PLACENTA ACCRETA

PLACENTA ACCRETA

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  PLACENTA ACCRETA SYNDROME RiskFactors and Management PRESENTED BY: DR. KIRAN PANDEY Prof. & HOD Dept. of Obs. & Gyne. GSVM MEDICAL COLLEGE KANPUR DR. PAVIKA LAL Assistant Professor Dept. of Obs. & Gyne. GSVM MEDICAL COLLEGE KANPUR
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  DR. KIRAN PANDEY Headof department, dept of OBG, GSVM Medical College,Kanpur. Secretary upsc AGOI 2017-2019 President 2016-2018,Kanpur obs&gynaesociety Organizing secretary: WWWCON-2018 Organizing chairperson: Adolescent Workshop, Emergency Obstetrics Workshop- oct 2018 Organizing chairperson: National Adolescent Conference Youth Summit and CME 2017 Organizing Secretary,National conf Obs&Gynae 2015 Organizing chairperson,Urogynecology,NDVH,Pelvic floor
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  PLACENTA PLACENTA ACCRETA ACCRETASYNDROME of an abnormal placental implantation and firm adherence which are classified according to the depth of invasion in to the uterus. PLACENTA ACCRETA PLACENTA ACCRETA SYNDROME
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  ADHERENT PLACENTA syndrome AccretaIncreta Percreta TOTAL PLACENTA ACCRETA (INVOLES ALL LOBES) FOCAL PLACENTA ACCRETA (INVOLVES SINGLE LOBE) PARTIAL PLACENTA ACCRETA (INVOLES ONLY TWO LOBES)
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  Partial or totalabsence of the decidua basalis and defective development of the fibrinoid or Nitabuch layer results in abnormally firm adherence defect of the biological functions of the trophoblast, leading to excessive invasion of the myometrium shift in placental blood supply from a spiral artery as found in normal placentation to a supply from a larger, deeper radial or arcuate artery High velocity blood flow in uteroplacental circulation in placental lacunae Hypervascularisation pattern under placental blood flow in color doppler
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  sharp rise overthe years, which may be attributed to rising number of cesarean deliveries .
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  Risk factors Placenta previa (5-10% risk) PreviousLSCS Advanced maternal age Previuos history of uterine surgeries - hysterotomy, myomectomy. Endometrial thermal ablation Vigorous multiple curretage Multiparity Uterine artery embolization Uterine pathologies (adenomyosis, bicornuate uterus, submucous fibroid,Asherman syndrome)
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  Elevated first trimesterPAPP-A Elevated second trimester MSAFP and free beta hCG Downreguation of specefic micro RNA Decreased TNF- related apoptosis including ligand (TRAIL) receptors level Myometrial fibers in thebasal plate(BPMYO) Maternal cell free beta hCG FEWRECENTLY ASSOCIATED BIOCHEMICAL RISKFACTORS
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  PLACENTA ACCRETA IS AN IATROGENIC 20TH CENTURY DISORDER Correct surgical technique while closing the uterine incision primary preventionof the first caesarean and encouraging trial of labour after caesarean treatment of postpartum endometritis avoiding vigorous curettage
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   Transvaginal scansare more sensitive in confirming placental location and diagnosing placenta previa at 20th week of gestation than transabdominal scans. has been the cornerstone in diagnosing placenta accreta due to its wide availability and high accuracy-
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  GREY SCALE LOW LYINGGESTATIONAL SAC
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  Findings suggestive ofplacenta accreta are-  Hypervascularity of serosa–bladder interface.  Diffuse or focal lacuna flow vascular lakes with turbulent flow (Peak systolic velocity over 15 cm/s).  Markedly dilated vessels over peripheral subplacentalzone. OBLITERATION OF CLEAR SPACE BETWEEN PLACENTA & UTERINE WALL MOTH -EATEN /SWISS CHEESE APPEARANCE DUE TO LACUNAE HYPERVASCULARITY
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  3-D power dopplerhas been shown to be superior In diagnosing placenta percreta from accreta. Findings on 3-D power doppler are:
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  Numerous coherent vesselsinvolving the whole uterine serosa–bladder junction (basal view) Inseparable cotyledon and intervillous circulations
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  Transverse transvaginl USG multiple tortuous hypoechoeic structures within the placenta Transverse transabdo m- inal 2D-Doppler USG Confirmthe hypoechoeic pattern 3D-Doppler ultrasound For diagnosis of bladder invasion in placenta percreta, seen as positive vasculari-zation
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  When to recommendMRI for diagnosis of Placenta Accreta -  equivocal USG findings of abnormal placentation  evaluation of posterior placenta in patients with risk factors  obese patients  complementary role in specifically delineating the extent of an USG-diagnosed placenta percreta
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  Imaging features ofnormal placentation on MRI  Homogeneous T2-intermediate signal intensity of placenta  Subtle, thin, regularly spaced placental septi.  Normal subplacental vascularity.  Triple-layered sandwich appearance of myometrium.  Pear-shape of normal gravid uterus with smooth contour.
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   Dark intra-placentalbands on T2-weighted images.  Abnormal disorganized placental vascularity.  Focal interruptions of the myometrial wall or extension through the myometrium with occasional invasion of adjacent structures. Heterogencity with in placenta .disruption of pear shaped pattern (lower segment wider than fundus)
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   G3p1+1,24years female,GA37 weeks 3 days presented with leaking PV.  History of preterm LSCS 3 years back and spontaneous abortion f/b D&C 1 years back.  No ANC visit single 3rd trimester USG showing SLIUF appropriate for GA,placenta posterior and low lying  The case was opened by obstetrician.  Delivery of the fetus f/b repeated attempts to remove placenta but within few minutes it was realised that it is adherent placenta as the patient started bleeding profusely(HORRIFYING !!!)
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  Hysterectomy was donebut patient went into irreversible shock and could not be revived back Forcible and unneccessary attempt to claw off placenta should not be done(may provoke further torrential hemorrhage). Multidisciplinary approach senior obstetrician, pelvic surgeon, uro-surgeon (if needed) neonatologist, anesthetist,
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  TRIPLE P PROCEDURE A novel uterine sparing procedure for PAS  Steps 1. Peri-operative placental ultra sound localization of the superior edge of the placenta 2. Pelvic devasularization – pre operative placement of intra arterial balloon catheters 3. No attempt to remove the entire placenta *FIGO consensus guidelines on placenta accreta spectrum disorders
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   25 years,unbooked, G4P1+2 with h/o FTLSCS 4 year back f/b 2 spontaneous abortions(D&C done) came in active stage of labor at 37wks + 2 days at CHC Kanpur Dehat.  Em LSCS was done and intraoperatively it was found to be placenta percreta with bladder involvement. Pt bled profusely.  Subtotal hysterectomy was done along with ligation of blood vessels going into the bladder but all in vain as the patient’s vitals deteriorated, pt developed DIC & anuria with ARF in postoperative period(d/t massive blood loss) CLINICAL SCENARIO 2
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  HOW COULD SHE BE BETTER MANAGED?? PreviousLSCS – Regular antenatal check ups  USG to diagnose placenta accreta. Elective cesarean is the choice ICU CARE- For proper management of complications ( DIC,ARF,Transfusion reactions , ARDS, Electrolyte imbalance).
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  RCOG 2011 Elective ceasereansection in asymptomatic women is not recommended before 38 weeks of gestation for placenta previa or before 36- 37 weeks of gestation for suspected placenta accreta. ACOG 2014 Elective delivery by ceaserean section at 34- 35 weeks of gestation for suspected placenta accreta
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  What makes hysterectomydifferent and difficult ? Genitourinary tract inuries . Prevention  Avoid cutting placenta => trans fundal approach  PREVENTIVE SURGICAL OR RADIOLOGICAL DEVASULARIZATION Placement of balloon occlusion catheter. Placement of pelvic pressure packing like laprotomy devices or balloon tamponade. Causes  unplanned Hysterectomy  Emergency hysterectomy in an undiagnosed placenta accreta Inadvertent attempt at removal of placenta  Delivery of baby by cutting through the placenta. MASSIVE BLOOD LOSS (3-5 ltrs)
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  Inspection  Presence ofany vascular channels noted(should not be disturbed. Uterine incision  CLASSICAL/TRANSFUNDAL cesarean section to avoid cutting through the placenta f/b delivery of fetus f/b closure of uterine incision by WHIP stitch
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  B/L anterior divisionof internal iliac artery ligation done f/b uterine artery ligation. cesarean hysterectomyCESAREAN HYSTERECTOMY IS CONSIDERED AS GOLD STANDARD TREATMENT FOR INVASIVE ACCRETA ALTHOUGH HIGH RATES OF SEVERE MATERNAL MORBIDITY(40-50%) AND MORTALITY(7%)
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  Postoperative management .
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   G6P1+4(none alive)GA 36 weeks with H/O previous 1 LSCS and 3 D&C was refferred to our hospital with the USG(3D Doppler)findings of complete central placenta with focal placent increta  Elective LSCS was done at 37 weeks  B/L uterine artery were ligated and gentle removal of placenta as much as possible with leaving the adherent part of placenta “insitu approach” closure of uterine incision. CLINICAL SCENARIO 3 Saving the uterus was our priority
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   Postoperatively 2units of blood was transfused along with methotrexate adjuvant treatment* given.  Patients managed successfully  Key points during conservative management-  Gentle attempt to remove the “non accreta” portion of placenta , thus the volume of villous tissue left insitu  Preventive radiological and surgical devascularization (uterine/hypogastric artery) prevents secondary hemorrhage placental reabsorption  Methotrexate hastens placental resolution although the risk of neutropenia sepsis secondary hemorrhage=> hysterectomy
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  Conservative management should alwaysbe attempted in patients who agree to long term monitoring,strongly desired to preserved their fertility with adequate expertise Insufficient evidence for the use of MRI and/or serum beta HCG for the monitoring of conservative management of PAS. * Use of methotrexate is not routinely recommended and therefore should only be given judiciously. FIGO consensus guidelines on placenta accreta spectrum disorder Int J Gynecol Obstet 2018;140:291-298
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  One step conservativesurgical approach for PAS  Vascular diconnection of newly formed feeder vessels and seperation of invaded Ut. Tissue from invaded bladder tissue  Upper segment hysterotomy and delivery of fetus  Resection of all invaded myometrium with placenta in one piece after local vascular control  Surgical procedure for hemostasis  Myometrial reconstruction in 2 planes  Bladder repair if necessary. *FIGO consensus guidelines on placenta accreta spectrum disorders
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   Though UAEis latest interventional technique in cases of accreta,but its not available in many of our set-ups, therefore uterine artery ligation may be life saving.  The role of interventional radiological procedure though looks promising, further research and prospective larger studies are required.
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  Pearls of wisdom Mypersonal experience….  In cases requiring hysterectomy I personally use double set of clamps to rapidly secure all bleeding points and remove the uterus as soon as possible and ligate the pedicles later. reduces blood loss effectively  I have found that uterine artery ligation prior to attempt of removal of placenta in cases of placenta accreta may be life saving. Feasible alternative to uterine artery embolization in low resource settings .
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  THE DEADLY D’Sof Accreta  DELAYED:  Delayed referral  Delayed caesarean: i.e. emergency (not elective)  Delayed decision for hysterectomy  DEFICIENCY:  Deficiency of time availability: extensive adhesions, no time for pre-op devascularization  Deficiency of blood and blood products  Deficiency of ICU beds  Deficiency of multi-disciplinary senior team.
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  PREOPERATIVE DIAGNOSIS ANEMIA CORRECTION PATIENTCOUNSELLING REGULAR FOLLW UP UTERINE ARTERY LIGATION HYSTERECTOMY WHEN NEEDE CAN SAVES LIFE!!!!