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Dr.

Mohammed Abdalla
Egypt, Domiat General Hospital
definition
placenta accreta occurs when there is
a defect of the decidua basalis, in
conjunction with an imperfect
development of the Nitabuch
membrane ( a fibrinoid layer that
separates the decidua basalis from
the placental villi). resulting in
abnormally invasive implantation of
the placenta
2
The ACOG committee
incidence
from 1930 to 1950--one case in
30,000 deliveries.
From 1950 to 1960, one in 19,000,
deliveries.
by 1980 to one in 7,000.
the incidence has now risen to one
in 2,500 deliveries,
The ACOG committee

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The incidence of placenta
accreta has increased 10-fold in
the past 50 years, to a current
frequency of 1 per 2,500
deliveries.
largely as a result of the
increase in the number
4
of cesarean sections
it is reported to have a
mortality rate of around
7 percent and is the
most common indication
for birth-related
hysterectomy.
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degrees of severity
(1) Accreta vera, in which the
placenta adheres to the
myometrium without invasion into
the muscle.
(2) Increta, in which it invades
into the myometrium.
(3) Percreta, in which it invades
the full thickness of the uterine
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wall and possibly other pelvic
Risk factors
Risk factors for placenta accreta include :
2. placenta previa with or without previous
uterine surgery.
3. previous myomectomy.
4. previous cesarean delivery.
5. Asherman's syndrome.
6. submucous leiomyomata.
7. maternal age of 36 years and older.

The ACOG committee


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the risk of maternal and fetal
complications increases
notably after the 35th week
exceeding 90% after the
36th week as associated
with the degree of invasion.

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Higher risk
The association between
placenta praevia and placenta
accreta is strong, with a relative
risk of 2,065 compared to
women with a normally sited
placenta.

Am J Obstet Gynecol 1997;177:210-4.

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Highest risk
Placenta praevia itself raises
the risk for accreta due to
implantation over a highly
vascular, poorly contractile
lower uterine segment; an
existing scar in this same
area, as well, obviously
compounds the risk.
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Risk association
C.S )No.( )%(P.P P.P+ accreta
%
0 0.26 5
1 0.56 24
2 1.8 40
3 3.0 47
4 10.0 67
Source: Modified from Clark SL, et al., , the American College of Obstetricians
and Gynecologists.
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Prenatal risk probability

Because of the fact that many of


these cases become evident only
at the first attempt to separate the
placenta at delivery, it is essential
to attempt to identify antenatally
both placenta accreta and its
attendant risk factors, the most
common of which is concurrent
12 placenta previa.
13
14
placenta praevia
Placenta previa is less frequently
diagnosed as gestational age
advances due to the so-called
"placental migration"
phenomenon. A diagnosis of
placenta previa is unlikely to
change after 32 weeks'
gestation,
15
placenta praevia
incidence of placenta praevia fell
with advancing gestational age :

• 76% at 17 weeks' gestation .


• 3% at term.

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placenta praevia

Prenatal diagnosis of this pathology relies on


the capacity to visualize the internal
cervical os and its relationship with the
lowermost edge of the placenta.
Placenta previa exists when the placenta is
inserted wholly or in part into the lower
segment of the uterus.

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placenta praevia
If it encroaches on the
cervical os it is considered
a major or complete
praevia if not then minor
or partial praevia exists.

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placenta praevia
The mode of delivery should be
based on clinical judgement in
each situation….

complete or major
placenta praevia,
should be delivered by
c.s
19 Evidence level III , grade B recommendation RCOG
but in partial praevias a
placenta encroaching
within 2cm of the internal
os is a contraindication to
attempting vaginal
delivery.

Evidence level III , grade B recommendation RCOG


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Diagnosis of
placenta
accreta
Gray-scale sonographic signs of
placenta accreta
normal placental
characterized by a hypoechoic boundary
between the placenta and the urinary
bladder that represents the myometrium
and normal retroplacental myometrial
vasculature.
The normal placenta has a homogenous
appearance as well.
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Gray-scale sonographic signs of
placenta accreta
• Loss of the retroplacental hypoechoic zone
• Progressive thinning of the retroplacental
hypoechoic zone
• Presence of multiple placental lakes ("Swiss
cheese" appearance)
• Thinning of the uterine serosa-bladder wall
complex (percreta)
• Elevation of tissue beyond the uterine serosa
(percreta)
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practical disadvantages of
TAUS
• A bladder that is too full may distort the lower
uterine segment by displacing it posteriorly; thus a
low-lying placenta may erroneously appear to be
covering the internal os.

• shadowing from the symphysis pubis or the fetus.

• suboptimal resolution when imaging patients who


are obese.

• the presence of myometrial contractions that can


distort the internal contour of the uterus, resulting in
false-positive diagnoses.

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TVUS
Transvaginal sonography. This simple,
widely available technique is now the
preferred route for evaluating a patient
suspected of having placenta previa.
sensitivity of 87.5%
specificity of 98.8%

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TVUS
• Using a transvaginal probe, the cervix is
evaluated in the sagittal plane.
• A small amount of urine in the bladder is
desirable to help delineate the anterior
cervical lip.
• The probe is placed under direct visualization
and does not need to touch the cervix to obtain
an adequate image. In fact, since the focal
length of the probe is 2 to 3 cm, placing the
probe too close to the cervix will blur the image.

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Color Doppler signs suggestive of
placenta accreta
 Dilated vascular channels with diffuse
lacunar flow.
 Irregular vascular lakes with focal
lacunar flow.
 Hypervascularity linking placenta to
bladder.
 Dilated vascular channels with pulsatile
venous flow over cervix.
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newly formed vessel + multiple placental
lakes

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newly formed vessels + loss
hypoechogenic security area

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The uterine segment is shown
totally destroyed.

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multiple layers of newly formed vessel

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Newly formed vessel+ multiples lakes

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the multiple layers of newly formed
vessel between uterus and the
bladder

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Color Doppler signs suggestive of
placenta accreta

wickler and associates observed that


when myometrial thickness was
greater than 1 mm and large
placental lakes existed, myometrial
invasion could be predicted with a
sensitivity and specificity of 100% and
72%, respectively.
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MRI

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MRI
certain occasions the information obtained by
the ultrasound is not conclusive, particularly
in the differentiation between the placenta
accreta and percreta. In these cases, or in
those in which additional anatomical
information is wanted on the placental
invasion, the vascularization or on the actual
state of the uterine and vesicle wall, the
Nuclear Magnetic Resonance (MRI) provides
precise anatomic images.

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MRI
The study must be recommended
in those patients with potential
life risk during the surgical
procedure. The examination
should be done with the
informed agreement of the
patient.
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MRI
The analysis cost benefit in the
risk cases is distinctly favorable
for the resonance, especially
when its result modifies the
opportunity and the most
adequate technique of vascular
control.
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MRI
The information obtained by the
Obstetric Magnetic Resonance has
shown an excellent correlation with
the surgical findings. Its use must
be recommended in the planning of
any surgery of placenta percreta,
being indispensable when a
conservative uterine treatment is
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planned.
Management of
intractable haemorrhage
associated with placenta
accreta
Management

1.Medical
2.Surgical.
3.Uterine packing.
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4.Conservative.
In the sever cases of placenta
percreta anterior, the uterovesical
vascular anastomotic net obliges to
fundal hysterotomy and creates the
necessity of a vascular, proximal
control of the iliac system,
impossible of reaching by a parietal
incision of Pfannestiel.

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misoprostol
• * Keep five 200-[micro]g tablets of
misoprostol in the delivery or operating
room.
• * If uterine atony occurs and doesn't
respond to oxytocin or ergometrine )or if
ergometrine is contraindicated(, place
the patient in the frog-leg position, and
while assessing the extent of vaginal
bleeding, place five tablets in her
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rectum.
-Lynch suture B
A woman meets the criteria for
the B-Lynch compression
suture if bimanual
compression decreases the
amount of uterine bleeding
by abdominal and perineal
inspection.
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Lynch suture- B

6 1

3
4

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the B-Lynch suturing technique

The uterus is exteriorised and rechecked to


identify any bleeding point.

where no obvious bleeding point is


observed then bi- manual compression is
first tried to assess the potential chance of
success of the B-Lynch, suturing technique.
The vagina is swabbed out to confirm
adequate control of bleeding.

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the B-Lynch suturing technique
1. A 70 mm round
bodied hand needle
on which a No. 2
chromic catgut
suture is mounted is
used to puncture the
uterus 3 cm from the
left lower edge of the 1

uterine incision and


3 cm from the left
lateral border.

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the B-Lynch suturing technique
2. The mounted No. 2
chromic catgut is
threaded through the
uterine cavity to
emerge at the upper
incision margin 3 cm 2

above and
approximately 4 cm
from the lateral
border (because the
uterus widens from
below upwards).

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1. The chromic
catgut now
visible is passed 3

over to
compress the
uterine fundus
approximately
3 - 4 cm from
the left cornual
border.
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the B-Lynch suturing technique
4. The catgut is
fed posteriorly
and vertically to
enter the
posterior wall of 4
the uterine
cavity at the
same level as
the upper
anterior entry
point.
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1. The chromic catgut
is pulled under
moderate tension
assisted by manual
compression
exerted by the first 5
assistant. The
length of the catgut
is passed back
posteriorly through
the same surface
marking as for the
right side the suture
lying horizontally.
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the B-Lynch suturing technique
6. The catgut is fed through
posteriorly and vertically
over the fundus to lie
anteriorly and vertically
compressing the fundus on
the right side as occurred
on the left. The needle is
passed in the same fashion
on the right side through
6
the uterine cavity and out
approximately 3 cm
anteriorly and below the
lower incision margin on
the right side.

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the B-Lynch suturing technique
7.The two lengths of catgut are
pulled taught assisted by bi-
manual compression to minimise
trauma and to achieve or aid
compression. During such
compression the vagina is checked
that the bleeding is controlled.

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the B-Lynch suturing technique
8-As good haemostasis is secured and
whilst the uterus is compressed by an
experienced assistant the principal
surgeon throws a knot (double throw)
followed by two or three further throws to
secure tension.

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the B-Lynch suturing technique
9-The lower
transverse uterine
incision is now
closed in the
normal way, in two
layers, with or
without closure of
the lower uterine
segment
peritoneum.

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Uterine Artery Ligation
Uterine artery ligation involves
taking large purchases
through the uterine wall to
ligate the artery at the
cervical isthmus above the
bladder flap .
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Hypogastric Artery Ligation
1. The hypogastric artery is exposed by
ligating and cutting the round ligament
and incising the pelvic sidewall
peritoneum cephalad, parallel to the
infundibulopelvic ligament
2. The ureter should be visualized and left
attached to the medial peritoneal
reflection to prevent compromising its
blood supply.
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Hypogastric Artery Ligation
1.The
. common, internal, and
external iliac arteries must
be identified clearly.
2.The hypogastric vein, which
lies deep and lateral to the
artery, may be injured as
instruments are passed
beneath the artery, resulting
in massive, potentially fatal
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Hypogastric Artery Ligation
• The hypogastric artery should be
completely visualized.
• A blunt-tipped, right-angle clamp is gently
placed around the hypogastric artery, 2.5
to 3.0 cm distal to the bifurcation of the
common iliac artery.
• Passing the tips of the clamp from lateral
to medial under the artery is crucial in
preventing injuries to the underlying
hypogastric vein .
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Hypogastric Artery Ligation
1.The artery is double-
ligated with a
nonabsorbable suture,
with 1-0 silk, but not
divided .
2.The ligation is then
64 performed on the
uterine packing
Use of condom
prospective study was done in the Obstetrics and
Gynecology Department of Dhaka Medical College and
Hospital, Bangladesh, between July 2001 and December
2002.
152 cases of PPH were identified; 109 were managed
medically; 20 were managed using the B-Lynch
procedure, and 23 were managed using the condom
catheter. Patients in whom PPH due to atonicity or
morbid adhesion (accreta) could not be controlled by
medical treatment or the surgical approach were selected
for intervention with the condom catheter.
Posted 9/11/2003
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Use of a Condom to Control Massive
Postpartum Hemorrhage
1. Under aseptic precautions a sterile
rubber catheter was inserted within the
condom and tied near the mouth of the
condom by a silk thread.
2. Urinary bladder was kept empty by
indwelling Foley's catheter.

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Use of a Condom to Control Massive
Postpartum Hemorrhage

1. After putting the patient in the


lithotomy position, the condom was
inserted within the uterine cavity.
2. Inner end of the catheter remained
within the condom.
3. Outer end of the catheter was
connected with a saline set and the
condom was inflated with 25-500 mL
of running normal saline.
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Use of a Condom to Control Massive
Postpartum Hemorrhage

1. Bleeding was observed, and when it was


reduced considerably, further inflation
was stopped and the outer end of the
catheter was folded and tied with thread.

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Use of a Condom to Control Massive
Postpartum Hemorrhage

1. Uterine contraction was maintained by


oxytocin drip for at least 6 hours after the
procedure.
2. The uterine condom was kept tight in
position by ribbon gauze pack or another
inflated condom placed in the vagina.

if the concern for concealed hemorrhage still


exists, ultrasound can more effectively detect
a developing hematoma when the contrast is
a fluid-filled balloon .
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Use of a Condom to Control Massive
Postpartum Hemorrhage

1. The condom catheter was kept for 24-48


hours and then was deflated gradually
over (10-15 minutes) and removed.
2. Patient was kept under triple antibiotic
coverage (amoxicillin [500 mg every 6
hrs] + metronidazole [500 mg every 8 hrs]
+ gentamicin [80 mg every 8 hrs])
administered intravenously for 7 days.
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Main Outcome Measures

In all 23 cases in which the condom


catheter was used, bleeding stopped
within 15 minutes. No patient needed
further intervention. No patient went into
irreversible shock. There was no
intrauterine infection as documented by
clinical signs and symptoms and culture
and sensitivity of high vaginal swab.

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Use of a Condom to Control Massive
Postpartum Hemorrhage

Conclusion: The hydrostatic


condom catheter can control
PPH quickly and effectively.
It is simple to use,
inexpensive, and safe.
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Use ofFoley catheter or a
Sengstaken-Blakemore tube
Balloon tamponade using either a
Foley catheter or a Sengstaken-
Blakemore tube has been shown to
effectively control postpartum
bleeding--and may be useful in
several settings: uterine atony,
retained placental tissue, and
placenta accreta.
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A Foley catheter
• A Foley catheter with a 30-mL balloon
capacity is easy to acquire -----Using a
No. 24F Foley catheter, the tip is guided
into the uterine cavity and inflated with
60 to 80 mL of saline.
Additional Foley catheters can be inserted
if necessary.

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the Sengstaken-Blakemore
tube
• the Sengstaken-Blakemore tube
has the advantage over the Foley
catheter due to the larger capacity
of its balloon tip.
• unlike the Foley catheter, this
device may be more difficult to
obtain in an emergency setting

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hysterectomy
Resort to hysterectomy
SOONER RATHER THAN
LATER (especially in
cases of placenta accreta
when future fertility is out
of concern)
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hysterectomy
Intraoperatively, bleeding is rarely a
problem until an attempt is made to
remove the placenta. Accordingly, the
uterine incision should be made
vertically and above the placental
insertion site.

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hysterectomy
Following delivery of the infant, the cord
is clamped and the uterine incision is
oversewn circumferentially to decrease
blood loss. A hysterectomy is then
performed with meticulous attention to
securing haemostasis. Electrocautery
and vascular clips may be of significant
benefit during the dissection.
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Selective arterial embolization

• While the availability of SAE


varies from institution to
institution, if it is available
at your institution, here are
some tips to keep in mind:
2. Ascertain the hours when SAE is
available and establish protocols of
accessibility.
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Selective arterial embolization

1. If a patient is at risk for PPH, we


advise pre-delivery consultation
with the interventional radiology
team. Place embolization
catheters prior to the procedure if
indicated, and make the team
aware of the potential need for
SAE to help them prepare for it.

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Selective arterial embolization

1.Make the decision to move to


the interventional radiology
suite as quickly as possible,
keeping in mind that transfer
can take 15 minutes and
embolization can take 30
minutes.

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Conservative treatment of
placenta accreta
An alternative but
unsubstantiated treatment is to
leave the placenta undelivered
and treat the patient with
methotrexate.
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Conservative treatment of
placenta accreta
Conservative treatment of placenta
accreta appears to be an efficient way to
preserve fertility with an associated
treatment in most of cases (Bilateral
hypogastric artery ligation , medical
treatment with methotrexate or uterine
artery embolization).

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