PREVALENCE AND TYPES OF ABNORMALLY ADHERENT PLACENTA IN WOMEN WITH CS

DISCUSSION

The goal of this work is to detect the incidence of morbidly adherent placenta among women with variety of numbers of previous cesarean sections.

Prospective cross-sectional research was caried out on pregnant women intended inpatient, outpatient and emergency of Sayed Galal gynaecological and obstetric hospital in the period of the 1st of August 2020 till the 1st of January 2021.

200 participants Cases were divided into 2 groups: Group (I): 100 who will be categorised according to the number of CS they have done (CS group). Group (II): 100 who have no previous uterine scars (control group).

All processes involving human subjects in this research were carried out in line with the Alazhar university ethics committee's ethical standards and subsequent amendments, or equivalent ethical standards. All participants in the research gave their informed written permission.

Full history was taking; Body mass index (BMI), Laboratory tests of the investigated patients and data was evaluated statistically.

In our study regarding demographic characteristics of the studied groups, there was a substantial variation between the two groups according BMI (p=0.011) and gravidity (p=0.025), the mean BMI were 27.89 ± 3.82 kg/m² in CS group and 26.68 ± 2.75 kg/m² in no uterine scar group, the mean gravidity were 3.67 ± 1.62 in CS group and 3.16 ± 1.44 in no uterine scar group. While there was no substantial variation between the two studied groups according age, Parity and GA (p>0.05), the mean maternal age were 33.54 ± 4.13 years in CS group and 32.76 ± 4.52 years in no uterine scar group, the mean Parity were 2.1 ± 0.977 in CS group and 1.88 ± 1.04 in no uterine scar group.

In agreement with our study was a recent research by Tovbin et al., ⁷ noted that, During the trial, 268 patients were enrolled in total. The trial comprised 258 women after ten patients delivered elsewhere and was lost to follow-up. Twenty-three women (8.9%) were diagnosed with MAP, whereas 235 (91.1%) had no clinical indications of an attached placenta. The median gestational age at identification was 33.9 (range, 16–41) weeks, and the median mother age at ultrasound examination was 33.8± 4.5 years. The mean ± SD for mother gravidity and parity were 4.0±1.6 and 2.0 1.2, respectively. The average gestational age at birth was 37.7± 1.7 weeks (range: 24–41).

In a recent research Li et al., ⁸ showed that, the cases of severe PPH ranged in age from 24 to 38 years old, with 7 of them having concomitant adherence/placenta accreta (median 29). The gestational age at which the surgery was conducted varied from 36 weeks plus 1 day to 38 weeks plus 6 days, and parity ranged from 0 to 1. (Median 37 weeks plus 3 days).

The clinical characteristics of the studied patients in the current research revealed that, there is a substantial variation between the two groups in term of number of previous cesareans (p=0.000) and history of abortion (p=0.009), the majority of patients 38(38%) cases in CS group and 66(66%) cases in no uterine scar have one previous cesareans.

Along with our study were the results by Richa et al., ⁹ showed that, twenty women fit the criteria for diagnosis for MAP. Fourteen (70%) previously cesarean delivery scar, four (20%) had had prior curettage, but they all had a cesarean delivery history. Placenta previa was found in 14 (70%) of the women. Two of the women (10%) had no identified risk factors.

In the current investigation, the incidence of complications between the two groups revealed a substantial variation in hysterectomy (p=0.001), adhesion (p=0.000), endometritis (p=0.030), wound infection (p=0.001), and scar discomfort (p=0.000). However, there was no substantial variation between the two groups in terms of Bladder damage, Uterine Rapture, or Bleeding (p-values 0.318, 0.315, and 0.097, respectively), although there was a substantial variation in terms of morbidly adherent placenta (p=0.024).

In agreement with our study was a recent study by Wei et al., ¹⁰ studied 96 people diagnosed with MAP Following earlier CS findings indicating only three women in the control group had hysterectomy compared to none in the study group, no peripartum mortality was observed in either group.

Recent research by Koroglu et al., ¹¹ showed that, there were no differences in parity, procedure time, hospital stay, or pre- and postoperative hemoglobin concentrations between the groups. The preceding CS and no CS groups had conversion rates of 2% and 1.7 percent, respectively, to laparotomy. Major problems occurred at a rate of 5% and 1.3 percent in the prior CS and no CS groups, respectively, and these outcomes did not vary substantially (P > 0.05).

Among total 26 studied cases Grönvall et al., ¹² reported that, twenty-five instances of placenta accreta were discovered, with one case of placenta precreta. Sixteen (61.5%) of the AIP cases were discovered before birth. One AIP patient was a primiparous lady with no risk factors. Six of the 10 mothers with antenatally undetected AIP had mild PP. Thirteen of the 26 women (50 percent) suffered a life-threatening bleeding (2500 ml). In all, 15 hysterectomies were carried out. AIP was verified in all of these women after a histological study of a hysterectomy specimens, and 13 of them had a history of CS.

Richa et al., ⁹ noted that, the majority of the lady death in their research is due to intensive surgery, which involves significant blood transfusions, infections, and urologic damage. Women with MAP had a significant rate of hemorrhage problems, with a median blood loss of 2.7 l and transfusions of up to 19 U of blood and 21 U of FFPs.

Bhide et al., ⁹ reported that, the placenta fails to detach from the uterine wall owing to improper implantation at the basal plate, resulting in morbidly adhered placenta (MAP). Massive obstetric bleeding and its complications, including the requirement for blood transfusions, multiorgan failure, morbid hysterectomy, and even death, are common.

Maternal characteristics and clinical data among CS group according to number of previous cesarean section showed that there is a substantial disparity between the groups in term of maternal age, BMI, parity (p=0.000) and gravidity (p=0.048).

In a previous systematic review Marshall et al., ¹³ reported that, the risk of morbidly adherent placenta rose from 0.3 percent in women who had one prior cesarean birth to 6.74 percent in those who had five or more.

On the other hand, Koroglu et al., ¹¹ noted that, the groups were equivalent in terms of BMI, parity, surgical indications, operation time, and inpatient stay. Patients who had already had CS had received one CS, 25% had gotten two CSs, and 8% had received three CSs. In both groups, uterine myoma was the most common reason for surgery.

In the current study maternal complications among CS group according to number of previous cesarean section showed that, there was a substantial variation between the groups in term of hysterectomy, adhesion, uterine rapture, scar tenderness, and hemorrhage p-values were 0.009, 0.010, 0.049, 0.000 and 0.012 respectively.

Along with our study Morlando et al., ¹⁴ reported that, CS delivered 41 women, 23 of whom needed transfusions, three of whom were treated successfully with curettage, and 26 of whom required a hysterectomy. As an adjuvant therapy for bleeding following cesarean hysterectomy, one lady had her hypogastric artery ligated. Only uterine packing was used to effectively treat twelve patients. Thirty hysterectomies were performed. Histology verified the PA in nine instances (30%) (four increta, five percreta); in 14 cases, the histological result was negative (46 percent). Due to missing or damaged papers, seven of the early instances from the first triennia could not be evaluated. There were 13 primiparous women, three of whom gave birth vaginally, and CS was performed on ten of them for various obstetrical reasons. There were no maternal deaths reported.

In a previous study by Field and Haloob, ¹⁵ A varieties of complications has become a direct result of increasing the rate of cesarean section which includes postpartum haemorrhage, sepsis, visceral injury, postoperative ileus, placenta previa and morbidly adherent placenta.

From all of the above, we can assume that the over-medicalization of the birth process in Egypt, as seen by the overuse of caesarean deliveries, is a serious public health problem that requires prompt attention because to the excessive pressure CS causes on the health system.

The rise in CS rates is due to a mix of medical and non-medical reasons. However, several studies imply that a significant proportion of CS births occurred without clear medical rationale. In the study hospitals, health care provider characteristics seem to be major contributors determining CS rates.

CONCLUSION

Overmedicalization of the birth process in Egypt, as seen by the overuse of cesarean delivery, is a serious public health problem that requires prompt attention because to the excessive pressure CS causes on the health system. Evidence-based interventions addressing these factors, including disseminating delivery procedures and practice guidelines, training providers in VBAC, and improving hospitals' monitoring and supervision systems, are essential to minimize this potentially avoidable surgical procedure that poses different risks to mothers and babies.