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Normal placental structural anatomy: ultrasound and doppler features elucidated with US-MR image fusion and ferumoxytol-enhanced MRI

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Abstract

Purpose

To elucidate ultrasound features of normal placental anatomy through correlation of gray-scale and ultrasound Doppler with ferumoxytol-enhanced MRI features using US-MR image fusion.

Methods

All patients referred to MR for ultrasound findings worrisome for PAS (placenta accreta spectrum) were included in this retrospective study. MR studies included a ferumoxytol-enhanced T1-weighted MRI. Ultrasound imaging included gray-scale, color Doppler, power Doppler, and spectral Doppler techniques. After the MR, US-MRI fusion was performed by co-registering a MR acquisition to real-time US, which allowed precise, point-to-point correlation of placental features.

Results

Fourteen patients at risk for PAS were studied using the US-MR image fusion. At delivery, there were six cases without PAS (gestational age range: 24 weeks 3 days to 34 weeks 0 days), and these composed the study cohort. Placental features that were on high signal intensity on post-ferumoxytol acquisitions represent spaces with maternal blood flow and corresponded to hypoechoic areas on ultrasound created by a paucity of reflective interfaces (villi). Color and spectral Doppler allowed the separation of maternal and fetal circulations in individual perfusional domains and demonstrated spiral artery inflow, circulation around the villous tree, and return of blood flow to the basal plate. Recognizable histopathologic features by ultrasound included the central cavity, villous tree, and venous return channels.

Conclusion

Internal placental architecture can be discerned on ultrasound. This anatomy can be correlated and confirmed with ferumoxytol-MR through US-MR fusion. Understanding this structural anatomy on ultrasound could serve as a basis to identify normal and abnormal placental features.

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Acknowledgements

The authors thank Megan Vadnais, BSRT (R)(MR) and Christina K. Hendricks, RDMS for help with the studies.

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Authors and Affiliations

  1. Department of Radiology, University of Wisconsin – Madison, E3/311, 600 Highland Avenue, Madison, WI, 53792-3252, USA

    Mark A. Kliewer & Scott B. Reeder

  2. Department of Radiology, The University of Vermont, 111 Colchester Avenue, Main Campus, McClure, Level 1, Burlington, VT, 05401-1473, USA

    Anjuli R. Bagley

  3. Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Wisconsin Medical School, 4th Floor McConnell Hall, 1010 Mound St, Madison, WI, 53715, USA

    Jesus Igor Iruretagoyena

  4. Department of Pathology and Laboratory Medicine, University of WI–Madison, E3/311, 600 Highland Avenue, Madison, WI, 53792-8550, USA

    Crystal G. Bockoven & Michael K. Fritsch

Authors
  1. Mark A. Kliewer
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  2. Anjuli R. Bagley
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  3. Scott B. Reeder
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  4. Jesus Igor Iruretagoyena
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  5. Crystal G. Bockoven
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  6. Michael K. Fritsch
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Corresponding author

Correspondence to Mark A. Kliewer.

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Conflict of interest

There was no industry or grant support for the project. The authors did not receive support from any organization for the submitted work. The authors have no relevant financial or non-financial interests to disclose. The authors have no conflicts of interest.

Ethical approval

This retrospective study was approved by our institutional review board with waiver of informed consent. All patients were prospectively studied according to our standard imaging protocol.

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Appendix

Appendix

Appendix. MR Protocol

1.5 T GE system; multichannel phased array abdominal coil; 30-35 minutes; radiologist at console to prescribe planes; Patient supine or left lateral decubitus (LLD).

  • T2 weighted SSFSE: sagittal, axial, coronal. 2D, slice/gap 3/0 mm, TE 100 ms, field of view (FOV) 30 × 30 cm, matrix 256 × 224, scan time ≈ 1.5 min

  • SSFP: sagittal, axial, coronal. 2D, slice/gap 4/0 mm, TR/TE Min/100 ms, flip angle 80°, 2 signal averages, FOV 30 × 30 cm, matrix 256 × 256, scan time ≈ 2 min

  • T1-weighted LAVA (breath hold). Prescibed plane. 3D, slice 3 mm TR/TE 4.1/Min Full, flip angle 12°, FOV 40 × 38 cm, matrix 288 × 160, scan time ≈ 20 s

  • DWI: Prescibed plane. b-value 50, 800. free breathing with respiratory triggering. 2D, slice/gap 4/0.5 mm, TE Min, FOV 38 × 40 cm, matrix 160 × 192. scan time ≈ 6 min

Ferumoxytol infusion: diluted in normal saline 5:1, slow infusion over 15 minutes. Scan after infusion is complete.

Post-contrast acquisitions (parameters as above).

High resolution non-fat saturated 3D T1w with low flip angle (prescribed plane)

Lava Flex T1 breath hold. Sagittal, axial, coronal planes.

SSFSE T2 (prescribed plane)

SSFP (prescribed plane)

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Kliewer, M.A., Bagley, A.R., Reeder, S.B. et al. Normal placental structural anatomy: ultrasound and doppler features elucidated with US-MR image fusion and ferumoxytol-enhanced MRI. Abdom Radiol 48, 744–751 (2023). https://doi.org/10.1007/s00261-022-03758-0

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  • DOI: https://doi.org/10.1007/s00261-022-03758-0

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