الفهرس 
MORBIIDLY ADHERENT PLACENTAOnly 14 pages are availabe for public view
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Abstract
Placenta accreta (morbidly adherent placenta) occurs in 5% of women with placenta previa (Cunningham et al., 1997). Placenta accreta is a condition in which all or part of the placenta is adherent to the uterine wall because of myometrial invasion by chorionic villi. It may occur when there is either a primary deficiency of or a secondary damage to chorionic villi or Nitabuch’s layer (Gielchinsky et al., 2004).
Alpha-fetoprotein (AFP) is a globulin produced in the liver and gastrointestinal tract of the fetus. AFP is secreted in the fetal urine and then excreted in the amniotic fluid. The maternal serum concentration of AFP increases during pregnancy and reaches a peak between 28 and 32 weeks of gestation. Abnormally elevated second trimester AFP has been associated with placenta accreta and it has been suggested that there is a direct relationship between the extent of invasion and the elevation of the analyte (Zelop et al., 1992).
In the current study a prospective observational study was carried out on 60 pregnant women with placenta previa and at least one previous C.S admitted to Ain Shams University Maternity Hospital during the period between March 2012 and December 2012.
The study was carried out to evaluate the presence of an elevated maternal serum AFP in a patient with suspected morbidly adherent placenta (placenta accreta/ increta/ percreta) is an indication for the presence of a morbidly adherent placenta at delivery and the more the elevation of the analyte, the more the extent of the invasion and to create a cut-off level of this parameter which may be helpful in predicting the presence of a morbidly adherent placenta.
All participants in this study were subjected to transvaginal ultrasound and colour Doppler U/S for assessment of gestational age, placental location, myometrial thickness, presence or absence of placental lacunae and after confirming the inclusion criteria, a serum sample will be withdrawn from all women for maternal serum AFP and outcomes will be known at delivery.
The results of our study showed that among all included women, a sonographic score ≥ 3 was associated with morbid placental adherence at a sensitivity of 82.6%, specificity of 92.1%, positive predictive value [PPV] of 97.4%, negative predictive value [NPV] of 61.9%, positive likelihood ratio [LR+] of 11.6, and a negative likelihood ratio [LR-] of 0.2.
The association between sonographic signs for morbid placental adherence and intra-operative complications was as follows: Loss of retro- placental zone was not significantly associated with any of the reported intra-operative complications. Myometrial thickness < 1 mm was significantly associated with almost 4-fold, 3-fold and 4-fold higher risk of intra-operative morbid placental adherence, PPH, and Caesarean hysterectomy, respectively. Presence of abnormal placental lacunae was significantly associated with almost 2-fold higher risk of intra-operative morbid placental adherence, PPH and Caesarean hysterectomy. Thinning or disruption of the hypoechoic serosa-bladder interface was significantly associated with almost 2-fold, 4-fold, 3-fold, 2-fold and 4-fold higher risk of intra-operative morbid placental adherence, bladder injury, PPH, transfusion of > 4 units of packed RBCs and Caesarean hysterectomy. Presence of focal exophytic masses invading the bladder was significantly associated with almost 2-fold, 3-fold, 2-fold, 3-fold and 2-fold higher risk of intra-operative morbid placental adherence, bladder injury, PPH, transfusion of > 4 units of packed RBCs and Caesarean hysterectomy.
The results of our study showed that among all included women, a serum AFP ≥ 86.7 ng/ml was associated with morbid placental adherence at a sensitivity of 93.3%, specificity of 71.4%, PPV of 91.3%, NPV of 71.4%, LR+ of 3.2, and an LR- of 0.1.
The association between maternal serum AFP level > 2 MoM and intra-operative complications was as follows: Maternal serum AFP > 2 MoM was significantly associated with almost 3-fold, 7-fold, 2-fold and 3-fold higher risk of intra-operative morbid placental adherence, bladder injury, PPH, and Caesarean hysterectomy.
The results of our study showed a significant positive correlation between maternal serum AFP and sonographic score for morbid placental adherence [spearman’s rank correlation coefficient rs=0.574, p<0.001].
The results of our study showed no significant correlation between no. of previous CS and each of sonographic score and maternal serum AFP.