![Reliability :
• SensiDvity
-‐
93%
• Specificity
-‐
79%
The
use
of
power
Doppler,
color
Doppler,
or
three-‐
dimensional
imaging
does
not
significantly
improve
the
diagnos%c
sensi%vity
compared
with
that
achieved
by
grayscale
Ultrasonography
alone.
[
Chou
MM,
Ho
ES,
Lee
YH.
Prenatal
diagnosis
of
placenta
previa
accreta
by
transabdominal
color
Doppler
ultrasound.
Ultrasound
Obstet
Gynecol
2000;15:28–35.
]
3-‐Feb-‐19
Dr
Shashwat
Jani.
99099
44160.
17](https://image.slidesharecdn.com/adherentplacentaadvancesinpredictiondiagnosismanagement-190203053938/85/Adherent-placenta-17-320.jpg)
![Laboratory Findings :
•
Several
series
and
case
reports
have
reported
an
associaDon
between
placenta
accreta
and
otherwise
unexplained
elevaDons
in
second
trimester
MSAFP
concentraDon
(>2
or
2.5
mulDples
of
the
median
[MOM]).
•
Although
an
elevated
MSAFP
level
supports
an
ultrasound-‐based
diagnosis
of
placenta
accreta,
it
is
an
inconsistent
finding
and
is
not
useful
by
itself
for
diagnosis
of
accreta.
3-‐Feb-‐19
Dr
Shashwat
Jani.
99099
44160.
22](https://image.slidesharecdn.com/adherentplacentaadvancesinpredictiondiagnosismanagement-190203053938/85/Adherent-placenta-22-320.jpg)
Uploaded byKawita Bapat
Adherent placenta
This document discusses adherent placenta, beginning with an introduction defining it as an abnormal invasion of the placenta directly into the uterus due to a defect in the decidua basalis. It then covers the types of adherent placenta, risk factors, incidence, significance, diagnosis, and methods for diagnosing adherent placenta antenatally through clinical suspicion and ultrasound techniques like color Doppler to improve outcomes. The goal is to emphasize the importance of early antenatal diagnosis to avoid catastrophic emergencies.
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Adherent placenta
- 1. ADHERENT PLACENTA Advances in Prediction Diagnosis & Management DR. KAWITA BAPAT INDORE
- 2. Welcome to One Centre for Gynaecological Excellence
- 4. INTRODUCTION Adherent placenta Occurs When there is a Defect in the Decidua Basalis ResulDng In an Abnormal invasion of the placenta Directly into the substance of the uterus
- 5. Types 1 ) Simple Adherent Placenta. 2 ) Morbidly Adherent Placenta : i ) Placenta Accreta ii ) Placenta Increta iii) Placenta Percreta DR. KAWITA BAPAT 5
- 6. INCIDENCE Ø It varies widely all over the world. Ø Increased dramaDcally over the last 3 decades ( Because of Increase in LSCS rate … J ). Ø A.C.O.G. à 1 Per 2500 deliveries. Accreta : 75 -‐78 % Increta : 15 – 18 % Percreta : 5 -‐7 % DR. KAWITA BAPAT 6
- 7. Associated Condition : Ø Placenta Previa Ø Previous Surgeries such as … -‐ Cesarean SecDon -‐ D & C -‐ Myomectomy -‐ M.R.P. -‐ Synecolysis -‐ Cornual ResecDon Ø Uterine MalformaDon Ø SepDc EndometriDs 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 7
- 8. Risk Factors : Ø High Parity Ø Advanced Maternal Age Ø Down Syndrome Ø High level of Maternal Serum AFP. Ø High level of Maternal free Beta hcg. 8
- 9. ETIOLOGY : Ø Defec%ve decidual forma%on : -‐ ParDal / total absence of decidua basalis -‐ Imperfect development of fibrinoid layer (Nitabuch layer) -‐ Placental villi are acached to the myometrium 9
- 10. Significance : Ø Increased Maternal Morbidity ( 2 – 7 % ) Ø Increased Maternal Mortality ( 7 – 10 % ) from, -‐ Severe Hemorrhage -‐ InfecDon -‐ Inversion of Uterus 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 10
- 11. InteresDngly, the sex ra%o associated with placenta accreta favors females, which is opposite to the normal sex ra%o in the general popula%on, which favors males… J 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 11
- 12. DIAGNOSIS Ø Earliest diagnosis of Adherent Placenta is must to avoid any catastrophic emergency in future. Ø Antenatal diagnosis is the single most important factor in improving the outcome in MAP. 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 12
- 13. METHODS… Ø Clinical suspicion Ø Ultrasound Ø Color Doppler Ø MRI Ø Biochemical Marker Ø Histopathology 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 13
- 14. USG • First-‐line invesDgaDon for suspected placental invasion of the myometrium. • The most useful modaliDes for evaluaDng placental posiDon and implantaDon are transabdominal and transvaginal ultrasonography 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 14
- 15. USG CRITERIA Ø 1st Trimester : G. Sac located in the lower uterine segment (rather than the fundus), next to or lower than the Prev. CS scar. Ø 2nd & 3rd Trimester : § Presence of irregular lacunae within the placenta § Loss of retro placental clear space § Loss or disrupDon of the white line – Bladder line 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 15
- 16. Moth – eaten OR Swiss Cheese Appearance 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 16 Oblitera%on of clear space between placenta and uterine wall
- 17. Reliability : • SensiDvity -‐ 93% • Specificity -‐ 79% The use of power Doppler, color Doppler, or three-‐ dimensional imaging does not significantly improve the diagnos%c sensi%vity compared with that achieved by grayscale Ultrasonography alone. [ Chou MM, Ho ES, Lee YH. Prenatal diagnosis of placenta previa accreta by transabdominal color Doppler ultrasound. Ultrasound Obstet Gynecol 2000;15:28–35. ] 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 17
- 18. 3 D USG DiagnosDc Criteria : Ø Irregular intraplacental vascularizaDon with tortuous confluent vessels crossing placental width. Ø Hypervascularity of uterine serosa– bladder wall interface. 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 18
- 19. Colour Doppler Ø Diffuse or focal intraparenchymal lacunar flow. Ø Vascular lakes with turbulent flow. Ø Hypervascularity of serosa-‐bladder interface. Ø Prominent subplacental venous complex. 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 19
- 20. M.R.I. Ø No more sensiDve than USG , But used as an adjunct to USG , when there is strong clinical suspicion of accreta. Ø MRI achieves becer images than Ultrasonography in -‐ Posteriorly sited MAP and -‐ With prior myomectomy, ( Because the ultrasound beam is impeded by the fetal head in the former and by the scar Dssue in the lacer ) 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 20
- 21.
- 22. Laboratory Findings : • Several series and case reports have reported an associaDon between placenta accreta and otherwise unexplained elevaDons in second trimester MSAFP concentraDon (>2 or 2.5 mulDples of the median [MOM]). • Although an elevated MSAFP level supports an ultrasound-‐based diagnosis of placenta accreta, it is an inconsistent finding and is not useful by itself for diagnosis of accreta. 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 22
- 23. Histology Ø Post Partum specimen shows : Placental villi anchored directly on, or invading into or through, the myometrium, without an intervening decidual plate. 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 23
- 24. Treatment : A mul%disciplinary team approach is relevant in managing these pa%ents in order to reduce morbidity and mortality associated with MAP. 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 24
- 25. Ø ParDcular consideraDon should be given to anDcipaDon and management of massive hemorrhage, including -‐ availability of packed cells, -‐ platelets, -‐ fresh frozen plasma, -‐ cryoprecipitate, and -‐ acDvated factor VII. Ø IntervenDonal Radiology and cell saver technology are useful. 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 25
- 26. 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 Dssues with the enDre placenta restoring uterine anatomy. Ø Each one has weaknesses and strengths, dependent on the condi%on itself and the specific preferences taken by the surgeon and the team. 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 26
- 27. Ø Women who have had a previous CS Ø who also have either placenta previa or Ø an anterior placenta underlying the old CS scar at 32 weeks of gestaDon are at increased risk of placenta accreta and should be managed as if they have placenta accreta, with appropriate preparaDons for surgery made. (RCOG 2011) Ø ElecDve delivery by caesarean secDon at 34–35 weeks of gestaDon for suspected placenta accreta (ACOG 2012). 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 27
- 28. Conservative Ø In case of ( focal defect / moderate blood Loss / ferDlity to be preserved ) à Localized ResecDon with uterine repair à Over sewing of the ut. Defect à Blunt dissecDon followed by curepng the uterine cavity Uterus fails to contract (MulDpara) : Hysterectomy 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 28
- 29. Non Surgical Ø Leave the Placenta in situ to resorb with methotrexate therapy Ø LigaDon of the Ut. And Int. iliac artery Ø Fluoroscopic bilateral UAE Ø Argon beam coagulaDon for haemostasis Ø InserDon of occluding Balloons in the Int. iliac art. (Bilat) 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 29
- 30. Surgical Ø Cesarean Hysterectomy. Ø Hysterectomy and parDal / total resecDon of bladder Ø Subtotal Hysterectomy with removal of large part of placenta and ProphylacDc occlusive Balloon catheter in int. iliac art. 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 30
- 31. Ø An ElecDve controlled condiDon is preferred rather than an emergency condiDon without adequate preparaDons. Ø A midline incision will facilitate becer exposure, especially if placenta Percreta is suspected. Ø Leaving the placenta undisturbed unDl compleDon of the hysterectomy would prevent unnecessary hemorrhage. Ø In cases where MAP is associated with placenta previa, total hysterectomy is preferred to a subtotal hysterectomy. 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 31
- 32. Uterine Incision: It is best to avoid cu3ng through a MAP because of the possibility of massive haemorrhage. 32
- 33. DR. KAWITA BAPAT 33 Various modificaDons of the uterine incision to avoid the placenta have been reported… -‐ Classical incision, -‐ High transverse incision, -‐ Fundal incision, -‐ Fundal transverse incision
- 34. remember Ø The presence of pericervical or lower-‐segment varicose veins proper of placenta praevia can be confused with the neovascularizaDon of placenta accreta. Ø Surgical exploraDon will make a differenDal diagnosis, thus avoiding unnecessary hysterectomies. 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 34
- 35. Excision of placentalsite Ø It is possible to "excise the placental site". Ø This is done by inverDng the uterus in order to provide good access to the placental site. Ø If the area of placental acachment is focal and the majority of the placenta has been removed, then a "wedge resecDon" of the area can be performed. DR. KAWITA BAPAT 35
- 36. Balloon Catheterization Ø Pre-‐operaDve placement of arterial catheters in internal iliac artery Ø Aser delivery balloons are inflated to achieve temporary homeostasis Ø SelecDve arterial embolizaDon (SAE) if necessary Ø Bil. Int. iliac artery ligaDon is performed prior to peripartum hysterectomy where IntervenDonal Radiology is not available. DR. KAWITA BAPAT 36
- 37. Placement of occlusion balloon catheters into both internal iliac arteries. DR. KAWITA BAPAT 37
- 38. Methotrexate Ø A Folate Antagonist Ø Acts primarily against rapidly dividing cells Ø EffecDve against proliferaDng trophoblasts. Ø Arulkumaran et al in 1986. Ø Intravenous infusion 50 mg of methotrexate as an on alternate days Ø Placental mass was expelled on 11th postnatal day. DR. KAWITA BAPAT 38
- 39. Methotrexate Ø However, more recently, Ø others have argued that, aser delivery of the fetus, the placenta is no longer dividing and therefore, methotrexate is of no value. DR. KAWITA BAPAT 39
- 40. Ø Methotrexate has been used in varying doses and routes, however, there are no randomized trials and no standard protocol regarding its dosage. Ø The outcome when the placenta is les in place aser methotrexate administraDon varies widely; it ranges from expulsion at 7 days to progressive resorpDon in roughly 6 months. Ø Mtx – 50 mg IM + Folic Acid 6mg IM on alternate day Dll β HCG comes to zero. 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 40
- 41. Other Modalities 1. Tamponade of the placental implantaDon site with inflated Intra Uterine balloon catheter bags. 2. Lower Segment Compression Sutures. 3. Pelvic pressure sponge packing. DR. KAWITA BAPAT 41
- 42. Follow up… 1.-‐ Ultrasound exams & Vascularity 2.-‐ HCG Dters weekly Dll become Zero. 3.-‐ Daily Temps, Other S&S of infecDon 4.-‐ Bleeding 5.-‐ CoagulaDon profile AnDbioDc Maximum for 10 days. DR. KAWITA BAPAT 42
- 43. 3-‐Feb-‐19 Dr Shashwat Jani. 99099 44160. 43 Resources Pa:ent, clinical and anatomic features Decision Defini:ve treatment • Limited experience or experDse • Poor resources • no faciliDes for safe paDent transfer ü lower segment invasion ü vaginal bleeding with high suspicion of accreta ü Possibility of percreta • Extraplacental hysterotomy • Placental les in situ • Followed by uterine closure Delayed hysterectomy or conservaDve procedure according clinical and surgical status • Qualified Experienced team • Adequate hospital resources Ø No desire for future pregnancy Ø Tissue destrucDon> 50% of uterine circumference Ø Intractable haemorrhage Ø DIC ResecDve surgery Subtotal hysterectomy for upper segment lesions Total hysterectomy for lower segment and cervical involvement • Qualified and experienced team, • Adequate Ø Desire for future pregnancy Ø DestrucDon < 50% of uterineaxial circumference Ø Minor coagulaDon disorders ConservaDve surgery 1-‐Placenta in situ with or wit MXT 2-‐One step surgery OR 3-‐ Two step surgery
- 44. Bladder Involvement Ø First , Involve UROLOGIST Ø PreoperaDve Ureteric stenDng aids in idenDfying the ureters Ø which will help reduce ureteric injuries 44
- 45. Care must be taken during surgery Ø Not to acempt to dissect the bladder off the lower uterine segment Ø which results in torrenDal bleeding Ø Anterior bladder wall incision is parDcularly helpful in defining dissecDon planes and the locaDon of the ureters DR. KAWITA BAPAT
- 46. Reality : • Eventoday, the ground reality is that a majority of morbidly adherent placenta are diagnosed during • Third stage of labour • During caesarean section • which results in adverse consequences including exanguinating haemorrhage.
- 47. To Conclude Ø Caesarean hysterectomy was the cornerstone in the management in the Past. Ø Antenatal diagnosis permits effecDve and safe conservaDve approaches Today. Ø The use of methotrexate, monitoring with serum hCG and follow up with USG is backed only by conflicDng evidence. DR. KAWITA BAPAT 47
- 48. 3-‐Feb-‐19 48 Dr Shashwat Jani. 9909944160