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Comments on: Conservative Surgical Treatment of a Case of Placenta Accreta

Dear Editor,

Placenta accreta describes pathological adherence or invasion of the placenta to the myometrium. It may be a consequence of any procedure affecting the integrity of the uterine lining.11 Jauniaux E, Chantraine F, Silver RM, Langhoff-Roos J; FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO consensus guidelines on placenta accreta spectrum disorders: Epidemiology. Int J Gynaecol Obstet 2018;140(03): 265-273 Doi: 10.1002/ijgo.12407
https://doi.org/10.1002/ijgo.12407...
The incidence is rising due to increase in the rate of cesarean delivery, which is the major risk factor. Published guidelines22 Royal College of Obstetricians and Gynecologists. Placenta Praevia, Placenta Praevia Accreta and Vasa Praevia: Diagnosis and Management. 2011. Green-top Guideline 27. https://www.rcog. org.uk/globalassets/documents/guidelines/gtg_27.pdf. Accessed September 16, 2018.
https://www.rcog. org.uk/globalassets/do...
33 Committee on Obstetric Practice. Committee opinion no. 529: placenta accreta. Obstet Gynecol 2012;120(01):207-211 Doi: 10.1097/AOG.0b013e318262e340
https://doi.org/10.1097/AOG.0b013e318262...
44 Royal Australian and New Zealand College of Obstetricians and Gynecologists. Placenta Accreta. 2015https://www.ranzcog.edu. au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women's%20Health/ Statement%20and%20guidelines/Clinical-Obstetrics/Placenta-Acc reta-(C-Obs-20)-Review-March-2014,-Amended-November-2015.pdf?ext=pdf. Accessed September 16, 2018.
https://www.ranzcog.edu. au/RANZCOG_SITE...
recommend delivery with planned cesarean hysterectomy and placenta left in situ, while application of conservative management must be individualized according to the patient's desire for future fertility.

In certain cases, the implementation of alternatives to standard or agreed interventions is necessary to preserve the potential for future fertility, but this may carry risk of morbidity and adverse events either from the procedure itself or due to deviation from the agreed management published in the guidelines. Such procedures should be individualized to each case according to history, clinical judgment and the patient's desire for future fertility.

Biyik et al55 Biyik I, Keskin F, Keskin EU. Conservative surgical treatment of a case of placenta accreta. Rev Bras Ginecol Obstet 2018;40(08): 494-496 Doi: 10.1055/s-0038-1668528
https://doi.org/10.1055/s-0038-1668528...
reported a case of placenta accreta managed conservatively with segmental uterine resection, with the aim of fertility preservation. From the scenario of the presented case, it is obvious that the patient had completed her family; at the time of the surgery, the patient will be para 4, 39 years old and she requested tubal ligation, which suggests that she is not interested in future fertility. Although the authors stated that blood loss was not measured, significant hemorrhage could be detected from the change in the hemoglobin level from 10.3 g/dL preoperative to 8.5 g/dL postoperative after transfusion of 1 blood unit.

In my opinion, subjecting the patient to hemorrhagic morbidity, with added risks of blood transfusion, to pursue future fertility in a patient requesting permanent contraception—which is already performed during the same operation—is not justified.

References

  • 1
    Jauniaux E, Chantraine F, Silver RM, Langhoff-Roos J; FIGO Placenta Accreta Diagnosis and Management Expert Consensus Panel. FIGO consensus guidelines on placenta accreta spectrum disorders: Epidemiology. Int J Gynaecol Obstet 2018;140(03): 265-273 Doi: 10.1002/ijgo.12407
    » https://doi.org/10.1002/ijgo.12407
  • 2
    Royal College of Obstetricians and Gynecologists. Placenta Praevia, Placenta Praevia Accreta and Vasa Praevia: Diagnosis and Management. 2011. Green-top Guideline 27. https://www.rcog. org.uk/globalassets/documents/guidelines/gtg_27.pdf Accessed September 16, 2018.
    » https://www.rcog. org.uk/globalassets/documents/guidelines/gtg_27.pdf
  • 3
    Committee on Obstetric Practice. Committee opinion no. 529: placenta accreta. Obstet Gynecol 2012;120(01):207-211 Doi: 10.1097/AOG.0b013e318262e340
    » https://doi.org/10.1097/AOG.0b013e318262e340
  • 4
    Royal Australian and New Zealand College of Obstetricians and Gynecologists. Placenta Accreta. 2015https://www.ranzcog.edu. au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women's%20Health/ Statement%20and%20guidelines/Clinical-Obstetrics/Placenta-Acc reta-(C-Obs-20)-Review-March-2014,-Amended-November-2015.pdf?ext=pdf Accessed September 16, 2018.
    » https://www.ranzcog.edu. au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women's%20Health/ Statement%20and%20guidelines/Clinical-Obstetrics/Placenta-Acc reta-(C-Obs-20)-Review-March-2014,-Amended-November-2015.pdf?ext=pdf
  • 5
    Biyik I, Keskin F, Keskin EU. Conservative surgical treatment of a case of placenta accreta. Rev Bras Ginecol Obstet 2018;40(08): 494-496 Doi: 10.1055/s-0038-1668528
    » https://doi.org/10.1055/s-0038-1668528
  • 6
    Bostanci E, Kilicci C, Özkaya E, et al. Ultrasound predictors of candidates for segmental resection in pregnants with placenta accreta. J Matern Fetal Neonatal Med 2018:1-4 Doi: 10.1080/14767058.2018.1514377
  • 7
    Polat I, Yücel B,Gedikbasi A, Aslan H, Fendal A. The effectiveness of double incision technique in uterus preserving surgery for placenta percreta. BMC Pregnancy Childbirth 2017;17(01):129 Doi: 10.1186/s12884-017-1262-3
    » https://doi.org/10.1186/s12884-017-1262-3
  • 8
    Kilicci C, Sanverdi I, Ozkaya E, et al. Segmental resection of anterior uterine wall in cases with placenta percreta: a modified technique for fertility preserving approach. J Matern Fetal Neonatal Med 2018;31(09):1198-1203 Doi: 10.1080/14767058. 2017.1311862
    » https://doi.org/10.1080/14767058
  • 9
    Karaman E, Kolusari A, Çetin O, et al. Local resection may be a strong alternative to cesarean hysterectomy in conservative surgical management of placenta percreta: experiences from a tertiary hospital. J Matern Fetal Neonatal Med 2017; 30(08):947-952 Doi: 10.1080/14767058.2016.1192119
    » https://doi.org/10.1080/14767058.2016.1192119
  • 10
    Simsek T, Saruhan Z, Karaveli S. Placenta percreta: conservative treatment-segmental uterine resection with placenta in one piece. J Obstet Gynaecol 2010;30(07):735-736 Doi: 10.3109/01443615.2010.501918
    » https://doi.org/10.3109/01443615.2010.501918
  • 11
    Acar A, Ercan F, Pekin A, et al. Conservative management of placental invasion anomalies with an intracavitary suture technique. Int J Gynaecol Obstet 2018. Doi: 10.1002/ijgo.12593
    » https://doi.org/10.1002/ijgo.12593
  • 12
    Çetin BA, Aydogan Mathyk B, Atis Aydin A, et al. Comparing success rates of the Hayman compression suture and the Bakri balloon tamponade. J Matern Fetal Neonatal Med 2018: 1-5 Doi: 10.1080/14767058.2018.1455184
    » https://doi.org/10.1080/14767058.2018.1455184

Authors' Reply

There are limited studies on conservative treatment in cases of placenta accreta spectrum (PAS) disorder.66 Bostanci E, Kilicci C, Özkaya E, et al. Ultrasound predictors of candidates for segmental resection in pregnants with placenta accreta. J Matern Fetal Neonatal Med 2018:1-4 Doi: 10.1080/14767058.2018.1514377 77 Polat I, Yücel B,Gedikbasi A, Aslan H, Fendal A. The effectiveness of double incision technique in uterus preserving surgery for placenta percreta. BMC Pregnancy Childbirth 2017;17(01):129 Doi: 10.1186/s12884-017-1262-3
https://doi.org/10.1186/s12884-017-1262-...
88 Kilicci C, Sanverdi I, Ozkaya E, et al. Segmental resection of anterior uterine wall in cases with placenta percreta: a modified technique for fertility preserving approach. J Matern Fetal Neonatal Med 2018;31(09):1198-1203 Doi: 10.1080/14767058. 2017.1311862
https://doi.org/10.1080/14767058...
99 Karaman E, Kolusari A, Çetin O, et al. Local resection may be a strong alternative to cesarean hysterectomy in conservative surgical management of placenta percreta: experiences from a tertiary hospital. J Matern Fetal Neonatal Med 2017; 30(08):947-952 Doi: 10.1080/14767058.2016.1192119
https://doi.org/10.1080/14767058.2016.11...
1010 Simsek T, Saruhan Z, Karaveli S. Placenta percreta: conservative treatment-segmental uterine resection with placenta in one piece. J Obstet Gynaecol 2010;30(07):735-736 Doi: 10.3109/01443615.2010.501918
https://doi.org/10.3109/01443615.2010.50...
1111 Acar A, Ercan F, Pekin A, et al. Conservative management of placental invasion anomalies with an intracavitary suture technique. Int J Gynaecol Obstet 2018. Doi: 10.1002/ijgo.12593
https://doi.org/10.1002/ijgo.12593...
Unfortunately, there is no randomized controlled study that compares hysterectomy and conservative methods according to maternal morbidity, bleeding and complications in cases of PAS disorder. It is not yet possible to say that the conservative method would increase the risk of bleeding and the morbidity of the patient.

It has been reported that in a limited number of studies, local/segmental resection can be tried in PAS disorder cases. Kilicci et al88 Kilicci C, Sanverdi I, Ozkaya E, et al. Segmental resection of anterior uterine wall in cases with placenta percreta: a modified technique for fertility preserving approach. J Matern Fetal Neonatal Med 2018;31(09):1198-1203 Doi: 10.1080/14767058. 2017.1311862
https://doi.org/10.1080/14767058...
applied segmental resection of the anterior uterine wall to 11 cases with placenta percreta, and they reported that the mean preoperative hemoglobin value was 11.6 g/dL, and postoperatively, it was 8.5 g/dl.88 Kilicci C, Sanverdi I, Ozkaya E, et al. Segmental resection of anterior uterine wall in cases with placenta percreta: a modified technique for fertility preserving approach. J Matern Fetal Neonatal Med 2018;31(09):1198-1203 Doi: 10.1080/14767058. 2017.1311862
https://doi.org/10.1080/14767058...
In our case, the placenta was on the anterior uterine wall. The hemoglobin levels were 10.3 g/dL in the preoperative period, and 8.5 g/dL in the postoperative period. Our hemogram values are similar to those of Kilicci et al.88 Kilicci C, Sanverdi I, Ozkaya E, et al. Segmental resection of anterior uterine wall in cases with placenta percreta: a modified technique for fertility preserving approach. J Matern Fetal Neonatal Med 2018;31(09):1198-1203 Doi: 10.1080/14767058. 2017.1311862
https://doi.org/10.1080/14767058...
In addition, other studies have reported that transfusion was applied to the patients who had conservative treatment.66 Bostanci E, Kilicci C, Özkaya E, et al. Ultrasound predictors of candidates for segmental resection in pregnants with placenta accreta. J Matern Fetal Neonatal Med 2018:1-4 Doi: 10.1080/14767058.2018.1514377 77 Polat I, Yücel B,Gedikbasi A, Aslan H, Fendal A. The effectiveness of double incision technique in uterus preserving surgery for placenta percreta. BMC Pregnancy Childbirth 2017;17(01):129 Doi: 10.1186/s12884-017-1262-3
https://doi.org/10.1186/s12884-017-1262-...
99 Karaman E, Kolusari A, Çetin O, et al. Local resection may be a strong alternative to cesarean hysterectomy in conservative surgical management of placenta percreta: experiences from a tertiary hospital. J Matern Fetal Neonatal Med 2017; 30(08):947-952 Doi: 10.1080/14767058.2016.1192119
https://doi.org/10.1080/14767058.2016.11...
Therefore, the fact that our transfusion application increases the morbidity in our patient is not correct, in this case. In addition, there is no evidence in the literature that patients who underwent hysterectomy present a lower transfusion rate than those who underwent conservative treatment.

The patient was 39 years old and requested permanent sterilization. However, the patient's lack of fertility request does not mean that she wants hysterectomy. We think that the decision to apply the conservative method would be more appropriate according to the patient's wish, clinical situation and physician's experience. The experience of the physician in making the decision about the most appropriate surgical technique is emphasized in various studies.1212 Çetin BA, Aydogan Mathyk B, Atis Aydin A, et al. Comparing success rates of the Hayman compression suture and the Bakri balloon tamponade. J Matern Fetal Neonatal Med 2018: 1-5 Doi: 10.1080/14767058.2018.1455184
https://doi.org/10.1080/14767058.2018.14...

As a result, that the practice of conservative treatment in women who do not expect fertility increases the morbidity of the patient reflects the personal opinion of the critic. There is not enough evidence in the literature to support this idea.

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  • Publication in this collection
    Oct 2018
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