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1. ABNORMAL ADHERENCEABNORMAL ADHERENCE
OF PLACENTAOF PLACENTA
Dr Uong SokhanDr Uong Sokhan

2. ObjectivesObjectives
1. Identify the different types of placenta1. Identify the different types of placenta
accretaaccreta
2. List the etio-factors of placenta accreta2. List the etio-factors of placenta accreta
3. Describe the clinical course of placenta3. Describe the clinical course of placenta
accretaaccreta

3. Certain placental abnomalities areCertain placental abnomalities are
documented and are clinical significance.documented and are clinical significance.
Their knowledge is very important inTheir knowledge is very important in
managing during the antenatal period andmanaging during the antenatal period and
the third stage of labor.the third stage of labor.

4. Normal implantation of placentaNormal implantation of placenta

5. Normal implantation of placentaNormal implantation of placenta

6. Normal implantation of placentaNormal implantation of placenta

7. Placenta accretaPlacenta accreta
I. DefinitionI. Definition
Placenta which is abnormally firmPlacenta which is abnormally firm
adherence to the uterine walladherence to the uterine wall
Placenta accreta: placetal villi arePlacenta accreta: placetal villi are
attached to the myometriumattached to the myometrium
Placenta increta: placetal villi invade thePlacenta increta: placetal villi invade the
myometriummyometrium
Placenta percreta: placetal villi penetrePlacenta percreta: placetal villi penetre
through the myometriumthrough the myometrium

8. A. Normal implantationA. Normal implantation
B Placenta accretaB Placenta accreta
C. Placenta incretaC. Placenta increta
D. Placenta PercretaD. Placenta Percreta

9. Placenta accretaPlacenta accreta (continued)(continued)
Abnormal adherenceAbnormal adherence may involve:may involve:
All of cotyledonsAll of cotyledons  total placenta accretatotal placenta accreta
A few to several cotyledonA few to several cotyledon  PartialPartial
placenta accretaplacenta accreta
A single cotyledonA single cotyledon  focal placenta accretafocal placenta accreta

10. Placenta accretaPlacenta accreta (continued)(continued)
II. Etiological factorsII. Etiological factors
Most often in circumstances whereMost often in circumstances where
decidual formation was likely to have beendecidual formation was likely to have been
defectivedefective
Placental implantation in the lower uterinePlacental implantation in the lower uterine
segment over a previous cesarean sectionsegment over a previous cesarean section
scar or others previous uterine incisionscar or others previous uterine incision
Or occurrence after uterine curettageOr occurrence after uterine curettage

11. Placenta accretaPlacenta accreta (continued)(continued)
III. Clinical courseIII. Clinical course
1.1. AntepartumAntepartum
HemorrhageHemorrhage is common, consequence ofis common, consequence of
coexisting placenta previacoexisting placenta previa
2. During labour2. During labour
Myometrial invasion by placental villi at theMyometrial invasion by placental villi at the
site of previous cesarean section maysite of previous cesarean section may
lead tolead to uterine rupture during laboruterine rupture during labor oror
even beforeeven before

12. Placenta accretaPlacenta accreta (continued)(continued)
3.3. Problems associated with delivery ofProblems associated with delivery of
placentaplacenta and subsequent developmentand subsequent development
vary appreciably depending upon:vary appreciably depending upon:
 site of implantation,site of implantation,
 depth of myometrial penetration,depth of myometrial penetration,
 and number of cotyledons involvedand number of cotyledons involved
It is very likely that focal placenta accreta withIt is very likely that focal placenta accreta with
implantation in the upper uterine segment isimplantation in the upper uterine segment is
much more often developsmuch more often develops

13. Placenta accretaPlacenta accreta (continued)(continued)
a)a) AnAn involved cotyledoninvolved cotyledon is eitheris either
-- pulled offpulled off the myometrium withthe myometrium with
somewhat excessive bleedingsomewhat excessive bleeding, or, or
-- torn from the placentatorn from the placenta andand
adheres to the implantation site withadheres to the implantation site with
increase bleeding immediately or laterincrease bleeding immediately or later

14. Placenta accretaPlacenta accreta (continued)(continued)
b)b) With more extensive involvement of cotyledonsWith more extensive involvement of cotyledons ::
Hemorrhage becomes profuseHemorrhage becomes profuse as delivery ofas delivery of
placenta is attempted,placenta is attempted,
Successful treatment depends upon immediate bloodSuccessful treatment depends upon immediate blood
replacement therapy and nearly always promptreplacement therapy and nearly always prompt
hysterectomyhysterectomy
C)C) With total placenta accretaWith total placenta accreta there may be:there may be:
 Little or no bleedingLittle or no bleeding
 Traction may cause inversion of uterusTraction may cause inversion of uterus
 Usual attempts at manual removal will not succeedUsual attempts at manual removal will not succeed
Prompt hysterectomy is the safest treatmentPrompt hysterectomy is the safest treatment