New trends in treatement of Placenta Accreta

BYDr. Manal Behery Professor Obs&GyneZagazig

University2013

New trends in the treatement of Placenta

Accreta

Definition

81.6%

11.8%

6.6%

J Clin Ultrasound 2008;9:551-9

Definition

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.

INCIDENCE

Frequency 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)SecondThirdFourth Fifth≥ 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 was

The 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

Which 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 alone

15.Chou MM, Ho ES, Lee YH. Prenatal diagnosis of placenta previa accreta by transabdominal color Doppler ultrasound. Ultrasound Obstet Gynecol 2000;15:28–35.

MRI findings suggestive of placenta accreta include

• Lower uterine bulging,

• Heterogeneous placenta

• Dark intraplacental linear bands

on T2-weighted images.

Which 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?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

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) Acute 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

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.

D

What 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 patient’s 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

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%

SO

Can the cell saver (salvage) be used in these cases?

Intraoperative 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 salvage

Surgical 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.

Resources Patient, clinical and anatomic features

Decision Definitive treatment

Limited experienceor expertise, poorresources or no facilities for safe patient transfer

lower segment invasionvaginal bleeding with high suspicion of accretaPossibility of percreta

Extraplacentalhysterotomy,Placental left in situFollowed by uterine closure

Delayed hysterectomyor conservative procedureaccording clinicaland surgical status

Qualified andexperiencedteam, adequatehospital resources

No desire for future pregnancyTissue destruction> 50% of uterine circumferenceIntractable haemorrhageDIC

Resective surgery

Subtotal hysterectomyfor upper segment lesionsTotal hysterectomyfor lower segmentand cervical involvement

Qualified andexperiencedteam, adequatehospital resources

Desire for futurepregnancyDestruction < 50% of uterine axial circumferenceMinor coagulation disorders

Conservativesurgery

Placenta in situ with or without MXT OR One step surgery

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

The 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 hysterectomy”total 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 DONE it is not recommended to close the peritoneum over the cervical stump, As rebleeding in these circumstances usually goes unnoticed.

Therapeutic 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.

Therapeutic practice points

In 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.

Planning of uterine incision

No attempt at placenta removaL Placenta left in situNo attempt at placenta removaL Placenta left in situ

With 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 significant hemorrhage

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 highStrict 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

Different 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 suture 6-Local excision, and repair or oversewing of the implantation site

Option of Conservative ttt

The 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 wallInternational Journal of Gynecology & ObstetricsVolume 117, Issue 2, May 2012, Pages 191–194

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 packing

Optimal 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

Conclusion

Conclusion

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 <50,000/mm 3, , fibrinogen <100

mg/dL, [PT] or [aPTT >1.5 normal). • These current transfusion guidelines fail to prevent

coagulopathy in massive bleedings.

Patients with crystalloid/PRBC-based resuscitation will frequently develop

• Dilution of clotting factors and platelets, leading to the so called dilutional coagulopathy. The latter

• may be complicated by hypothermia and acidosis, both of which lead to coagulation dysfunction.

What Is Hemostatic Resuscitation, And Does It Improve Outcomes?What Is Hemostatic Resuscitation, And Does It Improve Outcomes?

Hemostatic resuscitation is a new concept that mainly involves 3 aspects:

1.Limited early aggressive use of crystalloids and consideration of permissive hypotension

2. Early administration of fresh frozen plasma and platelets (with concomitant packed red blood cells) achieving a ratio of 1:1:1

3. Early use of rFVIIa

Aggressive crystalloid resuscitation is avoided to prevent hemodilution and early clot dislodgement secondary to increases in blood pressure as a result of volume expansion.

Prior to surgical control of hemorrhage, permissive hypotension with systolic blood pressures between 80 and 100 mmHg may be optimal to limit ongoing blood loss.

the rationale for early administration of fresh frozen plasma and platelets with PRBC in a ratio of 1:1:1. is to achieves hemostasis earlier, thus decreasing the total number of blood products given

• 17 RCT have been reported in different subgroups

of patients in which r FVIIa was used to control hemorrhage. 4 of them found a reduction in transfusion requirements or blood loss, and none reported a survival benefit.

• Overall, r FVIIa decrease the amount of blood transfused, but data on survival benefit are lacking

Is there a role for the use of recombinant factor vii a?

What Is Abdominal Compartment

Syndrome?

In cases where massive resuscitation takes place

Any space-occupying mass, like a hematoma, will increase intra-abdominal pressure.

Both crystalloid and colloid administration lead to third spacing of fluid with subsequent bowel edema and ascitis. Extensive surgical procedures are commonly associated with ileus, which may also favor intra-abdominal hypertension.

Put together, all these factors may increase the intra-abdominal pres-sure to a point where compression

of the abdominal and retroperitoneal vessels will

compromise preload to the heart, leading to a drop in cardiac output

and, consequently, in blood pressure

Obstetricians need to be familiar with this complication, as the administration of more fluid in an attempt to increase blood pressure and urine output will only worsen intra-abdominal pressures and hemodynamics.

Obstetricians need to be familiar with this complication, as the administration of more fluid in an attempt to increase blood pressure and urine output will only worsen intra-abdominal pressures and hemodynamics.

If the condition is suspected, a bladder pressure should be obtained at the bedside as a surrogate of abdominal pressure.

Normal abdominal pressures are 0 to 10 mm Hg. Abdominal hypertension is defined as an intracavitary pressure greater than 12 mm Hg. Abdominal compartment syndrome includes a pressure greater than 20 mm Hg

If the condition is suspected, a bladder pressure should be obtained at the bedside as a surrogate of abdominal pressure.

Normal abdominal pressures are 0 to 10 mm Hg. Abdominal hypertension is defined as an intracavitary pressure greater than 12 mm Hg. Abdominal compartment syndrome includes a pressure greater than 20 mm Hg

Once the diagnosis is established, most patients will require

surgical decompression, with a vacuum-assisted closure

Enteral feeding and limitation of fluid therapy are beneficial.

If fluids are required, the use of colloids (eg, albumin) is recommended over crystalloids.

surgical decompression, with a vacuum-assisted closure

Enteral feeding and limitation of fluid therapy are beneficial.

If fluids are required, the use of colloids (eg, albumin) is recommended over crystalloids.