Management of morbidly adherent placenta

Abstract

Morbidly adherent placenta (MAP) or abnormal invasion of the placenta (AIP) refers to an abnormal invasion of the placental tissue (trophoblasts) into uterine myometrium, with or without the perforation of the uterine serosa. AIP is associated with significant maternal morbidity and a reported worldwide maternal mortality of 7–10% secondary to massive obstetric haemorrhage and/or injury to adjacent pelvic organs. Current management options for this potentially life-threatening condition include radical surgery, such as elective peripartum hysterectomy with or without bowel/bladder resection or ureteric re-implantation (for placenta percreta infiltrating these organs), and conservative surgical measures such as myometrial compression sutures with uterine balloon tamponade.Intentional retention of the placenta (IRP) is an option where radical procedures are not appropriate or are refused by the patient in view of a desire for future fertility. Unfortunately, it may lead to serious maternal morbidity and mortality including septic shock and secondary haemorrhage.A new conservative surgical technique called the ‘Triple-P Procedure’ involves peri-operative placental localization and delivery of the fetus via transverse uterine incision above the upper border of the placenta, pelvic devascularization and placental non-separation with myometrial excision and reconstruction of the uterine wall. It has been described as a safe and effective alternative to intentional retention of the placenta or peripartum hysterectomy.