Conservative management of clinically diagnosed placenta accreta following vaginal delivery

High-intensity focused ultrasound in management of placenta accreta spectrum: A systematic review

BACKGROUND

High-intensity focused ultrasound (HIFU) is a non-invasive procedure that has been studied in the management of placenta accreta spectrum (PAS).

OBJECTIVE

To appraise HIFU in the management of PAS and highlight the restrictions on converting uterus-preserving studies into evidence-based practice.

SEARCH STRATEGY

A search on Scopus, Cochrane, PubMed and Web of Science was conducted from date of inception to January 2020.

SELECTION CRITERIA

Studies on using HIFU in the management of PAS were eligible. Review articles, conference papers, and case reports were excluded.

DATA COLLECTION

A standardized sheet was used to abstract data from eligible studies. CON-PAS registry was used to include studies on other conservative modalities.

RESULTS

Four studies were eligible (399 patients). Average residual placental volume was 61.74 cm³ (6.01-339 cm³ ). Treatment was successful in all patients. Normal menstruation recovered after 48.8 days (15-150 days). No major complications were encountered. Sixty-one studies were retrieved from the CON-PAS registry; uterine artery embolization (23 studies), balloon placement (15 studies), compression sutures (10 studies), placenta in situ (7 studies), and uterine resection (6 studies) were successful in 83.7%, 92.9%, 87.9%, 85.2%, and 79.3% of cases, respectively.

CONCLUSIONS

HIFU may fit certain clinical situations in the management of PAS. A global research strategy is recommended to incorporate conservative approaches within a comprehensive management protocol.

Failed manual removal of the placenta after vaginal delivery

PURPOSE

A retained placenta after vaginal delivery where manual removal of placenta fails is a clinical challenge. We present six cases that illustrate the heterogeneity of the condition and discuss the etiology and terminology as well as the clinical management.

METHODS

Members of the European Working group on Abnormally Invasive Placenta (EW-AIP) were invited to report all recent cases of retained placenta that were not antenatally suspected to be abnormally adherent or invasive, but could not be removed manually despite several attempts.

RESULTS

The six cases from Denmark, The Netherlands and the UK provide examples of various treatment strategies such as ultrasound-guided vaginal removal, removal of the placenta through a hysterotomy and just leaving the placenta in situ. The placentas were all retained, but it was only possible to diagnose abnormal invasion in the one case, which had a histopathological diagnosis of increta. Based on these cases we present a flow chart to aid clinical management for future cases.

CONCLUSION

We need properly defined stringent terminology for the different types of retained placenta, as well as improved tools to predict and diagnose both abnormally invasive and abnormally adherent placenta. Clinicians need to be aware of the options available to them when confronted by the rare case of a retained placenta that cannot be removed manually in a hemodynamically stable patient.

[Massive obstetric haemorrhage in a patient with placenta percreta]

We present a case of a 38 year-old patient with prenatal diagnosis of placenta praevia. When the elective caesarean began it was found a placenta accreta. In spite of an emergency hysterectomy, embolisation using interventional radiography was needed after a massive obstetric haemorrhage. The post-operative period progressed without incidents.

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.

Emergency peripartum hysterectomy: a 10-year review at the Royal Hospital for Women, Sydney

BACKGROUND

There appears to be a rise in the rate of emergency peripartum hysterectomy (EPH) in the developed world.

AIMS

  To determine the incidence, indications, risk factors, complications and management of EPH in our tertiary level teaching hospital, the Royal Hospital for Women (RHW) in Sydney, over the last decade.

METHODS

A retrospective analysis was conducted of all cases of EPH performed at the RHW between the years 1999-2008 inclusive. EPH was defined as one performed after 20 weeks gestation for uncontrollable uterine bleeding not responsive to conservative measures occurring at any time after delivery but within the first 6 weeks post-partum. Cases were ascertained via our hospital obstetric database.

RESULTS

There were 33 EPH among 38,998 births, a rate of 0.85 per 1000 births. Indications for EPH were morbid adherence of the placenta (54.8%), placenta praevia (19.4%), uterine atony (12.9%) and uterine rupture or cervical laceration (9.7%). A significant association between previous caesarean section (CS) and abnormal placentation was confirmed (P=0.011), especially for morbid adherence of the placenta (P=0.004). There was one maternal death. Maternal morbidity was significant, with disseminated intravascular coagulation and urinary tract injury among the most common complications. All women required blood transfusions, and over a quarter were admitted to the intensive care unit.

CONCLUSIONS

In our series, abnormal placentation causing severe haemorrhage was the commonest indication for EPH. Previous CS is a risk factor for abnormal placentation and particularly for morbid adherence of the placenta. The morbidity associated with EPH is considerable.