SMFM Special Report

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Special Report of the Society for Maternal-

Fetal Medicine Placenta Accreta Spectrum
Ultrasound Marker Task Force: Consensus on
definition of markers and approach to the
ultrasound examination in pregnancies at risk for
placenta accreta spectrum
Scott A. Shainker, DO, MS; Beverly Coleman, MD, FACR; Ilan E. Timor, MD; Amarnath Bhide, MRCOG, MD;
Bryann Bromley, MD; Alison G. Cahill, MD, MSCI; Manisha Gandhi, MD; Jonathan L. Hecht, MD, PhD;
Katherine M. Johnson, MD; Deborah Levine, MD; Joan Mastrobattista, MD; Jennifer Philips, MD; Lawrence J. Platt, MD;
Alireza A. Shamshirsaz, MD; Thomas D. Shipp, MD; Robert M. Silver, MD; Lynn L. Simpson, MD; Joshua A. Copel, MD;
Alfred Abuhamad, MD; On behalf of the Society for Maternal-Fetal Medicine

The Society for Maternal Fetal Medicine (SMFM), American Institute of Ultrasound in Medicine (AIUM), American College of
Radiologists (ACR), and Gottesfeld Hohler Memorial Society (GOHO) endorse this document. The American College of
Obstetricians and Gynecologists (ACOG) and International Society of Ultrasound In Obstetrics and Gynecology (ISUOG)
support this document. The Society of Radiologists in Ultrasound (SRU) approves this document.

Placenta accreta spectrum includes the full range of abnormal placental attachment to the uterus or other
structures, encompassing placenta accreta, placenta increta, placenta percreta, morbidly adherent
placenta, and invasive placentation. The incidence of placenta accreta spectrum has increased in recent
years, largely driven by increasing rates of cesarean delivery. Prenatal detection of placenta accreta
spectrum is primarily made by ultrasound and is important to reduce maternal morbidity associated with the
condition. Despite a large body of research on various placenta accreta spectrum ultrasound markers and
their screening performance, inconsistencies in the literature persist. In response to the need for stan-
dardizing the definitions of placenta accreta spectrum markers and the approach to the ultrasound ex-
amination, the Society for Maternal-Fetal Medicine convened a task force with representatives from the
American Institute of Ultrasound in Medicine, the American College of Obstetricians and Gynecologists, the
American College of Radiology, the International Society of Ultrasound in Obstetrics and Gynecology, the
Society for Radiologists in Ultrasound, the American Registry for Diagnostic Medical Sonography, and the
Gottesfeld-Hohler Memorial Ultrasound Foundation. The goals of the task force were to assess placenta
accreta spectrum sonographic markers on the basis of available data and expert consensus, provide a
standardized approach to the prenatal ultrasound evaluation of the uterus and placenta in pregnancies at
risk of placenta accreta spectrum, and identify research gaps in the field. This manuscript provides infor-
mation on the Placenta Accreta Spectrum Task Force process and findings.

Key words: accreta, cesarean, increta, maternal morbidity, maternal mortality, placenta accreta
spectrum, percreta, previa

Introduction morbidly adherent placenta, and invasive placentation, in-

Placenta accreta spectrum (PAS), encompassing the terms
placenta accreta, placenta increta, placenta percreta,
Corresponding author: Society for Maternal-Fetal Medicine, Publications
Committee. pubs@smfm.org
cludes the full range of abnormal placental attachment to the
uterus or other structures. There has been a dramatic rise in
the incidence of PAS over recent years.1 This rise is most
notably driven by increasing rates of cesarean delivery. The
risk is highest in the presence of placenta previa and previous
cesarean deliveries.1,2

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PAS is associated with a marked increase in maternal

morbidity and mortality. The morbidity is primarily related to TABLE 1
Task force participating members and societies
massive hemorrhage with associated organ damage, ce-
sarean hysterectomy, and need for critical care re- Alfred Abuhamad SMFM, Co-Chair
sources.1,2 Prenatal detection of PAS allows for mobilization
Scott A. Shainker SMFM, Co-Chair
of multidisciplinary care teams and surgical planning, which
reduces maternal morbidity.3e8 Furthermore, the ability to Beverly Coleman ACR
correctly stratify the risk of PAS, including decreasing the Ilan E. Timor GOHO
risk with a “normal” ultrasound, reduces the possibility of Amarnath Bhide ISUOG
iatrogenic complications associated with planned prema-
Bryann Bromley AIUM
ture delivery, preoperative invasive procedures, and patient
and provider anxiety. Alison G. Cahill ACOG
The prenatal detection and risk stratification for PAS are Joshua A. Copel GOHO
primarily made by ultrasound. However, ultrasound is an Manisha Ghandi ACOG
operator-dependent imaging modality with substantial a
Jonathan L. Hecht
variability in image quality among providers. Furthermore,
placental location and challenging imaging conditions, Katherine M. Johnson SMFM
including elevated body mass index (BMI) or posterior Deborah Levine SRU
placentation, may impede the sonographic detection of
Joan Mastrobattista AIUM
PAS markers. There has been limited consensus on the
optimal approach to the ultrasound evaluation of patients at Jennifer Philips SMFM
risk of PAS, such as the appropriate timing of screening, Lawrence J. Platt GOHO
need for transvaginal ultrasound (TVUS) imaging, use of Alireza A. Shamshirsaz GOHO
color and pulsed Doppler, angle of placental insonation, and
Thomas D. Shipp ARDMS
equipment settings.
Despite a large body of literature on various PAS ultra- Robert M. Silver SMFM
sound markers and their screening performance, important Lynn L. Simpson SMFM
inconsistencies in screening results persist. This is primarily ACOG, American College of Obstetricians and Gynecologists; ACR, American College of
because of the retrospective design of most studies, lack of Radiologists; AIUM, American Institute of Ultrasound in Medicine; ARDMS, American Reg-
istry for Diagnostic Medical Sonography; GOHO, Gottesfeld-Hohler Memorial Society; ISUOG,
standardized definitions of PAS markers, lack of agreement International Society of Ultrasound in Obstetrics and Gynecology; SMFM, Society for
on the optimal gestational age for assessment, and in- Maternal-Fetal Medicine; SRU, Society of Radiologists in Ultrasound.
a
consistencies in the approach to the ultrasound evaluation Pathology consultant, Department of Pathology, Beth Israel Deaconess Medical Center and
Harvard Medical School, Boston, MA.
of the placenta.9 Furthermore, patients’ a priori risks have a Shainker. Special Report of the SMFM: Definition of markers and ultrasound ex-
significant influence on the positive predictive value (PPV) of amination in pregnancies at risk of PAS. Am J Obstet Gynecol 2021.
PAS markers. Recent data have shown that these markers
are frequently present in women at low risk for PAS.10
In response to the need for standardizing the defini- Memorial Ultrasound Foundation (GOHO) to the PAS Task
tions of PAS markers and the approach to the ultra- Force (Table 1). The PAS Task Force was organized into 4
sound examination, the Society for Maternal-Fetal subcommittees: first-trimester markers, placental lacunae,
Medicine (SMFM) convened a task force with the goals uteroplacental interface, and uterovesical interface, which
of assessing PAS sonographic markers on the basis of also included miscellaneous markers (cervical invasion,
available data and expert consensus, providing a stan- placental bulge, and exophytic mass). Each subcommittee
dardized approach to the prenatal ultrasound evaluation was chaired by a PAS Task Force member and included at
of the uterus and placenta in pregnancies at risk of least 2 additional members. The authors S.A.S. and A.A.
PAS, and identifying research gaps in the field. This participated on all 4 subcommittees. Each subcommittee
manuscript provides information on the PAS Task Force performed a detailed literature review of respective markers.
process and outcomes. This included the definitions of each marker, indication for
the examination, reported diagnostic accuracy of each
Procedure marker, gestational age at assessment, and optimal ultra-
SMFM invited representatives from the American Institute of sound approach for evaluation.6,7,11e42 The task force held
Ultrasound in Medicine (AIUM), American College of Ob- a face-to-face meeting in December 2018 in Boston, MA, to
stetricians and Gynecologists (ACOG), American College of review each subcommittee’s findings and recommenda-
Radiology (ACR), International Society of Ultrasound in tions. Expert consensus opinion was obtained when avail-
Obstetrics and Gynecology (ISUOG), Society for Radiolo- able data could not provide clear definitions for each PAS
gists in Ultrasound (SRU), American Registry for Diagnostic marker and/or the optimal approach for screening. In addi-
Medical Sonography (ARDMS), and Gottesfeld-Hohler tion, research gaps were noted.

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FIGURE 1
Placenta lacunae

Grayscale imaging of placenta lacunae (asterisk) in the setting of placenta previa with placenta accreta spectrum. A, Transvaginal midline sagittal image.
B, Transabdominal midline sagittal image.
Shainker. Special Report of the SMFM: Definition of markers and ultrasound examination in pregnancies at risk of PAS. Am J Obstet Gynecol 2021.

Literature Review Task force members identified several significant limita-

As outlined in a recent Obstetrics Care Consensus, ultra-
sound is the primary screening modality for PAS.7 Ultra-
sound markers of PAS can be seen early in the first
trimester, although historically screening is predominantly
performed in the second and third trimesters of pregnancy.
The ultrasound marker with the strongest association with
PAS is a persistent placenta previa at the time of delivery, in
the setting of a previous cesarean delivery.5,43 Other classic
sonographic markers of PAS include the presence of
placental lacunae (Figure 1), loss of the retroplacental
hypoechoic zone (Figure 2), thinning of the retroplacental
myometrium (Figure 3), hypervascularity of the uterovesicle
or retroplacental space (Figure 4), extension of placental
tissue into the uterus and/or bladder, and placental bridging
vessels (Figures 5 and 6).11,39e41,44e46 The presence of
excessive color Doppler flow in the retroplacental space
along with abnormal placental bridging vessels has also
been associated with PAS (Figure 6).6,7,46,47
tions to the current literature on this subject. Most studies
are retrospective in design, lack control “low-risk” com-
parison groups, and do not provide clear definitions of the
PAS markers being studied, which limits the ability to make
comparisons among studies and combines many of the
reported diagnostic performance statistics.9 It is important
to note that most studies were designed to highlight asso-
ciations between ultrasound markers and PAS; thus, results
cannot be inferred to reflect on the diagnostic and predictive
accuracy of these markers. Furthermore, most of the
studies included cases with surgically or histologically
confirmed placenta accreta, making it difficult to extrapolate
information regarding the validity of PAS markers in the first-
trimester ultrasound.
First Trimester
Several PAS ultrasound markers have been described in the
first trimester. The prevalence and type of markers of PAS in

FIGURE 2
Retroplacental hypoechoic zone

Transvaginal midline sagittal grayscale imaging of placenta previa. A, Normal-appearing retroplacental hypoechoic zone (arrows). B, Abnormal or loss of
the retroplacental hypoechoic zone (arrows) in placenta accreta spectrum.
Shainker. Special Report of the SMFM: Definition of markers and ultrasound examination in pregnancies at risk of PAS. Am J Obstet Gynecol 2021.

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FIGURE 3
Myometrial thinning
Transabdominal midline sagittal grayscale imaging from a patient with
focal placenta accreta spectrum. The area with normal myometrial
thickness (asterisks) is compared to areas with myometrial thinning
(arrows).
Shainker. Special Report of the SMFM: Definition of markers and ultrasound examination in
pregnancies at risk of PAS. Am J Obstet Gynecol 2021.
the first trimester vary between the early first trimester of
pregnancy (6e9 weeks of gestation) and the later first
trimester of pregnancy (11e14 weeks of gestation).11
In a patient with a previous cesarean delivery, implanta-
tion of a gestational sac in the lower uterine segment on
ultrasound early in the first trimester is one of the most
common markers for PAS in the first trimester. A cesarean
scar pregnancy (CSP), defined as a gestational sac
implanted in the lower uterine segment within or in close
proximity to the cesarean scar, markedly increases the risk
of PAS (Figures 7 and 8).11,48,49 When a gestational sac is
implanted within a cesarean scar “niche,” extrauterine
FIGURE 4
Hypervascularity of the uterovesical space
Transabdominal midline sagittal ultrasound in grayscale imaging (A) and color Doppler imaging (B) of placenta accreta spectrum demonstrating
hypervascularity of the uterovesical space. Note the presence of a large blood clot (asterisk) in the lower uterine segment.
Shainker. Special Report of the SMFM: Definition of markers and ultrasound examination in pregnancies at risk of PAS. Am J Obstet Gynecol 2021.
SMFM Special Report
extension of placental tissue and the need for hysterectomy
is substantially increased.50 Histopathologically, a CSP is
not distinguishable from that of second trimester PAS,
suggesting that they represent a continuum in the patho-
genesis of the disease.51 In 1 study of 68 patients with
prenatally identified PAS confirmed at delivery and a tech-
nically adequate ultrasound examination between 6 and 9
weeks of gestation, all were noted to have a low implanta-
tion of the gestational sac.11
In the late first trimester, a low implantation of the gesta-
tional sac is identified in approximately 28% of patients with
PAS (Figure 9).11 This is explained by the growth of the
gestational sac toward the fundal portion of the endome-
trium as the pregnancy progresses. If the placenta is anterior
and under the cesarean scar, it can remain anchored to the
cesarean scar significantly raising the risk of PAS.
In a recent systematic review and meta-analysis evalu-
ating the first-trimester detection of PAS in high-risk
women, a gestational sac implanted in close proximity to a
uterine scar was identified in 82.4% of women (95% confi-
dence interval [CI], 85.8e95.7) with confirmed PAS.52
However, the sensitivity of this finding in the same anal-
ysis was found to only be 44% (95% CI, 21.5e69.2), high-
lighting the limitations of assessing the risk in the first
trimester.52
Other markers that have traditionally been described in
the second and third trimesters have also been identified in
the late first trimester and are variably associated with
PAS.52 The definitions of the individual markers have been
inconsistent but include the presence of placental lacunae,
an abnormal bladder interface, uterovesicular hyper-
vascularity, and loss of the retroplacental clear
zone.11,16,28,53 This last marker is particularly helpful in
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FIGURE 5
Uteroplacental interface
Transvaginal midline sagittal imaging of placenta previa with placenta accreta spectrum. A, Grayscale imaging demonstrating irregularities along the
uteroplacental interface (arrows) and bulging of the lower uterine segment into the bladder (asterisk). B, Color Doppler imaging highlighting hyper-
vascularity within the uteroplacental interface.
Shainker. Special Report of the SMFM: Definition of markers and ultrasound examination in pregnancies at risk of PAS. Am J Obstet Gynecol 2021.
determining the extent of PAS, carrying a sensitivity of
84.3% and diagnostic odds ratio (DOR) of 23.8 (95% CI,
10.6e57.2).53 For cases that were ultimately determined to
be placenta percreta at the time of delivery, the sensitivity of
this marker was 92.1% with a DOR of 20.4 (95% CI,
6.0e108.7). Placental lacunae and posterior bladder wall
interruption or abnormalities were also noted in the late first
trimester in cases of percreta, each with sensitivities be-
tween 80% and 90%.53 Anterior placentation at the first-
trimester sonographic evaluation is more common in
women with PAS at delivery.11,16,28 Similar to findings in the
second and third trimesters, the presence of multiple PAS
markers in the first trimester increased the diagnostic
accuracy.52e54
Second and Third Trimesters
Placental lacunae
The presence of placental lacunae has been commonly re-
ported in association with PAS.39,55,56 Often described as
numerous, large, and irregular echolucencies within the
parenchyma of the placenta, placental lacunae should raise
the concern for underlying PAS.55,56 Previous studies in
PAS differ substantially in the definition of lacunae with re-
gard to the required size, number, and presence of blood
flow in lacunae. Lacunar blood flow has been described as
low-velocity flow in some reports, although others report
turbulent high-velocity flow.9,26,34,57 Finberg and Williams,55
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in their 1992 seminal work on ultrasound markers of PAS,
proposed a placental lacunae vascular space grading sys-
tem, with grade 0 indicating no placental lacunae, grade 1þ
including placentas with 1 to 3 small lacunae, grade 2þ
containing 4 to 6 larger and irregular lacunae, and grade 3þ
describing a placenta with many large and “bizarre-
appearing” lacunae throughout (Figure 1). Grade 3þ should
raise a high degree of concern for PAS. Yang et al38 inves-
tigated the association of lacunae with maternal complica-
tions in 51 pregnancies at risk of PAS, with previous
cesarean delivery and persistent placenta previa. The au-
thors found that the need for cesarean hysterectomy and
maternal complications positively correlated with the num-
ber of lacunae.38 Furthermore, the absence of lacunae in
pregnancies with placenta previa and previous cesarean
delivery is a reassuring sign with negative predictive values
(NPV) ranging from 88% to 100% for PAS.9,38,55
Abnormal uteroplacental interface
Abnormal uteroplacental interface has been described as
loss of the retroplacental hypoechoic zone, myometrial
thinning, and increased vascularity on color Doppler.6,10,46
There is substantial variation in the definition and statisti-
cal performance of the loss of the retroplacental hypoechoic
zone for predicting PAS.9,13,39,46 The classic definition of
myometrial thinning is a retroplacental myometrial thickness
of <1 mm. However, only 50% of cohort studies of PAS
smfm.org SMFM Special Report

FIGURE 6
Abnormal uterine contour and bridging vessel

Transabdominal midline sagittal ultrasound image of placenta previa with placenta accreta spectrum. A, Grayscale imaging of an abnormal uterine
contour with bulging of the lower uterine segment (small arrows) into the posterior bladder wall and interruption of the bladder wall (large arrow). B, Color
Doppler imaging demonstrating bridging vessel at the site of the bladder wall interruption (large arrow).
Shainker. Special Report of the SMFM: Definition of markers and ultrasound examination in pregnancies at risk of PAS. Am J Obstet Gynecol 2021.

provided a working definition of this marker.46,47 In addition,
myometrial thinning is often seen in advancing gestation
and can be more pronounced in women with previous ce-
sarean delivery.58 This marker can be iatrogenically pro-
duced and/or exaggerated with undue transducer pressure,
FIGURE 7
Cesarean scar pregnancy
Transvaginal midline sagittal ultrasound in grayscale imaging demon-
strating a cesarean scar pregnancy. Note the teardrop shape of the
gestational sac (A) in close proximity to an empty bladder (B) and touching
the internal cervical os (arrow) of the cervix (C).
Shainker. Special Report of the SMFM: Definition of markers and ultrasound examination in
pregnancies at risk of PAS. Am J Obstet Gynecol 2021.
highlighting the need to minimize transducer pressure on
the abdomen when examining the placenta.41,46
Uterovesical interface
Uterovesical interface markers include bridging vessels,
increased vascularity between the uterus and bladder, and
interruption of the bladder wall. Bridging vessels represent
neovascularity atop the uterine serosa and frequently within
the uterovesical interface, depending on placental posi-
tion.42,47,59 The color Doppler finding of neovascularity is
found in most cases of PAS and reflects the engorged
myometrial vessels in the area of placentation. The hyper-
vascular uterovesicle interface also reflects the dilation of
the uteroplacental vasculature and the chaotic vascular
growth and flow within this space.46 Sensitivity and speci-
ficity of hypervascular uterovesical interface are variably
reported as ranging from 11% to 100% and 36% to 100%,
respectively.24,37,60e64 Bladder varicosities are often seen in
the absence of PAS and in the setting of placenta pre-
via.42,59 In addition, hypervascularity of the lower uterine
segment and/or cervix can be seen in placenta previa
without PAS, highlighting the difficulty in assessing this
marker. Interruption of the echogenic bladder wall, espe-
cially with placental tissue, is a clear marker of PAS as it
represents an extension of placental tissue beyond the
uterus (Figure 6). Engorged vessels in the uterovesical

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FIGURE 8
Ultrasound markers commonly seen in cesarean scar pregnancy

Transvaginal ultrasound in grayscale imaging (A) and color Doppler imaging (B) of a cesarean scar implantation (arrow) and bulging of the bladder line
(arrowheads).
Shainker. Special Report of the SMFM: Definition of markers and ultrasound examination in pregnancies at risk of PAS. Am J Obstet Gynecol 2021.

interface may result in ultrasound echo dropout, thus
mimicking placental extension into the uteroplacental
interface.47
Miscellaneous markers
There are numerous other miscellaneous markers for PAS
that have been described. Of these, placental bulge, exo-
phytic placental mass, and cervical vascular extension were
reviewed by the committee. The placental bulge is
described as a deviation of the uterine serosa, away from
the expected planes, changing the uterine contour
(Figures 5, 6, and 10).13,23,47 In a small study comparing
ultrasound and magnetic resonance imaging (MRI) features
that may predict placental invasion, the placental bulge was
found to have a specificity of 88%, highlighting this marker
as a reassuring sign when absent.23 An exophytic mass
represents a protrusion of placental tissue outside the
uterus and is diagnostic of placenta percreta when seen.
Similarly, the absence of this finding is reassuring, as it
carries an 80% to 100% specificity, albeit with a maximal
sensitivity of 42%.23,34,61 In 1 systematic review of PAS,
only cases of placenta increta and placenta percreta had a
placental bulge or an exophytic mass, highlighting their
relative rarity in clinical practice.46 Vascular cervical exten-
sion is defined by placental extension into the cervix
involving at least the inner one-third, best seen on TVUS.
This marker performs poorly, however, as it was identified in
greater than 50% of the time in a low-risk cohort without
PAS.10
Combined markers
When ultrasound markers are combined, their performance
improves substantially, yielding a sensitivity of 81.1% (95%
CI, 69e94), specificity of 98.9% (95% CI, 98e100), PPV of
90.9% (95% CI, 82e100), and NPV of 97.5 (95% CI,
96e99).18 Thinning of the myometrium and loss of the ret-
roplacental clear zone seem to have the highest interob-
server agreements.13 Most data regarding the predictability
of PAS ultrasound markers have been derived in single
centers with a relatively high volume of PAS cases. The true

FIGURE 9
Low implantation pregnancy

A, TVUS at 11 weeks of gestation in grayscale imaging in a pregnancy with low implantation of the gestational sac. Note that the placenta is covering the
internal os (arrow) of the cervix (C). B, TVUS at 11 weeks of gestation in color Doppler imaging in a pregnancy with low implantation of the gestational sac.
Note the presence of an extensive vascularity extending into the cervix (C).
TVUS, transvaginal ultrasound.
Shainker. Special Report of the SMFM: Definition of markers and ultrasound examination in pregnancies at risk of PAS. Am J Obstet Gynecol 2021.

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FIGURE 10
Abnormal uterine contour
Transabdominal midline sagittal ultrasound imaging with an extended view
of a pregnancy with placenta accreta spectrum. Note the presence of a
placental bulge and thickening in the lower uterine segment (arrows) and
into the bladder (B). Double arrows indicate the difference in the placental
thickness in the upper and lower segments of the uterus.
Shainker. Special Report of the SMFM: Definition of markers and ultrasound examination in
pregnancies at risk of PAS. Am J Obstet Gynecol 2021.
sensitivity of these markers in the community setting re-
mains unknown.
Existing Consensus Guidelines
The European Working Group on Abnormally Invasive
Placenta (EW-AIP) and the International Federation of Gy-
necology and Obstetrics (FIGO) developed language out-
lining various PAS ultrasound markers and suggested
standardized definitions for each.40,41 The EW-AIP estab-
lished a list of 11 PAS ultrasound markers (6 in 2-
dimensional [2D] grayscale, 4 in 2D color Doppler, and 1 in
3-dimensional [3D] power Doppler). This was derived from
the analysis of 23 manuscripts reviewed by an expert panel.
The panel placed importance on defining each PAS marker
without ambiguity but did not report on their predictive
values.41 The recent FIGO consensus guidelines for PAS
prenatal screening and diagnosis listed the EW-AIP 11
markers along with their definitions. These guidelines did
not recommend using certain markers over others, and
acknowledged that none carries 100% sensitivity and
specificity. The FIGO consensus guidelines also com-
mented on the role of a CSP as the first-trimester precursor
to PAS.40 Taking these published definitions into account,
we reviewed the general utility of each ultrasound marker
and utilized the these published definitions when possible
and appropriate. We also attempted to consolidate some
ultrasound PAS markers to simplify language and stream-
line definitions.
Ultrasound Approach and Definitions of
Placenta Accreta Spectrum Markers
General considerations
We recommend starting the assessment with trans-
abdominal imaging to obtain an overview of placental
SMFM Special Report
TABLE 2
Definitions of placenta accreta spectrum
markers in the first trimester of pregnancy
Marker Definition
Cesarean scar Gestational sac implantation in part or totally within
pregnancy the cesarean scar.
Gestational sac may have a teardrop or triangular
shape.
Low implantation Gestational sac located close to the internal cervical
pregnancy os (up to 8 6/7 weeks of gestation) and/or placental
implantation located posterior to a partially filled
maternal bladder (up to 13 6/7 weeks of gestation).
Shainker. Special Report of the SMFM: Definition of markers and ultrasound ex-
amination in pregnancies at risk of PAS. Am J Obstet Gynecol 2021.
location and start assessing the regions of concern. TVUS is
strongly recommended for the assessment of PAS. Trans-
vaginal imaging optimizes resolution and allows for a
detailed assessment of the lower uterine segment, posterior
bladder wall, and cervix. The bladder should be partially full.
Color Doppler should be utilized to assess for vascularity
and placental extension into the uterine wall and sur-
rounding structures. The transducer should be adjusted to
operate at the highest clinically appropriate frequency,
realizing that there is a trade-off between resolution and
beam penetration.65 Ultrasound image magnification
should be performed to enhance the visualization of target
regions. When assessing the retroplacental region,
perpendicular orientation of the angle of insonation and
applying minimal transducer pressure are recommended.
Given the continuum of disease from CSP to PAS, screening
for PAS should begin early in the first trimester and continue
throughout the pregnancy until practitioners have
concluded whether there is sonographic concern for PAS.
First trimester
In the first trimester, a detailed evaluation of the uterus is
necessary to determine the location of the gestational sac
or placenta (depending on gestational age) in reference to
the bladder, internal os, and cesarean scar. When per-
forming TVUS, the maternal bladder should be partially
filled, enough to allow for a sonographic window, without
overfilling, which can result in distortion of the uteroves-
ical interface. The target area should be magnified to
occupy at least one-half of the ultrasound image, and
focal zones should be appropriately placed. After 10
weeks of gestation, color Doppler can be used to assess
for the presence of hypervascularity and lacunae; when
possible, color Doppler should be limited to the placental
region and not overlap the fetus. The definition of first-
trimester PAS markers and the proposed ultrasound
approach are presented in Table 2 and Box 1,
respectively.
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BOX 1
Approach to ultrasound examination in the first trimester of pregnancy
 Transvaginal ultrasound is recommended in early pregnancy, and transabdominal ultrasound may be performed when appropriate.
 Detailed evaluation of the uterus in the midsagittal plane to document the gestational sac (up to 8 6/7 weeks of gestation) and/or the placental location
(up to 13 6/7 weeks of gestation).
 Documentation should include reference to the position of the sac and/or placenta relative to the bladder, cesarean scar (if present), and internal
cervical os.
 Color Doppler imaging using a low-velocity scale, low wall filter and high gain to maximize detection of flow (adjusting as needed for body habitus and
other clinical factors).a
 Evaluate shape of gestational sac (up to 8 6/7 weeks of gestation).
 Imaging should be performed with a partially filled maternal bladder.
— The area of interest should be magnified so that it occupies at least half of the ultrasound image with the focal zone at an appropriate depth.
a
Color Doppler should be limited to the areas of interest and avoid the embryo or fetus whenever possible.
Shainker. Special Report of the SMFM: Definition of markers and ultrasound examination in pregnancies at risk of PAS. Am J Obstet Gynecol 2021.

Second and third trimesters
The antenatal diagnosis of PAS is most often made in the
second and third trimesters of pregnancy. Classic sono-
graphic markers of PAS are typically described in women
with anterior placentae previa and previous cesarean
deliveries.6,7
Table 3 lists the proposed definitions of PAS ultrasound
markers in the second and third trimesters of pregnancy.
Other than placenta previa, placenta lacunae are
frequently described as classic ultrasound markers of
PAS. Lacunae can often be found in low-risk non-PAS
pregnancies; however, when present in women with risk
factors, they carry the highest sensitivity of all 2D gray-
scale markers.10,66 When lacunae are large, numerous,
and with irregular borders, their association with PAS is
increased.55 Lacunae tend to congregate near the area of
placental invasion; thus, the presence of lacunae blood
flow on grayscale and color Doppler is also associated
with PAS.
Sonographic assessment of the uteroplacental inter-
face includes evaluation of the loss of the retroplacental
hypoechoic zone and thinning of the retroplacental
myometrium.6,9,13,39,46,47 The uteroplacental interface is
often inferior to the posterior bladder wall. Similar to
other PAS markers in women with an anterior placenta
and previous cesarean delivery, the uteroplacental
interface is best seen utilizing a combination of trans-
abdominal and transvaginal imaging with a partially fil-
led bladder.
The uterine contour is optimally evaluated when the
placenta is anterior, utilizing a partially filled bladder as the
acoustic window. This marker, often referred to as the
“placental bulge,” can be seen on both transabdominal and
transvaginal imaging. The bulge does not always reflect a
“through-and-through” defect of the uterine wall; rather, it
highlights the area of scar dehiscence and thinning of the
myometrium in areas of PAS.12,46,67 Although this finding
has not been correlated specifically with increased
morbidity or mortality, its presence raises the concern for
extrauterine placental extension (placenta percreta). Color
Doppler is often helpful to determine the extent of vascular
invasion.
Bridging vessels are defined as vessels, identified on
color Doppler, that extend from the placenta across the
myometrium and/or beyond the uterine serosa. This has
been considered as one of the “classic markers” of PAS
over the years but has lacked consistency in its defi-
nition.6,9 Typically seen running perpendicular to the
long axis of the uterus, bridging vessels are often
associated with the presence of a placental bulge with
placental tissue extending beyond the uterine serosa.41
Unlike other markers that can often be seen in cases
without PAS, this marker is rarely seen in cases without
PAS.10
It is important to note that the placenta is a 3D
structure, and thus, comprehensive sonographic
assessment is required in pregnancies at risk of PAS.
This is best performed by obtaining several parasagittal
and transverse planes of the placenta during the ultra-
sound examination. Special attention should be given to
the retroplacental area and the lower segment and cer-
vical regions. This is best achieved with a combined
transabdominal and transvaginal approach. Table 4
presents the sonographic approach in the second and
third trimesters of pregnancy.
Discussion
This document, endorsed by AIUM, SMFM, ACR, and
GOHO, supported by ACOG and ISUOG, and approved
by SRU, with ARDMS participating in the development
and production of the document, presents a
consensus-based approach to ultrasound examination
and assessment of PAS. Pregnancies with PAS are at a
significantly increased risk of maternal and fetal mor-
bidities and mortalities. Prenatal detection of PAS re-
duces pregnancy complications and improves
outcomes.3,7,8,43 Several PAS markers have been
identified and studied. There has been an effort to
standardize the definitions of PAS markers, with the
ultimate goal of improving risk stratification by

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TABLE 3 TABLE 4
Definitions of PAS markers in the second and Approach to ultrasound examination in the
third trimesters of pregnancy second and third trimesters of pregnancy
Marker Definition Marker Approaches
Placental lacunae Irregular, hypoechoic spaces within the Lacunae Detailed evaluation of the entire placenta in
placenta containing vascular flow (which can be orthogonal planes.
seen on grayscale and/or color Doppler
Lacunae should be evaluated using grayscale
imaging).
and color Doppler imaging.
The following lacunae findings are associated
Doppler assessment should generally be
with high risk of PAS:
performed with a low-velocity scale, low wall
Multiple (often defined as 3)
filters, and high gain to maximize detection of
 Large size
flowa (adjusting as needed for body habitus
 Irregular borders
and other clinical factors).
 High velocitya and/or turbulent flow within
Abnormal uteroplacental Evaluation of the uteroplacental interface is
Abnormal Loss of the retroplacental hypoechoic zone
interface optimized by perpendicular orientation of the
uteroplacental between the placenta and myometrium.b
transducer to the area of interest with
interface
This marker is often located along the posterior minimal transducer pressure.
bladder wall resulting in partial or complete
Transvaginal ultrasound is recommended in
interruption or irregularities of the uterovesical
the setting of an anterior, low-lying placenta
interface.
or placenta previa.
Thinning of the retroplacental myometrium
Imaging should be performed with a partially
(previously described as myometrial thickness
filled maternal bladder.
of <1 mm).
Optimization of gain settings to help
Abnormal uterine Placental tissue distorting the uterine contour
differentiate between placental and
contour (placental resulting in a bulge-like appearance.
myometrial tissues.
bulge)
The area of interest should be magnified so
Exophytic mass Placental tissue extruding beyond the uterine
that it occupies at least half of the ultrasound
serosa.
image with the focal zone at appropriate
Bridging vessel Vessel that extends from the placenta across the depth.
myometrium and beyond the uterine serosa.
Myometrial measurement should be made
PAS, placenta accreta spectrum. perpendicular to the long axis of the uterus
a
Some studies suggest a velocity of >15 cm/s as the threshold for high peak systolic and measured at the thinnest site (commonly
velocity; b This space represents the uterine decidua and has been described as the “clear along the uterine scar).
zone.”
Shainker. Special Report of the SMFM: Definition of markers and ultrasound ex- Abnormal uterine Placental tissue distorting the uterine contour
amination in pregnancies at risk of PAS. Am J Obstet Gynecol 2021. contour (placental bulge) resulting in a bulge-like appearance (this is
best appreciated in a midsagittal plane of the
uterus).
Exophytic mass Placental tissue visualized beyond the uterine
serosa.
ultrasound resulting in improved prenatal detection and Bridging vessel Doppler assessment of vessels extending
thus positively impacting pregnancy outcomes. This from the placenta across the myometrium
task force, assembled by SMFM with representation and beyond the uterine serosa.b
from multiple societies and organizations, provides a
Some studies suggest a velocity of >15 cm/s as the threshold for high peak systolic
definitions for PAS markers along with a standardized velocity; b Bridging vessels need to be differentiated from bladder varicosities, which are
approach to the ultrasound examination in pregnancies not placental in origin and do not increase risk of placenta accreta spectrum.
Shainker. Special Report of the SMFM: Definition of markers and ultrasound ex-
at risk of PAS. amination in pregnancies at risk of PAS. Am J Obstet Gynecol 2021.
It is important to recognize that the proposed definitions
of PAS markers are based on the current literature, along
with expert opinion when data are lacking. As ultrasound detection of low-velocity vascular flow. Accordingly, this
technology advances with improved tools, the detection of may result in difficulty differentiating normal from abnormal
abnormal placental invasion and vasculature should be placental flow.
greatly enhanced. Advancement in ultrasound technology It is also important to note that many of the markers pre-
may render the definitions of some existing PAS markers sented in this document have been studied in women with
obsolete. An example is the current definition of abnormal previous cesarean deliveries and placenta previa. In women
placental vasculature. Emerging ultrasound technology has without these risk factors, however, the markers are seen
resulted in significant improvements in the sonographic often and typically in the absence of PAS.10 As such, the

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SMFM Special Report
BOX 2
PAS ultrasound marker research gaps
 What is the utility of transvaginal ultrasound screening in the first trimester of pregnancy in all women with previous cesarean delivery?
 What is the appropriate timing of screening in the first trimester of pregnancy in women with previous cesarean delivery?
 Does location, size, and number of lacunae predict extent of invasion?
 How to define “high” peak systolic velocity in lacunae?
 Are the vessels resulting in uterovesicular hypervascularity placental or maternal in origin?
 What is the significance of increased placental thickness?
 Does the role of vascular imaging change with newer techologies?
 What is the role of 3D ultrasound when assessing placental volume, exophytic masses, and bridging vessels?
 How to define and assess cervical hypervascularity?
 How do PAS ultrasound markers correlate with maternal biomarkers?
 How do placental ultrasound markers progress with advancing gestational age?
 What is the role of MRI in the evaluation of PAS?
3D, 3-dimensional; MRI, magnetic resonance imaging; PAS, placenta accreta spectrum.
Shainker. Special Report of the SMFM: Definition of markers and ultrasound examination in pregnancies at risk of PAS. Am J Obstet Gynecol 2021.
recommended ultrasound approach to women without
these risk factors remains largely unknown and is an area of
great interest.
There are several limitations of ultrasound in
detecting PAS. Ultrasound is an operator-dependent
imaging modality and, thus, is highly dependent on
the skills of the examiner performing the ultrasound.
The detection rates will depend on placental location
and maternal imaging conditions that impact sono-
graphic visualization of markers. A standardized
approach to the performance of the ultrasound ex-
amination along with consensus-based definitions of
PAS markers will result in more consistency in diag-
nosis and allows for the evaluation of markers across
centers to improve diagnostic performance. Despite
optimizing a systematic approach to ultrasound ex-
amination for PAS markers, inherent limitations of ul-
trasound may diminish detection rates. These include
posterior placentation, with limited sound penetration
and resolution; elevated maternal BMI; and uterine
leiomyomata. The task force also identified research
gaps for sonographic markers of PAS (Box 2). We
hope that future research will use the definitions
hereby provided along with a standardized approach
to the ultrasound examination to facilitate data
comparison. In addition, although the scope of this
task force was focused on ultrasound examination, we
hope similar efforts are made in the future to provide
guidance on the use of MRI for the evaluation of PAS.
As PAS has become more prevalent, the need for agree-
ment on the definitions of ultrasound markers and sono-
graphic approach to the patient at risk of PAS is crucial. This
document provides necessary steps toward consistency in
the definitions of PAS markers and the approach to diag-
nosis. Accurate antenatal diagnosis is paramount in opti-
mizing maternal and fetal outcomes. Further work will be
needed to measure the impact of the proposed
B12 JANUARY 2021
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standardized definitions, along with the approach to ultra-
sound examination. n
REFERENCES
1. Creanga AA, Bateman BT, Butwick AJ, et al. Morbidity associated
with cesarean delivery in the United States: is placenta accreta an
increasingly important contributor? Am J Obstet Gynecol 2015;213:
384.e1–11.
2. Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated
with multiple repeat cesarean deliveries. Obstet Gynecol 2006;107:
1226–32.
3. Shamshirsaz AA, Fox KA, Salmanian B, et al. Maternal morbidity in
patients with morbidly adherent placenta treated with and without a
standardized multidisciplinary approach. Am J Obstet Gynecol 2015;212:
218.e1–9.
4. Shamshirsaz AA, Fox KA, Erfani H, et al. Multidisciplinary team learning
in the management of the morbidly adherent placenta: outcome im-
provements over time. Am J Obstet Gynecol 2017;216:612.e1–5.
5. Warshak CR, Ramos GA, Eskander R, et al. Effect of predelivery diag-
nosis in 99 consecutive cases of placenta accreta. Obstet Gynecol
2010;115:65–9.
6. Publications Committee, Society for Maternal-Fetal Medicine,
Belfort MA. Placenta accreta. Am J Obstet Gynecol 2010;203:430–9.
7. American College of Obstetricians and Gynecologists, Society for
Maternal-Fetal Medicine. Obstetrics Care Consensus No. 7: placenta
accreta spectrum. Obstet Gynecol 2018;132:e259–75.
8. Erfani H, Fox KA, Clark SL, et al. Maternal outcomes in unex-
pected placenta accreta spectrum disorders: single-center experi-
ence with a multidisciplinary team. Am J Obstet Gynecol 2019;221:
337.e1–5.
9. Bhide A, Sebire N, Abuhamad A, Acharya G, Silver R. Morbidly adherent
placenta: the need for standardization. Ultrasound Obstet Gynecol
2017;49:559–63.
10. Philips J, Gurganus M, DeShields S, et al. Prevalence of sonographic
markers of placenta accreta spectrum in low-risk pregnancies. Am J
Perinatol 2019;36:733–80.
11. Calì G, Timor-Trisch IE, Palacios-Jaraquemada J, et al. Changes in
ultrasonography indicators of abnormally invasive placenta during preg-
nancy. Int J Gynaecol Obstet 2018;140:319–25.
12. Hubinont C, Mhallem M, Baldin P, Debieve F, Bernard P, Jauniaux E.
A clinico-pathologic study of placenta percreta. Int J Gynaecol Obstet
2018;140:365–9.
smfm.org
13. Zosmer N, Jauniaux E, Bunce C, Panaiotova J, Shaikh H,
Nicholaides KH. Interobserver agreement on standardized ultrasound and
histopathologic signs for the prenatal diagnosis of placenta accreta
spectrum disorders. Int J Gynaecol Obstet 2018;140:326–31.
14. Calì G, D’Antonio F, Forlani F, Timor-Tritsch IE, Palacios-
Jaraquemada JM. Ultrasound detection of bladder-uterovaginal anasto-
moses in morbidly adherent placenta. Fetal Diagn Ther 2017;41:239–40.
15. Fujisaki M, Furukawa S, Maki Y, Oohashi M, Doi K, Sameshima H.
Maternal morbidity in women with placenta previa managed with predic-
tion of morbidly adherent placenta by ultrasonography. J Pregnancy
2017;2017:8318751.
16. Rac MW, Moschos E, Wells CE, McIntire DD, Dashe JS, Twickler DM.
Sonographic findings of morbidly adherent placenta in the first trimester.
J Ultrasound Med 2016;35:263–9.
17. Tovbin J, Melcer Y, Shor S, et al. Prediction of morbidly adherent
placenta using a scoring system. Ultrasound Obstet Gynecol 2016;48:
504–10.
18. Pilloni E, Alemanno MG, Gaglioti P, et al. Accuracy of ultrasound in
antenatal diagnosis of placental attachment disorders. Ultrasound Obstet
Gynecol 2016;47:302–7.
19. Cho HY, Hwang HS, Jung I, Park YW, Kwon JY, Kim YH. Diagnosis of
placenta accreta by uterine artery Doppler velocimetry in patients with
placenta previa. J Ultrasound Med 2015;34:1571–5.
20. Gilboa Y, Spira M, Mazaki-Tovi S, Schiff E, Sivan E, Achiron R. A novel
sonographic scoring system for antenatal risk assessment of obstetric
complications in suspected morbidly adherent placenta. J Ultrasound Med
2015;34:561–7.
21. Rac MW, Dashe JS, Wells CE, Moschos E, McIntire DD, Twickler DM.
Ultrasound predictors of placental invasion: the placenta accreta index. Am
J Obstet Gynecol 2015;212:343.e1–7.
22. Collins SL, Stevenson GN, Al-Khan A, et al. Three-dimensional power
Doppler ultrasonography for diagnosing abnormally invasive placenta and
quantifying the risk. Obstet Gynecol 2015;126:645–53.
23. Riteau AS, Tassin M, Chambon G, et al. Accuracy of ultrasonography
and magnetic resonance imaging in the diagnosis of placenta accreta.
PLoS One 2014;9:e94866.
24. Bowman ZS, Eller AG, Kennedy AM, et al. Accuracy of ultrasound for the
prediction of placenta accreta. Am J Obstet Gynecol 2014;211:177.e1–7.
25. Maher MA, Abdelaziz A, Bazeed MF. Diagnostic accuracy of ultra-
sound and MRI in the prenatal diagnosis of placenta accreta. Acta Obstet
Gynecol Scand 2013;92:1017–22.
26. Calì G, Giambanco L, Puccio G, Forlani F. Morbidly adherent
placenta: evaluation of ultrasound diagnostic criteria and differentiation
of placenta accreta from percreta. Ultrasound Obstet Gynecol
2013;41:406–12.
27. Peker N, Turan V, Ergenoglu M, et al. Assessment of total placenta
previa by magnetic resonance imaging and ultrasonography to detect
placenta accreta and its variants. Ginekol Pol 2013;84:186–92.
28. Ballas J, Pretorius D, Hull AD, Resnik R, Ramos GA. Identifying
sonographic markers for placenta accreta in the first trimester.
J Ultrasound Med 2012;31:1835–41.
29. Wong HS, Cheung YK, Williams E. Antenatal ultrasound assessment of
placental/myometrial involvement in morbidly adherent placenta. Aust N Z
J Obstet Gynaecol 2012;52:67–72.
30. Lim PS, Greenberg M, Edelson MI, Bell KA, Edmonds PR, Mackey AM.
Utility of ultrasound and MRI in prenatal diagnosis of placenta accreta: a
pilot study. AJR Am J Roentgenol 2011;197:1506–13.
31. Stirnemann JJ, Mousty E, Chalouhi G, Salomon LJ, Bernard JP, Ville Y.
Screening for placenta accreta at 11-14 weeks of gestation. Am J Obstet
Gynecol 2011;205:547.e1–6.
32. Hamada S, Hasegawa J, Nakamura M, et al. Ultrasonographic findings
of placenta lacunae and a lack of a clear zone in cases with placenta previa
and normal placenta. Prenat Diagn 2011;31:1062–5.
33. Chou MM, Chen WC, Tseng JJ, Chen YF, Yeh TT, Ho ES. Prenatal
detection of bladder wall involvement in invasive placentation with
sequential two-dimensional and adjunctive three-dimensional ultraso-
nography. Taiwan J Obstet Gynecol 2009;48:38–45.
SMFM Special Report
34. Shih JC, Palacios-Jaraquemada JM, Su YN, et al. Role of three-
dimensional power Doppler in the antenatal diagnosis of placenta
accreta: comparison with gray-scale and color Doppler techniques. Ul-
trasound Obstet Gynecol 2009;33:193–203.
35. Wong HS, Zuccollo J, Tait J, Pringle K. Antenatal topographical
assessment of placenta accreta with ultrasound. Aust N Z J Obstet
Gynaecol 2008;48:421–3.
36. Wong HS, Cheung YK, Strand L, et al. Specific sonographic features of
placenta accreta: tissue interface disruption on gray-scale imaging and
evidence of vessels crossing interface-disruption sites on Doppler imaging.
Ultrasound Obstet Gynecol 2007;29:239–40.
37. Japaraj RP, Mimin TS, Mukudan K. Antenatal diagnosis of placenta
previa accreta in patients with previous cesarean scar. J Obstet Gynaecol
Res 2007;33:431–7.
38. Yang JI, Lim YK, Kim HS, Chang KH, Lee JP, Ryu HS. Sonographic
findings of placental lacunae and the prediction of adherent placenta in
women with placenta previa totalis and prior cesarean section. Ultrasound
Obstet Gynecol 2006;28:178–82.
39. Comstock CH, Love JJ Jr, Bronsteen RA, et al. Sonographic detection
of placenta accreta in the second and third trimesters of pregnancy. Am J
Obstet Gynecol 2004;190:1135–40.
40. Jauniaux E, Bhide A, Kennedy A, et al. FIGO consensus guidelines on
placenta accreta spectrum disorders: prenatal diagnosis and screening.
Int J Gynaecol Obstet 2018;140:274–80.
41. Collins SL, Ashcroft A, Braun T, et al. Proposal for standardized ul-
trasound descriptors of abnormally invasive placenta (AIP). Ultrasound
Obstet Gynecol 2016;47:271–5.
42. Levine D, Hulka CA, Ludmir J, Li W, Edelman RR. Placenta accreta:
evaluation with color Doppler US, power Doppler US, and MR imaging.
Radiology 1997;205:773–6.
43. Eller AG, Bennett MA, Sharshiner M, et al. Maternal morbidity in cases
of placenta accreta managed by a multidisciplinary care team compared
with standard obstetric care. Obstet Gynecol 2011;117:331–7.
44. Esakoff TF, Sparks TN, Kaimal AJ, et al. Diagnosis and morbidity of
placenta accreta. Ultrasound Obstet Gynecol 2011;37:324–7.
45. Warshak CR, Eskander R, Hull AD, et al. Accuracy of ultrasonography
and magnetic resonance imaging in the diagnosis of placenta accreta.
Obstet Gynecol 2006;108:573–81.
46. Jauniaux E, Collins SL, Jurkovic D, Burton GJ. Accreta placentation: a
systematic review of prenatal ultrasound imaging and grading of villous
invasiveness. Am J Obstet Gynecol 2016;215:712–21.
47. Jauniaux E, Collins S, Burton GJ. Placenta accreta spectrum: patho-
physiology and evidence-based anatomy for prenatal ultrasound imaging.
Am J Obstet Gynecol 2018;218:75–87.
48. Timor-Tritsch IE, Monteagudo A, Cali G, et al. Cesarean scar preg-
nancy is a precursor of morbidly adherent placenta. Ultrasound Obstet
Gynecol 2014;44:346–53.
49. Calì G, Timor-Tritsch IE, Palacios-Jaraquemada J, et al. Outcome of
cesarean scar pregnancy managed expectantly: systematic review and
meta-analysis. Ultrasound Obstet Gynecol 2018;51:169–75.
50. Kaelin Agten A, Cali G, Monteagudo A, Oviedo J, Ramos J, Timor-
Tritsch I. The clinical outcome of cesarean scar pregnancies implanted “on
the scar” versus “in the niche.” Am J Obstet Gynecol 2017;216:510.e1–6.
51. Timor-Tritsch IE, Monteagudo A, Cali G, et al. Cesarean scar preg-
nancy and early placenta accreta share common histology. Ultrasound
Obstet Gynecol 2014;43:383–95.
52. D’Antonio F, Timor-Tritsch IE, Palacios-Jaraquemada J, et al. First-
trimester detection of abnormally invasive placenta in high-risk women:
systematic review and meta-analysis. Ultrasound Obstet Gynecol
2018;51:176–83.
53. Cali G, Forlani F, Foti F, et al. Diagnostic accuracy of first-
trimester ultrasound in detecting abnormally invasive placenta in
high-risk women with placenta previa. Ultrasound Obstet Gynecol
2018;52:258–64.
54. Panaiotova J, Tokunaka M, Krajewska K, Zosmer N, Nicolaides KH.
Screening for morbidly adherent placenta in early pregnancy. Ultrasound
Obstet Gynecol 2019;53:101–6.
JANUARY 2021 B13
SMFM Special Report
55. Finberg HJ, Williams JW. Placenta accreta: prospective sonographic
diagnosis in patients with placenta previa and prior cesarean section.
J Ultrasound Med 1992;11:333–43.
56. Guy GP, Peisner DB, Timor-Tritsch IE. Ultrasonographic
evaluation of uteroplacental blood flow patterns of abnormally
located and adherent placentas. Am J Obstet Gynecol 1990;163:
723–7.
57. El Behery MM, Rasha LE, El Alfy Y. Cell-free placental mRNA in
maternal plasma to predict placental invasion in patients with placenta
accreta. Int J Gynaecol Obstet 2010;109:30–3.
58. Hoffmann J, Exner M, Bremicker K, Grothoff M, Stumpp P, Stepan H.
Comparison of the lower uterine segment in pregnant women with and
without previous cesarean section in 3 T MRI. BMC Pregnancy Childbirth
2019;19:160.
59. Chou MM, Ho ES, Lee YH. Prenatal diagnosis of placenta previa
accreta by transabdominal color Doppler ultrasound. Ultrasound Obstet
Gynecol 2000;15:28–35.
60. Haidar ZA, Papanna R, Sibai BM, et al. Can 3-dimensional power
Doppler indices improve the prenatal diagnosis of a potentially morbidly
adherent placenta in patients with placenta previa? Am J Obstet Gynecol
2017;217:202.e1–13.
61. Wong HS, Cheung YK, Zuccollo J, Tait J, Pringle KC. Evaluation of
sonographic diagnostic criteria for placenta accreta. J Clin Ultrasound
2008;36:551–9.
62. Twickler DM, Lucas MJ, Balis AB, et al. Color flow mapping for myo-
metrial invasion in women with a prior cesarean delivery. J Matern Fetal
Med 2000;9:330–5.
63. Maged AM, Abdelaal H, Salah E, et al. Prevalence and diagnostic
accuracy of Doppler ultrasound of placenta accreta in Egypt. J Matern
Fetal Neonatal Med 2018;31:933–9.
64. Kumar I, Verma A, Ojha R, Shukla RC, Jain M, Srivastava A. Invasive
placental disorders: a prospective US and MRI comparative analysis. Acta
Radiol 2017;58:121–8.
65. AIUM-ACR-ACOG-SMFM-SRU practice parameter for the perfor-
mance of standard diagnostic obstetric ultrasound examinations.
J Ultrasound Med 2018;37:E13–24.
66. D’Antonio F, Iacovella C, Bhide A. Prenatal identification of invasive
placentation using ultrasound: systematic review and meta-analysis. Ul-
trasound Obstet Gynecol 2013;42:509–17.
B14 JANUARY 2021 ª 2020 Published by Elsevier Inc. https://doi.org/10.1016/j.ajog.2020.09.001
smfm.org
67. Dannheim K, Shainker SA, Hecht JL. Hysterectomy for placenta
accreta; methods for gross and microscopic pathology examination. Arch
Gynecol Obstet 2016;293:951–8.
All authors and Committee members have filed a conflict of interest
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content of this publication.
This document has undergone an internal peer review through a
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Review Committees and final approval by the SMFM Executive Com-
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