INDIANAPOLIS - Placenta accreta is a growing cause of postpartum hemorrhage and an increasing cause of emergency hysterectomy, according to Dr. Gary Dildy III.
"The incidence of placenta accreta is increasing, and it's thought this may have to do with the increasing rate of cesarean sections since the 1960s," he said at the annual meeting of District V of the American College of Obstetricians and Gynecologists.
Research has shown that the incidence of placenta previa and accreta correlates highly with the number of prior cesarean sections that a woman has had. In addition, while placenta accreta accounted for only about 10% of emergency hysterectomies in the 1950s, it accounted for 50% of these procedures in the mid-1980s.
Currently, the incidence of placenta accreta is about 1 per 2,500 pregnancies and has increased 10-fold in the past 50 years, said Dr. Dildy, professor of ob.gyn. at Louisiana State University New Orleans.
Although placenta accreta remains one of the rarer causes of postpartum hemorrhage, Dr. Dildy urged physicians to be aware of it. Occasionally the condition can be diagnosed prenatally, which can be highly advantageous.
"It is always nice to know ahead of time whether a problem like this exists. Although nothing that we currently have available is exact, including ultrasound or MRI, it can at least give us a heads up in many cases, he said, adding that a combination of the patient's history of a previous cesarean section plus ultrasound imaging is probably the most reliable means of investigating a suspected placenta accreta.
Other risk factors for placenta accreta include placenta previa with or without previous uterine surgery, prior myomectomy, prior cesarean delivery Asherman's syndrome, submucous leiomyomata, and maternal age older than 35 years.
Women who have had at least two cesarean deliveries with anterior or central placenta previa have nearly a 40% risk of developing placenta accreta in the future.
"By using ultrasound and assessing risk factors, we can identify patients that require a greater degree of advance preparation," he said in an interview.
The ACOG Committee Opinion No. 266, issued in January 2002, recommends that when placenta accreta is suspected prenatally appropriate measures need to be taken to acquire blood for transfusion, arrange for Cell Saver technology when available, arrange a preoperative anesthesia consultation, and recruit the appropriate backup expertise.
"If you have vascular involvement, you may need a vascular surgeon; if you have urologic involvement, you may need a urologist or a gynecologic oncologist," he explained.
The ACOG committee opinion states that "profuse hemorrhage can occur when attempting to separate the placenta. If the clinician is extremely confident in the diagnosis, it maybe prudent to complete the delivery of the infant and proceed with hysterectomy while the placenta remains attached."
Cell Saver technology is starting to gain popularity in obstetrics and can greatly reduce the need for blood transfusions in the case of placenta accreta. The device suctions blood out of the pelvic cavity filters it, and reinfuses the red cells into the patient.
"It's relatively new to obstetrics, and in the past, we've always been afraid to use it because of concerns about putting amniotic fluid and fetal cells back into the maternal circulation. But the filtration system seems be effective against this, and the cases that are published thus far, although the numbers are small, suggest that Cell Saver is safe in pregnancy and [that] the benefits probably outweigh the risks," he said.
COPYRIGHT 2002 International Medical News Group
COPYRIGHT 2002 Gale Group
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