INCIDENCE OF PLACENTA ACCRETA AND ITS COMPLICATIONS IN CASES OF PREVIOUS CESAREAN SECTIONS WITH PLACENTA PREVIA ANTERIOR

INTRODUCTION

Placenta previa is still estimated to occur in about 0.5 percent of pregnancies, and this increase is linked to the increased use of caesarean sections.¹

Due to the significant prenatal and intrapartum haemorrhage associated with placenta previa, this condition is a leading cause of maternal complications and death. ²

Preterm delivery is also linked to placenta previa, and prematureness increases the risk of baby death by three times^{. 3}

While placenta previa is accompanying with antepartum haemorrhage, massive bleeding necessitating a preterm caesarean section does not

occur in all women with the disease. In the treatment of placenta previa, the capacity to anticipate significant antepartum bleeding and emergency caesarean delivery is critical.⁴

Until now, there has been no agreement on the risk of premature birth linked with distinct forms and sites of placenta previa. Only a few papers have looked at the maternal and perinatal implications of various forms of placenta previa.⁵

When the myometrium unexpectedly split into three types based on histology, the result is placenta accreta.Chorionic villi communicate through the myometrium in accreta.

Wherever A chorionic villi enter the myometrium, incerta.Wherever A chorionic villi enter the uterine serosa, the placenta percerta.⁶

Accreta's precise pathophysiology is unknown. Decidua maldevelopment, a severe trophoblastic attack, or a combination of the two types are all included in a proposed explanation.  Imperfect decidualization, atypical maternal vascular remodelling, superfluous trophoblastic invasion, and mixing are all quantified by prior instrumentation as significant.⁷

The prevalence of placenta accreta has been progressively rising over the past fifty years, mirroring the increasing frequency of caesarean sections.⁸

Births with a placenta accreta incidence of 1:533 were reported from 1990 to 2005, A significant increase over earlier reports from 1970 to 1980. The prevalence of placenta accreta, which is regarded as a serious pregnancy complication that may be linked to enormous, potentially fatal intrapartum and postpartum haemorrhage, is rising.The placenta accreta is now the main reason for emergency hysterectomy in cases of severe uterine haemorrhage, which may necessitate substantial life-saving surgical operations such hysterectomy and ligation of major pelvic arteries.⁹

As a result of placental invasion into an adjacent organ, reconstruction of the bowel or bladder may be required. Massive blood and blood product infusions are the usual in these extreme cases; other problems include neonatal death, infection, and so on.In adding to neonatal morbidity, such as preterm delivery and small for gestational age, maternal morbidity has been observed to occur up to 60% of the time, with placenta accreta women having a 7% mortality risk.¹⁰

There are numerous risk factors for placenta accreta, including previous caesarean surgeries with concurrent placenta previa. The risk of placental accreta increases considerably as the number of caesarean sections performed increases.¹¹

Other risk factors have been found, including as multiparity, prior uterine scarring, and uterine scarring.¹²

The best time to diagnose placenta accreta is during the prenatal period using magnetic resonance imaging or sonography.Numerous studies have shown the value of ultrasonography in making this diagnosis, particularly in cases where the gestational age is greater than 20 weeks.Sadly, some cases of placenta accerta are discovered during delivery when the mother experiences excessive vaginal bleeding or persistent bleeding when the placenta is attempted to be removed.¹³

The aim of the current study is to determine the relationship between the placenta accreta and its problems in cases delivered by cesarean section previously,and suffered from placenta previa anterior

PATIENTS AND METHODS

50 pregnant women were included in a cohort observational research after the 26th week of pregnancy. The candidates will be chosen from the Al Hussein Hospital and Al-Azhar University Obstetric clinic. From June 2021 to January 2022, the study was conducted. This research was conducted at the Al Husseiun Hospital in Obstetrics and Gynecology division. About 50 pregnants  in total  diagnosed of placenta previa newely and a prior history of C-section were included. statistical studies to ascertain the connection between a prior caesarean delivery and the following occurrence of placenta previa accreta

Methods:

Each case was given a thorough medical history review, a full physical examination, laboratory testing, a colour Doppler evaluation, and other investigative procedures (Hemoglobin concentration, bleeding time, clotting time, prothrombin time, prothrombin activity and INR). The amount of units of blood, plasma, platelets, and/or cryoprecipitate transfused to the patients, as well as caesarean sections and conservative approaches, were documented as part of the interventions.

Maternal outcome (admission to Ward's, admission to an intensive care unit, problems, and length of stay). Fetal outcomes included newborn mortality, gestational age at CS, Apgar scores at one and five minutes, admission to neonatal intensive care, and admission duration.

Inclusion criteria: the participants whom achieved the Inclusion criteria included in the study: Signle fetus, patient with placenta previa anterior and previous delivery by caesarean section, ³

Doppler ultrasound was used to determine placenta previa accreta from the 26th week of pregnancy. Onwards, in patients who have had a previous caesarean section and were proven intraoperatively and clear of medical disease at the time of the caesarean section.

Exclusion Criteria: Cases of marginal and low lying placenta previa diagnosed on ultrasonography but delivered vaginally.Multiple gestations.

History taking: maternal and gestational age, gravidity, parity, date of last menstrual period & EDD, present, past, obstetrics and family history, number of previous CS and any history of placenta pervia .

Clinical examination: any signs of bleeding during pregnancy, fundal level, fundal grip, umblical grip, pelvic grip, paw lick grip, ultra sound during pregnancy, cervical length, signs of hemorrhage, body mass index, blood pressure measurement, abdominal examination. The following lab values are going to be measured once in every participant: routine CBC, Pt, ptt, INR, liver functions, kidney functions and FBS,RBS,GTT

RESULTS

50 pregnant women were used in this investigation after the 26th week of pregnancy. The participants were attended to obstetrics and gynaecology departmrnt  at Al Hussein Hospital.

The study comprised 50 patients with such a new diagnosis of placenta previa and a history of caesarean surgery.

Before CS, patients were split into two groups as follows:

Group I: included 26 patients with acreta.

Group II: included 24 patients without acreta.

Table 1: The prevalence of the examined groups in terms of the acreta.

Table (1) shows distribution of studied groups regarding acreta. Patient with acreta were 26 (52%) and patient without acreta were 24(48%).

Table 2: Comparing  the two studied collections regarding to demographic data, anthropometric measurements, maternal history, previous cesarean section and previous history of placenta pervia.

Table (2demonstrates that there was no statistical significance variation in relation to  age and gestational age among the both examined groups (P > 0.05). There was no statistical significance difference in Wt, Ht, or BMI among the both groups of study (P > 0.05). There was no statistically significant difference in GA, gravidity, parity, or previous abortion between the two groups tested (P > 0.05). There was no statistically significant difference between the two groups in terms of previous caesarean section and history of placenta pervia (P > 0.05).

Table 3: Comparison of the two research groups as regard to blood transfusions.

Table (3) shows that, patients need blood transfusion in acreta group were 20 (76.92%) and 10 (41.67%) in non acreta respectively. There was a statistical significant increase in blood transfusion in acreta group more than non acreta (P < 0.05).

Table 4: Comparison of the two research groups as regard to systolic Blood pressure and diastolic blood pressure.

Table (4) shows that, systolic blood pressure in group I have mean value 111.58±9.96 and in group II was 109.71±9.76. Diastolic blood pressure in group I have mean value 82.73±5.10 and in group II was 81.83±4.60. There was no statistical significant difference between the two studied groups regarding systolic blood pressure and diastolic blood pressure (P > 0.05).

Table 5: Comparison of the two research groups as regard to laboratory findings.

Table (5) demonstrates that there was no statistically significant difference in the laboratory results between the two investigated groups (P > 0.05).

Table 6: Comparing the both studied collections regarding to operative and intra-operative data.

Table (6) clarifies the variation among the two studied groups regarding to operative and intra operative data, the mean duration of preparation to peration was 7 days, 20 cases (76.9%) internal iliac ligation, 16 cases (61.5%) hysterectomy and 18 cases (69.2%) B-lynch.

Table 7: Comparing the two researched collections in realtion to  maternal out come.

Table (7) demonstrates that there was no mortality in our study, but there was a statistically significant difference in the admission to the intensive care unit (P 0.05), injury to the urinary bladder, and intrapartum haemorrhage between the two investigated groups related bowel injury complications.

Table 8: Comparison between the two studied groups regarding Fetal out come.

Table (8) shows that, Apgar at 1 min in group I ranged from 5-8 with mean value 6.23±0.95 and in group II ranged from 5-8 with mean value 6.96±0.86. Apgar at 5 min in group I ranged from 5-10 with mean value 7.62±1.68 and in group II ranged from 6-10 with mean value 8.63±1.35, and APAGR score significantly increased in the non-acreta group more than in the acreta group.

Table 9: Comparing the two researched collections in realtion to  admission in NICU.

Table (9), shows the nenota who needed NICU were in acreta group was 7 (26.92%) and 4(16.677%) in non acreta collection correspondingly. There was statistically significance variation in-between the two studied collections regarding to admission in NICU (P <0.05).