PLACENTA ACCRETA

KEMATIAN IBU DI JATIM

BERDASARKAN PENYEBAB TAHUN 2010 - 2012

TAHUN 2013
 PENYEBAB KEMATIAN IBU DI RSUD DR SOETOMO TAHUN 2014
JANTUNG PE HPP LUPUS GINJAL
DM TUMOR SEPSIS HIV RUPTURA UTERI
CEDERA OTAK KANKER SUFOKASI LIVER PARU

11

10

5 5

2 2 2 2 2

1 1 1 1 1
PENYEBAB KEMATIAN IBU di SURABAYA
Periode tahun 2012 - 2015

AKI PE HPP
2012 60 18 14
2013 49 14 14
2014 39 11 11
2015 38 8 15
KEMATIAN MATERNAL
DI SURABAYA 2015

Jumlah kematian : 38
Causa mortis :
HPP = 15
 5 Plasenta akreta
 Preeklamsia = 8
PLACENTA ACCRETA
 INCIDENCE

1960’s 1970’s 1980’s 2000’s

1 : 30.000 1 : 4.027 1 : 2,510 1 : 533
deliveries ±7x ± 14 x ± 60 x
> > >

Committee opinion, Am J Obstet Gyneol 2012

RISK FACTORS
• First  3%
previous • Second  11%
cesarean
• Third  40%
delivery
+ PPT • Fourth  61%
• Fifth  67%

maternal
age &
multiparity

myometr • previous
ial tissue myomectomy
damage • curettage

Committee opinion, Am J Obstet Gyneol Reaffirmed 2014

Rac, et al. Am J Obstet Gynecol 2014
 RISK FACTORS

1. Cesarean Delivery
2. Cesarean Section
3. Operasi Sesar
4. Bedah Sesar
5. Partus Perabdominam
6. Abdominal Episiotomy
7. Others…..
 INCIDENCE CESAREAN SECTION

China 2010
50%

India 18%

WHO (World Health Organization)

“Angka SC > 15%  terlalu banyak SC yang dikerjakan.”
ANGKA SC di beberapa Negara
(1971 – 1990)
 Delivery at
Soetomo Hospital
2009 – 2012

• Caesarean rate in
US, 2012 : 32,8 % 38 %
34 %
(Births: Final Data for 2012)
30 %
• Caesarean rate at 27 %

referral hospital /
Teaching hospital :
20%
(Indonesian Ministry of
health)

Caesarean Delivery Characteristic – Dr. Soetomo Hospita;l Manggala PW., dr.- Ernawati, dr., SpOG
DIAGNOSIS
Cesarean Scar GS at Cesarean Scar
 TRIMESTER II
 Greyscale ultrasound : 95% sensitivity
and 82% positive predictive value.
 Look for…
 Loss of the retroplacental echolucent
zone (Plac-Myometrial interface)
 An irregular retroplacental echolucent
zone
 Thinning or disruption of the hyperechoic
serosa/bladder zone
 Exophytic masses invading bladder
 Abnormal placental lacunae
 TRIMESTER
LANJUT
RETROPLAC SPACE (-) UTERINE-BLADDER INTERFACE
UTERINE-BLADDER INTERFACE MYOMETRIAL THICKNESS
PLAC LACUNAR SPACES BRIDGING VEINS
 PLACENTA
ACCRETA INDEX
Placenta Accreta Index (PAI)
 Sensitivity, specificity, and positive and
negative predictive values at each PAI score

Rac, et al. Am J Obstet Gynecol 2014

 MANAGEMENT
MULTIDISCIPLINARY APPROACH :
- MFM Specialist
- Gyn Oncologist
- Anasthesiologist
- Intensivist
- Urologist
- Interventional Radiologist
- Hematologist
- Neonatologist
 PAI vs RESULTS

Placenta Accreta Index Jumlah Kejadian Plasenta

Akreta di RSDS tahun 2015

lacuna

5 3 BSC 3
4 bridging vessel
5
myometrial
8 4 thickness
plasenta anterior

AKRETA TIDAK
 MANAGEMENT

Surgical Conservative

Caesarean hysterectomy - Expectant management

- Embolisation of selective
pelvic artery
- Methotrexate therapy
- Uterus preserving
surgeries
Charlotte et al, 2011
 MANAGEMENT

 Intra-uterine balloon packing

 Uterine compression suture
 Internal iliac artery ligation
 Embolization
 SVH – TAH
 Placenta left in situ
 TIME of DELIVERY
Individualized
Decisions :
- Patient
- Obstetrician
- Neonatologist

COUNSELING :
- risks of profuse hemorrhage
- need for hysterectomy
- possible maternal death
 TAKE HOME MESSAGE
Literature review
 Average blood loss 3,000 – 5,000 mL at the time of
delivery
 Most common surgical complication cystotomy
(often intentional)
 Ureteral injury in 10 – 15% of cases
 Less common injuries to bowel, pelvic nerves and
large vessels and vesico-vaginal fistulas
 RISK FACTORS :
 Post CS

 PACENTA PREVIA

Hudon L et al: Diagnosis and management of placenta percreta: a review. Obstet Gynecol Surv 1998
MANAGEMENT ???
RUJUK SAJA……….
AMAAAAAAN………
Wkwkwk……
 Gambaran Umum Penanganan Perdarahan Postpartum
Primer Sekunder Tersier
Pemeriksaan Antenatal
Pemeriksaan Antenatal
Skrining risiko perdarahan
Skrining risiko
postpartum pada semua pasien
perdarahan postpartum
pada semua pasien
BSC + plasenta previa
Curiga Plasenta Akreta

(+), rujuk untuk persalinan

(-) Intrapartum
•Skrining risiko intrapartum
•Infus RL lifeline
Intrapartum (+)
•Manajemen aktif kala 3
•Faktor risiko intrapartum
•Partus lama
•Evaluasi perdarahan Rujuk
postpartum (Mat/underpad)
(-) (+), rujuk untuk persalinan •Misoprostol 3tab/rektal Tersier
•Observasi ketat 6 jam

Intrapartum
•Manajemen aktif kala 3 Perdarahan Postpartum
•Evaluasi perdarahan •Atasi sesuai penyebabnya
postpartum (Mat/underpad)
Tidak
Perdarahan Postpartum teratas Tidak teratasi
• Atasi sesuai penyebabnya i •Stabilisasi
MATUR
NUWUN