ASSOCIATION OF AN INCREASE INCIDENCE OF MORBIDLY ADHERENT PLACENTA WITH PREVIOUS CAESAREAN SECTION AND ITS OUTCOMES: A 3 YEARS ANALYSIS IN A TERTIARY CARE HOSPITAL
Objective: To determine the association of morbidly adherent placenta with previous caesarean section and its management.
Place and duration: Department of Obstetrics and Gynaecology unit-III, Lahore General Hospital Lahore from December 2014 to December 2017.
Patient and Methods: During this three year study a total of sixty pregnant women with history of previous cesarean sections beyond 32 weeks of gestation, whether booked or unbooked irrespective number of caesarean scars with or without bleeding per vagina diagnosed of having low lying placenta previa on ultrasound were include in this study. The number of cesarean section, treatment, complications and maternal morbidity and mortality associated with morbidly adherent placenta were described.
Results: A total of 60 cases of morbidly adherent placenta was studied over three year period. 40 (66.6%) patients with morbidly adherent placenta were unbooked.
30 (50%) patients were the age group between 26-30 years. The average gestational age was between 32-36 weeks. In 40 (66.6%) type IV placenta previa was found. In 20 (33.3%) type III placenta previa was detected. In 5 (8.3%) patient with morbidly adherent placenta had previous once caesarean section while 55 (91.6% ) patients had two or more caesarean section.
In 40 (66.6%) patients the presentation was bleeding per vagina while 20 (33.3%) patients were asymptomatic at presentation. In 20 (33.3%) patients placenta accreta was found while placenta increta and percreta were found in 40 (66.6%) patients. Total abdominal hysterectomy done in 35 (58.33%) patients and subtotal hysterectomy performed in 5 (8.3%) cases. Uterine sparing along with internal iliac artery, ligation was carried out in 5 (8.33%). Bladder invasion which needed bladder repair was found in 6 (10%) cases. 4 (6.66%) maternal deaths were noted in this study. Mean Intraoperative blood loss was between 2.5-3 litres . Blood transfusion was needed in 58 (96.6%) patients.
Conclusion: The percentage of placenta previa and morbidly adherent placenta has risen with increasing number of caesarean sections. It is a life threatening hemorrhagic condition associated with high rate of maternal morbidity and mortality. Antenatal diagnosis by Doppler ultrasound, multi-disciplinary approach with involvement of senior obstetrician, anesthetist and haematologist is pivotal. In most of cases caesarean hysterectomy with or without internal iliac artery ligation is standard management protocol. In less serious conditions conservative measures can be practiced.
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