adherent placenta diagnosis & management by dr shashwat jani

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 : drshashwatjani@gmail.com

22-Dec-14 Dr Shashwat Jani. 9909944160 2

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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