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ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 1  |  Page : 368-374

Maternal and neonatal outcomes of placenta accreta: a descriptive case series study


1 Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Shibin El Kom, Menoufia, Egypt
2 Department of Obstetrics and Gynecology, Student Hospital, Menoufia University, Shibin El Kom, Menoufia, Egypt

Date of Submission17-Oct-2017
Date of Acceptance08-Jan-2018
Date of Web Publication17-Apr-2019

Correspondence Address:
Nehal M. A. Al Gilanyb
Shibin El Kom, Menoufia, 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_673_17

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  Abstract 


Objective
The objective of this study was to evaluate maternal and neonatal outcomes of placenta accreta.
Background
Placenta accreta is the leading cause of maternal and neonatal morbidity and mortality.
Patients and methods
This descriptive case series study included 40 pregnant women with placenta accreta and was carried out at Department of Obstetrics and Gynecology of Menoufia University Hospitals for 10 months. The study cohort included all admitted pregnant women with the diagnosis of placenta previa accreta whether presenting with or without vaginal bleeding after 28 weeks of gestation confirmed by ultrasound scan. Data were collected and confirmed by positive ultrasonographic criteria of placenta accreta. The study outcomes included maternal mortality, urinary tract injuries, cesarean hysterectomy admission to ICU, preoperative and postoperative hospital stay, perinatal mortality, neonatal birth weight, Apgar score at 1 and 5 min, admission to neonatal ICU, or any other complications.
Results
Our study included 40 patients, and there was a highly significant statistical difference between patients who underwent hysterectomy (n = 21) and who did not (n = 19) regarding type of cesarean delivery (elective or emergency) (P = 0.005). There was a significant statistical difference in neonatal mortality in cases that were admitted to ICU (P = 0.040).
Conclusion
Morbidly adherent placenta is becoming an increasingly common complication of pregnancy with increasing rates of cesarean births. Prenatal diagnosis and management is the most important factor in optimizing the treatment and outcome of women with adherent placenta.

Keywords: hysterectomy, maternal mortality, outcome, placenta accreta, vaginal bleeding


How to cite this article:
Kandil MA, Sayyeda TM, Salaha A, Al Gilanyb NM. Maternal and neonatal outcomes of placenta accreta: a descriptive case series study. Menoufia Med J 2019;32:368-74

How to cite this URL:
Kandil MA, Sayyeda TM, Salaha A, Al Gilanyb NM. Maternal and neonatal outcomes of placenta accreta: a descriptive case series study. Menoufia Med J [serial online] 2019 [cited 2019 Aug 23];32:368-74. Available from: http://www.mmj.eg.net/text.asp?2019/32/1/368/256139




  Introduction Top


Placenta accreta (morbidly adherent placenta) is a severe pregnancy compilation and is currently the most common indication for peripartum hysterectomy. It is becoming an increasingly common complication mainly owing to the increasing rate of cesarean delivery [1].

Main risk factor for placenta accreta is a previous cesarean delivery particularly when accompanied with a coexisting placenta previa [2]. Antenatal diagnosis seems to be a key factor in optimizing maternal outcome. Diagnosis can be achieved by ultrasound in most cases [2]. Women with placenta accreta are usually delivered by an elective cesarean delivery. To avoid an emergency cesarean delivery and to minimize complications of prematurity, it is acceptable to schedule cesarean birth at 34–35 weeks. A multidisciplinary team approach and delivery at a center with adequate resources, including those for massive transfusion, are both essential to reduce neonatal and maternal morbidity and mortality. Cesarean hysterectomy is probably the preferable treatment. In carefully selected cases, when fertility is desired, conservative management may be considered with caution [2]. Placenta accreta occurs when the chorionic villi invade the myometrium abnormally. It is divided into three grades based on histopathology: placenta accreta, increta, and percreta [3]. Placenta accreta is considered a severe pregnancy complication that may be associated with massive and potentially life-threatening intrapartum and post-partum hemorrhage [3]. Maternal morbidity had been reported to occur in up to 60% and mortality in up to 7% of women with placenta accreta. In addition, the incidence of perinatal compilations is also increased mainly owing to preterm birth and small-for-gestational-age fetuses [4]. The incidence of placenta accreta is likely to continue to increase [5]. The exact pathogenesis of placenta accreta is unknown. A proposed hypothesis includes a maldevelopment of decidua, excessive trophoblastic invasion, or a combination of both [6]. Defective decidualization, abnormal maternal vascular remodeling, and excessive trophoblastic invasion are the consequences of previous instrumentation. [7]. Conservative options which include leaving all or part of the placenta in situ when fertility preservation is desired have also been suggested [8]. Several adjuvant techniques have been proposed alongside surgery. This included methotrexate treatment and/or placement of preoperative internal iliac artery balloon catheters for occlusion and/or arterial embolization to reduce intraoperative blood loss and transfusion requirements [2].

Our study aims to evaluate maternal and neonatal outcome of morbidly adherent placenta.


  Patients and Methods Top


A total of 40 women with adherent placenta were observed. This prospective descriptive case series study was carried out at Department of Obstetrics and Gynecology of Menoufia University Hospitals for 10 months. The study cohort included all admitted pregnant women with the diagnosis of placenta previa accreta whether presenting with or without vaginal bleeding after 28 weeks of gestation confirmed by ultrasound scan. The approval of the hospital's ethical committee board was obtained in addition to an informed consent from all study participants.

Exclusion criteria include antepartum hemorrhage owing to placenta previa without suspicious ultrasonographic signs of placenta accreta and pregnant women with gestational hypertension, pre-eclampsia, and twins.

Data were collected on patient age, parity, gestational age at time of cesarean delivery, history of previous cesarean birth(s), hematinic indices at time of hospital admission, and degree of placenta previa by ultrasound, with recording of positive ultrasonographic criteria of placenta accreta.

The evaluation also included whether cesarean birth was done electively or as an emergency, operative time, maneuvers used to establish and control intraoperative bleeding, estimated blood loss during surgery, and given units of packed red blood cell (RBC) transfusion.

The diagnosis was suspected preoperatively by the following ultrasonographic and color Doppler criteria: absence of a hypoechoic zone or clear space between the placenta and the myometrium; loss of continuity of the uterine wall (interruptions of the echogenic area at the interface of the serosa and the bladder); multiple vascular lacunae (irregular vascular spaces) within placenta, giving 'Swiss cheese' appearance adjacent to the placental implantation site; bulging of the placental/myometrial site into the bladder; and increased amount of blood vessels (turbulent blood flow) evident on color Doppler sonography.

However, the diagnosis was confirmed intraoperatively (abnormal adherence of the placenta or evidence of gross placenta invasion at the time of surgery).

Protocol for the management of patients with heavy vaginal bleeding was that an emergency cesarean delivery was performed after resuscitation, irrespective of gestational age, type of placenta previa, or absence of fetal heart sound.

In those with major degree placenta previa and mild bleeding before term, the patient was admitted and managed expectantly.

All patients had gray-scale ultrasound done preoperatively by both senior obstetrician and senior radiologist.

The study outcomes included maternal mortality, urinary tract injuries, cesarean hysterectomy admission to ICU, preoperative and postoperative hospital stay, perinatal mortality, neonatal birth weight, Apgar score at 1 and 5 min, admission to neonatal ICU, or any other complications.

Data were collected, revised, coded, and entered to the statistical package for social science (IBM SPSS, Armonk, New York, USA), version 20. The qualitative data were presented as number and percentages, whereas quantitative data were presented as mean, SDs, and ranges when their distribution found parametric, and nonparametric data were presented as median with interquartile range.

The comparison between groups with qualitative data were done by using χ2-test and/or Fisher's exact test instead of the χ2-test only when the expected count found less than 5 in any cell.

The comparison between two independent groups with quantitative data and parametric distribution was done by using independent t-test, whereas quantitative data with nonparametric distribution were compared by using Mann–Whitney test.

The confidence interval was set to 95%, and the margin of error accepted was set to 5%. So, the P value was considered significant as the following: P value more than 0.05 as nonsignificant, P value less than 0.05 as significant, and P value less than 0.01 as highly significant.


  Results Top


Our results had high significant statistics between neonatal ICU admission and Apgar score, complication, mortality, and neonatal weight (P = 0.000 and 0.016, respectively) [Table 1].
Table 1: Relation of neonatal neonatal ICU admission with the studied parameters

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There are also highly significant statistical differences between maternal ICU admissions and hemoglobin index postoperatively (P = 0.005), highly significant statistical difference regarding type of cesarean delivery (P = 0.01), and significant statistical difference regarding number of parity (P = 0.05), but no significant difference regarding maternal age and degree of accretion [Table 2].
Table 2: Relation of maternal ICU admission with other studied parameters

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There is highly significant statistical difference between patients who underwent hysterectomy (n = 21) and who did not (n = 19) regarding type of cesarean delivery (elective or emergency) (P = 0.005). There was a significant statistical difference in neonatal mortality in cases that were admitted to ICU (P = 0.040) [Table 3].
Table 3: Relation of hysterectomy with other studied parameters

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According to total blood therapy given to mothers, total packed RBC units range is between 0 and 11 U, with mean of 3.6 U, and total plasma units range is between 0 and 10, with mean of 3.5 [Table 4].
Table 4: Total blood therapy

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  Discussion Top


Morbidly adherent placenta increasingly proves as one of the serious complications in pregnancy. The aims of our study are observe pregnant women confirmed as having placenta accreta to find the best protocol to manage and decrease maternal and neonatal complications [Figure 1] and [Figure 2].
Figure 1: Percentage of types of c-sections.

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Figure 2: ReIation of neonataI NICU admission with the studied parameters.

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In our study, there were 40 cases presented with morbidly adherent placenta. As shown, patients with placenta accreta are older and have higher parity. The mean age was 30.13 ± 5.08 years, with a range between 20 and 43 years, whereas the results of Kassem and Al-Zahrani [9] stated that 25 patients with placenta accreta had a mean age of 35.2 ± 4.6 years.

We also noticed that 100% of these patients had a history of previous cesarean deliveries. Our results are comparable to Kassem and Al-Zahrani [9] who found that 96% of the patients had placenta accreta in their study.

As early diagnosis of placenta accreta becomes more common, the rate of elective well-planned cesarean deliveries is more than emergency cesarean deliveries. In our study, the incidence of selective cesarean deliveries is 67.0% and emergency rate is 32.5%, which is unlike the statistical results of Kassem and Al-Zahrani [9], where the incidence of elective cesarean sections was 54.1% at 36–40 weeks and emergency cesarean deliveries was done in 45.9% of the patients.

The risk of placenta accreta increases with increasing numbers of repeated cesarean deliveries. As shown, the increased rate of placenta accreta in the past decade is probably because of rising cesarean delivery rates. Therefore, it would be reasonable to consider stringent measures to reduce the rate of primary and repeated cesarean deliveries without increasing maternal-fetal compromise. Many strategies are proposed, among them reducing cesarean deliveries upon maternal request and encouraging a trial of vaginal delivery after cesarean deliveries. Counseling of such patients should include the remote complications of repeated cesarean deliveries, such as placenta accreta [10].

Among operative data, our study reported lower results in comparison with other studies regarding total blood therapy, with median RBCs transfusion requirement of 6 U among 40 patients, whereas Wright et al. [11] reported a median RBCs transfusion requirement of 5 U in 77 patients undergoing hysterectomy for placenta accreta.

There is a global consensus that women with placenta accreta should undergo surgery performed by an experienced team including an obstetric surgeon and other surgical specialists including urologists, general surgeons, gynecologic oncologists, and an interventional radiologist [12].

According to [Table 1] regarding the relation of neonatal ICU admission with the studied parameters, our study had a highly significant statistical positive correlation between neonatal admission to ICUs and neonatal weight (P = 0.016) and a high significant results as regarding Apgar score, complication, and mortality rate (P = 0.000). We noted that there was a progressive decrease in neonatal morbidity incidence with 12.5% in the form of improving Apgar scores (mean ± SD = 8) and fewer admissions to the neonatal ICU as gestation advanced. To avoid an emergency cesarean delivery and to minimize complications of prematurity, it is acceptable to schedule cesarean delivery at 34–35 weeks.

According to [Table 2], we have lower incidence of maternal ICU admission compared with the results of Fitzpatrick et al. [13], which showed 80% of all cases that were suspected antenatally were admitted to ICUs. Our study shows highly significant statistics between maternal ICU admissions (22.5%) and hemoglobin index postoperatively (P = 0.005) and high significant statistics regarding type of cesarean deliveries (P = 0.01) and significant statistics regarding number of parity (P = 0.05), but no significant difference regarding maternal age and degree of accretion.

Regarding the hysterectomies done in the study by Fitzpatrick et al. [13], there were 65% of cases that were suspected antenatally to have placenta accreta.

According to [Table 3] in our study, there is highly significant statistical difference between patients who underwent hysterectomy (n = 21) (52.5%) and who did not (n = 19) regarding type of cesarean deliveries (elective or emergency) (P = 0.005). There was a significant statistical difference in neonatal mortality in cases that were admitted to ICU (P = 0.040).


  Conclusion Top


In view of the increased risk of maternal morbidity, placenta accreta should be excluded in every case of placenta previa, especially in those with risk factors such as previous uterine surgery, high parity, and advanced maternal age. Prenatal diagnosis seems to be the key factor in optimizing counseling and treatment of patients with placenta accreta.

Arrangement should be made for planned delivery by trained placenta accreta team in tertiary care hospitals that have facilities to manage morbidly adherent placenta.

Uterine-sparing techniques are getting worldwide acceptance and applicability. Researches on these techniques will keep increasing until the techniques become standardized in the management of placenta accrete. Uterine-sparing surgeries should be used in selected cases by trained experienced team.

The accurate use of compression sutures is the key to achieve vascular control and hemostatic procedures. At present, there is no need to consider antenatal fetal surveillance programs for fetal growth restriction in women with placenta accrete.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Garmi G, Salim R Epidemiology, etiology, diagnosis, and management of placenta accreta. Obstet Gynecol Int 2012; 2012:873929.  Back to cited text no. 1
    
2.
Tan CH, Tay KH, Sheah K, Kwek K, Wong K, Tan HK, et al. Perioperative endovascular internal iliac artery occlusion balloon placement in management of placenta accrete. Am J Roentgenol 2007; 189:1158–1163.  Back to cited text no. 2
    
3.
Faranesh R, Shabtai R, Eliezer S, Raed S. Suggested approach for management of placenta percreta invading the urinary bladder. Obstet Gynecol 2007; 110:512–515.  Back to cited text no. 3
    
4.
Hudon L, Belfort MA, Broome DR. Diagnosis and management of placenta percreta: a review. Obstet Gynecol Surv 1998; 53:509–517.  Back to cited text no. 4
    
5.
Warshak CR, Ramos GA, Eskander R, Benirschke K, Saenz CC, Kelly TF, et al. Effect of predelivery diagnosis in 99 consecutive cases of placenta accreta. Obstet Gynecol 2010; 115:65–69.  Back to cited text no. 5
    
6.
Garmi G, Goldman S, Shalev E, Salim R. The effects of decidual injury on the invasion potential of trophoblastic cells. Obstet Gynecol 2011; 117:55–59.  Back to cited text no. 6
    
7.
Tantbirojn P, Crum CP, Parast MM. Pathophysiology of placenta accreta: the role of decidua and extra villous trophoblast. Placenta 2008; 7:639–645.  Back to cited text no. 7
    
8.
Kayem G, Davy C, Goffinet F, Thomas C, Cleent D, Cabrol D. Conservative versus extirpative management in cases of placenta accreta, Obstet Gynecol 2004; 104:531–536.,  Back to cited text no. 8
    
9.
Kassem GA, Al-Zahrani A. Maternal and neonatal outcomes of placenta previa and placenta accreta: three years of experience with a two-consultant approach. Int J Womens Health 2013; 5:803–810.  Back to cited text no. 9
    
10.
Morlando M, Sarno L, Napolitano R, Capone A, Tessitore G, Maruotti GM, et al. Placenta accreta: incidence and risk factors in an area with a particularly high rate of cesarean section. Acta Obstet Gynecol Scand 2013; 92:457-460.  Back to cited text no. 10
    
11.
Wright JD, Pri-Paz S, Herzog TJ, Shah M, Bonanno C, Lewin SN, et al. Predictors of massive blood loss in women with placenta accreta. Am J Obstet Gynecol 2011; 205:38.e1-38.e6.  Back to cited text no. 11
    
12.
Committee on Obstetric Practice. Committee opinion no 529: placenta accreta. Obstet Gynecol 2012; 120:207–211.  Back to cited text no. 12
    
13.
Fitzpatrick KE, Sellers S, Spark P, Kurinczuk JJ, Brocklehurst P, Knight M. The management and outcomes of placenta accreta, increta, and percreta in the UK: a population-based descriptive study. BJOG 2014; 121:62–70.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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