Clinical features and diagnosis of the morbidly adherent placenta (placenta accreta, increta, and percreta)
- Robert Resnik, MD
Robert Resnik, MD
- Professor of Reproductive Medicine
- UCSD School of Medicine
- Robert M Silver, MD
Robert M Silver, MD
- Professor of Obstetrics and Gynecology
- University of Utah School of Medicine
- Section Editors
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Deborah Levine, MD
Deborah Levine, MD
- Section Editor — Imaging
- Professor of Radiology
- Director of Ob/Gyn Ultrasound
- Department of Radiology
- Beth Israel Deaconess Medical Center
Morbidly adherent placenta is a general term that includes placenta accreta, increta, and percreta. The clinical features and diagnosis of the three types of morbidly adherent placenta have many similarities. Therefore, unless otherwise noted, the following discussion of placenta accreta applies to all depths of placental invasion.
This topic will discuss the clinical features and diagnosis of the morbidly adherent placenta. Management of patients with a morbidly adherent placenta is reviewed separately. (See "Management of the morbidly adherent placenta (placenta accreta, increta, and percreta)".)
Placenta accreta refers to an abnormality of placental implantation in which the anchoring placental villi attach to myometrium rather than decidua, resulting in a morbidly adherent placenta.
Placenta increta (chorionic villi penetrate into the myometrium) and placenta percreta (chorionic villi penetrate through the myometrium to the uterine serosa or adjacent organs) are related, but more severe, abnormalities of placental implantation. The pathogenesis is primarily attributed to defective decidualization of the implantation site .
Placenta accreta is much more common than placenta increta and percreta. In a pooled analysis of results from two series involving a total of 138 histologically confirmed, abnormally implanted placentas from hysterectomy specimens, the type and frequency of abnormal placentation were [2,3]:
- Tantbirojn P, Crum CP, Parast MM. Pathophysiology of placenta creta: the role of decidua and extravillous trophoblast. Placenta 2008; 29:639.
- Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol 1997; 177:210.
- Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol 2005; 192:1458.
- Read JA, Cotton DB, Miller FC. Placenta accreta: changing clinical aspects and outcome. Obstet Gynecol 1980; 56:31.
- Mehrabadi A, Hutcheon JA, Liu S, et al. Contribution of placenta accreta to the incidence of postpartum hemorrhage and severe postpartum hemorrhage. Obstet Gynecol 2015; 125:814.
- Khong TY. The pathology of placenta accreta, a worldwide epidemic. J Clin Pathol 2008; 61:1243.
- Jauniaux E, Jurkovic D. Placenta accreta: pathogenesis of a 20th century iatrogenic uterine disease. Placenta 2012; 33:244.
- Clark SL, Koonings PP, Phelan JP. Placenta previa/accreta and prior cesarean section. Obstet Gynecol 1985; 66:89.
- Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107:1226.
- National Institutes of Health Consensus Development Conference Statement. NIH Consensus Development Conference: Vaginal Birth After Cesarean: New Insights. March 8–10, 2010.
- Nageotte MP. Always be vigilant for placenta accreta. Am J Obstet Gynecol 2014; 211:87.
- Timor-Tritsch IE, Monteagudo A, Cali G, et al. Cesarean scar pregnancy is a precursor of morbidly adherent placenta. Ultrasound Obstet Gynecol 2014; 44:346.
- Silver RM, Fox KA, Barton JR, et al. Center of excellence for placenta accreta. Am J Obstet Gynecol 2015; 212:561.
- Kaser DJ, Melamed A, Bormann CL, et al. Cryopreserved embryo transfer is an independent risk factor for placenta accreta. Fertil Steril 2015; 103:1176.
- Fitzpatrick KE, Sellers S, Spark P, et al. Incidence and risk factors for placenta accreta/increta/percreta in the UK: a national case-control study. PLoS One 2012; 7:e52893.
- Hayashi M, Nakai A, Satoh S, Matsuda Y. Adverse obstetric and perinatal outcomes of singleton pregnancies may be related to maternal factors associated with infertility rather than the type of assisted reproductive technology procedure used. Fertil Steril 2012; 98:922.
- Esh-Broder E, Ariel I, Abas-Bashir N, et al. Placenta accreta is associated with IVF pregnancies: a retrospective chart review. BJOG 2011; 118:1084.
- Khong TY, Healy DL, McCloud PI. Pregnancies complicated by abnormally adherent placenta and sex ratio at birth. BMJ 1991; 302:625.
- James WH. Sex ratios of offspring and the causes of placental pathology. Hum Reprod 1995; 10:1403.
- Zelop CM, Harlow BL, Frigoletto FD Jr, et al. Emergency peripartum hysterectomy. Am J Obstet Gynecol 1993; 168:1443.
- Glaze S, Ekwalanga P, Roberts G, et al. Peripartum hysterectomy: 1999 to 2006. Obstet Gynecol 2008; 111:732.
- Gielchinsky Y, Mankuta D, Rojansky N, et al. Perinatal outcome of pregnancies complicated by placenta accreta. Obstet Gynecol 2004; 104:527.
- Seet EL, Kay HH, Wu S, Terplan M. Placenta accreta: depth of invasion and neonatal outcomes. J Matern Fetal Neonatal Med 2012; 25:2042.
- O'Brien JM, Barton JR, Donaldson ES. The management of placenta percreta: conservative and operative strategies. Am J Obstet Gynecol 1996; 175:1632.
- Grosvenor, A, Silver, R, Porter, TF, Zempolich, K. Optimal Management of Placenta Accreta. Am J Obste Gynecol 2007; 195. Abstr No. 238. p. S82.
- Warshak CR, Ramos GA, Eskander R, et al. Effect of predelivery diagnosis in 99 consecutive cases of placenta accreta. Obstet Gynecol 2010; 115:65.
- Shamshirsaz AA, Fox KA, Salmanian B, et al. Maternal morbidity in patients with morbidly adherent placenta treated with and without a standardized multidisciplinary approach. Am J Obstet Gynecol 2015; 212:218.e1.
- Comstock CH. Antenatal diagnosis of placenta accreta: a review. Ultrasound Obstet Gynecol 2005; 26:89.
- Warshak CR, Eskander R, Hull AD, et al. Accuracy of ultrasonography and magnetic resonance imaging in the diagnosis of placenta accreta. Obstet Gynecol 2006; 108:573.
- D'Antonio F, Iacovella C, Bhide A. Prenatal identification of invasive placentation using ultrasound: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2013; 42:509.
- Bowman ZS, Eller AG, Kennedy AM, et al. Accuracy of ultrasound for the prediction of placenta accreta. Am J Obstet Gynecol 2014; 211:177.e1.
- Jauniaux E, Collins SL, Jurkovic D, Burton GJ. Accreta placentation: a systematic review of prenatal ultrasound imaging and grading of villous invasiveness. Am J Obstet Gynecol 2016; 215:712.
- Finberg HJ, Williams JW. Placenta accreta: prospective sonographic diagnosis in patients with placenta previa and prior cesarean section. J Ultrasound Med 1992; 11:333.
- Guy GP, Peisner DB, Timor-Tritsch IE. Ultrasonographic evaluation of uteroplacental blood flow patterns of abnormally located and adherent placentas. Am J Obstet Gynecol 1990; 163:723.
- Comstock CH, Lee W, Vettraino IM, Bronsteen RA. The early sonographic appearance of placenta accreta. J Ultrasound Med 2003; 22:19.
- Stirnemann JJ, Mousty E, Chalouhi G, et al. Screening for placenta accreta at 11-14 weeks of gestation. Am J Obstet Gynecol 2011; 205:547.e1.
- Ballas J, Pretorius D, Hull AD, et al. Identifying sonographic markers for placenta accreta in the first trimester. J Ultrasound Med 2012; 31:1835.
- Rac MW, Moschos E, Wells CE, et al. Sonographic Findings of Morbidly Adherent Placenta in the First Trimester. J Ultrasound Med 2016; 35:263.
- Timor-Tritsch IE, Monteagudo A, Cali G, et al. Easy sonographic differential diagnosis between intrauterine pregnancy and cesarean delivery scar pregnancy in the early first trimester. Am J Obstet Gynecol 2016; 215:225.e1.
- Chou MM, Ho ES, Lee YH. Prenatal diagnosis of placenta previa accreta by transabdominal color Doppler ultrasound. Ultrasound Obstet Gynecol 2000; 15:28.
- Twickler DM, Lucas MJ, Balis AB, et al. Color flow mapping for myometrial invasion in women with a prior cesarean delivery. J Matern Fetal Med 2000; 9:330.
- Shih JC, Palacios Jaraquemada JM, Su YN, et al. Role of three-dimensional power Doppler in the antenatal diagnosis of placenta accreta: comparison with gray-scale and color Doppler techniques. Ultrasound Obstet Gynecol 2009; 33:193.
- Calì G, Giambanco L, Puccio G, Forlani F. Morbidly adherent placenta: evaluation of ultrasound diagnostic criteria and differentiation of placenta accreta from percreta. Ultrasound Obstet Gynecol 2013; 41:406.
- Collins SL, Stevenson GN, Al-Khan A, et al. Three-Dimensional Power Doppler Ultrasonography for Diagnosing Abnormally Invasive Placenta and Quantifying the Risk. Obstet Gynecol 2015; 126:645.
- D'Antonio F, Iacovella C, Palacios-Jaraquemada J, et al. Prenatal identification of invasive placentation using magnetic resonance imaging: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2014; 44:8.
- Horowitz JM, Berggruen S, McCarthy RJ, et al. When Timing Is Everything: Are Placental MRI Examinations Performed Before 24 Weeks' Gestational Age Reliable? AJR Am J Roentgenol 2015; 205:685.
- Lax A, Prince MR, Mennitt KW, et al. The value of specific MRI features in the evaluation of suspected placental invasion. Magn Reson Imaging 2007; 25:87.
- Derman AY, Nikac V, Haberman S, et al. MRI of placenta accreta: a new imaging perspective. AJR Am J Roentgenol 2011; 197:1514.
- Kilcoyne A, Shenoy-Bhangle AS, Roberts DJ, et al. MRI of Placenta Accreta, Placenta Increta, and Placenta Percreta: Pearls and Pitfalls. AJR Am J Roentgenol 2017; 208:214.
- Millischer AE, Salomon LJ, Porcher R, et al. Magnetic resonance imaging for abnormally invasive placenta: the added value of intravenous gadolinium injection. BJOG 2016.
- Maldjian C, Adam R, Pelosi M, et al. MRI appearance of placenta percreta and placenta accreta. Magn Reson Imaging 1999; 17:965.
- Kirkinen P, Helin-Martikainen HL, Vanninen R, Partanen K. Placenta accreta: imaging by gray-scale and contrast-enhanced color Doppler sonography and magnetic resonance imaging. J Clin Ultrasound 1998; 26:90.
- Kupferminc MJ, Tamura RK, Wigton TR, et al. Placenta accreta is associated with elevated maternal serum alpha-fetoprotein. Obstet Gynecol 1993; 82:266.
- Hung TH, Shau WY, Hsieh CC, et al. Risk factors for placenta accreta. Obstet Gynecol 1999; 93:545.
- Zelop C, Nadel A, Frigoletto FD Jr, et al. Placenta accreta/percreta/increta: a cause of elevated maternal serum alpha-fetoprotein. Obstet Gynecol 1992; 80:693.
- Washecka R, Behling A. Urologic complications of placenta percreta invading the urinary bladder: a case report and review of the literature. Hawaii Med J 2002; 61:66.
- Tikkanen M, Paavonen J, Loukovaara M, Stefanovic V. Antenatal diagnosis of placenta accreta leads to reduced blood loss. Acta Obstet Gynecol Scand 2011; 90:1140.
- CLINICAL FEATURES
- Risk factors
- Clinical presentation
- - Ultrasonography
- Color Doppler
- Three-dimensional power Doppler ultrasound
- - Magnetic resonance imaging
- Laboratory findings
- - Elevated maternal serum alpha-fetoprotein
- - Hematuria
- Diagnostic approach
- SUMMARY AND RECOMMENDATIONS