Research

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OBSTETRICS

Screening for placenta accreta at 11-14 weeks of gestation

Julien J. Stirnemann, MD; Eve Mousty, MD; Gihad Chalouhi, MD; Laurent J. Salomon, MD, PhD;
Jean-Pierre Bernard, MD; Yves Ville, MD
OBJECTIVE: We sought to describe the potential value of 11-14 weeks

screening for placenta accreta (PA).

STUDY DESIGN: Patients with a history of lower segment cesarean

section were prospectively included between 11-136 weeks over a

1.5-year period. The first 258 were offered standard screening
whereas the following 105 underwent screening for PA. Women were
considered high-risk when the trophoblast overlapped the scar visualized by transvaginal ultrasound and low-risk otherwise.
RESULTS: The group screened for PA did not differ from the non-

screened group for demographic characteristics. In all, 6 of 105 (5.8%)

women were considered high-risk. In the nonscreened group, 1 case of

PA was discovered during an elective repeat cesarean. In the screened
population, 1 case of PA occurred in a high-risk patient allowing a conservative planned management at 35 weeks.
CONCLUSION: At 11-14 weeks, ultrasound may help risk stratification

for PA with a specific follow-up. Early recognition of patients at risk

might improve the perinatal outcome of PA.
Key words: cesarean, first trimester, placenta accreta, screening,
ultrasound

Cite this article as: 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.e1-6.

lacenta accreta (PA) is a life-threatening obstetrical condition that occurs when a defect of the decidua basalis
enables the direct apposition of chorionic villi to the myometrium. As a result,
at least part of the placenta cannot separate after delivery and this may lead to
severe obstetric hemorrhage.1-5 It has
become the principal indication for
postpartum hysterectomy as well as for
related surgical injuries.6-10 The incidence of PA has increased 4-fold from
199411 through 2002,12 following the increase in cesarean delivery rates over the
same period of time. Most PA present as
placenta previa in the third trimester

From the Department of Obstetrics and

Maternal-Fetal Medicine, GHU Necker
Enfants Malades, Universit Paris Descartes,
Paris, France.
Received Feb. 9, 2011; revised May 29, 2011;
accepted July 13, 2011.
This study was supported by the Socit
Franaise pour lAmlioration des Pratiques
Echographiques in setting teaching sessions.
The authors report no conflict of interest.
Reprints: Yves Ville, MD, Maternit, Hpital
NeckerEnfants Malades, 149 rue de Svres,
75015 Paris, France. ville.yves@gmail.com.
0002-9378/$36.00
2011 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2011.07.021

with an incidence of 9.3% in this group

compared with 0.005% when the placenta is normally inserted.11 Among
women with placenta previa, maternal
age 35 years and previous cesarean delivery are independent risk factors, with
an incidence of 2% for women aged 35
years and no cesarean section up to 38%
in women aged 35 years and 2 previous cesarean sections.11
It is important to diagnose PA prior to
delivery, to allow for optimal concerted
management planning and prevention
of severe maternal morbidity and mortality.13-17 The diagnosis of PA by ultrasound and magnetic resonance imaging
(MRI) in the second and third trimester
of pregnancy remains largely speculative,
even in high prevalence cohorts,18-21 and
most cases are only diagnosed at the time
of delivery in cases with prepartum or
postpartum hemorrhage.13-16 The timing
of the defective trophoblast implantation
leading to PA suggests that this condition
could be identified during the 11-14 weeks
ultrasound.
Signs of PA have been recognized as
early as the first trimester in several case
reports.22-26 However, these findings
have never been implemented in a prospective early screening strategy. The
main aim of our study was to describe
the potential use of routine 11-14 weeks

scan27 for screening for PA in women

with a history of delivery by lower segment cesarean section (LSCS).

M ATERIALS AND M ETHODS

The screening procedure for PA was defined in patients with a history of LSCS as
follows: a transvaginal midsagittal plane
was defined, including the cervical canal,
the bladder, and the lower part of the
gestational sac.28 Both the uterine scar
and the location of the trophoblast were
recognized and located. The relationship
between the uterine scar and the trophoblast thus defined the high-risk group. A
patient was considered high-risk when
the scar was exposed within the uterine
cavity above the lowest part of the gestational sac, which encompasses the cervix
and part of the inferior segment together
with a covering low-lying placenta (Figure 1).28 A patient was considered lowrisk either when the uterine scar was protected within the cervicoisthmic canal
(Figure 2, A) or when the trophoblast
was not covering the internal os (Figure
2, B).28
The population considered for this
study comprises all consecutive cases of
patients with a history of lower segment
uterine scar over a 1.5-year period (September 2008 through March 2010) attending our unit for first-trimester

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FIGURE 1

Exposed scar with overlapping trophoblast (T) defining high-risk group

Arrows uterine scar.

B, bladder; C, cervix; GS, gestational sac.
Stirnemann. Screening for placenta accreta at 11-14 weeks. Am J Obstet Gynecol 2011.

FIGURE 2

Protected and exposed scars

www.AJOG.org
screening at 11-136 weeks as defined
by a crown-rump length between 45-84
mm. During a first period of time, patients were not specifically screened for
placenta and scar location. In a second
period, patients were screened for PA by
transvaginal ultrasound.
All ultrasounds were performed using
a General Electrics Voluson E8 or 730
Expert (GE Medical System Europe, Buc,
France) with a 3.5- to 5-MHz or 6- to
8-MHz transvaginal transducer.
Demographic data as well as obstetrical and perinatal management and outcome were prospectively recorded in our
electronic database (Astraia, Munich,
Germany). Patients considered high-risk
were followed up prospectively with serial ultrasound focusing on ultrasound
signs of placental invasion in our unit up
until delivery.
The statistical analysis was conducted
using R (www.r-project.org). Quantitative variables are summarized by the median and interquartile range (25th-75th
centile) and qualitative variables are described by N (%). Comparisons of demographic characteristics between the
screened and nonscreened populations
were performed using Mann-Whitney U
tests for quantitative variables and Fisher
exact tests for qualitative variables.
Since transvaginal ultrasound is offered routinely for first-trimester screening in our practice, this study did not require an institutional review board;
however, written informed consent was
obtained from all women.

R ESULTS

A, Protected scar with trophoblast (T) overlapping internal os. B, Exposed scar with nonoverlapping T.
Arrows uterine scar.
B, bladder; C, cervix; GS, gestational sac.
Stirnemann. Screening for placenta accreta at 11-14 weeks. Am J Obstet Gynecol 2011.

547.e2

American Journal of Obstetrics & Gynecology DECEMBER 2011

Over the study period, 363 women with a

history of LSCS attended our unit for
first-trimester screening at 11-136
weeks gestation. Among these, the first
258 women were screened only for aneuploidy and fetal defects whereas the following 105 were also prospectively
screened for PA. No significant differences in demographic characteristics
were found between the screened and the
nonscreened populations (Table 1). In
particular, considering risk factors for
PA, maternal age (P .12), parity (P
.46), number of scars (P .28), and rates
of emergency cesarean operations (P

Obstetrics

www.AJOG.org
.06) were similar. The overall rate of loss
to follow-up was 38/363 (10.5%) and
was similar in both groups (9/105 [8.6%]
and 29/258 [11.2%], P .57). The delivery mode was unknown in 5 cases.
Obstetrical and perinatal management of the study population is summarized in Figure 3. Two patients underwent termination of pregnancy and 3
miscarried 24 weeks gestation. These
patients together with 3 cases of intrauterine fetal demise delivered vaginally.
All live-born pregnancies with at least 2
uterine scars delivered by elective cesarean whereas patients with only 1 scar
attempted vaginal birth in 162/262
(61.8%) with a 105/262 (64.8%) success
rate.
Perinatal complications related to prior
cesarean included 2 cases (0.6%) of PA, 16
cases (5%) of severe postpartum hemorrhage requiring sulprostone or surgery, 2
cases (0.6%) of placenta previa, and 2 cases
(0.6%) of complete uterine rupture. The
occurrence of PA in the study population is
summarized in Figure 4 with respect to
screening results.
Within the nonscreened population, 1
case of placenta percreta was discovered
during elective cesarean at 395 weeks
in a 31-year-old, 4-parous patient with a
history of 2 cesareans. This patient had
an uneventful follow-up until delivery.
Upon opening of the peritoneum, placental bulging through the anterior uterine wall required a fundal incision. A conservative management was performed
leaving the placenta and the uterus. Embolization of uterine and internal iliac arteries
was subsequently performed. Follow-up
was uneventful apart from episodic bleeding without signs of infection, with MRI
examinations showing progressive involution of the placenta at 8 months after
cesarean.
Within the screened population, 1 scar
was not visualized, 6 of 104 (5.8%) patients were considered high-risk based
upon a trophoblast overlapping an exposed scar, and 98 of 104 were considered low-risk. One case of PA was discovered in the sixth high-risk patient. This
patient had been followed-up by serial
ultrasound at 161, 181, 221, 251,
and 291 weeks confirming signs of PA
both on ultrasound and MRI with a low-

Research

TABLE 1

Comparison of demographic characteristics between

screened and nonscreened populations
Overall
n 363

Characteristic

Without 11-14 wk With 11-14 wk

screening
screening
n 258
n 105
P value

Age, y

.12

..............................................................................................................................................................................................................................................

Median (IQR)

35 (3138)

35 (3239)

34 (3038)

.....................................................................................................................................................................................................................................

Missing

..............................................................................................................................................................................................................................................

Parity

.46

.....................................................................................................................................................................................................................................

212 (58.4%) 157 (60.9%)

52 (55.9%)

139 (38.3%) 101 (39.1%)

41 (44.1%)

.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................

Missing

12 (3.3%)

..............................................................................................................................................................................................................................................

No. of scars

.28

.....................................................................................................................................................................................................................................

305 (84.0%) 221 (85.7%)

84 (80%)

.....................................................................................................................................................................................................................................

54 (14.9%)

34 (13.2%)

20 (19%)

4 (1.1%)

3 (1.1%)

1 (1%)

Missing

.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

Interval since last delivery, mo

.14

.....................................................................................................................................................................................................................................

Median (IQR)

28 (1249)

26.5 (11.745.5)

32 (1454)

.....................................................................................................................................................................................................................................

Missing

137 (37.7%)

..............................................................................................................................................................................................................................................

History of vaginal birth

.36

.....................................................................................................................................................................................................................................

Yes

64 (17.6%)

42 (17.4%)

22 (21.8%)

279 (76.9%) 200 (82.6%)

79 (78.2%)

.....................................................................................................................................................................................................................................

No

.....................................................................................................................................................................................................................................

Missing

20 (5.5%)

..............................................................................................................................................................................................................................................

VBAC

.16

.....................................................................................................................................................................................................................................

Yes

33 (9.1%)

27 (11.3%)

6 (5.8%)

.....................................................................................................................................................................................................................................

No

309 (85.1%) 212 (88.7%)

97 (94.2%)

.....................................................................................................................................................................................................................................

Missing

21 (5.8%)

..............................................................................................................................................................................................................................................

Emergency cesarean

.06

.....................................................................................................................................................................................................................................

Yes

119 (32.8%)

77 (29.8%)

42 (40%)

No

244 (67.2%) 181 (70.2%)

63 (60%)

.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................

Missing

..............................................................................................................................................................................................................................................

Postpartum pyrexia

.38

.....................................................................................................................................................................................................................................

Yes

15 (4.1%)

9 (3.5%)

6 (5.7%)

.....................................................................................................................................................................................................................................

No

348 (95.9%) 249 (96.5%)

99 (94.3%)

.....................................................................................................................................................................................................................................

Missing

..............................................................................................................................................................................................................................................

IQR, interquartile range; VBAC, vaginal birth after cesarean.

Stirnemann. Screening for placenta accreta at 11-14 weeks. Am J Obstet Gynecol 2011.

lying anterior placenta. Elective cesarean

section was performed at 35 weeks under
epidural anesthesia after a course of betamethasone given for fetal lung maturity enhancement. The inferior segment
was richly vascularized. Hysterotomy
was performed through a fundal vertical

incision. No attempt was made to extract

the placenta. Uterine and internal iliac
arteries embolization was then performed systematically. Blood loss was
300 mL and the postpartum period was
uneventful. The placenta was still intrauterine at 3 months when she developed

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FIGURE 3

Obstetric management of delivery in study population

www.AJOG.org
endometritis and hysterectomy was easily performed without technical problems. She was discharged home after 54
days. Pathology examination confirmed
placenta increta. The 5 other patients
considered high-risk based upon 11-14
weeks ultrasound had an uneventful follow-up (Table 2) and delivered vaginally
(n 2) or by cesarean (n 3) without
complications at between 38-40 weeks
gestation.

C OMMENT

IUFD, intrauterine fetal demise; LSCS, lower segment cesarean section; LTFU, lost to follow-up; TOP, termination of pregnancy.
Stirnemann. Screening for placenta accreta at 11-14 weeks. Am J Obstet Gynecol 2011.

FIGURE 4

Flowchart of study population with respect to

screening and occurrence of placenta accreta

LSCS, lower segment cesarean section; LTFU, lost to follow-up.

Stirnemann. Screening for placenta accreta at 11-14 weeks. Am J Obstet Gynecol 2011.

547.e4

American Journal of Obstetrics & Gynecology DECEMBER 2011

PA is a life-threatening obstetrical emergency. Its incidence has risen in parallel

with that of cesarean deliveries and it remains a major cause of maternal mortality and morbidity as the principal indication for postpartum hysterectomy
with high blood loss, intensive care unit
admission, and intraoperative injury to
the bladder or bowel.13,15,16
Efforts have been made to refine the
ultrasound diagnosis of PA in the second
and third trimester of pregnancy, consisting in the presence of placental lacunae (irregularly shaped vascular spaces
with turbulent blood flow at the color
Doppler), loss of retroplacental clear
space, thinning of the myometrium
overlying the placenta and interruption
of the bladder line with protrusion of the
placenta into the bladder, or evidence of
hypervascularization by Doppler.21,29-31
The performance of ultrasound has been
studied in very high-risk populations,
with a prevalence of PA ranging from
9-44%. In these studies the sensitivity
of ultrasound, with 1 contemporary
signs, varies from 77-93% and the positive predictive value from 65-93%.18-21
Although MRI may help refine the diagnosis following ultrasonography,32,33 its
overall sensitivity remains unclear.19,29
However, most cases of PA remain undiagnosed until the time of delivery.13,15,16
PA, however, is likely to develop at the
time of the trophoblast invasion in the
first trimester.34,35 The study of the trophoblasts location in the first trimester
is feasible as part of the routine 11-136
weeks scan. Mustaf et al36 in 2002 have
well established the probability of placenta previa at term in relation to the distance/overlap of the lower placental edge

Obstetrics

www.AJOG.org
with respect to the internal cervical os.
The cesarean scar has been studied and
described in nonpregnant women as part
of the investigation of the relationship
between scar defects and postmenstrual
spotting, dysmenorrhea, and pelvic
pain.37-40
The sonographic diagnosis in the first
trimester has been reported in a few
cases22-25 mainly as a low gestational sac
in early first trimester, suggesting a direct
implantation of the trophoblast over the
scar.26 However, these cases are difficult
to differentiate from ectopic pregnancies
developing in the LSCS scar. These cases
of PA detected in early pregnancy all
showed very specific sonographic features. These findings, however, are unlikely to be fit for 11-14 weeks screening
policy, since their prevalence in PA as
well as in normal pregnancies has not
been formally studied. We believe these
ultrasound findings should be used in
second-line diagnostic scans in screenpositive patients.
Ultrasound examination is now routinely offered to all pregnant women at
11-14 weeks of gestation in many developed countries.41 To date, the aim of this
examination is mainly to confirm viability and gestational age, diagnose and determine chorionicity of multiple pregnancies, as well as screening for fetal
aneuploidy and for some severe malformations. Promising attempts at predicting severe obstetrical conditions developing in the second or third trimester
such as preeclampsia by ultrasound and
Doppler examination at 12 weeks are
promising.42,43 We believe that screening for PA in a high-risk group with previous cesarean section is justified by the
severity of this condition at the time of
delivery and by the feasibility of both scar
and placental examination at 11-14
weeks.28 Early recognition of PA is likely
to be associated with lesser maternal
morbidity.15,16 Elective cesarean section
with a conservative approach of the placenta left in place has shown to improve
the prognosis for the mother.14 In our
population, a case of placenta percreta
went to delivery undiagnosed in the nonscreened group, whereas early recognition of PA in the high-risk group allowed
for planning optimal management. This

Research

TABLE 2

Ultrasound follow-up of 6 cases considered high-risk

for placenta accreta by 11-14 weeks screening
Cases
1

Gestational age at
follow-up, wk

Placental location

215

Posterior, high

322

Posterior, high

176

Anterior, high

............................................................................................................................................................................

..............................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................

183

Posterolateral, low lying

222

Posterior, high

160

Posterior, high

284

Posterior, high

161

Anterolateral low-lying

181

US signs of placenta accreta

............................................................................................................................................................................

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

............................................................................................................................................................................
............................................................................................................................................................................

221

............................................................................................................................................................................

251

............................................................................................................................................................................

291
..............................................................................................................................................................................................................................................

US, ultrasound.
Stirnemann. Screening for placenta accreta at 11-14 weeks. Am J Obstet Gynecol 2011.

suggests that the rationale for 11-14

weeks screening is to help plan further
investigations and follow-up thus avoiding unanticipated peripartum discoveries of PA as well as to reassure patients
otherwise at risk based upon demographic characteristics. Nonetheless, it is
likely that a trophoblast overlapping the
scar is not the only factor that determines
the occurrence of PA. Indeed, as shown
by Miller et al,11 PA may develop at a
distance from the scar at a rate of 3.7%
and 9.1% for patients 35 years and
35 years with 1 previous cesarean section. Therefore, although 11-14 weeks
screening is likely to identify most cases
it is anticipated that it will fail in identifying all cases.
We propose that systematic evaluation
of the uterine scar and placental location
be tested in a large prospective study at
the time of the 11-14 weeks ultrasound
examination in women with a uterine
scar. Our data suggest that 5.8% of
women with 1 previous LSCS could be
considered at high risk of PA with scars
covered by the trophoblast insertion
at 12 weeks. Conversely, scars located
within the cervical canal or yet undeveloped isthmus appear to be protected
from this risk even with a low-lying trophoblast over the internal os. Account-

ing for maternal age and history could

lead to objective individual risk calculation for PA as early as 12 weeks and help
refine the care of women, including specialized imaging investigations such as
an early ultrasound at 16-18 weeks21 or
MRI together with a planned delivery in
an appropriate obstetrical unit.
f
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