1. SCAR PREGNANCY AND PLACENTA ACCRETA AFTER CESAREAN. Mandruzzato G.P. Trieste,italy

2. SCAR PREGNANCY:DEFINITION IMPLANTATION OF A PREGNANCY ON A UTEROTOMIC SCAR (IN THE MAJORITY OF THE CASES AFTER CESAREAN).

3. CSP : EPIDEMIOLOGY. The prevalence of CSP is estimated 1/1800-1/2500 after one or more cesarean. PROBABLY UNDERESTIMATED! EXPECTED TO INCREASE !

4. ABNORMAL ADHERENT PLACENTATION PLACENTA: ACCRETA, INCRETA,PERCRETA.

5. PLACENTA ACCRETA: EPIDEMIOLOGY 1/533 PREGNANCIES 0.3 % OF ALL DELIVERIES 10 FOLD INCREASE IN THE LAST 50 YEARS!

6. SCAR PREGNANCY: RISK FACTORS PREVIOUS CESAREAN,MYOMECTOMY, HYSTEROSCOPY, CURETTAGE,MANUAL REMOVAL OF THE PLACENTA.

7. PLACENTA ACCRETA RISK FACTORS PREVIOUS CESAREAN,MYOMECTOMY, RESECTOSCOPIC MYOMECTOMY, ENDOMETRIUM THERMAL ABLATION.

8. CSP AND PLCENTA ACCRETA RISK FACTORS AND ETIOLOGY. are similar for the two conditions:trophoblastic invasion of the myometrium where the endometrium layer is strongly reduced or absent and the decidual reaction is scant or absent. Timor-Trotsh I.and co. Cesarean scar pregnancy and early placenta accreta share a common histology. Ultrasound Obstet.Gynecol. 21013,dec 19.

9. CLINICAL MANIFESTATION CSP: early and first half of pregnancy. PLACENTA ACCRETA : late pregnancy,delivery,post partum.

10. COMPLICATIONS. HEMORRHAGE OFTEN DIFFICULT TO CONTROL,LIFE THREATENING,OFTEN REQUIRING HISTERECTOMY,INVASION OF PROXIMAL ORGANS.

11. CSP: DIAGNOSIS. DIFFICULT! MISSED DIAGNOSIS IN 14 % OF THE CASES! Unforeseen consequences of the increaasing rate of cesarean deliveries :early placenta accreta and cesarean scar pregnancy:A review. Timor-Trietsh I. and co. Am.J.Obstet.Gynaecol. 2012,207,14.

12. CSP DIAGNOSIS : METHOD OF CHOICE: TVS ULTRASOUND WITH COLOR FLOW MAPPING. IN SOME CASES TA ULTRASOUND AND NMR.

13. CSP:MANAGEMENT 1.PHARMACOLOGICAL 2.SURGICAL

14. CSP PHARMACOLOGOCAL TREATEMENT METOTREXATE 1.LOCALLY 2.SYSTEMIC 3.COMBINED

15. CSP:SURGICAL TREATEMENT 1.UTERINE ARYTERY EMBOLIZATION 2.RESECTION(HYSTEROSCOPIC,LAPARO SCOPIC,LAPAROTOMIC).

16. CSP MANAGEMENT. ALL THE STUDIES ARE CASE REPORTS OR BASED ON SMALL NUMBERS! IMPOSSIBLE AT THE MOMENT TO OFFER EVIDENCE BASED RECOMMENNDATIONS!

17. CSP PREVENTION. 1.RESECTION OF THE UTERINE WALL DEFECT? 2.TECHNIQUE OF UTEROTOMY REPAIR AT CESAREAN?

18. PLACENTA ACCRETA: DIAGNOSIS METHOD OF CHOICE: TV OR TA ULTRASOUND WITH COLOR FLOW MAPPING. SOMETIME NMR.

19. PLACENTA ACCRETA: MANAGEMENT. 1.SURGICAL. 2.MECHANICAL. 3.PHARMACOLOGICAL.

20. PLACENTA ACCRETA:ANTEPARTAL DIAGNOSED. MOST COMMONLY PERFORMED IS CESAREAN HYSTERECTOMY. TIMING OF DELIVERY ? UTERINE ARTERIES EMBOLIZATION REFERRAL CENTERS! PERCRETA: URETERAL STENTS

21. CONSERVATIVE TREATEMENT. 1.UTERINE SUTURES(B-LYNCH) 2.BAKRY BALLON 3.SULPROSTONE 4.PARTIAL PLACENTA REMOVAL 5.UTERINE DEVASCULARIZATION

22. FERTILITY AFTER CONSERVATIVE TREATEMENT. 1.SMALL SERIES 2.NO RCT

23. TAKE HOME MESSAGES

24. CONCLUSIONS 1. EARLY RECOGNITION OF THE SITE OF IMPLANTATION IN CASE OF PREVIOUS CS IS CRUCIAL obstetrical ultrasound in early pregnancy EXSAUSTIVE COUNSELLING ABOUT RISKS AND POSSIBILITIES!

25. CONCLUSIONS 2. REFER TO CENTERS WITH POSSIBILITY OF MULTIDISCIPLINARY APPROACH.

26. CONCLUSIONS 3. AVOID UNECCESARY PRIMARY CS !!!

27. THANK YOU FOR ATTENTION.