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Khalta et al. World Journal of Pharmacy and Pharmaceutical Sciences
PLACENTA PREVIA ACCRETA: A CASE REPORT AND
LITTERATURE REVIEW
Soukaina Khalta*2, Manar Rhemimet
1, Najia Zraidi
1, Amina Lakhdar
1, Abdelaziz
Baidada1 and Aicha Kharbach
2
1Gynaecology-Obstetrics and Endoscopy Department, Maternity Souissi, University Hospital
Center IBN SINA, University Mohammed V, Rabat, Morocco.
2Gynaecology-Obstetrics and Endocrinology Department, Maternity Souissi, University
Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco.
ABSTRACT
Summary: Placenta accreta spectrum disorders (PAS) have become an
obstetrical problem potentially fatal due to its increased incidence over
the past 30 years.[1]
This condition is associated with considerable
maternal morbidity and mortality. Recently, several studies have
attempted to identify risk factors for placenta accreta spectrum
disorders (PAS), maternal age (≥ 35 years) and placenta previa were
reported to be Significantly associated with the development of PAS
disorders.[2.3]
Similarly, the increase in the number of previous
caesarean sections was a major risk factor for PAS disorders.[3]
Pre-
antenatal screening is done by a morphological ultrasound in the
second trimester, allows the patient to be directed to an experimental
team and with a high-performance technical tray to ensure optimal
management. We present a case of placenta previa accreta diagnosed
by ultrasound and magnetic resonance imaging techniques, in which we have realised
surgical treatment with abdominal total hysterectomy.
INTRODUCTION
Placenta accreta spectrum disorders is defined by an invasion of the myometrium by
chorionic villi.[4]
Depending on the depth, the penetration of the chorionic villi, it is
described: the accreta form that is characterized by the superficial penetration of chorionic
villi in myometrium, while the increta form is defined by a deep penetration of villi in the
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*Corresponding Author
Soukaina Khalta
Gynaecology-Obstetrics and
Endocrinology Department,
Maternity Souissi,
UniversityHospital Center
IBN SINA, University
Mohammed V, Rabat,
Morocco.
Article Received on
02 May 2021,
Revised on 23 May 2021,
Accepted on 13 June 2021
DOI: 10.20959/wjpps20217-19339
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Khalta et al. World Journal of Pharmacy and Pharmaceutical Sciences
myometrium without passing the myometrial serosa, and percreta where the Penetration of
villi up to the peritoneal coat and even beyond the pelvic organs and their
vascularizations.[5.6]
As the incidence of Caesarean have increased, Placenta accreta also has increased, there is a
run-up in the frequency of placenta accreta 3%, 11%, 40%, 6 1% and 67% in first, second,
third, fourth and fifth caesarean it seem to be parallel to the increasing caesarean delivery
rate.
CASE REPORT
A 39-year-old woman, no pathological antecedents, gravida 3 par3 2 (G3P3), two living
child, with previous two caesarean section for pelvic dystocia. For the third pregnancy,
antenatal period was not well followed until she was referred to our hospital due to abnormal
placentation diagnosed during a sonographic examination at 33 weeks of gestation. On
admission, The clinical examination found a pulse at 80 beats per minute, blood pressure at
120/65 mm Hg, Temperature at 37, the obstetric examination objectified a fundal height at
26cm, fetal heart tones perceived, the vaginal examination showed a closed cervix, an
abdominal ultrasound examination showed a viable fetus with appropriate biometrical
parameters and normal amniotic fluid, while transvaginal Eco-Doppler images suggested the
diagnosis of placenta previa accreta pelvic non contrast magnetic resonance imaging (MRI)
confirmed the ultrasound diagnosis found the myometrium very thinned with focal
interruption of the basal line at the level of its anterior and upper part of the placenta, given
the age of the patient and the number of child, an elective caesarean delivery was planned at
35 weeks of gestation. After opening the abdominal wall, intra-abdominal inspection showed
hypervascularisation at level of the lower uterine segment. a transverse uterine incision was
made above the lower uterine segment in order to avoid placenta. Total hysterectomy was
performed with the start of bleeding, a healthy female baby, with weight 3000 g was
delivered. During the surgery, the patient lost 1500 ml of blood, she was transfused
intraoperatively. The post-operative suites were good. Patient declared outgoing on d + 6 of
the postoperative period accompanied by her baby. the resulting material was sent to
histological examination.
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Khalta et al. World Journal of Pharmacy and Pharmaceutical Sciences
Figure 1: MRI of a placenta previa accrete: absence of hypoechogenous zone between
placenta and myometrium.
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Khalta et al. World Journal of Pharmacy and Pharmaceutical Sciences
Figure 2: Longitudinal section of a hysterectomy piece with placenta invading the
myometrium (placenta accreta).
Figure 3: chorionic villi adhere abnormally to the myometrium.
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Khalta et al. World Journal of Pharmacy and Pharmaceutical Sciences
DISCUSSION
The incidence of placenta accreta continues to increase in recent years. This progression
seems to be directly correlated with the increase in alterations of the uterine mucosa during
the genital life of the patients and more particularly to the increase in the caesarean section
rate over the past five decades.[7-8]
Baldwin and Patterson report that one pregnancy on 403-
533 is now complicated by PAS disorders.[9]
Other predisposing conditions for placenta
accreta are instrumentation of the endometrium, placenta praevia, uterine malformations,
septic endometritis, previous manual removal of placenta and multiparity.
Clinically, Placenta accreta is a pathology with little symptoms during pregnancy. The main
symptoms reported are the metrorrhagia of the second and third trimester, and which are
mainly related to placenta praevia.[7][10]
Macroscopic hematuria may occur in cases of
placenta percreta with invasion of the bladder. However, the most frequent mode of
presentation of the placenta accreta is the failure of natural and manual delivery of the
placenta.
Screening is an essential means of improving maternal prognosis in optimizing management,
thus reducing the risk of morbidity, particularly hemorrhagic morbidity, The diagnosis is
usually made by ultrasound, then MRI in patients with risk factors.[11][12][13]
Ultrasound is the reference examination to detect a placenta accreta. His sensitivity varies
from 77% to 93%[14]
and its specificity is 95%.[6]
The classically described ultrasound signs
are the presence of placental gaps, the absence of a hypoechoic border between the placenta
and the myometrium, an interruption of the hyperechoic zone at the interface of the uterine
serosa and the bladder, and the presence of a pseudotumoral aspect of the placenta opposite
the uterine serosa.[15]
Placental MRI is an important means for the diagnosis of placenta accreta but is indicated
only in the event of high ultrasound suspicion, It appears to be complementary to ultrasound,
particularly in posterior-insertions,and confirms a diagnosis of placenta accrete.[16]
Lax et al
have tried to define diagnostic criteria and especially retained: the presence of Dark
intraplacental bands, the presence of a mass effect on the uterus with a localized bulge, the
appearance of a heterogenous placenta in low signal, thinning of the myometrium with
disappearance of the internal border in low signal.[17]
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Some recent studies have studied the contribution of MRI with gadolinium injection and have
been able to demonstrate that this would improve the specificity of MRI.[18]
It should be
noted that there is a discrepancy between ultrasound results and MRI in 30% of cases.
The choice of management strategy depends mainly on the anatomical type of placenta and
desire of patients to preserve their fertility.
If the diagnosis of is made antenatally, there are essentially three options for the management
of placenta accreta:
Caesarean section-hysterectomy without attempted artificial delivery is currently
recommended in case of strong prenatal suspicion of placenta accreta by the American
College of Obstetrics and Gynecology (ACOG).[19]
The extirpative method, this procedure consists of performing a forcible manual removal of
the placenta delivery in an attempt to obtain an empty uterus but it is associated with a higher
rate of massive PPH resistant to non-radical hemostatic techniques leading to
hysterectomy.[20,21,22-23]
Conservative treatment with placenta left in place, Allows to avoid a hysterectomy in about
75–80% of cases but is associated with a risk of transfusion, infection and severe maternal
morbidity, required women to undergo treatment for a long period of postpartum.[18,24,25]
If the diagnosis of is made intraoperatively, in case of moderate bleeding, arterial ligation
possibly associated with uterine padding (in case of cesarean section) or arterial embolization
(in case of vaginal delivery) can be performed but a hysterectomy must be performed in case
of failure or severe hemorrhage from the start.
CONCLUSION
The placenta accreta is a pathology at risk of serious hemorrhagic complications during
pregnancy and postpartum. Antenatal screening is essential by allowing an optimization of
the treatment. Multidisciplinary management consists of either a hysterectomy for prevent a
PPH, or a conservative approach, but it imposes a rigorous follow-up until complete
resorption of the placenta.
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