SCAR PREGNANCY AND PLACENTA ACCRETA AFTER

CESAREAN.

Mandruzzato G.P.Trieste,italy

SCAR PREGNANCY:DEFINITION

IMPLANTATION OF A PREGNANCY ON A UTEROTOMIC SCAR(IN THE MAJORITY OF THE CASES AFTER CESAREAN).

CSP : EPIDEMIOLOGY.

The prevalence of CSP is estimated1/1800-1/2500 after one or more cesarean.

PROBABLY UNDERESTIMATED!EXPECTED TO INCREASE !

ABNORMAL ADHERENT PLACENTATION

PLACENTA: ACCRETA,INCRETA,PERCRETA.

PLACENTA ACCRETA: EPIDEMIOLOGY

1/533 PREGNANCIES0.3 % OF ALL DELIVERIES

10 FOLD INCREASE IN THE LAST 50 YEARS!

SCAR PREGNANCY: RISK FACTORS

PREVIOUS CESAREAN,MYOMECTOMY,HYSTEROSCOPY,

CURETTAGE,MANUAL REMOVAL OF THE PLACENTA.

PLACENTA ACCRETARISK FACTORS

PREVIOUS CESAREAN,MYOMECTOMY,RESECTOSCOPIC MYOMECTOMY,

ENDOMETRIUM THERMAL ABLATION.

CSP AND PLCENTA ACCRETA RISK FACTORS AND ETIOLOGY.

are similar for the two conditions:trophoblastic invasion of the myometrium where the endometrium layer is strongly reduced or absent and the decidual reaction is scant or absent.

Timor-Trotsh I.and co.Cesarean scar pregnancy and early placenta accreta share a common histology.

Ultrasound Obstet.Gynecol. 21013,dec 19.

CLINICAL MANIFESTATIONCSP:

early and first half of pregnancy.PLACENTA ACCRETA :

late pregnancy,delivery,post partum.

COMPLICATIONS.HEMORRHAGE OFTEN DIFFICULT TO CONTROL,LIFE THREATENING,OFTEN

REQUIRING HISTERECTOMY,INVASION OF PROXIMAL ORGANS.

CSP:DIAGNOSIS.

DIFFICULT!MISSED DIAGNOSIS IN 14 % OF THE CASES!

Unforeseen consequences of the increaasing rate of cesarean deliveries :early placenta accreta and cesarean scar pregnancy:A review.Timor-Trietsh I. and co.

Am.J.Obstet.Gynaecol. 2012,207,14.

CSP DIAGNOSIS:

METHOD OF CHOICE:TVS ULTRASOUND WITH COLOR FLOW MAPPING.

IN SOME CASES TA ULTRASOUND AND NMR.

CSP:MANAGEMENT

1.PHARMACOLOGICAL2.SURGICAL

CSP PHARMACOLOGOCAL TREATEMENT

METOTREXATE1.LOCALLY

2.SYSTEMIC3.COMBINED

CSP:SURGICAL TREATEMENT

1.UTERINE ARYTERY EMBOLIZATION2.RESECTION(HYSTEROSCOPIC,LAPAROSCOPIC,LAPAROTOMIC).

CSP MANAGEMENT. ALL THE STUDIES ARE CASE REPORTS OR BASED ON SMALL NUMBERS!

IMPOSSIBLE AT THE MOMENT TO OFFER EVIDENCE BASED RECOMMENNDATIONS!

CSP PREVENTION.

1.RESECTION OF THE UTERINE WALL DEFECT?2.TECHNIQUE OF UTEROTOMY REPAIR AT CESAREAN?

PLACENTA ACCRETA: DIAGNOSISMETHOD OF CHOICE:

TV OR TA ULTRASOUND WITH COLOR FLOW MAPPING.

SOMETIME NMR.

PLACENTA ACCRETA:MANAGEMENT.

1.SURGICAL. 2.MECHANICAL.

3.PHARMACOLOGICAL.

PLACENTA ACCRETA:ANTEPARTAL DIAGNOSED.

MOST COMMONLY PERFORMED IS CESAREAN HYSTERECTOMY.

TIMING OF DELIVERY ?UTERINE ARTERIES EMBOLIZATION

REFERRAL CENTERS!PERCRETA: URETERAL STENTS

CONSERVATIVE TREATEMENT.1.UTERINE SUTURES(B-LYNCH)

2.BAKRY BALLON3.SULPROSTONE

4.PARTIAL PLACENTA REMOVAL5.UTERINE DEVASCULARIZATION

FERTILITY AFTER CONSERVATIVE TREATEMENT.

1.SMALL SERIES2.NO RCT

TAKE HOME MESSAGES

CONCLUSIONS 1.EARLY RECOGNITION OF THE SITE OF IMPLANTATION IN CASE OF PREVIOUS CS IS CRUCIAL

obstetrical ultrasound in early pregnancy

EXSAUSTIVE COUNSELLING ABOUT RISKS AND POSSIBILITIES!

CONCLUSIONS 2.

REFER TO CENTERS WITH POSSIBILITY OF

MULTIDISCIPLINARY APPROACH.

CONCLUSIONS 3.AVOID UNECCESARY PRIMARY CS !!!

THANK YOU FOR ATTENTION.