adherent placenta

1. ADHERENT
PLACENTA
Advances in
Prediction
Diagnosis &
Management
DR.
KAWITA
BAPAT
INDORE

2. Welcome
to
One
Centre
for
Gynaecological
Excellence

4. INTRODUCTION
Adherent
placenta
Occurs
When
there
is
a
Defect
in
the
Decidua
Basalis
ResulDng
In
an
Abnormal
invasion
of
the
placenta
Directly
into
the
substance
of
the
uterus

5. Types
1
)
Simple
Adherent
Placenta.
2
)
Morbidly
Adherent
Placenta
:
i
)
Placenta
Accreta
ii
)
Placenta
Increta
iii)
Placenta
Percreta
DR.
KAWITA
BAPAT
5

6. INCIDENCE
Ø
It
varies
widely
all
over
the
world.
Ø Increased
dramaDcally
over
the
last
3
decades
(
Because
of
Increase
in
LSCS
rate
…
J
).
Ø
A.C.O.G.
à
1
Per
2500
deliveries.
Accreta
:
75
-­‐78
%
Increta
:
15
–
18
%
Percreta
:
5
-­‐7
%
DR.
KAWITA
BAPAT
6

7. Associated Condition :
Ø
Placenta
Previa
Ø
Previous
Surgeries
such
as
…
-­‐
Cesarean
SecDon
-­‐
D
&
C
-­‐
Myomectomy
-­‐
M.R.P.
-­‐
Synecolysis
-­‐
Cornual
ResecDon
Ø
Uterine
MalformaDon
Ø
SepDc
EndometriDs
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
7

8. Risk Factors :
Ø
High
Parity
Ø
Advanced
Maternal
Age
Ø
Down
Syndrome
Ø
High
level
of
Maternal
Serum
AFP.
Ø
High
level
of
Maternal
free
Beta
hcg.
8

9. ETIOLOGY :
Ø
Defec%ve
decidual
forma%on
:
-­‐
ParDal
/
total
absence
of
decidua
basalis
-­‐
Imperfect
development
of
fibrinoid
layer
(Nitabuch
layer)
-­‐
Placental
villi
are
acached
to
the
myometrium
9

10. Significance :
Ø
Increased
Maternal
Morbidity
(
2
–
7
%
)
Ø
Increased
Maternal
Mortality
(
7
–
10
%
)
from,
-­‐
Severe
Hemorrhage
-­‐
InfecDon
-­‐
Inversion
of
Uterus
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
10

11. InteresDngly,
the
sex
ra%o
associated
with
placenta
accreta
favors
females,
which
is
opposite
to
the
normal
sex
ra%o
in
the
general
popula%on,
which
favors
males…
J
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
11

12. DIAGNOSIS
Ø
Earliest
diagnosis
of
Adherent
Placenta
is
must
to
avoid
any
catastrophic
emergency
in
future.
Ø
Antenatal
diagnosis
is
the
single
most
important
factor
in
improving
the
outcome
in
MAP.
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
12

13. METHODS…
Ø Clinical
suspicion
Ø
Ultrasound
Ø
Color
Doppler
Ø
MRI
Ø
Biochemical
Marker
Ø
Histopathology
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
13

14. USG
•
First-­‐line
invesDgaDon
for
suspected
placental
invasion
of
the
myometrium.
•
The
most
useful
modaliDes
for
evaluaDng
placental
posiDon
and
implantaDon
are
transabdominal
and
transvaginal
ultrasonography
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
14

15. USG CRITERIA
Ø
1st
Trimester
:
G.
Sac
located
in
the
lower
uterine
segment
(rather
than
the
fundus),
next
to
or
lower
than
the
Prev.
CS
scar.
Ø
2nd
&
3rd
Trimester
:
§ Presence
of
irregular
lacunae
within
the
placenta
§ Loss
of
retro
placental
clear
space
§ Loss
or
disrupDon
of
the
white
line
–
Bladder
line
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
15

16. Moth
–
eaten
OR
Swiss
Cheese
Appearance
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
16
Oblitera%on
of
clear
space
between
placenta
and
uterine
wall

17. Reliability :
• SensiDvity
-­‐
93%
• Specificity
-­‐
79%
The
use
of
power
Doppler,
color
Doppler,
or
three-­‐
dimensional
imaging
does
not
significantly
improve
the
diagnos%c
sensi%vity
compared
with
that
achieved
by
grayscale
Ultrasonography
alone.
[
Chou
MM,
Ho
ES,
Lee
YH.
Prenatal
diagnosis
of
placenta
previa
accreta
by
transabdominal
color
Doppler
ultrasound.
Ultrasound
Obstet
Gynecol
2000;15:28–35.
]
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
17

18. 3 D USG
DiagnosDc
Criteria
:
Ø
Irregular
intraplacental
vascularizaDon
with
tortuous
confluent
vessels
crossing
placental
width.
Ø
Hypervascularity
of
uterine
serosa–
bladder
wall
interface.
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
18

19. Colour Doppler
Ø
Diffuse
or
focal
intraparenchymal
lacunar
flow.
Ø
Vascular
lakes
with
turbulent
flow.
Ø
Hypervascularity
of
serosa-­‐bladder
interface.
Ø
Prominent
subplacental
venous
complex.
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
19

20. M.R.I.
Ø
No
more
sensiDve
than
USG
,
But
used
as
an
adjunct
to
USG
,
when
there
is
strong
clinical
suspicion
of
accreta.
Ø
MRI
achieves
becer
images
than
Ultrasonography
in
-­‐
Posteriorly
sited
MAP
and
-­‐
With
prior
myomectomy,
(
Because
the
ultrasound
beam
is
impeded
by
the
fetal
head
in
the
former
and
by
the
scar
Dssue
in
the
lacer
)
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
20

21.
M.R.I. Criteria
Ø
Uterine
bulging
into
the
bladder
Ø
Heterogeneous
signal
intensity
within
the
placenta
Ø
Presence
of
intra
placental
bands
on
the
T2W
imaging
Ø Abnormal
placental
vascularity
Ø
Focal
interrupDon
of
the
myometrium
21

22. Laboratory Findings :
•
Several
series
and
case
reports
have
reported
an
associaDon
between
placenta
accreta
and
otherwise
unexplained
elevaDons
in
second
trimester
MSAFP
concentraDon
(>2
or
2.5
mulDples
of
the
median
[MOM]).
•
Although
an
elevated
MSAFP
level
supports
an
ultrasound-­‐based
diagnosis
of
placenta
accreta,
it
is
an
inconsistent
finding
and
is
not
useful
by
itself
for
diagnosis
of
accreta.
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
22

23. Histology
Ø
Post
Partum
specimen
shows
:
Placental
villi
anchored
directly
on,
or
invading
into
or
through,
the
myometrium,
without
an
intervening
decidual
plate.
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
23

24. Treatment :
A
mul%disciplinary
team
approach
is
relevant
in
managing
these
pa%ents
in
order
to
reduce
morbidity
and
mortality
associated
with
MAP.
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
24

25. Ø
ParDcular
consideraDon
should
be
given
to
anDcipaDon
and
management
of
massive
hemorrhage,
including
-­‐
availability
of
packed
cells,
-­‐
platelets,
-­‐
fresh
frozen
plasma,
-­‐
cryoprecipitate,
and
-­‐
acDvated
factor
VII.
Ø
IntervenDonal
Radiology
and
cell
saver
technology
are
useful.
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
25

26. At
present
,
placenta
accrete
can
be
managed
in
three
ways:
(
1
)
Carry
out
a
hysterectomy;
(
2
)
Leave
the
placenta
in
situ
;
and
(
3
)
Resect
the
invaded
Dssues
with
the
enDre
placenta
restoring
uterine
anatomy.
Ø
Each
one
has
weaknesses
and
strengths,
dependent
on
the
condi%on
itself
and
the
specific
preferences
taken
by
the
surgeon
and
the
team.
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
26

27. Ø
Women
who
have
had
a
previous
CS
Ø who
also
have
either
placenta
previa
or
Ø an
anterior
placenta
underlying
the
old
CS
scar
at
32
weeks
of
gestaDon
are
at
increased
risk
of
placenta
accreta
and
should
be
managed
as
if
they
have
placenta
accreta,
with
appropriate
preparaDons
for
surgery
made.
(RCOG
2011)
Ø
ElecDve
delivery
by
caesarean
secDon
at
34–35
weeks
of
gestaDon
for
suspected
placenta
accreta
(ACOG
2012).
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
27

28. Conservative
Ø
In
case
of
(
focal
defect
/
moderate
blood
Loss
/
ferDlity
to
be
preserved
)
à
Localized
ResecDon
with
uterine
repair
à
Over
sewing
of
the
ut.
Defect
à
Blunt
dissecDon
followed
by
curepng
the
uterine
cavity
Uterus
fails
to
contract
(MulDpara)
:
Hysterectomy
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
28

29. Non Surgical
Ø Leave
the
Placenta
in
situ
to
resorb
with
methotrexate
therapy
Ø LigaDon
of
the
Ut.
And
Int.
iliac
artery
Ø Fluoroscopic
bilateral
UAE
Ø Argon
beam
coagulaDon
for
haemostasis
Ø InserDon
of
occluding
Balloons
in
the
Int.
iliac
art.
(Bilat)
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
29

30. Surgical
Ø
Cesarean
Hysterectomy.
Ø
Hysterectomy
and
parDal
/
total
resecDon
of
bladder
Ø
Subtotal
Hysterectomy
with
removal
of
large
part
of
placenta
and
ProphylacDc
occlusive
Balloon
catheter
in
int.
iliac
art.
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
30

31. Ø
An
ElecDve
controlled
condiDon
is
preferred
rather
than
an
emergency
condiDon
without
adequate
preparaDons.
Ø
A
midline
incision
will
facilitate
becer
exposure,
especially
if
placenta
Percreta
is
suspected.
Ø
Leaving
the
placenta
undisturbed
unDl
compleDon
of
the
hysterectomy
would
prevent
unnecessary
hemorrhage.
Ø
In
cases
where
MAP
is
associated
with
placenta
previa,
total
hysterectomy
is
preferred
to
a
subtotal
hysterectomy.
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
31

32. Uterine Incision:
It
is
best
to
avoid
cu3ng
through
a
MAP
because
of
the
possibility
of
massive
haemorrhage.
32

33. DR.
KAWITA
BAPAT
33
Various
modificaDons
of
the
uterine
incision
to
avoid
the
placenta
have
been
reported…
-­‐
Classical
incision,
-­‐
High
transverse
incision,
-­‐
Fundal
incision,
-­‐
Fundal
transverse
incision

34. remember
Ø
The
presence
of
pericervical
or
lower-­‐segment
varicose
veins
proper
of
placenta
praevia
can
be
confused
with
the
neovascularizaDon
of
placenta
accreta.
Ø
Surgical
exploraDon
will
make
a
differenDal
diagnosis,
thus
avoiding
unnecessary
hysterectomies.
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
34

35. Excision of placental site
Ø
It
is
possible
to
"excise
the
placental
site".
Ø
This
is
done
by
inverDng
the
uterus
in
order
to
provide
good
access
to
the
placental
site.
Ø
If
the
area
of
placental
acachment
is
focal
and
the
majority
of
the
placenta
has
been
removed,
then
a
"wedge
resecDon"
of
the
area
can
be
performed.
DR.
KAWITA
BAPAT
35

36. Balloon Catheterization
Ø Pre-­‐operaDve
placement
of
arterial
catheters
in
internal
iliac
artery
Ø Aser
delivery
balloons
are
inflated
to
achieve
temporary
homeostasis
Ø SelecDve
arterial
embolizaDon
(SAE)
if
necessary
Ø Bil.
Int.
iliac
artery
ligaDon
is
performed
prior
to
peripartum
hysterectomy
where
IntervenDonal
Radiology
is
not
available.
DR.
KAWITA
BAPAT
36

37. Placement
of
occlusion
balloon
catheters
into
both
internal
iliac
arteries.
DR.
KAWITA
BAPAT
37

38. Methotrexate
Ø
A
Folate
Antagonist
Ø Acts
primarily
against
rapidly
dividing
cells
Ø EffecDve
against
proliferaDng
trophoblasts.
Ø Arulkumaran
et
al
in
1986.
Ø Intravenous
infusion
50
mg
of
methotrexate
as
an
on
alternate
days
Ø Placental
mass
was
expelled
on
11th
postnatal
day.
DR.
KAWITA
BAPAT
38

39. Methotrexate
Ø However,
more
recently,
Ø
others
have
argued
that,
aser
delivery
of
the
fetus,
the
placenta
is
no
longer
dividing
and
therefore,
methotrexate
is
of
no
value.
DR.
KAWITA
BAPAT
39

40. Ø
Methotrexate
has
been
used
in
varying
doses
and
routes,
however,
there
are
no
randomized
trials
and
no
standard
protocol
regarding
its
dosage.
Ø
The
outcome
when
the
placenta
is
les
in
place
aser
methotrexate
administraDon
varies
widely;
it
ranges
from
expulsion
at
7
days
to
progressive
resorpDon
in
roughly
6
months.
Ø
Mtx
–
50
mg
IM
+
Folic
Acid
6mg
IM
on
alternate
day
Dll
β
HCG
comes
to
zero.
3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
40

41. Other Modalities
1. Tamponade
of
the
placental
implantaDon
site
with
inflated
Intra
Uterine
balloon
catheter
bags.
2. Lower
Segment
Compression
Sutures.
3. Pelvic
pressure
sponge
packing.
DR.
KAWITA
BAPAT
41

42. Follow up…
1.-­‐
Ultrasound
exams
&
Vascularity
2.-­‐
HCG
Dters
weekly
Dll
become
Zero.
3.-­‐
Daily
Temps,
Other
S&S
of
infecDon
4.-­‐
Bleeding
5.-­‐
CoagulaDon
profile
AnDbioDc
Maximum
for
10
days.
DR.
KAWITA
BAPAT
42

43. 3-­‐Feb-­‐19
Dr
Shashwat
Jani.
99099
44160.
43
Resources
Pa:ent,
clinical
and
anatomic
features
Decision
Defini:ve
treatment
• Limited
experience
or
experDse
• Poor
resources
• no
faciliDes
for
safe
paDent
transfer
ü lower
segment
invasion
ü vaginal
bleeding
with
high
suspicion
of
accreta
ü Possibility
of
percreta
• Extraplacental
hysterotomy
• Placental
les
in
situ
• Followed
by
uterine
closure
Delayed
hysterectomy
or
conservaDve
procedure
according
clinical
and
surgical
status
• Qualified
Experienced
team
• Adequate
hospital
resources
Ø No
desire
for
future
pregnancy
Ø Tissue
destrucDon>
50%
of
uterine
circumference
Ø Intractable
haemorrhage
Ø DIC
ResecDve
surgery
Subtotal
hysterectomy
for
upper
segment
lesions
Total
hysterectomy
for
lower
segment
and
cervical
involvement
• Qualified
and
experienced
team,
• Adequate
Ø Desire
for
future
pregnancy
Ø DestrucDon
<
50%
of
uterineaxial
circumference
Ø Minor
coagulaDon
disorders
ConservaDve
surgery
1-­‐Placenta
in
situ
with
or
wit
MXT
2-­‐One
step
surgery
OR
3-­‐
Two
step
surgery

44. Bladder Involvement
Ø
First
,
Involve
UROLOGIST
Ø
PreoperaDve
Ureteric
stenDng
aids
in
idenDfying
the
ureters
Ø
which
will
help
reduce
ureteric
injuries
44

45.
Care
must
be
taken
during
surgery
Ø Not
to
acempt
to
dissect
the
bladder
off
the
lower
uterine
segment
Ø which
results
in
torrenDal
bleeding
Ø
Anterior
bladder
wall
incision
is
parDcularly
helpful
in
defining
dissecDon
planes
and
the
locaDon
of
the
ureters
DR.
KAWITA
BAPAT

46. Reality :
• Even today, the ground reality is that a
majority of morbidly adherent placenta are
diagnosed during
• Third stage of labour
• During caesarean section
• which results in adverse consequences
including exanguinating haemorrhage.

47. To Conclude
Ø
Caesarean
hysterectomy
was
the
cornerstone
in
the
management
in
the
Past.
Ø
Antenatal
diagnosis
permits
effecDve
and
safe
conservaDve
approaches
Today.
Ø
The
use
of
methotrexate,
monitoring
with
serum
hCG
and
follow
up
with
USG
is
backed
only
by
conflicDng
evidence.
DR.
KAWITA
BAPAT
47

48. 3-­‐Feb-­‐19
48
Dr
Shashwat
Jani.
9909944160