1. Placenta Accreta-Lessons Learnt
Dr Leena Wadhwa
Associate Professor
ESI-PGIMSR,Basaidarapur,Delhi

2. Maternal Mortality-Magnitude and Causes
About 28 million pregnancies and 67,000 maternal deaths per year in India
Source: RGI-SRS
* Other Conditions includes Anemia.
Source: RGI-SRS

3. Placenta accreta/ increta/ percreta
Significant cause of maternal morbidity and mortality
significant maternal hemorrhage at delivery
Mortality rate %
(O brien et al AM J Obstet Gynecol 1996)
Normally the placenta adhere to decidua basalis layer, allowing for a smooth separation of the placenta from the uterus after delivery
In patients with abnormal placentation, placenta is firmly bound to the defective decidua basalis layer or even to the myometrium, the condition is called as placenta accreta.
Varying degrees of placenta accreta are*
Placenta accreta vera (placenta adheres to myometrium)
Placenta increta ( placenta invades the myometrium)
Placenta percreta (placenta invades through the myometrium to the uterine serosa and may include invasion into other pelvic organs)

4. Most common reason for emergency postpartum hysterectomy.
Incidence -increasing(secondarily to the rise of Caesarean section)
/7000
/ 2,510**
/ 533 ***
**(Miller- Am J Obstet Gynecol 1996 )
***(Wu et al Am J Obstet Gynecol 2005)

5. Case 1 Unbooked, G4P2L2A1, 26 weeks, previous LSCS, fever dysuria
USG:Placenta antr,covering os
Em laprotomy (GA) : hematuria ? Rupture uterus
Per-operative details
Hemoperitoneum (1 litre+)
Posterior wall of bladder found adhered to LUS
Bladder lying open (3cm)
Clots presents inside the bladder removed. large bleeders present on the posterior bladder wall , clamped & sutured

6. Case 1 hysterotomy done and fetus delivered
fails to recognize percreta going into bladder & anticipate complications
tries partial MRP hysterectomy with difficulty by 2 consultantsuncontrollable hgg from bladder- cystectomy & B/L Int iliac art ligation
6 units Blood
Patient died in ICU

7. Case 1
HPE- Placental tissue invading the full thickness myometrium and the overlying serosa.(placenta percreta)

8. ‘Placenta accreta mindedness’

9. Placenta Percreta Catastrophic event
Placenta percreta induced uterine rupture as early as 9 &14 wks
75% cases of percreta are assoc with placenta previa
Maternal mortality-20%
Perinatal mortality-30%
(Obstet Gynecol 1991)

10. What could have been done?
Anticipation
Multidisciplinary team
Preoperative cystoscopy and placement of ureteric stents may aid in identification of the ureters.
biopsy contraindicated
placement of catheters in both int iliac A
Hysterectomy by postr approach
Involved portion of bladder is resected with hyst specimen

11. Case 2:
G3P2L2 ( Prev 2 LSCS ) at 34 weeks of gestational age was admitted due to bleeding PV for 2 days
USG-SLF cephalic ,placenta, anterior low lying covering Os
With informed written consent for possibility of hysterectomy (if required)and adequate blood patient was shifted to OT for emergency caesarean section.

12. Case 2 . Per-operative details Post operative HPE- Placenta Increta
LUS was thinned out
Placenta did not separate from LUS after the delivery of baby
Bleeding ++
Decision of hysterectomy taken and done
Three units of BT done
Post operative
Uneventful
HPE- Placenta Increta

13. Have we become wiser?
Management of a case where pre-operative diagnosis was made

14. Case 3
G2P1L1 with 35 weeks and 5 days was admitted in antenatal ward in view of placenta previa with moderate anemia (no H/O bleeding PV)
Obstetric history-
1st FT LSCS for CPD 2 years back at govt. hospital
USG(8/8/2011)-SLF 29 weeks 4 days ,placenta anterior low lying covering Os
Hb-7.1

15. Case 3
After admission
USG-Placenta anterior extending to LUS, with extensive placental lakes within. Overlying myometrium intact with no evidence of placental invasion.
MRI-Myometrium grossly thinned out and placental interface with myometrium not properly visualized. Possibility of placenta accreta could not be ruled out

16. Case 3 Elective LSCS -at 37 weeks
LUS distended with increase vascularity with purple hue with boggy feeling(?placenta increta)
classical CS
Placenta did not separate
Subtotal hysterectomy done.
Bleeding from stump present.
B/L Internal Iliac Artery Ligation done.
3 units of PRBC given

17. Case 3
Post operative details
Uneventful
HPE-Placenta Increta.

18. Others risk factors
Major risk factor -Placenta previa with history of Caesarean section
previous uterine surgery,
Previous Dilatation and Curettage,
Previous Myomectomy
Asherman Syndrome (Endometrial defects)
Submucous leiomyomata
Advanced maternal age
Multiparity
Tobacco use

19. Risk association : C.S. delivery P.P 30,132 723 P.P.+ACCRETA%
30,
P.P.+ACCRETA%
No P.P. ,ACCRETA%
Hysterectomy
First
(6201)
13(3.3%)
2(0.03%)
40(0.65%)
Second
(15,808)
23(11%)
26(0.2%)
67(0.42%)
Third
(6324)
29(40%)
7(0.1%)
57(0.90%)
Fourth
(1452)
20(61%)
11(0.8%)
35(2.41%)
Fifth
(258)
4(67%)
2(0.8%)
9(3.49%)
Silver RM et al Obstet Gynecology 2006

20. 23 yr,G3P2 ,previous cesearean,shock with acute pain abdomen
23 yr,G3P2 ,previous cesearean,shock with acute pain abdomen.no USG, em laprotomy,blood loss-2 lts,HPE-placenta percreta

21. Diagnosis Clinical suspicion Ultrasound Color Doppler MRI
Biochemical Marker
Histopathology

22. Ultrasonic features
Moth eaten / Swiss Cheese appearance of placenta .

23. Ultrasonic features
Obliteration of clearspace between placenta and uterine wall

24. Ultrasonic features
Sensitivity -93%
Specificity-79%

25. Color Doppler USG High velocity and turbulent flow Sensitivity 82-100%
Specificity 92-97%
Distance <1mm between the uterine serosa-bladder interface and the retroplacental vessels
High velocity and turbulent flow
(Twickler et al 2000)

26. MR Imaging
MRI is no more sensitive than USG for diagnosing placenta accreta*
MRI is used as an adjunct to USG when there is a strong clinical suspicion of accreta**
(Yinka et al 2006)*(Lax et al 2007)**

27. Women who have had a previous CS who also have either placenta praevia or an anterior placenta underlying the old CS scar at 32 weeks of gestation are at increased risk of placenta accreta and should be managed as if they have placenta accreta, with appropriate preparations for surgery made.
(RCOG 2011)

28. Management
Elective delivery by caesarean section at 34–35 weeks of gestation for suspected placenta accreta
(AICOG 2012)

29. Lessons learnt (Pre-operative)
Prenatal imaging for placental location in previous CS
Rule out MAP in prev. CS* with pl. previa
Consent for hysterectomy
Arrange sufficient blood and component therapy
Consultant obstetrician , alert surgeons

30. Lessons learnt (Intraoperative)
NEVER PULL PLACENTA
Resort to hysterectomy SOONER RATHER THAN LATER
Uterine incision should be made vertically and above the placental insertion site.

31. POSTOP COMPLICATION Transfusion reaction ,sepsis DIC
Urinary stasis ,infection
Pelvic and renal abscess formation ,Renal compromise
ARDS
Multi organ failure
Fistula formation
Ureteral stricture

32. Uterus preserving modalities

33. Balloon catheterisation and embolisation of pelvic vessels
Expectant management
Balloon catheterisation and embolisation of pelvic vessels
Methotrexate therapy
Uterus preserving surgeries
(Charlotte et al, Arch Gynecol Obstet.2011)*

34. Balloon catheterisation /SAE
Pre-delivery consultation with the interventional radiology team
Pre-operative placement of arterial catheters in internal iliac artery
After delivery balloons are inflated to achieve temporary homeostasis
Selective arterial embolization(SAE) if necessary

35. Advantages Avoidance of hysterectomy and preservation of fertility
Lower estimated blood loss
Reduced blood transfusion
Low frequency of complications
Post procedure fever
Pelvic infection

36. SAE Disadvantages Illiac artery thrombosis Uterine necrosis Sepsis
MODS
(Gupta et al. Cochrane database Syst Rev 2006)*
Infertility for succeeding pregnancy
Fetal radiation exposure

37. Methotrexate ? controversial
It acts by inducing placental necrosis & expediting a more rapid involution of placenta.
MTX should be administered (1 mg/kg) on alternate days for a total of 4 to 6 doses*

38. Methotrexate Complication- Hemorrhage
Disseminated intrauterine infection (sepsis)
Pancytopenia
Nephrotoxicity
Failure Rate-22%

39. Expectant management Few case reports A series of 7 cases *
Placenta was left in situ,
uterus involuted spontaneously
woman returned to a normal menstrual cycle.
Placenta was never expelled but was presumably absorbed.
A series of 26 cases**
Placenta partially removed in 19/26
4/26 conservative therapy failed
(Mark Gabot et al 2010)* (Timmermans et al 2007)**

40. Follow-up management 2.- HCG titers
1.- Ultrasound exams  Vascularity
2.- HCG titers
3. Daily Temps, Other S&S of infection
4.- Bleeding
5.- Coagulation profile

41. Thank you