This document discusses the diagnosis and management of morbidly adherent placenta (MAP). It notes that the incidence of MAP has increased substantially in recent decades. Ultrasound is the primary tool for antenatal diagnosis, with findings like myometrial thinning and placental lacunae. MRI can be used as an adjunct. Treatment options include preterm cesarean hysterectomy or conservative approaches like leaving the placenta in situ or attempting placental resection. Conservative approaches aim to reduce morbidity while preserving fertility but carry risks of hemorrhage.

1. Morbidly
Adherent
Placenta
Prof.
Aboubakr
Elnashar
Benha University Hospital
Egypt
elnashar53@hotmail.com

2. CONTENTS
I. INTRODUCTION
II. DIAGNOSIS
1.2 DUS
2. Color Doppler
3. MRI
4. Placenta accreta index
III. CLINICAL OUTCOME
IV. TREATMENT
1. Antenatal diagnosis
2. Treatment
V. PROTOCOLS

3. I. INTRODUCTION
1. Incidence
In the last 20 years
Substantial increase
Now:
1/533 pregnancies
Significant obstetric challenge
The Leading
cause of postpartum hge
indication for a gravid hysterectomy.

4. 2. Definition
Placenta accreta
often used as a general term
defined by the levels of invasion of chorionic villi into
maternal myometrium.

5. Abnormal placentation
Based on the depth of myometrial invasion:
superficial, deep, and through the uterine serosa
Accreta:
Increta
Percreta
The greater the invasion:
the greater the risks for
hemorrhage
maternal morbidity
Worldwide maternal mortality
7%–10%.

6. Morbidly adherent placenta
75%: accretas
18%: incretas
7%: percretas.

7. 3. Pathogenesis
3 Theories:
1. Defect of trophoblast function:
excessive invasion of myometrium.
2. Defect of decidua basalis:
{failure of normal decidualization in area of uterine
scar}:
abnormally deep trophoblastic infiltration.
3. Abnormal vascularization
{scaring process after surgery: localized hypoxia}:
defective decidualization:
exessive trophoblastic invasion.

8.  Defective decidual formation
 Partial/total absence of decidua basalis
 Imperfect development of Nitabuch layer
(fibrinoid layer that separates the decidua basalis
from the placental villi).
Defect in the decidua basalis:
Adherent placenta:
:Abnormal invasion of the placenta directly into
the substance of the uterus.

9. The Placental villi are attached to the myometrium

10. 4. Risk factors
All invasive procedures on the uterus
1. uterine curettage
2. hysteroscopic surgery
3. endometrial ablation
4. uterine artery embolization
5. myomectomy

11. The most important risk factor
 Prior CS
First: 0.24%
Second: 0.31%
Third: 0.57%
Fourth: 2.13%
Fifth, and sixth or more: 6.74%

12. The risk for accreta formation are markedly increased
with
Prior CS
Presence of placenta previa
First: 3%
Second: 11%
Third: 40%
Fourth: 61%
Fifth or more: 67%

14. II. DIAGNOSIS
1.2 DUS
2. Color Doppler
3. MRI
4. Placenta accreta index

15. 1. 2 D Ultrasound
TAS:
Reliable
Primary tool for the antenatal diagnosis
TVS:
More detailed assessment of invasiveness:
improving diagnostic accuracy
The sensitivity of ultrasound: 100%

16. Ultrasound findings suggesting MAP:
First trimester
1. Gestational sac that is located in lower uterine
segment
2. Gestational sac imbedded into CS scar
3. Multiple irregular vascular spaces noted within
placental bed

17. Second trimester
Multiple vascular lacunae within placenta
86% of patients had abnormal findings
between 15 and 20 w:
diagnosis can be made at the routine
anatomic scan.
(Comstock et al, 2004).

18. Third trimester
1. Myometrial Thinning
 <1 mm:
 best combination of sensitivity and specificity
2. Loss of hypoechoic retroplacental zone
3. Vascular lacunae
 Swiss-cheese appearance
 highest sensitivity: 93%
(Comstock et al, 2004).
4. Interrupted serosa
 interruption of line, thickening of line, irregularity
of line, and increased vascularity
 best specificity for predicting accreta
(Silver, 2015)

19. 1. Myometrail thinning
±the only sign

20. 2. Loss of hypoechoic retroplacental zone
 Normal hypoechoic retroplacental zone

21. Normal Hypoechoic Retroplacental zone

22.  Loss of hypoechoic retroplacental zone

23. Loss of hypoechoic Retroplacental zone

24. False positive rate: 21% or higher.
 Should not be used alone.
 Angle dependent:
can be absent in normal anterior placenta.

25. 3. Placental lacunae
intervillous spaces are enlarged spaces in the
placenta filled with maternal blood appears black.

27. The Lacunae in Placenta accreta
1. moth-eaten appearance
2. Irregular and linear
3. Do not have the highly echogenic border that standard
venous sinuses have.

28. Multiple vascular lacunae
within placenta

29. Pathogenesis of placental lacunae
Placental tissue alterations
{long-term exposure to pulsatile blood flow}

30. Grade intraplacental lacunae
Grade 0: no lacunae
Grade 1: 1 to 3
Grade 2: 4 to 6
Grade 3: ≥6 large and irregular lacunae
100% sensitive in predicting abnormal
vasculature on color Doppler US
Sensitivity of
87% with Grade 1 lacunae
100% with Grade 3.
(Yang et al,2006)

32. • Sensitivity: 77%
• Specificity: 95%
• Accuracy: 88%
(SR of 13 studies)

33. 4. Interrupted serosa
Normal Serosa.
 Most commonly seen in
the bladder view but may
be seen anywhere.

34. No visible serosa at the
bladder interface
Placenta has penetrated
into the bladder.

35. 2. Color flow mapping
1. Turbulent blood flow through lacunae
2. Increased subplacental vascularity
3. Vessels bridging from placenta to uterine margin
4. Gaps in myometrial blood flow
Specificity: 72%
PPV: 72%
NPV: 100%
(Twickler et al ,2002).

36. Normal flow.
Color Doppler is abnormal
due to chaotic flow and
direction of flow.

37.  Dilated vascular channels with pulsatile venous flow
over cervix.
 Irregular vascular lakes with turbulent flow
(PSV > 15 cm/s)

38. Hypervascularity linking placenta to bladder.

40. Placenta accreta
increased vascularity in interface between placenta and bladder
turbulent flow in placental lacunae

44. 3. 3D power Doppler
dd between the degrees of placental invasion
1. Irregular intraplacental vascularization with
tortuous confluent vessels affecting the entire
placental width
2. Hypervascularity of the entire serosa-bladder
wall interface

45. TVS
2D grey scale and
Color and power Doppler:
dd between normal placentation/accreta and
increta/percreta with a 100% accuracy
(Chalubinski et al, 2013).
Sensitivity
61% to 100%
Pooled sensitivity
91%
(D’Antonio et al MA, 2013)

46. 4. MRI:
3 findings
1.Abnormal Uterine bulging
2.Heterogeneity of signal intensity within the body
of the placenta
3.Presence of dark intraplacental bands on T2
weighted images

47. MRI VS U/S
(Antonio, et al, 2014)
MRI is not more sensitive than U/S
used as an adjunct to U/S
(ACOG 2014)
Sensitivity Specificity
MRI 81.3–95.1% 76.7–94.4%
U/S 77.2–91.4% 73.0–95.7%

48.  Ultrasound
 the more sensitive imaging modality
 MRI
complementary to ultrasound, especially in
1. Few ultrasound signs
2. Suspicion for invasion into the parametrium or
surrounding organs
3. Suspected posterior placenta accreta
4. Obese patient
(Riteau et al,2014)
 If ultrasound findings is suggestive of accreta don’t
arrange an MRI.
.

49. MRI:
 rarely changing surgical management.
 When MRI downgraded ultrasound diagnosis, in every
case the patient still underwent C hysterectomy.
 diagnosis of placenta previa was still associated
with both false positive and false negative.

50. 4. Placenta Accreta Index
Rac, 2014

51. Helpful in
1. antenatal diagnosis of MAP
2. Reducing maternal and fetal morbidity and
mortality
3. allowing multidisciplinary counseling, and planning
and timing of delivery.

52. Score Probability
0 - 5 low
6 - 7 moderate
8 - 12 high
Tovbin et al 2016

53. 2 stage protocol in evaluating a patient at risk for
abnormal placentation using
1. Ultrasonography then
2. MRI for cases that are inconclusive
(Warshak et al, 2006 ).

54. III. CLINICAL OUTCOMES
1. Hemorrhage
 most common complication at the time of delivery
 Massive blood loss:
1. Consumptive coagulopathy
2. Renal failure
3. Acute respiratory distress syndrome
4. Need for re-operation and death

55. Blood loss
exceeded 2000cc in 66%
5000cc in 15%
10,000cc in 6.5%
55% of women required transfusion
21% of the patients required more than 5U units
of blood.
(Miller et al 1997)

56. 2.Peripartum hysterectomies for placenta accretas
1. Infection
2. Cystotomy
3. Ureteral injury
4. Need for re-operation for hemoperitoneum

57. IV. MANAGEMENT
1. Antenatal Diagnosis
2. Treatment
I. Preterm CS hysterectomy
II. Conservative
 Definotin
 Objectives
 Consideration
 Definition of failure
1. Leaving placenta
2. Placenta myometrial excision and repair

58. 1. Antenatal Diagnosis
Critical:
decreased maternal hgic morbidity.

59. Delivery timing :
Between
34+0 - 35+6 weeks
(Spong et al, 2011)

60. Warshak et al, 2010
99 women with placenta accreta
62: diagnosed pre-delivery
37: diagnosed intrapartum.
fewer units of PRBCs (4.7 units compared to 6.9)
lower estimated blood loss (2,344 cc vs 2,951cc).
delivered electively at 34 to 35 w
reduce the morbidity associated with emergent
hysterectomy
not associated with increased neonatal
morbidity (NICU length of stay, RDS, need for
surfactant administration or intubation)
{increased use of antenatal steroid}.

61. Eller et al , 2009
Elective CS and hysterectomy at 34 w after antenatal
steroids
69 patients
57 prenatally diagnosed versus
17 unsuspected
lower ICU admission rates (23 vs 43%),
lower large volume of blood transfusions (5 vs
9%
less ureteric injury (5 vs 9%
less intra-abdominal infection (6 vs 9%),
decreased hospital readmission (5 vs 18%)
less vesicovaginal fistula formation (0 vs 6%).

62.  Criteria for accreta referral center
(Silver et al, 2015)
1. Multidisciplinary team
a. Experienced maternal–fetal medicine physician or obstetrician
b. Imaging experts (ultrasound and MRI)
c. Pelvic surgeon (gynecologic oncology or urogynecology)
d. Anesthesiologist (obstetric anesthesia or cardiac anesthesia)
e. Urologist
f. Trauma surgeon or general surgeon
g. Interventional radiologist
h. Neonatologist
2. ICU and facilities
a. Interventional radiology
i. Capability within the operating suite—hybrid operating room
b. Surgical or medical ICU
i. 24-hour availability of intensive care specialists
c. Neonatal ICU
i. Gestational age appropriate for neonate
3. Blood services
a. Massive transfusion capabilities
b. Cell-saver and perfusionists
c. Experience and access to alternative blood products
d. Guidance of transfusion medicine specialists or blood bank pathologists

63. 2. Treatment for placenta accreta
(ACOG Committee Opinion.,2015)
I. Preterm Cesarean hysterectomy without removal of
placenta
II. Conservative with
1. Placenta left in situ
2. Placental resection .

64. I. Preterm Cesarean hysterectomy without removal of
placenta
Significant decrease in morbidity.
Fundal or high classical incision
(Belfort et al, 2010).
Pre or peri-operative use of ureteral stents:
decrease the risk of ureteral injury
Hypogastric artery ligation:
no decrease the mean blood loss or the need for
large volume of blood transfusions.
(Eller at al, 2009)

65. Preoperative bilateral common iliac artery balloon
catheter placement with inflation after delivery of the
fetus

66. Interventional radiological embolization followed by a
hysterectomy
Reductions in
blood loss (553 vs 4517 ml)
need for transfusion (2 vs 16)
 units of blood transfused (0.5 vs 7.9;
p=0.0013).
(Angstmann et al 23).

67. Urinary tract injury:
most common
29%
(Tam Tam et al 2012).
To decrease
1. Pre-op cystoscopy
{check for obvious bladder wall involvement
assure urologic backup for bladder preservation}
2. large bore ureteral stents:
make for easier palpation
3. Allen stirrups:
allow three surgeons to be at the operative field
4. Filling the bladder with sterile milk
prior to bladder mobilization.

68. Surgical approach
1. Dorsal lithotomy position
2. Vertical midline skin incision
3. Dissect bladder flap before delivery
4. Classical uterine incision away from the placenta
ultrasound mapping of the placenta implantation site preoperatively
Intraoperative ultrasound for the uterine incision
Avoid puncture of the uterine serosa overlying placenta.
5. No attempt at placenta removal
6. Placenta left in situ
7. Hysterectomy

69. II. Conservative treatment
Cesarean hysterectomy
management of choice
It is associated with
significant morbidity
psychological consequences of the loss of fertility.
Objective
1. Reduce the morbidity of peripartum hysterectomy
2. Allow for future fertility in selected women.
One must distinguish the two distinct goals when
counseling patients
Define:
Any approach whereby hysterectomy is avoided.

70. Should be considered only
Patient:
Desire to have more children
Haemodynamically stable
 No heavy bleeding or DIC at time of surgery
{Conservative management when the woman is already
bleeding is unlikely to be successful and risks wasting
valuable time} .
(RCOG Green-top Guidelines 2011)
Patient counseling:
 short- and long-term risks
need for close, potentially lengthy monitoring.

71. Placenta percreta
invading adjacent organs (bladder, ureter, bowel).
Centers
Equipped to manage the initial procedure and any
subsequent complications.
An experienced interventional radiology
The clinical team
must be willing to abandon conservative
management , and clear endpoints must be
established a priori.
all cases be considered a ―trial of conservative management‖
and monitored accordingly.
{large proportion of conservatively managed patients require
delayed hysterectomy}

72. Criteria to identify Failed Trial of Conservative
Management
1. Contraindications to conservative management
(lateral or deep cervical invasion)
2. Maternal request for definitive surgical
management (hysterectomy)
3. Ongoing hemorrhage
(no time limit- may occur hours to weeks after delivery)
4. Severe pain
5. Cardiovascular instability or signs of hemorrhagic
shock
(hypotension, tachycardia, decreased urine output DIC)
6. Complications
(arterial injury after attempted intra-arterial balloon
occlusion or embolization)

73. 1. Leaving the placenta in situ
1.Uterine artery embolization followed by
2.Adjuvant medical therapy
1.Methotrexate
2.Misoprostol
3.Mifepristone
4.GnRH analogues.

74. Attempts to remove the placenta are best avoided in
1. deep invasion
2. invasions behind the bladder, cervix, broad
ligaments or retroperitoneal regions inaccessible
to immediate hemostatic control.
Conservative methods
 should only be considered with preparations for
immediate conversion to hysterectomy.

75. 167: Conservative treatment
 successful in: 78.4%
 36 patients needed a hysterectomy either primarily
or delayed.
 Severe maternal morbidity: 6%.
(Sentilhes et al, 2010).

76.  Complications
1. Pulmonary edema
2. Septic shock
3. Acute renal failure
4. Infection
5. DVT
6. Pulmonary embolism
7. Secondary postpartum hemorrhage.
 There was one maternal death
{myelosuppression and nephrotoxicity related to
Methotrexate administration}.

77. 46 patients:
treated conservatively
Additional treatments
1. bilateral hypogastric artery ligation
2. uterine artery ligation
3. uterine sutures
4. Embolization
5. Methotrexate
6. oxytocin and/or prostaglandins.
The median time of follow-up: 65 months.
The median time for the resumption of menses:130 days and
none had amenorrhea.
12/14 patients desiring another pregnancy got pregnant
2 had recurrent placenta accreta.
5 spontaneous abortions
 median term of delivery was 37 weeks.
(Sentilhes et al 2010).

78. Methotrexate
The risks of use of methotrexate outweigh potential
benefits and it should not be used for MAP.
first described in 1986.
a dihydrofolate reductase inhibitor that targets rapidly dividing cells
commonly for the treatment of ectopic pregnancy and gestational
trophoblastic disease.
the decrease in placental cell division in the third trimester limits the
biologic plausibility of purported benefits
 is associated with rapid placental expulsion,yet there is significant overlap
in the time to resolution with or without its use, and outcomes do not appear
to differ significantly.
contraindicated during breastfeeding,which is widely accepted to promote
neonatal short- and long-term health outcomes, maternal bonding and
neonatal attachment, and may mitigate the risk of postpartum depression or
perceived stress related to a ―traumatic‖ delivery. .
no convincing evidence supports the efficacy of methotrexate in cases of
placenta accreta left in situ, and methotrexate-related pancytopenia and
nephrotoxicity are possible adverse effects.‖

79. 2. Placental-myometrial en bloc excision and repair
Rationale:
1. US diagnosis: for patients at risk for accreta.
5.9% false positive rate
16% false negative rate
12.3% uncertain diagnosis rate
2. Morbidity of Cesarean hysterectomy
3. Placentas that detach easily
in patients suspected to be at risk for morbidly
adherent placentation may be candidates for
placental removal or conservative management.
(Bowman et al 2014).

80. Not suitable in patients with
extensive lateral or cervical invasion.
(Fox et al, 2015)
Reasonable in women with
clearly delineated, focal area of involvement
an accessible border of healthy myometrium
In these cases
an initial, gentle attempt at placental removal is
also acceptable
but only when sufficiently confident that
any remaining placenta and/or myometrium
can be removed en bloc or
bleeding stopped with compression sutures.

81. 1. One- Step Conservative Surgery.
(Palacios et al, 2004)
68 cases.
when < 50% of the anterior uterine circumference was involved.
1. bleeding controlled by dissection and ligation of any
neovascularization.
2. Resection of invaded myometrium
3. Complete placental excision
4. Fibrin glue, uterine artery ligation, and brace or box sutures
for local hemostasis.
5. Repair of the resulting defect in the myometrium with
―myometrial pulley sutures,‖ similar to horizontal mattress
sutures.
6. The defect was then covered with absorbable mesh.

82. Uterine conservation was completed: 74%.
26% patients still required hysterectomy
Of these, 42 had 3 year follow up, 10 became pregnant
and were delivered at 36 weeks by scheduled cesarean
section

83. One-step conservative surgery

84. One-step conservative

85. 2. Two- Step Conservative Surgery
(Palacios-Jaraquemada ,2013)
 similar to one-step surgery
 tissue dissection, myometrial and bladder sutures
are delayed for 3-5 days later.
 less difficult and bleeding is not severe .

86. 3. Triple P‖ procedure
(Chandraharan et al; 2006)
Patients with central, anterior placenta percreta.
Not done if:
lateral extension of a percreta into the broad ligaments,
deep infiltration into the cervix or the ureters
3 steps:
1. Preoperative placental localization:
 transabdominal ultrasound to identify the superior
border of the placenta, with transverse hysterotomy
planned 2-fingerbreadths above the uppermost
placental edge
2. Pelivc devascularization
reoperative placement of intra-arterial balloon catheters
(with inflation after delivery), or ligation of the uterine
arteries when catheterization is unavailable

87. 3. Placental non removal with en bloc myometrial excision and
uterine repair.
During the excision, a 2cm margin of myometrium is
preserved above the bladder edge to allow hysterotomy
closure.
In cases involving bladder invasion or low-lying placenta,
hemostatic clamps are placed along the incision edges, the
lower segment is everted, placental fragments are removed
piecemeal, and compression sutures are placed as needed for
hemostasis.
The resulting myometrial defect is then closed in the same way
as a hysterotomy made at the time of cesarean section.
All patients opted for bilateral tubal ligation at the time of
delivery, thus no follow-up data with regard to subsequent
pregnancy are available.

89. The benefits
Low blood loss: 800 to 1500 mL
reduction in:
need for delayed hysterectomy, and length of inpatient
stay when compared to leaving the placenta in situ plus
arterial occlusion.
surgical dissection necessary to attain adequate
hemostasis while removing all or most of the placenta.

90. ADJUNCTIVE PROCEDURES
I. Areterial occlusion
More effective when combined with a surgical
approach rather than leaving the placenta in situ.
1. Uterine artery occlusion
1. Temporary use of intra-arterial balloon catheters
2. Uterine artery embolization
(Clausen et al 2013)
Routine intravascular occlusion remains controversial
{lack of adequately powered RCT demonstrating benefit}.

91. 2. Bilateral internal iliac artery ligation
 :Significant decrease in blood loss.
 Many authors advocate its routine ligation in placenta
accrete
[Joshi et al .,2007]
 Others reported no value for its ligation
[Iwata et al .,2010]

92. 3. Temporary clamping of
 infra-renal aorta
 common iliac arteries

93. II. Sutures:
1. Vertical Compression Sutures
2. Longitudinal lateral sutures at the site of bleeding
3. Suturing both uterine walls
(Hwu et al., 2005)

94. 4. Stepwise Double Vertical Compression Sutures
(Makino et al .,2012)

95. 5. Transverse B-lynch sutures-
 Effective in controlling bleeding from placenta
accreta
 making horizontal sutures passed in avascular
area in the broad ligament make more tension
around and pressure in the lower segment

96. 7. Cho suture
haemostatic multiple square suture to approximate the
anterior and posterior uterine wall
(Cho et al ., 2000)
8. Hayman suture
two vertical apposition sutures together with two transverse
horizontal cervicoisthmic sutures
(Hayman et al .,2002)

97. III. Using the cervix to stop
bleeding
(Dawlaty et al.,2007;El Gelany et al ., 2015)
 Suturing an inverted lip of cervix over
the bleeding placental bed
 The inverted cervical lips grasped by
2 Allis forceps with Hegar dilator in
between.
 Suturing the posterior cervical lip to
the posterior wall of the lower uterine
segment
 suturing the anterior cervical lip to the
anterior wall of the lower uterine
segment.
 safe, simple, time-saving and
potentially effective

98. LONG-TERM CONSIDERATIONS
1. Risk of recurrence
depends upon the type and number of treatments
rendered.
recurrence of accreta: 29%
severe uterine synechiae and amenorrhea: 14%
(Sentilhes et al.,2010)

99. 2. Cost of planned hysterectomy versus conservative
management
. The actual direct and indirect costs of
conservative management is far more than that for
planned cesarean hysterectomy
(Sentilhes et al.,2010)

100. Delayed hysterectomy
1. As an emergent procedure
performed as a consequence of delayed
complications
2. As planned procedure
 not a ―conservative‖ approach
 aimed at
 prevention of complications that may occur with
either immediate hysterectomy, or
prolonged placental retention.
By allowing spontaneous regression of some of the
placental bulk: risk of hemorrhage at the time of
hysterectomy can be reduced.
Optimal timing of planned delayed hysterectomy is
unclear.

101. V. PROTOCOLS
1. Antepartum management of suspected accreta
(Silver et al, 2015)
1. Confirm diagnosis
1.US to assess the probability of accreta.
2. Consideration of MRI: if unclear based on sonogram, in
cases of posterior previa or if suspected percreta.
2. Rest
 Pelvic rest.
 Consideration of bed rest and/or hospitalization if stable.
3. Corticosteroids
 enhance fetal pulmonary maturity in cases of antepartum
bleeding at the time of hospital admission.
If no antepartum bleeding, empiric administration at 34 w

102. 4. Consultation
with the patient and her family to discuss delivery options,
risks of the disease, potential complications, and impact of
treatment on fertility.
with a multidisciplinary team to plan the delivery
5. The optimal timing of delivery
should be accomplished in a scheduled and controlled
fashion.
The risk of maternal hemorrhage must be weighed against
the fetal risk of prematurity.
In cases without antepartum bleeding, delivery at 34–35 w
It is not necessary to assess fetal pulmonary maturity with
amniocentesis.
In cases with episodic bleeding, delivery between 32 and 34w
is advised, depending on the severity of bleeding.
Heavy bleeding may require earlier delivery.
(Silver et al, 2015)

103. 2. Surgical management of suspected accreta
(Silver et al, 2015)
1. Multidisciplinary team.
 include surgeons with experience in accreta
 critical care specialists
 Anesthesiologists
 blood bank specialists.
 Gynecologic oncologists are ideal because of their experience with
bladder and ureteral surgery in addition to difficult pelvic surgery.
 Interventional radiologists
 vascular surgeons
 If all of the requirements under (1) are not available, consider transfer
to a center with appropriate expertise.

104. 2. Adequate blood products should be available.
20 U of packed red blood cells and fresh frozen plasma
12 U of platelets.
Additional blood products should be available in reserve.
Recombinant activated factor VII

105. 3. A vertical skin incision
Regardless of prior abdominal or pelvic scars.
Cherney incision is a reasonable alternative.
4. General anesthesia
should be used.
It is reasonable to use a regional anesthetic for the delivery of
the infant, followed by general anesthetic for the hysterectomy
in stable patients.
The patient should be kept warm and a (relatively) normal pH
maintained.

106. 5.Preoperative consideration:
1.ureteral stents.
2.Regular or balloon catheters in the uterine arteries.
These can be infused with material for embolization or the
balloons inflated after the delivery of the fetus. In turn,
this may decrease blood loss at the time of hysterectomy
or allow for the avoidance of hysterectomy
Alternatively, catheters can be placed and only used if
needed.
This practice is controversial and serious adverse events
with balloon placement have been reported.

107. 5. Ideally, in cases of strongly suspected accreta:
planned cesarean hysterectomy
 classical hysterotomy that does not compromise the
placenta should be used to deliver the infant.
 No attempt should be made to remove the placenta.
 The hysterotomy should be quickly sutured to achieve
some measure of hemostasis, followed by hysterectomy.
 If the case is difficult to accomplish or if the patient is
unstable, consideration should be given to supracervical
hysterectomy.

108. 6. Consideration may be given to
1. Hypogastric artery ligation.
 Our group has not found this to be helpful.
2. Leaving the placenta in situ, closing the hysterotomy, and
planning a ―delayed‖ hysterectomy in 6 weeks.
 In theory, this may allow some of the enhanced vascularity
associated with pregnancy to regress, facilitating the
hysterectomy.
 This approach has been advocated in women with
percretas to avoid bladder resection.
 Our group has not found this to be helpful.

109. Management of unsuspected placenta percreta
discovered at laparotomy
1. Delay uterine incision if things appear abnormal:
Distorted or ballooned lower segment
Blood vessels on uterine serosa
Invasion into bladder or surrounding tissue
2. Assess location and extent of placental invasion
visually and by ultrasound
3. Evaluate for presence of active bleeding
4. Inquire about availability of resources:
blood/blood products, surgical assistance, and
equipment

110. Placental invasion and increased vascularity visible in lower
uterine segment at time of laparotomy

111. 5. If patient is stable and facility is not currently
prepared:
Cover uterus with warm laparotomy packs and await
assistance and supplies before proceeding with
operative intervention
or
Close fascial incision, place staples in skin, and
consider transfer to tertiary facility with
experience in management of percreta

112. 6. If patient is actively bleeding, apply local pressure to
bleeding areas (other than areas where placental tissue
is at risk), then prepare for
hysterotomy for delivery followed by
surgical or
conservative management of placenta percreta
(Silver. 2015).

113. Resources Patient, clinical and
anatomic features
Decision Definitive treatment
Limited
experience
or expertise,
poor
Resources
no facilities for
safe patient
transfer
lower segment invasion
vaginal bleeding with
high suspicion of accreta
Possibility of percreta
Extraplacental
hysterotomy,
Placental left in
situ
Followed by
uterine closure
Delayed hysterectomy
or conservative procedure
according clinical
and surgical status
Qualified and
experienced
team
adequate
hospital
resources
No desire for future
pregnancy
Tissue destruction> 50%
of uterine circumference
Intractable haemorrhage
DIC
Resective
surgery
Subtotal hysterectomy
for upper segment lesions
Total hysterectomy
for lower segment
and cervical involvement
Qualified and
experienced
team
adequate
hospital
Desire for future
pregnancy
Destruction < 50% of
uterine axial
circumference
Conservative
surgery
Placenta in situ with or wit
MXT
OR
One step surgery

114. CONCLUSION
The incidence
rising with the rates as high as 1/533 pregnancies.
Accretas
chief cause of postpartum he
significant cause of both maternal and neonatal
morbidity and occasionally mortality.
The main risk factor
a history of a prior CS.
Prenatal diagnosis
Crucial
significant reduction in maternal blood loss and of
post partum complications.

115. Cesarean hysterectomy
management of choice
It is associated with
significant morbidity
psychological consequences of the loss of fertility.
Conservative management with leaving placenta
using embolization techniques, methotrexate and
observation must be balanced with a significant rate
of complications such as infection and DIC.
Placental-myometrial en bloc excision and repair
Not suitable in patients with
extensive lateral or cervical invasion.
Reasonable in women with
clearly delineated, focal area of involvement and
an accessible border of healthy myometrium

116. Thanks