Post on 16-Jan-2017
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AL_AZHAR ASSIUT MEDICAL JOURNAL AAMJ, VOL (12), NO (4), OCT 2014 SUPPL - 2
A NEW SURGICAL TECHNIQUE IN MANAGEMENT OF
ANTERIOR PLACENTA PREVIA ACCRETA
Rashed Mohammad Rashed
Department Of Obstetrics and Gynecology, Faculty Of Medicine,
Damietta- Al-Azhar University
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ABSTRACT
Background: Placenta accreta has become the leading reason for cesarean
hysterectomy, massive obstetric hemorrhage, disseminated intravascular
coagulopathy, surgical injury to the ureters, bladder, and other viscera, adult
resp. Due to increasing incidence of placenta previa accrete, a new surgical
approach for management of placenta previa accreta anterior was tested.
Patients and Methods: From October 1st, 2012 to December 30th, 2013, twenty
patients diagnosed by ultrasound (US) and Doppler to have placenta
abnormally attached to the lower part of the anterior wall of the uterus
(placenta previa accreta anterior) were managed at Al-Azhar university
hospital by resection of the lower flap of the lower uterine segment (LUS) and
placental tissue attached to it. Results: Out of the recruited 20 patients, the
uterus was conserved in 18 patients. One patient needed immediate
hysterectomy and one patient needed 'delayed' hysterectomy. The incidence of
less than 1000 cc blood loss was 25% (5 cases) and of more than 1000 cc blood
loss was 75% (15 cases). Six months after CS, HSG was done to evaluate the
uterus; All HSGs done on 17 cases showed normal uterine cavity. Conclusion:
The conservative new surgical approach for management of placenta previa
accreta anterior succeeded to save uteri and preserve fertility. so It can be used
for the management of cases with placenta previa accreta anterior.
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INTRODUCTION
Placenta accreta is the placenta that is abnormally adherent to the uterus.
When the placenta invades the myometrium, the term placenta increta is used,
whereas placenta percreta refers to a placenta that has invaded through the
myometrium to the serosa, sometimes into adjacent organs, such as the bladder
(Oyelese and Smulian 2006). Wu and colleagues looked at placenta accreta
over a 20-year period (1982–2002); they reported an incidence of 1 in 533
pregnancies. Risk factors for placenta accreta include placenta previa, prior
myomectomy, prior cesarean delivery, focal intrauterine adhesion, sub mucous
leiomyomata, and maternal age older than 35 years (Clark, et al. 1985). Silver,
et al. (2006) reported pro-portionally increasing risk of placenta accreta with
increasing number of prior cesarean sections in women with or without placenta
previa. Placenta accreta has become the leading reason for cesarean
hysterectomy, massive obstetric hemorrhage, disseminated intravascular
coagulopathy (DIC), surgical injury to the ureters, bladder, and other viscera,
adult respiratory distress syndrome (ARDS), renal failure, and even death
(Kastner, et al. 2002). It is better to perform surgery for placenta accreta under
elective controlled conditions rather than as an emergency without adequate
preparation. Therefore, scheduled delivery at 36–37 weeks' gestation, after
documentation of fetal lung maturity seems reasonable (Hudon, et al. 1998).
The patient should be counseled preoperatively about the need for hysterectomy
and the likely requirement for transfusion of blood and blood products
(O’Brien, et al. 1996). There has been some interest in attempting to conserve
the uterus and avoid hysterectomy. Generally, in these cases the placenta is left
in situ, with no attempt at removal (RCOG 2011). Adjunctive procedures
include treatment with methotrexate (Lipscomb, et al 2002), embolization of
the internal iliac vessels (Alvarez, et al 1992), and resection of the affected
segment of the uterus, use of uterine compression sutures and over sewing of the
placental bed, with a resultant less profuse hemorrhage (Levine, et al 1999).
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AL_AZHAR ASSIUT MEDICAL JOURNAL AAMJ, VOL (12), NO (4), OCT 2014 SUPPL - 2
Aim of this study was Assessment of management of placenta previa accreta
anterior with resection of the anterior part of the lower uterine segment and its
attached placenta as a new surgical technique in those cases.
PATIENTS AND METHODS
At Al-azhar university hospital New Damietta, from October 1st, 2012 to
December 30th, 2013, a prospective cohort study was done on 20 patients who
were managed by resection of the anterior part of the LUS as a conservative
management of placenta previa accreta. Exclusion included patients with
placenta previa not accreta or not attached to the LUS or attached to the
posterior wall of the uterus. All patients were counseled about all items of the
operation such as pre-operative preparation, elective nature of the operation, the
incidence of bladder injury, hysterectomy and blood transfusion. The new
approach steps were:
Through Pfannenstiel skin incision.
Subcutaneous and anterior rectus sheath incision.
Dissection of sheath from rectus muscle.
Opening of the anterior abdominal wall by splitting the two recti muscles.
Exposure of the uterus then dissection of urinary bladder by sharp and blunt
dissection to push down as low as possible.
Transverse incision of the uterus above the upper margin of the placenta.
Delivery of the fetus.
Removal of an elliptical piece of the lower uterine segment and its attached
placenta en block.
Repair of uterine incision as usual by vicryle no1.
Intraperitonial drain to be left behind.
Closure of subcutaneous and skin as usual.
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RESULTS
The study was conducted on 20 patients. Demographic data of all cases
participated in the study as regard patient’s age, it ranged from25-37 years while
gravidity ranged from 2 to 4 with the median of 4 while parity ranged from 0 to
5 and number of CS ranged from 0 to 5with the median as in table1and figure 1.
Table (1): Demographic data of all cases participate
Age in years Mean(±SD) 31 (±5.34)
Gravidity Median(Range) 4 ( 2 - 4 )
Parity Median(Range) 3 ( 0 - 5 )
No of CS Median(Range) 2 ( 0 - 5 )
No of CSParityGravidity
9
8
7
6
5
4
3
2
1
0
Data
Figure (1): The demographic data of all cases participated in the study as
regard for gravidity, parity and No of CS.
-
Figure (2): u/s revealed placenta previa anterior with evidence of
accretion
This new approach conserved the uterus in 18 cases and hysterectomy was
done only in 2 cases (one of them needed immediate hysterectomy and the other
needed remote hysterectomy Four cases were complicated by bladder injury;
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bladder was repaired and Foley's catheter was left in the bladder for a week .
Table (2): Short follow up of complications.
Complications
None 14 70.0%
bladder injury 4 20.0%
Hysterectomy 2 10.0%
Total 20 100.0%
Figure (3): Follow up of complications with 4 cases had bladder injury, 2
cases had hysterectomy and no complication in 14 cases.
The incidence of less than 1000 cc blood loss was 25% (5 cases) and of
more than 1000 cc blood loss was 75% (15 cases; Table 3).
Table (3): The incidence of blood loss and blood transfusion in all cases.
<1000 cc >1000 cc P
Median Range No % Median Range No %
Blood loss 500.00 300-
500 5 25% 1200
1000-
2500 15 75% <0.001
Blood
transfusion .00
.00-
500 5 25% 1500
1000-
2000 15 75% <0.001
Six months after CS, HSG was done to evaluate the uterus; All HSGs done
on 17 cases showed normal uterine cavity. as seen in figure 4
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Figure 4:Six months later after CS, HSG showed normal uterine cavity.
DISCUSSION
Silver, et al. (2006) reported proportionally increasing risk of placenta
accreta with increasing numbers of prior cesareans in women with or without
placenta previa. They reported incidence of placenta previa accreta in women
with previous one C.S 3.3%, 11% in women with previous two C.S, 40% in
women with previous three C.S, 61% in women with previous four C.S, and
67% in women with previous five C.S. It is important to diagnose placenta
accreta prenatally to minimize morbidity. Prenatal diagnosis seems to be a key
factor in optimizing the counseling, treatment and outcome of patients with
placenta accreta (Japaraj, et al 2007). Prenatal diagnosis of placenta previa
accreta included ultrasonography and magnetic resonance imaging (MRI), but
ultrasonography remains the mainstay of placental imaging in the ante-partum
period during all trimesters. In the first trimester, it is known that placenta
accreta and percreta occur as a subsequent for pregnancy on CS scar which
occurs due to implantation of blastocyst on fibrous scar. In the second and third
trimesters, diagnosis of placenta previa is as intra placental lacunae which are
vascular structures of varying size and shape that are found in the placental
parenchyma, creating a “moth-eaten” or “Swiss-cheese” placental appearance.
All cases of placenta accreta had turbulent flow in placental lacunae by color
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Doppler (Comstock and Bronsteen 2012). Placenta previa accreta can also be
diagnosed by MRI as a focal outward contour bulge, or disruption of the normal
pear shape of the uterus, with the lower uterine segment being wider than the
fundus (Palacios, et al. 2005). Patients with prenatally suspected placenta
accreta should be extensively counseled about potential risks and complications
as a preoperative management of placenta previa accreta. In patients with strong
suspicion for placenta accreta, it is strongly advised to perform the delivery
before labor begins. Therefore, consideration should be given to perform the
cesarean birth electively after corticosteroids treatment for fetal lung maturation
(O’Brien, et al. 1996).Two studies reviewed intra-operative management of
placenta accreta have been described either cesarean hysterectomy (Shellhaas,
et al. 2009) or conservative management (Zelop, et al. 1992) which included
leaving the placenta undisturbed with prophylactic antibiotics and oxytocics,
interval placental removal, excision of placental site, bilateral uterine artery
embolization, Hypogastric/uterine artery ligation, uterine tamponade, suturing
of placental bed, B-Lynch suture. The new approach was conducted at Al-Azhar
university hospital, Damietta to evaluate resec-tion of the anterior part of the
lower uterine segment and its attached placenta. The study included 20 cases
which were diagnosed as placenta previa accreta anterior by ultrasonography
and colour Doppler. In all patients after investigations and pre-operative
assessment, counselling about complications, blood transfusion and the
possibility of hysterectomy and bladder injury was done. The new approach
depends on simple and almost timeless operative procedure which can be done
as reasonable solving for placenta previa accreta anterior. The incidence of
blood loss less than 1000 cc which is normally accepted in CS is 25% (5 cases)
while the incidence of blood loss more than 1000 cc which needed blood
transfusion was 75% (15 cases) with the mean blood transfusion more or less
than 1400 cc. Along 20 cases of the study only 2 cases needed hysterectomy
(preservation rate for the uterus is 80%). Four cases had bladder injury as a
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complication for the procedure while 14 cases reported no complications. Long-
term follow up: 6 months later the cases by histosalpingo-graphy: 3 out of 20
cases were missed from follow up, while 17 cases had normal
histosalpingography. In comparison with other methods for conservative
management of placenta previa accreta:
Descargues, et al. (2001) performed uterine arterial embolization (UAE)
on 9 patients whose median age was 35 years. We recruited 20 cases in our
study; their median age was 31 years. The median gestational age at delivery
was 38 weeks (36 to 40 weeks) as in our approach and. Deliveries in the UAE
study were 5 cesarean sections (CS) and 4 inductions with vaginal deliveries,
but in our study all deliveries were CS. In the UAE approach placenta accreta
was diagnosed in 8 cases but in our approach placenta accreta was diagnosed in
all the 20 cases. The embolization procedures involved bilateral uterine arteries
in 6 cases, right uterine artery in 2 cases, and left uterine artery in 1 case. In the
UAE approach the success rate was 100% in conserving the uterus but the
success rate in our approach was 90%.Ferrazzani, et al. (2004) applied the
uterine balloon tamponade (Bakri) approach on 39 cases who suffered PPH;
placenta accreta anterior and posterior were diagnosed in 22 cases. In our study
we handled 20 cases of placenta accrete, only anterior. In the uterine balloon
tamponade study the median age was 34.6 years but in our approach it was 31
years. The median gestational age at delivery was 35.9 weeks but in our
approach it was 38 weeks. In the uterine balloon tamponade study 8 cases could
not be controlled by this approach while in our approach only 2 cases could not
controlled and they needed hysterectomy. The success rate in the uterine balloon
tamponade approach was 79% but the success rate in our approach was 90%.
In 2006 B-Lynch invented transverse compression suture. The procedure
was offered to 12 cases with placenta previa accreta anterior and posterior,
while our approach was offered to 20 cases with placenta accreta anterior. In the
B-Lynch transverse compression suture approach the lower segment incision is
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closed in the traditional way in 1 or 2 layers then the lower segment was
compressed, whilst both limbs of the suture are milked through with sufficient
tension to maintain haemostasis. Our approach depends on resection of the
lower flap of the anterior lower uterine segment, then closing the incision in 1 or
2 layers. In the B-Lynch transverse compression suture approach the success
rate was 100% but in our approach was 90%.Suturing of placental bed was done
on 3 cases (Abu-Musa et al. 1998), but in our approach the number of cases
was 20. All cases in both approaches were diagnosed placenta accreta. All
placentas in our approach were anterior only; in the other approach one case
was anterior and two cases were posterior. The success rate in the placental bed
suturing approach was 100% but in our approach it was 90%.
CONCLUSION AND RECOMMENDATIONS:
The studied technique of excising the lower flap of the lower uterine
segment is a simple quick approach with high success rate. It can be used for the
management of cases with placenta previa accreta anterior.
Extended study to evaluate these patients during future pregnancies and
their outcome and effect of removal of lower uterine segment on pregnancy
outcome is recommended.
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???
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SUPLL - 2 في عالج المشيمة المتقذمة الملتحمة األمامية نهج جراحي جذيذ
راشذ محمذ راشذ
دمياط –بنين -كلية الطب جامعة األزهر -قسم النساء والتىليذ
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انذثهش انه ثخد يشخ يزقذي إيبي يهزحخ قذ أخشذ ن الدح قصش يع اسزئصبل اندضء
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سبعبد كب يعذل فقذ انذو إثبء انعهخ اقم ي 6حبن أخشي إن اسزئصبل سحى ثعذ انقصشخ ة
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. أشش ي انعهخ أ ردف انشحى سهى ربيب
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انشخ انزقذيخ فبءح ف عالج حبالد خهصذ انذساسخ أ ز انح اندشاح اندذذ ر ك
.د إخشاء اسزئصبل انشحى انحفبظ عه عه خصثخ انشأح انهزحخ األيبيخ