4 placenta accreta dr. sharda jain
TRANSCRIPT
Dr LEENA WADHWA
DR. SANGEETA GUPTA
DR. MANJU PURI
Placenta Accreta-Lessons Learnt
Maternal Mortality-Magnitude and Causes
Haemorrhage,
38%
Sepsis, 11%
Abortion, 8%
Other
Conditions,
34%
Obstructed
Labour, 5% Hypertensive
disorders, 5%
About 28 million pregnancies and 67,000 maternal deaths per
year in India
Source: RGI-SRS 2001-03
* Other Conditions includes Anemia.
Source: RGI-
SRS 2001-03
Placenta accreta/ increta/ percreta
Significant cause of maternal
morbidity and mortality
significant maternal hemorrhage at
delivery
Mortality rate -7 -10% (O brien et al AM J Obstet Gynecol 1996)
Most common reason for emergency postpartum
hysterectomy.
Incidence -increasing(secondarily to the rise of
Caesarean section)
1970 1/7000
1985 - 1994 - 1/ 2,510**
1992 - 2002- 1/ 533 ***
**(Miller- Am J Obstet Gynecol 1996 )
***(Wu et al Am J Obstet Gynecol 2005)
Case 1 Unbooked, G4P2L2A1, 26 weeks, previous LSCS,
fever dysuria
USG:Placenta antr,covering os
Em laprotomy (GA) : hematuria ? Rupture uterus
Per-operative details
Hemoperitoneum (1 litre+)
Posterior wall of bladder found adhered to LUS
Bladder lying open (3cm)
Clots presents inside the bladder removed. large bleeders
present on the posterior bladder wall , clamped & sutured
Case 1 hysterotomy done and fetus delivered
fails to recognize percreta going into bladder & anticipate complications
tries partial MRP hysterectomy with difficulty by 2 consultantsuncontrollable hgg from bladder-cystectomy & B/L Int iliac art ligation
6 units Blood
Patient died in ICU
Case 1
HPE- Placental tissue invading the full thickness
myometrium and the overlying serosa.(placenta
percreta)
‘Placenta accreta mindedness’
Placenta Percreta
Catastrophic event
Placenta percreta induced uterine rupture as early as
9 &14 wks
75% cases of percreta are assoc with placenta previa
Maternal mortality-20%
Perinatal mortality-30%
(Obstet Gynecol 1991)
What could have been done?
Anticipation
Multidisciplinary team
Preoperative cystoscopy and placement of
ureteric stents may aid in identification of the
ureters.
biopsy contraindicated
placement of catheters in both int iliac A
Hysterectomy by postr approach
Involved portion of bladder is resected with hyst
specimen
Case 2:
G3P2L2 ( Prev 2 LSCS ) at 34 weeks of gestational
age was admitted due to bleeding PV for 2 days
USG-SLF cephalic ,placenta, anterior low lying covering
Os
With informed written consent for possibility of
hysterectomy (if required)and adequate blood patient
was shifted to OT for emergency caesarean section.
Case 2.
Per-operative details
LUS was thinned out
Placenta did not separate from LUS after the delivery of baby
Bleeding ++
Decision of hysterectomy taken and done
Three units of BT done
Post operative
Uneventful
HPE- Placenta Increta
Have we become wiser?
Management of a case where pre-operative
diagnosis was made
Case 3
G2P1L1 with 35 weeks and 5 days was admitted in
antenatal ward in view of placenta previa with
moderate anemia (no H/O bleeding PV)
Obstetric history-
1st FT LSCS for CPD 2 years back at govt. hospital
USG(8/8/2011)-SLF 29 weeks 4 days ,placenta anterior
low lying covering Os
Hb-7.1
Case 3
After admission
USG-Placenta anterior extending to LUS, with extensive
placental lakes within. Overlying myometrium intact
with no evidence of placental invasion.
MRI-Myometrium grossly thinned out and placental
interface with myometrium not properly visualized.
Possibility of placenta accreta could not be ruled out
Case 3
Elective LSCS -at 37 weeks
LUS distended with increase vascularity with purple hue
with boggy feeling(?placenta increta)
classical CS
Placenta did not separate
Subtotal hysterectomy done.
Bleeding from stump present.
B/L Internal Iliac Artery Ligation done.
3 units of PRBC given
Case 3
Post operative details
Uneventful
HPE-Placenta Increta.
Others risk factors
Major risk factor -Placenta previa with history of Caesarean section
previous uterine surgery,
Previous Dilatation and Curettage,
Previous Myomectomy
Asherman Syndrome (Endometrial defects)
Submucous leiomyomata
Advanced maternal age
Multiparity
Tobacco use
Risk association :
C.S. delivery P.P
30,132 723
P.P.+ACCRETA
%
No P.P.
,ACCRETA%
Hysterectomy
First 398
(6201)
13(3.3%) 2(0.03%) 40(0.65%)
Second 211
(15,808)
23(11%) 26(0.2%) 67(0.42%)
Third 72
(6324)
29(40%) 7(0.1%) 57(0.90%)
Fourth 33
(1452)
20(61%) 11(0.8%) 35(2.41%)
Fifth 6
(258)
4(67%) 2(0.8%) 9(3.49%)
Diagnosis
Clinical suspicion
Ultrasound
Color Doppler
MRI
Biochemical Marker
Histopathology
Ultrasonic features Moth eaten / Swiss
Cheese appearance of
placenta .
Ultrasonic featuresObliteration of clearspace
between placenta and
uterine wall
Ultrasonic features
Sensitivity -93%
Specificity-79%
Color Doppler USG Sensitivity 82-100%
Specificity 92-97%
Distance <1mm between the uterine serosa-bladder interface and the retroplacental vessels
High velocity and turbulent flow
(Twickler et al 2000)
MR Imaging
MRI is no more sensitive than USG for diagnosing placenta accreta*
MRI is used as an adjunct to USG when there is a strong clinical suspicion of accreta**
(Yinka et al 2006)*(Lax et al 2007)**
Women who have had a previous CS who also have
either placenta praevia or an anterior placenta
underlying the old CS scar at 32 weeks of gestation are
at increased risk of placenta accreta and should be
managed as if they have placenta accreta, with
appropriate preparations for surgery made.
(RCOG 2011)
Management
Elective delivery by caesarean section at 34–35
weeks of gestation for suspected placenta accreta
(AICOG 2012)
Lessons learnt (Pre-operative)
Prenatal imaging for placental location in previous CS
Rule out MAP in prev. CS* with pl. previa
Consent for hysterectomy
Arrange sufficient blood and component therapy
Consultant obstetrician , alert surgeons
NEVER PULL PLACENTA
Resort to hysterectomy SOONER RATHER THAN LATER
Uterine incision should be made vertically and above the placental insertion site.
Lessons learnt (Intraoperative)
POSTOP COMPLICATION
Transfusion reaction ,sepsis
DIC
Urinary stasis ,infection
Pelvic and renal abscess formation ,Renal compromise
ARDS
Multi organ failure
Fistula formation
Ureteral stricture
Uterus preserving modalities
Expectant management
Balloon catheterisation and embolisation of pelvic
vessels
Methotrexate therapy
Uterus preserving surgeries
(Charlotte et al, Arch Gynecol Obstet.2011)*
Balloon catheterisation /SAE
Pre-delivery consultation with the interventional
radiology team
Pre-operative placement of arterial catheters in internal
iliac artery
After delivery balloons are inflated to achieve
temporary homeostasis
Selective arterial embolization(SAE) if necessary
Advantages
1. Avoidance of hysterectomy and preservation of
fertility
2. Lower estimated blood loss
3. Reduced blood transfusion
4. Low frequency of complications
1. Post procedure fever
2. Pelvic infection
SAE Disadvantages
Illiac artery thrombosis Uterine necrosis Sepsis MODS(Gupta et al. Cochrane database Syst Rev 2006)*
Infertility for succeeding pregnancy
Fetal radiation exposure
(Gupta et al. Cochrane database Syst Rev 2006)*
Methotrexate ? controversial
It acts by inducing placental necrosis & expediting
a more rapid involution of placenta.
MTX should be administered (1 mg/kg) on
alternate days for a total of 4 to 6 doses*
Methotrexate
Complication-
Hemorrhage
Disseminated intrauterine infection (sepsis)
Pancytopenia
Nephrotoxicity
Failure Rate-22%
Expectant management Few case reports
A series of 7 cases *
Placenta was left in situ,
uterus involuted spontaneously
woman returned to a normal menstrual cycle.
Placenta was never expelled but was presumably absorbed.
A series of 26 cases**
Placenta partially removed in 19/26
4/26 conservative therapy failed
(Mark Gabot et al 2010)* (Timmermans et al 2007)**
Follow-up management
1.- Ultrasound exams Vascularity
2.- HCG titers
3. Daily Temps, Other S&S of infection
4.- Bleeding
5.- Coagulation profile
Thank you