Maternal Outcome After Conservative Treatment of Placenta Accreta

Université de Poitiers, Poitiers, Poitou-Charentes, France
Obstetrics and Gynecology (Impact Factor: 5.18). 03/2010; 115(3):526-34. DOI: 10.1097/AOG.0b013e3181d066d4
Source: PubMed


To estimate maternal outcome after conservative management of placenta accreta.
This retrospective multicenter study sought to include all women treated conservatively for placenta accreta in tertiary university hospital centers in France from 1993 to 2007. Conservative management was defined by the obstetrician's decision to leave the placenta in situ, partially or totally, with no attempt to remove it forcibly. The primary outcome was success of conservative treatment, defined by uterine preservation. The secondary outcome was a composite measure of severe maternal morbidity including sepsis, septic shock, peritonitis, uterine necrosis, fistula, injury to adjacent organs, acute pulmonary edema, acute renal failure, deep vein thrombophlebitis or pulmonary embolism, or death.
Of the 40 university hospitals that agreed to participate in this study, 25 institutions had used conservative treatment at least once (range 1-46) and had treated a total of 167 women. Conservative treatment was successful for 131 of the women (78.4%, 95% confidence interval [CI] 71.4-84.4%); of the remaining 36 women, 18 had primary hysterectomy and 18 had delayed hysterectomy (10.8% each, 95% CI 6.5-16.5%). Severe maternal morbidity occurred in 10 cases (6.0%, 95% CI 2.9-10.7%). One woman died of myelosuppression and nephrotoxicity related to intraumbilical methotrexate administration. Spontaneous placental resorption occurred in 87 of 116 cases (75.0%, 95% CI 66.1-82.6%), with a median delay from delivery of 13.5 weeks (range 4-60 weeks).
Conservative treatment for placenta accreta can help women avoid hysterectomy and involves a low rate of severe maternal morbidity in centers with adequate equipment and resources.

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Available from: Franck Perrotin, Aug 20, 2014
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    • "According to the previously published literature evaluating expectant management of invasive placentation, the maternal mortality rate was reported to be 0.3% and a delayed hysterectomy occurred in 19% of cases.15 The median interval from delivery to delayed hysterectomy was 22 days, and the major causes of delayed hysterectomy included secondary postpartum hemorrhage, sepsis or both (72.2%).16 In selected cases, especially when the patient is hemodynamically stable and there is no evidence of sepsis, it may be reasonable to wait for the spontaneous delivery of the placenta. "
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    ABSTRACT: Objective The objective of this report is to describe a rare case of interstitial pregnancy ultimately resulting in a viable infant coexistent with massive perivillous fibrin deposition (MPFD). Study Design This study is a case report and literature review. Results A 35-year-old female patient underwent cesarean section at 32 weeks of gestation due to fetal growth restriction (FGR) and breech presentation. During the operation, a diagnosis of interstitial pregnancy was established. There was no evidence of placental separation. We decided to complete surgery without removal of the placenta and waited until the placenta delivered spontaneously. The conservative management was successful, and the patient was discharged on postoperative day 13. The pathologic examination showed MPFD. Conclusion If interstitial pregnancies are not diagnosed at an early gestational age, it can result in a viable fetus, but such pregnancies may be associated with FGR or placenta accreta.
    AJP Reports 05/2014; 4(1):29-32. DOI:10.1055/s-0034-1370354
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    • "However, conservative treatment required women adherence to treatment over a long postpartum period, which suggests that women may continue to be at risk for severe morbidity and possibly mortality for weeks or even months after delivery. In view of that and until randomized trials are performed, the authors suggested that cesarean hysterectomy without attempt of placental removal should be strongly considered for placenta accreta in multiparous women not interested in preserving their fertility according to The authors [49]. In a subsequent study, the same group described the fertility and pregnancy outcomes after successful conservative treatment for placenta accreta, that is, uterine preservation. "
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    ABSTRACT: Placenta accreta is a severe pregnancy complication and is currently the most common indication for peripartum hysterectomy. It is becoming an increasingly common complication mainly due to the increasing rate of cesarean delivery. Main risk factor for placenta accreta is a previous cesarean delivery particularly when accompanied with a coexisting placenta previa. Antenatal diagnosis seems to be a key factor in optimizing maternal outcome. Diagnosis can be achieved by ultrasound in the majority of cases. Women with placenta accreta are usually delivered by a cesarean section. In order to avoid an emergency cesarean and to minimize complications of prematurity it is acceptable to schedule cesarean at 34 to 35 weeks. A multidisciplinary team approach and delivery at a center with adequate resources, including those for massive transfusion are both essential to reduce neonatal and maternal morbidity and mortality. The optimal management after delivery of the neonate is vague since randomized controlled trials and large cohort studies are lacking. Cesarean hysterectomy is probably the preferable treatment. In carefully selected cases, when fertility is desired, conservative management may be considered with caution. The current review discusses the epidemiology, predisposing factors, pathogenesis, diagnostic methods, clinical implications and management options of this condition.
    Obstetrics and Gynecology International 05/2012; 2012:873929. DOI:10.1155/2012/873929
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    • "Studies suggest that antenatal diagnosis may reduce obstetric hemorrhage-related morbidity [5,6]. Furthermore, in some cases a morbidly adherent PA can be left in situ [7,8]. Such conservative management may allow delayed removal of the placenta to avoid massive hemorrhage during an attempted forced removal of the adherent placenta. "
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    ABSTRACT: Placenta percreta is an obstetric emergency often associated with massive hemorrhage and emergency hysterectomy. We present the case of a 30-year-old African woman, gravida 7, para 5, with placenta percreta managed by an alternative approach: the placenta was left in situ, methotrexate was administered, and a delayed hysterectomy was successfully performed. Further studies are needed to develop the most appropriate management option for the most severe cases of abnormal placentation. Delayed hysterectomy may be a reasonable strategy in the most severe cases.
    Journal of Medical Case Reports 08/2011; 5:418. DOI:10.1186/1752-1947-5-418
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