Morbidly Adherent

Placenta

By S Manisha
(CRRI)
- Characterized by abnormally
implanted,invasive,or adherent placenta

- Also called accrete syndromes i.e to adhere or

become attach to
CLASSIFICATIO
Based on depth of trophoblastic
N growth

1. Placenta accreta- villi attached to

myometrium- 80%

2. Placenta increta-villi invade

myometrium-15%

3. Placenta percreta-villi penetrate

through myometrium and to or
through serosa- 5%
 PLACENTA ACCRETA

abnormal adherence if all or part of single lobule

involving all lobe is abnormally attached

total placenta focal placenta

accreta accreta
• Recurrence is high
• If hysterectomy avoided, 20%
incidence of recurrence
• Risk of placenta previa/uterine
rupture/ hysterectomy
 myometrial
trauma- curettage 8 fold higher
or endometrial withbMSAPP
ablation level>2.5MoM

prior c/section or
associated previa combination of both

RISK FACTORS
4fold higher with
classical hysterotomy has
beta hcg >2.5MoM
higher risk
 • PATHOGENESIS
- partial/total absence of decidua basalis and imperfect
development of fibrinoid/nitabuch layer
- abnormal placental adherence
- if decidual spongy layer lacking either partially or totally
- physiological line of cleavage is absent so some/all
cotyledons densely anchored
- microscopically-villi attached to smooth muscle fibre
- hence this decidual deficiency prevents normal placental
separation after delivery
 CLINICAL PRESENTATION
AND DIAGNOSIS
1st and 2nd trimester-

1.haemorrhage-consequence of co existing previa

2.if no previa then in some it is not identified until 3rd
stage
3.ideally USG is used for identification-1st trimester
measurement of smallest myometrial thickness can be
used to predict necessity for peripartum hysterectomy
4.other findings in USG -
loss of normal hypoechoeic
retroplacental zone b/w
placenta and uterus,
placental vascular lacunae
and placental bulging
into posterior bladder wall
trans abdominal sonogram
of placenta percreta -
multiple and massive
placental lakes or lacunae
• doppler color flow
imaging has a high
predictive value-
suspected if distance b/w
uterine serosa and
bladder wall interface and
retroplacental vessel
• measures <1mm and if
there are large
intraplacental lacunae
MANAGEMENT
 3 Ps

- Peri-operative placental edge localisation

- Pelvic devascularization
- Placental non separation with
myometrial excision and repair
- planned delivery in a tertiary center
- criteria for consideration of delivery in an Accrete
center of excellance
1.suspicion of mrobidly adherent placenta on USG
2.placenta previa with abnormal USG appearance
3.placenta previa with>3or =3 prior c/section
4.prior classical c/section and ant placentation
5.prior endometrial ablation or pelvic irradiation
6.inability to adequately evaluate or exclude placenta
accreta
7.any other reason to suspect morbidly adherent
placenta
 timing of delivery- 34-37wks
•
pre op prophylactic catheterisation
1.ureteral catherterisation - aid in
dissection/identification/repair
2.balloon tipped intra arterial catheters - in internal
iliac artery , after delivery they
are inflated to occlude pelvic blood flow
- complication-thrombosis to common/left iliac
artery
• - no obvious benefits seen
 Cesarian Delivery and Hysterectomy
• after fetal delivery extent of placental invasion is
assesed without attempts at
manual removal

• obvious percreta / increta - hysterectomy is

best and placenta is left insitu
for blood loss-blood replacement therapy and other measure
like uterine/internal
• iliac artery ligation , balloon occlusion or embolisation
can be thought
 CONSERVATIVE
TREATMENT
- if abnormal placentation was not suspected before c/section
or -- if women has strong desire for fertility even after
counselling
- if bleeding stops, trim the umbilical cord,repair
hysterotomy incision and
leave the placenta insitu
donot pursue hysterectomy
in such case placenta spontaneously gets reabsorbed by 1-12
months(average by 6 months)
COMPLICATIONS: Sepsis,DIC,Pulmonary
embolism, AV Malformation

- Eventually may end up in hysterectomy

days/week after post partum when blood loss
would be less

- Serial USG/ MR is recommended in follow

up
S
T
A
Y

S
A
F
E