ABNORMAL ADHERENCE ABNORMAL ADHERENCE OF PLACENTAOF PLACENTA

Dr Uong SokhanDr Uong Sokhan

ObjectivesObjectives1. Identify the different types of 1. Identify the different types of

placenta accretaplacenta accreta2. List the etio-factors of placenta 2. List the etio-factors of placenta

accretaaccreta3. Describe the clinical course of 3. Describe the clinical course of

placenta accretaplacenta accreta

Certain placental abnomalities are Certain placental abnomalities are documented and are clinical documented and are clinical significance.significance.

Their knowledge is very important in Their knowledge is very important in managing during the antenatal managing during the antenatal period and the third stage of labor.period and the third stage of labor.

Normal implantation of placentaNormal implantation of placenta

Normal implantation of placentaNormal implantation of placenta

Normal implantation of placentaNormal implantation of placenta

Placenta accretaPlacenta accretaI. DefinitionI. Definition

Placenta which is abnormally firm Placenta which is abnormally firm adherence to the uterine walladherence to the uterine wall

Placenta accreta: placetal villi are Placenta accreta: placetal villi are attached to the myometriumattached to the myometrium

Placenta increta: placetal villi invade Placenta increta: placetal villi invade the myometriumthe myometrium

Placenta percreta: placetal villi Placenta percreta: placetal villi penetre through the myometrium penetre through the myometrium

A. Normal implantationA. Normal implantationB Placenta accretaB Placenta accretaC. Placenta incretaC. Placenta incretaD. Placenta PercretaD. Placenta Percreta

Placenta accreta Placenta accreta (continued)(continued)

Abnormal adherenceAbnormal adherence may involve: may involve:All of cotyledons All of cotyledons total placenta total placenta

accretaaccretaA few to several cotyledon A few to several cotyledon Partial Partial

placenta accretaplacenta accretaA single cotyledon A single cotyledon focal placenta focal placenta

accretaaccreta

Placenta accreta Placenta accreta (continued)(continued)

II. Etiological factorsII. Etiological factorsMost often in circumstances where Most often in circumstances where

decidual formation was likely to have decidual formation was likely to have been defectivebeen defective

Placental implantation in the lower Placental implantation in the lower uterine segment over a previous uterine segment over a previous cesarean section scar or others previous cesarean section scar or others previous uterine incisionuterine incision

Or occurrence after uterine curettageOr occurrence after uterine curettage

Placenta accreta Placenta accreta (continued)(continued)

III. Clinical courseIII. Clinical course1.1.Antepartum Antepartum

HemorrhageHemorrhage is common, consequence is common, consequence of of coexisting placenta previacoexisting placenta previa

2. During labour2. During labourMyometrial invasion by placental villi at Myometrial invasion by placental villi at the site of previous cesarean section the site of previous cesarean section may lead to may lead to uterine rupture during uterine rupture during labor labor or even beforeor even before

Placenta accreta Placenta accreta (continued)(continued)

3. 3. Problems associated with delivery of Problems associated with delivery of placentaplacenta and subsequent development and 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 It is very likely that focal placenta accreta with implantation in the upper uterine with implantation in the upper uterine segment is much more often developssegment is much more often develops

Placenta accreta Placenta accreta (continued)(continued)

a) a) AnAn involved cotyledoninvolved cotyledon is either is either - - pulled off pulled off the myometrium the myometrium

with with somewhat excessive bleedingsomewhat excessive bleeding, , oror

- - torn from the placenta torn from the placenta and and adheres to the implantation site with adheres to the implantation site with increase bleeding immediately or increase bleeding immediately or later later

Placenta accreta Placenta accreta (continued)(continued)

b) b) With more extensive involvement of cotyledons With more extensive involvement of cotyledons ::Hemorrhage becomes profuse Hemorrhage becomes profuse as delivery of as delivery of placenta is attempted,placenta is attempted,

Successful treatment depends upon immediate blood Successful treatment depends upon immediate blood replacement therapy and nearly always prompt replacement 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