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Emerging of Abnormally invasive

placenta (AIP):
SURABAYA Experience & new strategies in AIP

“The A TEAM”
Maternal Fetal Medicine Div.
Obstetric & gynecology department
Dr. soetomo general hospital, Universitas
Airlangga
Surabaya, Indonesia

Introduction

• The incidence of placenta accreta or Abnormally
Invasive Placenta (AIP) increases
• Placenta accreta is a 20th century iatrogenic disease
• The main cause is cesarean scars

8 in 1000 2010 : 3 in 1000 . World Cesarean Section Rate “Abdominal 1994-2002 : episiotomy” era?? 1 in 2000-2500 Placenta Acreta Cesarean Scar Pregnancy 1980 : 0.

4% HPP 3.0% 0.0% 1. Post Partum Hemorrhage in Dr.0% 2.6% 2.8% 2.7% 4. Soetomo Hospital 7.0% 4.0% 6.0% 3.9% 5.0% 2012 2013 2014 2015 2016 .0% 5.

4% Tone 40.6% 20.0% 46.0% 14.0% 25.0% Trauma 17.0% 0.6% 39.0% 2.0% 0.2% Tissue 30.0% Thrombin 14.0% 10.3% 1.4% 2012 2013 2014 2015 2016 .0% 28.Causative of Post Partum Hemorrhage In Dr.9% 6.0% Morbidly adherent placenta 50.8% 0.2% 60. Soetomo General Hospital 70.0% 66.

Incidence of abnormally invasive placenta (2013 – May 2018) 5% 4% 2% 1% 0% 0% 2013 2014 2015 2016 2017 MAY-18 1 case 4 cases 7 cases 24 cases 60 cases 29 cases Still on going .

Learning curve 5% 4% 2% 1% 0% 0% 2013 2014 2015 2016 2017 MAY-18 Feb 2015 Oct 2016 Nov 2017 .

Learning curve 4 maternal death in Surabaya → 3 death due 5% 4% to AIP 1st Symposium of Invasive and Adherent Placenta (SIAP)2% 1% 0% 0% 2013 2014Feb 2015 2015 2016 2017 MAY-18 Total maternal death in Surabaya due to AIP = 5 (in 2015) .

4% 2% 3 cases Left Placental In situ 1% 1 case succeed after 1.5 year follow up 0% 0% 2013 2014 2015 Workshop 2017 2016 of PlacentaMAY-18 Accreta in APCMFM. Learning curve Referral with AIP case was increase 5% 4% Almost Routinely Hysterectomy 2 maternal death with AIP Complication → 30. Penang Malaysia Feb 2015 Oct 2016 .

Cininta N. Vol. Gumilar KE. Learning curve Surabaya Modified Procedure for Uterine Conservation in AIP 4% 5% (SUMPUC) 2% 1% 0% 0% 2013 2014 2015 2016 2017 MAY-18 Nov 2016 Aryananda R. 2017. No. Wardhana MP. Gynaecol. et al. S1: 56–82. Obstet. J. 43. June 2017 . Akbar A. Surabaya modified procedure for uterine conservation (SuMPUC) in morbidly adherent placenta. Wicaksono B. Res.

MATERNAL DEATH IN PLACENTA ACCRETA • 1 case with left 5% 4% placental insitu → sepsis from other city • 1 case with 2% post hysterectomy in • 1 case 1% other hospital 0% Internal 0% with Bleeding uncontrolled 2013 2014 • 1 case Post 2015 2016 2017 MAY-18 bleeding CS and • 2 cases with referred sudden and with active 2 4 massive vaginal bleeding bleeding .

67 minute (± 15. Wicaksono B. Gynaecol. Blood loss No. et al. Cininta N. S1: 56–82. CS (Week) (S1/S2)* surgery skin closed)- min 1 23 3 1 37 Increta S1 90 1500 2 mean The 33 estimated 3 2 loss during blood 35 Percreta was 1533 surgery S1 cc (± 540100 cc) 2000 3 mean The 34 duration 3 2 of surgical 36 procedure Increta S1 was 86. No. Gumilar KE. Wardhana MP. Surabaya modified procedure for uterine conservation (SuMPUC) in morbidly adherent placenta. J. Res. Our first series (9 patients) → November – February 2017 Duration of Result Surgery Patient Previous GA Implantation Age Gravida from (incision. Akbar A. June 2017 . 43.860minute) 1600 4 36 2 1 26 Percreta S1 70 1000 5 35 4 3 36 Percreta S2 100 2000 6 36 3 2 40 Increta S1 70 1000 7 35 2 1 36 Percreta S1 100 2500 8 36 3 2 36 Percreta S1 90 1000 9 37 3 1 32 Percreta S1 100 1200 Aryananda R.Vol. Obstet.

PROBLEMS – 1 6 cases was failed in conservative surgery – SuMPUC PARAMETRIUM CERVICAL IMPLANTATION INVASION S2 UTERINE SEGMENT OF VASCULAR INVOLVEMENT .

Problem – 2 (the disaster) Diffuse AIP Massive collateral uterine blood supply Massive Adhesion and invasion Different Approach .

Learning curve 2nd Symposium of Invasive and Adherent Placenta (SIAP2) Attended by 14 Medical Center in Indonesia Improve in Detection and Referral system (secondary hospital level) 5% Improve Ultrasound Placental and vascular 4% Mapping (tertiary hospital level) Improve Surgical Technique (tertiary hospital level) 2% Make Recommendation (secondary and tertiary hospital level) 1% 0% 0% The Accreta Team Declaration “The A Team” 2013 2014 2015 2016 2017 MAY-18 Nov 2017 .

. 2nd edition. Dumfriesshire. et al. Palacios-Jaraquemada JM. cervix. upper part of the vagina and the respective parametria. p. S1 segment comprises the body of the uterus S2 segment corresponds to the lower uterine segment. A Comprehensive Textbook of Postpartum Haemorrhage 2012.19. Scotland: Sapiens Publishing.

Placental mapping Placental Topography Invasion Placental diffuse or focal S1/S2 uterine segment Placental invasion to other organ Vascular involvement .

PREOPERATIVE CLASSIFICATION  Focal → less than 50% uterine surface of placental invasion  Diffuse → more than 50% uterine surface of placental invasion Uterine anterior surface Placental invasion surface .

514 GA in surgery (Median)** 36 36 0.7% (10) *independent T test **Mann whitney U test .3% (4) 5% (3) Vascular injury 3.000 Complication Reopen/ resurgery 3.7% (22) History of Termination of 35.7% (1) Uterine atony 0 10% (6) Major Implantation Accreta 14.9% (12) 45% (27) Percreta 42.3% (38) 2 CS 50% (14) 36.3% (4) 38.9% (12) 16.7% (10) 20% (12) pregnancy (TOP) Haemorrhagic (median)** 2900 (400-8500) 1450 (200-4000) cc 0. Maternal Outcome in Focal Invasion (2013 – May 2018) Hysterectomy Uterine Conservative p (n = 28) surgery (n = 60) Age (Median)* 35 (26-41) y.o 0.541 Number of CS 1 CS 50% (14) 63.6% (1) 1.o 33 (22-43) y.3% (23) Increta 42.6% (1) - Bladder injury 14.030 GA in diagnosis (median)** 35 34 0.

Posterior invasion 90. 66 case series of conservative surgery in placenta accreta spectrum disorder 9. Diffuse placental invasion 2.1% 6 cases failed : 1. Parametrial invasion 3. Cervical invasion 5.9% 4. Majority S2 uterine vascular involvement Berhasil Gagal .

3% (1) 14.09) 0.7% (15) 85.000 (mean)* Complication Bladder/ urinary 6 5 tract injury Vascular injury .25 ( 5568.1% (8) 2 CS 56.8% (7) 57.7% (12) *independent T test . - Major Implantation Accreta .87) 2457.3% (2) Percreta 93.165 GA in diagnosis 33 (24-38) 32 (25-39) 0. Total hysterectomy with Aortic Clamp with p internal iliac ligation (n = Modified Hysterectomy (n 16) = 14) Age (Median)* 33 (25-41) 36 (28-42) 0.897 (median)* GA in surgery 34 (24-38) 34 (25-39) 0.650 (Median)* Number of CS 1 CS 43.9% (6) History of 43. - Increta 6.8% (7) 50% (7) Termination of pregnancy (TOP) Haemorrhagic 8681.14 ( 1460.2% (9) 42.

VASCULAR Collateral system MORE COMPLEX Upper Uterine Artery 100% from Iliac Internal Artery pedicle Middle Cervical Artery 67% from Uterine Artery pedicle 23% from Vaginal artery 10% lower Vesical artery Lower Upper vaginal artery pedicle → 18% from Uterine Artery Middle vaginal artery → 11% from Iliac Internal Artery Lower vaginal artery → 71% from Pudendal Internal 75% as as descending branch artery 25% as ascending branch .

IMPROVE SURGICAL TECHNIQUE Focal AIP Diffuse AIP Placental Invasion <50% from Placental Invasion >50% from uterine surface uterine surface + 1. Pelosi Manouver The “A” Team . One step conservative Cervical invasion surgery by Prof Palacios Massive adhesion and invasion Temporary Aortic Clamp and followed by : 1. Total Hysterectomy 2. SuMPUC with modification Parametrial invasion 2. Retrograde Hysterectomy 3.

WHY WE NEED THE “A” TEAM ??? Aortic clamp by thorax Diffuse invasion Aortic compression surgeon .

Still many cases referred from outside East Java Province…. .

Conclusion  Incidence of placenta accreta increase  PLACENTAL MAPPING & PREOPERATIVE CLASSIFICATION are crucial : focal or diffuse → deciding the management/ Surgical plan .