accreta the nightmares

1. Placenta Accreta
Waled ayad
Assist. prof.obs&gynae.

4. PLACENTA ACCRETA
Any placental implantation in which there is an
abnormally firm adherence to the uterine wall.
This occurs as a result of partial or total absence
of the decidua basalis and imperfect development
of the fibrinoid layer (Nitabuch’s layer).

5. Placenta accreta, increta, and percreta
(focal or total)

7. CLINICAL SIGNIFICANCE
Maternal morbidity
Mortality
hemorrhage
Placenta accreta cesarean
hysterectomy

9. INCIDENCE
The incidence, due to rising CS rates.
ACOG (2002) 1 in 2500 (10-fold increase past 50).
Wu et al. (2005) reported an incidence of 500

10. RISK FACTORS
1. Placenta previa
50-fold increase in the relative
risk for placenta accreta)

11. TVS of a complete placenta previa
Placenta Previa

12. TVS of a complete placenta previa at 18 weeks
Placenta Previa

13. TAS of a partial placenta previa at 36 weeks
Placenta Previa

14. RISK FACTORS
2. cesarean delivery.
4fold with one CS
14fold with two CS
34 with 3 or more CS)

17. RISK FACTORS
3. Uterine surgry
4. Maternal age more than 35 years
5. High gravidity

18. Prediction of placenta accreta
MRI
Biochemical
markers
US

19. normal placental us

20. Us for previa

28. 1-Placenta previa
93% ppv))2-Placental lacunae with turbulent flow
3-Irregular bladder wall with extensive
associated
vascularity
85%ppv))4-Loss of retro placental clear space
5-Myometrial thickness <1 mm
6-Turbulent blood flow through lacunae
,2005)(costomok
US

29. Gray scale sensitivity 92
Color Doppler 95
Power 3D 100

30. TVS of Placenta Accreta
Note the intraplacental lacunae and loss of the
hypoechoic retroplacental myometrial zone

31. Iss
Placental lacunae (swiss
cheese appearance)
Loss of myometrial
thickness and infilteration
of bladder.

35. MRI
Uterine bulging
Focal inturuption in uterine wall
Tenting of the bladder
Direct visualisation of invasion

36. MRI of a placenta percreta at 24 weeks
Note complete absence of myometrium between the
placenta and the bladder

37. Biochemical markers
1- MSAFP
2-CK
3-BHCG

38. Odds Ratio of Placenta Accreta
• Placenta previa: 54x
• MSAFP > 2.5 MOM : 8.3
• Beta HCG >2.5 MOM: 3.9

39. prediction Prevention.
Emergency
team
Scheduled
delivery
MANAGEMENT

40. Secrets of 3 p

41. When to deliver

43. Blood cell salvage
Reduce need for allogenic transfusion
Reduce transfusion reaction
Reduce transfusion related infection

47. MANAGEMENT WITHOUT HYSTERECTOMY
Aiming to preserve fertility and decrease the
incidence of hysterectomy-related complications
The placenta is left in situ and adjunctive
procedures are applied such as:
 Embolization of internal iliac vessels.
 Treatment with methotrexate.
Use of uterine compression sutures.
Oversewing of the placental bed. (Kayem et al., 2004;
Weinstein et al., 2005).

49. S &
Cont 3

50. BLADDER INVOLVEMENT
The bladder is the most frequently involved extra
uterine organ when there is a placenta percreta..
In only one-third of cases diagnosis was made
prenatally by U/S or MRI. (Washecka and Behling,
2002; Caliskan et al., 2003).
Management requires careful perioprative
planning and should involve a urogynecologist, a
urologist and/or gynecological oncologist.

52. conclusion
Prevention , prediction ,early diagnosis
•and standby to face the
drama