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Adherent Placenta

The term placenta accreta is used to describe any placental implantation in which there is abnormally firm adherence to the uterine wall. As a consequence of partial or total absence of the decidua basalis and imperfect development of the fibrinoid layer (Nitabuch layer), placental villi are attached to the myometrium in placenta accreta; these actually invade the myometrium in placenta increta, or penetrate through the myometrium in placenta percreta. The abnormal adherence may involve all of the cotyledons (total placenta accreta) or a single cotyledon (focal placenta accreta).

  1. The incidence of placenta accreta, increta, and percreta has increased, most likely because of the increased cesarean delivery rate.
  2. Abnormal placental adherence is found when decidual formation is defective. Associated conditions include implantation in the lower uterine segment over a previous surgical scar or after uterine curettage.
  3. Ultrasound Doppler color flow mapping: Two factors are highly predictive of myometrial invasion (sensitivity of 100% and positive predictive value of 78%): (1) a distance less than 1 mm between the uterine serosal bladder interface and the retroplacental vessels and (2) the presence of large intrapIcental lakes.
  4. With more extensive involvement, hemorrhage becomes profuse as delivery of the placenta is attempted.
  5. Successful treatment depends on immediate blood replacement therapy and prompt hysterectomy.
  6. Alternative measures include uterine or internal iliac artery ligation or angiographic embolization.
  7. Another possible option for women who are not bleeding significantly is to leave the entire placenta in place and giving postoperative methotrexate.

Blood Products Commonly Transfused in Obstetrical Hemorrhage


One Unit

Volume per Unit

Contents per Unit

Effect(s) in Obstetrical


Whole blood

About 500 ml., Hct -40%

RBCs, plasma, 600-700 mg

of fibrinogen, no platelets

Restores TBV and fibrinogen,

increases Hct 3-4 volume% per unit

Packed RBCs

("packed cells")

About 250 mL plus additive

solutions, Hct -55-80%

RBCs only, no fibrinogen,

and no platelets

Increases Hct 3-4 volume% per unit

Fresh frozen


About 250 mL, 30 min thaw

needed before use

Colloid plus about 600-700

mg fibrinogen, no platelets

Restores TBV and fibrinogen


About 15 mL, frozen

About 200 mg fibrinogen

plus other clotting factors,

no platelets

About 3000-4000 mg total is needed

to restore maternal fibrinogen to

>150 mg/dL


About 50 ml., stored at

room temperature

One unit has 5.5 x 1010

platelets in 50 mL plasma

6-10 units usually transfused, each

increases platelets 5000/micro L

A fibrinogen level of less than 100 mg/ dL or sufficiently prolonged prothrombin or partial thromboplastin times in a woman with surgical bleeding is an indication for fresh frozen plasma administration in doses of 10-15 mL/kg.

Inversion of the Uterus

  1. Complete uterine inversion after delivery almost always the consequence of strong traction on an umbilical cord attached to a placenta implanted in the fundus.
  2. Contributing to uterine inversion is a tough cord that does not readily break away from the placenta, combined with fundal pressure and a relaxed uterus.
  3. Placenta accreta may be implicated, although uterine inversion can occur without the placenta being so firmly adherent.


Delay in treatment increases the mortality rate. It is necessary that a number of steps be taken immediately and simultaneously:

  1. Call for help, including an anesthesiologist immediately.
  2. Immediately push up on the fundus with the palm of the hand and fingers in the direction of the long axis of the vagina to replace the freshly inverted uterus.
  3. If placenta is attached, do not remove the placenta until fluids are being given, and anesthesia, preferably halothane or enflurane, has been administered. Terbutaline ritodrine, or magnesium sulfate have been used successfully for uterine relaxation and repositioning.
  4. After removing the placenta, the palm of the hand is placed on the center of the fundus, with the fingers extended to identify the margins of the cervix. Pressure is then applied with the hand so as to push the fundus upward through the cervix.
  5. As soon as the uterus is restored to its normal configuration, oxytocin drip starts to contract the uterus while the operator maintains the fundus in normal position.

Various Surgeries for Inversion of Uterus


Hydrostatic Technique












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