Clinical aspects and conservative management of placenta accreta

The role of prophylactic internal iliac artery ligation in abnormally invasive placenta undergoing caesarean hysterectomy: a randomized control trial

Objective: To identify the role of bilateral internal iliac artery (IIA) ligation on reducing blood loss in abnormally invasive placenta (AIP) undergoing caesarean hysterectomy. Methods: In this parallel-randomized control trial, 57 pregnant females with ultrasound features suggestive of AIP were enrolled. They were randomized into two groups; IIA group (n = 29 cases) performed bilateral IIA ligation followed by caesarean hysterectomies, while Control group (n = 28 cases) underwent caesarean hysterectomy only. The main outcome was the difference in the estimated intraoperative blood loss between the two groups. Results: There was no significant difference between the two groups regarding the intraoperative estimated blood loss (1632 ± 804 versus 1698 ± 1251, p value .83). The operative procedure duration (minutes) (223 ± 66 versus 171 ± 41.4, p value .001) varied significantly between the two groups. Conclusions: Bilateral internal iliac artery ligation, in cases of AIP undergoing caesarean hysterectomy, is not recommended for routine practice to minimize blood loss intraoperatively.

A novel sonographic scoring system for antenatal risk assessment of obstetric complications in suspected morbidly adherent placenta

OBJECTIVES

The purpose of this study was to evaluate a novel sonographic scoring system for risk assessment of complications in patients suspected of having morbidly adherent placenta.

METHODS

This retrospective study evaluated the association between maternal complications and a grayscale sonographic scoring system for adherent placenta before surgery. Criteria for adherent placenta included uteroplacental and uterobladder demarcation lines and the presence of lacunae. Placentas were classified into 4 stages: stage 0, normal placentation; stage 1, low probability of adherence; stage 2, moderate possibility of adherence; and stage 3, high suspicion of adherence. Placental adherence as assessed by a surgical team, estimated blood loss, and postoperative hospitalization days were determined for each group, as well as the rates of the need for packed blood cells, cryoprecipitate units, and hysterectomy.

RESULTS

One hundred nine women were included in the study. Twenty-six (23.8%) women were given a score of stage 0, 22 (20.2%) stage 1, 28 (25.7%) stage 2, and 33 (30.3%) stage 3. Linear regression analysis demonstrated that the sonographic staging was the only variable significantly associated with the number of packed cells or cryoprecipitate units transfused (P< .001) and a clinical diagnosis of adherent placenta (P< .001). In addition, both sonographic staging and a history of cesarean delivery were significantly associated with hysterectomy (P = .01; P = .03, respectively), treatment with any blood products (P< .001; P= .01), and the duration of postoperative hospitalization (P< .001; P = .006).

CONCLUSIONS

A scoring system based on simple grayscale parameters may be effective for antenatal risk assessment of maternal complications in cases of suspected morbidly adherent placenta.

Morbidity associated with nonemergent hysterectomy for placenta accreta

OBJECTIVE

The purpose of this study was to report the morbidity of nonemergent hysterectomy for suspected placenta accreta.

STUDY DESIGN

This was a retrospective study of all patients who underwent nonemergent hysterectomy for placenta accreta at Tampa General Hospital from June 1, 2003 to May 31, 2009.

RESULTS

Twenty-nine patients were identified. Diagnosis was suspected on ultrasound scanning in 26 women (6 women also underwent magnetic resonance imaging) and on direct vision at repeat cesarean section delivery in 3 women. All of the women were multiparous, and 18 women had undergone > or =2 cesarean section deliveries. Twenty-one women had a placenta previa, and 8 women had a low anterior placenta. Final pathologic findings revealed accreta (20 specimens), increta (6 women), and percreta (3 women). Mean total operative time was 216 minutes; blood loss was 4061 mL. Two women had ureteral transection (1 was bilateral); 3 women had cystotomy, and 3 women had partial cystectomy. Postoperative hemorrhage occurred in 5 women; 1 hemorrhage resolved after catheter embolization, and the other 4 hemorrhage required reoperation.

CONCLUSION

Nonemergent hysterectomy for placenta accreta is associated with significant morbidity in the forms of hemorrhage and urinary tract insult.

A life threatening uterine inversion and massive post partum hemorrhage caused by placenta accrete during Caesarean section in a primigravida: a case report

BACKGROUND

A 32-year-old Caucasian primigravida was admitted for elective Caesarean Section at 36 weeks and 6 days with the diagnosis of preeclampsia.

CASE PRESENTATION

Traction of the umbilical cord after delivery of a healthy baby resulted in uterine inversion. The placenta was found to be densely adherent to the posterior uterine wall. Piecemeal excision of the placenta as close as possible to the uterine lining was then performed.

CONCLUSION

In this way we were able to control a massive post partum hemorrhage and preserve the fertility of the patient.