Study of Maternal Morbidity Associated with Morbidly Adherent Placenta

Background and Aims: Morbidly Adherent Placenta (MAP) is associated with severe morbidity like severe postpartum haemorrhage (PPH), probable need for massive blood transfusion and invasive procedures such as hysterectomy. We reviewed all cases of MAP in our institute between May 2015 to July 2019. The main objectives of the study were to determine the incidence, risk factors and both fetomaternal outcome in these women. Material and Methods: This was a retrospective study done in the department of Obstetrics and Gynaecology, Father Muller Medical College, Mangalore from May 2015 to July 2019. There were 12 women with MAP during this period. Results: In the present study, there were a total of 12 cases of MAP over 5 year period with incidence of MAP being 0.017 % (1/983 live births). The mean age of the women was 31 years. Among 12 women, 10 (84 %) were multigravida, 7 (58 %) were within 28 weeks to 37 weeks period of gestation (POG). Risk factors associated with MAP included 11 (90 %) cases had a history of previous lscs with 7 (58 %) having history of previous 2 lscs, placenta previa in 4 cases (32 %) among whom 3 had previous 2 lscs. In 3 (25 %) subjects, peripartum hysterectomy was planned electively while emergency hysterectomy was done in 8 (75 %). In addition to hysterectomy, bladder repair was done in 6 (50 %) cases and bilateral uterine artery ligation was done in 3 (25 %). Majority of the cases needed massive blood transfusion (50 %). Elective cases were found to have lesser intraoperative complications, need for blood product transfusion and postoperative complications compared to emergency cases.6 (50 %) patients needed ventilatory support and recovery was good.50 % of the subjects developed disseminated intravascular coagulation which was managed with transfusion of cryoprecipitate and fresh frozen plasma along with other blood components. One woman was treated medically with methotrexate injection 65 mg (1mg/kg) IM. There were no maternal deaths. Conclusions: Early antenatal diagnosis of MAP, proper counselling of patients regarding associated risks followed by well-planned caesarean hysterectomy with no attempt at placental delivery, adopting a multidisciplinary approach is the management option to decrease the maternal morbidity and mortality. Therefore, it is recommended that women suspected to have placenta accreta should be transferred to major centers for delivery which have access to large blood banks, prompt availability of well trained surgeons and experienced intensive care units. Alternative approaches, such as leaving the placenta in situ without hysterectomy, have increased risks and should be adopted only for selective patients.