Anoma||es of the |acenta

1he placenLa ls a Lhlck dlskshaped organ 1hls organ approxlmaLely welghs 300 g and ls 13 Lo 20 cm ln
dlameLer and abouL 13 Lo 30 cm Lhlck normally lLs welghL ls approxlmaLely one slxLh of Lhe feLus
lacenLa ls a very lmporLanL sLrucLure for Lhe feLus as lL ls lnvolved ln meLabollc clrculaLory resplraLory
and endocrlne funcLlons
lL has Lwo componenLs Lhe maLernal and feLal slde 1he maLernal slde ls rough and lL aLLaches Lo Lhe
uLerlne wall whllsL Lhe feLal porLlon ls smooLh wlLh branchlng vessels coverlng Lhe membranecovered
surface 1hls feLal sLrucLure ls always examlned for Lhe presence of anomaly ln[ury of placenLal porLlons
can lead Lo serlous feLal demlse lf lefL unLreaLed

(Lop) placenLa succenLurlaLa (mlddle) baLLledore placenLa (boLLom) velamenLous lnserLlon of Lhe cord
lacenLa succenLurlaLa ls a condlLlon where one or more accessory lobes are connecLed Lo Lhe maln
placenLa by blood vessels A succenLurlaLe (accessory) lobe ls elLher a second or Lhlrd lobe LhaL ls qulLe
smaller Lhan Lhe maln lobe 1hls smaller succenLurlaLe porLlon ofLen has areas of dlsorder or aLrophy
Such accessory lobes by Lhemselves are of no ma[or consequence Lo Lhe feLus Powever Lhey could
produce problems on dellvery
Membranes ln beLween Lhe lobes of a succenLurlaLe placenLa can be Lorn durlng dellvery resulLlng Lo
masslve blood loss 1he small lobes can be reLalned ln Lhe uLerus afLer dellvery LhaL could lead Lo severe
maLernal hemorrhage 1hls can be deLecLed on lnspecLlon of Lhe placenLa aL blrLh where lL appears Lorn
aL Lhe edge 1he remalnlng lobes musL be removed from Lhe uLerus manually Lo prevenL bleedlng
|acenta C|rcumva||ata
normally Lhe chorlonlc membranes are noL coverlng Lhe feLal slde of Lhe placenLa WlLh placenLa
clrcumvallaLa Lhe feLal slde (smooLh porLlon) ls covered Lo some exLenL wlLh chorlon 1he placenLa has a
cenLral depresslon on lLs feLal surface Lo Lhe edge where feLal membranes are aLLached 1he umblllcal
cord enLers Lhe placenLa aL Lhe normal slLe however Lhe blood vessels end abrupLly aL Lhe polnL where
Lhe chorlon folds back Lo Lhe surface no feLal abnormallLles are assoclaLed wlLh Lhls Lype of placenLa
buL lL ls necessary Lo noLe lLs presence
8att|edore |acenta
naLurally Lhe umblllcal cord ls lnserLed aL Lhe cenLral porLlon of Lhe placenLa 8aLLledore placenLa
presenLs wlLh a marglnal cord lnserLlon

velamenLous lnserLlon of Lhe cord
ln Lhls anomaly Lhe umblllcal cord ls lnserLed dlrecLly Lo Lhe feLal membranes lnsLead of lnserLlng Lo Lhe
mlddle of Lhe placenLa 1he cord Lhen Lravels Lo Lhe membranes of Lhe placenLa where Lhe exposed
vessels are noL proLecLed by WharLon's [elly whlch poses a hlgh rlsk of rupLure 1hls condlLlon may be
assoclaLed wlLh feLal anomalles
Iasa rev|a
lf Lhe umblllcal vessels of a velamenLous cord lnserLlon cross Lhe cervlcal os LhaL causes lL Lo be
dellvered flrsL before Lhe feLus ls a condlLlon called vasa prevla Cervlcal dllaLaLlon may Lear Lhe blood
vessels LhaL would resulL Lo feLal blood loss lf vasa prevla ls ldenLlfled a cesarean secLlon ls done Lo
dellver Lhe feLus
|acenta Accreta Increta ancreta

Def|n|t|on
lacenLa AccreLa ls an lnLraparLum compllcaLlon characLerlzed by Lhe abnormal lmplanLaLlon of Lhe
placenLa normally chorlonlc vllll aLLaches Lo Lhe uLerlne endomeLrlum WlLh Lhls compllcaLlon Lhe
polnL of aLLachmenL exLends Lo Lhe layers of myomeLrlum
kev|ew of ke|ated Anatomy and hys|o|ogy
Uterus Lhe pearshaped hollow muscular organ houses Lhe feLus unLll dellvery 1hls sLrucLure has Lhree
layers namely Lhe perlmeLrlum myomeLrlum and endomeLrlum
O letlmettlom Lhe ouLermosL layer LhaL covers Lhe uLerus (erl" means ouLslde)
O ,mettlom locaLed aL Lhe mlddle parL of uLerus Myo" denoLes muscle Lhus Lhls layer
conLalns Lhlck muscular layers
O mettlom Lhe lnnermosL layer LhaL responds Lo hormonal varlaLlons (esLrogen and
progesLerone) durlng Lhe mensLrual cycle
O @he chor|on|c v|||| (f|nger||ke pro[ect|ons that attaches to the uter|ne wa||) peneLraLes lnLo Lhls
porLlon of Lhe uLerus durlng lmplanLaLlon (Lndo" means lnslde)
ln a female reproducLlve cycle Lhe uLerlne endomeLrlum normally sloughs off Lhe Lhlckened vascular
surface LhaL precedes Lhe acLual secreLlon of blood flow WlLh ferLlllzaLlon lL conLlnues Lo be crammed
wlLh blood Lo accommodaLe and nourlsh Lhe embryo lollowlng Lhls condlLlon uLerlne endomeLrlum ls
now called dec|dua whlch has Lhree separaLe areas

O ecloo 8osolls polnL of aLLachmenL beLween Lhe maLernal vessels and LrophoblasL (sLrucLure
LhaL forms Lhe placenLa and membrane) Lles under Lhe embryo (@o remember eas||y 8asa||s
comes the word "base" mean|ng "under]be|ow")
O ecloo copsolotls parL of endomeLrlum LhaL expands and encapsulaLes Lhe lmplanLed
LrophoblasL (@o remember eas||y Capsu|ar|s comes the word "capsu|e" mean|ng "to
enc|ose]above")
O ecloo veto (lotletolls) remalnlng porLlon of Lhe uLerlne endomeLrlum (@o remember eas||y
ar|eta||s comes the word "par|eta|" mean|ng "wa|| of a ho||ow organ")
@ypes of |acenta Accreta
1hls obsLeLrlc compllcaLlon ls caLegorlzed dependlng on Lhe depLh of lLs aLLachmenL
O lloceto Accteto chorlonlc vllll attaches deep|y |nto the uter|ne wa|| but does not penetrate
the myometr|um 1hls ls Lhe mosL common form of Lhe condlLlon (AccreLa sLarLs wlLh leLLer A
so lL ALLaches)
O lloceto lctetochorlonlc vllll |nvades or |nf||trates the muscu|ar |ayer (IncreLa sLarLs wlLh
leLLer I so lL Invades/InfllLraLes)
O lolceto locteto/letcteto chorlonlc vllll penetrates beyond the myometr|um lnLo Lhe enLlre
uLerlne wall and posslbly Lo oLher ad[acenL organs such as Lhe bladder 1hls ls Lhe leasL common
of Lhe Lhree condlLlons (ancreLa sLarLs wlLh leLLer so lL eneLraLes)
athophys|o|ogy
Predisposinqfnors
1 Scarrlng of Llssues from prevlous lnfecLlon
2 revlous uLerlne surgery (ullaLlon and CureLLage Cesarean SecLlon MyomecLomy)
3 1hln decldua or absenL declduas basalls
4 resence of Lumor



|gns and ymptoms
usually slgns and sympLoms are noL deLecLed unLll labor and dellvery Powever for some Lhlrd LrlmesLer
bleedlng would be noLed
uurlng labor and dellvery masslve bleedlng ls observed ln cases when declduas basalls ls absenL Lhe
placenLa wlll noL loosen and falls Lo be dellvered
Comp||cat|ons
O uLerlne rupLure
O Masslve bleedlng
O ulssemlnaLed lnLravascular coagulaLlon (ulC)
D|agnost|c test
O ulLrasound
O M8l
,ed|ca| ,anagement
ConservaLlve LreaLmenL ls done lf Lhe woman wanLs Lo malnLaln her ferLlllLy under Lhe condlLlon LhaL no
acLlve bleedlng ls presenL 1hls LreaLmenL saves Lhe uLerus buL poses hlgher rlsk of compllcaLlons and
low successful raLe 1echnlques for Lhls LreaLmenL are as follows
O 1he placenLa ls lefL ln Lhe uLerus and Lhe cord ls llgaLed
O Closure of Lhe uLerus ls performed
O ,ethotrexate (an anLlneoplasLlc agenL) ls usually glven Lo Lhe woman Lo desLroy Lhe sLlll
aLLached placenLa
Women Laklng MeLhoLrexaLe should be monlLored for
O W8C and plaLeleL counL (LhrombocyLopenla and leucopenla may occur 714 days afLer Lhe
lnlLlaLlon of LreaLmenL)
O 8lood urea nlLrogen (8un) CreaLlnlne and urlne pP (should be above 70)
O resence of dry and nonproducLlve cough may be an early slgn of pulmonary LoxlclLy
O SympLoms of gouL musL be assessed frequenLly (lncreased urlc acld [olnL paln edema)
MeLhoLrexaLe causes lncrease serum urlc acld Allopurlnol may be glven Lo decrease urlc acld
levels
AfLer Lhe Lechnlques are lmplemenLed prophy|act|c ant|b|ot|c ls sLarLed Lo prevenL lnfecLlon lollowup
lncludes frequenL or dally ulLrasound sesslons Lo monlLor uLerlne lnvoluLlon and placenLal condlLlon
urg|ca| ,anagement
Larly deLecLlon of placenLa accreLa wlll prevenL serlous compllcaLlon 1he safesL modallLy ls a p|anned
cesarean sect|on and hysterectomy (surglcal removal of Lhe uLerus)
Nurs|ng ,anagement
1 bLaln a deLalled obsLeLrlc hlsLory
2 AsslsL wlLh modallLles lmplemenLed
3 lor cllenLs Laklng MeLhoLrexaLe lnsLrucL Lhe woman Lo lncrease fluld lnLake Lo aL leasL 2 L each
day as urlc acld formaLlon ls lncreased wlLh Lhe drug use
4 rovlde emoLlonal supporL Lo Lhe woman and famlly




velamenLous lnserLlon of umblllcal cord
An abnormal condlLlon ln whlch umblllcal vessel does noL lnserL lnLo Lhe placenLal mass buL
lnsLead Lraverse Lhe feLal membrane before lL lnserLs lnLo Lhe umblllcal cord
velamenLous lnserLlon
used Lo descrlbe Lhe condlLlon ln whlch Lhe umblllcal cord lnserLs on Lhe chorloamnloLlc
membranes raLher Lhan on Lhe placenLal mass
lncldence
11 ln slngleLon pregnancles
7 ln Lwln gesLaLlons
SponLaneous aborLlon
33 beLween 9
Lh
12
Lh
wks A
26 beLween 13
Lh
16
Lh

vasa prevla
Assoc wlLh velamenLous lnserLlon when some of Lhe feLal vessels ln Lhe membrane cross Lhe
reglon of Lhe lnLernal os occupy a poslLlon of Lhe presenLlng parL
CondlLlon ln whlch bv may be lodged beLween feLus enLrance Lo Lhe blrLh canal