Transcript Placenta Accereta

Placenta Accreta-Lessons Learnt
Dr LeenaWadhwa
Associate Professor
ESI-PGIMSR,Basaidarapur,Delhi
Maternal Mortality-Magnitude and Causes
About 28 million pregnancies and 67,000 maternal deaths per
year in India
Other
Conditions,
34%
Haemorrhage,
38%
Source: RGI-SRS
2001-03
Abortion, 8%
Obstructed
Labour, 5%
Sepsis, 11%
Hypertensive
disorders, 5%
* 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
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


hysterectomy.
Incidence -increasing(secondarily to the rise of
Caesarean section)
1970
1/7000
1985 - 1994 1/ 2,510**
1992 - 20021/ 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
consultantsuncontrollable hgg from bladdercystectomy & 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
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

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
30,132
P.P
723
P.P.+ACCRETA%
No P.P.
,ACCRETA%
Hysterectomy
First
(6201)
398
13(3.3%)
2(0.03%)
40(0.65%)
Second
(15,808)
211
23(11%)
26(0.2%)
67(0.42%)
Third
(6324)
Fourth
(1452)
Fifth
(258)
72
29(40%)
7(0.1%)
57(0.90%)
33
20(61%)
11(0.8%)
35(2.41%)
6
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 features
Obliteration 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
(Twickler et al 2000)
flow
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
Lessons learnt (Intraoperative)
 NEVER PULL PLACENTA
 Resort to hysterectomy SOONER RATHER THAN
LATER
 Uterine incision should be made vertically and above
the placental insertion site.
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.
2.
3.
4.
Avoidance of hysterectomy and preservation of
fertility
Lower estimated blood loss
Reduced blood transfusion
Low frequency of complications
1.
2.
Post procedure fever
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