الفهرس 
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Abstract
Placenta accreta is an extremely serious complication in pregnancy. It occurs when the placenta invades more deeply than normal, into the wall of the uterus (placenta accreta), and sometimes even growing through the full thickness of the wall to the outside of the uterus (placenta increta or percreta) (Dickinson et al.,2008)
Abnormal placental invasion (placenta accreta) can result in major obstetric hemorrhage during delivery. The most important risk factors are the following: previous cesarean delivery, placenta previa, maternal age over 35, smoking, previous myomectomy, dilatation and curettage. Ascribing to the trend of rising cesarean delivery rates in the last decades, placenta accreta has become the most important cause of peripartum hysterectomy. (Beer et al.,2013)
The antenatal diagnosis of placenta accreta is pivotal, because it allows both the medical team and the patient to be prepared for the suspected complications during delivery Many markers were studied for the early prediction of placenta accreta with varying results, Ultrasound findings associated with placental invasion in the second and third trimesters (gray-scale ultrasonography) include the presence of placenta previa, obliteration of the clear space between the uterus and placenta, multiple placental lacunae, extension of the villi into the myometrium or beyond, interruption of the posterior bladder wall-uterine interface An anterior myometrial thickness less than 1 mm (as measured between the echogenic serosa and the retroplacental vessels) was also reported to be as predictive as placental lacunae for PA Also, A thin myometrium may be due to partial dehiscence (the so-called uterine window) of the uterine wall In a recent study by Rac et al., (2015),They found that some characteristics found to be positively associated with morbidly adherent placenta include placental location, smallest myometrial thickness, and bridging vessels (Rac et al., 2015),
Many chemical markers were studied for the early prediction of placenta accreta with varying results. Of these, laboratory biomarkers such as alpha-fetoprotein and protein.P53 (Handwerger et al.,2009)
Alpha-fetoprotein (AFP) is a serum glycoprotein that was discovered early in human fetal serum by Bergstrand and Czar in 1956. It is the chief mammalian tumor-associated fetal protein found in adult’s blood (by a small amount of 10-20 ng/ml) Maternal serum alpha-fetoprotein is elevated in some pregnancy complications such as spontaneous abortion, pre-elampsia, gestational hypertension, preterm delivery and premature rupture of membranes (PROM) Also, poor maternal and fetal outcome is strongly related to the elevation of maternal AFP (probably as a result of placental injury) In addition, a significant association was found between increasing maternal AFP and the greater likelihood of persistent placenta previa Furthermore, the risk for abnormal placental adherence was increased in women with an elevated maternal serum AFP level, especially in the presence of a placenta previa. (Kupferminc et al.,2013)
The P53 protein is involved in DNA repair and is an encoprotective antigen .this gene when damaged leads to production of anti P53 and predispose to various cancers however its role in normal physiologic process including female reproduction remain poorly understood beside its role as a tumor suppressor gene in human tumor it may play a significant role in regulating angiogenesis.P53 is a potential mediation of pregnancy. Recent studies have suggested that PA has an intrinsic abnormality, which causes pathological maturation of the trophoblast, rather than of the damaged uterine cavity that expressed by affection of senescence-related markers such as Cyclin-dependent kinase inhibitors p21, p15, p16, and the tumor suppressor protein p53 (Chuprin et al.,2013)
The aim of our study was to evaluate the role of measurement of retro-placental myometrial thickness, maternal serum alfa fetoprotein and maternal serum p53 in peridiction of placental invasion
This study was a prospective study that was carried out at Minia Maternity University Hospital, during the period from October 2017 to March 2019 (18 months).
The study included a total of 200 pregnant women with previous one or more CS who were admitted to the hospital for CS between 28:38 weeks of gestation. They were classified to 4 groups (50 women per each) as follow:
group (I) Diffuse PA: include women with diffuse placenta accreta.
group (II) focal PA: include women with focal placenta accreta.
group (III) placenta previa with no signs of accreta: include women with placenta previa with no signs of accreta
group (IV) Control group: include women with normally situated placenta
Placental localization, the diagnosis of placenta previa was based on the presence of placental tissue covering the internal cervical os, retro-placental myometrial thickness is measured in a saggital plane, evaluation of the retro-placental clear zone, irregularity and thickness of the uterine-bladder interface Lacunar spaces.
Maternal serum alpha-fetoprotein was measured.
Maternal serum protein p53 was measured methods of operative interference were reported, given blood units for each case was recorded.
Postoperatively, patients who were admitted to ICU were subjected to close daily follow-up.interaoperative and Postoperative complications and hospital stay duration were recorded histopathological examination for hysterectomy speicemen was done
The demographic criteria; the mean age of all studied cases was 30.25 years and the Placenta accreta group had a significantly higher number of cases with ≥ 2 previous CSs than other groups.
Maternal serum alpha-fetoprotein was significantly elevated in diffuse placenta accreta group compared to other groups
Also, serum alpha-fetoprotein has a high predictive value for placenta accreta in women with placenta previa with cutoff > 0.94MoM, area under curve of 0.907, with a sensitivity of 88%, specificity = 81% PPV = 82,4%, NPV = 88,1% and accuracy of 84,5% (p<0.01).
p53 was significantly reduced in diffuse placenta accreta group compared to other groups Also, p53 has a high predictive value for placenta accreta in women with placenta previa with cutoff < 315 (pg/ml) area under curve 0.934, with a sensitivity of 92%, specificity = 77% PPV = 80%, NPV = 90.5% and diagnostic accuracy of 84.5% (p<0.01).
myometrial thickness was significantly reduced in diffuse placenta accreta group(0.74 a ± 0.11mm) compered to other groups
Myometrial thickness has high predictive value for placenta accreta with cut of point < 0.82mm, AUC 0.941, sensitivity = 95.0 % specificity = 77.0%, PPV = 80.5 %, NPV = 93.3 % and diagnostic value of 86.0 % (p<0.01). , incidence of complications was obviously higher in diffuse placenta accreta group (41 cases, 82%, p<0.01) with high occurrence of post-partum hemorrhage,bladder injury , Coagulopathy , ICU admission and Re-exploration This was attributed to the high number of cases that had hysterectomy in this group (35 cases, 70%) compared to other groups.