**2.10 Management of morbidly adherent placenta**

Morbid attachment of the placenta (MAP) can encompass many forms ranging from small focal areas of attachment, which may not be recognized, to overt trophoblastic invasion of the bladder or other structures. Some complications can occur in both these situations. Difficult removal of a placenta at the time of a cesarean section should always suggest an MAP; in such cases, it is necessary to prepare what is necessary to stop a possible bleeding (which can develop before, during, and after the closure of the hysterotomy), to perform a blood transfusion, and to prevent the development of coagulopathy. Even small focal areas of placenta accreta can weaken uterine integrity and predispose to placental bed rupture, broad ligament hemorrhage, and development of intramyometrial hematoma. In the recognition of a focal MAP, observation of the placental bed and an in-depth evaluation of the uterine wall are fundamental; in most cases, the use of hemostatic sutures will be sufficient to control bleeding but if these fail, O'Leary-type uterine artery ligation [30], uterine compression sutures (B-Lynch or some modification thereof), or gradual devascularization [31]. Ongoing bleeding, despite these efforts, should lead to a necessary reassessment of the strategy. In the presence of dangerous bleeding and a persistent risk to maternal life, a hysterectomy must be performed as a last resort, and appropriate measures must be taken for this type of surgery. In such cases, arterial embolization is not an option, given the temporal latency of this procedure and the consequent risk of delays. Very important is the development of algorithms for the treatment of postpartum hemorrhage and the establishment of regular training and simulation courses to ensure staff readiness and familiarity with the disease. Once a decision has been made for an emergency hysterectomy, sustained pressure on the bleeding areas can allow the bleeding to be contained sufficiently to ensure resuscitation and preparation for the procedure. In cases where rapid and safe surgical access to the uterine and utero-ovarian arteries is possible, early clamping or ligation of these vessels (via O'Leary-type sutures or progressively higher lateral uterine sutures) can reduce the loss of blood. In any case, as long as preparations for definitive surgery are in place, blood loss should be attenuated in order to stabilize the patient, maintaining a good hemodynamic situation and normal coagulation and electrolyte parameters [32]. The intervention performed more often is as follows: direct uterine compression – B-Lynch suture [31] – direct aortic compression – endo-aortic balloon placement [33] – crossed aortic clamping. In those situations in which the bleeding continues persistently, the hemorrhage of the placental bed can be controlled with the implementation of hemostatic sutures and, after the hysterotomy has been closed, with the inflation of a Bakri-type balloon. Following inflation of the balloon with sterile saline, the hysterotomy suture can be visually inspected and its integrity checked. Particular attention should be paid to progressive distension of the lower uterine segment (including after contraction of the upper segment or balloon placement), as such distension suggests that there is ongoing bleeding and may signal the need for further procedures. In those hospital units where arterial embolization instruments are available in the operating room and in the presence of a hemodynamically stable patient, the use of selective arterial embolization is very effective in controlling bleeding. In

those contexts where this procedure is not feasible, it is recommended to proceed with the hysterectomy rather than transporting the patient to a radiology department where rapid hysterectomy cannot be performed. Sometimes, focal MAP is recognized only once most of the placenta has been removed, with areas of deep invasion found; when accompanied by massive bleeding, this circumstance becomes one of the most dangerous situations in obstetrics. In these cases, there is a rapid deterioration of vital parameters and hemodynamic instability; therefore, the workload of both the surgical and anesthetic teams increases exponentially, often with delays in communicating the mutual needs. Concerted efforts for effective interteam communication will ensure that both teams have minute-by-minute situational awareness and the ability to coordinate their actions. Rapid recognition of the need for hysterectomy is essential, and all efforts should be directed to performing this procedure with minimal blood loss; in the immediate future, blood loss can be minimized by applying pressure to the infrared portion of the aorta and with bimanual uterine compression. If these efforts succeed in reducing bleeding, they could allow the patient to be resuscitated and stabilized so that definitive surgery can be performed. The start of a massive transfusion protocol should be practiced in all units where a C-section is performed; both before and after the infusion of red blood cells, it is necessary to measure and determine the basal electrolyte levels (in particular potassium and calcium), blood count, and coagulation profile. If conservative management fails, the team has to proceed with the hysterectomy, and a post-operative investigation should be performed for any surgical complications (section or ureter ligature, bladder or intestinal injury, nerve injury or development of bruising). The general principles regarding emergency surgery for placenta accreta include those described below. The following suggestions are in most cases anecdotal, gathered from about 50 years of operational experience and from the results of the international literature [30–35].
