PLASENTA AKRETA

Agus Sulistyono
 Time lapse pada Kematian Maternal

Vermeiden et al. BMC Pregnancy and

ChildBirth (2018) 18:38 DOI 10.1186/s12884-
018-1670-z
 PELAJARAN dari AKI di SURABAYA
Periode tahun 2012 - 2019
PENYEBAB TERBANYAK : PE & HPP
2012 = AKI = 60; HPP !14; PE = 18
2013 =AKI = 49; HPP !14: PE = 14
2014 = AKI = 39; HPP !11; PE = 11
2015 = AKI = 38; HPP !13; PE = 8
2016 = AKI = 37; HPP !7 ; PE = 14
2017 = AKI = 34; HPP !3 ; PE = 8
2018 = AKI = 31; HPP !5 ; PE = 10
2019 = AKI = 25; HPP !5 ; PE = 10
2014 = AKI = 39; HPP ! 11
2015 = AKI = 38; HPP ! 13
! AKI KARENA HPP Meningkat

!4 karena Plasenta akreta

 plasenta akreta
34% kausa lain

66%

➢ Secondary hospital
➢ Trimester III
!UNDIAGNOSED
➢ Peri-operasi
➢ Emergency or unplanned
Causative of Post Partum Hemorrhage In 

Dr. Soetomo General Hospital
70,0% 66,2%
Morbidly adherent
52,5% placenta
46,4% 45,6%
44,1%
38,6% 39,2%
35,0% 29,5% 29,8%
28,6% 27,3% 28,8%
25,0%
18,6% 19,3% 17,6% Tone
17,5% 14,0% 14,9%
Tissue
8,5%
4,5% 6,8% 5,3% Trauma
0,0%
0,0% 2,3% 1,4%
0,0% Thrombin
2012 2013 2014 2015 2016
Mortalitas Rujukan Terlambat Plasenta Akreta

Hamil
40% 40% Plasenta insitu
post partum

20% Luaran Maternal Jumlah

Hamil
- Syok hipovolemik irreversible 2 (5%)
Plasenta insitu
- Sepsis 1 (2,5%)
Post partum
- Syok hipovolemik irreversible 2 (5%)
 INCIDENCE

1960’s 1970’s 1980’s 2000’s 2016

1:30.000 1 :4.027 1 :2,510 1 : 533
deliveries
1 : 216
! ±7x !± 14 x !± 60x
à 150x
(Cahill,2018)

➢ Maternal Morbidity ! 60%

➢ Maternal Mortality ! 7% Sumigama et al, 2007 ; Eller et al, 2009
➢ Perinatal Complication! Preterm Committee opinion, Am J Obstet Gyneol 2012
 World Cesarean Section Rate

Placenta Acreta

Cesarean Scar
Pregnancy
 LITERATURE REVIEW
Definition
Placenta accreta spectrum (PAS) disorders is a 20th century iatrogenic disease in
the placenta, which is characterized by abnormalities or abnormal invasion of
placenta to myometrium. (Jauniaux, 2012).

Increta

Percreta
Accreta
 SCREENING

RISK FACTOR

SONOGRAPHY

IDEALLY : placenta accreta should Dx on asymptomatic Px

 Table. Placenta Previa and Placenta Accreta by
Number of Cesarean Deliveries

Previa:Accreta No Previa‡:Accreta†
Cesarean Delivery Previa [n (%)] [n (%)]

First§ 398 13 (3) 2 (0.03)

Second 211 23 (11) 26 (0.2)

Third 72 29 (40) 7 (0.1)

Fourth 33 20 (61) 11 (0.8)

Fifth 6 4 (67) 2 (0.8)

≥6 3 2 (67) 4 (4.7)
† Increased risk with increasing number of cesarean deliveries; P < .001.

‡ Percentage of accreta in women without placenta previa.

§ Primary cesarean.
 MODALITY IN DIAGNOSIS
Ultrasound
• Trim I ! GS ~ Niche
• PAI score !screening in secondary
Screening ?
hospital
• ISUOG by proforma !diagnosis,
detection, and surgical strategies
MRI
MRI was performed only in cases in which
• Doubtful case ultrasound signs of extrauterine invasion of the placenta
(focal exophytic mass, distortion of cervix or parametrial
• Cervical invasion anatomy) were detected.
Coutinho, 2021
Diagnostic approach: ULTRASONOGRAPHY

Sensitivity 91%; Specificity 97% D’Antonio, 2013

 SCREENING
➢ Early pregnancy
➢ Late pregnancy
EARLY PREGNANCY

American Journal of Obstetrics & Gynecology, 2016

G2P1001, 6 minggu, post SC 1x, ANC pertama, tanpa keluhan
CESAREAN SCAR PREGNANCY
1st trimester approach: ULTRASONOGRAPHY

Who
• Previous cesarean section
• Got pregnant
When
• Early pregnancy

Important points
• GS
• Location of implantation
• Internal os vs fundal / corpus
• CSP Cornstock, 2003; D’Antonio, 2013; Stirnemann, 2011
21
TRIMESTER LANJUT
PLACENTA ACCRETA
INDEX
PLACENTA ACCRETA INDEX

Analisis di Surabaya Ketepatan : 72%

Study in Surabaya th 2015 - 2017
Pregnancy with suspect placenta accreta
evaluated in fetomaternal sonograph
2015-2017 (n : 266)

Evaluated outpatient clinic and

hospitalized medical record
n : 202

Durante operation Durante operation

Accreta (+) Accreta (-)
n : 76 n : 126
Risk Factor (+) Risk Factor (-) Risk Factor Risk Factor
(+) (+)

ANALYSIS
Multivariate regression
CI 95%
PARAMETER p value Odd ratio
Lower Upper

Placenta previa 0.001 0,128 0,036 0,453

Bladder wall interruption 0.000 0.089 0.030 0.349

Loss of Retroplacental
0.000 0.030 0.009 0,099
clear-zone
Trias Surabaya : Placenta previa and history of prior cesarean
Placenta Previa delivery remain the most important predictors
Loss of Retroplacental Clearzone of placenta accreta
Bladder wall Interruption
Plasenta Praevia
LACUNAE

Colins, et al, 2016

 CLEAR ZONE
RETROPLACENTA

Presence of clear zone

Loss of clear zone

Colins, et al, 2016
 RETROPLACENTAL MYOMETRIAL THICKNESS

TVS : sagital view of LUS in normal pregnancy, thin, uniform

shape of the posterior bladder-LUS interface
Thinning of the myometrial thickness assessed
transabdominally
PLACENTAL
BULGE

Focal exophytic
 INCREASED PLAC VASCULARITY
(Color Doppler)
An adjunct to 2D USG
Differentiate :
Normal subplac venous complex
! non pulsatile
pulsatility flow + marked dilated vascular channel
! plac accreta
Bridging : plac – bladder
! flow
! invasion
Sensitivity : 86 – 100%
Specificity 92-94%
Berkley & Abuhamad, in Silver Placental Accreta Syndrome, 2017
Bridging/crossing vessels
 INCREASED PLAC VASCULARITY
(Color Doppler)

*** vascular subplasenta normal

 Perbedaan Color Flow Doppler vs Power
Doppler Pada KSPA
Color Flow Doppler Power Doppler

*** ***

Perbandingan Hipervaskular uteroplasenta Color Flow Doppler dengan

Power Doppler pada Plasenta Perkreta (usia kehamian 27 minggu)
 Perbedaan Color Flow Doppler vs Power
Doppler Pada KSPA
Color Flow Doppler Power Doppler

*** ***

Perbandingan Hipervaskular uteroplasenta Color Flow Doppler dengan

Power Doppler pada fokal Plasenta Inkreta (usia kehamian 35 minggu)
 Perbedaan Color Flow Doppler vs Power
Doppler Pada KSPA
Color Flow Doppler Power Doppler

***
***
Perbandingan Placental lacunae feeder vessels Color Flow Doppler dengan
Power Doppler pada Plasenta Perkreta (usia kehamian 27 minggu)
 Perbedaan Color Flow Doppler vs Power
Doppler Pada KSPA
Color Flow Doppler Power Doppler

*** ***
Perbandingan Placental lacunae feeder vessels Color Flow Doppler dengan
Power Doppler pada Plasenta Perkreta (usia kehamian 27 minggu)
***
Algoritme diagnosis dan sistem rujukan
plasenta akreta

Faktor risiko plasenta akreta (Bekas SC, riwayat

operasi uterus/ kuretase)

USG trimester 1

Kantong Gestasi di dekat Kantong Gestasi pada

Implantasi Normal Ostium Uteri Internum bekas SC

Kontrol biasa Rujuk diagnostik

Satgas Plasenta Akreta POGI

 USG
trimester 2

Plasenta
Implantasi previa + Bekas
normal SC, operasi
uterus,
kuretase
Konfirmasi diagnosis dan
USG evaluasi kesejahteraan janin
trimester 3 oleh konsultan fetomaternal

USG konsultan Fetomaternal (Pemetaan Placenta):

Diagnosis
Pemetaan topografi placenta
Pemetaan vascular, neovaskular, dan kolateral plasenta
akreta
Penentuan segmen uterus

Kecurigaan
Kecurigaan rendah sedang / tinggi

Persalinan di Persalinan di Satgas Plasenta Akreta POGI

RS sekunder RS tersier
TERIMA
KASIH