PLACENTA ACCRETA

Definition :
Placenta

Accreta is an intrapartum complication characterized by the abnormal implantation of the placenta. Normally, chorionic villi attaches to the uterine endometrium. With this complication, the point of attachment extends to the layers of myometrium.

Review of Related Anatomy and Physiology

Uterus,the pear-shaped hollow muscular organ, houses the fetus until delivery. This structure has three layers namely: the perimetrium, myometrium and endometrium. Perimetrium the outermost layer that covers the uterus. (Peri means outside) Myometrium located at the middle part of uterus. Myo denotes muscle, thus, this layer contains thick muscular layers. Endometrium the innermost layer that responds to hormonal variations (estrogen and progesterone) during the menstrual cycle.

 The

chorionic villi (finger-like projections that attaches to the uterine wall)penetrates into this portion of the uterus during implantation. (Endo means inside) In a female reproductive cycle, the uterine endometrium normally sloughs off the thickened vascular surface that precedes the actual secretion of blood flow. With fertilization, it continues to be crammed with blood to accommodate and nourish the embryo.

Types of Placenta Accreta

This obstetric complication is categorized depending on the depth of its attachment: Placenta Accreta chorionic villiattaches deeply into the uterine wall butdoes not penetrate the myometrium.This is the most common form of the condition. (Accreta starts with letterA, so itAttaches) Placenta Incretachorionic villiinvades or infiltrates the muscular layer. (Increta starts with letterI,so itInvades/Infiltrates) Palcenta Pancreta/Percretachorionic villipenetrates beyond the myometriuminto the entire uterine wall and possibly to other adjacent organs such as the bladder.This is the least common of the three conditions. (Pancreta starts with letterP,so itPenetrates)

Type

Description

Percent

placenta accreta

placenta increta

Aninvasionofthe 7578% myometriumwhichdoes notpenetratetheentire thicknessofthemuscle. Thisformofthe Occurswhenthe conditionaccountsfor 17% placentafurtherextends around75%ofallcases. intothemyometrium.

Type

Description Percent

placenta percreta

Theworstformofthe conditioniswhenthe placentapenetrates theentiremyometrium totheuterineserosa (invadesthrough entireuterinewall). Thisvariantcanlead totheplacenta attachingtoother organssuchasthe rectumorbladder

Predisposing Factors
Scarring

of tissues from previous infection Previous uterine surgery (Dilation and Curettage, Cesarean Section, Myomectomy) Thin decidua or absent deciduas basalis Presence of tumor

Complications
Uterine

rupture Massive bleeding Disseminated intravascular coagulation (DIC) Diagnostic test Ultrasound MRI

Signs and Symptoms

Usually

signs and symptoms are not detected until labor and delivery. However, for some third trimester bleeding would be noted. During labor and delivery massive bleeding is observed. In cases when deciduas basalis is absent, the placenta will not loosen and fails to be delivered.

Medical Management
Conservative treatment is done if the woman wants to maintain her fertility under the condition that no active bleeding is present. This treatment saves the uterus but poses higher risk of complications and low successful rate. Techniques for this treatment are as follows: The placenta is left in the uterus and the cord is ligated. Closure of the uterus is performed.

Treatment
The

safest treatment is a planned caesarian section and abdominal hysterectomy if placenta accreta is diagnosed before birth If it is important to save the woman's uterus (for future pregnancies) then resection around the placenta may be successful If the woman decides to proceed with a vaginal delivery, blood products for transfusion should be prepared.

Methotrexate(an antineoplastic agent) is usually given to the woman to destroy the still attached placenta. Women taking Methotrexate should be monitored for: WBC and platelet count (thrombocytopenia and leucopenia may occur 7-14 days after the initiation of treatment) Blood Urea Nitrogen (BUN), Creatinine, and urine pH (should be above 7.0) Presence of dry and nonproductive cough may be an early sign of pulmonary toxicity

Prepared by: Demi Rose Z. Bolivar L-BSN3A