Emerging of Abnormally invasive

placenta (AIP):
SURABAYA Experience & new strategies in AIP

“The A TEAM”
Maternal Fetal Medicine Div.
Obstetric & gynecology department
Dr. soetomo general hospital, Universitas
Airlangga
Surabaya, Indonesia
 Introduction

• The incidence of placenta accreta or Abnormally

Invasive Placenta (AIP) increases
• Placenta accreta is a 20th century iatrogenic disease
• The main cause is cesarean scars
 World Cesarean Section Rate
“Abdominal
1994-2002 :
episiotomy” era??
1 in 2000-2500

Placenta
Acreta

Cesarean Scar
Pregnancy 1980 : 0,8 in 1000 2010 : 3 in 1000
 Post Partum Hemorrhage
in Dr. Soetomo Hospital
7.0%

6.0% 5.9%
5.0%
4.7%
4.0%
3.4% HPP
3.0%
2.6% 2.8%
2.0%

1.0%

0.0%
2012 2013 2014 2015 2016
Causative of Post Partum Hemorrhage In
Dr. Soetomo General Hospital
70.0%
66.2%
60.0% Morbidly adherent
placenta
50.0%
46.4%
Tone
40.0%
28.6% 39.2% Tissue
30.0%
Trauma
17.6%
20.0% 25.0% Thrombin
14.0%
10.0% 14.9%
6.8%
0.0% 0.0%
0.0%
2.3% 1.4%
2012 2013 2014 2015 2016
 Incidence of abnormally
invasive placenta
(2013 – May 2018)
5%
4%

2%

1%
0% 0%

2013 2014 2015 2016 2017 MAY-18

1 case 4 cases 7 cases 24 cases 60 cases 29 cases

Still on going
 Learning curve

5%
4%

2%

1%
0% 0%

2013 2014 2015 2016 2017 MAY-18

Feb 2015 Oct 2016 Nov 2017

 Learning curve

4 maternal death in
Surabaya → 3 death due 5%
4%
to AIP

1st Symposium of Invasive and

Adherent Placenta (SIAP)2%

1%
0% 0%

2013 2014Feb 2015

2015 2016 2017 MAY-18

Total maternal death

in Surabaya due to
AIP = 5 (in 2015)
 Learning curve

Referral with AIP case was increase

5%
4%
Almost Routinely Hysterectomy
2 maternal death with AIP
Complication → 30,4%
2%
3 cases Left Placental In situ
1%
1 case succeed after 1,5 year follow up
0% 0%

2013 2014 2015 Workshop 2017

2016 of PlacentaMAY-18
Accreta in
APCMFM, Penang Malaysia
Feb 2015 Oct 2016
 Learning curve

Surabaya Modified Procedure for

Uterine Conservation in AIP 4% 5%
(SUMPUC)

2%

1%
0% 0%

2013 2014 2015 2016 2017 MAY-18

Nov 2016
Aryananda R, Cininta N, Wardhana MP, Gumilar KE, Akbar A, Wicaksono B, et
al. 2017. Surabaya modified procedure for uterine conservation (SuMPUC) in
morbidly adherent placenta. J. Obstet. Gynaecol. Res. Vol. 43, No. S1: 56–82, June 2017
 MATERNAL DEATH IN
PLACENTA ACCRETA

• 1 case with left

5%
4% placental insitu
→ sepsis from
other city
• 1 case with
2% post
hysterectomy in
• 1 case 1% other hospital
0% Internal
0% with
Bleeding uncontrolled
2013 2014
• 1 case Post 2015 2016 2017 MAY-18
bleeding
CS and • 2 cases with
referred sudden and
with active
2 4
massive vaginal
bleeding bleeding
 Our first series (9 patients) → November – February 2017

Duration of
Result Surgery
Patient Previous GA Implantation
Age Gravida from (incision- Blood loss
No. CS (Week) (S1/S2)*
surgery skin closed)-
min
1 23 3 1 37 Increta S1 90 1500
2 mean
The 33 estimated
3 2 loss during
blood 35 Percreta was 1533
surgery S1 cc (± 540100
cc) 2000
3 mean
The 34 duration
3 2
of surgical 36
procedure Increta S1
was 86,67 minute (± 15,860minute) 1600
4 36 2 1 26 Percreta S1 70 1000
5 35 4 3 36 Percreta S2 100 2000
6 36 3 2 40 Increta S1 70 1000
7 35 2 1 36 Percreta S1 100 2500
8 36 3 2 36 Percreta S1 90 1000
9 37 3 1 32 Percreta S1 100 1200

Aryananda R, Cininta N, Wardhana MP, Gumilar KE, Akbar A, Wicaksono B, et al. Surabaya
modified procedure for uterine conservation (SuMPUC) in morbidly adherent placenta. J.
Obstet. Gynaecol. Res.Vol. 43, No. S1: 56–82, June 2017
 PROBLEMS – 1

6 cases was failed in conservative surgery –

SuMPUC
PARAMETRIUM CERVICAL
IMPLANTATION INVASION

S2 UTERINE SEGMENT
OF VASCULAR
INVOLVEMENT
 Problem – 2 (the disaster)

Diffuse AIP

Massive collateral uterine blood supply

Massive Adhesion and invasion

Different Approach
 Learning curve
2nd Symposium of Invasive and Adherent Placenta (SIAP2)
Attended by 14 Medical Center in Indonesia
Improve in Detection and Referral system (secondary
hospital level)
5%
Improve Ultrasound Placental and vascular
4% Mapping
(tertiary hospital level)

Improve Surgical Technique (tertiary hospital level)

2%
Make Recommendation (secondary and tertiary hospital
level)
1%
0% 0% The Accreta Team Declaration
“The A Team”
2013 2014 2015 2016 2017 MAY-18

Nov 2017
 S1 segment comprises the body
of the uterus

S2 segment corresponds to the

lower uterine segment, cervix,
upper part of the vagina and the
respective parametria.

Palacios-Jaraquemada JM, et al. A Comprehensive Textbook of Postpartum Haemorrhage 2012, 2nd edition.
Dumfriesshire, Scotland: Sapiens Publishing; p.19.
 Placental mapping

Placental Topography Invasion Placental diffuse or focal S1/S2 uterine segment

Placental invasion to other organ Vascular involvement

 PREOPERATIVE
CLASSIFICATION
 Focal → less than 50% uterine surface of placental
invasion
 Diffuse → more than 50% uterine surface of placental
invasion

Uterine anterior surface

Placental invasion surface

 Maternal Outcome in Focal Invasion (2013 – May 2018)
Hysterectomy Uterine Conservative p
(n = 28) surgery (n = 60)
Age (Median)* 35 (26-41) y.o 33 (22-43) y.o 0.030
GA in diagnosis (median)** 35 34 0.514
GA in surgery (Median)** 36 36 0.541
Number of CS
1 CS 50% (14) 63.3% (38)
2 CS 50% (14) 36.7% (22)
History of Termination of 35.7% (10) 20% (12)
pregnancy (TOP)
Haemorrhagic (median)** 2900 (400-8500) 1450 (200-4000) cc 0.000
Complication
Reopen/ resurgery 3.6% (1) -
Bladder injury 14.3% (4) 5% (3)
Vascular injury 3.6% (1) 1.7% (1)
Uterine atony 0 10% (6)
Major Implantation
Accreta 14.3% (4) 38.3% (23)
Increta 42.9% (12) 45% (27)
Percreta 42.9% (12) 16.7% (10)
*independent T test
**Mann whitney U test
 66 case series of conservative
surgery in placenta accreta
spectrum disorder

9.1% 6 cases failed :

1. Diffuse placental
invasion
2. Parametrial invasion
3. Posterior invasion
90.9% 4. Cervical invasion
5. Majority S2 uterine
vascular involvement

Berhasil Gagal
 Total hysterectomy with Aortic Clamp with p
internal iliac ligation (n = Modified Hysterectomy (n
16) = 14)
Age (Median)* 33 (25-41) 36 (28-42) 0.165
GA in diagnosis 33 (24-38) 32 (25-39) 0.897
(median)*
GA in surgery 34 (24-38) 34 (25-39) 0.650
(Median)*
Number of CS
1 CS 43.8% (7) 57.1% (8)
2 CS 56.2% (9) 42.9% (6)
History of 43.8% (7) 50% (7)
Termination of
pregnancy (TOP)
Haemorrhagic 8681.25 ( 5568.87) 2457.14 ( 1460.09) 0.000
(mean)*
Complication
Bladder/ urinary 6 5
tract injury
Vascular injury - -

Major Implantation

Accreta - -
Increta 6.3% (1) 14.3% (2)
Percreta 93.7% (15) 85.7% (12)
*independent T test
 VASCULAR Collateral system

MORE COMPLEX

Upper Uterine Artery 100% from Iliac Internal Artery

pedicle
Middle Cervical Artery 67% from Uterine Artery
pedicle 23% from Vaginal artery
10% lower Vesical artery
Lower Upper vaginal artery
pedicle → 18% from Uterine Artery
Middle vaginal artery
→ 11% from Iliac Internal Artery
Lower vaginal artery
→ 71% from Pudendal Internal 75% as as descending branch
artery 25% as ascending branch
 IMPROVE SURGICAL TECHNIQUE

Focal AIP Diffuse AIP

Placental Invasion <50% from Placental Invasion >50% from

uterine surface uterine surface

+
1. SuMPUC with modification Parametrial invasion
2. One step conservative Cervical invasion
surgery by Prof Palacios Massive adhesion and invasion

Temporary Aortic Clamp

and followed by :
1. Total Hysterectomy
2. Retrograde Hysterectomy
3. Pelosi Manouver

The “A” Team

 WHY WE NEED THE “A” TEAM ???

Aortic clamp by thorax

Diffuse invasion Aortic compression
surgeon
Still many cases referred from outside East Java Province….
 Conclusion

 Incidence of placenta accreta increase

 PLACENTAL MAPPING & PREOPERATIVE
CLASSIFICATION are crucial : focal or diffuse
→ deciding the management/ Surgical plan