Editorial: Slow progress in management of the morbidly adherent placenta
Dr Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South Florida, Tampa.
I admit I am a bit of an adrenaline junkie and this may account for my fascination with what is now termed morbidly adherent placenta (MAP), formerly designated as placenta accreta, increta, and percreta. In accreta, the anchoring trophoblast attaches not to the decidua basalis but directly to the myometrium. In the case of placenta increta, trophoblasts penetrate into the myometrium, whereas in percreta, they penetrate through the myometrium to the serosa or adjacent organs.
During the course of my career I have seen massive intraperitoneal hemorrhage from placenta percreta at 14 weeks and yet nearly bloodless cesarean hysterectomies for the same diagnosis at 36 weeks. I have become convinced that early, accurate diagnosis, meticulous preoperative preparation, and definitive extirpative surgery are the keys to optimal outcomes.
One of the mainstays of my approach over the past 20 years has been the nearly universal use of intraoperative intermittent occlusion of the internal iliac arteries using balloon catheters placed preoperatively. However, recent studies have called into question the utility of this approach. In addition, there is growing evidence that conservative management is appropriate in select cases. Thus, while MAP has become an epidemic we are only now perfecting rational management strategies.