بسم الله الرحمن الرحيم

بسم الله الرحمن الرحيم

New trends in treatement of Placenta Accreta

BYDr. Manal Behery Assistant ProfessorObs&GyneZagazig

University

New trends in the treatement of Placenta

Accreta

Definition

81.6%

11.8%

6.6%

J Clin Ultrasound 2008;9:551-9

Definition

Frequency of placenta accreta according to number of cesarean deliveries and presence or absence of

placenta previa

Adapted from SMFM. Am J Obstet Gynecol 2010.

Cesarean Delivery

First (primary)SecondThirdFourth Fifth≥ Sixth

Placenta previa

3.3%11%40%61% 67%67%

No Placenta previa

0.03%0.2%0.1%0.8% 0.8%4.7%

In a large prospective observational study that considered the number of prior cesarean deliveries and presence or absence of placenta previa,the risk of placenta accreta was

Which Imaging Modalities Are Necessary For The Diagnosis Of Placenta Accreta?

• In the vast majority of cases, placenta accreta may be diagnosed on the basis of ultra-sound alone.

• Sonographic findings suggestive of accreta include

Which imaging modalities are necessary for the diagnosis of placenta accreta?

The use of power Doppler, color Doppler, or three-dimensional imaging does not significantly improve the diagnostic sensitivity compared with that achieved by grayscale ultrasonography alone

15.Chou MM, Ho ES, Lee YH. Prenatal diagnosis of placenta previa accreta by transabdominal color Doppler ultrasound. Ultrasound Obstet Gynecol 2000;15:28–35.

MRI findings suggestive of placenta accreta include

• Lower uterine bulging,

• Heterogeneous placenta

• Dark intraplacental linear bands

on T2-weighted images.

Preparation for Delivery

The preferred strategy was delivery at 34 weeks without amniocentesis for placenta previa with suspected accreta,and cases with recurrant bleeding .

An expert opinion in 2010 recommended delivery for uncomplicated previa at 36 to 37 weeks and 34 to 35 weeks for suspected placental invasion.

The different risks and treatment options should have been discussed and a plan agreed, which should be reflected clearly in the consent form. This should include the anticipated skin and uterine incisions and whether conservative management of the placenta or proceeding straight. to hysterectomy is preferred in the situation where accreta is confirmed at surgery.

What should be included in the consent form for caesarean section?What should be included in the consent form for caesarean section?

Thorough discussion with PT of the on

the suspected diagnosis,the anticipated surgical procedure high potential for hysterectomy,

profuse hemorrhage, probable transfusion, increased complications

Thorough discussion with PT of the on

the suspected diagnosis,the anticipated surgical procedure high potential for hysterectomy,

profuse hemorrhage, probable transfusion, increased complications

A preoperative checklist would be helpful in confirming necessary preparations and for identifying contact persons in case perioperative assistance is required.

Which preoperative interventions are beneficial for patients with suspected accreta to decrease transfusion needs?

Acute normovolemic hemodilution (ANH) Acute normovolemic hemodilution (ANH)

Preoperative bilateral common iliac artery balloon catheter placement with inflation after delivery of the fetus

preoperative placement of femoral access by IR with selective embolization of uterine vessels at the time of delivery

If extensive dissection, prolonged operative time, and massive hemorrhage are anticipated, general anesthesia is commonly recommended.

If extensive dissection, prolonged operative time, and massive hemorrhage are anticipated, general anesthesia is commonly recommended.

When regional anesthesia was first used a reported rate of conversion to general anesthesia of about 28% to 30%

What is the optimal anesthetic technique for patients with placental accreta?

What Is Hemostatic Resuscitation, And Does It Improve Outcomes?What Is Hemostatic Resuscitation, And Does It Improve Outcomes?

Hemostatic resuscitation is a new concept that mainly involves 3 aspects:

1.Limited early aggressive use of crystalloids and consideration of permissive hypotension

2. Early administration of fresh frozen plasma and platelets (with concomitant packed red blood cells) achieving a ratio of 1:1:1

3. Early use of rFVIIa

Surgical strategy

• There is no unique approach to the management of placenta accreta.

• Surgical team expertise, availability of resources and local conditions are determining factors when choosing the safest procedure.

At present,placenta accrete can be managed in three ways:

(1)Carry out a hysterectomy;

(2) Leave the placenta in situ;and (3) Resect the invaded tissues with the entire

placenta restoring uterine anatomy.

Each one has weaknesses and strengths, dependent on the condition itself and the specific preferences taken by the surgeon and the team.

Resources Patient, clinical and anatomic features

Decision Definitive treatment

Limited experienceor expertise, poorresources or no facilities for safe patient transfer

lower segment invasionvaginal bleeding with high suspicion of accretaPossibility of percreta

Extraplacentalhysterotomy,Placental left in situFollowed by uterine closure

Delayed hysterectomyor conservative procedureaccording clinicaland surgical status

Qualified andexperiencedteam, adequatehospital resources

No desire for future pregnancyTissue destruction> 50% of uterine circumferenceIntractable haemorrhageDIC

Resective surgery

Subtotal hysterectomyfor upper segment lesionsTotal hysterectomyfor lower segmentand cervical involvement

Qualified andexperiencedteam, adequatehospital resources

Desire for futurepregnancyDestruction < 50% of uterineaxial circumferenceMinor coagulation disorders

Conservativesurgery

1-Placenta in situ with or without MXT 2-One step surgery

OR

3- Two step surgery

With the exception of upper-segment invasions, hysterectomy for placenta accreta must be total; otherwise there is a high percentage of rebleeding in subtotal resections within the lower-segment invasions.

IF SUBTOTAL IS DONE it is not recommended to close the peritoneum over the cervical stump, As rebleeding in these circumstances usually goes unnoticed.

Therapeutic practice points• The presence of pericervical or lower-segment

varicose veins proper of placenta praevia can be confused with the neovascularization of placenta accreta.

• Surgical exploration will make a differential diagnosis, thus avoiding unnecessary hysterectomies.

Therapeutic practice points

In cases of placental accreta, the areas of placental invasion outside the uterus may also

be affected by the abnormal blood supply.

• Care should be taken not to compromise the parasitic vasculature when entering the abdomen and exposing the uterus.

• In cases of bladder involvement, most obstetricians choose a conservative approach with arterial embolisation. If

In cases of bladder involvement

Bladder invasion

Most obstetricians choose a conservative approach with arterial embolisation.

If bleeding cannot stop, packing with laparotomy pads can promote haemodynamic stabilisation in the patient.

Later the original problem can be resolved in a secondary surgical procedure.38

When hazardous dissection is anticipated aortic or bilateral common iliac occlusion Is needed to practise safe surgery.

withInIn

Morbidity can be high and that further intervention will often be necessaryPatient should also be willing to

accept that

Outcome is unpredictable Morbidity can be highStrict prolonged followc up is needed and that further intervention will often be necessary

One-step surgery

• One-step surgery involves wide mobilization of tissue, tissue resection, myometrial and bladder sutures,

• Meticulous dissection allows an accurate haemostasis, which makes it possible to resect the invaded tissue and have adequate tissue repair

This procedure is similar to one-step surgery, but, in this case, the tissue dissection is less difficult and bleeding is not severe .

A few days after delivery, the newly formed vessels are collapsed and some light oedema occurs between the anterior uterine surface and the bladder.

Two-step conservative surgery

• area.

No attempt at placenta removal Placenta left in situ

With uteroplacental blood flow at 700 to 900 mL/min near term, every minute of hemorrhage avoided is significant.

Incisions made through the placenta and any attempts to deliver the placenta will often incite significant hemorrhage .

In this option, hysterotomy has to avoid placental invasion, the baby is delivered through a safe area, and the umbilical cord is cut near the placenta. The invaded area and the placenta are left in situ without any attempt to remove them, and the uterus is closed avoiding any tissue dissection of invaded area.In this option, hysterotomy has to avoid placental invasion, the baby is delivered through a safe area, and the umbilical cord is cut near the placenta. The invaded area and the placenta are left in situ without any attempt to remove them, and the uterus is closed avoiding any tissue dissection of invaded area.In this option, hysterotomy has to avoid placental invasion, the baby is delivered through a safe area, and the umbilical cord is cut near the placenta. The invaded area and the placenta are left in situ without any attempt to remove them, and the uterus is closed avoiding any tissue dissection of invaded area.

1-One step suregery

2-Placenta in situ with or without Adjuvant methotrexate (MTX)

3-Tamponade of the placental implantation site with inflated IU ballon catheter bags,

4- Lower segmant compression suture

Option of Conservative ttt

For persistent diffuse non arterial bleeding that is not amenable to surgical control,

Placement of pelvic pressure packing(laparotomy sponges) may be considered as a temporizing step to allow time for hemodynamic stabilization, correction of coagulopathy, and eventual completion of surgery.

Pelvic pressure packing

• area.

Optimal post-delivery follow-up

No guidelines exist regarding the optimal postdelivery follow-up

Postpartum hemorrhage may happen up to 105 days after the initial procedure Serial US to assess placental involution and frequent visits to screen for delayed hemorrhage and early signs of sepsis

In this option, hysterotomy has to avoid placental invasion, the baby is delivered through a safe area, and the umbilical cord is cut near the placenta. The invaded area and the placenta are left in situ without any attempt to remove them, and the uterus is closed avoiding any tissue dissection of invaded area.In this option, hysterotomy has to avoid placental invasion, the baby is delivered through a safe area, and the umbilical cord is cut near the placenta. The invaded area and the placenta are left in situ without any attempt to remove them, and the uterus is closed avoiding any tissue dissection of invaded area.In this option, hysterotomy has to avoid placental invasion, the baby is delivered through a safe area, and the umbilical cord is cut near the placenta. The invaded area and the placenta are left in situ without any attempt to remove them, and the uterus is closed avoiding any tissue dissection of invaded area.

Conclusion

Conclusion

Access to pelvic subperitoneal spaces

Wide opening of vesicouterine space

Planned hysterotomy

Management of proximal vascular control,

Accurate use of compression sutures

Keys to achieving vascular control and haemostatic procedures. Keys to achieving vascular control and haemostatic procedures.

Carrying out hysterectomy during shock or coagulopathy has a high risk of immediate and late complications.

Effective vascular control, such as internal aortic compression may provide time to improve haemodynamic status, and increases the effectiveness of compression sutures later

Conclusion

Hysterectomy or one-step conservative surgery is complex at first, but offers a relatively known outcome.

To leave placenta in situ provides a bloodless surgery initially, but with risks of unpredictable complications later.

Conclusion