Fertility Post Placenta Accrete
Condition: Fertility
Study type: Interventional

Summary: 
      This study is the first to investigate the fertility outcome and the influence on ovarian
      reserve after using uterine artery embolization during cesarean delivery.
    

Detailed description: 
      Placenta accreta is an abnormal adherence of the placenta to the uterine wall. Three variants
      of abnormally invasive placentation have been described: placenta accreta, in which placental
      villi invade the surface of the myometrium; placenta increta, in which placental villi extend
      into the myometrium; and placenta percreta, where the villi penetrate through the myometrium
      to the uterine serosa and may invade adjacent organs, such as the bladder.

      Placenta accrete is an increasingly prevalent and potentially dangerous complication of
      pregnancy. It appears to be most strongly predicted by a history of cesarean deliveries and
      low-lying placenta/previa. Additional risk factors include in vitro fertilization pregnancy,
      prior myomectomy, Asherman's syndrome, submucous leiomyomata, maternal age older than 35
      years, elevated second-trimester levels of α-fetoprotein and β-human chorionic gonadotropin.

      Pregnancies complicated with placenta accrete are associated with adverse maternal outcomes,
      including life-threatening maternal haemorrhage, large-volume blood transfusion, uterine
      rupture and peripartum hysterectomy. Moreover , strong association was found between abnormal
      placentation to significant perinatal morbidity and mortality such as small for gestational
      age, preterm delivery, neonatal intensive care unit hospitalization, perinatal death and
      neonatal death.

      Prenatal diagnosis and adequate planning, particularly in high-risk populations, is indicated
      for the reduction of these adverse outcomes. Advances in grayscale and Doppler ultrasound
      have facilitated prenatal diagnosis. Despite advances in imaging techniques, no diagnostic
      technique affords the clinician complete assurance of the presence or absence of placenta
      accreta.

      Management of placenta accrete could be conservative (aiming for uterine preservation) or
      interventional ( elective cesarean hysterectomy ) depending on the patients will to maintain
      the uterus for future fertility, the degree of placentation abnormality or complications
      during delivery. The extent (area, depth) of the abnormal attachment will determine the
      response-curettage, wedge resection, medical management, or hysterectomy. Uterine conserving
      options may work in small focal accretas, but abdominal hysterectomy usually is the most
      definitive treatment.

      Post-partum hemorrhage is the major concern dealing with placenta accrete. Women with
      placenta accreta have a higher incidence of postpartum hemorrhage and are more likely to
      undergo emergency hysterectomy .

      If the diagnosis or a strong suspicion is formed before delivery, a number of measures should
      be taken including counseling the patient about the likelihood of hysterectomy and blood
      transfusion, preparing blood products and clotting factors and considering using cell saver
      technology.The appropriate location and timing for delivery should be considered to allow
      access to adequate surgical personnel and equipment and a preoperative anesthesia assessment
      should be obtained.

      A patient with stable vital signs and persistent bleeding, especially if the rate of loss is
      not excessive, may be a candidate for arterial embolization. Radiographic identification of
      bleeding vessels allows embolization with gelfoam, coils, or glue. Balloon occlusion is also
      a technique used in such circumstances. Embolization can be used for bleeding that continues
      after hysterectomy or can be used as an alternative to hysterectomy to preserve fertility.

      Studies estimating the fertility and pregnancy outcomes after successful conservative
      treatment for placenta accrete have demonstrated placenta accreta does not appear to
      compromise the patients' subsequent fertility or obstetrical outcome.

      By reviewing the literature, no prospective studies have specifically evaluated fertility,
      following uterine artery embolization during cesarean section due to placenta accrete .

      Methods:

      Women that were operated and fit inclusion criteria will be invited to participate in the
      study after getting advanced notice on requirements . After giving informed consent to
      participate in the study, demographic parameters and medical history will be taken, including
      - age , Body Mass Index ( BMI), parity, gravity, past medical history, past operations.

      preoperative intra operative and post operative information will be collected.

      All women participating will complete -

        1. Day 2 blood sample for hormonal profile - follicle stimulating hormone ( FSH), estrogen
           (E2), progesterone (P)

        2. Blood sample for anti mullarian hormon (AMH)

        3. Vaginal ultrasound assessing antral follicle count (AFC)
    

Intervention name(s): Vaginal ultrasound; Blood sample
Intervention type(s): Device; Biological
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Diagnostic
Keywords: placenta accreta; cesarean section; artery embolization