The rising rate of caesarean delivery has led to a dramatic increase in the incidence of placenta accreta and its variants. In the USA, placenta accreta is now estimated to occur in approximately 3 per 1000 deliveries. The entity is associated with substantial maternal morbidity and mortality, with some estimates suggesting a maternal mortality rate of up to 6–7% (Belfort et al. Am J Obstet Gynecol 2010;203:430–9). The morbidity associated with morbidly adherent placenta is due almost entirely to haemorrhage-associated complications. The bleeding that accompanies placenta accreta can be profound—hard to predict preoperatively and difficult to control intraoperatively. The central tenet of the surgical management of placenta accreta is to make every effort to minimise bleeding. This involves leaving the placenta in situ during hysterectomy, planning the hysterotomy site to avoid the placental bed, and minimising the disruption of the uterine tissue overlying the placenta during the dissection. Despite these efforts, avoiding placental disruption is often challenging in women with significant placental invasion. In an attempt to minimise bleeding at the time of hysterectomy for placenta accreta, the author presents a case series of women who underwent retrograde caesarean hysterectomy. In essence, the retroperitoneum is opened, the anterior division of the internal iliac artery is ligated, and the utero-ovarian ligament is divided. [Correction added on 22 January 2016, after first online publication: ‘infundibulopelvic ligament’ has been changed to ‘utero-ovarian ligament’ in the preceding sentence.] The posterior fornix is then exposed and opened. After identification of the ureters, the dissection is carried around the cervix and eventually to the vesicouterine space, at which time the bladder is mobilised from the uterus. The technique mimics an en bloc resection of a pelvic malignancy. In the case series, the authors describe 11 women who underwent the operation and tolerated the procedure well without major morbidity. The author's work is an important consideration to help limit blood loss at the time of hysterectomy. Other operative interventions such as uterine artery embolisation and placement of vascular balloon occlusion catheters have also been suggested, and there is great interest in conservative management of placenta accreta in which the placenta is left in situ (Perez-Delboy et al. BJOG 2014;121:163–9). However, to date, prospective trials are largely lacking and when to use each of these management strategies is based in large part on expert opinion. Perhaps the most important point that this series raises is the complexity of the management of women with placenta accreta. In essence, every case is somewhat different and often requires complex decision-making in the absence of high-quality data. Therefore, any novel surgical approach that may reduce the blood loss and the need for transfusion in women with placenta accreta adds an important component to our surgical armamentarium. Previous work has shown that women cared for at high-volume hospitals and referral centres have better outcomes (Eller et al. Obstet Gynecol 2011;117:331–7). From a policy perspective, efforts have now focused on developing guidelines and recommendations for referral of women with placenta accreta to centres of excellence in an attempt to reduce maternal morbidity (Silver et al. Am J Obstet Gynecol 2015;212:561–8). Given that the incidence of placenta accreta is likely to continue to rise, efforts such as these to optimise outcomes for women and further studies to help guide best management are urgently needed. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
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Dec 28, 2017
Doaa Abdelnaby Marey + 3
