Gupta AS
Tertiary referral medical college centers like ours are
seeing an increased number of cases with morbidly adherent placenta. With the rising
incidence of cesarean births the incidence of placenta previa and placenta
accreta has increased. Any cause that prevents a good decidual reaction like
previous cesarean, hysterotomy, myomectomy scars, Asherman syndrome, multiparity
can result in a morbidly adherent placenta. The decidua basalis and the Nitabuch's layer interface
between the invading trophoblast and the myometrium is deficient due to the
scar tissue. This allows the invading trophoblast to invade the myometrium or the
uterine serosa to varying depths. The degree of invasion determines the 3
categories of the adherent placenta, accreta, increta or percreta. The placenta
may be totally adherent or only part of the placenta may be focally or
partially adherent. Antenatally about 50% cases are diagnosed. Antenatal
detection rates can be improved with increased awareness and meticulous effort
by the obstetrician, sonologist especially in cases of previous hysterotomies
with an anteriorly implanted placenta. USG, Doppler flowmetry and MRI have
allowed almost 100% detection rates.
The clinician can encounter either a totally or a focally
adherent placenta. Antenatal diagnosis allows the clinician to organize a
proper management strategy and team. Proper counseling and consent of the
patient, availability of adequate cross matched blood, blood products, team of anesthetists,
interventional radiologists, urologists, or surgeons can be arranged prior to
delivery. Both the varieties pose management challenges especially in a woman
desiring future child bearing. In a totally adherent placenta accreta, increta or
percreta a classical cesarean section with ligation of the cord at its placental
root, followed by post operative chemotherapy with methotrexate and antibiotics
with close monitoring is the mainstay of treatment in a woman desiring future
pregnancies. Treatment in cases with involvement of adjacent viscus like the
bladder in placenta percreta is very tricky. Any attempts to separate the
placenta can lead to torrential life threatening bleeding. Inflation of
balloons placed preoperatively in the anterior division of the internal iliac
arteries after delivery of the child, intra operative blood replacements,
postoperative oxytocics and methotrexate with intensive monitoring may be the
best management protocol for patients with placenta percreta. Hysterectomy after
the cesarean birth is probably preferred with placenta accreta and increta where
the patient does not desire future child birth.
Focally adherent placenta separates out partially compelling
the obstetrician to remove the adherent area of the placenta piecemeal at the
time of delivery or proceed with a hysterectomy to control the profuse bleeding
from the separated placental bed. In patients desiring future childbearing an
attempt to preserve the uterus can be tried by underrunning the placental bed
with delayed absorbable sutures. Affronti's, Cho and B Lynch sutures may be
used to control bleeding from the placental bed. Balloon tamponade, selective
devascularization of the uterine vasculature have been attempted.
In this issue of JPGO we
bring two cases of focally adhered placenta with varied presentations which
were managed successfully. We hope the readers gainfully benefit from the various
interesting cases present in this issue.