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Placenta Accreta Spectrum: Value of Placental Bulge As a Sign of Myometrial Invasion on MR Imaging

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Placenta Accreta Spectrum: Value of Placental Bulge As a Sign of Myometrial Invasion on MR Imaging Abdominal Radiology (2019) 44:2572–2581 https://doi.org/10.1007/s00261-019-02008-0 PELVIS Placenta accreta spectrum: value of placental bulge as a sign of myometrial invasion on MR imaging Priyanka Jha1 · Joseph Rabban2 · Lee‑may Chen3 · Ruth B. Goldstein1 · Stefanie Weinstein1 · Tara A. Morgan1 · Dorothy Shum1 · Nancy Hills4 · Michael A. Ohliger1 · Liina Poder1 Published online: 9 April 2019 © Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract Purpose To evaluate correlation of “placental bulge sign” with myometrial invasion in placenta accreta spectrum (PAS) disorders. Placental bulge is defned as deviation of external uterine contour from expected plane caused by abnormal out- ward bulge of placental tissue. Materials and methods In this IRB-approved, retrospective study, all patients undergoing MRI for PAS disorders between March 2014 and 2018 were included. Patients who delivered elsewhere were excluded. Imaging was reviewed by 2 independ- ent readers. Surgical pathology from Cesarean hysterectomy or pathology of the delivered placenta was used as reference standard. Fisher’s exact and kappa tests were used for statistical analysis. Results Sixty-one patients underwent MRI for PAS disorders. Two excluded patients delivered elsewhere. Placental bulge was present in 32 of 34 cases with myometrial invasion [True positive 32/34 = 94% (95% CI 0.80–0.99)]. Placental bulge was absent in 24 of 25 cases of normal placenta or placenta accreta without myometrial invasion [True negative = 24/25, 96% (95% CI 80–99.8%)]. Positive and negative predictive values were 97% and 96%, respectively. Placental bulge in conjunction with other fndings of PAS disorder was 100% indicative of myometrial invasion (p < 0.01). Kappa value of 0.87 signifed excellent inter-reader concordance. In 1 false positive, placenta itself was normal but the bulge was present. Surgical pathol- ogy revealed markedly thinned, fbrotic myometrium without accreta. One false-negative case was imaged at 16 weeks and may have been imaged too early. Conclusions Placental bulge in conjunction with other fndings of invasive placenta is 100% predictive of myometrial inva- sion. Using the bulge alone without other signs can lead to false-positive results. Keywords Placenta accreta spectrum · PAS disorder · Placental bulge · Uterine bulge · MR imaging · Placenta increta · Myometrial invasion Introduction Placenta accreta spectrum (PAS) includes disorders of abnormal placental adherence and invasion where the pla- centa is directly implanted on the myometrium without inter- * Priyanka Jha [email protected] vening decidua [1]. Depending on the degree of invasion, it has been further classifed as placenta accreta (placenta 1 Department of Radiology and Biomedical Imaging, adherent to the decidua and myometrium), placenta increta University of California San Francisco, 505 Parnassus Ave., (placenta invading the myometrium), and placenta percreta Box 0628, San Francisco, CA 94131, USA (placenta invading through and beyond the uterine serosa) 2 Department of Pathology, University of California San [1, 2]. The most likely initial inciting event is believed to be Francisco, San Francisco, USA a defect in the endometrial–myometrial interface [2], leading 3 Department of Obstetrics and Gynecology, University to inadequate decidualization at the implantation site [1]. of California San Francisco, San Francisco, USA This happens most commonly secondary to prior Cesarean 4 Department of Epidemiology and Biostatistics, University section delivery but also due to uterine instrumentation, of California San Francisco, San Francisco, USA Vol:.(1234567890)1 3 Abdominal Radiology (2019) 44:2572–2581 2573 placenta previa (implantation over cervix), and Asherman’s bulge is deviation of external uterine contour from expected syndrome, among other etiologies for decidual paucity [1, plane caused by abnormal outward bulge of placental tissue 2]. The estimated incidence of PAS disorders is about 1 in [2, 17, 18, 24]. To date, no specifc imaging feature has been 300 pregnancies and has increased 10-fold in the last dec- identifed, which allows the confdent diagnosis of myo- ade, largely secondary to increased incidence of Cesarean metrial in PAS disorders. Delineation of presence versus section deliveries [1, 3–5]. The incidence is projected to be absence of myometrial invasion is an important observa- 9000 cases per year by the year 2020 [6]. It is a major cause tion as it may lead to increased complications at the time of maternal morbidity from severe maternal hemorrhage, of delivery [7, 10–12]. It may also allow for activation of a disseminated intravascular coagulation and other coagu- multidisciplinary team to discuss perioperative considera- lopathies, infection, urologic injury, and can even result tions. Most importantly clinical management algorithm can in maternal death [6, 7]. In a study performed in United vary from planned Cesarean hysterectomy for cases with States, studying current trends, the Cesarean delivery rate is myometrial invasion (placenta increta or percreta) to more expected to be 56.2% with resulting 4504 cases of PAS dis- conservative surgery with attempted delivery of placenta orders and 130 annual maternal deaths by 2020 [3]. The risk and uterine preservation for some cases of suspected lesser of PAS disorders also increases with multiple C-sections, invasion such as accreta [7, 25]. Diagnosing placenta per- with the disorder being 2.13 times more likely in women creta is possible with the presence of placental tissue invad- who underwent repeat C-sections [8]. Massive obstetric ing through the serosa and into adjacent organs. However, hemorrhage remains a one of the most severe and poten- fndings diferentiating placenta accreta without myometrial tially avoidable cause of maternal death [1]. Hence, accurate invasion from cases with myometrial invasion remain to be imaging diagnosis prenatally and preoperatively is pivotal. established. In this study, we evaluated placental bulge sign In addition to the diagnosis of this disorder, evaluating for and correlated it with the pathologic presence or absence of the depth of invasion is extremely important in management myometrial invasion. of these high-risk cases [7, 9]. The deeper the invasion, the higher the likelihood of associated complications, including increased requirement for blood products, urologic injury, Materials and methods and prolonged intensive care unit admission [2, 7, 10–12]. Imaging during pregnancy is performed primarily with Patient selection ultrasound [13, 14]. An anatomy scan is performed at 18–20 weeks, which includes a complete evaluation of the In this IRB-approved, HIPPA compliant study, pregnant placenta [2, 15, 16]. MR imaging has an important com- women undergoing MR imaging for suspected placenta plementary role to ultrasound in the evaluation of placental accreta spectrum consecutively between over 4 years of invasion [17–21]. MR imaging features of PAS disorders duration (March 2014–March 2018) were included. Patient include presence of heterogeneous placenta, loss of retro- list was created by searching PACS for the exam type—MR placental clear space, T2 dark bands, prominent intrapla- placenta without contrast. The patients were referred based cental vascularity, myometrial invasion, cervical invasion, on clinical suspicion of placenta accreta spectrum, sono- and invasion of adjacent organs [17–22]. Cervical invasion graphic fndings suspicious of placenta accreta spectrum or can be suggested by the protrusion of the placenta within the both. Ultrasound was performed prior to MR imaging for all cervical canal, and adjacent organs invasion is evidenced by the cases, but not reviewed for the purposes of this study. extrauterine placental mass as well as extensive hypervas- Incomplete studies or studies severely degraded by motion cularity at vesico-uterine interface [23]. While MR imaging artifact were excluded from evaluation. Patients who deliv- has similar sensitivity and specifcity to ultrasound, it has ered elsewhere were excluded from the cohort. been shown to have a high predictive accuracy in assessing both the depth and topography of placental invasion [18]. MR imaging It has also been benefcial in cases with posterior placenta previa and in any case with clinical suspicion for accreta MR imaging was performed at 3T MR scanner (General and discordant US fndings, and in cases in which percreta Electronics, Milwaukee, WI). Briefy, the sequences per- is suspected [17]. MR imaging is also helpful for surgical formed were multiplanar single-shot fast spin echo (SSFSE), planning. Knowing the location of the placenta and its rela- Axial liver imaging with volume acceleration-flexible tionship to cervix, bladder, and pelvic sidewall allows for (LAVA FLEX) or Multipoint Dixon Dual Echo, high-reso- preoperative planning for stents, embolization, and extent lution multiplanar SSFSE focused on the placenta–myome- of dissection anticipated. trial interface, axial and sagittal difusion-weighted images Placental bulge has also been identifed as a fnding of (DWI). Technical details of these sequences are mentioned invasive placenta [2, 17, 18, 24]. By defnition, placental in Table 1. 1 3 2574 Table 1 MRI protocol at 3T for suspected placenta accreta spectrum (PAS) disorder NOTES TR TE Flip Nex Slice Matrix FOV Phase oversample IPAT Patient should drink water prior to commencing study Coronal, Axial and Sagittal Single-Shot Fast Spin Uterus to below cervix 2000 100
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