Surgical management of abnormally invasive placenta: a retrospective cohort study demonstrating the benefits of a standardized operative approach

Acta Obstet Gynecol Scand. 2015 Dec;94(12):1380-6. doi: 10.1111/aogs.12768. Epub 2015 Oct 15.

Abstract

Introduction: Abnormally invasive placenta is a major cause of maternal morbidity and mortality. The aim of this study was to assess the effectiveness of a standardized operative approach performed by gynecological oncologists in the surgical management of abnormally invasive placenta.

Materials and methods: We performed a retrospective analysis of all cases of morbid placental adherence managed at the Mater Mothers' Hospitals, Brisbane, Australia between January 2000 and June 2013. A standard operative approach involving extensive retro-peritoneal and bladder dissection before delivery of the fetus, was undertaken when a gynecological oncologist was present at the start of the procedure. Main outcome measures were estimated blood loss, transfusion requirements, and maternal and neonatal morbidity.

Results: The study includes 98 cases of histologically confirmed abnormally invasive placenta. Median estimated blood loss for the entire cohort was 2150 mL (range 300-11 500 mL). Women were divided into three groups, (1) those who had a gynecological oncologist present at the start of the procedure (group 1; n = 43), (2) those who had a gynecological oncologist called in during the procedure (group 2; n = 23), and (3) those who had no gynecological oncologist involved (group 3; n = 32). Group 2 had a significantly higher blood loss than the other groups (p = 0.001) (median 4400 mL). Transfusion requirements were higher in groups 2 and 3 compared with group 1 (p = 0.004). Other maternal and neonatal morbidity was similar across all three groups.

Conclusion: This study supports the early presence of a gynecological oncologist at delivery when abnormally invasive placenta is suspected and demonstrates that a "call if needed" approach is not acceptable for these complex cases.

Keywords: Abnormally invasive placenta; gynecological oncology; morbidity; placenta accreta; surgery.

MeSH terms

  • Adult
  • Blood Loss, Surgical
  • Blood Transfusion / statistics & numerical data
  • Cesarean Section
  • Delivery, Obstetric / methods*
  • Female
  • Humans
  • Hysterectomy / methods*
  • Infant, Newborn
  • Obstetrics*
  • Placenta Diseases / surgery*
  • Pregnancy
  • Retrospective Studies
  • Risk Factors
  • Treatment Outcome
  • Workforce