**3. Surgical management**

Identifying a PAD preoperatively will give the surgeon the chance to plan and modify the surgical technique in order to reduce morbidity [16]. In addition, a prenatal diagnosis or suspicion of placenta percreta can alert the obstetrician in charge to the need for an experienced pelvic surgeon in critical cases. A preoperative preparation is essential in accreta cases and requires multidisciplinary efforts. It is mandatory to involve all specialized peers in the preoperative assessment as well as in operative management: obstetrics anesthesiologist, gynecologic oncologist, urologist, vascular surgeon, and interventional radiologist [16]. This was also emphasized on in the Committee Opinion 29, where the American College of Obstetrics and Gynecologists (ACOG) has advocated the involvement of a multidisciplinary team in the management of morbid placental adherence to minimize potential maternal or neonatal morbidity and mortality [17]. Coordination with the blood bank before beginning the procedure is essential to ensure adequate supplies of red cells, platelets, and fresh frozen plasma [16]. In their study, Brennan et al. have also specified that the early presence of a gynecologic oncologist at delivery is a key predictor of reduced blood loss and transfusion requirements when abnormally invasive placenta is suspected [18]. Furthermore, other authors have reported that outcomes are improved if delivery takes place in centers with multidisciplinary expertise and experience in PAS disorders [19].

Cesarean hysterectomy in cases of placenta percreta is often technically challenging due to the anatomic and physiologic changes of pregnancy, including a massive increase in blood flow to the uterus at term. The vessels that supply the uterus, ovaries, and bladder are substantially larger and more tortuous in pregnancy than they are in the nonpregnant state. Meticulous care in the manipulation of clamps, cutting of pedicles, and placement of sutures is required to prevent severe bleeding. Scarring from previous surgery, particularly previous cesarean sections, is a common complicating feature of cesarean hysterectomy [20]. These cesarean hysterectomies often require difficult dissection of poorly defined tissue planes, particularly of the bladder interface, and partial bladder resection is often required [21]. All these factors make this procedure associated with a higher risk of complications in comparison with abdominal hysterectomies performed for benign indications [22].

### **3.1. Surgical technique**

**3. Surgical management**

percreta on surgery and histopathology.

76 Placenta

Identifying a PAD preoperatively will give the surgeon the chance to plan and modify the surgical technique in order to reduce morbidity [16]. In addition, a prenatal diagnosis or suspicion of placenta percreta can alert the obstetrician in charge to the need for an experienced pelvic surgeon in critical cases. A preoperative preparation is essential in accreta cases and requires multidisciplinary efforts. It is mandatory to involve all specialized peers in the preoperative assessment as well as in operative management: obstetrics anesthesiologist, gynecologic oncologist, urologist, vascular surgeon, and interventional radiologist [16]. This was also emphasized on in the Committee Opinion 29, where the American College of Obstetrics and Gynecologists (ACOG) has advocated the involvement of a multidisciplinary team in the

**Figure 1.** A 26-week-old fetus with placenta praevia showing: **A**. An increased vascularity seen in the lower uterine segment and the interface with the bladder seen on a sagittal image on US. **B**. On 1.5 MRI, sagittal sequence T2WI: a heterogeneity in the placenta (arrow) overlying the internal os (double arrows) with involvement of surrounding structures and focal myometrial interruption with extension into the bladder wall (**C**, arrowhead). **D**. On axial sequence T2WI: a heterogeneity in the placenta with dark intraplacental bands (double arrowheads). This was consistent with In the literature, few reports of a well-standardized technique describe the steps of a cesarean hysterectomy among women with placenta percreta who need radical treatment. When performing such a procedure, the major concern is to prevent ureteral lesions in a pelvis with a distorted anatomy and to reduce blood loss. A recent study has demonstrated the effectiveness and safety of a well-standardized approach for managing all cases of placenta percreta and in all circumstances [23].

It is preferable to schedule cesarean hysterectomy in case of placenta percreta starting at 34 weeks of gestational age. However, cesarean is sometimes carried out as an emergency procedure irrespective of gestational age in cases of heavy bleeding or fetal distress.

The technique that we intend to describe was developed based on collected experience in gynecologic oncology. First of all, the placement of ureteral stents is not necessary according to this technique since it is not always possible especially during emergencies in cases with massive bleeding [24]. The surgeon starts with a vertical midline incision under general anesthesia. A peroperative US is performed to localize the placenta and to guide the surgeon while performing the hysterotomy. After delivery of the baby, the surgeon proceeds with a closure of the uterine incision with Vicryl® "0" hepatic needle sutures (Ethicon, Johnson and Johnson Companies, Somerville, NJ, USA). In a next step, the surgeon approaches the retroperitoneum just lateral to the adnexal ligaments to secure the ureters and to clip the uterine arteries at their origin after opening the paravesical space. The uteroadnexal ligaments also need to be ligated as close as possible to the uterus. After clipping the uterine arteries, these are lifted up 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 surgeon will be compromising the safety of the patient.

On a similar note, the absence of ureteral injuries is guaranteed when performing a cesarean hysterectomy according to the aforementioned steps [23]. To prevent the development of

**Figure 4.** The specimen of hysterectomy with placenta percreta anteriorly is on the left side. A more close view on the right side allows to see the vesical patch that was resected in a case of placenta percreta invading the bladder.

Placental Malformation: Accreta and Beyond http://dx.doi.org/10.5772/intechopen.80588 79

Another technique was described in the literature based on a posterior approach but was criticized for the ligature of the anterior division of the internal iliac artery with the concomitant risk of bladder devascularization [23, 26]. Also, the fact of grasping a gravid cervix, as described in the latter technique, will lead to massive bleeding and is not always feasible in case of cervical effacement. However, positioning the surgeon's fingers through anterior and

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 myome-

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

vesicovaginal fistulas, an omentoplasty is recommended after bladder reparation [23].

posterior vaginal incision will prevent hazardous bleeding as well as cervical tears.

**4. Conservative management**

trium without invading the whole uterine wall.

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

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

**Figure 4.** The specimen of hysterectomy with placenta percreta anteriorly is on the left side. A more close view on the right side allows to see the vesical patch that was resected in a case of placenta percreta invading the bladder.

On a similar note, the absence of ureteral injuries is guaranteed when performing a cesarean hysterectomy according to the aforementioned steps [23]. To prevent the development of vesicovaginal fistulas, an omentoplasty is recommended after bladder reparation [23].

Another technique was described in the literature based on a posterior approach but was criticized for the ligature of the anterior division of the internal iliac artery with the concomitant risk of bladder devascularization [23, 26]. Also, the fact of grasping a gravid cervix, as described in the latter technique, will lead to massive bleeding and is not always feasible in case of cervical effacement. However, positioning the surgeon's fingers through anterior and posterior vaginal incision will prevent hazardous bleeding as well as cervical tears.
