Hi everyone,

Thanks for joining us again, this week I am joined by my colleague Prof Yee Leung, Head of Gynaecological Oncology in Western Australia, to discuss the obstetric and surgical aspects of managing the patient with an abnormally invasive placenta (accreta / increta / percreta). Please join us, listen to our conversation on the podcast and let us know if you have any comments or questions.

Definitions:

Accreta = the chorionic villi are in contact with the myometrium (78%)

Increta =  the chorionic villi invade the myometrium. (17%)

Percreta = the chorionic villi penetrate the uterine serosa. (5%)

Risk factors:

Previous caesarean delivery: The authors of one study found that in the presence of a placenta previa, the risk of placenta accreta was 3%, 11%, 40%, 61%, and 67% for the first, second, third, fourth, and fifth or greater repeat cesarean deliveries, respectively.

Placenta previa (without previous uterine surgery): 1–5% risk of placenta accreta.

Any condition resulting in myometrial tissue damage followed by a secondary collagen repair, eg myomectomy, vigorous curettage resulting in Asherman syndrome, submucous leiomyomas, thermal ablation , and uterine artery embolization.

ACOG

https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Placenta-Accreta

RANZCOG

https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women's%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Placenta-Accreta-(C-Obs-20)-Review-March-2014,-Amended-November-2015.pdf?ext=.pdf

Diagnosis - Imaging Modalities:

https://radiopaedia.org/articles/placenta-accreta

USS or MRI

Surgical management

Surgical management of placenta accreta: to leave or remove the placenta?

A Perez-Delboy, JD Wright 2014

Timing of Delivery

Placenta Accreta: When is the optimal time to deliver?

Manual Aortic Occlusion

Our podcast discussion on this topic

Interventional Radiology

3) REBOA during unexpected uterine rupture

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5628233/

2) Comment urging caution before embracing interventional radiology techniques:

http://www.obstetanesthesia.com/article/S0959-289X(16)30075-9/pdf

Communication and Having an Effective Team

Fostering a culture of safety: The OR team huddle

Conservative Management

Leaving the placenta in situ, Methotrexate, En bloc resection, Hysteroscopic resection