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

• PP (Placenta Percreta)

What is Placenta Percreta? (Definition/Background Information)

• Placenta Percreta (PP) is a potentially serious condition in pregnancy where the placenta grows into the wall of uterus too deeply. In this condition, the placenta grows through and ruptures the muscle wall of the uterus. Here, the chorionic villi invade through the uterine wall layers to rupture it
• Placenta Percreta is described as the most severe form of morbidly adherent placenta (MAP). It is a serious condition that often requires emergency treatment (hysterectomy). It can cause significant complications during delivery for both the baby and mother that can result in fatalities without adequate treatment
• There are three forms of morbidly adherent placenta (MAP), which is described as the abnormal attachment of the placenta to the uterus. The three forms include placenta accreta, placenta increta, and Placenta Percreta (which is classified as a third-degree abnormal placental attachment)
• 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 Placenta Percreta, a part or the entire placenta remains attached to the wall of the uterus after childbirth. This may lead to heavy bleeding while separation, and present severe complications
• The risk factors for Placenta Percreta 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
• Placenta Percreta can cause major 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
• In some cases, Placenta Percreta can be managed effectively, if it is diagnosed during pregnancy and treated appropriately. The condition 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
• However, the prognosis of Placenta Percreta is based on several factors, such as 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, but may be unpredictable

Who gets Placenta Percreta? (Age and Incidence)

• Placenta Percreta constitute about 5% of all morbidly adherent placenta cases and is extremely rare
• 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 Placenta Percreta? (Predisposing Factors)

The following risk factors may be observed for Placenta Percreta:

• Previous Cesarean section greatly increases the risk for Placenta Percreta
• Placenta previa during current pregnancy or in an earlier pregnancy are both major risk factors
• 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, there is a high risk for Placenta Percreta
• Women older than 35 years
• Uterine abnormalities
• Multiparity: The more the number of pregnancies, the greater is the risk
• Myomectomy procedure; a surgical procedure to remove fibroids in the uterus
• Maternal smoking
• Assisted reproductive techniques such as in vitro fertilization (IVF)
• 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 Placenta Percreta? (Etiology)

In Placenta Percreta, the placental villi extend through the complete thickness of the uterine wall. This is called transmural myometrium invasion. It is the rarest type of morbidly adherent placenta. Placenta Percreta is termed as “third-degree abnormal placental attachment”.

• It is believed to be caused due to scarring of the lining of uterus, which may have occurred from C-section or other surgeries such as fibroid removal
• In few cases, Placenta Percreta is known to occur without a history of uterine surgery

What are the Signs and Symptoms of Placenta Percreta?

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

How is Placenta Percreta Diagnosed?

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

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

• 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. In Placenta Percreta, increased AFP levels are noted
• Human chorionic gonadotropin (hCG) test: A urine/blood test to assess the levels of hCG hormone. It is used to detect pregnancy and also to detect any associated complications. Increased levels of hCG are noted in the test result
• 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 morbidly adherent placenta. 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 Placenta Percreta?

Placenta Percreta can lead to very severe complications (compared to placenta accreta and placenta increta), both for the mother and the fetus.

Maternal complications include:

• Shock
• Uterine rupture
• Blood-clotting issues, such as disseminated intravascular coagulation (DIC)
• Severe blood loss: Uncontrollable blood loss may necessitate an emergency hysterectomy procedure (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:

• Placenta Percreta can lead to early labor
• It can result in premature birth
• Intrauterine growth retardation (IUGR)
• Miscarriage
• Birth defects

How is Placenta Percreta Treated?

A prenatal diagnosis of Placenta Percreta is generally rare. Patients diagnosed with the condition may require a Cesarean section to decrease mortality and morbidity of both the fetus and the expectant mother.

The treatment 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 Placenta Percreta 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 preterm pregnancies, medications may be given to assist the fetus in maturing

How can Placenta Percreta be Prevented?

Currently, there are no definite measures available for preventing Placenta Percreta. However, the following may be observed to lower one’s risk for the same:

• As Placenta Percreta 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 Placenta Percreta, a discussion with the healthcare provider before conceiving again is highly recommended

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

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

• The severity of Placenta Percreta and the amount of blood loss that has taken place
• 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

In general, the prognosis of Placenta Percreta is poorer than that of placenta accreta and placenta increta.

Additional and Relevant Useful Information for Placenta Percreta:

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

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