New trends in the treatment of placenta accreta


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New trends in accreta treatment,Post graduate course lecturers in Obstetrics&Gynecology ,Faculty of medicine,Zagazig University

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New trends in the treatment of placenta accreta

  1. 1. ‫بسم ا الرحمن‬ ‫الرحيم‬
  2. 2. New trends inin treatement ofof New trends the treatement Placenta Accreta Placenta Accreta BY Dr. Manal Behery Assistant Professor Obs&Gyne Zagazig University
  3. 3. Definition Definition 11.8% 81.6% J Clin Ultrasound 2008;9:551-9 6.6%
  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 Which Imaging Modalities Are Necessary For for the diagnosis of placenta accreta? 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. 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.
  9. 9. 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.
  10. 10.  Thorough discussion with PT of the on the suspected diagnosis, the anticipated surgical procedure high potential for hysterectomy, profuse hemorrhage, probable transfusion, increased complications
  11. 11. A preoperative checklist would be helpful in confirming necessary preparations and for identifying contact persons in case perioperative assistance is required.
  12. 12. Which preoperative interventions are beneficial for patients with suspected accreta to decrease transfusion needs?
  13. 13. Acute normovolemic Acute normovolemic hemodilution (ANH) 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
  14. 14. What is the optimal anesthetic technique for patients with placental accreta? If extensive dissection, prolonged If extensive dissection, prolonged operative time, and massive hemorrhage operative time, and massive hemorrhage are anticipated, general anesthesia is are anticipated, general anesthesia is commonly recommended. commonly recommended. When regional anesthesia was first used a reported rate of conversion to general anesthesia of about 28% to 30%
  15. 15. 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:
  16. 16. 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
  17. 17. 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.
  18. 18. 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.
  19. 19. 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 uterineaxial circumference Minor coagulation disorders 1-Placenta in situ with or wit MXT 2-One step surgery OR Conservative surgery 3- Two step surgery
  20. 20. 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.
  21. 21. 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.
  22. 22. 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.
  23. 23. Bladder invasion with In In cases of bladder involvement Most obstetricians choose a conservative approach •arterial embolisation. In cases of bladder involvement, most with obstetricians choose a conservative If bleeding cannotwith packing with laparotomy pads can approach stop, arterial embolisation. If 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.
  24. 24. 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
  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. Two-step conservative surgery  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.
  27. 27. a safe area, and the umbilical cord is cut near the placenta. The invaded area and the placenta are left in situ without any attemp No attempt at placenta removal Placenta left in situ • area. 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 .
  28. 28. Option of Conservative ttt 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
  29. 29. 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.
  30. 30. a safe area, and the umbilical cord is cut near the placenta. The invaded area and the placenta are left in situ without any attemp Optimal post-delivery follow-up • area. 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
  31. 31. Conclusion Conclusion
  32. 32. Keys to achieving vascular control and Keys to achieving vascular control and haemostatic procedures. haemostatic procedures. Access to pelvic subperitoneal spaces Wide opening of vesicouterine space Planned hysterotomy  Management of proximal vascular control, Accurate use of compression sutures
  33. 33. Conclusion 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
  34. 34. 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.