Accuracy of Prenatal Sonography for Detecting Circumvallate Placenta

Robert 0. Harris1 Wendy A. Wells2 William C. Black1 Jocelyn 0. Chertoff1 Steven P. Poplack1 Steven K. Sargent1 Harte C. Crow1
OBJECTIVE.
circumvallation,

We determined
a placental

the accuracy

of prenatal

sonography

for detecting

placental

abnormality

MATERIALS
weeks) using cental entire findings
nitely

AND
with focused criteria

METHODS.
placental

associated with increased fetal morbidity We analyzed 62 healthy pregnant sonography placenta sonograms sonologists images
Receiver

and mortality. (range, I 8-36 abnormality margin, or pla-

patients the published

for detection (irregular were taken who were and graded

operating

of morphologic edge. uplifted

for circumvallate

sheet or shelf). Placental marginal placental margin. Five experienced independently normal) reviewed to 5 (definitely
circumvallate).

at 30#{176} intervals around the unaware of the pathologic the placentas

characteristic

the placental

from
(ROC)

1 (deficurves pathol-

and area under the ROC curve were calculated for each ogy was used as the gold standard for all cases.

reader. 49 normal

Gross

and microscopic (79%), (2%).

RESULTS.
circumvallate

In the 62 patients,
placentas (19%),

sonography

revealed

placentas placenta

12 partially ROC curves

and one completely

circumvallate

for the reviewers resulted in values for area under the curve ranging from .39 to .58. The sonologist who achieved the highest value for the area under the curve classified the I 3 cases of proven circumvallation ocal. were as one case of definite circumvallation, four cases as uncertain or equivand eight cases as probably or definitely normal placentas. graded as probably or definitely circumvallate by at least the case of complete Focused edge the placental circumvallation placental abnormality as normal. sonograms in most interpreted cases by experienced sonologists In our study, 17 of circumvallation. Of the normal one sonologist. placentas, 35% All sonologists

misgraded fail to detect

CONCLUSION.
of 49 normal more observers.
vallation

placentas were diagnosed as probably or definitely circumvallate by one or Our sonologists interpretations of sonograms showed that complete circumto assess. Although our study had a limited circumvallation number appears of patients, to be limited. the acof the placenta for revealing

was difficult of sonography

curacy

C
insertion the edge cumvallate
Received May 29, 1996; accepted December 12, 1996. after revision a higher

ircumvallate placenta is an abnormality of placental shape resulting from chorioamniotic membrane from with cirwith at some inward of the placenta with placenta
incidence

the detection of circumvallation is unknown. This experimental study with pathologic correlation simple, pregnant was designed focused patients. to assess the accuracy a group of a of placental placentas sonogram among to identify

distance away [1]. Compared placentation, associated

placental

circumvallate

pregnancies

normal has been

of

abruption.

premature growth anomalies cumvallate plications raphy graphic

labor retardation, [1,

and

delivery, death,

intrauterine and fetal of cir-

Materials

and Methods

1 Department of Radiology, Dartmouth-Hitchcock Medical Center, One Medical Center Dr., Lebanon, NH 03756. Address correspondence to R. D. Harris. 2

perinatal

2]. Prenatal

diagnosis

Department

of Pathology,

Dartmouth-Hitchcock

Medical

Center, Lebanon, NH 03756.

AJR 1997;168:1603-1608 0361-803X197/1686-1603

placenta may have important imfor detection of patients at risk for Several have reports described in the sonogthe sono[2-6]. for

complications. literature

appearance

of circumvallation of prenatal sonography

American

Roentgen

Ray Society

but the accuracy

We studied 100 randomly selected pregnancies from July 1993 to December 1994 (99 patients; one patient was pregnant twice). All patients were examined by one experienced sonologist. Thirtyeight patients were lost to follow-up or did not have placental specimens submitted for analysis; 62 placentas (61 patients; one patient with two singleton births) were obtained for inclusion in the study. We performed all studies with standard

AJR:168, June

1997

1603

Harris

et al.

nosis
focused

based

upon

the margin sonograrns sitting

of the placenta. were 4 months individually after response

The in-

placental

terpreted
examination
part

(at a single

the last on the sowho

to encourage (with

amnesic 3-24

of the sonologist experience). the original

perfomiing including examination.

the examination) years of obstetric the sonologist findings. the largest All sonologists Sonoloet of rewere was diag(where or as of series

by five sonologists nography performed were

unaware

of the pathologic

gists were given

a copy of the paper by McCarthy reported the studies. The to date-to Results who

al. 121-to
PLACENTA cases view before

our knowledge.
interpreting

of circumvallation independently of the pathology. criteria

recorded unaware

fcr each observer. sonographic placenta rounded)

A
Fig. 1.-Focused sonography of placenta. A and B, Diagrams of placenta en face (A) and in profile (B) show position oftransducer
of placenta. We obtained 12 approximately evenly spaced during focused images (every 301 at placental margin. sonography

nostic

for circumvallate uplifted margin (where

was

were based

on an irregular, the placental shelf or rim

edge of the placenta edge

or a marginal was thin

the placental

sheetlike) [2-61. These two criteria were chosen being representative of the sonographic spectrum
sonography ers) equipment (3.5Acuson. and 5-MHz transducView. (n
=

(HDI; Advanced Bothell, WA: XP-128;

following

Technologies Mountain fetal

Laboratories. CA) 14). survey

performed by one fellowship-trained with 10 years of obstetric sonography

This ensure from weeks standardized comparative the study if gestational protocol studies. the was followed

sonologist experience. to miniand excluded than 16 visiplaA marThis or funperdiagto variation were less

circumvallation Placentas were 2

oti the scored

=

basis

of published 1 normal. 3

papers.
=

on a scale of 1-5:
=

deft-

nitely
4
=

normal.

probably

equivocal.

for the

indications:

mize differences

in interobserver Patients patient

probably

circumvallate. operating

and 5

definitely
(ROC) were

circumcurves calcuwere

dates or growth (ii = 13). hiophysical profile (ii = I 3. and miscellaneous (ii = 22). Gestational ages at the time of sonography were I 7 patients between 16 and 23 weeks, 2 1 patients between 24 and 32 weeks.
and 24 patients between 33 and 40 weeks.

vallate.

Receiver curve

characteristic error given

=

was

were generated
the ROC obtained nologist

for each observer. and its standard scores the scores or normal
=

and the area under

age or if a sonographically or retroplacental or placenta than 25%

previa

ble subchorionic

hemorrhage.
was

lated [7J. Cumulative by summing (mininiuni circumvallate were delivery. rim.

for each placenta 5. maximum formaldehyde and degree a pale of

cental hydrops.
patient frequency the obscured dal in location. To forming avoid bias with gin obscured

present.

by each so-

After the routine sonogram was obtained, a focused placental sotiographic examination was performed (Fig. 1 1. requiring approximately 2-3 mm
at

greater by fetal placenta

of the placental

or
for of

parts was also excluded. was posterior. lateral.

deflnitely
24 hr after

25). in l0% presence associated

was estimated

to be 5%, and in all cases

Placentas

fixed The

of additional
approximately ence tions (one sheet

scanning. Images were obtained 30#{176} intervals around the circumfermargin ftr a total of film). All focused studies

circumferential
in the study. the sonologist white peripheral made no prospective (amnion-chorion)

involvement with tethering

yellowmembrane from the

of the placental

of I 2 secwere

the examination

at a distance

Fig. 2.-Gross specimens of circumvallate placentas. A, Fetal surface of placental specimen after fixation shows pale white-yellow area (arrows) at circumference and thickened, tethered membranes. Pale discoloration caused by placental infarction and thickened membranes. B, Partially circumvallate placenta. Fetal surface of placenta after fixation shows area of circumvallation (arrows) equal to approximately 35% of circumference.

is

1604

AJR:168,

June

1997

18-16
S 14

j.
a.
I-.

c 1oJ.

12

T
U
*

0.5 :

8+

U U

U U U

U U

0.4 03 0.2 0.1

4f
U
0 0 0.2 0.4 0.6 0.8 0
--

60 80 100

20

40

False-Positive

% Clrcumvallation

Fig. 3.-Receiver
accurate

characteristic (ROC) curve of sonologist who was most of focused sonograms. Slope of line closely approximates diagonal line (area under ROC curve = .50). which represents no predictive

operating at interpretation

power for diagnostic test under analysis.

Fig. 4.-Scatterplot reveals cumulative placental score (sum of five observers individual scores) versus percentage of placental margin involved with circumvallation. Mean score for 49 normal placentas (0% of placenta circumvallate) was 9. No observable correlation was evident. Asterisk = cumulative placental score for normal placentas, dagger = two partial circumvallate placentas with same score and percentage of circumvallation. nilicantly greater
was

periphery.
tion
ulent.

were

recorded.

Cotiiplete

circuns

alla-

Results Sonography cumvallate

tially and circurnvallate

than

.50, the expected

power). who The sonologist

score

was

diagno.cd
l)L01Ll

I (XY

marginal
was

involvediagnosed

revealed
placenta (2e%)

one (Fig.

completely 2A),

cir12 par-

for est

a test with score

fl() predictive

high-

wherca

circuiuvallation

l()r the

obtained

in instances in vhicli less than I (8Y2 of the placental ri ologic

iti
iii

placentas
(79fl%)

( 19c4)

(Fig.

s as abnormal

. (iross svere

and

niicroscopic for

pathl)lacefltas for the

evaluations the studs . Flic

01

reci)rded

all

49 noniialplacentas
involvement cases was

The degree
of the

2B). of

the onginal

sonogram

(Fig.
the

3).
cumulative scores

marginal lation

in the partial

circurnvalplacental

Figure 4 summarizes of all placentas. both centas

placentas and

the circurnvallate score score

=

planlost was fir only (Fig. curnu-

liistopatliologic svas annion.

criterion

diagnosis

circunisallation

a ni)nnlargltlal clrion. nttrction. correlaand

tiienhrane
decidual

told
tissue

cotaprising
svith :tssoci:ited

circumference grade three and patients

407 or less in nine patients than

or

the mean cumulative

for the 49 normal

0). The

(designated
equal to

low 7S% in

((% circumvallation

niargtnal Precise

greater

abnormal
IS for which IOn4

in the study
placenta. revealed

heniorrliage.

or tlbrin was impossible

;Lscert:iiil
55

deposition.

(designated
for the area intervals)

high grade). under the ROC curve

for the sonologists

a partially

circumvallate

tion of the l)reilatal

analysis reliably niargin

sonographv
because

v ith the pathologic no niethod of the could placental

The scores

pathologic
involvement

examination
of the with pathologic

(9S/( confidence

circumference the highest

hich

sectu)n

ssas abnoriaal

in utero.

ranged froiii .39 . I 6 to .58 . I 6. None of the scores was statistically significant (i.e.. not sig-

5). Ofthe
lative

I I placentas

scores

I3

).

examination

Fig. 5.-Sonograms of circumvallate placentas. A, Focused sonogram of fetus of 17 weeks gestation reveals partially circumvallate placenta. Placental margin is uplifted (arrowheads). Cumulative score by five sonologists was 18 (highest in study). Pathologic examination revealed minimal (10%) circumvallation. F = fetus, p = placenta. B, Placental sonogram of true-positive example of complete circumvallation (not from study). Shelf of extrachorial (C) placenta is evident. A = amniotic fluid, p = placenta.

AJR:168,

June

1997

1605

Harris Discussion In
smooth

et al. perinatal death. and congenital anomalies [8121. Partial circumvallate placenta is much more more
clinically

normal chorion fetal

placental transition from

development. the parenchymal chorion placental branching of the

the vilocplate.

common frequent)
significant

(approximately but is not

10-20

times

bus The

to the membranous (subchorionic) umbilical cord, the parenchyma rim. placentation. tethered, infarct, continues placenta often hemorrhage, vessels,

considered with focused

to be
pla-

curs at the periphery from the throughout cental branes with onic tethered ally Fig. 6.-Focused sonogram of false-negative cornplete circurnvallate placenta (same placenta as in Fig.
2A) at 38 weeks or irregularity gestation reveals F
=

[81.
study

Our experimental

grow diagonally to reach the plathe memor fibrin chorithe The vessels. must be horizonperipheral beyond out peripher-

cental sonography had no diagnostic power in predicting circumvallation. Although only one found, (75%) case of partial complete additional not detected
placental

plate

circumvallation cases with were

was present is not

to

In circumvallate become The membranes a marginal tissue (so-called

three

of high-grade sonography.
authorities

in association villous

circumvallation

that also were

deposition.

parenchymal to grow and bulges

Realizing that partial recognized by most

circumvallation

extrachorialis).

be clinically significant. with a significant degree ment

with as

we included those of marginal involvedetectable abnormality

no significant high-grade found rate

growth halted diverted

pathway of the chorionic with the tethered membranes, first downward to supply and then the most

a potentially
We in detection

sonography.

difference and normal

among

normal parts,

margin arrows

of
=

placental (p) edge. Cumulative score was 6. No shelf

was evident. fetal

tally to continue

circumvallation. or complete

low-grade placentas.
a score

circumvallation. high-grade
by any of 3 (equivo-

placental basal calcifications. measure amniotic fluid pocket. showed partially

placentas

Electronic

calipers

parts of the placental plate. The cause of circumvallation sial: reduced

ferential

placentas.

In the four score given that

findings even looking by

is controverpressure. circumor deep [ 1 ]. The if the is ininis but

amniotic

fluid

one placenta circumvallate to be normal.

( 10% involvement) and the remaining circumvallation

in the

to be 10 image is

hemorrhage, implantation have circumference and partial Complete rare

abruption.
(-

and superficial been implicated complete of the placenta if it is incompletely circumvallate

1% of

cal) was the highest vidual observer. Our published able enced marginal
ences among

mdi-

findings screening. sonologists

indicate

the
are highly specifically

currently
not reliexperifor

circumvallation

is considered

sonographic

A representative

of the case of complete shown in Figure 6.

No significant difference

entire volved volved.

for

placenta

irregularity.
sonologists

The

observed
slightly

differbetunder
per-

gestational

considered clinically
placental

pregnancies)

showed

age the

occurred high-grade

at time of sonography between or complete circumvallation

significant, premature

with
premature

increased
labor

risk for and de-

ter performance ROC

formed curve
=

in the ROC .58) for the study

curve

(area
who

sonologist

group normal time

and the low-grade circumvallation or placentas. The mean gestational age at of sonography for the high-grade placentas was for the low-grade existed third toward placentas trimester.
or corn-

livery.

rupture

of

membranes.

the focused

of placentas

origi-

plete circumvallate versus 30 weeks placentas. diagnosing as compared that were A trend with scored

32 weeks or normal sonologists abnormal Placentas

midtrimester

as equivocal

(score

3),

probably circumvallate (score = 4), or circumvallate (score = 5) by the sonologists occurred earlier whole The tween vallate, placentas)
ing chi-square

in gestation than (22 weeks versus

rank

in the group 3 1 weeks, p of pregnancies (high-grade and significant

1 ). Higher

<

as a .05, be-

Wilcoxons the

sum test). outcome groups circumnormal usrates

clinical three was low-grade

circumvallate, not statistically

(Table

analysis

of preterm
cental

labor,

preterm

delivery,

and pla-

abruption

plete normal too

occurred in the partially corncircumvallate group compared with patients, but the number of cases was to
support

small

definitive

conclusions. highgroups

The difference in outcomes between grade and low-grade circumvallation was also not statistically significant.

Note.-Circumvallate
aAll categories, p
>

placenta = complete and partial ci .05 Ichi-square analysis).

1606

AJR:168, June 1997

Prenatal

Sonography

for

Revealing

Circumvallate

Placenta

Fig. 1.-Diagram of circumvallate placenta shows thickened insertion site of membranes, including decidua. Thickened membranes leave ring of placenta uncovered by amnion and chorion (placenta extrachorialis). In theory, the farther away from edge of placenta that membranes insert, the higher the likelihood of placental margin becoming irreguar or uplifted and therefore capable of being revealed by sonography. Cross-hatched area depicts portion of placenta that has become infarcted.

cord

Fetal

Membranes

Marginal

maternal

infarct or fibrin deposition tethering the membranes at their peripheral

attachment

Re-directed blood vessel growth around the infarct

Dedua

nally,

but

this

difference

significant.
ages analyzed

The

decision
instead

was not statistically to have recorded imof real-time studies was

[2]. Our
such severe

series

did

not include

any cases of

problem logic prenatal These

for all placental

findings suggest

sonographic-pathothat the accuracy of circumvallaplacental sonoperformance placenta on diagof criteria diagnosed or study the of

circumvallation.

studies. sonographic detection focused adequate

made for two reasons: first, the method simulated the method used by most sonography laboratories, the films (before examine
section for with the the technologist to review presenting initially sonologist

had

The reason that midtrimester sonograrns a higher false-positive rate is unknown, this finding
of

but we speculate
trophotropism

is caused

by the

namic placenta

the actively that may often

growing, dyappear to have would seem prevalent in subsided. [14] which macrofor the diagof our
number of

tion is poor. A single, gram did not have characteristics the basis
nostic

for

circumvallate

the sonologist the patient).

with

decides to personally and second, examina-

an irregular margin. This to be, at least theoretically, the later third cental
of

finding less when and

25

of the published Sonologists,

morphologic knowledgeable

criteria.

tion time could The

ably

be saved in a busy sonography only one attending sonologist. observer

in large

trimester Benirschke

the rate of pladegree Kaufman weeks, for this reason

growth

has to a large change

2 1 and

the for
35%

currently published sonographic circumvallation, prospectively

of placentas
( 17/49)

poor

performance
part, is, by the the

was
severity

probfrom in-

Alternatively, reported
histology

with

at least one obconstituting circumvalassess diagnostic significant

caused,

a dramatic
between

in the placental

servers definitely of more screening

sonography abnormality.

placental

score diagnosis. with is needed

of 4 or 5 (probably thereby complete to further A prospective

circumvallation-that the placental sertion edge and the amount ing of the membranes. the insult

distance

circumvallate), patients

to the site of membrane of folding Generally, occurs,

the 1-2

they
scopic

speculated finding. edge)

may This

account marginal

a false-positive late placentas

and tetherthe earlier severe inthe of complete

irregularity

(uplifted

was the primary

in gestation

the more

the circumvallation.

In our case
cm

significant number of noses of circumvallation We recognize

study complete in addition

false-positive in our study. shortcomings

the small circumvallation

potential of prenatal for this clinically

circumvallation (Fig. 2A). serted a maximum ofonly

edge. centa In addition, was not the severely

membranes
in from

several
to

fetal

surface

of the plaor deformed

or high-grade

plaAcknowledgments
We thank Tern Soule for secretarial support

irregular

on

gross

pathologic

examination, whereby adherent

probably the fetal to the pla-

centas. All prospective, focused sonograms were obtained by the same sonologist, which
may have introduced observer bias. Fetal

reflecting membranes

the phenomenon may become

and William
placental

Young

for assistance

in obtaining

parts though
by

could

have

obscured

the portion circumvallate,

of the al-

specimens.

cental surface in the second trimester and are problematic to detect [131. These examples of normal
ing,

placenta
limiting

that was partially we attempted

our study

appearance

at

prenatal

sonography

to minimize to include edge

no

this effect placentas sonographimethod was

are in contrast
resulting membranes

to cases of more severe tetherin a larger rolled-up ring of

distance from the

with cally

at least 75%
visible. In

of the
addition,

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P Ptaenta1

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