Ater etal delivery, the extent of placental invasion is assessed without attempts at manual placental removal. In a report from the United Kingdom, attempts for partial or total placental removal prior to hysterectomy were associated with twice as much blood loss (Fitzpatrick, 2014). Generally speaking, with obvious percreta or increta, hysterectomy is usually the best course, and the placenta is left in situ (Eller, 2011). With more extensive placental ingrowth, there may be little or no bleeding until manual placental removal is attempted. Unless there is spontaneous separation with bleeding that mandates emergency hysterectomy, the operation begins after full assessment is made. With bleeding, successful treatment depends on immediate blood replacement therapy and other measures that can include uterine or internal iliac artery ligation, balloon occlusion, or embolization.
he group at Baylor College of .Medicine has described a modified radical hysterectomy for surgical management of the morbidly adherent placenta (Shamshirsaz, 2015). For a description of this technique, refer to Cunningham and Gilstrap s Operative Obstetrics (Yeomans, 2017). At Parkland Hospital, we have had cases in which a traditional radical hysterectomy was necessary to excise all abnormally implanted placenta.
Occasionally, it may be possible to trim the umbilical cord, repair the hysterotomy incision, leave the placenta in situ, and not pursue hysterectomy. This option may be used for women in whom abnormal placentation was not suspected before cesarean delivery and in whom uterine closure stops bleeding. After this, she can be transferred to a higher-level facility for definitive management. Another consideration is the woman with a strong desire for fertility and who has received extensive counseling.
Conservative management was reviewed by Perez-Delboy (2014) and Fox (2015) and their colleagues. In some of these cases, the placenta spontaneously resorbed between 1 and 12 months with a mean of6 months. Numerous complications can occur and include sepsis, disseminated intravascular coagulation, pulmonary embolism, and arteriovenous malformation (Fox, 2015; Judy, 2015; Roach, 2015).
In some of these women, a subsequent hysterectomyeither planned or prompted by bleeding or infection-is performed days to weeks postpartum when blood loss might be lessened (l-Khan, 2014; Sentilhes, 2009). In one study, only 21 percent of such women ultimately required hysterectomy (Bretelle, 2007). In other reports, however, up to 60 percent eventually required emergency hysterectomy (Clausen, 2013; Pather, 2014). Evidence that treatment with methotrexate aids resorption is lacking. Last, for women in whom the placenta is left in situ, serial serum �-hCG measurements are not informative, and serial sonographic or MR imaging is recommended (Timmermans, 2007; Worley, 2008).
At this time, we agree with the American College of Obstetricians and Gynecologists (2017 c) that leaving the placenta in situ is seldom indicated. Exceptions are for temporization to permit transfer to a higher level of care.