Presented at CPC, Quaid-e-Azam Medical College

1. CLINICO-PATHOLOGICAL CONFERENCE
Thursday, 28th July 2022
Placenta Accreta Spectrum
&
Challenges in its management
GYNAECOLOGY WARD -II

2. OBJECTIVES:
1. Elicit the sign and symptoms with the disease.
2. Enlist the differential diagnosis.
3. Interpret the investigations
4. Make a treatment plan for the patient.
5. To highlight the challenges which we encounter in
management of patients with PAS

3. HISTORY

4. INTRODUCTION:
My patient Mrs. Saman Manzoor wife of M. Amir, a 22-
year-old housewife, has done B.A., Consanguineous
marriage since last 1 year with P1A0E0M0, her last
menstrual period on 12th Sept 2021, Date of delivery
5th June 2022, resident of Ahmadpur, admitted on 5th
June 2022 in Central Labour Room via Emergency
department.

5. PRESENTING COMPLAINTS:
 History of SVD/Epi in some private hospital – 8 hours back
followed by retained placenta.
 Mild per vaginal bleeding – since delivery

6. HISTORY OF PRESENTING ILLNESS
My patient conceived spontaneously while having regular menstrual
cycle and practicing no contraception. She assumed herself to be
pregnant when she missed her period and confirmed her pregnancy by
urine for pregnancy test at her home. She did her 1st antenatal visit at
2 months of gestation by Gynaecologist where her ultrasonography
was done and she was told about single, alive intrauterine gestation.
Her BP was also checked at that time and it was normal. Her other
investigations were also performed and were normal according to my
patient. She was prescribed Folic acid 1 tablet daily which she took
regularly. Her 1st trimester was supervised and uneventful with no
complaint of excessive nausea, vomiting, pain in lower abdomen, high
grade fever with rash and flu like symptoms.

7. She appreciated fetal movements at 5th month of gestation. Her
anomaly scan was done at 5th month of gestation and was normal
according to my patient. She remained satisfied with her fetal movement
and increase in abdominal girth according to period of gestation. She
took oral Iron and Calcium regularly. She did her 2nd antennal visit at 6th
month of gestation where her ultrasonography was done and told about
fetal well-being. Her BP was also checked which was normal and other
investigations were carried out which were normal according to patient.
2nd trimester was supervised and uneventful with no history of vaginal
bleeding and vaginal discharge. No change in bladder and bowel habit.

8. She got tetanus toxoid vaccination at 7th and 8th month of
gestation and remained satisfied with her pregnancy. Her 3rd
Trimester was also uneventful.

9. Now one day back, my patient developed labour pain for which she
was admitted in some private hospital where she delivered a male
baby with good APGAR score. Her 1st and 2nd stage of labour were
uneventful but 3rd stage of labour was complicated by retained
placenta in situ and referred from the private hospital to tertiary care
hospital for further evaluation and management.
While admitted in the hospital, her various investigations and
the blood arrangement were done.

10. OBSTETRIC HISTORY:
 Married for 1 year
 P1 A0 E0 M0
 It was her 1st pregnancy.
 LMP 12th September 2021
 EDD 19th June 2022
 She was delivered on 5th June 2022 at 38 weeks of gestation
followed by retained placenta.

11.  She delivered a baby boy of average weight with no gross
anomaly.
 No history of antenatal complications.
 No history of prior abdominal/pelvic surgery
 No history of uterine instrumentation
 Spontaneous conception and NVD

12. GYNECOLOGICAL HISTORY :
 Menarche : 13 years
 Last Menstrual Period : 12th Sept 2021
 Menstrual Cycle : 4-5/30 days
 Menstrual flow : Normal
 No dyspareunia but she had mild-moderate pain during
menstruation.
 No H/O of intermenstrual bleeding
 No H/O of post-coital bleeding
 Pap smear : Never taken
 Couple never practiced any contraceptives methods

13. PAST MEDICAL/SURGICAL HISTORY:
 No H/O Diabetes, Hypertension, Asthma, IHD.
 No any past surgical history.

14. PERSONAL HISTORY:
 Housewife
 Non-smoker, non-addict.
 Normal appetite
 Normal sleep
 Normal bladder and bowel habits.

15. FAMILY HISTORY:
No history of:
 TB
 Hypertension
 Diabetes mellitus
 Asthma
 Allergy
 Breast or Cervical cancer in her family.

16. SOCIOECONOMIC STATUS:
 She belongs to a Middle Class Family.
(Her husband is a teacher by profession and the only earning
person in her family of 6 people and she has her own house).

17. COVID-19 VACCINATION HISTORY:
 Complete but no booster dose.

18. EXAMINATION

19. GENERAL PHYSICAL EXAMINATION:
 A young lady of normal height and built lying uncomfortably
on bed with anxious look but well oriented in time, place and
person, answering my questions cooperatively. Her BMI was
22.5 (Height is 5’2’’ and Weight is 52 kg). She had the
following vitals of :
 Pulse : 100 beats/min
 Blood pressure : 100/60mmHg
 Respiratory rate : 20/min
 Temperature : 99.0F

20.  Pallor positive (++)
 No clubbing, jaundice or koilonychia.
 All accessible lymph nodes not palpable.
 Thyroid not enlarged.
 No pedal edema and both breasts were bilaterally symmetrical
with no lump palpable in any of the four quadrants.
 Hernial orifices intact.

21. EXAMINATION:
Respiratory System:
 Trachea central
 Normal vesicular breathing in both lungs fields
 No added sounds
 Lung bases clear.

22. Cardiovascular System :
 Apex beat palpable in left 5th intercostal space medial to mid-
clavicular line.
 1st and 2nd heart sounds are heard with no added sounds.

23. Per Abdominal examination:
Inspection:
1. Abdomen protruberant and moving with respiration.
2. Central inverted umbilicus
3. No scar marks, stria, prominent veins or visible pulsations
seen.
Palpation:
Uterus enlarged upto 22 week size, well contracted and mild
tenderness in lower abdomen.

24. Per Vaginal Examination:
 Mild vaginal bleeding.
 Cervical os closed.

25. DIFFERENTIAL DIAGNOSIS:
1. Retained placenta
2. Fibroid uterus
3. Endometrial polyp

26. LAB INVESTIGATIONS

27. BASELINE INVESTIGATIONS:
 Blood group – O positive
 Hb – 8.0g/dL
 TLC – 10,800 /mm3
 Platelets – 250,000 /mm3
 BSR – 78mg/dL
 Viral markers (HBsAg and AntiHCV Ab) – Negative
 Urine C/E – Normal

28. SPECIFIC INVESTIGATIONS
 Sr. B-hCG – 5084miu/L at admission.
 LFTs:
 Bilirubin 0.2 mg/dL
 ALT 24 U/L
 Alkaline Phosphatase 65 U/L
 RFTs:
 Urea 24 mg/dL
 Creatinine 0.6 mg/dL

29. IMAGING:
ULTRASOUND:
Postpartum bulky hyperemic uterus,
Placental tissue seen in situ
In fundal region, diminished, hypoechoic margin between
placenta and myometrium (normal margin 2mm) with indistinct
placental/myometrial interface.

31. Colour Doppler:
Showed placental vessels traversing myometrium up to serosal
surface suggestive of PLACENTA INCRETA.

34. MRI PELVIS:
Placental tissue seen in endometrial cavity extending into
myometrium reaching up to anterior wall of uterus in fundal
region, suggestive of RETAINED PLACENTA INCRETA.

37. Management

38. MANAGEMENT OPTIONS:
1. Conservative:
Monitoring with B-hCG level.
2. Medical:
Methotrexate
3. Surgical:
i. Partial segmental resection.
ii. Obs Hysterectomy

39. OUR MANAGEMENT PLAN INCLUDES:
 Resuscitation
 Conservative management
 Monitoring with B-hCG level.
 Counselling of patient and her family
 Blood arrangement
 I/V antibiotics
 Emergency laparotomy in hand
 Consent of Obs hysterectomy

40. MEDICAL MANAGEMENT:
 Inj. Methotrexate -1mg/Kg IM (5th postnatal day)
(B-hCG on 4th day – 2328miu/ml
B-hCG on 7th day – 493miu/ml)
Single dose given b/c >50% fall of B-hCG
 Repeat ultrasound showed retained placental tissue.

41. SURGICAL MANAGEMENT:
 Massive hemorrhage on 12th postpartum day.
 Blood transfusion, resuscitation of patient.
 EUA & proceed.
 Laparotomy
 Bilateral uterine artery ligation
 Incision over serosa to remove adherent placenta on left side of fundus.
 Uterus closed in double layers.
 Pt remained stable in post-op period.
 Discharge on 6th post op day.

42. RETAINED PLACENTAL LOBE

43. BILATERAL UTERINE ARTERY LIGATION:

44. INCISION MADE OVER UTERINE SEROSA

45. REMOVAL OF PLACENTA

47. COMPLETE REMOVAL OF PLACENTA

48. EMPTY UTERUS

49. UTERINE CLOSURE

50. INTRODUCTION TO PAS
 Placenta Acreta spectrum disorder (PAS), also called abnormally invasive
placenta (AIP), describes a clinical situation where the placenta does not
detach spontaneously after delivery and cannot be forcibly removed
without causing massive and potentially life threatening bleeding.
 Definition:
According to depth of trophopblastic invasion into the myometrium, three
known variants of PAS can be differentiated by pathologists;
Placenta acreta, Placenta increta and Placenta percreta.

51. 1. Placenta Acreta
Chorionic Villi attach directly to the surface of myometrium in the
absence of decidual layer.
2. Placenta Increta
Chorionic Villi penetrate deeply into the myometrium reaching the
external layer.
3. Placenta Percreta
Invasive Chorionic Villi reach and penetrate through uterine serosa.
Definition & Classification

52. ETIOLOGY OF PAS
 Placenta Accreta:
 Etiology can be manual removal of placenta, uterine
curettage and endometritis.
 Placenta Increta and Percreta:
 These two have similar etiology which can be full thickness
surgical scar associated with absence of endometrial re-
epithelialization and vascular remodeling.

53. CHALLENGES
1. Delay and referral from Periphery
2. Most of patients remain undiagnosed and unbooked
3. Problem in arrangement of blood and blood products
4. Issues regarding anesthesia fitness, availability of OT and ICU
Care
5. Lack of Color Doppler Facility in Emergency Ward
6. Lack of services for Interventional Radiology (Uterine Artery
Embolization)

54. CHALLENGES
7. Conservative Management/Surgery for patients with low parity
and primipara
8. Counselling of the patients and her family regarding prolonged
hospital stay
9. Need for multiple surgeries specially in patients with placenta
percreta d/t involvement of bladder and bowel
10.Involvement of social media that pressurizes working staff
11.Complain to PM Portal regarding the delay in management and
mismanagement without knowing the actual facts and figures

55. Thank you