Radiol med
DOI 10.1007/s11547-016-0689-3
URO-GENITAL RADIOLOGY
MRI of placenta percreta: differentiation from other entities
of placental adhesive disorder
Shanigarn Thiravit1 · Sukanya Lapatikarn1 · Kobkun Muangsomboon1 ·
Voraparee Suvannarerg1 · Phakphoom Thiravit1 · Pornpim Korpraphong1
Received: 1 May 2016 / Accepted: 12 September 2016
© Italian Society of Medical Radiology 2016
Abstract  signal heterogeneity. The size of the T2 dark band alone,
Objectives To retrospectively review the MRI findings of
placenta percreta and identify those helpful for differentia-
tion from non-placenta percreta.
Materials and methods The MRI images of 21 patients
with a preliminary diagnosis of placental adhesive disorder
scanned between 2005 and 2014 were evaluated. Radiolo-
gists blinded to the final diagnosis evaluated six previously
described MRI findings of placenta adhesive disorder. The
sensitivity, specificity, accuracy, negative predictive value
(NPV), and positive predictive value (PPV) of MRI for the
diagnosis of placenta percreta were also calculated.
Results The study included 12 cases of placenta per-
creta and 9 cases of non-placenta percreta. Invasion of
placental tissue outside the uterus was found only in pla-
centa percreta (p  = 0.045; sensitivity 41.7 %; specificity
100 %). All placenta percreta cases also had a moderate to
marked degree of heterogeneous placental signal intensity
(p = 0.063; sensitivity 100 %; specificity 33.3 %). The size
of the dark bands on T2-weighted imaging, and the pres-
ence of disorganized intra-placental vessels, showed no sta-
tistically significant difference between placenta percreta
and non-placenta percreta. The sensitivity, specificity, NPV,
PPV, and accuracy of MRI for detection of placenta per-
creta were 91.7, 44, 80, 68, and 71.4 %, respectively.
Conclusions MRI is recommended for the evaluation of
placenta percreta, with the most specific signs including
the invasion of placental tissue outside the uterus on B-FFE
sequences, and consideration of the degree of placental
* Shanigarn Thiravit
thiravit.mahidol@gmail.com
1
Department of Radiology, Faculty of Medicine Siriraj
Hospital, Mahidol University, Bangkok 10700, Thailand
 
or bizarre disorganized intra-placental vessels, did not cor-
relate with the severity of invasion.
Keywords  Placenta percreta · Placental adhesive disorder ·
Placenta accreta · MRI
Introduction
Placenta adhesive disorder (PAD) or placenta accreta is a
rare obstetric condition that yields high maternal mortality
resulting from massive blood loss at the time of placental
separation. Prior caesarean delivery and placenta previa
are the two most important risk factors for placenta accreta
[1, 2]. Wu et al. [1] reported that the incidence of PAD
increased to about 1 in 533 deliveries during 1982–2002,
corresponding with an increase in the rate of caesarian
deliveries over the last few decades. Grobman et al. [3] also
found an association between the risk of placenta accreta
and the number of caesarean deliveries in women with pla-
centa previa; the increase in risk was about 11 % for one
prior caesarean delivery, and as high as 61 % for three or
more caesarean deliveries. Vahanian et al. [4] mentioned
that the increasing rate of caesarean section was not only
associated with invasive placental abnormality, but also
with an increasing rate of preterm births.
PAD is classified into three entities according to the
degree of myometrial invasion. Placenta accreta vera is
the mildest form, occurring when the chorionic villi pen-
etrate the decidua. Placenta percreta is the most severe
form, where the chorionic villi invade through the myome-
trium, up to and beyond the uterine serosa. Placenta increta
is the form in between placenta accreta vera and placenta
percreta. The accurate diagnosis of placenta percreta is
13

crucial for surgical planning and multidisciplinary consul-
tation. Use of the well-established preoperative prepara-
tion measures reduces maternal morbidity, with reduced
post-operative blood loss reported [5]. The recommended
treatment for placenta percreta is hysterectomy, while local
resection or conservative treatment may be options for
non-placenta percreta (NP; placenta accreta vera and pla-
centa increta) [6]. Although ultrasound has been recognized
as the primary tool for the diagnosis of PAD [7], MRI, a
currently available and accessible tool in many healthcare
centers, has been shown to be significantly superior for the
assessment of the degree of invasion, especially when the
placenta is in a posterior location, or with placenta previa
[8]. To date, there are no specific MRI criteria described to
establish a diagnosis of placenta percreta, even though pre-
vious studies [8–11] have tried to evaluate this condition.
The proposed classification by Maldijan et al. [9] recom-
mended that type 2 with a transmural extension of abnor-
mal signal intensity (SI) through the myometrium, and type
3 with a placental invasion of local structures or bladder,
should be classified as placenta percreta. Nevertheless,
there were only two placenta percreta cases evaluated in
their study.
The purpose of this study was therefore to retrospec-
tively determine the MRI findings of placenta percreta that
are helpful for the differentiation of placenta percreta from
other entities of PAD.
Materials and methods
Patient selection
This retrospective study was approved by our institutional
review board with a waiver for informed consent. We col-
lected MRI images from 24 consecutive patients imaged
between 2005 and 2014. These patients had a preliminary
prenatal ultrasound-based diagnosis of PAD. Twenty-one
patients who underwent hysterectomy with available surgi-
cal and pathological reports were included. The remaining
three patients were excluded due to referral to other hos-
pitals and unavailability of surgical reports. The medical
history and risk factors for PAD were reviewed, including
age, gestational age, prior uterine surgery, number of prior
caesarean sections, presence of placenta previa, prior dila-
tation and curettage, and hypertension. An age of 35 years
or older was recorded as an advanced maternal age.
Imaging acquisition
MRI was performed using either a 1.5-T (Achieva,
Philips Medical Systems, Best, The Netherlands) or 3-T
(Ingenia, Philips Medical Systems, Best, The Netherlands)
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Radiol med
scanner, with a phased-array body coil. The field of view
was adjusted to around 35–40 cm to cover the uterus. The
MR images were obtained in the standard three orthogonal
planes. The sequences included T2-weighted echo train
spin-echo (single-shot fast spin-echo, SSFSE) with a TR/
TE of 2500/80 ms, flip angle of 90°, and a 5-mm slice
thickness. T1-weighted gradient-echo imaging was per-
formed for the studies before the year 2010, and steady-
state free-precession (balanced fast field echo, B-FFE) with
a TR/TE of 3.5/1.7 ms, flip angle of 60°, and 5-mm slice
thickness, was performed in the studies after and including
the year 2010. Gadolinium contrast was not administered
because of the potential of unknown effects on the fetus.
Image interpretation
The MRI findings of PAD described in previous studies
[10–12] were recorded. These included heterogeneous sig-
nal (SI) within the placenta, dark intra-placental bands on
T2-weighted images (T2WI), lower uterine bulging, disor-
ganized abnormal intra-placental vascularity [13], invasion
of placental tissue outside of the uterus, and tenting of the
urinary bladder.
The heterogeneous SI within the placenta was fur-
ther classified into either a mild, or a moderate to marked
degree, by visual assessment. Dark intra-placental bands on
T2WI were further classified into small (<1 cm), medium
(=1–2 cm),) and large (>2 cm) sizes. Disorganized abnor-
mal intra-placental vascularity was defined as a dark intra-
placental band on the T2-weighted SSFSE sequence, with
a corresponding high signal on B-FFE, and measuring
more than 6 mm. Invasion of placental tissue outside of the
uterus was defined as either obvious placental invasion of
tissue in adjacent organs, or that involving the entire myo-
metrial thickness abutting the bladder serosa, with a pres-
sure effect or some nodularity on the bladder wall.
Two radiologists with a subspecialty of body imaging
(4 and 12 years of experience), who were blinded to the
surgical and pathological results, reviewed the MRI find-
ings and made the final diagnosis of placenta percreta or
NP. The final diagnosis of placenta percreta was decided on
by occurrence of any of the following: invasion of placen-
tal tissue outside of the uterus, no demonstrable subjacent
thin myometrium combined with large dark intra-placental
bands on T2WI, and/or a moderate-marked degree of het-
erogeneous placental SI, and/or bizarre disorganized abnor-
mal intra-placental vascularity. A diagnosis of NP was
made if there was a traceable subjacent thin myometrium in
the area of the invasive placenta and/or mild heterogeneous
SI of the placenta. Any discordance between readers was
remedied by consensus. The final diagnosis of placenta per-
creta or NP was confirmed in all cases by surgical and path-
ological reports. In the case of a discordant result between
Radiol med

the surgical and pathological reports, the more severe form Table 1  Demographic data of the patients with placenta percreta and
was considered to be the final diagnosis, owing to the pos- non-placenta percreta
sibility of inadequate pathological sampling or underesti- Demographics PP (N = 12) NP (N = 9) p value
mation on the surgical field.
Age (year) 36 ± 4.0 32.5 ± 5.2 0.107
GA at MR (weeks) 32.83 ± 2.9 30.9 ± 5.1 0.283
Statistical analysis
Placenta previa 10 (83.3 %) 8 (88.8 %) 1.0
Prior CS 12 (100 %) 7 (77.8 %) 0.171
Statistical analysis was performed using SPSS version 18
(SPSS Inc., Chicago, IL, USA). Descriptive statistics were >1 CS 4/12 (33.3 %) 0/9 (0 %) 0.104
used for reporting demographic data, with mean and SD Uterine surgery 1 (8.3 %) 2 (22.2 %) 0.553
for quantitative data, and number and percentage for quali- Prior curettage 3 (25 %) 2 (22.2 %) 1.0
tative data. Comparisons between two groups were made Aging 9 (75 %) 4 (44.4 %) 0.203
using Student’s t test. Chi square and Fisher’s exact test Hypertension 1 (8.3 %) 1 (11.1 %) 1.0
were used for comparisons of the MRI findings between PP placenta percreta, NP non-placenta percreta, GA at MR gesta-
the two groups. p values <0.05 were considered statistically tional age at the time of MR examination, CS caesarean section
significant. The sensitivity, specificity, positive predic-
tive value (PPV), and negative predictive value (NPV) of
each MRI finding were also calculated, including the cor- placenta percreta (12/12) had moderate to marked hetero-
responding 95 % confidence intervals (CI). geneous SI within the placenta (p = 0.063), with no mild
heterogeneous SI of the placenta being found in placenta
percreta. Uterine bulging was found in nine patients with
Results placenta percreta and eight patients with NP (p  = 0.603).
The presence of a moderate to large placental band on
Twenty-one consecutive patients with a preliminary diag- T2WI was found in 10 patients with placenta percreta, and
nosis of PAD were included in the study, and these were 8 patients with NP (p = 1.0). Disorganized abnormal intra-
further classified into 12 patients with placenta percreta, placental vascularity was found in only three patients with
and 9 patients with NP. All cases were confirmed by surgi- placenta percreta and two patients with NP (p = 1.0). Tent-
cal and pathological reports. The mean age and gestational ing of the urinary bladder was found in six patients with
age (GA) of the placenta percreta and NP groups were not placenta percreta and two patients with NP (p = 0.367). In
significantly different (p  = 0.107 and p  = 0.283, respec- the patients with placenta percreta, the combined findings
tively). All patients in both the placenta percreta and NP of moderate to marked heterogeneous SI of the placenta
groups had a history of uterine surgery, either caesarean and a large placental band on T2WI showed a sensitivity
resection or myomectomy. Four of the 12 patients with pla- of 83.3 %. In a specific analysis limited to cases without a
centa percreta (33.3 %) had a history of more than one cae- finding of invasion of placental tissue outside of the uterus,
sarean section, while none of the NP group had. A slightly the aforementioned combination slightly increased sensitiv-
higher percentage of the placenta percreta group had an ity to 85.7 % (Table 4). The MRI findings in non-placenta
advanced maternal age in comparison with the NP group percreta cases are also reported in Table 5.
(75 vs 44.4 %). The demographic data are listed in Table 1.
Placenta percreta was correctly diagnosed from MRI in
11 of the 12 patients (true positive). There were also 5 false Discussion
positives, 1 false negative, and 4 true negative cases in our
study. The summarized data are displayed in Table 2. Placenta percreta is considered to be the most severe form
The MRI findings in all patients with PAD are reported of PAD, with the potential to cause massive intraopera-
in descending order in Table 3. All of the patients dem- tive bleeding during the time of placental separation. The
onstrated heterogenous SI of the placenta and a dark pla- increasing rate of caesarian deliveries over the last few dec-
cental band on T2WI. Abnormal uterine bulging was also ades has contributed to an increasing incidence of PAD.
common. The remaining MRI findings (tenting of urinary Therefore, preoperative evaluation of those patients who
bladder, disorganized abnormal intra-placental vascular- are clinically suspected as having this condition is neces-
ity, and invasion of placental tissue outside of the uterus) sary, including confirmation with either ultrasound or MRI
were infrequent. When further subcategorized into placenta investigations [7]. Obstetricians expect to know whether
percreta and NP, the MRI finding of invasion of placental placenta percreta is present, as it will alter the delivery plan
tissue outside of the uterus was found only in placenta per- and need multidisciplinary team consultation. Good preop-
creta, in 5 of the 12 patients (p = 0.045). All patients with erative planning may provide good postoperative outcomes

13
 Radiol med

Table 2  Overall MRI performance in the diagnosis of placenta per- and less maternal morbidity [4–6]. Currently, the three
creta most helpful MRI findings for diagnosis of PAD are well-
Sensitivity (95 % CI) Specificity (95 % CI) PPV NPV Accuracy established, having been described in many studies [10–12,
14]. These include uterine bulging, heterogenous SI within
91.7 % (61.5–99.8) 44.4 % (13.7–78.8) 68.7 80 71.4
the placenta, and a dark intra-placental band on T2WI.
PPV positive predictive value, NPV negative predictive value However, MRI determination of the degree of invasion,
including the percreta subtype, is still difficult [10, 11].
Our study found that the only significant finding in
Table 3  Summarized MRI findings in all patients with placenta diagnosis of placenta percreta with 100 % specificity
adhesive disorder was invasion of the placental tissue outside of the uterus
Heterogeneous SI within the placenta 21/21 (100 %) (p  = 0.045). We recommend that this is the most impor-
Dark intra-placental bands on T2WI 21/21 (100 %) tant finding to look out for when performing placental
Lower uterine bulging 17/21 (81 %) MRI. Placenta percreta rarely demonstrates gross invasion
Tenting of the urinary bladder 8/21 (38 %) of adjacent organs, with invasion usually being limited to
Disorganized abnormal intra-placental vascularity 5/18 (28 %)a the serosa. The most commonly invaded organ is the blad-
Invasion of placental tissue outside of the uterus 5/21 (24 %)
der. According to our observations, when placental tissue
involves the entire myometrial thickness abutting the blad-
SI signal intensity, T2WI T2-weighted image der serosa, with a pressure effect or some nodularity of the
a
  No steady-state free-precession sequence for three patients bladder wall (Fig. 1), this finding can be defined as invasion

Table 4  Sensitivity, specificity, PPV and NPV of MRI findings in placenta percreta

MRI features Sensitivity Specificity PPV NPV p

Moderate to marked degree of heterogeneous SI within the placenta 100 33.3 66.7 100 0.063
Moderate to large size of dark intra-placental bands on T2WI 83.3 11.1 55.6 33.3 1.000
Lower uterine bulging 75 11.1 52.9 25 0.603
Disorganized abnormal intra-placental vascularity 27.3 71.4 60 38.4 1.000
Invasion of placental tissue outside of the uterus 41.7 100 100 56.2 0.045
Tenting of the urinary bladder 50 77.8 75 53.8 0.367
Combination Aa 83.3 33.3 62.5 60 0.353
Combination A in specific groupb 85.7 33.3 50 75 0.585

SI signal intensity, T2WI T2-weighted image, PPV positive predictive value, NPV negative predictive value
a
  Combined moderate to marked heterogeneous SI of the placenta and a large placental band on T2WI
b
  Excluding patients with a finding of invasion of placental tissue outside of the uterus (N = 16)

Table 5  Summarized MRI MRI features Accreta vera Increta Non-placenta percreta

findings in non-placenta
percreta categorized into Heterogeneous SI within the placenta
placenta accreta vera and
 Mild 0/2 3/7 3/9 (33 %)
increta subtypes
 Moderate to marked 2/2 4/7 6/9 (67 %)
Dark intra-placental bands on T2WI
 Small size 0/2 1/7 1/9 (11 %)
 Moderate to large size 2/2 6/7 8/9 (89 %)
Lower uterine bulging 1/2 7/7 8/9 (89 %)
Disorganized abnormal intra-placental vascularitya 0/1 2/6 2/7 (28 %)
Invasion of placental tissue outside the uterus 0/2 0/7 0/9 (0 %)
Tenting of the urinary bladder 1/2 1/7 2/9 (22 %)

SI signal intensity, T2WI T2-weighted image

a
  No steady-state free-precession sequence for one patient with placenta accreta vera and one patient with
placenta increta

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Fig. 1  Invasion of placental
tissue outside of the uterus
in placenta percreta show-
ing abnormal placental tissue
abutting the bladder wall with
some nodularity on the B-FFE
image (a; white arrow). The
SSFSE T2-weighted image (b)
appeared less conspicuous in
the same area. Images were
taken on a 1.5-T scanner

Fig. 2  A 33-year-old woman

with placenta increta demon-
strated mild heterogeneous
placental signal intensity on
coronal B-FFE (a) and SSFSE
T2-weighted images (b) taken
on a 1.5-T scanner

of placental tissue outside of the uterus. This is in agree-
ment with the study by Teo et al. [12], which described this
feature as bladder involvement. We encourage the use of a
B-FFE sequence to evaluate this finding, as this sequence
nicely demonstrates the outline of placental tissue or the
outer low SI line of uterine serosa upon the bladder wall.
Kim et al. found the B-FFE sequence to be superior to the
HASTE sequence for evaluation of the fetal central nerv-
ous system and small volumes of tissue, such as markedly
thinned myometrium [15].
In the absence of invasion of placental tissue outside of
the uterus, the diagnosis of placenta percreta could be made
with high sensitivity (85.7 %) and NPV, using a combina-
tion of a moderate to marked heterogeneous SI of the pla-
centa and a large dark band on T2WI, as reported in our
study. We believe that this combination is easy to recognize
and has shown good inter-reader agreement, as demon-
strated in previous reports [10, 11].
Our results showed that no one in the placenta per-
creta group demonstrated mild heterogeneous placental SI
(Fig. 2), and the absence of moderate to marked heteroge-
neous placental SI could exclude placenta percreta with an
NPV of 100 %. This result is in accord with previous stud-
ies [10, 11, 13] that described a markedly heterogeneous
placenta as being likely to be associated with invasive pla-
centation. In general, the heterogeneity of the placenta may
relate to the quantity of T2 dark bands, as well as infarct or
hemorrhage of mature placenta. In our study, all cases were
in the 3rd trimester, and the difference in the degree of het-
erogeneity between placenta percreta and NP seemed not to

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Fig. 3  Example of a T2 dark
band (white arrow) of small size
found in a patient with placenta
percreta which appeared with
low signal intensity on both
SSFSE T2-weighted (a) and
B-FFE images (b) taken on a
1.5-T scanner

Fig. 4  A bizarre disorganized

vessel (white arrow) in a patient
with placenta increta which
showed low signal intensity on
SSFSE T2-weighted images (a)
and correspondingly high signal
intensity on B-FFE images (b)
taken on a 1.5-T scanner

be affected by a change in maturity. Leyendecker et al. [16]
found uncertainty in the classification of the degree of pla-
cental heterogeneity, as it was somewhat subjective. From
our observations, the difficulty may occur when discrimi-
nating between a moderate or marked degree. However, the
discrimination between a mild and a moderate to marked
degree, would not be problematic. Additionally, Alamo
et al. [11] showed no significant difference in the detec-
tion of the MRI finding of heterogenous intra-placental SI,
regardless of practitioner experience.
Other MRI findings, including T2 dark bands, abnormal
uterine bulging, disorganized intra-placental vessels, and
tenting of the urinary bladder, showed no significant differ-
ence between the NP and placenta percreta groups.
A study by Lim et al. [17] showed that the volumes of
T2 dark bands were significantly different between accreta,
increta, and percreta. However, we note that their study
only included one case of placenta percreta. In our study,
all PAD cases, including 12 cases of placenta percreta, had
dark intra-placental bands on T2WI; however, the large size
alone did not correlate with severity of placental invasion
(Fig. 3).
Derman et al. [13] suggested that the degree of disor-
ganized vessels may correspond with the depth of pla-
cental invasion. We found disorganized vessels in 5 out
of 18 patients and the bizarre form of disorganized ves-
sel was found in the NP case (Fig. 4). With the higher
number of patients examined in our study, we think

13
Radiol med
that a disorganized vessel is an uncommon finding, and
cannot be used to determine the severity of symptoms.
However, it can still be a helpful finding for the diagno-
sis of PAD.
Lower uterine bulging is a quite common finding in
patients with PAD [18]; however, this finding is not help-
ful for differentiating between placenta percreta and NP, as
demonstrated in our study.
We report a high sensitivity (91 %) but low specificity
(44 %) of MRI for the diagnosis of placenta percreta. The
low specificity of MRI may imply some difficulty in estab-
lishing a spot diagnosis. However, we appreciate the high
sensitivity in this situation, as it means that we would not
expect to miss a serious condition. To our knowledge, other
investigators have also reported on a low rate of specific-
ity and PPV for both ultrasound and MRI in the detection
of placental adhesive disorder [18, 19]. With regard to only
the placenta percreta subtype, we could not find any similar
data in a PubMed search, and consider our results could be
a pilot study.
We also summarized the MRI findings found in all
patients, regardless of invasive degree. The three most com-
mon findings of PAD were heterogenous SI of the placenta
(100 %), a dark placental band on T2WI (100 %), and
abnormal uterine bulging (81 %); these findings are similar
to previous reports [14, 18].
Gadolinium-enhanced MRI was advocated for diagnosis
of PAD by Warshak et al. [20], because the placental-myo-
metrial interface is well defined by gadolinium enhance-
ment. They also presumed that gadolinium-enhanced MRI
may be helpful for evaluation of the depth of myometrial
invasion. In our study, we did not use gadolinium based
contrast, as we concerned about the unknown effects on the
fetus.
There are some limitations to our study, which include
its retrospective nature and small sample size. However,
we had no selection bias, as obstetricians routinely trans-
ferred suspected patients to MRI, and the small sample
size results from the rare etiology. We also used both 1.5-T
and 3-T MRI scanners in this study; however, most of the
cases were performed with a 1.5-T magnet, with exceptions
being due to special situations e.g. scanner availability in
an emergency condition. We did not statistically evaluate
the MRI findings between the scanner types, as the uses of
3-T were too infrequent for analysis. We did not calculate
the agreement between readers, with discordance being
remedied by consensus.
Conclusions
MRI is a helpful tool for the evaluation of the placenta, as
it can identify the most specific signs of placenta percreta,
such as invasion of placental tissue outside of the uterus,
and consideration of the degree of placental signal hetero-
geneity. A large T2 dark band alone, or bizarre disorgan-
ized intra-placental vessels, did not correlate with depth of
invasion.
Compliance with ethical standards 
Financial support  This study has not received any funding.
Conflict of interest  We declare that we do not have any conflict of
interest.
Informed consent This retrospective study was approved by our
institutional review board with a waiver for informed consent.
Ethical standards All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
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