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Obstetrics and Gynecology Dec 2018Placenta accreta spectrum, formerly known as morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta,...
Placenta accreta spectrum, formerly known as morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta. The most favored hypothesis regarding the etiology of placenta accreta spectrum is that a defect of the endometrial-myometrial interface leads to a failure of normal decidualization in the area of a uterine scar, which allows abnormally deep placental anchoring villi and trophoblast infiltration. Maternal morbidity and mortality can occur because of severe and sometimes life-threatening hemorrhage, which often requires blood transfusion. Although ultrasound evaluation is important, the absence of ultrasound findings does not preclude a diagnosis of placenta accreta spectrum; thus, clinical risk factors remain equally important as predictors of placenta accreta spectrum by ultrasound findings. There are several risk factors for placenta accreta spectrum. The most common is a previous cesarean delivery, with the incidence of placenta accreta spectrum increasing with the number of prior cesarean deliveries. Antenatal diagnosis of placenta accreta spectrum is highly desirable because outcomes are optimized when delivery occurs at a level III or IV maternal care facility before the onset of labor or bleeding and with avoidance of placental disruption. The most generally accepted approach to placenta accreta spectrum is cesarean hysterectomy with the placenta left in situ after delivery of the fetus (attempts at placental removal are associated with significant risk of hemorrhage). Optimal management involves a standardized approach with a comprehensive multidisciplinary care team accustomed to management of placenta accreta spectrum. In addition, established infrastructure and strong nursing leadership accustomed to managing high-level postpartum hemorrhage should be in place, and access to a blood bank capable of employing massive transfusion protocols should help guide decisions about delivery location.
Topics: Cesarean Section; Conservative Treatment; Female; Fertility Preservation; Humans; Hysterectomy; Organ Sparing Treatments; Perioperative Care; Placenta Accreta; Pregnancy; Prenatal Diagnosis; Watchful Waiting
PubMed: 30461695
DOI: 10.1097/AOG.0000000000002983 -
Best Practice & Research. Clinical... Nov 2019The increasing incidence of caesarean delivery (CD) has resulted in an increase in placenta accreta spectrum (PAS), adversely impacting maternal outcomes globally.... (Review)
Review
The increasing incidence of caesarean delivery (CD) has resulted in an increase in placenta accreta spectrum (PAS), adversely impacting maternal outcomes globally. Currently, more than 90% of women diagnosed with PAS present with a placenta praevia (praevia PAS). Praevia PAS can be reliably diagnosed antenatally with ultrasound, and it is unclear whether magnetic resonance imaging improves diagnosis beyond what can be achieved by skilled ultrasound operators. Therefore, any screening programme for PAS will require improved training in the diagnosis of placental disorders and development of targeted scanning protocols. Management strategies for praevia PAS vary depending on the accuracy of prenatal diagnosis, findings at laparotomy and local surgical expertise. Current epidemiological data for PAS are highly heterogeneous, mainly due to wide variation in the clinical criteria used to diagnose the condition at birth. This significantly impacts research into all aspects of the condition, especially comparison of the efficacy of different management strategies.
Topics: Cesarean Section; Female; Humans; Magnetic Resonance Imaging; Placenta Accreta; Placenta Previa; Pregnancy; Prenatal Diagnosis
PubMed: 31126811
DOI: 10.1016/j.bpobgyn.2019.04.006 -
NeoReviews Nov 2021Placenta accreta spectrum (PAS) refers to the range of pathologic adherence of the placenta to the uterine myometrium, including the placenta accreta, increta, and... (Review)
Review
Placenta accreta spectrum (PAS) refers to the range of pathologic adherence of the placenta to the uterine myometrium, including the placenta accreta, increta, and percreta. The incidence of PAS is rising primarily because of an increase in related risk factors, such as the rate of cesarean deliveries and pregnancies resulting from assisted reproductive technology. The maternal risks associated with PAS are significant, including hemorrhage, hysterectomy, and death. Fetal and neonatal risks are primarily the result of premature delivery. Antenatal diagnosis via ultrasonography and magnetic resonance imaging remains imperfect. Management of PAS varies, however, and there is a clear improvement in maternal outcomes with an antenatal diagnosis compared with unexpected diagnosis at the time of delivery. Studies that evaluate the balance between maternal and fetal/neonatal risks of expectant management versus preterm delivery have found that planned delivery between 34 and 35 weeks' gestation optimizes outcomes. Multidisciplinary PAS care teams have become the norm and recommended approach to management, given the complexity of caring for this obstetrical condition. Although significant advances have been made over the years, large knowledge gaps remain in understanding the pathophysiology, diagnosis, and clinical management.
Topics: Cesarean Section; Female; Gestational Age; Humans; Hysterectomy; Infant, Newborn; Placenta Accreta; Pregnancy; Prenatal Diagnosis
PubMed: 34725137
DOI: 10.1542/neo.22-11-e722 -
American Journal of Obstetrics and... Sep 2022Placenta accreta has been described as a spectrum of abnormal attachment of villous tissue to the uterine wall, ranging from superficial attachment to the inner... (Review)
Review
Placenta accreta has been described as a spectrum of abnormal attachment of villous tissue to the uterine wall, ranging from superficial attachment to the inner myometrium without interposing decidua to transmural invasion through the entire uterine wall and beyond. These descriptions have prevailed for more than 50 years and form the basis for the diagnosis and grading of accreta placentation. Accreta placentation is essentially the consequence of uterine remodeling after surgery, primarily after cesarean delivery. Large cesarean scar defects in the lower uterine segment are associated with failure of normal decidualization and loss of the subdecidual myometrium. These changes allow the placental anchoring villi to implant, and extravillous trophoblast cells to migrate, close to the serosal surface of the uterus. These microscopic features are central to the misconception that the accreta placental villous tissue is excessively invasive and have led to much confusion and heterogeneity in clinical data. Progressive recruitment of large arteries in the uterine wall, that is, helicine, arcuate, and/or radial arteries, results in high-velocity maternal blood entering the intervillous space from the first trimester of pregnancy and subsequent formation of placental lacunae. Recently, guided sampling of accreta areas at delivery has enabled accurate correlation of prenatal imaging data with intraoperative features and histopathologic findings. In more than 70% of samples, there were thick fibrinoid depositions between the tip of most anchoring villi and the underlying uterine wall and around all deeply implanted villi. The distortion of the uteroplacental interface by these dense depositions and the loss of the normal plane of separation are the main factors leading to abnormal placental attachment. These data challenged the classical concept that placenta accreta is simply owing to villous tissue sitting atop the superficial myometrium without interposed decidua. Moreover, there is no evidence in accreta placentation that the extravillous trophoblast is abnormally invasive or that villous tissue can cross the uterine serosa into the pelvis. It is the size of the scar defect, the amount of placental tissue developing inside the scar, and the residual myometrial thickness in the scar area that determine the distance between the placental basal plate and the uterine serosa and thus the risk of accreta placentation.
Topics: Cicatrix; Female; Humans; Myometrium; Placenta; Placenta Accreta; Placentation; Pregnancy
PubMed: 35248577
DOI: 10.1016/j.ajog.2022.02.038 -
American Journal of Obstetrics and... Jan 2021Placenta accreta spectrum includes the full range of abnormal placental attachment to the uterus or other structures, encompassing placenta accreta, placenta increta,...
Special Report of the Society for Maternal-Fetal Medicine Placenta Accreta Spectrum Ultrasound Marker Task Force: Consensus on definition of markers and approach to the ultrasound examination in pregnancies at risk for placenta accreta spectrum.
Placenta accreta spectrum includes the full range of abnormal placental attachment to the uterus or other structures, encompassing placenta accreta, placenta increta, placenta percreta, morbidly adherent placenta, and invasive placentation. The incidence of placenta accreta spectrum has increased in recent years, largely driven by increasing rates of cesarean delivery. Prenatal detection of placenta accreta spectrum is primarily made by ultrasound and is important to reduce maternal morbidity associated with the condition. Despite a large body of research on various placenta accreta spectrum ultrasound markers and their screening performance, inconsistencies in the literature persist. In response to the need for standardizing the definitions of placenta accreta spectrum markers and the approach to the ultrasound examination, the Society for Maternal-Fetal Medicine convened a task force with representatives from the American Institute of Ultrasound in Medicine, the American College of Obstetricians and Gynecologists, the American College of Radiology, the International Society of Ultrasound in Obstetrics and Gynecology, the Society for Radiologists in Ultrasound, the American Registry for Diagnostic Medical Sonography, and the Gottesfeld-Hohler Memorial Ultrasound Foundation. The goals of the task force were to assess placenta accreta spectrum sonographic markers on the basis of available data and expert consensus, provide a standardized approach to the prenatal ultrasound evaluation of the uterus and placenta in pregnancies at risk of placenta accreta spectrum, and identify research gaps in the field. This manuscript provides information on the Placenta Accreta Spectrum Task Force process and findings.
Topics: Cesarean Section; Cicatrix; Female; Gestational Age; Gynecology; Humans; Obstetrics; Placenta; Placenta Accreta; Pregnancy; Sensitivity and Specificity; Societies, Medical; Ultrasonography, Prenatal; United States; Uterus
PubMed: 33386103
DOI: 10.1016/j.ajog.2020.09.001 -
American Journal of Obstetrics and... Aug 1955
Topics: Female; Humans; Placenta; Placenta Accreta; Pregnancy
PubMed: 13238477
DOI: 10.1016/s0002-9378(16)37686-4 -
International Journal of Gynecological... Nov 2021
Topics: Adult; Diagnosis, Differential; Female; Humans; Placenta Accreta; Pregnancy; Tomography, X-Ray Computed; Trophoblastic Tumor, Placental Site
PubMed: 34725244
DOI: 10.1136/ijgc-2021-002988 -
American Journal of Obstetrics and... Nov 2010We sought to review the risks of placenta accreta, increta, and percreta, and provide guidance regarding interventions to improve maternal outcomes when abnormal... (Review)
Review
OBJECTIVE
We sought to review the risks of placenta accreta, increta, and percreta, and provide guidance regarding interventions to improve maternal outcomes when abnormal placental implantation occurs.
METHODS
Relevant documents were identified through a search of the English-language literature for publications including ≥1 of the key words "accreta" or "increta" or "percreta" using PubMed (US National Library of Medicine; January 1990 through January 2010); with results limited to studies involving human beings. Additional information was obtained from references identified within selected articles; from additional review articles; and from guidelines by organizations including the American College of Obstetricians and Gynecologists. Each included article was evaluated according to study design and quality in accordance with the scheme outlined by the US Preventative Services Task Force.
RESULTS AND RECOMMENDATIONS
Abnormal placentation--encompassing placenta accreta, increta, and percreta--is increasingly common. While randomized controlled trials and large observational cohort studies that can be used to define best practice are lacking, strategies to enhance early diagnosis, enhance preparation, and coordinate peripartum management can be undertaken. Women with a placenta previa overlying a uterine scar should be evaluated for the potential diagnosis of placenta accreta. Women with a placenta previa or "low-lying placenta" overlying a uterine scar early in pregnancy should be reevaluated in the third trimester with attention to the potential presence of placenta accreta. When the diagnosis of placenta accreta is made remote from delivery, the need for hysterectomy should be anticipated and arrangements made for delivery in a center with adequate resources, including those for massive transfusion. Intraoperatively, attention should be paid to abdominal and vaginal blood loss. Early blood product replacement, with consideration of volume, oxygen-carrying capacity, and coagulation factors, can reduce perioperative complications.
Topics: Female; Humans; Placenta Accreta; Pregnancy; Risk; Ultrasonography, Prenatal
PubMed: 21055510
DOI: 10.1016/j.ajog.2010.09.013 -
Indian Journal of Pathology &... Feb 2020Abnormal placentations such as placenta accreta, placenta increta and placenta percreta are important causes of hemorrhage after delivery causing maternal morbidity and...
BACKGROUND
Abnormal placentations such as placenta accreta, placenta increta and placenta percreta are important causes of hemorrhage after delivery causing maternal morbidity and mortality. Risk factors for abnormal placentation are prior caesarean section, placenta previa and pre-eclampsia. There is a need for reliable antenatal diagnosis for these serious conditions. If these pregnancies can be identified, antepartum, site and time of delivery as well as the surgical approach can be planned ahead; this decreases the incidence of maternal mortality due to massive hemorrhage.
AIM
(1) To study the incidence of abnormal placentation in emergency peripartum hysterectomy specimen. (2) To evaluate various risk factors associated with abnormal placentation.
MATERIALS AND METHOD
Retrospective cross-section study done in patients with abnormal placentation leading to emergency peripartum hysterectomy during a course of eight-year period.
RESULT
We received total of 18 emergency hysterectomy specimens during eight-year period of which placenta accreta accounts 55.5 percent (10/18), placenta increta upto 38.8 percent (7/18) and placenta percreta 5.5 percent (1/18). Analysis of result with parity shows uniparous women up to 22.2 percent (4/18), and multiparous women 77.7 percent (14/18). Risk factor analysis shows previous caesarean section in 55.5 percent (10/18), placenta previa in 33.3 percent (6/18) and pre-eclampsia in 11.1 percent (2/18).
CONCLUSION
In our study, among abnormal placentation, incidence of placenta accreta accounts for 55.5 percent and it is more common in multiparous women than uniparous women. Among risk factors in our study, previous caesarean section is commonly associated with abnormal placentation followed by a placenta previa and pre-eclampsia.
Topics: Adult; Cesarean Section; Cross-Sectional Studies; Female; Humans; Hysterectomy; Incidence; Peripartum Period; Placenta; Placenta Accreta; Placenta Previa; Pre-Eclampsia; Pregnancy; Retrospective Studies; Risk Factors
PubMed: 32108636
DOI: 10.4103/IJPM.IJPM_229_19 -
Fetal and Pediatric Pathology Jun 2019Morbid adherence is a risk factor for retained placenta (RP). We encountered three cases of placenta increta presenting clinically as delayed postpartum hemorrhage.
OBJECTIVES
Morbid adherence is a risk factor for retained placenta (RP). We encountered three cases of placenta increta presenting clinically as delayed postpartum hemorrhage.
METHODS
This was a retrospective study of three cases of placenta increta presenting as RP.
RESULTS
One "routine" term placenta had heavy bleeding 2 weeks later; one missed abortion at 16 weeks with fetal and placental tissue submitted, had heavy bleeding 6 weeks later; and one elective abortion (no tissue submitted), had delayed postpartum bleeding leading to a curettage with blood only, then 6 weeks later a hysterectomy for menorrhagia. All 3 pathology specimens showed necrotic villi. However, all three also showed myometrium with keratin-positive interstitial trophoblasts in a zone of damaged myometrium, consistent with increta. All three cases had basal plate myofibers (BPMF) in the placenta, with BPMF recurrence in the two cases with another pregnancy.
CONCLUSION
RP may be a presenting clinical manifestation of placenta increta.
Topics: Adult; Female; Hemorrhage; Humans; Placenta; Placenta Accreta; Placenta, Retained; Pregnancy; Retrospective Studies; Trophoblasts
PubMed: 30888250
DOI: 10.1080/15513815.2019.1582121