- Evaluation of pregnancy outcomes & different management
options used in Morbid Adherent placenta
- Introduction
- Morbidly adherent placenta (MAP) is defined as placental chorionic
villi adherence either whole (total) or part (partial) to the
myometrium ; superficially (accreta), deeply (increta) & fully
(percreta)& . While focal adherence (when part of the cotyledon is
involved) (1).
- MAP Previa especially with previous CS Section (CS) is a
life-threatening complication of pregnancy, with 10 folds rising rate
in the past 50 years because of the increasing (CS) rate worldwide.
It’s incidence is 1:2500 per delivery. It may be asymptomatic or
presented with antepartum (APH) or postpartum hemorrhage(PPH),
abdominal pain, acute abdomen, retained placenta, uterine rupture, DIC
or occasionally maternal death (2),(3).
- Early antenatal diagnostic criteria of MAP using Doppler U/S & MRI,
which can reduce it’s morbidity & mortality includes:(4)
- Thinning of anterior Lower uterine segment(LUS)of less than 1mm.
- Lacunae vascular spaces (Swiss cheese appearance) & inter parenchymal
placental lacunar flow.
- Extension of placental tissue beyond uterine serosa & bladder uterine
serosa hypervascularity.
- Prominence of subplacental venous complexes.
- MAP management with a multidisciplinary approach includes hemorrhage
anticipation & management , availability of packed cells,
platelets, fresh frozen plasma, cryoprecipitate, & activated factor
VII. Interventional radiology & cell saver technology are useful(5).
- Classical, high transverse, fundal & fundal transverse uterine
incisions with pre-operative &/or intra-operative U/S MAP areas
mapping, have been used to avoid the placental hemorrhage & to
deliver the fetus (6) .
- Traditional management of MAP is CS hysterectomy, but it is
associated with postoperative complications & fertility loss.
However, if hysterectomy is done without removal of the placenta,
this would prevent unnecessary hemorrhage & reduce maternal
mortality. In cases where MAP is associated with placenta previa,
total hysterectomy is preferred to a subtotal hysterectomy(7) .
- Balloon catheter occlusion of the pelvic vessels or Selective Arterial
Embolization decreases blood flow to the uterus & makes it possible
to perform surgery under controlled circumstances. Bilateral internal
iliac artery ligation is performed prior to peripartum hysterectomy to
reduce blood loss especially when interventional radiology is not
available (8) .
- Other uterus sparing strategies are described to achieve hemostasis by
resecting the area of placental attachment, if it is focal & the
majority of the placenta has been removed (9) .
- In conservative approach, once the baby is delivered the placenta is
left undisturbed. The cord is cut short & the uterine incision is
closed with monitoring for bleeding & sepsis (10) .
- Morbidity was defined as the occurrence of 1 or more of the following(11):
- Maternal admission to the intensive care unit (ICU) for >
24 hours.
- Transfusion of ≥ 4 units of packed red blood cells.
- Coagulopathy (platelets ≤100000/ microliter, international normalized
ratio ≥1.2, &/or fibrinogen≤200mg/dl).
- Ureteral injury.
- Bladder injury.
- Reoperation.
- Aim of the Work
- The aim of this work is evaluation of different management options for
MAP patients & their effects on pregnancy outcomes to find the best
option & to decrease MAP associated morbidity & mortality .
- Patients & Methods
- This is a prospective study that includes 42 hospitalized pregnant
women diagnosed with MAP between December 2019 & May 2020 at Ain
Shams & Zagazig Universities Hospitals.
- All cases of placenta previa in the third trimester admitted to
Hospitals & diagnosed antenatally as MAP
- Exclusion criteria :
- Any medical disorder with pregnancy as anemia, hypertension, diabetes,
cardiac lesion, liver diseases or kidney diseases.
- Steps of performance & techniques that were used:
- Each woman was subjected to the following:
- Full history taking:
- Examination:
- Laboratory investigations:
- A blood sample was withdrawn to check for complete blood count,
coagulation profile, liver function tests, renal function tests &
random blood sugar.
- A urine sample was taken to check for proteinuria, hematuria &
presence of urinary tract infection.
- Blood group , cross matching for blood & plasma before operation
- U/S:
- U/S was performed for each patient to confirm viability, gestational
age, fetal biometry, fetal presentation, amount of liquor & detailed
assessment of placental site, degree of adherence by 2D U/S & Doppler
- U/S machine : (GE voluson healthcare Austria with 3.5 MHz
sector transducer for TAS& 7.5 MHz sector transducer for TVS)
- Sonographic features of MAP by 2D U/S:
- Deficiency of retroplacental sonolucent zone.
- Vascular lacunae.
- Myometrial thinning.
- Interruption of bladder line.
- Presence of exophytic masses.
- Characteristic findings on color Doppler U/S include:
- A diffuse lacunar flow pattern with high-velocity pulsatile venous
type flow (peak systolic velocity more than 15cm/s) spread
throughout the placenta, myometrium & cervix.
- A central lacunar flow pattern with turbulent flow distributed
regionally or focally in the parenchyma.
- Bladder–uterine serosal interphase hyper vascularity.
- Markedly dilated vessels over the peripheral sub placental zone.
- An absence of sub placental vascular signals in the areas lacking
the peripheral sub placental hypo echoic zone.
- Abnormal vascular channels linking the placenta to the bladder.
- Consenting :
- An informed written consents about different management options
including hysterectomy , blood products needs during the operation &
risk of mortality were taken from all patients & their husbands .
- Preoperative preparation:
- Fasting at least 6 hours preoperative.
- Preservation of adequate amount of blood & plasma from the same ABO
group, platelets & recombinant activated factor vii.
- Notification to neonatal, gynecological oncologists, urology,
interventional radiologists & vascular surgeons’ teams to be
available if needed.
- Surgical techniques:
- Different management were performed in MAP patients with placenta
previa according to the degree of adhesion, amount of bleeding & the
future fertility desire.
- All cases with MAP were operated by a senior obstetrician with
attendance of a senior anesthesiologist.
- General anesthesia &Prophylactic antibiotic were given before skin
incision.
- Skin incision: midline or pfannenstiel incision.
- Uterine incision: high transverse or vertical upper segment incision.
- Delivery of the baby.
- Hysterectomy without or with placental removal followed by
conservatives’ procedures were left to the experience of the senior
obstetrician.
- Bilateral internal iliac balloon was inserted before operation &
inflated after delivery of the baby to decrease blood loss during
surgery.
- If bladder or ureteric injury was suspected urological consultation
was done.
- Postoperative care:
- Close monitoring to vital signs (blood pressure, pulse, temperature &
respiratory rate), urine output (color & amount) & drains was done
in ICU or in the ward according to patient condition.
- Complete blood count & packed RBCs transfusion if the patient was
anemic.
- Early mobilization, good hydration & prophylactic anticoagulant if
needed to prevent DVT.
- After discharge the patients returned to outpatient clinic to remove
stitches & their wounds were examined for infection.
- Postoperative histopathological assessment of the placental remains.
- Estimation of blood loss:
- Actual blood loss (ABL) was calculated from a modification of the
gross formula (13)
- Actual blood loss = BV {Hct(i) − Hct(f)}/ Hct(m)
- BV: Blood volume. Blood volume is calculated from the body weight by
multiplying the Body weight (in Kg) by × 70
- Hct (i): Initial hematocrit
- Hct (f): Final hematocrit
- Hct (m): Mean hematocrit
- Neonatal care:
- All neonates were examined by pediatrician with detection of APGAR
score, gender & birth weight.
- Statistical analysis:
- Data collected throughout history, basic clinical examination,
laboratory investigations & outcome measures coded, entered &
analyzed using Microsoft Excel software. Statistical Package for the
Social Sciences (SPSS version 20.0) (Statistical Package for
the Social Sciences) software for analysis was used afterwards for
further analysis of the data in this study.
- Results
- All cases had placenta previa & 41 cases had at least one previous
CS, 18 of the 42 patients (42.9%) had a history of at least one
previous uterine curettage, the mean age of the included women was
32.21± 5.28 years (range: 21-43 years), the median parity was 3
(range: 1-5), 20 (47.61%) presented with APH,14 (33.3%) cases had
urgent surgery due to APH or uterine contraction.
- Midline incision was done in 13 (31%) cases & pfannenstiel incision
was done in 29 (69%) women, there are 20 cases had hysterectomy from
the start without trial of placental removal while attempt placental
removal was tried in 22 cases that succeeded in 13 cases had CS only
& failed in 9 cases had hysterectomy.
- Different uterus sparing methods were tried including bilateral
uterine artery ligation in 13 (59%) cases, bilateral ovarian artery
ligation in 3 (13.6%) cases, bilateral internal iliac artery ligation
in 3 (13.6%) cases, intrauterine tamponade in 4 (18.1%) cases &
hemostatic sutures in placental bed in 11(50%) cases, while B-lynch
suture was not done, while procedures which were performed to control
pelvic hemorrhage after hysterectomy included internal iliac artery
ligation in 8 (27.5%) cases, pelvic packing in 5 (17.2%) cases &
internal iliac balloon inflation to control hemorrhage in 1 (3.4%)
case.
- Bladder injury occurred in 7(16.7%) cases & ureteric injury occurred
in only 1 (2.4%) case, the median estimated intraoperative blood loss
was 2 L (range: 1–8 L), all cases need blood transfusion. The median
was 4 units (range: 1–17 units), the overall rate of FFP transfusion
was 39/42 (92.85%). The median was 2 units (range: 1–8 units), only
2 (4.76%) woman received platelet transfusion & only 3 (7.14%)
woman received cryoprecipitate transfusion, only 1 (2.4%) woman
needed Recombinant activated factor vii.
- The postoperative complications are DIC, postpartum collapse,
reoperations in (2 cases ;4.8%), ICU admission in (5 cases ,11.9%),
Wound infection, decidual cast, retained products of conception,
chorioamnionitis & pulmonary embolism in (1 case ;2.4%). Median
duration of hospital stay was 4 days (range: 2-25).
- Table (1):Patient clinical characteristics: