الفهرس 
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Abstract
•MAP is a severe pregnancy complication, associated with massive obstetrical haemorrhage and high maternal mortality. .Nowadays,MAP is acommon complication of pregnancy due to increasing rate of C.S worldwide. .In Egypt the incidence of MAP is rising due to increasing rate of primary C.S.
• Our study aims to know our local practices toward these cases and to study the fetal and maternal outcomes of MAP in Sohag University Hospital for better management of these cases.
• MAP is characterized by an abnormal adherence of the placenta to the implantation site. .MAP is divided into three types accreta (when the placental villi simply adhere to the myometrium),increta (invade the myometrium) and percreta (penetrate the uterine serosa). The urinary bladder is the most frequently involved extrauterine organ ( placenta percreta).
• The most important risk factors are previous caesarean delivery, previous uterine surgeries,placenta praevia, multiparity and advanced maternal age.
• Antenatal diagnosis of MAP is done by U.S,color Doppler and MRI may be needed but a majority of MAP are diagnosed during the third stage of labour or during C.S.
• Accreta Center of Excellence should include a multidisclipinary team, ICU, NICU and blood services.
• Hysterectomy has traditionally been advised in the management of placenta accreta, but there has been a recent movement towards conservative management and preservation of fertility by different routes: Triple-P procedure ,IUC, Transverse B-Lynch, vertical compression sutures, Internal iliac artery balloon catheters,methotrexate and interventional radiology.
• Emergency cesarean hysterectomy carries greater risk than planned cesarean hysterectomy.
• There are high rates of neonatal mortality and intraoperative complications which include vascular, bladder , ureteral, and bowel injury. other complications include torrential haemorrhage, DIC, massive blood transfusion, hysterectomy, need for intensive care and even death.
• The incidence of perinatal complications is also increased due to preterm birth and small for gestational age fetuses
• Conservative management of placenta accreta can preserve fertility, although the risk of recurrent placenta accreta appears to be high.
• This observational study was conducted at Sohag University Hospital, Obstetrics & Gynecology Department (Inpatient and Emergency Sectors) from Septemper 2017 to Septemper 2018. .Total 132 cases were studied with placenta previa and previous cesarean section scar.
• Amulti disclipinary team were adopted including senior obstetrician, senior anaesthesiologist,vascular surgeon,urologist and neonatologist.
• The frequency of the studied cases is 1 in 27.8 deliveries
• The majority of cases had previous 2 C.S(30,3 %) and had placenta previa centralis (72%).
• The majority of babies were good (78%).
• Blood transfusion is needed in conservative management and emergency hysterectomy more than in planned hysterectomy.
• Bladder injury is the commonest intra-operative complications 34 cases (25.7%).
• Some patients were kept in ICU postoperatively (25.7%).
• There was one mortality in our study,which reexplored 3 times and lastly died of pneumonia and burst abdomen in ICU.
• Control of bleeding was done by bilateral uterine artery ligation ,IUC ,Transverse B-lynch ,vertical compression sutures while Cesarean hysterectomy was done in 36 cases27 % of cases.
• High C.S is the leading cause of MAP,So we should attempt to decrease first C.S
• Color Doppler is the preferred choice for diagnosis of MAP ,while MRI can be complementary.
• Well –planned cesarean hysterectomy has been advised to reduce maternal morbidity and moratality.
• Recently, there is amovement toward conservative management. Conservation is done in astepwise approach.
• We should have ateam for MAP and awell-developed blood bank to decrease mortality and morbidity of the cases.
• Reduction of C.S rate is amust in order to decrease risk of morbidly adherent placenta.
• Well-planned total cesarean hysterectomy with non-separation of the placenta is the best surgical option in patient antenatally-diagnosed as MAP and completed her family.
• Conservation in MAP in stepwise approach in patient who desire fertility by:
1.Bilateral uterine artery ligation before removal of the placenta.
2.Haemostatic sutures in the placental bed after removal of the placenta.
3.Vertical compression sutures.
4.Transverse B-Lynch.
5.IUC or intra-uterine packing to compress the placental bed.
6.Internal iliac artery ligation if patient is vitally stable.
7.Cesarean hysterectomy if vitally unstable.
• We should have ateam for MAP including senior obstetrician, senior anaesthesiologist, vascular surgeon, urologist and neonatologist,and awell-developed blood bank to decrease mortality and morbidity of the cases.