Prepared by : Dr . Amani A.A Rajabi , MD (AL_QUDS UNIV.)
Resident at Makassed Islamic Charitable Hospital
Supervised by :Dr . Saadeh S.Jaber MBBS, MRCOG, MRCPI,
Head of OBGYN department Al_quds univ.Consultant at Makassed Islamic Charitable
Hospital
MAKASSED EXPERIENCE IN MANAGEMENT OF PLACENTA
ACCRETA
DEFINITION & PATHOGENESISPlacenta accreta occurs when there is a defect of the decidua basalis , in conjunction
with an imperfect development of the Nitabuch membrane , resulting in abnormally
invasive implantation of the placenta .
Nitabuch membrane is a fibrinoid layer that separates the decidua basalis from the
placental villi.
HISTOLOGICAL CLASSIFICATION
INCIDENCE There is marked increase in the incidence
of placenta accreta .In 1950----- 1 in 30,000 deliveries .In 1977-----1 in 7,000 deliveries .In 1985-1994-----1 in 2500 deliveries .In 1982-2002-----1 in533 deliveries .
(Am J Obstet Gynecol 1997;177:210-4) (Am J Obstet and Gynecol (2005) 192, 1458–61)
placenta accreta has been reported to result in a 7% mortality rate .
The most common indication for birth related hysterectomy, accounting for 40–60% of cases.
ACOG committee opinion . International Journal of Gynecology & Obstetrics 77 (2002) 77-78.
J. Obstet. Gynaecol. Res. Vol. 33, No. 4: 431–437, August 2007 .
DIAGNOSIS Placenta previa -accreta
Color Doppler
Demonstrating turbulent flow through placental lacunae ,with abnormal vessels linking the placenta to the bladder.
Magnetic resonance imagingThe role of MRI is to complement, rather than
replace, information obtained via standard sonographic imaging.
The main advantage offered by this type of imaging is : The ability to diagnose posterior placenta
accreta more confidently. The assessment of bladder invasion in cases
of placenta percreta.
The mean gestational age at diagnosis of placenta accreta by ultrasound is 29 weeks (range:28–33 weeks) .
The mean gestational age at delivery is 36 weeks (range: 32–38 weeks).
J. Obstet. Gynaecol. Res. Vol. 33, No. 4: 431–437, August 2007 .
COMPLICATIONS
Massive obstetric hemorrhage is the most common complication .
Disseminated intravascular coagulopathy .Adult respiratory distress syndrome .Renal failure .Infection Death.
Abstract STUDY DESIGN : Retrospective analysis of medical records &
histopathological finding .POPULATION : Women delivered at Makassed Hospital 2007 /
2008 of whom 15 cases of invasive placenta identified.A finding confirmed by histopathology .
METHODS : Retrospective analysis complemented with direct
communication with patient ,using SPSS to analyze data .
CONCLISIONS : at the end of presentation .
year of delivery
year of delivery
20082007
Freq
uenc
y
10
8
6
4
2
0
9
6
Incidence in 2007 ….1:460 deliveries.Incidence in 2008 ….1:300 deliveries.
Source of referal
source of referal
bookedPrivate HospitalGovernental Hospital
Perc
ent
50
40
30
20
10
0
33
40
27
All of our cases were diagnosed antenatally .
Identified risk factorshistory of :
C S .
E &C .
IUCD .
Other uterine instrumentation .
MINIMUM MAXIMUM
AGE 24 44
PARITY 2 7
# CESAREAN SECTION
2 5
Gestational age ……MINIMUM MAXIMUM MEAN
GA _ US Diagnosis
24 34 29
GA _ Delivery 26 36 31
Preoperative managementThe woman should be informed of the diagnosis
and potential complications .Antenatal corticosteroid to be given .Consent form of caesarean hysterectomy .Delivery should be scheduled for optimal
availability of necessary personnel and facilities.A preoperative anaesthesia consultation should be
obtained.Adequate blood and clotting factors should be
available at the time of delivery .An intensive care unit should be available for
postoperative care, as needed.
Immediate preoperative bilateral uretric stents were
inserted in a couple of cases .
Intraoperative management of planned cesarean hysterectomy : A vertical skin incision provides good
exposure .A vertical uterine incision is made above
the upper edge of placenta .Delivery of the baby .Placenta left "in situ“, with minimal
manipulation. Extrafascial hysterectomy is then
performed .
Blood transfusion Case number Pre operative Intra
operativePost
operative 1 NA 6 PRBC
4 FFP4 PLT
2 whole Blood
2 NA 4 PRBC4 FFP
9 whole Blood
3 NA 3 PRBC2 FFP
4 whole Blood
4 NA 4 PRBC 2 PRBC5 NA 4 PRBC
4 FFP2whole Blood
4 PRBC9 FFP
4 whole Blood6 NA 2 PRBC 2 PRBC
2 whole Blood7 NA 8 PRBC
4 FFPNA
Continued Case number Pre
operative Intra
operative Post
operative 8 NA 3 PRBC 1 PRBC
4 FFP9 NA 4 PRBC 2 whole Blood
2 FFP10 NA 2 PRBC 2 PRBC11 2 PRBC 2 PRBC 2 PRBC
2 FFP12 NA 2 PRBC NA13 NA 2 PRBC 2 PRBC
2 FFP14 NA NA NA15 NA 2 PRBC
4 whole Blood2 FFP
2 whole Blood
Histopathology
6.7%
33.3%
60.0%
NO histopathology
percreta
accreta
MINIMUM MAXIMUM
HOSPITALIZATION PERIOD 5 38
PRE DELIVERY HOSPITALIZATION
0 27
ICU HOSPITALIZATION
1 2
Neonatal outcome MINIMUM MAXIMUM
GA _ delivery 26 36
Birth weight 1337 3130
Neonatal outcome
Neonatal outcome
IUFDNEONATAL DEATHNICUNL NURSERY
Perc
ent
60
50
40
30
20
10
077
50
36
CONCLUSIONSIncidence of invasive placenta at Makassed
hospital is one case in 370 deliveries .
Invasive placenta associated with significantly high morbidity & mortality world wide , proudly the outcome in our hospital was excellent , with NO MORTALITY & MINIMUM MORBIDITY .
Excellent neonatal outcome .
Continued ….Finally , maternal & neonatal outcome can be
optimized by the availability of :
Senior obstetrician with advanced surgical skills .
Senior anesthesiologist & intensive care facilities .
Advanced lab & blood banking facilities .Urological back up . Intensive care baby unit .
