Optimal management strategies for placenta accreta

Department of Obstetrics and Gynecology, Divisions of Maternal Fetal Medicine and Gynecologic Oncology, University of Utah, Salt Lake City, UT 84132, USA.
BJOG An International Journal of Obstetrics & Gynaecology (Impact Factor: 3.45). 03/2009; 116(5):648-54. DOI: 10.1111/j.1471-0528.2008.02037.x
Source: PubMed


To determine which interventions for managing placenta accreta were associated with reduced maternal morbidity.
Retrospective cohort study.
Two tertiary care teaching hospitals in Utah.
All identified cases of placenta accreta from 1996 to 2008.
Cases of placenta accreta were identified using standard ICD-9 codes for placenta accreta, placenta praevia, and caesarean hysterectomy. Medical records were then abstracted for maternal medical history, hospital course, and maternal and neonatal outcomes. Maternal and neonatal complications were compared according to antenatal suspicion of accreta, indications for delivery, preoperative preparation, attempts at placental removal before hysterectomy, and hypogastric artery ligation.
Early morbidity (prolonged maternal intensive care unit admission, large volume of blood transfusion, coagulopathy, ureteral injury, or early re-operation) and late morbidity (intra-abdominal infection, hospital re-admission, or need for delayed re-operation). Results Seventy-six cases of placenta accreta were identified. When accreta was suspected, scheduled caesarean hysterectomy without attempting placental removal was associated with a significantly reduced rate of early morbidity compared with cases in which placental removal was attempted (67 versus 36%, P=0.038). Women with preoperative bilateral ureteric stents had a lower incidence of early morbidity compared with women without stents (18 versus 55%, P=0.018). Hypogastric artery ligation did not reduce maternal morbidity.
Scheduled caesarean hysterectomy with preoperative ureteric stent placement and avoiding attempted placental removal are associated with reduced maternal morbidity in women with suspected placenta accreta.

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    • "Both early and late complications of this diagnosis occur resulting in maternal morbidity and mortality, including large volume blood loss requiring transfusion, prolonged admission to intensive care units, coagulopathy, and ureteral injury. Late complications include infection, hospital readmission, and multiple surgeries [17]. Other obstetrical complications including preterm birth and intrauterine growth restriction are also increased with this diagnosis [18]. "
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    ABSTRACT: Background. Placenta accreta is a potentially life-threatening obstetrical condition and is responsible for many emergency Caesarean hysterectomies. Early prenatal diagnosis may help minimize maternal morbidity and mortality. This report highlights risk factors, early diagnostic findings and complications associated with placenta accreta, and the role of first trimester sonography in diagnosis. Case. A 38-year-old pregnant woman, G2P1L1 with history of one previous Caesarean section, presented with vaginal bleeding at 13 weeks' gestation. Ultrasound examination was highly suspicious of placenta previa with accreta. During an earlier 12-week scan for nuchal translucency measurement, the placenta was suboptimally visualized. She was counselled regarding potential maternal and fetal complications as well as management options. At 33 weeks' gestation Caesarean hysterectomy was performed due to vaginal bleeding. Conclusion. Early ultrasound screening in high-risk patients may be advantageous in order to identify placenta accreta and conduct appropriate patient counseling regarding risks and management options.
    Full-text · Article · Jun 2014
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    • "In 15 cases an attempt was made to remove the placenta manually, but these entire women required immediate hysterectomy for uncontrollable bleeding. The authors of this study concluded that, in case of suspected placenta accreta, scheduled caesarean hysterectomy without attempting placental removal is associated with a significantly reduced rate of early morbidity compared with cases in which placental removal is attempted [22]. "
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    ABSTRACT: The third stage of labor is associated with considerable maternal morbidity and mortality. The major complication is postpartum hemorrhage (PPH), which is the leading cause of maternal morbidity and mortality worldwide. Whereas in the event of PPH due to atony of the uterus there exist numerous treatment guidelines; for the management of retained placenta the general consensus is more difficult to establish. Active management of the third stage of labour is generally accepted as standard of care as already its duration is contributing to the risk of PPH. Despite scant evidence it is commonly advised that if the placenta has not been expelled 30 minutes after delivery, manual removal of the placenta should be carried out under anaesthesia. Pathologic adhesion of the placenta in the low risk situation usually is diagnosed at the time of delivery; therefore a pre- or intrapartum screening opportunity for placenta accreta would be desirable. But diagnosis of abnormalities of placentation other than placenta previa remains a challenge. Nevertheless the use of ultrasound and doppler sonography might be helpful in the third stage of labor. An improvement might be the implementation of standardized operating procedures for retained placenta which could contribute to a reduction of maternal morbidity.
    Full-text · Article · Apr 2014 · Journal of pregnancy
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    • "Maternal morbidity of placenta accreta therefore entails the immediate consequences of postpartum hemorrhage, but, equally important, higher risks for developing pneumonia, thromboembolisms, and wound infections [3]. Within the last years, many authors have reported an increase in placenta accreta diagnoses concomitantly with the worldwide increase in cesarean deliveries, suggesting that a uterine defect leads to imperfect intact decidua basalis development in subsequent pregnancy [1] [6]. Despite this concern, randomized controlled trials about the best method of uterine closure during cesarean sections or about antenatal diagnosis and therapeutic management of placenta accreta are scarce. "
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    ABSTRACT: Objective: We sought to investigate the incidence, maternal risk factors, and perinatal outcomes of women with complete and partial placental retention in a tertiary care teaching hospital in Southwestern Germany. Study design: We performed an unmatched case-control study with cases occurring between July 2000 and June 2007. Women were included into the study if they completed at least the 24th week of gestation and were diagnosed with placental retention requiring surgical intervention. We selected two controls per case and performed univariate and multivariate logistic regression analyses to identify risk factors for complete and partial placental retention. Results: A total of 161 cases (2.02%) were identified out of 7978 deliveries. The 1-year prevalence of all types of placental retention continuously increased during the 6-year study period from 0.93% to 3.26%. A significant independent risk factor for all types of placental retention in the multivariate logistic regression model was a previous retention of the placenta [odds ratio (OR)=21.723, 95% confidence interval (CI) 6.07-77.7]. Independent protective factors against all types of placental retention were a non-anterior and non-posterior placenta location (OR=0.561, 95% CI 0.35-0.91), and a cesarean delivery with (OR=0.193, 95% CI 0.09-0.40) and without labor (OR=0.482, 95% CI 0.27-0.86). Women without partial placental retention delivered neonates with better 5-min APGAR scores (OR=0.78, 95% CI 0.65-0.95). Conclusion: A thorough medical history and a vigilant prepartum ultrasound help in identifying women at risk for placental retention.
    Full-text · Article · Apr 2013 · Journal of Perinatal Medicine
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