MANAGEMENT AND MATERNAL OUTCOME IN MORBIDLY ADHERENT PLACENTA

Authors

  • Nighat Sultana
  • Sobia Mohyuddin
  • Tahira Jabbar

Abstract

Background: Morbidly adherent placenta (MAP) with its variants is one of the most fearedcomplications causing high morbidity and mortality in obstetrics. The objective of this study was toanalyse different management options and maternal outcome in diagnosed cases of morbidly adherentplacenta. Methods: Descriptive case series was carried out in Obstetrics and GynaecologyDepartment, Combined Military Hospital, Rawalpindi and one private hospital from Jan 2008 to Dec2010. During this period all cases of morbidly adherent placenta diagnosed by colour flow Dopplerand MRI were analysed. Operative delivery was carried out in all patients. Three different surgicalmanagements namely total abdominal hysterectomy with non separation of placenta, subtotalhysterectomy and trial haemostasis with uterine sparing surgery were carried out on when and whererequired basis. The outcome like total blood loss, blood transfused, Intensive unit care, postnatalcomplications including febrile morbidity, hospital stay and prolonged follow ups, were recorded.Results: Total 32 cases of morbidly adherent placenta diagnosed by colour Doppler ultrasound/MRI(magnetic resonance imaging) were identified. In this study the frequency of morbidly adherentplacenta found to be 1/274.8 deliveries and 1/122.6 caesarean sections. Initially total caesareanhysterectomy was performed in 16 patients, while subtotal hysterectomy in 9 and Trial haemostasiswith uterine sparing in 7 cases out of which two cases underwent total hysterectomy due to massivepostpartum haemorrhage same day. One case in subtotal hysterectomy for placenta percreta withbladder invasion had re-laparotomy for bladder fistula, while two for severe postpartum haemorrhage.Two needed ventilator support. Maternal morbidity was greater in subtotal hysterectomy and uterinesparing group. One patient died in this study. Conclusion: Antenatal diagnosis of morbidly adherentplacenta followed by well-planned total abdominal hysterectomy with non-separation of placentaadapting multidisciplinary approach is the best surgical option to reduce maternal morbidity/mortality.Keywords: morbidly adherent placenta, total abdominal hysterectomy, Trial haemostasis

References

Gielchinsky Y, Rojansky N, Fasouliotis ST, Ezra Y. Placenta

accreta–summary of 10 years: a survey of 310 cases. Placenta

;23:210–4.

Usta IM Hobeika EM, Musa AA, Gabriel GE, Nassar AH. et al.

Placenta previa-accreta: risk factors and complications. Am J

Obstet Gynecol 2005;193:1045–9.

Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation

twenty year analysis. Am J Obstet Gyaecol 2005;192:1458–61.

Chou M, Ho E, Lee Y. Prenatal diagnosis of placenta previa

accreta by transabdominal color Doppler ultrasound. Ultrasound

Obstet Gynecol 2000;15(1):28–35.

Dwyer BK, Belogolovkin V, Tran L, Rao A, Carroll I, Barth R,

et al. Prenatal diagnosis of placenta accreta: sonography or

magnetic resonance imaging? J Ultrasound Med 2008

Sep;27:1275–81.

Warshak CR, Eskander R, Hull AD, Scioscia AL, Mattrey RF,

Benirschke K, et al. Accuracy of ultrasonography and magnetic

resonance imaging in the diagnosis of placenta accreta. Obstet

Gynecol 2006;108(3 Pt 1):573–81.

Gielchinsky Y, Rojansky N, Fasouliotis ST, Ezra Y. Placenta

accreta – summary of 10 years: a survey of 310 cases.

Placenta 2002;23:210–4.

Clark SL, Koonings RP, Phelan JP. Placenta praevia accrete and

prior cesarean section. Obstet Gynecol 1985:66:89–92.

ACOG committee on obstetric practice ACOG committee

opinion number 266 January 2002 planenta accreta. Obstet

Gynecol 2002;99:169–70

Ramos GA, Kelly TF, Moov TR. The importance of preoperative

evolution in patients with risk factors for placenta accreta. Obstet

Gynecol 2007;109(4 Suppl):7S.

Comstock CH, Love JJ Jr, Bronsteen RA, Lee W, Vettraino

IM, Huang RR, et al, Sonographic detection of placenta accreta

inthe second and third trimester of pregnancy.Am J Obstet

Gynecol 2004;190:1135–40.

Wong HS, Zuccollo J, Straw L, Tait J, Pringle KC. The use of

ultrasound in assessing the extent of myometrial involvement in

partial placenta accreta. Ultrasound Obstet Gynecol

;30:228–30.

Silver LE, Hobel CJ. Lagasse L, Luttrull JW, Platt LD.. Placenta

previa percreta with bladder involvement new considerations and

review of the literature. Ultrasound Obstet Gynecol 1997;9:131–8.

Shukenami K, Hottori K, Nishijima K, Kotsuji F. Transverse

fundal uterine incision in a patient with placenta increta. J Matern

Fetal Neonatal Med 2004;16:355–6.

Yap YY, Pervin LC, Pain SR, Wong SF, Chan FY. Manual

removal of suspected placenta accreta at caesarean hysterectomy.

Int J Gynecol Obstet 2008;100:186–7.

Oyelese Y, Smulian JC. Placenta previa placenta accreta and

vasa previa. Obstet Gynecol 2006;107:927–41.

Leung TK, Au HK, Lin YH, Lee CM, Shen LK, Lee WH, et al.

Prophylactic transuterine embolization to reduce intraoperative

blood loss for placenta percreta invading the urinary bladder: a

case report. J Obstet Gynecol Res 2007;33:722–5.

O’Brian JM, Barton JR, Donaldson ES. The management of

placenta percreta: conservative and operative stratigies. Am J

Obstect Gynecol 1996;175:1632–8.

Ojala K, Perala J, Karinuemi J, Ranta P, Raudaslosi T, Tekay A.

Arterial embolization and prophylactic catheterization for the

treatment of severe obstetric haemorrhage . Acta Obstet Gynecol

Scand 2005;84:1075–80.

Arukumaran S, Ng CS, Ingemasson I, Ratnam SS. Medical

treatment of placenta accreta with methotrexate. Acta Obstet

Gynecol Scand 1986;65:285–6.

Eller AG, Porter TF, Soisson P, Silver RM. Optimal management

strategies for placenta accreta. Br J Obstet Gynecol

;115:648–54.

Legros RS, Price FV, Hill LM, Caritis SN. Non-surgical

management of placenta previa percreta: a Case Repoart. Obstet

Gynaecol 1994;83;847–9.

Published

2011-06-01

Issue

Vol. 23 No. 2 (2011): JOURNAL OF AYUB MEDICAL COLLEGE, ABBOTTABAD

Section

ORIGINAL ARTICLE

License

Journal of Ayub Medical College, Abbottabad is an OPEN ACCESS JOURNAL which means that all content is FREELY available without charge to all users whether registered with the journal or not. The work published by J Ayub Med Coll Abbottabad is licensed and distributed under the creative commons License  CC BY ND Attribution-NoDerivs. Material printed in this journal is OPEN to access, and are FREE for use in academic and research work with proper citation. J Ayub Med Coll Abbottabad accepts only original material for publication with the understanding that except for abstracts, no part of the data has been published or will be submitted for publication elsewhere before appearing in J Ayub Med Coll Abbottabad. The Editorial Board of J Ayub Med Coll Abbottabad makes every effort to ensure the accuracy and authenticity of material printed in J Ayub Med Coll Abbottabad. However, conclusions and statements expressed are views of the authors and do not reflect the opinion/policy of J Ayub Med Coll Abbottabad or the Editorial Board.

USERS are allowed to read, download, copy, distribute, print, search, or link to the full texts of the articles, or use them for any other lawful purpose, without asking prior permission from the publisher or the author. This is in accordance with the BOAI definition of open access.

AUTHORS retain the rights of free downloading/unlimited e-print of full text and sharing/disseminating the article without any restriction, by any means including twitter, scholarly collaboration networks such as ResearchGate, Academia.eu, and social media sites such as Twitter, LinkedIn, Google Scholar and any other professional or academic networking site.