Maternal Outcome After Conservative Treatment of Placenta Accreta

Maternal Outcome After Conservative
Treatment of Placenta Accreta
Loïc Sentilhes, MD, Clémence Ambroselli, MD, Gilles Kayem, MD, PhD, Magali Provansal, MD,
Hervé Fernandez, MD, PhD, Franck Perrotin, MD, PhD, Norbert Winer, MD, PhD,
Fabrice Pierre, MD, PhD, Alexandra Benachi, MD, PhD, Michel Dreyfus, MD, PhD, Estelle Bauville,
Dominique Mahieu-Caputo, MD, PhD, Loïc Marpeau, MD, PhD, Philippe Descamps, MD, PhD,
Franc¸ois Goffinet, MD, PhD, and Florence Bretelle, MD, PhD
OBJECTIVE: To estimate maternal outcome after conservative management of placenta accreta.
METHODS: This retrospective multicenter study sought
to include all women treated conservatively for placenta
accreta in tertiary university hospital centers in France
from 1993 to 2007. Conservative management was defined by the obstetrician’s decision to leave the placenta
in situ, partially or totally, with no attempt to remove it
forcibly. The primary outcome was success of conservative treatment, defined by uterine preservation. The
secondary outcome was a composite measure of severe
maternal morbidity including sepsis, septic shock, peritonitis, uterine necrosis, fistula, injury to adjacent organs,
acute pulmonary edema, acute renal failure, deep vein
thrombophlebitis or pulmonary embolism, or death.
RESULTS: Of the 40 university hospitals that agreed to
participate in this study, 25 institutions had used conservative treatment at least once (range 1– 46) and had
For a list of participating centers and collaborators associated with this study, see
the Appendix online at http://links.lww.com/AOG/A157.
From the Departments of Obstetrics and Gynecology, Angers University Hospital,
Angers; Rouen University Hospital, Charles Nicolle, Rouen; Rennes University
Hospital, Rennes; Maternité Port-Royal Hospital, Cochin APHP, University René
Descartes, Paris; Centre Hospitalier Intercommunal de Créteil, University of Paris
XII, Henri Mondor, Créteil; Conception Hospital, University of Mediterranee,
Marseille; North Hospital, University of Mediterranee, Marseille; Antoine Béclère
Hospital, University Paris Sud, Paris; Kremlin-Bicètre Hospital, University Paris
Sud, Paris; Tours University Hospital, Tours; Nantes University Hospital, Nantes;
CHU La Milétrie Hospital, University of Poitiers, Poitiers; Hôpital Necker-Enfants
Malades, University René Descartes, Paris; Caen University Hospital, Caen; and
Hôpital Bichat Claude-Bernard, APHP, University Paris-VII, Paris, France.
Corresponding author: Dr. Loïc Sentilhes, Department of Obstetrics and
Gynecology, Angers University Hospital, 4, rue Larrey, 49000 Angers, France;
e-mail: [email protected].
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2010 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/10
526
VOL. 115, NO. 3, MARCH 2010
MD,
treated a total of 167 women. Conservative treatment was
successful for 131 of the women (78.4%, 95% confidence
interval [CI] 71.4 – 84.4%); of the remaining 36 women, 18
had primary hysterectomy and 18 had delayed hysterectomy (10.8% each, 95% CI 6.5–16.5%). Severe maternal
morbidity occurred in 10 cases (6.0%, 95% CI 2.9 –10.7%).
One woman died of myelosuppression and nephrotoxicity
related to intraumbilical methotrexate administration.
Spontaneous placental resorption occurred in 87 of 116
cases (75.0%, 95% CI 66.1– 82.6%), with a median delay
from delivery of 13.5 weeks (range 4 – 60 weeks).
CONCLUSION: Conservative treatment for placenta accreta can help women avoid hysterectomy and involves a
low rate of severe maternal morbidity in centers with
adequate equipment and resources.
(Obstet Gynecol 2010;115:526–34)
LEVEL OF EVIDENCE: II
P
lacenta accreta, broadly defined here to include
placenta increta and percreta, is a life-threatening
condition defined as abnormal attachment of a part of
or the entire chorionic plate to the myometrium,
secondary to a defect in the decidua basalis or fibrinous Nitabuch layer. Morbidity associated with placenta accreta is mainly caused by massive hemorrhage and by surgical attempts to remove the uterus,
which cause intraoperative and postoperative maternal morbidity associated with large-volume blood
transfusions, intraabdominal infection, ureteral damage, and fistula formation.1,2 Mortality rates as high as
7% are reported to be associated with placenta percreta.1 The rising incidence of cesarean deliveries
combined with increasing maternal age has resulted
in a 10-fold increase in the incidence of placenta
accreta over the past 50 years: reported rates today in
developed countries range from as low as 1 per 2,500
to as high as 1 per 530 deliveries.3,4
OBSTETRICS & GYNECOLOGY
The three primary options for managing placenta
accreta are the cesarean hysterectomy, and the extirpative and conservative approaches. The extirpative
approach involves forced manual removal of the
placenta in an attempt to obtain an empty uterus.5–7 It
should be avoided because it is associated with higher
rate of massive postpartum hemorrhage than either
cesarean hysterectomy2,7 or the conservative approach6,8 and with a higher rate of subsequent peripartum hysterectomy than the conservative approach.6,8 The cesarean hysterectomy is generally
considered the standard treatment for placenta accreta. The hysterectomy is performed after cesarean
delivery of the fetus and there is normally no attempt
to detach the placenta.7,9 This option may reduce
maternal morbidity,10 but by definition it leaves
women sterile. Accordingly, conservative treatment
may be applied for some women who want to be able
to have more children. In this approach, the placenta
adhering either partially or totally to the myometrium
is left in situ, either after the failure of a prudent
manual attempt at placental removal or no attempt at
all.6,7 Its advantage is the potential preservation of a
functional uterus that may allow subsequent uneventful pregnancies.11,12 The conservative approach may
also be safest in cases of placenta percreta, in particular when the bladder is involved, for it may reduce
severe maternal morbidity, such as ureteral injury,
cystotomy, and urinary fistula, in comparison with
cesarean hysterectomy.13–15 It nevertheless remains
controversial for it may expose the patient to the risk
of intraabdominal infection and especially major
bleeding.7
To date, only very limited data about maternal
outcome after conservative management of placenta
accreta are available. Because our current knowledge
is mainly based on case reports and short case series,6,8 the frequency and type of severe adverse
events associated with this approach remain unknown.7 Moreover, these case series mainly come
from individual tertiary-care institutions, diminishing
their generalizability.6,8
The aim of this study was to estimate maternal
outcome after conservative management of placenta
accreta in a large multicenter cohort.
MATERIALS AND METHODS
This French multicenter retrospective study was approved by the national Ethics Committee (Comite´
d’Ethique de la Recherche en Obste´trique et Gynecologie). Of 45 university tertiary hospital centers in
France, 40 agreed to participate and retrieved data
from their databases for women who had conserva-
VOL. 115, NO. 3, MARCH 2010
tive management for placenta accreta from January
1993 through December 2007. The maternal outcome
of some of these women has been reported earlier in
two previous case series.6,8 As previously reported,6
placenta accreta was diagnosed according to the
following clinical and histologic criteria: 1) manual
removal of the placenta partially or totally impossible
and no cleavage plane between all or part of the
placenta and uterus, 2) prenatal diagnosis of placenta
accreta, confirmed by the failure of gentle attempts to
remove it during the third stage of labor, 3) evidence
of gross placental invasion at the time of surgery, 4)
histologic confirmation of accreta on a hysterectomy
specimen. Women treated with an extirpative approach or a cesarean hysterectomy were excluded
from this study.
Conservative management in case of placenta
accreta was defined by the decision of the obstetrician
to leave the placenta partially or totally in situ, with no
attempt to remove it forcibly. When placenta accreta
was not suspected before delivery, it was diagnosed
when it was impossible to detach the placenta by
gentle manipulation, and conservative treatment left
part or all of it in the uterus. Cases for which placenta
accreta was strongly suspected before labor because
of history or imaging findings were usually discussed
in staff meetings. When considered appropriate,
women were offered the possibility of conservative
treatment in an informative discussion. Although the
hospitals did not have a common written protocol at
that time, or even necessarily their own written protocol, the practitioner or institution or both generally
chose one of two options: 1) to leave the entire
placenta in situ, hoping to reduce the risk of subsequent hemorrhage by making no attempt to remove the placenta, or 2) to attempt prudent delivery
of the placenta, applying moderate cord traction to
reduce the risk of leaving a normal placenta in situ
(except when placenta percreta was strongly suspected). At the obstetrician’s discretion and depending on the circumstances and course, additional treatment could include uterotonic drugs (oxytocin or
sulprostone or both), prophylactic antibiotic therapy,
methotrexate, preoperative ureteric stent placement,
balloon catheter occlusion, and uterine devascularization procedure such as pelvic arterial embolization,
surgical vessel ligation (uterine or hypogastric artery
ligation, stepwise uterine devascularization), or
uterine compression sutures (B-Lynch and Cho
sutures). Stepwise uterine devascularization, as previously reported by AbdRabbo,16 consisted of normal and low bilateral uterine artery ligation, fol-
Sentilhes et al
Conservative Treatment for Placenta Accreta
527
25
Conservative treatment for placenta accreta
Cases (n)
20
15
10
5
8
9
133
07
20
06
20
Sentilhes et al
11
10
05
20
04
528
03
lowed by bilateral utero-ovarian ligament ligation
when bleeding persisted.17–19
The investigators sent an e-mail stating the goal of
the study to all obstetrics professors and chairs of
obstetrics departments in French university hospitals.
All participating hospitals collect data prospectively
every day and record it in a computerized database,
which may differ from one hospital to another. Midwives and residents enter data during hospitalization,
immediately after delivery, and later for subsequent
events. The hospitals searched their databases for
1993–2007 using the following key words to identify
cases: placenta previa, placenta accreta, placenta percreta, postpartum hemorrhage, and peripartum hysterectomy.
The hospitals then retrieved the paper files for
each patient. An independent investigator (C.A.) carefully examined the clinical notes from all files to
exclude cases that met the exclusion criteria and to
collect data about the women’s characteristics and
history, risk factors for and prenatal diagnosis of
placenta accreta, type of delivery and conservative
treatment, additional treatments, blood transfusion,
immediate complications, and outcome.
The primary outcome was success of conservative treatment, defined as uterine preservation, ie, the
absence of either primary or delayed hysterectomy
due to placenta accreta. The secondary outcome was
a composite score for severe maternal morbidity,
defined as any of the following: sepsis, septic shock,
peritonitis, uterine necrosis, postpartum uterine rupture, fistula, injury to adjacent organs, acute pulmonary edema, acute renal failure, deep vein thrombophlebitis or pulmonary embolism, or maternal death.
A postpartum hemorrhage was defined as bleeding
requiring medical or interventional treatment and was
7
20
20
02
20
01
99
97
00
20
7
20
4
98
6
19
19
96
94
95
19
19
93
3
1
2
19
1
19
1
19
0
Fig. 1. Annual number of cases receiving conservative treatment for
placenta accreta during the study period. The numbers in white correspond to the number of centers offering conservative treatment each year
during the study period.
Sentilhes. Conservative Treatment for
Placenta Accreta. Obstet Gynecol 2010.
considered primary if it occurred within the first 24
hours of delivery and secondary if it occurred more
than 24 hours after delivery. Similarly, a primary
hysterectomy was due to placenta accreta and took
place within the first 24 hours, whereas a delayed
hysterectomy took place more than 24 hours after
delivery. Sepsis was defined by a positive blood
culture; septic shock also required vasopressors to
reverse sepsis-induced hypotension.20 Acute renal failure was defined by the need for dialysis.
Descriptive characteristics were calculated for the
variables of interest. Statistical analysis included determination of rates with their 95% confidence intervals (CIs) and was conducted with StatXact.4 (Cytel
Software Corporation, Cambridge, MA).
RESULTS
Of the 45 university hospitals in France, 40 (88.9%)
agreed to participate in the study and 25 reported to
have used conservative treatment for placenta accreta
at least once. Of the 311 women with placenta
accreta, 144 (46.3%) were excluded from the study
because they were treated by an extirpative approach
(n⫽91) or cesarean hysterectomy (n⫽53). The study
population thus included 167 women from 25
university hospitals (62.5%). Each center included a
median of three (range 1 to 46) cases. The first
conservative treatment took place in 1993, and the
number of procedures increased regularly each
year, reaching 25 in 2007 (Fig. 1). At least one risk
factor for placenta accreta was identified in 160
women (95.8%) (Table 1).
Table 2 summarizes the patients’ demographic
and obstetric characteristics. Ultrasound findings suggestive of placenta accreta were observed in 74 of the
167 cases (44.3%) and in 40 of the subgroup of 53
Conservative Treatment for Placenta Accreta
OBSTETRICS & GYNECOLOGY
Table 1. Risk Factors for Placenta Accreta
Risk Factor
Previous abortion or miscarriage
One curettage
Two or more curettages
Previous uterine surgery
Myomectomy*
By hysteroscopy
By laparotomy
Polypectomy*
Endometrectomy*
Synechia*
Metroplasty*
Previous cesarean delivery
One
Two or more
Previous accreta
Previous endometritis
Age 35 y or older
Placenta previa
At least one risk factor
Placenta Accreta
(nⴝ167)
66 (39.5)
54 (32.3)
12 (7.2)
33 (19.8)
11 (6.6)
6 (3.6)
5 (3.0)
4 (2.4)
1 (0,6)
5 (3.0)
5 (3.0)
90 (53.8)
48 (28.7)
42 (25.1)
6 (3.6)
3 (1.8)
64 (38.3)
87 (52.1)
160 (95.8)
Data are n (%).
* The total number of previous uterine surgical procedures exceeds
the number of patients because some patients had more than
one uterine surgery.
women (75.5%) who had both placenta previa and
a previous cesarean. Magnetic resonance imaging
(MRI) of the pelvis was performed for 45 patients
and confirmed the diagnosis of placenta accreta in
Table 2. Patients’ Demographic and Obstetric
Characteristics
Characteristic
Age (y)
Geographic origin
European
Sub-Saharan Africa
North Africa
Asia
Parity
Number of pregnancies
Twin pregnancy
Pregnancy termination
Gestational age at delivery (wk)
Less than 24
24–31
32–36
37 or more
Mode of delivery
Planned cesarean
Emergency cesarean due
to hemorrhage
Cesarean during labor
Vaginal
Placenta Accreta
(nⴝ167)
33.15⫾4.78
122 (73.0)
23 (13.8)
18 (10.8)
4 (2.4)
1 (0–8)
3 (1–12)
6 (3.6)
5 (3.0)
34.5⫾4.75
8 (4.8)
34 (20.4)
39 (23.3)
86 (51.5)
113 (67.6)
27 (23.9)
26 (15.6)
28 (16.8)
Data are mean⫾standard deviation, n (%), or median (range).
VOL. 115, NO. 3, MARCH 2010
41 (91.1%). A cesarean delivery was planned for all
the cases diagnosed prenatally (n⫽74). In all, 113
cesarean deliveries were planned. For 27 (23.9%) of
these patients, cesarean nonetheless was performed
on an emergency basis before labor because of
hemorrhaging.
Peripartum management and modalities of conservative treatment are summarized in Table 3.
Primary postpartum hemorrhage occurred in 86
of 167 cases (51.5%). In 15 of these cases (17.4%), it
stopped after the administration of uterotonic agents
and no other treatment. In the other 71 cases, primary
postpartum hemorrhage required uterine devascularization procedures (n⫽57) or primary hysterectomy
(n⫽18) or both. There were 109 uterine devascularization procedures including pelvic arterial embolization combined with conservative treatment (Table 3),
57 (52.3%) for primary postpartum hemorrhage and
52 (47.7%) prophylactic, ie, in absence of any primary
postpartum hemorrhage.
Table 3. Peripartum Management and Modalities
of Conservative Treatment for Patients
With Placenta Accreta, Including
Placenta Percreta
Characteristic
Hysterotomy (n⫽139)
Fundal
Low transverse
Placenta left in situ
Partially
Entirely
Preoperative ureteric stent
placement
Uterotonic administration
Primary postpartum hemorrhage
No additional uterine devascularization
procedure
Additional uterine devascularization
procedure
Pelvic arterial embolization*
Vessel ligation*
Stepwise uterine devascularization
Hypogastric artery ligation
Stepwise uterine devascularization
and hypogastric artery ligation
Uterine compression suture*
Balloon catheter occlusion
Methotrexate administration
Placenta Accreta,
Including Percreta
(nⴝ167)
71 (51.1)
68 (48.9)
167 (100)
99 (59.3)
68 (40.7)
6 (3.6)
167 (100)
86 (51.5)
58 (34.7)
109 (65.3)
62 (37.1)
45 (26.9)
15 (9.0)
23 (13.8)
7 (4.2)
16 (9.6)
0
21 (12.6)
Data are n (%).
* The total number of additional uterine devascularization
procedures exceeds the number of patients because some
patients had more than one such procedure.
Sentilhes et al
Conservative Treatment for Placenta Accreta
529
Table 4 summarizes maternal morbidity for the
entire cohort. Conservative treatment for placenta
accreta was successful in 131 of 167 cases (78.4%, 95%
CI 71.4 – 84.4%); 18 patients (10.8%, 95% CI 6.5–
16.5%) had primary hysterectomies, related in all
cases to primary postpartum hemorrhage, and another 18 (10.8%, 95% CI 6.5–16.5%) delayed hysterectomies (Table 4). Histopathological examination
confirmed the diagnosis of placenta accreta in all
primary hysterectomies and all except one delayed
hysterectomy. Severe maternal morbidity was identified in 10 cases (6.0%, 95% CI 2.9 –10.7%), including
one maternal death due to aplasia, nephrotoxicity
with acute renal failure, and then peritonitis with
septic shock after intraumbilical cord administration
of methotrexate (50 mg per m2 of body-surface area)
(Table 5).
Follow-up information about the subsequent
outcome of the placenta was available for 116 of the
131 (88.5%) women with successful conservative
treatment. In 75% (95% CI 66.1– 82.6%) of the cases
(87/116), spontaneous placental resorption was observed on follow-up examination, at a median of
13.5 weeks (range 4 – 60 weeks) after delivery.
Hysteroscopic resection or curettage or both were
used to remove the retained placenta in 29 (25.0%)
cases, at a median of 20 weeks (range 2– 45 weeks)
after delivery.
Placenta percreta was diagnosed before labor by
ultrasonography or MRI (n⫽14) and during labor (at
the time of the cesarean) (n⫽4) in 18 women. Bladder
involvement was observed for eight of these 18
women, five of whom had had prenatal ultrasonography and MRI, all at least suggestive of this complication. The mean gestational age at delivery for the 18
women with placenta percreta was 35.3 weeks (range
29.2– 40.1 weeks). The entire placenta was left in situ
after a fundal hysterotomy in all cases. Additional
uterine devascularization procedures were performed
in 13 cases (eight pelvic arterial embolizations and
five vessel ligations). Three patients received a dose of
methotrexate—in situ in two cases and intramuscularly
in the other. Four primary hysterectomies were performed owing to hemorrhage (one complicated by
bladder injury [Tables 4 and 5]). Delayed hysterectomies were performed at a median duration of 39 days
(range 9 –105 days) after delivery because of secondary postpartum hemorrhage (one case), secondary
postpartum hemorrhage and sepsis (one case), vesicouterine fistula (one case), and arteriovenous malformation (one case). No ureteral damage occurred.
Conservative treatment was thus successful for 10 of
18 cases (55.6%, 95% CI 30.8 –78.5%) of placenta
530
Sentilhes et al
Table 4. Maternal Morbidity After Conservative
Treatment for Placenta Accreta,
Including Placenta Percreta
Placenta Accreta,
Including Percreta
(nⴝ167)
Characteristic
Primary hysterectomy
Cause of primary hysterectomy
Primary postpartum hemorrhage
Postpartum prophylactic antibiotic
therapy more than 5 d
Transfusion patients
Units of packed RBCs transfused
more than 5
Transfer to intensive care unit
Duration of stay in intensive care
unit (d)
Acute pulmonary edema
Acute renal failure
Adjacent organ injury
Septic shock
Sepsis*
Infection
Endometritis
Wound infection
Peritonitis
Pyelonephritis
Vesicouterine fistula
Uterine necrosis
Isolated postpartum fever higher
than 38.5°C for 24 h
Deep vein thrombophlebitis or
pulmonary embolism
Secondary postpartum hemorrhage
stopped after
Uterotonics
Manual exploration of the
uterus
Hysteroscopy and curettage
Pelvic arterial embolization
Delayed hysterectomy
Delayed hysterectomy
Median interval from delivery to
delayed hysterectomy (d)
Cause of delayed hysterectomy
Secondary postpartum
hemorrhage
Sepsis
Secondary postpartum hemorrhage
and sepsis
Vesicouterine fistula
Uterine necrosis and sepsis†
Arteriovenous malformation
Maternal request
Death
Success of conservative treatment
Severe maternal morbidity
18 (10.8)
18/18 (100)
54 (32.3)
70 (41.9)
25 (15.0)
43 (25.7)
2.36⫾1.93
1 (0.6)
1 (0.6)
1 (0.6)
1 (0.6)
7 (4.2)
47 (28.1)
15 (9.0)
8 (4.7)
2 (1.2)
2 (1.2)
1 (0.6)
2 (1.2)
17 (10.2)
3 (1.8)
18 (10.8)
2/18 (11.1)
2/18 (11.1)
2/18 (11.1)
4/18 (22.2)
8/18 (44.5)
18 (10.8)
22 (9–45)
8/18 (44.4)
2/18 (11.1)
3/18 (16.7)
1/18 (5.6)
2/18 (11.1)
1/18 (5.6)
1/18 (5.6)
1 (0.6)
131 (78.4)
10 (6.0)
RBC, red blood cell.
Data are n (%), mean⫾standard deviation, or median (interquartile
range).
Some patients had more than one type of morbidity.
* Sepsis included sepsis and septic shock.
†
These two patients had bilateral supraselective embolization of
the uterine arteries owing to primary postpartum hemorrhage
on the day of delivery.
Conservative Treatment for Placenta Accreta
OBSTETRICS & GYNECOLOGY
Table 5. Characteristics of the Women With Severe Maternal Morbidity
Type
Term
Placenta
Uterine
of Abnormal Mode of (Weeks of Left in
Primary
Devascularization
Case Placentation Delivery Gestation)
Situ
Hemorrhage
Procedure
MTX
1
Accreta
CD
37
Entirely
No
PAE
No
2
Percreta with
bladder
involvement
CD
37
Entirely
Yes
PAE⫹BL
No
3
Accreta
VD
37
Partially
Yes
PAE
Yes
4
Accreta
CD
6
Partially
Yes
PAE
No
5
Percreta
CD
38
Entirely
Yes
HAL
No
6
Percreta with
bladder
involvement
CD
39
Entirely
Yes
No
No
7
Accreta
CD
39
Partially
Yes
HAL
No
8
Accreta
CD
37
Partially
Yes
BL
No
9
10
Accreta
Accreta
CD
CD
30
32
Entirely
Entirely
Yes
No
PAE
PAE
No
Yes
Severe Maternal
Morbidity
Delayed hysterectomy on
day 45 because of sepsis
and peritonitis
Delayed hysterectomy on
day 105 because of
vesicouterine fistula and
excision of the tract and
reinforcement of the
repair with a graft; this
patient subsequently
complained of irritable
bladder symptoms.
Delayed hysterectomy on
day 23 because of
uterine necrosis and
sepsis
Delayed hysterectomy on
day 9 because of uterine
necrosis and sepsis
complicated by deep
vein thrombophlebitis
Delayed hysterectomy on
day 9 because of sepsis
and hemorrhage
complicated by acute
pulmonary edema
Bladder injury during
primary hysterectomy
with no long-term
sequela
Delayed hysterectomy on
day 2 because of sepsis
and hemorrhage
complicated by deep
vein thrombophlebitis
Delayed hysterectomy on
day 3 because of sepsis
Pulmonary embolism
Aplasia, nephrotoxicity
with acute renal failure,
followed by peritonitis
with septic shock and
hemorrhage requiring
delayed hysterectomy on
day 9; maternal death
occurred on day 126
related to multiorgan
failure
CD, cesarean delivery; PAE, pelvic arterial embolization; BL, B-Lynch suture; VD, vaginal delivery; HAL, hypogastric artery ligation;
MTX, methotrexate.
percreta, and severe maternal morbidity occurred in 3
of the 18 (16.7%, 95% CI 3.6 – 41.4%) (Table 5).
Histopathological examination confirmed the diagnosis of placenta percreta in all primary and delayed
hysterectomies. Of the eight cases of placenta per-
VOL. 115, NO. 3, MARCH 2010
creta with bladder involvement, one primary hysterectomy (complicated by bladder injury) and one
delayed hysterectomy (owing to vesicouterine fistula)
were required: conservative treatment was successful
in six cases (75%, 95% CI 34.9 –96.8%) and severe
Sentilhes et al
Conservative Treatment for Placenta Accreta
531
maternal morbidity occurred in two (25%, 95% CI
3.2– 65.1%).
DISCUSSION
This multicenter study of conservative management
of placenta accreta in 167 women treated in 25
French university hospitals showed that conservative
treatment for placenta accreta is a valuable option
with a success rate of 78.4% and a severe maternal
morbidity rate of 6.0%.
The main strengths of this study include not only
the number of cases but also the number of participating centers, which increases the study’s external
validity and makes it possible to extrapolate our
results to centers with limited experience in conservative treatment of placenta accreta. Nevertheless, all
our cases were managed in university teaching hospitals, where blood banks, pelvic arterial embolizations,
obstetric subspecialties, obstetric anesthesia, interventional radiology, urology, and gynecological oncology
were readily available. Therefore, our results can be
extrapolated only to centers with similar equipment
and resources.
Two case series have assessed conservative treatment of placenta accreta, for a limited number of
patients.6,8 As stated in the Material and Methods
section, these women were also included in this study,
so comparison of our results to these studies is inappropriate. Surprisingly, our rates of patients requiring
transfusion, transfer to intensive care unit, infectious
complications, and delayed re-operations were similar to those reported in the largest series of cesarean
hysterectomies for placenta accreta/percreta.2 Nevertheless, this comparison too is inappropriate, as the
rate of placenta percreta, a condition that is associated
with higher morbidity,1 was 10.7% in our study, a little
more than half that in the study of cesarean hysterectomies by Eller et al (18.4%).2 Nonetheless, until a
randomized controlled trial is performed, we believe
that cesarean hysterectomy without attempted placental removal should be strongly considered for placenta accreta in multiparous women not interested in
preserving their fertility,9 especially given that conservative treatment requires patient adherence to treatment over a long postpartum period. In particular, the
median period until delayed hysterectomy in our
series was 22 weeks (interquartile range, 9 – 45), which
suggests that women may continue to be at risk for
severe bleeding or infection for weeks or even months
after delivery.
Methotrexate has been proposed as adjuvant
treatment to improve the success rate of conservative
treatment and hasten the postpartum involution of the
532
Sentilhes et al
placenta.7 Nevertheless, no standard dosing regimen
exists, and the mode of administration (in situ, intramuscular, or intraumbilical) varies widely according
to author.6 – 8,21 No convincing evidence currently
supports the efficacy of methotrexate in cases of
placenta accreta left in situ, and methotrexate-related
pancytopenia and nephrotoxicity are possible adverse
effects.22,23 In these women who might subsequently
need uterine devascularization (embolization or ligation or both) or develop severe and potentially lifethreatening infection, use of methotrexate therapy
seems to be inappropriate. In particular, intraumbilical-cord administration should be avoided because of
the risk of toxic accumulation of methotrexate. The
only maternal death observed in our study occurred
after methotrexate administration into the umbilical
cord and severe methotrexate-related adverse events.
In our study, some practitioners performed additional uterine devascularization procedures in absence of any hemorrhage to improve the maternal
outcome and decrease the risk of secondary postpartum hemorrhage.24 Nevertheless, no evidence currently proves the benefit of this strategy.17,25 Similarly,
several authors advocate the preoperative placement
of ureteric stents or occlusive balloon catheters or
both in the internal iliac arteries to reduce, respectively, the rate of ureteric injury2 and the volume of
blood loss.26 The interest of these strategies is still
being debated.27–29 It is very likely, however, that the
most useful intervention for improving maternal outcome is scheduling delivery2 with an experienced
obstetric surgeon, an anesthesiologist skilled in obstetric anesthesia, and with other surgical specialists (such
as urologists) readily available if required.7 Prenatal
identification of placenta accreta is therefore essential
for planning delivery but also for counseling women
about the possibilities of management of placenta
accreta. No recommendation can be made about the
optimal gestational age of delivery, because the potential maternal benefits of earlier scheduled delivery
must be weighed against the consequence of premature birth on a case-by-case basis.2 Interestingly, in
our study, 27% of the women for whom cesarean
delivery was planned because of prenatal diagnosis of
placenta accreta nonetheless had emergency cesarean
deliveries because of early hemorrhage. This finding
emphasizes the need for contingency plans for possible emergency delivery.
The rate of severe maternal morbidity was 25%
(2/8) for placenta percreta with bladder involvement and 16.7% (3/18) for all cases of placenta
percreta. No ureteral damage occurred in this latter
subgroup. There were only two urologic complica-
Conservative Treatment for Placenta Accreta
OBSTETRICS & GYNECOLOGY
tions (one bladder injury and one vesicouterine
fistula). In comparison, a meta-analysis of 54 reported cases of placenta percreta with bladder
involvement treated by conventional surgical therapy reported a high maternal morbidity with 39
urologic complications.30 These included bladder
laceration (20%), urinary fistula (13%), ureteral
transection (6%), and small capacity bladder (4%).
Partial cystectomy was necessary in 24 cases (44%)
and there were three maternal deaths (5.6%).30 We
speculate that conservative treatment in cases of
placenta percreta with bladder involvement may
have the advantage of avoiding a difficult hysterectomy fraught with risks including urologic complications, in an acutely bleeding patient.
Several limitations of our study must be underlined. The first is its retrospective design, common to
all studies that have thus far assessed maternal outcome after placenta accreta. Accordingly, all the flaws
of retrospective analyses apply. In particular, some
eligible cases may not have been detected, especially
insofar as databases may differ from one hospital to
another. Second, the length of the observation period
raises concerns about possible changes in management and outcome during this time. Third, it is
possible that some cases did not have a placenta
accreta, because pathological confirmation was impossible in cases without a hysterectomy specimen,
generally unavailable except when treatment fails.
Nevertheless, our results reflect what happens in
real life when a team decides to perform conservative treatment for placenta accreta. Fourth, although this study includes a large number of cases
that had conservative treatment of placenta accreta,
the series may lack statistical power to estimate
adequately the risks of rare severe events, such as
death.
In conclusion, in centers with adequate equipment and resources, conservative management is an
option for patients who are properly counseled and
motivated, in particular, for women who want the
option of future pregnancy and who agree to close
follow-up monitoring. Nevertheless, there are significant risks of serious morbidity and possibly mortality
associated with conservative management.
REFERENCES
1. O’Brien JM, Barton JR, Donaldson ES. The management of
placenta percreta: conservative and operative strategies. Am J
Obstet Gynecol 1996;175:1632– 8.
2. Eller AG, Porter TF, Soisson P, Silver RM. Optimal management strategies for placenta accreta. BJOG 2009;116:648 –54.
VOL. 115, NO. 3, MARCH 2010
3. Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation:
twenty-year analysis. Am J Obstet Gynecol 2005;192:
1458 – 61.
4. Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for
placenta previa-placenta accreta. Am J Obstet Gynecol 1997;
177:210 – 4.
5. American College of Obstetricians and Gynecologists. Postpartum hemorrhage. ACOG Educational Bulletin 243. Washington, DC: ACOG; 1998.
6. Kayem G, Davy C, Goffinet F, Thomas C, Clement D, Cabrol
D. Conservative versus extirpative management in cases of
placenta accreta. Obstet Gynecol 2004;104:531– 6.
7. Oyelese Y, Smulian JC. Placenta previa, placenta accreta, and
vasa previa. Obstet Gynecol 2006;107:927– 41.
8. Bretelle F, Courbiere B, Mazouni C, Agostini A, Cravello L,
Boubli L, et al. Management of placenta accreta: morbidity
and outcome. Eur J Obstet Gynecol Reprod Biol 2007;133:
34 –9.
9. Placenta accreta. ACOG Committee Opinion No. 266. American College of Obstetricians and Gynecologists. Int J Gynecol
Obstet 2002;77:77– 8.
10. Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA,
Hankins GD. Maternal death in the 21st century: causes,
prevention, and relationship to cesarean delivery. Am J Obstet
Gynecol 2008;199:36.e1–5.
11. Kayem G, Pannier E, Goffinet F, Grange G, Cabrol D. Fertility
after conservative treatment of placenta accreta. Fertil Steril
2002;78:637– 8.
12. Alanis M, Hurst BS, Marshburn PB, Matthews ML. Conservative management of placenta increta with selective arterial
embolization preserves future fertility and results in a favorable
outcome in subsequent pregnancies. Fertil Steril 2006;86:
1514.e3–7.
13. Descargues G, Clavier E, Lemercier E, Sibert L. Placenta
percreta with bladder invasion managed by arterial embolization and manual removal after cesarean. Obstet Gynecol
2000;96:840.
14. Cle´ment D, Kayem G, Cabrol D. Conservative treatment of
placenta percreta: a safe alternative. Eur J Obstet Gynecol
Reprod Biol 2004;114:108 –9.
15. Sentilhes L, Resch B, Clavier E, Marpeau L. Extirpative or
conservative management for placenta percreta? Am J Obstet
Gynecol 2006;195:1875– 6.
16. AbdRabbo SA. Stepwise uterine devascularization: a novel
technique for management of uncontrollable postpartum hemorrhage with preservation of the uterus. AJOG 1994;171:
694 –700.
17. Sentilhes L, Gromez A, Descamps P, Marpeau L. Why stepwise uterine devascularization should be the first-line conservative surgical treatment to control severe postpartum hemorrhage? Acta Obstet Gynecol Scand 2009;88:490 –2.
18. Sentilhes L, Trichot C, Resch B, Sergent F, Roman H, Marpeau L, et al. Fertility and pregnancy outcomes following
uterine devascularization for postpartum haemorrhage. Hum
Reprod 2008;23:1087–92.
19. Sentilhes L, Gromez A, Razzouk K, Resch B, Verspyck E,
Marpeau L. B-Lynch suture for massive persistent postpartum
hemorrhage following stepwise uterine devascularization. Acta
Obstet Gynecol Scand. 2008;87:1020 – 6.
20. American College of Chest Physicians/Society of Critical Care
Medicine Consensus Conference: definitions for sepsis and
organ failure and guidelines for the use of innovative therapies
in sepsis. Crit Care Med 1992;20:864 –74.
Sentilhes et al
Conservative Treatment for Placenta Accreta
533
21. Chauleur C, Fanget C, Tourne G, Levy R, Larchez C, Seffert
P. Serious primary post-partum hemorrhage, arterial embolization and future fertility: a retrospective study of 46 cases.
Human Reprod 2008;23:1553–9.
22. Lim Ay, Gaffney K, Scott DG. Methotrexate-induced pancytopenia: serious and under-reported? Our experience of 25
cases in 5 years. Rheumatology 2005;44:1051–5.
23. Widemann BC, Adamson PC. Understanding and managing
methotrexate nephrotoxicity. Oncologist 2006;11:694 –703.
24. Judlin P, Thiebaugeorges O. The ligation of hypogastric arteries is a safe alternative to balloon occlusion to treat abnormal
placentation. Am J Obstet Gynecol 2008;199:e11.
25. Sentilhes L, Gromez A, Clavier E, Resch B, Verspyck E,
Marpeau L. Predictors of failed pelvic arterial embolization for
severe postpartum hemorrhage. Obstet Gynecol 2009;113:
992–9.
534
Sentilhes et al
26. Le Ray C, Audibert F, Dubois J. Prophylactic balloon occlusion of the internal iliac arteries to treat abnormal placentation.
Am J Obstet Gynecol 2008;199:e11–2.
27. Kayem G, Sentilhes L, Deneux-Tharaux C. Management of
placenta accreta. BJOG 2009;116:1536 –7.
28. Greenberg JI, Suliman A, Iranpour P, Angle N. Prophylactic
balloon occlusion of the internal iliac arteries to treat abnormal
placentation: a cautionary case. Am J Obstet Gynecol 2007;
197:470.e1– 4.
29. Shrivastava V, Nageotte M, Major C, Wing D. Case-control
comparison of cesarean hysterectomy with and without placement of intravascular balloon catheters for placenta accreta.
Am J Obstet Gynecol 2007;197:402.e1–5.
30. Washecka R, Behling A. Urologic complications of placenta
percreta invading the urinary bladder: a case report and review
of the literature. Hawaii Med J 2002;61:66 –9.
Conservative Treatment for Placenta Accreta
OBSTETRICS & GYNECOLOGY