9. Diagnostic approach

11. Sonographic finding: 1-Loss of placental homogeneity, which is replaced by multiple intraplacental sonolucent spaces (venous lakes or placental lacunae) adjacent to the involved myometrium. This is the most consistent ultrasound finding 2-Loss or thinning of the normal hypoechoic area behind the placenta (termed the ‘clear space’) ( Retroplacental myometrial thickness of <1 mm. 3-Loss or disruption of the normally continuous white line representing the bladder wall-uterine serosa interface (termed the ‘bladder line’), bulging of the placenta into the posterior wall of the bladder

14. Specific findings on color Doppler ultrasonography : ●Diffuse or focal intraparenchymal lacunar flow ●Vascular lakes with turbulent flow ●Hypervascularity of serosa-bladder interface ●Prominent subplacental venous complex

16. Magnetic resonance findings in placenta accreta ●Uterine bulging into the bladder ●Heterogeneous signal intensity within the placenta ●Presence of intraplacental bands on the T2W imaging ●Abnormal placental vascularity ●Focal interruption of the myometrium

18. 34-35w(addmition 2w before termination) 48h after betametasone termination Correct anemia, reserve of pc, icu reserve Balloon cataterization

19. hysterectomy

20. Multidisciplinary team Two lage bore IVC Pnumatic compression General anesthesia Cross-maching Adequate pc,ffp,plt & cryo

21. Vertical skin incision Inspect the pelvis for sign of percreta and blood supply Intraoperative ulterasonography to mapping placental margine Determine the best position of hysterotomy incision Vertical hysterotomy two fingerbreadths above the placental adge

22. Fluid and blood resusitation Correcting acidosis Checking body tempreture Determinatio n source of bleeding

24. Fib<200 Cryopercipitate infusion Plt<100000 Plt infusion INR>1.5 FFp infudsion

25. Decrease blood loss with Hypogastric ligation Uterine artery and utero ovarian artrey ligation Balloon catatarization and arterial embolization

26. Uterine conservation with the placenta accreta Uterotonic drugs Compression suture Balloon tamponade Uterin artery embolization or ligation MTX

32. Thanks fore your attention