Placenta accreta for postgraduate

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. Definition
Definition
11.8%
81.6%
J Clin Ultrasound 2008;9:551-9
6.6%

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. 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. 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. 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. MRI findings suggestive of placenta
accreta include
• Lower uterine bulging,
• Heterogeneous placenta
• Dark intraplacental linear bands
on T2-weighted images.

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. 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. 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. 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.  Thorough discussion with patient
on
the suspected diagnosis,
the anticipated surgical procedure
high potential for hysterectomy,
profuse hemorrhage,
probable transfusion needs,
increased complications

13. A preoperative checklist would be
helpful in confirming necessary
preparations and for identifying contact
persons in case perioperative assistance
is required.

14. Which preoperative interventions are
beneficial for patients with suspected accreta
to decrease transfusion needs?

15. Acute normovolemic
Acute normovolemic
hemodilution(ANH)
hemodilution (ANH)

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. 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. 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. 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. 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. Can the cell saver (salvage) be
used in these cases?

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. 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. 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. 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. 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. Cesarean
hysterectomy”
total or subtotal ?“

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. 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. 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.

32. Planning of uterine incision

33. 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

35. Is there a role for
conservative treatment in
placental accreta?

36. 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)

37. 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

38. 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

39. 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,

40. 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

41. 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

42. 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.

43. 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

44. Conclusion
Conclusion

45. 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.

46. 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

47. 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.

48. 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.

49. 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.

50. 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:

51. 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

52. Aggressive crystalloid
resuscitation is avoided to
prevent hemodilution and early
clot dislodgement secondary to
increases in blood pressure as
a result of volume expansion.

53. 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.

54. 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

55. 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

56. What Is
Abdominal Compartment
Syndrome?

57. 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.

58. 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

59. 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

60. 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.