Placenta accreta for post graduate

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Postgraduate course lectures in Obstetrics&Gynecology
Prepared by Dr Manal Behery ,Professor of Ob &Gyne-Faculty of medicine,Zagazig University

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Placenta accreta for post graduate

  1. 1. New trends in thetreatementof New trends in treatment of Placenta Accrete Accreta Placenta DR Manal Behery Professor of Obstetrics&Gynecology Zagazig University 2013
  2. 2. Definition Definition 11.8% 81.6% J Clin Ultrasound 2008;9:551-9 6.6%
  3. 3. INCIDENCE üIn a 1977 report, the incidence in the published literature was estimated to be 1 in 7000 deliveries. üMiller and colleagues reported an incidence of abnormal placentation of 1 in 2510 for a 10-year period at their center ending in 1994. üWu 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 ? ØDiagnostic accuracy of both US and MRI are similar. ØIn 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. ØIn such cases MRI can be complmentary to US
  9. 9. How is prenatal care different in the patient with placenta accreta? Ø 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 ü The preferred strategy was delivery at 34 weeks without amniocentesis for placenta previa with suspected accreta,and for cases with recurrant bleeding ü ü üAn 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 form for caesarean section? ØThe different risks and treatment options should have been discussed and a plan agreed, which should be reflected clearly in the consent form. ØThis 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. Ø Thorough discussion with patient on üthe suspected diagnosis, üthe anticipated surgical procedure ühigh potential for hysterectomy, profuse hemorrhage, üprobable transfusion needs, üincreased 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 of femoral preoperative placement of femoral access access by IR with selective embolization by IRvessels at the time of delivery with selective embolization of of uterine uterine vessels at the time of delivery
  18. 18. Level of evidance D ØNo sufficient evidences for a firm recommendation on the use of balloon catheter occlusion or embolization to reduce blood loss and improve surgical outcome. Ø ØThere 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 operating time, and massive hemorrhage are anticipated, general anesthesia is 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. 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
  25. 25. 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.
  26. 26. Cesarean hysterectomy” total or subtotal ?“
  27. 27. 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.
  28. 28. 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.
  29. 29. 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.
  30. 30. . • Neoformation vessels should not be electrocoagulated because of poor development of the middle layer • This procedure can be the cause of bleeding difficult to control, or of a postsurgical haemorrhage.
  31. 31. Planning of uterine incision
  32. 32. 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 in these cases will often incite significant hemorrhage
  33. 33. Surgical difficulties and possibility of complications in placenta accreta are directly related to the invaded anatomical area, its specific circulation the dissection of the organs involved.
  34. 34. Is there a role for conservative treatment in placental accreta?
  35. 35. In selected cases acases a conservative In selected conservative approach may be attempted. approach may be attempted. üHemodynamically stable patients with no heavy bleeding or DIC at time of surgery • üwomen who desire to have more children üCases with placenta percreta invading adjacent organs (eg, bladder, ureter, bowel) • •
  36. 36. Morbidity can be high and that further Patient shouldoften bebe willing to intervention will also necessary accept that üOutcome is unpredictable üMorbidity can be high üStrict prolonged followc up is needed üand that further intervention will often be necessary
  37. 37. Different techniques have been described. Different techniues have been üIn cases involving only focal accreta found incidentally at the time of surgery, attempts to place local haemostatic sutures may control bleeding after placental removal) ü üAlternatively, the placenta may be partially left in situ
  38. 38. The conservative approach may be The conservative approach combined with may be combined with • 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,
  39. 39. 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
  40. 40. 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
  41. 41. Pelvic pressure packing q qFor persistent diffuse non arterial bleeding that is not amenable to surgical control, q q qPlacement 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.
  42. 42. Optimal postdelivery follow-up of patients treated with this pproach. üNo guidelines exist regarding the optimal postdelivery follow-up üPostpartum hemorrhage may happen up to 105 days after the initial procedure üSerial ultrasounds to assess placental involution and frequent visits to screen for delayed hemorrhage and early signs of sepsis
  43. 43. Conclusion Conclusion
  44. 44. Conclusion üAccess to pelvic subperitoneal spaces üwide opening of vesicouterine space ü üplanned hysterotomy, ümanagement of proximal vascular control, üand accurate use of compression sutures are key to achieving vascular control and haemostatic procedures.
  45. 45. Conclusion üCarrying out hysterectomy during shock or coagulopathy implies a high risk of immediate and late complications. ü üUse 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
  46. 46. Conclusion üHysterectomy or one-step conservative surgery is complex at first, but offers a relatively known outcome. ü ü üTo leave placenta in situ provides a bloodless surgery initially, but with risks of unpredictable complications later.
  47. 47. 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.
  48. 48. 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.
  49. 49. What Is Hemostatic Resuscitation, And Does It Improve Outcomes? Hemostatic resuscitation is a new concept that mainly involves 3 aspects:
  50. 50. 1. Limited early aggressive use of crystalloids and consideration of permissive hypotension 2. 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
  51. 51. Aggressive crystalloid resuscitation is avoided to prevent hemodilution and early clot dislodgement secondary to increases in blood pressure as a result of volume expansion.
  52. 52. 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.
  53. 53. 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
  54. 54. 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
  55. 55. What Is Abdominal Compartment Syndrome?
  56. 56. In cases where massive resuscitation takes place ØAny space-occupying mass, like a hematoma, will increase intra-abdominal pressure. Ø ØBoth crystalloid and colloid administration lead to third spacing of fluid with subsequent bowel edema and ascitis. ØExtensive surgical procedures are commonly associated with ileus, which may also favor intraabdominal hypertension.
  57. 57. Put together, all to be familiar Obstetricians need these factors may increase the intra-abdominal preswith this complication, as the sure to a point where compression administration of more fluid in an of the abdominal and attempt to increase blood pressure retroperitoneal vessels will andcompromise preload to the heart, urine output will only worsen intra-abdominal pressures and leading to a drop in cardiac output and, consequently, in blood hemodynamics. pressure
  58. 58. If the condition is suspected, a bladder pressure should be obtained at the bedside as a surrogate of abdominal pressure. Normal abdominal pressures are 0 to 10 mm Hg. Abdominal hypertension is defined as an intracavitary pressure greater than 12 mm Hg. Abdominal compartment syndrome includes a pressure greater than 20 mm Hg
  59. 59. Once the diagnosis is established, most patients will require üsurgical decompression, with a vacuumassisted closure ü üEnteral feeding and limitation of fluid therapy are beneficial. ü üIf fluids are required, the use of colloids (eg, albumin) is recommended over crystalloids.
  60. 60. Thanks for your attention!

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