Postpartum Hemorrhage

New trends in treatement of Placenta Accreta

Placenta PercretaDR Manal BeheryProfessor of Obstetrics&GynecologyZagazig University 2013Full-size image (106 K)New trends in the treatment of Placenta AccreteDefinition

http://www.fetalsono.com/teachfiles/Images/AccDrw.jpghttp://upload.wikimedia.org/wikipedia/commons/thumb/5/54/Placenta_accreta.png/230px-Placenta_accreta.pnghttp://www.jmedicalcasereports.com/content/figures/1752-1947-5-418-5.jpg81.6%11.8%6.6%J Clin Ultrasound 2008;9:551-9Definition

In a 1977 report, the incidence in the published literature was estimated to be 1 in 7000 deliveries.

Miller and colleagues reported an incidence of abnormal placentation of 1 in 2510 for a 10-year period at their center ending in 1994.

Wu and colleagues reported an incidence of

1 in 533 over a 20-year period ending in 2002.

INCIDENCEFrequency of placenta accreta according to number of cesarean deliveries and presence or absence of placenta previa

Adapted from SMFM. Am J Obstet Gynecol 2010. Cesarean Delivery

First (primary)SecondThirdFourthFifth Sixth

Placenta previa

3.3%11%40%61%67%67%

No Placenta previa

0.03%0.2%0.1%0.8%0.8%4.7%

In a large prospective observational study that considered the number of prior cesarean deliveries and presence or absence of placenta previa,the risk of placenta accreta wasThe Diagnosis Of Placenta Accreta?

In the vast majority of cases, placenta accreta may be diagnosed on the basis of ultra-sound alone.

Sonographic findings suggestive of accreta include

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data:image/jpeg;base64,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data:image/jpeg;base64,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data:image/jpeg;base64,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http://radiographics.rsna.org/content/29/5/1371/F31.large.jpghttps://encrypted-tbn3.gstatic.com/images?q=tbn:ANd9GcQ-CvZnNe5lHaeYV3qGZRXqxHk2IlU6W4P41qhZUDeherS4Npn_8Ahttp://origin-ars.els-cdn.com/content/image/1-s2.0-S0002937897705829-gr1.jpgWhich imaging modalities are necessary for the diagnosis of placenta accreta?

The use of power Doppler, color Doppler, or three-dimensional imaging does not significantly improve the diagnostic sensitivity compared with that achieved by grayscale ultrasonography alone15.Chou MM, Ho ES, Lee YH. Prenatal diagnosis of placenta previa accreta by transabdominal color Doppler ultrasound. Ultrasound Obstet Gynecol 2000;15:2835.
MRI findings suggestive of placenta accreta include

Lower uterine bulging,

Heterogeneous placenta

Dark intraplacental linear bands

on T2-weighted images.

http://www2.rsna.org/timssnet/rsna/media/pr2009/Malhorta--MRIPregnancy/JPG/MRPlacentaAccreta.jpghttp://radiographics.rsna.org/content/29/5/1371/F33.large.jpghttp://radiographics.rsna.org/content/28/7/1905/F15.small.gifWhich is better ?

Diagnostic accuracy of both US and MRI are similar.

In patients with suspected placenta percreta MRI can provide information on depth of invasion and may be particularly useful in the diagnosis of posteriorly located placenta.

In such cases MRI can be complmentary to US

How is prenatal care different in the patient with placenta accreta?

Patients should ideally be referred to a tertiary center with adequate surgical facilities and a multidisciplinary team

Occasionally, patients may require recombinant erythropoietin as adjuvant therapy

sonographic follow up every 3 to 4 weeks to evaluate placental location, depth of invasion, and fetal growth

Delivery planning

The preferred strategy was delivery at 34 weeks without amniocentesis for placenta previa with suspected accreta,and for cases with recurrant bleeding

An expert opinion in 2010 recommended delivery for uncomplicated previa at 36 -37 weeks and 34 to 35 weeks for suspected placental invasion.

The different risks and treatment options should have been discussed and a plan agreed, which should be reflected clearly in the consent form.

This should include the anticipated skin and uterine incisions and whether conservative management of the placenta or proceeding straight. to hysterectomy is preferred in the situation where accreta is confirmed at surgery.

What should be included in the consent form for caesarean section?

Thorough discussion with patient on

the suspected diagnosis,

the anticipated surgical procedure

high potential for hysterectomy, profuse hemorrhage,

probable transfusion needs,

increased complications

A preoperative checklist would be helpful in confirming necessary preparations and for identifying contact persons in case perioperative assistance is required.

Which preoperative interventions are beneficial for patients with suspected accreta to decrease transfusion needs?Acute normovolemic hemodilution (ANH)

http://pennstatehershey.adam.com/graphics/images/en/19455.jpghttp://www.neuros.net/es/images/hemodilucion_normovolemica.gifhttp://promelab.8m.com/cs5or.jpgAcute normovolemic hemodilution (ANH) Preoperative bilateral common iliac artery balloon catheter placement with inflation after delivery of the fetus

Preoperative bilateral common iliac artery balloon catheter placement with inflation after delivery of the fetus

preoperative placement of femoral access by IR with selective embolization of uterine vessels at the time of delivery

Figure F2 preoperative placement of femoral access by IR with selective embolization of uterine vessels at the time of delivery

Level of evidance

No sufficient evidences for a firm recommendation on the use of balloon catheter occlusion or embolization to reduce blood loss and improve surgical outcome.

There have been other reports of no benefits and even of significant complications.

DWhat is the optimal anesthetic technique for patients with placental accreta?

When massive blood loss is expected, a complete sympathectomy (eg, spinal anesthesia) could impair the patients ability to cope with sudden hypovolemia, as the capacity to vasoconstrict and increase systemic vascular resistances will be limited.

Regional anesthesia with a continuous epidural technique is safe and may be appropriate for patients with placental accreta

What is the optimal anesthetic technique for patients with placental accreta?

If extensive dissection, prolonged operating time, and massive hemorrhage are anticipated, general anesthesia is commonly recommended. 1

When regional anesthesia was first used a reported rate of conversion to general anesthesia of about 28% to 30%SOCan the cell saver (salvage) be used in these cases?

http://www.transfusionguidelines.org.uk/docs/graphics/bbt-03_icsag-fs-03.gifhttp://www.tdgnews.it/en/wp-content/uploads/2010/08/blood-save.jpghttp://www.tdgnews.it/en/wp-content/uploads/2010/08/blood-save.jpgIntraoperative cell salvage

It has been used successfully in obstetric hemorrhage lacerations of the genital tract(6%)

A theoretical concern with the use of the cell saver in obstetrics is the occurrence of iatrogenic amniotic fluid embo-lism (AFE)

Rh negative should receive anti-D immunoglobulin as soon as possible with a dose given according to results of a Kleihauer Betke

Intraoperative cell salvageSurgical strategy

There is no unique approach to the management of placenta accreta.

Surgical team expertise, availability of resources and local conditions are determining factors when choosing the safest procedure.

One-step surgery

One-step surgery involves wide mobilization of tissue, tissue resection, myometrial and bladder sutures,

Meticulous dissection allows an accurate haemostasis, which makes it possible to resect the invaded tissue and have adequate tissue repair

http://i1.ytimg.com/vi/XtPD8atfqzY/hqdefault.jpgThe definite treatment for placental accreta is

Cesarean hysterectomy, ideally without attempts to remove the placenta.

In cases in which the placenta has been distorted and massive hemorrhage ensues, any delays in definite treatment (hysterectomy) may seriously compromise maternal hemodynamics

Patients with no interest in future child-bearing likely will also benefit from hysterectomy without delay.

Cesarean hysterectomytotal or subtotal ?With the exception of upper-segment invasions, hysterectomy for placenta accreta must be total; otherwise there is a high percentage of rebleeding in subtotal resections within the lower-segment invasions.

IF SUBTOTAL IS DONEit is not recommended to close theperitoneum over the cervical stump,As rebleeding in these circumstancesusually goes unnoticed.placenta accreta02Therapeutic practice points

The presence of pericervical or lower-segment varicose veins proper of placenta praevia can be confused with the neovascularization of placenta accreta.

Surgical exploration will make a differential diagnosis, thus avoiding unnecessary hysterectomies.

C:\Users\Yudania\Desktop\43_acretismo_5[1].jpgTherapeutic practice pointsAn external file that holds a picture, illustration, etc.Object name is ijwh-4-587f6.jpgIn cases of placental accreta, the areas of placental invasion outside the uterus may also be affected by the abnormal blood supply.

Care should be taken not to compromise the parasitic vasculature when entering the abdomen and exposing the uterus.

placenta accreta01.Neoformation vessels should not be electrocoagulated because of poor development of the middle layer

This procedure can be the cause of bleeding difcult to control, or of a postsurgical haemorrhage.

https://encrypted-tbn1.gstatic.com/images?q=tbn:ANd9GcTUR3BiE-N06afkpLV0EZFtf1A3fyBxE1QeM5_p9jJZl1YVIHB-https://encrypted-tbn1.gstatic.com/images?q=tbn:ANd9GcR0HvPk_qODIrFahYkzWPP4xNcA6EL6UCPZpxYCd-QM-NOtzzPRPlanning of uterine incision

No attempt at placenta removaL
Placenta left in situWith uteroplacental blood flow at 700 to 900 mL/min near term, every minute of hemorrhage avoided is significant.Incisions made through the placenta and any attempts to deliver the placenta in these cases will often incite signicant hemorrhage

Surgical difculties and possibility of complications in placenta accreta are directly related to

the invaded anatomical area,

its specic circulation

the dissection of the organs involved.

Is there a role for conservative treatment in placental accreta?In selected cases a conservative approach may be attempted.

Hemodynamically stable patients with no heavy bleeding or DIC at time of surgery

women who desire to have more children

Cases with placenta percreta invading adjacent organs (eg, bladder, ureter, bowel)

In selected cases a conservative approach may be attempted.

Morbidity can be high and that further intervention will often be necessaryPatient should also be willing to accept that

Outcome is unpredictable

Morbidity can be high

Strict prolonged followc up is needed

and that further intervention will often be necessary

Different techniues have been

In cases involving only focal accreta found incidentally at the time of surgery, attempts to place local haemostatic sutures may control bleeding after placental removal)

Alternatively, the placenta may be partially left in situ

http://resources.ama.uk.com/glowm_www/graphics/figures/v1/0730/pph_5.jpgauto0Different techniques have been described. The conservative approach may be combined with

Administration of uterotonics, intraoperative uterine devascularization, or pelvic arterial embolization by interventional radiology.

The use of prophylactic antibiotics may be considered,despite lack of clinical data.

No convincing evidence exists for or

against the use adjuvant methotrexate,

The conservative approach may be combined with

1-One step suregery

2-Adjuvant methotrexate (MTX) treatment,3-Curettage,4-Tamponade of the placental implantation site with inflated intrauterine ballon catheter bags,5- Lower segmant compression suture6-Local excision, and repair or oversewing of the implantation sitehttps://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcSyiXUGphD1y8b9PpgD0mLPFo039CaWzE78sI44SLX7qr1U5BP4http://origin-ars.els-cdn.com/content/image/1-s2.0-S0020729212000252-gr4.jpgOption of Conservative tttThe Triple-P procedure for placenta percreta

1-perioperative placental

localization and delivery by incision above the upper border of the placenta

2- pelvic devascularization;

3- placental non-separation with

myometrial excision and

reconstruction of the uterine wall

http://origin-ars.els-cdn.com/content/image/1-s2.0-S0020729212000252-gr3.jpgFull-size image (39 K) International Journal of Gynecology & ObstetricsVolume 117, Issue 2, May 2012, Pages 191194http://origin-ars.els-cdn.com/content/image/1-s2.0-S0020729212000252-gr4.jpgFull-size image (36 K)

For persistent diffuse non arterial bleeding that is not amenable to surgical control,

Placement of pelvic pressure packing(laparotomy sponges) may be considered as a temporizing step to allow time for hemodynamic stabilization, correction of coagulopathy, and eventual completion of surgery.

Pelvic pressure packinghttp://www.mdconsult.com/books/bbmapAsset?appID=MDC&isbn=978-1-4160-5908-0&eid=4-u1.0-B978-1-4160-5908-0..00075-2..f075-009-9781416059080..t&assetType=thumbOptimal postdelivery follow-up of patients treated with this pproach.

No guidelines exist regarding the optimal postdelivery follow-up

Postpartum hemorrhage may happen up to 105 days after the initial procedure

Serial ultrasounds to assess placental involution and frequent visits to screen for delayed hemorrhage and early signs of sepsis

ConclusionConclusion

Access to pelvic subperitoneal spaces

wide opening of vesicouterine space

planned hysterotomy,

management of proximal vascular control,

and accurate use of compression sutures

are key to achieving vascular control and haemostatic procedures.Conclusion

Carrying out hysterectomy during shock or coagulopathy implies a high risk of immediate and late complications.

Use of effective vascular control, such as internal aortic compression may provide time to improve haemodynamic and haemostatic status, which increases the effectiveness of compression sutures later

Conclusion

Hysterectomy or one-step conservative surgery is complex at first, but offers a relatively known outcome.

To leave placenta in situ provides a bloodless surgery initially, but with risks of unpredictable complications later.

Conclusion

Which mechanisms lead to acute coagulopathy?

Classically, hemorrhage resuscitation has been centered on administration of crystalloids and (PRBC).

Use of other blood products, like FFP,CPPT,PTS

is indicated if laboratory values are abnormal

(eg, platelet count