Placenta accreta spectrum: Risk factors, diagnosis and management with special reference to the Triple P procedure

Abstract

Abnormal invasion of placenta or placenta accreta spectrum disorders refer to the penetration of the trophoblastic tissue through the decidua basalis into the underlying uterine myometrium, the uterine serosa or even beyond, extending to pelvic organs. It is classified depending on the degree of invasion into placenta accreta (invasion <50% of the myometrium), increta (invasion >50% of the myometrium) and percreta (invading the serosa and adjacent pelvic organs). Clinical diagnosis is made intra-operatively; however, the confirmative diagnosis can only be made after a histopathological examination. The incidence of abnormal invasion of placenta has increased worldwide, mostly as a consequence of the rise in caesarean section rates, from 1 in 2500 pregnancies to 1 in 500 pregnancies. The importance of the disease is due to the increased maternal and foetal morbidity and mortality. Foetal implications are mainly due to iatrogenic prematurity, while maternal implications are mostly the increased risk of obstetric haemorrhage and surgical complications. The average blood loss is 3000–5000 mL, and up to 90% of the patients require a blood transfusion. An accurate and timely antenatal diagnosis is essential to improve outcomes. The traditional management of abnormal invasion of placenta has been a peripartum hysterectomy; however, the increased incidence and the short- and long-term consequences of a radical approach have led to the development of more conservative techniques, such as the intentional retention of the placenta, partial myometrial excision and the ‘Triple P procedure’. Irrespective of the surgical technique of choice, women with a high suspicion or confirmed abnormally invasive placenta should be managed in a specialist centre with surgical expertise with a multi-disciplinary team who is experienced in managing these complex cases with an immediate availability of blood products, interventional radiology service, an intensive care unit and a neonatal intensive care unit to optimize the outcomes.

Placenta accreta spectrum disorders—experience of management in a German tertiary perinatal centre

“…While there is agreement on the optimal setting for therapy in PAS, the preferred approach currently remains the result of individual experience. Not infrequently, emergency solutions have been translated into innovative, further pursued treatment methods [18][19][20][21]. In addition to the often used primary caesarean section hysterectomy, the guidelines mention several initial or definitive uterine-preserving treatment options, including leaving the placenta in situ after child development with delayed placental removal or expectant management [22,23].…”

Suspected Placenta Accreta: Using Imaging to Stratify Risk of Morbidity

“…21 There remains wide variation in the management of accreta, both within the United States [24][25][26][27] and worldwide. 2,6,[28][29][30] However, it is well known that the use of invasive interventions, such as IR balloons and ureteral stents, is not without risk. IR balloon placement carries with it a risk of vascular injury, abscess formation, arterial thrombosis and hematoma, with rates of complications reported as high as 15%.…”

Latvian experience in conservative management of abnormally invasive placenta: two case reports

“…This technique is associated with a lower perioperative blood loss if performed by experienced surgeons in a well-equipped hospital, but is technically very sophisticated (7-9). In the case of conservative surgical management, even though uterus is preserved, it is not recommended to plan future pregnancies as there is a big post-operative myometrial defect and a high risk of uterine rupture (10). However, conservative management option allows fertility conservation in patients who desire future pregnancies.…”