الفهرس 
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Abstract
Summary
The present study was carried out at Ain Shams University Maternity Hospital during the period from March 2015 to January 2016. Women approached were recruited from Special Care Center of the fetus – Ain Shams University Maternity Hospital.
All included 50 women were scanned by 2D grayscale, 3D power Doppler ultrasound, 3 D U / S TUI and delivered by cesearian sections where about 42 cases were delivered at term while 8 patients were delivered earliar ranging between 32- 35 wks as a result of attack of antepatum hemorrhage. Of the included 50 women, 46% had considerable intraoperative blood loss, and 58% needed intraoperative blood transfusion.
Placental separation was difficult in 40% women. In women with low parity, young age, or those who desired to preserve their fertility, conservative approach was followed, where devascularization was performed in 28% women; intrauterine balloon inflation was performed in 6% women; and multiple square sutures were performed in 4%women.
Cesearian hysterectomy was performed in 22%women; of them the histopathological analysis showed placenta accreta in 5 cases, placenta increta in 4 cases and placenta percreta in 2 cases. Of the included 20 women who had difficult placental delivery, 9 had it delivered by piece-meal removal together with devascularization without the need for CS hysterectomy. No cases with easily separated placenta underwent C.S
Summary
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hysterectomy .There were 10% cases of bladder injury that was repaired primarily and 2 cases of unilateral ureteric injury that were reconstructed.
Neither age, body mass index, duration from the last CS nor gestational age at delivery was significantly associated with difficult placental separation, considerable intraoperative blood loss or incidence of caesarean hystretomy. However, Parity and no. of previous CS were significantly associated with higher incidence of difficult placental separation, intraoperative blood loss and CS hysterectomy.
There was a significant association between all 2D-GS ultrasound findings (with the exception of abnormal placental lacunae) and each of difficult placental separation, considerable intraoperative blood loss, need for added intraoperative steps, need for CS hysterectomy and bladder injury. The current study showed that presence of focal exophytic mass invading the bladder and disruption of the hyperechoic serosa-bladder interface were the most specific 2D-GS predictors of difficult placental separation, considerable intraoperative blood loss, need for CS hysterectomy and intraoperative bladder injury.
The current study, however, 2 D GS showed a poor sensitivity and NPV of those two diagnostic criteria (focal exophytic mass invading the bladder and disruption of the serosa bladder interface) in difficult placental separation and for considerable intraoperative blood loss
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The current study found that presence of abnormal placental lacunae by 2D-GS ultrasound was poor specificity and relatively low sensitivity criterion for prediction of morbid placentation. However for difficult placental separation, for caesarean hysterectomy and for bladder injury.
All of the 3DPD ultrasound criteria tested in the current study (with the exception of abnormal placental lacunae) showed a quite higher sensitivity and specificity in prediction of difficult placental separation when compared to 2D-GS ultrasound findings, considerable intraoperative blood loss, when compared to 2D-GS ultrasound findings, with the finding of crowded vessels over the peripheral sub-placental zone and disruption of hyperechoic serosa-bladder interface being the most sensitive and specific.
The current study showed that 3DPD-TUI finding of disruption of the hyperechoic serosa-bladder interface, numerous coherent vessels invading serosa-bladder interface and crowded vessels over peripheral sub-placental zone had fair specificities and PPVs in prediction of difficult placental separation, considerable intraoperative blood, need for CS hysterectomy and intraoperative bladder injury. These figures are relatively lower when compared to the corresponding figures of the 2D-GS ultrasonographic findings. The 3DPD-TUI findings, however, had better sensitivity and NPV parameters, particularly in the concern of need for CS hysterectomy and the risk of intraoperative bladder injury