The management of placenta percreta: Conservative and operative strategies,☆☆,

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Abstract

OBJECTIVE: Our purpose was to assess preferences for the management of placenta percreta and identify aspects of care related to an improved outcome. STUDY DESIGN: Both an analysis of a questionnaire issued to members of the Society of Perinatal Obstetricians and a retrospective study at our institution were used to obtain case histories of women with placenta percreta during a recent 3-year period. RESULTS: Fifty-five of the 109 cases (50%) reported by members of the Society of Perinatal Obstetricians were suspected ante partum. Complications associated with this disorder included uterine rupture (3 cases), transfusion of >10 units (44 cases, 40%), ureteral ligation or fistula formation (5 cases each, 5%), infection (31 cases, 28%), perinatal death (10 cases, 9%), and maternal death (8 cases, 7%). Management options included surgical removal of the uterus and involved tissues (101 cases, 93%) and conservative treatment with the placenta left in situ after delivery (8 cases, 7%). More members of the Society of Perinatal Obstetricians responding to our survey opted for conservative management if adjacent tissues were involved (69% with extension into the bladder or gastrointestinal tract) compared with 31% when the percreta was confined to the uterus, p < 0.001. Conservative therapy was also associated with less blood loss in reported cases (median units red blood cells transfused, 0 vs 7, p = 0.003). Two of the three cases of placenta percreta at our institution were identified ante partum. The third case represents the first reported with antepartum identification of percreta followed by deliberate conservative treatment. CONCLUSIONS: With greater involvement of surrounding tissues, conservative treatment was preferred in hemodynamically stable patients. If surgical excision of the placenta is attempted or necessary, physicians experienced in pelvic dissection must be involved because of the frequency of maternal morbidity and mortality. (Am J Obstet Gynecol 1996;175:1632-8.)

Section snippets

PATIENTS AND METHODS

In June 1995, 1450 questionnaires were mailed to members of the Society of Perinatal Obstetricians. The survey assessed the experience of the membership in treating placenta percreta within the past 3 years. For individuals with recent experience the method and timing of the diagnosis, mode of management, and associated morbidity and mortality were assessed in reported cases. Preferences for surgical versus conservative therapy were also determined given four hypothetic clinical situations. For

RESULTS

A total of 335 surveys were returned (23%) providing information on 109 cases of placenta percreta encountered during the preceding 3 years. The diagnosis of placenta percreta was suspected ante partum in 55 cases (50%). An abnormal ultrasonographic examination was noted in 44 of these cases (80%) and an elevated maternal serum α-fetoprotein (AFP) level was reported in 6 cases (11%). Magnetic resonance imaging (MRI) was used with 5 patients to assist in the diagnosis. The majority of cases were

CASE SERIES

Three cases of placenta percreta were identified at our institution during the study interval (1:3052 births). The diagnosis of placenta percreta was suspected ante partum in two women and the only perinatal death occurred in our unrecognized case.

COMMENT

Our findings affirm that placenta percreta is associated with a substantial risk for fetal and maternal death. In addition, morbidities such as uterine rupture, urinary tract injury, serious infectious complications, and massive transfusion are common.

The current investigation attempts to identify strategies that may be associated with an improved outcome in these patients. Perhaps the single greatest factor affecting outcome is the antepartum identification of abnormal placentation. The

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  • Cited by (0)

    From the Divisions of Maternal-Fetal Medicinea and Gynecologic Oncology,b Department of Obstetrics and Gynecology, Central Baptist Hospital.

    ☆☆

    Reprint requests: John M. O'Brien, MD, Perinatal Diagnostic Center, Central Baptist Hospital, 1740 Nicholasville Road, Lexington, KY 40503.

    0002-9378/96 $5.00 + 0 6/1/76386

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