Incidence Of Placenta Accreta Research Articles

Hubungan Skor Plasenta Akreta Indeks (PAI) dengan Kejadian Plasenta Akreta pada pasien bersalin di bagian kebidanan RSUP.dr.M.Djamil Padang

Objective: To determine the relationship between PAI scores and the incidence of placenta accreta in placenta previa accreta suspects who gave birth at RSUP M. Djamil Padang. Method: This study is an analytical study using a cross-sectional study design with a sample of all patients with placenta previa totalis suspected accreta who gave birth in the obstetrics department of RSUP M. Djamil Padang during the period January 1, 2017 - April 30, 2018. The data were taken from the patient's medical records that included age, parity status, labor history, and PAI score from ultrasound examination results. The relationship between PAI scores and the incidence of placenta accreta was analyzed using an independent T-test with a significant degree of <0.05. The research results are presented in tabular form. Results: During the study period, 30 patients with placenta previa suspected of accreta at RSUP M. Djamil Padang. It is known that cases of placenta accreta were more common in multiparous (57.7%), suspected accreta (57.7%), had a history of SC (65.2%), and the mean age of patients with accreta was 34.7 ± 3.5 years. Furthermore, it can be concluded that the mean PAI score in patients with placenta accreta is higher than non-accreta, and there is a significant relationship between PAI scores and cases of placenta accreta (p> 0.05).Conclusion: The mean PAI score in patients with placenta accreta is higher than without accreta and there is a significant relationship between PAI scores and cases of placenta accreta.Keywords: Placenta Accreta, PAI Score

Hubungan Skor Plasenta Akreta Indeks (PAI) dengan Kejadian Plasenta Akreta pada pasien bersalin di bagian kebidanan RSUP.dr.M.Djamil Padang

Objective : To determine the relationship between PAI scores and the incidence of placenta accreta in placenta previa accreta suspects who gave birth at RSUP M. Djamil Padang. Method : This study is an analytical study using a cross-sectional study design with a sample of all patients with placenta previa totalis suspected accreta who gave birth in the obstetrics department of RSUP M. Djamil Padang during the period January 1, 2017 - April 30, 2018. The data were taken from the patient's medical records that included age, parity status, labor history, and PAI score from ultrasound examination results. The relationship between PAI scores and the incidence of placenta accreta was analyzed using an independent T-test with a significant degree of <0.05. The research results are presented in tabular form. Results : During the study period, 30 patients with placenta previa suspected of accreta at RSUP M. Djamil Padang. It is known that cases of placenta accreta were more common in multiparous (57.7%), suspected accreta (57.7%), had a history of SC (65.2%), and the mean age of patients with accreta was 34.7 ± 3.5 years. Furthermore, it can be concluded that the mean PAI score in patients with placenta accreta is higher than non-accreta, and there is a significant relationship between PAI scores and cases of placenta accreta (p> 0.05). Conclusion : The mean PAI score in patients with placenta accreta is higher than without accreta and there is a significant relationship between PAI scores and cases of placenta accreta. Keywords: Placenta Accreta, PAI Score

A systematic review and meta-analysis of cesarean delivery and other uterine surgery as risk factors for placenta accreta.

The incidence of placenta accreta has increased in recent years and it has been suggested that the rising trend in cesarean delivery and other uterine surgery is the underlying cause. To explore the magnitude of the effect of performing single and repeat cesarean deliveries or other uterine surgery on the incidence of placenta accreta. Relevant databases were searched for papers published before August 1, 2018, using terms including "accreta" and "cesarean." Cohort studies assessing the risk of placenta accreta according to women's history of uterine surgery. Meta-analyses were performed to assess the risks associated between uterine surgery and placenta accreta, hysterectomy, and uterine rupture. The I2 statistic was used to examine between-study heterogeneity. The risk of placenta accreta in a second pregnancy increased for women who had undergone a cesarean in their first pregnancy compared with vaginal delivery (OR 3.02; 95% CI, 1.50-6.08). Absolute risk of placenta accreta increased with the number of previous cesareans. The risk of uterine rupture and hysterectomy was also associated with the number of cesareans. Risk of placenta accreta, hysterectomy, and uterine rupture increases with the number of previous cesarean deliveries. CRD42016050646.

Uterine Artery Doppler Velocimetry in Placenta Previa and Placenta Accreta

AbstractBackground: Placenta previa and placenta accreta are common obstetrical problem. Placenta previa is partially or totally implanted placenta in the lower uterine segment, this abnormality in the site occurs with different degrees, placenta previa lateralis, marginalis and centralis either incomplete or complete. Abnormal placental adhesion means that the placenta invades the uterine myometrium with different degree. This morbid adhesion is called “Placenta Accreta”, with different grades according to the degree of the trophoblastic invasion through the myometrium and bladder serosa as placenta accreta vera, placenta increta and placenta percreta. Incidence of placenta accreta is increased over the past years mainly due to increasing rates of cesarean delivery. Placenta accreta may lead to massive obstetric hemorrhage with attempt to remove the placenta leading to several complications up to death. Diagnosis of placenta accreta can be done by different modalities such as Ultrasound Grey scale, Color Doppler, Magnetic Resonance Imaging (MRI). Ultrasonography is usually employed as the primary modality for antenatal diagnosis of invasive placentation. Over recent years, Color Doppler Sonography (CDS) have been started to be used to predict placental abnormalities. CDS, a noninvasive and simple tool, is useful indistinguishing normal and abnormal placentation.Aim of Study: The aim of this work was to study uterine artery doppler velocimeteric changes in patients with placenta previa and placenta accrete.Patients and Methods: 30 pregnant females were included in this comparative prospective clinical study subdivided into two group; Group (A) Includes 15 patients with anterior placenta previa, and Group (B) Include 15 patients with anterior placenta previa accrete. Both groups were diagnosed by trans-abdominal Ultrasonography either from outpatient clinics or inpatient department of Tanta University Hospital seeking for antenatal care from Octorber 2017 to August 2018. All patients underwent uterine artery Doppler velocimetry to measure the mean Resistive Index (RI) and Pulsatility Index (PI) in the third trimester and compared between both groups.Results: the mean uterine artery velocemtric changes including mean Resistive Indices (RI) and mean Pusitility Indices (PI) were significantly lower in the placenta accreta group compared to placenta previa group (with mean for RI 0.41 versus 0.45; p=0.001) and (with mean for PI 0.50 versus 0.56; p=0.001), the uterine artery Doppler values in combina-tion with maternal characteristics, such as previous history of cesarean deliveries, will improve screening accuracy of placenta accrete (p=0.022). Conclustion: This study suggests that the mean PI and RI measured by uterine artery Doppler velocimetry is reduced in patients with placenta accreta compared to those without accreta. Accuracy of diagnosis can be potentially improved in invasive placentation if uterine artery Doppler values and the history of cesarean delivery are combined.

The use of pre-caesarean prophylactic intra-arterial balloon catheters for suspected placenta accreta.

The incidence of placenta accreta (PA) has markedly increased in the United States, from 1/30000 in 1950 to 1/731 deliveries in 2011. Although placenta praevia after prior caesarean sections (CS) is the most important risk factor for PA, other risk factors make up 1-5% of PA occurrences. At our referral hospital, we use the pre-caesarean prophylactic balloon catheter with or without post-surgery embolisation in a hybrid room. Here, we evaluate the role of prior CS and placenta praevia on the outcome of this procedure. This retrospective cohort analysis included 61 women during the years 2004-2016 with sonographic suspicion of PA who underwent balloon catheterisation prior to CS. Eleven women had no previous CS (18%). Mean previous CS rate was 1.85. Six women (9.8%) had previous dilatation and curettage (D&C); 36.4% of women with no previous CS had previous D&C compared with 4% of women with previous CS (P=0.008). Placenta praevia was sonographically diagnosed in 55 women (90.2%). There was a higher rate of caesarean hysterectomy in women with previous CS than in those without (32% vs 0%, P=0.052) but no significant difference in blood product requirements (45.5% vs 66%, P=0.303). There was no significant difference in hysterectomy rate, blood transfusion or surgery duration between women with and without placenta praevia (P=0.648, 0.594, 0.995, respectively). Previous CS rather than placenta praevia is a strong indicator of hysterectomy in cases of PA. Different risk factors for PA do not affect blood transfusion rates or surgery duration.

Incidence of Placenta Accreta and its Complications in Cases of Previous Cesearean Sections with Placenta Previa Anterior at Al Hussein University Hospital

Objective: Incidence of placenta accreta and its complications in cases of previous cesarean sections with placenta previa anterior at Al Hussein University Hospital. Materials and Methods:Ultrasound is the recommended first step in the diagnosis of placenta previa accreta. Color Dopplerultrasound has been suggested to aid in the diagnosis of placenta previa accreta. Magnetic Resonance Imaging also was used. Results: Cesarean Hysterectomy performed in all cases of accretion, bladder injury in 19 (47.5%) cases, bowel injury in 1 (2.5%) case, all cases received intraoperative blood transfusion, postoperative blood transfusion in 38 (95%) cases and ICU admission in 25 (62.5%) cases. Conclusion: The incidences of placenta accreta in cases of previous cesarean section with placenta previa anterior were 63%. Incidence, risk factors and Feto-maternal outcome of management of Patients with placenta accreta at Al Hussein University Maternity Hospital are comparable with those presented in several literatures.

Incidence of Placenta Accreta and Its Complications in Cases of Previous Cesearean Sections with Placenta Praevia Anterior at El-Sayed Galal Hospital

Background: due to the increasing rate of cesarean delivery, there has been a 10-fold rise in the incidence of placenta accreta since the 1970. In a recent survey, placenta accreta was even found to become the leading cause of emergency peripartum hysterectomy which represented 40–60% of cases. Aim of the Work: the purpose of this study was to determine the incidence of placenta accreta and its complications in cases of previous cesarean sections with placenta praevia anterior at El-Sayed Galal Univerity Hospital. Patients and Methods: this prospective study was done at El-Sayed Galal Maternal Unevirsity Hospital during the period from March 2017 to March 2018 on 100 pregnant women diagnosed by ultrasound as placenta praevia or low lying placenta anterior with previous cesarean section, they were selected from Outpatient Clinic, Ultrasound Unit and women admitted in El-Sayed Galal Maternal University Hospital Departments. Results: the incidence of placenta accreta in cases of previous cesarean section with placenta praevia anterior were 63%. Risk factors of placenta accreta were: 1) Placenta praevia with prior cesarean section. All cases had placenta praevia and had at least one previous CS, 2) Increased maternal age (the mean age 32.60±5.018 years in cases of placenta accrete ), and 29.14±4.889 years in cases with normal placenta. 3) Multiparity [the median parity was 3 (range: 1-6). The ultrasonography and Doppler was suggestive of morbid adherence in 60 cases (95.2%)of cases approved with placenta accreta, with accuracy 96, sensiyivity 95.24, specificity 97.3, +ve predictive value 98.36, and -ve predictive value 92.31. The intraoperative data were:, - Cesarean hysterectomy performed in all cases of placenta accrete (63 cases), and 2 cases (5.4%) of normal placenta due to severe bleeding from placental ped and uterine atony. , - Bladder injury occured in 31 cases(49.2%) all of them approved placenta accreta, all of them do C.S hystrectomy and performed bladder repair. Bowel injury in 2 cases (3.2%) all of them have placenta accreta and C.S hysterectomy done. All cases of placenta accreta received intra operative blood transfusion. Uterine preserving procedures (Bakry balloon) done in one case after spontaneous separation of the placenta. The postoperative data were:, - ICU admission occurred in 40 cases (63.5%) of cases with placenta accrete, and in 2 cases (5.4%) of cases with normal placenta. 61 cases (96.8%) of cases with placenta accreta received postoperative blood transfusion. -No cases complicated with DIC or death. Conclusion: from the above our results showed that the incidence, risk factors and Feto-maternal outcome of management of Patients with placenta accreta at El-Sayed Galal University Maternity Hospital are comparable with those in the previous literatures.

Incidence of Placenta Accreta and its Complications in Cases of Previous Cesearean Sections with Placenta Previa Anterior at Al Hussein University Hospital

Objective: Incidence of placenta accreta and its complications in cases of previous cesarean sections with placenta previa anterior at Al Hussein University Hospital. Materials and Methods:Ultrasound is the recommended first step in the diagnosis of placenta previa accreta. Color Dopplerultrasound has been suggested to aid in the diagnosis of placenta previa accreta. Magnetic Resonance Imaging also was used. Results: Cesarean Hysterectomy performed in all cases of accretion, bladder injury in 19 (47.5%) cases, bowel injury in 1 (2.5%) case, all cases received intraoperative blood transfusion, postoperative blood transfusion in 38 (95%) cases and ICU admission in 25 (62.5%) cases. Conclusion: The incidences of placenta accreta in cases of previous cesarean section with placenta previa anterior were 63%. Incidence, risk factors and Feto-maternal outcome of management of Patients with placenta accreta at Al Hussein University Maternity Hospital are comparable with those presented in several literatures.

Incidence of Placenta Accreta and Its Complications in Cases of Previous Cesearean Sections with Placenta Praevia Anterior at El-Sayed Galal Hospital

Incidence of Placenta Accreta and Its Complications in Cases of Previous Cesearean Sections with Placenta Praevia Anterior at El-Sayed Galal Hospital

The Relationship Between Gelatin Sponge Preparation Methods and the Incidence of Intrauterine Synechia Following Uterine Artery Embolization for Postpartum Hemorrhage

To evaluate the relationship between gelatin sponge preparation methods and the incidence of intrauterine synechia following uterine artery embolization (UAE) for postpartum hemorrhage (PPH). In a retrospective monocentric study, we used data from 20 consecutive UAE procedures (19 patients) for PPH, performed in 2007-2016, in which gelatin sponge had been used. The gelatin sponge was processed either into a slurry by pumping it back and forth about 10 times through two syringes connected to a three-way stopcock or into pledgets using a scalpel and small scissors to obtain pieces approximately 2 × 2 × 2mm in size. Patient information was obtained from medical records, and the data were compared between patients treated with the slurry (n = 7) or pledgets (n = 13) forms. Due to the lack of follow-up data and hysterectomy after UAE, the sample size was 6 and 12 because 1 patient with 2 procedures was excluded. The rate of intrauterine synechia was significantly higher in the slurry group (5/6, 83.3%) than that in the pledgets group (0/12, 0%; P < 0.001). In contrast, there were no significant differences in population characteristics, such as the incidence of placenta accreta, non-placental diseases, and severity of shock (DIC score, shock index, or blood loss) between the groups. Although non-randomization and small sample size were the two main limitations, our observations suggest that UAE using gelatin sponge slurry may be associated with a high incidence of intrauterine synechia compared to UAE using pledgets.

Conservative Management of Placenta Accreta of Seven Cases

Introduction: Placenta accreta is a potentially life threatening obstetrical condition. The incidence has increased. Diagnosis before delivery allows multidisciplinary planning in an attempt to minimize potential maternal or neonatal morbidity and mortality. Prenatal ultrasonography is used to support the diagnosis and guide clinical management leading probably to favorable outcomes. Actually a conservative option which includes leaving all or part of the placenta in situ when fertility preservation is desired is recommended. Methods: We retrospectively reviewed the medical records of all patients diagnosed with placenta accreta in gynecology-obstetrics department of the university hospital Mohammed the VI of Marrakesh; Morocco; from January the first 2014 to January the second 2016. Results: We found seven cases. We described: The epidemiological characteristics, risk factors, management of placenta accreta, outcomes and prognosis. The incidence of placenta accreta was 1/3847 deliveries. The mean term of delivery was 35 weeks. We have adopted a successful conservative treatment in six cases (71.4%). The radical treatment was adopted in one patient initially admitted for severe post-partum hemorrhage; the prognosis was good in 85.7% cases. Conclusion: Conservative management of placenta accreta is a safe and efficient and is an interesting alternative for hysterectomy.

A Standardized Approach for Transfusion Medicine Support in Patients With Morbidly Adherent Placenta.

The incidence of placenta accreta (PA) has increased from 0.8 to 3.0 in 1000 pregnancies, driven by increased rates of cesarean deliveries (32.2% in 2014) of births in the United States. The average blood loss for a delivery complicated by PA ranges from 2000 to 5000 mL, frequently requiring substantial transfusion medicine support. We report our own institutional multidisciplinary approach for managing such patients, along with transfusion medicine outcomes, in this setting over a 5-year period. We reviewed records for patients referred to our program in placental disorders from July 1, 2009, to July 1, 2014. A placental disorders preoperative checklist was implemented to ensure optimal management of patients with peripartum hemorrhage. Of 136 patients whose placentas were reviewed postpartum, 21 had PA, 39 had microscopic PA, 17 had increta, 17 had percreta, and 42 had no accreta (of which 11 had placenta previa). For each subtype, the percentage of patients receiving blood products were 71% (PA), 28% (microscopic PA), 82% (increta), 82% (percreta), and 19% (no accreta). Among patients with PA or variants, 89% of patients with PA or variants underwent postpartum hysterectomy, compared to only 5% of patients with no or microscopic PA. Based on our experience and on the findings of our retrospective analysis, patients presenting with either antepartum radiological evidence or clinical suspicion of morbidly adherent placenta will benefit from a standardized protocol for clinical management, including transfusion medicine support. We found that massive hemorrhage is predictable when abnormal placentation is identified predelivery and that blood product support is substantial regardless of the degree of placental invasiveness. The protocol at our institution provides immediate access to sufficient volumes and types of blood products at delivery for patients at highest risk for life-threatening obstetric hemorrhage. Therefore, for patients with a diagnosis of morbidly adherent placenta scheduled for planned cesarean delivery with possible hysterectomy, a programmatic checklist that mobilizes a multidisciplinary team, including proactive transfusion medicine support, represents best practices.

Correlation of Probability Scores of Placenta Accreta on Magnetic Resonance Imaging With Hemorrhagic Morbidity

(J Clin Anesth. 2016;34:261–269) Owing to increases in both cesarean delivery rates and maternal age, the incidence of placenta accreta is rising. Placenta accreta is an abnormal form of placentation with increased depth of placental invasion that is associated with maternal hemorrhage and is an important cause of maternal death. The objective of this study was to assess whether routine stratification of antepartum magnetic resonance imaging (MRI) findings of abnormal placentation correlated with severe maternal hemorrhage and blood product requirements with the goal of appropriately identifying and preparing patients at risk for these outcomes.

Correlation of Probability Scores of Placenta Accreta on Magnetic Resonance Imaging With Hemorrhagic Morbidity

(Abstracted from J Clin Anesth, 34:261–269, 2016) Owing to increases in both cesarean delivery rates and maternal age, the incidence of placenta accreta is rising. Placenta accreta is an unusual type of placentation that is associated with maternal hemorrhage, which is one of the leading causes of maternal death in both developed and developing countries.

In through the backdoor: surgical considerations for the morbidly adherent placenta.

The rising rate of caesarean delivery has led to a dramatic increase in the incidence of placenta accreta and its variants. In the USA, placenta accreta is now estimated to occur in approximately 3 per 1000 deliveries. The entity is associated with substantial maternal morbidity and mortality, with some estimates suggesting a maternal mortality rate of up to 6–7% (Belfort et al. Am J Obstet Gynecol 2010;203:430–9). The morbidity associated with morbidly adherent placenta is due almost entirely to haemorrhage-associated complications. The bleeding that accompanies placenta accreta can be profound—hard to predict preoperatively and difficult to control intraoperatively. The central tenet of the surgical management of placenta accreta is to make every effort to minimise bleeding. This involves leaving the placenta in situ during hysterectomy, planning the hysterotomy site to avoid the placental bed, and minimising the disruption of the uterine tissue overlying the placenta during the dissection. Despite these efforts, avoiding placental disruption is often challenging in women with significant placental invasion. In an attempt to minimise bleeding at the time of hysterectomy for placenta accreta, the author presents a case series of women who underwent retrograde caesarean hysterectomy. In essence, the retroperitoneum is opened, the anterior division of the internal iliac artery is ligated, and the utero-ovarian ligament is divided. [Correction added on 22 January 2016, after first online publication: ‘infundibulopelvic ligament’ has been changed to ‘utero-ovarian ligament’ in the preceding sentence.] The posterior fornix is then exposed and opened. After identification of the ureters, the dissection is carried around the cervix and eventually to the vesicouterine space, at which time the bladder is mobilised from the uterus. The technique mimics an en bloc resection of a pelvic malignancy. In the case series, the authors describe 11 women who underwent the operation and tolerated the procedure well without major morbidity. The author's work is an important consideration to help limit blood loss at the time of hysterectomy. Other operative interventions such as uterine artery embolisation and placement of vascular balloon occlusion catheters have also been suggested, and there is great interest in conservative management of placenta accreta in which the placenta is left in situ (Perez-Delboy et al. BJOG 2014;121:163–9). However, to date, prospective trials are largely lacking and when to use each of these management strategies is based in large part on expert opinion. Perhaps the most important point that this series raises is the complexity of the management of women with placenta accreta. In essence, every case is somewhat different and often requires complex decision-making in the absence of high-quality data. Therefore, any novel surgical approach that may reduce the blood loss and the need for transfusion in women with placenta accreta adds an important component to our surgical armamentarium. Previous work has shown that women cared for at high-volume hospitals and referral centres have better outcomes (Eller et al. Obstet Gynecol 2011;117:331–7). From a policy perspective, efforts have now focused on developing guidelines and recommendations for referral of women with placenta accreta to centres of excellence in an attempt to reduce maternal morbidity (Silver et al. Am J Obstet Gynecol 2015;212:561–8). Given that the incidence of placenta accreta is likely to continue to rise, efforts such as these to optimise outcomes for women and further studies to help guide best management are urgently needed. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Always be Vigilant for Placenta Accreta

erhaps there is no greater obstetrical surgical challenge P than that of managing a delivery complicated by placenta accreta. Placenta accreta results from a defect of the decidua basalis, which allows invasive placental implantation into varying depths of the myometrium, thus preventing normal separation of the placenta from the uterine wall at the time of delivery. Even when suspected, placenta accreta in whatever form (accreta, increta, or percreta) challenges the skills of the operating surgeon and assistants as well as those of the anesthesiologists, nurses, blood bank, perfusionists, and interventional radiologists involved in the management of such cases. When such placental pathology is encountered unexpectantly, these challenges and associated maternal complications increase markedly. Placenta accreta risks include a 7% maternal mortality rate as well as maternal morbidity related to the massive transfusion of blood and blood products, infection, venous thromboembolism, injury to bowel, bladder or ureters, and subsequent fistula formation. The incidence of placenta accreta has increased 10-fold over the past 50 years occurring in 1 of every 2500 deliveries. Because this pathology appears to be primarily driven by the cesarean delivery rate, the frequency of this complication is likely to be increasing further. Awareness of such complications and their further complexity when placenta accreta is unexpectedly encountered has led efforts to accurately identify this placental abnormality in advance of delivery. Rarely reported in patients without identifiable risks, the majority of pregnancies complicated by placenta accreta have one or more clinical findings or surgical histories. These specifically include a current pregnancy complicated with a placenta previa in a patient with or without a history of uterine surgery (cesarean delivery, myomectomy, hysteoscopic removal of submucous fibroids or adhesions, cornual resection of ectopic pregnancy, and dilatation and curettage) and maternal age greater than 35 years. It appears that the greater risk factor remains that reported by Clark et al. Namely, in patients with a history of cesarean

Placenta ACCRETA: can prenatal diagnosis be performed?

Placenta accreta is a potentially life-threatening obstetric condition that requires a multidisciplinary approach to management. The incidence of placenta accreta has increased and seems to parallel the increasing cesarean delivery rate.

Multidisciplinary Approach to Reduce the Risk of Morbidity and Mortality Related to Placenta Accreta

Poster Presentation Background Placenta previa and accreta can be life threatening and have a high risk of morbidity for mother and infant. The incidence of placenta accreta has increased significantly during the last 30 years. Multidisciplinary planning may reduce the risk of maternal and neonatal morbidity and mortality. The American College of Obstetricians and Gynecologists recommended a planned preterm cesarean hysterectomy with the placenta left in situ. Case A 36‐year‐old, G3P1 woman at 32 weeks gestation was admitted to the antepartum unit with a diagnosis of complete placenta previa and placenta accreta. A multidisciplinary approach was used to plan for a scheduled cesarean with hysterectomy. Multidisciplinary meetings were used to prepare staff for potential complications. The woman was transferred to labor and delivery (L&D) at 36 3/7 weeks gestation. The woman was taken to the operating room (OR) where she received an epidural and had ureteral stents placed per urology. She was then transferred to interventional radiology where arterial balloons were placed. The woman was transferred back to L&D OR for delivery accompanied by the radiologist who prepared to inflate the balloons as needed. The blood bank prepared for the case with four units of blood in the OR and 14 units on hold. After the woman was placed under general anesthesia and the neonatal team was present, the OR team proceeded with the cesarean. A viable infant was born with Apgar scores of 3, 6, 9, and weight of 2520 grams. The placenta was left in situ and the hysterectomy was completed. The woman received 500 ml of albumin and two units of packed red blood cells. The estimated blood loss was 750 ml. The woman had an uneventful recovery and was discharged three days later. Conclusion Although it is not always possible to prepare for an emergent patient who presents to the L&D unit with an acute bleeding episode due to an abnormal placentation, the admission of this woman to the antepartum unit at 32 weeks gestation and multidisciplinary planning ensured that the woman and infant had safe passage. It is essential that all providers be aware of the potential complications and the potential interventions. It is imperative that preparation for massive transfusion is in place and that all necessary equipment is available.

Contribution of placenta accreta to the incidence of postpartum hemorrhage and severe postpartum hemorrhage.

To quantify the contribution of placenta accreta to the rate of postpartum hemorrhage and severe postpartum hemorrhage. All hospital deliveries in Canada (excluding Quebec) for the years 2009 and 2010 (N=570,637) were included in a retrospective cohort study using data from the Canadian Institute for Health Information. Placenta accreta included placental adhesion to the uterine wall, musculature, and surrounding organs (accreta, increta, or percreta). Severe postpartum hemorrhage included postpartum hemorrhage with blood transfusion, hysterectomy, or other procedures to control bleeding (including uterine suturing and ligation or embolization of pelvic arteries). Rates, rate ratios, population-attributable fractions (ie, incidence of postpartum hemorrhage attributable to placenta accreta), and 95% confidence intervals (CIs) were estimated. Logistic regression was used to quantify associations between placenta accreta and risk factors. The incidence of placenta accreta was 14.4 (95% CI 13.4-15.4) per 10,000 deliveries (819 cases among 570,637 deliveries), whereas the incidence of placenta accreta with postpartum hemorrhage was 7.2 (95% CI 6.5-8.0) per 10,000 deliveries. Postpartum hemorrhage among women with placenta accreta was predominantly third-stage hemorrhage (41% of all cases). Although placenta accreta was strongly associated with postpartum hemorrhage (rate ratio 8.3, 95% CI 7.7-8.9), its low frequency resulted in a small population-attributable fraction (1.0%, 95% CI 0.93-1.16). However, the strong association between placenta accreta and postpartum hemorrhage with hysterectomy (rate ratio 286, 95% CI 226-361) resulted in a population-attributable fraction of 29.0% (95% CI 24.3-34.3). Placenta accreta is too infrequent to account for the recent temporal increase in postpartum hemorrhage but contributes substantially to the proportion of postpartum hemorrhage with hysterectomy.

Medical Management of Placenta Accreta with Methotrexate: Review of Two Cases

ABSTRACT Placenta accreta is a potentially life-threatening obstetric condition that requires a multidisciplinary approach for its management. The incidence of placenta accreta has increased over the years. Women at greatest risk of placenta accreta are those who have myometrial damage caused by a previous cesarean delivery. Although recognized obstetric risk factors allow the identification of most cases during the antepartum period, the diagnosis is occasionally discovered at the time of delivery when there is difficulty in delivery of placenta. In general, the recommended management of suspected placenta accreta is planned preterm cesarean hysterectomy with the placenta left in situ because attempts at removal of the placenta are associated with significant hemorrhagic morbidity. Recently, adjuvant therapy with methotrexate has been used in the treatment of morbidly adherent placenta in patients desiring further child bearing. We present two cases where medical management was successful. How to cite this article Singh Y, Raghav V, Kapur A. Medical Management of Placenta Accreta with Methotrexate: Review of Two Cases. J South Asian Feder Obst Gynae 2015;7(2):86-88.