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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 2  |  Page : 480-486

Menoufia University Hospital experience in management of the patients with morbidly adherent placenta


1 Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Obstetrics and Gynecology, Basyun Central Hospital, Gharbia, Egypt

Date of Submission16-Aug-2019
Date of Decision25-Sep-2019
Date of Acceptance29-Sep-2019
Date of Web Publication27-Jun-2020

Correspondence Address:
Hoda I Assaf
Department of Obstetrics and Gynecology, Ministry of Health, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_249_19

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  Abstract 

Objective
To determine the outcome of management of placenta accreta when the policy of hysterectomy was adopted without attempt of manual separation of placenta.
Background
Placenta accreta occurs when the chorionic villi invade the myometrium abnormally. The incidence of placenta accreta has been steadily increasing, attributed to the increasing prevalence of cesarean delivery in recent years.
Patients and methods
A retrospective randomized study was conducted on 70 cases of morbidly adherent placenta accreta attending the Obstetrics and Gynecology Outpatient Clinic at Menoufia Teaching Hospital over a 4-year interval, during the period between January 2015 and December 2018.
Results
The incidence of placenta accreta was 1.67% of cesarean deliveries. The ultrasonography was suggestive of morbid adherent in only 32 (45.7%) cases. ICU admission occurred in eight (11.4%) cases. Two (2.8%) patients had wound infection. One (1.4%) case needed reoperation. Postpartum pyrexia occurred in one (1.4%) case. Median duration of hospital stay was 5 days (range, 3–35 days). The mean gestational age at delivery was 36.87 weeks (range, 32–39 weeks), and 11 (15.7%) infants were admitted to neonatal ICU.
Conclusion
Placenta accreta is highly associated with placenta previa, especially in cases with previous cesarean section. When placenta accreta is diagnosed or suspected antenatally, the patient must be referred to tertiary center. Generally, the recommended management is cesarean hysterectomy with placenta left in situ after bilateral clamping of uterine artery below insertion of placenta with blunt dissection of urinary bladder from lateral to medial.

Keywords: hysterectomy, intensive care unit, management, morbidly adherent placenta, neonatal outcome


How to cite this article:
Abdel Khalek ME, Elhalaby AE, Elkhouly NI, Anter ME, Assaf HI. Menoufia University Hospital experience in management of the patients with morbidly adherent placenta. Menoufia Med J 2020;33:480-6

How to cite this URL:
Abdel Khalek ME, Elhalaby AE, Elkhouly NI, Anter ME, Assaf HI. Menoufia University Hospital experience in management of the patients with morbidly adherent placenta. Menoufia Med J [serial online] 2020 [cited 2020 Jul 13];33:480-6. Available from: http://www.mmj.eg.net/text.asp?2020/33/2/480/287765




  Introduction Top


Placenta accreta is an abnormal condition in which all or part of the placenta is attaching, invading, and/or penetrating the myometrium or adjacent organs, which obstructs its correct separation at delivery; consequently, it leads to massive maternal hemorrhage and threatens maternal and neonatal lives[1]. Depending on the depth of invasion, it is further defined as placenta accreta, increta, and percreta. Accreta is an umbrella term most commonly used to refer to all these conditions[2]. The most important risk factor for placenta accreta is placenta previa after a prior cesarean delivery. Other risk factors for placenta accreta include uterine instrumentation, intrauterine scarring, smoking, maternal age over 35 years, grand multiparty, and recurrent miscarriage[3]. Patients who are at risk should be identified by ultrasound examination and the characteristic findings searched for. In the first trimester, these include a low-lying sac that appears to be attached to the anterior wall of the uterus, and in the third trimester, appearance of placenta lacunae, interruption or bulging of bladder line, loss of clear space between the placenta and myometrium, and thinning of myometrium[4]. Color Doppler will show that some of the placental sinuses traverse the uterine wall. MRI is used to complement rather than replace the information obtained via sonographic imaging. The main advantage is to diagnose the placenta percreta and its invasion to the bladder[4]. The first clinical manifestation of placenta accreta is usually profuse, life-threatening hemorrhage that occurs at the time of attempted manual placental separation. Poorly controlled hemorrhage related to placenta accreta, increta, and percreta is the indication for one- to two-thirds of peripartum hysterectomies, disseminated intravascular coagulopathy, adult respiratory distress syndrome, renal failure, unplanned surgery, and death[5]. Generally, the recommended management of suspected placenta accreta is planned preterm cesarean hysterectomy with the placenta left in situ, because removal of the placenta is associated with significant hemorrhagic morbidity. Women who have a strong desire for future fertility, uterine-sparing approaches may be used, such as methotrexate, local resection of placental implantation site, systematic pelvic revascularization, uterine tamponade, and interventional radiology with internal iliac artery ligation, but these approaches may be complicated by sepsis and hemorrhage, and hysterectomy can become necessary[6]. The aim of this study was to determine the outcome of management of placenta accreta when the policy of hysterectomy was adopted without attempt of manual separation of placenta at Menoufia Teaching Hospital.


  Patients and Methods Top


A retrospective randomized study was conducted on 70 cases of morbidly adherent placenta accreta that attended the Obstetrics and Gynecology Outpatient Clinic at Menoufia Teaching Hospital over a 4-year interval, during the period between January 2015 and December 2018.

Ethical consideration

All participants were volunteers. All of them signed a written informed consent and were explained the aim of the study before the study initiation. Approval was obtained from ethical committee in Faculty of Medicine, Menoufia University.

Inclusion criteria

Patients were diagnosed as having placenta previa with gestational age (GA) above 28 weeks with ultrasound signs suggestive of placenta accreta (vascular lacunae, myometrial thinning, and loss of the retroplacental 'clear space' and interruption of bladder line owing to placental bulge)[7].

Patients fulfilling the following two criteria were referred to a specialist MAP clinic for further assessment: first, history of uterine surgery, including cesarean section (CS) or myomectomy that involved opening of the uterine cavity, and second, low-lying placenta, defined as the edge reaching to within 2 cm from the internal cervical os in the case of anterior placenta and reaching or covering the internal cervical os in the case of posterior placenta.

Exclusion criteria

Patients with GA below 28 weeks were excluded, and all those with normally sited placenta were excluded.

Technique of management

Preoperative management, history taking [age, gravidity, parity, number of previous CS, GA at diagnosis and at the time of delivery, and antepartum hemorrhage (APH)], examination (general, abdominal), full investigation (complete blood count, kidney function test, and coagulation profile), and Doppler ultrasound to confirm diagnosis (color Doppler show that some of the placental sinuses traverse the uterine wall) were done. The women were informed of the diagnosis and potential complication (maternal hemorrhage, renal failure, infection, death). Consent of CS hysterectomy was obtained. The women were evaluated before the delivery by the urology and vascular surgeon. Preoperative anesthetic consultation was done. Adequate blood and blood products were available at the time of delivery, and ICU was available for the patient, if needed.

Intraoperative management

Regarding skin incision, the use of a midline vertical incision was preferred, as it provides sufficient exposure if hysterectomy becomes necessary. Sharp entry through the skin into subcutaneous fat and rectus sheath at midline followed by blunt extension laterally was done. It is advisable to avoid Blunt entry to peritoneal cavity to avoid bladder and intestinal injury. Vertical uterine incision above the edge of placenta was done, and delivery of the baby was performed.

While waiting for spontaneous delivery of the placenta, if it is delivered completely or partially (focal), preservation of the uterus is through ligation of uterine artery in both side, multiple compression suture if needed, excision of the lower segment if needed, and closure of uterine incision.

If the placenta is not separated spontaneously, closure of uterine incision is done and proceeded to hysterectomy after bilateral clamping of uterine artery below the insertion of the placenta after blunt dissection of the bladder from lateral to medial without attempt to remove the placenta.

Postoperative management

It included close observation, vital data (blood pressure, pulse, temperature, urine output, respiratory rate), examination of abdomen for distention and rigidity and if the uterus was preserved, assessment of its tone, observation of vaginal bleeding, blood transfusion if needed, and ICU admission if needed.

Outcome variables

These include demographic data; maternal outcome including maternal mortality and maternal morbidity, which included urological injuries (bladder, bladder and ureter, or no involvement); amount of blood transfusion; whether the patient needs whole blood or packed red blood cells or fresh frozen plasma or platelet or no need, and if needed, transfused preoperatively, intraoperatively, or postoperatively; predelivery and postdelivery hospitalization; ICU admission; and colonic injuries.

Neonatal outcome

It included neonatal sex, neonatal intensive care admission, and neonatal mortality, in addition to booked or not booked, correct antenatal diagnosis, and identified risk factor (number of previous CS, delivery, and uterine instrumentation).

Statistical analysis

Results were analyzed and tabulated using Microsoft Excel, version 7 (Microsoft Corporation, New York, New York, USA) and statistical package for the social sciences, version 16 (SPSS Inc., Chicago, Illinois, USA). Descriptive of statistics were done, for example, percentage, mean, median, and SD. χ2 test was used to compare the two variables. P value less than or equal to 0.05 considered a significant.


  Results Top


In the current study, of the included 70 women with morbidly adherent placenta previa, 39 (55.7%) presented with APH and only 32 (45.7%) cases were suggestive of morbid adherent placenta by the ultrasonography. All cases needed blood transfusion. Uterine-preserving procedures included in 26 (37.1%) cases, and all of them were by uterine artery ligation; 15 (21.4%) of them with resection of lower uterine segment and 11 (15.7%) cases of them with compression suture. Cesarean hysterectomy was performed in 44 (62.9%) cases, and one of them was accompanied by internal iliac artery ligation. Moreover, eight (11.4%) cases were admitted to ICU, two patients had wound infection, one cases needed reoperation, and postpartum pyrexia occurred in one (1.4%) case. The mean GA at delivery was 36.87 weeks (range, 32–39 weeks). Eleven (15.7%) infants were admitted to neonatal ICU, and the mean age of the included women with morbidly adherent placenta was 30.11 ± 3.54 years (range, 24–38 years). The mean GA at delivery was 36.31 ± 1.97 weeks of gestation (range, 32–39 weeks of gestation) [Table 1].
Table 1: Incidence of morbidly adherent placenta previa cases in relation to total number of cesarean deliveries and placenta previa as well as demographic data

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Additionally, all the included cases had at least one previous CS, except for only one case that was primigravida. Of the included 70 women with morbidly adherent placenta previa, 39 (55.7%) presented with APH. Antenatal ultrasonography was suggestive of placenta accreta in only 32 cases (resulting in a false-negative rate of 54.3%). Of the included 70 women with morbidly adherent placenta, 28 (40%) cases were with anterior placenta and 42 (60%) with complete centralis placenta [Table 2].
Table 2: Risk factors, antepartum hemorrhage, antenatal ultrasonography, and placental localization in women with morbidly - adherent placenta previa

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Furthermore, intraoperatively, hysterectomy was performed in 44 (62.9%) cases; two (2.9%) were tried with conservation first but ended up in hysterectomy: one of them during the same session, whereas the other via second laparotomy. Conservative management was performed in 26 (37.1%) cases: 11 (15.7%) cases by compression suture and bilateral uterine artery ligation and 15 (21.4%) cases by resection of lower uterine segment and bilateral uterine artery ligation [Table 3].
Table 3: Operative technique and intraoperative complication, and surgical management in women with morbidly - a adherent placenta previa

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Moreover, of the included 70 women, six (11.6%) were admitted to ICU postoperatively, only one (1.4%) patient was reoperated because of severe postpartum hemorrhage ended by hysterectomy after trial of conservative management, two (2.8%) cases developed wound infection, and only one (1.4%) case developed postpartum pyrexia. No maternal death occurred. The median hospital stay was 5 days (range, 3–35 days). Complications were more common in hysterectomy group, with the most significant being bladder injury and postoperative ICU admission; thus, there was longer hospital stay, as in this group, placenta was invasive. Of the included 44 (62.9%) neonates, 34 (48.6%) were males, whereas 36 (51.4%) were females [Table 4].
Table 4: Postoperative complication and neonatal outcome in women with morbidly adherent placenta previa

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  Discussion Top


In the current study, over a 4-years period, there were 4188 cesarean deliveries and 70 cases diagnosed as having placenta accreta. The incidence of placenta accreta was 1.67% of cesarean deliveries. The incidence of placenta accreta at Menoufia University Hospital is increased owing to increase the rate of cesarean delivery, as there were 0.76, 1.4, 1.86, and 2.2% in 2015, 2016, 2017, and 2018, respectively. Although, until recently, placenta accreta was considered a rare event, its annual incidence appears to be increasing[8]. In 1994, the incidence of placenta accreta for the previous 10 years was reported to be one in 2510 cases, whereas a study in 2002 reported an incidence of one in 533 cases for the previous 20 years and the incidence in 2006 was one in 210 cases. This alarming increase appears to be directly related to the rising rates of cesarean delivery, which is a major risk factor for placenta accreta[9]. According to the current study, the rate of placenta accreta appears to be rising over the 4-year period, as there were 11, 15, 20, and 24 cases in 2015, 2016, 2017, and 2018, respectively. During the 3-year period of the retrospective study done by Kong et al.[10], which was conducted at two tertiary referral hospitals in China in the period from 2011 to 2015, the total number of CS was 14 529. Forty-seven patients were diagnosed with placenta accreta, and the incidence of placenta accreta was 1/667. These highly significant differences between the current study and this study could be explained by the great difference between the study populations, with high order parity rather than high order section being quite low in the Chinese population due to local national legislation.

In our study, all the included cases had at least one previous CS, except for only one case that was primigravida. Of the remaining 69 patients, the number of patients with placenta previa and a history of one, two, three, and four CS delivery were 72 923 and 10 cases, respectively. In the current study, the mean age of included women with morbidly adherent placenta was 30.11 years (range, 24–38 years) with no significant difference with the mean maternal age of 32.9 years reported by Morlando et al.[3]. A study done by Chen et al.[11] done on 16 cases, age at hospitalization ranged from 25 to 35 years, and cesarean delivery was performed between 32 and 38 weeks of pregnancy. All cesarean deliveries were elective. Bleeding was markedly reduced in the operative field and the mean estimated blood loss was 1550 ml (range, 1000–2500 ml). This result is in agreement with the current study, as the age of included women with morbidly adherent placenta ranged from 24 to 38 years, and cesarean delivery was performed between 32 and 39 weeks of pregnancy. The results of the current study confirm that old age, multiparty, placenta previa, and previous uterine operations, for example, CS, dilation, and curettage, are important risk factors for placenta accreta and support the reports from previous literature[12],[13]. In this study, 39 (55.7%) of patients with morbidly adherent placenta presented with APH, with no difference in comparison with the results of Pri-Paz et al.[14] in which 54.16% patients with placenta accreta had antepartum hemorrhage. According to the current study, the antenatal ultrasonography was suggestive of morbid adherence in only 26 cases (resulting in a false-negative rate of 53.6% and a sensitivity of 46.4%). Although there still appears to be a difference of opinion in the literature regarding the accuracy of ultrasound for the diagnosis of placenta accreta, the current sensitivity of 46.4% unfortunately does not support several previous reports, with exception of the study by Lame et al.[15], which reported sensitivity of 33%, and all other studies reported sensitivities of 77–93%[16],[17],[18].

In the present study, all cases received packed red bold cells and fresh frozen plasma. Only one (1.4%) women received platelet transfusion. The present findings are similar to other reported rates of transfusion. For example, a more recent study, which analyzed 99 placenta accreta cases, found that ∼75% required blood transfusion, with a mean of 5.4 ± 2.1 U of red bold cells[19]. Thus, blood transfusion should be anticipated, and massive transfusion is not rare in these obstetric patients. In the current study, 17 (24.3%) cases had bladder injury. In another study by Pri-Paz et al.[14] there were 45.8% (22/48) of cases with bladder injury. These differences are owing to lateral dissection of bladder from lateral to medial at Menoufia Hospital. Matsuzaki et al.[20] concluded that urologic complication occurs in ∼72% of cesarean hysterectomies during placenta accreta cases. These urologic complications include bladder lacerations (44%, 24/54), urethral resection (6%), and other injuries. In comparison with the present study, there was a difference in cases of bladder injuries, as there were 29.5% of cases (13/44). However, there was no difference in ureteric injuries, which represent 9% of the cesarean hysterectomies' cases. Our study showed that eight of the 70 (11.4%) patients were admitted to the ICU postoperative care. This proportion shows difference when compared with the results of Eller et al.[21] and highly significant difference when compared with the results of Pri-Paz et al.[14]. This difference between studies could be explained by demographic factors of the patients and higher proportion of patients receiving massive blood transfusion.

In current study, 44 (62.9%) cases underwent CS hysterectomy: five of them in 2015, eight of them in 2016, 15 of them in 2017, and 20 of them in 2108. Although conservative management has lower morbidities than hysterectomy during management of placenta accreta, it may fail and severe bleeding can occur which can be uncontrollable, and the procedure will end up in hysterectomy to save patient's life. de Marcillac et al.[22] reported that it happened in four (33.3%) of their patients. In current study, two patients had CS hysterectomy after failure of conservative measures: one of them during the same session after bilateral internal iliac artery ligation, whereas the other via second laparotomy. In the present study, during the postpartum period, two (2.8%) patients had surgical site infection and required secondary suture. The study was done by Vinograd et al.[23], who reported that 0.4% of patient with morbidly adherent placenta had surgical wound infection. The difference may be attributed to maneuvers or measures of infection control and other factors affecting wound healing and integrity.

In the present study, the mean GA at delivery was 36.87 weeks (range, 32–39 weeks' gestation). Nasrullah et al.[24] reported that the sex ratio associated with placenta accreta favors females. In the present study, of the included 70 neonates, 34 (48.5%) were males, whereas 36 (51.4%) were females. In the present study, 11 (15.7%) infants were admitted to the neonatal ICU. In comparison with a retrospective study done by Asicioglu et al.[25] at two tertiary hospitals in Istanbul to investigate patient characteristics and fetal and maternal outcomes of placenta previa and accreta in the 5-year period from 2005 to 2010, the perinatal outcomes for 46 patients who had placenta accreta were as follows: 19.5% neonatal ICU admission and 4.3% neonatal mortality.

Neonatal outcome in the current study was uniformly good. Maternal mortality has been reported in up to 7% of cases[26]. No maternal death was recorded in Gharib et al.[27] and Angstmann et al.[28]. In the current study, there is no maternal death because of better care in our hospital. From the aforementioned results, it can be concluded that the incidence, risk factors, and feto-maternal outcome of management of patients with placenta accreta at Menoufia University Hospital are comparable with those in the previous literature.


  Conclusion Top


Placenta accreta is highly associated with placenta previa, especially in cases with previous CS. When placenta accreta is diagnosed or suspected antenatally, the patient must be referred to tertiary center. Generally, the recommended management is cesarean hysterectomy with placenta left in situ after bilateral clamping of uterine artery below insertion of placenta with blunt dissection of urinary bladder from lateral to medial.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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