Placenta percreta - a management dilemma: an institutional experience and review of the literature

Abstract

Objective: Placenta percreta is an extremely high-risk obstetric condition often associated with significant maternal morbidity and mortality. To date, there is no consensus on its management. This article aimed to identify an optimum management option to improve maternal outcomes in patients with placenta percreta.

Material and methods: This was an observational study conducted at a tertiary care institute from October 2019 to June 2020. A well-defined plan of preoperative, bilateral, uterine artery catheter placement, cesarean delivery (CD) of the baby followed by uterine artery embolization (UAE), and elective delayed hysterectomy after 2-4 weeks, was made by a multidisciplinary team. Demographic variables such as age, parity, period of gestation, presenting complaints, imaging findings, mode of management, intraoperative findings, blood loss, the requirement for blood and blood products, and complications were noted.

Results: We encountered seven cases of placenta percreta over a period of nine months. UAE was performed in 6/7 patients. UAE was not performed in one patient as she presented to the emergency department in shock. Elective delayed hysterectomy was performed after 2-4 weeks in three patients, three patients required emergency hysterectomy (two during CD and one on the seventh postoperative day) and one patient was managed conservatively by leaving the placenta in situ after CD and UAE. Patients who underwent UAE had notably less intraoperative blood loss and requirement of blood and blood products than the patient who could not receive UAE. During cesarean hysterectomy, blood loss was 1,700 mL in embolized (case 4) vs 3,000 mL in unembolized patient (case 7). In embolized patients, the median blood loss during CD (case 1,2,3,5,6) was 200 mL (interquartile range: 165-200 mL) and during delayed elective hysterectomy (case 1,3,5) was 150 mL (range: 125-225 mL). Blood loss in case 2 was 1,000 mL during emergency hysterectomy on the 7^th day of CD and UAE. The blood loss was appreciably higher in patients who underwent immediate cesarean hysterectomy rather than elective delayed hysterectomy.

Conclusion: Placenta percreta, if not managed in a preplanned manner, may lead to disastrous maternal outcomes. Prophylactic devascularization during CD and leaving the placenta in situ followed by elective delayed hysterectomy, might be a reasonable management option in most severe cases of placenta percreta.

Keywords: Placenta percreta; elective delayed hysterectomy; immediate cesarean hysterectomy; uterine artery embolization.

Figure 1

Algorithm for management of placenta percreta at our centre USG: Ultrasound, MRI: Magnetic resonance imaging

Figure 2

(a) T2 weighted magnetic resonance imaging (coronal section) showing placenta invading through the lower uterine segment reaching up to bladder serosa; (b) Cystoscopy showing placental bulge with intact bladder mucosa

Figure 3

Intraoperative image of showing placenta percreta with an anterior bulge in case 1 (a) and a posterior bulge in case 2 (b)

Figure 4

Hysterectomy specimen showing placenta percreta in case 1 (a) and 2 (b)

Figure 5

Hematoxylin and eosin (40x) stained sections of case 1, showing chorionic villi implanted into the myometrium without intervening decidua and full thickness invasion of the myometrium