Imaging of the Placenta with Pathologic Correlation

Dustin Nguyen, DO,* Cameran Nguyen, DO,†

Margaret Yacobozzi, MD,* Fadi Bsat, MD,‡ and Dmitry Rakita, MD*

The placenta functions to nourish and protect the fetus. Imaging of the placenta can have
a profound impact on patient management, owing to the morbidity and mortality associated
with various placental conditions. To fully appreciate placental pathology, its physiology,
anatomy, and variant anatomy will be outlined. Placental conditions affecting the mother
and fetus include molar pregnancies, placental hematoma, abruption, previa, accreta, vasa
previa, choriocarcinoma, and retained products of conception. Ultrasonography remains
the definitive modality in diagnosing most of these conditions, with magnetic resonance
imaging remaining an adjunctive measure. Computed tomography is occasionally used in
cases of trauma and tumor staging.
Semin Ultrasound CT MRI 33:65-77 © 2012 Published by Elsevier Inc.

Physiology of the Placenta hormones independently produced by the placenta include

The placenta is a discoid organ connected to the fetal circu-
lation that is composed of specialized cells directly contacting
the maternal blood.1 Between these cells are multiple tissue
layers that separate the fetus from the mother. The placenta
plays an important role in pregnancy as a physiological bar-
rier between mother and fetus, with nourishment and endo-
crine functions.2
As a physiological barrier, the placenta possesses enzy-
matic pumps that actively work to decrease the exposure of
certain insults to the fetus, which include viruses, bacteria,
maternal immunoglobulins, toxins, and drugs.2 As a nour-
ishing organ, the placenta has multiple transport mecha-
nisms that selectively transport nutrients to the fetus. Gases
like oxygen and carbon dioxide reach the fetus via diffusion.2
Nutrients such as glucose and amino acids are actively trans-
ported by pumps to the fetus while other nutrients such as
lactose and glycine are produced by the placenta from ma-
ternally supplied precursors.2 As an endocrine organ, the
placenta secretes and transports a variety of hormones that
are critical to the fetus’ growth and well-being.2 Examples
include thyroid hormone, oxytocin, progestin, estrogens,
and prolactin, which are all maternally derived. Some of the
*Department of Radiology, Tufts School of Medicine, Baystate Medical Cen-
ter, Springfield, MA.
†Department of Pathology, Baylor University Medical Center, Dallas, TX.
‡Department of Obstetrics and Gynecology, Maternal-Fetal Medicine, Tufts
School of Medicine, Baystate Medical Center, Springfield, MA.
Address reprint requests to Dustin Nguyen, DO, Radiology Department,
Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199.
E-mail: Dustinforward@gmail.com
chorionic gonadotropin, growth hormone, corticotrophin-
releasing hormone, and placental growth hormone, to name
a few.2
Anatomy and Variant
Anatomy of the Placenta
The term placenta is a discoid organ with an average diameter
of 22 cm and central thickness of 2.5 cm.3 The fetal surface of
the placenta comprises the chorionic plate that is covered by
the amnion, which, in turn, is made up of amniotic mesen-
chyme and a single layer of epithelial cells.3 The umbilical
cord ideally attaches centrally to the chorionic plate and con-
tains vessels that are continuous with the chorionic plate,
which then go on to supply the villi.3
The maternal side of the placenta is arbitrarily defined and
comprises the basal plate, which is composed of maternal
cells, extravillous trophoblasts, and other cells. The basal
plate is divided by grooves, forming lobes, containing villous
trees of the fetus. The villous trees are immersed in maternal
blood and absorb nutrients and metabolic products.3 The
placenta usually implants at any location in the uterus, but
most commonly, the anterior or posterior locations.3 The
fundus is a less common location.
Usually discoid in shape, the placenta can exhibit various
morphologies. The placenta can have a separate lobule that is
not contiguous with the main placental body, which is called
a succenturiate placenta (Fig. 1). This condition can predis-
pose the pregnancy to rupture of the bridging vessels (which
run in between the lobules) or postpartum hemorrhage sec-
ondary to a retained lobule.4 The placenta can be bilobed

0887-2171/$-see front matter © 2012 Published by Elsevier Inc. 65

doi:10.1053/j.sult.2011.10.003
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Figure 1 Succenturiate placenta (accessory placenta). The extra pla-
cental tissue is separated from the main placenta by interconnecting
membrane and blood vessels. (Color version of figure is available
online.)
(2%-8% incidence), which can present as two fairly equal-
size lobes with a thin intervening segment of tissue and will
have complications similar to that of a succenturiate pla-
centa.4,5 The placenta can rarely demonstrate a very thin and
membranous configuration in a condition called placenta
membranacea, almost covering the entire gestational sac.5
With such increased surface area, there is a predisposition to
placenta previa, vaginal bleeding, or premature delivery.3,5
The placenta may take on a circumvallate configuration (Fig.
2) in which the amniotic covering inserts at an area more
medial than the junction of the chorion and placenta (due to
a small chorionic plate) and folds upon itself, giving it a
Figure 2 Circumvallate placenta. The membranes fold back on
themselves for a short distance over the fetal surface because of the
small size of the chorionic plate. This condition predisposes the
pregnancy to premature membrane rupture, placental abruption,
and premature bleeding, and thus, fetal demise. (Color version of
figure is available online.)
D. Nguyen et al
Figure 3 Circummarginate placenta. The membrane inserts just a
short distance inward from the outer circumference of the placental
disk. There is no folding or rolling of the membrane. This condition
is rarely associated with fetal malformation. (Color version of figure
is available online.)
prominent ridge and rolled appearance.5 The condition is
present in 1.0%-6.5% of cases and predisposes the preg-
nancy to premature membrane rupture, placental abruption,
and premature bleeding.3,5 A similar condition called cir-
cummarginate placenta also exists (Fig. 3), but in this condi-
tion, the margins of the membrane do not fold upon them-
selves and, therefore, no ridge is present. Lastly, in placenta
fenestrata, the placenta may also demonstrate a central defect
in which placental tissue is nonexistent, leaving only a mem-
branous sheath.5
Ultrasonography Techniques
in Evaluating the Placenta
For several decades, ultrasonography has been in use for the
evaluation of the placenta in obstetrics. Although less empha-
sized in literature than the fetus or the pregnant uterus, the
pivotal roles of the placenta in pregnancy emphasize the im-
portance of its evaluation.1 The advantages of ultrasonogra-
phy evaluation include its lack of ionizing radiation, dynamic
nature, functional applications (vascular), cost, and portabil-
ity. During the sonographic evaluation of the placenta, atten-
tion should be given to its location, size, anatomy, morphol-
ogy, implantation, and any other abnormalities.1
The placenta will usually appear as a homogenous mass
within the uterus that is hyperechoic to the myometrium
(which is hypoechoic and rim like), indenting the gestational
sac.6 As the pregnancy progresses to the third trimester, the
placenta will appear more heterogeneous because of the pres-
ence of calcifications and vascular lakes. The vascular lakes
are thought to represent maternal blood and will appear as
anechoic regions in the intervillous space.6,7
Imaging of the placenta 67

Magnetic Resonance
Imaging Techniques in
Evaluating the Placenta
Slowly emerging as an important modality in imaging the
fetus and placenta, magnetic resonance imaging (MRI) still
remains as a complementary modality to ultrasonography.8
First used in 1983 to image the fetus by Smith et al, the
limitation of motion artifact is slowly being overcome with
improved acquisition times and sequences.8,9 MRI provides
superior soft tissue contrast resolution, multiplanar imaging
capabilities, and image quality independent of the mother’s
size or fetus’ positioning, and it lacks ionizing radiation. Its
drawbacks, however, include prolonged imaging time, cost,
lack of skilled experience, claustrophobia, challenges of re-
maining supine and still for a prolonged period in advanced
gravid state, and unknown safety to the fetus.8
MRI sequences include multiplanar single-shot fast spin
echo, which are most useful because of their rapid acquisi-
tion. These can be prescribed in oblique planes if necessary.
Higher tissue contrast sequence includes T2 fast spin echo;
however, these can be limited by motion artifact due to lon-
ger acquisition times. These are most useful in the deep pel-
vis, which is typically not affected by fetal motion, to help
determine the relationship of placental tissue to the myome-
trium in cases of suspected placental invasion. T1-weighted
sequences include single– breath-hold fast spoiled gradient
echo (FSPGR) T1 with or without fat saturation. On MRI, the
placenta demonstrates intermediate to high signal intensity
on T2-weighted sequences and low signal intensity on T1-
weighted sequences.10 Subchorionic or retroplacental hem-
orrhage typically demonstrates low T2 and intermediate to
high T1 signal. Diffusion-weighted imaging (DWI) has been
recently demonstrated to be very useful in the detection of
retroplacental hematoma.11

Twin Gestation
Twin pregnancies account for roughly 1% of live births in the
United States but make up 10% of all perinatal mortality and
morbidity.12 Higher incidences of twinning are present with
advanced maternal age, fertility treatment, specific maternal
race (Asian, Caucasian, Black), or maternal family history.12
Monozygotic twinning (identical twins) results from fertiliza-
tion of one ovum by one sperm.1,12 The timing when the Figure 4 (A) Diamniotic-dichorionic twin placenta. A dividing mem-
zygote divides determines its chorionicity. If it divides on brane with a layer of amnion on each side and 2 chorions that are
days 1-3, it will be dichorionic-diamniotic (Fig. 4A and B); if adherent together. This picture depicts the chorions fused together.
on days 3-8, it will be monochorionic-diamniotic (Fig. 4C); if (B) Diamniotic-dichorionic twin placenta. A diamnionic-dichori-
on days 8-10, it will be monochorionic-monoamniotic; and onic twin placenta with separate chorions. (C) Diamniotic-mono-
after day 12, it will be conjoined.1,12 Monochorionic twins chorionic twin placenta. There is a dividing membrane composed of
amnion with no visible chorion. Notice how the dividing membrane
will have an increased propensity for complications such as
is thinner than that in (A). (Color version of figure is available
twin–twin transfusion syndrome and abnormal umbilical
online.)
cord insertion sites.1 Dizygotic twinning (fraternal twins) oc-
curs when there is fertilization of 2 separate ova forming 2
zygotes. These pregnancies will always be dichorionic-diam-
niotic.
68
Figure 5 (A) Lambda/twin peak sign in dichorionic-diamniotic twin
gestations. Notice the “peak-shaped” chorionic tissue (arrow) ex-
tending between the twin membranes (AA, BB). (B) Trichorionic-
triamniotic triplet gestation. Multiple lambda signs (arrows) are
seen.
Ultrasonography Role
and Sensitivity/Specificity
in Determination of Chorionicity
Considering that twin gestations already have a 3- to 7-fold
increased chance of morbidity and mortality with complica-
tion rates increasing with monochorionicity and/or monoam-
niocity, accurate determination is paramount in developing
early management strategies.12,13 In a study conducted by
Stenhouse et al, chorionicity, which is determined by the
number of placental masses, fetal sex, intertwin membrane,
and the twin peak sign (also known as lambda sign, Fig. 5), is
accurately determined 95% of the time. From that, mono-
chorionicity is diagnosed accurately 91% of the time, and
dichorionic pregnancies are diagnosed accurately 96% of the
time. If ultrasonography is performed before 14 weeks’ ges-
tation, the overall accuracy is roughly 99%.13 In a more re-
cent study by Dias et al, ultrasonographic evaluation in the
first trimester is 99.8% accurate with a sensitivity and speci-
ficity of 100% and 99.8%, respectively. Optimal assessment
D. Nguyen et al
is from 10 to 14 weeks’ gestation for visualizing the lambda
sign (dichorionic-diamniotic pregnancy) or intertwin mem-
brane (diamniotic pregnancy, Fig. 6), and 6-10 weeks for the
number of gestational sacs, which correlates with the chorio-
nicity.12
In determining the chorionicity of the pregnancy, discrete
placental masses can be identified, and if 2 discrete placental
masses are seen, the pregnancy is dichorionic. This method
can be less accurate if there is a prominent succenturiate lobe
or a bilobed placenta.4,13 Another method is in visualizing the
twin-peak sign (also known as the lambda sign), which was
first described by Finberg in 1982.14 When the placenta is
dichorionic, the chorion reflects with the amnion at the in-
tertwin membrane, causing a potential space for villi to grow,
causing a “peak” that is visible on ultrasonography.14,15 When
it is monochorionic, a thin membrane attaches perpendicu-
larly to the placenta and a contiguous appearance of the
placenta is seen.14,15 Another method involves evaluating for
a thick intertwin membrane, which was described by Hertz-
berg et al as measuring ⬎1 mm in thickness, well defined,
and seen over long portions.16 In the study, the identification
of a thick membrane has a 91% sensitivity with a 100%
predictive value in determining dichorionicity. Sensitivity of
chorionicity determination decreases with more advanced
pregnancy. A thick membrane is seen in 100% of dichorionic
pregnancies in the first trimester, in 89% in the second tri-
mester, and in 36% in the third trimester.16
MRI Role in Determination of Chorionicity
Although there is not much literature regarding the use of
MRI for determining chorionicity, Trop and Levine reviewed
20 MRI examinations at a mean gestational age of 24 weeks
and were able to identify the intertwin membrane in 19 of
them.17 They did note, however, evaluation during the later
stages of gestation was limited because of the progressive
Figure 6 “T sign” in a monochorionic-diamniotic twin gestation.
Thin echogenic intertwin membrane (arrows) composed of appos-
ing twin amnions (twins AA, BB). Notice its perpendicular orienta-
tion to the placenta.
Imaging of the placenta 69

Figure 7 Hematoma locations. (A) Retroplacental hematoma. The hematoma (red in the online version) is posterior to
the placenta (asterisk). Chorion (pink in the online version), amnion (green in the online version), and myometrium
(black). (B) Subchorionic hematoma. The hematoma is interposed between the myometrium and the chorion. (C)
Subamniotic hematoma. The hematoma is interposed between the chorion and amnion. (Color version of figure is
available online.)

thinning (due to increasing fetal size) of the intertwin mem-
brane.17
Placental Hematoma
Placental hematomas are a frequent complication of preg-
nancy, which can predispose to premature delivery and
spontaneous abortion.18 The incidence of placental hema-
toma in the first trimester ranges from 4% to 22%.18 There are
3 types of placental hematoma, including retroplacental, sub-
chorionic, and subamniotic (Fig. 7). Retroplacental hemato-
mas are defined as being posterior to the placenta, represent-
ing 43% of hematomas. Subchorionic hematomas are
between the chorion and the endometrium, representing ap-
proximately 57% of hematomas.18 Subamniotic hematomas
are rare and are located between the amnion and chorion.19 A
placental hematoma predisposes the pregnancy to pre-
eclampsia, placental abnormalities, and pregnancy-induced
hypertension and is strongly associated with fetal mortality,
depending on its size and location.18,20 The management of a
hematoma consists of close observation, with some authors
suggesting bed rest.1
of which careful attention should be given to prior studies to
differentiate amongst the two.19 Subamniotic hematomas will
be positioned between the placenta and its overlying amni-
otic covering, on the fetal side, near the fetal vessels without
contacting the endometrial lining.19,21 It will usually manifest
as a nonvascular, anechoic to hypoechoic collection that is
convex toward the fetal plate; this is considerably less com-
mon than the previously described hematomas.19,21
MRI Role and Appearance
Although the role of MRI in the evaluation of placental he-
matomas is not well delineated, a recent study by Masselli et
al showed the superior sensitivity and specificity of MR com-
pared with ultrasonography (100% vs 53% and 100% vs
85%, respectively, n ⫽ 19).4,11 Subchorionic or retroplacen-

Ultrasonography Role and Appearance

Ultrasonography is usually the study of choice in evaluating
for a hematoma because of its cost and convenience. Most
hematoma will be seen as a crescent-shaped fluid collection
that is hyperechoic to isoechoic in the first week after hem-
orrhage, hypoechoic at 1-2 weeks, and finally, anechoic at 2
weeks and thereafter.20 No vascular flow will be demon-
strated on Doppler. Retroplacental hematoma (Fig. 8) will
involve strictly the region behind the placenta, whereas a
subchorionic hematoma (Fig. 9) will involve the chorion be-
yond the margins of the placenta. If the hematoma involves
the margin of the placenta, it is termed a marginal subchori-
onic hematoma (Fig. 10).19 Sometimes marginal subchori- Figure 8 Retroplacental hematoma. Hypoechoic collections (arrows)
onic hematomas can be mistaken for a second gestational sac, posterior to the placenta (asterisk).
70
Figure 9 Subchorionic hematoma. Hypoechoic collection (arrow)
representing a subchorionic hemorrhage adjacent to the margin of
the placenta. Care must be taken to not mistake it for a gestational
sac (arrowhead). (Color version of figure is available online.)
tal hematomas will usually be low signal on T2-weighted
images and intermediate to high signal on T1-weighted im-
ages (Fig. 11). Additionally, MRI can date the age of the
hematoma, of which the signal characteristics are similar to
those of hemorrhage in other areas, and it has larger field of
view compared with ultrasonography.11 As with ultrasonog-
raphy, false-negative results can occur when a retroplacental
or subchorionic hematoma dissects through the placental
attachments and drains out through the cervix.4
Placental Abruption
The diagnosis of placental abruption (Fig. 12) is clinical and
is characterized as the premature detachment of the placenta
from its implantation site.11 The condition may be sudden
and painful or clinically silent.20 It may manifest as a placen-
tal hematoma as discussed above, without other symptoms
such as pain or vaginal bleeding. Placental abruption affects
approximately 1% of births and is the leading cause of vaginal
bleeding in the final trimester.11,20 The pathogenesis of ab-
ruption is not entirely clear, but risk factors include pre-
eclampsia, cocaine use, maternal hypertension, advanced
maternal age, trauma, and prior history of abruption.1 Asso-
ciated complications include preterm delivery and fetal
death.4
Ultrasonography Role and Appearance
Ultrasonography is relatively poor at detecting placental ab-
ruption, which was reported in a study by Glantz and Purnell
to have a sensitivity of 53%.4 Typically, abruption is not
evident ultrasonographically, unless a secondary sign, such
as a hematoma, is large enough to detect.20 In addition, when
detected sonographically, abruption is usually more associ-
ated with greater morbidity and mortality, necessitating more
aggressive management.3,20 Occasionally, false negatives can
occur when the hematoma dissects and drains from the cer-
vix or when the sonographic appearance of the hematoma is
similar to that of the adjacent soft tissues (ie, placenta).4
D. Nguyen et al
Computed Tomography Role and
Appearance (Used in Trauma Cases)
In the setting of trauma, computed tomography (CT) is often
used because it allows the simultaneous evaluation of the
fetus and mother.4 The appearance of CT can vary from non-
enhancement of the placenta due to sudden devasculariza-
tion or presence of high-density material behind the placenta
or in the amniotic fluid related to hemorrhage.4 The disad-
vantage of CT would include exposure of mother and fetus to
ionizing radiation.
MRI Role and Appearance
MRI has an increasing role in diagnosis of placental abrup-
tion, offering many advantages. First and foremost is its su-
perior sensitivity for detection of abruption (100% vs 53%).11
Additionally, MRI is independent of the placental location
and the operator, MRI can approximate the age of the hema-
toma, differentiate it from other fluid collections, and can
possibly identify other placental pathology.11 Disadvantages
include cost, time, patient monitoring, and the general lack of
expertise in interpreting the studies.11,22
Multiple sequences can be used in the evaluation of the
placenta: T1, T2, and DWI. The T1 and T2 sequences are
used for soft tissue characterization and anatomy; T1—and
in particular, DWI—is used for the detection of blood prod-
ucts (hematoma), with a reported sensitivity and specificity
of 100% for DWI.11 The appearance of the hematoma is seen
as a well-circumscribed collection with intensity similar to
that for hemorrhage elsewhere, depending on its chronic-
ity.11 The location of the hematoma is similar to what was
discussed earlier.
Placenta Previa
Placenta previa is one of the most common causes of bleeding
during pregnancy and occurs when the placenta is abnor-
mally implanted in the lower uterine segment, near to or
covering the cervical os.4,20 Placenta previa affects approxi-
Figure 10 Marginal subchorionic hematoma. Heterogeneous collec-
tion (arrow) representing hemorrhage is seen at the margin of the
placenta (arrowhead). Fetus (asterisk).
Imaging of the placenta 71

Figure 12 Placental abruption. There is premature detachment of the

placenta from its implantation site, which is grossly seen as a large
retroplacental blood clot. These cross sections of the placental de-
pict the retroplacental blood clot (arrows). (Color version of figure is
available online.)

mately 25% of pregnancies before 20 weeks’ gestation, but by

term, only about 1% will be affected because of the expansion
of the lower uterine segment.7 Placenta previa tends to occur
in higher frequency in multiparous women, women with
prior cesarean sections, smokers, and cocaine users.20,23
There is a higher disposition for a patient with placenta previa
to develop placenta accreta (6.8%-10% of affected women).6
In fact, when placenta previa is observed, more detailed eval-
uation for placenta accreta should be performed, as 88% of
cases of placenta accreta will have placenta previa.6
The normal relationship of the placental edge to the inter-
nal cervical os is greater than 2 cm, and when it is less,
placenta previa is present. Subtypes include a low-lying pla-
centa, marginal previa, complete previa, and central previa. A
low-lying placenta is defined by a placental edge within 2 cm
or less of the internal cervical os. A marginal placenta previa
contacts the edge of the internal os without covering it. A
complete placenta previa covers the internal os. Lastly, a
central placenta previa implants directly over the internal os.4

Ultrasonography Role and Appearance

Ultrasonography is the standard in making the diagnosis of
previa and will usually demonstrate the placenta (hyper-

Figure 11 (A) Marginal subchorionic hematoma. Axial T1-weighted

image demonstrates a crescentic subchorionic T1 intermediate to
high signal collection (arrow) at the left placental margin. (B) Mar-
ginal subchorionic hematoma. Axial T2-weighted image demon-
strates a crescentic subchorionic T2 hypointense collection (arrow)
at the left placental margin. (C) Subchorionic hematoma. Sagittal
T2-weighted image demonstrates a low signal collection (arrow)
beneath the placenta overlying the internal cervical os (arrowhead).
72
Figure 13 (A) Complete placenta previa. Transabdominal ultra-
sonography demonstrates the placenta (asterisk) completely overly-
ing the internal cervical os (arrow). (B) Placenta previa on transvag-
inal view. Internal cervical os (arrow) is covered by the placenta
(asterisk).
echoic to the myometrium) covering varying portions of the
internal cervical os (Fig. 13).4 False-positive results may oc-
cur secondary to lower uterine segment contractions, fi-
broids, and placental clots.23 Similarly, ultrasonography per-
formed early in pregnancy showing previa may resolve by the
second trimester, usually from lower uterine segment expan-
sion and more superior migration of the placenta.20 Transab-
dominal ultrasonography is usually sufficient (sensitivity of
93%-97%), but with more difficult cases (body habitus and
posterior placental position), transvaginal ultrasonography
may be performed with the caveat that there is a risk of
prematurely rupturing the membranes or infection if the
membranes have already ruptured.24 Some studies, however,
show transvaginal ultrasonography to be safe and useful in
more difficult cases.4,20
MRI Role and Appearance
MRI appearance of placenta previa (Fig. 14A and B) is anal-
ogous to the sonographic findings, but it is not routinely used
for this indication. It may be most useful as an adjunct in
D. Nguyen et al
difficult cases where ultrasonography is equivocal, the pa-
tient is difficult to scan, or if the placenta is implanted in the
posterior uterus.
Vasa Previa
Vasa previa is the condition when the fetal vessels abnormally
run along the membranes and cross the internal cervical os
under the fetal presenting part.4,20,25,26 The incidence is esti-
mated to be 1 in 2500 deliveries.26 Because the fetal vessels
are running along the membrane unprotected by the placenta
or Wharton’s jelly, there is a predisposition to rupture during
delivery, which can lead to rapid fetal exsanguination and
death (60% mortality).26 Risk factors usually include multi-
ple pregnancies, abnormal positioning of the placenta, and
placental anatomic variants (bilobed, succenturiate, etc).23
Management consists of cesarean section.23
Ultrasonography Role and Appearance
On Doppler imaging, ultrasonography will demonstrate tu-
bular hypoechoic structures containing vascular flow that
overly the internal cervical os (Fig. 15).4,27 Arterial and ve-
nous waveforms will be observed during pulsed Doppler.26
Another reliable method is to observe for the umbilical cord
insertion and confirm its normal attachment to the placenta,
which rules out a velamentous cord insertion, the most com-
mon cause of vasa previa.24,26
MRI Role and Appearance
No large studies have been performed evaluating the effec-
tiveness of MRI in detecting vasa previa. There has been a case
study by Kikuchi et al, in which MRI was used as a problem
solving measure in identifying the placenta and expediting
management when ultrasonography proved to be inconclu-
sive.28
Placenta
Accreta, Increta, Percreta
Placenta accreta, increta, and percreta are in the spectrum of
a pathologic process in which there are varying degrees of
myometrial invasion by the chorionic villi secondary to a
defective or damaged decidua basalis layer.7 Approximately
0.9% of pregnancies are complicated by this condition, with
prior uterine surgery, cesarean sections, and placenta previa
being the main risk factors.27 Ten to fifty percent of patients
with prior cesarean sections or placenta previa will present
with this condition.20,27
The placenta will usually be retained after delivery, form-
ing a conduit for postpartum hemorrhage.20 Significant mor-
bidity and mortality are associated with this condition, which
includes damage to the surrounding structures (bladder,
bowel, or ureters) or massive hemorrhage.27 Treatment usu-
ally consists of hysterectomy, and occasionally, hemorrhage
can be alleviated by uterine artery embolization.
Placenta accreta is the abnormal attachment of the chori-
onic villi to the myometrium (without actual invasion).7,25
Imaging of the placenta 73

Figure 15 Vasa previa on Doppler ultrasonography. Tubular struc-

ture demonstrating vascular flow (arrow) overlies the internal cer-
vical os (arrowhead). (Color version of figure is available online.)

When the villi partially invade the myometrium but do not

extend to the serosa, it is called placenta increta.25 With pla-
centa percreta, the villi invade through the myometrium and
involve or extend beyond the uterine serosa, occasionally
involving adjacent structures.24,27

Ultrasonography Role and Appearance

Ultrasonography is the primary modality used for the evalu-
ation of placenta accreta, with sensitivities ranging from
⬍50% to 93%.6,7,20,27 A high-frequency transducer should be
used via a transabdominal or translabial technique unless the
patient has abnormal positioning of the placenta (previa),
which may then necessitate a transvaginal examination.6,20
With the transabdominal technique, care should be taken to
ensure that the bladder is full in order to have an appropriate
acoustic window. With the transvaginal technique, the blad-
der should be left somewhat distended to evaluate the uter-
ine– bladder interface.29
With placenta accreta (Fig. 16), the most sensitive sign will
usually be the presence of prominent placental lacunae—
which are small, irregularly shaped hypochoic regions in the
placenta, demonstrating turbulent flow on Doppler— during
the second and third trimesters (sensitivity of 79%).6,29 Dis-
ruption of the uterine– bladder interface, which is usually a
smooth echogenic band between the bladder and placenta, is
another indicator of placenta accreta.6,29 Obliteration or thin-
ning of the retroplacental clear space, which is an approxi-

Figure 14 (A) Marginal previa. T2 fat-saturation sequence demonstrates

an intermediate signal placenta (arrow) with its edge at the internal
cervical os (arrowhead). (B) Placenta previa and placenta percreta (pa-
thology proven). Sagittal (B) and axial (C) fast spin echo T2 images
focused on the area of interest over the lower uterine segment. There is
indistinctness of the lower anterior uterine wall (arrow). The placenta
overlies the internal cervical os. (C) Placenta percreta. T2 fast spin echo
axial view of same patient in (B) demonstrates visible placental tissue
invasion (arrow) into the myometrium.
74
Figure 16 (A) Placenta accreta. The interface of the placenta (aster-
isk) and uterus (arrow) is indistinct secondary to placental invasion
into the myometrium. (B) Placenta percreta. Color Doppler demon-
strates invasion of placental blood vessels (arrow) all the way into
the myometrium. (Color version of figure is available online.)
mately 1-cm thick hypoechoic region between the placenta
and myometrium, can indicate possible placenta accreta
(sensitivity of 57%).7,30 Other sonographic signs of placenta
accreta include a discontinuity of the myometrial blood flow,
which is thought to be due to disruption by villous invasion
into the myometrium and abnormal thickness of the myome-
trium of ⬍1 mm (distance between the echogenic uterine
serosa and the retroplacental vessels).6
MRI Role and Appearance
MRI is usually an adjunct to ultrasonography in the diagnosis
of placenta accreta. The indications are not concrete, al-
though some authors argue that MRI should be used in the
setting of inconclusive ultrasonographies or abnormal pla-
cental positioning (posterior position) or to better define the
anatomy and extent of the myometrial invasion to facilitate
management.6 The efficacy of MRI in diagnosing placenta
accreta is inconclusive. Prior studies by Warshak et al dem-
onstrated a sensitivity of 88% and specificity of 100% in
D. Nguyen et al
detecting placenta accreta with gadolinium-enhanced MRI.31
Another study by Lam et al showed a poor sensitivity of
38%.32 A more recent study of 32 patients by Dwyer et al
revealed a sensitivity of 80% and specificity of 65%.27
No definitive criteria are set for diagnosing placenta accreta,
but suggestions from multiple authors are similar to those of
ultrasonography: presence of placenta previa, abnormal thin-
ning of the myometrium underlying the placenta (may also hap-
pen in normal pregnancies), T2 dark bands in the placenta,
visualization of placental tissue invasion of surrounding struc-
tures, nodular appearance of the placenta– uterus interface, het-
erogeneous placenta, distortion of the uterus by the placenta,
and loss of uterine– bladder interface (Figs. 14C and 17).6,10
Gestational
Trophoblastic Disease
Gestational trophoblastic disease is the uncontrolled growth
of trophoblastic tissue, which occurs in about 1 in 1200
pregnancies.24 Risk factors include a prior history of gesta-
tional trophoblastic disease, Asian ethnicity, and advanced
maternal age.1,24 Common clinical symptoms will include a
large uterine size for gestational age, elevated beta-human
chorionic gonadotropin, hyperemesis gravidum, preeclamp-
sia, and first trimester bleeding.4,23 Patients with prior history
of molar pregnancy should be followed up to 6 months be-
fore pregnancy is again attempted.23
Complete and Partial Moles
The most common gestational trophoblastic disease is the com-
plete mole (Fig. 18), which is a result of fertilization of an empty
ovum, with 90% having a 46, XX karyotype instead of 46, XY.
Histology will usually demonstrate diffusely hydropic villi, tro-
phoblastic hyperplasia, and absence of fetal tissue.4,20,24 Around
15%-25% of women with an untreated complete mole will have
persistent gestational trophoblastic disease.23 Early diagnosis
and treatment are essential as the condition is curable.1 Treat-
ment consists of either dilation and curettage or hysterectomy.
A partial mole results when the normal ovum is fertilized
by 2 sperm, which results in a triploid karyotype of 69, XXX
or 69, XXY.4 The main difference is that a partial mole is
much less common and will usually present with fetal parts,
focal hydropic villi and focal trophoblastic hyperplasia on
ultrasonography.20 Management of a partial mole is the same
as that of a complete mole.
Ultrasonography Role and
Appearance of Complete and Partial Moles
Ultrasonography is the main modality in evaluating molar
pregnancies and will typically demonstrate a heterogeneous
placenta with a complex echogenic endometrial mass con-
taining a multitude of small cysts classically described as a
“snow storm” or “grape clusters” (Fig. 19). Color Doppler will
show increased vascularity in the spiral arteries in the
uterus.4,20,24 Large ovarian theca-lutein cysts may be seen in
up to 30%-50% of cases secondary to elevated beta-human
chorionic gonadotropin levels.1 No fetal parts will be seen in
Imaging of the placenta 75

Figure 18 Complete hydatidiform mole. The mole consists of a mass

of dilated “grape-like” chorionic villi. No fetus should develop.
(Color version of figure is available online.)

a complete molar pregnancy; meanwhile, a partial molar

pregnancy will demonstrate fetal parts such as the umbilical
cord, fetus, and fetal membranes.4,23

MRI Role and Appearance

of Complete and Partial Moles
Because of the nonspecific imaging findings that coincide with
retained products of conception, MRI is not frequently used in
the evaluation of molar pregnancies.4 Moles will usually be seen
as enhancing heterogeneous tissue containing multiple cystic
spaces within the distended uterus that is T1 hypointense and
T2 hyperintense.4 Noninvasive moles will have a normal hy-
pointense layer of myometrium surrounding it.4

Invasive Moles and Choriocarcinoma

An invasive mole is present when there is extension of the
tissue into and, sometimes, beyond the myometrium.4 Be-
cause they tend to invade locally, invasive moles are consid-
ered invasive nonmetastasizing neoplasms.4 Choriocarcino-
mas, on the other hand, are metastasizing with frequent sites
being the lung and pelvis.4 Fifty percent of choriocarcinomas
are complications of a molar pregnancy, and the remaining
50% are from abortions or normal pregnancies.4 Choriocar-
cinoma and invasive molar pregnancies have similar appear-
ances on imaging and are difficult to distinguish between the
noninvasive molar pregnancies.4,20

Figure 17 (A) Placenta percreta. Intermediate T2 signal placenta is

seen inferior and to the right of the fetus. There is gross transmyo-
metrial extension of the placenta inferiorly on the right (arrow). (B)
Placenta percreta with bladder invasion. The intermediate- to high-
signal placenta is seen adjacent to the bladder wall (arrow), which is
indistinct and disrupted. (C) Placenta percreta with invasion into
the cervix. Heterogeneous signal is seen at the cervix (arrows),
which is also indistinct. (Images are courtesy of Shirley McCarthy,
MD, PhD, Yale New Haven Hospital.)
76
Figure 19 (A) Complete molar pregnancy. There are multiple cystic
structures in the placenta (arrow), giving it a “grape-like” appear-
ance. No fetus is present. (B) Partial molar pregnancy. A few cyst-
like areas (arrow) are seen in the placenta. Fetus (asterisk).
Ultrasonography Role and Appearance
Similar to molar pregnancies, invasive moles and choriocar-
cinoma will demonstrate heterogeneous echogenic masses in
the uterine cavity with vascularity on ultrasonography.4,20
CT Role and
Appearance in Choriocarcinoma
CT plays an important role in staging choriocarcinoma.4 The
tumor will typically be seen on imaging as a nonspecific
enhancing heterogeneous soft tissue density in the uterus.
Attention should be paid for metastatic lesions in other parts
of the body, such as the lung or pelvis.4
MRI Role and Appearance
MRI is uncommonly used in imaging choriocarcinoma, al-
though it may be of use in evaluating the extent of myometrial
invasion.4 Choriocarcinomas will typically appear as enhanc-
ing, vascular (will show flow voids), heterogeneous masses
that are hyperintense on T2-weighted sequences.4 Invasion is
demonstrated via enhancing, hyperintense foci in the myo-
D. Nguyen et al
metrium. Enhancing soft tissue adjacent to the uterus is seen
with local spread.4
Retained
Products of Conception
Retained products of conception (which may result from an
aborted pregnancy or retained placental remnants) are one of
the most common reasons for hospital readmission during
the postpartum period and can present as abdominal pain,
fever, and prolonged postpartum hemorrhage.33-35 The inci-
dence of postpartum hemorrhage secondary to retained
products of conception is approximately 1%.33 Treatment
usually consists of dilatation and curettage, with significant
associated morbidity (8.5% incidence) such as infection,
uterine adhesions (leading to infertility), uterine perforation,
and hollow viscus damage.33,34,36 Considering the accompa-
nying risks of evacuating a retained product of conception, it
is important to accurately assess for it when suspected.
Ultrasonography Role and Appearance
Transvaginal ultrasonography is usually an effective and in-
expensive way of diagnosing a retained product of concep-
tion. When an endometrial mass is detected alone, the sen-
sitivity is 81% and specificity is 71%; with vascularity,
sensitivity is even higher, ranging from 94% to 98%, with a
positive predictive value of 96%.33-35 Ultrasonography has
been shown to be more sensitive than utilizing physical signs
and symptoms such as fever and abdominal pain (sensitivi-
ties of 28% and 7%, respectively) or cervical dilatation (sen-
sitivity of 70%) in diagnosing retained products of concep-
tion.33 Key sonographic features are as follows: the presence
of a focal echogenic endometrial mass, complex fluid in the
endometrial canal, or an abnormally thickened endome-
trium. Observation of vascularity within the endometrial
mass is more suggestive of a retained product (Fig. 20).33,34
MRI Role and Appearance
MRI is usually not the initial study of choice in the evaluation
for retained products, but rather is used as an adjunctive and
problem solving measure. Because their appearance is similar
to that of gestational trophoblastic disease, as discussed by
Noonan et al, it is relatively nonspecific.4,37 Retained prod-
ucts usually appear as heterogeneously enhancing soft tissue
masses with variable T1 and T2 intensities within the uterine
cavity.4,36,37
Conclusions
Ultrasonography is the primary modality of obstetric placen-
tal imaging because of its rapid availability, portability, and
low cost. Its limitations include posterior placental position-
ing and patient body habitus. MRI, on the other hand, is
excellent in the evaluation of the placenta, irrespective of its
anatomical position within the uterus. Drawbacks include
long acquisition time, cost, unknown effect on the fetus, and
challenges of remaining supine and still for a prolonged pe-
Imaging of the placenta
Figure 20 Retained products of conception. Heterogeneous material
(arrow) is seen in the endometrial cavity.
riod, in advanced gravid state. Having a working knowledge
of the imaging presentations of various placental pathologies
will aid in the appropriate and timely care of the pregnant
patient.
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