Placenta accreta is associated with :

Ans. :D.)All of the above: a, b and c i.e. Placenta pre; Uterine scar and Multipara.Placenta accreta It is a type of morbidly adherent placenta, where the placenta is firmly adherent to the uterine wall due to paial or total absence of the decidua basalis and the fibrinoid layer (Nitabuch layer). The main aetiology is defective decidua formation.Pathological findingsAbsence of decidua basalisAbsence of Nitabuch's fibrinoid layerVarying degree of penetration of the villi into the muscle bundle.Classification / variants :Placenta accreta - chorionic villi are attached to the superficial myometrium.Placenta increta - villi invade the myometrium.Placenta percreta - villi penetrate the full thickness myometrium up to the serosal layer.Risk factors:An impoant risk factor for placenta accreta is placenta pre in the presence of a uterine scar.Additional repoed risk factors for placenta accreta include maternal age and multiparity, other prior uterine surgery, prior uterine curettage, uterine irradiation, endometrial ablation, Asherman syndrome, uterine leiomyomata, uterine anomalies, hypeensive disorders of pregnancy, and smoking.Other risk factors include low-lying placenta, anterior placenta, congenital or acquired uterine defects (such as uterine septa), leiomyoma, ectopic implantation of placenta (including cornual pregnancy).Pregnant people above 35 years of age who have had a Caesarian section and now have a placenta pre overlying the uterine scar have a 40% chance of placenta accretaPrior to delivery : presumptive diagnosis made byTransvaginal sonography - absence of the subplacental sonoluscent zone(which represents the normal decidua basalis) indicates a placenta accrete.Doppler imagingMRIComplications:Antepaum haemorrhage (due to associated placenta pre)Uterine rupture before labour (due to myometrial invasion by placental villia at the site of previous C- section scar.Postpaum haemorrhageInfectionInversion of uterus (rare).ManagementIn paial morbid adherent placenta In total placenta accretaRemoval of placental tissue in piecemealThe uterus should be actively contracting.deg (So GA is not used)Oxytocics should be used for this purposeHemostasis should be maintainedComplications :- Shock- Infection- Rupture uterusIf female has completed her family HysterectomyIf female has not completed her family Conservative approach :Cut the umblical cord as high as possible & leave the placenta as such. This is now the most recommended approach. The patient should be given antibiotics & methotrexate in hope of autolysis. R hCG