1. Adherent placenta occurs when there is a defect in the decidua basalis, resulting in abnormal invasion of the placenta directly into the uterus. 2. Diagnosis is usually made using ultrasound and MRI to detect irregularities in the placenta and loss of tissue planes between the placenta and uterus. 3. Treatment depends on the extent of invasion and patient desires, ranging from conservative surgeries like resection to hysterectomy, with the goal of managing blood loss and preserving the uterus if possible.

1. ADHERENT PLACENTA
Diagnosis & Management
Dr. Shashwat K. Jani.
M. S. ( Obs – Gyn )
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : 99099 44160.
E-mail : drshashwatjani@gmail.com

2. 22-Dec-14 Dr Shashwat Jani. 9909944160 2
Greetings From Ahmedabad …

3. INTRODUCTION
Adherent placenta occurs
when there is a defect in the decidua basalis ,
Resulting
in an abnormal invasion of the placenta
directly into the substance of the uterus.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 3

4. Types
1 ) Simple Adherent Placenta.
2 ) Morbidly Adherent Placenta :
i ) Placenta Accreta
ii ) Placenta Increta
iii) Placenta Percreta
22-Dec-14 Dr Shashwat Jani. 99099 44160. 4

5. INCIDENCE
 It varies widely all over the world.
Increased dramatically over the last 3 decades
( Because of Increase in LSCS rate …  ).
 A.C.O.G.  1 Per 2500 deliveries.
Accreta : 75 -78 %
Increta : 15 – 18 %
Percreta : 5 -7 %
22-Dec-14 Dr Shashwat Jani. 99099 44160. 5

6. Associated Condition :
 Placenta Previa
 Previous Surgeries such as …
- Cesarean Section - D & C
- Myomectomy - M.R.P.
- Synecolysis - Cornual Resection
 Uterine Malformation
 Septic Endometritis
22-Dec-14 Dr Shashwat Jani. 99099 44160. 6

7. Risk Factors :
 High Parity
 Advanced Maternal Age
 Down Syndrome
 High level of Maternal Serum AFP.
 High level of Maternal free Beta hcg.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 7

8. ETIOLOGY :
 Defective decidual formation :
- Partial / total absence of decidua basalis
- Imperfect development of fibrinoid layer
(Nitabuch layer)
- Placental villi are attached to the myometrium
22-Dec-14 Dr Shashwat Jani. 99099 44160. 8

9. Significance :
 Increased Maternal Morbidity ( 2 – 7 % )
 Increased Maternal Mortality ( 7 – 10 % )
from,
- Severe Hemorrhage
- Infection
- Inversion of Uterus
22-Dec-14 Dr Shashwat Jani. 99099 44160. 9

10. Interestingly,
the sex ratio associated with placenta
accreta favors females, which is opposite to
the normal sex ratio in the general
population, which favors males…

22-Dec-14 Dr Shashwat Jani. 99099 44160. 10

11. DIAGNOSIS
 Earliest diagnosis of Adherent
Placenta is must to avoid any
catastrophic emergency in future.
 Antenatal diagnosis is the single
most important factor in improving the
outcome in MAP.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 11

12. METHODS…
 Clinical suspicion
 Ultrasound
 Color Doppler
 MRI
 Biochemical Marker
 Histopathology
22-Dec-14 Dr Shashwat Jani. 99099 44160. 12

13. USG
• First-line investigation for
suspected placental invasion of the
myometrium.
• The most useful modalities for
evaluating placental position and
implantation are transabdominal and
transvaginal ultrasonography
22-Dec-14 Dr Shashwat Jani. 99099 44160. 13

14. USG CRITERIA
 1st Trimester :
G. Sac located in the lower uterine segment
(rather than the fundus), next to or lower than
the Prev. CS scar.
 2nd & 3rd Trimester :
 Presence of irregular lacunae within the placenta
 Loss of retro placental clear space
 Loss or disruption of the white line – Bladder line
22-Dec-14 Dr Shashwat Jani. 99099 44160. 14

15. Moth – eaten
OR
Swiss Cheese
Appearance
22-Dec-14 Dr Shashwat Jani. 99099 44160. 15
Obliteration of clear space
between placenta and
uterine wall

16. Reliability :
• Sensitivity - 93%
• Specificity - 79%
The use of power Doppler, color Doppler, or three-
dimensional imaging does not significantly improve
the diagnostic sensitivity 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. ]
22-Dec-14 Dr Shashwat Jani. 99099 44160. 16

17. 3 D USG
Diagnostic Criteria :
 Irregular intraplacental vascularization
with tortuous confluent vessels crossing
placental width.
 Hypervascularity of uterine serosa–
bladder wall interface.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 17

18. Colour Doppler
 Diffuse or focal
intraparenchymal
lacunar flow.
 Vascular lakes with
turbulent flow.
 Hypervascularity of
serosa-bladder
interface.
 Prominent
subplacental venous
complex.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 18

19. M.R.I.
 No more sensitive than USG , But used as an adjunct
to USG , when there is strong clinical suspicion of
accreta.
 MRI achieves better 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 tissue in the latter )
22-Dec-14 Dr Shashwat Jani. 99099 44160. 19

20. M.R.I. Criteria
 Uterine bulging into the
bladder
 Heterogeneous signal
intensity within the placenta
 Presence of intra placental
bands on the T2W imaging
Abnormal placental vascularity
 Focal interruption of the
myometrium
22-Dec-14 Dr Shashwat Jani. 99099 44160. 20

21. Laboratory Findings :
• Several series and case reports have reported
an association between placenta accreta and
otherwise unexplained elevations in second
trimester MSAFP concentration (>2 or 2.5 multiples
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.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 21

22. Histology
 Post Partum specimen shows :
Placental villi anchored directly on, or invading into
or through, the myometrium, without an intervening
decidual plate.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 22

23. Treatment :
A multidisciplinary team approach is relevant
in managing these patients in order to reduce
morbidity and mortality associated with MAP.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 23

24.  Particular consideration should be given to
anticipation and management of massive
hemorrhage,
including
- availability of packed cells,
- platelets,
- fresh frozen plasma,
- cryoprecipitate, and
- activated factor VII.
 Interventional Radiology and cell saver
technology are useful.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 24

25. 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 tissues with the entire placenta
restoring uterine anatomy.
 Each one has weaknesses and strengths,
dependent on the condition itself and the specific
preferences taken by the surgeon and the team.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 25

26.  Women who have had a previous CS who also
have either placenta previa or an anterior placenta
underlying the old CS scar at 32 weeks of gestation
are at increased risk of placenta accreta and should
be managed as if they have placenta accreta, with
appropriate preparations for surgery made.
(RCOG 2011)
 Elective delivery by caesarean section at 34–35
weeks of gestation for suspected placenta accreta
(ACOG 2012).
22-Dec-14 Dr Shashwat Jani. 99099 44160. 26

27. Conservative
 In case of
( focal defect / moderate blood Loss / fertility to be
preserved )
 Localized Resection with uterine repair
 Over sewing of the ut. Defect
 Blunt dissection followed by curetting the uterine
cavity
Uterus fails to contract (Multipara) :
Hysterectomy
22-Dec-14 Dr Shashwat Jani. 99099 44160. 27

28. Non Surgical
Leave the Placenta in situ to resorb with
methotrexate therapy
Ligation of the Ut. And Int. iliac artery
Fluoroscopic bilateral UAE
Argon beam coagulation for haemostasis
Insertion of occluding Balloons in the Int. iliac
art. (Bilat)
22-Dec-14 Dr Shashwat Jani. 99099 44160. 28

29. Surgical
 Cesarean Hysterectomy.
 Hysterectomy and partial / total resection of
bladder
 Subtotal Hysterectomy with removal of large part
of placenta and Prophylactic occlusive Balloon
catheter in int. iliac art.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 29

30.  An Elective controlled condition is preferred
rather than an emergency condition without
adequate preparations.
 A midline incision will facilitate better exposure,
especially if placenta Percreta is suspected.
 Leaving the placenta undisturbed until
completion of the hysterectomy would prevent
unnecessary hemorrhage.
 In cases where MAP is associated with placenta
previa, total hysterectomy is preferred to a subtotal
hysterectomy.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 30

31. Uterine Incision:
It is best to avoid cutting through a
MAP because of the possibility of massive
haemorrhage.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 31

32. 22-Dec-14 Dr Shashwat Jani. 99099 44160. 32
Various modifications of the uterine
incision to avoid the placenta have been
reported…
- Classical incision,
- High transverse incision,
- Fundal incision,
- Fundal transverse incision

33. remember
 The presence of pericervical or lower-segment
varicose veins proper of placenta praevia can be
confused with the neovascularization of placenta
accreta.
 Surgical exploration will make a differential
diagnosis, thus avoiding unnecessary hysterectomies.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 33

34. Excision of placental site
 It is possible to "excise the placental site".
 This is done by inverting the uterus in order
to provide good access to the placental site.
 If the area of placental attachment is focal
and the majority of the placenta has been
removed, then a "wedge resection" of the
area can be performed.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 34

35. Balloon Catheterization
Pre-operative placement of arterial catheters
in internal iliac artery
After delivery balloons are inflated to achieve
temporary homeostasis
Selective arterial embolization (SAE) if
necessary. . .
Bil. Int. iliac artery ligation is performed prior
to peripartum hysterectomy where
Interventional Radiology is not available.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 35

36. Placement of occlusion balloon catheters
into both internal iliac arteries.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 36

37. Methotrexate
 A folate antagonist, acts primarily
against rapidly dividing cells and
therefore is effective against proliferating
trophoblasts.
 First described by Arulkumaran et al
in 1986. They reported administration 50
mg of methotrexate as an intravenous
infusion on alternate days and the
placental mass was expelled on 11th
postnatal day.
 However, more recently, others
have argued that, after delivery of the
fetus, the placenta is no longer dividing
and therefore, methotrexate is of no
value.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 37

38.  Methotrexate has been used in varying
doses and routes, however, there are no
randomized trials and no standard protocol
regarding its dosage.
 The outcome when the placenta is left in
place after methotrexate administration varies
widely; it ranges from expulsion at 7 days to
progressive resorption in roughly 6 months.
 Mtx – 50 mg IM + Folic Acid 6mg IM on
alternate day till β HCG comes to zero.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 38

39. Other Modalities
 Tamponade of the placental implantation site
with inflated Intra Uterine balloon catheter bags.
 Lower Segment Compression Sutures
 Pelvic pressure sponge packing.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 39

40. Follow up…
1.- Ultrasound exams & Vascularity
2.- hCG titers weekly till become Zero.
3.- Daily Temps, Other S&S of infection
4.- Bleeding
5.- Coagulation profile
Antibiotic Maximum for 10 days.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 40

41. 22-Dec-14 Dr Shashwat Jani. 99099 44160. 41
Resources Patient, clinical and
anatomic features
Decision Definitive treatment
Limited
experience
or expertise, poor
resources or no
facilities for safe
patient transfer
lower segment invasion
vaginal bleeding with high
suspicion of accreta
Possibility of percreta
Extraplacental
hysterotomy,
Placental left in
situ
Followed by
uterine closure
Delayed hysterectomy
or conservative procedure
according clinical
and surgical status
Qualified and
experienced
team, adequate
hospital
resources
No desire for future
pregnancy
Tissue destruction> 50% of
uterine circumference
Intractable haemorrhage
DIC
Resective surgery
Subtotal hysterectomy
for upper segment lesions
Total hysterectomy
for lower segment
and cervical involvement
Qualified and
experienced
team,
adequate
hospital
resources
Desire for future
pregnancy
Destruction < 50% of
uterineaxial circumference
Minor coagulation
disorders
Conservative
surgery
1-Placenta in situ with or wit
MXT
2-One step surgery
OR
3- Two step surgery

42. Bladder Involvement
 First , Involve UROLOGIST.
 Preoperative Ureteric
stenting aids in identifying
the ureters, which will
help reduce ureteric
injuries.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 42

43. Care must be taken during
surgery not to attempt to
dissect the bladder off the
lower uterine segment
which results in torrential
bleeding.
 Anterior bladder wall
incision is particularly
helpful in defining
dissection planes and the
location of the ureters.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 43

44. Reality :
Even today, the ground reality is
that a majority of morbidly adherent
placenta are diagnosed during the
third stage of labour or during
caesarean section and which results
in adverse consequences including
exanguinating haemorrhage.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 44

45. To Conclude…
 Caesarean hysterectomy was the
cornerstone in the management in the past.
 Antenatal diagnosis permits effective and
safe conservative approaches today.
 The use of methotrexate, monitoring with
serum hCG and follow up with USG is backed
only by conflicting evidence.
22-Dec-14 Dr Shashwat Jani. 99099 44160. 45

46. 22-Dec-14 46Dr Shashwat Jani. 9909944160