5/13/2016

Screeening and Early detection of

Placenta Accreta
by
Placetal Accreta Index Scoring

Aditiawarman
Depart /SMF Obstetri Ginekologi
FK Unair/RSUD Dr Sutomo
Surabaya

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Incidence
Retained placentas affect 0.5 3% of
women following delivery
The incidence of placenta accreta
increased ten-fold in the past 50 years
and is now encountered in 1 in 2500
pregnancies
A blood transfusion rate 70% is
needed following diagnosis of
placenta accreta

Risk factors

Placenta previa compared without

placenta previa RR= 20.7 (95%;
CI= 9.445.2)
The risk of placenta accreta for those
younger than 35 years less < 2%
with no previous cesarean to 39% for
those with two or more previous
cesarean sections

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Placenta previa and history of prior

cesarean delivery remain the most
important predictors of placenta
accreta
Accurate antenatal diagnosis of placenta
accreta arrangements to be made for
a planned delivery at a tertiary care
center utilizing a multidisciplinary
approach,
which has been shown to significantly
reduce maternal morbidity.

Pathology

Placenta accreta is defined as the

direct apposition of placental villi to
the myometrium

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The pathophysiology

Balance between decidualisation and

trophoblast invasion .
Pathological diagnosis relies on the
finding of placental villi in direct
apposition to myometrium

Classification
According to the degree to which the
myometrium is penetrated by
placental villi.
In placenta accreta vera, placental villi
embed directly onto myometrium in the
absence of decidua;
In placenta increta, placental villi are
found deeper into the myometrium
In placenta percreta, the villi have
penetrated through the uterine serosa

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How to diagnose

Specific USG findings that associated with

placenta accreta
Grey scale
Number of lacunae
Loss of retroplacental clear space
Loss of visualization of the myometrium,
Bladder wall irregularity
Color Doppler (presence or absence ) of the
following:
Subplacental vascularity
vessels bridging from the placenta to the uterine
margin
gaps in myometrial blood flow
Vessels crossing interface disruption sites
Turbulent lacunae.

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The sensitivity 91.4% (95% CI=

77.697.0%)
Specificity 95.9% (95% CI= 92.2
97.9%)
Positive predictive value for placental
invasion 80.0% (95% CI= 65.2
89.5%)
Negative predictive values of
ultrasound for placental invasion were)
98.4% (95% CI= 95.599.5%).

Screening

First trimester screening

Second trimester screening

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The usual location of a normal early gestation is in the

fundus or very occasionally in the lower uterine
segment
The sac is surrounded by thick myometrium on all
sides.
Retrospectively reviewed the USG performed >10
gestational weeks in women later proven to have
placenta accreta on pathological examination.
In 6 patients who had scans at 10 weeks or less low-
lying gestational sacs, the majority of which were
clearly attached to the uterine scar.
The myometrium was thin in the area of the scar to
which the sac was attached compared to normal in four
of the six patients.

The low-lying sac attached to the anterior wall

of the lower uterine segment needs to be
distinguished from a sac that is low lying but
surrounded by an equal amount of
myometrium, both anteriorly and posteriorly,
because sacs may develop into a normal
pregnancy

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Low laying sac, overlay scar

Second trimester

Any uterine surgery increases her

risk for placenta accreta

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Sonography correctly identified the presence of placenta accreta

in 14 of 15 patients (93% sensitivity; 95% confidence interval
[CI], 80%100%) and the absence of placenta accreta in 12 of 17
patients (71% specificity; 95% CI, 49%93%).
Magnetic resonance imaging correctly identified the presence of
placenta accreta in 12 of 15 patients (80% sensitivity; 95% CI,
60%100%) and the absence of placenta accreta in 11 of 17
patients (65% specificity; 95% CI, 42%88%). In 7 of 32 cases,
sonography and MRI had discordant diagnoses: sonography was
correct in 5 cases, and MRI was correct in 2.
There was no statistical difference in sensitivity (P = .25) or
specificity (P = .5) between sonography and MRI.

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Sensitivity: 53.5%,
Specificity: 88.0%
Positive predictive value: 82.1%
Negative predictive: 64.8%
Accuracy: 64.8%,

Structure founded during

Ultrasound

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Lacunae
The lacunae give a moth-eaten appearance
to the placenta and usually, but not always,
have turbulent flow within them.
Appear irregular, often more linear rather
than rounded and smooth bordered.
They do not have the highly echogenic
border that standard venous sinuses have.
Tornado-shaped flow of venous, arterial or
mixed blood is typical

the lacunae did not need to be near

the area of invasion.
the likelihood of placenta accreta
increased with the number of
lacunae.

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Not all large sinuses or vessels are

associated with placenta accreta

In 12 of the 14 pathology proven cases who had

had a scan at 1520 weeks there was at least
one finding at the screening scan which
suggested placenta accreta.
In 11 of 14 cases this was placental lacunae
only one patient with pathologically proven
Placenta accreta did not have lacunae on
ultrasound examination some time during
pregnancy
Visualization of lacunae had the highest
sensitivity (79%) in the 1520-week range and a
sensitivity of 93% in the 1540-week
gestational age time frame

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Lacunae

Bladder border
The border between the bladder and
myometrium is normally highly
echogenic and smooth
In the case of placenta accreta,
interruptions or bulging can occur
this is a specific sign, but not a
sensitive one, i.e. interruptions or
bulging are not present in every
patient with placenta accreta

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Important to differentiate between

bulging due just to enlarged or
increased number of vessels and actual
growth through the myometrium.
Bulging of the bladder wall may
indicate accreta but does not diagnose
percreta.
Care must be taken to examine the
bladder wall with the ultrasound
transducer at 90 so that it is clearly
seen

Budging

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Myometrial thickness

Measured the thickness of the lower

uterine segment in women who had
had a previous Cesarean
Had a low-lying anterior placenta or
placenta previa by measuring
between the bladder wall and the
retroplacental vessels (Color
Doppler).

All patients later proven to have

placenta accreta had a myometrium
of less than 1 mm, which was as
predictive of accreta as lacunae

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Loss of the clear space

The usual dark line between the
myometrium and the placenta is thought to
represent the decidua basalis
Since the decidua basalis is absent in
placenta accreta, it has been suggested that
the absence of this line suggests placenta
accreta.
We found overall sensitivity of 7% (1/14)
for clear space alone at 1520 weeks and
7% (1/15) from 1540 weeks.
The positive predictive value was 6%.

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Color flow

Turbulent blood flow extending from the

placenta into surrounding tissues was very
sensitive and correctly identified all
patients with accreta
This finding was not present in any of the
patients without accreta.
Levine et al in a blinded study, found
that power Doppler did not improve the
diagnosis of placenta accreta.

Bridging/crossing vessels

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MRI

Although MRI will probably never be

used as a screening tool for placenta
accreta, it theoretically should be
useful in determining which patients
with obvious ultrasound evidence for
placenta accreta have placenta
percreta, and in confirming placenta
accreta in those identified by
ultrasound.

Risk of placenta accreta for

consequences for subsequent births
Previous placenta accreta was
significantly associated with
uterine rupture (3.3% vs 0.3%,
P.01)
peripartum hysterectomy (3.3% vs
0.2%, P.001),
need for blood transfusions (16.7%
vs 4%, P .001)

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Mathematical model to predict Placenta

Accreta
Placental Accreta Index

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Resume

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Highly Risk for plasenta accreta is

myometrial damage because of
posterior or anterior placenta previa
overlying scar
Multi-disciplinary planning.
Gray-scale sensitive and specific
enaough to diagnose placenta previa
MRI confirmed invasiveness
Occasionally placenta accreta
discovered during delivery

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The reccomendation for suspect

placenta accreta preterm delivery
with placenta left insitu
Contigency plan for emergency
should be prepared.

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