This document describes a case of a 25-year-old woman who was 38 weeks pregnant with her second child. She had a previous cesarean delivery and was diagnosed with placenta praevia and placenta increta for her current pregnancy. She underwent a planned cesarean section and peripartum hysterectomy due to life-threatening bleeding from the morbidly adherent placenta that could not be removed manually. The surgery was successful and she recovered well after receiving multiple blood transfusions.

1. A Case of Placenta Praevia with
Morbidly Adherent Placenta
Surg Lt Cdr Ankur Shah
Moderator: Lt Col M K Tangri

2. 30/10/2014
 25 yr old
 G2P1L1 at 38 weeks POG
 Post LSCS pregnancy
 Placenta Praevia with Placenta Increta
 LMP: 7/2/2014
 EDD: 14/11/2014
 Steroids given for fetal lung maturity

3. Obstetric History
 G1
- 2011, FTLSCS (Non progress of Labour)
- Male, 4.5 kg birth weight
 G2
- Present pregnancy, spontaneous conception
- Booked and registered case at our hospital
- On regular antenatal visits

4. Antenatal Investigations
 Hb: 11.0 gm%
 ABO Rh: O positive
 BS (F): 90 (PP): 98
 OGTT with 75 gm glucose: 87/124 mg/dl
 HIV/HbsAg/VDRL: Neg

5. Antenatal Ultrasound
Date
(POG)
24/5/14
(15w1d)
7/6/14
(16w1d)
20/10/14
()
Gestation SLIUF SLIUF SLIUF
USMA 16w 1d 34w 6d
Placenta Ant, NP Completely
covering os
Lower
segment
completely
covering os
Liquor Adequate AFI = 11 cm
Anomaly Nil No obvious
invasion in
myometrium
noted
EFW 2549 gm
USEDD 25/11/14

6. MRI dated 25/10/14
 Placenta noted in lower part of uterine cavity, overlying the
expected location of scar, completely covering the os
 No myometrial tissue identified in region of placental
implantation
 Focal bulging of uterine contour at placental site
 Increase vascularity noted surrounding uterus esp in lower
segment

9. 03/11/2014, 0530 hrs
 Pt reported to Labour Room:
- C/o pain lower abdomen
 Evaluated, not in active labour
 Planned for scheduled LSCS at 0800 hrs
 Couple counselled, consent for peripartum hysterectomy
taken
 Blood demand for 4 units PRBC and 4 units FFP sent
- Blood bank informed regarding need for increased
requirement

10. 03/11/2014, 0900 – 1250 hrs
 Pt taken up for surgery under SA
 Intra-op findings:
- Pfannensteil incision given over previous surgical scar
- Dense adhesions between ant abd wall and ant uterine
surface
- Bladder pulled up, adherent to uterine surface and
extremely vascular
- UV fold of peritoneum opened and bladder attempted to
be pushed down. No clear plane identified
- Live male baby delivered by vertex

11. Intra-op Findings
- Angle of uterine incision sutured, while awaiting
placental separation
- Uterus contracted, partial separation of placenta seen
from posterior lower uterine segment
- Sudden brisk haemorrhage with loss of approx 1.5-2
litres of blood in about 1.5 min
- Separation of placenta attempted and removed
piecemeal
- Pt developed sudden bradycardia, hypotension,
collapse – converted to GA
- Fluid resuscitation done, followed by transfusion of
blood and FFP

12. Intra-op Findings
- In view of retained adherent placental tissue in lower
uterine segment and multiple failed attempts at
hemostasis, decision for peripartum hysterectomy taken
- Inadvertent injury to bladder vault occured during
dissection of UV fold – primary repair done in two layers
- Suture integrity checked by methylene blue dye
instillation
- B/L ureteric peristalsis seen after hysterectomy
 Approx blood loss ~ 3.5 litres
 Total of 8 units PRBC and 12 FFP transfused

13. Post op Course
 Post op – pt monitored in ICU for 48 hrs
 Subsequent recovery in ward uneventful
 Foley's catheter removed on Day 12 post op
 Pt discharged on Day 14 with well established feeding and
healthy baby

14. PLACENTA ACCRETE
SYNDROMES

15. Introduction
 Derived from Latin ac- + crescere, to grow from adhesion
or coalesce
 Any placental implantation with
- Abnormally firm adherence to myometrium
- Partial or total absence of decidua basalis
- Imperfect development of Nitabuch layer
 Associated with
- Life-threatening intrapartum/postpartum haemorrhage
- Maternal mortality ~ 7%

16. Etiopathogenesis
 Exact pathogenesis unknown
 Proposed hypotheses:
- Maldevelopment of decidua
- Excessive trophoblastic invasion (hyperinvasiveness)
- Combined theory
 Abnormal expression of growth factors, angiogenesis and
invasion-related factors in trophoblastic cells
 Role of decidua – controversial

17. Classification
 Depth of trophoblastic growth:
- Accreta: villi attached to myometrium
- Increta: villi invade the myometrium
- Percreta: penetrate through myometrium and/or serosa
 Area of placenta involved:
- Total
- Focal

19. Incidence/Risk Factors
 1 in 533 deliveries
 Increasing incidence with rise in no of Caesarean
deliveries
 Risk Factors:
- Placenta praevia
- Asherman's syndrome
- Previous uterine scar
- Advanced maternal age and parity
 Risk 3%, 11%, 40%, 60%, 67% with 1 to 5 previous
cesarean deliveries

20. Diagnosis
 Grayscale ultrasound
- Sensitivity (93%), specificity (76%), positive predictive value
(82%)
- 3D doppler, colour doppler do not increase diagnostic sensitivity
 Ultrasound criteria for diagnosis of morbidly adherent placenta:
- Loss of retroplacental sonolucent zone
- Irregular retroplacental sonolucent zone
- Thinning or disruption of hyperechoic serosa-bladder interface
- Focal exophytic mass involving bladder
- Abnormal placental lacunae (swiss cheese or moth eaten
appearance)

22.  Colour Doppler
- Diffuse or focal lacunar flow
- Vascular lakes with turbulent flow (PSV > 15 cm/s)
- Hypervascularity of serosa-bladder interface
- Markedly dilated vessels over peripheral subplacental
zone
 MRI
- Uterine bulging
- Heterogenous signal intensity within placenta
- Dark intraplacental bands on T2 weighted imaging

24. Management
 Timing of delivery
- Individualised decision
- Recommended at 34 weeks after fetal lung maturity
- In a tertiary care centre
 Cesarean section
- Consent for peripartum hysterectomy
- Prepared for massive haemorhage and blood
transfusion
- PRBC and FFP arranged for in 1:1 ratio

25.  Surgical Approach
- Anaesthesia: Spinal vs GA
- Midline skin incision vs Pfannensteil
- Uterine incision at site away from placenta
- Avoid manual removal of placenta
 Alternative approach
- Conservative measures: placenta left in situ
- Use of methotrexate
- High risk of bleeding, later hysterectomy
 Interventinal radiology
- Use of balloon catheter occlusion or embolisation
- Risk of arterial thrombi formation

26. THANK YOU