**4. Conservative management**

**Figure 3.** In this case, dissection was impossible so partial cystectomy was performed.

surgeon will be compromising the safety of the patient.

the inserted fingers.

78 Placenta

to expose the underlying uterine veins, which are also clipped. This is followed by a freeing of the ureters from their crossing with the uterine arteries. A crucial following step is to dissect the rectovaginal space and to perform a posterior vaginal incision aided with a flat retractor in the posterior vaginal fornix (**Figure 2**). This will aid the subsequent lifting of the uterus through this posterior incision. The bladder is filled to identify the right plane, and then it is cautiously dissected and separated. After exposing the bladder-vaginal interface, an anterior vaginal incision is done aided by placing the vaginal retractor in the anterior cul-de-sac. Subsequently, the surgeon will be able to position his index and middle fingers through both anterior and posterior incisions, to lift the uterus and to place the clamps alongside the cervix after making sure that ureters are at distance. In case of severe adherence or bladder invasion, a cystotomy or partial bladder resection might be needed [23, 24], (**Figures 3** and **4**). Of note, this procedure should not be performed by any surgeon; only a surgeon with appropriate expertise in pelvic surgery should operate on these critical cases [25]. Otherwise, the operating

**Figure 2.** After filling the bladder helping its separation and dissection, incision of the anterior vagina is done right on

While a radical treatment in terms of cesarean hysterectomy is often the standard of care in case of abnormally invasive placenta, conservative treatment may be applied in limited cases and when women wish to conserve fertility. This is to mention that conservative management is not an approach that fits all cases. Actually, such an alternative can be attempted in cases of placenta accreta or increta where the placenta is adhering partially or totally to the myometrium without invading the whole uterine wall.

Conservative management consist of two options: (1) to attempt prudent delivery of the placenta, applying moderate cord traction to reduce the risk of leaving a normal placenta in situ, or (2) to leave the entire placenta in situ for resorption or spontaneous delivery hoping to reduce the risk of subsequent hemorrhage by making no attempt to remove the placenta [27]. First of all, placental separation can only be attempted when obstetricians are well 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 confirm the diagnosis, and (3) the aberrant vessels are less severe than expected [28].

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 of 36 cases) [30].
