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Placental adhesive spectrum disorders (PASD) are on the increase. Histologically, the placenta may be adherent to the myometrium without intervening decidua (acreta), invade the myometrium (increta) and/or extend beyond the myometrium and seen via the serosa of the uterus or invade into adjacent tissues like the bladder or parametrium (percreta). Since there are difficulties in defining each entity by ultrasound or by histology and also due to the possibility of histology showing different degrees of invasion in the same case, PASD is the term now commonly used and the previous terminology of morbidly adherent placenta is no longer used. The main contributor towards PSAD is previous caesarean section (CS). With the global increase in CS, the incidence of PASD and related morbidity and mortality is on the increase.
This is the most common cause of maternal collapse in the immediate postnatal period, and in the most recent MBRRACE report, the number of maternal deaths as a result of this has risen from 13 to 21 in the last triennium . Postpartum haemorrhage (PPH) occurs following approximately 1%–5% of deliveries. Primary PPH is defined as more than 500 mL of blood lost from the genital tract with 24 hours of delivery and is categorised as minor (500–1000 mL) and major (>1000 mL). A loss of more than 2000 mL of blood is often classed as massive postpartum haemorrhage and is often audited . The causes of primary PPH can be remembered as ‘the 4 T’s’ – tone, trauma, tissue and thrombin. Secondary PPH occurs after 24 hours of delivery and is attributable mostly to retained products of conception (placental fragments) and endometritis.
Maternal collapse is an acute event involving the cardiorespiratory system and/or brain, resulting in a reduced or absent consciousness level (and potentially death), in the immediate period following delivery and up to 6 weeks after delivery. The use of an Early Warning Score system modified for pregnancy (MEOWS) is being encouraged for early recognition of acutely unwell women. Circulatory arrest is diagnosed by absence of a palpable carotid or femoral pulse and resuscitation with external chest compressions should be commenced immediately. Circulatory collapse secondary to haemorrhagic shock is one of the leading causes of postpartum collapse. Glasgow Coma Scale can be used as an objective assessment of patient's level of consciousness. Automated external defibrillators or external monitors to assess cardiac rhythm should be applied as per advanced life-support guideline. Early involvement of relevant specialists should be encouraged to maintain high standards of care and reduced maternal morbidity and mortality.