Dr LEENA WADHWA

DR. SANGEETA GUPTA

DR. MANJU PURI

Placenta Accreta-Lessons Learnt

Maternal Mortality-Magnitude and Causes

Haemorrhage,

38%

Sepsis, 11%

Abortion, 8%

Other

Conditions,

34%

Obstructed

Labour, 5% Hypertensive

disorders, 5%

About 28 million pregnancies and 67,000 maternal deaths per

year in India

Source: RGI-SRS 2001-03

* Other Conditions includes Anemia.

Source: RGI-

SRS 2001-03

Placenta accreta/ increta/ percreta

Significant cause of maternal

morbidity and mortality

significant maternal hemorrhage at

delivery

Mortality rate -7 -10% (O brien et al AM J Obstet Gynecol 1996)

Most common reason for emergency postpartum

hysterectomy.

Incidence -increasing(secondarily to the rise of

Caesarean section)

1970 1/7000

1985 - 1994 - 1/ 2,510**

1992 - 2002- 1/ 533 ***

**(Miller- Am J Obstet Gynecol 1996 )

***(Wu et al Am J Obstet Gynecol 2005)

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

Case 1 hysterotomy done and fetus delivered

fails to recognize percreta going into bladder & anticipate complications

tries partial MRP hysterectomy with difficulty by 2 consultantsuncontrollable hgg from bladder-cystectomy & B/L Int iliac art ligation

6 units Blood

Patient died in ICU

Case 1

HPE- Placental tissue invading the full thickness

myometrium and the overlying serosa.(placenta

percreta)

‘Placenta accreta mindedness’

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)

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

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.

Case 2.

Per-operative details

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

Have we become wiser?

Management of a case where pre-operative

diagnosis was made

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

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

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

Case 3

Post operative details

Uneventful

HPE-Placenta Increta.

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

Risk association :

C.S. delivery P.P

30,132 723

P.P.+ACCRETA

%

No P.P.

,ACCRETA%

Hysterectomy

First 398

(6201)

13(3.3%) 2(0.03%) 40(0.65%)

Second 211

(15,808)

23(11%) 26(0.2%) 67(0.42%)

Third 72

(6324)

29(40%) 7(0.1%) 57(0.90%)

Fourth 33

(1452)

20(61%) 11(0.8%) 35(2.41%)

Fifth 6

(258)

4(67%) 2(0.8%) 9(3.49%)

Diagnosis

Clinical suspicion

Ultrasound

Color Doppler

MRI

Biochemical Marker

Histopathology

Ultrasonic features Moth eaten / Swiss

Cheese appearance of

placenta .

Ultrasonic featuresObliteration of clearspace

between placenta and

uterine wall

Ultrasonic features

Sensitivity -93%

Specificity-79%

Color Doppler USG 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)

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)**

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)

Management

Elective delivery by caesarean section at 34–35

weeks of gestation for suspected placenta accreta

(AICOG 2012)

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

NEVER PULL PLACENTA

Resort to hysterectomy SOONER RATHER THAN LATER

Uterine incision should be made vertically and above the placental insertion site.

Lessons learnt (Intraoperative)

POSTOP COMPLICATION

Transfusion reaction ,sepsis

DIC

Urinary stasis ,infection

Pelvic and renal abscess formation ,Renal compromise

ARDS

Multi organ failure

Fistula formation

Ureteral stricture

Uterus preserving modalities

Expectant management

Balloon catheterisation and embolisation of pelvic

vessels

Methotrexate therapy

Uterus preserving surgeries

(Charlotte et al, Arch Gynecol Obstet.2011)*

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

Advantages

1. Avoidance of hysterectomy and preservation of

fertility

2. Lower estimated blood loss

3. Reduced blood transfusion

4. Low frequency of complications

1. Post procedure fever

2. Pelvic infection

SAE Disadvantages

Illiac artery thrombosis Uterine necrosis Sepsis MODS(Gupta et al. Cochrane database Syst Rev 2006)*

Infertility for succeeding pregnancy

Fetal radiation exposure

(Gupta et al. Cochrane database Syst Rev 2006)*

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*

Methotrexate

Complication-

Hemorrhage

Disseminated intrauterine infection (sepsis)

Pancytopenia

Nephrotoxicity

Failure Rate-22%

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)**

Follow-up management

1.- Ultrasound exams Vascularity

2.- HCG titers

3. Daily Temps, Other S&S of infection

4.- Bleeding

5.- Coagulation profile

Thank you