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Morbidly Adherent Placenta (MAP): Lessons learnt  [PDF]
Leena Wadhwa, Sangeeta Gupta, Pratibha Gupta, Bhawna Satija, Rupali Khanna
Open Journal of Obstetrics and Gynecology (OJOG) , 2013, DOI: 10.4236/ojog.2013.31A040

Context: Once a rare occurrence, MAP is becoming an increasing threat to maternal lives. Aims: To summarize our experience in the management of patients with morbidly adherent placenta. Introduction: MAP is a potentially life threatening hemorrhagic condition responsible for 7% - 10% maternal mortality. Settings and Design: Tertiary care center. Methods and Material: Retrospective study in which data of twelve patients with clinical diagnosis of morbidly adherent placenta was reviewed from Jan 2009 till Sept 2012. Results: The incidence of placenta accreta was found to be increasing every year. Out of twelve cases with clinical diagnosis of MAP, placenta previa was present in 10/12 patients with MAP. All patients had history of previous section. Two patients with preoperative diagnosis of MAP on USG/MRI were found to be normal intra-operative and in one patient focal accreta was diagnosed intraoperatively. Nine patients of MAP underwent caesarean hysterectomy due to excessive bleeding during placental separation and were confirmed histo-pathologically (3 accreta vera, 3 increta and 3 percreta). Internal iliac artery ligation was done in 2 patients. Two patients with placenta percreta had bladder rupture which was repaired and these two patients subsequently expired. Conclusions: The incidence of placenta accreta is increasing due to higher cesarean section (C/S) rate. Key to successful outcome is awareness, anticipation, preoperative counseling, planning and multidisciplinary approach.

Association between etiopathogenesis of morbidly adherent placenta and adenomyosis  [PDF]
Christopher A. Enakpene, Ozgul Muneyyirci-Delale
Open Journal of Obstetrics and Gynecology (OJOG) , 2012, DOI: 10.4236/ojog.2012.23067
Abstract: The association between etio-pathogenesis of morbidly adherent placenta (MAP) or placenta cretas and adenomyosis has never been described in medical literature. Contrary to the believe that MAP is due to direct invasion of trophoblastic tissues into the adjacent normal myometrium due to prior uterine surgeries, this article describes how pre-existence of adenomyosis acts as a precursor for the development of placenta cretas. It elucidates how prior uterine traumas such as surgeries, repeated childbirths and endometritis cause endometrial tissues to invade the myometrium as a result of disruption of decidua basalis. The invaded endometrial tissues cause hyper-plasia and hypertrophy of surrounding myometrium to form the clinical entity called adenomyosis. The over-expression of bcl-2 oncogene in the endometrium causes inhibition of apoptosis of endometrial cells removing the barrier of trophoblastic tissues to invade the myometrium to form MAP. This hypothesis is based on the similarity of their clinical perspectives, similar pathological description of the two disease entities and their common molecular components. Both diseases increase with age; more in women older than 35 years and also in those with history of previous endometrial traumas such as surgeries, childbirth and endometritis. Both diseases also share common pathological factors and molecular components due to absence of deciduas basalis and over-expression of bcl-2 oncoprotein gene, inhibition of cell apoptosis and failure to find genetic abnormalities such as mutations of K-ras, P53 or LOH. An ongoing study looking at uterine specimens from cesarean hysterectomies and pelvic MRI evaluation of patients with retained placentas to prove that pre-existing adenomyosis may be a precursor to the development of morbidly adherent placenta is near to conclusion.
Maternal Outcome of Cases of Placenta Previa with and without Morbidly Adherent Placenta at King Abdul-Aziz University Hospital, Saudi Arabia  [PDF]
Ashraf Radwan, Abdel Magid Abdou, Sausan Kafy, Mamdouh Sheba, Hassan Allam, Moaz Bokhari, Majed Almutairi
Open Journal of Obstetrics and Gynecology (OJOG) , 2018, DOI: 10.4236/ojog.2018.813142
Abstract: Introduction:Worldwide increasing cesarean section rates are expected to have a parallel increase in the number of cases of Placenta Previa with all the expected complications, including pathologically adherent placenta. This morbidly adherent placenta constitutes a serious and possibly a life threatening complication. An efficient team capable for managing possible complicated situations will be able to reduce mortality and morbidity. Objectives: The aim of our study was to evaluate maternal outcome in cases of Placenta Previa with and without morbidly adherent placenta. Methods: Analysis of all pregnancies complicated by antepartum hemorrhage during the period from January 2013 to September 2017 at King Abdul-Aziz University Hospital (KAUH), Jeddah, Kingdom of Saudi Arabia (KSA) was done. Cases of Placenta Previa with gestational age > 28 weeks were included. They were classified into 2 groups; Group (A) included Placenta Previa cases without morbidly adherent placenta and Group (B) included cases with morbidly adherent placenta
Detecting Accuracy of Three Dimensional Power Doppler (3DPD) Vascular Indices for Prenatal Diagnosis of Morbidly Adherent Placenta in Patients with Placenta Previa  [PDF]
Ahmed Sherif Abdel-Hamid, Maged Mahmoud Elshourbagy, Mohamed Sayed Aly, Shahira Zakaria Mohamed Ali Ghaly
Open Journal of Obstetrics and Gynecology (OJOG) , 2020, DOI: 10.4236/ojog.2020.101005
Abstract: Objective:?The studys objective was to assess the accuracy of using prenatal 3-dimensional power Doppler analysis of vascular placental indices to accurately diagnose morbidly adherent placenta objectively. Background:?Traditionally, 2D ultrasound was used for the diagnosis of a suspected morbidly adherent placenta (MAP) previa. More objective techniques like 3D power Doppler havent been well studied. Study Design:?A prospective cohort study?is?designed for women with gestational age between 28 and?32 weeks with suspected placenta previa. Patients were examined by 2D ultrasound which was used in management decisions.3D Power Dopplers VI, FI and VFI were measured during the same examination after manual tracing of placenta; data were blinded to obstetricians. Histopathology was performed to confirm MAP. Results: Our results showed that the 3D power Doppler VI ≥ 16 predicted the diagnosis of MAP with 100% sensitivity, 100% specificity which is better than those of 2D ultrasound. While VI > 33.1 measured by 3D Doppler predicted severe MAP with a sensitivity of 73.9% and specificity of 86.4%, which was superior to 2D ultrasound. Conclusion:?In patients with placenta previa, the 3D Dopplers vascular index accurately predicts MAP. Furthermore, vascular and vascular flow indices of 3D Doppler were more predictive of severe cases of MAP compared to 2D ultrasound.
Evaluation of Different Ultrasonographic Modalities in the Diagnosis of Morbidly Adherent Placenta: A Cross-Sectional Study  [PDF]
Mostafa Hussein, Mohammed F. Ramadan Abd, Ahmad M. Abu-Elhassan, Ahmed M. Abbas, Alaa Eldin A. Youssef
Open Journal of Obstetrics and Gynecology (OJOG) , 2019, DOI: 10.4236/ojog.2019.94041
Abstract: Objective: To compare the accuracy of different ultrasonographic modalities; two-dimensional ultrasound (2D-US), color Doppler and three-dimensional power Doppler (3D-PD) in the antenatal diagnosis of the morbidly adherent placenta. Setting: Obstetrics and Gynecology Department, Faculty of Medicine, Assiut University, Assiut, Egypt. Study Design: A cross-sectional study. Methods: All patients fulfill the inclusions criteria: gestational age > 28 weeks, previous one or more cesarean delivery, previous uterine surgery, placenta previa, vitally stable patient and women accepted to participate in the study were included. All patients were evaluated using 2D-US, color Doppler and 3D-PD before delivery. The final diagnosis was established by laparotomy and by histopathology of hysterectomy sample if hysterectomy would be done. Results: One-hundred fifty patients were enrolled in the study. 2D-US has higher sensitivity (86.96%) than 2D color Doppler (84.06%) and 3D-PD (79.71%) in the diagnosis of placenta accreta. On the other hand, 3D-PD has slightly higher specificity (83.95%) than color Doppler (82.72%) and
Psychological Repercussions of Morbid Adherent Placenta (MAP) Patients  [PDF]
Laila Yahya A. Alhubaishi
Open Journal of Obstetrics and Gynecology (OJOG) , 2019, DOI: 10.4236/ojog.2019.99124
Abstract: Morbidly adherent placenta (MAP) is a major cause of maternal morbidity and cause of severe fear and stress to the patient, family and the treating staff. Proper counseling and sympathetic case handling and management is of great relief. Detailed explanation for the pathology and the treatment plan will support the psychology of the patient and surrounding.
Cellular Changes in the Placenta in Pregnancies Complicated with Diabetes
Verma,Ranjana; Mishra,Sabita; Kaul,Jagat Mohini;
International Journal of Morphology , 2010, DOI: 10.4067/S0717-95022010000100038
Abstract: placenta is the most accurate record of the infant prenatal experience. after delivery if the placenta is examined minutely, it provides much insight into the prenatal health of the baby and the mother. in diabetic pregnancy, placental weight is higher in comparison to normal pregnancy. to study the cellular differences that might contribute to larger size of placenta, light microscopic analysis was performed on 25 full term placentas, out of which 20 were of gestational diabetes mellitus (12 controlled on diet, 8 controlled on insulin) and 5 control group. tissue sections were processed and analyzed. birth weight of neonate, placental weight, vascular pattern of chorionic blood vessels and site of attachment of umbilical cord were recorded. in the placenta of diabetic pregnants, gross abnormalities were uncommon but microscopic examination exhibited, to a varying degree, lesions like syncytial knots, fibrinoid necrosis, villous edema, villous fibrosis and capillary proliferation. these findings indicate that control of hyperglycemia only partially prevents the development of placental abnormalities which must be due to some other constituent factor of diabetic state.
Placenta previa percreta left in situ - management by delayed hysterectomy: a case report
Minna Tikkanen, Vedran Stefanovic, Jorma Paavonen
Journal of Medical Case Reports , 2011, DOI: 10.1186/1752-1947-5-418
Abstract: We present the case of a 30-year-old African woman, gravida 7, para 5, with placenta percreta managed by an alternative approach: the placenta was left in situ, methotrexate was administered, and a delayed hysterectomy was successfully performed.Further studies are needed to develop the most appropriate management option for the most severe cases of abnormal placentation. Delayed hysterectomy may be a reasonable strategy in the most severe cases.Placenta accreta (PA) is characterized by abnormal invasion of the placenta into the myometrium. PA is defined as superficial invasion, placenta increta as middle layer invasion and placenta percreta as deep invasion, which is the most severe form of PA with an incidence of one in 7000. All three types are collectively known as placenta accreta. The incidence of PA has dramatically increased due to increasing Caesarean section rates [1,2]. Although rare, PA is one of the most severe pregnancy complications. Maternal morbidity and mortality associated with PA is mainly caused by massive obstetric hemorrhage or emergency hysterectomy, and PA is often diagnosed during delivery or immediately post-partum leading to an obstetric emergency [1,3,4]. Studies suggest that antenatal diagnosis may reduce obstetric hemorrhage-related morbidity [5,6]. Furthermore, in some cases a morbidly adherent PA can be left in situ [7,8]. Such conservative management may allow delayed removal of the placenta to avoid massive hemorrhage during an attempted forced removal of the adherent placenta. We describe a case in which placenta percreta was left in situ. Subsequent post-partum hemorrhage was successfully managed by delayed hysterectomy.Our patient was a 30-year-old African woman, gravida 7, para 5. Her second screening ultrasound at 21 weeks of gestation showed normal fetal anatomy and placenta previa. She was referred in her 28th gestational week from her antenatal clinic to the University Hospital Outpatients Maternity Clinic because of anemia
Delayed and successful manual removal of abnormally adherent placenta necessitated by uterine sepsis following conservative management with adjuvant methotrexate – a rewarding clinical experience
S Shekhar, N Chauhan, K Singh, C Sharma, M Surya
South African Journal of Obstetrics and Gynaecology , 2013,
Abstract: Abnormally adherent placenta is characterised by direct attachment of chorionic villi to the uterine wall, often resulting in life-threatening postpartum haemorrhage. Traditionally this complication has been managed by peripartum hysterectomy, which is associated with massive blood loss, injuries to the urinary tract and, importantly, permanent loss of fertility. Encouraging results reported in recent years have led to a gradual shift towards conservative management of select cases of placenta accreta, with the primary aim of conservation of the uterus and fertility. This strategy also avoids the surgical morbidity of peripartum hysterectomy. We report a case of placenta accreta in which delayed manual removal necessitated by uterine sepsis following conservative management with methotrexate was completely successful. S Afr J OG 2013;19(1):19-21. DOI:10.7196/SAJOG.570
Morbidly Obese Woman Unaware of Pregnancy until Full-Term and Complicated by Intraamniotic Sepsis with Pseudomonas  [PDF]
H. Muppala,J. Rafi,I. Arthur
Infectious Diseases in Obstetrics and Gynecology , 2007, DOI: 10.1155/2007/51689
Abstract: A 32-year-old Caucasian woman of body mass index (BMI) 46 presented with urinary symptoms to accident and emergency (A&E). Acute pyelonephritis was the diagnosis. Transabdominal scan revealed a live term fetus. Both the partners were unaware of the ongoing pregnancy until diagnosed. She underwent emergency cesarean under general anaesthesia (GA) for nonreassuring CTG, severe chorioamnionitis, and moderate preecclampsia. A live male baby weighing 4400 grams delivered in poor condition. Placental tissue on culture exhibited scanty growth of pseudomonas aeruginosa. Chorioamnionitis due to pseudomonas is rare, with high neonatal morbidity and mortality. It is mostly reported among preterm prelabor rupture of membranes (PPROM). Educating the community especially morbidly obese women if they put on excessive weight or with irregular periods should seek doctor's advice and exclude pregnancy. For the primary care provider, it is of great importance to exclude pregnancy in any reproductive woman presenting with abdominal complaints. This case also brings to clinicians notice that pseudomonas can be community-acquired and can affect term pregnancies with intact or prolonged rupture of membranes.
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