New trends in accreta treatment,Post graduate course lecturers in Obstetrics&Gynecology ,Faculty of medicine,Zagazig University

1. ‫بسم ا الرحمن‬
‫الرحيم‬

2. New trends inin treatement ofof
New trends the treatement
Placenta Accreta
Placenta Accreta
BY
Dr. Manal
Behery
Assistant Professor
Obs&Gyne
Zagazig University

3. Definition
Definition
11.8%
81.6%
J Clin Ultrasound 2008;9:551-9
6.6%

4. Frequency of placenta observational study that
In a large prospective accreta according to number of
cesarean deliveries and presence or absence of
considered the number of prior cesarean deliveries
placenta previa
and presence or absence of placenta previa,the risk
of placenta accreta was
Cesarean Delivery
First (primary)
Second
Third
Fourth
Fifth
≥ Sixth
Placenta previa
No Placenta previa
3.3%
11%
40%
61%
67%
67%
0.03%
0.2%
0.1%
0.8%
0.8%
4.7%
Adapted from SMFM. Am J Obstet Gynecol 2010
.

5. Which imaging modalities are necessary
Which Imaging Modalities Are Necessary For
for the diagnosis of placenta accreta?
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

6. 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.

7. MRI findings suggestive of placenta
accreta include
• Lower uterine bulging,
• Heterogeneous placenta
• Dark intraplacental linear bands
on T2-weighted images.

8. Preparation for Delivery
The preferred strategy was delivery at 34
weeks without amniocentesis for placenta
previa with suspected accreta,and cases
with recurrant bleeding .
An expert opinion in 2010 recommended
delivery for uncomplicated previa at 36 to
37 weeks and 34 to 35 weeks for suspected
placental invasion.

9. What should be included in the consent
What should be included in the consent
form for caesarean section?
form for caesarean section?
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.

10.  Thorough discussion with PT of
the on
the suspected diagnosis,
the anticipated surgical procedure
high potential for hysterectomy,
profuse hemorrhage,
probable transfusion,
increased complications

11. A preoperative checklist would be
helpful in confirming necessary
preparations and for identifying contact
persons in case perioperative assistance
is required.

12. Which preoperative interventions are
beneficial for patients with suspected accreta
to decrease transfusion needs?

13. Acute normovolemic
Acute normovolemic
hemodilution (ANH)
hemodilution (ANH)
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

14. What is the optimal anesthetic technique
for patients with placental accreta?
If extensive dissection, prolonged
If extensive dissection, prolonged
operative time, and massive hemorrhage
operative time, and massive hemorrhage
are anticipated, general anesthesia is
are anticipated, general anesthesia is
commonly recommended.
commonly recommended.
When regional anesthesia was first used
a reported rate of conversion to general
anesthesia of about 28% to 30%

15. What Is Hemostatic Resuscitation,
What Is Hemostatic Resuscitation,
And Does It Improve Outcomes?
And Does It Improve Outcomes?
Hemostatic resuscitation is a new
concept that mainly involves
3 aspects:

16. 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

17. 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.

18. At present,placenta accrete can be managed
in three ways:
(1)Carry out a hysterectomy;
(2) Leave the placenta in situ;and
(3) Resect the invaded tissues with the entire
placenta restoring uterine anatomy.

Each one has weaknesses and strengths,
dependent on the condition itself and the
specific preferences taken by the surgeon and
the team.

19. Resources
Patient, clinical and
anatomic features
Decision
Definitive treatment
Limited
experience
or expertise, poor
resources or no
facilities for safe
patient transfer
lower segment invasion
vaginal bleeding with high
suspicion of accreta
Possibility of percreta
Extraplacental
hysterotomy,
Placental left in
situ
Followed by
uterine closure
Delayed hysterectomy
or conservative procedure
according clinical
and surgical status
Qualified and
experienced
team, adequate
hospital
resources
No desire for future
pregnancy
Tissue destruction> 50% of
uterine circumference
Resective surgery
Intractable haemorrhage
DIC
Subtotal hysterectomy
for upper segment lesions
Total hysterectomy
for lower segment
and cervical involvement
Qualified and
experienced
team,
adequate
hospital
resources
Desire for future
pregnancy
Destruction < 50% of
uterineaxial circumference
Minor coagulation
disorders
1-Placenta in situ with or wit
MXT
2-One step surgery
OR
Conservative
surgery
3- Two step surgery

20. 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.

21. Therapeutic practice points
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.

22. 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.

24. Bladder invasion
with
In
In cases of bladder involvement
Most obstetricians choose a conservative approach
•arterial embolisation.
In cases of bladder involvement, most
with
obstetricians choose a conservative
If bleeding cannotwith packing with laparotomy pads can
approach stop, arterial embolisation. If
promote haemodynamic stabilisation in the patient.
Later the original problem can be resolved in a secondary
surgical procedure.38
When hazardous dissection is anticipated
aortic or bilateral common iliac occlusion
Is needed to practise safe surgery.

26. Morbidity can be high and that further
Patient shouldoften bebe willing to
intervention will also necessary
accept that
Outcome is unpredictable
Morbidity can be high
Strict prolonged followc up is
needed
 and that further intervention
will often be necessary

27. 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

28. Two-step conservative surgery
 This procedure is similar to one-step surgery,
but, in this case, the tissue dissection is less
difficult and bleeding is not severe .
A few days after delivery, the newly formed
vessels are collapsed and some light oedema
occurs between the anterior uterine surface
and the bladder.

29. a safe area, and the umbilical cord is cut near the placenta. The invaded area and the placenta are left in situ without any attemp
No attempt at placenta removal
Placenta left in situ
• area.
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 will often
incite significant hemorrhage .

30. Option of Conservative ttt
1-One step suregery
2-Placenta in situ with or without Adjuvant
methotrexate (MTX)
3-Tamponade of the placental implantation
site with inflated IU ballon catheter bags,
4- Lower segmant compression suture

31. Pelvic pressure
packing
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.

32. a safe area, and the umbilical cord is cut near the placenta. The invaded area and the placenta are left in situ without any attemp
Optimal post-delivery follow-up
• area.
No guidelines exist regarding the optimal
postdelivery follow-up
Postpartum hemorrhage may happen up to
105 days after the initial procedure
 Serial US to assess placental involution and
frequent visits to screen for delayed
hemorrhage and early signs of sepsis

33. Conclusion
Conclusion

34. Keys to achieving vascular control and
Keys to achieving vascular control and
haemostatic procedures.
haemostatic procedures.
Access to pelvic subperitoneal spaces
Wide opening of vesicouterine space
Planned hysterotomy
 Management of proximal vascular control,
Accurate use of compression sutures

35. Conclusion
Carrying out hysterectomy during shock
or coagulopathy has a high risk of
immediate and late complications.
Effective vascular control, such as internal
aortic compression may provide time to
improve haemodynamic status, and
increases the effectiveness of compression
sutures later

36. 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.