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Does MRI Help or Hurt When Making a Diagnosis of Placenta Accreta?

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Learning Objectives and CME/Disclosure Information

BACKGROUND AND PURPOSE: 

  • Incidence of Placenta Accreta Spectrum Disorder is rising  
    • Estimated at 1/500-1/300 pregnancies  
  • Ultrasound is the standard radiologic modality, while MRI remains controversial  
  • Einerson et al. (AJOG 2018) sought to determine if MRI contributes to the sonographic diagnosis of Placenta Accreta Spectrum Disorder

METHODS: 

  • Retrospective cohort study  
  • Participants 
    • Patients undergoing both ultrasound and MRI during 2nd and 3rd trimesters
    • Placenta Accreta Spectrum Disorder suspected (ultrasound or risk factors)  
  • Ultrasound risk factors 
    • Numerous echolucent placental lacunae | Loss of a normal retroplacental hypoechoic space | Loss of detectable myometrium | Bladder wall irregularity | Presence of abnormal subplacental vascularity 
  • Other clinical risk factors (if no suggestive US findings) included  
    • History of endometrial ablation or cavity-entering myomectomy | ≥3 cesarean deliveries in the setting of placenta previa | Suboptimal visualization of the placenta by US 
  • MRI decision left to MFM/surgical and radiology providers  
  • Diagnostic accuracy was verified by surgical and histopathologic diagnosis at the time of delivery 
  • Primary outcome  
    • Change in diagnosis from sonographic interpretation that could alter clinical management 
  • Secondary outcomes 
    • Correlation of radiologic diagnoses with surgical and histopathologic diagnosis

RESULTS: 

  • 78 patients were included   
  • Diagnosis that could alter clinical management occurred in 36% of cases 
  • MRI correctly  
    • Changed diagnosis in 19%  
    • Confirmed diagnosis in 44% 
  • MRI incorrectly  
    • Changed diagnosis in 17% 
    • Confirmed diagnosis in 21% 
  • MRI was not more likely to change a diagnosis in the 24 cases of posterior and lateral placental location compared to anterior location (33% vs 37%, P = .84) 
  • MRI resulted in overdiagnosis in 23% and in underdiagnosis in 14% of all cases 
  • In 14 severe Placenta Accreta Spectrum Disorder (percreta) cases, MRI altered only 2 diagnoses, both downgraded  
    • One was a correct downgrade to Placenta Accreta Spectrum Disorder (accreta and increta) and the other was an incorrect downgrade  
  • PPV for severe Placenta Accreta Spectrum Disorder 
    • MRI: PPV 61% (95% CI, 0.41–0.78) 
    • Ultrasound: PPV 73% (95% CI, 0.45–0.91) 
  • Proportion of accurate diagnoses with MRI did not improve over time despite increasing volume and increasing numbers of changed diagnoses

CONCLUSION: 

  • The addition of MRI to the assessment of Placenta Accreta Spectrum Disorder can often lead to an incorrect diagnosis  
  • The authors advise that MRI should not be used routinely as an adjunct to ultrasound in the diagnosis of Placenta Accreta Spectrum Disorder

Learn More – Primary Sources: 

Magnetic resonance imaging is often misleading when used as an adjunct to ultrasound in the management of placenta accreta spectrum disorders

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Placenta Accreta Spectrum Disorder: Definitions and Management
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