PLACENTA ACCRETA

Recently there has been a tremendous increase in it's incidence, which has led the importance of role of conservative management.

1. PLACENTA ACCRETA SYNDROME Risk Factors and Management PRESENTED BY: DR. KIRAN PANDEY Prof. & HOD Dept. of Obs. & Gyne . GSVM MEDICAL COLLEGE KANPUR DR. PAVIKA LAL Assistant Professor Dept. of Obs. & Gyne . GSVM MEDICAL COLLEGE KANPUR

2. DR. KIRAN PANDEY Head of department, dept of OBG, GSVM Medical College,Kanpur. Secretary upsc AGOI 2017-2019 President 2016-2018,Kanpur obs&gynaesociety Organizing secretary: WWWCON-2018 Organizing chairperson: Adolescent Workshop, Emergency Obstetrics Workshop- oct 2018 Organizing chairperson: National Adolescent Conference Youth Summit and CME 2017 Organizing Secretary,National conf Obs&Gynae 2015 Organizing chairperson,Urogynecology,NDVH,Pelvic floor Repair Workshop,National Conference 2015

3. introduction PLACENTA PLACENTA ACCRETA ACCRETA SYNDROME Spectrum of an abnormal placental implantation and firm adherence which are classified according to the depth of invasion in to the uterus . PLACENTA ACCRETA PLACENTA ACCRETA SYNDROME

4. ADHERENT PLACENTA syndrome Accreta Increta Percreta TOTAL PLACENTA ACCRETA (INVOLES ALL LOBES ) FOCAL PLACENTA ACCRETA (INVOLVES SINGLE LOBE ) PARTIAL PLACENTA ACCRETA (INVOLES ONLY TWO LOBES)

5. PATHOPHYSIOLOGY

6. RECENT INCIDENCE Of PLACENta accreta sharp rise over the years, which may be attributed to rising number of cesarean deliveries . 0.8 per 1000 deliveries in1980’s has increased to 3 per 1000 in the last decade. * International FEDERATION OF PLACENTA ASSOCIATION 2011. Silve RM,Landon MB,Rouse DJ et al.Mternal Morbidity associated with multiple cesarean deliveries.Obstet Gynecol.2006;107:1226-32

7. Risk factors Placenta previa (5-10% risk ) Previous LSCS (0.2% for the fi rst, 0.3% for second, 0.6% for third, 2.1% with the fourth, up to 6.7% with the sixth or greater) Advanced maternal age Previuos history of uterine surgeries - hysterotomy, myomectomy. Endometrial thermal ablation Vigorous multiple curretage Multiparity Uterine artery embolization Uterine pathologies (adenomyosis, bicornuate uterus, submucous fibroid,Asherman syndrome)

8. Elevated first trimester PAPP-A Elevated second trimester MSAFP and free beta hCG Downreguation of specefic micro RNA Decreased TNF- related apoptosis including ligand (TRAIL) receptors level Myometrial fibers in the basal plate(BPMYO) Maternal cell free beta hCG FEW RECENTLY ASSOCIATED BIOCHEMICAL RISK FACTORS

9. ultrasonography Transvaginal scans are more sensitive in confirming placental location and diagnosing placenta previa at 20 th week of gestation than transabdominal scans. Grey scale has been the cornerstone in diagnosing placenta accreta due to its wide availability and high accuracy- SENSTIVITY: 96-98% SPECIFICITY: 77-78% PPV: 93%, NPV: 98%

10. USG image showing normal placenta (white arrow heads showing hypoechoic retroplacental space ) RETROPLACENTAL ZONE

11. GREY SCALE First trimester The presence of an anteriorly placed,low lying gestational sac on a transvaginal scan between 6 and 8 weeks of gestation in a patient with previous cesarean delivery has been considered a risk factor for development of placenta accreta. LOW LYING GESTATIONAL SAC

12. SECOND TRIMESTER Loss of the retroplacental sonolucent zone (RPZ zone). Finding has a high sensitivity (100%) but low specificity(73%) *Camstock et al and Wong et al LOSS OF RETROPLACENTAL ZONE BLADDER ABNORMAL PLACENTAL LACUNAE P B placenta is seen extending to the serosal surface of the bladder without any intervening myometrium (white arrowheads). SAGITAL VIEW

13. Colour Doppler (2-D) Findings suggestive of placenta accreta are- Hypervascularity of serosa–bladder interface. Diffuse or focal lacuna flow vascular lakes with turbulent flow (Peak systolic velocity over 15 cm/s). Markedly dilated vessels over peripheral subplacentalzone . OBLITERATION OF CLEAR SPACE BETWEEN PLACENTA & UTERINE WALL MOTH -EATEN /SWISS CHEESE APPEARANCE DUE TO LACUNAE HYPERVASCULARITY

14. Colour Doppler (3-D) 3-D power doppler has been shown to be superior In diagnosing placenta percreta from accreta. Findings on 3-D power doppler are: Intrasplacental high vascularity Tortuos vascularity and chaotic branch LATERAL VIEW

15. Numerous coherent vessels involving the whole uterine serosa–bladder junction (basal view) Inseparable cotyledon and intervillous circulations Lateral view Basal view Hypervascularity of uterine - bladder interface

16. Magnetic Resonance Imaging When to recommend MRI for diagnosis of Placenta Accreta - equivocal USG findings of abnormal placentation evaluation of posterior placenta in patients with risk factors obese patients complementary role in specifically delineating the extent of an USG-diagnosed placenta percreta

17. Imaging features of normal placentation on MRI Homogeneous T2-intermediate signal intensity of placenta Subtle, thin, regularly spaced placental septi. Normal subplacental vascularity. Triple-layered sandwich appearance of myometrium. Pear-shape of normal gravid uterus with smooth contour . PLACENTAL SEPTI TRIPLE LAYERED PATTERN SAGITAL OBLIQUE MRI PEAR SHAPED UTERUS

18. The most acceptable cardinal imaging findings for diagnosis of placenta accreta are – Other findings- Dark intra-placental bands on T2-weighted images. Abnormal disorganized placental vascularity. Focal interruptions of the myometrial wall or extension through the myometrium with occasional invasion of adjacent structures. Uterine bulging Heterogencity with in placenta .disruption of pear shaped pattern (lower segment wider than fundus)

19. MRI is useful in showing parametrial extension which is not apparent on USG P LOSS OF VASCULARIZATION

20. Clinical scenario 1 G3p1+1,24years female,GA 37 weeks 3 days presented with leaking PV. History of preterm LSCS 3 years back and spontaneous abortion f/b D&C 1 years back. No ANC visit single 3 rd trimester USG showing SLIUF appropriate for GA ,placenta posterior and low lying The case was opened by obstetrician. Delivery of the fetus f/b repeated attempts to remove placenta but within few minutes it was realised that it is adherent placenta as the patient started bleeding profusely (HORRIFYING !!!)

21. Hysterectomy was done but patient went into irreversible shock and could not be revived back Risk factors should always be borne in mind in previous LSCS should be investigated for placenta accreta if high index of suspicion delivery should be planned in tertiary centre. Multi disciplinary approach. Blood and blood products should be ready Forcible and unneccessary attempt to claw off placenta should not be done(may provoke further torrential hemorrhage). What went wrong ? Multidisciplinary approach senior obstetrician, pelvic surgeon, uro -surgeon (if needed) neonatologist, anesthetist,

22. TRIPLE P PROCEDURE A novel uterine sparing procedure for PAS Steps Peri -operative placental ultra sound localization of the superior edge of the placenta Pelvic devasularization – pre operative placement of intra arterial balloon catheters No attempt to remove the entire placenta *FIGO consensus guidelines on placenta accreta spectrum disorders

23. 25 years, unbooked , G4P1+2 with h/o FTLSCS 4 year back f/b 2 spontaneous abortions(D&C done) came in active stage of labor at 37wks + 2 days at CHC Kanpur Dehat. Em LSCS was done and intraoperatively it was found to be placenta percreta with bladder involvement. Pt bled profusely. Subtotal hysterectomy was done along with ligation of blood vessels going into the bladder but all in vain as the patient’s vitals deteriorated, pt developed DIC & anuria with ARF in postoperative period(d/t massive blood loss) CLINICAL SCENARIO 2

24. HOW COULD SHE BE BETTER MANAGED?? Previous LSCS – Regular antenatal check ups USG to diagnose placenta accreta . Elective cesarean is the choice For percreta patients – bladder resection and reconstruction with the help of uro -surgeon ICU CARE- For proper management of complications ( DIC,ARF,Transfusion reactions , ARDS, Electrolyte imbalance).

25. TIMING OF DELIVERY RCOG 2011 Elective ceaserean section in asymptomatic women is not recommended before 38 weeks of gestation for placenta previa or before 36-37 weeks of gestation for suspected placenta accreta. ACOG 2014 Elective delivery by ceaserean section at 34-35 weeks of gestation for suspected placenta accreta

26. What makes hysterectomy different and difficult ? Genitourinary tract inuries Reported cases of cystotomy (6-29%) and ureteral injuries (7%). pre-operative stenting of ureters is preferred for better palpation intraoperatively and thus reducing ureteral trauma . Prevention Avoid cutting placenta => trans fundal approach PREVENTIVE SURGICAL OR RADIOLOGICAL DEVASULARIZATION Placement of balloon occlusion catheter. Placement of pelvic pressure packing like laprotomy devices or balloon tamponade. Causes unplanned Hysterectomy Emergency hysterectomy in an undiagnosed placenta accreta Inadvertent attempt at removal of placenta Delivery of baby by cutting through the placenta. MASSIVE BLOOD LOSS (3-5 ltrs)

27. Surgical techniques Inspection Anterior surface of the uterus preferably the lower segment should be inspected followed by the lateral surface. Presence of any vascular channels noted( should not be disturbed. Uterine incision CLASSICAL/TRANSFUNDAL cesarean section to avoid cutting through the placenta f/b delivery of fetus f/b closure of uterine incision by WHIP stitch Venous sinusoid

28. B/L anterior division of internal iliac artery ligation done f/b uterine artery ligation. cesarean hysterectomy HYSTERECTOMY CAN BE THE LIFE SAVING MEASURE Cesarean hysterectomy Is considered as gold Standard treatment for Invasive accreta although High rates of severe maternal Morbidity(40-50%) and mortality(7%)

29. Postoperative management Continuous monitoring of vitals (BP,PR,RR,spO2) in ICU and high care speciality ward due to massive blood transfusion . monitoring for recurrent intra- abdominal or retroperitoneal bleeding Due to hypoperfusion and subsequent organ ischemia, renal, cardiac or other organ dysfunction can like Sheehan syndrome can occur Early ambulation and compression devices can be used to prevent thromboembolic complications .

30. G6P1+4(none alive) GA 36 weeks with H/O previous 1 LSCS and 3 D&C was refferred to our hospital with the USG(3D Doppler)findings of complete central placenta with focal placent increta Elective LSCS was done at 37 weeks B/L uterine artery were ligated and gentle removal of placenta as much as possible with leaving the adherent part of placenta “ insitu approach” closure of uterine incision. CLINICAL SCENARIO 3 Saving the uterus was our priority

31. Postoperatively 2 units of blood was transfused along with methotrexate adjuvant treatment* given. Patients managed successfully Key points during conservative management- Gentle attempt to remove the “non accreta” portion of placenta , thus the volume of villous tissue left insitu Preventive radiological and surgical devascularization (uterine/hypogastric artery) prevents secondary hemorrhage placental reabsorption Methotrexate hastens placental resolution although the risk of neutropenia sepsis secondary hemorrhage=> hysterectomy

32. Patient on conservative management need strict follow up- Weekly FU for first 2 months Monthly visit till complete resoption. Follow up consultation include- Clinical examination (bleeding,temp,pelvic pain) Pelvic ultrasound(size of RPOCs) Lab test to r/o infection(Hb,TLC,HVS) Conservative management should always be attempted in patients who agree to long term monitoring,strongly desired to preserved their fertility with adequate expertise Insufficient evidence for the use of MRI and/or serum beta HCG for the monitoring of conservative management of PAS. * Use of methotrexate is not routinely recommended and therefore should only be given judiciously. FIGO consensus guidelines on placenta accreta spectrum disorder Int J Gynecol Obstet 2018;140:291-298

33. One step conservative surgical approach for PAS Vascular diconnection of newly formed feeder vessels and seperation of invaded Ut. Tissue from invaded bladder tissue Upper segment hysterotomy and delivery of fetus Resection of all invaded myometrium with placenta in one piece after local vascular control Surgical procedure for hemostasis Myometrial reconstruction in 2 planes Bladder repair if necessary. *FIGO consensus guidelines on placenta accreta spectrum disorders

34. Role of uterine artery embolization (uae) good or bad? Though UAE is latest interventional technique in cases of accreta,but its not available in many of our set-ups, therefore uterine artery ligation may be life saving. The role of interventional radiological procedure though looks promising, further research and prospective larger studies are required. Even RCOG does not recommend it routinely.

35. Pearls of wisdom My personal experience…. In cases requiring hysterectomy I personally use double set of clamps to rapidly secure all bleeding points and remove the uterus as soon as possible and ligate the pedicles later. reduces blood loss effectively I have found that uterine artery ligation prior to attempt of removal of placenta in cases of placenta accreta may be life saving. Feasible alternative to uterine artery embolization in low resource settings .

36. THE DEADLY D’S of Accreta D ELAYED: Delayed referral Delayed caesarean: i.e. emergency (not elective) Delayed decision for hysterectomy D EFICIENCY: Deficiency of time availability: extensive adhesions, no time for pre-op devascularization Deficiency of blood and blood products Deficiency of ICU beds Deficiency of multi-disciplinary senior team.

37. EXPERTISe AND APTNESS MATTERS PREOPERATIVE DIAGNOSIS ANEMIA CORRECTION PATIENT COUNSELLING REGULAR FOLLW UP UTERINE ARTERY LIGATION HYSTERECTOMY WHEN NEEDED CAN SAVES LIFE!!!!