DEFINITION: Placental adhesion anomaly or placental invasion anomaly (placenta accreta, placenta increta, placenta percreta) means that the placenta, the partner of the baby in the womb, spreads and adheres, like a cancer, first to the uterine wall and then to neighboring organs (see Figure 1).
Figure 1. A case of placenta percreta that has spread to a large part of the uterus. Note the borders of the vagina, the bladder and the ureters, the urinary tubes from the kidneys to the bladder.
How many types of placental adhesion anomaly are there?
Placenta acreata
Placenta increata
There are 3 histopathologic types includingplacenta percreta (see Figure 2).
Figure 2. A case of placenta percreta with a large proportion of placenta percreta, all three seen together on macroscopy.
Experience: According to our experience of around 600 cases of placental adhesion anomaly between 2015 and 2024, all 3 types of this adhesion anomaly are seen in the same case, i.e. all three together (placenta acreata, increata, percreata); contrary to popular belief, due to the fact that we are a reference center, the cases that come to us are usually the more challenging cases of placenta percreata (see Figure 2).
Frequency: The frequency of placenta percreta has steadily increased, with an average of one in 300 deliveries (1/300).
To which organs does it adhere? In some cases of placenta percreta, adhesions begin when entering the abdominal cavity (see Figure 3).
Figure 3. Ultrasound image of a case of placenta percreta percreta, which has spread beyond the uterine wall (myometrium), past the serosa and even further into the entrance to the abdominal cavity.
Naturally, the uterine wall is completely invaded by the placenta, with subsequent adhesion, most commonly to the bladder (see Figure 4).
Figure 4. Ultrasound shows vascular invasion of the placenta into the bladder. Note the vascular network in the form of a mass on the underside of the bladder.
Figure 5. The vascular network in Figure 4 is clearly seen with cystoscopy. You can see the vascular network in the form of a mass in the bladder.
The placenta may have spread and adhered to thecervix and even into the vagina (see Figures 6 and 7).
The placenta can also spread to the sides of the uterus (parametrial areas), including one or both ureters (ureters) (see Figures 6 and 7).
Rarely, placenta percreta may adhere to the large intestine (we have seen 6 cases in our practice).
Figure 6. In Figure 7 you can see the uterus from behind and the cervix as if it were an eye. A case where the uterus has spread to the lower part of the cervix and the placenta has spread to the vagina.
Figure 7. A case requiring surgery up to the uterine ligaments at the upper level, to the parametrial areas including the ureters on both sides and down to the bladder and vagina at the lower level.
The most important risk factor is a previous cesarean section. If the placenta has settled on the previous cesarean section, placenta adhesion anomaly, placenta percreta, is almost inevitable. Fibroid surgeries in which the uterine wall is damaged are also a risk factor.
Curettage deep enough to damage the uterine wall can also cause placenta adhesion anomaly. Adhesion of the placenta can cause severe bleeding that can endanger the mother’s life.
Ultrasonography is 100% diagnosed by experienced specialists.
In addition to the diagnosis, our center also diagnoses the degree of placental invasion at the macroscopic level.
(Experience: Macroscopic pathology examination (see Figure 2) of an average of 600 cases of placental adhesion anomaly is our most important accumulation).
UTERINE SPARING ADVANCED PLACENTA PERCRETA SURGERY
Surgery for extensive placenta percreta is a difficult operation and there may be a risk of serious bleeding.
Contrary to the literature and conventional textbook knowledge, placenta percreta surgeries can usually be performed without bleeding or with very little blood requirement; advanced placenta percreta surgery can be successfully performed without removing the uterus. In our practice, we perform advanced percreata surgery without removing the uterus. Removal of the uterus is very rarely necessary.
Complications include excessive bleeding, damage to the bladder (urinary bladder), damage to the urethra (ureter) from both kidneys and, very rarely, damage to the large intestine. Large blood vessels can also be damaged and serious blood loss can occur. However, in experienced hands, complications are extremely rare.
Note: Only 6 cases had adhesions to the large intestine (according to our case series between 2015 and 2024). In these 6 cases, we performed the operations without damaging the intestines and without removing the uterus (uterine sparing).
Note: The placenta of each case we operated on was invaded into the mother’s bladder, i.e. completely adherent. We had 4 bladder complications between 2015-2020 and treated all of them, none of them developed permanent damage.
Thanks toour advanced percreata surgery and experience, we have not had any bladder complications since 2020.
Note: Thanks to our technique and experience, we have not given blood transfusion to any of our patients since 2020.
It is ideal to perform surgery between 34-36 weeks of pregnancy. Depending on the case, these weeks may vary slightly. We use corticosteroids for the baby’s lungs.
Aftera meticulous examination and after all precautions have been taken, usually if these pregnancies are severe premature (small for gestational age), they can be followed up a little more and the baby can be allowed to grow.
The physician who will carry out this follow-up should take full responsibility and follow-up day and night, 24 hours a day; in short, he/she should be responsible for every stage of planning.
However, if there is vaginal bleeding and uterine contraction between 34-36 weeks of pregnancy, the surgery should not be postponed and should be performed as soon as possible.
Not required.
In highly experienced hands, removal of the uterus (hysterectomy) is very rarely necessary in cases of placenta perforata. Unless the placenta has spread to the four sides of the uterus – anterior, posterior, right and left – we perform the operation without removing the uterus in 99% of cases.
The more surgeries and experience we have, the less likely the uterus will be removed and the lower the risk of complications.
Of course it is possible to conceive again.
It is possible to conceive again with advanced surgical methods. This requires very good reconstructive surgery of the uterus. We have many cases in which we have performed this type of surgery and conceived again.
In some cases, because we have removed a very large section of the uterus, because the sutures extend to the ligaments of the uterus (ligamentum rotundum) and because these patients have enough children, we advise these patients not to get pregnant again.
These patients who have not had their uterus removed have regular menstrual periods every month and enjoy the psychological advantage of not having had their uterus removed; the risk of uterine or bladder prolapse naturally does not increase.
In percreta surgery, we have been performing uterine sparing surgery since 2015.
Our number of casesbetween 2015 and 2024, which is around 600 , is our most important experience.
InJanuary 2017, we published our article on these issues and we drew attention to not removing the uterus in those years.
İsmail Özdemir, Salim Sezer, Deniz Acar, et al. Changing Trends in the Management of Placental Incersion Anomalies in a Tertiary Center: Uterus Preserving Treatment Modalities (Tersiyer Bir Merkezde Plasenta İnsersiyon Anomalileri Yönetiminde Değişen Trendler: Uterus Koruyucu Tedavi Yöntemleri). İKSST Derg 9:30-36 (2017)
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