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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
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%
Still on going
Learning curve
5%
4%
2%
1%
0% 0%
4 maternal death in
Surabaya → 3 death due 5%
4%
to AIP
1%
0% 0%
2%
1%
0% 0%
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
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
S2 UTERINE SEGMENT
OF VASCULAR
INVOLVEMENT
Problem – 2 (the disaster)
Diffuse AIP
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)
Nov 2017
S1 segment comprises the body
of the uterus
Palacios-Jaraquemada JM, et al. A Comprehensive Textbook of Postpartum Haemorrhage 2012, 2nd edition.
Dumfriesshire, Scotland: Sapiens Publishing; p.19.
Placental mapping
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
+
1. SuMPUC with modification Parametrial invasion
2. One step conservative Cervical invasion
surgery by Prof Palacios Massive adhesion and invasion