This document discusses morbidly adherent placenta, which occurs when the placenta attaches abnormally deeply into the uterine wall. The incidence has increased from 1 in 2500 deliveries in the 1980s to 1 in 553 deliveries in 2015. Risk factors include prior C-sections, uterine surgery, and multiple pregnancies. Ultrasound is useful for diagnosis but may miss some cases. Management options include C-section hysterectomy, leaving the placenta in situ, myometrial resection, the triple P procedure, compression sutures, and lower segment folding. Conservative options have high risks of infection and bleeding requiring additional surgery.

1. Morbidly
adherent
placenta
By
Magdy A. Elkardosy
Lecturer of OB/GYN
2019

2. Nomelclature:
Morbidly adherent placenta.
Placenta accreta spectrum.

4. Placenta accreta spectrum results
from the absence of the normal
decidua basalis, usually from surgical
trauma.
Trophoblaste attaches to or invades
the exposed and scarred
myometrium.

5. INCIDENCE
1 in 2500 deliveries in the 1980s.
(Miller DA et al, 1997)
1 in 553 deliveries in 2015.
(Bailit JL et al 2015)

6. Risk factors
All invasive procedures on the uterus
1. Previous CS.
2. Uterine curettage
3. Hysteroscopic surgery
4. Endometrial ablation
5. Uterine artery embolization
6. Myomectomy

7. Risk factors
The most important risk factor is Prior CS.
First: 0.24%
Second: 0.31%
Third: 0.57%
Fourth: 2.13%
Fifth, and sixth or more: 6.74%

8. DIAGNOSIS

9. Diagnosis of placenta previa.
TVS more accurate than TAS
Clinical suspicious
Absence of antepartum Hge.

10. Ultrasound
Sensitivity 77-90%, Specificity 71-97%.
 Loss of hypo-echoic retro-placental myometrial
zone
 Thinning, disruption of serosa-bladder interface
 Increased vascularity at uterine-bladder interface
 Increased intra-placental vascular lacunae

12. MANAGEMENT
OPTIONS

14. Timing of elective termination
34w …….. International guideline.
37w ???

15. Pre-requisite for Operation
Cross matched blood.
Available ICU place.
Senior obstetrician & anesthetist.
Consent for hysterectomy & bladder injury.

16. Management options
CS hysterectomy
Conservative management
Leaving the placenta in situ.
Myometrial resection.
Triple p procedure.
Compression sutures.
Lower segment folding. ( pouch closure)

17. CS Hysterectomy
Upper segment CS followed by planned
total hysterectomy.
No attempt to remove the placenta.
Disadvantage:
 Serious morbidity & loss of fertility.
 Psychological sequences.
 Bladder & ureteral injuries.

19. Leaving the placenta in situ
Adjuvant management.
Methotrexate.
Uterine artery embolization.
Results:
Disappointing, high rate of infection & 2nd
post-partum Hge….interval hysterectomy.

20. Triple P procedure
Preoperative placental localization.
Pelvic de-vascularization.
Placental non removal with en bloc
myometrial excision and uterine repair.

21. Compression sutures
Parallel vertical compression suture.
Suturing both anterior & posterior
wall of lower uterine segment leaving
central part patent.
Need good dissection of bladder below
level of internal os.

23. Lower segment folding
Use lower segment as self tamponade.
Catch the internal os by two Allis forceps &
sutured to upper edge of lower segment.
Internal os patency should maintained.
Folded lower segment sutured to upper
segment.