الفهرس 
IntroductionOnly 14 pages are availabe for public view
 |  | from | 11 |  |  |
| | | from | 11 | | |
Abstract
SUMMARY
A
s one of the leading causes of postpartum hemorrhage, PAS involves attachment of placental villi directly to the myometrium with potentially deeper invasion into the uterine wall or surrounding. PAS poses a diagnostic and treatment challenge for all care providers for pregnant women. Previous surgical procedures that disrupt the integrity of uterus, including cesarean section, dilatation and curettage, and myomectomy, have been implicated as risk factors for placenta accreta.
Placenta previa is an obstetric complication that classically presents as painless vaginal bleeding in the third trimester secondary to an abnormal placentation near or covering the internal cervical os. However, with the technologic advances in ultrasonography, the diagnosis of placenta previa is commonly made earlier in pregnancy. Historically, there have been three defined types of placenta previa: complete, partial, and marginal. More recently, these definitions have been consolidated into two definitions: complete and marginal previaThe pooled prevalence of placenta previa is about 4 per 1000 births, but varies worldwide.
The most important risk factor for development of a PAS is placenta previa after a prior cesarean delivery. In a prospective study including 723 women with placenta previa undergoing cesarean delivery, the frequency of PAS increased with an increasing number of cesarean deliveries as follows first, second, third, fourth, and fifth or greater cesarean birth, was 3, 11, 40, 61, 67 percent, respectively.
In the absence of placenta previa, the frequency of a PAS in women undergoing cesarean delivery was much lower first, second, third, fourth or fifth, and sixth or greater cesarean birth, was 0.03, 0.2, 0.1, 0.8, 4.7 percent, respectively. Placenta accreta spectrum (PAS) is a general term used to describe placenta accreta, increta, and percreta. It results from placental implantation at an area of defective decidualization typically caused by preexisting damage to the endometrial-myometrial interface.
Placenta accreta should also be suspected in pregnant women with elevated MSAFP levels, with no other obvious cause. The defect in the layer normally separating the placenta and uterus allows leakage of foetal AFP into the mother’s circulation. Up to 45% of women with placenta accreta have elevated MSAFP levels in the absence of an obvious cause.
Unexplained elevation of maternal serum AFP (MSAFP) level in the absence of chromosomal abnormalities; fetal structural anomalies (e.g. open neural defects, abdominal wall defect); placental anomalies such as chorioangioma, multiple pregnancy, or fetal demise; or maternal conditions such as ovarian tumor or choriocarcinoma.
In the second and third trimesters, the following transabdominal and transvaginal sonographic findings have been associated with PAS: Placental lacunae, disruption of the bladder line, loss of the clear zone, myometrial thinning and exophytic mass.
This study was designed to evaluate if the maternal serum creatine kinase and α-fetoprotein concentrations served in addition to ultrasonography in the diagnosis of placenta acreta spectrum.
This prospective study was conducted between October 2017 and October 2019, at Beni Suef University Maternity Hospital and MUST Teaching Hospital, 36 cases (PAS) and 36 control had been recruited in this study.
Inclusion criteria of the studied cases were, Pregnant lady with history of previous cesarean section or hysterotomy, Placenta previa with its lower edge covering the scar of previous cesarean section as diagnosed by 2DU/S and Gestational age ranging after 28 wks.
Exclusion criteria of the studied cases were, Women with one or more of conditions contributing to rhabdomyolysis like, Crush injury and prolonged surgery, embolism, thrombosis, D.V.T., myocardial or brain infarction, drug overdose; antipsychotics, antidepressants, hypnotics, narcotics, alcohol, halothane, salicylates, excessive muscle activity as epileptic fit, chronic hypertension & PIH and endocrine disorders as hyper-/hypothyroidism, diabetes mellitus, history of liver disease or renal disease.
Then the patients who are included in the study were subjected to the following: Serum alfa-fetoprotein, serum creatine kinase and 2/D ultrasound which was carried out in Gynecology and Obstetrics department in Beni Suef University hospital and MUST Teaching Hospital.
The control’s age ranged from 22 to 39 years old with a mean value of 30.8±4.03 (SD) while the cases’s age ranged from 20 to 39 years old with a mean value of 31±4.5 (SD).There was no significant difference in gravidity, parity, gestational age and previous DC. However, cases significantly have higher incidence of previous CS than the control (p value=0.03).
This study showed significant increase in both CK (p value =0.014) and msAFP (P value=0.028) in cases compared to the control group.
2D ultrasonography findings of the studied cases showed that Intra-placental blood lake was detected in 19 cases out of 36(52.7%), loss of the retro-placental sono-lucent zone (Interruption of interface between the posterior bladder wall and the uterus) was detected in 22 cases out of 36 (61.1%), thinning or disruption of the hyper-echoic serosa-bladder interface was detected only in 10 cases out of 36 (27.7%)with 26 patients (72.3%) significantly have no thinning (p value=0.008), exophytic masses invading the urinary bladder was detected only in 3 cases out of 36 (8.3%) with 33 patients (91.7%) significantly have no exophytic masses. significant thinning of myometrium in 25 cases out of 36 (69.4%) (p value =0.02).
By giving each 2D US criterion a score of (1) present or (0) absent, the total sono-graphic score of our population was ranged from 0 to 5 points with a mean value of 2.26 ±1.5.
Intra-Operative assessment of the studied groups reveled that; PAS cases significantly needed blood transfusion 29 (80.6%) compared to the controls; post-partum hemorrhage was significantly detected in 5 (13.9%) of PAS cases compared to only one patients (2.8%) in the control (p value <0.001). CS HST was significantly higher in cases than the control (p value <0.001)
Regarding intra-operative visceral injuries; bladder injury was reported significantly higher in PAS cases 6 (16.7%) compared to only one patients (2.8%) in the control (p value =0.047). no other visceral injuries were reported in both cases and control showed that post-operative ICU admission was significantly required for 28(77.8%) PAS cases compared only one case out of 36 studied controls (2.8%) (p value <0.001). No significant difference in the survival rate between cases and controls (p value =0.17).