This document discusses placenta accreta spectrum disorders, including challenges in management. Key points include: PAS disorders occur when the placenta invades the uterine wall abnormally. Risk factors include prior c-sections and placenta previa. Incidence has risen with increasing c-section rates. Ultrasound is used to diagnose but risks false positives/negatives. Management involves a multidisciplinary team and individualized delivery timing/plan. Surgery poses challenges like hemorrhage, but techniques like leaving the placenta in situ and internal iliac ligation can help. Careful dissection is needed to avoid injury to structures like the bladder and ureters.

1. Placenta Accreta Spectrum
Disorders
Challenges and management
By
Ahmed Elbohoty MSc, MD, MRCOG, MIGSC
Associate professor of obstetrics and gynecology
Ain Shams University

2. What I am
going to
discuss
Amplitude of the problem
Complications
Relation to caesarean delivery
Classification
Challenges in its
Management
1/4/20 2ELBOHOTY

3. Definition
• The clinical condition when part
of the placenta, or the entire
placenta, invades and is
inseparable from the uterine
wall
1/4/20 3ELBOHOTY

4. Pathogenesis
• A secondary defect of the endometrial–myometrial
interface
• A failure of normal decidualization in the area of the
uterine scar allowing
• An abnormally deep trophoblast infiltration of
myometrial vasculatures
1/4/20 4
excessive neovascularity
ELBOHOTY

5. Risk Factors for Placenta Accreta
•Placenta previa
•Prior CS(s) (particularly with a placenta previa)
•In vitro fertilization (IVF)
Consistent Evidence from Controlled Studies
•Maternal age ≥35
•Prior dilation and curettage of the uterus
•Prior myomectomy or other uterine surgery (besides CS)
•Maternal smoking
Inconsistent evidence from controlled studies
•Prior history of accreta
•Uterine synechiae or Asherman’s syndrome
•Prior endometrial ablation
•Prior uterine fibroid embolization
•Congenital uterine anomalies (such as a rudimentary horn)
•Prior uterine irradiation
Anecdotal evidence from case series and reports
1/4/20 5ELBOHOTY

6. Incidence
• In 1937: 1 in 30 000 deliveries.
• In 1970: 1 in 4000 deliveries in the 1970s
• In 1980: 1 in 2500 deliveries
• In 2010: 3 in 1000 deliveries
• Rising rate of Caesarean delivery
• It is also related to the technique of uterine closure & development of CS scar defect
1/4/20 6ELBOHOTY

7. PAS increases with Number of Cesarean Deliveries
No. of
previous
cesareans
Incidence of PAS
disorders
Incidence of PAS
disorders if
placenta previa
Chance to have
hyterectomy
0 0.24% 3% 0.65%
1 0.3 % 11% 0.42%
2 0.57 % 40 % 0.9 %
3 2.1 % 61 % 2.4%
4 2.3 % 67 % 3.5%
5 6.75 % 67 % 9 %
Silver et al1/4/20 7ELBOHOTY

8. Why is it
dangerous?
Maternal death may occur despite optimal planning,
transfusion management, and surgical care
Maternal mortality as high as 7%.
40% require more than 10 units of packed red blood
cells
90% of PAS women require blood transfusion.
The average blood loss at delivery is 3,000–5,000 mL.
1/4/20 8ELBOHOTY

9. Complications
• Failure to separate from the uterus
• Massive hemorrhage
• Hysterectomy
• Surgical injury to the ureters,
bladder, bowel, or neurovascular
structures
Surgical:
• DIC
• ARDS
• Acute transfusion reaction
• Electrolyte imbalance
• Acute renal failure.
Medical:
1/4/20 9ELBOHOTY

10. Accreta and Maternal Co-Morbidity
NIH/MFM Cesarean Registry Study
Morbidity No Accreta Accreta
Cystotomy
Ureteral Injury
PE
Ventilator
0.15%
0.02%
0.13%
0.8%
15.4%
2.1%
2.1%
26.6%ICU
0.3% 14%
1/4/20 10ELBOHOTY

11. Classification of PAS
HISTOLOGICAL
CLASSIFICATION
Clinical grading
1/4/20 11ELBOHOTY

12. HISTOLOGICAL CLASSIFICATION
1/4/20 12ELBOHOTY

13. A clinical grading system to assess and categorize placental
adherence or invasion at delivery
1/4/20 13ELBOHOTY

14. No placental tissue seen invading through the surface of the uterus.
1. Partial
(A) Cesarean/laparotomy: Incomplete separation on with uterotonics and
gentle cord traction, and manual removal of placenta required for
remaining tissue and parts of placenta thought to be abnormally adherent
(B) Vaginal delivery: Manual removal of placenta required and parts of
placenta thought to be abnormally adherent
2. Complete
(A) Cesarean/laparotomy: No separation with uterotonics and gentle cord
traction with manual removal of placenta required and the whole placental
bed thought to be abnormally adherent
(B) Vaginal delivery: Manual removal of placenta required and the whole
placental bed thought to be abnormally adherent
Placental tissue seen to have invaded through the serosa of the uterus
(Cesarean/laparotomy):
3. A clear surgical plane can be identified between the bladder and uterus to allow
nontraumatic reflection on of the urinary bladder at surgery
4. A clear surgical plane cannot be be identified between the bladder and uterus to
allow nontraumatic reflection on of the urinary bladder at surgery
5. Infiltrating the parametrium or any organ other than the urinary bladder1/4/20 14ELBOHOTY

15. No placental tissue seen invading through the surface of the
uterus.
1. Partial : Incomplete separation on with uterotonics & Manual
removal of placenta required
2. Complete: Incomplete separation on with uterotonics & Manual
removal of placenta required
(A) Cesarean/laparotomy:
(B) Vaginal delivery:
Placental tissue seen to have invaded through the serosa of the
uterus (Cesarean/laparotomy):
3. A clear surgical plane can be identified between the bladder
and uterus
4. A clear surgical plane cannot be be identified between the
bladder and uterus
5. Infiltrating the parametrium or any organ other than the
urinary bladder
1/4/20 15ELBOHOTY

16. How to predict ?
Prepregnancy
1st and early 2nd trimester scan
1/4/20 16ELBOHOTY

17. Prepregnancy
CS scar defect
1/4/20 17ELBOHOTY

18. 1st trimester scan
Low uterine
segment
implantation
Cesarean scar
pregnancy
1/4/20 18ELBOHOTY

19. Low uterine
segment
implantation
• GS typically implants in
or near the cesarean
section scar
• The anterior
myometrium appears
thin
• The placental–
myometrial and
bladder–uterine wall
interfaces often appear
irregular
• Multiple vascular
lacunaes (arrows) within
the placenta
1/4/20 19ELBOHOTY

20. Cesarean scar pregnancy:
• GS embedded in the cesarean section
scar.
• It is surrounded on all sides by
myometrium
• It is separate from the endometrium.
• Color Doppler in a low-velocity scale
demonstrates surrounding vascularity
of placental tissue.
1/4/20 20ELBOHOTY

21. Diagnosis
The sensitivity and
specificity are not 100%.
Imaging: The only
method for prenatal
identification of invasive
placenta on.
1/4/20 21ELBOHOTY

22. Risks of false prenatal diagnosis:
• Use a low transverse uterine incision
• Massive intraoperative hemorrhage, even before the fetus is delivered.
False-negative diagnosis:
• Unnecessary midline vertical skin incision and a fundal uterine incision
• Increasing the risk of intraoperative and postoperative complications
• The risk of uterine rupture in subsequent pregnancies.
False-positive diagnosis :
1/4/20 22ELBOHOTY

23. Which to use MRI or Ultrasound?
• MRI sensitivity 92.9%, US sensitivity
87.8%, p = 0.24
• MRI specificity 93.5%, US specificity
96.3%, p = 0.91
Ultrasound and
MRI performed
similarly for
primary diagnosis
in all studies:
• Relatively availability
• Ease of performance
• Lower cost
Advantages of US:
1/4/20 23ELBOHOTY

24. Ultrasound should be the primary
screening tool for accreta in at-risk
patients
• Antenatal sonographic
imaging can be
complemented by
magnetic resonance
imaging in
• Equivocal cases
• Diagnosis of
posterior placenta
accreta more
confidently.
• Assessment of
bladder invasion
in cases of
placenta percreta.
1/4/20 24ELBOHOTY

25. Cystoscope
1/4/20 25ELBOHOTY

26. Sonographic Markers of Placental Accreta
Multiple Vascular Lacunae
Loss of the normal hypoechoic retroplacental zone
Abnormality of the uterine serosa–bladder interface
Thinning of the retroplacental myometrium
Bulging of the lower uterine segment
Increased placental vascularity on color Doppler
1/4/20 26ELBOHOTY

27. Multiple Vascular Lacunae
1/4/20 27ELBOHOTY

28. Loss of the
normal
hypoechoic
retroplacental
zone
NormalLoss
1/4/20 28ELBOHOTY

29. Thickening
of posterior
bladder
wall
1/4/20 29ELBOHOTY

30. Delivery
Time
Setting
Team
Individualized Plane
1/4/20 30ELBOHOTY

31. Time
Risks of urgent delivery to maternal health must be balanced with
the neonatal complications associated with late preterm delivery.
ACOG: 34 weeks
NICHD: 34–35
weeks and 6 days.
RCOG: 35 – 36 +6
weeks .
With corticosteroid
cover
National Institute of Child Health and Human Development (NICHD)
1/4/20 31ELBOHOTY

32. Individualized time?
The timing of the caesarean section should consider the desirability of performing it as an elective
rather than an emergency procedure
Stable
No APH, PPROM, or
uterine contractions
may be
considered for
planned delivery
at 36 weeks.
Recurrent APH
PPROM
Contractions
planned preterm
delivery around
34 weeks
1/4/20 32ELBOHOTY

33. Transfusion service
Massive transfusion capability
Cell saver and perfusionist
Alternative blood products
Transfusion medicine specialists or blood bank pathologists
1/4/20 33ELBOHOTY

34. Facilities
Interventional radiology
Intensive care unit
Neonatal intensive care unit
1/4/20 34ELBOHOTY

35. Multidisciplinary
Team
Maternal–fetal medicine physician or obstetrician
Pelvic surgeon (gynecologic oncology)
Obstetric anesthesiologist
Urologist
Trauma surgeon
Imaging experts
Interventional radiologist
Neonatologist
1/4/20 35ELBOHOTY

36. Preoperative plane
• Ultrasound mapping of the placental attachment site to plane the skin and
uterine incision.
• Plane individualized Surgical management
• The available choices if it is confirmed PAS are :
• A planned cesarean-hysterectomy
• Leaving the placenta
• Other Conservative managements
1/4/20 36ELBOHOTY

37. Anesthesia
Historically, most patients
with PAS disorders were
managed with general
anesthesia
Recently, greater
experience has permitted
more frequent use of
epidural with or without
spinal.
1/4/20 37ELBOHOTY

38. Challenges during the
surgery
• Multiple cesarean deliveries often
present with pelvic adherences
• Thin and hypervascular lower uterine
segment
• Bulky in-situ placenta
• Deep pelvis neovascularization
• Possible invasion to bladder, bowel,
cervix, and parametrium in cases of
placenta percreta.
1/4/20 38ELBOHOTY

39. A planned cesarean en bloc
hysterectomy
• It is the standard
management especially
if the woman is
multiparous, older, grade
3, 4, 5.
1/4/20 39ELBOHOTY

40. Balloon occlusion catheters?
Need specialist interventional radiologists
Inserted under fluoroscopic guidance
Prophylactic insertion and keep deflated
Inflate balloons before starting bladder dissection and
hysterectomy
Many studies fail to demonstrate any benefits and critize
their use.
Women who decline donor blood transfusion should be
cared for in a unit with an interventional radiology service.
1/4/20 40ELBOHOTY

41. Uterine artery embolization (UAE)
It is used in two ways for prophylactically or
emergently.
In bleeding that is difficult to be managed
surgically
UAE can be the sole endovascular treatment or
combined with balloon occlusion catheter
placement.
1/4/20 41ELBOHOTY

42. Position
Modified dorsal lithotomy
position with left lateral tilt
• Allow for direct assessment of
vaginal bleeding
• Provide access for placement of
a vaginal pack
• Allow additional space for a
surgical assistant.
1/4/20 42ELBOHOTY

43. Ureter stent
placement?
• It has a role when the
urinary bladder is
invaded by placental
tissue
• Preoperative cystoscopy
with placement of
ureteral stents can
reduce the risk of
urinary tract injury from
33% to 6%.
• It should be placed in
the operating theater
just before surgery with
all the staff prepared.
1/4/20 43ELBOHOTY

44. Use Tranexamic acid
• Tranexamic acid before
cesarean delivery significantly
reduces intra- and
postoperative blood loss
• No trials have specifically
examined the role of
tranexamic acid in the surgical
management of PAS disorders.
• Uterotonics may cause partial placental
separation.
• It may lead to massive bleeding just at
the beginning of hysterectomy.
Don’t use uterotonics
1/4/20 44ELBOHOTY

45. “Holding
the
cervix”
technique
• It eliminates exit of blood through the vagina
• It enables cell salvage
• The metal consistency of the forceps clearly indicates the
site to be transected
1/4/20 45ELBOHOTY

46. Incision
•Skin incision: midline vertical
incision
•it provides sufficient
exposure if hysterectomy
becomes necessary.
•Uterine incision: A classic
incision, often transfundal
•to avoid the placenta and
allow delivery of the
infant.
1/4/20 46ELBOHOTY

47. Deliver the baby
Avoid manual placental removal
1/4/20 47ELBOHOTY

48. Internal iliac artery ligation
Needs proper skillset
It is suitable in low- and middle-income
countries, where access to
interventional radiology may be limited.
Studies didn’t show difference in mean
blood loss or blood loss greater than 5 L
or transfusion requirements
1/4/20 48ELBOHOTY

49. Steps of hysterectomy
• To Dissect bladder flap (before or after
delivery????)
• To leave the placenta in situ
• Quickly use a “whip stitch” to close the
hysterotomy incision
• IAL or inflation of balloons?!
• To Proceed with hysterectomy.
• Total hysterectomy if it is possible
1/4/20 49ELBOHOTY

50. Trying to avoid urinary tract injury
• limit visibility
• create urgency for bladder dissection.
Avoid major intraoperative bleeding
• Placement of ureteric stents preoperatively
• Opening the retroperitoneal space and visualizing the ureters
Avoid ureteric injury
• It determine the appropriate site for separating the bladder
• The bladder is filled with 300 mL saline solution
Filling the bladder
1/4/20 50ELBOHOTY

51. When to
dissect
the
urinary
bladder?
• It is done prior to delivery
• It allow sufficient time to identify and
create the vesicouterine plane before an
intraoperative bleed.
If there is no placenta percreta:
• Delay the dissection
If there is placenta percreta:
1/4/20 51ELBOHOTY

52. If bladder invasion
is confirmed
• Instead of separating
the bladder, it can be
intentionally cut without
touching the engorged
vessels.
• Adopting a posterior
approach may allow
stepwise
devascularization of the
uterus and may aid in
the hysterectomy
1/4/20 52ELBOHOTY

53. Posterior
retrograde
approach
•Posterior vaginal fornix
exposed with sponge stick
into vagina
•Opened transversely, 1–2 cm
below the cervicovaginal
junction
•Ureters identified, dissected,
and preserved though
anterior bladder pillar
1/4/20 53ELBOHOTY

54. From back to front
• Cervix grasped, pulled up behind
uterus
• Cardinal ligaments, uterosacrals, and
bladder pillars are sequentially
divided
• Vesicouterine space is developed
until bladder detached from anterior
aspect of uterus or cystotomy and
resection of posterior bladder wall if
placental invasion
1/4/20 54ELBOHOTY

55. Conservative management
Patients should be properly counseled and motivated
Agree to close follow-up monitoring in centers with adequate equipment
and resources.
The patient has a strong desire for future fertility
Hemodynamic stability
Normal coagulation status
She is willing to accept the risks involved in this conservative approach
1/4/20 55ELBOHOTY

56. Leaving the
placenta in situ
• It is the standard conservative management
• It may be the most appropriate choice in the
most severe cases of MAP, in particular,
• In cases of organ adjacent invasion,
where radical surgery is often associated
with severe maternal morbidity
1/4/20 56ELBOHOTY

57. Suggested
benefits
This will result in secondary necrosis
of the villous tissue and theoretically
the placenta should progressively
detach itself from the uterus and the
percreta villi from the adjacent pelvic
organs.
A progressive decrease in blood
circulation on within the uterus,
parametrium, and the placenta.
1/4/20 57ELBOHOTY

58. Steps
• Preoperative ultrasound: to determine the exact
position on of the placenta
• Skin Incision: according to placental location
• A low transverse incision: if the upper margin
of the anterior aspect of the placenta does
not rise into the upper segment of the
uterus.
• A midline incision: If the placenta is anterior
and extending toward the level of the
umbilicus
• Uterine incision: a transverse incision at a
distance from the placental bed.
• Backup plane: the required surgical equipment
for an emergent hysterectomy should available in
the operating theatre.
1/4/20 58ELBOHOTY

59. After delivery of the fetus:
• The surgeon may carefully attempt to remove the
placenta by a controlled cord traction and the use of
uterotonics.
• Failure to do so suggests the diagnosis of a PAS
disorder
No clinical
evidence of
percreta
placenta
• The cord should be cut close to its placental insertion
• Full repair of the uterus
• Postoperative antibiotic therapy is usually
administered prophylactically to minimize the risk of
infection.
Placenta
accrete
syndrome
1/4/20 59ELBOHOTY

60. Efficacy & safety
The overall success rate: 78% (95% CI, 71%–84%)
An empty uterus was obtained spontaneously in 75% of cases at a median time
of 13.5 weeks (range, 4–60 weeks)
Severe maternal morbidity including sepsis, septic shock, peritonitis, uterine
necrosis, postpartum uterine rupture, fistula, injury to adjacent organs, acute
pulmonary edema, acute renal failure, deep vein thrombophlebitis or
pulmonary embolism, or maternal death was reported in 10 (6%) cases.
1/4/20 60ELBOHOTY

61. 1/4/20 61ELBOHOTY

62. Follow up visits
• 1st 2 months: Weekly visits
• From 3rd month till complete resorption of the placenta: monthly
visits .
Schedule:
• Clinical assessment on (bleeding, temperature, pelvic pain)
• Pelvic ultrasound (size of retained tissue)
• Laboratory tests:
• serum β-hCG
• Infection screen on (hemoglobin and leukocytes count, vaginal
sample for bacteriological analysis)
Structure of the follow-up consultation:
1/4/20 62ELBOHOTY

63. Long-term obstetric and fertility outcomes
Successful conservative
treatment for PAS disorders
does not appear to compromise
subsequent fertility or obstetric
outcome, but data are limited.
Pregnancies following prior PAS
disorders are at increased risk
for adverse outcomes
Recurrent PAS disorders 30%,
uterine rupture, postpartum
hemorrhage, and peripartum
hysterectomy.
Early postpartum hemorrhage
12%
1/4/20 63ELBOHOTY

64. Planned delayed hysterectomy
• It is an alternative surgical management strategy for PAS disorders especially if it is
diagnosed intraoperatively
• Justification:
• Delayed hysterectomy may be undertaken where extensive invasion (percreta) of
surrounding structures would render immediate cesarean hysterectomy extremely
difficult.
• Time: between 3 and 12 weeks postpartum
• Advantages:
• The estimated blood loss in this staged surgical approach, including both initial
delivery and subsequent hysterectomy, has been reported to be less or similar to
immediate surgery.
• Delaying hysterectomy in complex cases may reduce other surgical morbidity.
• Disadvantages:
• There is an associated risk of coagulopathy, hemorrhage, and sepsis during the
interim period.
1/4/20 64ELBOHOTY

65. uterus preserving surgery may be appropriate in :
• Extent of the placenta accreta is limited in depth and surface area
• The entire placental implantation area is accessible and visualised (i.e.
completely anterior, fundal or posterior without deep pelvic invasion)
1/4/20 65ELBOHOTY

66. Other
Conservative
surgeries
one-step conservative surgery (removal
of the accreta area)
Stepwise surgical approach
The Triple-P procedure (suturing
around the accreta area after
resection).
Cervical tamponades after placental
removal
Use of compression sutures after
placental removal
1/4/20 66ELBOHOTY

67. One-Step Conservative
Surgery
• Resecting the invasive accreta area
(partial myometrial resection)
followed by
• Immediate uterine reconstruction
• Uterine preservation was achieved
in 44 out of 46 (95.7%) and 6 out of
22 (27.3%) cases, respectively.
• Palacios-Jaraquemada etal., 2004
1/4/20 67ELBOHOTY

68. Stepwise surgical approach
• Selective Hemostasis
• Retrovesical ligature of vesicouterine vessels (upper
pedicle)
• Stitch occlusion of the colpouterine vessels in the
cervical–vaginal junction (lower pedicle).
• Removal of the area completely invaded by placental
tissue and uterine reconstruction using surrounding
healthy myometrial tissues
• 71 patients presening with placenta percreta and
preserving the uterus in 65 (91.5%) of the cases
(Shabana et al., 2015)
• This procedure may be less reproducible than other
approaches for conservative treatment, mainly because
efficient hemostasis is operator dependent.
1/4/20 68ELBOHOTY

69. The Triple-P
procedure
• 3 main steps
1. Preoperative placental localization
and deliver the fetus by an incision
above the upper border of the
placenta
2. Placement of intra-arterial balloon
catheters with inflation after
delivery
3. Enbloc myometrial excision and
uterine repair.
• If the posterior wall of the bladder is
involved, placental tissue invading the
bladder is left in situ to avoid cystotomy
• Chandraharan et al., 2012
1/4/20 69ELBOHOTY

70. Tamponade techniques
• If the placenta was forcibly removed and there is a bleeding from placental bed
• Using the cervix as a natural tamponade by inverting it into the uterine cavity
and suturing the anterior and/or the posterior cervical lips into the anterior
and/or posterior walls of the lower uterine segment.
El Gelany etal., 2015
1/4/20 70ELBOHOTY

71. Compression sutures?
1/4/20 71ELBOHOTY

72. Nausicaa procedure
Shih etal, 2018
a 3/8-circle curved needle (70 mm in length, with a tapered point) 1-0 coated Vicryl
suture
1/4/20 72ELBOHOTY

73. Which is the
best
conservative
approach?
• The best-studied conservative
approach is leaving placenta in
situ . However, even this
approach is of uncertain efficacy
due to bias in case selection and
uncertainty regarding the
diagnosis of MAP.
1/4/20 73ELBOHOTY

74. Conclusion and recommendation
• US screening is mandatory in pregnant ladies with identified risk factors for placenta
accreta.
• CS scar pregnancy should be actively managed as early as soon in pregnancy
• The antenatal diagnosis and surgical avoidance of the placenta, and its separation, may be
associated with reduced maternal morbidity.
• Planned delivery in well equipped centre with accrete team
• Doing Caesarean section in the presence of a suspected placenta praevia accrete:
• Opening the uterus at a site distant from the placenta
• Delivering the baby without disturbing the placenta
• Caesarean hysterectomy is the standard management however leaving the placenta should
be considered in difficult cases and when the woman is keen on conservation of her uterus
or extremely difficult situations.
• Other conservative measures shouldn’t be the standard practice and they are only done on
the discretion of surgeon who is qualified to do.
1/4/20 74ELBOHOTY

75. References
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Med 2008: 27 (9): 1275-1281.
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Woodward PJ. Assessing the role of Magnetic Resonance Imaging in the Management of Gravid Patients at Risk for Placenta Accreta. Acad Radiol 2011; 18: 1175-1180.
• RCOG Green-top Guideline No.27 Jan 2011. Placenta praevia, placenta praevia accreta and vas praevia: diagnosis and management.
• Jyoti R, Robertson M. Imaging placenta accreta. O&G Magazine. 2010 Winter Edition; v.12 n2.
• Sentilhes L ,Kayem G, Ambroselli C et al. Fertility and pregnancy outcomes following conservative treatment for placenta accreta. Human Reproduction, Vol.25, No.11
pp.2803-2810, 2010.
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• El Gelany SA, Abdelraheim AR, Mohammed MM, et al. The cervix as a natural tamponade in postpartum hemorrhage caused by pla- centa previa and placenta previa
accreta: A prospec ve study. BMC Pregnancy Childbirth. 2015;15:295.
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• Shellhaas et al: The frequency and complication rates of hysterectomy accompanying cesarean delivery. Obstet Gynecol 2009
• Flood et al: Changing trends in peripartum hysterectomy over the past 4 decades. Am J Obstet Gynecol 2009
• Pather S. et al., Maternal outcome after conservative management of placenta percreta at caesarean section: A report of three cases and a review of the literature.
ANZJOG 2014: 54, 84-87
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76. Thank you
7
6
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