الفهرس 
Morbidly adherent placenta (MAP)Only 14 pages are availabe for public view
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Abstract
Morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta accreta. (Allen et al., 2018). It is a clinicopatho-logical condition in which the placenta fails to separate partially or totally from the uterine wall (Jauniaux et al., 2018).
The incidence of MAP has paralleled the increase in caesarean deliveries, and now occurs in approximately three in every thousand
A 10-fold increase in the incidence of morbidly adherent placenta (MAP) has been reported in most medium- and high-income countries over the last 40 years due to the increase in cesarean delivery rates around the world from less than 10% to over 30%.(ACOG, 2002).
Factors associated with higher incidence of placenta accreta include: multiparty, prior uterine surgery such as myomectomy, previous cesarean section and curettage, advanced maternal age, exposure to pelvic irradiation (Gielchinsky et al., 2004).
MAP is considered a severe complication of pregnancy and may be associated with massive and potentially life‐threatening intrapartum and postpartum haemorrhage. As many as 90% of women with placenta accreta require blood transfusion, and 40% require more than 10 units of packed
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red blood cells. In fact, it remains the leading indication for caesarean hysterectomy (Selman, 2015).
The main risk associated with any form of MAP is massive obstetric haemorrhage, which leads to secondary complications including coagulopathy, multi system organ failure, and death (Allen et al., 2018).
Prenatal diagnosis of MAP is typically based upon the presence of characteristic findings on ultrasound examination it is one most useful modalities for evaluating placental position and implantation, (Warshak et al., 2006), Color Doppler also has specific findings that suggest MAP (Chou et al., 2000).
Magnetic resonance imaging can be more useful especially: evaluation of a possible posterior placenta accreta and assessment of the depth of myometrial and parametrial involvement, and, if the placenta is anterior, bladder involvement (Derman et al., 2011).
Recognition of the high morbidity and mortality associated with morbidly adherent placenta requires multidisciplinary approach. The interventional radiologist, the anesthetist, the neonatologist and an experienced consultant obstetrician play crucial role. Particular considerations should be given to the anticipation and management of massive hemorrhage, including availability of pack RBCs, platelets, fresh frozen plasma, cryoprecipitate etc… (Yap et al., 2008).
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Previous reviews advised against attempts at placenta removal before hysterectomy, Antenatal diagnosis, scheduled cesarean hysterectomy without attempts at placental removal reduce maternal morbidity (Oyelese and Smulian, 2006).
The Strategies of conservative management and preservation of fertility include leaving the placenta after cesarean delivery with surgical uterine devascularization, embolization of the uterine vessels, uterine compression sutures and / or over sewing of the placental vascular bed followed by close observation and antibiotic (Ojala et al., 2005).
Caesarean hysterectomy is considered the reference standard treatment for placenta accreta. In young women who want the option of future pregnancy and agree to close follow--up monitoring, conservative treatment is a valid option.
There are many complications for caesarean hysterectomy one of them is urological injury.
In a systematic review of surgical techniques used for MAP , the overall rate of unintentional urinary tract injury at peripartum hysterectomy was 29%. 78% of injuries involve the bladder, whereas 17% involve the ureter (Allen et al., 2018).
Modification of surgical technique has the ability to reduce urinary tract injury compared with standard hysterectomy (Allen et al., 2018).