Proposal for standardized ultrasound descriptors of abnormally invasive placenta ( AIP )
Open accessAbstract
Abnormally invasive placenta (AIP) is a clinical term used to describe a placenta that does not separate spontaneously at delivery and cannot be removed without causing abnormally high blood loss1. It encompasses the histopathological diagnoses of placenta accreta, placenta increta and placenta percreta. It is a spectrum disorder, ranging from placentae containing a small area of abnormally adherent tissue (focal accreta) to those which have invaded into the adjacent viscera (percreta). It is potentially life-threatening, as forced removal of an AIP can lead to catastrophic maternal hemorrhage2, 3. In developed countries, AIP is the most common reason cited for Cesarean hysterectomy4. Maternal mortality for the most severe end of the AIP spectrum (placenta percreta) has been reported to be as high as 7%5, although this information was published in 1996 and may now be an overestimate given the advances in perinatal care and facilities. Prior Cesarean section (CS), other uterine surgery, assisted reproduction techniques and placenta previa are all risk factors for AIP and their prevalence has increased steadily over the last few decades6-8. The incidence of AIP has increased from 1:25 000 in the 1950s to 1:25008, 9 in the 1980s, paralleling the rise in CS rates, and AIP rates as high as 1:533 (USA)7 and 1:588 (Canada)10 have been reported recently. If these trends continue, it has been estimated that, by 2020, the USA will have a 56% CS rate, accounting for an additional 4504 cases of AIP and 130 maternal deaths annually11. Maternal mortality and morbidity are reduced when AIP is diagnosed antenatally and women deliver in a tertiary care hospital with a multidisciplinary care team12-14. Currently, diagnosis relies on 'typical' sonographic findings15, 16, such as 'placental lacunae' and 'loss of the retroplacental clear zone'17. Magnetic resonance imaging, although employed widely in cases of suspected AIP, has yet to be demonstrated clearly to improve management or pregnancy outcome15. Irrespective of the imaging modality, diagnosis of AIP is subjective, with accuracy depending on the training and level of experience of the operator. Several studies have assessed the predictive value of different ultrasound markers of AIP. However, the performance of these markers shows considerable variability among studies using the same signs16. These differences have been attributed previously to a combination of limited sample size, retrospective design and variability of study inclusion criteria and eventual diagnosis of AIP16. Furthermore, as with all diagnostic techniques reliant on subjective opinion, the recorded presence or absence of each sign will be influenced by the operator's interpretation of what constitutes that marker. This is particularly important to clinicians, who may not have much experience with ultrasonography of the placenta or diagnosing AIP. Additionally, there is no published consensus on the definition of the ultrasound markers used commonly for AIP. Many signs have been described under different names, and in other cases the same term has been used for different findings. The aim of our study, therefore, was to provide unified definitions of ultrasound markers used commonly for AIP ('ultrasound descriptors of AIP'). The 'European Working Group on Abnormally Invasive Placenta' (www.EW-AIP.org) is an international non-profit group, currently consisting of 29 obstetricians, gynecologists, pathologists, anesthesiologists and basic science researchers from 11 European countries. The aim of the group is to advance diagnosis and treatment and to promote research and knowledge on AIP. To improve comparability of future studies, to increase diagnostic capabilities and to facilitate international collaboration, the EW-AIP here proposes standardized definitions of the AIP imaging descriptors. These standardized definitions were produced by analysis of all 23 studies included in a recent systematic review of the antenatal sonographic diagnosis of AIP16 (Appendix S1). The exact wording used to describe the ultrasound signs of AIP was extracted, the descriptions were grouped according to ultrasound modality (two-dimensional (2D) grayscale ultrasound, 2D color Doppler and three-dimensional (3D) ultrasound) and synonymous or identical terms were unified under a common heading (Table S1). Following discussion by an expert panel (EW-AIP members present at the 7th EW-AIP meeting in Nancy, November 2014) the various wordings were unified into a set of 11 descriptors, six for 2D grayscale ultrasound, four for 2D color Doppler and one for 3D power Doppler (Table 1). The occurrence of each descriptor in the 23 papers used, grouped according to ultrasound modality, are listed in Table S2. Four of the papers18-21 included descriptions considered by the expert panel to be insufficiently comprehensive or specific and were not included in the unifying descriptors. Compound signs (e.g. 'uterovesical hypervascularity AND b
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Ultrasound is the mainstay for PAS clinical imaging and non-invasive prenatal diagnosis.
“Ultrasound is the mainstay for PAS clinical imaging and non-invasive prenatal diagnosis, [13]”
From An effective and non-invasive prediction model for placenta accreta spectrum early diagnosis: Ultrasound image-based novel deep learning network (2026) · cites this paper as [13]
Ultrasound and MRI are the imaging modalities of choice for diagnosing PAS antenatally.
“Ultrasound and magnetic resonance imaging (MRI) are the imaging modalities of choice for diagnosing PAS antenatally [5, 6].”
From Radiomics-based prediction of FIGO grade for placenta accreta spectrum (2023) · cites this paper as [6]
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- Authors
- Collins, S. L., Ashcroft, A., Braun, T., Calda, P., Langhoff‐Roos, J., Morel, O., Stefanovic, V., Tutschek, B., Chantraine, F., & on behalf of the European Working Group on Abnormally Invasive Placenta (EW‐AIP)
- Affiliations
- John Radcliffe Hospital (GB)
- Stiftung Charité (DE)
- Charles University (CZ)
- University of Copenhagen (DK)
- Centre Hospitalier Régional et Universitaire de Nancy (FR)
- Fetomaternal Medical Center, Department of Obstetrics and Gynecology Helsinki University Hospital and University of Helsinki Helsinki Finland
- Prenatal Zürich Zürich Switzerland
- University of Liège (BE)
- Corresponding author
- Collins, S. L.
- Venue
- Ultrasound in Obstetrics & Gynecology
- Publisher
- Wiley
- Published
- 2016-03
- Volume
- 47
- Issue
- 3
- Pages
- 271-275
- ISSN
- 0960-7692 (ISSN-L)
- 1469-0705
- OpenAlex
- W1563285215
- Cited by
- 331
- References
- 25
- Citations by year
- 2026: 27 · 2025: 28 · 2024: 36 · 2023: 34 · 2022: 45 · 2021: 43 · 2020: 33 · 2019: 29 · 2018: 30 · 2017: 20 · 2016: 3 · 2015: 1
- FWCI
- 17.97
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Ultrasound in Obstetrics and Gynecology (publishedVersion)
- PubMed (publishedVersion)
- HAL (submittedVersion)
- ORBi (University of Liège) (submittedVersion)
- Hirsla (Landspítali University Hospital) (submittedVersion)
- Funders
- Ministerstvo Zdravotnictví Ceské Republiky
- Topics
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Maternal and fetal healthcare
- Health Sciences › Medicine › Obstetrics and Gynecology › Pregnancy and preeclampsia studies
- Health Sciences › Medicine › Obstetrics and Gynecology › Maternal and Perinatal Health Interventions
- Keywords
- abnormally invasive placenta, placental invasion, placenta accreta spectrum, diagnostic criteria
- MeSH terms
- Female, Humans, Placenta, Placenta Accreta, Placenta Diseases, Predictive Value of Tests, Pregnancy, Ultrasonography
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