Transcript PLACENTA ACCRETA - An-Najah National University

MAKASSED EXPERIENCE IN
MANAGEMENT OF PLACENTA ACCRETA
Prepared by :
Dr . Amani A.A Rajabi , MD (AL_QUDS UNIV.)
Resident at Makassed Islamic Charitable Hospital
Supervised by :
Dr . Saadeh S.Jaber
MBBS, MRCOG, MRCPI,
Head of OBGYN department Al_quds univ.
Consultant at Makassed Islamic Charitable Hospital
DEFINITION & PATHOGENESIS
 Placenta accreta occurs when there is a defect of the decidua
basalis , in conjunction with an imperfect development of the
Nitabuch membrane , resulting in abnormally invasive
implantation of the placenta .
 Nitabuch membrane is a fibrinoid layer that separates the
decidua basalis from the placental villi.
HISTOLOGICAL CLASSIFICATION
INCIDENCE
 There is marked increase in the incidence of placenta
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accreta .
In 1950----- 1 in 30,000 deliveries .
In 1977-----1 in 7,000 deliveries .
In 1985-1994-----1 in 2500 deliveries .
In 1982-2002-----1 in533 deliveries .
(Am J Obstet Gynecol 1997;177:210-4)
(Am J Obstet and Gynecol (2005) 192, 1458–61)
 placenta accreta has been reported to result in a 7%
mortality rate .
 The most common indication for birth related hysterectomy,
accounting for 40–60% of cases.
ACOG committee opinion . International Journal of Gynecology & Obstetrics
77 (2002) 77-78.
J. Obstet. Gynaecol. Res.Vol. 33, No. 4: 431–437, August 2007 .
DIAGNOSIS
Placenta previa -accreta
Color Doppler
 Demonstrating turbulent
flow through placental
lacunae ,with abnormal
vessels linking the placenta
to the bladder.
Magnetic resonance imaging
 The role of MRI is to complement, rather than replace,
information obtained via standard sonographic imaging.
 The main advantage offered by this type of imaging is :
 The ability to diagnose posterior placenta accreta more
confidently.
 The assessment of bladder invasion in cases of placenta
percreta.
 The mean gestational age at diagnosis of placenta accreta
by ultrasound is 29 weeks (range:28–33 weeks) .
 The mean gestational age at delivery is 36 weeks
(range: 32–38 weeks).
J. Obstet. Gynaecol. Res.Vol. 33, No. 4: 431–437, August 2007 .
COMPLICATIONS
 Massive obstetric hemorrhage is the most common
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complication .
Disseminated intravascular coagulopathy .
Adult respiratory distress syndrome .
Renal failure .
Infection
Death.
Abstract
 STUDY DESIGN :
Retrospective analysis of medical records & histopathological
finding .
 POPULATION :
Women delivered at Makassed Hospital 2007 / 2008 of
whom 15 cases of invasive placenta identified.A finding
confirmed by histopathology .
 METHODS :
Retrospective analysis complemented with direct
communication with patient ,using SPSS to analyze data .
 CONCLISIONS : at the end of presentation .
year of delivery
10
8
9
6
6
Frequency
4
2
0
2007
2008
year of delivery
 Incidence in 2007 ….1:460 deliveries.
 Incidence in 2008 ….1:300 deliveries.
Source of referal
50
40
40
33
30
27
Percent
20
10
0
Governental Hospital
source of referal
Private Hospital
booked
All of our cases were diagnosed
antenatally .
Identified risk factors
history of :
 CS.
 E &C .
 IUCD .
 Other uterine instrumentation .
MINIMUM
MAXIMUM
AGE
24
44
PARITY
2
7
# CESAREAN
SECTION
2
5
Gestational age ……
MINIMUM
MAXIMUM
MEAN
GA _ US Diagnosis
24
34
29
GA _ Delivery
26
36
31
Preoperative management
 The woman should be informed of the diagnosis and
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potential complications .
Antenatal corticosteroid to be given .
Consent form of caesarean hysterectomy .
Delivery should be scheduled for optimal availability of
necessary personnel and facilities.
A preoperative anaesthesia consultation should be obtained.
Adequate blood and clotting factors should be available at the
time of delivery .
An intensive care unit should be available for postoperative
care, as needed.
Immediate preoperative bilateral uretric
stents were inserted in a couple of cases .
Intraoperative management of
planned cesarean hysterectomy :
 A vertical skin incision provides good exposure .
 A vertical uterine incision is made above the upper edge of
placenta .
 Delivery of the baby .
 Placenta left "in situ“, with minimal manipulation.
 Extrafascial hysterectomy is then performed .
Blood transfusion
Case number
Pre operative
Intra operative
Post operative
1
NA
6 PRBC
4 FFP
4 PLT
2 whole Blood
2
NA
4 PRBC
4 FFP
9 whole Blood
3
NA
3 PRBC
2 FFP
4 whole Blood
4
NA
4 PRBC
2 PRBC
5
NA
4 PRBC
4 FFP
2whole Blood
4 PRBC
9 FFP
4 whole Blood
6
NA
2 PRBC
2 PRBC
2 whole Blood
7
NA
8 PRBC
4 FFP
NA
Continued
Case number
Pre operative
Intra operative
Post operative
8
NA
3 PRBC
1 PRBC
4 FFP
9
NA
4 PRBC
2 whole Blood
2 FFP
10
NA
2 PRBC
2 PRBC
11
2 PRBC
2 PRBC
2 PRBC
2 FFP
12
NA
2 PRBC
NA
13
NA
2 PRBC
2 PRBC
2 FFP
14
NA
NA
NA
15
NA
2 PRBC
4 whole Blood
2 FFP
2 whole Blood
Histopathology
NO histopathology
6.7%
percreta
33.3%
accreta
60.0%
MINIMUM
MAXIMUM
HOSPITALIZATION PERIOD
5
38
PRE DELIVERY
HOSPITALIZATION
0
27
ICU
HOSPITALIZATION
1
2
Neonatal outcome
MINIMUM
MAXIMUM
GA _ delivery
26
36
Birth weight
1337
3130
Neonatal outcome
60
50
50
40
36
30
Percent
20
10
7
7
NEONATAL DEATH
IUFD
0
NL NURSERY
Neonatal outcome
NICU
CONCLUSIONS
 Incidence of invasive placenta at Makassed hospital is
one case in 370 deliveries .
 Invasive placenta associated with significantly high morbidity
& mortality world wide , proudly the outcome in our
hospital was excellent , with NO MORTALITY &
MINIMUM MORBIDITY .
 Excellent neonatal outcome .
Continued ….
 Finally , maternal & neonatal outcome can be optimized by
the availability of :
 Senior obstetrician with advanced surgical skills .
 Senior anesthesiologist & intensive care facilities .
 Advanced lab & blood banking facilities .
 Urological back up .
 Intensive care baby unit .