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SCAR PREGNANCY AND PLACENTA ACCRETA AFTER CESAREAN.

SCAR PREGNANCY AND PLACENTA ACCRETA AFTER CESAREAN. Mandruzzato G.P. Trieste, italy. SCAR PREGNANCY:DEFINITION IMPLANTATION OF A PREGNANCY ON A UTEROTOMIC SCAR (IN THE MAJORITY OF THE CASES AFTER CESAREAN).

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SCAR PREGNANCY AND PLACENTA ACCRETA AFTER CESAREAN.

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  1. SCAR PREGNANCY AND PLACENTA ACCRETA AFTER CESAREAN. Mandruzzato G.P. Trieste,italy

  2. SCAR PREGNANCY:DEFINITIONIMPLANTATION OF A PREGNANCY ON A UTEROTOMIC SCAR(IN THE MAJORITY OF THE CASES AFTER CESAREAN).

  3. CSP : EPIDEMIOLOGY.The prevalence of CSP isestimated1/1800-1/2500 afterone or more cesarean.PROBABLY UNDERESTIMATED!EXPECTED TO INCREASE !

  4. ABNORMAL ADHERENT PLACENTATIONPLACENTA: ACCRETA,INCRETA,PERCRETA.

  5. PLACENTA ACCRETA: EPIDEMIOLOGY1/533 PREGNANCIES0.3 % OF ALL DELIVERIES10 FOLD INCREASE IN THE LAST 50 YEARS!

  6. SCAR PREGNANCY: RISK FACTORSPREVIOUS CESAREAN,MYOMECTOMY,HYSTEROSCOPY,CURETTAGE,MANUAL REMOVAL OF THE PLACENTA.

  7. PLACENTA ACCRETARISK FACTORSPREVIOUS CESAREAN,MYOMECTOMY,RESECTOSCOPIC MYOMECTOMY,ENDOMETRIUM THERMAL ABLATION.

  8. CSP AND PLCENTA ACCRETA RISK FACTORS AND ETIOLOGY.are similarfor the twoconditions:trophoblasticinvasion of the myometriumwhere the endometriumlayerisstronglyreduced or absent and the decidualreactionisscant or absent.Timor-TrotshI.andco.Cesareanscarpregnancy and early placenta accreta share a common histology.Ultrasound Obstet.Gynecol. 21013,dec 19.

  9. CLINICAL MANIFESTATIONCSP:early and first half of pregnancy.PLACENTA ACCRETA :latepregnancy,delivery,post partum.

  10. COMPLICATIONS.HEMORRHAGE OFTEN DIFFICULT TO CONTROL,LIFE THREATENING,OFTEN REQUIRING HISTERECTOMY,INVASION OF PROXIMAL ORGANS.

  11. CSP:DIAGNOSIS.DIFFICULT!MISSED DIAGNOSIS IN 14 % OF THE CASES!Unforeseenconsequences of the increaasing rate of cesareandeliveries :early placenta accreta and cesareanscarpregnancy:A review.Timor-Trietsh I. and co.Am.J.Obstet.Gynaecol. 2012,207,14.

  12. CSP DIAGNOSIS:METHOD OF CHOICE:TVS ULTRASOUND WITH COLOR FLOW MAPPING.IN SOME CASES TA ULTRASOUND AND NMR.

  13. CSP:MANAGEMENT1.PHARMACOLOGICAL2.SURGICAL

  14. CSP PHARMACOLOGOCAL TREATEMENTMETOTREXATE1.LOCALLY2.SYSTEMIC3.COMBINED

  15. CSP:SURGICAL TREATEMENT1.UTERINE ARYTERY EMBOLIZATION2.RESECTION(HYSTEROSCOPIC,LAPAROSCOPIC,LAPAROTOMIC).

  16. CSP MANAGEMENT. ALL THE STUDIES ARE CASE REPORTS OR BASED ON SMALL NUMBERS!IMPOSSIBLE AT THE MOMENT TO OFFER EVIDENCE BASED RECOMMENNDATIONS!

  17. CSP PREVENTION.1.RESECTION OF THE UTERINE WALL DEFECT?2.TECHNIQUE OF UTEROTOMY REPAIR AT CESAREAN?

  18. PLACENTA ACCRETA: DIAGNOSISMETHOD OF CHOICE:TV OR TA ULTRASOUND WITH COLOR FLOW MAPPING.SOMETIME NMR.

  19. PLACENTA ACCRETA:MANAGEMENT.1.SURGICAL. 2.MECHANICAL. 3.PHARMACOLOGICAL.

  20. PLACENTA ACCRETA:ANTEPARTAL DIAGNOSED.MOST COMMONLY PERFORMED IS CESAREAN HYSTERECTOMY.TIMING OF DELIVERY ?UTERINE ARTERIES EMBOLIZATIONREFERRAL CENTERS!PERCRETA: URETERAL STENTS

  21. CONSERVATIVE TREATEMENT.1.UTERINE SUTURES(B-LYNCH)2.BAKRY BALLON3.SULPROSTONE4.PARTIAL PLACENTA REMOVAL5.UTERINE DEVASCULARIZATION

  22. FERTILITY AFTER CONSERVATIVE TREATEMENT.1.SMALL SERIES2.NO RCT

  23. TAKE HOME MESSAGES

  24. CONCLUSIONS 1.EARLY RECOGNITION OF THE SITE OF IMPLANTATION IN CASE OF PREVIOUS CS IS CRUCIALobstetrical ultrasound in earlypregnancyEXSAUSTIVE COUNSELLING ABOUT RISKS AND POSSIBILITIES!

  25. CONCLUSIONS 2.REFER TO CENTERS WITH POSSIBILITY OF MULTIDISCIPLINARY APPROACH.

  26. CONCLUSIONS 3.AVOID UNECCESARY PRIMARY CS !!!

  27. THANK YOU FOR ATTENTION.

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