GREGORIO, MUTYA S. MS.RHYSYL G.

MOHILLO
BSN-2B CLINICAL INSTRUCTOR

Placenta Accreta

Placenta accreta is a severe obstetric complication involving an abnormally

deep attachment of the placenta, through the endometrium and into the
myometrium (the middle layer of the uterine wall). There are three forms of
placenta accreta, distinguishable by the depth of penetration.

The placenta usually detaches from the uterine wall relatively easily, but
women who encounter placenta accreta during childbirth are at great risk of
haemorrhage during its removal. This commonly requires surgery to stem the
bleeding and fully remove the placenta, and in severe forms can often lead to
a hysterectomy or be fatal.

Placenta accreta affects approximately 1 in 2,500 pregnancies.

A. DESCRIPTION. Placenta accrete is an uncommon condition in which the

chorionic villi adhere to the myometrium. It can be exhibited as:

1. Placenta Accreta – the placental chorionic will adhere to the superficial

layer of the uterine myometrium.
2. Placenta Increta – the placental chorionic will invade deeply into the
uterine myometrium.
3. Placenta Pecreta – the placental chorionic will go through the uterine
myometrium and often adhere to abdominal structures such as the bladder
or intestine)

B. ETIOLOGY. Predisposing factors are prior uterine surgery and placenta

previa.

C. PATHOPHYSIOLOGY. Implantation in an area of defective endometrium

with no zone separation between the placenta and the myometrium.

D. ASSESSMENT FINDINGS.
1.Associated findings. Placenta accrete is usually diagnosed in the immediate
postpartum period when the placenta fails to separate.
2. Clinical manifestations
a. Placenta fails to separate
b. Profuse hemorrhage may result depending on the portion of placenta
involved.

E. NURSING MANAGEMENT
1.Identify placenta accrete in the client. Be aware of the client’s risk status.
2. Assist with rapid treatment and intervention. Be prepared for a dilation and
curettage or hysterectomy.
3. Provide physical and emotional support.
4. Provide client and family education.

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 section and hysterectomy
(surgical removal of the uterus).

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

Reference:

Ramesh Avva, Hemendra R. Shah, and Teresita L. Angtuaco. US Case of the Day.
RadioGraphics 1999 19: 1089-1092.

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Categories: GU | Ob/gyn | Uterus | Placenta

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