Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

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Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

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Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

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MD, DM (Clinical Pharmacology)
Assistant Professor
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Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
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Best regards,
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Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : August | Volume : 15 | Issue : 8 | Page : TC15 - TC20 Full Version

Emerging Role of Prenatal Magnetic Resonance Imaging in the Diagnosis of Placental Adhesion Disorders and its Relation with Intraoperative Findings- A Cross-sectional Study

Published: August 1, 2021 | DOI:
Saryu Gupta, Preetkanwal Sibia, Sarabhjit Kaur, Puneet Gambhir

1. Associate Professor, Department of Radiodiagnosis, Government Medical College and Rajindra Hospital, Patiala, Punjab, India. 2. Professor, Department of Obstetrics and Gynaecology, Government Medical College and Rajindra Hospital, Patiala, Punjab, India. 3. Associate Professor, Department of Obstetrics and Gynaecology, Government Medical College and Rajindra Hospital, Patiala, Punjab, India. 4. Assistant Professor, Department of Community Medicine, Government Medical College and Rajindra Hospital, Patiala, Punjab, India.

Correspondence Address :
Dr. Puneet Gambhir,
80, New Majithia Enclave, Phase II, Patiala, Punjab, India.


Introduction: Placental Adhesion Disorders (PADs) aka Placenta Accreta Spectrum (PAS) of disorders are a common cause of postpartum haemorrhage, which in turn is an avoidable cause of significant maternal morbidity and mortality. The exponential increase in the prevalence of PADs worldwide primarily ascribed to increasing percentage of caesarean section deliveries therefore contributes significantly to potentially life-threatening obstetrical emergencies. Accurate prenatal diagnosis of PAD is hence fundamental for patient management and prognostication. Imaging plays an indispensable role in the antenatal diagnosis of PAD thereby translating to improved maternal outcomes.

Aim: To determine the diagnostic accuracy of prenatal Magnetic Resonance Imaging (MRI) in predicting abnormal invasive placentation and to associate MRI findings with intraoperative findings.

Materials and Methods: The present cross-sectional study was conducted between March 2019 to March 2020. Pregnant females with clinically and/or sonographically suspected PAD and having major risk factors of PAD {Lower Segment Caesarean Section (LSCS) in previous and placenta previa in present gestation} were subjected to dedicated placenta protocol MRI examination. The placental morphology, localisation and adhesion suggestive features were evaluated in detail. Descriptive statistical analysis was done for final assessment.

Results: A total of 27 study participants, with mean age of 28±2.15 years, showed MRI findings compatible with PAD. Placenta previa complete (66.67%); was the dominant subtype observed in the study. In terms of degree of invasion, placenta accreta in 44.44% (n=12) was predominantly observed on preliminary MRI based assessment. The most reliable MRI features predictive of placental invasion in the present study (seen in 100% cases of PAD) included T2 dark intraplacental bands, heterogenous intraplacental signal intensity, disorganised intraplacental vascularity, myometrial thinning, loss of the uteroplacental interface and maternal neovascularity. In one case, MRI erroneously over-diagnosed increta as percreta. The overall diagnostic performance of these MRI parameters was with sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of 100%, 95%; 87.5% and 100% in those with placenta percreta compared to 94.12%, 100.00%, 100% and 95% for the placenta accreta or increta cases, respectively.

Conclusion: MRI has high diagnostic accuracy in detection of PADs among the high-risk patients. Dedicated placenta protocol prenatal MRI should hence be incorporated in diagnostic work-up of all high-risk patients of PAD for reaping benefits of timely management, planning and saving lives.


Accreta, Increta, Morbidly adherent placenta, Percreta

Placental Adhesion Disorders (PAD) occur due to a defect in the decidua basalis which allows the invasion of chorionic villi into the myometrium (1),(2). It is classified on the basis of depth of myometrial invasion categorised as shown (Table/Fig 1) (3),(4).

PAD is a significant cause of maternal morbidity and mortality and the most common indication for emergent postpartum hysterectomy in the present times (3),(5),(6),(7). It is a clinical and diagnostic challenge being encountered with increasing frequency due to ever increasing percentage of women undergoing primary and repeat caesarean sections (3),(8),(9),(10),(11),(12),(13),(14),(15). Placenta previa and prior caesarean section are the two major risk factors for developing PAD with probability ranging from 3% in those with placenta previa alone to 24% in those with placenta previa and one prior caesarean delivery (1). Also, noteworthy is the fact that this risk compounds with the number of previous caesarean section procedures to about 40% in those with previous two to 61% in those with previous three and 67% in those with four or more caesarean section deliveries (10),(16),(17),(18),(19),(20),(21). The additional but relatively minor risk factors include advanced maternal age, uterine anomalies and previous uterine surgical interventions (dilatation and curettage, myomectomy and previous uterine surgery) (10),(22).

Several studies have shown that PAD remain undiagnosed during pregnancy in upto half of all patients (23),(24),(25). Due to the risk of life-threatening postpartum haemorrhage, rapid haemostasis is the cornerstone of management in these cases (25). Prenatal diagnosis is hence crucial for planning the timing and site of delivery, availability of blood products and recruitment of a multidisciplinary team with expertise in high-risk obstetrics (gynaecologic surgeon, urologist, interventional radiologist and obstetric anaesthetist) to reduce maternal morbidity and mortality (13),(14),(26),(27).

MRI is a problem-solving technique in placental evaluation if ultrasound evaluation is insufficient or confusing. Placenta evaluation has been done in MRI obstetric imaging done for other indications also. The present study aimed to determine the diagnostic accuracy of prenatal MRI in predicting abnormal invasive placentation and to correlate MRI findings with intraoperative findings.

Material and Methods

This was a cross-sectional study conducted jointly by the Departments of Radiodiagnosis and Obstetrics and Gynaecology, Government Medical College and Rajindra Hospital, Patiala, Punjab, India. The study was of one year duration (March 2019 to March 2020) and was conducted after obtaining approval of the Institutional Research and Ethics Committee (vide letter No.TRG.9(310)2019/2235 dated March 6, 2019).

Inclusion criteria: A total of 35 consenting pregnant females (ongoing singleton gestation) with clinically suspected PAD and having major risk factors of PAD (LSCS in previous and/or placenta previa in present gestation) who reported during the study period were enrolled in the study.

Exclusion criteria: All those who did not give informed consent, had contraindications to MRI per se, were severely claustrophobic, had prior diagnosed placental pathology in present gestation or were lost on follow-up were excluded from the study. Postnatal cases with placental adherence were also excluded from the present study.

Study Procedure

MRI was performed on 1.5 Tesla (T) platform (SIEMENS MAGNETOM-Aera, SIEMENS Medical Systems, Erlangen, Germany) using a multichannel phased array body coil and “head-first” approach. The “feet-first” approach was followed in exceptional cases with severe claustrophobia. The mother was positioned in the supine or left lateral posture (the latter in cases of advanced gestation to avoid caval compression by the gravid uterus). No maternal sedation, intravenous paramagnetic contrast administration or oxygen supplementation was used in any case. A moderate level of urinary bladder distension was ensured prior to the commencement of the scan both to ensure patient comfort as well as to avoid under or overdistension, which could potentially hamper bladder invasion assessment. In all cases, sequences were acquired during maternal breath holding. The entire MRI examination was carried out under direct supervision of the reporting radiologist so as to ensure optimal image acquisition (repeat/additional planes wherever indicated) and subsequent accurate image interpretation.

MRI protocol: Dedicated placenta protocol MRI sequences were acquired using standard parameters as follows:

1. Three plane localisers of the maternal anatomy.
2. T2-weighted Half-Fourier Acquisition Single-shot Turbo spin-echo (HASTE) in all three orthogonal planes (axial, sagittal and coronal) relative to the gravid uterus.
3. True Fast Imaging with Steady-State Free Precession (TRUFI) in sagittal and coronal planes.
4. T1-weighted Volumetric Interpolated Breath-hold Examination (VIBE) sequences.
5. Additional images in planes perpendicular to the placenta-myometrium or myometrium-bladder interface on case-to-case basis.

Alternate interleaved slices were acquired to reduce cross-talk while planning sequences with thinner or contiguous slices. Sequences were repeated when the image quality was degraded by foetal motion or maternal respiratory-motion induced artifacts.

MRI image interpretation and analysis: Image stacks were transferred to advanced workstation and interpretation was done by a radiologist with 17 years of experience in female pelvic imaging who was blinded to the clinical history and antenatal ultrasound. The placental morphology, localisation and adhesion suggestive features were evaluated in detail on a dedicated MRI workstation in all cases. The diagnosis was confirmed in all cases by intraoperative findings and/or relevant histopathological correlation. Intraoperative and/or pathologic findings were the standard of reference.

Statistical Analysis

The data was collected and analysed using Epi-info (CDC, Atlanta) version 7.2.4. Descriptive statistical analysis was done for final assessment.


There were a total 35 consenting participants, among them 27 with mean age of 28 years±2.15 years had placental adhesions disorders and were analysed in the study. The youngest member was 24 years and oldest was 31 years of age. The gestation age at MRI examination ranged from 17 weeks to 37 weeks. The gravida status of the mothers varied from one to four while the parity ranged from zero (primigravida) to three in number (Table/Fig 2).

After being diagnosed with PAD, 15 patients (55.56%) underwent complete hysterectomy of which 10 patients (37.04%) had prior bilateral internal iliac artery and uterine artery ligation; while the remaining 12 out of the total 27 patients (44.44%) underwent LSCS (Table/Fig 3).

Significant morbidity was seen as postoperative ureteral injury related complications in 7.41% (n=2), infection in 29.63% (n=8) and persistent postpartum haemorrhage for three months partum period in 3.7% (n=1) cases. 7.41% cases (n=2) had increased need for blood products as more than 10 units in the intraoperative setting while maternal death due to excessive uncontrolled intra and immediate postoperative haemorrhage was seen in 3.7% (n=1). No case of uterine rupture was seen (Table/Fig 4).

Blood products used during treatment was nil in 29.64% (n=8) cases, 3 units in 22.22% (n=6), 4 in 14.81% (n=4), 6 in 11.11% (n=3), 7 in 14.81% (n=4) and more than 10 units in 7.41% (n=2) cases, respectively. Majority of cases (62.96%) were referred to a higher institute.

MRI parameters: In the present study, majority of cases had placental bulk located anteriorly; (59.26%) and 66.67% had grade 4 placenta previa. T2 dark intraplacental bands, heterogenous intraplacental signal intensity, disorganised intraplacental vascularity, myometrial thinning, loss of the uteroplacental interface and maternal neovascularity were present in all the study subjects. In terms of degree of invasion, placenta accreta was the predominant finding observed in 44.44% (n=12) cases on preliminary MRI based assessment (Table/Fig 5)a-c.

In the present study, MRI was able to detect even subtle focal myometrial disruption at prior LSCS scar site, whenever present, with 100% intraoperative concordance. The various clinical and demographic characteristics of the study population showed no statistically significant difference with management and MRI findings. Few images from the archives are shown in (Table/Fig 6), (Table/Fig 7), (Table/Fig 8), (Table/Fig 9), (Table/Fig 10).


The present study shows there was no statistical difference among the women in terms of maternal age, gestational age (at diagnosis and/or management), and the number of prior caesarean deliveries with management and MRI findings. This was in consonance with a similar study by Clark HR et al., who conducted a study among 64 females and reported no significant difference among the women in terms of maternal age, gestational age, or the number of prior caesarean deliveries to management (8).

The observations related to MRI parameters were in concurrence with some of the previously reported factors having higher generalisability as predictors of placental invasion including the presence of placental features (praevia, heterogeneous signal intensity with T2 hypointense bands, bulge, lumpy placental contour), placental-myometrial interface disruption, myometrial thinning and focal myometrial disruption similar to studies by several authors (28),(29),(30),(31),(32),(33).

The present study reported a sensitivity of 100% and specificity of 95% for placenta percreta. Familiari A et al., conducted a meta-analysis on the utility of MRI in placenta evaluation reported a sensitivity of 86.5% and specificity 96.8% for placenta percreta (30). The meta-analysis further concluded that of the different MRI signs intraplacental dark bands showed the best sensitivity for the detection of placenta accreta, increta and percreta; abnormal intraplacental vascularity, uterine bulging was associated with a higher risk of increta and percreta; exophytic mass and bladder tenting with placenta percreta. They however cautioned that although MRI has excellent diagnostic accuracy in identifying the depth and the topography of placental invasion but as it is used as a secondary imaging tool in women already screened for Abnormally Invasive Placenta (AIP) on ultrasound it might not reflect its actual diagnostic performance in detecting the severity of these disorders (30).

The present observations pertaining to extrauterine invasion were also similar to a study by Warshak CR et al., Bourgioti C et al., Masselli G et al., Kim JA et al., Leyendecker JR et al., Levine D and Levine D et al., (28),(34),(35),(36),(37),(38),(39). In placenta percreta, loss of T2 hypointense bladder wall signal is the most reliable and specific sign (34),(40) while intra-vesical extension/adjacent organ invasion is unreliable as it is witnessed less frequently. All cases with bladder wall signal disruption were peroperatively confirmed as percreta. However, there was one exception in which case MRI over-diagnosed it as percreta but was later confirmed as increta intraoperatively. Placental cervical protrusion sign (1) seen in 3.7% cases (n=1) was of particular significance in clinching the diagnosis of percreta.

Maternal neovascularity was observed in all PAD cases in the present study. Clark HR et al., also surmised that increased vascularity was the rule as expected from the multiparous population of women with placental implantation in the lower uterine segment with co-existent previa and observed that maternal vascularity does not have a significant association with placental invasion (8). This finding was contradictory to findings in the established literature, which have described a correlation between increased vascularity and increased risk of invasion (30),(31),(32),(33). The variance could be due to its small sample being the confounding factor (8).

In the present study, the timely and accurate diagnosis enabled judicious management across all gestation ages (at time of diagnosis and management) and degrees of invasion in terms of referral to higher obstetric emergency dedicated multidisciplinary institute in 62.96% (n=17), reduced need for caesarean hysterectomy in 44.44% (n=12) and favourable maternal outcomes in 96.3% (n=26) cases. In fact, no case of uterine rupture was recorded during the study which is otherwise a significant life-threatening complication of PAS. The clinical outcome was also favourable by way of healthy term babies in 92.59% (n=25) cases with perinatal mortality in only 7.41% (n=2) with both of the latter being preterm babies.

Another clinical outcome was the reduced need for blood products of more than 10 units in 7.41% cases only. This is likely ascribed to timely management including preoperative vascular intervention procedures (ligation or embolisation) carried out in a total of 44.45% (n=12) of all such PAS positive cases. Among these prior bilateral internal iliac and uterine arteries’ ligation was carried out in 37.04% (n=10) cases and prior bilateral uterine artery embolisation procedures were performed in 7.41% (n=2) cases, respectively (Table/Fig 3). Clark HR et al., showed significant blood requirement among patients who underwent hysterectomy (8).


Prospective studies in larger cohorts than the present study would enhance the diagnostic confidence based on MRI features alone, enabling quantitative evaluation of placental invasion and development of standardised multiple variable-based reporting templates. Being single observer-based study, analysis of inter-observer differences between at least two readers could not be done which is desirable for all future studies. High pretest probability for invasion due to selection bias targeting enhanced presence of PAS candidates; but this was intentional so as to increase the diagnostic yield. Lack of ultrasound correlation too was aimed at avoiding observer bias thereby emphasising the diagnostic utility of MRI from a complementary to a robust essential imaging modality in the work-up of suspected PAS cases.


Prenatal MRI has high predictive accuracy in diagnosing disorders of invasive placentation among high-risk patients. At present ultrasound is the initial screening and diagnostic modality with MRI reserved for the sonographically inconclusive/incomplete cases due to modality related limitations per se, operator incompetence, maternal obesity and posterior placentation. However, the additional benefits of MRI in all cases include precise delineation of placental topography, depth of placental invasion and presence or absence of extra-uterine extension through defined features esp. T2 dark intraplacental bands, heterogenous intraplacental signal intensity, disorganised intraplacental vascularity, myometrial thinning, loss of the uteroplacental interface and maternal neovascularity- these factors in turn determine final surgical outcomes and also influence patient counselling in the context of fertility preservation options. Hence, it is recommended to incorporate dedicated placenta protocol prenatal MRI in the routine investigative work-up of all clinically suspected cases of PAD.


The authors are grateful to all the MRI technicians (S. Jarnail Singh, Mr. Sanjeev and S. Hardeep Singh) for their sincerity, dedication and hard work during their involvement in this research work.


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Date of Submission: Jun 25, 2021
Date of Peer Review: Jun 28, 2021
Date of Acceptance: Jul 31, 2021
Date of Publishing: Aug 01, 2021

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

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