Meirowitz PPH - Event & Meeting Management Technology€¦ · b) Delivery is recommended at a tertiary center after mature amniocentesis. c) Intraoperative placental mapping aims
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11/2/2015
1
MOC UPDATEACOG Annual District II Meeting
October 2015
Natalie Meirowitz, M.D.
Division Chief, Maternal‐Fetal Medicine
Long Island Jewish Medical Center
Learning Objectives
Participants should be able to:1. Appreciate the prenatal diagnosis of accreta
2. Develop a safe delivery plan
3. Apply effective surgical techniques
11/2/2015
2
Which statement about placenta accretaMOST accurate?
a) MRI is superior to ultrasound for diagnosis.
b) Delivery is recommended at a tertiary center after mature amniocentesis.
c) Intraoperative placental mapping aims to avoid injuring the placenta at the time of hysterotomy.
d) Balloon occlusion catheters reduces blood loss.
e) Conservative management is offered to patients who do not accept blood products.
PLACENTA ACCRETA
• Incidence increasing
– 1:7,000 1:300
• Major Risk Factors
– Placenta Previa
– Previous uterine surgery
Previous C/S Silver et al-2006MFM Network
none 3%
1 10%
2 40%
3 60%
4 60%
5 60%
Accreta Incidence with Placenta Previa
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PLACENTA ACCRETA -Morbidity-
Average blood loss 3,000‐3,500 cc
EBL > 5,000cc 15%
Transfusion 60‐100%
Median RBC’s 7 units
ICU admission 25%
Ventilatory support 15%
Bladder injury 15%
Prenatal diagnosis and planned delivery before term by a multidisciplinary team
significantly reduces maternal and neonatal morbidity and mortality.
MFM/OBPelvic surgeonAnesthesiologist
UrologistIntensivist
Transfusion Medicine Specialist
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Prenatal Diagnosis of Accreta
• Clinical risk factors plus imaging
• Ultrasound is primary modality, MRI is adjunct
Sonographic features:
-Loss of the hypoechoic retroplacental zone
-Multiple intraplacental vascular lacunae
-Thinning of serosa-bladder interface
-Increased vascularity on color Doppler.
NSLIJ Algorithm for Prenatal Diagnosis
Patients with previous C/S and placenta previa or low lying placenta on second trimester ultrasound
High index of suspicion for placenta accreta
MRI reserved for for depth of invasion or posterior placenta
Delivery 34-36wks
Targeted ultrasound for signs of accreta at 28 weeks gestation
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INTERVENTIONAL RADIOLOGYVascular Catheters
• Hybrid OR vs. fluoroscopy C- arm• Balloon occlusion of internal iliac artery
– Inflates in seconds– Large catheter, potential for injury
• Uterine artery embolization – Goal: reduce blood loss with conservative
management– Drawback: Time required to complete
procedure
NSLIJ Algorithm for Vascular and Ureteral Catheters
Suspected Accreta Vascular Catheters Ureteral Catheters
Planned C- hyst No Yes
Planned conservative management
Yes (UAE) No
Multiple gestation Yes (Balloon Occlusion)
Yes
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• Vertical skin incision• 3-way Foley• Map placental location (upper margin)• Upon entering abd cavity :Inspect lower ut. segment
• High transverse incision (2-3 cm above placental edge)• Close uterine incision without disrupting placenta• Proceed to hysterectomy• Don’t develop bladder flap until uterine arteries are
devascularized• Inflate bladder before dissecting off lower ut segment
Confirmed
PLACENTA ACCRETASurgical Approach
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Conservative Management of Placenta Accreta
Conservative (Uterus and placenta left in situ)
-Delayed bleeding-Coagulopathy-Sepsis
Definitive therapy is hysterectomy
20-50% delayed hysterectomy
11/2/2015
8
Which statement about placenta accretaMOST accurate?
a) MRI is superior to ultrasound for diagnosis.
b) Delivery is recommended at a tertiary center after mature amniocentesis.
c) Intraoperative placental mapping aims to avoid injuring the placenta at the time of hysterotomy.
d) Balloon occlusion catheters reduces blood loss.
e) Conservative management is offered to patients who do not accept blood products.
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