Latar belakang dan Patogenesis

Kelainan Spektrum Plasenta Akreta

Yudianto Budi Saroyo
Divisi Fetomaternal Departemen Obstetri dan Ginekologi
RSUPN Cipto Mangunkusumo
Fakultas Kedokteran Universitas Indonesia
 Placenta accreta spectrum (PAS)
• Placenta accreta is a histopathologic term for a condition first described in
1937 by obstetrician Frederick C. Irving and pathologist Arthur T. Hertig at
the Boston Lying-In Hospital. Their study described 18 new cases of
placenta accreta presenting with “the abnormal adherence of the
afterbirth in whole or in parts to the underlying uterine wall
• Placenta accreta spectrum is the general term applied to abnormal
adherence of the placental trophoblast to the uterine myometrium; it is
also referred to as morbidly adherent placenta

Silver RM, Branch DW. Placenta Accreta Spectrum. N Engl J Med. 2018;378(16):1529-36
Jauniaux E, Ayres-de-Campos D, Diagnosis FPA, Management Expert Consensus P. FIGO consensus guidelines on placenta accreta spectrum
disorders: Introduction. Int J Gynaecol Obstet. 2018;140(3):261-4.
 Placenta Accreta, Increta, and Percreta
PAS disorders were first defined by Luke et al. to include both
abnormally adherent and invasive placentas. Three categories
are now considered:
(1) adherent placenta accreta, also described by pathologists as
“placenta creta, vera or adherenta” when the villi simply adhere
to the myometrium; Placenta accreta (attachment of the
placenta to myometrium without intervening decidua),
(2) placenta increta, when the villi invade the myometrium; and
(3) placenta percreta, when villi invade the full thickness of the
myometrium including the uterine serosa and sometimes
adjacent pelvic organs.
Variations in the lateral extension of myometrial invasion also
divide PAS disorders into the focal, partial, or total categories,
depending on the number of placental cotyledons involved.

Silver RM, Branch DW. Placenta Accreta Spectrum. N Engl J Med. 2018;378(16):1529-36
Jauniaux E, Ayres-de-Campos D, Diagnosis FPA, Management Expert Consensus P. FIGO consensus guidelines on placenta accreta spectrum
disorders: Introduction. Int J Gynaecol Obstet. 2018;140(3):261-4.
 Photomicrograph of the utero-placental

Photomicrograph of the utero-placental interface of a placenta accreta at term. The

villous tissue invades deeply (arrow) into the myometrium (H&E 60).
Jauniaux E, Jurkovic D. Placenta accreta pathogenesis of a 20th century iatrogenic uterine disease. Placenta. 2012
Apr;33(4)244-51.
 Angka Kejadian di Dunia

Kejadian Plasenta Akreta

1932: Irving et al: 1/30.000

2005: Wu er al: 1/533
2010: Irish study:3.37/1000 Hx CS

Peningkatan angka Seksio sesaria di SELURUH

DUNIA

Wu S, Kocherginsky M, Hibbard JU. Abnormal placenta on: Twenty- year analysis. Am J Obstet Gynecol. 2005;192:1458–1461.
 Estimates of prevalence of placenta accreta
spectrum in different types of population studies
Median prevalence, %
Type of study I2,%
(95% confidence interval)
All studies (n=29) 0.15 (0.13-0.17) 99.4
Retrospective studies (n=22) 0.18 (0.15-0.21) 99.5
Prospective studies (n=7) 0.09 (0.07-0.11) 98.5
Institution studies (n=21) 0.16 (0.13-0.20) 98.9
Network studies (n=2) 0.17 (0.15-0.19) —
Regional studies (n=2) 0.19 (0.19-0.20) —
a
National/international studies (n=4) 0.17 (0.13-0.22) 99.5

Jauniaux E, Bunce C, Gronbeck L, Langhoff-Roos J. Prevalence and main outcomes of placenta accreta
spectrum: a systematic review and meta-analysis. Am J Obstet Gynecol. 2019;221(3):208-18
 Changes in cesarean delivery rate and placenta accreta
spectrum (PAS) disorder prevalence over time.
Country Cesarean delivery Cesarean delivery PAS disorders PAS disorders
Author Type of study of rate period A rate period B period A (years) period B (years)
origin (years) (years)
a
Wu et al. (2005) Matched case– USA 12.5% (1982) 23.5% (2002) 0.38 per 1000 1.88 per 1000
control study births (1982) births (2002)
Higgins et al. Cohort study Ireland 4.1% (1975) 20.7% (2010) 1.65 per 1000 2.37 per 1000
b
(2013) births after prior births after prior
cesarean (2003) cesarean (2010)
Morlando Cohort study Italy 17% (1970s) 64% (2000s) 1.20 per 1000 3.11 per 1000
c
et al. (2013) births after prior births after prior
cesarean (1976– cesarean (2000s)
1978)
Cheng and Lee Cohort study Hong 19.5% (1999–2003) 27.1% (2009– 0.17 per 1000 0.79 per 1000
d
(2015) Kong 2013) births after prior births after prior
cesarean caesarean (2009–
(1999–2003) 2013)

Jauniaux E, Chantraine F, Silver RM, Langhoff-Roos J, Diagnosis FPA, Management Expert Consensus P. FIGO consensus
guidelines on placenta accreta spectrum disorders: Epidemiology. Int J Gynaecol Obstet. 2018;140(3):265-73.
 Primary and secondary uterine pathologies reported to be
associated with placenta accreta spectrum (PAS) disorders

Classification Type of uterine pathologies

Direct surgical scar Cesarean delivery Myomectomy
Surgical termination of pregnancy Endometrial resection
Dilatation and curettage Asherman’s syndrome
Nonsurgical scar IVF procedures Intra-uterine device
Uterine artery embolization Manual removal of placenta
Chemotherapy and radiation Previous accreta
Endometritis
Uterine anomalies Bicornuate uterus Submucous fibroids
Adenomyosis Myotonic dystrophy

Jauniaux E, Chantraine F, Silver RM, Langhoff-Roos J, Diagnosis FPA, Management Expert Consensus P. FIGO consensus
guidelines on placenta accreta spectrum disorders: Epidemiology. Int J Gynaecol Obstet. 2018;140(3):265-73.
 Distribution of the different grades of placenta accreta spectrum (PAS) disorders in older
case series and more recent cohorts of women with a prenatal diagnosis
Total no. of No. of placenta No. of placenta No. of placenta
Author (year)
cases creta increta percreta
Luke et al. (1966) 21 14 7 0
Weekes et al. (1972) 7 6 0 1
Breen et al. (1977) 40 31 7 2
Morison et al. (1978) 50 31 14 5
Total case series (%) 118 82 (69.5%) 28 (23.7%) 8 (6.8%)
Twickler et al. (2000) 9 3 2 4
Comstock et al. (2004) 15 8 3 4
Woodring et al. (2011) 10 8 1 1
Lim et al. (2011) 9 5 3 1
Cali et al. (2013) 41 15 9 17
Maher et al. (2013) 42 28 13 1
Riteau et al. (2014) 26 16 0 10
Algebally et al. (2014) 32 16 12 4
Satija et al. (2015) 10 3 4 3
Kumar et al. (2016) 9 1 2 6
Total cohorts with a prenatal diagnosis (%) 203 103 (50.7%) 49 (24.2%) 51 (25.1%)

Jauniaux E, Chantraine F, Silver RM, Langhoff-Roos J, Diagnosis FPA, Management Expert Consensus P. FIGO consensus
guidelines on placenta accreta spectrum disorders: Epidemiology. Int J Gynaecol Obstet. 2018;140(3):265-73.
 Risk of Abnormal Placentation by Number
of Previous Cesarean Deliveries
Abnormal Placentation %
Previous Cesarean Deliveries
(n =143)
None 0,2
One 0,3
Two 0,6
Three 2,3
Four 2,3
Five or More 6,7

Silver RM, Landon MB, Rouse DJ, et al: Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet
Gynecol 107:1226-1232, 2006. In :Bauer ST, Bonanno C. Abnormal Placentation. Semin Perinatol. 2009;33:88-96
 Risk of Abnormal Placentation by Number
of Previous Cesarean Deliveries
Previous Clark 1985 MFMU 2006
Cesarean Previa–Accreta % Previa–Accreta %
Deliveries (n = 29) (n = 91)
None 5 3,3
One 24 11
Two 47 40
Three 40 61
Four or More 67 67

Silver RM, Landon MB, Rouse DJ, et al: Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol
107:1226-1232, 2006.
Clark AL, Koonings PP, Phelan JP: Placenta previa/accreta and prior cesarean section. Obstet Gynecol 66:89-92, 1985. In :Bauer
ST, Bonanno C. Abnormal Placentation. Semin Perinatol. 2009;33:88-96
 Risiko Plasenta Akreta dan Histerektomi
berdasarkan Jumlah Bedah Sesar yang dijalani

No. of Cesarean
Accreta, n (%) OR (95% CI) Hysterectomy, n (%) OR (95% CI)
Deliveries
First 15 (0.2) — 40 (0.7) —
Second 49 (0.3) 1.3 (0.7–2.13) 67 (0.4) 0.7 (0.4–0.97)
Third 36 (0.6) 2.4 (1.3–4.3) 57 (0.9) 1.4 (0.9–2.1)
Fourth 31 (2.1) 9.0 (4.8–16.7) 35 (2.4) 3.8 (2.4–6.0)
Fifth 6 (2.3) 9.8 (3.8–25.5) 9 (3.5) 5.6 (2.7–11.6)
≥6 6 (6.7) 29.8 (11.3–78.7) 8 (9.0) 15.2 (6.9–33.5)

Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet
Gynecol 2006;107(6);1229
 Rates of placenta accreta spectrum (PAS) disorders,
placenta previa, and hysterectomy by number of
previous cesarean deliveries
No. of Rate of PAS
No. of Incidence of PAS No. of
previous disorders if
women disorders hysterectomies
cesareans placenta previa
0 6201 15 (0.24%) 3% 40 (0.65%)
1 15 808 49 (0.31%) 11% 67 (0.42%)
2 6324 36 (0.57%) 40% 57 (0.9%)
3 1452 31 (2.13%) 61% 35 (2.4%)
4 258 6 (2.33%) 67% 9 (3.49%)
5 89 6 (6.74%) 67% 9 (8.99%)

Jauniaux E, Chantraine F, Silver RM, Langhoff-Roos J, Diagnosis FPA, Management Expert Consensus P. FIGO consensus
guidelines on placenta accreta spectrum disorders: Epidemiology. Int J Gynaecol Obstet. 2018;140(3):265-73.
 Recommendations for the evaluation of epidemiological data
on placenta accreta spectrum (PAS) disorders
Quality of evidence and strength of
Recommendations Resource settings
recommendation
The recent increase in the incidence and prevalence of PAS disorders is a
All High and Strong
consequence of the rise in cesarean deliveries over the last two decades
A cesarean delivery scar increases the risk of placenta previa in subsequent
All High and Strong
pregnancies
A myomectomy scar increases the risk of PAS disorders in subsequent
High Low and Weak
pregnancies
Minor surgical procedures such as uterine curettage can lead to PAS disorders in
All Low and Weak
subsequent pregnancies
Women with a previous history of cesarean delivery presenting with a low-lying
placenta or placenta previa in the second trimester of pregnancy have become All High and Strong
the largest group of women with the highest risk of PAS disorders
Women should be informed that their risk of PAS disorders increases with each
All High and Strong
cesarean delivery
Women who request a pre-labor elective cesarean delivery should be informed
that their risk of developing PAS disorders is higher than after High Low and Weak
emergency/emergent cesarean delivery
Women presenting with cesarean scar pregnancy in the first trimester of
pregnancy should be informed of the high risk of invasive placentation and/or
High Moderate and Strong
major placenta previa later in pregnancy and should be offered the option of
terminating the pregnancy
The use of standardized protocol and terminology for both the clinical diagnosis
and histopathological confirmation of PAS disorders is essential to obtaining new All High and Strong
and more accurate epidemiological data
Jauniaux E, Chantraine F, Silver RM, Langhoff-Roos J, Diagnosis FPA, Management Expert Consensus P. FIGO consensus guidelines on placenta
accreta spectrum disorders: Epidemiology. Int J Gynaecol Obstet. 2018;140(3):265-73.
ICTEC 2018 15
 Diagram of normal and accreta placental cotyledons
A. Normal B. Increta

Placental cotyledon in A, normal and B, increta placentation reaching deep myometrial

circulation. Note distortion of normal cotyledon anatomy in increta placentation with
loss of intercotyledon septa and formation of lacuna (L).
Jauniaux E, Collins S, Burton GJ. Placenta accreta spectrum: pathophysiology and evidence-based anatomy for
prenatal ultrasound imaging. Am J Obstet Gynecol. 2018;218(1):75-87
 Histological view of increta villous tissue

Microscopic view of placental bed from hysterectomy specimen at 34 weeks in pregnancy

complicated by placenta previa increta (hematoxylin-eosin stain X4) showing disruption
of decidua (D) by placental villi (PV) and very thin myometrium (M).
Jauniaux E, Collins S, Burton GJ. Placenta accreta spectrum: pathophysiology and evidence-based anatomy for
prenatal ultrasound imaging. Am J Obstet Gynecol. 2018;218(1):75-87
 Histological changes in the decidual layer
with advancing gestation

Microscopic views of placental bed from hysterectomy specimens with placenta in situ (Boyd Collection, Center
for Trophoblast Research, University of Cambridge, Cambridge, United Kingdom). A, Specimen H1094 crown
rump length (CRL) 73 mm showing thick decidua (D) between placental villi (PV) and myometrium (M)
(hematoxylin-eosin stain X2.5). B and C, Specimen H751 CRL 260 mm. D is much thinner (hematoxylin-eosin
stain X2.5) and absent in some areas (reticulin X10). Scale bar = 0.5 mm (A and B) or 0.1 mm (C).

Jauniaux E, Collins S, Burton GJ. Placenta accreta spectrum: pathophysiology and evidence-based anatomy for
prenatal ultrasound imaging. Am J Obstet Gynecol. 2018;218(1):75-87
 Pathogenesis of abnormal invasion of the placenta

Pinas-Carrillo A, Chandraharan E. Management of morbidly adherent placenta. Obstetrics, Gynaecology & Reproductive
Medicine. 2016; 26(10):283-90.
 Hilangnya mekanisme pencegahan
kedalaman invasi trofoblas

Perlukaan Desidua Basalis Lingkungan Hipoksik (rendah PO2)

Invasi Trofoblas kedalam
Mengapa bisa terjadi? miometrium

Akreta Inkreta Perkreta

Neovaskularisasi dan sumber perdarahan abnormal

(A. Vesikalis, A. Vaginalis, A. Pudenda)
Pendarahan ante dan post partum
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Terima Kasih