What are the other Names for this Condition? (also known as/Synonyms)

• MAP (Morbidly Adherent Placenta)
• Placenta Accreta Spectrum

What is Morbidly Adherent Placenta? (Definition/Background Information)

• Morbidly Adherent Placenta (MAP) may be described as the abnormal attachment of the placenta to the uterus, which can result in life-threatening bleeding and/or peripartum hysterectomy (surgical removal of uterus). It is also referred to as Placenta Accreta Spectrum
• The placenta is a thin membrane-like organ and covered with chorionic villi (tiny units of placenta) that connects the developing fetus to the uterine wall. It is a disc-shaped red-brown structure that connects the fetus to the mother through the umbilical cord
• Normally, the placenta should separate from the uterine wall after childbirth. In Morbidly Adherent Placenta, a part or the entire placenta remains attached to the wall of the uterus after childbirth. This may lead to heavy bleeding while separation
• The risk factors for the condition include age of expectant mother over 35 years, smoking during pregnancy, abnormalities of the uterus, placenta previa, surgery to remove uterine fibroids, and other invasive procedures that involve the uterus
• According to medical literature, Morbidly Adherent Placenta is categorised into the following three grades:
  • Placenta accreta: In this type, the placental villi extend beyond the endometrial lining into the superficial muscular wall of uterus (myometrium). This is called superficial invasion of the myometrium. The most common type of MAP is placenta accreta
  • Placenta increta: In this type, the placental villi extend beyond the endometrial lining into the deep muscular wall of uterus (myometrium). This is called deep invasion of the myometrium
  • Placenta percreta: In this type, the placental villi extend through the complete thickness of the uterine wall. This is called transmural myometrium invasion. Placenta percreta is the rarest and most severe form of MAP
• Morbidly Adherent Placenta can cause complications during delivery for both the baby and mother. These include severe blood loss, organ failure, and shock, for the mother; and, early labor and premature births affecting the child. The greater the depth of placental villi invasion into the uterus, the more severe are the complications
• In some cases, Morbidly Adherent Placenta can be managed effectively, if it is diagnosed during pregnancy and treated appropriately. MAP needs to be treated under the supervision of experienced clinicians at a healthcare facility that is equipped to handle such events. This may involve the removal of the uterus after early C-section
• The prognosis of Morbidly Adherent Placenta is based on several factors, such as the type of MAP, the promptness and adequacy of medical care provided, and the presence of any associated complications. The prognosis is typically assessed on a case-by-case basis. In general, placenta percreta has worse prognosis than placenta accreta and placenta increta

Who gets Morbidly Adherent Placenta? (Age and Incidence)

• Morbidly Adherent Placenta is an uncommon condition involving pregnant women
• Women of advanced maternal age, defined as being over 35 years of age, are at a greater risk for the condition
• All races and ethnic groups can be affected, and no specific predilection is noted

What are the Risk Factors for Morbidly Adherent Placenta? (Predisposing Factors)

The following risk factors may be observed for Morbidly Adherent Placenta. In some cases, more than one risk factor may be present.

• Previous Cesarean section is a key risk factor
• Placenta previa during current pregnancy or in an earlier pregnancy are both major risk factors for MAP
• If the placenta is in an abnormal position i.e. if it covers the cervix (placenta previa), or is at the lower portion of the uterus
• Uterine abnormalities
• Multiparity: The more the number of pregnancies, the greater is the risk
• Maternal age greater than 35 years
• Myomectomy procedure; a surgical procedure to remove fibroids in the uterus
• Maternal smoking
• Assisted reproductive techniques, such as in vitro fertilization (IVF), is known to increase the risk
• Asherman syndrome
• Thermic endometrial ablation
• Submucosal hysteroscopic removal
• Uterine artery embolization
• Dilatation and curettage (D & C) of the uterus

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Morbidly Adherent Placenta? (Etiology)

Morbidly Adherent Placenta (MAP) is believed to be caused due to scarring of the lining of uterus, which may have occurred from a variety of factors such as surgery or abnormalities of the uterus.

There are three types of MAP that are graded based on the severity of the condition:

• Placenta accreta is the least severe of the MAP and is termed “first degree abnormal placental attachment”
• Placenta increta is termed “second degree abnormal placental attachment”
• Placenta percreta is the most severe of the MAP and is termed “third degree abnormal placental attachment”

What are the Signs and Symptoms of Morbidly Adherent Placenta?

• In most cases, there are no symptoms of Morbidly Adherent Placenta in the early stages of pregnancy
• However, sometimes vaginal bleeding may occur during the third trimester

How is Morbidly Adherent Placenta Diagnosed?

The prenatal diagnosis of Morbidly Adherent Placenta is generally difficult. It is often diagnosed during a Cesarean section, while removing the placenta. The placenta is difficult to remove, consequently resulting in excessive bleeding.

The following tests and examinations may be performed to diagnose Morbidly Adherent Placenta:

• Physical examination to evaluate for vaginal bleeding
• Evaluation of medical history including history of earlier pregnancies
• Complete blood count (CBC) and other blood tests as needed
• Alpha fetoprotein (AFP) blood test in pregnancy, to determine the apparent risk for certain congenital abnormalities
• Human chorionic gonadotropin (hCG) test: A urine/blood test to assess the levels of hCG hormone. It is used to detect pregnancy and any associated complications
• Fetal monitoring to assess the fetal heart and for any lack of oxygen
• Abdominal or vaginal ultrasound scan, wherein sound waves are used to create an image of the uterus and placenta on a monitor screen
• MRI scans can evaluate how deeply the placenta is implanted in the uterine wall
• 3D Doppler ultrasound scan is very helpful in establishing a diagnosis of MAP. When combined with imaging studies from an MRI scan, the results can help in differentiating between placenta accreta, placenta increta, and placenta percreta

A definitive diagnosis is made by examining the placenta and uterus (if a hysterectomy procedure is performed). 

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Morbidly Adherent Placenta?

Morbidly Adherent Placenta can lead to complications for both the mother and the fetus.

Maternal complications include:

• Shock
• Blood-clotting issues, such as disseminated intravascular coagulation (DIC)
• Blood loss: Uncontrollable blood loss may necessitate a hysterectomy (a surgical procedure to remove the uterus)
• Need for blood transfusion
• Kidney failure; failure of other organs
• Excess loss of blood may sometimes lead to fatalities

Complications involving the fetus:

• Morbidly Adherent Placenta can lead to early labor
• Intrauterine growth retardation (IUGR)
• It can result in premature birth

How is Morbidly Adherent Placenta Treated?

Patients diagnosed with Morbidly Adherent Placenta may have to undergo a Cesarean section to decrease mortality and morbidity of both the fetus and the expectant mother.

A prenatal diagnosis of Morbidly Adherent Placenta is generally rare. The treatment of MAP may involve the expertise of a multidisciplinary team of healthcare professionals, and may have to be availed in a healthcare facility of repute having the following capabilities:

• Intensive care unit for babies (neonatal ICU)
• Prophylactic hypogastric artery balloon occlusion
• Uterine artery embolization
• Adequate blood units for potential blood transfusion

The treatment of Morbidly Adherent Placenta may involve the following:

• Fluid administration through the veins
• Blood transfusion
• Cesarean section (C-section) may be required, as opposed to a vaginal delivery
• Uncontrollable blood loss may necessitate a hysterectomy (removal of the uterus). Emergency peripartum hysterectomy may be necessary
• In some cases, conservative measures such as dilatation and curettage (D & C) may be attempted
• Ligation procedures, such as uterine artery ligation, may be considered to save the uterus, in case of severe postpartum bleeding
• In preterm pregnancies, medications may be given to assist the fetus in maturing

How can Morbidly Adherent Placenta be Prevented?

Currently, there are no definite measures available for preventing Morbidly Adherent Placenta. Adequate prenatal care may help in early detection of the condition and planning delivery options.

The following may be observed to lower one’s risk for MAP and associated complications:

• As Morbidly Adherent Placenta is associated with a prior C-section or surgery of the uterus, being aware of the risk factors may help prevent potential complications
• It is important to seek out a healthcare provider towards prenatal care early, in order to completely monitor the course of the pregnancy
• If there is history of Morbidly Adherent Placenta, a discussion with the healthcare provider before conceiving again is highly recommended

What is the Prognosis of Morbidly Adherent Placenta? (Outcomes/Resolutions)

The prognosis of Morbidly Adherent Placenta varies and depends on several factors including:

• The type/grade of MAP - whether it is placenta accreta, placenta increta, or placenta percreta. In general, the outcome for placenta percreta is much worse than that of placenta increta and placenta accreta. Comparatively, placenta accreta has the best outcome
• The amount of blood loss noted
• Timeliness of medical attention; the sooner the condition is recognised, with appropriate treatment, the better is the prognosis
• Development of maternal and/or fetal complications

A diagnosis of MAP during pregnancy greatly helps decrease the mortality and morbidity in both the fetus and the mother. Hence, early prenatal diagnosis is critical, when possible.

In a vast majority of pregnant women, a diagnosis of Morbidly Adherent Placenta is not established during the antenatal period. Hence, treatment can be difficult, since not all healthcare facilities are equipped with the capabilities to handle MAP and its associated complications.

Additional and Relevant Useful Information for Morbidly Adherent Placenta:

The following DoveMed website link is a useful resource for additional information:

https://www.dovemed.com/diseases-conditions/pregnancy-related-disorders/