Ultrasound Obstet Gynecol 2016; 48: 504–510

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.15813

Prediction of morbidly adherent placenta using a scoring

system
J. TOVBIN*, Y. MELCER*, S. SHOR*, M. PEKAR-ZLOTIN*, S. MENDLOVIC†, R. SVIRSKY*
and R. MAYMON*
*Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Zerifin, Israel; †Department of Pathology, Assaf Harofeh
Medical Center, Zerifin, Israel, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

K E Y W O R D S: Doppler; morbidly adherent placenta; prenatal diagnosis; scoring system; ultrasound

ABSTRACT Conclusions Our proposed scoring system is highly

Objective To evaluate the accuracy of an ultrasound-
based scoring system for diagnosing morbidly adherent
placenta (MAP).
Methods This study included pregnant women referred
to our ultrasound unit during 2013–2015 because of
suspected MAP on a previous ultrasound examination
or because they had at least one previous Cesarean
delivery. All women were assessed using a scoring system
based on the following: number and size of placental
lacunae; obliteration of the demarcation between the
uterus and placenta; placental location; color Doppler
signals within placental lacunae; hypervascularity of the
placenta–bladder and/or uteroplacental interface zone;
and number of previous Cesarean deliveries. Each
criterion was assigned 0, 1 or 2 points and the sum
of points yielded the final score. Patients were classified
into low, moderate or high probability for MAP based
on the final score. The presence of MAP was determined
by the surgeon at delivery and clinical descriptions were
documented in the electronic patient file. Pathological
diagnoses were available only in cases that underwent
hysterectomy.
Results In total, 258 pregnant women were included
in the study, of whom 23 (8.9%) were diagnosed with
MAP. There was a statistically significant difference in
the prevalence of MAP when women were grouped
according to the scoring system, with 0.9%, 29.4% and
84.2% in the low, moderate and high probability groups,
respectively (P < 0.0001). All sonographic criteria of the
scoring system were significantly associated with MAP
(P < 0.0001). Receiver–operating characteristics (ROC)
curves for prediction of MAP using the number of
placental lacunae and obliteration of the uteroplacental
demarcation yielded an area under the ROC curve of 0.94
(95% CI, 0.86–1.00).
predictive of MAP in patients at risk. This allows
an adequate multidisciplinary team approach for the
planning and timing of delivery in such cases. Copyright
© 2015 ISUOG. Published by John Wiley & Sons Ltd.
INTRODUCTION
Morbidly adherent placenta (MAP) defines a spectrum
of conditions, including placenta accreta, increta and
percreta, which are associated with significant maternal
and fetal morbidity and mortality1 . As a result of
the notably increased rate of Cesarean deliveries, the
reported incidence of placenta accreta has increased from
approximately 0.8 per 1000 deliveries in the 1980s to 3
per 1000 deliveries in the past decade2 . Placenta previa
and previous uterine surgery represent the major risk
factors for MAP1,3 – 12 .
Antenatal diagnosis of MAP and a multidisciplinary
team approach to care have the potential to reduce
maternal and fetal intrapartum complications, including
maternal blood loss, requirement for transfusion, hys-
terectomy, intraoperative urological and gastrointestinal
injuries, and even maternal death13 – 16 .
Ultrasound evaluation, with grayscale and color
Doppler imaging, is the recommended first-line modality
for diagnosing MAP17,18 . Grayscale ultrasound features
suggestive of placenta accreta include the loss of
myometrial interface or retroplacental clear space,
reduced myometrial thickness and the presence of
intraplacental lacunae19 – 37 .
The next step in predicting placental invasion by
ultrasound is to integrate some of the abovementioned
individual sonographic parameters associated with MAP
into a well-defined scoring system. Previous investigators
have proposed a standardized evaluation of women at
risk for MAP38,39 . However, these reports were based on

Correspondence to: Prof. R. Maymon, Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Zerifin, 70300, Israel
(e-mail: maymonrb@bezeqint.net)
Accepted: 11 November 2015

Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd. ORIGINAL PAPER
Scoring system for prediction of morbidly adherent placenta
small retrospective studies and both groups recommended
further study to validate their scoring model.
In the current study, our aim was to develop a scoring
system for predicting MAP based on an assessment of
ultrasound and clinical characteristics in a cohort of
women at risk of MAP. Based on the assessment outcome,
patients were offered specific antepartum and intrapartum
management.
SUBJECTS AND METHODS
We conducted a single-center study for predicting MAP in
high-risk pregnant women attending our ultrasound unit
between December 2013 and February 2015 for suspected
MAP on an ultrasound examination performed elsewhere
or at least one previous Cesarean delivery. All women
were recruited and scanned during either the second
or third trimester of pregnancy using two-dimensional
(2D) grayscale imaging and color Doppler flow mapping.
Inclusion criteria were one or more of the following:
previous Cesarean delivery, myomectomy, history of
adherent placenta, ultrasound suspicion of MAP. Patients
were excluded from the study if they did not deliver at
our hospital. The study was approved by the Institutional
Review Board.
The examination was based on a scoring system,
developed and used routinely in our department, that
determines the probability for MAP. All ultrasound
images were reviewed and scored according to six different
criteria (Table 1): number and size of placental lacunae
(an irregular area of low echogenicity larger than 1 × 1 cm
in the placental parenchyma40 ); obliteration of the
demarcation between the uterus and the placenta; number
of previous Cesarean deliveries; placental location; and
color Doppler assessment of flow in the placental lacunae
and placenta–bladder and/or uteroplacental interface
hypervascularity27 – 35 .
Each criterion was assigned 0, 1 or a maximum
of 2 points and the sum of the points obtained
from each criterion yielded the final score. Based on
this suggested scoring system, patients were classified
into one of three groups: low (≤ 5 points), moderate
(6–7 points) or high (8–12 points) probability for
MAP (Figure 1 and Table 1). The images and
measurements (obtained using electronic calipers) were
printed as a thermal hard copy for the patient
record file. Only satisfactory ultrasound images were
included for data processing. Ultrasound examinations
were performed with either a 2–5-MHz curvilinear
transabdominal transducer or a 5–9-MHz transvaginal
probe. Ultrasound images and associated reports used
in the clinical management of each patient were stored
electronically in a picture-archiving and communication
system throughout the study period. Therefore each
patient had both a hard copy and an archived electronic
file of the images. Each patient file was evaluated by
a single physician with expertise in imaging (R.M.)
using the scoring system and all cases with high
probability of MAP were scanned and assessed by
Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
505
Table 1 Detailed scoring system for ultrasound evaluation of
suspected morbidly adherent placenta according to six different
criteria
Parameter Score
Number of previous Cesarean deliveries
1 1
≥2 2
Lacuna maximum dimension
≤ 2 cm 1
> 2 cm 2
Number of lacunae
≤2 1
>2 2
Obliteration of uteroplacental demarcation 2
Location of placenta
Anterior 1
Placenta previa 2
Doppler assessment
Blood flow in placental lacunae 1
Hypervascularity of placenta–bladder 2
and/or uteroplacental interface
this physician in consultation with another one (R.M.
and J.T.).
The scoring system was used not only for stratifying
individual risk of MAP but also for counseling and
preoperative planning in each patient, by either raising
awareness of MAP or providing reassurance to women
who desired a future pregnancy. As part of our protocol,
all pregnant women with suspected MAP were followed
up antenatally in a specialized clinic by a multidisciplinary
medical team including an experienced sonographer, a
perinatologist, obstetricians and anesthesiologists, which
allows for multidisciplinary planning and delivery before
the onset of labor and/or vaginal bleeding.
The follow-up of patients with low probability of
having MAP was based on obstetric indications other than
adherent placenta. If a woman categorized as medium or
high probability was not hospitalized because of placenta
previa or unrelated indications, we conducted follow-up
scans every 2–3 weeks. All women with a high probability
were seen at least once in a joint work-up meeting with a
multidisciplinary team.
Our antenatal care approach included supplemen-
tation with oral iron to maximize iron stores and
oxygen-carrying capacity. In selected patients, concur-
rent parenteral iron infusion was given preoperatively.
Preoperative ultrasound mapping of the placental loca-
tion was performed to assist in determining the optimal
approach for abdominal wall and uterine incisions and to
avoid disturbance of the placenta before delivery of the
fetus.
As part of our protocol, the results of the scoring system
were reported to the patients and the surgical team. In
all cases of medium and high probability of MAP, a
preoperative checklist was completed to confirm that the
required preparations had been made and to identify
the name and contact information of the consultant in
case they were needed for intraoperative or perioperative
Ultrasound Obstet Gynecol 2016; 48: 504–510.
506 Tovbin et al.

Figure 1 Scoring system for predicting morbidly adherent placenta in a case with two prior Cesarean deliveries (2 points). Obliteration of
demarcation ( ) between uterus and placenta (2 points). b, bladder. (b) Placental lacunar size ≥ 2 cm (arrow; 2 points). (c) Placenta previa
(note outline of cervix; 2 points). (d) Number of placental lacunae ≥ 2 cm (arrows; 2 points). (e) Hypervascularity between placenta and
bladder shown by color Doppler assessment (arrows; 2 points). The sum of points obtained from each criterion yields a maximum score of
12 points, indicating high probability of morbidly adherent placenta.

assistance18 . Thus patients who were classified as high
probability for MAP (8–12 points) underwent surgery
by a highly experienced senior obstetrician and a
multidisciplinary team.
According to our protocol, in all cases of moderate
and high probability of MAP, preoperative consultation
and notification of the blood bank was conducted and
adequate access to replacement blood was secured. In
the high-risk group, an ultrasound examination was
conducted by R.M. and J.T. just before surgery to map
again the placenta and identify its location in the uterine
cavity in relation to the bladder and the array of various
large blood vessels.
Patients with a low probability of MAP were scheduled
for vaginal delivery if Cesarean section was not indicated
for other reasons. In these patients, the obstetric team
waited for spontaneous placental separation and the
placenta was subsequently examined. MAP was defined
in this group by failed attempts to remove the placenta
during the third stage of labor. Patients with medium or
high probability of MAP were scheduled for Cesarean
section at 36 weeks of gestation.
When gross placental invasion was evident at surgery
(Figure 2), massive bleeding occurred, the placenta was
difficult to detach from the uterus or a part of the
placenta remained attached, the common practice in
our institute was not to attempt to remove the pla-
centa manually1 and a B-Lynch procedure or Cesarean
hysterectomy was performed, where appropriate. The
presence and severity of placental adherence was deter-
mined by the surgeons, and the clinical descriptions were
documented in the electronic patient file. The need for
a hysterectomy was decided at surgery dependent on
the surgical findings. Pathological diagnoses were avail-
able only in cases that underwent wedge resection or
Cesarean hysterectomy (Figure 2). The pathologist was
not blinded to the suspected diagnosis but was blinded to
the sonographic score. All patients who underwent hys-
terectomy had massive placenta percreta diagnosed during
surgery.
For the purpose of the current study, the medical
records of all cases were reviewed, and information
regarding demographics, obstetric and gynecological
history, operative procedure and maternal postoperative
complications was obtained for each probability group.
Statistical analysis was conducted in the statistical labo-
ratory at Tel Aviv University using SPSS Statistics version
21 software (IBM Corp., Armonk, NY, USA). Continuous
variables are presented as mean ± SD or as median (range).
Frequencies are presented as percentages. The accuracy of
the various criteria in discriminating MAP from non-MAP
was examined in terms of sensitivity, specificity, pos-
itive predictive value and negative predictive value. A
two-tailed Fisher’s exact test or Pearson’s chi-square test
was used to determine the association of various sono-
graphic criteria with the presence of MAP. A two-tailed
P-value < 0.05 was considered statistically significant.
Logistic regression analysis was used to determine which
sonographic parameters of the scoring system were sig-
nificantly associated with a clinical diagnosis of MAP by
the surgeons. Odds ratios (OR) with 95% CIs are given.
The receiver–operating characteristics (ROC) curves for
the sonographic criteria and the composite score were
plotted.

Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2016; 48: 504–510.
Scoring system for prediction of morbidly adherent placenta
Figure 2 Specimen showing morbidly adherent placenta diagnosed antenatally and managed by Cesarean hysterectomy. (a,b) Vasculari-
zation over uterine serosa was observed. (c) Hysterectomy specimen demonstrating morbidly adherent placenta. (d) The placenta had
invaded the myometrium and could not be separated from the uterus. (e) Chorionic villi (cv) had penetrated into necrotic decidua (d)
(hematoxylin and eosin stain, original magnification × 20). (f) Chorionic villus (cv) within necrotic decidua (hematoxylin and eosin stain,
original magnification × 40).
RESULTS
In total, 268 patients were recruited during the study
period. Ten patients delivered elsewhere and were lost
to follow-up, and thus 258 women were included in the
study. Twenty-three (8.9%) women had a diagnosis of
MAP and 235 (91.1%) had no clinical evidence of an
adherent placenta (Figure 3). The mean ± SD maternal
age at ultrasound evaluation was 33.8 ± 4.5 years and
mean gestational age at diagnosis was 33.9 (range,
16–41) weeks. Mean ± SD maternal gravidity and
parity were 4.0 ± 1.6 and 2.0 ± 1.2, respectively. Mean
gestational age at delivery was 37.7 ± 1.7 (range, 24–41)
weeks.
There was a statistically significant difference in the
prevalence of MAP when women were grouped according
to the probability category derived from the sonographic
score, with 0.9%, 29.4% and 84.2% in the low, moderate
and high probability groups, respectively (Figure 3)
(P < 0.0001). Two patients in the low-probability group
had placental adherence (false negative), but this was
minimal and was not associated with significant blood
loss and postoperative outcome was normal in both cases.
Nine (47.4%) of the 19 women in the high-probability
group underwent Cesarean hysterectomy and in all cases
the histopathological report confirmed the diagnosis of
MAP (Figure 2). Each individual sonographic parameter
that we assessed in the scoring system was significantly
associated with MAP (P < 0.0001). The overall sensitivity,
specificity, and positive and negative predictive values
of a high probability score diagnosing MAP were
Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
507
cv
d
cv
cv
69.6% (16/23), 98.7% (232/235), 84.2% (16/19) and
97.1% (232/239), respectively. The positive and negative
likelihood ratios were 54.5 and 0.31, respectively. The
overall sensitivity (detection rate) of a high or moderate
probability score diagnosing MAP was 91.3% (21/23)
and the specificity was 93.6% (220/235).
Logistic regression was used to examine the rela-
tionship between sonographic variables found to be
significantly associated with MAP on univariable analysis
and a clinical diagnosis of an invasive placenta, presented
as OR (95% CI). The OR for MAP was 28.1 (95% CI,
5.34–147.67) for the presence of one placental lacuna
and 220.7 (95% CI, 42.11–1156.84) when two lacunae
were present, which yielded the greatest prediction of
MAP. For obliteration of the uteroplacental demarcation,
the OR was 87.24 (95% CI, 26.21–290.35). The OR for
lacuna size ≤ 2 cm was 19.43 (95% CI, 4.86–77.57) and
when lacuna size was > 2 cm, the OR was 203.23 (95%
CI, 49.54–1493.26). The OR for Doppler flow in the pla-
cental lacunae was 29.73 (95% CI, 4.03–218.97) and for
placenta–bladder and/or uteroplacental interface hyper-
vascularity was 79.28 (95% CI, 23.75–264.61). The OR
for anterior placenta was 2.7 (95% CI, 0.3–23.76) and
for placenta previa was 83.7 (95% CI, 11.65–769.97).
The ROC curves for each sonographic parameter
predicting MAP are shown in Figure 4. The ROC curve
of the composite score of the number of placental
lacunae and obliteration of the demarcation between
the uterus and placenta was plotted (Figure 5), yielding
an area under the ROC curve of 0.94 (95% CI,
0.86–1.00).
Ultrasound Obstet Gynecol 2016; 48: 504–510.
508 Tovbin et al.

Initial study
(n = 268)

Lost to follow-up
(n = 10)

Final study
(n = 258)

Low probability Moderate probability High probability

(n = 222; 86%) (n = 17; 6.6%) (n = 19; 7.4%)

+ – + – + –

(n = 2; 0.9%) (n = 220; 99.1%) (n = 5; 29.4%) (n = 12; 70.6%) (n = 16; 84.2%) (n = 3; 15.8%)

Figure 3 Flowchart summarizing detection rate of morbidly adherent placenta in low-, moderate- and high-probability groups. +, morbidly
adherent placenta; −, normal placentation. P < 0.0001, Pearson’s chi-square test.

1.0 1.0

0.8
0.8

0.6
Sensitivity

0.6
Sensitivity

0.4

0.4 0.2

0.2 0 0.2 0.4 0.6 0.8 1.0

1 – Specificity

Figure 5 Receiver–operating characteristics (ROC) curve for

0 0.2 0.4 0.6 0.8
1 – Specificity
Figure 4 Receiver–operating characteristics (ROC) curves for
prediction of morbidly adherent placenta. Curves represent
prediction of probability of invasion using lacunar size (
area under the ROC curve (AUC), 0.89 (95% CI, 0.81–0.98)),
number of placental lacunae ( ; AUC, 0.92 (95% CI,
0.85–0.99)), obliteration of demarcation between uterus and
placenta ( ; AUC, 0.83 (95% CI, 0.72–0.95)), interface
hypervascularity ( ; AUC, 0.87 (95% CI, 0.76–0.97)) and
location of placenta ( ; AUC, 0.86 (95% CI, 0.77–0.95)).
DISCUSSION
Prenatal diagnosis of placenta accreta is paramount,
as most pregnant women with this condition are
asymptomatic. Correct prenatal diagnosis allows time for
a multidisciplinary team to make delivery plans, which
will help decrease surgical complications, maternal blood
loss and prolonged intensive care unit admissions41 – 43 .
The main findings of the current study are that
the sonographic score derived from the number of
1.0 prediction of morbidly adherent placenta using a combination of
number of placental lacunae and obliteration of hypoechoic
uteroplacental demarcation (area under the ROC curve, 0.94 (95%
CI, 0.86–1.00)).
; Cesarean deliveries, the placental location and lacunae
features, obliteration of the uteroplacental demarcation
and color Doppler flow assessment was highly predictive
of MAP, allowing for antenatal and intrapartum
specific management. Although two (0.9%) of the 222
women in the low-probability group had MAP (false
negative), only minimal placental adherence was observed
intraoperatively. They had both normal intrapartum
blood loss and postoperative outcome. In our series, the
most effective ultrasound criteria for detection of MAP
were a combination of two parameters, the number of
placental lacunae and obliteration of the uteroplacental
demarcation, which yielded an area under the ROC
curve of 0.94 (95% CI, 0.86–1.00) (Figure 5). Previous
reports showed similar results to ours19,29,31,44 – 46 ;
however, a prospective study that combines several
ultrasound parameters in one coherent scoring system

Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2016; 48: 504–510.
Scoring system for prediction of morbidly adherent placenta
Table 2 Summary of studies predicting placental invasion by a scoring system based on sonographic parameters associated with morbidly
adherent placenta (MAP)
Study Trimester
Reference design Inclusion criteria at scan
Rac Retro Previous CS and PP or 3 Pathology
(2015)39 low-lying placenta
Gilboa Retro PP and previous CS or 3 Surgical findings,
(2015)38 placenta overlying
any uterine scar or
ultrasound suspicion
of MAP or findings
of multiple lacunae
Present Retro PP and/or previous CS 2–3
study or ultrasound
suspicion of MAP
Only first author of each study is given. CS, Cesarean section; PP, placenta previa; Retro, retrospective.
to estimate the probability of MAP has not yet been
reported.
Two retrospective studies proposed a standardized
evaluation of women at risk for MAP38,39 (Table 2).
Gilboa et al.38 reported a series of 21 women with
placenta percreta that was identified at surgery and
proposed a scoring system based on the sonographic
findings. Their detection rate of placenta percreta was
63.6%. However, the main goal of their scoring system
was to identify patients with Stage 3 MAP and offer
a prophylactic pelvic artery catheterization. Rac et al.39
created a predictive equation for placental invasion
based on sonographic parameters that were studied in
88 cases.
The pathophysiology of placental lacunae is not
clear, although a strong relationship between lacu-
nar spaces and placental invasion has been described
previously19,21,45,47,48 . Lacunae may be present even
in women with placenta previa without myometrial
invasion47 . Finberg and Williams19 found that the
number and abnormal appearance of lacunar spaces
were directly correlated with certainty and severity of
MAP. In a recent systematic review, the overall pooled
sensitivity and specificity from 13 studies of lacunar
spaces diagnosing MAP was 77% and 95%, respec-
tively, with an overall diagnostic accuracy of 88.4%37 .
The rationale for including the presence or absence of
the demarcation between the uterus and placenta in the
suggested scoring system is based on the premise that inva-
sion of trophoblastic tissue into the myometrium and the
absence of decidua basalis in invasive placentation pro-
gressively lead to a reduction in myometrial thickness and
a loss of space between the myometrium and placenta31 .
Cali et al.49 reported recently that the absence of the utero-
placental demarcation was the most effective sonographic
criterion for detection of an invasive placenta, with a neg-
ative predictive value of 96.7%. However, evaluation of
Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
509
Reference Women MAP
standard Diagnostic criteria scanned (n) (%)
Location of placenta, loss of the 184 29
retroplacental clear zone,
irregularity and thickness of the
uterus–bladder interface, the
smallest myometrial thickness,
presence of lacunar spaces and
bridging vessels
Presence and number of placental 109 69.7
pathology lacunae, interruption of the
uterus–bladder interface,
obliteration of demarcation
between the uterus and the
placenta
Surgical findings, Number and size of placental 258 8.9
pathology lacunae, obliteration of
demarcation between uterus and
placenta
the interface between the myometrium and the placenta
may be difficult on conventional transabdominal ultra-
sound during the late third trimester because the lower
uterine segment appears as a thin line.
Assigning a score in clinical practice may be helpful
in the antenatal diagnosis of MAP and seems to be
a key factor in reducing maternal and fetal morbidity
and mortality, by allowing multidisciplinary counseling,
and planning and timing of delivery. During the
antenatal period, care is taken to increase hemoglobin
levels by administration of appropriate medication and
to evaluate the patient for any potential obstetric
complications. Surgery is planned with an experienced
surgeon, anesthetic and perinatal intensive care team.
In addition, an adequate number of blood units are
made available in the operating room. This multitask
approach can only be achieved if early detection of
such a potentially life-threatening obstetric disorder is
achieved.
Some limitations of this study should be acknowledged.
The main one was the fact that the surgical team
was not blinded to the ultrasound findings and the
diagnosis of MAP during surgery was made by the
surgeons in all cases in which hysterectomy was avoided.
Despite these limitations, the study presents a novel and
effective method that enables preoperative preparation of
women with MAP who are at risk of major maternal
complications.
Factors such as maternal age, parity, mode of con-
ception and history of other uterine surgical procedures
associated with MAP such as dilation and curettage, and
endometrial ablation were not included in our model.
Additional studies are needed to validate our scoring
system model, and to incorporate those parameters.
In conclusion, the present simple ultrasound and
clinical scoring system may be highly predictive of MAP,
allowing for adequate antenatal risk assessment. It is
Ultrasound Obstet Gynecol 2016; 48: 504–510.
510
helpful for patient counseling and delivery planning with
a multidisciplinary team approach, all of which may
ultimately improve pregnancy outcome in women at risk
of MAP.
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