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Placenta Accreta Management

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Placenta Accreta Management Brief history 39 y/o, female Past medical/surgical history: not remarkable G4 P0 SA1 AA2 LMP: 91-5-27 Admitted to 5B for C/S: 37 ... – PowerPoint PPT presentation

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Title: Placenta Accreta Management


1
Placenta Accreta Management
2
Brief history
  • 39 y/o, female
  • Past medical/surgical history not remarkable
  • G4 P0 SA1 AA2
  • LMP 91-5-27
  • Admitted to 5B for C/S 37 gestational weeks
    with placenta previa and suspected placenta
    accreta

3
Brief history
  • Prenatal examinations
  • 91-7-9 Bicornuate uterus or septate uterus
  • 91-9-3 Placenta previa
  • 91-11-19 r/o Placenta accreta
  • 92-1-7 Breech
  • Cesarean section with possible
    hysterectomy

4
Cesarean hysterectomy
  • Pre-op Intra-arterial balloon insertion
  • Double-J
  • Anesthesia
  • Induction Atropine, Pentothal, S.C.C., Fentanyl,
    Midazolam, Atracurium
  • Neosynesin once when BP dropped
  • G/S, L/R, N/S, HESS, PRBC?input 4200 c.c.
  • Blood loss 1500 c.c., u/o 600 ml
  • Post-op recovery smooth, discharged in a week

5
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6
Cesarean hysterectomy
7
Cesarean hysterectomy
8
Discussion
  • Placenta previa
  • Placenta accreta/increta/percreta
  • Obstetric managements
  • Multidisciplinary approaches
  • Intra- and post-operative managements
  • Conclusions

9
Placenta previa
  • Def. Implantation of the placenta in the lower
    uterine segment in advance of the fetal
    presenting part
  • Grade
  • ? Low-lying placenta
  • ? Marginal placenta previa
  • ? Partial placenta previa
  • ? Total placenta previa

10
Placenta previa
  • Low-lying placenta
  • Placenta implanting in the lower uterine
    segment placenta edge does not reach the
    internal os but is close to it
  • Marginal placenta previa
  • The edge of the placenta is at the margin
    of the internal os
  • Partial placenta previa
  • The internal os is partially covered by
    placenta
  • Total placenta previa
  • The internal os is covered completely by
    placenta

11
Placenta previa
12
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13
Placenta previa
  • Incidence 0.1 to 1.0 in third-trimester
    pregnancies
  • Maternal mortality 0.9
  • Risk factors
  • Multiparity
  • Prior cesarean delivery
  • Smoking

14
Placenta previa
  • Symptoms recurring painless hemorrhage
  • Diagnosis
  • Double set-up examination
  • Rarely used now replaced by ultrasound
  • Transabdominal ultrasound
  • Accuracy 9397
  • Transvaginal ultrasound
  • Reserved when transabdominal u/s results
    uncertain
  • MRI
  • Reserved when u/s is non-diagnoistic

15
Placenta previa
  • Obstetric management
  • Cesarean delivery is necessary in practically all
    cases of placenta previa

  • --Textbook of obstetrics, Williams
  • A minor degree of placenta previa (grade??? with
    anterior placenta) and when the head is engaged,
    vaginal delivery is considered
  • --ltAnesthetic management of peripartum
    hemorrhagegt, S.A.Azeez Pasha, Seminars in
    Anesthesia, perioperative medicine, and pain

16
Placenta accreta/increta/percreta
  • Def. Placenta implantation with abnormally firm
    adherence to the uterine wall
  • Placenta accreta
  • placental villi attached to the myometrium
  • Placenta increta
  • placental villi invading the myometrium
  • Placenta percreta
  • placental villi penetrating through the
    myometrium

17
Placenta accreta/increta/percreta
18
Placenta accreta/increta/percreta
  • Etiology partial or total absence of the decidua
    basalis and imperfect development of the
    fibrinoid layer
  • Incidence 1 in 2500 pregnancies
  • Mortality rate as high as 10 with percreta

19
Placenta accreta/increta/percreta
  • Risk factors
  • Placenta previa
  • Previous c/s
  • Previous curettage
  • Multiparity
  • Materal age gt 35y/o
  • Endometrial defects(Ascherman syndrome)
  • Submucous leiomyoma

20
Placenta accreta/increta/percreta
21
Placenta accreta/increta/percreta
  • S/S Antopartum and postpartum hemorrhage
  • Diagnosis
  • Ultrasound
  • loss of the normal hypoechogenic zone between
    the placenta and myometrium
  • abnormality of the smooth interface between
    the uterus and bladder
  • a Swiss-cheese appearance to the placenta,
    with hypoechogenic spaces within
  • pulsatile flow of maternal blood into the
    hypoechogenic spaces
  • MRI

22
Placenta accreta/increta/percreta
23
The Main Problem
  • Abnomal growth of placenta into the uterine wall
  • Massive hemorrhage that occurs at the time of
    placenta separation can be life-threatening
  • Hysterectomy is usually required to achieve
    adequate hemostasis

24
Cesarean hysterectomy
  • Procedure
  • Abdominal incision
  • Delivery of the infant by cesarean section
  • Leave the placenta in place
  • Subtotal or total hysterectomy
  • About 66 to 85 of placenta accreta require
    cesarean hysterectomy1,2
  • Catanzarite et al. Contemporary OB/GYN 1996
  • Chattopadhyay Eur J Obs Gyn Reprod Biol 1993
    52 151-156

25
Conservative treatment1
  • 1. Manually remove the placenta
  • 2. Leaving the placenta in situ. In some
    instances, the placenta may reabsorbs completely
  • Numerous hemorrhagic and infectious complications
  • Maternal mortality is much higher than cesarean
    hysterectomy

1. Robert Resnik, Contemporary OB/GYN 2001
11122-129
26
Effective treatment strategy
  • For a patient with known placenta accreta, the
    desired approach is to deliver by elective
    cesarean section, recognize the high probability
    of cesarean hysterectomy, and to be well-prepared.

27
Preoperative planning
  • Explain to the patient the need for a cesarean
    hysterectomy
  • Selecting the proper time of delivery
  • Greater risk of severe spontaneous hemorrhage
    with increasing gestational age
  • Fetal lung maturation 36 weeks gestation
  • Multidisciplinary approach

28
Multidisciplinary approach
  • Obstetrician
  • Anesthesiologist
  • Hematologist and Blood bank
  • Neonatology
  • Radiologist
  • Urologist

29
Blood bank preparations
  • Mean estimated blood loss 3000 to 5000 ml1
  • Cross matched blood at least 4 to 6 units
  • Fresh frozen plasma or cryoprecipitates
  • Autologous blood donation
  • Blood donation from the patients family

1. Catanzarite et al. Contemporary OB/GYN 1996
30
Neonatology intervention
  • Increased risk of preterm delivery
  • Antenatal steroid administration to enhance lung
    maturation is recommended
  • Advanced neonatal resuscitation might be required
    due to significant maternal hypotension

31
Urology intervention
  • Preoperative cystoscopy to evaluate bladder
    involvement
  • Ureteral stents to identify the ureter and avoid
    ureter injury during surgery

32
Radiology intervention
  • Selective arterial embolization

33
Selective arterial embolization
  • Widely used for various sources of uncontrollable
    hemorrhage
  • First obstetrical case published in 1979
  • High successful rate for postpartum bleeding
  • Prophylactic use for high-risk patient

34
Prophylactic embolization(1)
  • Arterial catheters are placed into internal iliac
    artery before operation
  • After delivery, balloons are inflated to achieve
    temporary hemostasis
  • Selective arterial embolization if necessary
  • If successful, the uterus can be preserved

35
Prophylactic embolization(2)
  • Advantages
  • Lower estimated blood loss
  • Reduced blood transfusion
  • More clean operative field
  • Avoidance of hysterectomy and preservation of
    fertility

36
Prophylactic embolization(3)
  • Low frequency of complication(6 to 7)1,2
  • Postprocedure fever
  • Pelvic infection
  • No ischemic complications were reported
  • No reports of infertility or IUGR in the
    succeeding pregnancy
  • Risk of fetal radiation exposure
  • Further prospective, randomized study is required
  • Vedantham American J of Obs and Gyn 1997
    176(4) 938-948
  • Hansch American J of Obs and Gyn 1999 180(6)
    1454-1460

37
Anesthetic preparation
  • Preparation for massive blood loss
  • Large-bore IV line
  • CVP
  • Arterial line
  • Blood warmer

38
Anesthetic consideration
  • General or regional anesthesia?
  • Risk of massive hemorrhage
  • Prolonged operative time
  • Excessive intraperitoneal manipulation
  • General anesthesia is usually favored

39
General anesthesia in parturients
  • Increased risk of difficult / failed intubation
  • Increased risk of aspiration of gastric content
  • Effect upon the neonate?
  • No significance difference was found between
    general and regional anesthesia in the terms of
    Apgar scores or depressed infants1,2
  • Qublan et al. Clin Exp Obstet Gynecol
    200128(4)246-8
  • Zagorzycki et al. Surg Gynecol Obstet 1982
    Nov155(5)641-5

40
Regional anesthesia
  • Regional anesthesia is not contraindicated for
    elective cesarean hysterectomy1
  • Lower estimated blood loss and lower transfusion
    requirement2
  • Sympathetic blockade a protective effect2
  • Immediate conversion from regional anesthesia to
    general anesthesia may be required

1. Chestnut et al Anesthesiology 1989 70
607-610 2. N. Parekh et al. British Journal of
Anaesthesia 2000 84(6) 725-730
41
Intraoperative management
  • Massive blood loss, hypovolemic shock
  • Rapid restoration of effective intravascular
    volume
  • Blood transfusion
  • Dilutional coagulopathy
  • Hypothermia
  • Acid-base imbalance
  • Electrolyte abnormalities

42
Measures to control hemorrhage
  • Aortic compression
  • Uterine artery ligation
  • Internal iliac artery ligation
  • Selective arterial embolization
  • Hysterectomy

43
Conclusion
  • Placenta accreta is a potentially
    life-threatening hemorrhagic condition
  • The incidence of placenta accreta is increasing
    due to higher C/S rate
  • Awareness of risk factors, preoperative planning
    and multidisciplinary team effort is crucial
  • The best combination of medical, surgical, and
    radiological strategies require further
    investigation

44
Thanks for your attention!
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