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 & PATHOGENESIS

Placenta 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 imaging

The 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

Fre

qu

en

cy

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

Pe

rce

nt

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 PRBC4 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 PRBC

5 NA 4 PRBC4 FFP

2whole Blood

4 PRBC9 FFP

4 whole Blood

6 NA 2 PRBC 2 PRBC2 whole Blood

7 NA 8 PRBC4 FFP

NA

Continued Case number Pre

operative Intra

operative Post

operative

8 NA 3 PRBC 1 PRBC4 FFP

9 NA 4 PRBC 2 whole Blood2 FFP

10 NA 2 PRBC 2 PRBC

11 2 PRBC 2 PRBC 2 PRBC2 FFP

12 NA 2 PRBC NA

13 NA 2 PRBC 2 PRBC2 FFP

14 NA NA NA

15 NA 2 PRBC4 whole Blood

2 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

Pe

rce

nt

60

50

40

30

20

10

0

77

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 .