Mm accreta


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Mm accreta

  1. 1. New trends inin treatement ofof New trends the treatement Placenta Accreta Placenta Accreta BY Dr. Manal Behery Professor Obs&Gyne Zagazig University 2013
  2. 2. Definition Definition 11.8% 81.6% J Clin Ultrasound 2008;9:551-9 6.6%
  3. 3. INCIDENCE In a 1977 report, the incidence in the published literature was estimated to be 1 in 7000 deliveries.  Miller and colleagues reported an incidence of abnormal placentation of 1 in 2510 for a 10-year period at their center ending in 1994. Wu and colleagues reported an incidence of 1 in 533 over a 20-year period ending in 2002.
  4. 4. Frequency of placenta observational study that In a large prospective accreta according to number of cesarean deliveries and presence or absence of considered the number of prior cesarean deliveries placenta previa and presence or absence of placenta previa,the risk of placenta accreta was Cesarean Delivery First (primary) Second Third Fourth Fifth ≥ Sixth Placenta previa No Placenta previa 3.3% 11% 40% 61% 67% 67% 0.03% 0.2% 0.1% 0.8% 0.8% 4.7% Adapted from SMFM. Am J Obstet Gynecol 2010.
  5. 5. Which imaging modalities are necessary The Diagnosis Of Placenta Accreta? 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
  6. 6. 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.
  7. 7. MRI findings suggestive of placenta accreta include • Lower uterine bulging, • Heterogeneous placenta • Dark intraplacental linear bands on T2-weighted images.
  8. 8. Which is better ? Diagnostic accuracy of both US and MRI are similar. In patients with suspected placenta percreta MRI can provide information on depth of invasion and may be particularly useful in the diagnosis of posteriorly located placenta.  In such cases MRI can be complmentary to US
  9. 9. How is prenatal care different in the patient with placenta accreta?  Patients should ideally be referred to a tertiary center with adequate surgical facilities and a multidisciplinary team • Occasionally, patients may require recombinant erythropoietin as adjuvant therapy • sonographic follow up every 3 to 4 weeks to evaluate placental location, depth of invasion, and fetal growth
  10. 10. Delivery planning  The preferred strategy was delivery at 34 weeks without amniocentesis for placenta previa with suspected accreta,and for cases with recurrant bleeding An expert opinion in 2010 recommended delivery for uncomplicated previa at 36 -37 weeks and 34 to 35 weeks for suspected placental invasion.
  11. 11. What should be included in the consent What should be included in the consent form for caesarean section? form for caesarean section? 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.
  12. 12.  Thorough discussion with patient on the suspected diagnosis, the anticipated surgical procedure high potential for hysterectomy, profuse hemorrhage, probable transfusion needs, increased complications
  13. 13. A preoperative checklist would be helpful in confirming necessary preparations and for identifying contact persons in case perioperative assistance is required.
  14. 14. Which preoperative interventions are beneficial for patients with suspected accreta to decrease transfusion needs?
  15. 15. Acute normovolemic Acute normovolemic hemodilution(ANH) hemodilution (ANH)
  16. 16. Preoperative bilateral common iliac Preoperative bilateral common iliac artery balloon catheter placement artery balloon catheter placement with with inflation after delivery of the inflation after delivery of the fetus fetus
  17. 17. preoperative placement femoral preoperative placement ofof femoral access by IR with selective embolization of access by IR with selective embolization uterine vessels at the time of delivery of uterine vessels at the time of delivery
  18. 18. Level of evidance D No sufficient evidences for a firm recommendation on the use of balloon catheter occlusion or embolization to reduce blood loss and improve surgical outcome. There have been other reports of no benefits and even of significant complications.
  19. 19. What the optimal anesthetic technique What isis the optimalanesthetic technique for patients with placental accreta for patients with placental accreta? ? • When massive blood loss is expected, a complete sympathectomy (eg, spinal anesthesia) could impair the patient’s ability to cope with sudden hypovolemia, as the capacity to vasoconstrict and increase systemic vascular resistances will be limited. • Regional anesthesia with a continuous epidural technique is safe and may be appropriate for patients with placental accreta
  20. 20. SO If extensive dissection, prolonged If extensive dissection, prolonged operating time, and massive hemorrhage operating time, and massive hemorrhage are anticipated, general anesthesia is are anticipated, general anesthesia is commonly recommended. 1 commonly recommended. 1 When regional anesthesia was first used a reported rate of conversion to general anesthesia of about 28% to 30%
  21. 21. Can the cell saver (salvage) be used in these cases?
  22. 22. Intraoperative cell salvage Intraoperative cell salvage • It has been used successfully in obstetric hemorrhage lacerations of the genital tract(6%) • A theoretical concern with the use of the cell saver in obstetrics is the occurrence of iatrogenic amniotic fluid embo-lism (AFE) • Rh negative should receive anti-D immunoglobulin as soon as possible with a dose given according to results of a Kleihauer Betke
  23. 23. 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.
  24. 24. Resources Patient, clinical and anatomic features Decision Definitive treatment Limited experience or expertise, poor resources or no facilities for safe patient transfer lower segment invasion vaginal bleeding with high suspicion of accreta Possibility of percreta Extraplacental hysterotomy, Placental left in situ Followed by uterine closure Delayed hysterectomy or conservative procedure according clinical and surgical status Qualified and experienced team, adequate hospital resources No desire for future pregnancy Tissue destruction> 50% of uterine circumference Resective surgery Intractable haemorrhage DIC Subtotal hysterectomy for upper segment lesions Total hysterectomy for lower segment and cervical involvement Qualified and experienced team, adequate hospital resources Desire for future pregnancy Destruction < 50% of uterine axial circumference Minor coagulation disorders Placenta in situ with or witho MXT OR One step surgery Conservative surgery
  25. 25. 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
  26. 26. The definite treatment for placental accreta is • Cesarean hysterectomy, ideally without attempts to remove the placenta. • In cases in which the placenta has been distorted and massive hemorrhage ensues, any delays in definite treatment (hysterectomy) may seriously compromise maternal hemodynamics • Patients with no interest in future child-bearing likely will also benefit from hysterectomy without delay.
  27. 27. Cesarean hysterectomy” total or subtotal ?“
  28. 28. 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.
  29. 29. Therapeutic practice points 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.
  30. 30. 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.
  31. 31. Planning of uterine incision
  32. 32. No attempt at placenta removaL No attempt at placenta removaL Placenta left in situ 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 in these cases will often incite significant hemorrhage
  33. 33. Is there a role for conservative treatment in placental accreta?
  34. 34. In selected conservative approach In selected cases acases a conservative may be attempted. approach may be attempted. Hemodynamically stable patients with no heavy bleeding or DIC at time of surgery women who desire to have more children Cases with placenta percreta invading adjacent organs (eg, bladder, ureter, bowel)
  35. 35. Morbidity can be high and that further Patient shouldoften bebe willing to intervention will also necessary accept that Outcome is unpredictable Morbidity can be high Strict prolonged followc up is needed  and that further intervention will often be necessary
  36. 36. Different techniques have been described. Different techniues have been In cases involving only focal accreta found incidentally at the time of surgery, attempts to place local haemostatic sutures may control bleeding after placental removal) Alternatively, the placenta may be partially left in situ
  37. 37. The conservative approach may be The conservative approach combined withcombined with may be • Administration of uterotonics, intraoperative uterine devascularization, or pelvic arterial embolization by interventional radiology. • The use of prophylactic antibiotics may be considered,despite lack of clinical data. • No convincing evidence exists for or against the use adjuvant methotrexate,
  38. 38. Option of Conservative ttt 1-One step suregery 2-Adjuvant methotrexate (MTX) treatment, 3-Curettage, 4-Tamponade of the placental implantation site with inflated intrauterine ballon catheter bags, 5- Lower segmant compression suture 6-Local excision, and repair or oversewing of the implantation site
  39. 39. The Triple-P procedure for placenta percreta • 1-perioperative placental localization and delivery by incision above the upper border of the placenta 2- pelvic devascularization; 3- placental non-separation with myometrial excision and reconstruction of the uterine wall International Journal of Gynecology & Obstetrics Volume 117, Issue 2, May 2012, Pages 191–194
  40. 40. Pelvic pressure packing 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.
  41. 41. Optimal postdelivery follow-up of patients treated with this pproach. No guidelines exist regarding the optimal postdelivery follow-up Postpartum hemorrhage may happen up to 105 days after the initial procedure  Serial ultrasounds to assess placental involution and frequent visits to screen for delayed hemorrhage and early signs of sepsis
  42. 42. Conclusion Conclusion
  43. 43. Conclusion Access to pelvic subperitoneal spaces wide opening of vesicouterine space planned hysterotomy,  management of proximal vascular control,  and accurate use of compression sutures are key to achieving vascular control and haemostatic procedures.
  44. 44. Conclusion Carrying out hysterectomy during shock or coagulopathy implies a high risk of immediate and late complications. Use of effective vascular control, such as internal aortic compression may provide time to improve haemodynamic and haemostatic status, which increases the effectiveness of compression sutures later
  45. 45. 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.
  46. 46. Which mechanisms lead to acute coagulopathy? • Classically, hemorrhage resuscitation has been centered on administration of crystalloids and (PRBC). • Use of other blood products, like FFP,CPPT,PTS is indicated if laboratory values are abnormal • (eg, platelet count <50,000/mm 3, , fibrinogen <100 mg/dL, [PT] or [aPTT >1.5 normal). • These current transfusion guidelines fail to prevent coagulopathy in massive bleedings.
  47. 47. Patients with crystalloid/PRBC-based resuscitation will frequently develop • Dilution of clotting factors and platelets, leading to the so called dilutional coagulopathy. The latter • may be complicated by hypothermia and acidosis, both of which lead to coagulation dysfunction.
  48. 48. What Is Hemostatic Resuscitation, What Is Hemostatic Resuscitation, And Does It Improve Outcomes? And Does It Improve Outcomes? Hemostatic resuscitation is a new concept that mainly involves 3 aspects:
  49. 49. 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
  50. 50. Aggressive crystalloid resuscitation is avoided to prevent hemodilution and early clot dislodgement secondary to increases in blood pressure as a result of volume expansion.
  51. 51. Prior to surgical control of hemorrhage, permissive hypotension with systolic blood pressures between 80 and 100 mmHg may be optimal to limit ongoing blood loss.
  52. 52. the rationale for early administration of fresh frozen plasma and platelets with PRBC in a ratio of 1:1:1. is to achieves hemostasis earlier, thus decreasing the total number of blood products given
  53. 53. Is there a role for the use of recombinant factor vii a? • 17 RCT have been reported in different subgroups of patients in which r FVIIa was used to control hemorrhage. 4 of them found a reduction in transfusion requirements or blood loss, and none reported a survival benefit. • Overall, r FVIIa decrease the amount of blood transfused, but data on survival benefit are lacking
  54. 54. What Is Abdominal Compartment Syndrome?
  55. 55. In cases where massive resuscitation takes place Any space-occupying mass, like a hematoma, will increase intra-abdominal pressure. Both crystalloid and colloid administration lead to third spacing of fluid with subsequent bowel edema and ascitis. Extensive surgical procedures are commonly associated with ileus, which may also favor intraabdominal hypertension.
  56. 56. Put together, all to be familiar Obstetricians need these factors may Obstetricians need to be familiar increase the intra-abdominal preswith this complication, as the with this complication, as the sure to a point where compression administration of more fluid in an administration abdominal and in an of more fluid of the attempt to increase blood pressure attempt to increase blood pressure retroperitoneal vessels will andcompromise preload to the heart, and urine output will only worsen urine output will only worsen intra-abdominal pressures andoutput intra-abdominal pressures and leading to a drop in cardiac and, consequently, in blood hemodynamics. hemodynamics. pressure
  57. 57. If the condition is suspected, a bladder If the condition is suspected, a bladder pressure should be obtained at the pressure should be obtained at the bedside as a surrogate of abdominal bedside as a surrogate of abdominal pressure. pressure. Normal abdominal pressures are 0 to Normal abdominal pressures are 0 to 10 mm Hg. Abdominal hypertension 10 mm Hg. Abdominal hypertension is defined as an intracavitary pressure is defined as an intracavitary pressure greater than 12 mm Hg. Abdominal greater than 12 mm Hg. Abdominal compartment syndrome includes a compartment syndrome includes a pressure greater than 20 mm Hg pressure greater than 20 mm Hg
  58. 58. Once the diagnosis is established, most patients will require surgical decompression, with a vacuum-assisted surgical decompression, with a vacuum-assisted closure closure Enteral feeding and limitation of fluid therapy are Enteral feeding and limitation of fluid therapy are beneficial. beneficial. If fluids are required, the use of colloids (eg, If fluids are required, the use of colloids (eg, albumin) is recommended over crystalloids. albumin) is recommended over crystalloids.