Keywords
placenta accreta - cesarean delivery - hysterectomy prevention
Introduction
Normal placentation occurs as a result of the placement of the placenta in the decidua.
The result of placenta adherence to the myometrium instead of to the decidua results
in placenta accreta. Abnormal adhesion is named according to the extent of myometrium
and uterine serosal involvement. All of these abnormalities are called placenta accreta
syndrome. The most common type of placenta invasion anomaly is placenta accreta, and
the most serious is placenta percreta, which is related with the increase in cesarean
delivery rates. The incidence of placenta invasion anomalies is up to 1/533 pregnancies.[1] Placenta accreta syndromes are associated with increased maternal mortality and
morbidity.[2] Cesarean hysterectomy is usually performed in cases of placenta accreta syndrome.
Nowadays, fertility sparing and conservative methods can be applied. These methods
include placenta left in situ, cervical inversion technique and triple-P procedure.[3]
[4] Placenta left in situ and methotrexate use have serious risks, such as late postpartum
hemorrhage, infection, and pulmonary embolism. In the cervical inversion technique,
the cervix is inverted using ring forceps or straight Allis forceps, after which the
placental bed is sutured to control bleeding.[4] In the triple-P procedure, a balloon is placed preoperatively in the hypogastric
arteries and the balloon is inflated after the baby is born. Recently, a limited number
of cases of segmental uterine resection have been reported. We reported a successful
segmental uterine resection method for placenta accreta in the anterior uterine wall
in a cesarean section case.
Case Report
A 39-year-old, gravida 4, para 3 pregnant woman underwent an elective cesarean section
at 38 + 2 weeks. The patient had a history of two previous cesarean sections. Under
regional anesthesia, the cesarean section was performed with Pfannenstiel incision
and transverse uterine incision. The patient had no placenta accreta diagnosis preoperatively.
A healthy 3,100 g male newborn was delivered. Twenty IU of oxytocin (Synptian Fort,
Deva, Turkey) was intravenously administered after the delivery of the fetus and the
removal of the involved area. The placental tissue was observed extending from the
anterior uterine wall to the serosa ∼ 2 cm above the uterine incision line ([Fig. 1]). Placenta percreta was thought with intraoperative. The placenta was not removed
due to the possibility of bleeding. The area of 10 cm, which is considered to be a
placenta percreta, was removed with the help of monopolar electrocautery. The remaining
placenta fragments were removed with gentle traction. The uterine incision was continuously
sutured with no.1 vicryl (Polyglactin 910 suture, Doğsan, Trabzon, Turkey) ([Fig. 2]). Hypogastric or uterine artery ligation was not performed because there was no
intensive bleeding. Due to the preoperative approval, tubal ligation was performed
with the Pomeroy method. The estimated amount of bleeding was not calculated. A total
of 3,000 mL of crystalloids and 500 mL of colloid fluid were administered intraoperatively,
assuming that the amount of bleeding was of 1,000 mL. Immediately, 3 units of erythrocyte
suspension were prepared for transfusion. The operation was completed in 60 minutes.
Hemoglobin 10.3 g/dL, hematocrit value of 31.4% in the preoperative period; hemoglobin
8.5 g/dL and hematocrit value of 31.4% after the transfusion of 1 unit of erythrocyte
suspension in the postoperative period. Intraoperative and postoperative complications
did not develop. The patient was discharged on the second postoperative day. The placental
pathology was reported as a placenta accreta.
Fig. 1 Placental tissue was observed ∼ 2 cm above the uterine incision line.
Fig. 2 Reconstruction of the uterine wall.
Discussion
Obstetric hemorrhage due to placenta accreta syndrome is one of the important reasons
of maternal mortality and morbidity. The American College of Obstetricano and Gynecologists
(ACOG) generally recommends cesarean section hysterectomy in cases of placenta accreta
because removal of placenta associated with significant hemorrhage.[5] However, conservative and fertility sparing methods can be applied in selected cases.[6] Subsequently, the uterine wall containing the placenta accreta is removed.[3] Another method is to perform bilateral hypogastric artery ligation intraoperatively,
after the removal of the baby, and to perform segmental uterine resection of the placenta
percreta area.[7]
[8] There are some studies reporting that segmental uterine resection is performed without
balloon placement or artery ligation.[9] The duration of the operation is increased in cases of placenta previa with uterine
artery ligation.[7] The duration of the operation is shortened when arterial ligation and balloon placement
are not performed.[9] Due to the absence of placenta previa and the absence of arterial ligation in our
case, the operation was completed within 60 minutes. The amount of bleeding due to
the absence of placenta previa was lower than that reported in other studies. For
this reason, 1 unit of erythrocyte suspension was sufficient.
Conclusion
Cesarean hysterectomy is usually performed in cases of placenta accreta syndrome.
Segmental uterine resection may be an alternative to cesarean hysterectomy, to preserve
fertility or to protect the uterus, in cases in which there is no placenta previa
