Elective Non-Removal of the Placenta and Prophylactic Uterine Artery Embolization Postpartum as a Diagnostic Imaging Approach for the Management of Placenta Percreta: A Case Report

Progressive Devascularization: A Novel Surgical Approach for Placenta Previa

Background  The gold standard for antenatal diagnosis of placenta previa is the transvaginal ultrasonography. In placenta previa cases, separation of placental and uterine tissues is challenging even for the most experienced surgeons. Life-threatening obstetrical complications from cesarean deliveries with placenta previa include peripartum hemorrhage, coagulopathy, blood transfusion, peripartum hysterectomy, and multiple organ failure. Cases  We detailed the 3 cases of placenta previa that underwent bilateral uterine artery ligation; if hemostasis was not achieved, horizontal mattress sutures were placed in the lower uterine segment. All patients were discharged with minimal morbidity. Conclusion  For patients with placenta previa and low risk for placenta creta, counseling should include the risk for maternal morbidity and criteria for pursuing peripartum hysterectomy. Our devascularization, a stepwise surgical approach, shows promising outcomes in placenta previa cases. Précis  We propose a novel surgical approach, using a progressive devascularization surgical technique, for management of women with placenta previa, undergoing cesarean delivery.

Intermittent aortic balloon occlusion combined with cesarean section for the treatment of patients with placenta previa complicated by placenta accreta: A retrospective study

AIM

To compare the efficacy of cesarean section (CS) combined with intermittent aortic balloon occlusion with that of CS alone for treating patients with placenta previa complicated by placenta accreta.

METHODS

Forty-five patients with placenta previa complicated by placenta accreta who underwent CS were retrospectively studied. Twenty-two patients had undergone CS combined with intermittent aortic balloon occlusion (combination group) and 23 patients received conventional hemostatic support only (control group). The postpartum hemorrhage, transfusion requirements, operation time and recovery time, and the ability to preserve the uterus and fertility were analyzed.

RESULTS

Intermittent aortic balloon occlusion significantly decreased the volume of blood loss in the combination group relative to the control group (597 ± 359 mL vs 2687 ± 575 mL; P < 0.001), and transfusion requirements were also reduced (498 ±195 mL vs 2390 ±789 mL; P <0.001). We observed shorter operation time in the combination group relative to the control group (63.8 ± 12.3 min vs 118.8 ± 22.4 min; P < 0.001), and fewer patients required uterine cavity stuffing followed by uterine artery embolization (n = 2 vs n = 10; P <0.05), uterine artery ligation (n = 1 vs n = 9; P < 0.05), and hysterectomy (n = 0 vs n =7; P < 0.05).

CONCLUSION

Intermittent aortic balloon occlusion may control postpartum hemorrhage in pregnancies complicated by placenta accreta, and improve the postoperative conditions.

A Case of Placenta Percreta Managed with Sequential Embolisation Procedures

Background

The incidence of morbidly adherent placenta, including placenta percreta, has increased significantly over recent years due to rising caesarean section rates. Historically, abnormally invasive placenta has been managed with caesarean hysterectomy; however nonsurgical interventions such as uterine artery embolisation (UAE) are emerging as safe alternative management techniques. UAE can be utilised to decrease placental perfusion and encourage placental resorption, thereby reducing the risk of haemorrhage and other morbidities.

Case

We describe one of the very few reported cases of placenta percreta which was successfully treated primarily with sequential artery embolisation. Our patient underwent four embolisation procedures over a period of 248 days, with no major morbidity or complications.

Conclusion

Repeat UAE may be a beneficial primary management modality in cases of placenta percreta with bladder involvement.

Urological Manifestations of Placenta Percreta

Placenta percreta is a condition of pregnancy associated with abnormal decidua placenta. It is characterized by invasion of chorionic villi past the myometrium and serosa, towards urogenital organs. Complications include massive hemorrhage, bladder dysfunction, and severe infections during delivery. Reports suggest an increasing prevalence of this condition. From a urological perspective, this review suggests how early diagnostic modalities, effective treatment plans, and appropriate surgical methods may aid in decreasing the morbidity and mortality of placenta percreta. The importance of maintaining bladder integrity during hysterectomy is emphasized.

Conservative Management of Invasive Placenta Using Combined Prophylactic Internal Iliac Artery Balloon Occlusion and Immediate Postoperative Uterine Artery Embolization

Purpose

The objective of the study was to evaluate the efficacy and safety of combined prophylactic intraoperative internal iliac artery balloon occlusion and postoperative uterine artery embolization in the conservative management (uterine preservation) of women with invasive placenta undergoing scheduled caesarean delivery.

Methods

Ten women (mean age 35 years) with invasive placenta choosing caesarean delivery without hysterectomy had preoperative insertion of internal iliac artery occlusion balloons, intraoperative inflation of the balloons, and immediate postoperative uterine artery embolization with absorbable gelatin sponge. A retrospective review was performed with institutional review board approval. Outcome measures were intraoperative blood loss, transfusion requirement, hysterectomy rate, endovascular complications, surgical complications, and postoperative morbidity.

Results

All women had placenta increta or percreta, and concomitant complete placenta previa. Mean gestational age at delivery was 36 weeks. In 6 women the placenta was left undisturbed in the uterus, 2 had partial removal of the placenta, and 2 had piecemeal removal of the whole placenta. Mean estimated blood loss during caesarean delivery was 1.2 L. Only 2 patients (20%) required blood transfusion. There were no intraoperative surgical complications, endovascular complications, maternal deaths, or perinatal deaths. Three women developed postpartum complications necessitating postpartum hysterectomy; the hysterectomy rate was therefore 30% and uterine preservation was successful in 70%.

Conclusion

Combined bilateral internal iliac artery balloon occlusion and uterine artery embolization may be an effective strategy to control intraoperative blood loss and preserve the uterus in patients with invasive placenta undergoing caesarean delivery.

Conservative management of placenta percreta: a stepwise approach

PURPOSE

To describe a modified surgical approach in the form of stepwise cesarean section in placenta percreta.

METHODS

We conducted a prospective observational study. A total of 71 patients with placenta percreta were subjected to the new stepwise surgical approach and uterine repair at the time of cesarean delivery.

RESULTS

The procedure was successful in controlling the bleeding and preserving the patient's uterus in 65 (91.5%) women. Ten patients (14.1%) had urinary tract complications, nine (90%) were managed during cesarean section and one presented late in the form of vesicouterine fistula.

CONCLUSIONS

A stepwise cesarean section is safe and effective procedure that can be applied in placenta percreta.

Maternal outcome after conservative management of placenta percreta at caesarean section: a report of three cases and a review of the literature

Retaining the placenta in situ at caesarean section for placenta percreta and awaiting placental reabsorption is widely practiced; however, there is limited evidence on the efficacy and complications of this strategy. We present three cases of placenta percreta managed conservatively and note that all three women experienced significant complications. A review of the literature showed that despite initial conservative management, 40% of women subsequently require emergency hysterectomy and 42% will experience major morbidity.

Placenta accreta: risk factors, perinatal outcomes, and consequences for subsequent births

OBJECTIVE

We sought to evaluate risk factors and perinatal outcomes of pregnancies complicated with placenta accreta and to study perinatal outcomes in subsequent pregnancies.

STUDY DESIGN

A retrospective study comparing all singleton cesarean deliveries (CD) of women with and without placenta accreta was conducted. In addition, a retrospective comparison of all subsequent singleton CD of women with a previous placenta accreta, with CD of women with no such history, was performed during the years 1988 through 2011. Stratified analysis using multiple logistic regression models was performed to control for confounders.

RESULTS

During the study period, there were 34,869 CD, of which 0.4% (n = 139) were complicated with placenta accreta. Using a multivariable analysis with backward elimination, year of birth (adjusted odds ratio [aOR], 1.06; 95% confidence interval [CI], 1.03-1.09; P < .001), previous CD (aOR, 5.11; 95% CI, 3.42-7.65; P < .001), and placenta previa (aOR, 50.75; 95% CI, 35.57-72.45; P < .001) were found to be independently associated with placenta accreta. There were 30 subsequent pregnancies of women with placenta accreta. Recurrent accreta occurred in 4 patients (13.3%). Previous placenta accreta was significantly associated with uterine rupture (3.3% vs 0.3%, P < .01) peripartum hysterectomy (3.3% vs 0.2%, P < .001), and the need for blood transfusions (16.7% vs 4%, P < .001). Nevertheless, increased risk for adverse perinatal outcomes such as low Apgar scores at 1 and 5 minutes and perinatal mortality was not found in these patients.

CONCLUSION

Prior CD and placenta previa are independent risk factors for placenta accreta. A pregnancy following a previous placenta accreta is at increased risk for adverse maternal outcomes such as recurrent accreta, uterine rupture, and peripartum hysterectomy. However, adverse perinatal outcomes were not demonstrated.

Epidemiology, etiology, diagnosis, and management of placenta accreta

Placenta accreta is a severe pregnancy complication and is currently the most common indication for peripartum hysterectomy. It is becoming an increasingly common complication mainly due to the increasing rate of cesarean delivery. Main risk factor for placenta accreta is a previous cesarean delivery particularly when accompanied with a coexisting placenta previa. Antenatal diagnosis seems to be a key factor in optimizing maternal outcome. Diagnosis can be achieved by ultrasound in the majority of cases. Women with placenta accreta are usually delivered by a cesarean section. In order to avoid an emergency cesarean and to minimize complications of prematurity it is acceptable to schedule cesarean at 34 to 35 weeks. A multidisciplinary team approach and delivery at a center with adequate resources, including those for massive transfusion are both essential to reduce neonatal and maternal morbidity and mortality. The optimal management after delivery of the neonate is vague since randomized controlled trials and large cohort studies are lacking. Cesarean hysterectomy is probably the preferable treatment. In carefully selected cases, when fertility is desired, conservative management may be considered with caution. The current review discusses the epidemiology, predisposing factors, pathogenesis, diagnostic methods, clinical implications and management options of this condition.

Placenta accreta

OBJECTIVE

We sought to review the risks of placenta accreta, increta, and percreta, and provide guidance regarding interventions to improve maternal outcomes when abnormal placental implantation occurs.

METHODS

Relevant documents were identified through a search of the English-language literature for publications including ≥1 of the key words "accreta" or "increta" or "percreta" using PubMed (US National Library of Medicine; January 1990 through January 2010); with results limited to studies involving human beings. Additional information was obtained from references identified within selected articles; from additional review articles; and from guidelines by organizations including the American College of Obstetricians and Gynecologists. Each included article was evaluated according to study design and quality in accordance with the scheme outlined by the US Preventative Services Task Force.

RESULTS AND RECOMMENDATIONS

Abnormal placentation--encompassing placenta accreta, increta, and percreta--is increasingly common. While randomized controlled trials and large observational cohort studies that can be used to define best practice are lacking, strategies to enhance early diagnosis, enhance preparation, and coordinate peripartum management can be undertaken. Women with a placenta previa overlying a uterine scar should be evaluated for the potential diagnosis of placenta accreta. Women with a placenta previa or "low-lying placenta" overlying a uterine scar early in pregnancy should be reevaluated in the third trimester with attention to the potential presence of placenta accreta. When the diagnosis of placenta accreta is made remote from delivery, the need for hysterectomy should be anticipated and arrangements made for delivery in a center with adequate resources, including those for massive transfusion. Intraoperatively, attention should be paid to abdominal and vaginal blood loss. Early blood product replacement, with consideration of volume, oxygen-carrying capacity, and coagulation factors, can reduce perioperative complications.

Prophylactic hypogastric artery ballooning in a patient with complete placenta previa and increta

Abnormal attachment of the placenta (Placenta accreta, increta, and percreta) is an uncommon but potentially lethal cause of maternal mortality from massive postpartum hemorrhage. A 33-yr-old woman, who had been diagnosed with a placenta previa, was referred at 30 weeks gestation. On ultrasound, a complete type of placenta previa and multiple intraplacental lacunae, suggestive of placenta accreta, were noted. For further evaluation of the placenta, pelvis MRI was performed and revealed findings suspicious of a placenta increta. An elective cesarean delivery and subsequent hysterectomy were planned for the patient at 38 weeks gestation. On the day of delivery, endovascular catheters for balloon occlusion were placed within the hypogastric arteries, prior to the cesarean section. In the operating room, immediately after the delivery of the baby, bilateral hypogastric arteries were occluded by inflation of the balloons in the catheters previously placed within. With the placenta retained within the uterus, a total hysterectomy was performed in the usual fashion. The occluding balloons were deflated after closure of the vaginal cuff with hemostasis. The patient had stable vital signs and normal laboratory findings during the recovery period; she was discharged six days after delivery without complications. The final pathology confirmed a placenta increta.

Conservative Management of Abnormally Invasive Placentation

Due to the growing number of cesarean deliveries, the frequency of abnormally invasive placentation is increasing. The optimal management of this condition remains unclear. This article reviews the efficacy and safety of conservative management of abnormally invasive placentation. We performed a MEDLINE and Embase search and reviewed all articles on conservative management of abnormally invasive placentation published from 1985 through 2006. Over the past 20 years, 48 reports have described outcomes of 60 women who were treated conservatively for abnormally invasive placentation. Twenty-six women were managed without any additional interventions. In most of these patients (19/26), the placenta had been partially removed. In 4 of these 26, conservative therapy failed. Twenty-two women received adjuvant methotrexate. In most of these women (19/22), the entire placenta was left in situ. In 5, therapy failed. Twelve women were managed with arterial embolization. In most of these (9/12), the diagnosis was made antepartum and the placenta was completely left in situ. In 3, therapy failed. Overall, 11 women experienced infection (11/60), 21 women experienced vaginal bleeding (21/60), and 4 suffered disseminated intravascular coagulopathy (4/60). Spontaneous loss of placental tissue was noted in 16 women. Subsequent pregnancies were reported in 8 women. Conservative management of abnormally invasive placentation can be effective and fertility can be preserved. It should only be considered in highly selected cases when blood loss is minimal and there is desire for fertility preservation. Whether adjuvant methotrexate or selective arterial embolization is beneficial is uncertain. Undetectable hCG values do not seem to guarantee complete resorption of retained placental tissue.

Conservative management of placenta increta with selective arterial embolization preserves future fertility and results in a favorable outcome in subsequent pregnancies

OBJECTIVE

To present a case of selective arterial embolization for the treatment of placenta increta in a patient with subsequent pregnancy.

DESIGN

Case report and literature review.

SETTING

Community-based hospital.

PATIENT(S)

A 31-year-old G2P1 woman with placenta increta presenting with delayed postpartum hemorrhage.

INTERVENTION(S)

Selective uterine artery embolization.

MAIN OUTCOME MEASURE(S)

Cessation of uterine hemorrhage, future pregnancy.

RESULT(S)

The patient's uterine bleeding immediately resolved. She subsequently delivered a healthy neonate at term without recurrence of abnormal placentation.

CONCLUSION(S)

Arterial embolization is effective for treating placenta increta in women who wish to preserve fertility. A review of the literature demonstrates a 76.9% success rate and an 11% complication rate.

Experience with Conservative Strategy of Uterine Artery Embolization in the Treatment of Placenta Percreta in the first Trimester of Pregnancy

OBJECTIVE

There is little prospective experience in the conservative treatment of placenta percreta during the first trimester in order to preserve uterine fertility. We describe herein our experience with uterine artery embolization (UAE) in the management of placenta percreta at 9 weeks of gestation.

CASE REPORT

A 36-year-old woman, gravida 3, para 1, was referred for ultrasonographic evaluation because of suspected molar pregnancy due to persistent vaginal spotting at 9 weeks of gestation. A Grade 3+ lacunar flow pattern with multiple bizarre and large irregular sonolucent spaces were observed. Color Doppler imaging revealed extensive turbulent lacunar blood flow perfusing throughout the whole surrounding uteroplacental tissues and fetus. The patient was informed of the situation and she had a strong desire to avoid surgery. Conservative management with bilateral UAE was performed using polyvinyl alcohol particles to promote involution and shedding of the abnormally adherent placenta. However, an unsatisfactory vessel-occluding effect caused by extensive collateral supply was still detected after repeated UAE. We, therefore, performed hysterectomy, and the patient had an uneventful postoperative course.

CONCLUSION

The efficacy and complications of UAE as a therapeutic modality for the conservative management of invasive placentation in the first trimester of pregnancy are not clear, as this is the first report of its kind. However, although UAE had failed in this case, it may still be a useful procedure as a prophylactic measure before surgical intervention, and hysterectomy can also be performed for better control of operative hemorrhage.