1. Placenta accreta

2. Definition
Placenta accreta occurs when there is a defect of the decidua basalis, in conjunction with an imperfect development of the Nitabuch membrane (a fibrinoid layer that separates the decidua basalis from the placental villi) resulting in abnormally invasive implantation of the placenta
The ACOG committee

3. According to Mudhaliar and Menon
Placenta accreta is defined as the abnormal adherence,either in whole or in part,of the afterbirth to the unlying uterine wall.
According to D.C.Dutta
Placenta accreta in extremely rare form in which the placen is directly anchored to the myometrium partially or completely thout any intervening decidua.

5. Incidence From 1930 to 1950--one case in 30,000 deliveries.
From 1950 to 1960, one in 19,000, deliveries.
by 1980 to one in 7,000.
the incidence has now risen to one in 2,500 deliveries
The ACOG committee

6. Degrees of severity/ Types of Placenta Accreta
(1) Accreta, in which the placenta adheres to the myometrium without invasion into the muscle.
(2) Increta, in which it invades into the myometrium.
(3) Percreta, in which it invades the full thickness of the uterine wall and possibly other pelvic structures, most frequently the bladder.

9. Depending on the area of involvement
Total
Partial
Focal

10. Risk factors Placenta previa with or without previous uterine surgery.
previous myomectomy.
previous cesarean delivery.
Asherman's syndrome.
submucous leiomyomata.
maternal age of 36 years and older.

11. Risk of developing placenta accreta in women with placenta previa
No previous C/S
1% - 5%
One previous C/S
30%
Two or more C/S
40% and higher

12. Etiology Defective decidual formation
Implantation in lower uterine segment
Caesarean scar
Uterine incision or curettage
Manual removal of placenta
Abortive agents
Uterine infections

13. Clinical Course Maternal Serum Alpha Fetoprotein level - increased
Ante partum hemorrhage
Uterine rupture before labour

14. Diagnosis Ultrasound MRI
loss of the normal hypoechogenic zone between the placenta and myometrium
abnormality of the smooth interface between the uterus and bladder
a Swiss-cheese appearance to the placenta,
pulsatile flow of maternal blood
MRI

15. Swiss cheese appearance

16. Management Partial Morbid Adherent Placenta
“Playing with the placenta with fingers”
Oxytocics
Intrauterine plugging
Hysterectomy

17. Total Placenta Accreta
Hysterectomy
Conservative :
Cutting umbilical cord
Antibiotics
Other measures
Blood replacement
Uterine and internal iliac artery ligation
Angiographic embolization
Argon beam coagulation

18. A tiny angiographic catheter is maneuvered into the uterine artery in preparation for embolization

19. Complications Hemorrhage Shock Infection Sub involution of uterus
Secondary postpartum hemorrhage
Formation of placental polyp

20. Thank you