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Update in Radiology
Placenta accreta spectrum in early and late pregnancy from an imaging perspective. A scoping review
El espectro de placenta acreta en la etapa temprana y final del embarazo. Un repaso a través de la imagen
B. Moradia,b, J. Azadbakhtc,
Corresponding author
Javidazadbakht2@gmail.com

Corresponding author.
, S. Sarmadid, M. Gitya,b, E. Shiralie, M. Azadbakhtf
a Departamento de Radiología, Hospital General Yas, Universidad de Ciencias Médicas de Teherán, Teheran, Iran
b Departamento de Radiología, Centro de Investigación de Diagnóstico Avanzado y Radiología Intervencionista (ADIR), Centro de Imagen Médica, Complejo Hospitalario Imán Jomeini, Universidad de Ciencias Médicas de Teherán, Teheran, Iran
c Departamento de Radiología, Facultad de Medicina, Universidad de Ciencias Médicas de Kashan, Kashan, Iran
d Departamento de Patología, Hospital General Yas, Universidad de Ciencias Médicas de Teherán, Teheran, Iran
e Departamento de Oncología Ginecológica, Hospital General Yas, Universidad de Ciencias Médicas de Teherán, Teheran, Iran
f Escuela de Farmacología, Universidad de Ciencias Médicas de Shiraz, Shiraz, Iran
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">MRI features</span>&#46; A 31-year-old woman at 24 weeks with placenta percreta&#46; <span class="elsevierStyleBold">A</span>&#8211;<span class="elsevierStyleBold">C&#46;</span> Placenta previa with heterogeneous signal in T2-weighted image is appreciated&#59; T2-dark bands &#40;narrow vertical arrow&#41; are more conspicuous in the SSFSE sequence &#40;A&#41; compared to SSFP sequence &#40;B&#41;&#46; Subplacental hypervascularity &#40;wide vertical arrow in A&#41;&#44; placental bulge &#40;wide horizontal arrow in A and C&#41;&#44; normal T2-hypointense placental&#8211;myometrial interface &#40;narrow horizontal arrow in A&#41;&#44; myometrial thinning &#40;narrow horizontal arrow in C&#41;&#44; and placental tissue protruding into the bladder lumen &#40;B&#41; are all shown&#46; <span class="elsevierStyleBold">D&#44; E&#46; Extrauterine extension&#46;</span> Large flow voids in the bladder wall &#40;bladder vessel sign&#44; small arrows in D&#41; imply bladder wall invasion&#44; and parametrial vessel sign &#40;large arrows in E&#41; suggests parametrial invasion&#46; <span class="elsevierStyleBold">F&#44; G&#46;</span> DWI clearly outlines the border between the placenta and myometrium&#44; as placenta shows a very high signal intensity in diffusion imaging&#46; Compare areas with normal myometrial thickness &#40;F&#41; to areas of significant myometrial thinning &#40;G&#41;&#46; Placenta &#40;p&#41;&#59; bladder &#40;B&#41;&#59; cervix &#40;Cx&#41;&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Placenta accreta spectrum &#40;PAS&#41; disorders are a group of serious and potentially morbid conditions&#44; with their incidence on a steady rise over the past decades&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> According to the literature&#44; the growing number of reported PAS disorders parallels the increased rate of cesarean deliveries &#40;the main predisposing factor&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The second main risk factor is placenta previa &#40;placental tissue overlying the internal os of the cervix to any extent&#41;&#44; as implantation in the lower uterine segment over cesarean section &#40;C&#47;S&#41; scar &#40;where decidua is deficient&#41; will compound the risk&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">PAS disorders are further divided in two groups&#44; &#40;a&#41; abnormally adherent placenta &#40;placenta accrete vera&#41;&#44; and &#40;b&#41; invasive placenta &#40;placenta increta and percreta&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However&#44; some authors disagree using the term placental invasion&#44; as extra-villous cytotrophoblasts invasion into the maternal endometrium is a normal process&#59; in this regard&#44; under-invasion is related to pre-eclampsia&#44; and over-invasion will lead to PAS disorders &#40;the preferred term&#41;&#46; PAS disorders result from a defect in the decidua basalis&#44; where the chorionic villi invade the myometrium&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Normally&#44; decidua basalis separates the chorionic villi from the myometrium&#44; and contracting myometrium leads to unhindered and clean detachment of the placenta&#46; Placenta accrete vera&#44; the least invasive and most common form of PAS disorders&#44; is abnormal fixation of the placenta directly onto the myometrium without intervening decidua basalis&#44; while in placenta increta&#44; placenta partially penetrates the myometrium &#40;not reaching to the uterine serosa&#41;&#46; In placenta percreta&#44; the least common and most invasive form&#44; chorionic villi invade the myometrium to the full thickness &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; and may even extend into the surrounding organs&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;7</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Antenatal and timely diagnosis of PAS disorders could be life-saving and greatly increases the chance of uneventful delivery&#46; With delayed diagnosis&#44; and thus&#44; underprepared delivery&#44; the clean detachment of the placenta from the uterus during the third phase of delivery fails&#44; and at the time of placental separation&#44; hemorrhage&#44; shock&#44; multisystem organ failure&#44; infectious morbidities&#44; coagulation disorders&#44; and postoperative thromboembolisms remarkably increase the risk of peri- and postpartum morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">On the other hand&#44; PAS disorders may cause many complications prior to delivery&#44; examples of which are damage to local organs&#44; such as the bladder&#44; ureters&#44; and bowel&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;9</span></a> Antenatal evaluation of the degree and topography of the placental invasion to myometrium is also invaluable&#44; as they are directly associated with intra- and postsurgical outcomes<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a>&#59; additionally&#44; placental invasion topography guides the surgical team to define the most appropriate method and trajectory for proximal vascular control&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Herewith&#44; we will review the reported US and MRI features of PAS disorders going over the normal placental imaging and imaging pitfalls&#44; and lastly&#44; we will discuss the imaging findings in PAS disorders in the first trimester&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Imaging evaluation of placenta for PAS</span><p id="par0030" class="elsevierStylePara elsevierViewall">Ultrasound exam &#40;through transabdominal and transvaginal probing&#41; is still imaging modalities of choice for evaluating the placenta&#46; MRI is considered as a supplementary imaging technique&#46; Both pathology and imaging &#40;US and MRI&#41; are posed to challenges to determine the presence and extent of invasion in PAS disorders &#40;especially focal and less severe forms of invasion&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;13&#44;14</span></a> However&#44; differentiating between placenta accreta vs&#46; increta is of no clinical importance&#44; as the treatment plan is the same&#46; On the other hand&#44; in placenta percreta&#44; chorionic villi invade adjacent structures &#40;e&#46;g&#46;&#44; bladder&#44; rectosigmoid&#44; pelvic sidewall&#41; that affect surgical planning and should be identified&#46; This extrauterine abnormal placentation would be detectable in MRI with a better accuracy than US&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> summarizes the common features of PAS&#46; Unfortunately&#44; none of the US or MR imaging features of accreta spectrum&#44; in isolation or even in combination&#44; can confidently predict the depth of invasion&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Ultrasound</span><p id="par0040" class="elsevierStylePara elsevierViewall">Currently&#44; 2-D greyscale imaging&#44; 2-D color Doppler ultrasound&#44; and 3-D power Doppler ultrasonography are techniques recommended for detecting PAS disorders&#44; despite its operator reliability and relatively high reported inter-observer variation&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Normally&#44; placenta is relatively uniform in thickness and echogenicity&#44; with 2&#8211;4&#8239;cm thickness in the midportion &#40;becomes thicker as pregnancy advances&#41;&#44; smooth external contour&#44; and gradually tapered edges&#46; In second-trimester&#44; placenta is homogenous&#44; granular&#44; and hyperechoic compared to the underlying rim of thin&#44; well-defined&#44; and hypoechoic myometrium&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Maternal veins drain the blood from the intervillous space and run parallel to the decidua&#44; forming the &#8216;retroplacental echolucent zone&#8217; in the US imaging of the normal placenta&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> The recommended gestational age for performing ultrasonography is between 18&#8211;20 weeks &#40;the time of second routine US scan&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;19</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows common US and MRI features of the PAS reported in literature&#44; as well as imaging techniques&#47;sequences recommended for PAS evaluation&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Placenta previa</span><p id="par0060" class="elsevierStylePara elsevierViewall">Accompanying placenta previa dramatically increases the risk of PAS disorder and should elicit a detailed examination for accrete spectrum&#44; including transvaginal examination&#44; Doppler imaging&#44; and were applicable&#44; three-dimensional power Doppler exam &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Focal exophytic mass&#40;es&#41;</span><p id="par0065" class="elsevierStylePara elsevierViewall">It is presented as a focal exophytic mass of placental echogenicity&#44; mostly located anteriorly&#44; near to the bladder&#44; or laterally&#44; extending to the parametrium &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>A and B&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> This US feature is of a very low sensitivity &#40;10&#37;&#41; but is highly specific &#40;99&#37;&#41; for detecting placenta percreta &#40;absent in placenta accreta or increta&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Adjacent bladder tenting will further increase the specificity&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Multiple placental lacunae &#40;Swiss cheese appearance&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall">This feature is of great importance in the third trimester and results from long-term exposure to a pulsatile blood flow and secondary placental tissue alterations&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Intraplacental lacunae are vascular spaces of varying size and shape within the placenta&#44; giving it a &#8220;Swiss cheese&#8221; appearance &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>A and B&#41;&#46; They are often parallel linear in shape and extend from the placenta into the myometrium&#46; They are indistinct in border and show internal turbulent flow &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>C and D&#41;&#44; as opposed to the vascular lake in third-trimester non-invasive placenta&#44; which is more rounded in shape with a laminar flow&#46; This feature&#44; along with abnormal color Doppler imaging patterns&#44; has been reported as the most sensitive US findings for diagnosing accreta &#40;particularly when multiple lacunae in the second trimester are found&#41;&#44; capable of detecting PAS within as early as 15 weeks&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;21&#8211;24</span></a> When there are multiple &#40;especially &#8805;4&#41; lacunae&#44; the detection rate for placenta accreta remarkably increases &#40;100&#37; according to an investigation&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Loss of the retroplacental clear space</span><p id="par0075" class="elsevierStylePara elsevierViewall">Obliteration of the retroplacental hypoechoic zone is angle-dependent and has also been seen in non-invasive placentas&#44; not being significantly predictive of PAS and with a high rate of false positivity &#40;21&#37; or more&#41; according to some investigations&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Myometrial thinning</span><p id="par0080" class="elsevierStylePara elsevierViewall">Anterior myometrial thickness &#40;measured between the echogenic uterine serosa and the retroplacental clear space&#41; of &#60;1&#8239;mm is another grayscale sign of PAS in US&#59; although&#44; it has been difficult to replicate even in transvaginal ultrasonography &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>A and B&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Twickler et al&#46; reported this feature in all studied cases&#44; but other studies didn&#8217;t confirm this finding and found the myometrial contour more dependable than the myometrial thickness&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Bladder wall abnormalities</span><p id="par0085" class="elsevierStylePara elsevierViewall">This feature has been related to placenta percreta&#44; with or without disruption of or increased hypervascularity at uterine serosa&#8211;bladder interface&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;20&#44;23</span></a> Normally&#44; uterine serosa&#8211;bladder interface presents as a wide&#44; thin&#44; and smooth echogenic line with no detectable vascularity in Doppler ultrasound exam&#46; Disruption&#44; irregularity&#44; thickening&#44; and increased vascularity of the interface&#44; or bulging of the placenta into the posterior wall of the bladder all predict placenta percreta with high sensitivity and specificity&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;23</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Abnormal Doppler imaging patterns</span><p id="par0090" class="elsevierStylePara elsevierViewall">Evaluating abnormal flow patterns can help in the diagnosis of PAS disorders&#44; especially when grayscale exam is inconclusive&#46; Transvaginal probing may highlight the areas of hypervascularity and add diagnostic value to the color Doppler ultrasound exam&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Shih et al&#46; tested 3-D power Doppler imaging accuracy for detecting PAS disorders&#46; According to their study&#44; parameters like increased intraplacental vascularity&#44; increased vascularity at bladder&#8211;uterine serosa interface &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>C and D&#41;&#44; intervillous circulations&#44; and vascular chaotic branching and tortuosity are all predictive of PAS disorders with decent accuracies&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In a study turbulent flow in the lacunae within placental parenchyma was recorded in all patients with PAS disorder&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Assessing the retroplacental blood flow may add information to grayscale evaluation of retroplacental clear space&#46; In an investigation&#44; obliteration&#47;disruption of the normal continuous color flow pattern with a gap in myometrial blood flow was noted in all cases with PAS disorder&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Numerous dilated&#47;varicose periuterine blood vessels may predict extrauterine chorionic villi invasion &#40;placenta percreta&#41;&#44; although it can be seen in milder forms of PAS as well&#44; and has been linked to the expression of the endothelial growth factors &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Increased subplacental vascularity&#44; bridging vessels coursing across the placenta and reaching out to the uterine margin&#44; and subserosal hypervascularity &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; are other PAS prognosticators in color&#47;power Doppler ultrasound evaluation&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;27</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">MRI</span><p id="par0100" class="elsevierStylePara elsevierViewall">When US exam is suspicious or inconclusive&#44; in cases of the posterior placenta where US beams cannot reach out to the placenta appropriately&#44; or when severe placenta percreta is suspected on US &#40;to determine the extrauterine spread of the placenta&#41;&#44; placental MRI comes into play&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;23&#44;27&#44;28</span></a> When US offers a definitive diagnosis&#44; MRI &#40;if performed&#41; would be often undertaken for surgical planning &#40;C&#47;S delivery and peripartum hysterectomy&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">MRI offers further detail on the uteroplacental interfaces and the surrounding periuterine environment&#44; which is far more difficult to be evaluated in US exam&#46; As mentioned previously&#44; it is also valuable in surgical planning&#59; nonetheless&#44; it should never be the one and only antenatal diagnostic test relied on&#46; Nevertheless&#44; according to a study by Einerson et al&#46;&#44; MRI have a chance of making an overdiagnosis in up to 14&#37; of cases&#44; with a false negativity of nearly 7&#37;&#46; MRI sequences with high temporal resolution and reasonable contrast-to-noise ratios are key sequences for placental imaging&#46; To maximize the signal-to-noise ratio&#44; an external multichannel surface phased-array coil is used whenever possible&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;9&#44;29</span></a> In obese patients and later in pregnancy&#44; a body coil may be employed&#46; Parallel imaging is beneficial and should be implemented when possible&#44; as it enhances the image sharpness and decreases the specific absorption rate&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The recommended practice is to take sequences orthogonal to the area of placental implantation&#44; in addition to images taken orthogonal to the maternal pelvis for evaluating the cervix and bladder&#46; The former might be very difficult to fulfill&#44; as numerous configurations for placenta implantation can be assumed&#44; and it often involves more than one side of the uterus&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Images are advised to be acquired in axial&#44; sagittal&#44; and coronal planes &#40;with respect to the uterus&#41; to cover all areas of the placental&#8211;myometrial interface&#44; with a slice thickness of &#8804;4&#8239;mm&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;31</span></a> Some experts recommend additional set of images taken with regard to the placental&#8211;myometrial interface &#40;including oblique axial plane&#58; perpendicular to placental&#8211;myometrial interface&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Recommended MRI sequences for diagnosing PAS include&#58; &#40;a&#41; T2-weighted single-shot fast &#40;turbo&#41; spin-echo images &#40;SSFSE&#41; to evaluate the uterine layers and placental architecture&#44; &#40;b&#41; T1-weighted gradient-echo sequences with fat suppression&#44; to identify intra- or retroplacental hematoma if placental abruption is a concern&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> T2-weighted fat-suppressed sequences are not recommended for evaluating PAS&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Recent studies have stated that contrast agents are not required in evaluating patients suspected of PAS&#59; moreover&#44; fetus may swallow the contrast agent that has crossed the placental membranes and entered the amniotic fluid&#44; where its half-life and adverse effects are yet unknown&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;32</span></a> A large-scale cohort study reported an increased rate of rheumatological&#44; inflammatory&#44; infiltrative conditions after using paramagnetic contrast at any gestational age&#44; as well as stillbirth or neonatal death&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Nonetheless&#44; some facilities use gadolinium-based contrast agents in certain cases for surgical planning &#40;in such cases&#44; patients are scheduled for delivery shortly after MRI&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;21</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Steady-state free precession &#40;SSFP&#41;</span> reduces the breathing artifacts&#44; accentuates the appearance of the placental vessels and lakes&#44; and differentiates true vessels from other sources of low T2 signal intensity when compared to SSFSE in a side-by-side manner through their &#8220;bright blood&#8221; and &#8220;dark blood&#8221; characteristics&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>D and E&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;32</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Diffusion-weighted imaging &#40;DWI&#41;</span> can discernibly differentiate the placenta from myometrium&#44; outlining the border between the placenta and underlying myometrium&#44; as well as aiding in the detection of a hematoma &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>F and G&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">On the maternal surface of the normal placenta&#44; placental septa &#40;thin connective tissue planes&#41; surround the cotyledons and can manifest as subtle thin bands of low T2 signal intensity&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Normally&#44; placenta shows imaging evidence of senescence across pregnancy that imaging interpreters should be aware of&#59; otherwise&#44; it can lead to misdiagnosis of PAS disorders in cases of normal non-invasive placentation&#46; As the placenta ages &#40;mainly in the third trimester&#41;&#44; it becomes heterogenous primarily due to small foci of calcification&#44; micro-hemorrhages&#44; and lacunae&#44; that presents as heterogenicity in signal intensity &#40;especially in T2 weighted and susceptibility images&#41;&#46; Authors mostly recommend 24th&#8211;30th &#40;or according to some papers 28th&#8211;32th&#41; week of gestation for performing MRI&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;29&#44;32</span></a> At this age&#44; placenta shows a uniform intermediate signal and is commonly distinct from the heterogeneous three-layer myometrium&#46; Myometrial layers include a middle layer &#40;hyperintense relative to the placenta&#41; sandwiched between dark inner and outer layers&#46; The middle layer becomes more hyperintense as pregnancy progresses&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">At the site of cord insertion&#44; the umbilical arteries and vein give rise to subchorionic vessels&#44; which run along the fetal surface of the placenta while dividing into smaller branches that dip into the placenta in a perpendicular fashion&#46; Some of these chorionic vessels might raise suspicion on PAS due to their vertical course&#44; but they generally are lower in number&#44; imperceptible in the deeper placenta&#44; and smaller in caliber &#40;&#8804;5&#8239;mm&#41;&#46; Therefore&#44; visualizing larger vessels at the cord insertion and in subchorionic distribution are considered normal&#44; while large intraplacental vessels could herald PAS disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Moreover&#44; myometrial &#40;subplacental&#41; flow voids could be seen in MRI of the non-invasive placenta and represent maternal spiral arteries that run perpendicular to the decidua surface at the myometrium-placenta interface&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;19</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">PAS-related MRI findings are divided into two main classes &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#58; major abnormalities &#40;when specificity of the finding is &#62;80&#37;&#41;&#44; and minor abnormalities &#40;if the specificity of the finding falls below 80&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Abnormal uterine bulge</span><p id="par0145" class="elsevierStylePara elsevierViewall">In PAS&#44; the lower uterine segment widens to an hourglass-like appearance rather than the normal inverted-pear configuration&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31&#44;36</span></a> This major sign of PAS is more readily identifiable on coronal or sagittal planes and has a reasonable sensitivity &#40;76&#46;7&#37;&#41; and specificity &#40;62&#46;5&#37;&#41; for diagnosing PAS&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Abnormal placental bulge</span><p id="par0150" class="elsevierStylePara elsevierViewall">In a meta-analysis&#44; uterine bulge&#44; placental bulge &#40;placenta with lumpy contour&#41;&#44; and placenta with rounded edges were grouped to gather and had a total sensitivity of 79&#46;1 &#40;60&#46;3&#8211;90&#46;4&#41; and specificity of 90&#46;2 &#40;76&#46;2&#8211;96&#46;4&#41; to predict PAS&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> Placental bulge is a major sign of PAS in MRI with two main types&#58; &#40;a&#41; type I is a slight outward placental bulge into the underlying myometrial wall with intact and undistorted uterine contour&#59; &#40;b&#41; type II is a focal placental bulge distorting the uterine contour &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>A&#8211;C&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Placental heterogeneity</span><p id="par0155" class="elsevierStylePara elsevierViewall">A normal non-invasive placenta shows an intermediate signal in T2WI and is homogeneous in texture&#46; However&#44; the normal placenta might show some signal heterogenicity in up to 30&#37; of the cases&#44; particularly when gestation progresses beyond 32 weeks and placental maturation takes place&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In the case of PAS&#44; areas of calcification&#44; hemorrhage&#44; abnormal hypervascularity&#44; focal pooling of blood&#44; intraplacental dark fibrotic bands&#44; and areas of placental infarction can all be the source of placental heterosignal change &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>A&#8211;C&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;36</span></a> Placental heterogenicity is subjective and mainly depends on the presence of abnormal intraplacental dark bands&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Focal exophytic masses</span><p id="par0160" class="elsevierStylePara elsevierViewall">As discussed among US features&#44; this sign could be appreciated in MRI&#44; similarly with a low sensitivity and high specificity for detecting placenta percreta&#59; although the sensitivity is higher in MRI&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Focal exophytic mass&#40;es&#41; is a major MRI sign of PAS and most commonly presents as an intermediate T2 signal mass bulging toward the bladder antroinferiorly &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>C and D&#41;&#46; Sometimes placenta protrudes to the cervical internal os&#44; a finding which has been stated as a major reliable sign of placenta accrete&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><elsevierMultimedia ident="fig0035"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Bladder wall abnormalities</span><p id="par0165" class="elsevierStylePara elsevierViewall">Visualizing placental tissue invading the bladder wall or protruding to the bladder lumen on MRI &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>A&#8211;C&#41; indicates placenta percreta with specificity of 100&#37;&#59; notwithstanding&#44; its sensitivity is very low&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Visualizing multiple tortuous vessels bridging between the uterus and bladder&#44; the so-called &#8216;bladder vessel sign&#8217;&#44; has been reported as a precise predictor of PAS with a diagnostic accuracy of 96&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Dark T2 intraplacental bands</span><p id="par0175" class="elsevierStylePara elsevierViewall">These are irregular margin&#44; randomly distributed&#44; thick &#40;maximum diameter of &#8805;6&#8239;mm&#41; bands of low T2 signal intensity crossing the placenta perpendicularly &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>A&#8211;C&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a> These bands are better visualized in SSFSE images &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>A and B&#41;&#46; They originate from the maternal surface of the placenta and may cross the entire thickness of the placenta&#44; reaching into the fetal surface&#46; Dark placental band represent band-like areas of fibrin deposition&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;13&#44;37</span></a> They are postulated to result from repetitive episodes of placental hemorrhage or infarcts&#46; This feature has been shown variably sensitive and specific for PAS and is most valuable if other supporting MRI findings are present&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> If a dark intraplacental band is visualized with adjacent placental recess&#44; it can be considered a major feature&#59; however&#44; dark band without adjacent placental recess is only a minor sign of PAS in MRI&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> The placental &#8216;recess sign&#8217; is a wedge-shaped deformity resulting from the contraction of the placenta and overlying myometrium&#44; accompanied by an intraplacental dark band&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> According to data from a meta-analysis&#44; dark T2 band is the most sensitive MRI sign of PAS &#40;82&#46;6&#37;&#8211;89&#46;7&#37;&#41;&#44; with moderate specificity &#40;49&#46;5&#37;&#8211;63&#46;4&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Their main differential diagnosis are placental septa&#46; Placental septa are thinner&#44; and are more often seen in MR images taken at magnetic field of 3T&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Irregular placental&#8211;myometrial interface</span><p id="par0180" class="elsevierStylePara elsevierViewall">This MRI feature is also known as loss of retroplacental hypointense line or uteroplacental interface&#44; and is best appreciated on T2W images when the imaging plane is perpendicular to the placental&#8211;myometrial interface &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>C&#41;&#46; Three parallel layers form the placental&#8211;myometrial interface&#58; the myometrial rim of intermediate T2 signal&#44; sandwiched between two low T2 signal layers &#40;the inner decidua and the outer uterine serosa&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> High vascularity of the middle layer is highlighted on SSFP&#59; thus&#44; it provides the clearest image of the tri-laminar appearance of the placental&#8211;myometrial interface&#46; Area&#40;s&#41; of thinning&#47;interruption in this interface &#40;especially the decidual layer&#41; strongly anticipates PAS&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;31</span></a> This MRI feature is highly sensitive &#40;97&#46;4&#37;&#41; and poorly specific &#40;36&#46;4&#37;&#41;&#44; with even lower specificity at the site of a previous C&#47;S or in advanced gestational age&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;32</span></a> MRI has the upper hand in the evaluation of the outer and middle layers &#40;myometrium and uterine serosa&#41;&#59; however&#44; more superficial invasions are best visualized in US as it provides a better resolution than MRI&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Myometrial thinning</span><p id="par0185" class="elsevierStylePara elsevierViewall">As pregnancy progresses&#44; the myometrium thinning normally occurs&#44; sometimes to the extent that even at a technically adequate examination&#44; myometrium may not be identified clearly&#46; This MRI finding&#44; as with US&#44; is sensitive &#40;63&#46;6&#37;&#44; 67&#46;9&#37;&#44; and 78&#46;6&#37;&#44; for placenta accreta&#44; increta&#44; and percreta&#44; respectively&#41;&#46; Interpreting the abnormal myometrial thinning might be extremely difficult&#44; particularly in third trimester&#44; or at the site of previous cesarean delivery &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>C&#44; F and G&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;37</span></a></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Abnormal uteroplacental vascularity</span><p id="par0190" class="elsevierStylePara elsevierViewall">Normal pregnancy can exhibit a few flow voids within the placenta &#40;usually located around umbilical cord insertion&#41;&#44; in the uterine wall &#40;commonly seen at the retroplacental region&#41;&#44; or at the outer edge of the uterus &#40;parauterine region&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> As gestational age advances&#44; particularly after the mid-second trimester&#44; these vessels show an increase in number and diameter to an expected extent&#44; which may draw the attention of the examiner&#46; In abnormal placentation&#44; area&#40;s&#41; of marked and disproportionate uteroplacental vascular expansion and proliferation signal the foci of PAS&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> These vascular alterations more frequently reside within or around the placental bed &#40;the decidua and adjacent underlying myometrium&#41; and have been reported as the most accurate MRI feature of PAS&#44; with specificity and positive predictive value of 100&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Uteroplacental vascular pattern alteration in PAS might be identified in the placenta&#44; placental bed&#44; throughout uterine serosa &#40;&#8216;parametrial vessel&#8217; sign&#44; <a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>E&#41;&#44; and in bladder wall &#40;&#8216;bladder vessel&#8217; sign&#44; <a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>D&#41;&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Abnormal intraplacental tortuous&#44; ectatic &#40;diameter &#62;6&#8239;mm&#41;&#44; proliferated&#44; and bizarre vessels with nonuniform size and distribution&#44; either in a diffuse manner&#44; or focally as a tangle of vessels are indirect signs of PAS with the extent of abnormal hypervascularity being correlated with the depth of placental invasion&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> These dilated and disorganized vessels are correlated with irregular and bizarre shape placental lakes with turbulent internal flow&#44; and are most commonly visualized next to dark T2 bands&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Given that contrast agents are not recommended for antenatal use&#44; finding abnormal vascularity in placenta mainly relies on comparing sequences with dark blood &#40;SSFSE&#41; and bright blood &#40;SSFP&#41; characteristics &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>D and E&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;31&#44;36</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">At the area of the C&#47;S scar&#44; or in cases of severe placenta percreta&#44; uteroplacental vascular pattern alteration could become obscured due to scar tissue or placental bulging&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p></span></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Imaging of PAS disorders in first trimester</span><p id="par0205" class="elsevierStylePara elsevierViewall">Features of PAS disorders in ultrasonography may present as early as the first trimester&#59; however&#44; the diagnosis is made mainly in the second or third trimester&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23&#44;26&#44;40</span></a> The first-trimester placenta accreta is relatively uncommon&#44; and at the moment&#44; widely accepted standardized sonographic criteria lack in the literature&#46; Reported first-trimester features of PAS detectable on US exam are finding a gestational sac &#40;GS&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Figs&#46; 8</a>A and B&#44; and <a class="elsevierStyleCrossRef" href="#fig0045">9</a>&#41; or placental mass &#40;<a class="elsevierStyleCrossRefs" href="#fig0035">Figs&#46; 7 and 8</a>D and E&#41; that is embedded in the lower uterine segment &#40;&#60;5&#8239;cm from the external cervical os&#41; or within the C&#47;S scar&#44; and the presence of multiple irregular lacunae within the placental bed&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;27</span></a></p><elsevierMultimedia ident="fig0040"></elsevierMultimedia><elsevierMultimedia ident="fig0045"></elsevierMultimedia><p id="par0210" class="elsevierStylePara elsevierViewall">Moreover&#44; US parameters discussed above for PAS in the second trimester&#44; including placenta previa&#44; irregularity in the developing placental&#8211;myometrial interface&#44; intra&#47;periplacental hypervascularity &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Figs&#46; 8</a>C and <a class="elsevierStyleCrossRef" href="#fig0045">9</a>B&#41;&#44; and placental bulge &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>D and E&#41; might be found as early as the first trimester&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;40</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Identifying placenta previa in the first and second trimesters does not help to diagnose PAS&#44; because it will often resolve as pregnancy progresses&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Cesarean scar pregnancy</span><p id="par0220" class="elsevierStylePara elsevierViewall">When the GS is implanted in the uterine window at bladder base at the level of cervical internal os&#44; diagnosis of cesarian section delivery is made&#46; There are a few imaging markers for CSP in the first trimester predicting a higher rate of following obstetric complications&#44; mainly applicable to ultrasound&#58; &#40;a&#41; the minimum myometrial thickness over the placenta&#58; overlying myometrium thickness of &#60;2&#8239;mm increases the chance of subsequent obstetric complications &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>A and B&#41;&#59; conversely&#44; myometrial thickness of &#62;4&#8239;mm over the placenta is associated with a substantially better pregnancy outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> &#40;b&#41; Cross over sign &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 10</a>A&#41;&#58; the position of GS in relation to the endometrial line &#40;a line drawn between internal cervical os&#44; passing through the endometrium and crossing uterine fundus&#41; is assessed in midsagittal view&#46; If &#62;2&#47;3 of the superior&#8211;inferior diameter of the GS &#40;traced perpendicular to the endometrial line&#41; is above this line&#44; pregnancy is at high risk for PAS&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> &#40;c&#41; Implantation in the niche vs&#46; on the C&#47;S scar &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 10</a>B and C&#41;&#58; GSs implanted in the &#8216;niche&#8217; &#40;i&#46;e&#46;&#44; deficient or dehiscent C&#47;S scar&#41; demonstrated a poorer pregnancy outcome compared to those implanted &#8216;on the scar&#8217; &#40;fully or partially over a healed C&#47;S scar&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a><a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a> shows two cases of CSP with the product of conception implanted deep in the niche&#46; &#40;d&#41; The location of GS in relation to the midpoint of the line drawn between external cervical os and uterine fundus &#40;uterine size&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 10</a>D&#41;&#58; if GS resides above the line&#44; the chances of CSP and related complications are significantly lower&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> In one study&#44; authors combined three latter criteria and introduced a high-risk-for-PAS triangle &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 10</a>E&#41;&#46;</p><elsevierMultimedia ident="fig0050"></elsevierMultimedia></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conclusion</span><p id="par0225" class="elsevierStylePara elsevierViewall">Imaging evaluation is mandatory in all cases of PAS&#44; as the clinical presentation of the invasive placenta will be quite subtle in some cases of abnormal placentation&#44; and the timely diagnosis could be life-saving&#46; Maternal serum biomarkers are not dependable for PAS diagnosis&#46; Neither pathology nor imaging &#40;US or MRI&#41; findings of PAS in isolation are not very strong and confident to predict PAS&#46; Both pathology and radiology may bring about false negative or positive results&#44; and none of them are capable of predicting the depth of abnormal placentation confidently&#46; A multidisciplinary approach considering clinical risk factors&#44; imaging features&#44; and pathological findings should make the diagnosis&#46; With all these being said&#44; diagnosing PAS is challenging and postoperative complications are quite common&#44; even in facilities with a high level of expertise in managing PAS disorders&#46;</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Authors&#8217; contributions</span><p id="par0230" class="elsevierStylePara elsevierViewall">BM and JA provided direction and guidance throughout the preparation of this manuscript&#46; SS&#44; MG&#44; ES and MA provided the images&#44; searched the literature and contributed to data extraction from relevant published studies&#46; BM&#44; JA and MA drafted the manuscript&#46; All authors reviewed the manuscript and made significant revisions and approved the final version of the manuscript draft&#46;</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Funding</span><p id="par0235" class="elsevierStylePara elsevierViewall">This research has not received specific aid from agencies from the public sector&#44; commercial sector or non-profit entities&#46;</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflict of interest</span><p id="par0240" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Placenta accreta spectrum &#40;PAS&#41; disorders &#40;with increasing order of the depth of invasion&#58; accreta&#44; increta&#44; percreta&#41; are quite challenging for the purpose of diagnosis and treatment&#46; Pathological examination or imaging evaluation are not very dependable when considered as stand-alone diagnostic tools&#46; On the other hand&#44; timely diagnosis is of great importance&#44; as maternal and fetal mortality drastically increases if patient goes through the third phase of delivery in a not well-suited facility&#46; A multidisciplinary approach for diagnosis &#40;incorporating clinical&#44; imaging&#44; and pathological evaluation&#41; is mandatory&#44; particularly in complicated cases&#46; For imaging evaluation&#44; the diagnostic modality of choice in most scenarios is ultrasound &#40;US&#41; exam&#59; patients are referred for MRI when US is equivocal&#44; inconclusive&#44; or not visualizing placenta properly&#46; Herewith&#44; we review the reported US and MRI features of PAS disorders &#40;mainly focusing on MRI&#41;&#44; going over the normal placental imaging and imaging pitfalls in each section&#44; and lastly&#44; covering the imaging findings of PAS disorders in the first trimester and cesarean section pregnancy &#40;CSP&#41;&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Los trastornos del espectro de placenta acreta &#40;EPA&#41; &#40;en orden ascendente en funci&#243;n de la profundidad de la invasi&#243;n&#58; acreta&#44; increta y percreta&#41; plantean un desaf&#237;o diagn&#243;stico y de tratamiento&#46; El examen patol&#243;gico o la evaluaci&#243;n por t&#233;cnicas de diagn&#243;stico por imagen no son muy fiables si se consideran como herramientas diagn&#243;sticas independientes&#46; Sin embargo&#44; un diagn&#243;stico temprano es de gran importancia&#44; ya que la mortalidad materna y fetal aumentan de forma dr&#225;stica si la paciente se encuentra en unas instalaciones inadecuadas en la tercera fase del parto&#46; Es imperativo adoptar un enfoque multidisciplinario para el diagn&#243;stico &#40;que incorpore la evaluaci&#243;n cl&#237;nica&#44; por imagen e histopatol&#243;gica&#41;&#44; en particular en los casos con complicaciones&#46; Para la evaluaci&#243;n mediante imagen&#44; la modalidad diagn&#243;stica de preferencia en la mayor&#237;a de los escenarios es la exploraci&#243;n mediante ecograf&#237;a&#59; las pacientes son derivadas para la resonancia magn&#233;tica &#40;RM&#41; cuando los resultados de la ecograf&#237;a son ambiguos&#44; no concluyentes o no permiten una visualizaci&#243;n adecuada de la placenta&#46; Este art&#237;culo repasa las caracter&#237;sticas ecogr&#225;ficas y de RM de los trastornos del EPA &#40;centr&#225;ndonos principalmente en la RM&#41;&#44; examinamos las im&#225;genes placentarias normales y los puntos d&#233;biles de las t&#233;cnicas de diagn&#243;stico por imagen en cada secci&#243;n&#46; Por &#250;ltimo&#44; comentamos los hallazgos de imagen de los trastornos del EPA en el primer trimestre&#46; Por ultimo comentaremos los hallazgos de imagen de los trastornos del EPA en el primer trimestre y en la cicatriz de ces&#225;rea anterior&#46;</p></span>"
      ]
    ]
    "multimedia" => array:12 [
      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1257
            "Ancho" => 2508
            "Tamanyo" => 604778
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 28-year-old woman at 15 weeks&#44; presenting with ectopic pregnancy with gestational sac implanted in rudimentary corn of uterus and placenta increta&#46; <span class="elsevierStyleBold">A&#44; B&#46;</span> Low and high-power field photomicrograph of a histologic section of placenta showing full-thickness myometrial invasion by chorionic villi&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 2270
            "Ancho" => 2175
            "Tamanyo" => 280938
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0010"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A schematic presentation of different depths of placental invasion in PAS&#46; Placenta previa and previous cesarean delivery are the most common risk factors&#46; Decidua basalis &#40;the continuous band of cerulean blue color&#41; is deficient in areas with PAS&#46; Make a note of bizarre high-flow intraplacental lacunae&#44; myometrial thinning and heterogenicity&#44; irregularity of the placental&#8211;myometrial interface&#44; loss of retroplacental clear space&#44; and fibrotic band with subjacent placental recess&#46; In placenta previa &#40;most invasive form&#41;&#44; placental tissue may reach out to the bladder lumen&#46; Subserosal hypervascularity&#44; bladder vessel sign&#44; and parametrial vessel sign are also evident&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1185
            "Ancho" => 2758
            "Tamanyo" => 404072
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0015"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A 42-year-old woman at 37 weeks with placenta percreta&#46; <span class="elsevierStyleBold">A&#46;</span> Ultrasound is showing placenta &#40;P&#41; previa and abnormal placentation with placental tissue invading into the lower segment of uterus&#44; on the cesarean scar&#46; Multiple intraplacental bizarre-shaped lacunae are seen in placenta&#46; Urinary bladder &#40;B&#41;&#46; <span class="elsevierStyleBold">B&#46;</span> Intraoperative view showing the uterine &#40;U&#41; serosa covered by dilated&#44; tortuous&#44; and disorganized vessels&#46; <span class="elsevierStyleBold">C&#46;</span> Gross pathology specimen showing full-thickness myometrial invasion by placental tissue&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 2121
            "Ancho" => 2758
            "Tamanyo" => 473352
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0020"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Ultrasound features</span>&#46; A 37-year-old woman at 28 weeks with placenta percreta&#46; <span class="elsevierStyleBold">A&#44; B&#46;</span> Normal myometrial thickness &#40;wide arrow&#41; in the superior part of the uterus&#44; very thin myometrium &#40;small arrows&#41;&#44; and placental &#40;P&#41; invasion into the lower part of the uterus on the cesarean scar are seen&#46; Multiple lacunae &#40;L&#41; are also noted&#46; Placenta has covered the cervical internal os &#40;IO&#41;&#46; <span class="elsevierStyleBold">C&#44; D&#46;</span> Transabdominal and transvaginal Doppler ultrasound depict increased vascularity along the placental&#8211;myometrial interface that has extended into the bladder wall &#40;small arrows&#41;&#46; Blood flow was detected in the lacunae &#40;L&#41;&#46; Bladder &#40;B&#41;&#59; cervix &#40;Cx&#41;&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
            "Alto" => 2314
            "Ancho" => 3341
            "Tamanyo" => 648534
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0025"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Low-lying posterior placenta and cervical varix suspected for accreta in a patient with a history of posterior myomectomy&#46; <span class="elsevierStyleBold">A&#46;</span> Numerous tortuous and disorganized branching echolucencies in the posterior lip of cervix &#40;Cx&#41;&#44; with a bright color signal of flow in Doppler study&#46; <span class="elsevierStyleBold">B&#44; C&#46;</span> Peak systolic velocity of the retroplacental veins &#40;of fetal origin&#41; was averagely about 25&#8239;cm&#47;s &#40;B&#41;&#44; which was higher than that of these tortuous veins in the cervix &#40;C&#41; &#40;6&#46;3&#8239;cm&#47;s&#41;&#46; <span class="elsevierStyleBold">D&#44; E&#46;</span> SSFP &#40;D&#41; and SSFSE &#40;E&#41; sequences show a normal non-invasive placenta&#44; with homogenous intermediate signal in SSFSE&#44; without T2 dark bands&#44; and with normal overlying myometrial thickness&#46; Tortuous high-flow vessels &#40;with flow-related signal in SSFP&#41; are noted in the posterior cervical lip&#46; Cervix &#40;Cx&#41;&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "fig0030"
        "etiqueta" => "Figure 6"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr6.jpeg"
            "Alto" => 3404
            "Ancho" => 2675
            "Tamanyo" => 683039
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0030"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">MRI features</span>&#46; A 31-year-old woman at 24 weeks with placenta percreta&#46; <span class="elsevierStyleBold">A</span>&#8211;<span class="elsevierStyleBold">C&#46;</span> Placenta previa with heterogeneous signal in T2-weighted image is appreciated&#59; T2-dark bands &#40;narrow vertical arrow&#41; are more conspicuous in the SSFSE sequence &#40;A&#41; compared to SSFP sequence &#40;B&#41;&#46; Subplacental hypervascularity &#40;wide vertical arrow in A&#41;&#44; placental bulge &#40;wide horizontal arrow in A and C&#41;&#44; normal T2-hypointense placental&#8211;myometrial interface &#40;narrow horizontal arrow in A&#41;&#44; myometrial thinning &#40;narrow horizontal arrow in C&#41;&#44; and placental tissue protruding into the bladder lumen &#40;B&#41; are all shown&#46; <span class="elsevierStyleBold">D&#44; E&#46; Extrauterine extension&#46;</span> Large flow voids in the bladder wall &#40;bladder vessel sign&#44; small arrows in D&#41; imply bladder wall invasion&#44; and parametrial vessel sign &#40;large arrows in E&#41; suggests parametrial invasion&#46; <span class="elsevierStyleBold">F&#44; G&#46;</span> DWI clearly outlines the border between the placenta and myometrium&#44; as placenta shows a very high signal intensity in diffusion imaging&#46; Compare areas with normal myometrial thickness &#40;F&#41; to areas of significant myometrial thinning &#40;G&#41;&#46; Placenta &#40;p&#41;&#59; bladder &#40;B&#41;&#59; cervix &#40;Cx&#41;&#46;</p>"
        ]
      ]
      6 => array:8 [
        "identificador" => "fig0035"
        "etiqueta" => "Figure 7"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr7.jpeg"
            "Alto" => 2879
            "Ancho" => 2675
            "Tamanyo" => 473037
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0035"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A complicated case of cesarean scar pregnancy with pseudoaneurysm&#46; <span class="elsevierStyleBold">A&#44; B&#46;</span> Transvaginal scan shows the scar pregnancy mass with a large pseudoaneurysm with to and fro pattern of flow detected in Doppler exam&#46; <span class="elsevierStyleBold">C&#44; D&#46;</span> Pre- and post-contrast T1-weighted imaging of the same case shows avid enhancement of the pseudoaneurysm&#46; Uterus &#40;U&#41;&#46;</p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "fig0040"
        "etiqueta" => "Figure 8"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr8.jpeg"
            "Alto" => 2634
            "Ancho" => 3008
            "Tamanyo" => 669551
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0040"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Two cases of cesarean scar pregnancy and placenta accreta are shown in MRI in the first trimester&#46; <span class="elsevierStyleBold">A&#44; B&#46;</span> T2-weighted image is showing cesarean scar pregnancy at 6 weeks&#46; The gestational sac &#40;GS&#41; is implanted deep in the &#8216;niche&#8217;&#44; and the overlying myometrium is thin&#46; <span class="elsevierStyleBold">C&#46;</span> Early post-contrast dynamic T1-weighted image shows a significant hypervascularity around the sac&#46; <span class="elsevierStyleBold">D&#44; E&#46;</span> T2-weighted imaging of the placenta shows the scar pregnancy manifesting as a sizable heterogeneous mass&#46; The mass resides in the &#8216;niche&#8217;&#44; and it has protruded into the vesicouterine septum&#46; <span class="elsevierStyleBold">F&#46;</span> Post-contrast T1-weighted image shows no hypervascularity within the hypo-&#47;non-enhanced mass&#46;</p>"
        ]
      ]
      8 => array:8 [
        "identificador" => "fig0045"
        "etiqueta" => "Figure 9"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr9.jpeg"
            "Alto" => 922
            "Ancho" => 2508
            "Tamanyo" => 273028
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0045"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Transvaginal scan of a cesarean scar pregnancy with placenta accreta in 6 weeks&#46; <span class="elsevierStyleBold">A&#44; B&#46;</span> The gestational sac has penetrated the scar &#40;arrows&#41;&#44; and hypervascularity around the sac is noted&#46; Fetus &#40;F&#41;&#46;</p>"
        ]
      ]
      9 => array:8 [
        "identificador" => "fig0050"
        "etiqueta" => "Figure 10"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr10.jpeg"
            "Alto" => 2190
            "Ancho" => 2758
            "Tamanyo" => 258030
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0050"
            "detalle" => "Figure 1"
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A schematic presentation of ultrasound criteria for differing cesarean section pregnancy from intrauterine pregnancy and predicting the PAS severity in the third trimester&#46; <span class="elsevierStyleBold">A&#46; Cross over signs</span>&#46; If at least two-thirds of the superior&#8211;inferior diameter of the gestational sac resides above the endometrial line &#40;sac 2&#41;&#44; the risk of cesarean section pregnancy and subsequent poor pregnancy outcome is higher&#46; Sac 1 more likely represents an intrauterine pregnancy&#46; <span class="elsevierStyleBold">B&#44; C&#46; On the scar or in the niche</span>&#46; If the gestational sac is deep in the dehiscent cesarean scar &#40;B&#41;&#44; the risk of more severe placentation abnormality would be higher in the third trimester&#46; If the sac is over a healed scar &#40;C&#41;&#44; normal intrauterine pregnancy is implied&#46; <span class="elsevierStyleBold">D&#46; Above or below the line</span>&#46; Gestational sacs above the uterine midpoint are more likely intrauterine pregnancies&#46; If the gestational sac falls below the midpoint&#44; the chance of cesarean section pregnancy and following severe PAS is higher&#46; <span class="elsevierStyleBold">E&#46; High-risk-for-PAS triangle</span>&#46; This triangle incorporates all criteria&#44; and if the gestational sac falls within it&#44; cesarean scar pregnancy is highly suggested&#44; and patient will be more likely diagnosed with severe PAS in the third trimester&#46;</p>"
        ]
      ]
      10 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0055"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">COS&#44; cross over sign&#59; CSP&#44; cesarean section pregnancy&#59; CSS&#44; cesarean section scar&#59; MRI&#44; magnetic resonance imaging&#59; US&#44; ultrasonography&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">US&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">MRI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">1st trimesters</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">1st trimesters</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">GS in the lower uterine segment&#47;CSP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">GS in the lower uterine segment&#47;CSP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multiple irregular vascular spaces within the placental bed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multiple irregular vascular spaces within the placental bed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Factor predicting pregnancy outcome in CSP&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">COS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Above vs&#46; below the line&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">On the CSS vs&#46; in the niche&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Myometrial thickness over placenta&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">2nd</span>&#8211;<span class="elsevierStyleBold">3rd trimesters</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">2nd</span>&#8211;<span class="elsevierStyleBold">3rd trimesters</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Gray scale</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Placenta previa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Placental bulge&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Focal exophytic mass&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Focal exophytic mass&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multiple placental lacunae&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Placental heterogeneity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Obliteration of the retroplacental clear space&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dark T2WI intraplacental bands&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Myometrial thinning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Myometrial thinning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bladder wall abnormalities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bladder wall abnormalities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Disruption of the uterine&#8211;bladder interface&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Loss of retroplacental hypointense line &#40;uteroplacental interface&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Doppler ultrasound</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Abnormal placental vascularity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Turbulent flow in placental lacunae&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Retroplacental venous proliferation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Disrupted retroplacental blood flow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Subserosal hypervascularity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Increased subplacental vascularity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Abnormal uterine bulge&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gaps in myometrial blood flow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vessels bridging the placenta to uterine margin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypervascularity in uterine&#8211;bladder interface&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab3443116.png"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Imaging &#40;US and MRI&#41; features of PAS disorders in early pregnancy and 2nd&#8211;3rd trimesters&#44; and recommended modalities&#47;sequences&#46;</p>"
        ]
      ]
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        "etiqueta" => "Table 2"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Major abnormalities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Minor abnormalities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Abnormal uterine bulge&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Irregular placental&#8211;myometrial interface&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Abnormal placental bulge&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Myometrial thinning&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Placental heterogeneity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Focal exophytic masses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bladder wall abnormalities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dark T2 intraplacental bands&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Abnormal uteroplacental vascularity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Major and minor PAS-related MRI findings&#46;</p>"
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        0 => array:2 [
          "identificador" => "bibs0005"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Maternal morbidity associated with multiple repeat cesarean deliveries"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46;M&#46; Silver"
                            1 => "M&#46;B&#46; Landon"
                            2 => "D&#46;J&#46; Rouse"
                            3 => "K&#46;J&#46; Leveno"
                            4 => "C&#46;Y&#46; Spong"
                            5 => "E&#46;A&#46; Thom"
                          ]
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                    0 => array:2 [
                      "doi" => "10.1097/01.AOG.0000219750.79480.84"
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                        "tituloSerie" => "Obstet Gynecol"
                        "fecha" => "2006"
                        "volumen" => "107"
                        "paginaInicial" => "1226"
                        "paginaFinal" => "1232"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16738145"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "FIGO consensus guidelines on placenta accreta spectrum disorders&#58; introduction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "E&#46; Jauniaux"
                            1 => "D&#46; Ayres-de-Campos"
                          ]
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Gynaecol Obstet"
                        "fecha" => "2018"
                        "volumen" => "140"
                        "paginaInicial" => "261"
                        "paginaFinal" => "264"
                      ]
                    ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The MRI features of placental adhesion disorder&#8212;a pictorial review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "F&#46; Cuthbert"
                            1 => "M&#46; Teixidor Vinas"
                            2 => "E&#46; Whitby"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1259/bjr.20160284"
                      "Revista" => array:5 [
                        "tituloSerie" => "Br J Radiol"
                        "fecha" => "2016"
                        "volumen" => "89"
                        "paginaInicial" => "20160284"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27355318"
                            "web" => "Medline"
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                        ]
                      ]
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                ]
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              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Placenta accreta&#58; spectrum of US and MR imaging findings"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "W&#46;C&#46; Baughman"
                            1 => "J&#46;E&#46; Corteville"
                            2 => "R&#46;R&#46; Shah"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1148/rg.287085060"
                      "Revista" => array:6 [
                        "tituloSerie" => "Radiographics"
                        "fecha" => "2008"
                        "volumen" => "28"
                        "paginaInicial" => "1905"
                        "paginaFinal" => "1916"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19001647"
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              "identificador" => "bib0025"
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ISSN: 21735107
Original language: English
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