Conservative Management of Morbidly Adherent Anterior Situated Placenta

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:

• Loss of normal hypoechoic retroplacental zone.
• Multiple vascular lacunae (irregular vascular spaces) within placenta, giving "Swiss cheese" appearance.
• Blood vessels or placental tissue bridging uterine-placental margin, myometrial-bladder interface.
• 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 .

Inclusion criteria

• 1- Patient with FIGO classification of PAS disorders Grade 1 & Grade 2 which diagnosed by :

• Loss of normal hypoechoic retroplacental zone.
• Multiple vascular lacunae (irregular vascular spaces) within placenta, giving "Swiss cheese" appearance.
• Retroplacental myometrial thickness of less 1 mm. 2- Patient welling to preserve fertility.

Exclusion criteria

• 1- Patient with FIGO classification of PAS disorders Grade 3 (interruption of the hyperechoic border between the uterine serosa and bladder by US).

2- Age : >40 years old. 3- Patient has medical disorders: cardiac disease, uncontrolled DM, chronic renal disease, chronic liver disease.

4- Patient who refuse to participate in the study.