The Most Common Indication For Peripartum

Hysterectomy Professor Galal Lotfi. MD, MRCOG.

Ostetrics & Gynecology Department. Suez Canal University

Ismailia. Egypt.

• In the past, the most common indication was atonic and traumatic post partum haemorrhage.

• Not anymore

Now we have Accrete

Placenta accreta is currently the most common indication for peripartum hysterectomy.

Placenta accreta occurs when the chorionic villi invade the myometrium abnormally.

Three grades:

Placenta accreta: The chorionic villi are in contact with the myometrium,

Placenta increta: There the chorionic villi invade the myometrium,

Placenta percreta: The chorionic villi penetrate the uterine serosa [1]

NOW

• Accreta

• Morbidly adherent placenta.

• Abnormal adherence of placenta.

We Call it

Different names for the same catastrophic

diagnosis

Nothing is worse surprise for the

obstetrician

Why?

Placenta accreta:Massive and potentially life-threatening intrapartum and postpartum hemorrhage[2]. Leading cause of emergency hysterectomy [3]. Maternal morbidity up to 60%Maternal mortality up to 7%. Perinatal complications is mainly due to preterm birth and small for gestational age fetuses.

Why it is the worst obstetric complication?

So, nothing is worse in

your speciality?

Incidence: 0.5-1%Earlier text books considered it rare complication, but not anymore due to the increasing rate of cesarean delivery over the past 50 years [8]. And will continue to expand.

Wu et al [10]. reported an incidence of 1 : 533 births for the period from 1982 to 2002, much greater than previous reports ranging from 1 : 4027 to 1 : 2510 births in the 1970s to1980s, [10].

1 : 1000 deliveries with a reported range from 0.04% rising up to 0.9% [10, 11, 22]

Most commonly occurs in women who have placenta previa and have had a cesarean delivery.

Risk in women who have placenta previa increases from about 10% if they have had one cesarean delivery to > 60% if they have had > 4 cesarean deliveries.

That is huge!!!

!

The incidence of accrete has increased mainly and solely because of the soaring increase of CS rate.Why is that??

• CS on request• 100% CS for ART pregnancies.• Increased intrapartum fetal monitoring • Advanced age of pregnant women• Loss of Obstetric Art:

• Breech Delivery??• Instrumental delivery??• Trial of CS Scar??• Lack of patience of the patient and the

obstetrician??• Weak doctor patient relationship and Litigation.

• Abuse of US:• Cord around the neck??• Decreased amniotic fluid??• Placental calcifications???

Egypt rate. Verbal communication

45% general85% private

Risk for accreta

Risk increase when you have: • Previous cesarean deliveries.• Myoma, submucous and Myomectomy • Previous curettage, ZEALOUS.• Endometrial ablation.• Asherman’s syndrome, • Advanced maternal age,• Grandmultiparity,• Smoking,• Chronic hypertension [14].• Prior placenta accreta is probably a major risk factor.

• Alanis et al. reviewed 72 cases of placenta accreta that were treated conservatively. Among 15% of women who had a subsequent pregnancy, 18% developed a repeated placenta accreta [25],.

Almost Always Iatrogenic

In the past. Emergency hysterectomy was mainly for postpartum hemorrhage either atonic or traumatic.

With increasing rates of CS that indication was on the decline. However that same cause just changed the reason for doing emergency hysterectomy but in a graver and more dire situation.

Diagnosis

.

If you can't prevent its occurrence try to prevent its complications.

Diagnosis cont...

First of all suspect it and put in mind if you have low placentation or even lower position of first early gestation sac especially in the presence of Uterine scar.

Prenatal diagnosis is very crucial if you want to avoid mortality and facing bleeding from everywhere.

Diagnosis cont...First trimester US.

Signs of accretion may be seen as early as in the first trimester.

Low-lying gestational sacs which are clearly attached to the uterine scar.

The myometrium was thin in the area of the scar to which the sac was attached compared to normal early gestational sacs

Preg 9w. Decidua basalis is hypoechoic region behind placenta.

Normal Situatio

n

Tvs. Gestational da implanted in LUS. Progressed later to percreta.

Tvs. LUS implantation. Multiple irregular vascular spaces in and around placenta (circles)

Gestational sac implanted in CS scar at int Os level

Diagnosis cont...Second and third trimester US:

Loss of continuity of the uterine wall,

Multiple vascular lacunae (irregular vascular spaces) within placenta, giving “Swiss cheese” appearance adjacent to the placental implantation site,

Lack of a hypoechoic border (myometrial zone) between the placenta and the myometrium,

Bulging of the placental/myometrial site into the bladder,

TAS. 18w. Color Doppler. Placenta accreta. Multiple vascular lacunae.

TAS. A: normal placenta with normal hypoechoic retroplacental zone. B: accreta with absent retroplacental

zone and multiple lacunae.

TAS. Accreta. Multiple lacunae.

A. TVS grey scale accreta. Multiple lacunae. B; color Doppler extensive vascularity and lacunae.

TVS. A: grey scale. B: color Doppler. accreta. Abnormal uterine serosa bladder interface line. Abnormal vascularity of posterior wall

of the bladder

Diagnosis cont...

Doppler sonography.

Increased vasculature evident on color Doppler.

Diagnosis cont...

3D ultrasound.

The observation of “numerous coherent vessels” detected by three-dimensional power Doppler in the basal view were the best single criterion for the diagnosis of placenta accreta, with a sensitivity of 97% and a specificity of 92%.

3D power Doppler-may be useful as a complementary technique for the antenatal diagnosis or exclusion of placenta accreta [33]

US findings

Diagnosis cont...

MRI

If the ultrasound findings are not considered definitive, or the placenta is located on the posterior wall, MRI could help.

MRI findings considered suspicious for the presence of placenta accreta:Placental heterogeneity, Mass effect of the placenta into the underlying bladder or extending laterally

or posteriorly beyond the normal uterine contour, Obliteration of the myometrial zone visible on initial uptake of gadolinium, Beading nodularity within the placenta [34].

Bladder, placenta

impinging

Diagnosis cont...

AFP, hCG

Elevated levels of alpha fetoprotein and human chorionic gonadotropin within the triple screening test have been reported to be associated with an increased risk of placenta accreta. Though the mechanism is unclear, abnormality of the placental-uterine interface that may lead to leakage into the maternal circulation-may explain this increase [35, 36].

Diagnosis tip

At this time no antenatal diagnostic technique affords the clinician 100% assurance of either ruling in or ruling out the presence of placenta accreta.

The definitive diagnosis of placenta accreta is usually made postpartum on hysterectomy specimens when an area of accretion shows chorionic villi in direct contact with the myometrium and absence of decidua [26,37]

Management

Management

What should I do!!!

• Elective. Elective. Elective Cesarean hysterectomy with multidisciplinary team . • There is a great benefit of planned as opposed to emergent peripartum

hysterectomy. In mothers with placenta previa and a suspected accreta who required peripartum.

• hysterectomy, (scheduled) delivery has been associated with shorter operative times and lower frequency of transfusions, complications, and intensive care unit admissions [39]

Increta

Increta

Increta

Increta

The multidisciplinary team

The multidisciplinary team should include.

• Gynecologic surgeon experienced in pelvic surgery,

• Blood bank team prepared to administer multiple blood components,

• Experienced anesthesiology personnel who are skilled in obstetric anesthesia,

• Urologists in case a bladder resection or repair might be required,

• Experienced intensivists for postpartum care,

• Experienced neonatologist.

• In cases where pelvic artery catheterizations are used, an experienced interventional radiologist.

Eller et al. showed that delivery at a medical center with a multidisciplinary care team resulted in a more than 50% risk reduction for composite early morbidity among all cases of placenta accreta and a nearly 80% risk reduction among those cases wherein accreta was suspected before delivery

Timing of operationTime of operation. 34-35w

O’Brien et al. reported that after 35 weeks, 93% of patients with placenta accreta experience hemorrhage necessitating delivery [5].

Warshak et al. reported that planned delivery at 34 to 35 weeks of gestation in a cohort of 99 cases of accreta did not significantly increase neonatal morbidity[9].

So don't wait more than 34-35w.

Don't try to avoid prematurity at the expense of facing emergency placenta accreta with bleeding in the middle of the night with no precautions. If mother life on stake, don't think much about prematurity.

Don't worry about me. Take care of mom.

Type of anesthesia Type of anesthesia.

Controversial. The American Society of Anesthesiologists task force on obstetric anesthesia suggested that general anesthesia may be the most appropriate. Extensive pelvic invasion and/or significant potential or intraoperative bleeding still favors general anesthesia [41].

Insertion of large-bore venous access to allow rapid crystalloid and blood productinfusion,

Availability of high flow rate infusion and suction devices,

Hemodynamic monitoring capabilities (central venous and peripheral arterial access),

Compression stockings and devices to prevent thromboembolism,

Padding and positioning to prevent nerve compression, and

Avoidance and treatment of hypothermia [31].

My case, when patient makes her decision

Referred at 20w

did not like the option HysterectomyDid not like the option 34w termination

showed up at 36weeks with bleeding and contractions

Bladder careBladder care.

Placenta accreta is most likely to affect the urinary bladder [23]. Placenta accreta that invades the urinary bladder may cause urinary fistula, and bladder laceration requiring partial or total cystectomy [23].

Data suggest that preoperative ureteric stent placement may help reduce the risk of ureteric injury.Moreover, cystoscopic placement of ureteric stents can usually be accomplished quickly and easily even in an emergency and is associated with relatively minimal risk [43].

If bladder involvement is suspected, cystotomy may be needed to clarify the extent of invasion after devascularization of the uterus is achieved and to ensure ureteric patency if stents were initially not inserted.

Optimal management

The optimal management.

Hysterectomy immediately after delivery of the baby without attempts at placental removal had been reported to lower mortality and morbidity rates compared to conservative management especially in cases of placenta percreta.

This procedure became, and still is, since 1972, the recommended treatment option [18, 19, 44].

Optimal management

Supra-cervical hysterectomy. It requires less operative time and is associated with less bleeding.

Proceed with cesarean hysterectomy while keeping the placenta attached.

On occasions however, a supra-cervical hysterectomy may not control bleeding and a complete hysterectomy is needed

Bleeding is not always surgical. Medical bleeding' DIC

No stitches needed

Conservative management. If you

have to!!!Conservative management If to preserve the uterus or hysterectomy is a hazardous choice:

Conservative management, which includes delivery by a cesarean section without hysterectomy, The primary idea of conservative management is to leave the entire placenta or just the part that is adherent to the myometrium in situ and to preserve the uterus. Manual removal of densely adherent placental areas should not be tried because forcefulseparation may result in severe bleeding [20, 45].

Kayem et al. compared maternal outcomes among women with a placenta accreta, within two consecutive periods: period A, the placenta was removed manually leaving the uterine cavity empty; period B, the placenta was left in situ. During period B, there was a significant reduction in the hysterectomy rate, the mean number of red blood cells transfused, and in the incidence of disseminated intravascular coagulation compared with period A [46].

Conservative complications

Postoperative complications reported with a conservative approach include:

• Severe postpartum hemorrhage,• Postoperative disseminated intravascular coagulopathy, and• Infection resistant to antimicrobial therapy that may require• Laparotomy and hysterectomy [17, 21, 47,

Conservative cont..

The conservative approach should be done if the risk of the hysterectomy is deemed higher than conservative management, especially where resources such as blood replacement or expert pelvic surgery is limited.

Conservative cont..The use of compression sutures, such as the B-Lynch suture may be helpful in tamponading bleeding and has been used in cases of placenta accreta (36). The physicians caring for pregnancies with placenta accreta should familiarize themselves with these compression sutures prior to the cesarean delivery

Lynch

Methotrexate or no methotrexate

Methotrexate or not. UncertainThe role of adjuvant methotrexate in cases of conservative management is uncertain. No large studies have compared methotrexate with no methotrexate in the treatment of placenta accreta, and at the present time, there are no convincing data for or against the use of Methotrexate incases of placenta accreta [21].

Uterine cooling

Uterine Cooling Reduces Bleeding in Cesareans, 2015

Intravascular Recently, inserting intravascular balloon catheter for occlusion and/or arterial embolization of the pelvic arteries was introduced as an invasive adjuvant therapy in order to minimize blood loss during cesarean hysterectomy. In selective cases the placement of a balloon catheter wasdone concurrently with conservative management with the intent of avoiding hysterectomy, thereby preserving fertility [51]. Failure of intravascular balloon catheters to reduce blood loss may be explained by the extensive degree of uterine blood flow with pregnancy and the extensive vascular anastomoses present in the gravid pelvis. In addition, whereas reduction of blood flow to the uterine arteries likely occurs following balloon inflation in the hypogastric arteries, collateral circulation from cervical,ovarian, rectal, femoral, lumbar, and sacral arteries likely contribute to the overall blood loss. Inflation of the balloons immediately following delivery of the infant may actuallyexacerbate collateral blood flow [57].

Arnold