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ORIGINAL ARTICLE  
Year : 2020  |  Volume : 63  |  Issue : 5  |  Page : 87-90
Retrospective study of placenta accreta, placenta increta and placenta percreta in Peripartum hysterectomy specimens


Department of Pathology, Dr. VRK Womens Medical College, Hyderabad, Telangana, India

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Date of Web Publication26-Feb-2020
 

   Abstract 


Background: Abnormal placentations such as placenta accreta, placenta increta and placenta percreta are important causes of hemorrhage after delivery causing maternal morbidity and mortality. Risk factors for abnormal placentation are prior caesarean section, placenta previa and pre-eclampsia. There is a need for reliable antenatal diagnosis for these serious conditions. If these pregnancies can be identified, antepartum, site and time of delivery as well as the surgical approach can be planned ahead; this decreases the incidence of maternal mortality due to massive hemorrhage. Aim: (1) To study the incidence of abnormal placentation in emergency peripartum hysterectomy specimen. (2) To evaluate various risk factors associated with abnormal placentation. Materials and Method: Retrospective cross-section study done in patients with abnormal placentation leading to emergency peripartum hysterectomy during a course of eight-year period. Result: We received total of 18 emergency hysterectomy specimens during eight-year period of which placenta accreta accounts 55.5 percent (10/18), placenta increta upto 38.8 percent (7/18) and placenta percreta 5.5 percent (1/18). Analysis of result with parity shows uniparous women up to 22.2 percent (4/18), and multiparous women 77.7 percent (14/18). Risk factor analysis shows previous caesarean section in 55.5 percent (10/18), placenta previa in 33.3 percent (6/18) and pre-eclampsia in 11.1 percent (2/18). Conclusion: In our study, among abnormal placentation, incidence of placenta accreta accounts for 55.5 percent and it is more common in multiparous women than uniparous women. Among risk factors in our study, previous caesarean section is commonly associated with abnormal placentation followed by a placenta previa and pre-eclampsia.

Keywords: Peripartum, placenta accreta, placenta increta, placenta percreta, pre-eclampsia

How to cite this article:
Heena AB, Kumari G. Retrospective study of placenta accreta, placenta increta and placenta percreta in Peripartum hysterectomy specimens. Indian J Pathol Microbiol 2020;63, Suppl S1:87-90

How to cite this URL:
Heena AB, Kumari G. Retrospective study of placenta accreta, placenta increta and placenta percreta in Peripartum hysterectomy specimens. Indian J Pathol Microbiol [serial online] 2020 [cited 2020 Apr 2];63, Suppl S1:87-90. Available from: http://www.ijpmonline.org/text.asp?2020/63/5/87/279526





   Introduction Top


Normal placentation and implantation are important for successful pregnancy outcome. Late complications of pregnancy such as pre-eclampsia and preterm labour have their pathogenesis early in pregnancy due to abnormal placenta development and implantation. Implantation of placenta in human involves three stages:

  1. Initial adhesion of the blastocyst to the uterine wall known as apposition—this is unstable process
  2. In second stage, micro villi present on syncytiotrophoblasts interdigitate on the apical surface of the luminal epithelium
  3. In the last stage, there is increased physical interaction between the trophectoderm and the uterine luminal epithelium.[1]


Mononuclear cytotrophoblasts proliferate out of the trophoblastic shell to invade the entire endometrium and inner third of the myometrium known as interstitial invasion[2] and also invade the maternal uterine vasculature known as endovascular invasion.[3] This process results in establishment of definitive uteroplacental circulation. This cytotrophoblast invasion during implantation is major determining factor for pregnancy outcome.

Excessive invasion due to failure of maternal tissue to restrain cytotrophoblast cell invasion lead to abnormal firm attachment of placenta to myometrium—placenta accrete,[4] extension of trophoblast into myometrium—placenta increta or invasion through myometrium into adjacent organs—placenta percreta.[3] Etiology of pre-eclampsia is unknown, however, improper cytotrophoblast invasion and restricted endovascular invasion is likely considered as pathological event.[5],[6],[7],[8]


   Materials and Method Top


This is retrospective cross-section study done on emergency peripartum hysterectomy specimen during course of eight years period from 2010 to 2018 to know the incidence of abnormal placentation.

Total 18 emergency peripartum hysterectomy specimens due to abnormal placentation were received during study period. Age group of patients in our study was between 30 and 36 years.

Inclusion criteria

  1. Pregnant women with abnormal placentation diagnosed by ultrasound
  2. Pregnant women with placenta previa
  3. Multiple pregnancy
  4. Previous caesarean section
  5. Advanced maternal age
  6. Pregnant women with late complications such as pre-eclampsia, preterm labour.


Specimen reception and grossing

We received fresh specimen in formalin-filled container labelled with patients' names, IP numbers along with proforma containing clinical details of patient and relevant history from obstetrics and gynaecology department of our hospital.

Specimen types include peripartum uterus with cervix along with placenta in-situ or in some cases. fragmented pieces of placenta after attempted removal. Grossing technique focus on:

  1. Proximity of invasion of placenta to uterus and its distance from cervix
  2. Implantation whether anterior or posterior
  3. Depth of invasion
  4. Involvement of any surrounding structure like bladder.


Bread loaf sections of posterior uterine wall to assess myometrial invasion in case of placenta increta and placenta percreta is done.

These findings were confirmed on histopathological examination.

Slide review and reporting

After staining the slide with haemotoxylin and eosin stain, microscopic examination of section is done if there is lack of decidua between placental villi and myometrium; it indicates placenta accreta. Assessment of myometrial invasion by trophoblast is done in case of placenta increta and percreta.


   Result Top


Of total 18 peripartum hysterectomy specimens we received during our study period, [Table 1] summarises the incidences of abnormal placentation. [Table 2] summarises association of parity with abnormal placentation. Risk factors such as previous caesarean section, placenta previa and pre-eclampsia are summarised in [Table 3].
Table 1: Incidence of abnormal placentation

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Table 2: Relationship of abnormal placentation with parity

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Table 3: Risk factors associated with abnormal placentation

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   Discussion Top


Placenta accreta refers to placenta that is abnormally adherent to uterus [Figure 1]a, placenta increta when placenta invades the myometrium [Figure 1]b and placenta percreta when placenta invades the myometrium and serosa sometimes even perforate into adjacent organs like bladder [Figure 1]c.
Figure 1: Gross image (a) Placenta accreta (b) Placenta increta (c) Placenta percreta

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Abnormal placentation can be diagnosed microscopically by assessing degree of trophoblastic adhesion or invasion into myometrium. Placenta accreta seen microscopically as placental villi interdigitating into a uterine myometrium without an intervening decidual plate [Figure 2]a. Morphologic subtypes of this condition are designated as placenta increta when the villi invade the myometrium [Figure 2]b and placenta percreta when the villous infiltration extends through the whole thickness of the myometrium and serosa sometimes even perforate into adjacent organs like bladder.
Figure 2: (a) Photomicrograph (H and E, ×40) placenta accreta showing the placental villi interdigitate directly with the uterine myometrium, without an intervening decidual plate. (b) Photomicrograph (H and E, ×40) placenta Increta showing trophoblast invading deep into myometrium

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Placenta accreta result from absence or deficiency of Nitabuch's layer or spongiosus layer of decidua.[9] Histology shows trophoblastic tissue invading myometrium without intervening decidua.[9] This causes massive bleeding as placenta does not separate after delivery and need for emergency peripartum hysterectomy to prevent maternal mortality.

Of total18 peripartum hysterectomy specimens we received during study period, incidence of abnormal placentation is as follows: placenta accreta accounts for 55.5 percent (10/18), placenta increta 38.8 percent (7/18) and placenta percreta 5.5 percent (1/18).

Similarly, in the study done by Breen JL et al. and Neubecker R et al.,[10] incidence of abnormal placentation including placenta accreta, placenta increta and placenta percreta ranges from 1 in 540 to 1 in 93,000 deliveries.

Placenta percreta is most serious among abnormal placentation as placenta invades through myometrium and serosa, even beyond the serosa sometimes leading to catastrophic blood loss. Also, causes multiple complications such as acute respiratory distress syndrome, sheehans syndrome, renal failure and even death. Placenta percreta causes very high maternal mortality and morbidity up to 10 percent.[11]

In our study, incidence of abnormal placentation is more in multiparous women (77.7 percent) compared to uniparous women (22.2 percent); no such data on comparison of parity is found in other studies.

Placenta accreta lead to massive hemorrhage and complications such as DIC, injury to ureter, bladder, ARDS, Renal failure and death.[12],[13] Placenta accreta causes higher incidence of caesarean hysterectomy in several hospitals.[14] Rarely placenta accreta also lead to spontaneous rupture of uterus during second and third trimester of pregnancy.[15]

Risk factors correlation in our study shows higher association in women with previous caesarean section (55.5 percent) followed by a placenta previa (33.3 percent) and pre-eclampsia (11.1 percent).

Similarly, Miller and colleagues concluded that placenta accreta incidence is increasing and results in more number of caesarean delivery rate.[16] Wu and Colleagues concluded that placenta accreta more frequently occur in women with one or more prior caesarean deliveries, and who have placenta previa in a current pregnancy.[17] Clarke and colleagues concluded that presence of placenta previa increases the risk of having placenta accreta from 24 percent in women with one prior caesarean delivery to 67 percent with three or more prior caesarean section.[18]

Reliable antenatal diagnosis of at risk cases to identify and have planned surgical approach to prevent massive blood loss so that morbidity and mortality decreases. According to Finberg HJ, Williams JW, 75 percent of cases of placenta percreta are associated with placenta previa. A total of 25 percent of women with a placenta previa and one previous caesarean delivery have placenta accreta or percreta whereas almost 50 percent with placenta previa and two previous caesarean deliveries have placenta accreta or percreta.[19]

Mostly, placenta percreta cases are diagnosed at the time of delivery; some suggested antenatal diagnosis by ultrasound or MRI in patients with clinical history of previous caesarean section, previous uterine surgery, suction dilatation and curettage.[20]

However, there is lack of data about how accurate is prenatal diagnosis of placenta increta or percreta. Antenatal detection rate of abnormal placentation on ultrasonography varies in literature from 33 percent (4/12) according to Finberg HJ,[19] to 100 percent (5/5) according to Lam G Kuller, MC Mohan et al.[21] According to Chou MM et al. and Chen WC et al., 7 out of 45 patients exhibit characteristics 2D ultrasound for a placenta increta or percreta.[22] Shih JC et al. and Palacious et al. considered 3D power doppler in antenatal diagnosis of placenta accreta.[23] Timmermans et al. reviewed efficacy and safety of conservative management of an abnormally invasive placenta.[24] Conservative management like attempted forcibly ablation of placenta increta or percreta is needed to achieve a hemostasis and partial resection of adjoining organs.

Acknowledgements

  1. To Obstetric And Gynaecology Department -Dr Vrk Womens Medical College
  2. To the technicians of histopathology section Dr. Vrk Womens Medical College.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Castellucci M, Classen-Linke I, Mühlhauser J, Kaufmann P, Zardi L, Chiquet-Ehrismann R. The human placenta: A model for tenascin expression. Histochemistry 1991;95:449-58.  Back to cited text no. 1
    
2.
Pijnenborg R, Bland JM, Robertson WB, Dixon G, Brosens I. The pattern of interstitial trophoblasticinvasion of the myometrium in early human pregnancy. Placenta 1981;2:303-15.  Back to cited text no. 2
    
3.
Pijnenborg R, Robertson WB, Brosens I, Dixon G. Trophoblast invasion and the establishment of haemochorial placentation in man and laboratory animals. Placenta 1981;2:71-91.  Back to cited text no. 3
    
4.
Hoozemans DA, Schats R, Lambalk CB, Homburg R, Hompes PG. Human embryo implantation: Current knowledge and clinical implications in assisted reproductive technology. Reprod Biomed Online 2004;9:692-715.  Back to cited text no. 4
    
5.
Brosens IA. Morphological changes in the utero-placental bed in pregnancy hypertension. Clin Obstet Gynaecol 1977;4:573-93.  Back to cited text no. 5
    
6.
Meekins JW, Pijnenborg R, Hanssens M, McFadyen IR, Van Asshe A. A study of placental bed spiral arteries and trophoblast invasion in normal and severe pre-eclamptic pregnancies. BJOG: An International Journal of Obstetrics & Gynaecology 1994;101:669-74.  Back to cited text no. 6
    
7.
Zhou Y, Damsky CH, Fisher SJ. Preeclampsia is associated with failure of human cytotrophoblasts to mimic a vascular adhesion phenotype. One cause of defective endovascular invasion in this syndrome? J Clin Invest 1997;99:2152-64.  Back to cited text no. 7
    
8.
Redman CW, Sargent IL. Latest advances in understanding preeclampsia. Science 2005;308:1592-4.  Back to cited text no. 8
    
9.
Benirschke K, Driscoll SG. The pathology of the human placenta. Inplacenta. Berlin, Heidelberg: Springer; 1967. p. 97-571.  Back to cited text no. 9
    
10.
Breen JL, Neubecker RO, Gregori CA, Franklin JJ. Placenta accreta, increta, and percreta. A survey of 40 cases. Obstet Gynecol 1977;49:43-7.  Back to cited text no. 10
    
11.
Price FV, Resnik E, Heller KA, Christopherson WA. Placenta previa percreta involving the urinary bladder: A report of two cases and review of the literature. Obstet Gynecol 1991;78:508-11.  Back to cited text no. 11
    
12.
Hudon L, Belfort MA, Broome DR. Diagnosis and management of placenta percreta: A review. Obstet Gynecol Surv 1998;53:509-17.  Back to cited text no. 12
    
13.
O'brien JM, Barton JR, Donaldson ES. The management of placenta percreta: Conservative and operative strategies. Am J Obstet Gynecol 1996;175:1632-8.  Back to cited text no. 13
    
14.
Kastner ES, Figueroa R, Garry D, Maulik D. Emergency peripartum hysterectomy: Experience at a community teaching hospital. Obstet Gynecol 2002;99:971-5.  Back to cited text no. 14
    
15.
Prendergast NC, Adsay NV. Spontaneous uterine rupture with fatal hemoperitoneum due to placenta accreta percreta: A case report and review of the literature. Int J Gynecol Pathol 1999;18:82-6.  Back to cited text no. 15
    
16.
Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa–placenta accreta. Am J Obstet Gynecol 1997;177:210-4.  Back to cited text no. 16
    
17.
Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: Twenty-year analysis. Am J Obstet Gynecol 2005;192:1458-61.  Back to cited text no. 17
    
18.
Clark SL, Koonings PP, Phelan JP. Placenta previa/accreta and prior cesarean section. Obstet Gynecol 1985;66:89-92.  Back to cited text no. 18
    
19.
Finberg HJ, Williams JW. Placenta accreta: Prospective sonographic diagnosis in patients with placenta previa and prior cesarean section. J Ultrasound Med 1992;11;333-43.  Back to cited text no. 19
    
20.
Yee YH, Kung FT, Yu PC, Hsu TY, Cheng YF. Successful conservative management of placenta previa totalis and extensive percreta. Taiwan J Obstet Gynecol 2008;47:431-4.  Back to cited text no. 20
    
21.
Lam G, Kuller J, Mcmahon M. Use of magnetic resonance imaging and ultrasound in the antenatal diagnosis of placenta accreta. J Soc Gynecol Investig 2002;9:37-40.  Back to cited text no. 21
    
22.
Chou MM, Chen WC, Tseng JJ, Chen YF, Yeh TT, Ho ES, et al. Prenatal detection of bladder wall involvement in invasive placentation with sequential two-dimensional and adjunctive three-dimensional ultrasonography. Taiwan J Obstet Gynecol 2009;48:38-45.  Back to cited text no. 22
    
23.
Shih JC, Jaraquemada JP, Su YN, Shyu MK, Lin CH, Lin SY, Lee CN, et al. Role of three-dimensional power Doppler in the antenatal diagnosis of placenta accreta: Comparison with gray-scale and color Doppler techniques. Ultrasound Obstet Gynecol 2009;33:193-203.  Back to cited text no. 23
    
24.
Timmermans S, van Hof AC, Duvekot JJ. Conservative management of abnormally invasive placentation. Obstet Gynecol Surv 2007;62:529-39.  Back to cited text no. 24
    

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Correspondence Address:
Azam Begum Heena
H. NO.20.5.366, First Floor Qazipura, Shakkergunj, Hyderabad . 500 065, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_229_19

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