Conservative Management of Morbidly Adherent Anterior Situated Placenta
Condition: Placenta Accreta
MeSH terms: Placenta Accreta
Study type: Interventional

Summary: 
      Placenta accreta is defined as abnormal trophoblast invasion of part or the entire placenta
      into the myometrium of the uterine wall. Placenta accreta spectrum (PAS), formerly known as
      morbidly adherent placenta, refers to the range of pathologic adherence of the placenta,
      including placenta increta, percreta, and accreta.

      An important risk factor of placenta accreta is placenta previa in the presence of a uterine
      scar. Placenta previa is an independent risk factor for placenta accreta.Additional reported
      risk factors for placenta accreta include increased maternal age and multiparity, other prior
      uterine surgery, prior uterine curettage,uterine irradiation, Asherman syndrome, uterine
      leiomyomata, uterine anomalies, hypertensive disorders of pregnancy and smoking. (1,2)
      Maternal morbidity and mortality can occur because of severe and sometimes life-threatening
      hemorrhage, which often requires blood transfusion also and rates of maternal death are
      increased for women with PAS. Additionally, patients with PAS are more likely to require
      hysterectomy at the time of delivery or during the postpartum period and have longer hospital
      stays states.(3) According to FIGO Classification of PAS Disorders 2019 There are three
      grades. Grade 1: abnormally adherent placenta (placenta adherent or accreta) - attached
      directly to the surface of the middle layer of the uterine wall (myometrium) without invading
      it, Grade 2: abnormally invasive placenta (increta) - invasion into the myometrium and Grade
      3: abnormally invasive placenta (percreta) invasion may reach surrounding pelvic tissues,
      vessels and organs.(4) Nowadays, fertility sparing and conservative methods can be applied.
      These methods include placenta left in situ, cervical inversion technique , triple-P
      procedure, cervico-isthmic compression suture and anterior wall uterine resection
    

Detailed description: 
      Study Design & Area:

      Randomized controlled trial (RCT) of pregnant women recruited from Department of Obstetrics
      and Gynecology Mansoura University Hospitals during September 2020 until September 2021 and
      may be extended if needed.

      The study groups will undergo:

      Informed consent

      History:

      Personal: (age, duration of marriage, special habits). Menstrual history Obstetric: (parity,
      mode of delivery, fetal outcome). Present history of any medical or obstetric problems. Past
      medical and surgical history. Clinical examination : General and obstetric examination

      Calculation of Gestational Age :

      Gestational age will be calculated by adding 280 days (40weeks) to the first day of the last
      menstrual period or by ultrasound.

      Investigation:

      Lab investigation:- Complete blood count , Bleeding profile, international normalization
      ratio, liver function tests, kidney function tests

      Ultrasound:

      Ultrasound Finding:- i. Establish the presence of a living fetus. ii. Estimate the age of the
      pregnancy. iii. Diagnose congenital abnormalities of the fetus. iv. Evaluate the position of
      the fetus. v. Determine the amount of amniotic fluid around the baby. vi. Assess fetal
      growth. vii. Assess fetal well-being. viii. Evaluate the position of the placenta.

      - When the antepartum diagnosis of placenta accreta is made, it is usually based on
      ultrasound findings in the second or third trimester. Sonographic findings that may be
      suggestive of placenta accreta include:

        1. Loss of normal hypoechoic retroplacental zone.

        2. Multiple vascular lacunae (irregular vascular spaces) within placenta, giving "Swiss
           cheese" appearance.

        3. Blood vessels or placental tissue bridging uterine-placental margin, myometrial-bladder
           interface.

        4. Retroplacental myometrial thickness of <1 mm. 3 - Color Doppler criteria:

             -  Diffuse or focal lacunar flow pattern.

             -  Sonolucent vascular lakes with turbulent flow typified by high-velocity (peak
                systolic velocity>15 cm/s) and low-resistance waveform.

             -  Markedly dilated vessels over the peripheral subplacental region (6)

      Surgical Procedure:

      Preparation of the patient before surgery:

        -  Patient will shave their pubic hair , take a shower with an antiseptic soap, antibiotic
           prophylaxis and urinary catheter insertion .

        -  Caesarean section steps :

      After spinal anesthesia and skin sterilization Abdominal Incision: Pfannenstiel incision then
      cut the subcutaneous fat and rectus sheath and blunt entry into the peritoneal cavity .
    

Intervention name(s): Cervico- isthmic compression suture; Anterior wall uterine resection:
Intervention type(s): Procedure; Procedure
Intervention description(s): Circular isthmic-cervical sutures will be applied . To avoid ureter and bladder injury, the bladder will be reflected downward. A silastic drain will be inserted into internal and through the external os , so as to drain the uterine cavity and to keep the cervical canal open. Firstly, at the left side of the uterus, a Vicryl number two (No..2) stitch will be inserted very close to the cervix from the anterior to the posterior side of the broad ligament.; After fetal delivery, two corners of the uterine incision and the superior and inferior lips will be clamped immediately by four Mayo clamps. Blunt dissection downward to the bladder-uterus peritoneal reflection will perform, to the partial anterior wall of the uterine myometrium where the placenta was deeply adherent (a myometrium defect, with only the serous layer of the uterus) will be respected, together with the placenta. It is important to ensure that sufficient myometrium above the peritoneal reflection will be available for an optimum closure. Then, as much remaining placenta as possible will be removed piecemeal from the edge of the uterine incision. Clamps and multiple hemostatic sutures will be applied rapidly
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: - Randomized controlled trial (RCT) of pregnant women recruited from Department of Obstetrics and Gynecology Mansoura University Hospitals for elective termination of pregnancy
Masking: None (Open Label)
Primary purpose: Treatment