MAKASSED EXPERIENCE IN

MANAGEMENT OF PLACENTA
ACCRETA
Prepared by :
Dr . Amani A.A Rajabi , MD (AL_QUDS UNIV.)
Resident at Makassed Islamic Charitable Hospital
Supervised by :
Dr . Saadeh S.Jaber
MBBS, MRCOG, MRCPI,
Head of OBGYN department Al_quds univ.
Consultant at Makassed Islamic Charitable Hospital
DEFINITION & PATHOGENESIS
Placenta accreta occurs when there is a defect of the
decidua basalis , in conjunction with an imperfect
development of the Nitabuch membrane , resulting in
abnormally invasive implantation of the placenta .

Nitabuch membrane is a fibrinoid layer that separates

the decidua basalis from the placental villi.
HISTOLOGICAL
CLASSIFICATION
INCIDENCE
 There is marked increase in the incidence of placenta
accreta .
In 1950----- 1 in 30,000 deliveries .
In 1977-----1 in 7,000 deliveries .
In 1985-1994-----1 in 2500 deliveries .
In 1982-2002-----1 in533 deliveries .

(Am J Obstet Gynecol 1997;177:210-4)

(Am J Obstet and Gynecol (2005) 192, 1458–61)
placenta accreta has been reported to result in a 7%
mortality rate .

The most common indication for birth related

hysterectomy, accounting for 40–60% of cases.

ACOG committee opinion . International Journal of Gynecology &

Obstetrics 77 (2002) 77-78.
J. Obstet. Gynaecol. Res. Vol. 33, No. 4: 431–437, August 2007 .
DIAGNOSIS
Placenta previa -accreta
Color Doppler

Demonstrating turbulent
flow through placental
lacunae ,with abnormal
vessels linking the
placenta to the bladder.
Magnetic resonance imaging
The role of MRI is to complement, rather than replace,
information obtained via standard sonographic imaging.

The main advantage offered by this type of imaging is :

 The ability to diagnose posterior placenta accreta more
confidently.
 The assessment of bladder invasion in cases of placenta
percreta.
The mean gestational age at diagnosis of placenta
accreta by ultrasound is 29 weeks (range:28–33
weeks) .

The mean gestational age at delivery is 36 weeks

(range: 32–38 weeks).

J. Obstet. Gynaecol. Res. Vol. 33, No. 4: 431–437, August

2007 .
COMPLICATIONS

 Massive obstetric hemorrhage is the most common

complication .
 Disseminated intravascular coagulopathy .
Adult respiratory distress syndrome .
Renal failure .
Infection
 Death.
Abstract
STUDY DESIGN :
Retrospective analysis of medical records &
histopathological finding .
POPULATION :
Women delivered at Makassed Hospital 2007 / 2008 of
whom 15 cases of invasive placenta identified.A finding
confirmed by histopathology .
METHODS :
Retrospective analysis complemented with direct
communication with patient ,using SPSS to analyze data .
CONCLISIONS : at the end of presentation .
 year of delivery
10

9
6

6
4
Frequency

0
2007 2008

year of delivery
Incidence in 2007 ….1:460 deliveries.
Incidence in 2008 ….1:300 deliveries.
 Source of referal
50

40
40

33
30

27

20

10
Percent

0
Governental Hospital Private Hospital booked

source of referal
All of our cases were diagnosed
antenatally .
Identified risk factors
history of :
C S .

E &C .

IUCD .

Other uterine instrumentation .

 MINIMUM MAXIMUM

AGE 24 44

PARITY 2 7

# CESAREAN 2 5
SECTION
Gestational age ……
MINIMUM MAXIMUM MEAN

GA _ US 24 34 29
Diagnosis

GA _ Delivery 26 36 31
Preoperative management
The woman should be informed of the diagnosis and
potential complications .
Antenatal corticosteroid to be given .
Consent form of caesarean hysterectomy .
Delivery should be scheduled for optimal availability of
necessary personnel and facilities.
A preoperative anaesthesia consultation should be obtained.
Adequate blood and clotting factors should be available at
the time of delivery .
An intensive care unit should be available for postoperative
care, as needed.
Immediate preoperative bilateral uretric
stents were inserted in a couple of cases
.
Intraoperative management of
planned cesarean hysterectomy :
A vertical skin incision provides good exposure .
A vertical uterine incision is made above the upper
edge of placenta .
Delivery of the baby .
Placenta left "in situ“, with minimal manipulation.
 Extrafascial hysterectomy is then performed .
Blood transfusion
Case number Pre operative Intra operative Post operative
1 NA 6 PRBC 2 whole Blood
4 FFP
4 PLT
2 NA 4 PRBC 9 whole Blood
4 FFP
3 NA 3 PRBC 4 whole Blood
2 FFP
4 NA 4 PRBC 2 PRBC
5 NA 4 PRBC 4 PRBC
4 FFP 9 FFP
2whole Blood 4 whole Blood
6 NA 2 PRBC 2 PRBC
2 whole Blood
7 NA 8 PRBC NA
4 FFP
Continued
Case number Pre operative Intra operative Post operative
8 NA 3 PRBC 1 PRBC
4 FFP
9 NA 4 PRBC 2 whole Blood
2 FFP
10 NA 2 PRBC 2 PRBC
11 2 PRBC 2 PRBC 2 PRBC
2 FFP
12 NA 2 PRBC NA
13 NA 2 PRBC 2 PRBC
2 FFP
14 NA NA NA
15 NA 2 PRBC 2 whole Blood
4 whole Blood
2 FFP
 Histopathology

NO histopathology

6.7%

percreta

33.3%

accreta

60.0%
 MINIMUM MAXIMUM

HOSPITALIZATION PERIOD 5 38

PRE DELIVERY 0 27
HOSPITALIZATION

ICU 1 2
HOSPITALIZATION
Neonatal outcome
MINIMUM MAXIMUM

GA _ delivery 26 36

Birth weight 1337 3130

 Neonatal outcome
60

50
50

40

36
30

20
Percent

10

7 7
0
NL NURSERY NICU NEONATAL DEATH IUFD

Neonatal outcome
CONCLUSIONS
Incidence of invasive placenta at Makassed hospital is
one case in 370 deliveries .

Invasive placenta associated with significantly high

morbidity & mortality world wide , proudly the
outcome in our hospital was excellent , with NO
MORTALITY & MINIMUM MORBIDITY .

Excellent neonatal outcome .

Continued ….
Finally , maternal & neonatal outcome can be
optimized by the availability of :

 Senior obstetrician with advanced surgical skills .

 Senior anesthesiologist & intensive care facilities .
 Advanced lab & blood banking facilities .
 Urological back up .
 Intensive care baby unit .