Universitätsklinik für Frauenheilkunde

Abnormal placentation: multidisciplinary

challenges

Universitätsklinik für Frauenheilkunde

Certified Gynecological Oncology

Center (DKG)

Certified Breast Cancer Center (DKG)

Certified Endometriosis Center (EEL)

Andrea Papadia M.D., Ph.D

Universitätsklinik für Frauenheilkunde, Inselspital

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Obstetrics is a bloody

business

DISCLOSURE


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Placenta accreta

• The most common indication for cesarean hysterectomy in

developed countries

• Average blood loss is 3,000–5,000 mL

• 90% of patients with placenta accreta require blood

transfusion,

• 40% require more than 10 uPRBCs

• Maternal mortality is as high as 7%

• Maternal death may occur despite optimal planning,

transfusion management and surgical care

Hudon L, Belfort MA, Broome DR. Diagnosis and management of placenta percreta: a review. Obstet Gynecol Surv 1998;53:509–17.

O’Brien JM, Barton JR, Donaldson ES. The management of placenta percreta: conservative and operative strategies.Am J Obstet Gynecol

1996;175:1632–8.


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Massive bleeding

disseminated intravascular coagulopathy

multiorgan failure

death


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Placenta accreta

• Placenta that is abnormally adherent to the uterus

due to absence of decidua basalis (75-78%)

• Increta: invades the myometrium (17%)

• Percreta: invades the serosa or other organs (5-7%)

Oyalese and Smulian; Obstet Gynecol 2006;102:927


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Placenta accreta – rates increasing

• Approximate rates

–1960s 1 in 30,000 deliveries

–1985 – 1994 1 in 2,510 deliveries

–1982 – 2002 1 in 533 deliveries

Wu S et al: Abnormal placentation: 20 year analysis. AJOG 2005

Miller et al., AJOG 1997


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Risk factors

• Cesarean section











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Risk of placenta accreta

Oyalese and Smulian; Obstet Gynecol 2006;102:927


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Diagnosis

• US

• MRI


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Clinical relevance

• Clinically, placenta accreta becomes problematic during

delivery when the placenta does not completely separate

from the uterus and is followed by massive obstetric

hemorrhage


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Maternal complications

• ICU admission

• Thromboembolism

• Acute renal failure

• Respiratoy insufficiency

• Pyelonephritis

• Pneumonia

• Wound infection

• Need for additional surgery to treat or control bleeding

• Operative injury/Fistula formation

• Death – mortality 7%


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Neonatal morbidity

• The mean gestational age for scheduled deliveries of

liveborn infants among women with antenatally suspected

placenta accreta was 35.4 weeks (range 33.6–37.9 weeks)

and 50% of infants were admitted to the neonatal intensive

care unit (NICU).

• The mean gestational age for emergency deliveries among

those with antenatally suspected placenta accreta was 2.2

weeks (range 25.6–37 weeks) and 94% of these neonates

required NICU admission.Eller AG et al, BJOG 2011


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Multidisciplinary approach

• Obstetrician (MFM)

• Gynecologic oncologist

• Anesthesiologist / Criticalc care specialist

• Interventional radiologist

• Neonatologist

• Blood bank

• Urologist

• Vascular surgeon


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Mulidisciplinary care team vs standard Ob team

At multivariate analysis a multidisciplinary team reduced composite morbidity by 80% among

those cases when accreta was suspected prior to delivery Eller AG et al Ob Gyn 2011


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Morbidly Adherent Placenta (MAP) - team


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Multi- vs non-multidisciplinary approach


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Outcome improvements Shamshirsaz et al Obstet Gynecol 2017


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Shamshirsaz et al Obstet Gynecol 2017


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Pacheco AJOG 2011


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Antepartum interventions

• Once the diagnosis is suspected, patients should receive

iron and/or folic acid as needed to maintain normal

hemoglobin values.

• Occasionally, patients may require recombinant

erythropoietin as adjuvant therapy.

• Occasionally, patients at risk for severe hemorrhage may

benefit from preoperative autologous blood donation.

Pacheco et al AJOG 2011

Catling Int J Obstet anesthesia 2007


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Delivery planning: WHEN?

• Timing should be individualized

• Joint decision (pt, obstetrician, neonatologist)

• Planned delivery reduces EBL and complications!!!

• Develop a contingency plan!

• Antenatal corticosteroids to induce fetal lung maturation

• Optimization of maternal and neonatal outcomes in stable

pts with delivery at 34 WKS

Chestnut DH, Dewan DM, Redick LF, Caton D, Spielman FJ. Anesthetic management for obstetric hysterectomy: a multi-institutional

study. Anesthesiology 1989;70:607–10.

Robinson BK, Grobman WA. Effectiveness of timing strategies for delivery of individuals with placenta previa and

accreta. Obstet Gynecol 2010;116:835–42.


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When?

Robinson et al Obstet Gynecol 2010


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Delivery planing: WHERE?

• The delivery should be performed in an operating

room with the personnel and support services

needed to manage potential complications.

• Interventional radiologist Hybrid OR

• Neonatologists

• Blood bank

• ICU

• Other surgical subspecialties available


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Delivery planing: HOW?


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Delivery planing: WHO?

• Experienced multidisciplinary team:

–Obstetrics (MFM)

–Gynecologic onology

–Anesthesist

–Critical care

–Transfusion Medicine

–Interventional radiologist

–Neonatology

–Urology

–Vascular Surgery


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Intrapartum interventions

• Avoid complete sympathectomy

• General anesthesia

• Regional anesthesia with continuous epidural technique

• Acute Normovolemic Hemodilution (ANH)

• Preoperative bilateral common iliac artery catheter?

• CellSaver®

• Recombinant factor VIIa

• TXA

Catling Inter J Obstet Anesthesia 2007

Tawes Semin Vasc Surg 1994

Rainaldi Br J Anaesthet 1998


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Massive Transfusion Protocol


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Tranexamic Acid


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Effect of TXA on bleeding realted mortality

WOMAN trial. Lancet 2017


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Hemostasis monitoring

• Conventional plasma-based coagulation analyses like PT,

aPTT and international normalized ratio (INR) are poor

predictors of transfusion requirements

• Thromboelastograph (TEG) is an easy test that provides

information on specific components of the coagulation

process


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Surgical technique

• Experienced pelvic surgeon

• Consider cystoscopy / ureteral stenting

• DO NOT attempt to remove the placenta

• Consider modified radical hysterectomy

• Consider partial cystectomy in case of suspected infiltration

• Consider using sealing devices


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Interventional radiology

• Temporary intraarterial balloon catheters

• Uterine artery embolization


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Shahin et al Eur J Radiol 2018


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Oliguria and hypotension

Fluid resuscitation

Third spacing

Bowel edema

and ascites

ileus

Increased

intraabdominal

pressure

Compromised

preload

Reduced

cardiac output

Reduced renal

perfusion

Cephalad displacemen

of the diaphragma

Atelectasis

Hypoxia

Acute renal

failure

Abdominal Compartment Syndrome


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The multidisciplinary approach in the

management of a morbidly adherent placenta is a

bundel of interventions


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Conservative management of MAP

• Leave placenta in situ

• Required:

–Hemodinamic stability

–Normal coagulation status

–Willing to accept risks


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Perioperative Outcomes

• PPH: 51.5%

–17.4% controlled medically

–66.2% UAE

–20.9% hysterectomy

• Severe maternal morbidity: 0.6%

–Sepsis

–Vescico-uterine fistula

–Bladder injury during primary hysterectomy

–Thromboembolism

–Death from complications of MTS

Sentilhes et al Obstet Gynecol 2010


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• If there is a strong suggestion of the presence of abnormal placental invasion,

health care providers practicing at small hospitals or at institutions with

insufficient blood bank supply or inadequate availability of subspecialty and

support personnel should consider patient transfer to a tertiary perinatal care

center.

• To enhance patient safety, it is important that the delivery be performed by an

experienced obstetric team that includes an obstetric surgeon, with other

surgical specialists, such as urologists, general surgeons, and gynecologic

oncologists, available if necessary.


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THANK YOU!


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Postpartum considerations

• Increased thromboembolic risk

–Mechanical prophylaxis (SCDs)

–Pharmacologic prophylaxis

• Oliguria and hypotension

–IV fluid administration / boluses

–Third spacing with bowel edema and ascites

– ileus

–Abdominal compartment syndrome


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Massive transfusion protocol

• Activated by Obstetrician

–Concerned for massive bleeding

• Managed by anesthesiologist in the OR

–2 large bore I.V. accesses

–Central line

–Arterial line


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Management strategies and maternal morbidity

Ellen AG et al BJOG 2009

30% reduction in early morbidity for women undergoing scheduled delivery (37 versus 57%, P = 0.09)


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Placenta accreta –

perinatal morbidity

–Placenta accreta associated with increased

perinatal morbidity

–most cases due to PTD

•prompted by vaginal bleeding

OR

•desire to avoid vaginal bleeding and optimize

surgical conditions


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perinatal morbidity

–In fact, iatrogenic preterm birth is advised for

antenatally diagnosed cases of accreta

– In some cases, bleeding may precipitate

abruption and compromise of fetal blood flow

Oyelese Y, Smulian JC: Placenta previa, placenta accreta, and vasa previa. Obstet

Gynecol 2005

Eller AG, Porter TF et al: Optimal management strategies for placenta accreta.

BJOG 2009

Bauer ST, Bonanno C: Abnormal placentation. Semin Perinatol 2009


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Placenta accreta

research summary

(cont)

Outcomes were

improved with

antenatal

diagnosis and

specialized care

Bauer ST, Bonanno C:

Abnormal placentation.

Semin Perinatol 2009


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• Clinically, placenta accreta becomes problematic during

delivery when the placenta does not completely separate

from the uterus and is followed by massive obstetric

hemorrhage

• , leading to

• disseminated intravascular coagulopathy;

• the need for hysterectomy;

• Surgical injury to the ureters, bladder, bowel, or

neurovascular structures;

• adult respiratory distress syndrome;

• acute transfusion reaction;

• electrolyte imbalance;

• and renal failure.


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Maternal morbidity

Eller AG et al BJOG 2011

30% reduction in early morbidity for women undergoing

scheduled delivery (37 versus 57%, P = 0.09).


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Anestesiology

• Assessment by the anesthesiologist should occur

as early as possible before surgery.

• Both general and regional anesthetic techniques

have been shown to be safe in these clinical

situations;

• The judgment of which type of technique to be

used should be made on an individual basis.

• Fluid resuscitation and management of

hemorrhagic shock


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Benefit derived from a multidisciplinary approach

• Women managed by a multidisciplinary care team

are less likely to:

–Require large volume transfusion ( 4 uPRBCs)

• 43% vs 61%, p= 0.031

–Reoperation within 7 days of delivery

• 3% vs 36%, p> 0.001

–Experience morbidity (prolonged maternal admission to

ICU, large volume blood transfusion, coagulopathy,

ureteral injury, early reoperation)

• 47% vs 74%, p= 0.26

Eller AG et al 2011


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Blood bank

• Alert the blood bank for a potential massive hemorrhage.

• Current recommendations for blood replacement in trauma

situations suggest a 1:1 ratio of PRBCs to FFP.

• PRBCs and thawed FFP should be available in the

operating room.

• Additional units of blood and coagulation factors should be

infused quickly and as necessitated by the patient’s vital

signs and hemodynamic stability.


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Abnormal placentation –

placenta accreta

Most clinically significant

long term maternal

morbidity after CS occurs

in subsequent

pregnancies in women

with placenta accreta

Placenta accreta

spectrum includes

placenta accreta, increta

and percreta


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Placenta Accreta - Risk Factors

•Cesarean delivery







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placenta accreta

Morbidity from

placenta accreta is

substantial and

includes problems

associated with

massive bleeding

such as disseminated

intravsacular disease

coagulation, multi-

organ failure and

death


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placenta accreta

In most cases, the only way to stop the bleeding is an oftendifficult hysterectomy that has it’s own set of complications as well as resulting in a loss of fertility

Placenta accreta has nowbecome the most commonreason for cesareanhysterectomy in developedcountries

Shellhaas et al: The frequency and complication rates of hysterectomy accompanying cesarean

delivery. Obstet Gynecol 2009

Flood et al: Changing trends in peripartum hysterectomy over the past 4 decades. Am J Obstet

Gynecol 2009


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Placenta accreta

research summary

•Case series (n=76)

Blood transfusion required in over 80%

Transfusion of 4 units of packed red blood

cells in over 40% of cases

Eller et al: Optimal management strategies for placenta accreta. BJOG 2009


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Placenta accreta

research summary (cont)

• Literature review

–Average blood loss 3,000 – 5,000 mL at the time of delivery

–Most common surgical complication cystotomy(often intentional)

–Ureteral injury in 10 – 15% of cases

–Less common injuries to bowel, pelvic nerves and large vessels and vesico-vaginal fistulas

Hudon L et al: Diagnosis and management of placenta percreta: a review. Obstet GynecolSurv 1998


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Physiology of placentation


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Placenta Previa


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Placenta accreta


• Prospective cohort study 1999-2002 from NIH/MFM Cesarean Registry Study

– 19 Academic medical centers

– 378,168 births• 57,068 CS• 30,132 CS no labor

– Daily ascertainment of CS

– Trained study nurses

Silver RM,al: Maternal morbidity associated with multiple cesarean deliveries. Obstet Gynecol 2006


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Placenta accreta and > number CS

Placenta Accreta among Women Who Had CS Without Labor

CS# N Accreta

1

2

3

4

6,195

15,805

6,326

260

15 (0.2%)

49 (0.3%)

36 (0.6%)

6 (2.3%)5

1,457 31 (2.1%)

≥ 6 89 6 (6.7%)

Silver et al., Ob Gyn 2006;107:1226


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research summary

• Combination of placenta previa and prior cesarean

delivery dramatically increases the risk for placenta

accreta

Silver et al: Maternal morbidity associated with multiple cesarean deliveries.

Obstet Gynecol 2006


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research summary

• In the 723 women in the cohort with placenta previa

– accreta occured in 3%, 11%, 40%, 61% and 67% in

those having their first, second, third, fourth, and fifth

or greater CS respectively

Silver et al: Maternal morbidity associated with multiple cesarean deliveries. Obstet

Gynecol 2006


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Table. Placenta Previa and Placenta Accreta by Number of Cesarean Deliveries

Previa:Accreta No Previa‡:Accreta†

Cesarean Delivery Previa [n (%)] [n (%)]

First§ 398 13 (3) 2 (0.03)

Second 211 23 (11) 26 (0.2)

Third 72 29 (40) 7 (0.1)

Fourth 33 20 (61) 11 (0.8)

Fifth 6 4 (67) 2 (0.8)

≥ 6 3 2 (67) 4 (4.7)† Increased risk with increasing number of cesarean deliveries; P < .001.

‡ Percentage of accreta in women without placenta previa.

§ Primary cesarean.


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maternal comorbidity


–25 to 50% of women required admission to an intensive care

–Increased risk of thromboembolism, pyelonephritis, pneumonia, wound and pelvicinfections, need for a second operation to control bleeding or treat infection

Silver et al: Maternal morbidity associated with multiple cesarean deliveries. Obstet Gynecol 2006


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Accreta and Maternal Co-

MorbidityNIH/MFM Cesarean Registry StudyMorbidity No Accreta Accreta

Cystotomy

Ureteral Injury

PE

Ventilator

0.15%

0.02%

0.13%

0.8%

15.4%

2.1%

2.1%

26.6%ICU

0.3% 14%


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Table. Odds Ratios With 95% Confidence Intervals for Placenta Accreta and Hysterectomy by Number

of Cesarean Deliveries Compared With First Cesarean Delivery

Cesarean Accreta OR Hysterectomy OR

Delivery [n (%)] (95% CI) [n (%)] (95% CI)

First* 15 (0.2) – 40 (0.7) –

Second 49 (0.3) 1.3 (0.7–2.3) 67 (0.4) 0.7 (0.4–0.97)

Third 36 (0.6) 2.4 (1.3–4.3) 57 (0.9) 1.4 (0.9–2.1)

Fourth 31 (2.1) 9.0 (4.8–16.7) 35 (2.4) 3.8 (2.4–6.0)

Fifth 6 (2.3) 9.8 (3.8–25.5) 9 (3.5) 5.6 (2.7–11.6)

≥ 6 6 (6.7) 29.8 (11–78.7) 8 (9.0) 15.2 (6.9–33.5)

OR, odds ratio; CI, confidence interval.

*Primary cesarean delivery.

This cohort is particularly informative because it

includes only cesareans without labor, thereby excluding

the morbidity associated with uterine rupture and

emergency cesarean


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Abnormal placental attachment

• First described in 1937 by Irving and Hertig

–Placenta accreta is the «abnormal adherence, either in whole

or in part of the afterbirth to the underlying uterine wall»

• Placenta accreta (75-78%): Abnormal attachment of the

placental villi directly to the myometrium due to an absence

of decidua basalis and an incomplete development of the

fibrinoid layer

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Universitätsklinik für Frauenheilkunde