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Placenta, umbilical cord

Morbid adherent placenta

Prevalence:
  • 1 in 400 pregnancies.
  • Placenta previa with history of previous cesarean section (CS): 3% for 1 CS, 10% for 2 CS, >50% for ≥3 CS.
  • A morbidly adherent placenta includes placenta accreta (chorionic villi attach to myometrium), increta (chorionic villi invade into the myometrium) and percreta (chorionic villi invade through the myometrium).
Ultrasound diagnosis:
  • Multiple vascular lacunae (spaces) within the placenta (‘Swiss cheese’ appearance) with turbulent flow (peak systolic velocity >15 cm/s),
  • Retroplacental myometrial thickness of <1 mm.
  • Loss of normal retroplacental hypoechogenic zone.
  • Blood vessels and placental tissue bridging uterine-placental margin, myometrial-bladder interface, or crossing uterine serosa. Exophytic masses invading the urinary bladder.
  • Irregular vascularization involving the whole uterine serosa–bladder junction, visualised with 3-dimensional power Doppler.
Investigations:
  • MRI is recommended if ultrasound findings are inconclusive.
  • Fetal antenatal surveillance should be standard.
Follow up:
  • Follow-up should be standard.
Delivery:
  • Place: hospital with expertise in the management of this condition and a blood bank that can facilitate transfusion of large amounts of various blood products. There is a high chance of hysterectomy and major hemorrhage.
  • Time: 36 to 37 weeks.
  • Method: cesarean section.
Prognosis:
  • Maternal mortality 5-10%, morbidity 75%.
  • Early diagnosis reduces mortality and morbidity by 50%.
Morbid adherent placenta
Morbid adherent placenta
Morbid adherent placenta
Contributions: Jeni Panaiotova; Nurit Zosmer