الفهرس 
The Placenta & The Morbidly Adherent PlacentaOnly 14 pages are availabe for public view
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Abstract
Morbidly adherent placenta (MAP) is now a significant obstetric challenge results in
significant maternal morbidity and mortality (it is responsible for 7-10% of maternal
mortality). The incidence of MAP have increased over the past few decades, this is mainly because
of the increasing caesarean delivery rate. Risk factors for MAP include placenta previa, cesarean
delivery, high maternal age and high parity.
Optimal management of MAP involves early recognition of high risk women based on clinical risk
factors, accurate preoperative diagnosis, detailed maternal counselling and meticulous planning at
the time of delivery. Although management of MAP depends on extent of the problem, literature
favours use of conservative treatment as it can help to avoid caesarean Hysterectomy and
involves a decreased rate of severe maternal morbidity in well- resourced centres. Inappropriate
management can comprise the maternal outcome resulting in many complications such as sepsis, septic
shock, peritonitis, uterine necrosis, fistula, injury to adjacent organs, acute pulmonary edema,
acute renal failure, deep vein thrombophlebitis or pulmonary embolism, or death due to
postpartum hemorrhage or myelosuppression and
nephrotoxicity.
This is a retrospective study which was carried out in Ain Shams University Maternity Hospital (a
major tertiary referral hospital in Egypt) during the period from January 2012 to December 2017 (6
years), the archives of the hospital were examined for hospital records fulfilling the criteria of
the study population during the study period. The objectives of this study were to evaluate the
incidence, risk factors, and outcomes of management modalities of patients with morbidly adherent
placenta. During the studied period, there were a total of
71121 deliveries in this hospital (36264 ”51.0%” were vaginal and 34857 ”49.0%” were by
caesarean section).
The results are summarized as follows:
The results revealed that morbidly adherent placenta was recorded during the
studied period in 467 cases with an incidence of 6.6/1000 deliveries (0.66%). Also,
cases with placenta accreta were 379 (81.2%) of the total MAP cases (the incidence
of placenta accrete was 5.36/1000 of the total deliveries).
The mean age of MAP patients was 31.7 ± 4.8 year. Regarding parity, only 9
cases were Primiparous, about half of them (226 cases, 48.4%) were P3:P4, 170
cases (36.4%) were P1:P, 62 cases 13.3% were grand MP (>5). The majority of
MAP cases (458 cases, 98.1%) had previous caesarean section (about two thirds of
them 264 cases, 56.5% had 2-3 CSs). These results revealed that increasing
maternal age, high parity, placenta previa and previous caesarean section were
significant risk for MAP.
Out of the 467 MAP patients, 212 cases (45.4%) were managed by hysterectomy
and the other 255 cases (54.6%) were managed conservatively.
The present results showed that anterior placental localization was strongly
correlated with MAP (354 cases, 75.8%).
Patients showing US findings suggestive of invasion were more likely to undergo
caesarean hysterectomy. Also, MRI grading of myometrial invasion was also highly
correlated with caesarean hysterectomy.
Of the total 467 included cases, 351 cases (75.2%) had elective CSs and 116 cases
had emergent CSs. The mean pre-operative Hb was 10.64 ± 0.95 and decreased
postoperative to 8.76 ± 1.19 however, the mean pre-operative Ht was 32.3 ± 2.6 and
decreased postoperative to 25.7 ± 3.8. The mean operative time was 2.47 ± 0.82 hrs.All patients received general anaesthesia and were operated upon by senior
consultants. 317 cases had lower segment uterine incision however, 150 cases had
upper segment uterine incision.
The present results demonstrated that 409 patients (87.6%) received blood product
transfusion with a mean of 8.74 ± 2.57 units and the mean estimated blood loss was
1978 ± 255 ml.
In the current study, 71 cases (15.2%) had bladder injury and 16 cases had uteric
injury, 27 cases (5.7%) were complicated with disseminated intravascular
coagulation and 31 cases (6.6%) were complicated by surgical site infection (SSI).
Regarding mortality, the present results showed that only one case (0.21%) was
recorded (it had DIC after massive blood loss) with a mortality rate of 2/1000. This
rate is obviously lower than that was reported in the literature.
About half of the cases were admitted to ICU (222, 47.5%) with a mean duration
of 1.67 ± 1.59 day. The mean of hospital admission duration was 7.7 ± 4.1 days.
Regarding the results of the perinatal outcomes for MAP, a total of 118 cases
(24.8%) had NICU admission, the healthy neonate were 381 (80.0%), intrauterine
fetal demise (IUFD) was recorded in 58 neonates (12.2%) and 35 neonates died
with a mortality rate of (7.4%).
The present results revealed that complications were more common in
hysterectomy group in general, CS hysterectomy had significantly lower
postoperative Hb and HCT compared to conservative management group (P≤ 0.01).
Also, CS hysterectomy group had significantly longer operative time and higher
amount of blood loss (P≤ 0.01).
Bladder injury and surgical site infection were more common in CS hysterectomy
group. In addition, CS hysterectomy group had significantly higher number of
patients admitted to ICU, with higher duration of hospital stay and ICU admission duration (P≤ 0.01). There was one CS hysterectomy case of maternal mortality
(0.5%) that had DIC after massive blood loss.
In this study, emergency CSs group had higher number of cases who managed by
CS hysterectomy (65 cases, 56.1%), however, about two thirds of cases of elective
CS group (204 cases, 58.1%) were managed conservatively.
Our results revealed that there was a significant reduction if postoperative
haematocrit in elective cases compared to emergency ones. The association of
marginally greater than blood loss with emergency cases would imply more
aggressive intra-operative replacement, thus a greater post-operative haematocrit.
Emergency CSs group had significantly higher number of cases with uterine
artery injury (18 cases, 15.5%). Also, DIC was significantly more presented in
emergency CSs group compared to elective one (12.1% vs. 1.7%), however, in
contrary, surgical site infection was more found in elective CSs group compared to
emergency CSs group (10.8% vs. 3.1%)
The incidence of MAP was 6.6/1000 deliveries (0.66%), this incidence was
obviously higher than that of previous studies and this may be attributed to the
rising CS delivery rates (49.0% in our study).
Maternal mortality rate associated with MAP was 2/1000 (0.21%) which is
obviously lower than that was reported in the literature.
The results revealed that increasing maternal age, high parity, placenta previa and
previous caesarean section were significant risk factors for MAP. Thus, planned
delivery and intervention are mandatory for women with these risk factors.
Caesarean hysterectomy was associated with higher maternal morbidity compared
to conservative management.
Early antenatal diagnosis of morbidly adherent placenta through imaging
(ultrasound colour Doppler and MRI) allows for multidisciplinary planning in an attempt to minimize potential maternal or neonatal morbidity and mortality. Also,
proper counselling of patients regarding associated risks reduce maternal morbidity
and mortality.
This study has some limitations, of these, the limitations related to the
retrospective study nature such as missed data from the hospital archives or records.
Also, a limitation of the availability of specific diagnostic modality for specific
cases.