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IN THE NAME OF GOD

This case presentation explores the diagnosis and management of placenta accreta, a condition where the placenta invades into the uterine wall. It includes risk factors, sonographic findings, and postoperative care.

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IN THE NAME OF GOD

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  1. IN THE NAME OF GOD

  2. ADHERENT PLACENTA

  3. Case presentation: 32yG3L2(2*c/s) CC: Vaginal bleeding + laborpain LMP:? Sono(11w):33+3 PMH: negative( decrease Pltin last admission) PSH: 2*c/s PDH: Prednisone

  4. Physical examination: Vital sign: BP: 100/60 PR:104 T:36/8 RR:14 FHR: 145 NO vaginal examination because of placenta previa Sono(6/14):/Ant.previa/ 31+2 placenta increata

  5. Lab data: 11/9 10 A+ 112000 88000 PIH: NL UA:NL Fib:201 VBG:NL Electrolyte:NL PBS: anizocytosis+ decreasing Plt+Gaintplt

  6. Surgery: 1-Reserve of PC, FFP & Plt 2-Midline incision 3-Explore+ placental invasion was seen with right broad ligament bulging 4-C/S with incision on fundal & posterior of uterus(classic incision) 5-Useing misoprostol and metergin & oxytocin 6-Bilateral hypogastric ligation 7- Hysterectomy 8-Insert two penrosederenage

  7. Placenta accreta

  8. Risk factors:  1- Placenta previa after a prior cesarean delivery(most important) 2-Myomectomy entering the uterine cavity 3-Hysteroscopicremoval of intrauterine adhesions 4-Cornual resection of ectopic pregnancy 5- Dilatation and curettage 6-Endometrial ablation 7-Cesarean scar pregnancy 8-Maternal age greater than 35 years 9-History of pelvic irradiation 10-Infertility and/or infertility procedures in vitro fertilization

  9. Diagnostic approach

  10. 1-sonographic evaluation of the interface between the placenta and myometrium between about 18 and 24 weeks of gestation 2-Color flow Doppler can help support a sonographic diagnosis of placenta accreta • 3- Magnetic resonance imaging (MRI) can be useful when the ultrasound findings are uncertain.

  11. Sonographic finding: 1-Loss of placental homogeneity, which is replaced by multiple intraplacentalsonolucent spaces (venous lakes or placental lacunae) adjacent to the involved myometrium. This is the most consistent ultrasound finding 2-Loss or thinning of the normal hypoechoic area behind the placenta (termed the ‘clear space’) ( Retroplacentalmyometrial thickness of <1 mm. 3-Loss or disruption of the normally continuous white line representing the bladder wall-uterine serosa interface (termed the ‘bladder line’), bulging of the placenta into the posterior wall of the bladder

  12. Specific findings on color Doppler ultrasonography: ●Diffuse or focal intraparenchymal lacunar flow ●Vascular lakes with turbulent flow ●Hypervascularity of serosa-bladder interface ●Prominent subplacental venous complex

  13. Magnetic resonance findings in placenta accreta ●Uterine bulging into the bladder ●Heterogeneous signal intensity within the placenta ●Presence of intraplacental bands on the T2W imaging ●Abnormal placental vascularity ●Focal interruption of the myometrium

  14. Correct anemia, reserve of pc, icu reserve Balloon cataterization

  15. hysterectomy

  16. Determine the best position of hysterotomy incision Vertical hysterotomy two fingerbreadths above the placental adge

  17. .

  18. Uterin artery embolization or ligation MTX

  19. Persistent bleeding after hysterectomy :  Patients with continued severe hemorrhage after hysterectomy can enter a lethal downward spiral characterized by hypothermia, coagulopathy, and metabolic acidosis . Criteria proposed for this "in extremis" state include pH <7.30, temperature <35 degrees Celsius, combined resuscitation and procedural time >90 minutes, nonmechanical bleeding, and transfusion requirement >10 units packed red blood cells (RBCs) . To abort the cycle, the bleeding area is tightly packed and the skin is closed to prevent heat and moisture loss (either with large sutures or with towel clamps). Under most circumstances, the patient should remain in the operating room with continuous monitoring, while replacement of appropriate blood products and correction of physiologic derangements ("damage control") occurs. Once stable and safe for transfer, the patient may be transferred to the intensive care unit for ongoing management until definitive surgery can be performed. This approach halts the downward spiral and lessens the risk of abdominal compartment syndrome. Compartment syndrome is more difficult to define postpartum since postcesareanintraabdominal pressure appears to be higher than in the general surgical population, especially in women with elevated body mass index and hypertensive disorders

  20. POSTOPERATIVE CARE An intensive care unit bed should be available for postoperative care, if needed. These patients may require ventilator support due to pulmonary edema from massive fluid resuscitation or fluid shifts, or from acute transfusion-related lung injury . Some patients need vasopressor support and invasive hemodynamic monitoring. Postoperative bleeding recurrence is not uncommon, and the availability of interventional radiology to provide angiographic embolization of deep pelvic vessels, thus avoiding reoperation, can safely enhance patient care

  21. Thanks fore your attention

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