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Placenta Accreta SpectrumRisk and Diagnosis
September 22, 2018
DisclosuresNone*
*I support Medicaid Expansion in UT
Placenta Accreta Spectrum DisordersAGENDA / OBJECTIVES• What is it?• Who is at risk?• How is it diagnosed?• What should I do about it?
Placenta Accreta
Clinical definitionPlacenta that is abnormally adherent to the uterus
Placenta Accreta
Pathological definitionDirect attachment of the placental trophoblast to the uterine myometrium, with no intervening decidual or basalis layer
Placenta Accreta
Practical definitionA placenta that doesn’t detach and, when ripped off, causes massive life threatening bleeding.
Terminology Potpourri• Creta• Accreta• Accreta spectrum• Placenta accreta spectrum
disorder(s)• Morbidly adherent placenta• Accreta/Increta/Percreta• Abnormally invasive placenta
• Abnormally adherent placenta• Retained placenta• Focal accreta• Occult accreta
Pathophysiology• Absence or deficiency certain
layers of the uterine decidua• Failed remodeling of the
endometrium after cesarean• Histology: direct trophoblastic
‘attachment’ to myometrium• Placenta does not separate
bleeding
Invasion or Spreading?
Incidence
1960s 80s-90s 2000s
1 in 30,0001 in 2,510
1 in 533
Miller et al., AJOG 1997;177:210 Wu et al., AJOG 2005;192:1458
Top 10 Reasons for the Epidemic1. Cesarean sections2. Cesarean sections3. Cesarean sections4. Cesarean sections5. Cesarean sections6. Cesarean sections7. Cesarean sections8. Cesarean sections9. Cesarean sections10. Some other trends or contributors we don’t understand well
Cesarean and Accreta Risk
3.3%
10.8%
40.3%
60.6%66.7% 66.7%
0.2% 0.3% 0.6% 2.1% 2.3%6.7%
1 CS 2 CS 3 CS 4 CS 5 CS 6+ CS
If PreviaAll pregnancies
Risk
of A
ccre
ta
Silver et al., Ob Gyn 2006;107:1226
Cesarean Rates
12%
Which pregnant women are at risk?
Multiple cesareans + PreviaCesarean + PreviaOther *Uterine SurgeryCesarean + LLP?Any suspicious findings on outside US
*Uterine SurgeryMyomectomy
AblationSeptum takedown
IVF?Ashermans
Prior focal accretaPrior D&C for retained placenta
DiagnosisDepends on several things
1. Awareness of the problem2. Low index of suspicion3. Referral of at-risk women to Accreta referral centers4. Experienced radiology/MFM