European Journal of Radiology 82 (2013) e51–e57

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European Journal of Radiology

journal homepage: www.elsevier.com/locate/ejrad

Detection of suspected placental invasion by MRI: Do the results depend

on observer’ experience?
Leonor Alamo a,∗ , Anass Anaye a , Jannick Rey a , Alban Denys a , Georg Bongartz b , Sylvain Terraz c ,
Simona Artemisia a , Reto Meuli a , Sabine Schmidt a
a
Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
b
Universitätsspital Basel, Switzerland
c
Hôpitaux Universitaires Genève, Switzerland

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: To evaluate the diagnostic value of previously described MR features used for detecting suspected
Received 25 May 2012 placental invasion according to observers’ experience.
Received in revised form 22 August 2012 Materials and methods: Our population included 25 pregnant women (mean age 35.16) investigated by
Accepted 29 August 2012
prenatal MRI (1.5 T, T1- and T2-weighted MR-sequences without i.v. contrast), among them 12 with
histopathologically proven placental invasion and 13 women (52%) without placental invasion used
Keywords:
as control group. Two senior and two junior radiologists blindly and independently reviewed MR-
Magnetic resonance imaging
examinations in view of 6 previously defined MR-features indicating presence and degree of placental
Placenta
Placental imaging
invasion (placenta increta, accreta or percreta). For each reader the sensibility, specificity, and receiver
Placental invasion operating curve (ROC) were calculated. Interobserver agreements between senior and junior readers
were determined. Stepwise logistic regression was performed including the 6 MR-features predictive of
placental invasion.
Results: Demographics between both groups were statistically equivalent. Overall sensitivity and speci-
ficity for placental invasion was 90.9% and 75.0% for seniors and 81.8% and 61.8% for juniors, respectively.
The best single MR-feature indicating placental invasion was T2-hypointense placental bands (r2 = 0.28),
followed by focally interrupted myometrial border, infiltration of pelvic organs and tenting of the blad-
der (r2 = 0.36). Interobserver agreement for detecting placental invasion was 0.64 for seniors and 0.41 for
juniors, thus substantial and moderate, respectively. Seniors detected placental invasion and depth of
infiltration with significantly higher diagnostic certitude than juniors (p = 0.0002 and p = 0.0282, respec-
tively).
Conclusion: MRI can be a reliable and reproducible tool for the detection of suspected placental invasion,
but the diagnostic value significantly depends on observers’ experience.
© 2012 Elsevier Ireland Ltd. All rights reserved.

1. Introduction maternal morbidity and mortality. Their prevalence is currently

Disorders of placental implantation are currently classified as
abnormal localization and abnormal attachment. Abnormalities in
placental localization are far more commonly encountered (1/250
pregnancies) than abnormalities in placental attachment (1/5000
pregnancies). Attachment abnormalities include three entities: pla-
centa accreta, increta and percreta, which represent a spectrum
of placental adhesive disorders, with increasing severity (Fig. 1).
These placental implantation disorders are a significant cause of
∗ Corresponding author at: Department of Diagnostic and Interventional Radi-
ology, University Hospital – CHUV, Rue du Bugnon, 46, CH-1011 Lausanne,
Switzerland. Tel.: +41 21 3143054; fax: +41 21 3144645.
E-mail address: leonor.alamo@chuv.ch (L. Alamo).
on the rise because of the growing percentage of older pregnant
women and those with previous abortions and/or caesarean sec-
tions [1,2].
The diagnosis and management of women at risk is not only
based on clinical parameters, but also driven by imaging, namely
ultrasound (US) and, more recently, magnetic resonance imaging
(MRI). Prenatal US is formerly considered as the routine diagnostic
standard examination, but fetal MRI is emerging as an alterna-
tive and complementary method, used in case of ultrasonographic
suspicion of placenta attachment anomalies, but equivocal diag-
nosis. In the past decade, several MR imaging features have been
described and considered useful for predicting abnormal placental
implantation [1–8]. However, these MR signs may be subtle and
difficult to detect, in particular when the radiologist has limited
experience.

0720-048X/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ejrad.2012.08.022
e52 L. Alamo et al. / European Journal of Radiology 82 (2013) e51–e57
Fig. 1. Abnormal placental implantation occurs when a defect of the decidua basalis
allows the invasion of chorionic villi into the myometrium. The spectrum includes
placenta accreta, increta and precreta, classified according to the depth of infiltra-
tion. Placenta accreta, the least severe entity, means the attachment of the chorionic
villi to the myometrium, without invasion, unlike in placenta increta that is defined
by partial myometrial invasion. In placenta percreta, the most severe form, the
chorionic villi penetrate the uterine serosa and may extend into adjacent pelvic
organs.
The purpose of this study was to exactly assess the diagnos-
tic value of specific MR features for detecting suspected placental
invasion according to the radiologists’ working experience.
2. Material and methods
2.1. Patients
Our study population included 25 pregnant women (mean age
35.16) who had been consecutively investigated by prenatal MRI
between June 2007 and December 2009 after obstetrician refer-
ral for suspected placental invasion upon standard pregnancy US
examinations. The patients were followed and treated in one of
the three different University Hospitals that took part in this ret-
rospective study. Nineteen patients presented placenta previa and
three out of them had an additional history of previous caesarean
delivery.
The 25 pregnant women were examined by three different 1.5 T
MR-units (Magnetom Symphony Siemens Healthcare, Erlangen,
Germany; Intera, Philips Healthcare, Best, The Netherlands or Signa,
General Electric Healthcare, Wisconsin, USA). The MRI protocols
were similar in all three hospitals and included T1-weighted (T1W)
volume interpolated gradient echo MR sequences (VIBE, THRIVE,
FAME) in the sagittal and axial plane, single-shot fast spin–echo
T2-weighted (T2W) MR sequences (HASTE, single shot TSE, SSFSE)
and true fast imaging with steady-state precession (TrueFISP, bal-
anced FFSE, FIESTA) in the axial, sagittal and coronal planes. The
breath-holding technique was used to minimize respiratory motion
artifacts. The MR-exams did usually not exceed 30 min. Gadolinium
was not used in our study.
Complementary information regarding clinical follow-up and
surgical–pathological diagnosis was available in all 25 cases. In 12
patients (48%) placental invasion was surgical and histologically
proven, whereas in the remaining 13 women (52%), no placental
invasion was finally detected, as it was concluded from unevent-
ful delivery with spontaneous separation of the placenta, normal
placental histopathology and clinical follow-up. These 13 patients
were considered the control group. This study complies with local
ethical guidelines and its protocol was approved by the institutional
ethical board.
2.2. Image analysis
MR-examinations of the two groups were rendered anonymous,
mixed and then retrospectively and independently reviewed by
two senior (L1 and L2, with practical experience in abdominal
MRI > 5 years) and two junior radiologists (L3 and L4, with prac-
tical experience in abdominal MRI < 3 years), which were blinded
to the final results.
All MR-examinations were reviewed in view of six well defined
features, previously described in the literature as useful for predict-
ing placental invasion. These features include dark intraplacental
bands on T2W images, a focally interrupted myometrial border,
heterogeneous intraplacental signal intensity (SI), abnormal uter-
ine bulging, “tenting” of the bladder and infiltration of the adjacent
pelvic organs.
Dark intraplacental bands appear as areas of low SI, with nodular
or linear disposition, extending from the uterine-myometrial sur-
face and representing abnormally thickened fibrous tissue or areas
of fibrin deposition [9]. Focally interrupted myometrial border
means lack of myometrial differentiation at the placental infiltra-
tion site. Heterogenicity of the placental SI on T2W MR images is
observed in cases of repetitive placental hemorrhages [1,3,7]. The
bulging of the outer uterine contour represents an inversion of the
normal pear-shaped morphology of the pregnant uterus. MR fea-
tures indicating placenta percreta are the transmural extension of
the signal abnormality through the whole myometrium and focal
interruption of the outer uterine wall contours. Invasion of the blad-
der may be suspected in case of irregularity or “tenting” of the
normal bladder wall architecture [1–6]. In a joint session held with
all four readers prior to their image analysis, these MR features were
accurately defined and explained.
For each case, each reader had to indicate the presence or not
of each of these six MR features and the presence or not of pla-
cental infiltration including its depth (accreta, increta or percreta).
The diagnostic certitude of the radiologists concerning each of the
selected MR features as well as concerning the presence/absence
and the depth of myometrial infiltration had to be determined by
each reader and expressed in 3 grades (60, 80 or 100%).
The readers also had to determine the best imaging plane and
sequence for each MR study. Finally, they had to estimate the time
they spent reading each case.
Each reader also had to document the possible presence of
placenta previa, however without inclusion into our statistical anal-
ysis. Placenta previa implies a partial or complete occlusion of the
uterine neck by the placenta’s location and is considered as a risk
factor for developing placental invasion.
2.3. Statistics
Demographic data of the two groups – including women’s ages
and mean gestational age - were compared using the Student’s t-
test.
The readers’ results were compared with patients’ clinical
follow-up and final surgical–pathological diagnosis; the latter was
considered the gold standard: either the placenta was normal or
pathological, with further differentiation in placenta accreta, inc-
reta or percreta. Sensitivity and specificity, were calculated for
junior and senior readers and for each of the six evaluated MR
features. Receiver operating curves (ROC) were calculated for the
detection of placental invasion including the correct depth.
The interobserver agreement for the detection of placen-
tal invasion and its depth between the two senior and the
two junior readers was assessed using the common kappa
 L. Alamo et al. / European Journal of Radiology 82 (2013) e51–e57 e53

Fig. 2. Placenta accreta in a 37-year-old woman: axial T2-weighted (HASTE) MR

image nicely shows discontinuity of the T2 hypointense inner myometrial layer in
the anterior and posterior uterine segment (arrows).

rating defined by Landis and Koch: k 0.00–0.20 = slight, k

0.21–0.40 = fair, k 0.41–0.60 = moderate, k 0.61–0.80 = substantial,
and k 0.81–1.00 = perfect agreement [10]. Stepwise logistic regres-
sion for each evaluated MR feature was calculated.
The diagnostic certitude between the junior and senior readers
concerning the evaluated MR features, the placental infiltration into
the myometrium and its depth were compared using the Student’s
t-test in the case of parametric data distribution or the Wilcoxon
test in the case of non-parametric data distribution. Statistical sig-
nificance was considered if p < 0.05.
3. Results
3.1. Patients population
Demographics between the two groups were similar. Neither
the mean age of the patients (p = 0.692) nor the gestational age
at MR examination (p = 0.672) differed significantly. For the group
with placental invasion, the mean age of the women was 35.5 years
and the mean gestational age 31.1 weeks, whereas for the control
group they were 34.8 years and 31.9 weeks, retrospectively.
Nineteen (76%) out of the 25 women had placenta previa, includ-
ing 11 of 12 patients with proven placental invasion. Histopathol-
ogy revealed placenta accreta in 4 cases (Fig. 2), placenta increta in
3 (Fig. 3), and placenta percreta in 5 (Figs. 4–6). Among the latter
group there were 3 women with placental invasion of the bladder
(Fig. 4b and c) and one with invasion of the rectum, while the fifth
woman did not present any organ infiltration.
Fig. 3. Placenta increta in a 34-year-old woman: sagittal T2-weighted (HASTE) MR
image reveals loss of the of visualization of the T2 hypointense inner myometrial
layer (arrow) associated with a thinned myometrium (M) due to placental infiltra-
tion (P), however without extension beyond the serosa. The hypointense border of
the bladder dome is thus preserved.
3.2. Image analysis
Reading time did not significantly differ between junior and
senior readers (mean 10.2 min, range 5–15 min). In 61% of the eval-
uated MR exams all four readers considered the single-shot fast
spin–echo T2-W MR sequence (HASTE, single shot TSE, SSFSE) as
the most useful one, followed by the true FISP sequence. The sagit-
tal plane was considered the best orientation in 53% of the cases,
followed by the axial (30%) and the coronal (17%) plane.
The overall sensitivity and specificity for detecting placental
invasion was 90.9% and 75.0%, respectively for senior readers, and
81.8% and 61.8% for junior readers. The area under the curve (ROC)
for detecting placental invasion was 0.83 for senior- and 0.71 for
junior readers. The overall sensitivity and specificity for indicating
the correct depth of placental invasion was 75.3% and 68.2%, respec-
tively for senior, and 62.2% and 43.1% for junior readers. The area
under the curve (ROC) for indicating the correct depth of placental
invasion was 0.84 for senior and 0.72 for junior readers.
Sensitivity and specificity, and interobserver agreement (kappa)
between senior and junior readers for the six MR features can be
seen in Tables 1 and 2, respectively. The results for the detection

Table 1
Sensitivity and specificity (expressed in percentages) of the six evaluated MR features indicating placental invasion.

MR-feature Sensitivity Specificity

Seniors Juniors Seniors Juniors

Dark intraplacental bands (T2-W sequences) 86.4 86.4 54.2 50.6

Focally interrupted myometrial border 90.9 81.8 62.4 42.6
Heterogeneous intraplacental SIa 68.2 50.1 28.9 26.0
Abnormal uterine bulging 59.1 77.3 41.3 13
Tenting of the bladder 89.7 78.6 92.3 65.3
Infiltration of pelvic organs 83.8 37.5 82.4 72.5
a
Signal intensity.
e54 L. Alamo et al. / European Journal of Radiology 82 (2013) e51–e57

Fig. 4. Placenta percreta in a 32-year-old woman: (a) sagittal T2-weighted MR image (HASTE) shows placenta previa and focal posterior bulging of the inferior part of
the uterus (white arrows) due to placental infiltration indicating mass effect. (b) Coronal MR image (true fast imaging with steady-state precession (TrueFISP)) clearly
demonstrates the abrupt discontinuity of the T2 hypointense inner myometrial layer (short black arrows) due to placental infiltration, even extending beyond the uterine
serosa and further into the bladder wall which was equally involved. (c) This bladder infiltration (long black arrow), which was consecutively proven by cystoscopy, is even
better shown in the axial plane of the T2-weighted MR sequence (HASTE).

of placenta percreta are demonstrated in Table 3. All the data are
grouped into junior and senior readers.
The best single MR feature predicting placental invasion was
the presence of dark intraplacental bands on T2W MR sequences
(r2 = 0.28) (Fig. 5) followed by focally interrupted myometrial bor-
der (Figs. 2–4) the infiltration of pelvic organs (Fig. 4), and tenting of
the bladder. Considering all four MR features together the multiple
regression coefficient r2 increased to 0.36.
The kappa values for the interobserver agreement for detecting
placental invasion were 0.64 for senior and 0.41 for junior readers,
thus substantial and moderate, respectively, while for the correct
Table 2
Interobserver agreement (kappa) of the six evaluated MR features indicating pla-
cental invasion between the two senior and junior readers.
depth of placental invasion the kappa was 0.49 for senior and 0.31
for junior readers, considered as moderate and fair, respectively,
according to Landis and Koch [10]. For the detection of placenta
percreta kappa was 0.75 for the seniors, and 0.62 for the juniors
(Table 3).
The differences in the diagnostic certitude of the junior readers
compared to the senior readers are shown in Table 4. Diagnostic
certitude of junior readers was significantly lower than the senior
group in both the prediction of placental invasion and the depth of
infiltration (p = 0.0002 and p = 0.0282, respectively). Junior readers
also evaluated the presence of an abnormal uterine bulging, dark
intraplacental bands on T2W sequences and a focally interrupted
myometrial border with significantly lesser diagnostic certitude
than the seniors. No significant difference between the two groups

MR-feature Seniors Juniors

Table 3
Dark intraplacental bands (T2-W sequences) 0.54 0.29 Detection of placenta percreta: sensitivity, specificity (expressed in percentages)
Focally interrupted myometrial border 0.59 0.26 and interobserver agreement between the two senior and junior readers.
Heterogeneous intraplacental SIa 0.46 0.21
Seniors Juniors
Abnormal uterine bulging 0.31 0.19
Tenting of the bladder 0.65 0.57 Sensitivity 92.5 75.2
Infiltration of pelvic organs 0.78 0.68 Specificity 90.2 88.5
a Interobserver agreement (kappa) 0.75 0.62
Signal intensity
 L. Alamo et al. / European Journal of Radiology 82 (2013) e51–e57 e55

Fig. 6. Placenta percreta in a 33-year-old woman: the heterogenous signal inten-

sity of the whole placenta reflecting the invasive character is nicely seen on this
coronal T2-weighted MR images (HASTE).

Fig. 5. Placenta percreta in a 41-year old woman: the two hypointense intrapla-
cental bands seen on this sagittal T2-weighted MR image (HASTE) (a) reflect
recent hemorrhage, since they correspond to a hyperintense signal intensity on
T1-weighted gradient-echo image (VIBE) (b).
was found in the presence of heterogeneous intraplacental SI
(Table 4).
4. Discussion
Abnormalities in placental attachment include three entities:
placenta accreta, increta and precreta. These are a spectrum of
placental adhesive disorders, with increasing grade of placental
Table 4
Significance of the differences in diagnostic certitude comparing junior and senior
radiologists at evaluation of the 6 observed MR-features.
MR feature
Prediction of placentar invasion
Prediction of depth of placentar infiltration
Dark intraplacental bands (T2W sequences)
Abnormal uterine bulging
Focally interrupted myometrial border
Heterogeneous intraplacental signal intensity
invasion into the myometrium (Fig. 1). Placenta accreta is the most
frequent and less severe form, caused by the penetration of the
deciduas by the chorionic villi. Placenta increta consists in a partial
invasion of the myometrium by the villi, and placenta percreta, the
most severe form, implies the invasion of the serosal uterine layer,
which can be associated with infiltration of the neighboring organs,
such as the bladder and/or the rectum [7,11].
The prevalence of abnormalities in placental attachment is con-
tinuously rising, due to the growing percentage of pregnant women
of advanced age and the increasing rate of uterine surgery, mostly
caesarean sections [1,2]. Placenta previa is also a well-known risk
factor for adhesive disorders. The incidence of placenta accreta has
been reported to be as high as 5% in women with a previous cae-
sarean section and increases up to 67% in the presence of both
placenta previa and multiple previous caesarean sections [2,12].
Our results support these data, as we found placenta previa in all
but one of the 12 women with proven placental infiltration, and
three of them had also a previous caesarean delivery.
Non detected abnormalities in placental attachment may pro-
duce intense hemorrhages at delivery, often requiring emergency
postpartum hysterectomy [6] and are also cause of high morbidity
and even mortality for mother and fetus [2]. Prenatal identification
of placental disorders is therefore crucial in order to plan delivery
and to reduce complications. Screening US at 18–20 weeks of preg-
nancy is the routine diagnostic imaging method used to evaluate
the placenta, but it may be inconclusive or equivocal in cases of a
difficult visualization of the placenta due to the patient’s body habi-
tus or to a posterior placental implantation [6,8,13]. Therefore, MRI
is increasingly being used for confirmation of suspected placental
anomalies or in case of equivocal US findings in patients at risk [14].
The normal pregnant uterus usually presents as an inverted
pear-shape organ. At MRI, the normal placenta appears as a soft-
tissue structure, located along the uterine walls, with variable
p-Value morphology and homogeneous, intermediate SI on T2W images.
The interface between the uterine myometrium and the placental
0.0002
0.0282
decidua can be identified in most of the cases as a low-SI line deep
0.0013 to the placenta [3]. Over the past few years, a set of MRI criteria has
0.0076 been established in order to predict attachment abnormalities of
0.0308 the placenta [1] and several publications have proven that some of
0.3969
them are consistently associated with placental invasion [1–8].
e56 L. Alamo et al. / European Journal of Radiology 82 (2013) e51–e57
In our study, T2-hypointense placental bands, a focally inter-
rupted myometrial border, infiltration of the pelvic organs and
tenting of the bladder were proven to be the best signs predicting
placental invasion. The combination of these four imaging features
shows a stepwise multiple regression coefficient of 0.36. Our data
suggest that this “gold combination” increases the specificity of MRI
and may enable a reliable detection of placental implantation dis-
orders. These results are consistent with the previously published
literature [1,2,8]. Hence, the particular strength of MRI is the assess-
ment of adjacent organ involvement, which is far more difficult
with ultrasound.
On the contrary, we found that heterogeneous intraplacen-
tal SI and uterine “bulging” were not very helpful for detecting
placental invasion. These results agree with Lax et al. [1], who,
despite obtaining a moderate interobserver reliability (kappa 0.48),
found that “bulging” of the outer uterine contour also occurs in
true negative subjects. Furthermore, the high vascularity of the
placenta at late pregnancy is often associated with irregular and
high flow distribution which can lead to small hemorrhagic foci.
These explain the different grades of heterogeneous intraplacental
SI seen on MRI; also inconsistently occurring in normal pregnancies
[1].
However, the main purpose of this study was to evaluate
whether the detection of these MR features was related to the
radiologists experience. The data shown in Tables 1 and 2 confirm
this hypothesis, as senior radiologists obtained a higher sensitiv-
ity, specificity, and interobserver agreement kappa in almost every
evaluated MR feature. The most important difference in sensitivity
and specificity of both groups was found in detecting a focally inter-
rupted myometrial border (sensitivity of 90.0 for seniors vs. 81.8
for juniors and specificity of 62.4 for seniors and 42.6 for juniors).
Although junior readers have a higher sensibility in the detection of
abnormal uterine bulging than seniors (77.25 vs. 59.1), their speci-
ficity was very low compared to that obtained by seniors readers
(13 for juniors vs. 41.3 for seniors) (Table 1).
According to our data, a focally interrupted myometrial bor-
der seems to be the MR feature that reveals the most important
differences between junior and senior readers. There is contro-
versy in the literature concerning the visualization of the interface
myometrium/placenta at MRI. Some studies describe the normal
myometrium as a well demarcated rim of hypointense tissue, easily
recognizable from the placenta on most MR studies, whereas others
consider that the progressive thinning of the normal myometrium
at late pregnancy makes it difficult to recognize this interface [1,15].
Our results support this latter idea and suggest that recognizing the
myometrium/placental interface requires experience in the evalu-
ation of placental MR studies. Therefore, we try and recommend to
perform MRI for suspectect placental invasion, if possible, before
the gestional age of 35 weeks.
Senior readers evaluated the presence of dark intraplacen-
tal bands on T2W images (p = 0.0013), of a focally interrupted
myometrial border (p = 0.0308) and of abnormal uterine bulging
(p = 0.0076) with a significantly better diagnostic certitude than
junior radiologists. We found no significant differences between
the diagnostic certitudes of junior and senior readers regarding
the detection of heterogeneous intraplacental SI (p = 0.3969). These
results may be explained by the multiplanar capacities and the high
soft-tissue differentiation of MRI, which enables the assessment of
the placental insertion, the depiction of its anatomical relation to
the uterus neck and the detection of any placental SI heterogenicity,
independently of reader experience.
The corresponding kappa values for the interobserver agree-
ment in the detection of placental invasion were 0.64 or substantial,
according to the rating of Landis and Koch [10] for seniors- and 0.41
or moderate for junior readers. Moreover, we found that the diag-
nostic certitude of the senior readers was significantly higher than
that of the juniors in predicting placentar invasion (p = 0.0002),
suggesting that, once more, experience plays a significant role in
the correct interpretation of MR images (Table 4).
Once placental invasion is detected, it is also important to eval-
uate the grade of infiltration, because the deeper the invasion, the
greater risk and the higher rate of complications for the patient.
In our study, the overall sensitivity and specificity for indicating
the correct depth of placental invasion was 75.3% and 68.2% for
senior, and 62.2% and 43.1% for junior readers, respectively. For
the detection of placenta percreta alone the sensitivity and speci-
ficity was 92.5% and 90% for senior, and 75.8% and 88.5% for junior
readers, respectively, thus far better in both groups. Indeed, the
task to differentiate between placenta accreta and increta on MRI
has proven to be the most difficult one, since the diagnostic values
were the lowest. However, this differentiation does not necessarily
contribute to the women’s clinical management, as both of them
have the same therapeutic approach [6], unlike the management of
placenta percreta. The latter is almost always associated with sig-
nificant hemorrhages at delivery, often requiring highly aggressive
and specialized surgical procedures for therapy [7], but detection
of a focal interruption of the outer uterine wall limits and/or dis-
tortion or “tenting” of the bladder wall may be difficult to identify
because of the thinned myometrium and the reduced anatomical
space between the superior bladder wall and the uterus at late
pregnancy [1,6]. Our results suggest that experience may help to
recognize and correctly identify these subtle signs on MR.
In our study, the sagittal plane was considered to be the best
imaging orientation, probably because it enables an optimal visu-
alization of the insertion of the placenta related to the uterus neck.
The T2W HASTE sequence was chosen as the most useful one.
This sequence reduces maternal motion artifacts and improves the
anatomical evaluation of the uteroplacental interface [5,12].
There were some limitations to our study: we had a reduced
number of cases of placenta percreta (n = 5) and consequently, the
MR features “tenting” of the bladder (n = 3) and infiltration of the
adjacent organs (n = 4) could only be evaluated in a few patients;
thus these results need to be interpreted with caution.
Secondly, this was a retrospective study involving three differ-
ent hospitals, with different MRI units and protocols and, therefore,
we believe that these results should be confirmed by larger, more
homogeneous trails.
5. Conclusions
In conclusion, the medical practice faces an increased preva-
lence of placental adhesive disorders in the near future because of
a higher mean maternal age and an increase of uterine surgery pro-
cedures. Today, MRI of the placenta has become a complementary
method to US for patients at risk and in selected, equivocal cases.
Different MR features have been described in association with pla-
cental disorders, but our results suggest that their recognition and
correct interpretation very much depend on readers’ experience.
Therefore, we consider that placental MRI should be performed in
selected reference centers in order to guarantee the radiological
level of experience required for the correct diagnosis.
Acknowledgment
We would like to thank Ms. Kevin Decitre for the drawing of
Fig. 1.
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