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Placenta Accreta

Placenta accreta is a type of morbidly adherent placenta where the placenta is firmly adherent to the uterine wall due to partial or total absence of the decidua basalis? and the fibrinoid layer (Nitabuch layer)".

The main aetiology is defective decidua formation.

Pathological Findings

  1. Absence of decidua basalis
  2. Absence of Nitabuch's fibrinoid layer
  3. Varying degree of penetration of the villi into the muscle bundle.

Classification / Variants

  1. Placenta accreta - chorionic villi are attached to the superficial myometrium.
  2. Placenta increta - villi invade the myometrium.
  3. Placenta percreta - villi penetrate the full thickness myometrium up to the serosal layer.

Risk Factors

  1. Placenta previa in present pregnancy (Note: previous placenta previa is not a risk factor)
  2. History of operative interference like: - Previous cesarean section
    - Previous curettage
    - Previous manual removal
    - Previously treated Asherman syndrome
    - Synaechiolysis
    - Myomectomy
    1. Multiparity
    2. Advanced maternal age> 35 years


It is made mostly during attempted manual removal of placenta when the plane of cleavage between the placenta and uterine wall cannot be made out?

Prior to delivery: presumptive diagnosis may be made by -

  1. Transvaginal sonography - absence of the subplacental sonolucent zone (which represents the normal decidua
  2. basalis) indicates a placenta accreta.
  3. Doppler imaging-shows
    1. A distance less than 1 mm between the uterine serosal bladder interface and retroplacental vessels.
    2. Presence of large intraplacental lakes.


  1. Antepartum haemorrhage (due to associated placenta previa)
  2. Uterine rupture before labour (due to myometrial invasion by placental villia at the site of previous C.S. scar.
  3. Postpartum haemorrhage
  4. Infection
  5. Inversion of uterus (rare)



In partial morbid adherent placenta

In total placenta accreta

1. Removal of placental tissue in piecemeal

2. The uterus should be actively

3. contracting (So GA is not used)

4. Oxytocics should be used for this purpose

5. Hemostasis should be maintained

- If female has completed her family

- Hysterectomy

- If female has not completed her family

- Conservative approach:

Cut the umblical cord as high as possible & leave the placenta as such. This is now the most recommended approach.

The patient should be given antibiotics and methotrexate in hope of autolysis. βhCG

  1. Uterine inversion is a condition in which there is inside out turning of the uterus.
  2. It is a rare cause of postpartum collapse but collapse occurs suddenly after labour.
  3. It is acute in onset.



First degree or dimpling

Second degree or partial

Third degree or complete


  1. Mismanagement of the third stage (M/C cause) - Attempting to deliver a placenta by cord traction that has not yet separated (Crede's method).
  2. Spontaneous inversion can occur with an atonic uterus (in 40% cases).
  3. Placenta accreta is a rare cause.

Clinical Features

  1. Patient present with shock and hemorrhage, degree of shock being out of proportion to the amount of bleeding.
  2. Bleeding is due to attempts to detach the placenta before correcting the inversion.
  3. Vaginal examination reveals a soft, globular swelling in the vagina or cervical canal.
  4. On abdominal palpation, the fundus of the uterus is felt to be absent",


Uterine inversion can lead to:

  1. Neurogenic shock
  2. Hemorrhage
  3. Pulmonary embolism
  4. Uterine sepsis and subinvolution


  1. Resuscitation and replacement of inverted uterus should be done simultaneously.
  2. Manual replacement -Best step if diagnosis is made immediately. The part which comes out first i.e fundus should be last to reposit. After replacing oxytocics should be given to promote contraction. This is called as 'John sons maneuver'.
  1. Hydrostatic O sullivan method-Warm saline is run into vagina with labia opposed to prevent leakage .The vagina ballons
  2. With the fluid and the inversion corrects on ots own.
    Surgery-is done if above mesures fail. Huntington’s repair is by traction on the round ligaments with Allis forceps to pull up the inverted uterus. If this method fails Haultains method is adopted.

Management of Postpartum Hemorrhage follows an algorithm, but it is important to understand that PPH is an obstetrical emergency where resuscitative measures, specific measures as well as investigations should all be done at the same time.

Stepwise Management of PPH

Step I

General Measures - Including Resuscitative Measures + Investigations + Confirmation of Diagnosis

The first and basic step in the management of PPH is resuscitation of the patient which includes:

a. Securing IN lines

b. Volume restoration by crystalloids (normal saline / Ringer lactate)

c. Oxygen inhalation

d. Crossmatching and arranging for blood.

At the same time investigations like Blood group, Hemoglobin, Clotting time, Coagulation profile, Electrolytes should be sent.

The Cause of PPH i.e., whether it is atonic (diagnosed by abdominal palpation) or traumatic should be looked and managed accordingly.

Step II

When diagnosis of Atonic PPH is confirmed - Uterus should be massaged continuously and medical methods should be adopted.

Step III

Medical Methods

For Atonic PPH - the following drugs should be tried.

a. 20 units oxytocin drip should be started.

b. Injection Ergometrine (0.25 mg) or Methergin (0.2 mg) should be given 11M or IN and repeated after 15 min.

If above medical methods fail

c. 15 Methyl PGF (Injection Prostodin / Carboprost) should be given both 11M and intramural into the uterine musculature and repeated after 15 minutes for a maximum of three doses OR

PGE1 (Tablet Misoprostol) can be inserted rectally or vaginally upto a maximum of 1000 μg.

Step IV

If above medical methods fail - following mechanical methods should be adopted.

Bimanual compression followed by uterine tamponade done by:

- Uterine packing under anaesthesia

- Insertion of Sengstaken black more tube into the uterine cavity and inflating the balloon with 200 ml of normal saline.

Step V

When all other methods fail - Surgical intervention should be carried.

 If female has not completed her family If female has completed her family

a. - Application of 13-lynch / Brace suture

b. - Uterine and ovarian artery ligation } fail Hysterectomy

c. - Internal iliac artery ligation }


Recombinant activated factor VII: This vitamin K-dependent protein has been licensed by the Food and Drug Administration for the treatment of bleeding in individuals with hemophilia, acquired antibodies to components of the intrinsic pathway, and congenital factor VII deficiency. Other clinicians have explored its usefulness for the control of hemorrhage due to other causes, including traumatic and surgical bleeding.

Obstetric hysterectomy is used as the last resort.


Hysterectomy performed at or following delivery may be lifesaving if there is severe obstetrical hemorrhage. It can be carried out in conjunction with cesarean delivery or following vaginal delivery.

The majority of procedures are performed to arrest hemorrhage from intractable uterine atony, lower-segment bleeding associated with the uterine incision or placental implantation, or a laceration of major uterine vessels. Placenta accreta, often in association with repeat cesarean delivery, and uterine atony are the most common indications today for cesarean or postpartum hysterectomy.

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