Placental Adhesive Disorders (Hot Topics in Perinatal Medicine, 1)

New series Abnormal placental adhesive disorders are associated to massive hemorrhage and high maternal morbidity and mortality. The main risk factor for abnormal invasive placentation is the repeated cesarean, although other factors were identified. There are specific techniques to provide a high confidence diagnosis. However, precise skills must be acquired to recognize detailed diagnostic signs, to avoid common technical mistakes, and also to know when, how and why it is necessary to use each of them. Presurgical study provides diagnosis, extension and compromise of neighboring structures such as the bladder or the parametrium. Knowledge of placental invasion extension is needed to plan any resective surgery such as hysterectomy or one-step conservative surgery. Due to the fact that topography of the invaded area has direct relation with the specific arterial pedicles, a map of the invasion is required to know which type of proximal vascular control can be more effective. Leaving the placenta in situ seems to be the best option when resources or a skilled team are not available, but it requires intensive postoperative controls to detect infection, bleeding or coagulation disorders. Hysterectomy can be an easy solution for non-experimented operators; however, it is usually a very complicated procedure with demonstrated morbidity and mortality due to hemodynamic and hemostatic problems. This book gathers the latest knowledge in relation with the etiology, diagnosis, treatment and also the authors personal experience in more than 500 cases. All aspects of this condition have been analyzed to provide an accurate management, which includes vascular control, urology, anesthesia and hemodynamic management among others. * Covers diagnosis trees, surgical alternatives, and expected complications * Additional multimedia material available online

Abnormal placental adhesive disorders are associated to massive hemorrhage and high maternal morbidity and mortality. The main risk factor for abnormal invasive placentation is the repeated cesarean, although other factors were identified. There are specific techniques to provide a high confidence diagnosis. However, precise skills must be acquired to recognize detailed diagnostic signs, to avoid common technical mistakes, and also to know when, how and why it is necessary to use each of them. Presurgical study provides diagnosis, extension and compromise of neighboring structures such as the bladder or the parametrium. Knowledge of placental invasion extension is needed to plan any resective surgery such as hysterectomy or one-step conservative surgery. Due to the fact that topography of the invaded area has direct relation with the specific arterial pedicles, a map of the invasion is required to know which type of proximal vascular control can be more effective. Leaving the placenta in situ seems to be the best option when resources or a skilled team are not available, but it requires intensive postoperative controls to detect infection, bleeding or coagulation disorders. Hysterectomy can be an easy solution for non-experimented operators; however, it is usually a very complicated procedure with demonstrated morbidity and mortality due to hemodynamic and hemostatic problems.

This book gathers the latest knowledge in relation with the etiology, diagnosis, treatment and also the authors personal experience in more than 500 cases. All aspects of this condition have been analyzed to provide an accurate management, which includes vascular control, urology, anesthesia and hemodynamic management among others.

Preface 5 Acknowledgements 7 1 General knowledge 11 1.1 Introduction 11 1.2 Epidemiology 13 1.3 Risk factors 14 1.4 Terminology 17 1.5 Types of placental invasion 18 1.6 Etiology 24 1.7 Intrinsic problems 25 2 Diagnosis 27 2.1 Presurgical stage 27 2.2 Clinical suspicion 27 2.3 Auxiliary diagnosis 28 2.3.1 Ultrasound, Doppler, Three-dimensional Doppler 30 2.3.2 Placental magnetic resonance imaging (pMRI) 40 2.3.3 Placental magnetic resonance imaging (pMRI) gallery 42 2.3.4 Serologic diagnosis 42 3 Surgical anatomy 53 3.1 Anatomic and surgical problems 53 3.2 Uterine blood supply 56 3.3 Induced vascular neoformation 61 3.4 Bladder dissection 63 3.5 Ureteral dissection 68 3.6 Pelvic access spaces 73 3.7 Proximal vascular control 76 3.7.1 Aortic 76 3.7.2 Common iliac 80 3.7.3 Internal iliac 82 3.7.4 Uterine 86 4 Tactics and strategy 89 4.1 Alternative management in different settings 89 4.2 Scheduled surgery 95 4.3 Emergency 96 4.4 Additional resources 97 4.5 Training 98 5 Clinical problems 101 5.1 Hemostatic problems 101 5.2 Hemodynamic management 103 5.3 Anesthesia 104 6 Surgical alternatives 105 6.1 Surgical approach 105 6.2 Resective procedure (hysterectomy) 111 6.3 Conservative procedures 117 6.3.1 In situ placenta 117 6.3.2 One-step conservative surgery 124 6.3.3 Two-step conservative surgery 133 6.3.4 Cesarean scar pregnancy 134 6.4 Surgical hemostasis 137 6.4.1 Arterial ligatures and compression methods 137 6.4.2 Embolization 139 6.5 Postoperative care 147 6.5.1 Thromboprophylaxis 147 6.5.2 Analgesia 148 7 Results 149 7.1 General overview 149 7.2 Maternal outcomes 151 7.3 Reproductive outcome 152 8 Summary 153 8.1 Quick guide 153 8.1.1 Clinical risk 153 8.1.2 Ultrasound 153 8.1.3 Placental magnetic resonance imaging (pMRI) 155 8.1.4 Doppler 155 8.1.5 Surgery 155 8.1.6 Interventional radiologist’s assistance 156 8.1.7 Hemodynamic and hemostatic status 157 8.1.8 Reproductive outcome 157 8.2 Conclusions 158 References 159 Index 171 Abnormal placental adhesive disorders are associated to profuse or catastrophic bleeding during delivery. Their incidence has grown in the last few decades according to the rise in Cesarean rates, and they are an important cause of maternal morbidity and mortality worldwide. This book gathers the latest knowledge in relation with the etiology, diagnosis, treatment, and also the authors personal experience in more than 500 cases. All aspects of this condition have been analyzed to provide an accurate management. José Miguel Palacios Jaraquemada, Centre for Medical Education and Clinical Research (CEMIC), Buenos Aires, Argentina; Scientific South Foundation, Lomas de Zamora, Argentina; University of Buenos Aires, Argentina