PROBLEMS AND CHALLENGE IN REDUCING

MATERNAL MORTALITY RELATED WITH

PLACENTA ACCRETA SPECTRUM
DISORDERS(PASD): AN OBSTETRICS
IATROGENESIS ENDEMY

Hermanto TJ
* Reproductive Health Magister Program
FoM UA
*Division of MaternalFetal Medicine Dep
ObGyn RS dr Soetomo
Different perspective
 Facts on PASD
•  Difficult diagnosis – especially asses the adnex and
cervix involvement
•  Management – high morbidity and high mortality – widely
interconnected vascular system incl extra aorta
•  Pathophysiology not completely understood but related
with cesarean delivery
•  Cesarean delivery still high in number – increasing
number of PASD
•  One cesarean delivery PASD phenomena
PASD at dr Soetomo Teaching
Hospital
World trend in Cesarean
Delivery(CD)
 Indonesia dichotomy (Anne Hyre – EMAS:
the Mystery of Maternal Mortality in
Indonesia 2016)
•  Economy growth 5-6 & yearly since 2000
•  Literacy rate 92 %
•  Contraceptive prevalence 60 %
•  High antenatal care, skilled attendant at birth, facility-
based at birth
•  More than 200000 midwives

yet

•  Maternal mortality ratio 359 in 2012

 so
• Prevention is the best option
• There are some preventative measures that
could be done during
- preconception,
- first trimester and
- third trimester
 Preconception
•  Every pregnancy should be planned:
timing, number and interval
•  Prewedding course
•  Eligibility to get pregnant
 Reducing primary cesarean
delivery
•  Cesarean delivery on maternal request:
recounseling
•  Breech presentation: external version,
vagiinal breech delivery
•  Category II cardiotocography
•  TOLAC – VBAC
Vaginal BREECH delivery?
CTG Category II – add one more
parameter
TOLAC N VBAC – in certain
cases and hospital
 Dystocia
•  Failure to progress = failure to wait
•  Use the new partograph – Zhang findings
 Prevention 2
in first trimester of pregnancy: identify and repair cesarean
scar pregnancy ;
second to third trimester of pregnancy: screening by
modified placenta accrete index, TOLAC & VBAC, refer the
suspected case to tertiary centre and
at tertiary center: multidiscipline approach, timely
intervention: 34 – 35 wop, blood transfusion management,
management of neovascular and anastomose between
bladder and uterine lower segment, intensive post
cesarean monitoring and immediate reopen if necessary.
Cross over sign Ultrasound obstet
gynecol 2017
 Referal guideline
•  All pregnant mother with history of
cesarean delivery should be refered and
giving birth to/at hospital
•  All women w history of 2 CD should be -
no TOLAC no VBAC, plus sterilization
•  All women w history of CD should be
screened for placenta accreta spectrum
disorder
 Widely interconnected system,
neovascularization n anastomose
 Post placenta IUD insertion
•  The right time to have new contraceptive
user
•  High leverage to reduce maternal mortality
•  Improve interpregnancy interval
•  Prevent women from
Other perspective
.”a vast amount of contemporary clinical care is incidental
to the curing of disease but the damage done by medicine
to the health of individuals and populations is very
significant. These facts are obvious, well documented and
well repressed”
Medicalization – a sociologic perspective, is the process by
which human conditions and problems come to be defined
and treated as medical conditions, and thus become the
subject of medical study, diagnosis, prevention, or
treatment
Iatrogenesis refers to any effect on a person, resulting
from any activity of one or more other persons acting as
healthcare professionals or promoting products or services
as beneficial to health, which does not support a goal of
the person affected
O’Mahoney R. 2016. Medical Nemesis 40 years on: the
enduring legacy of Ivan Illich

•  Medical Nemesis is a paradox: it

is bombastic, barely readable,
and over-stated, but at its core, is
a powerful argument.
•  Forty years after its publication,
llich’s thesis has only grown in
strength
 Iatrogenesis
1950: 1 in 30,000 deliveries
1990: 1 in 731 deliveries
2016: 1 in 272 delivery-related discharges in
the United States

Inline with the increasing cesarean delivery

•  Too little and too late actions have no
place in management of PASD, over
treatment is better than delay nor
neglected
 Take home messages
•  Prevention is the best option
•  The best way to prevent PASD and its morbidities and
mortality is to prevent primary Cesarean Delivery
•  To prevent primary CD: recounsel CDoMR, category II
ctg, vaginal breech delivery, dystocia
•  Planned pregnancy, asses the CD scar, detect Cross
Over Sign and cesarean scar pregnancy, screening PAI
and Surabaya trias in every pregnancy,
•  Refer timely PASD cases