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| Rajiv Mahendru* and Saloni Bansal | |
| Dept of Obstetrics and Gynaecology, BPS Govt Medical College for Women, Khanpur Kalan (Sonepat), Haryana, India | |
| *Corresponding Author : | Rajiv Mahendru Professor and Head, Deptt of Obstetrics and Gynaecology BPS Govt Medical College for Women Khanpur Kalan(Sonepat), Haryana, India Tel: 91 9416086483 E-mail: dr.rmahendru@gmail.com |
| Received date: Feb 11, 2016; Accepted date: Mar 26, 2016; Published date: April 6, 2016 | |
| Citation: Mahendru R, Bansal S (2016) Placenta Accreta: Then and Now. J Preg Child Health 3:e124. doi:10.4172/2376-127X.1000e124 | |
| Copyright: © 2016 Mahendru R, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. | |
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| An Overview |
| Placenta that is morbidly adherent is considered as an abnormal placentation leading to its firm attachment to the myometrium and hence incomplete separation at the time of delivery. There is absence of the decidua basalis and incomplete development of the Nitabuch's layer. |
| Types |
| Three forms have been described depending upon the depth of penetration - placenta accreta, placenta increta and placenta percreta. Placenta accreta is the term used when a part of the placenta or the entire placenta invades and is inseperable from the uterine wall. Whereas if the chorionic villi invade only the myometrium it is described as placenta increta, but if the invasion is through the myometrium and serosa, sometimes might also involve the adjacent organs then it is the placenta percreta. |
| Incidence |
| The incidence of placenta accrete is on a continuous rise paralleling the rise in the rate of caesarean deliveries. Reported incidence is 1 in 533 pregnancies, which was much less 1 in 4027 pregnancies in 1970’s, rising to 1 in 2510 pregnancies in 1980’s. |
| Risk Factors |
| Multiple risk factors have been defined for the same like previous caesarean section, myomectomy, asherman’s syndrome following dilatation and curettage, increasing maternal age, multiparity, congenital and acquired uterine defects (Uterine septa, Leiomyoma, Cornual pregnancy), thermal ablation and UAE. With every additional caesarean section risk increases, being 24% with one and 67% with 4 C.S. |
| Risks Involved |
| Placenta accrete is a problematic condition as placenta might not separate completely from the uterine wall at the time of delivery and be a source of massive PPH amounting to mammoth transfusions and even hysterectomy. Average calculated loss is 3000-5000ml, which needs atleast more than 10 units of blood transfusion in 40% of cases. List of complications goes on like Disseminating Intravascular Coagulations (DIC), Transfusion reactions, Electrolyte imbalance, Surgical complications (bowel injury, urological injuries etc.), Pulmonary embolism, Adult Respiratory Distress Syndrome (ARDS), Renal failure and ultimately maternal death in as many as 7% cases. |
| Management |
| Diagnosis |
| The risk of potential life threatening complications makes the timely and accurate diagnosis of utmost importance. Ultrasonography supplemented by magnetic resonance imaging help in establishing the diagnosis for planning a multidisciplinary approach for delivery so as to reduce maternal and neonatal morbidity and mortality. With a high index of suspicion based on history ultrasound has a sensitivity of 50-80%, specificity 95-98% and positive predictive value 65-93%. About 88% of accretas are associated with placenta praevia which further insist a detailed evaluation. Loss of placental-myometrial interface, thinning of anterior myometrium to less than 1mm, placental lacunae and bulging of placenta into bladder on 2-D ultrasound points towards placenta accrete. Further color Doppler (Figure 1)finding of increased vascularity, turbulent flow in lacunaes and disruption of continuous color flow resulting in gap in myometrial blood flowon mapping supports the suspicion.MRI is more costly and requires both experience and expertise, however when there are ambiguous ultrasound findings, suspicion of posterior placenta accrete, MRI is required. Most useful findings on MRI are uterine bulging, heterogenous signal intensity within the placenta, dark intraplacental bands on T2 weighted images, focal interruptions in the myometrial wall, tenting of the bladder and direct visualization of placental invasion of the adjacent structures. Controversy still surrounds the use of gadolinium contrast enhancement for the matter of fetal safety concerns. |
| Treatment |
| Delivery should be considered at a tertiary care centre with involvement of multiple specialities like expert obstetrician, anaesthesiologist, neonatologist, urologist, haematologist and intervention radiologist. Delivery should be timed in best interest of mother and fetus with a thorough discussion among the parents, obstetrician and neonatologist. Planned elective delivery should be the goal and both neonatal and maternal concerns are optimized when delivered at 34 completed weeks. Counselling about the risk of profuse haemorrhage, need for hysterectomy and chances of maternal death is an important issue. Operating room needs to be fully equipped. Prior ultrasound mapping for the placental attachment site to decide for uterine incision extension needs to be done. Prophylactic antibiotics, pneumatic compression stockings, preoperative placement of ureteral stents to avoid inadvertent injury to urinary tract and may be three way Foley catheter to allow drainage, irrigation and distension during dissection should be considered. Adequate quantities of blood and blood products should be available in hand and blood bank should be kept informed of the need for massive blood transfusions. Because the procedure is anticipated to be prolonged care should be taken for proper positioning, padding (to avoid nerve compression) and vaginal estimation of blood loss as well apart from abdominal site. Put the patient on the operating table in a modified dorsal lithotomy position with left lateral tilt to allow for assessment of vaginal bleeding, access for vaginal pack and extra space for surgical assistant. Abdomen is opened by midline vertical incision to allow for sufficient exposure and surgical procedures. Classical uterine incision is employed to deliver the fetus in an attempt to avoid placenta. Allow for spontaneous placental separation, any forced attempts may call for massive haemorrhage. Surgical approach needs to be individualized depending upon the future fertility needs. Once accrete is confirmed and future fertility is not an issue, safest option is to go ahead with hysterectomy. One owes to be vigilant for increased vascularity and bladder dissection which can be performed little latter after ligating the uterine arteries. Subtotal hysterectomy may be a safe option sometimes but continuous bleeding from cervix makes total hysterectomy necessary. |
| Conservative approach |
| In case of strong desire for future fertility a more conservative approach, with leaving the placenta in situ while cutting the cord as close is an option, but only when patient is hemodynamically stable and is ready to accept the potential complications. Additional procedures for minimizing vascularity might be necessary like –stepwise devascularisation and arterial embolization. Uterine artery embolization has been relatively successful in controlling PPH in approximately 95% of cases. Also preoperative prophylactic internal iliac artery embolization apparently reduces blood loss and transfusion requirements. Gelatin sponge particles, used for the same provide transient vascular blockade from 2-4 weeks. Use of endovascular coiling has also been reported. Occlusion balloons can be placed from as proximal as aorta to more distally within the anterior division of the internal iliac arteries. Further methotrexate is a viable option postoperatively, although no convincing data available as yet, while patient needs to be on a regular Bhcg follow-up. Sometimes latter the placenta might shed off itself or needs a hysteroscopic approach. Patient should be counselled for the need of emergency hysterectomy even with the conservative approach and a guarded opinion about future fertility. Uterine artery embolization has also been probed preoperatively to reduce vascularisation; however available data are insufficient on its utility [1-6]. |
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| Figure 1 |
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