Assessment of different management options used in morbidly adherent placenta and pregnancy outcomes

Corresponding author: Waleed Tawfik, Lecturer of Obstetrics and Gynecology, Faculty of Medicine, Benha University, Benha, Egypt. Received Date: March 29, 2020; Accepted Date: April 04, 2020; Published Date: April 10, 2020. Citation: Waleed Tawfik(2020) Assessment of different management options used in morbidly adherent placenta and pregnancy outcomes. J Women Health Care and Issues, 3(2): Doi: 10.31579/ 2642-9756/026

The total number of morbidly adherent placenta previa cases admitted to Hospitals per month about 7 cases, so all admitted cases during the period of the study were included equal 42 cases. Each woman was subjected to the following: Examination: A. General examination: B.
Abdominal examination: Laboratory investigations:  A blood sample was withdrawn to check for complete blood count, coagulation profile, liver function tests, renal function tests and random blood sugar.  A urine sample was taken to check for proteinuria, hematuria and presence of urinary tract infection.  Blood group, cross matching for blood and plasma before operation

Ultrasound:
Ultrasound was performed for each patient to confirm viability, gestational age, fetal biometry, fetal presentation, amount of liquor and detailed assessment of placental site, degree of adherence by 2D ultrasound and Doppler Sonographic features of morbidly adherent placenta by 2D ultrasound: 1) Retroplacental sonolucent zone deficiency; 2) The lacunae vascular.

5) Exophytic masses present.
Characteristic findings on color Doppler ultrasound include: (1) A diffuse lacunar flow pattern with high-velocity pulsatile venous type flow (peak systolic velocity more than 15cm/s) spread throughout the placenta, myometrium and cervix.
(2) A central lacunar flow pattern with turbulent flow distributed regionally or focally in the parenchyma.
(3) Bladder-uterine serosal interphase hyper vascularity. (4) Markedly dilated vessels over the peripheral sub placental zone. Counselling about the desire for future fertility.

Consenting:
An informed written consent about different management options that may reach to hysterectomy was taken from all patients and their husbands and about the need to blood and blood products during the operation and risk of mortality. After discharge the patients returned to outpatient clinic to remove stitches and their wounds were examined for infection.

Estimation of blood loss:
Real blood loss (ABL) was estimated from a gross formula modification (

Discussion
.Although, until recently, Morbidly attached placenta has been considered a relatively rare occurrence, its annual incidence seems to be rising. In 1994, the incidence of morbidly adherent placenta over the previous 10 years was estimated to be 1 in 2510 cases, while a 2002 study recorded an incidence of 1 in 533 cases over the preceding 20 years and an incidence of 1 in 210 cases in 2006 (8,9).
In the current study 42 cases diagnosed prenatal as morbidly adherent placenta, In 20(47.6%) women hysterectomy was done without trial of placenta removal, In 22(52.4%) women trial of placental removal was done preceded by uterine massage and uterotonics and followed by conservatives procedures to control bleeding from the placental bed. Due to absence of management protocol for morbidly adherent placenta in our emergency hospital, so hysterectomy without attempt placental removal or trial placental removal followed by conservatives procedures was left to the experience of the senior obstetrician operating the patient. Generally speaking, trial placental removal was performed in many cases mainly due to low parity of many patients and their desire for future fertility and prenatal U/S (greyscale and Doppler) not has 100% accuracy for diagnosis morbidly adherent placenta. Intraoperative findings of percreta and high vascularity of the lower uterine segment are the main two factors that forced the obstetrician to perform hysterectomy from the start without attempt of placental removal. In a study by Deeba F.N et al., (2016) they reported the following incidences of abnormal placentation by U/S: placenta accreta in 16 (69.6%) women, placenta increta in 3 (13%) women and placenta percreta in 4 (17.4%) women. In the present study the incidences of abnormal placentation: placenta accreta 64.28% (24 cases); placenta increta 23.8% (10 cases) and placenta percreta 11.9% (5 cases). (10,11) In the current study 20 (47.61%) cases presented with antepartum hemorrhage (APH), 14 (33.3%) women had urgent surgery due to antepartum hemorrhage or uterine contraction In our study population there was no significant difference (P: 0.64) between elective and urgent surgery as regard blood loss, also Biler A, et al., 2016 reported in their study that no observed significant differences between patients underwent elective and emergency surgery as regard blood loss . (12) In the current study midline incision was done in 31% cases and pfannenstiel incision was done in 69% women Intraoperatively trial placental removal plus conservative procedures were performed in 22(52.4%) cases that succeeded in 13 (59%) women who had CS only, failed in 9 (40.9%) women who had hysterectomy, while hysterectomy was done in 20(47.6%) women with placenta lift in situ without attempts of placental removal, While Biler A, et al. 2016 (12) in their study reported that 11(22%) women had hysterectomy without removal of the placenta, while 38 (78%) Women have been guided conservatively. After delivery in all these cases the placenta was removed. Uterine compression sutures, bilateral uterine artery ligation, bilateral hypogastric artery ligation were used according to the degree of bleeding, and two or more techniques were performed if needed. Because of hemodynamic instability, 8 (21%) patients were hysterectomized during the cesarean section,while in a study by Deeba F.N et al., (2016) they reported that majority of patients 17(74%) underwent caesarean hysterectomy without trial removal of the placenta, Placental removal was performed in 6 (26%) patients all having focal adherence of placenta (11). Uterine preserving procedures were performed and succeeded in 13(31%) cases, bilateral uterine artery ligation in 13  were females. Therefore, the conclusion of the present research is contradictory to that of the previous literature.
prospective population-based architecture is a major strength of our research, not depending on regularly coded data to determine cases. There were some drawbacks to the prospective analysis. The sample size was inadequate to distinguish variations in complications with different management approaches, regulation of bleeding differentiated in each case, management decisions were taken at the discretion of the case

Conclusion:
In conclusion, up till now there is not completely sensitive and specific test for the diagnosis of MAP, when morbidly adherent placenta is diagnosed or suspected antenatally, delivery should be scheduled in a tertiary care center with appropriate expertise and facilities. Generally, the recommended management is cesarean hysterectomy. However, this approach might not be considered the first line of treatment in women who have a strong desire for future fertility. Therefore, surgical management of morbidly adherent placenta may be individualized, available quantity of blood products and multidisciplinary approach may reduce maternal morbidity and mortality in these patients, Good anticipation and timely decision is the key to success in this lifethreatening condition.

Recommendations:
The recommended management for morbidly adherent placenta is hysterectomy without attempt placental removal especially if there are signs of placental invasion, but in nulliparous women we recommended conservative measures to safe the uterus and no hurry for hysterectomy to give the chance for placental separation.