Placenta Accreta -Spectrum
Gaurav Kumar
Roll no. 46
Batch 2020
Introduction
• It is also known as morbidly adherent placenta
• It is the invasion of placenta directly to myometrium
without any intervening decidua basalis
• Incidence:- 3 per 1000 deliveries
Types
1. Placenta Accreta- MC variety –villi are attached
superficially to myometrium
2. Placenta Increta- villi infilterate into myometrium
3. Placenta Percreta- villi infilterate into serosa
Risk factors
• Placenta previa
• Prior cesarean delivery
It increase from 3% with prior no CD to 40% with
prior two CD and as much as 61% with prior 3 CD
• Previous history of PAS
Diagnosis
• Early diagnosis can prevent maternal complication like
hemorrhage and blood transfusion
• Ultrasonograohy(USG)
1. Large placental lacunae
2. Absence of normal hypoechoic placental and myometrial
zone
3. Thinning of retro placental myometrium
4. Bridging vessels from placenta to bladder serosa interface
5. Disruption of uterine and bladder interface
• 3D Power Doppler
• MRI:-
1. Uterine bulging
2. Heterogeneous placental signals
3. Myometrial thinning
4. Placental protrusion
Management
• PAS is ideally managed by multidisciplinary team involving
obstetrician,neonatologist,anesthesist,pelvic surgeon and urologist
• Delivery is planned with prior arrangement of surgical team
members and availability of resources
• It is often associated with massive hemorrhage leading peripartum
hysterectomy and at times maternal death
PRACTICAL GUIDE FOR CESAREAN DELIVERY
• The operation should be performed by a senior obstetrician
• Choice of anesthesia is to be made by the anesthetist(GA)
• If the patient is in hypovolemic state and the bleeding continues, the
operation has to be performed immediately
• Counseling and consent for possible other interventions (hysterectomy)
should be taken.
• Blood and blood products should be made available
• Availability of a bed in a critical care unit to be ensured
• Interventional radiology service is of help, especially in a case with
placenta previa and accreta.
Type of incision:-
[Link] cesarean section:
Advantages:
(1) The operation can be done more quickly
(2) Baby is delivered without disturbing the placenta
(3) There is no risk of fetal exsanguination
(4) Placenta may be left in situ (in case of placenta accreta) if no
bleeding and
uterus may be preserved
(5) Reduction of morbidity in terms of hemorrhage,blood transfusion,
admission and urological injury
Disadvantages:
(1) The lower segment over which the placenta is implanted
cannot be visualized and as such, it is difficult to control bleeding
when it is present.
(2) All the hazards (immediate and remote) of classical cesarean
Immediate : PPH,Shock,Anesthetic hazards,Infections
Remote: Gynecological,Surgical,Future pregnancy
2. Lower segment cesarean section :
Advantages:
(1) Conversant technique
(2) Placenta accreta, if accidentally met, can also be tackled
effectively
(3) The bleeding sinuses at the placental site can be better dealt
with under direct vision and as such the decision to preserve or
to remove the uterus can easily be made
Disadvantages:
1. Engorged vessels on the anterior lower segment (anterior
placenta previa) bleed profusely when they are cut
2. In anteriorly situated placenta, the placenta has to be cut or
separated to deliver the baby. This causes massive hemorrhage
3. Risks of cesarean hysterectomy is high in such a case
4. The edges of uterine cut margins become so vascular and
friable, that the tissues may cut through during suturing
Bibliography
• DC Dutta’s Textbook of OBSTETRICS
