Placenta Accreta -Lessons Learnt

1. Placenta Accreta-Lessons Learnt Dr LeenaWadhwa Associate Professor ESI-PGIMSR,Basaidarapur,Delhi

2. Maternal Mortality-Magnitude and Causes About 28 million pregnancies and 67,000 maternal deaths per year in India Source: RGI-SRS 2001-03 * Other Conditions includes Anemia. Source: RGI-SRS 2001-03

3. Placenta accreta/ increta/ percreta • Significant cause of maternal morbidity and mortality • significant maternal hemorrhage at delivery • Mortality rate -7 -10% • (O brien et al AM J ObstetGynecol 1996)

4. Most common reason for emergency postpartum hysterectomy. • Incidence -increasing(secondarily to the rise of Caesarean section) • 1970 1/7000 • 1985 - 1994 - 1/ 2,510** • 1992 - 2002- 1/ 533 *** **(Miller- Am JObstetGynecol 1996 ) ***(Wu et al Am J ObstetGynecol 2005)

5. Case 1 • Unbooked, G4P2L2A1, 26 weeks, previous LSCS, fever dysuria • USG:Placenta antr,covering os • Emlaprotomy(GA) : hematuria ? Rupture uterus • Per-operative details • Hemoperitoneum (1 litre+) • Posterior wall of bladder found adhered to LUS • Bladder lying open (3cm) • Clots presents inside the bladder removed. large bleeders present on the posterior bladder wall , clamped & sutured

6. Case 1 • hysterotomy done and fetus delivered • fails to recognize percreta going into bladder & anticipate complications • tries partial MRP hysterectomy with difficulty by 2 consultantsuncontrollablehgg from bladder- cystectomy & B/L Int iliac art ligation • 6 units Blood • Patient died in ICU

7. Case 1 • HPE- Placental tissue invading the full thickness myometrium and the overlying serosa.(placenta percreta)

8. ‘Placenta accreta mindedness’

9. Placenta Percreta • Catastrophic event • Placenta percreta induced uterine rupture as early as 9 &14 wks • 75% cases of percreta are assoc with placenta previa • Maternal mortality-20% • Perinatal mortality-30% (ObstetGynecol 1991)

10. What could have been done? • Anticipation • Multidisciplinary team • Preoperative cystoscopy and placement of ureteric stents may aid in identification of the ureters. • biopsy contraindicated • placement of catheters in both int iliac A • Hysterectomy by postr approach • Involved portion of bladder is resected with hyst specimen

11. Case 2: • G3P2L2 ( Prev 2 LSCS ) at 34 weeks of gestational age was admitted due to bleeding PV for 2 days • USG-SLF cephalic ,placenta, anterior low lying covering Os • With informed written consent for possibility of hysterectomy (if required)and adequate blood patient was shifted to OT for emergency caesarean section.

12. Case 2 . • Per-operative details • LUS was thinned out • Placenta did not separate from LUS after the delivery of baby • Bleeding ++ • Decision of hysterectomy taken and done • Three units of BT done • Post operative • Uneventful • HPE- Placenta Increta

13. Have we become wiser? Management of a case where pre-operative diagnosis was made

14. Case 3 • G2P1L1 with 35 weeks and 5 days was admitted in antenatal ward in view of placenta previawith moderate anemia (no H/O bleeding PV) • Obstetric history- • 1stFT LSCS for CPD 2 years back at govt. hospital • USG(8/8/2011)-SLF 29 weeks 4 days ,placenta anterior low lying covering Os • Hb-7.1

15. Case 3 • After admission • USG-Placenta anterior extending to LUS, with extensive placental lakes within. Overlying myometrium intact with no evidence of placental invasion. • MRI-Myometrium grossly thinned out and placental interface with myometrium not properly visualized. Possibility of placenta accreta could not be ruled out

16. Case 3 • Elective LSCS -at 37 weeks • LUS distended with increase vascularity with purple hue with boggy feeling(?placenta increta) • classical CS • Placenta did not separate • Subtotal hysterectomy done. • Bleeding from stump present. • B/L Internal Iliac Artery Ligation done. • 3 units of PRBC given

17. Case 3 • Post operative details • Uneventful • HPE-Placenta Increta.

18. Others risk factors • Major risk factor -Placenta previa with history of Caesarean section • previous uterine surgery, • Previous Dilatation and Curettage, • Previous Myomectomy • Asherman Syndrome (Endometrial defects) • Submucousleiomyomata • Advanced maternal age • Multiparity • Tobacco use

19. Risk association : Silver RM et al Obstet Gynecology 2006

21. Diagnosis • Clinical suspicion • Ultrasound • Color Doppler • MRI • Biochemical Marker • Histopathology

22. Ultrasonic features • Moth eaten / Swiss Cheese appearance of placenta .

23. Ultrasonic features Obliteration of clearspace between placenta and uterine wall

24. Ultrasonic features • Sensitivity -93% • Specificity-79%

25. Color Doppler USG • Sensitivity 82-100% • Specificity 92-97% • Distance <1mm between the uterine serosa-bladder interface and the retroplacental vessels • High velocity and turbulent flow (Twickler et al 2000)

26. MR Imaging • MRI is no more sensitive than USG for diagnosing placenta accreta* • MRI is used as an adjunct to USG when there is a strong clinical suspicion of accreta** (Yinka et al 2006)*(Lax et al 2007)**

27. Women who have had a previous CS who also have either placenta praevia or an anterior placenta underlying the old CS scar at 32 weeks of gestation are at increased risk of placenta accreta and should be managed as if they have placenta accreta, with appropriate preparations for surgery made. (RCOG 2011)

28. Management Elective delivery by caesarean section at 34–35 weeks of gestation for suspected placenta accreta (AICOG 2012)

29. Lessons learnt (Pre-operative) • Prenatal imaging for placental location in previous CS • Rule out MAP in prev. CS* with pl. previa • Consent for hysterectomy • Arrange sufficient blood and component therapy • Consultant obstetrician , alert surgeons

30. Lessons learnt (Intraoperative) • NEVER PULL PLACENTA • Resort to hysterectomy SOONER RATHER THAN LATER • Uterine incision should be made vertically and above the placental insertion site.

31. POSTOP COMPLICATION • Transfusion reaction ,sepsis • DIC • Urinary stasis ,infection • Pelvic and renal abscess formation ,Renal compromise • ARDS • Multi organ failure • Fistula formation • Ureteral stricture

32. Uterus preserving modalities

33. Expectant management • Balloon catheterisation and embolisation of pelvic vessels • Methotrexate therapy • Uterus preserving surgeries (Charlotte et al, Arch Gynecol Obstet.2011)*

34. Balloon catheterisation /SAE • Pre-delivery consultation with the interventional radiology team • Pre-operative placement of arterial catheters in internal iliac artery • After delivery balloons are inflated to achieve temporary homeostasis • Selective arterial embolization(SAE) if necessary

35. Advantages • Avoidance of hysterectomy and preservation of fertility • Lower estimated blood loss • Reduced blood transfusion • Low frequency of complications • Post procedure fever • Pelvic infection

36. SAE • Disadvantages • Illiac artery thrombosis • Uterine necrosis • Sepsis • MODS (Gupta et al. Cochrane database Syst Rev 2006)* • Infertility for succeeding pregnancy • Fetal radiation exposure (Gupta et al. Cochrane database Syst Rev 2006)*

37. Methotrexate ? controversial • It acts by inducing placental necrosis & expediting a more rapid involution of placenta. • MTX should be administered (1 mg/kg) on alternate days for a total of 4 to 6 doses*

38. Methotrexate • Complication- • Hemorrhage • Disseminated intrauterine infection (sepsis) • Pancytopenia • Nephrotoxicity Failure Rate-22%

39. Expectant management • Few case reports • A series of 7 cases * • Placenta was left in situ, • uterus involuted spontaneously • woman returned to a normal menstrual cycle. • Placenta was never expelled but was presumably absorbed. • A series of 26 cases** • Placenta partially removed in 19/26 • 4/26 conservative therapy failed (Mark Gabot et al 2010)* (Timmermans et al 2007)**

40. Follow-up management 1.- Ultrasound exams  Vascularity 2.- HCG titers 3. Daily Temps, Other S&S of infection 4.- Bleeding 5.- Coagulation profile

41. Thank you