PLACENTA ACCRETA SYNDROME - CLASSIFICATION & RISK ASSESSMENT BY DR SHASHWAT JANI.pptx

PLACENTA ACCRETA SYNDROME - CLASSIFICATION & RISK ASSESSMENT

1. PAS : Clinical Classification Risk Assessment Dr. Shashwat Jani M. S. ( Obs – Gyn ), F.I.A.O.G., F.I.C.O.G. Diploma in Advance Laparoscopy . Consultant Assistant Professor , Smt. N.H.L. Municipal Medical College. S.V.P. Hospital , Ahmedabad. Mobile : [phone]. E-mail : [email protected]

2. Defined as… Placenta accreta spectrum (PAS) is a general term used to describe abnormal trophoblast invasion into the myometrium, and sometimes to or beyond the serosa . It is clinically important because the placenta does not spontaneously separate at delivery and attempts at manual removal result in hemorrhage, which can be life-threatening 21-Sep-24 Dr Shashwat Jani 99099 44160 2

3. Derivation Of Accrete Comes From Latin Ac Crescent = To Adhere Or Become Attached To. 21-Sep-24 Dr Shashwat Jani 99099 44160 3

4. Placenta accreta is a histopathological term first defined by the obstetrician frederick c. Irving and the pathologist arthur t. Hertig from the boston lying- in hospital in 1937. They defined it as “abnormal adherence of the afterbirth in whole or in parts to the underlying uterine wall in the partial or complete absence of decidua ”. CLINICAL OBSTETRICS AND GYNECOLOGY VOLUME 00, NUMBER 00, 000–000 COPYRIGHT © 2018 WOLTERS KLUWER HEALTH, INC. 21-Sep-24 Dr Shashwat Jani 99099 44160 4

5. Magnitude Of The Problem In 1937 : 1 in 30 000 deliveries. In 1970 : 1 in 4000 deliveries in the 1970s In 1980 : 1 in 2500 deliveries In 2010 : 3 in 1000 deliveries In a 2019 systematic review that included 7001 cases of PAS among nearly 5.8 million births, the overall pooled prevalence was 0.17 percent (range 0.01 to 1.1 percent). The marked increase in PAS, which began in the 1980s and 1990s and has been observed worldwide, is attributed to the increasing prevalence of cesarean birth in recent decades . 21-Sep-24 Dr Shashwat Jani 99099 44160 5

6. Shah SR, Chudasama T], Patel BS, et al Placenta Accreta spectrum (pas) disorders: A 10-year study at tertiary care center , Ahmedabad, western India. International Journal of 6. Clinical Obstetrics and Gynaecology.2020; 4:161-6 21-Sep-24 Dr Shashwat Jani 99099 44160 6

7. Shah SR, Chudasama T], Patel BS, et al Placenta Accreta spectrum (pas) disorders: A 10-year study at tertiary care center , Ahmedabad, western India. International Journal of 6. Clinical Obstetrics and Gynaecology.2020; 4:161-6 21-Sep-24 Dr Shashwat Jani 99099 44160 7

8. How…??? The prevailing hypothesis is that an iatrogenic defect of the endometrium–myometrial interface leads to a failure of normal decidualization at the site of a uterine scar, enabling abnormally deep trophoblast infiltration. Disruption of the decidua , for example by a previous cesarean delivery incision, may result in loss of the inherent regulation and uncontrolled invasion of extravillous trophoblast through the entire depth of the myometrium . 21-Sep-24 Dr Shashwat Jani 99099 44160 8

9. Risk Factors : ( FIGO 2019) Jauniaux E, Chantraine F, Silver RM, Langhoff-Roos J; FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO consensus guidelines on placenta accreta spectrum disorders: Epidemiology. Int J Gynecol Obstet. 2018;140:265–273. Jauniaux E, Jurkovic D. Placenta accreta: Pathogenesis of a 20th century iatrogenic uterine disease. Placenta. 2012;33:244–251. Luke RK, Sharpe JW, Greene RR. Placenta accreta: The adherent or invasive placenta. Am J Obstet Gynecol. 1966;95:660–668. 21-Sep-24 Dr Shashwat Jani 99099 44160 9

10. Predisposing Factors Identified In The 1920s And 1930s Were Previous Manual Removal Of Placenta And/Or “Vigorous” Uterine Curettage . There Is Now Compelling Epidemiological Evidence that Accreta Placentation Has Become Essentially An Iatrogenic Condition , Secondary To The Modern-era Cesarean Section Epidemic. 21-Sep-24 Dr Shashwat Jani 99099 44160 10

11. Biochemical Markers MSAFP (8 times higher risk) > 2.5 MoM Beta hCG (4 times higher risk)>2.5 MoM 21-Sep-24 Dr Shashwat Jani 99099 44160 11

12. PLACENTA PREVIA An Important independent risk factor with an odds ratio of 50-100. Accreta incidence has of 1/9 to 1/16 has been observed among patient with placenta previa at the time of delivery. Maybe due to presence of placenta previa allowing easier identification of accreta cases but precluding identification of other independent risk factors. 21-Sep-24 Dr Shashwat Jani 99099 44160 12

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14. Previous Cesarean Section Incidence of PAS disorders increase with the number of previous cesarean deliveries form about 0.3% in women with one prior cesarean section to 7% for those having more than 5 cesarean deliveries. Incidence of placenta previa and PAS disorders: First CS- 3% Second CS- 11% Third CS- 40% Fourth CS- 61% Fifth of more- 67% 21-Sep-24 Dr Shashwat Jani 99099 44160 14

15. There is now compelling evidence that placenta accreta spectrum disorders are related to medical intervention: specifically the caesarean section epidemic . More than 90 percent of women presenting with a placenta accreta have had at least one prior cesarean delivery, and with the continuous rise in cesarean delivery rates in most countries around the world, both the prevalence and incidence of placenta accreta spectrum disorders will continue to increase. 21-Sep-24 Dr Shashwat Jani 99099 44160 15

16. In the absence of placenta previa , the frequency of a PAS in patients undergoing cesarean birth was much lower . First (primary) cesarean birth, 0.03 percent Second cesarean birth, 0.2 percent Third cesarean birth, 0.1 percent Fourth or fifth cesarean birth, 0.8 percent Sixth or greater cesarean birth, 4.7 percent 21-Sep-24 Dr Shashwat Jani 99099 44160 16

17. IVF PREGNANCIES The accepted hypothesis is differences in the endometrial environment, or endometrial changes due to drug protocols for IVF. The odds ratio of PAS disorders due to IVE-ET is between 3-14. Association of PAS disorders with Cryopreserved Embryo Transfer or Frozen Embryo Transfer is three times higher than fresh embryo transfer- one possible mechanism to explain this association is that the degree of trophoblastic invasion and extent of vascular remodeling at the time of implantation maybe modulated by serum E2- level. Low E2 level associated with thin endometrium in FET cycle leading to exuberant trophoblastic growth during a protracted window of implantation. 21-Sep-24 Dr Shashwat Jani 99099 44160 17

18. PAS Grading & Classification The process of clarifying the reporting data on placenta accreta in the international literature started recently with the development of a grading system for the clinical diagnosis of PAS . The classification described was developed from this grading scheme, and reviewed by members of the FIGO Placenta Accreta Spectrum Disorders Diagnosis and Management Expert Consensus Panel . For use of the classification, I have summarized the recommendations of the recent FIGO guidelines for the conservative and non-conservative surgical management of PAS according to the grade of accreta invasiveness defined in the present classification. 18

19. FIGO Classification 2019 General classification of placenta accreta spectrum Grade 1: Abnormally adherent placenta (placenta adherent or creta ) Grade 2: Abnormally invasive placenta (Increta) Grade 3: Abnormally invasive placenta ( Percreta )

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21. Grade 1: Abnormally Adherent Placenta (Placenta Adherent Or Creta) Clinical Criteria • At Vaginal Delivery No separation with synthetic oxytocin and gentle controlled cord traction Attempts at manual removal of the placenta results in heavy bleeding from the placenta implantation site requiring mechanical or surgical procedures. • If Laparotomy is required (including for cesarean delivery) Same as above. Macroscopically, the uterus shows no obvious distension over the placental bed (placental “bulge”), no placental tissue is seen invading through the surface of the uterus, and there is no or minimal neovascularity . Dr Shashwat Jani 99099 44160 21

22. Grade 2: Abnormally Invasive Placenta ( Increta) Clinical Criteria • At Laparotomy Abnormal macroscopic findings over the placental bed: bluish/purple coloring, distension (placental “bulge”) Significant amounts of hypervascularity ( dense tangled bed of vessels or multiple vessels running parallel cranio-caudally in the uterine serosa) No placental tissue seen to be invading through the uterine serosa. Gentle cord traction results in the uterus being pulled inwards without separation of the placenta (so-called The Dimple Sign ) 21-Sep-24 Dr Shashwat Jani 99099 44160 22

23. Grade 3: Abnormally Invasive Placenta (Percreta) Grade 3a : Limited to the uterine serosa : Clinical Criteria At L aparotomy Abnormal macroscopic findings on uterine serosal surface (as above) and placental tissue seen to be invading through the surface of the uterus No invasion into any other organ , including the posterior wall of the bladder (a clear surgical plane can be identified between the bladder and uterus) 21-Sep-24 Dr Shashwat Jani 99099 44160 23

24. Grade 3b: With Urinary Bladder Invasion: Clinical Criteria • At laparotomy Placental villi are seen to be invading into the bladder but no other organs Clear surgical plane cannot be identified between the bladder and uterus 21-Sep-24 Dr Shashwat Jani 99099 44160 24 Grade 3: Abnormally Invasive Placenta (Percreta)

25. Grade 3c: With invasion of other pelvic tissue/organs Clinical Criteria At Laparotomy Placental villi are seen to be invading into the broad ligament, vaginal wall, pelvic sidewall or any other pelvic organ (with or without invasion of the bladder) 21-Sep-24 Dr Shashwat Jani 99099 44160 25 Grade 3: Abnormally Invasive Placenta (Percreta)

26. Prenatal Screening And Diagnosis Prenatal screening and diagnosis are important so that the patient can be counseled about the suspected placental abnormality and an appropriate site and plan for delivery can be developed. Candidates And Procedure For Screening- Patients with a placenta previa or a low anterior placenta and prior uterine surgery should have thorough transabdominal and transvaginal sonographic evaluation of the interface between the placenta and myometrium between approximately 18 and 24 weeks of gestation. At this gestational age, the prenatal diagnosis of PAS often can be made or ruled out, although in population-based studies, prenatal diagnosis was not made in one-half to two-thirds of cases . 21-Sep-24 Dr Shashwat Jani 99099 44160 26

27. Risk Assessment Clinical risk assessment may be the most important tool to assess for placenta accreta spectrum, many studies report very high sensitivity and specificity for obstetric ultrasonography in the diagnosis of placenta accreta spectrum . For example, a systematic review, including 23 studies and 3,707 pregnancies , noted an average sensitivity of 90.72% (95% CI, 87.2–93.6) and specificity of 96.94% (95% CI, 96.3–97.5% 21-Sep-24 Dr Shashwat Jani 99099 44160 27

28. ACOG A reasonable approach is to perform  ultrasound examinations at approximately 18–20, 28–30, and 32–34 weeks of gestation in asymptomatic patients . This allows for the assessment of previa resolution, placental location to optimize timing of delivery, and possible bladder invasion. 21-Sep-24 Dr Shashwat Jani 99099 44160 28

29. Ultrasound Findings: In the second and third trimesters, the following transabdominal and transvaginal sonographic findings have been associated with PAS; all of the findings need not be present Multiple placental lacunae Disruption of the bladder line Loss of the clear zone Myometrial thinning Abnormal vascularity Abnormal uterine contour Exophytic mass 21-Sep-24 Dr Shashwat Jani 99099 44160 29

30. First-trimester Ultrasound PAS should be suspected if ultrasound examination before 9 weeks reveals implantation of the gestational sac in the lower anterior segment of the uterus, particularly in the niche of the prior cesarean scar. Subsequent placental development in this area should also raise suspicion for PAS. 21-Sep-24 Dr Shashwat Jani 99099 44160 30

31. COLOR DOPPLER Color Doppler is useful for confirming the diagnosis of PAS when used in conjunction with the other ultrasound findings described above. Turbulent lacunar blood flow (>15 cm/sec) Bridging vessels Diffuse or focal intraparenchymal flow Hypervascularity of serosa-bladder interface Prominent sub-placental venous complex 21-Sep-24 Dr Shashwat Jani 99099 44160 31

32. 3- D Power Doppler Ultrasound Three-dimensional ultrasound has been used successfully for evaluation of PAS. Diagnostic C riteria include: Irregular intra-placental vascularization with tortuous confluent vessels crossing placental width. Hypervascularity of uterine serosa-bladder wall interface 21-Sep-24 Dr Shashwat Jani 99099 44160 32

33. MRI Uterine bulging into the bladder ("placental/uterine bulge") Interruption of the bladder wall Loss of retroplacental hypointense line on T2W images Abnormal vascularization of the placental bed Dark intraplacental bands on T2W imaging ("T2-dark bands") Myometrial thinning Focal exophytic mass 21-Sep-24 Dr Shashwat Jani 99099 44160 33

34. To Conclude. . . PAS is a potentially life-threatening condition. Given the increasing rates of cesarean section worldwide, the incidence of PAS will be likely to increase further over time . Therefore , clinicians should be aware of the difficulties related with the diagnosis and the challenges associated with the management of this condition . 21-Sep-24 Dr Shashwat Jani 99099 44160 34

35. Scope Of Research… It should focus on the collection of data for prospective studies on the diagnosis and management of PAS providing correlation between prenatal imaging, clinical grading of PAS at the time of delivery, and histopathology . This is of paramount importance to provide the best screening, diagnosis, and management options to women affected by PAS disorders. 21-Sep-24 Dr Shashwat Jani 99099 44160 35

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