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

1. Dr. Laxmi Shrikhande MD; FICOG; FICMU
•Director-Shrikhande Fertility Clinic, Nagpur
•President Menopause Society, Nagpur
•National Corresponding Editor-The Journal of Obstetrics & Gynecology of India
•Senior Vice President FOGSI 2012
•Vice Chairperson ICOG
•Governing Council member ICOG 2012-2017
•Governing Council Member ISAR 2014-2019
•Governing Council Member IAGE for 3 terms
•Patron-Vidarbha Chapter ISOPARB
•Chairperson-HIV/AIDS Committee, FOGSI (2007-09)
•Received Best Committee Award of FOGSI
•Received Bharat excellence Award for women’s health
•President Nagpur OB/GY Society 2005-06
•Associate member of RCOG
•Member of European Society of Human Reproduction
•Visited 96 FOGSI Societies as invited faculty
•Delivered 5 orations
•Publications-Twenty National & eleven International
•Presented Papers in FIGO, AICOG, SAFOG, AICC-RCOG conferences
•Conducted adolescent health programme for more than 15,000 adolescent girls

2. Adherent placenta
Dr Laxmi Shrikhande
Director-Shrikhande IVF & Surrogacy
Centre, Nagpur

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.

4. Types
1 ) Simple Adherent Placenta.
2 ) Morbidly Adherent Placenta :
i ) Placenta Accreta
ii ) Placenta Increta
iii) Placenta Percreta

5. Degrees of severity
(1) Accreta in which the placenta adheres to the
myometrium without invasion into the muscle.
(80% of cases)
(2) Increta in which it invades into the
myometrium. (15% of cases)
(3) Percreta in which it invades the full thickness
of the uterine wall and possibly other pelvic
structures, most frequently the bladder. (5% of
cases)

6. INCIDENCE
 It varies widely all over the world.
Increased dramatically over the last 3 decades
( Because of Increase in LSCS rates )
 A.C.O.G.  1 Per 2500 deliveries.
Accreta : 75 -78 %
Increta : 15 – 18 %
Percreta : 5 -7 %

7. Risk factors
Risk factors for placenta accreta include :
1. placenta previa with or without previous uterine
surgery.
2. previous myomectomy.
3. previous cesarean delivery.
4. Asherman's syndrome.
5. submucous leiomyomata.
6. maternal age of 36 years and older.
The ACOG committee

8. 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 Morbidly Adherent Placenta.

9. 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
torrential haemorrhage.

10. Significance
 Increased Maternal Morbidity ( 2 – 7 % )
 Increased Maternal Mortality ( 7 – 10 % )
from,
- Severe Hemorrhage
- Infection
- Inversion of Uterus

11. Diagnosis
 Clinical suspicion
 Ultrasound
 Color Doppler
 MRI
 Biochemical Marker
 Histopathology

12. USG
• First-line investigation for suspected
placental invasion of the myometrium.
• The most useful modalities for
evaluating placental position and
implantation are TAS and TVS

13. characterized by a
hypoechoic boundary between the placenta and the
urinary bladder that represents the myometrium
and normal retroplacental myometrial
vasculature.
The normal placenta has a homogenous appearance
as well.
Gray-scale sonographic signs of normal placenta

14. Gray-scale sonographic signs of placenta accreta
• Loss of the retroplacental hypoechoic zone
• Progressive thinning of the retroplacental hypoechoic
zone
• Presence of multiple placental lakes ("Swiss cheese"
appearance)
• Thinning of the uterine serosa-bladder wall complex
(percreta)
• Elevation of tissue beyond the uterine serosa
(percreta)

15. Moth – eaten
OR
Swiss Cheese
Appearance
Obliteration of clear
space between
placenta and uterine
wall

16. 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

17. 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.

18. 3 D USG
Diagnostic Criteria :
 Irregular intraplacental vascularization
with tortuous confluent vessels crossing
placental width.
 Hypervascularity of uterine serosa–
bladder wall interface.

19. Colour Doppler
 Diffuse or focal
intraparenchymal
lacunar flow.
 Vascular lakes with
turbulent flow.
 Hypervascularity of
serosa-bladder interface.
 Prominent subplacental
venous complex.

20. wickler and associates observed that when
myometrial thickness was greater than 1
mm and large placental lakes existed,
myometrial invasion could be predicted
with a sensitivity and specificity of 100%
and 72%, respectively.
Color Doppler signs suggestive of placenta
accreta

21. Magnetic Resonance Imaging
Useful in –
• Posterior Placenta
• Assessing deep myometrial, bladder and
parametrial invasion
• Ultrasound findings are equivocal
Colour Doppler

22. 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

23. 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

24. The information obtained by the Obstetric
Magnetic Resonance has shown an excellent
correlation with the surgical findings.
Its use must be recommended in the planning
of any surgery of placenta percreta, being
indispensable when a conservative uterine
treatment is planned.
MRI

25. MRI
• Must at 26 weeks in cases of previous LSCS and
anterior low lying placenta placenta
• In cases of previous H/o myomectomy / uterine
surgery and anterior placenta

26. 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.

27. Histology
 Post Partum specimen shows :
Placental villi anchored directly on, or invading into or
through, the myometrium, without an intervening
decidual plate.

28. Treatment :
A multidisciplinary team
approach is relevant in managing
these patients in order to reduce
morbidity and mortality associated
with MAP.

29. Uterine Incision:
It is best to avoid cutting through a
MAP because of the possibility of massive haemorrhage.

30. Various modifications of the uterine incision
to avoid the placenta have been reported…
- Classical incision,
- High transverse incision,
- Fundal vertical incision,
- Fundal transverse incision

31. 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.

32. Bladder Involvement
 First , Involve UROLOGIST.
 Preoperative Ureteric
stenting aids in identifying the
ureters, which will help
reduce ureteric injuries.

33.  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.

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.

35. Uterine artery ligation
involves taking large
purchases through
the uterine wall to
ligate the artery at
the cervical isthmus
above the bladder
flap .
Uterine Artery Ligation

36. 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.

37. it is reported to have a mortality rate of
around 7 percent and is the most
common indication for birth-related
hysterectomy
Hysterectomy

38. Hysterectomy
Resort to hysterectomy
SOONER RATHER THAN LATER
(especially in cases of placenta accreta
when future fertility is out of concern)

39.  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.
Hysterectomy

40. Intraoperatively, bleeding is rarely a problem until
an attempt is made to remove the placenta.
Accordingly, the uterine incision should be made
vertically and above the placental insertion site.
Bil. Int. iliac artery ligation is performed prior to
peripartum hysterectomy where Interventional
Radiology is not available.
Hysterectomy

41. Following delivery of the infant, the cord is clamped
and the uterine incision is oversewn
circumferentially to decrease blood loss.
A hysterectomy is then performed with meticulous
attention to securing haemostasis.
Electrocautery and vascular clips may be of
significant benefit during the dissection.
Hysterectomy

42. Conservative treatment of placenta accreta
to preserve fertility
• Bilateral hypogastric artery ligation
• medical treatment with methotrexate or
• uterine artery embolization

43. Selective arterial embolization
While the availability of SAE
varies from institution to
institution, if it is
available at your
institution, here are
some tips to keep in
mind:
Placement of occlusion balloon catheters
into both internal iliac arteries

44. Selective arterial embolization
1.Ascertain the hours when SAE is available and
establish protocols of accessibility.
2.If a patient is at risk for PPH, we advise pre-
delivery consultation with the interventional
radiology team. Place embolization catheters
prior to the procedure if indicated, and make
the team aware of the potential need for SAE
to help them prepare for it.

45. 3.Make the decision to move to the
interventional radiology suite as quickly
as possible, keeping in mind that transfer
can take 15 minutes and embolization
can take 30 minutes.
Selective arterial embolization

46. 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. . .

47. An alternative but unsubstantiated
treatment is to leave the placenta
undelivered and treat the patient
with methotrexate.
Methotrexate

48. 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.
 others have argued that, after delivery of the fetus,
the placenta is no longer dividing and therefore,
methotrexate is of no value.

49.  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 HCG comes to zero.β

50. 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.

51. Placenta accreta – maternal comorbidity
– 25 to 50% of women required admission to an intensive
care
– Increased risk of thromboembolism, pyelonephritis,
pneumonia, wound and pelvic infections, need for a
second operation to control bleeding or treat infection
Silver et al: Maternal morbidity associated with multiple
cesarean deliveries. Obstet Gynecol 2006

52. Placenta accreta – perinatal morbidity
– Placenta accreta associated with increased
perinatal morbidity
– most cases due to PTD
• prompted by vaginal bleeding
OR
• desire to avoid vaginal bleeding and optimize surgical
conditions

54. Summary of management options
1. Manual removal of placenta if PPH
2. Leave in situ. and monitor provided no PPH
3. Administer Methotrexate
4. Perform curettage once B.HCG levels becomes
undetectable
5. During C.S. haemostasis by over sewing
implantation site, resection of implantation site,
stepwise uterine devascularization
6. Hysterectomy –last resort but not too late

55. Take Home Message
• All out efforts at all levels to decrease the primary
LSCS rates
• Be alert of the possibility in high risk cases
• Antenatal diagnosis is ideal
• MRI is must at 26 weeks if H/o previous uterine
surgery and anterior placenta
• Be prepared to deal with the crisis when faced with
undetected adherent placenta during delivery or CS

56. Dr. Laxmi Shrikhande
Shrikhande IVF & Surrogacy Center
Ph-96234 59766 / shrikhandedrlaxmi@gmail.com

57. 'Spiritual blossoming' simply means
blossoming in life in all
dimensions.
Being happy, at ease with yourself
and with everybody around you.
Sri Sri Ravi Shankar
The Art of Living