OB Hemorrhage - Placenta Acreta Mgmt Resources

The common hemorrhagic complications of pregnancy remain among the leading causes of maternal mortality. We review new methods of diagnosis and offer suggestions for management. Abruptio placenta, disseminated intravascular coagulation, placenta previa, uterine rupture, and postpartum hemorrhage are included in this review

BACKGROUND: Placenta accreta is a rare event in pregnancy and may cause life-threatening hemorrhage. This obstetric complication is a diagnostic and management challenge. When the condition is diagnosed, medical management is usually employed first for hemostasis. If the bleeding cannot be controlled, conservative surgical management is attempted, but hysterectomy is often required for definitive care.
CASE: The diagnosis of placenta accreta was made intraoperatively at cesarean section undertaken for breech presentation. The placenta was densely adherent to the anterior lower uterus. Severe hemorrhage, which resulted from attempts to manually remove it, was treated with oxytocin, carboprost tromethamine and methylergonovine without success. The uterus was everted to provide access to the placental site, which was excised; the myometrial defect was sutured closed. Three Foley balloons were used to provide uterine tamponade. Methotrexate was administered prophylactically. These measures effectively controlled the hemorrhage.
CONCLUSION: Because placenta accreta might not be diagnosed antepartum or during labor, especially when no risk factors are present, adequate preparations cannot be made. If it is diagnosed at the time of cesarean section, a combined conservative approach may prove helpful in controlling bleeding and avoid hysterectomy and hypovolemia.

Placenta percreta is a rare but potentially life-threatening condition associated with high maternal mortality and morbidity rates, usually arising from severe obstetric haemorrhage. Due to rising caesarean section rates, an increase in the incidence of morbidly adherent placentas (accreta, increta and percreta) has been observed. Various treatment strategies have been employed in different centres, ranging from performing a caesarean hysterectomy at the time of delivery to leaving the placenta in situ, with or without adjuvant internal iliac and uterine arterial embolisation and/or methotrexate therapy. In the case of placenta percreta, irrespective of the treatment method employed, women are still at high risk of life-threatening haemorrhage and morbidity secondary to placental invasion beyond the confines of the uterine serosa into surrounding organs, most commonly the bladder. We describe an unusual case of a partially adherent placenta percreta in which partial separation of the normally implanted placenta led to torrential haemorrhage on the third postoperative day after the placenta was left in situ at the time of delivery. We therefore advise caution in following a conservative approach in the treatment of cases of placenta percreta in which the percreta feature is only partial and will discuss the merits and disadvantages of alternative options.

PURPOSE OF REVIEW: Haemorrhage remains a cause of significant maternal morbidity and mortality. This review summarizes the prevention, management and treatment of obstetric haemorrhage and highlights recent advances and developments.
RECENT FINDINGS: Postpartum haemorrhage is the most common cause of major obstetric haemorrhage and is usually due to uterine atony. Pharmacological treatment has not altered much in recent years with oxytocin and ergometrine remaining first-line options. Although controversy surrounds its advantages over other uterotonics, the use of misoprostol has been increasing, especially in resource-poor countries. Placenta accreta is becoming more common, a sequelae to the rising caesarean section rate. Interventional radiology may reduce blood loss in these cases. Uterine compression sutures, intrauterine tamponade balloons and cell salvage have all made their debut in the last decade.
SUMMARY: Accurate diagnosis and appropriate management of obstetric haemorrhage can reduce maternal morbidity and mortality. This review outlines the current evidence.