Professional Documents
Culture Documents
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Deward Voss, MD
James Pavelka, MD
Placenta Accreta, Increta, Percreta
• Goals:
• Review management
• accreta
• increta
• percreta
• Gravida 6 or more.
Prenatal Diagnosis
• When the diagnosis is made it is usually made by ultrasound in the second or third trimester.
• multiple vascular lacunae (irregular vascular spaces) within the placenta “swiss cheese”
appearance
• numerous coherent vessels visualized with 3-D color/power Doppler in a basal view.
• If sonographic findings are inconclusive or a placenta percreta is suspected, MRI may be useful.
Ultrasound Findings Suggesting Morbidly Adherent
Placenta
• First trimester
• Second trimester
• Third trimester
• Loss of normal hypoechoic retroplacental zone
• Presence of multiple vascular lacunae within placenta (Swiss-cheese appearance)
• Abnormalities of uterine serosa-bladder interface (intertuption of line, thickening of line,
irregularity of line, and increased vascularity
• Extension of villi into myometrium, series, or bladder
• Retro-placental myometrial thickness of< 1 mm
• Turbulent blood flow through lacunae on Doppler ultrasonography
• Increased subplacental vascularity
• Vessels bridging form placenta to uterine margin
• Gaps in myometrial blood flow
Prenatal Care
• hemorrhage
• blood transfusion
• cesarean hysterectomy
• Maternal-fetal medicine
• Gynecologic oncology
• Urology
• Anesthesiology
• Neonatology
• Interventional radiology
• Blood bank
• Nursing
Multidisciplinary Team
• 0-46 RBC
• Decreased blood loss associated with cesarean section with the placenta
left undisturbed in situ when the prenatal diagnosis of placenta accreta is
reasonably certain based on imaging studies, particularly in women with
placental implantation at the site of prior uterine surgery.
• Placenta is left in situ after delivery of the fetus and the umbilical cord is
ligated near the placental insertion site.
• Prolonged course and significant risk have been associated with uterine
conservation with the placenta left in situ:
• Sepsis 6%
• Focal accreta
• How we do it
Intra-operative management strategies
• Place
• Paraphrenalia (Instruments)
• Personnel
• Positioning
• Prep
• Products (Blood)
• Pharmacy
• PLAN
• (prayer)
Place
• Anesthesia
• Attending anesthesiologist
• Nurse anesthetist
• OR
• Circulator(s)
• Scrub nurse/tech
• Obstetrics
• Attending
• Resident/Assist
• OB RN
• Urology
• Gynecology/Gyn Onc
• Attending
• Resident/assist
• Pediatrics
• Attending
• Resident/Fellow
• Nurse
Positioning
• Considerations
• Access/exposure
• Retractor placement
• Patient safety/comfort
Prep
• Abdomen: Chloraprep
• Perineum: Betasept
• Cell Saver(?)
Pharmacy
• Antibiotic prophylaxis
• Antibiotic redose
• Calcium replacement
Plan
• Anesthesia
• General vs Epidural to general
Plan
• Obstetricians
• Vertical incision to above umbilicus
• Obstetricians
• Fundal uterine incision
• Deliver infant
• GYN team
• Survey field
• Elevate uterus
• GYN team
• Mobilize bladder flap
• Cover the uterus with warm laparotomy packs and await assistance and
supplies before proceeding with operative intervention
or
• Close fascial incision, place staples in skin, and consider transfer to tertiary
facility with experience in management of perorate
• If the patient is actively bleeding, apply local pressure to bleeding areas (other
than areas where placental tissue is at risk), then prepare for hysterotomy for
delivery followed by surgical or conservative mangement of placenta percreta.
Criteria for Consideration of Delivery in Accreta Center
of Excellence
• Multidisciplinary team
• Urologist
• Interventional radiologist
• Neonatologist
Suggested Criteria for Accreta Center of Excellence
• Interventional radiology
• Blood services
American Journal of Obstetrics and Gynecology May 2015, patient safety series:
“Clearly planned coordinated delivery and care is win-win-win, for the referring
provider, the patient , and the teams poised to be centers of excellence in care of
women with placenta accreta.”
“The importance of maintaining a high level of suspicion and of early referral for
antenatal imaging whenever accrete is suspected cannot be overstated.”