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1. Evaluation of Maternal Outcomes with Abnormal Placentation In Women With >\=2 Previous Caesarean Sections In a Tertiary Care Centre Presenter:- Dr.Shivani Pal Guide:-Dr.Rehana Najam

2. INTRODUCTION Anemia is a major cause of Maternal Mortality and Morbidity,with haemorrhage during Antepartum,Intrapartum and Postpartum being the key contributor. Placenta Previa is the most common cause of Antepartum Haemorrhage ,affecting 1 in 200 pregnancies and increases with multiple cesareans. Placenta Previa with Abnormal adherence(Accreta,Increta,Percreta) is the leading cause of postpartum hemorrhage,particularly in women with >/=2 previous caesarean sections. Transabdominal ultrasonography is a reliable tool for diagnosing invasive placental implantation, particularly morbidly adherent placenta,key features indicating a higher risk include placental lacunae ("Swiss cheese" appearance), retroplacental myometrial thickness <1 mm, loss of the hypoechoic retroplacental zone, and bladder-myometrium interface anomalies. Doppler ultrasound further distinguishes degrees of placental invasion, identifying markers such as irregular intraplacental vascularization, hypervascularity at the serosa-bladder interface, and abnormal uterine-bladder interface, which offers the best specificity for diagnosing accreta. Twickler et al. demonstrated that ultrasound color flow mapping showed 100% sensitivity for accreta prediction when myometrial thickness was <1 mm or large intraplacental lakes were present. With abnormal Placentation there is a rise in Postpartum Haemorrhage ,which if not managed vigilantly the need for emergency hysterectomy increases.

3. AIM To evaluate maternal outcomes with abnormal placentation in women with two or more previous cesarean sections at a tertiary care center. OBJECTIVE To assess placental location and adherence using usg and Doppler in women with >\= 2 LSCS. To evaluate maternal outcomes in terms of Mortality,Morbidity .

4. MATERIAL AND METHODS This is a retrospective study conducted in Venkateshwara Institute of Medical Sciences,Gajraula,Uttar pradesh, from January 2023 to December 2023 for All antenatal cases getting admitted with previous 2 or more LSCS beyond 28 weeks of gestation and diagnosed with placental abnormalities on ultrasound were included in study conducted in department of Obstetrics and Gynaecology in VIMS,Gajraula. Pregnant women with history of any other uterine surgeries were excluded from study. A detailed proforma consisting of patients personal details including history regarding age, parity, gestational age at presentation, indication of previous cesarean section, course and complication in previous pregnancies, course of present pregnancy in antepartum,Intrapartum and postpartum periods. General physical and obstetric examination was done along with assessment of placentation and adherence by means of USG and Doppler. Intraoperatively the outcome was noted in terms of tables below. All the data collected was compiled simultaneously and updated in microsoft excel for the further evaluation. Frequencies and proportions were used to represent categorical data. Categorical data were compared using Chi square test. P value < 0.05 was considered statistically significant and the results stipulated.

5. RESULTS Age group Parity G3 G4 >/= G5 23-24 yrs 2 2 1 25-30 yrs 10 17 6 31- 37 yrs 4 6 6 Percent 9.25 61.1 29.6 Distribution of cases according to Age Group and Parity and Placental location In our study among 54 patients 50 patients were with history of previous 2 LSCS (92.5%) whereas 4 patients had previous 3 LSCS (5.5%). Mean Age group of patients was around 25-30 yrs of which majority were 4th Gravida. Majority of the cases (65%) were referred from outside and were taken up for surgery in emergency in the conditions of Antepartum Haemorrhage (majority),followed by Scar Tenderness.

6. Present Absent Number Percentage Number Percentage Placenta Previa 12 22.2% 42 77.8% Adherent Placenta in Placenta Previa 10 83.3 % 2 16.7% Distribution of cases according to presence of Placenta Previa and Adherent Placenta in Placenta Previa It was observed that out of 54 women a total of 12 (22.2%) had placenta previa and 42(77.8%) had upper segment placentation . In our study it was observed that among the 12 patients with placenta previa 10(83.3%) patients had adherent placenta. In women with previous 2 LSCS 12% had placenta previa whereas in women with previous 3 LSCS 50% had placenta previa with p value of 0.039 and that is found to be significant

7. CONCLUSION Increased Caesarean section has its own consequences on future pregnancy out of the patients of which Placenta Previa and Placenta Accreta Spectrum is one of the major challenges encountered in subsequent pregnancies. In our study it was concluded that regular ANC checkup along with timely diagnosis with Ultrasound and Doppler play a major role in identifying such high risk groups. Patients with Placenta Previa must be handled by Multidisciplinary team approach to prevent Maternal Mortality and Morbidity due to Haemorrhage.

8. REFERENCE Chamua B, Lalwani A, Najam R. An observational study on abnormal placentation in women with 2 or more previous cesarean sections in a tertiary care centre. The New Indian Journal of OBGYN. 2022; 8(2): 285 - 88. Goh WA, Zalud I. Placenta accreta: diagnosis, management and the molecular biology of the morbidly adherent placenta. The Journal of Maternal-Fetal & Neonatal Medicine. 2016 Jun 2;29(11):1795-800. Cunningham F.G. Williams Obstetrics. 25th ed. New York: McGraw-Hill education; 2018.Chapter 41, Obstetrical haemorrhage; p. 773. Fan D et al. Prevalence of antepartum hemorrhage in women with placenta previa: a systematic review and meta-analysis. Sci. Rep. 7, 40320; doi: 10.1038/srep40320 (2017). Jauniaux ER, Alfirevic Z, Bhide AG, Belfort MA, Burton GJ, Collins SL, Dornan S, Jurkovic D, Kayem G, Kingdom J, Silver R. Placenta praevia and placenta accreta: diagnosis and management: green-top guideline No. 27a. BJOG: An International Journal of Obstetrics & Gynaecology. 2019 Jan;126(1):e1-48. Z Parvin et al. Relation of Placenta Previa with Previous Lower Segment Caesarean Section (LUCS) in our Clinical Practice. Faridpur Med. Coll. J. 2017;12(2):75-77 Lee HJ, Lee YJ, Ahn EH, et al. Risk factors for massive postpartum bleeding in pregnancies in which incomplete placenta previa are located on the posterior uterine wall. Obstet Gynecol Sci 2017;60:520-6. Silver RM. Abnormal Placentation: Placenta Previa, Vasa Previa, and Placenta Accreta.Obstet Gynecol 2015;126:654-68.

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