Placenta Accreta, Increta, Pancreta

Placenta Accreta, Increta, Pancreta

Definition

Placenta Accreta is an intrapartum complication characterized by the abnormal implantation of the placenta. Normally, chorionic villi attaches to the uterine endometrium. With this complication, the point of attachment extends to the layers of myometrium.

Review of Related Anatomy and Physiology

Uterus, the pear-shaped hollow muscular organ, houses the fetus until delivery. This structure has three layers namely: the perimetrium, myometrium and endometrium.

• Perimetrium – the outermost layer that covers the uterus. (“Peri” means outside)
• Myometrium – located at the middle part of uterus. “Myo” denotes muscle, thus, this layer contains thick muscular layers.
• Endometrium – the innermost layer that responds to hormonal variations (estrogen and progesterone) during the menstrual cycle. The chorionic villi (finger-like projections that attaches to the uterine wall) penetrates into this portion of the uterus during implantation. (“Endo” means inside)

In a female reproductive cycle, the uterine endometrium normally sloughs off the thickened vascular surface that precedes the actual secretion of blood flow. With fertilization, it continues to be crammed with blood to accommodate and nourish the embryo. Following this condition, uterine endometrium is now calleddecidua, which has three separate areas:

• Decidua Basalis – point of attachment between the maternal vessels and trophoblast (structure that forms the placenta and membrane). Lies under the embryo. (To remember easily Basalis comes the word  “base” meaning “under/below”)
• Decidua Capsularis – part of endometrium that expands and encapsulates the implanted trophoblast. .(To remember easily Capsularis comes the word  “capsule” meaning  “to enclose/above”)
• Decidua Vera (Parietalis) – remaining portion of the uterine endometrium.  (To remember easily Parietalis comes the word  “parietal” meaning “wall of a hollow organ”)

Types of Placenta Accreta

This obstetric complication is categorized depending on the depth of its attachment:

• Placenta Accreta – chorionic villi attaches deeply into the uterine wall but does not penetrate the myometrium. This is the most common form of the condition. (Accreta starts with letter A, so it Attaches)
• Placenta Increta – chorionic villi invades or infiltrates the muscular layer. (Increta starts with letter I, so itInvades/Infiltrates)
• Palcenta Pancreta/Percreta – chorionic villi penetrates beyond the myometrium into the entire uterine wall and possibly to other adjacent organs such as the bladder. This is the least common of the three conditions. (Pancreta starts with letter P,so it Penetrates)

Pathophysiology

Predisposing Factors

1. Scarring of tissues from previous infection
2. Previous uterine surgery (Dilation and Curettage, Cesarean Section, Myomectomy)
3. Thin decidua or absent deciduas basalis
4. Presence of tumor

Signs and Symptoms

Usually signs and symptoms are not detected until labor and delivery. However, for some third trimester bleeding would be noted.

During labor and delivery massive bleeding is observed. In cases when deciduas basalis is absent, the placenta will not loosen and fails to be delivered.

Complications

• Uterine rupture
• Massive bleeding
• Disseminated intravascular coagulation (DIC)

Diagnostic test

• Ultrasound
• MRI

Medical Management

Conservative treatment is done if the woman wants to maintain her fertility under the condition that no active bleeding is present. This treatment saves the uterus but poses higher risk of complications and low successful rate. Techniques for this treatment are as follows:

• The placenta is left in the uterus and the cord is ligated.
• Closure of the uterus is performed.
• Methotrexate (an antineoplastic agent) is usually given to the woman to destroy the still attached placenta.

Women taking Methotrexate should be monitored for:

• WBC and platelet count (thrombocytopenia and leucopenia may occur 7-14 days after the initiation of treatment)
• Blood Urea Nitrogen (BUN), Creatinine, and urine pH (should be above 7.0)
• Presence of dry and nonproductive cough may be an early sign of pulmonary toxicity
• Symptoms of gout must be assessed frequently (increased uric acid, joint pain, edema). Methotrexate causes increase serum uric acid. Allopurinol may be given to decrease uric acid levels.

After the techniques are implemented, prophylactic antibiotic is started to prevent infection.  Follow-up includes frequent or daily ultrasound sessions to monitor uterine involution and placental condition.

Surgical Management

Early detection of placenta accreta will prevent serious complication. The safest modality is a planned cesarean sectionand hysterectomy (surgical removal of the uterus).

Nursing Management

1. Obtain a detailed obstetric history.
2. Assist with modalities implemented.
3. For clients taking Methotrexate, instruct the woman to increase fluid intake to at least 2 L each day as uric acid formation is increased with the drug use.
4. Provide emotional support to the woman and family.

Possible Nursing Diagnosis

Diagnosis of Placenta accrete with a massive blood loss is an emergency; objective should consider the brief time frame of the emergency condition.

1. Impaired tissue integrity R/T deep attachment of the placenta
2. Fear R/T pregnancy outcome secondary to placenta accrete
3. Grieving, dysfunctional R/T loss of a body part after hysterectomy

image from embryology.med.unsw.edu.au, picsdigger.com