Conservative management of placenta accreta was described in 3 case studies. Placenta accreta occurs when the placenta abnormally invades the uterine wall. The women were hemodynamically stable and wished to preserve fertility, so expectant management was chosen over hysterectomy. They were monitored closely and expelled placental tissue over time. Two women later had successful pregnancies, while one had two subsequent children. Conservative management can preserve fertility but carries risks of hemorrhage and infection.

1. CONSERVATIVE MANAGEMENT OF
PLACENTA ACCRETA,ITS OUTCOME ON
FERTILITY AND SUBSEQUENT
PREGNANCY – CASE REPORT
Dr.Reshmi S Nair, DGO, DNB
Consultant
Vijayalakshmi Medical Centre
Kochi
1

2. Glimpses
 Test Cases & Its Detailed Analysis
 Placenta Accreta - Discussion
 Roadmap to Successful Subsequent
Pregnancy
 Conclusion & Take Away Message
2

3. Case-1
 26yr, P1L1A1, FTND in peripheral hospital, referred
with retained adherent placenta.
 h/o D&C - missed abortion, 1yr back .
 ANC uneventful.
 Baby had complex heart disease- and died on D-20
post surgery.
 She was hemodynamically stable.
A decision for conservative expectant
management was taken on grounds:
 Baby had remote chance of long term survival.
 She had no other living child.
 They were willing for expectant management.
 She was stable.
3

4. Post natal day – 2.
 βhCG -1562mIU/ml
 Hb-10.5gm%
 TC-11500, CRP- 8.
 USS :- placenta increta
invading posterior
uterine myometrium
[9.7x4.5x5.8cm].
 MRI – heterogenous
mass 10.2x5x4.5cm in
the region of posterior
wall of uterus. Lesion is
partially invading
myometrium – Placenta
increta.
4

5. Monitoring
 Monitored with USS and βhCG on day 2 & day 3,
and then weekly.
 Antibiotics (cefixime and metrogyl) × 4 days.
Uterotonics (Pitocin and PGF2ɑ).
 Discharged on post natal D - 6.
 Beta HCG –
856mIU/ml→542→258→110→69→18→8→0.2mIU
/ml.
 Hb., TC & CRP checked at each visit for evidence
of infection.
 USS- showed involuting uterus, with placental lobe
shrinking and no vascularity.
 Expelled placental lobe on day-116, which was
sent for HPE & confirmed diagnosis.
5

6. Future Fertility
 She conceived spontaneously 1yr later.
 2nd trimester MS-AFP was 1.5MoM.
 Placenta was posterior with no evidence of
myometrial invasion by USS.
 No antenatal complications .
 LSCS done at 39weeks for breech and previous
increta.
 She again conceived 2yr later.
 MS- AFP-0.97MoM in 2nd trimester, placenta
anterior & no recurrence of placenta accreta.
 LSCS done at 39wks.
 Both babies alive and healthy.
6

7. Case 2
 25yr old G2P1L1, booking visit at 33w.
 Had spontaneous onset of labour at 38w.
 FTND normally of a baby of 3.35kg.
 Expelled placenta with membranes. It looked
incomplete.
 A bedside USG confirmed a lobar adherent placenta.
 There was no active uterine bleeding, she was
hemodynamically stable and wanted to preserve her
fertility.
7

8.  USS- heterogenous placental mass 8x5 cm at fundus
with thinning of myometrium at postero-superior
aspect.
 MRI- heterogenous placental mass 8x5x6.5cm at
fundus towards left side with focal myometrial invasion
[1cm] and underlying thinning in postero-superior
aspect – placenta increta.
 Managed with prophylactic antibiotics, & discharged on
postnatal day 6.
 Monitored with USS, βhcg,TC, CRP weekly and
expelled placenta on day 26 which was sent for HPE
and confirmed.
 She conceived spontaneously 3yr later and is now
uneventful 24weeks pregnant.
8

9. Case 3
 25yr old primi, booking visit at 36wks, had leaking p/v at
39wks and delivered normally a 2.12kg baby.
 Placenta did not separate spontaneously and manual
removal of placenta [piecemeal] was done ↓SAB.
 Bleeding was WNL.
 USS done to check completeness showed a hypo-intense
mass at fundus 6x5cm.
 MRI –heterogenous mass 8x5x7cm in the region of fundus
of uterus extending to cornual region. Lesion is partially
invading myometrium – placenta increta.
 Patient was keen to conserve her uterus and there was no
active uterine bleeding. Managed expectantly as cases
before.
She expelled the placental lobe on 58th day. She has one
more child conceived spontaneously in another country.
9

10. 10
Discussion

11. Placenta Accreta
 Placenta accreta is an
uncommon but
potentially lethal
complication of
pregnancy.
 Occurs when the
placenta is abnormally
adherent to the
uterine myometrium
as a result of partial
or complete absence
of the decidua
basalis and
Nitabuch’s layer
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12. 12
 The incidence of placenta accreta ranges from
1 : 2500 to 1 : 533 births , with a tenfold increase
reported over the last 50 years
 Risk factors include placenta previa, ashermans
syndrome, existence of prior Caesarean &
hysterotomy scar and advanced maternal age or
parity.
 MRI combined with USS has a sensitivity of 100% in
identifying placenta accreta.
 Almost 50% of all cases of placenta accreta are
diagnosed antepartum.

13. Diagnostic Methods
Ultrasound criteria for diagnosis
Greyscale:
● loss of the retroplacental sonolucent zone.
● irregular retroplacental sonolucent zone.
● thinning or disruption of the hyperechoic serosa–bladder
interface.
● presence of focal exophytic masses invading the urinary
bladder.
● abnormal placental lacunae.
Colour Doppler:
● diffuse or focal lacunar flow.
● vascular lakes with turbulent flow.
● hypervascularity of serosa–bladder interface, markedly
dilated vessels over peripheral subplacental zone.
13

14. Placental Lacunae
The presence and increasing number of lacunae within the placenta at
15–20 weeks of gestation - the most predictive USS signs of placenta
accreta, [sensitivity of 79% and a positive predictive value of 92% ].
These lacunae may result in the placenta having a “moth-eaten” or
“Swiss cheese” appearance
14

15. MRI
 uterine bulging
 heterogeneous signal intensity within
the placenta
 dark intraplacental bands on T2-
weighted imaging
15

16. Biochemical Markers
 AFP > 2.5 MoM in second trimester.
 Leakage of foetal alpha-fetoprotein into the
mother’s circulation.
 Up to 45% of women with placenta accreta have
elevated MSAFP levels in the absence of an
obvious causes
16

17. Managing Options for Morbidly
Adherent Placenta
Caesarean hysterectomy
Extirpative approach [forced manual removal of
the placenta in an attempt to obtain an empty uterus]
Conservative approaches –
 Medical.
 Uterine artery embolization
 Expectant [when vascularity is no longer present on
ultrasound examination of the placenta].
17

18. Conservative management
shall be considered...
 only when the patient wishes to preserve her
fertility.
 when no active uterine bleeding is present.
 Adequate discussion of the potential risks and
benefits also is crucial
Conservative Management
18

19.  At the time of delivery, the cord and membranes
should be ligated as high as possible.
 Broad-spectrum antibiotics, for prophylaxis and
oxytocin should be administered during the initial
72 hours.
 Ultrasound should be performed daily to monitor
involution and placental vascularity, which should
decrease over time.
Conservative Management
19

20. Medical Management
Methotrexate (1 mg/kg) on alternate days
administered when -
 hCG levels plateau
 placental vascularity persists
 or placental involution fails after the initial 72-hour
period.
Controversy- After delivery, the trophoblasts are no
longer dividing, thereby rendering methotrexate
ineffective
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21. Follow Up After
Conservative Management
 During the postpartum period, all patients are seen
weekly until complete resorption of the
placenta.[may take-6 months]
 Ultrasonography and clinical examination are
performed to detect hemorrhage, pain or signs of
infection.
 C-reactive protein and blood counts are checked to
help choose antibiotics in case of endometritis.
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22. RCOG guidelines
 The woman should be warned of the risks of
bleeding and infection postoperatively.
 Prophylactic antibiotics may be helpful in the
immediate postpartum period to reduce the risk of
infection.
 Neither methotrexate nor arterial embolisation
reduces these risks and neither is recommended
routinely.
 Measuring serum βhCG on a weekly basis to check its
falls can reassure, but low levels do not guarantee
complete placental resolution and so this should be
supplemented by imaging. 22

23. 23
Advantages
 Preserve fertility[success
rate -78%]
 Avoid gravid
hysterectomy
associated with
mortality rate of 7.4%,
90% incidence of
transfusion, 28%
incidence of
postoperative infection,
5% incidence of ureteral
injuries or fistula
formation
 Failure rate –18%
 infection – 18%
 Bleeding- 35%
 Disseminated
intravascular
coagultion-7%.
 Unpredictable - may
need hysterectomy.
Disadvantages

24. Subsequent Pregnancy
 Recurrence of placenta accreta-16-28%.
 Blood transfusion -90%.
 Fistula -3.3%.
 Uterine rupture-3.3%.
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25. Conclusion
 Placenta Accreta - usually managed with Caesarean
hysterectomy.
 Conservative Mx is an option for patients who are
properly counselled and motivated, particularly, for
who want the option of a future pregnancy and who
agree close follow-up.
 Adequate discussion of potential risk and benefit is
crucial.
 There is increased risk of sudden hemorrhage,
infection and emergency surgery.
 Successful conservative treatment for placenta
accreta does not appear to compromise the
subsequent fertility or obstetrical outcome.
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