08/04/2010
Placenta accreta/percreta.
California Hospital Medical Center
30-year-old female with placenta accreta/percreta and repeat C-section.
Procedure: Total abdominal hysterectomy.
Gross: The specimen consists of an enlarged dilated gravid uterus containing placental tissue and a detached segment of umbilical cord. The protruding placenta parenchyma at the dilated uterine cervix measures 6.5 x 6.5 x 4 cm. Probing through the dilated uterine cervix cannot separate the placental tissue from the dilated uterine wall. The entire uterus with the adherent placental tissue is bi-valved longitudinally. The cut surface reveals complete placenta previa with the entire placenta located at the lower uterine segment and over the cervical opening. The placental tissue grow into the full thickness of the uterine wall at the lower uterine segment to the subserosal area grossly. The fetal membrane is largely attached to the enlarged uterine cavity. A portion of the fetal membrane is disrupted by the transmural C-section at the fundic region. There is another segment of the umbilical cord attached to the retained placenta.
Micro: Sections through the uterine wall show adherent mature placental tissue with intervillous fibrin deposition, scattered calcifications, and focal intervillous thrombosis formation. The chorionic villi are focally directly contacting to the myometrium layer. The fetal membrane is tightly adherent to the decidual plate to the uterine wall. H & E stain.
Diagnosis:
1) Complete placenta previa; 2) Placenta accreta; 3) Status post repeat C-section.
Discussion:
Placenta previa, placenta accreta, and vasa previa are important causes of bleeding in the second half of pregnancy and in labor. Risk factors for placenta previa include prior cesarean delivery, pregnancy termination, intrauterine surgery, smoking, multifetal gestation, increasing parity, and maternal age. The diagnostic modality of choice for placenta previa is transvaginal ultrasonography, and women with a complete placenta previa should be delivered by cesarean. Small studies suggest that, when the placenta to cervical os distance is greater than 2 cm, women may safely have a vaginal delivery. Regional anesthesia for cesarean delivery in women with placenta previa is safe. Delivery should take place at an institution with adequate blood banking facilities. The incidence of placenta accreta is rising, primarily because of the rise in cesarean delivery rates. This condition can be associated with massive blood loss at delivery. Prenatal diagnosis by imaging, followed by planning of peripartum management by a multidisciplinary team, may help reduce morbidity and mortality. Women known to have placenta accreta should be delivered by cesarean, and no attempt should be made to separate the placenta at the time of delivery. The majority of women with significant degrees of placenta accreta will require a hysterectomy. Although successful conservative management has been described, there are currently insufficient data to recommend this approach to management routinely. Vasa previa carries a risk of fetal exsanguination and death when the membranes rupture. The condition can be diagnosed prenatally by ultrasound examination. Good outcomes depend on prenatal diagnosis and cesarean delivery before the membranes rupture.
References:
Oyelese Y, Smulian JC. Placenta previa, placenta accreta, and vasa previa. Obstet Gynecol. 2006 Apr;107(4):927-41.
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