Placenta Accreta Spectrum.pptx

Presented at CPC, Quaid-e-Azam Medical College

1. Clinico-PATHOLOGICAL CONFERENCE Thursday, 28 th July 2022 Placenta Accreta Spectrum & Challenges in its management GYNAECOLOGY WARD -II

2. OBJECTIVES: Elicit the sign and symptoms with the disease. Enlist the differential diagnosis. Interpret the investigations Make a treatment plan for the patient. To highlight the challenges which we encounter in management of patients with PAS

3. HISTORY

4. Introduction: My patient Mrs. Saman Manzoor wife of M. Amir, a 22-year-old housewife, has done B.A., Consanguineous marriage since last 1 year with P1A0E0M0 , her last menstrual period on 12 th Sept 2021 , Date of delivery 5 th June 2022 , resident of Ahmadpur , admitted on 5th June 2022 in Central Labour Room via Emergency department.

5. Presenting complaints: History of SVD/Epi in some private hospital – 8 hours back followed by retained placenta. Mild per vaginal bleeding – since delivery

6. History of Presenting illness My patient conceived spontaneously while having regular menstrual cycle and practicing no contraception. She assumed herself to be pregnant when she missed her period and confirmed her pregnancy by urine for pregnancy test at her home. She did her 1 st antenatal visit at 2 months of gestation by Gynaecologist where her ultrasonography was done and she was told about single, alive intrauterine gestation. Her BP was also checked at that time and it was normal. Her other investigations were also performed and were normal according to my patient. She was prescribed Folic acid 1 tablet daily which she took regularly. Her 1 st trimester was supervised and uneventful with no complaint of excessive nausea, vomiting, pain in lower abdomen, high grade fever with rash and flu like symptoms.

7. She appreciated fetal movements at 5 th month of gestation. Her anomaly scan was done at 5 th month of gestation and was normal according to my patient. She remained satisfied with her fetal movement and increase in abdominal girth according to period of gestation. She took oral Iron and Calcium regularly. She did her 2 nd antennal visit at 6 th month of gestation where her ultrasonography was done and told about fetal well-being. Her BP was also checked which was normal and other investigations were carried out which were normal according to patient. 2 nd trimester was supervised and uneventful with no history of vaginal bleeding and vaginal discharge. No change in bladder and bowel habit.

8. She got tetanus toxoid vaccination at 7 th and 8 th month of gestation and remained satisfied with her pregnancy. Her 3 rd Trimester was also uneventful.

9. Now one day back, my patient developed labour pain for which she was admitted in some private hospital where she delivered a male baby with good APGAR score. Her 1 st and 2 nd stage of labour were uneventful but 3 rd stage of labour was complicated by retained placenta in situ and referred from the private hospital to tertiary care hospital for further evaluation and management. While admitted in the hospital, her various investigations and the blood arrangement were done.

10. Obstetric History: Married for 1 year P1 A0 E0 M0 It was her 1 st pregnancy. LMP 12 th September 2021 EDD 19 th June 2022 She was delivered on 5th June 2022 at 38 weeks of gestation followed by retained placenta.

11. She delivered a baby boy of average weight with no gross anomaly. No history of antenatal complications. No history of prior abdominal/pelvic surgery No history of uterine instrumentation Spontaneous conception and NVD

12. Gynecological History : Menarche : 13 years Last Menstrual Period : 12th Sept 2021 Menstrual Cycle : 4-5/30 days Menstrual flow : Normal No dyspareunia but she had mild-moderate pain during menstruation. No H/O of intermenstrual bleeding No H/O of post-coital bleeding Pap smear : Never taken Couple never practiced any contraceptives methods

13. Past Medical/Surgical History: No H/O Diabetes, Hypertension, Asthma, IHD. No any past surgical history.

14. Personal History: Housewife Non-smoker, non-addict. Normal appetite Normal sleep Normal bladder and bowel habits.

15. Family History: No history of: TB Hypertension Diabetes mellitus Asthma Allergy Breast or Cervical cancer in her family.

16. Socioeconomic status: She belongs to a Middle Class Family. (Her husband is a teacher by profession and the only earning person in her family of 6 people and she has her own house).

17. Covid-19 Vaccination history: Complete but no booster dose.

18. EXAMINATION

19. General Physical Examination: A young lady of normal height and built lying uncomfortably on bed with anxious look but well oriented in time, place and person, answering my questions cooperatively. Her BMI was 22.5 (Height is 5’2’’ and Weight is 52 kg). She had the following vitals of : Pulse : 100 beats/min Blood pressure : 100/60mmHg Respiratory rate : 20/min Temperature : 99.0F

20. Pallor positive (++) No clubbing, jaundice or koilonychia . All accessible lymph nodes not palpable. Thyroid not enlarged. No pedal edema and both breasts were bilaterally symmetrical with no lump palpable in any of the four quadrants. Hernial orifices intact.

21. Examination: Respiratory System: Trachea central Normal vesicular breathing in both lungs fields No added sounds Lung bases clear.

22. Cardiovascular System : Apex beat palpable in left 5th intercostal space medial to mid-clavicular line. 1st and 2nd heart sounds are heard with no added sounds.

23. Per Abdominal examination: Inspection : Abdomen protruberant and moving with respiration. Central inverted umbilicus No scar marks, stria , prominent veins or visible pulsations seen. Palpation : Uterus enlarged upto 22 week size, well contracted and mild tenderness in lower abdomen.

24. Per Vaginal Examination: Mild vaginal bleeding. Cervical os closed.

25. Differential Diagnosis: Retained placenta Fibroid uterus Endometrial polyp

26. LAB INVESTIGATIONS

27. Baseline Investigations: Blood group – O positive Hb – 8.0g/ dL TLC – 10,800 /mm3 Platelets – 250,000 /mm3 BSR – 78mg/ dL Viral markers ( HBsAg and AntiHCV Ab) – Negative Urine C/E – Normal

28. Specific Investigations Sr. B- hCG – 5084miu/L at admission. LFTs: Bilirubin 0.2 mg/ dL ALT 24 U/L Alkaline Phosphatase 65 U/L RFTs: Urea 24 mg/ dL Creatinine 0.6 mg/ dL

29. IMAGING: ULTRASOUND: Postpartum bulky hyperemic uterus, Placental tissue seen in situ In fundal region, diminished, hypoechoic margin between placenta and myometrium (normal margin 2mm) with indistinct placental/ myometrial interface.

30. Colour Doppler: Showed placental vessels traversing myometrium up to serosal surface suggestive of PLACENTA INCRETA.

31. MRI PELVIS: Placental tissue seen in endometrial cavity extending into myometrium reaching up to anterior wall of uterus in fundal region, suggestive of RETAINED PLACENTA INCRETA.

32. MANAGEMENT OPTIONS: 1. Conservative:           Monitoring with B- hCG level. 2. Medical :           Methotrexate 3. Surgical :           i . Partial segmental resection.           ii. Obs Hysterectomy

33. Our management plan includes: Resuscitation Conservative management Monitoring with B- hCG level. Counselling of patient and her family Blood arrangement I/V antibiotics Emergency laparotomy in hand Consent of Obs hysterectomy

34. medical management: Inj. Methotrexate -1mg/Kg IM (5 th postnatal day)           (B- hCG on 4 th day – 2328miu/ml           B- hCG on 7 th day – 493miu/ml)           Single dose given b/c >50% fall of B- hCG   Repeat ultrasound showed retained placental tissue.

35. Surgical management: Massive hemorrhage on 12 th postpartum day. Blood transfusion, resuscitation of patient. EUA & proceed. Laparotomy Bilateral uterine artery ligation Incision over serosa to remove adherent placenta on left side of fundus. Uterus closed in double layers. Pt remained stable in post-op period. Discharge on 6 th post op day.  

36. RETAINED PLACENTAL LOBE

37. BILATERAL UTERINE ARTERY LIGATION:

38. INCISION MADE OVER UTERINE SEROSA

39. REMOVAL OF PLACENTA

40. COMPLETE REMOVAL OF PLACENTA

41. EMPTY UTERUS

42. UTERINE CLOSURE

43. Introduction to PAS Placenta Acreta spectrum disorder (PAS), also called abnormally invasive placenta (AIP), describes a clinical situation where the placenta does not detach spontaneously after delivery and cannot be forcibly removed without causing massive and potentially life threatening bleeding.  Definition: According to depth of trophopblastic invasion into the myometrium, three known variants of PAS can be differentiated by pathologists;  Placenta acreta , Placenta increta and Placenta percreta .

44. Placenta Acreta           Chorionic Villi attach directly to the surface of myometrium in the absence of decidual layer.  Placenta Increta           Chorionic Villi penetrate deeply into the myometrium reaching the external layer.   Placenta Percreta           Invasive Chorionic Villi reach and penetrate through uterine serosa. Definition & Classification

45. Etiology of PAS Placenta Accreta: Etiology can be manual removal of placenta, uterine curettage and endometritis.  Placenta Increta and Percreta : These two have similar etiology which can be full thickness surgical scar associated with absence of endometrial re-epithelialization and vascular remodeling.

46. Challenges Delay and referral from Periphery Most of patients remain undiagnosed and unbooked Problem in arrangement of blood and blood products Issues regarding anesthesia fitness, availability of OT and ICU Care Lack of Color Doppler Facility in Emergency Ward Lack of services for Interventional Radiology (Uterine Artery Embolization)

47. Challenges Conservative Management/Surgery for patients with low parity and primipara Counselling of the patients and her family regarding prolonged hospital stay Need for multiple surgeries specially in patients with placenta percreta d/t involvement of bladder and bowel Involvement of social media that pressurizes working staff Complain to PM Portal regarding the delay in management and mismanagement without knowing the actual facts and figures

48. Thank you