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CC BY-NC-ND 4.0 · Surg J (N Y) 2021; 07(S 01): S28-S37
DOI: 10.1055/s-0040-1721492
Precision Surgery in Obstetrics and Gynecology

Placenta Previa Accreta Spectrum: Cesarean Hysterectomy

Satoru Takeda
1   Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University, Tokyo, Japan
2   Aiiku Research Institute for Maternal, Child Health and Welfare, Imperial Gift Foundation Boshi-Aiiku-Kai, Tokyo, Japan
,
Jun Takeda
1   Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University, Tokyo, Japan
,
Yoshihiko Murayama
3   Department of Obstetrics and Gynecology, Nerima Hikarigaoka Hospital, Tokyo, Japan
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Abstract

When cesarean hysterectomy is scheduled in cases of placenta previa accreta/increta/percreta, it is necessary that the departments of obstetrics, anesthesiology, blood transfusion, urology, and radiology hold a preoperative conference to assure full preparation for the surgery. A ureteral stent inserted just before cesarean section serves as a marker. A uterine incision should be made at a site free of placental contact. The presence/absence of bladder invasion by villi, adhesions, and the degree of vascularization greatly influence the amount of bleeding, and bleeding control is a key point. For prevention of massive hemorrhage, methods of blood flow blockage, such as balloon occlusion catheterization of the aorta or common iliac artery, should be considered. Stored autologous blood and Cell Saver should be prepared. When hysterectomy is performed with the placenta left in situ, handling of the elongated cardinal ligament, ureteric injury, and bladder injury are important issues because the lower uterine segment is enlarged with the placenta. If blood flow is not blocked, separation of the bladder at the area of placenta percreta should be performed as the last step, to reduce bleeding (Pelosi's method). At this time, after handling of the cardinal ligament, bladder separation can be performed more safely if the posterior vaginal wall is incised and exposed first.

In cases of placenta accreta or partial placenta accreta/increta/percreta, a diagnosis of morbidly adherent placenta may not be obtained until separation of the placenta is performed. If bleeding from the placental separation surface cannot be controlled, total hysterectomy should be performed without hesitation.

Keywords

bladder invasion - cesarean hysterectomy - massive hemorrhage - placenta accreta spectrum - placenta previa percreta - previous cesarean section


Publication History

Article published online:
25 May 2021

© 2021. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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