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    Editorial: Slow progress in management of the morbidly adherent placenta

     

    Conservative management

    Given the rapidly increasing prevalence of MAP, from 1 in 2000 deliveries in the 1980s to 1 in 500 today,9 efforts at preserving the uterus to permit additional childbearing have increased. Sentilhes and associates conducted a retrospective multicenter study of 167 conservatively managed patients with placenta accreta from 1993 to 2007 in 40 French university hospitals.10

    Conservative treatment was successful in 78.4% (95% CI: 71.4–84.4%). Severe maternal morbidity occurred in 6.0% (95% CI: 2.9–10.7%), including one woman who died of myelosuppression and nephrotoxicity after intraumbilical methotrexate administration. Spontaneous placental resorption occurred in 75.0% of cases (95% CI: 66.1–82.6%), with a median delay from delivery of 13.5 weeks (range 4–60 weeks). While initial conservative management efforts were limited to placenta accreta, more recently this approach has been extended to cases of placenta percreta with less favorable results.

    Clausen and colleagues recently reviewed 19 published cases of conservatively managed placenta percreta and reported that 58% of affected patients eventually required hysterectomy for delayed infection or hemorrhage.11

    Take-home message

    What then is the optimal management of patients with MAP? First, precision in diagnosis is crucial. Patients with prior CDs, particularly those with placenta previa, should be carefully evaluated for sonographic evidence of accreta. Magnetic resonance imaging can be employed to better define the extent of invasion.

    The defect should be carefully mapped, not only to avoid disrupting the placenta during delivery, but to ascertain if it is likely to be so focal as to be amendable to en bloc wedge excision or more dispersed but still superficial enough to permit conservative management, leaving the placenta in situ in motivated, fully informed patients. In the latter cases, delayed hysteroscopic resection maybe an option12 but methotrexate should not be used. In all other cases the placenta should be left undisturbed, the cesarean incision repaired and an expeditious C-hys performed.

    Preoperatively, establish 2 large-bore intravenous access points, employ pneumatic compression boots, ensure adequate quantities of readily available pRBCs, fresh frozen plasma, platelets, and cryoprecipitate, and have your team trained in implementing a massive hemorrhage protocol. Use of a cell saver seems reasonable, especially when the diagnosis is percreta. Finally, I would still recommend preoperative placement of prophylactic balloon catheters when there is a high degree of suspicion for percreta, especially involving adjacent organs. 

     

    References

    1. Silver RM, Landon MB, Rouse DJ, et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006;107(6):1226–1232.

    2. Irwin JC, Giudice LC. Insulin-like growth factor binding protein-1 binds to placental cytotrophoblast alpha5beta1 integrin and inhibits cytotrophoblast invasion into decidualized endometrial stromal cultures. Growth Horm IGF Res. 1998;8(1):21–31.

    3. Lockwood CJ, Krikun G, Caze R, et al. Decidual cell-expressed tissue factor in human pregnancy and its involvement in hemostasis and preeclampsia-related angiogenesis. Ann N Y Acad Sci. 2008;1127:67–72. Review.

    4. Schatz F, Krikun G, Runic R, et al. Implications of decidualization-associated protease expression in implantation and menstruation. Semin Reprod Endocrinol. 1999;17(1):3-12.

    5. Tan CH, Tay KH, Sheah K, et al. Perioperative endovascular internal iliac artery occlusion balloon placement in management of placenta accreta. AJR Am J Roentgenol. 2007;189(5):1158–1163.

    6. Levine AB, Kuhlman K, Bonn J. Placenta accreta: comparison of cases managed with and without pelvic artery balloon catheters. J Matern Fetal Med. 1999;8(4):173–176.V.

    7. Shrivastava V, Nageotte M, Major C, et al. Case-control comparison of cesarean hysterectomy with and without prophylactic placement of intravascular balloon catheters for placenta accreta. Am J Obstet Gynecol. 2007;197(4):402.e1–5.

    8. Salim R, Chulski A, Romano S, et al. Precesarean prophylactic balloon catheters for suspected placenta accreta: a randomized controlled trial. Obstet Gynecol. 2015;126(5):1022–1028.

    9. Silver RM, Fox KA, Barton JR, et al. Center of excellence for placenta accreta. Am J Obstet Gynecol. 2015;212(5):561–568. Review.

    10. Sentilhes L, Ambroselli C, Kayem G, et al. Maternal outcome after conservative treatment of placenta accreta. Obstet Gynecol. 2010;115(3):526–534.

    11. Clausen C, Lönn L, Langhoff-Roos J. Management of placenta percreta: a review of published cases. Acta Obstet Gynecol Scand. 2014;93(2):138–143. Review.

    12. Hequet D, Morel O, Soyer P, et al. Delayed hysteroscopic resection of retained tissues and uterine conservation after conservative treatment for placenta accreta. Aust N Z J Obstet Gynaecol. 2013;53(6):580–583. 

     

    Charles J. Lockwood, MD, MHCM
    Dr. Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South ...

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