Updated: 3/8/2017

Placenta Accreta

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Overview

Snapshot
  • A 28-year-old G3P2 female is in the labor and delivery floor due to being in active labor. The patient is 10 centimeters dilated and preparations are made for delivery of the newborn. A male neonate is born with appropriate Apgar scores and without any perinatal complications. After an attempt at manual placental separation, there is profuse bleeding. Obstetric history is significant for previous cesarean delivery. She has missed a number of prenatal visits. 
Introduction
  • Clinical definition
    • an abnormal placental implantation on the myometrium instead of the decidua 
  • Epidemiology
    • incidence
      • 79% of abnormal placental implantation cases
      • there may be an increasing incidence due to an increase in cesarean deliveries
    • location
      • uterus
    • risk factors
      • current placenta previa
      • history of cesarean delivery
  • Pathophysiology
    • pathoanatomy
      • not fully understood; however, one theory suggests there may be a defect in decidualization secondary to prior surgery or abnormal anatomy, which results in
        • direct placental attachment to the myometrium
  • Prognosis
    • 7% mortality rate
    • may increase the risk of a complicated perinatal course
Presentation
  • Physical exam
    • failure to separate the placenta from the mother after delivery of the fetus
    • hemorrhage that can be life-threatening
Imaging
  • Transvaginal or transabdominal ultrasonography
    • indications in patients with 
      • a history of cesarean delivery or other uterine surgeries
      • placenta previa
      • low anterior placenta
    • findings
      • placental lacunae are irregularly shaped in the placenta
        • placental lacunae are vascular spaces
        • may have a "swiss cheese" appearance
      • the retroplacental space is disrupted or lost
Studies
  • Histology
    • placental villi attached to the myometrium in the absence of a decidual plate
  • Diagnostic criteria
    • clinical diagnosis
      • typically by ultrasonography when diagnosing placenta accreta antenatally
      • histologic findings when diagnosing placenta accreta postnatally
Differential
  • Placenta increta
    • occurs when chorionic villi invade into the myometrium only
  • Placenta percreta
    • occurs when chorionic villi invade the myometrium and serosa
      • can invade adjacent organs (e.g., bladder)
Treatment
  • Operative
    • cesarean section with total abdominal hysterectomy 
      • indication
        • typically for the treatment for placenta accreta

 

 

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