*Courtesy:* _PROMISE ULTRASOUND AND FETAL MEDICINE CENTRE_
We have two case scenarios which would help us to understand this dilemma:
*Case 1:* A 28 year old primigravida with 8 weeks pregnancy comes to your clinic with frank chicken pox?
*Case 2:* A 32 year old primigravida with 36 weeks pregnancy comes to your clinic with frank chicken pox?
*In the First case where Primi with 8 weeks pregnancy developed frank chicken pox (rashes),First thing that comes to clinician and patient’s mind is termination, Remember, No Guidelines recommend Direct termination of pregnancy, However surveillance is recommended*
The probable reason for this is due to the fact that the risk of fetal affection (Congenital Varicella syndrome) is *just 0.4% prior to 13 weeks of gestation and 2% between 13–20 weeks and Almost 0% between 20–36 weeks of gestation.* Now for the symptomatic relief to the pregnant mother with frank chicken pox at 8 weeks, Acyclovir 800 mg, five times a day, for seven days can be given. *Remember RCOG doesn’t recommend using Acyclovir before 20 weeks and 24 hours after development of rash, other international guidelines (Canadian and Swiss) support its use at any time.*And yes to reassure you all, we have enough Data to suggest that there is *no increase in the risk of major foetal malformation with acyclovir exposure in pregnancy.*
Also there is a *limited role of intravenous immunoglobulins (VZVIg)* in the treatment of chickenpox once the rashes have already developed. Coming to a concern about foetal surveillance in this case, Although PCR of amniotic fluid (Through Amniocentesis) for VZV DNA is the method of choice for the determination of whether or not the foetus has been infected, *Prenatal diagnosis relies on the identification of a combination of signs on a detailed ultrasound examination, such as limb deformities, microcephaly, hydrocephaly, polyhydramnios, soft tissue calcification and intrauterine growth restriction.*As the clinical features are a result of reactivation of VZV, *time is needed for this damage to manifest itself* . Accordingly, *no less than 5 weeks from the time of maternal rash should be permitted before the first detailed scan is performed,* as scans at less than 4 weeks intervals have resulted in missed diagnoses. A suscpiuos ultrasound finding of CVS confirmed by Amniocentesis PCR warrants detailed discussion with the couple and is highly recommended for termination of pregnancy.
*In the second case where Frank Chicken pox develops at 36 weeks, the major concern now is to protect the “would be delivering” baby from developing clinical chicken pox (Neonatal Varicella) as congenital problems(congenital Varicella Syndrome) are not seen at this gestation*
Ideally A planned delivery should be *avoided for at least 7* days after the onset of the maternal rash to allow for the passive transfer of antibodies from mother to child. In cases where delivery has to be conducted in this time frame ( e.g. foetal Distress, patient going in labour or a bleeding Previa etc), One should be aware of the fact that *Delivery in viremia may precipitate maternal haemorrhage and/or coagulopathy due to thrombocytopenia or hepatitis.*
If a Caesarean section is planned (Elective or Emergency) *General anaesthesia is avoided* and more preferred choices are *Spinal* (avoided if active lesion on the site of spinal) and *Epidural* (Preferred as Dura is not punctured and hence transmission of virus from skin to CNS is less).
*A neonatologist must be informed and prophylaxis with VZIG with or without acyclovir should be administered to the neonate as soon as possible* there is no need to test in these circumstances. The neonate should be monitored for any complications as the immunity is expected to be low. *Breast feeding is allowed* unless active lesions are close to nipple for a hindrance .In that case expressed milk can be taken.
*PROMISE* *ULTRASOUND AND FETAL MEDICINE CENTRE*
*302, DEFENCE COLONY NEAR BUS STAND JALANDHAR*
*Placenta Accreta Important Message*
*How many times, while operating a previous caesarean section patient, we have thought beyond adhesions and ruled out placenta accreta / Increta or Percreta*
*So far PROMISE ULTRASOUND AND FETAL MEDICINE CENTRE was able to correctly diagnose placenta accreta / Increta in 11 cases. These were duly informed to the concerned Obstetrician and thus the surgery was planned with all the necessary consents and preparations. All these 11 cases ultimately landed up in Obstetrical hysterectomy.*
Let’s discuss placenta accreta in brief:
*Placenta accreta* is described when a part or entire placenta invades and becomes inseparable from the uterine wall (decidua). In *placenta Increta* the chorionic villi invade the myometrium whereas in *placenta* *percreta* invasion progresses through the myometrium and serosa, and occasionally into adjacent organs, such as the bladder.
Placenta accreta becomes problematic during delivery when the placenta does not completely separate from the uterus and is followed by *massive obstetric hemorrhage, leading to disseminated intravascular coagulopathy; the need for hysterectomy; surgical injury to the ureters, bladder, bowel, or neurovascular structures; adult respiratory distress syndrome; acute transfusion reaction; electrolyte imbalance; and renal failure.*
*The average blood loss at delivery in women with placenta accreta is 3,000–5,000 mL* .
*As many as 90% of patients with placenta accreta require blood transfusion, and 40% require more than 10 units of packed red blood cells* .
Maternal mortality with placenta accreta has been reported to be as high as *7%.*
The Most Important risk factor for Placenta accreta is *previous cesarean delivery* with other being advanced maternal age and multiparity, or *any condition resulting in myometrial tissue damage followed by a secondary collagen repair, such as previous myomectomy, endometrial defects due to vigorous curettage resulting in Asherman syndrome, submucous leiomyomas, thermal ablation, and uterine artery embolization*
The ultrasonographic features suggestive of placenta accreta include *irregularly shaped placental lacunae (vascular spaces) within the placenta ( Most predictive sign)* , thinning of the myometrium overlying the placenta, loss of the retroplacental “clear space,” protrusion of the placenta into the bladder, increased vascularity of the uterine serosa–bladder interface, and turbulent blood flow through the lacunae on Doppler Ultrasonography.
Although most studies have suggested comparable diagnostic accuracy of MRI and ultrasonography for placenta accreta, MRI is considered an adjunctive modality and adds little to the diagnostic accuracy of ultrasonography. However, when there are ambiguous ultrasound findings or a suspicion of a posterior placenta accreta, with or without placenta previa, ultrasonography may be insufficient
*So In conclusion,* Suspicion and early diagnosis of Accreta helps in counselling and planning the management so that it saves the obstetrician from catastrophic obstetrical emergency and unnecessary legal hassles.