Morbidly Adherent Placenta and Peripartum Hysterectomy

A Case of Placenta Praevia with Morbidly Adherent Placenta

Surg Lt Cdr Ankur ShahModerator: Lt Col M K Tangri

30/10/2014

25 yr old

G2P1L1 at 38 weeks POG

Post LSCS pregnancy

Placenta Praevia with Placenta Increta

LMP: 7/2/2014

EDD: 14/11/2014

Steroids given for fetal lung maturity

Obstetric History

G1

− 2011, FTLSCS (Non progress of Labour)

− Male, 4.5 kg birth weight G2

− Present pregnancy, spontaneous conception

− Booked and registered case at our hospital

− On regular antenatal visits

Antenatal Investigations

Hb: 11.0 gm%

ABO Rh: O positive

BS (F): 90 (PP): 98

OGTT with 75 gm glucose: 87/124 mg/dl

HIV/HbsAg/VDRL: Neg

Antenatal Ultrasound

Date(POG)

24/5/14(15w1d)

7/6/14(16w1d)

20/10/14()

Gestation SLIUF SLIUF SLIUF

USMA 16w 1d 34w 6d

Placenta Ant, NP Completely covering os

Lower segment

completely covering os

Liquor Adequate AFI = 11 cm

Anomaly Nil No obvious invasion in

myometrium noted

EFW 2549 gm

USEDD 25/11/14

MRI dated 25/10/14

Placenta noted in lower part of uterine cavity, overlying the expected location of scar, completely covering the os

No myometrial tissue identified in region of placental implantation

Focal bulging of uterine contour at placental site

Increase vascularity noted surrounding uterus esp in lower segment

03/11/2014, 0530 hrs

Pt reported to Labour Room:

− C/o pain lower abdomen Evaluated, not in active labour

Planned for scheduled LSCS at 0800 hrs

Couple counselled, consent for peripartum hysterectomy taken

Blood demand for 4 units PRBC and 4 units FFP sent

− Blood bank informed regarding need for increased requirement

03/11/2014, 0900 – 1250 hrs

Pt taken up for surgery under SA

Intra-op findings:

− Pfannensteil incision given over previous surgical scar

− Dense adhesions between ant abd wall and ant uterine surface

− Bladder pulled up, adherent to uterine surface and extremely vascular

− UV fold of peritoneum opened and bladder attempted to be pushed down. No clear plane identified

− Live male baby delivered by vertex

Intra-op Findings

− Angle of uterine incision sutured, while awaiting placental separation

− Uterus contracted, partial separation of placenta seen from posterior lower uterine segment

− Sudden brisk haemorrhage with loss of approx 1.5-2 litres of blood in about 1.5 min

− Separation of placenta attempted and removed piecemeal

− Pt developed sudden bradycardia, hypotension, collapse – converted to GA

− Fluid resuscitation done, followed by transfusion of blood and FFP

Intra-op Findings

− In view of retained adherent placental tissue in lower uterine segment and multiple failed attempts at hemostasis, decision for peripartum hysterectomy taken

− Inadvertent injury to bladder vault occured during dissection of UV fold – primary repair done in two layers

− Suture integrity checked by methylene blue dye instillation

− B/L ureteric peristalsis seen after hysterectomy Approx blood loss ~ 3.5 litres

Total of 8 units PRBC and 12 FFP transfused

Post op Course

Post op – pt monitored in ICU for 48 hrs

Subsequent recovery in ward uneventful

Foley's catheter removed on Day 12 post op

Pt discharged on Day 14 with well established feeding and healthy baby

PLACENTA ACCRETE SYNDROMES

Introduction

Derived from Latin ac- + crescere, to grow from adhesion or coalesce

Any placental implantation with

− Abnormally firm adherence to myometrium

− Partial or total absence of decidua basalis

− Imperfect development of Nitabuch layer Associated with

− Life-threatening intrapartum/postpartum haemorrhage

− Maternal mortality ~ 7%

Etiopathogenesis

Exact pathogenesis unknown

Proposed hypotheses:

− Maldevelopment of decidua

− Excessive trophoblastic invasion (hyperinvasiveness)

− Combined theory Abnormal expression of growth factors, angiogenesis and

invasion-related factors in trophoblastic cells

Role of decidua – controversial

Classification

Depth of trophoblastic growth:

− Accreta: villi attached to myometrium

− Increta: villi invade the myometrium

− Percreta: penetrate through myometrium and/or serosa Area of placenta involved:

− Total

− Focal

Incidence/Risk Factors

1 in 533 deliveries

Increasing incidence with rise in no of Caesarean deliveries

Risk Factors:

− Placenta praevia

− Asherman's syndrome

− Previous uterine scar

− Advanced maternal age and parity Risk 3%, 11%, 40%, 60%, 67% with 1 to 5 previous

cesarean deliveries

Diagnosis

Grayscale ultrasound

− Sensitivity (93%), specificity (76%), positive predictive value (82%)

− 3D doppler, colour doppler do not increase diagnostic sensitivity Ultrasound criteria for diagnosis of morbidly adherent placenta:

− Loss of retroplacental sonolucent zone

− Irregular retroplacental sonolucent zone

− Thinning or disruption of hyperechoic serosa-bladder interface

− Focal exophytic mass involving bladder

− Abnormal placental lacunae (swiss cheese or moth eaten appearance)

Colour Doppler

− Diffuse or focal lacunar flow

− Vascular lakes with turbulent flow (PSV > 15 cm/s)

− Hypervascularity of serosa-bladder interface

− Markedly dilated vessels over peripheral subplacental zone

MRI

− Uterine bulging

− Heterogenous signal intensity within placenta

− Dark intraplacental bands on T2 weighted imaging

Management

Timing of delivery

− Individualised decision

− Recommended at 34 weeks after fetal lung maturity

− In a tertiary care centre Cesarean section

− Consent for peripartum hysterectomy

− Prepared for massive haemorhage and blood transfusion

− PRBC and FFP arranged for in 1:1 ratio

Surgical Approach

− Anaesthesia: Spinal vs GA

− Midline skin incision vs Pfannensteil

− Uterine incision at site away from placenta

− Avoid manual removal of placenta Alternative approach

− Conservative measures: placenta left in situ

− Use of methotrexate

− High risk of bleeding, later hysterectomy Interventinal radiology

− Use of balloon catheter occlusion or embolisation

− Risk of arterial thrombi formation

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