Surgical management of placenta accreta: a cohort series and suggested approach

Article Outline

• Abstract
• Materials and Methods
• Results
• Comment
• Acknowledgments
• References
• Copyright

Objective

The purpose of this study was to describe the use of a staged procedure that involved femoral artery catheterization, classic cesarean section delivery, and uterine and placental embolization before hysterectomy for placenta accreta.

Study Design

We conducted a cohort study of retrospective and prospective data from cases of histologically identified placenta accreta at a tertiary teaching hospital with access to interventional radiology.

Results

Twenty-six cases of placenta accreta were identified histologically (7 accretas, 5 incretas, and 14 percretas); 8 cases were successful staged embolization procedures. These cases had significant reductions in blood loss (553 vs 4517 mL; P = .0001), need for transfusion (2 vs 16; P = .001), and units of blood transfused (0.5 vs 7.9; P = .0013). The total operation time was no different between the 2 groups, but there was a longer length of anesthesia (2.7 vs 6.6 hours; P = .0001). There were nonsignificant reductions in admission to the intensive care unit and length of hospital stay.

Conclusion

We found that the successful use of a staged embolization hysterectomy procedure for placenta accreta is associated with decreased maternal morbidity.

Key words: cesarean section delivery, embolization, hemorrhage, hysterectomy, placenta accreta

Disorders of placentation, which are important conditions with significant problems at delivery because of incomplete placental separation, include hemorrhage, neonatal death, infection, fistula formation, ureteral damage, and bladder injury. A maternal mortality rate of 7% has been quoted previously for this condition.¹ Placenta accreta occurs where chorionic villi attach to the myometrium without normal intervening decidua basalis, with the placental bed being partially or completely affected.² The most severe manifestations of this process result in placenta increta, when chorionic villi invade into myometrium, and placenta percreta, when chorionic villi invade to or through the uterine serosa.³ The major risk factor is placenta previa with a previous cesarean section delivery. Among women with placenta previa, the incidence of placenta accreta is nearly 10%, which rises to 40% in women who have an anterior (or central) previa and ≥2 previous cesarean deliveries.⁴ Placenta accreta is becoming more common because of a number of factors, which include advancing maternal age and higher cesarean delivery rates.⁵ The incidence varies, with a range of 1:533–1:2500.⁴, ⁵, ⁶ Life-threatening bleeding is the most common complication to be associated with this condition; the average blood loss at time of delivery is reported to be 3000–5500 mL, which leads to significant postoperative morbidity and death.⁷, ⁸, ⁹ A recent retrospective study found an average blood loss of 3630 ± 2216 mL for placenta increta and 12,140 ± 8343 mL for placenta percreta.¹⁰

Placenta accreta is diagnosed ideally in the antenatal period by either sonographic or magnetic resonance imaging techniques. Several studies have demonstrated the usefulness of ultrasonography in making this diagnosis, particularly at >20 weeks' gestation.¹¹, ¹², ¹³

There is debate over the ideal therapeutic approach for management of placenta accreta. The generally held opinion is that the placenta accreta should be treated by cesarean hysterectomy, without attempts at removal of the placenta.³ Conservative management, whereby the placenta is left within the uterus, is advocated by some investigators who cite that this approach has the benefits of preservation of fertility, prevention of massive hemorrhage, and protection against damage to adjacent organs.¹⁴ This conservative approach, however, is not without risks, which include significant bleeding, infection, fistula formation, and failure of placental resorption.¹⁴, ¹⁵, ¹⁶

Interventional radiologic techniques, particularly balloon catheter occlusion and embolization, have been described as an adjunct to surgery for this condition. A number of approaches are described in the literature. One group of techniques involves the preoperative placement of balloon catheters into the common iliac arteries bilaterally, with inflation after the delivery of fetus. This is to facilitate reduced blood loss at hysterectomy by temporarily occluding the primary blood supply to the uterus.², ¹⁷, ¹⁸, ¹⁹ A retrospective review has questioned the benefits of balloon catheter occlusion and embolization in this setting, finding no difference in blood loss when compared with historic controls.²⁰, ²¹ There are also reports of embolic complications after balloon occlusion.²², ²³ The other main group of techniques involves embolization. Uterine artery embolization for treatment for heavy menstrual bleeding because of fibroid tumors has been established as an efficacious practice. A number of approaches have been described for the utilization of this technique in the management of placenta accreta.², ⁴, ⁸, ²⁴ In the 2007 review of placenta increta/percreta published by Sumigama et al, ¹⁰ they suggested that, in 4 cases, embolization at the time of delivery with subsequent hysterectomy a week later was the significant management intervention in reducing maternal morbidity and mortality rates for placenta increta/percreta. This article outlines our unit's approach to placenta accreta.

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Materials and Methods 

We report on a case series of women who had a histologically proven diagnosis of placenta accreta from 2001–January 2009. Since 2005, our unit has used a staged delivery technique when suitable for the management of this condition that involves close collaboration between obstetricians, anesthetists, radiologists, hematologists, neonatologists, intensivists, midwives, and gynecologic oncologists. The cases were identified retrospectively before 2005 and collected prospectively since then. We evaluated all the outcomes for histologically proven cases of placenta accreta that included both cesarean hysterectomy and the staged delivery method at our institution. Not all patients since 2005 have been treated with the staged delivery technique. The staged delivery algorithm (Figure 1) approach to treatment of patients with this condition is similar to the techniques suggested by Oyelese and Smulian³ and Sumigama et al.¹⁰

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• FIGURE 1. 

  The staged delivery algorithm

• The asterisk indicates that the manufacturer is Codman & Shurtleff, Inc, Raynham, MA.

• IDC, indwelling catheter (bladder); PVA, polyvinyl alcohol.

• Angstmann. Surgical management of placenta accreta. Am J Obstet Gynecol 2010.

This project was approved by the Northern Sydney Central Coast Area Health Service Research and Ethics Committee. The retrospective cases were identified by a number of database searches, which included pathology, blood bank, radiology, intensive care unit (ICU), OBSTET and OBSTETRIX (both midwifery databases that are used in our unit), operating room, birth register, and hospital ICD-10 coding. To account for data entry errors, particular operations had individual case notes reviewed. The cases that were reviewed included all cesarean hysterectomies, postpartum hysterectomies, hysterectomies performed on women aged 16–48 years (when the indication was not specified), all obstetric operations in which a gynecologic oncologist was in attendance, and any obstetric operation in which time in the operating room was >2 hours. To be included in the series, a case required a histopathologic report that documented placenta accreta. In this time period, the hospital has been staffed by only 3 gynecologic oncologists, who were asked to identify cases from their own experience and records.

In patients with ultrasonographic features of accreta, a decision is made for delivery at 37 weeks' gestation. Antenatal corticosteroids are administered routinely before delivery, if not previously administered. Either the day before or on the morning of the surgery, duplex ultrasound is used to measure the internal diameter of the common iliac arteries bilaterally. On the morning of surgery, two 7F sheaths are inserted into the common femoral arteries bilaterally under ultrasound guidance. The distance to the aortic bifurcation is then premeasured with guide wires and flash fluoroscopy (fluoroscopy time, 5 seconds). This preoperative measurement is to ensure correct sighting of the intravascular occlusive balloon catheters in the common iliac arteries. The patient is then transferred to the operating room and undergoes anesthetic preparation, which involves the insertion of 2 rapid-infusion 7F cannulae in the upper extremities, a triple lumen central venous catheter, and a radial-arterial line. After this preparation, a rapid-sequence-induction general anesthetic is established. An indwelling Foley bladder catheter is inserted. The laparotomy is performed through a midline incision from the mons pubis to above the umbilicus. The interventional radiologist then places the deflated tamponade balloon catheters into the common iliac arteries to a premeasured distance. A classic cesarean section delivery is performed high in the upper uterine segment, which avoids the placenta and its edge; the infant is delivered, and the cord is tied after delivery, with the aim of the placenta remaining undisturbed in situ. If significant hemorrhage occurs, such as in the circumstance of partial placental separation, the common iliac balloon catheters are inflated, and hysterectomy is immediately performed.

If the placenta does not separate and there is no bleeding, the uterine and the abdominal incisions are closed. The patient remains anesthetized and is moved to the angiography suite, which is situated in the same building on a different level. This movement takes 10 minutes, with the anesthetic and surgical team in attendance. In the angiography suite, the patient undergoes angiography with selective embolization of the entire uterus and placental bed. The technique utilizes the in situ sheaths; a 5F guide catheter followed by a microcatheter are used to subselect multiple branches of the internal iliac artery for embolization, mainly with 500–700 μm polyvinyl alcohol (PVA) particles, gel foam pledgets, and fiber coils for intravascular occlusion (FIGURE 2, FIGURE 3). After the patient is returned to the operating suite, the hysterectomy is completed routinely by a gynecologic oncologist (with histopathologic examination of the specimen after the operation). The mean total anesthetic time is 6.6 hours.

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• FIGURE 2. 

  Uterus in situ after embolization before hysterectomy and hysterectomy specimen

• A, View of the uterus in situ after embolization before hysterectomy (case 6) shows the abdominal incision held open with the Bookwalter retractor (Codman & Shurtleff, Inc, Raynham, MA); B, the hysterectomy specimen shows the large dilated vascular collections that are typical of a placenta percreta in the lower uterine segment. The suture line from the classic cesarean section delivery can be seen in the upper uterine segment.

• Angstmann. Surgical management of placenta accreta. Am J Obstet Gynecol 2010.

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• FIGURE 3. 

  Angiographic studies show before and after uterine embolization through the left iliac artery

• A, Angiography through the left iliac artery before embolization; B, angiography after embolization shows the marked decrease in placental vascularity.

• Angstmann. Surgical management of placenta accreta. Am J Obstet Gynecol 2010.

The maternal demographics and outcomes that were assessed were age, parity, gestation at delivery, blood loss (measured by weighing drapes and sponges and the volume aspirated by suction), need for blood products, and complications. Statistical analysis was performed with the nonparametric Mann-Whitney U test, χ² test, and Fisher exact test; a probability value of .05 was considered to be the level of significance (Minitab software, release 12; Minitab Inc, State College, PA).

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Results 

Our series contains 26 cases (TABLE 1, TABLE 2). Four cases that occurred before 2005 were identified retrospectively. There were 5 women who were not diagnosed antenatally (Table 3). Histologically there were 7 placentae accreta, 5 placentae increta and 14 placentae percreta. The position of the placentas is listed in Table 1. Eight cases were treated successfully with a staged delivery, which enabled embolization of the placenta (cases 6, 12, 13, 14, 16, 18, 19, and 24). Fourteen women had primary cesarean hysterectomies without embolization. One woman experienced failed conservative treatment (case 2), which required a hysterectomy for sepsis 9 months after delivery. Three women were treated with the intention to undertake a staged delivery with embolization; however, because of placental separation and hemorrhage, primary hysterectomy was performed (cases 10, 11, 12). There was no difference in age, parity, and gestation at delivery or histopathologic findings among the women who had a successful staged procedure and those who did not. The patient demographics are listed in Table 4.

TABLE 1. Patient details, diagnosis, and treatment

Case	Age, y	History	Previa grade	Previous cesarean section delivery	Gestation	Antenatal diagnosis	Disease found	Treatment
1	36	G2P1; PPH after cesarean delivery	0	0	39	Nil	Accreta	Curettage; laparotomy; hysterectomy
2	40	G3P2	4	2	37.5	Increta	Percreta	Percreta found at cesarean delivery; conservative treatment; hysterectomy at 9 mo for infection
3	34	G3P1	4	1	39.2	Accreta	Percreta	Cesarean hysterectomy
4	41	G3P2	4	1+1hysterotomy	37.3	Percreta	Percreta	Cesarean hysterectomy
5	41	G5P2	4	2	38	Accreta	Accreta	Cesarean hysterectomy
6	33	G3P2	3anterior	2	37.5	Percreta	Percreta	Staged delivery; cesarean delivery; embolization; hysterectomy
7	40	G5P2	4	2	34.1	Percreta	Accreta	Cesarean hysterectomy
8	34	G2P1; TPL-APH	0	1	30	Nil	Percreta	Uterine rupture; fetal death in utero; hysterectomy
9	39	G3P1; Trisomy 21; TOP	4	1	25.2	Accreta	Percreta	Cesarean hysterectomy
10	23	G3P1	3anterior	1	38.5	Percreta	Percreta	Staged delivery; cesarean delivery; placental separation; hysterectomy
11	44	G4P2	4	2	37.3	Accreta	Accreta	Staged delivery; cesarean delivery; placental separation; hysterectomy
12	37	G3P2	1anterior	2	37.5	Percreta	Percreta	Staged delivery; cesarean delivery; embolization; hysterectomy
13	36	G2P1	4	1	36.5	Percreta	Percreta	Staged delivery; cesarean delivery; embolization; hysterectomy
14	33	G5P2	1anterior	2	33	Percreta	Percreta	Staged delivery; cesarean delivery; embolization; hysterectomy
15	36	G3P3; Trisomy 21	0	2	16	Nil	Percreta	Dilation and evacuation for TOP; intraperitoneal bleed; hysterectomy
16	41	G4P3	1anterior	2	37.1	Accreta	Increta	Staged delivery; cesarean delivery; embolization; hysterectomy
17	38	G4P2	4	0	37.5	Placenta praevia	Accreta	PPH after cesarean delivery; failed SOS Bakri tamponade balloon;a hysterectomy
18	32	G3P2	4	1	38.1	Percreta	Increta	Staged delivery; cesarean delivery; embolization; hysterectomy
19	37	G3P2	3anterolateral	2	38.5	Accreta	Increta	Staged delivery; cesarean delivery; embolization; hysterectomy
20	43	G6P1	3anterior	1	37.6	Accreta	Increta	Cesarean hysterectomy
21	28	G5P2; TPL	4	2	38	Accreta	Accreta	Staged delivery; cesarean delivery; placental separation; hysterectomy
22	40	G11P4	3 posterior and covering previous cesarean section scar	2	31.6	Placenta praevia	Increta	Cesarean hysterectomy
23	37	G9P4; MC/DC twins	3anterior	1	30.2	Accreta	Accreta	Cesarean hysterectomy
24	37	G3P2; APH from 18 wk	4	2	37	Percreta	Percreta	Staged delivery; cesarean delivery; embolization; hysterectomy
25	32	G3P2; APH-PPROM from 22 wk	4	2	25	Percreta	Percreta	Cesarean hysterectomy
26	38	G3P2; APH-PPROM; chorioamnionitis	4	2	30	Percreta	Percreta	Cesarean hysterectomy

APH, antepartum hemorrhage; G, gravidity; MC/DC, monochorionic/dichorionic; P, parity; PPH, postpartum hemorrhage; PPROM, preterm premature rupture of membranes; TOP, termination of pregnancy; TPL, threatened preterm labor.

Angstmann. Surgical management of placenta accreta. Am J Obstet Gynecol 2010.

TABLE 2. Details for embolization, catherization, need for blood and blood products, complications, and length of stay

FDIU, fetal death in utero; FFP, fresh frozen plasma; ICU, adult intensive care unit; LOS, length of stay.

Angstmann. Surgical management of placenta accreta. Am J Obstet Gynecol 2010.

TABLE 3. Cases of placenta accreta undiagnosed before delivery

G, gravidity; LSCS, lower segment cesarean section; P, parity; PPH, postpartum hemorrhage; PTL, preterm labor; TOP, termination of pregnancy.

Angstmann. Surgical management of placenta accreta. Am J Obstet Gynecol 2010.

TABLE 4. Patient demographics and outcomes

Variable	Staged procedure	Cesarean hysterectomy	P value
Age, ya	35.8±1.1(33–41)	36.9±1.24(23–44)	.28
Parity, n	2.0±0.19	1.9±0.20	.55
Gestation at delivery, wka	36.9±0.6(33–38.5)	33.4±1.50(16–39)	.54
Blood loss, mLa	553±119(200–1200)	4517±711(700–11,000)	.0001
Units transfused, na	0.5±0.38(0–3)	7.9±1.83(0–32)	.0013
Required transfusion, n	2	16	.001
In the intensive care unit, da	0.13±0.125(0–1)	0.89±0.332(0–5)	.152
Admission to the intensive care unit, n	1	7	.16
Length of postoperative stay, da	6.63±0.8(4–10)	8.28±0.41(5–13)	.107
Preoperative radiology, ha	0.59±0.09	0.59±0.09
Total operative time, ha	2.91±0.37	2.67±0.26
Total anesthetic time, ha	6.59±0.35	2.67±0.26	.0001

Angstmann. Surgical management of placenta accreta. Am J Obstet Gynecol 2010.

There were statistically significant differences (mean ± SE) in blood loss (553 ± 119 mL vs 4517 ± 711 mL; P = .0001), units of blood transfused (0.5 ± 0.38 units vs 7.9 ± 1.83 units; P = .0013), and need for transfusion (2 vs 16; P = .001; Table 1). There were fewer ICU admissions (1 vs 7; P = .16) and a shorter length of stay in hospital, but these did not reach significance (6.6 ± 0.80 days vs 8.3 ± 0.41 days; P = .107; Table 4). There was a significantly longer length of anesthesia for the embolized group: 6.59 ± 0.35 hours vs 2.67 ± 0.26 hours (P = .0001, Mann-Whitney U test). The total operating time was similar for both groups (2.67 ± 0.26 hours vs 2.91 ± 0.37 hours; Table 4).

Three complications were encountered in the postoperative period: 1 vesicovaginal fistula (staged procedure; case 6), 1 repeat laparotomy for hemorrhage (cesarean hysterectomy; case 11), and 1 case of pneumonia 2 weeks after the surgery that required high dependency unit (HDU) admission to another hospital (staged procedure; case 18). There have been no maternal deaths in our series and no neonatal complications in the group that underwent staged delivery. One intrauterine fetal death occurred at 25 weeks' gestation in a pregnancy that was complicated by prolonged oligohydramnios and repeated vaginal bleeding from 20 weeks' gestation (case 25), and 1 fetal death occurred in utero when spontaneous uterine rupture occurred at 30 weeks' gestation (case 8).

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Comment 

Placenta accreta is becoming more common. Although the question of which technique is most appropriate for the definitive management of placenta accreta needs to be answered in a condition as uncommon and serious as placenta accreta, it is hard to envisage at this stage the design and conduct of a randomized controlled trial to answer this question.

This is the largest series to date to describe the outcomes of placenta accreta that were managed prospectively with preoperative insertion of intraarterial balloon catheters for the control of intraoperative hemorrhage, followed by selective embolization of the uterine and placental vascular bed before hysterectomy. As seen in the aforementioned 23 cases of third-trimester placenta accreta, there can be significant morbidity for the women involved. In 7 of the patients, the bladder was entered at the time of hysterectomy. We believe that, in the initial case of a staged delivery in which a vesicovaginal fistula developed (case 6), the bladder catheter was removed too early on postoperative day 7. In subsequent cases, in which radiologic embolization was performed, the bladder catheter remained in situ for 14 days and was removed after discharge from hospital.

When we could deliver the fetus without disturbing the placenta and therefore could embolize the uterus and placenta, there were significantly less blood loss and need for transfusion of blood products. Although not significant, we did observe a shorter length of hospital stay. The initial staged procedure case (case 6) was admitted routinely to the ICU but did not require any ICU treatment and was discharged to the standard postnatal ward within 24 hours. Since then, patients in whom the embolization is successful have not required admission to ICU. If this initial case is not included in the aforementioned analysis, there is a significant reduction in the necessity for ICU admission (P = .02). Embolization for uterine fibroid tumors is a common practice, and the radiation exposure with this technique is comparable with embolization of the placenta in our cases. Because the uterus is removed, reproductive capacity is not affected by the imaging required.

Developing new therapeutic approaches that integrate techniques from different disciplines can be challenging, with an attendant learning curve. The use of a large midline incision provides excellent exposure and helps to mitigate the risk of incising the uterus too low. Our experience is that, when possible, the use of embolization makes the difficult task of completing a hysterectomy with placenta percreta technically much easier. Embolization takes away the pressure of pending hemodynamic instability, and meticulous dissection may be performed because there is no bleeding. The ready identification of pelvic structures in a near-bloodless field makes damage to other organs less likely. This is particularly useful in cases with extensive invasion into bladder or sidewall.

There are many different surgical approaches to the management of placenta percreta. Simply ligating the internal iliacs does not control the collateral supply from the profunda femoris and common femorals, nor is it feasible to access the hypogastics with vesiloops before cesarean section delivery because of the size of a gravid uterus. There are several possible criticisms of this technique. One is that the diagnosis of placenta accreta has been “overcalled” as described by Mok et al.²¹ However, all of our cases were confirmed on histologic examination of the tissue that was obtained at hysterectomy, and no cases of spontaneous placental separation were seen after embolization. Also there have been reports of vascular damage from the intraarterial catheterization that have resulted in acute limb ischemia.¹⁷, ¹⁸ To decrease this risk, we undertake preoperative assessment of correctly sized and positioned catheters in the radiology department, with the appropriate intensive imaging. The procedure is more lengthy and requires close coordination of operating rooms and the radiology department. We believe that the duration of anesthesia is not out of keeping with anesthesia for other major general surgical cases.

Although some groups advocate conservative management of placenta accreta, when offered as an alternative to hysterectomy, all our patients except 1 (case 2) requested definitive treatment in the form of hysterectomy. This probably relates to the age of our patients (mean, 36.0 years). The patient in whom conservative treatment was attempted required hysterectomy 9 months after delivery, after sepsis developed. This experience is in keeping with the known complications of conservative management.¹, ¹⁴, ¹⁵, ¹⁶

The report of Levine et al²⁰ suggested that there was no significant difference in blood loss with arterial catheterization. Both of their groups of patients experienced a mean blood loss in excess of 4500 mL, and 7 of 8 patients required blood transfusion. Shrivastava et al⁹ also observed no difference in outcomes when balloon catheters alone were used. Chou et al²⁴ have reported less blood loss (however, their mean blood loss was 1213 mL) with combined balloon catheterization plus embolization in mid gestation, but with a higher rate of blood transfusion in their patients than we report in this article. Fourteen of our reported 26 cases were placentae percreta, and 5 cases were placentae increta. In the 8 cases in which there was no partial placental separation and the embolization procedure was able to be performed, the mean blood loss was significantly lower. Therefore, we have found that the added embolization does appear to be successful in reducing the operative blood loss that Levine et al²⁰ did not see with just intraarterial balloon catheters alone. Our mean blood loss for those women for whom embolization was not successful was identical to that of 2 groups of Levine et al.²⁰ We also observed a reduction in admissions to ICU and a shorter length of postoperative hospital stay, although the numbers that we report did not reach statistical significance. It is important to note that the technique will not be able to be performed in all cases because of acute bleeding, the presence of infection, or the choice of the operator; as described earlier, significant hemorrhage is still likely in such cases.

We have reported this prospective series of cases because there has been a paucity of rigorous evidence to date, as highlighted by Greenberg et al.¹⁸, ²³ We therefore propose that, in cases of placenta accreta in which there is no placental separation after delivery of the fetus, the use of interventional radiologic techniques can be used to embolize the uterine and placental circulation. This allows a hysterectomy to be performed with less patient morbidity and need for blood products. In cases in which there is partial separation of the placenta and the ensuing hemorrhage necessitates immediate progression to hysterectomy, the previously placed intraarterial balloon catheters may result in less blood loss, but the postoperative transfusion of blood products is still to be expected. Clearly, to be able to achieve improvements in outcomes in cases of placenta accreta, there must be close coordination of a multidisciplinary team that is able to undertake the invasive radiologic techniques.

We believe this technique has resulted in significantly improved outcomes, when compared with the literature and our own historic experience. We acknowledge the limitations of this type of report; however, with the severity of this condition, a prospective randomized controlled trial would not be possible. Although the question about the reason that this condition is increasing at such alarming rates is presently unanswered, we suggest that definitive management of this condition may be best achieved with a staged delivery approach in centers with the appropriate resources and skill mix.

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Acknowledgments 

We thank Professor J Morris, whose initial thoughts of using a combined approach for this condition were followed by us.

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