Ultrasound diagnosis of

Placenta
Accreta Spectrum Disorder
Incidence and epidemiology report

• Retained placentas affect 0.5 – 3% of women following delivery

• The incidence of placenta accreta  increased ten-fold in the past 50

years and is now encountered in 1 in 2500 pregnancies
• A blood transfusion rate  70% is needed following diagnosis of
placenta accreta
 Causative of Post Partum Hemorrhage (PPH) In
Dr. Soetomo
70.0%
General Hospital
66.2%
60.0% Adherent placenta
50.0%
46.4%
40.0% 39.2%
Tone P
28.6% Tissue
30.0% Trauma P
20.0% 25.0%
17.6% Thrombin H
14.0%
10.0% 6.8% 14.9%
0.0% 2.3% 1.4%
0.0% 0.0%
2012 2013 2014 2015 2016
Total case of adherent placenta : 42 (during 2012-2016)
Hysterectomy : 73.3% (Morbidity : 18.8%)

The mean estimated blood loss during surgery was 1533 cc (± 540 cc)
The mean duration of surgical procedure was 86,67 minute (± 15,8 minute)
Post SC pregnant women

Placenta previa vs RR for Accreta = 20.7 (95%;

normal placenta CI= 9.4–45.2)

2 ≥ SC vs vaginal 39% vs less < 2%

deliveries.

Placenta previa and history of prior cesarean delivery

remain the most important predictors of placenta accreta
 Accurate antenatal
diagnosis of
placenta accreta

It has been
shown to
Arrangements to
be made for
significantly
reduce maternal
morbidity.
1. a planned
delivery at a
tertiary care
center

2. a
multidisciplinary
approach
• Highly Risk for plasenta accreta is myometrial damage because of
posterior or anterior placenta previa overlying scar
• Multi-disciplinary planning.
• Gray-scale sensitive and specific enaough to diagnose placenta previa
• MRI  confirmed invasiveness
• Occasionally placenta accreta discovered during delivery
Classification

• According to the degree to which the

myometrium is penetrated by placental villi.
– In placenta accreta vera, placental villi
embed directly onto myometrium in the
absence of decidua;
– In placenta increta, placental villi are
found deeper into the myometrium
– In placenta percreta, the villi have
penetrated through the uterine serosa
How to diagnose
 Specific USG findings that associated with
placenta accreta
• Grey scale
– Number of lacunae
– Loss of retroplacental clear space
– Loss of visualization of the myometrium,
– Bladder wall irregularity
• Color Doppler (presence or absence ) of the following:
– Subplacental vascularity
– vessels bridging from the placenta to the uterine margin
– gaps in myometrial blood flow
– Vessels crossing interface disruption sites
– Turbulent lacunae.
Ultrasound as diagnostic modality
• The sensitivity  91.4% (95% CI= 77.6–97.0%)
• Specificity  95.9% (95% CI= 92.2–97.9%)
• Positive predictive value for placental invasion  80.0% (95%
CI= 65.2–89.5%)
• Negative predictive values of ultrasound for placental
invasion were)  98.4% (95% CI= 95.5–99.5%).
 First trimester
screening
Screening 
When
Second trimester
screening
 First trimester
• The usual location of a normal early gestation is in the fundus or very
occasionally in the lower uterine segment
• The sac is surrounded by thick myometrium on all sides.
• Retrospectively reviewed the USG performed >10 gestational weeks in
women later proven to have placenta accreta on pathological examination.
– In 6 patients who had scans at 10 weeks or less  low-lying gestational
sacs, the majority of which were clearly attached to the uterine scar.
– The myometrium was thin in the area of the scar to which the sac was
attached compared to normal in four of the six patients.
• The low-lying sac attached to the anterior wall of the
lower uterine segment needs to be distinguished
from a sac that is low lying but surrounded by an
equal amount of myometrium, both anteriorly and
posteriorly, because sacs may develop into a normal
pregnancy
Low laying sac, overlay scar
 Second trimester
• Any uterine surgery  increases her risk for placenta accreta
• Sonography correctly identified the presence of placenta
accreta in 14 of 15 patients (93% sensitivity; 95% (CI)= 80%–
100% and the absence of placenta accreta in 12 of 17 patients
(71% specificity; 95% CI= 49%–93%).
• Magnetic resonance imaging correctly identified the presence
of placenta accreta in 12 of 15 patients (80% sensitivity; 95%
CI= 60%–100%) and the absence of placenta accreta in 11 of 17
patients (65% specificity; 95% CI= 42%–88%).
• In 7 of 32 cases, sonography and MRI had discordant diagnoses:
sonography was correct in 5 cases, and MRI was correct in 2.
• There was no statistical difference in sensitivity (P = .25) or
specificity (P = .5) between sonography and MRI.
• Sensitivity: 53.5%,
• Specificity: 88.0%
• Positive predictive value: 82.1%
• Negative predictive: 64.8%
• Accuracy: 64.8%,
Structure founded during
Ultrasound
Lacunae

• The lacunae give a ‘moth-eaten’ appearance to the placenta and usually,

but not always, have turbulent flow within them.
• Appear irregular, often more linear rather than rounded and smooth
bordered.
• They do not have the highly echogenic border that standard venous
sinuses have.
• Tornado-shaped flow of venous, arterial or mixed blood is typical
• the lacunae did not need to be near the area of invasion.
• the likelihood of placenta accreta increased with the number of lacunae.
• Not all large sinuses or vessels are associated with placenta accreta
• Visualization of lacunae had the highest sensitivity (79%) in the 15–20-week
range and a sensitivity of 93% in the 15–40-week gestational age time frame

• In 12 of the 14 pathology proven cases who had had a scan at 15–20 weeks 
there was at least one finding at the screening scan which suggested placenta
accreta.
• In 11 of 14 cases this was placental lacunae only one patient with pathologically
proven

• Placenta accreta did not have lacunae on ultrasound examination some time
during pregnancy
Lacunae
Bladder border

• The border between the bladder and myometrium is normally highly

echogenic and smooth
• In the case of placenta accreta, interruptions or bulging can occur
• this is a specific sign, but not a sensitive one, i.e. interruptions or bulging
are not present in every patient with placenta accreta
• Important to differentiate between bulging due just to enlarged or
increased number of vessels and actual growth through the
myometrium.
• Bulging of the bladder wall may indicate accreta but does not diagnose
percreta.
• Care must be taken to examine the bladder wall with the ultrasound
transducer at 90◦ so that it is clearly seen
Budging
Myometrial thickness

• Measured the thickness of the lower uterine segment in women who

had had a previous Cesarean
• Had a low-lying anterior placenta or placenta previa by measuring
between the bladder wall and the retroplacental vessels (Color
Doppler).
• All patients later proven to have placenta accreta had a myometrium of
less than 1 mm, which was as predictive of accreta as lacunae
Loss of the clear space

• The usual dark line between the myometrium

and the placenta is thought to represent the
decidua basalis
• Since the decidua basalis is absent in placenta
accreta, it has been suggested that the
absence of this line suggests placenta accreta.
• We found overall sensitivity of 7% (1/14) for
clear space alone at 15–20 weeks and 7%
(1/15) from 15–40 weeks.
• The positive predictive value was 6%.
Color flow

• Turbulent blood flow extending from the

placenta into surrounding tissues was very
sensitive and correctly identified all patients
with accreta
• This finding was not present in any of the
patients without accreta.
• Levine et al  in a blinded study, found that
power Doppler did not improve the
diagnosis of placenta accreta.
Bridging/crossing vessels
MRI

• Although MRI will probably never be used as a screening tool for

placenta accrete
•
• Confirming placenta accreta in those identified by ultrasound.
• Theoretically should be useful in determining which patients with
obvious ultrasound evidence for placenta accreta have placenta percreta
Mathematical model to predict Placenta Accreta
Placental Accreta Index
• The reccomendation for suspectreffered tertiary hospital.
• Placenta accreta  preterm delivery
• Contigency plan for emergency should be prepared.
• Delivery with placenta left insitu  referred tertiary centre
Subsequent births after preserve uterus of Placenta accreta.

• Previous placenta accreta was significantly associated

with
– Uterine rupture (3.3% vs 0.3%, P.01)
– Peripartum hysterectomy (3.3% vs 0.2%, P.001),
– Need for blood transfusions (16.7% vs 4%, P .001)
 Pregnancy with suspect placenta accreta spectrum
disorder evaluated in MFM division on 2015-2017
(n : 266)

Ultrasound was performed by Resident

n : 202
 

Record the risk and ultrasound parameter

Blind

Surgical Diagnosis with 2 Surgical Diagnosis with 2

MFM and compared with MFM and compared with
pathology result pathology result
N (+) : 76 n (-) : 126

Surgical Result

Analysis
Result
PASD (+) PASD (-)
n = 76 n = 126 p OR
Maternal age (year)* 34 (+ 4,1) 34 (+ 4,5) 0,363 -
Gestational age USG (weeks)** 34 (22-39) 34 (15-39) 0,730 -
Post Sesarean Section***
Non BSC - 12 (9,5%) 0,816 -
BSC 1x 39 (51,3%) 43 (34,1%)
BSC 2x 32 (42,1%) 64 (50,8%)
BSC 3x 5 (6,6%) 7 5(,6%)
Curretage (+) + post SCSC**** 25 (32,9%) 17 (13,5%) 0,002# 1.87
Interval of Pregnancy <2 years (+) 68 (90,7%) 116 (92,1%) 0,935 -
Myomectomy 1 (1,3%) 3 (2,4%) 0,516 -
*T-test
**Mann-Whitney
***Kruskal-wallis
****Chi-Square
#
p<0,05
 Result (Ultrasound parameters)
Sensitivity Spesivicity PPV NPV p DOR
Lacuna > gr 3 89% (1,03-2,89) 70% (1,21-2,71) 64% (1,26-2,66) 92% (1,02-2,90) 0,000* 7.70
Myometrium <1mm 45% (1,46-2,46) 93% (1,01-2,91) 79% (1,12-2,80) 74% (1,18-2,74) 0,000* 2.99
Plac previa 91% (1,03-2,90) 62% (1,29-2,63) 59% (1,31-2,61) 92% (1,02-2,90) 0,000* 7.16
Plac previa anterior 84% (1,08-2,84) 71% (1,20-2,72) 64% (1,26-2,66) 88% (1,05-2,87) 0,000* 5.44
Bridging vessel 83% (1,09-2,83) 85% (1,08-2,84) 77% (1,14-2,78) 89% (1,04-2,88) 0,000* 7.09
Loss of retroplac clear zone 92% (1,01-2,91) 90% (1,04-2,88) 84% (1,07-2,85) 95% (0,99-2,93) 0,000* 16.73
Bladder wall interruption 72% (1,19-2,73) 95% (0,99-2,93) 90% (1,02-2,90) 85% (1,08-2,84) 0,000* 5.83
*p<0,05
Multivariate regression
CI 95%
PARAMETER p value Odd ratio Lower Upper
Placenta previa 0.001 0,128 0,036 0,453

Bladder wall interruption 0.000 0.089 0.030 0.349

Loss of Retroplacental
clear-zone 0.000 0.030 0.009 0,099

Trias Surabaya :
Placenta previa and history of prior cesarean
Placenta Previa
delivery remain the most important
Loss of Retroplacental Clearzone
predictors of placenta accreta
Bladder wall Interruption
Resume
• Placenta accreta is iatrogenic desease.
• Highlyry hospital risk for morbidity and mortality
• Should be managed by multidicipline approuch and in tertial
• Mathematical model of Placental Invassiveness is very good tool for
screening
• Tertiary hospital should have modalities for confirmatory diagnosis
• Accurate antenatal diagnosis of placenta accreta  arrangements to be
made for  a planned delivery at a tertiary care center utilizing a
multidisciplinary approach,
– which has been shown to significantly reduce maternal morbidity.
Bridging/crossing vessels