Timing of Delivery maternal consequences of emergency cesarean delivety (Stephen son, 2016). The American College of Obstetricians and Gynecolo gists (2017 c) recommends individualization of delivery timing. It fetal lung maturity testing ater 34 completed weeks (Robinson, 2010). he Society for Maternal-Fetal Medicine (2017) recom mends delivery between 34 and 37 weeks. Two recent surveys weeks or later (Esako, 2012; Wright, 2013). At Parkland Hos pital, we generally schedule these procedures ater 36 completed weeks but are prepared also to manage them in nonelective situ ations (Rac, 2015b). Perlman and colleagues (2017) recommend individualization based on speciic risk criteria.
In some cases, placenta accrete syndrome is not recognized until laparotomy. If there are inadequate resources to surgically manage the percreta, and if the woman is stable and not bleed ing, then the fetus is not delivered, the abdominal incision is closed, and she is transferred to a tertiary-care facility .
In cases that may involve one or both ureters, catheterization may aid in dissection or identification and repair of injury. Some, but not all, advocate preoperative ureteral catheterization (Eller, 2011; Society for Maternal-Fetal Medicine, 2010; Tam Tam, 2012).
Balloon-tipped intraarterial catheters to mitigate blood loss and thereby enhance surgical visibility have also gained supporters. Catheters are advanced preoperatively into the internal iliac arteries, and then after delivery, they are inflated to occlude pelvic blood low (Ballas, 2012; Desai, 2012). Alternatively, the catheters can be used to deliver occluding emboli to bleeding arterial sites. Others have concluded that these procedures ofer borderline eicacy and have serious risks (Salim, 2015; Sentilhes, 2009). Complications have included thromboses of the common and left iliac arteries (Bishop, 2011). At this time, the American College of Obstetricians and Gynecologists (2017 c) concludes that a irm recommendation cannot be made for or against intraarterial catheter use. Similarly, there are no obvious benefits to internal artery ligation (Eller, 2011; Po, 2012).
Before commencing with delivery, the risk of hysterectomy to prevent exsanguination should be estimated. Some of these abnormal placentations, especially if partial, may be amenable to placental delivery with hemostatic suture placement. Conirmation of a percreta or increta almost always mandates hysterectomy. Because the scope of invasion may not be apparent before delivery of the fetus, we complete many dissection steps early. This also minimizes blood loss during potentially tedious dissection after hysterotomy. Thus, we usually attempt to create a wide bladder flap bore making the hysterotomy incision (Cunningham, 2017b). The round ligaments are divided, and the lateral edges of the peritoneal relection are dissected downward. If possible, these incisions are extended to encircle the entire placental implantation site that visibly occupies the prevesical space and posterior bladder wall. Following this, a classical hysterotomy or transverse fundal incision is made to avoid the placenta (Kotsuji, 2013).