A NEW SURGICAL TECHNIQUE IN MANAGEMENT OF ANTERIOR ...

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AL_AZHAR ASSIUT MEDICAL JOURNAL AAMJ, VOL (12), NO (4), OCT 2014 SUPPL - 2

A NEW SURGICAL TECHNIQUE IN MANAGEMENT OF

ANTERIOR PLACENTA PREVIA ACCRETA

Rashed Mohammad Rashed

Department Of Obstetrics and Gynecology, Faculty Of Medicine,

Damietta- Al-Azhar University

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ABSTRACT

Background: Placenta accreta has become the leading reason for cesarean

hysterectomy, massive obstetric hemorrhage, disseminated intravascular

coagulopathy, surgical injury to the ureters, bladder, and other viscera, adult

resp. Due to increasing incidence of placenta previa accrete, a new surgical

approach for management of placenta previa accreta anterior was tested.

Patients and Methods: From October 1st, 2012 to December 30th, 2013, twenty

patients diagnosed by ultrasound (US) and Doppler to have placenta

abnormally attached to the lower part of the anterior wall of the uterus

(placenta previa accreta anterior) were managed at Al-Azhar university

hospital by resection of the lower flap of the lower uterine segment (LUS) and

placental tissue attached to it. Results: Out of the recruited 20 patients, the

uterus was conserved in 18 patients. One patient needed immediate

hysterectomy and one patient needed 'delayed' hysterectomy. The incidence of

less than 1000 cc blood loss was 25% (5 cases) and of more than 1000 cc blood

loss was 75% (15 cases). Six months after CS, HSG was done to evaluate the

uterus; All HSGs done on 17 cases showed normal uterine cavity. Conclusion:

The conservative new surgical approach for management of placenta previa

accreta anterior succeeded to save uteri and preserve fertility. so It can be used

for the management of cases with placenta previa accreta anterior.

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AAMJ, VOL (12), NO (4), OCT 2014 SUPPL - 2

SUPLL - 2

INTRODUCTION

Placenta accreta is the placenta that is abnormally adherent to the uterus.

When the placenta invades the myometrium, the term placenta increta is used,

whereas placenta percreta refers to a placenta that has invaded through the

myometrium to the serosa, sometimes into adjacent organs, such as the bladder

(Oyelese and Smulian 2006). Wu and colleagues looked at placenta accreta

over a 20-year period (1982–2002); they reported an incidence of 1 in 533

pregnancies. Risk factors for placenta accreta include placenta previa, prior

myomectomy, prior cesarean delivery, focal intrauterine adhesion, sub mucous

leiomyomata, and maternal age older than 35 years (Clark, et al. 1985). Silver,

et al. (2006) reported pro-portionally increasing risk of placenta accreta with

increasing number of prior cesarean sections in women with or without placenta

previa. Placenta accreta has become the leading reason for cesarean

hysterectomy, massive obstetric hemorrhage, disseminated intravascular

coagulopathy (DIC), surgical injury to the ureters, bladder, and other viscera,

adult respiratory distress syndrome (ARDS), renal failure, and even death

(Kastner, et al. 2002). It is better to perform surgery for placenta accreta under

elective controlled conditions rather than as an emergency without adequate

preparation. Therefore, scheduled delivery at 36–37 weeks' gestation, after

documentation of fetal lung maturity seems reasonable (Hudon, et al. 1998).

The patient should be counseled preoperatively about the need for hysterectomy

and the likely requirement for transfusion of blood and blood products

(O’Brien, et al. 1996). There has been some interest in attempting to conserve

the uterus and avoid hysterectomy. Generally, in these cases the placenta is left

in situ, with no attempt at removal (RCOG 2011). Adjunctive procedures

include treatment with methotrexate (Lipscomb, et al 2002), embolization of

the internal iliac vessels (Alvarez, et al 1992), and resection of the affected

segment of the uterus, use of uterine compression sutures and over sewing of the

placental bed, with a resultant less profuse hemorrhage (Levine, et al 1999).

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Aim of this study was Assessment of management of placenta previa accreta

anterior with resection of the anterior part of the lower uterine segment and its

attached placenta as a new surgical technique in those cases.

PATIENTS AND METHODS

At Al-azhar university hospital New Damietta, from October 1st, 2012 to

December 30th, 2013, a prospective cohort study was done on 20 patients who

were managed by resection of the anterior part of the LUS as a conservative

management of placenta previa accreta. Exclusion included patients with

placenta previa not accreta or not attached to the LUS or attached to the

posterior wall of the uterus. All patients were counseled about all items of the

operation such as pre-operative preparation, elective nature of the operation, the

incidence of bladder injury, hysterectomy and blood transfusion. The new

approach steps were:

Through Pfannenstiel skin incision.

Subcutaneous and anterior rectus sheath incision.

Dissection of sheath from rectus muscle.

Opening of the anterior abdominal wall by splitting the two recti muscles.

Exposure of the uterus then dissection of urinary bladder by sharp and blunt

dissection to push down as low as possible.

Transverse incision of the uterus above the upper margin of the placenta.

Delivery of the fetus.

Removal of an elliptical piece of the lower uterine segment and its attached

placenta en block.

Repair of uterine incision as usual by vicryle no1.

Intraperitonial drain to be left behind.

Closure of subcutaneous and skin as usual.

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RESULTS

The study was conducted on 20 patients. Demographic data of all cases

participated in the study as regard patient’s age, it ranged from25-37 years while

gravidity ranged from 2 to 4 with the median of 4 while parity ranged from 0 to

5 and number of CS ranged from 0 to 5with the median as in table1and figure 1.

Table (1): Demographic data of all cases participate

Age in years Mean(±SD) 31 (±5.34)

Gravidity Median(Range) 4 ( 2 - 4 )

Parity Median(Range) 3 ( 0 - 5 )

No of CS Median(Range) 2 ( 0 - 5 )

No of CSParityGravidity

9

8

7

6

5

4

3

2

1

0

Data

Figure (1): The demographic data of all cases participated in the study as

regard for gravidity, parity and No of CS.

-

Figure (2): u/s revealed placenta previa anterior with evidence of

accretion

This new approach conserved the uterus in 18 cases and hysterectomy was

done only in 2 cases (one of them needed immediate hysterectomy and the other

needed remote hysterectomy Four cases were complicated by bladder injury;

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bladder was repaired and Foley's catheter was left in the bladder for a week .

Table (2): Short follow up of complications.

Complications

None 14 70.0%

bladder injury 4 20.0%

Hysterectomy 2 10.0%

Total 20 100.0%

Figure (3): Follow up of complications with 4 cases had bladder injury, 2

cases had hysterectomy and no complication in 14 cases.

The incidence of less than 1000 cc blood loss was 25% (5 cases) and of

more than 1000 cc blood loss was 75% (15 cases; Table 3).

Table (3): The incidence of blood loss and blood transfusion in all cases.

<1000 cc >1000 cc P

Median Range No % Median Range No %

Blood loss 500.00 300-

500 5 25% 1200

1000-

2500 15 75% <0.001

Blood

transfusion .00

.00-

500 5 25% 1500

1000-

2000 15 75% <0.001

Six months after CS, HSG was done to evaluate the uterus; All HSGs done

on 17 cases showed normal uterine cavity. as seen in figure 4

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SUPLL - 2

Figure 4:Six months later after CS, HSG showed normal uterine cavity.

DISCUSSION

Silver, et al. (2006) reported proportionally increasing risk of placenta

accreta with increasing numbers of prior cesareans in women with or without

placenta previa. They reported incidence of placenta previa accreta in women

with previous one C.S 3.3%, 11% in women with previous two C.S, 40% in

women with previous three C.S, 61% in women with previous four C.S, and

67% in women with previous five C.S. It is important to diagnose placenta

accreta prenatally to minimize morbidity. Prenatal diagnosis seems to be a key

factor in optimizing the counseling, treatment and outcome of patients with

placenta accreta (Japaraj, et al 2007). Prenatal diagnosis of placenta previa

accreta included ultrasonography and magnetic resonance imaging (MRI), but

ultrasonography remains the mainstay of placental imaging in the ante-partum

period during all trimesters. In the first trimester, it is known that placenta

accreta and percreta occur as a subsequent for pregnancy on CS scar which

occurs due to implantation of blastocyst on fibrous scar. In the second and third

trimesters, diagnosis of placenta previa is as intra placental lacunae which are

vascular structures of varying size and shape that are found in the placental

parenchyma, creating a “moth-eaten” or “Swiss-cheese” placental appearance.

All cases of placenta accreta had turbulent flow in placental lacunae by color

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Doppler (Comstock and Bronsteen 2012). Placenta previa accreta can also be

diagnosed by MRI as a focal outward contour bulge, or disruption of the normal

pear shape of the uterus, with the lower uterine segment being wider than the

fundus (Palacios, et al. 2005). Patients with prenatally suspected placenta

accreta should be extensively counseled about potential risks and complications

as a preoperative management of placenta previa accreta. In patients with strong

suspicion for placenta accreta, it is strongly advised to perform the delivery

before labor begins. Therefore, consideration should be given to perform the

cesarean birth electively after corticosteroids treatment for fetal lung maturation

(O’Brien, et al. 1996).Two studies reviewed intra-operative management of

placenta accreta have been described either cesarean hysterectomy (Shellhaas,

et al. 2009) or conservative management (Zelop, et al. 1992) which included

leaving the placenta undisturbed with prophylactic antibiotics and oxytocics,

interval placental removal, excision of placental site, bilateral uterine artery

embolization, Hypogastric/uterine artery ligation, uterine tamponade, suturing

of placental bed, B-Lynch suture. The new approach was conducted at Al-Azhar

university hospital, Damietta to evaluate resec-tion of the anterior part of the

lower uterine segment and its attached placenta. The study included 20 cases

which were diagnosed as placenta previa accreta anterior by ultrasonography

and colour Doppler. In all patients after investigations and pre-operative

assessment, counselling about complications, blood transfusion and the

possibility of hysterectomy and bladder injury was done. The new approach

depends on simple and almost timeless operative procedure which can be done

as reasonable solving for placenta previa accreta anterior. The incidence of

blood loss less than 1000 cc which is normally accepted in CS is 25% (5 cases)

while the incidence of blood loss more than 1000 cc which needed blood

transfusion was 75% (15 cases) with the mean blood transfusion more or less

than 1400 cc. Along 20 cases of the study only 2 cases needed hysterectomy

(preservation rate for the uterus is 80%). Four cases had bladder injury as a

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SUPLL - 2

complication for the procedure while 14 cases reported no complications. Long-

term follow up: 6 months later the cases by histosalpingo-graphy: 3 out of 20

cases were missed from follow up, while 17 cases had normal

histosalpingography. In comparison with other methods for conservative

management of placenta previa accreta:

Descargues, et al. (2001) performed uterine arterial embolization (UAE)

on 9 patients whose median age was 35 years. We recruited 20 cases in our

study; their median age was 31 years. The median gestational age at delivery

was 38 weeks (36 to 40 weeks) as in our approach and. Deliveries in the UAE

study were 5 cesarean sections (CS) and 4 inductions with vaginal deliveries,

but in our study all deliveries were CS. In the UAE approach placenta accreta

was diagnosed in 8 cases but in our approach placenta accreta was diagnosed in

all the 20 cases. The embolization procedures involved bilateral uterine arteries

in 6 cases, right uterine artery in 2 cases, and left uterine artery in 1 case. In the

UAE approach the success rate was 100% in conserving the uterus but the

success rate in our approach was 90%.Ferrazzani, et al. (2004) applied the

uterine balloon tamponade (Bakri) approach on 39 cases who suffered PPH;

placenta accreta anterior and posterior were diagnosed in 22 cases. In our study

we handled 20 cases of placenta accrete, only anterior. In the uterine balloon

tamponade study the median age was 34.6 years but in our approach it was 31

years. The median gestational age at delivery was 35.9 weeks but in our

approach it was 38 weeks. In the uterine balloon tamponade study 8 cases could

not be controlled by this approach while in our approach only 2 cases could not

controlled and they needed hysterectomy. The success rate in the uterine balloon

tamponade approach was 79% but the success rate in our approach was 90%.

In 2006 B-Lynch invented transverse compression suture. The procedure

was offered to 12 cases with placenta previa accreta anterior and posterior,

while our approach was offered to 20 cases with placenta accreta anterior. In the

B-Lynch transverse compression suture approach the lower segment incision is

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closed in the traditional way in 1 or 2 layers then the lower segment was

compressed, whilst both limbs of the suture are milked through with sufficient

tension to maintain haemostasis. Our approach depends on resection of the

lower flap of the anterior lower uterine segment, then closing the incision in 1 or

2 layers. In the B-Lynch transverse compression suture approach the success

rate was 100% but in our approach was 90%.Suturing of placental bed was done

on 3 cases (Abu-Musa et al. 1998), but in our approach the number of cases

was 20. All cases in both approaches were diagnosed placenta accreta. All

placentas in our approach were anterior only; in the other approach one case

was anterior and two cases were posterior. The success rate in the placental bed

suturing approach was 100% but in our approach it was 90%.

CONCLUSION AND RECOMMENDATIONS:

The studied technique of excising the lower flap of the lower uterine

segment is a simple quick approach with high success rate. It can be used for the

management of cases with placenta previa accreta anterior.

Extended study to evaluate these patients during future pregnancies and

their outcome and effect of removal of lower uterine segment on pregnancy

outcome is recommended.

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SUPLL - 2

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???

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SUPLL - 2 في عالج المشيمة المتقذمة الملتحمة األمامية نهج جراحي جذيذ

راشذ محمذ راشذ

دمياط –بنين -كلية الطب جامعة األزهر -قسم النساء والتىليذ

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رعزجش انش انهزحخ سجت سئس السزئصبل انشحى أثبء انالدح انقصشخ ضف يب ثعذ

انالدح ثسجت صبدح يعذل حذس انش انهزحخ كبذ بك حبخ يبس الخزجبس دسخخ كفبءح طشق

انذساسخ ف و انخصثخ قذ أخشذ زذخشاح خذذح نعالج يثم ز انحبالد انحفبظ عه انش

شهذ عشش حبن رى رشخص ثبألشعخ انزهفضخ 2013دسجش حزى 2012انفزشح ي أكزثش

انذثهش انه ثخد يشخ يزقذي إيبي يهزحخ قذ أخشذ ن الدح قصش يع اسزئصبل اندضء

قذ أظشد زبئح انذساسخ ا رى انحفبظ . انهزصقخ ثبانسفه ي خذاس انشحى األيبي شبيه انش

حبن احزبخذ حبن احذ إن اسزئصبل سحى فسي احزبخذ 20حبن ي إخبن 18عه انشحى ف

سبعبد كب يعذل فقذ انذو إثبء انعهخ اقم ي 6حبن أخشي إن اسزئصبل سحى ثعذ انقصشخ ة

سى يكعت ف 1000ب كب يعذل فقذ انذو إثبء انعهخ أكثش ي حبالد ث5سى يكعت ف 1000

6حبن ي ثعذ يشس 17حبنخ أضحذ األشعخ ثبنصجغخ عه انشحى األبثت انز أخشذ ل15

. أشش ي انعهخ أ ردف انشحى سهى ربيب

:الخالصــــــــــة

انشخ انزقذيخ فبءح ف عالج حبالد خهصذ انذساسخ أ ز انح اندشاح اندذذ ر ك

.د إخشاء اسزئصبل انشحى انحفبظ عه عه خصثخ انشأح انهزحخ األيبيخ

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A NEW SURGICAL TECHNIQUE IN MANAGEMENT OF ANTERIOR ...

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