TUGAS

PAGI KLINIK

PLACENTA ACCRETA SPECTRUM DISORDER

BENNY HARMOKO

DEPARTEMEN OBSTETRI DAN GINEKOLOGI

RSUP HAM/FK USU
MEDAN 2019

Introduc*on




In early millenial years increased
cesarean delivery rates

From less than 10% to over 30%

INTRODUCTION

DEFINITION From USA es*mated by 2020 the

cesarean delivery rate will be over 50%
EPIDEMIOLOGY
Addi*onal 4504 annual cases of PAS
ETIOLOGY disorders
GRADING
130 maternal deaths due to its
DIAGNOSIS complica*ons
CONSERVATIVE

SURGICAL

PICTURE
Vet J, Boer Md, Akker Bvd, et al. Bri*sh Journal of Cancer 2008; 99: 214-8.
Sitopu SD. Repository USU 2011; 1-50.
Domingo EJ, Noviani R, Rushdan M, et al. Vaccine 2008; 26S: M71-9.

Defini*on

PAS disorders were first
defined by Luke et


Abnormally adherent and

invasive placentas. Three
categories are now considered:
INTRODUCTION
DEFINITION
Accreta, vera, adherenta
EPIDEMIOLOGY

ETIOLOGY

GRADING Increta
DIAGNOSIS

CONSERVATIVE Percreta
SURGICAL
•  Luke RK, Sharpe JW, Greene RR. Placenta accreta: The adherent or invasive placenta. Am J Obstet Gynecol. 1966;95:660–668.
PICTURE •  Fox H. Placenta accreta: 1945-1969. Obstet Gynecol Survey. 1972;27:475–490.
•  Solheim KN, Esakoff TF, Lible SE, Cheng YW, Sparks TN, Caughey AB. The effect of cesarean delivery rates on the future incidence of
placenta previa, placenta accreta, and maternal mortality. J Matern Fetal Neonatal Med. 2011;24:1341–1346.

Cesarean rate and PAS Prevalence

INTRODUCTION
DEFINITION

EPIDEMIOLOGY

ETIOLOGY

GRADING

DIAGNOSIS

CONSERVATIVE

SURGICAL

PICTURE
Sharma R, Firdaus H, Maheswari V, Siddiqui S. Iranian Journal of Pathology (2012) 7 (4), 224 – 230.

History of Cesarean, PAS, Hysterectomy

INTRODUCTION
DEFINITION

EPIDEMIOLOGY

ETIOLOGY

GRADING

DIAGNOSIS

CONSERVATIVE

SURGICAL

PICTURE
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Distribu*on of Different Grade of PAS

INTRODUCTION
DEFINITION

EPIDEMIOLOGY

ETIOLOGY

GRADING

DIAGNOSIS

CONSERVATIVE

SURGICAL

PICTURE
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Uterine Pathology Associated with PAS

INTRODUCTION
DEFINITION

EPIDEMIOLOGY

ETIOLOGY

GRADING

DIAGNOSIS

CONSERVATIVE

SURGICAL

PICTURE
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PAS Grading


PAS 0 Placenta previa with no US signs of invasion
or placenta previa with placental
lacunae but no evidence of abnormal

uterine-bladder interface

PAS 1 Presence of at least two ultrasound signs
INTRODUCTION
among: placental lacunae, loss of the clear
DEFINITION
zone or bladder wall interrup*on.
EPIDEMIOLOGY

ETIOLOGY PAS 2 PAS1 + uterovescical hypervascularity

GRADING PAS 3 PAS1/PAS2 + evidence of increased
DIAGNOSIS vascularity in the inferior part of the lower
CONSERVATIVE uterine segment poten*ally extending in the
SURGICAL parametrial region.
PICTURE
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FIGO Grading

INTRODUCTION
DEFINITION

EPIDEMIOLOGY

ETIOLOGY

GRADING

DIAGNOSIS

CONSERVATIVE

SURGICAL

PICTURE
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INTRODUCTION
DEFINITION

EPIDEMIOLOGY

ETIOLOGY

GRADING

DIAGNOSIS

CONSERVATIVE

SURGICAL

PICTURE
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Prenatal Diagnosis




Bladder wall Myometrial
interrup*on thinning

Abnormal
placental Placental
INTRODUCTION lacunae bulge
84.6%
DEFINITION

EPIDEMIOLOGY

ETIOLOGY Loss of the

“clear zone”
USG Focal
exophy*c
GRADING

DIAGNOSIS
62.1%
2D mass

CONSERVATIVE

SURGICAL
Collins SL, Ashcrok A, Braun T, et al. Proposal for standardized ultrasound descriptors of abnormally invasive placenta (AIP). Ultrasound
PICTURE Obstet Gynecol. 2016;47:271–275.
Jauniaux E, Collins SL, Jurkovic D, Burton GJ. Accreta placenta*on: A systema*c review of prenatal ultrasound imaging and grading of
villous invasiveness. Am J Obstet Gynecol. 2016;215:712–721.

Prenatal Diagnosis




Bridging vessels
71.4%

Subplacental Placental
hypervascularity lacunae feeder
INTRODUCTION 54.5% vessels 82.4%

DEFINITION

EPIDEMIOLOGY

ETIOLOGY
Uterovesical Color 3D intraplacental
GRADING hypervascularity
Doppler hypervascularity
DIAGNOSIS

CONSERVATIVE

SURGICAL
Collins SL, Ashcrok A, Braun T, et al. Proposal for standardized ultrasound descriptors of abnormally invasive placenta (AIP). Ultrasound
PICTURE Obstet Gynecol. 2016;47:271–275.
Jauniaux E, Collins SL, Jurkovic D, Burton GJ. Accreta placenta*on: A systema*c review of prenatal ultrasound imaging and grading of
villous invasiveness. Am J Obstet Gynecol. 2016;215:712–721.

Timing of Delivery


•  Delivery of women with placenta previa accreta from 34 to 39
weeks demonstrated that under a variety of circumstances.
34-39


•  Delivery at 34 weeks aker administra*on of cor*costeroid for
lung maturity may be the preferred *ming as reflected in
Lung
Matura*on quality-adjusted life years.
INTRODUCTION
DEFINITION
•  There is no role for assessing fetal lung maturity with
EPIDEMIOLOGY No amniocentesis .
amniocentesis
ETIOLOGY

GRADING •  Modelling did indicate that when the risk of prepartum

hemorrhage is low, delivery at 37 weeks may be op*mal.
DIAGNOSIS > 37 wga

CONSERVATIVE

SURGICAL Bowman ZS, Manuck TA, Eller AG, Simon M, Silver RM. Risk factors for unscheduled delivery in pa*ents with placenta accreta. Am J Obstet
Gynecol. 2014;210:241.e1–241.e6.
Rac MW, Wells CE, Twickler DM, Moschos E, McIn*re DD, Dashe JS. Placenta accreta and vaginal bleeding according to gesta*onal age at
PICTURE delivery. Obstet Gynecol. 2015;125:808–813.
Robinson BK, Grobman WA. Effec*veness of *ming strategies for delivery of individuals with placenta previa and accreta. Obstet Gynecol.
2010;116:835–842.

Leaving Placenta Insitu Approach




Gentle aGempted removal of the placenta


Methotrexate adjuvant treatment
INTRODUCTION
DEFINITION

EPIDEMIOLOGY PrevenOve surgical or radiological uterine

devascularizaOon
ETIOLOGY

GRADING
SystemaOc hysteroscopic resecOon of retained
DIAGNOSIS accreta Ossue
CONSERVATIVE

SURGICAL

PICTURE
Ferlay J, Soerjomataram I, Ervik M, all e. Available at: hbp:// [Link]/Pages/fact_sheets_Cancer.aspx

Surgical approach for PAS

INTRODUCTION
DEFINITION

EPIDEMIOLOGY

ETIOLOGY

GRADING

DIAGNOSIS

CONSERVATIVE

SURGICAL

PICTURE
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PAS 0







INTRODUCTION
DEFINITION
EPIDEMIOLOGY
ETIOLOGY
GRADING
DIAGNOSIS
CONSERVATIVE
SURGICAL
PICTURE

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PAS 1

INTRODUCTION
DEFINITION

EPIDEMIOLOGY

ETIOLOGY

GRADING

DIAGNOSIS

CONSERVATIVE

SURGICAL

PICTURE
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PAS 2

INTRODUCTION
DEFINITION

EPIDEMIOLOGY

ETIOLOGY

GRADING

DIAGNOSIS

CONSERVATIVE

SURGICAL

PICTURE
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PAS 3

INTRODUCTION
DEFINITION

EPIDEMIOLOGY

ETIOLOGY

GRADING

DIAGNOSIS

CONSERVATIVE

SURGICAL

PICTURE
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