Is there a place of leaving the placenta in-situ without removal or any other conservative measures
Hello Ahmed.
Here is a recent review article that probably asks more questions than it answers.... http://www.ncbi.nlm.nih.gov/pubmed/25935779 (Fox et al DEC 2015 AJOG)
I think you can consider conservative management of accreta in a patient with low parity who desires future fertility, but counseling carefully future pregnancy is at high risk of recurrence of this life threatening condition.
The current gold standard of treatment is hysterectomy for placenta accreta.
For placenta percreta, I think that for cases were irreparable damage to vital structures or uncontrollable haemorrhage could result from attempts at hysterectomy and removal of remnants, conservatve management can be considered. Again, if feasible, hysterectomy would be the first line treatment for these cases.
A multi-disciplinary team experienced in these cases is a must!!!
optimal management is: delivery at 36-37 weeks. median skin incision, clasic cesarean incision. Donot attempt to remove placenta. consider the feasibility of dissecting the bladder from the attached placental tissues. if it is feasible treatment with hysterectomy. if you can not seperate the bladder youcan leave the placenta and repair the uterus bu it is highy compilcated with infection and sepsis. generaly it goes to hysterectomy in a month interval. In some cases discoidal resection may be an alternative before this attempt you have to make bilateral hypogasric artery ligation. In all cases atleast four units of red blood cells ,Fresh frozen plasma and trombocyt suspension shoud be ready for massive blood transfusion.
Fortunately, placenta percreta is very rare. specially that involved the bladder.If fertility is desire leave placenta insitu and give methotrexate, otherwise hysterectomy is the only solution and in most cases you need a urologist.
Metotrexat treatment is not a recommended treatment option. It has no effect on placental shrinking. Most of the cases are placenta previa wiht prevous cesarean deliveries. Fertility sparing attempts are related with morbidity and mortality
Optimum management depends on whether it is focal (involving a few cotyledons) or it is total, the fertility wishes of the patient and of course the skills of the surgeon.If it is focal and the patient desires more children, one can attempt removing as much of the attached placenta manually and then putting in compression stichtes to stop any bleeding vessels. If it is totalis, then irrespective of the patient's wishes, a total hysterectomy is best. In the case of increta, a total hysterectomy is best option. If it is percreta and adjoining structurual involvement is minimal and separation can be safely managed, then total hysterectomy is best.
The use of cytotoxics is very debatable, since the drugs work on dividing cells.
Hi, Dr.Michel, could You kindly present whole article?
It seems that i am not able to see it.
Thank You.
Since Ultrasound is not 100% definitive about anything other than whether the fetus is vertex, i am wondering what your prenatal diagnosis is based on? Surely after the birth, everyone sees 20-20 in retrospect. I just posted a picture of a placenta accreta
https://www.researchgate.net/post/Does_anyone_have_photos_of_completely_adherent_manually_removed_placenta?_tpcectx=profile_highlights
which was totally attached 50 minutes after the birth, no bleeding (because it was completely attached). On the third try to manually remove it, i was able to get an 2 cm gap between the placenta and the uterus and separate and deliver the placenta manually. I immediately gave her methergine po 0.25 mg to contract the uterus (because IM is unavailable), but expected a hemorrhage, presuming that i would be unable to completely remove an accreta. But there was no hemorrhage whatsoever at any time in the next 2 weeks and the placenta was apparently completely removed manually. Hope this is helpful. It means that management also depends on the choice of the woman, where she is given a choice. No one has yet mentioned the participation of the woman in the decision.
Considering the high prevalence of home delivery particularly in developing countries, we should consider minimum management of placenta. Hence.we should promote institutional delivery and each HF should be accompanied by sanitary placenta pit.
You should read the RCOG recommendations. If diagnosis has been made antenatal rather than at surgery, optimum management should involve a multidisciplinary team of Urologists, General surgeons and colpoproctologists at surgery. Ideally such patients must be managed in tertiary centres where blood is easily available to obtain.
Please bear in mind that antenatal diagnosis of placenta praevia is not accurate regardless the use of gray scale ultrasound or MRI
placenta acreta should be suspected in every patient with anterior low lying placenta & prviuos C section. Unfortunately, we are seeing more & more. I totally agree with Dr. Ekin, hysterctomy is the treatment of choice either immediately or within 4-6 weeks (if the urinary bladder invasion was extensive or involve the trigone. I also agree that it should be done in teriary hospitals with massive tranfusion available. Preoperative cystoscopy is sometimes useful in cases of percreta. My advice is never try to remove the placenta, use pent-rose torniquet
Use a pent rose drain as a tourniquet below the level of the uterine artery
