Placenta accreta

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Classification according to ICD-10
O43.2 Morbidly adherent placenta
ICD-10 online (WHO version 2019)

In obstetrics, placenta accreta is a disorder of placental adhesion , in which the placenta has grown together with the uterine muscles ( myometrium ). As a result, the placenta does not loosen after the child is born ( placenta retention ) and significant bleeding can occur. The placenta accreta occurs in around 1 in 2,500 pregnancies with increasing frequency.

causes

Normal structure of a placenta
Different forms of placentation

In the placenta accreta , the decidua basalis is partially or completely absent . This allows trophoblasts to grow up to the uterine muscles ( placenta accreta ) or even immigrate and grow into them ( placenta increta / percreta ).

All forms are 10 to 45% associated with a placenta previa . Other causes are cicatricial changes in the uterus, such as those in Asherman's syndrome , which occurs primarily after operations on the uterus, such as curettages and after removal of myomas, or after caesarean sections .
Some studies have also shown an increased frequency in pregnancies with female fetuses .

The increasing incidence is seen as a consequence of the increase in the rate of caesarean sections. Pregnant women over 35 years of age also have an increased risk of placental implantation disorders.

diagnosis

A distinction is made between three types of placenta accreta according to the depth of their adhesion with the uterine wall :

shape description proportion of
Placenta accreta The villi grow up to the muscles of the uterus.

 75-78%
Placenta increta The villi grow deep into the wall of the uterus.

 17%
Placenta percreta In the most severe form, the placenta penetrates the entire myometrium up to the serosa . The placenta can even grow into the bladder and rectum. 5-7%

Placenta accreta is rarely recognized before birth and can be difficult to diagnose. In the Doppler sonography to newly formed blood vessels in the muscle of the uterus can be detected. Also in the magnetic resonance imaging (MRI) to instructions can be found on a placental implantation disorder. However, they cannot be proven with either the ultrasound or the MRI examination.

In the second trimester of pregnancy , increased alpha-1-fetoprotein levels can be detected in the maternal blood serum , but these are also indicators for many other things. In the third trimester, in some cases of placentation disorders, vaginal bleeding occurs, but the cause is rarely the disorder itself. If placenta and egg shells are not born within 30 minutes of the birth of the child, placenta accreta must be included in the differential diagnosis .

treatment

If a placenta accreta is diagnosed before birth, a planned caesarean section, possibly with removal of the uterus , is the safest mode of delivery.

Manual detachment of the placenta due to placental retention can result in significant bleeding. A complete solution of the placenta only succeeds with the placenta adhera and the lightest form of the placenta accreta . In the case of placenta accreta , firmly adhering parts of the placenta can usually only be removed by curettage . In the more severe forms ( pl. Increta / percreta ), a hysterectomy can usually not be avoided. To reduce the bleeding rate, contractions and an infusion treatment for volume replacement are temporarily necessary.

If the uterus is to be preserved because the desire to have children has not yet been fulfilled, an operative resection around the placenta can be successful for the placenta increta . However, uterine preservation treatment has a higher risk of complications and is not always successful.

Possible conservative techniques are:

  • leaving the placenta in the uterus
  • intrauterine balloon catheterization to compress blood vessels
  • an embolization of the uterine arteries

If a pregnant woman opts for vaginal delivery when placenta accreta is suspected , blood products should be provided for transfusion .

literature

Web links

Individual evidence

  1. ↑ S. Capella-Allouc, F. Morsad, C. Rongieres-Bertrand et al .: Hysteroscopic treatment of severe Asherman's syndrome and subsequent fertility . In: Hum Reprod . 14, No. 5, 1999, pp. 1230-1233. doi : 10.1093 / humrep / 14.5.1230 . PMID 10325268 .
  2. Jump up ↑ A. Al-Serehi, A. Mhoyan, M. Brown, K. Benirschke, A. Hull, DH Pretorius: Placenta accreta: an association with fibroids and Asherman syndrome . In: J Ultrasound Med . 27, No. 11, 2008, pp. 1623-8. PMID 18946102 .
  3. ^ American Pregnancy Association : Placenta Accreta. ( Memento of the original from January 16, 2006 in the Internet Archive ) Info: The @1@ 2Template: Webachiv / IABot / www.americanpregnancy.org archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. January 2004, last accessed March 21, 2011
  4. ↑ David A. Miller: accreta Obstetric Hemorrhage High Risk Pregnancy Directory on ObFocus , November 2, 2004, last accessed 21 March 2011
  5. ↑ M. Mayes, BR Sweet, D. Tiran: Mayes' Midwifery - A Textbook for Midwives. 12th Edition, Baillière Tindall 1997, ISBN 0-7020-1757-4 , pp. 524, 709.
  6. ↑ Royal College of Obstetricians and Gynecologists (RCOG): 2005 guideline on placenta previa and placenta previa accreta. National Guideline Clearinghouse 2006, 8570
  7. ↑ a b Y. Oyelese, JC Smulian: Placenta previa, placenta accreta, and vasa previa. Obstet Gynecol 107 (2006), 927-941
  8. ^ American College of Obstetricians and Gynecologists (ACOG) committee opinion. Committee on Obstetric Practice: Placenta accreta. Int J Gynaecol Obstet 77 (2002), 77-78.