Conservative management of placenta accreta

Maternal and neonatal outcomes in morbidly adherent placenta: a developing country experience

BACKGROUND

Morbid adherent placenta, a severe pregnancy complication, is associated with massive obstetrical haemorrhage and high maternal mortality. Antenatal diagnosis and meticulous multidisciplinary planning at delivery is crucial for optimal outcome. We aim to identify the maternal and neonatal outcome in women with morbid adherent placenta.

METHOD

It was a retrospective evaluation of cases of clinically suspected and/or histologically confirmed morbid adherent placenta over a 1-year period.

RESULTS

The incidence of morbid adherent placenta was 1 per 306 deliveries. Previous Caesarean section with placenta praevia was the commonest risk factor. Among all, 71.4% had no antenatal care. Of all, 38.9% women needed transfer to critical care. There were five (23.8%) maternal deaths. Of the 21 neonates, four were stillborn, nine needed NICU transfer and eight had an Apgar score of 9 at 5 min of birth.

CONCLUSION

Morbid adherent placenta is associated with poor maternal and neonatal outcome.

Morbidly adherent placenta: a critical review

OBJECTIVE

To evaluate the demographic profile, high risk factors, fetomaternal outcome and management options in morbidly adherent placenta (MAP).

STUDY DESIGN

Retrospective analysis.

METHODOLOGY

Review of 20 case records of women with MAP during year 2001-2006.

RESULTS

The mean age and parity of the women was 27.7 ± 4.2 years and 2.5 respectively. 70 % women had previous uterine scar, and similar number had placenta previa. 60 % women presented with antepartum hemorrhage and 20 % with retained placenta. 85 % women underwent hysterectomy with 5 % requiring internal iliac artery ligation, another 5 % partial cystectomy and 15 % bladder repair. Blood loss was between one and nine litres requiring an average of six units whole blood and 4 units FFP. There were six (30 %) maternal deaths. 55 % of the newborns were preterm and the perinatal mortality was 33.3 %.

CONCLUSION

Cesarean section and placenta previa are significant risk factors. MAP is associated with high fetomaternal morbidity and mortality.

Invasive placentation and uterus preserving treatment modalities: a systematic review

Purpose

We present a systematic review to evaluate failure rates (secondary hysterectomy or maternal mortality) and success rates (subsequent menstruation or pregnancy) after different uterus preserving treatment modalities in women with invasive placentation.

Methods

A review of English, German or Dutch language-published research, using Medline and Embase databases, was performed. Studies of any design were included.

Results

Ten cohort studies and 50 case series or case reports were included. Expectant management reported a secondary hysterectomy in 55/287 (19%), maternal mortality in 1/295 (0.3%), a subsequent menstruation in 44/49 (90%) and a subsequent pregnancy in 24/36 (67%). Embolization of the uterine arteries described a secondary hysterectomy in 8/45 (18%), a subsequent menstruation in 8/13 (62%) and a subsequent pregnancy in 5/33 (15%). Methotrexate therapy presented a secondary hysterectomy in 1/16 (6%), a subsequent menstruation in 4/5 (80%) and a subsequent pregnancy in 1/2 (50%). Uterus preserving surgery showed a secondary hysterectomy in 24/77 (31%), maternal mortality in 2/55 (4%), a subsequent menstruation in 28/34 (82%) and a subsequent pregnancy in 19/26 (73%).

Conclusions

This review indicates that different uterus preserving treatment modalities may be effective in managing invasive placentation. Despite the extensive review of the literature, no conclusions about the superiority of any modality can be drawn.