1. Data presented as number (percentage)
  2. Figure(1): microscopic picture of retained product of conception & atrophic villi lined by syncito & cytotrophoblast with infiltration of decidua by inflammatory cells(×400,H&E).
  3. Figure(2): microscopic picture of chorioamnionitis showing inflamed chorionic membranes & infiltration by inflammatory cells(×400,H&E
  4. Discussion
  5. In our study, all cases had at least 1 previous CS, except for only 1 case that had no previous CS. While Melissa et al., (2013)reported that only 2 (6.1%) cases had no previous CS, while 11 (33.3%) women had 1 previous CS (12 ).
  6. In this study, hysterectomy was done without placenta removal in 20 cases (47.6%) & with its removal in 22 cases (52.4%). The decision of placental removal was left to the experience of the senior due to absence of management protocol for MAP in our hospital.
  7. Our results revealed that 20 cases (47.61%) presented with APH, 14 of them (33.3%) had urgent surgery, while Eller et al., 2009reported APH in 29(62%) cases & urgent surgery in 13(45%) cases (19).
  8. Biler A, et al., 2016 agreed with our study that, there is no significant difference (P: 0.64) between elective & urgent surgery as regard blood loss, while Eller et al., 2009 reported that scheduled surgery associated with reduced maternal morbidity in MAP patients. The reason of contradiction may be due to availability of senior obstetrician, anesthesiologists & blood bank in our hospital (19,20 ).
  9. In this study midline incision was done in 31% cases & pfannenstiel incision was done in 69% of cases, while Melissa et al., 2013 reported that midline incision was done in 30(90.9%) cases & pfannenstiel incision was done in 3 (9.1%) women. (12 )
  10. Intraoperatively trial placental removal plus conservative procedures were performed in 22(52.4%) cases that succeeded in 13 (59%) women who had CS only, failed in 9 (40.9%) women who had hysterectomy, while hysterectomy with placenta lift in situ was done in 20(47.6%) women.
  11. While Biler A, et al. 2016 reported that 11(22%) women had hysterectomy without removal of the placenta, while 38 (78%) women were managed conservatively. The placenta was removed after delivery in all these patients. (20 ) .
  12. While Deeba F.N et al., (2016) reported that majority of patients 17(74%) undergone CS hysterectomy without removal of the placenta, Placental removal was performed in 6 (26%) patients all having focal adherence of placenta. (16 )
  13. Intraoperatively, many procedures were performed to control pelvic hemorrhage after hysterectomy, internal iliac artery ligation in 8 (27.5%) cases, pelvic packin2009 reported cases & internal iliac balloon was inflated to control hemorrhage in 1 (3.4%) case,Eller et al., 2009 reported that 20 (36%) cases need bilateral internal iliac artery ligation, while Fitzpatrick KE et al., 2014 reported that 11 (8%) women had internal iliac balloon was inflated to control hemorrhage, & 16 (12%) women had intra-abdominal packing. (19,21 )
  14. In this study, the rate of FFP transfusion was 92.85%. Moreover platelets &Recombinant activated factor VII transfusion rate was (7.14%) (2.4%), respectively. While Melissa et al., 2013reported transfusion of FFP in 11 cases (33.3%), platelets in 4 cases (36.4%) &cryoprecipitate in 2 cases (18.2%). Fitzpatrick KE et al., 2014 revealed that 5 (4%) cases needed Recombinant activated factor VII. (12,21 )
  15. Fitzpatrick KE et al., 2014 also reported in agreement with this study that, there is highly significant increase in blood loss in patients undergoing CS hysterectomy with placental removal when compared to those with same procedure but without placental removal. But they disagreed with us, as regard the difference between them in the hospital stay (21 ).
  16. Biler A et al.2016 reported in accordance with our study, that intraoperative complications, bladder & ureteric injury occurred, while bowel & vascular injuries have not occurred. However,Eller et al., 2009 revealed that bowel, ureteric & vascular injury occurred.
  17. The median hospital stay in this study was 4 days in comparison to 5 days in a study by Melissa et al., 2013 (12).
  18. In our study, maternal mortality was reported in only 1 case (2.4%). Morbidity like DIC, postpartum collapse, pulmonary embolism occurred only in cases with hysterectomy & placental removal, due to internal hemorrhage. Deeba F.N et al 2016 reported mortality rate in 2 cases 8.69% (18,22 ).
  19. This study, revealed a mean gestational age of 36.61 weeks, the median birth weight of 3400 g& Apgar score of 7 with uniformly good neonatal outcome. Eller et al., 2009 reported that mean of gestational age at time of delivery was 35.4 weeks (19 ).
  20. A major strength of our study is its prospective population-based design, not relying on routinely coded data to ascertain cases. But the limitations include the sample size. As it was insufficient to identify differences in complications with the use of different management strategies, control of bleeding differed in every patient.
  21. Additionally, management decisions were made at the discretion of the responsible clinician, & protocols were not employed.
  22. Conclusion
  23. Up till now there is no completely sensitive & specific test for MAP diagnosis. Early antenatal diagnosis of MAP& timely delivery decision in tertiary care center with appropriate expertise & facilities are the key to success in the management.
  24. Multidisciplinary approach individualized according to hemodynamic stability; future fertility desire may reduce maternal morbidity & mortality in MAP patients. As CS hysterectomy, should be avoided in women with future fertility desire.
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