Managing placenta accreta
In the past, surgery was the only option for women with abnormally adherent placentae, but conservative medical management may be an alternative for select patients. Here, the authors review recent trends and describe medical and surgical options.
In cases of balloon occlusion or embolization of the internal iliac arteries for pelvic hemorrhage, a reduction in blood loss and improved visualization of the operative field have been reported, although use in the specific setting of placenta accreta is limited.18,19,25-27 The common approach is axillary, with the catheter tip placed in the bilateral anterior hypogastric arteries prior to beginning the surgery.19 Balloon inflation occurs after delivery of the fetus.
Hysterectomy may become necessary if uterine bleeding cannot be controlled. While attempts may be made to salvage the uterus, immediate hysterectomy is indicated should the patient become unstable.16 Given the significant vascular supply of the cervical branch of the uterine artery and the abnormal placentation in the noncontractile portion of the uterus, the cervix will likely need to be removed at the time of hysterectomy.
Surgical management carries the potential for significant morbidity and mortality. O’Brien and colleagues found a mortality rate of 7.4% with a 90% incidence of transfusion, a 28% incidence of postoperative infection, and a 5% incidence of ureteral injuries or fistula formation in 109 cases of gravid hysterectomy for placenta accreta.5 All maternal deaths were directly related to excessive blood loss, and the median transfusion quantity was 7 units of packed red blood cells for patients managed surgically. This compares to a rate of 5% for infection28 and 0.1% for ureteral injuries29 in simple cesarean sections.
Conclusion
Although hysterectomy traditionally has been the definitive treatment for placenta accreta, clinicians should consider medical management for patients who are clinically stable and wish to preserve fertility. Adequate transfusion facilities; sensitive ultrasound examination and hCG assays; and rapidly responding, highly skilled surgical and anesthesia teams should be available nonetheless. When surgical management is indicated, proper preparation is crucial. If hemorrhage occurs, surgeons should follow a stepwise approach to ensure hemostasis. Further research should focus on preventing hemorrhage, better understanding the mechanism of abnormal placentation, and optimizing medical management regimens.
The authors report no financial relationship with any companies whose products are mentioned in this article.
