| | Diagnosis and management of placenta accreta published online 28 August 2008. The diagnosis of placenta accreta begins with clinical suspicion in patients at risk. Ultrasound and Doppler are first-choice diagnostic methods because of their accessibility and high sensitivity. Placental MRI is an accurate method of topographic stratification that makes it possible to define anatomy, to plan the surgical approach and to consider other therapeutic possibilities. Management of placenta percreta involves great technical dexterity and significant clinical support. The main challenges include controlling the haemorrhage and dissection of the invaded tissues. Nowadays, there are two treatment options: caesarean hysterectomy or a conservative approach. With the latter, there is a choice between leaving the placenta in situ and waiting for its later resolution, and a one-step surgery that addresses the problems of invasion, vascular control and myometrial damage in a single surgical act. Introduction  Placenta accreta is a disorder characterized by abnormal placental penetration into the uterine wall. It is currently one of the main causes of maternal morbidity and mortality. This entity has been historically classified according to the degree of pathological penetration and includes superficial invasions (placenta accreta), middle-layer invasions (placenta increta), and deep invasions (placenta percreta). This chapter refers to all these varieties as placenta accreta. As a result of its close relation to caesarean section1, 2, the incidence of placenta accreta has grown in the last few decades. Myometrial damage secondary to repeated caesarean sections, and other myometrial injuries associated with dilatation and curettage (D&C) and corrective surgeries, among others, are the main predisposing factors. Ultrasound (US) and Doppler*3, *4 are two first-line methods for the diagnosis of placenta accreta; both have a high degree of diagnostic sensitivity and both methods have made it possible to establish diagnostic signs that allow the suspicion of an abnormally implanted placenta in a high percentage of cases. In addition, placental nuclear magnetic resonance imaging (pMRI) has proved to be a noteworthy auxiliary when it comes to plan the surgery of placenta accreta.5 Placental MRI (pMRI) makes it possible to have total acquisition of images; its multiplane characteristic allows a correct three-dimensional (3D) reconstruction, necessary for surgical planning. Placenta accreta causes morbidity and mortality due to haemorrhage, coagulopathy and its inherent surgical difficulty; these facts make this disorder the first cause of obstetric hysterectomy.6 Traditionally, the treatment of placenta accreta has consisted of puerperal hysterectomy. This is a high-risk procedure, especially when haemorrhage and coagulation disorders coexist. To minimize damage and conserve the reproductive potential in women, a series of procedures that aim to preserve the uterus affected by placenta accreta have been incorporated.*7, *8 These conservative tactics have proved to be effective and safe under controlled conditions. Below, we provide a synthesis of the current knowledge about placenta accreta, including practical data for obstetricians and surgeons. We emphasize early detection of risk factors, diagnostic guidelines and treatment alternatives in accordance with the human and technical resources available. Terminology From a histopathological perspective, there are marked differences among placenta accreta, increta and percreta. However, from a clinical–surgical point of view, sectors that show a different degree of invasion can coexist in the same patient. This phenomenon leads to discrepancies between what is observed during surgery and the final pathological diagnosis. This difference is not only semantic; it makes comparisons of surgical techniques and clinical results from different authors virtually impossible. Unlike other illnesses, the histopathological study of invasive placenta does not always constitute a diagnostic “gold standard”. This phenomenon occurs when biopsy is obtained in an area without invasion or with a degree of minor penetration. In these cases, there is a mismatch between histology and the surgical finding. We prefer to define placenta accreta according to its clinical–surgical characteristics.9, *10 Risk factors Patients with myometrial damage secondary to repeated caesarean sections in association with placenta praevia constitute the main risk factor for placenta accreta.11, 12 Multiple uterine D&C, particularly those performed in patients who have had previous caesarean section(s)13, are closely associated with adherent placentation. Myometrial tissue damage, whether surgical, instrumental or physical14, followed by a secondary collagen repair, is closely related to the appearance of placenta accreta. The challenge of confirming or discarding the diagnosis of invasive placenta is greatest when the topography of the uterine lesion coincides with the placentation zone. Diagnostic methods Ultrasound Transabdominal ultrasound (US) is the simplest, most widespread and cost-effective method for the initial diagnosis of placenta accreta. However, US does not allow adequate visualization of a low-segment cervix or common areas of placental invasions after multiple caesareans. Transvaginal ultrasound (TVUS) enables a more accurate examination of the distal uterine sector (Figure 1). However, the posterior wall cannot be assessed correctly by this method. It is worth highlighting that this is a safe imaging method for patients with placenta praevia. Detailed visualization of the cervix and low segment with TVUS increases diagnostic accuracy in low-insertion placentas.15, 16 Ultrasound signs Certain patterns have been associated with placenta accreta. One such sign is the presence of placental lagoons, which, unlike those seen in the second trimester, are large, irregular and multiple. The aetiology of these placental lagoons is unknown. Their presence, characteristics and number are not directly related to the gravity of placenta accreta. The sensitivity of this ultrasound sign is 79%, with a positive predictive value of 92%, when identified between weeks 15 and 40.16 The loss of the retroplacental hypoecogenic zone, represented by the absence of the retroplacental vascular bed, basal decidua and placental advancement over the myometrium is another ultrasound sign associated with the presence of placenta accreta. This sign does not have great significance when found in isolation. Certain authors question its importance due to its low diagnostic and predictive sensitivity and a false-positive rate of nearly 50%. Progressive thinning of the retroplacental myometrium indicates the extreme proximity of the placental tissue to the peritoneal serosa or to the neighbouring organs, another sign of placenta accreta. Segmental myometrial thinning of less than 1 mm is suggestive of abnormal placental adherence, with sensitivity of 93%, specificity of 79% and predictive value of 73%.17 Thinning or disruption of the uterine–vesical serosa occurs due to the lack of myometrial tissue, leaving the visceral serosa exposed. It is not easy to make a differential diagnosis between placenta accreta and the irregularities of the vesical wall. Disruption of the serosa indicates a higher degree of compromise; the presence of extrauterine placental parenchyma confirms placenta percreta. US grey-scale general capacity is enough to diagnose placenta accreta with sensitivity 87%, specificity 98%, a positive predictive value 93% and a negative predictive value 98%.18 The presence of vessels perpendicular to the uterine axis indicates the presence of placental vessels from and towards the myometrium or other neighbouring tissues*17, 18, 19; this pattern is associated with the presence of different degrees of placenta accreta. Magnetic resonance imaging of the placenta Initially, the aim was to determine whether placental magnetic resonance imaging (pMRI) can improve the diagnostic sensitivity of ultrasound in the detection of placenta accreta.*20, 21, 22 The first prospective study was performed in 1997. The report included 18 patients and did not find any diagnostic differences between the techniques, although it did identify a higher diagnostic sensitivity in pMRI in the case of posterior placenta accreta. In 2005, a prospective series comprising 300 cases showed that pMRI adequately outlined the topographic anatomy of the invasion, relating it to the regional anastomotic vascular distribution. The characteristics of the invasion confirmed the possibility of bleeding, the occurrence of complications, and the inherent technical difficulty in certain cases. It is the only published study to date that has been able to confirm the presence of parametrial invasion (axial slices)5; an important factor associated with the possibility of urethral damage during surgery. Diagnostic practice points •Clinical risk factors for placenta accreta: repeated caesarean sections+placenta praevia, multiple D&C, caesarean and D&C, placenta inserted in the site of previous uterine surgeries, pelvic radiation, endometrial thermoablation. •US signs of morbidly adherent placentae: loss or thinning of the retroplacental hypoecogenic zone, multiple intraplacental lagoons, thinning or disruption of the uterine–vesical serosa, extrauterine placental tissue mass. •Signs of morbidly adherent placentae: absence of Doppler signal in the hypoecogenic zone, diffuse lacunar colour flow pattern, turbulent flow with pericervical vascular dilation, arterial vessels emanating from the placenta towards neighbouring organs or tissues Technical aspects Like other diagnostic methods, pMRI has certain technical details that can enhance or emphasize its diagnostic accuracy. The main aim of the imaging study is to obtain the best definition of the uterine–placental interphase and its relation to the bladder (Figure 2). Newly formed vessels (NFV) secondary to the development of placenta accreta are underdeveloped in the middle layer. This particularity requires the pMRI study to be performed with a semi-full bladder, to avoid false negatives as a result of overdistension and/or collapse of the NFV, as well as false negatives due to an empty bladder. It is important that the bladder is only partially full; an empty bladder next to the pubic bone would prevent an adequate sign of the uterine–vesical interphase, resulting in diagnostic error. The use of ultrafast techniques that minimize artefacts produced by fetal movement is recommended.23 T2-weighted imaging highlights urine as a naturally white contrast, thus allowing better delineation of the vesical muscle in relation to the placenta and the underlying myometrium.24 In the presence of risk factors (multiple D&C, myomectomies or corrective surgery), if there are clinical antecedents for the T2 mode allowing a naturally white contrast and a suspicion of posterior placenta accreta, the use of gadolinium is recommended to improve diagnostic accuracy. Without this, a combination of placenta, myometrium, abdominal viscera and the vertebrae form a complex image, which makes an adequate diagnosis of posterior myometrial placental invasion virtually impossible. So far, gadolinium has not shown any side effects during pregnancy, and there are no toxicity reports. However, and as a precaution, its use is generally recommended for cases in which diagnosis by other techniques is not possible.25, 26 It is prudent to use pMRI in all cases with a resulting non-conclusive ultrasound or Doppler examination, when it is important to rule out or confirm the presence of parametrial invasion. Therapeutic options depend on the size of the invasions and exact anatomy of the lesion.5, *27, 28 Therapeutic management of placenta accreta Preoperative evaluation The objective of preoperative evaluation is to gather and analyse diagnostic information, with the aim of determining the best procedure for each case. Imaging diagnostic studies, ultrasound and pMRI will allow us to establish the degree, extension and location of the placental invasion. The level of penetration will determine the timing of the caesarean (Figure 3). As a rule, we perform surgery at 37 weeks for superficial invasions (accreta), and at 35 weeks for deep invasions.5, 6, *7, *8, 9, *10, 11, 12, 13, 14, 15, 16, *17, 18, 19, *20, 21, 22, 23, 24, 25, 26, *27 In cases of lateral–inferior placental invasion, uretheral catheterization is recommended to avoid inadverted lesions during surgery. In those cases with extensive parametrial invasion, cervical pregnancies or pregnancies after hysterotomy, identifying and isolating the urether at its crossing with the iliac artery before surgery noticeably reduces the possibility of lesions.8 Surgical strategy The primary objective is to perform the caesarean section in the safest conditions possible, according to the resources available. Placental removal is s not an essential step and can be postponed. However, initiation of the removal manoeuvre is usually the point of no return. If placental detachment, dissection or proximal vascular control is ineffective, serious complications are generally immediate. 3D imaging of the invasion5, 6, *7, *8, 9, *10, 11, 12, 13, 14, 15, 16, *17, 18, 19, *20, 21, 22, 23, 24, together with the corresponding anatomical profile will facilitate the planning and performance of the surgical procedure. Nevertheless, 3D anatomical mapping acquisition of the lower pelvis is usually available only after hours of training in an anatomy laboratory, which limits its practical application and adds an inherent difficulty to this procedure. Correct dissection of the interfascial surgical planes8 will make it easier to recognize the anatomical elements adjacent to the invasion and will increase the safety of the procedure. Proximal vascular control Regional irrigation The pelvic vascular system widely interconnects the internal iliac, external iliac and femoral systems.*17, 18, 19, *20, 21, 22, 23, 24, 25, 26, *27, 28, 29 External and internal compression of the abdominal aorta reduces distal flow significantly.30, 31 This haemostatic manoeuvre, whether external or internal, is essential when there is active and uncontrolled bleeding due to adherent placenta, and allows control of the haemorrhage quickly and effectively. Ligature, occlusion or embolization of the internal iliac artery (IIA) is a procedure with a high number of failures in placenta accreta.32, 33 Anastomotic compensation following IIA ligature or occlusion is almost immediate.34 This, added to the fact that the procedure should be bilateral, makes it unsuitable for low-insertion placenta accreta. Paradoxically, several authors recommend the use of occlusion of the iliac artery in placenta accreta. This apparent contradiction arises from the use of inconsistent classifications of invasion, which do not take into account the invasion topography. The topographic features of the uterine body and of the lower segment and cervix differ in that the arterial pedicles supplying the uterine body are irrigated by the uterine artery and the upper vesical artery, whereas the lower segment is irrigated by the cervical artery, the inferior vesical artery and by the upper, middle and lower vaginal arteries.5 These differences imply a deep dissection for lower segment surgical haemostasis, and inherent difficulties for the endovascular procedures in this area.35 Using a uniform haemostasis for all types of placental invasions has resulted in vascular complications.36, 37 The presence of a highly vascularized structure, such as placenta accreta, a cervical myoma or a cervical ectopic pregnancy, predisposes to the opening of anastomotic channels that are usually closed. There are two main supplementary irrigation systems, one from the bladder and the other from the vagina. Both systems must be recognized when performing a hysterectomy or a one-step surgery. These anastomotic networks are connected to the lower segment and are usually the most common cause of postoperative bleeding.*35, 36, 37, 38 Ligature or occlusion of the uterine arteries can be an insufficient or useless in lower-segment invasions. However, if the lower anastomotic system needs to be occluded, there is high risk of uterine necrosis, as well as undesired devascularization. Arterial embolization followed by haemostatic procedures involving ligature or compression has a high possibility of ischaemic complications in conservative treatments due to the massive occlusion of the anastomotic components. Obstetric hysterectomy With the exception of upper-segment invasions, hysterectomy for placenta accreta must be total; otherwise there is a high percentage of rebleeding in subtotal resections within the lower-segment invasions.38, 39 If it is necessary to perform a subtotal hysterectomy, it is not recommended to close the peritoneum over the cervical stump, as rebleeding in these circumstances usually goes unnoticed.17 If a subtotal hysterectomy has been performed, diagnosis of rebleeding should be suspected whenever there is haemodynamic deterioration after an effective replacement. Exploration by ultrasound is often inefficient, because it examines only the pelvis, and a retroperitoneal haematoma might be hidden, unnoticed, behind the colon. Computerized tomography (CT) has a high diagnostic sensitivity in these cases; however, it is not usually available. Angiography might be recommended, although it can be ineffective due to shock vessel spasm or venous bleeding. All of the above result in a recommendation for early surgical re-exploration in patients with haemodynamic deterioration and a history of subtotal hysterectomy for placenta accreta. Therapeutic practice points •The primary objective of surgery for placenta accreta consists of applying the simplest and most efficient procedure that minimizes the risk of haemorrhage. •The presence of pericervical or lower-segment varicose veins proper of placenta praevia can be confused with the neovascularization of placenta accreta. In these cases, surgical exploration will make a differential diagnosis, thus avoiding unnecessary hysterectomies. •Surgical difficulties and possibility of complications in placenta accreta are directly related to the invaded anatomical area, its specific circulation and to the dissection of the organs involved. •When total hysterectomy must be performed in the presence of non-dissectable lower-segment invasion, it is useful to apply some kind of aortic vascular control (internal compression, endoluminal balloon or loop) before performing dissection of the invaded tissues. •Indications for hysterectomy in placenta accreta include: (1) anticipated technical problems with the technical impossibility of repair; (2) the technical impossibility of performing a safe haemostasis; and (3) when, after performing conservative techniques, complications such as infection or untreatable haemorrhage arise. •Neoformation vessels should not be electrocoagulated because of poor development of the middle layer. This procedure can be the cause of bleeding difficult to control, or of a postsurgical haemorrhage. Conservative treatment The first successful conservative treatment of placenta accreta was performed in 193340; the decision was taken because it was not possible to perform a puerperal hysterectomy. Nowadays, conserving the uterus, avoiding the possibility of haemorrhage and making future pregnancies possible are the main objectives of conservative treatments in placenta accreta. There are two main options. One consists of leaving the placenta in situ41, 42 and waiting for its later reabsorption, the other involves resecting the invaded area together with the placenta and performing the reconstruction as a one-stop procedure.43 Table 1 shows an overall comparative analysis of these two conservative procedures. | | |  | Conservative approach | Placenta in situ with or without methotrexate: 1985–2006 (n=60) | One-step surgery: 1989–2004 (n=300) 2004–2006 (n=94, unpublished) | |
|---|
| Advantages | Less bleeding | Less bleeding | | | Primary uterine conservation (selected patients) | Primary uterine conservation s1:95–100%; s2: 27–60% (consecutive and unselected patients) | | | Medium-complexity technique | Evaluation of early fibrinolysis | | | Lower hospital costs | | | Damaged area removed | | | No evidence of recurrence of accreta in a next pregnancy | | | | | | Disadvantages | Damaged area not removed | Secondary haemorrhage | | | High possibility of accreta recurrence | High-complexity technique | | | Secondary infection | | | Secondary DIC | Possibility of ureteral or bladder damaged | | | Secondary haemorrhage | | | Secondary hysterectomy | Additional pain following uterine reconstruction and pelvic dissection in the first 24h | | | High hospital costs | | | Retained placenta | | | | |
When the placenta is left in situ, the baby is delivered through the incision that should avoid placental implantation. Following delivery of the baby, the uterus is closed and the placenta is expected to be reabsorbed or expelled. During the period of placental involution, haemorrhage, infection44, 45 and disseminated intravascular coagulation (DIC) can occur. Methrotrexate has been used by several authors as an auxiliary treatment to reduce placental mass and its vascularization. However, there is no evidence to shows conclusive advantages from its use. From 1985 to 2006, 60 cases of conservative treatment, in which the placenta was left in situ, were published, and eight subsequent pregnancies were reported. The recurrence of placenta accreta in this group was over 60%. With a one-step surgery, anatomical and vascular separation of the invaded organs, usually uterus and bladder, is achieved through Pfannenstiel or median incision. Meticulous dissection allows an accurate haemostasis, which makes it possible to resect the invaded tissue and have adequate tissue repair (Figure 4, Figure 5).8 Since 1989, 45 pregnancies have been reported in patients who underwent a one-step surgery; 43 had posterior of fundal placenta, and in 2 cases, anterior placenta. Only one recurrence was reported, in a patient who became pregnant a few months after the repair (Palacios-Jaraquemada, unpublished data). As mentioned above, there is no unique approach to the management of placenta accreta. Surgical team expertise, availability of resources and local conditions are determining factors when choosing the safest procedure. Table 2 shows the choice of procedures according to the technical and material resources available; these actions have proved to be the safest procedures that make it possible to solve the problem delivery with an acceptable maternal risk. | | | | Resources | Patient, clinical and anatomic features | Decision | Definitive treatment | |
|---|
| Limited experience or expertise, poor resources or no facilities for safe patient transfer | Possibility of percreta, lower segment invasion or vaginal bleeding with high suspicion of accreta | Extraplacental hysterotomy, delivery and delayed placental extraction followed by uterine closure | Delayed hysterectomy or conservative procedure according clinical and surgical status | | | | | | Qualified and experienced team, adequate hospital resources | No desire for future pregnancy | Resective surgery | Subtotal hysterectomy for upper segment lesions | | | Tissue destruction more than 50% of uterine axial circumference | | | Total hysterectomy for lower segment and cervical involvement | | | Intractable haemorrhage | | | DIC | | | | | | Qualified and experienced team, adequate hospital resources | Desire for future pregnancy | Conservative surgery | Placenta in situ with or without methotrexate | | | Destruction less than 50% of uterine axial circumference | | | Minor coagulation disorders | One-step surgery | | | | |
Postsurgical care The most frequent postsurgical complication of placenta accreta is haemorrhage, regardless of the procedure used, and bleeding should be considered whenever there is haemodynamic instability. With the possibility of rebleeding, clinical data are more relevant at a higher level in hierarchy than imaging, especially ultrasound, as false negatives are common. Conservative surgery in placenta in situ requires extensive clinical follow-up looking for early signs of haemorrhage, infection or DIC (Figure 6). One-step surgery involves wide mobilization of tissue, tissue resection, myometrial and bladder sutures, which cause additional pain. Morphine administration, together with non-steroid anti-inflammatory drugs (NSAIDs) from the beginning of the postoperative period, results in better management. Thromboprophylaxis is an unavoidable step in extensive pelvic surgery46, especially in pregnancy and during the puerperium with bed rest. If available, it is advisable to use an intermittent pneumatic compressor before beginning the surgery. Unless there are contraindications, low-molecular-weight heparin should be started with a platelet count over 100,000mm and continued until there is full mobility. Summary The identification of patients at clinical risk is an inescapable step in the diagnosis of placenta accreta. Directed search will enable the echographer to look for direct and indirect signs of placental invasion, and allow the choice of the most appropriate US method to find them. pMRI allows the study of topographic stratification and helps to resolve non-conclusive cases or posterior invasions. Therapeutic planning will have to take into account the human and technical resources available for each case. Haemostatic evaluation and clinical support are essential before, during and after the surgical act, and their inadequate application often causes severe complications. Surgery needs to enable the safe birth of the baby, while minimizing the risks of maternal haemorrhage. Proximal vascular control is essential when a puerperal hysterectomy for placenta accreta is performed, or in the case of a one-step surgical procedure. This measure, together with adequate dissection of the interfascial planes, is the key to safe surgery. The two options for conservative treatments differ in their complexity, complication rates and follow up. As caesarean rates are growing globally, and with these the cases of placenta accreta, the best strategy for the future consists of identifying the aetiological factors and avoiding them as much as possible. Research agenda•3D ultrasound47 has made it possible to describe the anatomy, topography and the haemodynamics of the neovascular components. This information is vital when haemostasis is planned, even though the actual value of 3D US will only be established with the modification of the surgical tactics and techniques. •No theory fully explains the biological behaviour of placenta accreta.48, 49 Currently, a wholly different approach is being developed. It is proposed that a morbidly adherent placenta is the result of the myometrial damage and the underlying collagen exposure (Palacios-Jaraquemada, unpublished data). Confirmation of this theory would lead to the application of corrective measures during caesarean section, which would eliminate the predisposing factor and prevent recurrent (damaged myometrium). •Therapeutic application of the diagnostic advances. •Scheduled training in pelvic–subperitoneal pelvic anatomy. •Correction of the aetiological cause of placenta accreta. References 1. 1Center for Disease Control and Prevention . Births: final data for 2002. Natl Vital Stat Rep. 2003;52:1–114. MEDLINE 2. 2Kozak LJ, Weeks JD. U.S. trends in obstetric procedures, 1990–2000. Birth. 2002;29:157–161. MEDLINE |
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CEMIC University Hospital, Department of Gynaecology and Obstetrics; J. J. Naón Morphological Institute, School of Medicine, University of Buenos Aires; and Fundación Científica del Sur, Lomas de Zamora, Buenos Aires, Argentina  Av. Corrientes 5087 4 a C14141 AJD Ciudad Autónoma de Buenos Aires, Argentina. Tel./Fax: +54 11 4857 1331.
PII: S1521-6934(08)00099-0 doi:10.1016/j.bpobgyn.2008.08.003 © 2008 Elsevier Ltd. All rights reserved. | |
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