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Similar to How to reduce maternal morbidity and mortality in women with morbidly adherent placenta (zakaria sanad,menoufiya,egypt )
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How to reduce maternal morbidity and mortality in women with morbidly adherent placenta (zakaria sanad,menoufiya,egypt )
- 1. How to reduce Maternal Morbidity and Mortality in women with MAP Zakaria Sanad , MD Professor,Obstetrics and Gynecology Department Faculty of Medicine , Menoufiya University , Egypt
- 2. Morbidly adherent placenta ( MAP ) • Occurs when the placenta is abnormally adherent to the myometrium as a result of partial or complete absence of the decidua basalis and Nitabuch layer . • MAP is an uncommon but potentially lethal complication of pregnancy . • Derived from Latin ac- + crescere , to grow from adhesion or coalesce .
- 3. Incidence and Risk factors 1 in 533 deliveries • Primary- uterine malformation,adenomyosis -submucous myoma,myotonic dystrophy • Secondary : - Placenta previa - uterine surgery ( CD, myomectomy, D&C, MRP, synecolysis, cornual resection ) - Advanced maternal age , multiparity - IVF , female fetus , septic endomet, Asherman Risk 3%,11%,40%,60%,67% in PP + 1-5 CDs
- 4. Classification Depth of Invasion of Trophoblast • Accreta : villi attached to the myometrium • Increta : villi invade the myometrium • Percreta : villi penetrate through the myometrium and / or serosa , adjacent organs Area of Placenta involved • Focal : single coteyledon involved • Partial : few cotyledons involved • Total : all cotyledons involved
- 7. Diagnosis • Clinical suspicion • Ultrasoud • Color and power Doppler • MRI • Biochemical markers • Histopathology
- 8. Diagnosis US (sensitivity 90% , specificity 97% )
- 10. TV US at 6 W gestation showing a large CDSD ( niche )
- 11. TV grey scale US at 20 W ( moth-eaten app )
- 14. TA color mapping US at 20 W gestation ( chaotic IP blood flow, abnormal retropl BVs, aberrant BVs traversing bet placental surfaces )
- 15. Color Doppler
- 16. Sagittal and axial MRI at 25 W preg w MAP (absent dark area of myometrium, prominent vessels invading the bladder )
- 19. Morbidity (60%) and Mortality (7-10%) • Postpartum hemorrhage • Transfusion reaction, DIC • Emergency hystrectomy • ARDS, renal compromise • Multi-organ failure, ICU • Infection, sepsis • Fistula, ureteral stricture • Future pregnancy (recurrence, bleeding, transfusion, fistula, uterine rupture)
- 20. How to reduce Maternal Morbidity and Mortality in MAP ?
- 21. Management of MAP • NO RCTs , few studies • Recommendatios based on case series and reports, personal experience, expert opinion, and good clinical judgment • Prenata care : counseling about diagnosis and potential risks (hemorrhage, blood tr, cesarean hystrectomy, ICU admission, ….) • Correction of anemia, anti D, avoidance of pelvic ex and rigorous activity
- 22. • Prenatal diagnosis is pivotal to reduce M&M • Ultrasound screening at 20 W and reevaluate at 32 W ( assess bladder involvement ) • Referral to a tertiary care center of excellence • Multidisciplinary team (pelvic surgeon,urologist, anesthesiologist, neonatologist, vascular surgeon, interv radiologist, hematologist, n..) • Preoperative conference (informed consent, plan interventions, review preop U/S ) • Scheduled (planned ) delivery : personnel, equip • Antenatal corticosteroids
- 24. I am well, take care of Mom !
- 25. • Timing of delivery : 34 – 35 W/6d (optimal M and P outcome ) to avoid emergency surgery • Delivery location : main OR (equip, fluroscopy) • Vascular access : central v line, arterial line • Rapid infusion devices ( up to 6 L/h ) • General anesthesia , continuous epidural • Ureteral stents before laparotomy (percreta ) • Interventional radiologist : balloon catheters and embolization
- 26. • Blood bank preparedness : 1 to 1 ratio - PRBCs ( 10 – 20 U ) - Fresh frozen plasma ( 10 – 20 U ) - Platelets ( 12 U ) • Blood products available before surgery • Cell salvage for autologous blood • Acute normovolemic hemodilution • Compression stockings and devices (TED) • Padding and positioning (nerve comp ) • Avoid hypothermia
- 27. • Cesarean Hysterectomy : most reasonable, safest1 • Uterine Conservation with Placenta left in situ - risky2 • Uterine Conservation with Placental Resection - succ3 Surgical management of MAP
- 29. MAP
- 32. Cesarean Hysterectomy • The most commonly performed procedure • Skin incision : midline , a Cherney • Pelvis : inspected for percreta and collaterals • Intraoperative U/S : may be needed to map out the placenta • Myometrium : thin, friable, dilated vessels • Uterine incision : vertical 2 figers above placental edge (classic/fundal/ or even post) • Deliver the infant, cut the cord, repair the uterus rapidly ( blood loss )
- 33. • Round lig divided, retroperitoneum opened, ureters visualized, UO lig divided, ovaries packed away • VU peritoneum gently opened, bladder dissected without P disruption • Uterine As and collaterals ligated, ligate other vessels running to Ut • Internal illiac A ligation is of little benefit, avoid • Continue dissection below P edge • Cystostomy may be required
- 34. • Removal of the entire cervix is required • Ring forceps on cervix (identification,bleeding) • Remove whole uterus and placenta, inspect • Vascular channels on post B wall : cauterized or ligated • GU tract at risk of injury (stents,cystoscopy) • Postoperative (febrile M,bowel dysfunction) • Reoperation is required in up to 1/3 of cases (3/4 for bleeding, 1/4 for repair of injuries)
- 36. • Attempted rarely , with fully informed consent • When patient very much wants to preserve F • When hystrectomy is very risky (hge, injury ) • Extensive counseling about risks • Deliver, leave placenta undisturbed , close hysterotomy • Uterotonics , compression sutures , balloon tamponade, uterine A embolization / ligation • Antibiotics, U/S, temp, CBC, hCG (resorption) • Delayed hysteroscopic resection or D&C
- 41. • May be successful without excessive risk in : 1- Focal accreta (U/S,intapartum hge/p retained) • Potential candidates are W w clear focal accreta and accessible border of healthy myometrium • Management involves oversewing bleeding sites or wedge resection (placental-myometrial en bloc excision and repair) • Triple P procedure : Preop P localization and delivery by T incision, Pelvic devascularization, P nonseparation w myometrial excision and repair 2- Fundal or posterior PA (Bleeding treated medically, radiologically,conserv surgery,or easy hystrectomy)
- 42. Postoperative Care • An ICU bed should be available • Patients may require ventilator support due to pulmonary edema (massive fluid,fluid shift,acute lung injury related to transfusion • Some patients need vasopressor support and invasive hemodynamic monitoring • Postoperative bleeding recurrence is not uncommon (interventional radiologist )
- 43. Take-home message • MAP refers to different grades of morbid placental attachment to the uterine wall • The most important risk factors are PP and CD • MAP is a significant cause of maternal morbidity & mortality • The optimal time of delivery is 34-35W/6D after corticosteroid therapy • Accurate prenatal diagnosis w US/Doppler and referral to a tertiary care unit with planned delivery by a multidisciplinary team reduce maternal morbidity and mortality
- 44. References • Obstetrics : Normal and Problem Pregnancies , 7th edition, 2017. • Morbidly Adherent Placenta : Up to Date , 2017 (Resnik R, Silver RM ). • Jauniaux et al, A J Obstet Gynecol, 2016. • ACOG, Placenta accreta, Obstet Gynecol, 2012. • Roeca et al, Obstet Gynecol, 2017. • Fox et al, Am J Obstet Gynecol, 2015.