Placenta Accreta Syndrome is an emerging obstetric emergency.How to suspect,antenatally detect and manage these cases have been described

1. Professor & Head
Department of Obstetrics & Gynecology
S. N. Medical College, Agra (UP)
Worked as Principal & Dean(2016-2018),SNMC,Agra.
Received many Gold Medals during UG & PG exams.
Received Best Teacher Award at SN Medical College in 2008.
Received FOGSI Star Award in 2016.
Awarded WOMAN OF THE YEAR- 2019 at Agra.
Chief Editor - The Journal of UPCOG (2011-16)
Vice President - UP Chapter of Obstetrics & Gynaecology
Vice President -UP Chapter of Gynaecological Oncologists of India
President- Agra Obstetrics & Gynecological Society (2011 &12)
Expert - Union&UP Public Service Commission, AIIMS & BHU Selection Boards
Project Co-ordinator - SIFPSA trainings, ICTC & RRTC Programme
Chairperson Scientific Committee- National Conference of AICOG 2016
Organizing Secretary - Annual Conference of UPCOG- 2011
Scientific publications Contributed Books, Chapters, Review articles and Original Research Papers in national &
international journals
Special interest - NDVH ,Reproductive Endocrinology and High Risk Pregnancy
Teaching experience: > 35 years
Dr. SAROJSINGH
MS, MAMS, FICOG, FIAJAGO, FICMCH

3. Placenta Accreta
Histopathological term
when placenta fails to separate partially
or totally from uterine wall.
( Described in 1937 by F C. Irving and AT. Hertig at Boston )
It remains the greatest challenge in
Modern Obstetrics
 Rarely diagnosed before birth few years back.
Even today about half of them remain
undiagnosed.
 Ultimately leading to
 Intractable PPH
 DIC
 Emergency Hysterectomy
 Severe Maternal Morbidity
 Sometimes even maternal death
(upto 10%)

4. 1937, Irving and Hertig estimated the
incidence of placenta accreta to be
1 in 30,000 deliveries in USA
 ACOG (1980) estimated MAP in 1 in 2500
deliveries
 It has risen to 10 folds in last 50 years
 1980 1 in 2500
 2002 1 in 535
 2006 1 in 210
(Stafford & Belfort, 2008)
Rising Caesarean Section rate
and Placenta Previa
are two important risk factors
10 % of Placenta Previa had associated accreta
(Zaki & associates, 1998)

5. ACOG warns of 40% accrete in previa with
previous two CS with anterior or central
placenta
Multiparty, Previous Curettage, MRP,
Septic Endometritis and Submucous Myoma
are other risk factors

6.  Abnormal adherence either in whole or
in part of the placenta to the underlying
uterine wall
 WHY ?
The defect of the endometrium–myometrial
interface, typically at the site of a prior
hysterotomy, leads to a failure of normal
decidualization in the corresponding
uterine area.This allows
extravillous trophoblastic infiltration and
villous tissue to develop deeply within the
myometrium, including its circulation

7. Degree of Adherence
Placenta Accreta- 78%
ChorionicVilli (CV) adherent to Superficial Myometrium
Placenta Increta- 17%
CV involving Myometrium
Placenta Percrta- 5%
CV penetrating full thickness myometrium and involving
Serosa
Amount of Placental Involvement
 Focal adherence- Part of the cotyledon is
involved
 Partial Adherence- More then one cotyledon
are involved
 Total Adherence- Whole Placenta is involved
(PAS) disorders include both adherent and
invasive placental disorders.

9. FIGO Classification of PAS disordes,2019
Grade 1.Abnormally adherent placenta (accreta)
At vaginal delivery
• No separation with oxytocin and gentleCCT
• Attempts at MRP results in heavy bleeding .
If laparotomy is required /CS
• Same as above
Uterus shows no obvious distension
over the placental bed (placental “bulge”),
no placental tissue invading at the surface
no or minimal neovascularity
Grade 2: Abnormally invasive placenta (Increta)
• Placental bed: bluish/purple colouring, distension
(Placental “bulge”)
• Significant hyper vascularity (dense tangled
bed of vessels running parallel or craniocaudially in the
uterine serosa)
• No placental tissue invading through the uterine
serosa.
• Gentle cord traction results in the uterus being pulled
inwards without separation of placenta (dimple sign)
Grade 3: Abnormally invasive placenta
(Percreta)
Grade 3a: Limited to the uterine serosa
•placental tissue seen to be invading through
the surface of the uterus
•No invasion into any other organ, including the
posterior wall of the bladder
• a clear surgical plane identified between the
bladder and uterus
Grade 3b: With urinary bladder invasion
•Placental villi invading into the bladder
but no other organs
•Clear surgical plane cannot be
identified between the bladder and uterus
Grade 3c: With invasion of other pelvic organs
• Placental villi invading broad ligament, vaginal
wall, pelvic sidewall or any other pelvic organ
• (with or without invasion of the bladder)

10. PRESENTATION
Asymptomatic
detected on OTTable or
duringUSG
APH
Acute Abdomen
Retained Placenta
PPH
Uterine Rupture
Identifying structural and vascular
abnormalities near the
utero-placental interface (UPI) is of
key importance.
UPI is the anatomical interface that separates the
placenta from the uterus. ...

11. Predictive Criteria
(USG)
Loss of Retroplacental
Clear Space
Uterine Serosa- Bladder
Interphase <1mm
Intraplacental Lacunae
Extension of Placental
tissue beyond Uterine Serosa

16. Placental imaging is currently largely
ignored in regular
ultrasound/radiology courses.
Specialized training programs will
have to be introduced given the
rising prevalence of this condition
.
...sensitivity and specificity of grey-
scale imaging alone in diagnosing
PAS are as high as 90% when
performed by experienced operators.
MRI gives additional information in
equivocal cases
Warshak et al (2006) suggested
Two Step Protocol
using MRI as an adjunct to
sonography in suspicious cases
of Placenta accreta

17. All women found to have an anterior
low‐lying
(placental edge <2 cm from the internal
os after 16 weeks ) should be asked if
they have had a previous cesarean
delivery and, if they do,
they should be referred to a centre
with expertise in the prenatal diagnosis
of PAS disorders.
PREDICTING PLACENTAACCRETA

18. FIGO consensus guidelines on placenta accreta spectrum disorders:
Prenatal diagnosis and screening
International Journal of Gynecology & Obstetrics 140(3):274-280 · February 2018

19. Elevated alpha feto
protein in second
trimester in absence of
foetal anomaly with low
lying placenta
Strongly positive EGFR
(Epidermal growth Factor
Receptor) and a reduced
VEGFR-2 (Vascular
Endothelial Growth
Factor)

21. Management
 Multidiscplinary approach is recommended
 Experienced Obstetrician
 Neonatologist and hematologist play crucial role
 Urological Surgeon may be required
 Elective delivery is preferred
 34-35 wks of after administration of
corticosteroid for lung maturity is most
suitable at places with good neonatal
support
 Caesarean Hysterectomy is the safest
option

22. Hysterectomy remains the definitive surgical
treatment for PAS disorders, especially for its
invasive forms, and a primary elective
cesarean hysterectomy is the safest and
most practical option for most low‐ and
middle‐income countries where diagnostic,
follow‐up, and additional treatments are not
available. FIGO 2018
Warshak Ramos et al, Jan. 2010 reported 99
cases of PlacentaAccreta
 Prenatal diagnosis was possible in 66 cases
 At 34- 35 wks EN BLOCK Hysterectomy was
planed without removal of Placenta.
 Maternal morbidity reduced dramatically

24. Preoperative uterine
arterial cathetarization
and embolization if
required and avalable
Preoperative bilateral
ureteral stunting

25. Attempts to remove placenta
Preoperative identification with Planned Caesarean
Hysterectomy without removal of Placenta was
associated with significantly reduced morbidity
(36 versus 67%) compared with those of attempted
removal of placenta.
Eller & co-workers, 2009, A review of 76 cases at University of Utah
Placental removal before Hysterectomy results in increased
maternal morbidity
Yep et al (2008) Int. J. Gynaecol. Obstetrics
Problems depend on site and depth of implantation and
number of lobules involved
OyeleseY. (2006) also advised against placental removal
before Hysterectomy

28. Conservative Management
(In focal defects and/or to preserve fertility)
Leave the entire placenta inside and close the uterine
incision
Intraoperative/Post operative Methotrexate
15 % required subsequent hysterectomy,
Planned or because of bleeding/ Infection

29. Localized resection with uterine repair

32. Impact of uterine surgical techniques
Surgical techniques used for entering and closing the
uterus during CS may play a role in the etiology of
PAS disorders
Yet to find ?
 Single-layer uterine closure versus a multiple
overlapping layer type of closure,
 locked continuous versus interrupted suturing,
? Continuous suture was associated with a
higher risk of PAS disorders than interrupted
sutures.
 Different suture material.
? Monofilament suture for hysterotomy closure
reduces the risks of having placenta previa and thus
PAS disorders in future pregnancies
 Emergent versus elective cesarean delivery.

33. High Index of clinical suspicion
in high risk cases
backed by directed scans and
advanced imaging techniques
are
Key to early antenatal diagnosis
Manage them at
Accreta centre of Excellence

34. Conclusion
 PAS disorders are still a great
challenge to the Obstetrician
 Incidence is rising because of
increase in C S and with each CS
 High index of clinical suspicion is
required
 Imaging modalities are of great value
in antenatal early diagnosis
 Management needs multidisciplinary
approach at tertiary centre

35. Conclusion
 Elective c-section with Enblock
Hysterectomy with arrangements for
massive blood transfusion is the safest
option
 No attempt to remove placenta gives
better results
 Conservative options may be reserved
for selected cases in expert hands only
 Uterine artery ligation/ preoperative
catheterization and embolization may
be used where facilities are available