Placenta Accreta

By Nisar Ajmeri-March 30, 2018

What is placenta accreta?

Placenta accreta is a high-risk pregnancy complication that
happens when the placenta becomes embedded too deeply in
the uterine wall. That occurs when blood vessels and other
parts of the placenta grow too deeply into the uterine wall.

Typically, the placenta detaches from the uterine wall after

childbirth. With placenta accreta, part or the entire placenta
remains firmly attached. This can cause severe blood loss after
delivery.
It's also possible for the placenta to invade the muscles of the
uterus (placenta increta) or grow through the uterine wall
(placenta percreta).
What are types of placenta accreta?
Sometimes the placenta attaches itself into the wall of the
uterus too deeply. This can cause problems, including:

 Placenta accreta –Chorionic villi attach to the

myometrium.Rather than being restricted within
the decidua basalis. The placenta attaches itself too
deeply and too firmly into the uterus.
 Placenta increta –Chorionic villi invade into the
myometrium. The placenta attaches itself even more
deeply into the muscle wall of uterus.
 Placenta percreta –Chorionic villi invade through
the perimetrium (uterine serosa). The placenta attaches
itself and grows through the uterus, sometimes extending
to nearby organs, such as the bladder.

Type Fraction Description

The placenta attaches strongly to the myometrium, but does not penetrate it. This
Placenta accreta 75–78%
form of the condition accounts for around 75% of all cases.

Placenta increta 17% Occurs when the placenta penetrates the myometrium.

The highest-risk form of the condition occurs when the placenta penetrates the
Placenta entire myometrium to the uterine serosa (invades through entire uterine wall). This
5–7%
percreta variant can lead to the placenta attaching to other organs such as the rectum or
urinary bladder.
In these conditions, the placenta doesn’t completely separate
from the uterus after you give birth. This can cause
dangerous bleeding. These conditions happen in about 1 in 530
births each year.

What is a Signs & Symptoms of

Placenta Accreta?
Placenta accreta symptoms during pregnancy: (What the
mother will experience)
1. No symptoms- Though this abnormality develops in the
early pregnancy itself it does not cause any trouble until the
time of delivery as the placental function is very much normal.
Even if associated with placenta praevia (wherein the placenta
is partly or completely inserted in the lower uterine wall) there
is a 21.7% chance of no bleeding at any time.
2. Vaginal bleeding- If you have placenta praevia you may
experience vaginal bleeding in the third trimester. The first
bleeding episode may occur prior to 30 weeks (33.7% chance)
or after 30 weeks (44.6% chance) or not at all (21.7%).
So, if you experience vaginal bleeding or pain and contractions
of the uterus in the third trimester it is important to meet your
healthcare provider.
Placenta accreta Signs: (What the doctor will note)
If not diagnosed before delivery of the baby, the placenta
accreta will present as:
1. Delay in the delivery of the placenta: Normally the
placenta spontaneously separates and is delivered within 30
min of the delivery. In placenta accreta the placenta fails to
deliver spontaneously and this will ring a bell to the doctor of
the possibility of placenta accreta.
2. Profuse vaginal bleeding: The doctor will notice that there
is more than normal vaginal bleeding, particularly when manual
separation of the placenta is attempted.
3. Soft uterus: Normally, after the baby is delivered, the
uterus begins to become hard. This also compresses the blood
vessels and stops bleeding. In placenta accreta due to the
retained placenta, the uterus remains soft and as a result, the
bleeding continues.
4. Reduced blood pressure and increase in the pulse
rate: This occurs when there is excessive blood loss.
Placenta accreta often causes no signs or symptoms during
pregnancy — although vaginal bleeding during the third
trimester is possible. Often, placenta accreta is detected during
a routine ultrasound.
If you experience vaginal bleeding during your third trimester,
contact your health care provider right away. If the bleeding is
severe, seek emergency care.

What causes these placental

conditions?
We don’t know what causes these kinds of placental conditions.
But they often happen where you have a scar from a surgery,
like removing a fibroid or having a c-section. A fibroid is a
tumor that grows in the wall of the uterus (womb). If you’ve
had a c-section, you’re more likely than if you had a vaginal
birth to have these kinds of conditions. And the more c-
sections you’ve had, the more likely you are to have these
placental problems.
Things that may make you more likely to have these kinds of
placental conditions include:
 Smoking cigarettes
 Being 35 or older
 Being pregnant before
 Having placenta previa

What are Risk factors of placenta

accreta?
Many factors can increase the risk of placenta accreta,
including:
 Previous uterine surgery- If you've had a C-section or
other uterine surgery, you're at increased risk of placenta
 accreta. The risk of placenta accreta increases with the
number of uterine surgeries.
 Placenta position- If your placenta partially or totally
covers your cervix (placenta previa) or sits in the lower
portion of your uterus, you're at increased risk of placenta
accreta.
 Maternal age- Placenta accreta is more common in
women older than 35.
 Previous childbirth- The risk of placenta accreta
increases each time you give birth.
 Uterine conditions- The risk of placenta accreta is
higher if you have abnormalities or scarring in the tissue
that lines your uterus (endometrium). Noncancerous
uterine growths that bulge into the uterine cavity
(submucosal uterine fibroids) also increase the risk.
 Cigarette smoking- Smoking raises the risk of placental
problems.
 Your age- Placenta accreta is more common in women
35 and older.

What are Complications of placenta

accreta?
Placenta accreta can cause serious complications,
including:
 Heavy vaginal bleeding- Placenta accreta poses a major
risk of severe vaginal bleeding (haemorrhage) after
delivery. The bleeding can cause a life-threatening
condition that prevents your blood from clotting normally
(disseminated intravascular coagulopathy), as well as lung
failure (adult respiratory distress syndrome) and kidney
failure. A blood transfusion will probably be necessary.
 Premature birth- Placenta accreta might cause labour to
begin early. If placenta accreta causes bleeding during
your pregnancy, you might need to deliver your baby
early.
 How can I prevent placenta
accreta?
There’s not much you can do to prevent placenta accreta,
however, there are some risk factors that you may or may not
have control over. These include:
 Primary prevention aims at reducing the risk factors. Plan
an early pregnancy (preferably).
 A life-threatening complication, placenta accreta can be
managed safely with an early diagnosis. Going for routine
scans, and being aware of the symptoms can assure
timely treatment to mitigate the risks.
 Being older than 35
 Multi-parity (having more than one child)
 Having certain uterine treatments that may leave scar
tissue (like fibroid removal, dilation and curettage (D&C),
abortion, etc)

How can assessment and Diagnosis

finding of placenta accreta?
If you have risk factors for placenta accreta during pregnancy
— such as the placenta partially or totally covering the cervix
(placenta previa) or a previous uterine surgery — your health
care provider will carefully examine the implantation of your
baby's placenta.
Techniques to help diagnose placenta accreta might
include:
 Imaging tests- Through ultrasound or magnetic
resonance imaging (MRI), your health care provider can
evaluate how the placenta is implanted in your uterine
wall.
 Blood tests- Your health care provider might test a
sample of your blood for an otherwise unexplained rise in
the amount of alpha-fetoprotein — a protein that's
 produced by the baby and can be detected in the mother's
blood. Such a rise has been linked to placenta accreta.

Diagnosing during pregnancy:

In at-risk mothers, the healthcare provider will attempt to rule
out any abnormality of placentation.
1. Routine ultrasound examination: For the initial diagnosis
of placenta accreta, ultrasound done as a routine can
accurately diagnose 80% of the times. It is done using a
handheld device placed on the abdomen or inside the vagina
and is painless.
2. MRI or Colour Doppler: In the remaining 20% cases if
ultrasonography is unclear or atypical, for diagnosing placenta
accreta, MRI or colour Doppler is the investigation of choice.

Diagnosing during delivery:

If placenta accreta was not diagnosed during pregnancy, the
diagnosis is clinical and the suspicion is made on the basis of
above-mentioned signs. In case of profuse bleeding, it
becomes an emergency with no time for any diagnostic tests.
It can only be confirmed in the operation theatre. But when
associated with severe placenta previa, the doctor will suspect
at the time of a per vaginal examination in the labour room
itself even before the delivery of the baby. In this scenario, the
doctor may decide to opt for an emergency C-section directly.

What is the treatment for Placenta

Accreta?
The main aim of placenta accreta treatment is to stop the
bleeding, restore the lost blood and save the mother by safely
removing the placenta with or without the uterus.
1. Planned Caesarean and Hysterectomy Due To Placenta
Accreta: In cases where the diagnosis is made in advance, the
medical care provider and the mother should discuss the
possible treatment modalities and understand the possible
outcomes. Usually, an elective C-section planned around 34
weeks, with hysterectomy (removal of the uterus with the
placenta) is the most appropriate choice. This prevents life-
threatening complications. But if you have a strong desire to
retain fertility, the doctor may attempt conservative uterus
saving techniques when the blood loss is minimal. But the
outcome is unpredictable and there is no guarantee of a
subsequent pregnancy. Most times, it is an on table decision
for the doctor and a prior consent for the possible uterus
removal will be taken from you for medico-legal purposes.
2. Emergency Laparotomy: If the diagnosis was made after
the delivery of the baby, the profuse bleeding and the non-
separating placenta call for an emergency laparotomy (a
surgery done to open the abdomen and the uterus) with or
without hysterectomy.
3. Steroid Injections the Mother: Some doctors may choose
to administer a steroid injection to the mother before the
planned Caesarean hysterectomy at 34-35 weeks to accelerate
the maturation of the baby.
4. Blood transfusions: Massive blood transfusions may be
needed to compensate for the blood loss which may be as high
as 3-5 litres.
 Risks and Complications of Placenta Accreta

Risk to the Mother

1. Life-threatening- Placenta accreta, if not diagnosed and
managed in time can be life-threatening. It carries a mortality
rate of up to 10%.
2. Loss of fertility- Hysterectomy or removal of the uterus is
the treatment of this condition in the majority of the cases.
This means that the mother loses all the chances of
childbearing in the future.
3. Damage to other organs- There is an increased risk of
bladder injury, ureteral injury, pulmonary embolism, need for
ventilator use, and an increased risk of ICU admission.
4. Surgery and anaesthesia related risks

Risk to the Foetus

There is no effect of placenta accreta on the baby. But
associated placenta praevia may cause difficulty and delay in
the delivery of the baby causing the complications related to
delayed labour.

Thank You