Am J Perinatol 2019; 36(10): 1031-1038
DOI: 10.1055/s-0038-1676111
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Placenta Accreta: A Spectrum of Predictable Risk, Diagnosis, and Morbidity

Christina M. Duzyj
1   Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
,
Anne Cooper
2   Department of Obstetrics and Gynecology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
,
Mohak Mhatre
3   Department of Obstetrics and Gynecology, Tufts University School of Medicine, Boston, Massachusetts
,
Christina S. Han
4   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, California
,
Michael J. Paidas
5   Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
6   Yale Women and Children's Center for Blood Disorders and Preeclampsia Advancement, New Haven, Connecticut
,
Jessica L. Illuzzi
5   Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
,
Anna K. Sfakianaki
5   Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
› Author Affiliations
Funding Dr. Illuzzi's research in placenta accreta is supported by the Albert McKern Scholar Award for Perinatal Research.
Further Information

Publication History

25 September 2018

13 October 2018

Publication Date:
30 November 2018 (online)

Abstract

Objective Placenta accreta is a feared pathology, in part, because prenatal diagnosis is imperfect. It is not known whether clinical risk factors or sonographic features equally predict the entire graded pathological spectrum of placental overinvasion disease nor whether clinical outcomes differ along the spectrum.

Study Design We conducted a mixed methods retrospective study of a cohort of women screened sonographically for placenta accreta, cross-referenced against cases identified by pathological diagnosis (N = 416). Demographic, diagnostic, and outcome information were compared across the spectrum of invasive placentation: percreta, increta, accreta, and focal accreta not requiring hysterectomy. The t-test, chi-square, Mann–Whitney, and Kruskal–Wallis tests were used for statistical analysis across groups.

Results As the depth of invasion decreased, risk factors for placental overinvasion were less common, especially placenta previa and previous cesarean. There was also reduced anticipation by sonographic examination of the placenta. Rates of adverse outcomes were lower among women with focal accreta compared with those with deeper invasion.

Conclusion As the depth of invasion decreases, clinical risk factors and sonographic evaluation are less reliable in the antenatal prediction of placenta accreta. The potential for unanticipated morbidity underscores the need for improved diagnostic tools for placenta accreta spectrum.

Condensation

Placenta accreta is a disease spectrum, with poor predictability at a decreased depth of invasion based on clinical and sonographic factors, and reduced but persistent morbidity.


All research was performed at the Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT.


 
  • References

  • 1 Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol 2012; 207 (01) 14-29
  • 2 Clark EAS, Silver RM. Long-term maternal morbidity associated with repeat cesarean delivery. Am J Obstet Gynecol 2011; 205 (6, Suppl): S2-S10
  • 3 Belfort MA. ; Publications Committee, Society for Maternal-Fetal Medicine. Placenta accreta. Am J Obstet Gynecol 2010; 203 (05) 430-439
  • 4 Silver RM. Abnormal placentation: placenta previa, vasa previa, and placenta accreta. Obstet Gynecol 2015; 126 (03) 654-668
  • 5 Silver RM, Landon MB, Rouse DJ. , et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107 (06) 1226-1232
  • 6 O'Brien JM, Barton JR, Donaldson ES. The management of placenta percreta: conservative and operative strategies. Am J Obstet Gynecol 1996; 175 (06) 1632-1638
  • 7 Silver RM, Fox KA, Barton JR. , et al. Center of excellence for placenta accreta. Am J Obstet Gynecol 2015; 212 (05) 561-568
  • 8 Duzyj CM, Buhimschi IA, Laky CA. , et al. Extravillous trophoblast invasion in placenta accreta is associated with differential local expression of angiogenic and growth factors: a cross-sectional study. BJOG 2018; 125 (11) 1441-1448
  • 9 Jauniaux E, Collins S, Burton GJ. Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging. Am J Obstet Gynecol 2018; 218 (01) 75-87
  • 10 Pri-Paz SM, D'Alton ME. Placenta accreta. In: Copel J, D'Alton ME, Feltovich H, Gratacos E, AO L, Tutschek B. , eds. Obstetric Imaging. Philadelphia, PA: Elsevier Saunders; 2012. , 474-475
  • 11 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 (04) e94866
  • 12 Bowman ZS, Eller AG, Kennedy AM. , et al. Interobserver variability of sonography for prediction of placenta accreta. J Ultrasound Med 2014; 33 (12) 2153-2158
  • 13 Einerson BD, Rodriguez CE, Kennedy AM, Woodward PJ, Donnelly MA, Silver RM. Magnetic resonance imaging is often misleading when used as an adjunct to ultrasound in the management of placenta accreta spectrum disorders. Am J Obstet Gynecol 2018; 218 (06) 618.e1-618.e7
  • 14 Grobman WA, Gersnoviez R, Landon MB. , et al; National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. Pregnancy outcomes for women with placenta previa in relation to the number of prior cesarean deliveries. Obstet Gynecol 2007; 110 (06) 1249-1255
  • 15 Callaghan WM, Kuklina EV, Berg CJ. Trends in postpartum hemorrhage: United States, 1994-2006. Am J Obstet Gynecol 2010; 202 (04) 353.e1-353.e6
  • 16 Provansal M, Courbiere B, Agostini A, D'Ercole C, Boubli L, Bretelle F. Fertility and obstetric outcome after conservative management of placenta accreta. Int J Gynaecol Obstet 2010; 109 (02) 147-150
  • 17 Committee on Obstetric Practice. Committee opinion no. 529: placenta accreta. Obstet Gynecol 2012; 120 (01) 207-211