Placenta accreta

Definition Placenta accreta occurs when there is a defect of the decidua basalis, in conjunction with an imperfect development of the Nitabuch membrane (a fibrinoid layer that separates the decidua basalis from the placental villi) resulting in abnormally invasive implantation of the placenta The ACOG committee

According to Mudhaliar and Menon Placenta accreta is defined as the abnormal adherence,either in whole or in part,of the afterbirth to the unlying uterine wall. According to D.C.Dutta Placenta accreta in extremely rare form in which the placen is directly anchored to the myometrium partially or completely thout any intervening decidua.

Incidence From 1930 to 1950--one case in 30,000 deliveries. From 1950 to 1960, one in 19,000, deliveries. by 1980 to one in 7,000. the incidence has now risen to one in 2,500 deliveries The ACOG committee

Degrees of severity/ Types of Placenta Accreta (1) Accreta, in which the placenta adheres to the myometrium without invasion into the muscle. (2) Increta, in which it invades into the myometrium. (3) Percreta, in which it invades the full thickness of the uterine wall and possibly other pelvic structures, most frequently the bladder.

Depending on the area of involvement Total Partial Focal

Risk factors Placenta previa with or without previous uterine surgery. previous myomectomy. previous cesarean delivery. Asherman's syndrome. submucous leiomyomata. maternal age of 36 years and older.

Risk of developing placenta accreta in women with placenta previa No previous C/S 1% - 5% One previous C/S 30% Two or more C/S 40% and higher

Etiology Defective decidual formation Implantation in lower uterine segment Caesarean scar Uterine incision or curettage Manual removal of placenta Abortive agents Uterine infections

Clinical Course Maternal Serum Alpha Fetoprotein level - increased Ante partum hemorrhage Uterine rupture before labour

Diagnosis Ultrasound MRI loss of the normal hypoechogenic zone between the placenta and myometrium abnormality of the smooth interface between the uterus and bladder a Swiss-cheese appearance to the placenta, pulsatile flow of maternal blood MRI

Swiss cheese appearance

Management Partial Morbid Adherent Placenta “Playing with the placenta with fingers” Oxytocics Intrauterine plugging Hysterectomy

Total Placenta Accreta Hysterectomy Conservative : Cutting umbilical cord Antibiotics Other measures Blood replacement Uterine and internal iliac artery ligation Angiographic embolization Argon beam coagulation

A tiny angiographic catheter is maneuvered into the uterine artery in preparation for embolization

Complications Hemorrhage Shock Infection Sub involution of uterus Secondary postpartum hemorrhage Formation of placental polyp

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