A prospective study of 20 cases of maternal outcome in morbidly adherent placenta in tertiary care hospital

Background: Morbidly adherent placenta with its variants is one of the most feared complication causing high morbidity and mortality in obstetrics. Aim of this study is to help in identifying high risk pregnancies, planning line of management of morbidly adherent placenta. The objective of the study wad to evaluate the risk factors, different modes of management, maternal outcome in case of morbidly adherent placenta.Methods: A prospective study for one year was done to describe the incidence, causes, treatment, complications, and maternal morbidity and mortality associated with morbidly adherent placenta.Results: A total of 20 cases of morbidly adherent placenta were studied over one-year span at our Institute. Most of the women with morbidly adherent placenta were in the age group of 26-30years (55%).The most common aetiology of morbidly adherent placenta was previous caesarean scar with placenta praevia (85%). In majority, placenta accreta found. Total abdominal hysterectomy done in 12 patient and subtotal hysterectomy in 6 cases. Trial haemostasis with uterine sparing in 2 cases out of which one case underwent total hysterectomy due to massive haemorrhage on same day. Associated Bladder repair in adherent placenta with invasion of bladder was needed in 10% cases. There was 1 maternal death noted in this study.Conclusions: Leading cause of morbidly adherent placenta is previous caesarean section with placenta praevia, high index of suspicion, early antenatal diagnosis, planned surgery at high care centre with multi-disciplinary expertise, anticipation of blood volume transfusion, Delivery of foetus without manipulating placenta are key steps to reduce morbidity and mortality in morbidly adherent placenta. The decision to perform hysterectomy and conservative management to be individualized. Timely decision is the key to get success in morbidly adherent placenta as in other obstetric emergencies

Predictive values of ultrasound-based scoring system in morbidly adherent placenta for high risk group

Background: The objective of the present study was to find out the predictive values of an ultrasound-based scoring system in diagnosis of morbidly adherent placenta (MAP) for high risk group. Obstetrics and Gynecology Department, Faculty of Medicine, South Valley University, Egypt.Methods: 63 full term pregnant women (≥37 weeks of gestation) with high risk of morbidly adherent placenta underwent elective cesarean section. Placental assessment by 2 D ultrasound based on ultrasound scoring system in morbidly adherent placenta, these data were recorded for further comparison with intraoperative data for degree of placental adherence.Results: Incidence of MAP was 7.93% (4.76% had a focal form and 3.17% had a complete form of accreta). As regarding to scoring system, 82.5 of cases had a low risk (< 5), 9.5% had a moderate risk (6-7) and 7.93% had a high risk (8-12) of development of morbidly adherent placenta with p value <0.0001. The sensitivity, specificity, positive and negative predictive values of the US scoring system for morbidly adherent placenta were (92.3%, 94.1%, 87.453% and 98.2%) respectively.Conclusions: Ultrasound based scoring system had a high predictive value (sensitivity, specificity, positive and negative predictive values) in diagnosis of morbidly adherent placenta for pregnant women have any risk factors for developing MAP

Morbidly adherent placenta: management is real challenge

Background: The objective of the present study was to describe management of morbidly adherent placenta with placenta previa and feto-maternal outcome.Methods: All antenatal USG diagnosed cases of morbidly adherent placenta were analyzed. The cases were managed by elective caesarean hysterectomy and non-separation of placenta at delivery. Amount of blood loss, blood transfused, ICU admission, postnatal complications and hospital stay was recorded.Results: From January 2010 to October 2018, 22 cases of morbidly adherent placenta were diagnosed on gray scale and color Doppler during antenatal ultrasound scan. Scheduled caesarean hysterectomy without attempting placental removal was done. Subtotal hysterectomy was performed in 17(77.2%) cases and total hysterectomy in remaining 5(22.8%) cases. All the patients required blood transfusion.  Seven (31.8%) patients had urinary bladder injury. One case developed DIC and One needed ventilatory support. No patient died in this series.Conclusions: Antenatal diagnosed cases of morbidly adherent placenta, avoidance of placental separation and caesarean hysterectomy results in better maternal outcome

Haemorrhage in early pregnancy: unusual presentation of placenta increta as complete mole

We report a case of haemorrhage in early pregnancy following suction evacuation for a complete hydatidiform mole which later turned out to be case of placenta increta. Morbidly adherent placenta in early pregnancy a is rare event. There are few reported cases of obstetric hysterectomy in early pregnancy due to undiagnosed morbidly adherent placenta

A case series on conservative management in pregnancies with abnormal placentation in obstetrics: placenta accrete, increta and percreta

Adherent placenta is one of the important causes of post- partum hemorrhage. Placenta accreta-related pathologies are an increasing contributor to maternal death from hemorrhage. With the rising caesarean delivery rate the incidence of placenta accreta has significantly increased. Morbidly adherent placenta (MAP) occurs when there is a defect in the decidua basalis, resulting in an abnormal invasion of the placenta into the substance of the uterus. A multidisciplinary approach is relevant in managing these patients in order to reduce morbidity and mortality associated with morbidly adherent placenta. A non-surgical conservative method is to leave the placenta in situ to reabsorb and institute treatment with chemotherapeutic agents, such as methotrexate. With improvement in the medical services conservative management for adherent placenta has gained significance

Foeto-Maternal Outcome in Women with Placenta Praevia and Morbidly Adherent Placenta Praevia

Objective: To determine the maternal and foetal outcome in pregnant women with placenta praevia and morbidly adherent placenta praevia Methodology: A prospective case series was carried out in a tertiary care institution between 2019 and 2021. All pregnant women with placenta praevia and placenta accreta spectrum who were over 28 weeks gestation were included, regardless of whether they received their diagnoses during pregnancy or during surgery. Data was collected on structured proforma regarding demographic characteristics, obstetric factors, management options, and intraoperative complications to determine foeto-maternal outcome in women with placenta praevia and morbidly adherent placenta praevia. Results: Total number of patients with placenta praevia was 140; out of which 31 (22.1%) had placenta accreta spectrum. All cases of morbid adherence were found in major degree placenta praevia (p= 0.00). Antepartum haemorrhage in current pregnancy was more associated with placenta praevia as compared to morbidly adherent placenta praevia (p=0.00). Both placenta praevia with and without morbid adherence led to preterm birth (p=0.00). LSCS as mode of delivery in previous pregnancy, step-wise-devascularization, caesarean hysterectomies, bladder injury, blood loss more than 1000ml, number of blood transfusions, and mothers required ICU care were significantly associated (p≤0.05) with morbidly adherent placenta praevia as compare to placenta praevia without morbid adherence. In cases of placenta accreta spectrum; 11(33.3%) babies were admitted in NICU as compare to 29(25.9%) in placenta praevia without placenta accreta spectrum. Conclusion: Placenta praevia is adversely affected by placenta accreta spectrum is associated with higher foeto-maternal morbidity as compared to placenta praevia without adherence

Conservative management options for morbidly adherent placenta

Background: Morbidly adherent placenta is still a very significant cause of obstetric hemorrhage.Methods: A retrospective, descriptive study was undertaken over a period of one and a half year in a tertiary care hospital of all diagnosed cases of morbidly adherent placenta which were managed conservatively and the maternal and perinatal outcomes were noted. Preparation for conservative management of cases of adherent placenta in the antenatal period included informing interventional radiologists and placement of internal iliac balloon catheters just before classical caesarean section. Post-operative methotrexate was used in a few patients.Results: 11 cases of morbidly adherent placenta diagnosed on Doppler ultrasound scan, and confirmed by MRI were identified. All patients underwent classical caesarean section. 9 patients had internal iliac balloon placement. 5 patients received methotrexate. 3 patients required obstetric hysterectomy. 1 maternal and 2 perinatal mortalities were noted.Conclusions: Interventional radiology and methotrexate can be used to avoid peripartum hysterectomy and to optimize maternal and perinatal outcome

Placenta praevia: percreta and accreta, our experience

Background: morbidly adherent placenta has an increasing incidence over decades. The purpose of this study is to identify risk factors and etiology of placenta previa- accreta and percreta.Methods: A cross sectional observational study of patients with morbidly adherent placenta previa including placenta accreta and placenta percreta were studied over a period of three years from June 2017 to June 2019 in a tertiary care centre, Mumbai.Results: Cases showed a higher incidence in patients with previous cesarean delivery (CS), grandmultiparity, abortions without the history of check curettage and anterior/central placentae.Conclusions: History of uterine surgeries and previous cesarean are some important risk factors for accreta in placenta previa patients

Demographic profile and high risk factors in morbidly adherent placenta

Background: Morbidly adherent placenta with its variants is one of the most feared complications causing high morbidity and mortality in obstetrics. The main objectives of the study were to evaluate the demographic profile and risk factors in morbidly adherent placenta.Methods: A retrospective study was done in which case records of 40 patients diagnosed to have morbidly adherent placenta were reviewed. Demographic data including age, parity, gestational age and previous caesarean delivery or other uterine surgery, details of medical and obstetric history were recorded.Results: A total of 24232 deliveries were conducted in the hospital. 40 patients were confirmed to have morbidly adherent placenta. The average age of the patients was 31.8 years and the mean parity was 1.80. 95% percent of the patients were booked in the study centre and only 5% percent were unbooked.  80% of the patients were from the rural area and 20 % from the urban region. The average gestational age of the patient at diagnosis was 35.3 weeks and average gestational age at delivery was 36.2 weeks. The risk factors included previous caesarean section in 32 patients (80%) , with history of  one C.S in 11 patients(27.5%),with two C.S in 19 patients(47.5%), and with history of three C.S in 4 patients (5%). 8 patients (20%) had history of both previous C.S and curettage and none had the history of curettage alone.Conclusion: Morbidly adherent placenta is a potentially life threatening condition. Management of such patients requires early recognition of high risk women based on their clinical risk factors, with accurate preoperative diagnosis, good maternal counselling and planning of delivery

Cesarean scar defects and placental abnormalities – a 3 year survey study

The placenta is an essential organ for embryonic and fetal development, ensuring nutrient uptake, gas exchange (via the mother\u27s blood supply), waste elimination, thermo-regulation, immunological and hormonal factors, etc. The most common placental abnormalities are represented by placenta previa, and a morbidly adherent placenta (in the form of accreta, increta, and percreta placenta). This study was performed on a sample of 99 patients diagnosed with abnormalities of placentation who underwent cesarian delivery during a period of 3 years in Bucur Maternity Hospital. Seven patients were diagnosed with morbidly adherent placenta (5 accreta and 2 percreta subtypes), the others having placenta previa (65 with lateral disposition, 18 marginal, and 9 central insertion). All patients had been diagnosed by ultrasound (which was also used for general monitoring), being confirmed during operation and histopathologically. Complications required 4 emergency peripartum hysterectomies, with no maternal mortality but with fetal death in one case. The research literature shows that about half of women with placenta previa have several episodes of bleeding, being the leading cause of antepartum hemorrhage. For some women with placenta previa/accrete, hemorrhaging is severe and requires hysterectomy as a necessary step to control the life-threatening situation. Thus, such patients should be carefully monitored to avoid as much as possible the medical, social, and psychological implications of this critical therapeutic procedure