Ultrasound in Med. & Biol., Vol. -, No. -, pp.

1–8, 2013
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http://dx.doi.org/10.1016/j.ultrasmedbio.2013.05.017

d Original Contribution

COMPARING THE DIAGNOSTIC VALUE OF ULTRASOUND AND MAGNETIC

RESONANCE IMAGING FOR PLACENTA ACCRETA: A SYSTEMATIC REVIEW
AND META-ANALYSIS

XINYUE MENG,* LIMEI XIE,* and WEIWEI SONGy

* Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China; and y Department of
Gynecology and Obstetrics, Shengjing Hospital of China Medical University, Shenyang, China

(Received 9 January 2013; revised 15 April 2013; in final form 24 May 2013)

Abstract—The aim of this study was to evaluate the diagnostic value of ultrasound (US) as compared with
magnetic resonance imaging (MRI) in the detection of placenta accreta. Sensitivity, specificity, summary receiver
operating characteristic curves and areas under the curve (AUCs) were described and calculated using Meta-Disc
Statistical Software, Version 1.4 (Unit of Clinical Biostatistics, Ram on y Cajal Hospital, Madrid, Spain). In the 13
studies included, US sensitivity was 83% (95% confidence interval [CI] 77%–88%), US specificity was 95% (95%
CI: 93%–96%) and the diagnostic odds ratio (DOR) was 63.41 (95% CI: 29.04–138.48). In the MRI studies, sensi-
tivity was 82% (95% CI: 72%–90%), specificity was 88% (95% CI: 81%–94%) and the DOR was 22.95 (95% CI:
3.19–165.11). Summary receiver operating characteristic analysis indicated that the diagnostic value of US in
detection of placenta accreta is not significantly different from that of MRI. Both US and MRI were highly sensitive
and specific in the detection of placenta accreta to support effective diagnostic methods. (E-mail: xielm72@yahoo.
cn) Ó 2013 World Federation for Ultrasound in Medicine & Biology.
Key Words: Ultrasound, Magnetic resonance imaging, Placenta accreta, Meta-analysis.

INTRODUCTION The risk of placenta accreta increases from 0.3% after

one prior cesarean section to 0.6%, 2.1%, 2.3% and
Placental invasion is characterized by abnormally firm
6.7% after two, three, four and more than four prior
attachment of the placenta to the uterine wall, collectively
cesarean sections, respectively (Silver et al. 2006).
termed placenta accreta (Sofiah and Fung 2009). This
Once placenta accreta occurs, it may threaten the life of
invasion occurs when the decidua is invaded by the cho-
the mother and fetus. Massive hemorrhage at the time
rionic villi or when the placenta abnormally implants in
of attempted placenta removal is the immediate clinical
the myometrium and serosa (Teo et al. 2009). Based on
consequence of placenta accreta, and it is the most
the degree of penetration of the chorionic villi, placental
common indication for emergent intrapartum or post-
invasion is graded into placenta accreta, increta and per-
partum hysterectomy (Zelop et al. 1993). The reported
creta. In this article, all of these varieties are referred to as
maternal mortality risk of placenta accreta may reach
placenta accreta.
7% (O’Brien et al. 1996). Given the dangers associated
Since the early 1900s, the incidence of placenta
with the condition, accurate prenatal diagnosis of
accreta has increased 13-fold, or approximately 1 in
placental accreta is paramount.
588 women, largely because of the rising rate of cesarean
Ultrasound (US) imaging and magnetic resonance
delivery. Cesarean delivery increased dramatically from
imaging (MRI) have been widely used as diagnostic tools
5.8% in 1970 to 32.9% in 2009 in the United States
in placenta accreta. The diagnostic criteria derived from
(Balayla and Bondarenko 2013; Blanchette 2011;
US that suggest placenta accreta, increta and percreta
Solheim et al. 2011; Wortman and Alexander 2013).
include one or more of the following: (i) loss of the
normal hypoechoic retroplacental myometrial zone; (ii)
thinning or disruption of the hyperechoic uterine
Address correspondence to: Limei Xie, Department of Ultra- serosa-bladder interface; (iii) presence of focal exophytic
sound, Shengjing Hospital of China Medical University, 36 Sanhao
Street, Heping District, Shenyang, Liaoning, 110004, China. E-mail: masses; (iv) myometrium thickness ,1 mm; (v) placental
xielm72@yahoo.cn lacunae with high-velocity turbulent venous-type flow;

1
2 Ultrasound in Medicine and Biology
and (vi) increased vascularity proximal to the bladder
wall on color Doppler (Chou et al. 2000; Finberg and
Williams 1992; Thia et al. 2007). In contrast, the
diagnostic criteria extracted with MRI include (i)
abnormal uterine bulging; (ii) heterogeneous signal of
the placenta on T2-weighted (T2 W) images; (iii) dark in-
traplacental bands on T2 W images; (iv) focal interrup-
tions in the myometrial wall; (v) tenting of the bladder;
and (vi) direct visualization of the invasion of pelvic
structures by placental tissue (Baughman et al. 2008;
Lax et al. 2007).
The reported diagnostic accuracy of US and MRI
varies widely for placenta accreta. Meta-analysis is
a statistical method that allows the results of individual
studies to be evaluated systematically (Irwig et al.
1994). Therefore, the purpose of this article was to
summarize the available publications and to compare
the diagnostic value of US and MRI in detection of
placenta accreta.
METHODS
Search strategy
A computerized literature search (Deville et al.
2000) of PubMed, EMBASE and the Cochrane Central
Register of Controlled Trials Database was conducted
to identify relevant published articles on the diagnostic
accuracy of US or MRI in detection placenta accreta.
We used a combination of the following terms: (i)
‘‘US’’ OR ‘‘ultrasound’’ OR ‘‘MRI’’ OR ‘‘magnetic reso-
nance imaging’’; (ii) ‘‘placenta accreta’’ OR ‘‘placenta in-
creta’’ OR ‘‘placenta percreta’’; and (iii) ‘‘sensitivity’’ OR
’’specificity’’ OR ‘‘accuracy’’ OR ‘‘diagnosis’’ OR
‘‘detection.’’ No date limits were specified, and the search
was current as of March 20, 2013. To expand our search,
the reference lists from all retrieved articles were
screened to identify additional studies.
Study selection
Only the studies that satisfied all of the following
criteria were included: (i) use of US or MRI in patients
with a history of previous cesarean section or a diagnosis
of placenta previa; (ii) sample size of at least eight
patients; (iii) English publications that could assess the
number of true positives (TPs), false positives (FPs), false
negatives (FNs) and true negatives (TN), either directly or
indirectly; (iv) confirmation of the diagnosis with the gold
standard of histopathologic analysis and/or intra-
operative finding; and (v) in cases in which data were pre-
sented more than once, the article with the most details or
the most recent publication date.
The exclusion criteria were: (a) articles not within
the field of interest of this review; (b) review articles,
editorials, letters, comments or conference proceedings;
Volume -, Number -, 2013
(c) case reports or case series; (d) insufficient data to re-
assess sensitivity and specificity from an individual
study; and (f) duplicate data.
Studies using US with or without Doppler imaging
were included; similarly, studies using MRI with or
without gadolinium contrast were included. All retrieved
articles were reviewed by two observers who applied the
inclusion and exclusion criteria described above.
Disagreements were resolved by consensus.
Data extraction
Data were extracted independently from all studies
that fit the inclusion criteria by the same observer of study
selection. When observer disagreements occurred, a third
reader reviewed the article, and the disagreement was
resolved by discussion. For each study included, certain
data were extracted: first author, year of publication,
study design (prospective or retrospective), patient char-
acteristics (average gestational age), technical aspects
(e.g., probe type and probe frequency used in the US
studies, magnetic field strength and contrast agent used
in the MRI studies), image interpretation (blinded or
not). For each study, the numbers of TPs, FPs, FNs and
TNs for US and MRI were recorded.
Quality assessment
The methodological quality of the articles was as-
sessed using the updated quality assessment tool
QUADAS-2 (Quality Assessment of Diagnostic Accu-
racy Studies) guidelines (Whiting et al. 2011) to evaluate
the risk of bias and applicability. Each item was rated as
‘‘low,’’ ‘‘high,’’ or ‘‘unclear.’’ The ‘‘unclear’’ category was
used only when insufficient data were reported. In the
publication that included two index tests (US and MRI),
it was necessary to assess each index test in QUADAS
DOMAIN 2 (index test). Certain items were omitted
because they were not relevant to this topic.
Meta-analysis
A random effect model was used for primary statis-
tical pooling of the data to obtain a summary estimate of
sensitivity and specificity with 95% confidence intervals
(CIs) for US and MRI. The summary receiver operating
characteristic (SROC) curve, the area under the curve
(AUC) and the Q* index (the points on the SROC curve
where sensitivity and specificity are equal) were also
calculated. Each study included provides an estimate of
true-positive rates (TPRs) and false-positive rates
(FPRs) in the meta-analysis, and a graph is made from
the TPRs and FPRs. The SROC curve can be created
using a regression model (Moses et al. 1993). Z-Value
tests were performed to determine whether the sensitivity,
specificity and AUC for US were significantly different
from those for MRI (p , 0.05 was considered statistically
 US vs. MRI in diagnosis of placenta accreta d X. MENG et al. 3

Table 1. TP, FP, FN, TN and other features of ultrasound (13 studies)
Average gestational Number Probe Probe Color andpower Image
Study age (wk) of patients TP FP FN TN type frequency (MHz) Doppler imaging interpretation

Finberg and Williams (1992)* — 4 14 4 1 15 TA/TV — Not used Blind

Lerner et al. (1995)y 34.2 (30–37) 21 5 1 0 15 TV 5.0–6.5 Used Blind
Levine et al. (1997)y 31.2 (26–37) 19 6 1 1 11 TA/TV 3.5–7.0 Used Blind
Chou et al. (2000)y 30.5 (16–36) 80 14 2 3 61 TA 3.5 Used Blind
Lam et al. (2002)y — 13 4 0 8 1 TA 5.0–7.0 Not used Blind
Warshak et al. (2006)y 25 (11–37) 453 30 16 9 398 TA/TV 3.5–5.0 Used Blind
Japaraj et al. (2007)y Third trimester 21 7 0 0 14 TA/TV 3.5–5.0 Used Blind
Dwyer et al. (2008)y — 32 14 5 1 12 TA 4.0–6.0 Used Blind
Masselli et al. (2008)y 30 (22–37) 50 11 0 1 38 TA — Used Blind
Lim et al. (2011)y Second trimester 13 6 2 3 2 TA 4.0–6.0 Used Not blind
Esakoff et al. (2011)y Third trimester 108 17 8 2 81 TA 4.0–6.0 Used Blind
Elhawary et al. (2013)z 29.3 (26–32) 39 8 3 2 26 TA 3.5–7.5 Used Blind
Chalubinski et al. (2013)y — 232 32 8 3 189 TA/TV 3.75–7.5 Used Blind

TP 5 true positive; FP 5 false positive; FN 5 false negative; TN 5 true negative; TA 5 transabdominal probe; TV 5 transvaginal probe.
* Prospective study design.
y
Retrospective study design.
z
Unknown study design.

significant). All statistics (sensitivity, specificity, diag-
nostic odds ratio [DOR], SROC, AUC and Q*) refer to
the diagnostic value of each index test.
Heterogeneity was assessed by calculating the I2
statistic, which is a quantitative measure of the amount
of heterogeneity with an upper limit of 100%. I2 values
of 25%, 50% and 75% were considered indicative of
low, moderate and high heterogeneity, respectively
(Higgins et al. 2003). When I2 exceeded 50%, a random
effect model was used in the meta-analysis. In all other
cases, a fixed effect model was used.
Statistical analyses were performed using Meta-
Disc Statistical Software Version 1.4 (Unit of Clinical
Biostatistics, Ram on y Cajal Hospital, Madrid, Spain)
(Zamora et al. 2006).
RESULTS
Literature search
A comprehensive literature search revealed 389
primary studies. After review of the titles, abstracts and
full texts, 376 articles were excluded. The reasons for
exclusion were as follows: (i) the articles were not in
the field of interest of this review (n 5 338); (ii) articles
were published as reviews, letters, case reports or case
series (n 5 19); (iii) the data from the articles could not
be used to construct or calculate TPRs, FPRs, FNRs or
TNRs (n 5 13); (d) publications were not written in
English (n 5 3); and (e) the articles were published
more than once (n 5 3). A total of 13 studies
(Chalubinski et al. 2013; Chou et al. 2000; Dwyer et al.
2008; Elhawary et al. 2013; Esakoff et al. 2011;
Finberg and Williams 1992; Japaraj et al. 2007; Lam
et al. 2002; Lerner et al. 1995; Levine et al. 1997; Lim
et al. 2011; Masselli et al. 2008; Warshak et al. 2006)
met all inclusion criteria and were selected for data
extraction and meta-analysis.
Details on examination
The TP, FP, FN and TN results and other details
related to the 13 studies are summarized in Tables 1
and 2. Eleven of the 13 studies were retrospective, one
study was prospective and the one was not defined. Gesta-
tional ages of the patients included in the studies ranged
from 11 to 37 wk. The diagnostic accuracy of US was
assessed in 13 papers, whereas six papers assessed the

Table 2. TP, FP, FN, TN and other features of magnetic resonance imaging (6 studies)
Average gestational Number Gadolinium Field Image
Study age (wk) of patients TP FP FN TN contrast material strength (T) interpretation

Lam et al. (2002)* — 9 3 1 5 0 Used 1.5 Blind

Warshak et al. (2006)* 28 (18–37) 40 23 0 3 14 Used 1.5 Blind
Dwyer et al. (2008)* — 32 12 6 3 11 Not used 1.5 Blind
Masselli et al. (2008)* 30 (22–37) 50 12 0 0 38 — 1.5 Blind
Lim et al. (2011)* Second trimester 13 7 1 2 3 Not used 1.5 Not blind
Elhawary et al. (2013)y 29.3 (26–32) 39 8 4 1 26 Not used 1.5 Blind

TP 5 true-positive; FP 5 false-positive; FN 5 false-negative; TN 5 true-negative.

* Retrospective study design.
y
Unknown study design.
4 Ultrasound in Medicine and Biology Volume -, Number -, 2013

Table 3. QUADAS-2 results for included studies performed with ultrasound (US) or magnetic resonance imaging (MRI)
Risk of bias Applicability concerns

Patient Reference Flow and Patient Reference

Study Modality selection Index test standard timing selection Index test standard

Finberg and Williams US [ [[ [ [[ [ [[ [

(1992)
Lerner et al. (1995) US [ [ [ [[ [[ [ [[
Levine et al. (1997) US [ [ [ [[ [ [[ [
Chou et al. (2000) US [ [ [ ？ [ [ [
Lam et al. (2002) US [ [ [ [ [ [ [
Warshak et al. (2006) US [ [ [ [[ [ [[ [
Japaraj et al. (2007) US [ [ [[ [[ [ [[ [
Dwyer et al. (2008) US [ [ [ [[ [ [ [[
Masselli et al. (2008) US [ [ [ [[ [ [ [
Lim et al. (2011) US [ [ [ [ [ [ [
Esakoff et al. (2011) US [ [ [ ？ [ [ [
Elhawary et al. (2013) US [ [ [ ？ [ [[ [
Chalubinski et al. (2013) US [ [ [ [[ [ [[ [
Lam et al. (2002) MRI [[ [ [ [ [[ [[ [
Warshak et al. (2006) MRI [[ [ [ [[ [[ [[ [
Dwyer et al. (2008) MRI [ [[ [ [[ [ [ [[
Masselli et al. (2008) MRI [ [ [ [[ [ [ [
Lim et al. (2011) MRI [ [ [ [ [ [ [
Elhawary et al. (2013) MRI [ [ [ ？ [ [ [

[ 5 Low risk; [[ 5 high risk; ? 5 unclear risk.

accuracy of MRI. In the six trials comparing US with
MRI, the relative accuracies of US and MRI were directly
compared within the same group of patients in four
studies (Dwyer et al. 2008; Elhawary et al. 2013; Lim
et al. 2011; Masselli et al. 2008). In two studies,
patients underwent MRI evaluation because of
suspicious findings on US or because US provided
inconclusive evidence of placenta accreta (Lam et al.
2002; Warshak et al. 2006). In the US studies, the 13
papers included 1115 patients who were available for
the analysis. Several studies used transabdominal or
transvaginal probes alone, whereas other studies
combined the methods. Color Doppler imaging and
power Doppler imaging were used in 11 studies. The
transducer frequency in US varied from 3.5 to
7.5 MHz. In the MRI studies, the six papers included
183 patients who were available for the analysis.
Gadolinium contrast materials were used in two studies
(Lam et al. 2002; Warshak et al. 2006).
Quality assessment
A quality assessment of the included studies based
on the updated QUADAS-2 is outlined in Table 3. Over-
all, the quality of the studies was satisfactory.

Fig. 1. Sensitivity of diagnosis of placenta accreta with ultrasound. CI 5 confidence interval.

 US vs. MRI in diagnosis of placenta accreta d X. MENG et al. 5

Fig. 2. Specificity of diagnosis of placenta accreta with ultrasound. CI 5 confidence interval.

Meta-analysis DISCUSSION
The pooled sensitivity, pooled specificity and DOR
Ultrasound is the most commonly used imaging
of the two diagnostic methods obtained on the basis of
modality for the diagnosis of placental accreta because
a random effect model, are illustrated in Figures 1–4.
it is an inexpensive, non-invasive and time-saving
The pooled sensitivities of US and MRI were 0.83 and
method. Color Doppler and power Doppler, as well as
0.82, respectively, and there was no statistically
the use of a transvaginal transducer, appeared to improve
significant difference in sensitivity between US and
the performance of conventional ultrasound in the assess-
MRI (p . 0.05). The pooled specificities were 0.95 and
ment of placenta accreta. Color and power Doppler high-
0.88 for US and MRI, respectively; there were no
lighted areas of increased vascularity caused by dilated
statistically significant differences in specificity
blood vessels crossing the placenta and uterine wall
between US and MRI (p . 0.05). The DORs of US and
(Chou et al. 2002), which further validated the conven-
MRI were 63.41 and 22.95, respectively.
tional gray-scale sonographic features. A transvaginal
To compare US and MR, we used SROC analysis
transducer can improve the near-field resolution of the
(Figs. 5, 6). The AUCs for US and MRI were 0.9485
interface between the placenta and the lower uterine
and 0.8963, respectively, and the Q* indices were
segment, especially in cases of placenta previa or poste-
0.8884 and 0.8273, respectively. Whether the AUC of
rior placenta (Lerner et al. 1995). Higher-frequency
SROC curves statistically differed between the two diag-
probes have been reported to improve spatial resolution
nostic tests can be determined by Z-value statistics anal-
for superficial structures, thereby affecting the accuracy
ysis (Hanley and McNeil 1982). The Z-value for US and
of US (Benacerraf et al. 2000). Given that it is more
MRI was 0.8193, and the corresponding p-value was
accessible to patients and physicians, US will continue
0.4126.
to be the mainstay for prenatal diagnosis of placenta

Fig. 3. Sensitivity of diagnosis of placenta accreta with magnetic resonance imaging. CI 5 confidence interval.
6 Ultrasound in Medicine and Biology
Fig. 4. Specificity of diagnosis of placenta accreta with magnetic resonance imaging. CI 5 confidence interval.
accreta (Teo et al. 2009). However, US may be unreliable
when imaging a posterior placenta; in such a case, MRI
can achieve superior diagnostic accuracy (Bakri et al.
1993; Thorp et al. 1992).
More recently, MRI with and without gadolinium
has been explored as an adjuvant modality for further
improving prenatal diagnosis of placenta accreta. It is
believed that the gadolinium delineates the outer
placental surface proximal to the myometrium more
clearly; as a consequence, the confusion between hetero-
geneous signals originating in the placenta from those
caused by maternal blood vessels is eliminated, thereby
enhancing the specificity of MRI. However, the use of ga-
dolinium in pregnancy is controversial given the potential
for negative effects (Dwyer et al. 2008; Warshak et al.
2006).
Fig. 5. Summary receiver operating characteristic (SROC)
curve for ultrasound. The size of the circle is proportional to
the weight of the individual study. AUC 5 0.9485;
SE(AUC) 5 0.0148; Q* 5 0.8884; SE(Q*) 5 0.0198.
AUC 5 area under the curve; SE 5 standard error.
Volume -, Number -, 2013
All but one of the studies found that US and MRI are
effective tools in the diagnosis of placenta accreta. Lam
et al. (2002) reported the sensitivity of US and MRI as
33% and 38%, respectively. However, the findings of an
individual study have limited generalizability because
of the relatively small number of patients. To derive
more rigorous estimates of the diagnostic performance
of US and MRI, we pooled published studies.
To the best of our knowledge, this systematic review
with meta-analysis is the first attempt to compare the
diagnostic value of US and MRI in the detection of
placenta accreta. Considering the fact that diagnostic
performance is determined by sensitivity as well as spec-
ificity, a meta-analysis that considers the two factors is
necessary. The relationship between sensitivity and spec-
ificity is non-linear, and SROC analysis is thus helpful in
transforming the information linearly to compare the
diagnostic methods subsequently. Analysis of the SROC
curves revealed that the AUC of US was 0.9485 with
a Q* index of 0.8884, whereas the AUC of MRI was
0.8963 with a Q* index of 0.8273. The above results indi-
cate that both US and MRI have a high degree of sensi-
tivity and specificity in diagnosing placenta accreta.
Significant difference analysis of the two diagnostic
methods was performed using the Z-value test from the
AUCs of the SROC curves. In this study, the Z-value
was 0.8193 with a corresponding p-value of 0.4126, indi-
cating the absence of a significant difference in diagnostic
value between US and MRI.
Massive hemorrhage and associated morbidities,
including cystotomy, ureteral injury, pulmonary embolus,
admission to the intensive care unit and re-operation, are
common with placenta accreta. When placenta accreta is
suspected on US or MRI, the attending obstetricians
should prepare and counsel the patients and assemble
a multidisciplinary team (including obstetricians, anes-
thetists, interventional radiologists, urologists, visceral
surgeons and neonatologists) to handle a potentially
life-threatening situation in the operation room (Japaraj
et al. 2007). It is reported that approximately 90% of
 US vs. MRI in diagnosis of placenta accreta d X. MENG et al.
Fig. 6. Summary receiver operating characteristic (SROC)
curve for magnetic resonance imaging. The size of the circle
is proportional to the weight of the individual study.
AUC 5 0.8963; SE(AUC) 5 0.0680; Q* 5 0.8273;
SE(Q*) 5 0.0719. AUC 5 area under the curve;
SE 5 standard error.
patients with placenta accreta require hysterectomy when
placenta removal is attempted because of massive
bleeding (Warshak et al. 2010). However, attention
should also be paid to patients with a high risk of placenta
accreta who have negative US and MRI results, as
placenta accreta that occurs unexpectedly may lead to
a serious situation and even maternal death.
Publication bias was the most commonly cited effect
related to sample size (Deeks et al. 2005). This bias poses
a major concern for pooled analysis, given that studies re-
porting positive results are easier to publish than those re-
porting negative results. Moreover, non-English
publications were excluded from our study. We cannot
exclude the possibility of a publication bias in our anal-
ysis, but we attempted to minimize any bias by using
a comprehensive search strategy to locate all relevant
studies.
We acknowledge the limitations of our study.
Because it is a meta-analysis, the validity of our results
is dependent on the validity of the reviewed studies. First,
this review combined studies that were clinically and
methodologically varied; as a result, this heterogeneity
may represent a potential source of bias that cannot be
avoided. Second, the number of studies included was
small, and thus we were unable to detect meaningful
differences in tolerability endpoints. Third, additional
factors in the included studies should be addressed.
Average gestational age, position of the placenta, degree
of bladder filling (especially when a transvaginal probe
7
was not used), type and frequency of probe, contrast
agent and experience of the physician may bring potential
bias. However, these biases were unavoidable because of
the retrospective nature of this study.
CONCLUSIONS
There is no significant difference in diagnostic value
between US and MRI in placenta accreta. Both US and
MRI are highly specific and sensitive in diagnosing or
excluding the presence of placenta accreta, and US
should be the first choice for patients with limited time
and financial support.
Acknowledgments—This study was supported by a grant from the Scien-
tific Research Programs of Higher Education Institutions of Liaoning
Education Department, China (No. 2012225019).
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