الفهرس 
The PlacentaOnly 14 pages are availabe for public view
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Abstract
P
lacenta accreta is described as deep adherence of placental villi to the myometrium. . It is caused by a defect in decidua basalis resulting in an abnormally invasive placental implantation. According to an epidemiological review, cases of placenta accreta have increased because of higher cesarean rates due to a greater number of accepted indications for cesarean sections, including maternal request.
Strong risk factors for abnormal placentation include previous caesarean scars and placenta previa. Other known risk factors are multi-parity, advanced maternal age, previous dilatation and curettage, a history of manual placenta removal, sub-mucous myoma resulting in atrophy of the endometrium, gestational products implanted in the uterine diverticulum, and previous radium insertion.
The main danger and most common complication of abnormal placentation is massive bleeding. Abnormal invasive placentation cause elevated maternal morbidity and mortality. Placental invasion abnormalities are classified according to the depth of penetration by the chorionic villi as placenta accreta, -increta, and -percreta. Placenta accreta is considered a severe pregnancy complication that may be associated with massive and potentially life-threatening intra-partum and postpartum hemorrhage.
It has become the leading cause of emergent hysterectomy; Women with placenta accreta are usually delivered by cesarean section. It is better to perform the surgery under elective, controlled conditions rather than urgently with inadequate preparation in an emergency. In addition, regardless of the management option taken, the prevention of complications ideally requires a multidisciplinary team approach.
Conservative, uterine-sparing approaches for the management of placenta accreta have been described to both reduce the morbidity of peri-partum hysterectomy as well as to allow for future fertility.
The first clinical manifestation of placenta accreta is usually profuse, life-threatening hemorrhage that occurs at the time of attempted manual placental separation. Part or the entire placenta remains strongly adherent to the uterine cavity, and no plane of separation can be developed. The severe uterine hemorrhage may lead to the need of extensive life-saving surgical interventions
A lot of morbidities can be detected in women diagnosed with placenta accreta, bleeding is still considered as the most common complication of placenta accreta, other complications may be kept in mind like sepsis, wound complication, blood transfusion and the need of admission in ICU.
One of the most serious complications of management of placenta accreta is injury to adjacent organs; urinary bladder, ureters and bowl .which requires multidisciplinary team approach.
The aim of this study is to compare between the two approaches of management of placenta accreta; hysterectomy and conservative surgery as regard maternal morbidities and mortalities.
The data were collected from the records of Ain shams maternal hospital through the period of 2011 to 2016 and from July 2016 to January 2017and the results showed the followings:
• Pre-operative data:-
1. Patients were treated with hysterectomy was older (mean age was 33.07 years) than patients underwent conservative surgery (mean age 30.83 years).
2. With increasing the number of previous CS, increasing the possibility of placenta accreta occurrence.
3. Placenta accreta incidence increasing with increasing numbers of previous D&C (98 cases has more than one D&C operations).
4. 9 cases had previous placenta accreta in past pregnancies 2 of them treated with conservative surgery while 7 treated by hysterectomy.
5. As regard patient’s past history 420 cases had previous CS, 10 cases had hystrotomy,8 had hysterscopic surgery, 4 cases with previous uterine rupture , 4 cases suffer from surgical site complication post CS and 28 cases with previous laparotomy.
6. There was 1 case of uterine rupture and 1 case of tender scar which were treated by hysterectomy.
• Intra operative data:-
1. Increased blood loss in hysterectomy (mean 2708 ±1881 ml) than in conservative surgery (mean 1452 ±1065 ml).
2. Operative duration was longer during hysterectomy than during conservative surgery, the mean/ hour was (3.15±0.8) and (2.2 ±0.76) respectively.
3. Patients underwent hysterectomy were more liable to suffer from adjacent organ injury ex: urinary bladder (60 case), ureters (13 cases), bowl (5 cases) or more than one organ at the same time; than conservatively managed patients (20 cases), (5 cases), (2 cases) respectively.
• Post-operative data:-
1. Hysterectomy patients were admitted in the hospital (max 43 days) longer than patients of conversation (max 30 days).
2. Also hysterectomy patients needed more ICU admission (100 cases with hysterectomy with mean of 2.17±2.43 days compared to 58 cases with conservative surgery with mean of 1.44 ±0.8 days).
3. Wound complication more likely to occur with hysterectomy (28 cases) than conservative surgery (11 cases).
4. Conservative management failed with 131 patients. They needed to have hysterectomy, failure was either due to failed suturing or severe bleeding which cannot be controlled.
5. 1 patient was diagnosed with DVT after conservative surgery.
6. One patient died after hysterectomy due to massive bleeding, DIC and brain edema.
7. NICU admission was higher in cases treated by hysterectomy 60 neonates compared to 18 neonates in conservatively managed cases.