**Author details**

experienced. They need to be able to identify whether placental separation can be attempted in an individual and to perform hysterectomy immediately after failure of placental separation to rescue the patient [28]. According to ACOG committee's opinion, placental separation by gentle external uterine massage is reasonable in selected women in whom no obvious signs of placenta accreta are seen based on the visual examination of the uterus [29]. Furthermore, placenta separation can be attempted in three situations: (1) the surgeon is unconfident with the preoperative diagnosis of abnormally invasive placenta, (2) the intraoperative US does not

Second, the entire placenta can be left in situ with or without postoperative administration of methotrexate and the placental expulsion will be expected after that. These patients might be subject to severe bleeding that may require emergent uterine embolization. This approach seems to be associated with severe long-term complications. According to a review of 119 women who had placenta left in situ, 61% (22 out of 36 cases) had complications occurring later than 24 hours postoperatively, compared with 12% of those who initially had a hysterectomy or local resection. The most frequently reported complications in these cases were secondary hysterectomy (58%, 21 out of 36 cases) and postoperative hemorrhage (44%, 16 out

The path to a reduced morbidity and mortality in women with AIP starts with an accurate antenatal diagnosis. However, we are not yet able to define specific US sign or set of signs when assessing the depth of placental malformation [31, 32]. Although many efforts were made to standardize the imaging description of PAD [33, 34], more prospective studies are needed to study the correlation between antenatal imaging findings and histopathology [35]. When suspecting a PAD prenatally, it is mandatory to refer the patient to a center of excellence with a dedicated multidisciplinary team and care plan [36]. Although the described techniques in the literature have shown satisfactory results in terms of safety and effectiveness, the reproducibility of the results might be improved by an analysis and an application

Obstetricians and gynecologists need to be counseled and advised about the indications and the situations where a conservative approach could be attempted. Case-control studies on large populations should be conducted to help the surgeon in making the decision when

In front of such an individualized problem, a surgeon managing a case of abnormally invasive placenta should be well experienced to master this challenge but also to win it with less maternal and neonatal morbidity and mortality. While concrete standards still lack in terms of management, there are evidences that accreta and percreta are different. This difference

confirm the diagnosis, and (3) the aberrant vessels are less severe than expected [28].

of 36 cases) [30].

80 Placenta

**5. Recommendations and future directions**

of these techniques on larger case series in the future.

tending to a conservative management.

**6. Conclusion**

David Atallah\*, Malak Moubarak, Souha Saliba, Malek Nassar, Sara Abboud, Assaad Kesrouani, Michel Ghossain and Nadine Elkassis

\*Address all correspondence to: david.atallah@gmail.com

Saint Joseph University, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
