For multivariate analyses, all
variables of interest were included in a
logistic regression model. Covariates
were then removed in a stepwise fashion
until all covariates in the nal model
for a particular outcome had a P value
of < .2. Receiver operating characteristic
curves were generated and the area un-
der the curve computed to determine the
discriminative ability of ultrasound to
correctly identify placenta accreta.25 A
P value of < .05 was considered statisti-
cally signicant. All statistical analyses
were performed using Stata 12.1 (Stata-
Corp, College Station, TX). The institu-
tional review board of the University of
Utah approved this study.

R ESULTS
After exclusions, we identied 55 women
with placenta accreta with available im-
aging studies at the University of Utah
between 2000 and 2012. Fifty-six women
with placenta previa but no accreta
and appropriate imaging studies and Areas under the curve are presented corresponding to inclusion or exclusion of uncertain or missing
matched to cases by year of delivery were diagnoses.
chosen as controls. Clinical data are Bowman. Accuracy of ultrasound for the prediction of placenta accreta. Am J Obstet Gynecol 2014.
summarized in Table 1. Compared with
patients with placenta previa only (no
accreta), those with placenta accreta had
signicantly higher parity, more prior controls and 591/696 (84.9%) of cases accreta), are shown in Figure 1. Overall,
cesarean deliveries and an earlier ges- (P .001). Of studies receiving a diag- the diagnostic performance characteris-
tational age at delivery. Maternal age and nosis, diagnostic performance charac- tics were improved when uncertain di-
body mass index at the time of delivery teristics were as follows: 371 true agnoses were excluded.
were similar. positives (30.8%), 81 false positives Given that individual patients may
The 55 women with placenta accreta (6.7%), 533 true negatives (44.2%), and have had more than one ultrasound
had a total of 116 ultrasound studies 220 false negatives (18.3%). 165/1374 study performed, we examined accuracy
and the 56 women with placenta studies (12.0%) were designated unable of diagnoses by patient. Diagnoses for
previa but no accreta had 113 studies. to determine and 4/165 studies (2.4%) the 56 women with previa only (ie, con-
Thus, a total of 229 ultrasound studies were not given a diagnosis. Results for trols) were correct signicantly more
were available for review. All ultra- sensitivity, specicity, positive predictive often than for the 55 cases (75% vs
sound images were collected, deiden- value, negative predictive value and 60.4%, respectively, P < .0068). Simi-
tied, and placed in a random order. overall accuracy are shown in Table 2. larly, concordant with higher overall
Each of the 6 investigators reviewed all Two analyses are presented; one ex- specicity, incorrect results were lower
studies for a total of 1374 independent cluding studies that were interpreted as for controls compared with cases (13.8%
observations. uncertain and one that assigned un- vs 27.0%, respectively, P .0093). The
A specic diagnosis regarding the certain diagnoses as no accreta. Re- ratio of unknown or missing diagnoses
presence or absence of placenta accreta ceiver operator characteristic curves, was not signicantly different between
was reported for 1205/1374 (87.7%) which accounted for ultrasound as a cases and controls (13.3% vs 10.2%,
studies, including 614/678 (90.6%) of binary test (absence or presence of respectively, P .21).

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vs 21.3%, P < .001) or abnormal color


FIGURE 2 Doppler ndings (60.4% vs 83.0%,
Receiver operating characteristic curve for multivariable regression P < .001). False negatives were similarly
model to predict placenta accreta based on specific ultrasound findings associated with these ndings.
Studies given an uncertain diagnosis
were associated with relatively poorer
image quality (4.0 vs 6.0, P < .001). Also,
the magnitude of the differences be-
tween cases and controls with regard
to placental lacunae, loss of the retro-
placental clear space, loss of visualization
of the myometrium, an irregular bladder
wall, and color Doppler abnormalities
was less pronounced than for studies
given a diagnosis.
For each diagnosis, an initial multi-
variate model was created that included
specic ultrasound ndings, perceived
image quality, gestational age at which
the study was performed, maternal age at
delivery, and maternal BMI. Covariates
were then removed in a stepwise fashion
until all covariates in the nal models
had a P value of < .2. True positives were
more likely to have placental lacunae
(OR, 1.5; 95% CI, 1.4e1.6), loss of the
Bowman. Accuracy of ultrasound for the prediction of placenta accreta. Am J Obstet Gynecol 2014. retroplacental clear space (OR, 2.4; 95%
CI, 1.1e4.9), or 1 or more abnormalities
on color Doppler (OR, 2.1; 95% CI,
To determine which ndings on ul- demographic factors were associated 1.8e2.4), earlier study year (OR, 0.93;
trasound were associated with the with accurate and inaccurate diagnoses 95% CI, 0.88e0.99), and absence of an
presence of placenta accreta, an initial (ie, true positives, true negatives, false irregular bladder wall (OR, 0.66; 95%
model was created with accreta as the positives, false negatives, and uncertain CI, 0.50e0.89). True negatives were
outcome and included the following diagnosis). The results of univariate an- more likely to have fewer lacunae (OR,
specic ndings as covariates: number alyses are shown in Table 3. True posi- 0.64; 95% CI, 0.57e0.73), better image
of lacunae, loss of the retroplacental tives were signicantly associated with quality (OR, 1.2; 95% CI, 1.12e1.29),
clear space, loss of visualization of the lower maternal BMI (26.9 vs 29.1, and more advanced gestational age at the
myometrium, irregular bladder wall, or P .0034), better image quality (6.1 vs time of the study (OR, 1.05; 95% CI,
any color Doppler abnormalities. After 5.7, P .0026), more lacunae (5 vs 1.2, 1.02e1.08). As might be expected, true
stepwise removal of covariates from P < .001), loss of the retroplacental clear negatives were less likely to have loss of
the model until remaining covariates space (91.9% vs 19.0%, P < .001), an the retroplacental clear space (OR, 0.34;
had a P value of < .2, only loss of irregular bladder wall (39.4% vs 4.3%, 95% CI, 0.15e0.75) or 1 or more color
visualization of the myometrium was P < .001) and color Doppler abnor- Doppler abnormalities (OR, 0.50; 95%
excluded in the nal model. Placenta malities (97.3% vs 65.7%, P < .001). CI, 0.39e0.65).
accreta was associated with more False positives were associated with False positives were associated with
placental lacunae (odds ratio [OR], 1.4; similar ndings, but color Doppler ab- loss of the retroplacental clear space
95% CI, 1.3e1.6), loss of the retro- normalities were not signicantly dif- (OR, 2.7; 95% CI, 1.9e3.8) or 1 or more
placental clear space (OR, 2.2; 95% CI, ferent from other diagnoses (P .45). color Doppler abnormalities (OR, 1.2;
1.6e3.0), an irregular bladder wall In contrast to the positive results 95% CI, 1.1e1.4) and absence of an
(OR, 1.3; 95% CI, 1.0e1.6) and color (accreta thought to be present), true irregular bladder wall (OR, 0.47; 95%
Doppler abnormalities (OR, 1.3; 95% negatives had fewer lacunae (0.7 vs 3.2, CI, 0.30e0.73). False negatives were
CI, 1.1e1.4). The receiver operating P < .001), and fewer instances of loss associated with an earlier gestational
characteristic curve for this model is of retroplacental clear space (5.3% vs age (OR, 0.96; 95% CI, 0.94e0.99),
shown in Figure 2. 59.9%, P < .001), loss of visualization placental lacunae (OR, 1.2; 95% CI,
Next, we examined whether specic of the myometrium (5.3% vs 59.2%, 1.1e1.3), and inversely associated with
ultrasound ndings and/or patient P < .001), irregular bladder wall (1.9% loss of visualization of the myometrium

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TABLE 3
Specific findings associated with accurate and inaccurate diagnoses
True positive True negative False positive False negative Diagnosis given
P P P P P
Variable Yes No value Yes No value Yes No value Yes No value Yes No value
Gestational age 28.9  4.9 28.3  5.5 .043 28.7  5.6 28.3  5.2 .28 28.0  5.3 28.5  5.4 .46 27.5  5.2 28.7  5.4 .0034 28.5  5.3 28.3  5.6 .59
at study, wk
Maternal age 33.0  5.0 31.8  6.7 .0015 32.4  5.5 31.6  7.5 .021 31.4  5.8 32.1  6.4 .28 31.3  5.8 32.2  6.4 .042 32.0  6.4 33.1  5.6 .029
at study, y
Maternal BMI 26.9  9.9 29.1  10.3 .0034 28.5  10.1 28.5  10.4 .94 23.6  11.6 28.8  10.1 < .001 31.8  9.5 27.7  10.3 < .001 28.4  10.2 29.4  10.6 .37
at delivery
Number of 5.0  2.7 1.2  2.7 < .001 0.74  1.0 3.2  2.8 < .001 2.9  2.4 2.2  2.6 .014 1.4  1.4 2.4  2.7 < .001 2.3  2.6 1.7  1.9 .009
placental
lacunae
Image qualitya 6.1  1.9 5.7  2.2 .0026 6.2  2.0 5.6  2.1 < .001 5.6  2.1 5.8  2.1 .32 5.7  2.0 5.9  2.1 .30 6.0  2.0 4.0  2.0 < .001
Confidence of 63.2  22.3 69.5  22.4 < .001 76.4  19.5 61.6  22.6 < .001 48.0  25.8 69.0  21.7 < .001 68.9  21.5 67.4  22.8 .39 69.0  22.7 49.0  9.4 < .001
interpretationb
Loss of 341 (91.9) 191 (19.0) < .001 28 (5.3) 504 (59.9) < .001 70 (86.4) 462 (35.7) < .001 25 (11.4) 507 (43.9) < .001 464 (38.5) 68 (40.2) < .001
retroplacental
clear space
AUGUST 2014 American Journal of Obstetrics & Gynecology

Loss of 338 (91.1) 188 (18.7) < .001 28 (5.3) 498 (59.2) < .001 67 (82.7) 459 (35.5) < .001 25 (11.4) 501 (43.4) < .001 458 (38.5) 68 (40.2) < .001
visualization
of the
myometrium
Irregular 146 (39.4) 43 (4.3) < .001 10 (1.9) 179 (21.3) < .001 18 (22.2) 171 (13.2) .014 12 (5.45) 177 (15.3) .001 186 (15.4) 3 (1.8) < .001
bladder wall
Any abnormal 361 (97.3) 659 (65.7) < .001 322 (60.4) 698 (83.0) < .001 66 (81.5) 954 (73.8) .45 149 (67.7) 871 (75.5) .022 898 (74.5) 122 (72.2) < .001
Doppler finding
Data are mean  SD or n (%); P value determined by Student t test or c2 test where appropriate.
a
Image quality was scored on a scale from 1 to 10 with 10 representing the best image quality; b Investigator confidence was scored on a scale from 0 to 100% with 100% representing the highest confidence.

Imaging
Bowman. Accuracy of ultrasound for the prediction of placenta accreta. Am J Obstet Gynecol 2014.

Research
177.e5
Research Imaging www.AJOG.org

(OR, 0.30; 95% CI, 0.19e0.46) and by total number of patients in the study) deliveries, the posttest probability is
1 or more color Doppler abnormalities were 95, 91, 95, and 94 percent. For each reduced from 40% to 10%, but for
(OR, 0.54; 95% CI, 0.43e0.68). Image study, patient history and risk for some providers this might not be a suf-
studies for which a diagnosis was unable accreta were known. When only studies cient reduction in risk to avoid a
to be determined were inversely associ- that were given a diagnosis were con- planned cesarean hysterectomy. Con-
ated with image quality (OR, 0.68; 95% sidered in our study, the sensitivity of sider then that these likelihood ratios
CI, 0.62e0.76) and 1 or more color 62.8% was lower than previously re- and diagnostic performance character-
Doppler abnormalities (OR, 0.62; 95% ported. If images with an uncertain istics have already taken into account
CI, 0.49e0.79), whereas loss of visuali- diagnosis are treated as a negative result, pre-test probabilities and may be overly
zation of the myometrium (OR, 3.7; our sensitivity of 53.5% and accuracy optimistic. If the blinded diagnostic
95% CI, 2.7e5.1) and an irregular of 65.8% are even worse with over 1/3 performance characteristics are consid-
bladder wall (OR, 1.7; 95% CI, 1.3e2.1) of cases misidentied. ered (sensitivity of 53.5% and specicity
showed positive associations. Chalubinski et al,27 Esakoff et al,15 of 88%), the likelihood ratio positive is
Warshak et al,11 and Chou et al10 re- only 4.5 (associated with only a moder-
C OMMENT ported specicities of 96, 91, 96, and 97 ate increase in the post-test probability)
Placenta previa and history of prior ce- percent respectively. Our specicity was and the likelihood ratio negative only
sarean delivery are known risk factors for similar regardless of how uncertain di- 0.53. Thus for a patient with a previa and
placenta accreta. The risk for placenta agnoses were treated, 86.8% if excluded 2 prior cesarean deliveries, the posttest
accreta with a previa and 1, 2, 3, or 4 and 88.1% if included. Although this probability of a positive and negative
prior cesarean deliveries is 11, 40, 61, and suggests that a negative ultrasound is ultrasound result would be approxi-
67 percent, respectively.4 Thus, with a able to accurately identify those patients mately 65% and 20%, respectively. Re-
previa and 2 prior cesarean deliveries, without accreta, the lower negative pre- gardless of the ultrasound result, these
the pretest probability for placenta dictive value (64.8%) suggests that an posttest probabilities are sufciently
accreta is approximately 40%. Ultra- important number of those with a neg- imprecise so as to be useful as an
sound is the mainstay for prenatal as- ative ultrasound will be misdiagnosed adjunctive test but not as a denitive
sessment of accreta, and the ability of (ie, have an accreta). gold standard.
ultrasound to accurately predict the When considering a diagnostic test, Previous studies have shown that the
presence of placenta accreta is reported ultimately one needs to decide whether number of placental lacunae,17-20 loss of
to be excellent. One recent systematic the results of that test will change retroplacental clear space,13,17,18,20,21
review and metaanalysis examined the the management of a given patient. loss of visualization of the myome-
diagnostic value of ultrasound and noted Accordingly, one should consider likeli- trium,20 and bladder wall irregularity,
a pooled sensitivity of 83% and a robust hood ratios, the percentage of affected and color Doppler abnormal-
area under the summary receiver oper- people with a positive test result divided ities12,13,15,21,23,24 are associated with
ating characteristic curve of 0.9485.26 by the percentage of unaffected in- placenta accreta. We found that each
However, the 13 studies included were dividuals with a negative test result, incremental increase in placental
limited by a low number of cases per along with pre- and posttest probabili- lacunae on a scale from 0 (none) to 10
study, a priori knowledge of risk factors, ties. 28 Using the pooled sensitivity and (many) was associated with a 1.4-fold
and single expert (or unspecied) ob- specicity from the previously men- increased risk for accreta as well as loss
servers. Our results show that when im- tioned metaanalysis (83% and 95%, of the retroplacental clear space, an
ages are reviewed by a diverse group respectively), the likelihood ratio posi- irregular bladder wall, and abnormalities
of providers, blinded to any clinical his- tive is calculated to be 16.6 with ratios using color Doppler, consistent with the
tory, ultrasound for the prediction of greater than 10 generally thought to observations of other studies. Further-
placenta accreta may not be as sensitive or yield a large increase in posttest proba- more, when the receiver operator char-
accurate as previously described. bility. Thus, in a patient with a previa acteristic curve was computed from this
Chalubinski et al,27 Esakoff et al,15 and 1 or 2 prior cesarean deliveries, logistic regression model, the area under
Warshak et al,11 and Chou et al10 re- the pretest probabilities would be 11 the curve was 0.82, suggesting that
ported the largest studies (80 patients) and 40%, respectively, and the posttest these factors may improve the diagnostic
of ultrasound for the prediction of probabilities would be approximately accuracy of ultrasound (Figure 2).
accreta with 232, 108, 453, and 80 pa- 65 and 90% for a positive ultrasound Although the presence of these factors
tients included, respectively. The total result. Conversely, the likelihood ratio were associated with positive ultrasound
number of patients with conrmed negative would be 0.18 with posttest result and the absence was associated
accreta in these studies (ie, cases) was 35, probabilities of approximately 2 and with negative results, they do not appear
19, 46, and 16 with sensitivities of 91, 10% respectively. Even with a relatively to be useful for distinguishing accurate
89, 77, and 82 percent, respectively. The good test, we cannot completely elimi- from inaccurate results (eg, true posi-
corresponding accuracies (number of nate the possibility of an accreta. In the tives from false positives or true nega-
true positives and true negatives divided case of a previa and 2 prior cesarean tives from false negatives).

177.e6 American Journal of Obstetrics & Gynecology AUGUST 2014


www.AJOG.org Imaging Research
Our study has several strengths. We performance characteristics of ultra- diagnostic criteria for placenta accreta. J Clin
were able to use a relatively large num- sound may not be as high as previously Ultrasound 2008;36:551-9.
14. Shih JC, Palacios Jaraquemada JM, Su YN,
ber of patients with accreta (55) that reported. -
et al. Role of three-dimensional power Doppler
represents the largest number in the in the antenatal diagnosis of placenta accreta:
literature for which ultrasound was ACKNOWLEDGMENTS comparison with gray-scale and color Doppler
evaluated. Each patient had the potential University of Utah Center for Clinical and
techniques. Ultrasound Obstet Gynecol
for multiple studies (116 total) that 2009;33:193-203.
Translational Sciences grant support (CTSA
15. Esakoff TF, Sparks TN, Kaimal AJ, et al.
were then evaluated independently by 5UL1RR025764-02) enabled the use of
Diagnosis and morbidity of placenta accreta.
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