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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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

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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

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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.