adherent placenta diagnosis & management by dr shashwat jani
TRANSCRIPT
ADHERENT PLACENTADiagnosis & Management
Dr. Shashwat K. Jani.M. S. ( Obs – Gyn )
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : 99099 44160.
E-mail : [email protected]
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Greetings From Ahmedabad …
INTRODUCTION
Adherent placenta occurs
when there is a defect in the decidua basalis ,
Resulting
in an abnormal invasion of the placenta directly into the substance of the uterus.
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Types1 ) Simple Adherent Placenta.
2 ) Morbidly Adherent Placenta :
i ) Placenta Accreta
ii ) Placenta Increta
iii) Placenta Percreta
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INCIDENCE
It varies widely all over the world.
Increased dramatically over the last 3 decades
( Because of Increase in LSCS rate … ).
A.C.O.G. 1 Per 2500 deliveries.
Accreta : 75 -78 %
Increta : 15 – 18 %
Percreta : 5 -7 %
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Associated Condition :
Placenta Previa
Previous Surgeries such as …
- Cesarean Section - D & C
- Myomectomy - M.R.P.
- Synecolysis - Cornual Resection
Uterine Malformation
Septic Endometritis
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Risk Factors :
High Parity
Advanced Maternal Age
Down Syndrome
High level of Maternal Serum AFP.
High level of Maternal free Beta hcg.
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ETIOLOGY :
Defective decidual formation :
- Partial / total absence of decidua basalis
- Imperfect development of fibrinoid layer (Nitabuch layer)
- Placental villi are attached to the myometrium
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Significance :
Increased Maternal Morbidity ( 2 – 7 % )
Increased Maternal Mortality ( 7 – 10 % )
from,
- Severe Hemorrhage
- Infection
- Inversion of Uterus
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Interestingly,
the sex ratio associated with placenta accreta favors females, which is opposite to the normal sex ratio in the general population, which favors males…
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DIAGNOSIS
Earliest diagnosis of Adherent Placenta is must to avoid any catastrophic emergency in future.
Antenatal diagnosis is the single most important factor in improving the outcome in MAP.
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METHODS…
Clinical suspicion
Ultrasound
Color Doppler
MRI
Biochemical Marker
Histopathology
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USG
• First-line investigation for suspected placental invasion of the myometrium.
• The most useful modalities for evaluating placental position and implantation are transabdominal and transvaginal ultrasonography
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USG CRITERIA
1st Trimester :
G. Sac located in the lower uterine segment (rather than the fundus), next to or lower than the Prev. CS scar.
2nd & 3rd Trimester :
Presence of irregular lacunae within the placenta
Loss of retro placental clear space
Loss or disruption of the white line – Bladder line
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Moth – eaten OR
Swiss Cheese Appearance
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Obliteration of clear spacebetween placenta and uterine wall
Reliability :
• Sensitivity - 93%
• Specificity - 79%
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.
[ Chou MM, Ho ES, Lee YH. Prenatal diagnosis of placenta previa accreta by transabdominal color Doppler ultrasound. Ultrasound Obstet Gynecol2000;15:28–35. ]
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3 D USG
Diagnostic Criteria :
Irregular intraplacental vascularizationwith tortuous confluent vessels crossing placental width.
Hypervascularity of uterine serosa–bladder wall interface.
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Colour Doppler
Diffuse or focal intraparenchymallacunar flow.
Vascular lakes with turbulent flow.
Hypervascularity of serosa-bladder interface.
Prominent subplacental venous complex.
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M.R.I.
No more sensitive than USG , But used as an adjunct to USG , when there is strong clinical suspicion of accreta.
MRI achieves better 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 tissue in the latter )
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M.R.I. Criteria
Uterine bulging into the bladder
Heterogeneous signal intensity within the placenta
Presence of intra placental bands on the T2W imaging
Abnormal placental vascularity
Focal interruption of the myometrium
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Laboratory Findings :
• Several series and case reports have reported an association between placenta accreta and otherwise unexplained elevations in second trimester MSAFP concentration (>2 or 2.5 multiples 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.
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Histology
Post Partum specimen shows :
Placental villi anchored directly on, or invading into or through, the myometrium, without an intervening decidual plate.
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Treatment :
A multidisciplinary team approach is relevant in managing these patients in order to reduce morbidity and mortality associated with MAP.
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Particular consideration should be given to anticipation and management of massive hemorrhage,
including
- availability of packed cells,
- platelets,
- fresh frozen plasma,
- cryoprecipitate, and
- activated factor VII.
Interventional Radiology and cell saver technology are useful.
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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 tissues with the entire placenta restoring uterine anatomy.
Each one has weaknesses and strengths, dependent on the condition itself and the specific preferences taken by the surgeon and the team.
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Women who have had a previous CS who also have either placenta previa or an anterior placenta underlying the old CS scar at 32 weeks of gestation are at increased risk of placenta accreta and should be managed as if they have placenta accreta, with appropriate preparations for surgery made.
(RCOG 2011) Elective delivery by caesarean section at 34–35
weeks of gestation for suspected placenta accreta
(ACOG 2012).
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Conservative
In case of( focal defect / moderate blood Loss / fertility to be
preserved )
Localized Resection with uterine repair
Over sewing of the ut. Defect
Blunt dissection followed by curetting the uterine cavity
Uterus fails to contract (Multipara) :
Hysterectomy
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Non Surgical
Leave the Placenta in situ to resorb with methotrexate therapy
Ligation of the Ut. And Int. iliac artery
Fluoroscopic bilateral UAE
Argon beam coagulation for haemostasis
Insertion of occluding Balloons in the Int. iliac art. (Bilat)
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Surgical
Cesarean Hysterectomy.
Hysterectomy and partial / total resection of bladder
Subtotal Hysterectomy with removal of large part of placenta and Prophylactic occlusive Balloon catheter in int. iliac art.
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An Elective controlled condition is preferred rather than an emergency condition without adequate preparations.
A midline incision will facilitate better exposure, especially if placenta Percreta is suspected.
Leaving the placenta undisturbed until completion of the hysterectomy would prevent unnecessary hemorrhage.
In cases where MAP is associated with placenta previa, total hysterectomy is preferred to a subtotal hysterectomy.
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Uterine Incision:
It is best to avoid cutting through a
MAP because of the possibility of massive haemorrhage.
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Various modifications of the uterine incision to avoid the placenta have been reported…
- Classical incision,
- High transverse incision,
- Fundal incision,
- Fundal transverse incision
remember
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.
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Excision of placental site
It is possible to "excise the placental site".
This is done by inverting the uterus in order to provide good access to the placental site.
If the area of placental attachment is focal and the majority of the placenta has been removed, then a "wedge resection" of the area can be performed.
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Balloon Catheterization
Pre-operative placement of arterial catheters in internal iliac artery
After delivery balloons are inflated to achieve temporary homeostasis
Selective arterial embolization (SAE) if necessary. . .
Bil. Int. iliac artery ligation is performed prior to peripartum hysterectomy where Interventional Radiology is not available.
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Placement of occlusion balloon catheters into both internal iliac arteries.
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Methotrexate A folate antagonist, acts primarily
against rapidly dividing cells and therefore is effective against proliferating trophoblasts.
First described by Arulkumaran et al in 1986. They reported administration 50 mg of methotrexate as an intravenous infusion on alternate days and the placental mass was expelled on 11th
postnatal day. However, more recently, others
have argued that, after delivery of the fetus, the placenta is no longer dividing and therefore, methotrexate is of no value.
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Methotrexate has been used in varying doses and routes, however, there are no randomized trials and no standard protocol regarding its dosage.
The outcome when the placenta is left in place after methotrexate administration varies widely; it ranges from expulsion at 7 days to progressive resorption in roughly 6 months.
Mtx – 50 mg IM + Folic Acid 6mg IM on
alternate day till β HCG comes to zero.
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Other Modalities
Tamponade of the placental implantation site with inflated Intra Uterine balloon catheter bags.
Lower Segment Compression Sutures
Pelvic pressure sponge packing.
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Follow up…
1.- Ultrasound exams & Vascularity
2.- hCG titers weekly till become Zero.
3.- Daily Temps, Other S&S of infection
4.- Bleeding
5.- Coagulation profile
Antibiotic Maximum for 10 days.
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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
Intractable haemorrhage
DIC
Resective surgery
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
uterineaxial circumference
Minor coagulation
disorders
Conservative
surgery
1-Placenta in situ with or without
MXT
2-One step surgery
OR
3- Two step surgery
Bladder Involvement
First , Involve UROLOGIST.
Preoperative Ureteric stenting aids in identifying the ureters, which will help reduce uretericinjuries.
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Care must be taken during surgery not to attempt to dissect the bladder off the lower uterine segment which results in torrential bleeding.
Anterior bladder wall incision is particularly helpful in defining dissection planes and the location of the ureters.
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Reality :
Even today, the ground reality is
that a majority of morbidly adherent
placenta are diagnosed during the
third stage of labour or during
caesarean section and which results
in adverse consequences including
exanguinating haemorrhage.
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To Conclude…
Caesarean hysterectomy was the cornerstone in the management in the past.
Antenatal diagnosis permits effective and safe conservative approaches today.
The use of methotrexate, monitoring with serum hCG and follow up with USG is backed only by conflicting evidence.
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