Research www. AJOG.

org

OBSTETRICS
Screening for placenta accreta at 11-14 weeks of gestation
Julien J. Stirnemann, MD; Eve Mousty, MD; Gihad Chalouhi, MD; Laurent J. Salomon, MD, PhD;
Jean-Pierre Bernard, MD; Yves Ville, MD

OBJECTIVE: We sought to describe the potential value of 11-14 weeks’
screening for placenta accreta (PA).
STUDY DESIGN: Patients with a history of lower segment cesarean
section were prospectively included between 11-13⫹6 weeks over a
1.5-year period. The first 258 were offered standard screening
whereas the following 105 underwent screening for PA. Women were
considered high-risk when the trophoblast overlapped the scar visual-
ized by transvaginal ultrasound and low-risk otherwise.
RESULTS: The group screened for PA did not differ from the non-
screened group for demographic characteristics. In all, 6 of 105 (5.8%)
women were considered high-risk. In the nonscreened group, 1 case of
PA was discovered during an elective repeat cesarean. In the screened
population, 1 case of PA occurred in a high-risk patient allowing a con-
servative planned management at 35 weeks.
CONCLUSION: At 11-14 weeks, ultrasound may help risk stratification
for PA with a specific follow-up. Early recognition of patients at risk
might improve the perinatal outcome of PA.
Key words: cesarean, first trimester, placenta accreta, screening,
ultrasound

Cite this article as: Stirnemann JJ, Mousty E, Chalouhi G, et al. Screening for placenta accreta at 11-14 weeks of gestation. Am J Obstet Gynecol
2011;205:547.e1-6.

P lacenta accreta (PA) is a life-threat-

ening obstetrical condition that oc-
curs when a defect of the decidua basalis
enables the direct apposition of chori-
onic villi to the myometrium. As a result,
at least part of the placenta cannot sepa-
rate after delivery and this may lead to
severe obstetric hemorrhage.1-5 It has
become the principal indication for
postpartum hysterectomy as well as for
related surgical injuries.6-10 The inci-
dence of PA has increased 4-fold from
199411 through 2002,12 following the in-
crease in cesarean delivery rates over the
same period of time. Most PA present as
placenta previa in the third trimester
From the Department of Obstetrics and
Maternal-Fetal Medicine, GHU Necker–
Enfants Malades, Université Paris Descartes,
Paris, France.
Received Feb. 9, 2011; revised May 29, 2011;
accepted July 13, 2011.
This study was supported by the Société
Française pour l’Amélioration des Pratiques
Echographiques in setting teaching sessions.
The authors report no conflict of interest.
Reprints: Yves Ville, MD, Maternité, Hôpital
Necker–Enfants Malades, 149 rue de Sèvres,
75015 Paris, France. ville.yves@gmail.com.
0002-9378/$36.00
© 2011 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2011.07.021
with an incidence of 9.3% in this group
compared with 0.005% when the pla-
centa is normally inserted.11 Among
women with placenta previa, maternal
age ⱖ35 years and previous cesarean de-
livery are independent risk factors, with
an incidence of 2% for women aged ⬍35
years and no cesarean section up to 38%
in women aged ⱖ35 years and ⱖ2 previ-
ous cesarean sections.11
It is important to diagnose PA prior to
delivery, to allow for optimal concerted
management planning and prevention
of severe maternal morbidity and mor-
tality.13-17 The diagnosis of PA by ultra-
sound and magnetic resonance imaging
(MRI) in the second and third trimester
of pregnancy remains largely speculative,
even in high prevalence cohorts,18-21 and
most cases are only diagnosed at the time
of delivery in cases with prepartum or
postpartum hemorrhage.13-16 The timing
of the defective trophoblast implantation
leading to PA suggests that this condition
could be identified during the 11-14 weeks’
ultrasound.
Signs of PA have been recognized as
early as the first trimester in several case
reports.22-26 However, these findings
have never been implemented in a pro-
spective early screening strategy. The
main aim of our study was to describe
the potential use of routine 11-14 weeks’
scan27 for screening for PA in women
with a history of delivery by lower seg-
ment cesarean section (LSCS).
M ATERIALS AND M ETHODS
The screening procedure for PA was de-
fined in patients with a history of LSCS as
follows: a transvaginal midsagittal plane
was defined, including the cervical canal,
the bladder, and the lower part of the
gestational sac.28 Both the uterine scar
and the location of the trophoblast were
recognized and located. The relationship
between the uterine scar and the tropho-
blast thus defined the high-risk group. A
patient was considered high-risk when
the scar was exposed within the uterine
cavity above the lowest part of the gesta-
tional sac, which encompasses the cervix
and part of the inferior segment together
with a covering low-lying placenta (Fig-
ure 1).28 A patient was considered low-
risk either when the uterine scar was pro-
tected within the cervicoisthmic canal
(Figure 2, A) or when the trophoblast
was not covering the internal os (Figure
2, B).28
The population considered for this
study comprises all consecutive cases of
patients with a history of lower segment
uterine scar over a 1.5-year period (Sep-
tember 2008 through March 2010) at-
tending our unit for first-trimester

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Research Obstetrics www.AJOG.org

screening at 11-13⫹6 weeks as defined

FIGURE 1
by a crown-rump length between 45-84
Exposed scar with overlapping trophoblast (T) defining high-risk group mm. During a first period of time, pa-
tients were not specifically screened for
placenta and scar location. In a second
period, patients were screened for PA by
transvaginal ultrasound.
All ultrasounds were performed using
a General Electrics Voluson E8 or 730
Expert (GE Medical System Europe, Buc,
France) with a 3.5- to 5-MHz or 6- to
8-MHz transvaginal transducer.
Demographic data as well as obstetri-
cal and perinatal management and out-
come were prospectively recorded in our
electronic database (Astraia, Munich,
Arrows ⫽ uterine scar. Germany). Patients considered high-risk
B, bladder; C, cervix; GS, gestational sac. were followed up prospectively with se-
Stirnemann. Screening for placenta accreta at 11-14 weeks. Am J Obstet Gynecol 2011. rial ultrasound focusing on ultrasound
signs of placental invasion in our unit up
until delivery.
The statistical analysis was conducted
FIGURE 2 using R (www.r-project.org). Quantita-
Protected and exposed scars tive variables are summarized by the me-
dian and interquartile range (25th-75th
centile) and qualitative variables are de-
scribed by N (%). Comparisons of de-
mographic characteristics between the
screened and nonscreened populations
were performed using Mann-Whitney U
tests for quantitative variables and Fisher
exact tests for qualitative variables.
Since transvaginal ultrasound is of-
fered routinely for first-trimester screen-
ing in our practice, this study did not re-
quire an institutional review board;
however, written informed consent was
obtained from all women.

R ESULTS
Over the study period, 363 women with a
history of LSCS attended our unit for
first-trimester screening at 11-13⫹6
weeks’ gestation. Among these, the first
258 women were screened only for aneu-
ploidy and fetal defects whereas the fol-
lowing 105 were also prospectively
screened for PA. No significant differ-
ences in demographic characteristics
were found between the screened and the
A, Protected scar with trophoblast (T) overlapping internal os. B, Exposed scar with nonoverlapping T. nonscreened populations (Table 1). In
Arrows ⫽ uterine scar. particular, considering risk factors for
B, bladder; C, cervix; GS, gestational sac. PA, maternal age (P ⫽ .12), parity (P ⫽
Stirnemann. Screening for placenta accreta at 11-14 weeks. Am J Obstet Gynecol 2011. .46), number of scars (P ⫽ .28), and rates
of emergency cesarean operations (P ⫽

547.e2 American Journal of Obstetrics & Gynecology DECEMBER 2011

www.AJOG.org Obstetrics Research

.06) were similar. The overall rate of loss

to follow-up was 38/363 (10.5%) and TABLE 1
was similar in both groups (9/105 [8.6%] Comparison of demographic characteristics between
and 29/258 [11.2%], P ⫽ .57). The deliv- screened and nonscreened populations
ery mode was unknown in 5 cases. Without 11-14 wk’ With 11-14 wk’
Obstetrical and perinatal manage- Overall screening screening
ment of the study population is summa- Characteristic n ⴝ 363 n ⴝ 258 n ⴝ 105 P value
rized in Figure 3. Two patients under- Age, y .12
..............................................................................................................................................................................................................................................
went termination of pregnancy and 3 Median (IQR) 35 (31–38) 35 (32–39) 34 (30–38)
miscarried ⬍24 weeks’ gestation. These .....................................................................................................................................................................................................................................
Missing 0
patients together with 3 cases of intra- ..............................................................................................................................................................................................................................................

uterine fetal demise delivered vaginally. Parity .46

.....................................................................................................................................................................................................................................
All live-born pregnancies with at least 2 1 212 (58.4%) 157 (60.9%) 52 (55.9%)
.....................................................................................................................................................................................................................................
uterine scars delivered by elective cesar- ⬎1 139 (38.3%) 101 (39.1%) 41 (44.1%)
.....................................................................................................................................................................................................................................
ean whereas patients with only 1 scar
Missing 12 (3.3%)
attempted vaginal birth in 162/262 ..............................................................................................................................................................................................................................................

(61.8%) with a 105/262 (64.8%) success No. of scars .28

.....................................................................................................................................................................................................................................
rate. 1 305 (84.0%) 221 (85.7%) 84 (80%)
.....................................................................................................................................................................................................................................
Perinatal complications related to prior 2 54 (14.9%) 34 (13.2%) 20 (19%)
.....................................................................................................................................................................................................................................
cesarean included 2 cases (0.6%) of PA, 16
ⱖ3 4 (1.1%) 3 (1.1%) 1 (1%)
cases (5%) of severe postpartum hemor- .....................................................................................................................................................................................................................................

rhage requiring sulprostone or surgery, 2 Missing 0

..............................................................................................................................................................................................................................................
cases (0.6%) of placenta previa, and 2 cases Interval since last delivery, mo .14
.....................................................................................................................................................................................................................................
(0.6%) of complete uterine rupture. The Median (IQR) 28 (12–49) 26.5 (11.7–45.5) 32 (14–54)
.....................................................................................................................................................................................................................................
occurrence of PA in the study population is
Missing 137 (37.7%)
summarized in Figure 4 with respect to ..............................................................................................................................................................................................................................................

screening results. History of vaginal birth .36

.....................................................................................................................................................................................................................................
Within the nonscreened population, 1 Yes 64 (17.6%) 42 (17.4%) 22 (21.8%)
.....................................................................................................................................................................................................................................
case of placenta percreta was discovered No 279 (76.9%) 200 (82.6%) 79 (78.2%)
.....................................................................................................................................................................................................................................
during elective cesarean at 39⫹5 weeks
Missing 20 (5.5%)
in a 31-year-old, 4-parous patient with a ..............................................................................................................................................................................................................................................

history of 2 cesareans. This patient had VBAC .16

.....................................................................................................................................................................................................................................
an uneventful follow-up until delivery. Yes 33 (9.1%) 27 (11.3%) 6 (5.8%)
.....................................................................................................................................................................................................................................
Upon opening of the peritoneum, pla- No 309 (85.1%) 212 (88.7%) 97 (94.2%)
.....................................................................................................................................................................................................................................
cental bulging through the anterior uter-
Missing 21 (5.8%)
ine wall required a fundal incision. A con- ..............................................................................................................................................................................................................................................

servative management was performed Emergency cesarean .06

.....................................................................................................................................................................................................................................
leaving the placenta and the uterus. Embo- Yes 119 (32.8%) 77 (29.8%) 42 (40%)
.....................................................................................................................................................................................................................................
lization of uterine and internal iliac arteries No 244 (67.2%) 181 (70.2%) 63 (60%)
.....................................................................................................................................................................................................................................
was subsequently performed. Follow-up
Missing 0
was uneventful apart from episodic bleed- ..............................................................................................................................................................................................................................................

ing without signs of infection, with MRI Postpartum pyrexia .38

examinations showing progressive involu-
tion of the placenta at 8 months after
cesarean.
Within the screened population, 1 scar
was not visualized, 6 of 104 (5.8%) pa-
tients were considered high-risk based
upon a trophoblast overlapping an ex-
posed scar, and 98 of 104 were consid-
ered low-risk. One case of PA was discov-
ered in the sixth high-risk patient. This
patient had been followed-up by serial
ultrasound at 16⫹1, 18⫹1, 22⫹1, 25⫹1,
and 29⫹1 weeks confirming signs of PA
both on ultrasound and MRI with a low-
.....................................................................................................................................................................................................................................
Yes 15 (4.1%) 9 (3.5%) 6 (5.7%)
.....................................................................................................................................................................................................................................
No 348 (95.9%) 249 (96.5%) 99 (94.3%)
.....................................................................................................................................................................................................................................
Missing 0
..............................................................................................................................................................................................................................................
IQR, interquartile range; VBAC, vaginal birth after cesarean.
Stirnemann. Screening for placenta accreta at 11-14 weeks. Am J Obstet Gynecol 2011.
lying anterior placenta. Elective cesarean incision. No attempt was made to extract
section was performed at 35 weeks under the placenta. Uterine and internal iliac
epidural anesthesia after a course of be- arteries embolization was then per-
tamethasone given for fetal lung matu- formed systematically. Blood loss was
rity enhancement. The inferior segment 300 mL and the postpartum period was
was richly vascularized. Hysterotomy uneventful. The placenta was still intra-
was performed through a fundal vertical uterine at 3 months when she developed

DECEMBER 2011 American Journal of Obstetrics & Gynecology 547.e3

Research Obstetrics www.AJOG.org

endometritis and hysterectomy was eas-

FIGURE 3
ily performed without technical prob-
Obstetric management of delivery in study population lems. She was discharged home after 54
days. Pathology examination confirmed
placenta increta. The 5 other patients
considered high-risk based upon 11-14
weeks’ ultrasound had an uneventful fol-
low-up (Table 2) and delivered vaginally
(n ⫽ 2) or by cesarean (n ⫽ 3) without
complications at between 38-40 weeks’
gestation.

C OMMENT
PA is a life-threatening obstetrical emer-
gency. Its incidence has risen in parallel
with that of cesarean deliveries and it re-
mains a major cause of maternal mortal-
ity and morbidity as the principal indi-
cation for postpartum hysterectomy
with high blood loss, intensive care unit
admission, and intraoperative injury to
the bladder or bowel.13,15,16
Efforts have been made to refine the
IUFD, intrauterine fetal demise; LSCS, lower segment cesarean section; LTFU, lost to follow-up; TOP, termination of pregnancy.
ultrasound diagnosis of PA in the second
Stirnemann. Screening for placenta accreta at 11-14 weeks. Am J Obstet Gynecol 2011.
and third trimester of pregnancy, con-
sisting in the presence of placental lacu-
nae (irregularly shaped vascular spaces
with turbulent blood flow at the color
Doppler), loss of retroplacental clear
FIGURE 4 space, thinning of the myometrium
Flowchart of study population with respect to overlying the placenta and interruption
screening and occurrence of placenta accreta of the bladder line with protrusion of the
placenta into the bladder, or evidence of
hypervascularization by Doppler.21,29-31
The performance of ultrasound has been
studied in very high-risk populations,
with a prevalence of PA ranging from
9-44%. In these studies the sensitivity
of ultrasound, with ⱖ1 contemporary
signs, varies from 77-93% and the posi-
tive predictive value from 65-93%.18-21
Although MRI may help refine the diag-
nosis following ultrasonography,32,33 its
overall sensitivity remains unclear.19,29
However, most cases of PA remain undi-
agnosed until the time of delivery.13,15,16
PA, however, is likely to develop at the
time of the trophoblast invasion in the
first trimester.34,35 The study of the tro-
phoblast’s location in the first trimester
is feasible as part of the routine 11-13⫹6
weeks’ scan. Mustafá et al36 in 2002 have
LSCS, lower segment cesarean section; LTFU, lost to follow-up. well established the probability of pla-
Stirnemann. Screening for placenta accreta at 11-14 weeks. Am J Obstet Gynecol 2011. centa previa at term in relation to the dis-
tance/overlap of the lower placental edge

547.e4 American Journal of Obstetrics & Gynecology DECEMBER 2011

www.AJOG.org
with respect to the internal cervical os.
The cesarean scar has been studied and
described in nonpregnant women as part
of the investigation of the relationship
between scar defects and postmenstrual
spotting, dysmenorrhea, and pelvic
pain.37-40
The sonographic diagnosis in the first
trimester has been reported in a few
cases22-25 mainly as a low gestational sac
in early first trimester, suggesting a direct
implantation of the trophoblast over the
scar.26 However, these cases are difficult
to differentiate from ectopic pregnancies
developing in the LSCS scar. These cases
of PA detected in early pregnancy all
showed very specific sonographic fea-
tures. These findings, however, are un-
likely to be fit for 11-14 weeks’ screening
policy, since their prevalence in PA as
well as in normal pregnancies has not
been formally studied. We believe these
ultrasound findings should be used in
second-line diagnostic scans in screen-
positive patients.
Ultrasound examination is now rou-
tinely offered to all pregnant women at
11-14 weeks of gestation in many devel-
oped countries.41 To date, the aim of this
examination is mainly to confirm viabil-
ity and gestational age, diagnose and de-
termine chorionicity of multiple preg-
nancies, as well as screening for fetal
aneuploidy and for some severe malfor-
mations. Promising attempts at predict-
ing severe obstetrical conditions devel-
oping in the second or third trimester
such as preeclampsia by ultrasound and
Doppler examination at 12 weeks are
promising.42,43 We believe that screen-
ing for PA in a high-risk group with pre-
vious cesarean section is justified by the
severity of this condition at the time of
delivery and by the feasibility of both scar
and placental examination at 11-14
weeks.28 Early recognition of PA is likely
to be associated with lesser maternal
morbidity.15,16 Elective cesarean section
with a conservative approach of the pla-
centa left in place has shown to improve
the prognosis for the mother.14 In our
population, a case of placenta percreta
went to delivery undiagnosed in the non-
screened group, whereas early recogni-
tion of PA in the high-risk group allowed
for planning optimal management. This
Obstetrics Research
TABLE 2
Ultrasound follow-up of 6 cases considered high-risk
for placenta accreta by 11-14 weeks’ screening
Gestational age at
Cases follow-up, wk Placental location
1 21⫹5 Posterior, high
............................................................................................................................................................................
32⫹2 Posterior, high
..............................................................................................................................................................................................................................................
2 17⫹6 Anterior, high
..............................................................................................................................................................................................................................................
3 18⫹3 Posterolateral, low lying
............................................................................................................................................................................
22⫹2 Posterior, high
..............................................................................................................................................................................................................................................
4 16⫹0 Posterior, high
..............................................................................................................................................................................................................................................
5 28⫹4 Posterior, high
..............................................................................................................................................................................................................................................
6 16⫹1 Anterolateral low-lying
............................................................................................................................................................................
18⫹1 US signs of placenta accreta
............................................................................................................................................................................
22⫹1
............................................................................................................................................................................
25⫹1
............................................................................................................................................................................
29⫹1
..............................................................................................................................................................................................................................................
US, ultrasound.
Stirnemann. Screening for placenta accreta at 11-14 weeks. Am J Obstet Gynecol 2011.
suggests that the rationale for 11-14 ing for maternal age and history could
weeks’ screening is to help plan further lead to objective individual risk calcula-
investigations and follow-up thus avoid- tion for PA as early as 12 weeks and help
ing unanticipated peripartum discover- refine the care of women, including spe-
ies of PA as well as to reassure patients cialized imaging investigations such as
otherwise at risk based upon demo- an early ultrasound at 16-18 weeks21 or
graphic characteristics. Nonetheless, it is MRI together with a planned delivery in
likely that a trophoblast overlapping the an appropriate obstetrical unit. f
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