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Placenta Accreta Spectrum-A Catastrophic Situation in Obstetrics

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Placenta Accreta Spectrum-A Catastrophic Situation in Obstetrics Review Article Obstet Gynecol Sci 2021;64(3):239-247 https://doi.org/10.5468/ogs.20345 eISSN 2287-8580 Placenta accreta spectrum-a catastrophic situation in obstetrics Bhabani Pegu, MD, Chitra Thiagaraju, MD, Deepthi Nayak, MD, Murali Subbaiah, MD Department of Obstetrics and Gynecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India Placenta accreta is a significant obstetric complication in which the placenta is completely or focally adherent to the myometrium. The worldwide incidence of placenta accreta spectrum (PAS) is increasing day by day, mostly due to the increasing trends in cesarean section rates. The accurate and timely diagnosis of placenta accreta is important to improve the feto-maternal outcome. Although standard ultrasound is a reliable and primary tool for the diagnosis of placenta accreta, the absence of ultrasound findings does not preclude the diagnosis of placenta accreta. Therefore, clinical evaluation of risk factors is equally essential for the prediction of abnormal placental invasion. Pregnant women with a high impression or established diagnosis of placenta accreta should be managed by a multidisciplinary team in a specialist center. Traditionally, PAS has been managed by an emergency obstetric hysterectomy. Previously, few studies suggested a satisfactory success rate of conservative management in well-chosen cases, whereas few studies recommended delayed hysterectomy to reduce the amount of bleeding. The continuously increasing trends of PAS and the challenges for its routine management are the main motives behind this literature review. Keywords: Placenta accreta spectrum; Massive hemorrhage; Maternal morbidity; Obstetric hysterectomy Introduction invasion during surgery, 3) ultrasound diagnosis of PAS con- firmed during the third stage of labor, and 4) histological Placenta accreta spectrum (PAS) is a potentially life-threat- confirmation of hysterectomy specimen [2]. ening obstetric complication. It is characterized by invasive Over the past few decades, the rate of cesarean delivery placentation due to the absence of the decidua basalis layer, has increased significantly, resulting in a 10-fold increase in resulting in placental anchoring villi coming in direct ap- the incidence of PAS, and this situation is expected to worsen position with the myometrium due to a deficient Nitabuch’s over the next few years [3]. Despite the advances made in layer. Different terminology has been used to explain this obstetric imaging, multiple studies have shown that a sig- condition; however, the recent consensus is to include ac- nificant number of PAS cases are unpredictable at the time creta, increta, and percreta in PAS [1]. Depending on the of delivery [4-6]. Management in a multidisciplinary center is extent of placental invasion, PAS is categorized into placenta accreta and placenta increta. In placenta accreta, placental villi remain attached to the myometrium without invading Received: 2020.11.13. Revised: 2021.01.23. Accepted: 2021.03.16. it, whereas in placenta increta, placental villi penetrate the Corresponding author: Bhabani Pegu, MD myometrium and extend up to or beyond the uterine serosa. Department of Obstetrics and Gynecology, Jawaharlal Institute of Placenta accreta is further divided into two types depending Postgraduate Medical Education and Research, Jipmer Campus Rd, on the timing of diagnosis; those diagnosed during the ante- Gorimedu, Puducherry 605006, India E-mail: [email protected] natal period by imaging are called expected PAS, and those https://orcid.org/0000-0002-5475-7856 diagnosed during the intrapartum period with adherent or retained placenta are called unexpected PAS. The diagnosis Articles published in Obstet Gynecol Sci are open-access, distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons. of PAS will be considered with the presence of one of the org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, following 1) the need for manual removal of the placenta and reproduction in any medium, provided the original work is properly cited. either completely or partially, 2) evidence of gross placental Copyright © 2021 Korean Society of Obstetrics and Gynecology www.ogscience.org 239 Vol. 64, No. 3, 2021 known to reduce maternal mortality and morbidity in women incidence of placenta accreta after CET than those who had with PAS, but timely referral and management are challeng- been prescribed transdermal or vaginal E2 [20]. ing in unexpected PAS [7-9]. In 2015, a multicenter study PAS is one of the most important causes of maternal from the Maternal-Fetal Medicine Units Network showed mortality and morbidity in the modern obstetrics; it has a that almost 50% of reported PAS cases were unexpected. mortality as high as 7% and even higher in underdeveloped Furthermore, they reported poorer outcomes in patients with countries [21,22]. Most of the time, unexpected PAS is di- expected PAS than those in patients with unexpected PAS; agnosed clinically for the first-time during delivery. Increased this could be attributed to the referral of patients with a high maternal morbidity is due to massive intrapartum or postpar- degree of placental invasion to specialists [10]. tum hemorrhage and its sequel, namely, blood transfusions, The frequency of PAS has progressively increased from 0.8 coagulopathy, sepsis, and multiorgan failure. These situations per 1,000 deliveries in the 1980s to 3 per 1,000 deliveries in necessitate medical intervention, and PAS-associated hemor- the last few years, a phenomenon ascribed to a rising rate rhage is one of the leading indications for emergency cesar- of cesarean section globally [11]. The most common and ean hysterectomy. defined risk factor associated with PAS is a previous cesarean section, and the risk is directly proportional to the number of prior cesarean deliveries [12,13]. Placenta previa is another Pathophysiology significant risk factor for PAS observed in 3% of women without a previous surgical scar in the uterus. The likelihood Over the years, various concepts have emerged to explain of PAS is high in women who have a placenta previa and one why and how PAS occurs. The most accepted hypothesis or more repeat cesarean deliveries. In such women, the risk explains the occurrence of PAS in a scarred uterus. Following of placenta accreta is 3%, 11%, 40%, 61%, and 67% for a uterine scar, there is failure in the normal decidualization the first, second, third, fourth, and fifth or more repeat ce- of the area is compromised, causing secondary defect in the sarean deliveries, respectively [12]. Other risk factors include endometrial-myometrial junction. This defect allows placen- advanced maternal age, multiparty, history of previous uter- tal anchoring villi, along with the trophoblast, to invade deep ine surgeries or curettage, and Asherman syndrome [14,15]. into the myometrium [23]. In normal pregnancy, the extent Recently, with the advent of in vitro fertilization (IVF) and of trophoblastic invasion is regulated by the decidua. In ec- advancements in cryopreservation techniques, cryopreserved topic pregnancy, scarce decidua leads to aggressive implan- embryo transfer (CET) has been proposed as an additional tation into the muscular and serosal layers of the fallopian risk factor for PAS [16-18]. Previous studies have shown that tube or the abdomen, indicating the important function of the stimulation protocols for IVF induce morphological and decidua as a barrier against abnormal placentation [24,25]. structural changes and disturb the expression of relevant The underlying pathology of PAS is scarred uterus and, in genes in the endometrium; such changes could contribute particular, uterine scar secondary to a cesarean section. A re- to abnormal implantation [19]. However, this theory failed cent study has shown that following a cesarean section, uter- to explain the occurrence of PAS in women who underwent ine vascular resistance is increased, which in turn decreases frozen-thawed embryo transfer or ovum donation cycles the blood flow to the endometrium in comparison to that without ovarian stimulation. Another study found that ovar- following a normal vaginal delivery [26]. This impaired blood ian stimulation cycles, which eventually led to a pregnancy circulation around the scar tissue hampers the vascularization with PAS, had thinner endometrial linings and lower peak in the scar cascading to permanent focal myometrial degen- serum estrogen (E2) levels when compared to cycles, which eration, along with absent or reduced re-epithelialization of led to a pregnancy without PAS. This allowed us to propose the scar area. In the scar area without re-epithelialization, the a threshold value for serum E2 level at which the risk of pla- trophoblast extensively invades beyond the decidua and into centa accreta was significantly high. They also suggested that the myometrium, reaching up to the underlying blood vessel the relationship between CET and placenta accreta might and nearby structures. Cellular changes in the trophoblast be mediated by E2 administration. They found that patients detected in PAS are not a primary defect of trophoblast biol- who had been prescribed oral E2 had significantly higher ogy but are possibly secondary to the rare myometrial condi- 240 www.ogscience.org Bhabani Pegu, et al. Placenta accreta spectrum disorder tion leading to excessive invasion into the myometrium [27]. observed between
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