Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 221–232

Contents lists available at SciVerse ScienceDirect

Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn

Caesarean section in cases of placenta praevia

and accreta
José M. Palacios-Jaraquemada, MD, PhD, Professor a, b, c, *
a
Centre for Medical Education and Clinical Research (CEMIC), Department of Gynecology and Obstetrics,
Buenos Aires, Argentina
b
Scientific South Foundation, Lomas de Zamora, Province of Buenos Aires, Argentina
c
J. J. Naón Morphological Institute, School of Medicine, University of Buenos Aires, Argentina

Keywords:
In the past decade, the incidence of placenta praevia and placenta
placenta praevia accreta has increased and seems to be associated with induced
placenta accrete labour, termination of pregnancy, caesarean section and pregnancy
placenta percreta at older age. These factors imply some degree of tissue damage,
abnormal placental adhesive disorders which can modify the decidualisation process, and produce
abnormal invasive placenta excessive vascular remodelling. Placenta praevia and accreta are
postpartum haemorrhage mainly located in the lower segment, a place that predisposes to
persistent uterine bleeding because of the development of new
vessels and because it is a poorly contractile area of the uterus. The
complexity, determined by tissue destruction, newly formed
vessels, and vascular invasion of surrounding tissues, warrants
multi-disciplinary management. When resective procedures are
undertaken, a suitable plan to tackle surgical problems allows
better control of bleeding and avoids unnecessary hysterectomies.
In cases of placenta accrete, and especially when skills or institu-
tional resources are not available, leaving the placenta in situ may
be the best option until definitive treatment is undertaken.
Ó 2012 Published by Elsevier Ltd.

Introduction

Placenta praevia and placenta accreta (abnormally invasive placenta) are two obstetric conditions
that are closely linked with massive obstetric haemorrhage. Occasionally, they present with some
degrees of intrauterine growth restriction. Placenta praevia is located in the lower uterine segment,
which could result in inappropriate placental development owing to the particular development of

* Centre for Medical Education and Clinical Research (CEMIC), Department of Gynecology and Obstetrics, Elias Galván 4102,
City of Buenos Aires C1431FWO, Argentina. Tel./Fax: þ54 11 4857 1331.
E-mail address: jpalacios@fmed.uba.ar.

1521-6934/$ – see front matter Ó 2012 Published by Elsevier Ltd.

http://dx.doi.org/10.1016/j.bpobgyn.2012.10.003
222 J.M. Palacios-Jaraquemada / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 221–232

their vessels.1 Placenta accreta is also known as abnormally morbid adherence of placenta or abnor-
mally invasive placenta. This condition includes all degrees of placental invasion within this generic
name of placenta accrete.2 Placenta percreta, however, which has the deepest degree of invasion, is
usually described separately. Diagnosis for placenta praevia and placenta accreta is usually achieved by
ultrasound; nevertheless, other investigations may be necessary when there is doubt or when the
precise anatomy of placental invasion is required.3 Placenta accreta has a special type of supplementary
circulation through newly formed vessels. The anatomical adhesion among vessels, and placental
invasion into the myometrium and the surrounding tissues, pose a great surgical challenge. In these
cases, the main objective of the caesarean section is to deliver the baby through a safe area and to avoid
uncontrollable bleeding, as massive blood loss could turn into severe shock and coagulopathy in
minutes.

General overview and definitions

Placenta praevia is a disorder that happens during pregnancy when the placenta is abnormally
placed in the lower uterine segment, which at times covers the cervix. Placenta praevia can be clas-
sified according to its position in relation to the internal cervical external orifice into totally occlusive,
partially occlusive or marginal. Normally, the placenta should develop relatively high up in the uterus,
on the front or back uterine wall but, on some, occasions the placenta will be located in the lower
uterus covering or near the external orifice. This location causes particular problems in late pregnancy,
when the lower part of the uterus begins to stretch and lengthen in preparation for delivery. When the
cervix begins to efface and dilate, the attachments of the placenta to the uterus are detached, resulting
in bleeding.1
Placenta accreta is defined as the abnormal adherence of the chorionic villi to the myometrium,
associated with partial or complete absence of the decidua basalis. Placenta accreta is a condition that
involves all degrees of placental invasion into the myometrium (until serosa or beyond it). The degree
of invasion is achieved by histological examination: accrete (superficial invasion of myometrium);
increta (over 50% of myometrium is involved); percreta (invasion through the entire myometrium);
however, this analysis may not provide a definitive diagnosis because many degrees of invasion could
co-exist in the same gross specimen or might be missed.4 For this reason, placenta accreta can be also
defined by clinical and surgical criteria.5–7

Risk factors

Knowledge of risk factors is particularly important to distinguish among mild cases or in those
that the image analysis is not in agreement with the individual’s background. The incidence of
placenta praevia is about one in every 250 births, and it is the cause of one-third of all cases of
antepartum haemorrhage. Placenta praevia is associated with previous uterine scar, smoking,
maternal age over 35 years, grandmultiparity, recurrent miscarriages, low socioeconomic status,
infertility treatment, previous curettage, previous myomectomy, previous uterine surgery, sub-
mucous myoma, Asherman’s syndrome, a short caesarean- or curettage-to-conception interval.8,9
Risk factors for placenta accreta are similar to placenta praevia, even though the main risk factor
for abnormal adherence of the placenta is the association between placenta praevia and the
caesarean scar.10,11

Diagnosis

Placenta praevia

Both placenta praevia and accreta are best diagnosed by ultrasound; this method is highly reliable,
low cost, and provides clear signs for image interpretation. Ultrasound examination may diagnose
placenta praevia and classify them in early stages. Although abdominal ultrasound can determine the
placental position in relation to the cervical external orifice, transvaginal ultrasound is now well
established as the preferred method for accurate localisation of a low-lying placenta. Because some
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technical details could modify the measurements, and consequently the obstetrician’s opinion,
placental magnetic resonance imaging and three-dimensional ultrasound have been proposed to
minimise diagnostic errors.3,12 Appropriate placental orientation could be verified by the three mul-
tiplanar images, which allows a better obstetrical decision.

Placenta accreta

No unique or optimal approach is available for all cases of placenta accreta. This is a condition that
can have variable appearances, which are not always in agreement with histological classification.13
The precise diagnosis and the knowledge of possible problems can help in deciding on the best
alternative for each case. Clinically, all degrees of placental invasion, such as placenta accreta, increta
and percreta, are described as placenta accreta. Although the damage in cases of placenta percreta is
greater than accreta and increta, percreta itself is not always a precise measure of surgical and technical
problems. Differential diagnosis between placenta praevia and accreta is needed to plan appropriate
surgery (Table 1). Both entities may share common diagnostic features that could cause confusion even
for well-trained operators, especially in mild cases. Experience has shown that not all ultrasound signs
for placenta accreta have the same diagnostic value. Some of them, for instance, the thinning of
myometrium or the lack of retroplacental safe area, could be caused by overdiagnosis and, conse-
quently, may result in inappropriate treatment. Some studies are in agreement that the presence of
confluent lagoons is the most accurate sign to make a diagnosis of placenta accrete.14,15 Where there is
doubt, placental magnetic resonance imaging or three-dimensional ultrasound can be carried out to
establish an accurate diagnosis and also to identify the degree of invasion; these data are essential for
planning specialist assistance and which surgical approach to take. Although it is well known that
placenta accreta is associated with multiple caesarean sections, this is not always true; many cases of
placenta accreta and percreta have been described in women with a simple caesarean section and
without any other significant risk factor. Cases of termination of pregnancy with curettage soon after
a previous caesarean (less than 7 months) must be properly evaluated, because of increased risk of
placenta accrete.16 After a complete pre-surgical evaluation, the surgical approach for placenta accreta
could be different according to experience, resources and obstetrics and gynaecology unit management
protocols.

Therapeutic management

Placenta praevia

An initial assessment to determine the status of the mother and fetus is required. Although
mothers used to be treated in the hospital from the first bleeding episode until birth, it is
considered safe to treat placenta praevia on an outpatient basis if the fetus is at less than 30 weeks
of gestation and the mother and the fetus are in good health. Clinical trials support the use of
outpatient management for stable individuals.17,18 The clinical outcomes of cases with placenta
previa are highly variable and cannot be predicted confidently from antenatal events.19 Immediate
delivery of the fetus may be indicated if it is mature, or earlier if the fetus or the mother’s condition
is at imminent risk.

Table 1
Ultrasound differential diagnosis between placenta praevia and accrete.

Differential diagnosis Location Presence of Vessel direction Placental Myometrial

enlarged vessels (according to uterus) lagoons thinning
Placenta praevia Lower segment Possible Parallel No Possible
Placenta accreta Usually located in Habitual Perpendicular Yes Yes
the lower segment
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Placenta accreta

The ideal time to carry out elective caesarean in placenta accreta is controversial; tacit consensus for
surgery is between 35 and 38 weeks.13 Delivery during this period is acceptable because of increased
fetal lung maturation and reduced risk of maternal haemorrhage.1 A statistical increase of complica-
tions occurs after week 35 reported in cases of placenta percreta,20 probably related to dynamic action
over the damaged area. Agreement is implicit that surgery should be carried out under elective and
controlled conditions rather than as an emergency.21 This is because placental blood flow at term is
between 600 and 700 ml/min,22 and massive postpartum bleeding could end in quick and severe
complications or even death.

Surgery for placenta praevia

Scheduled surgery

When the placenta covers the lower uterine segment, it may be necessary to cross the placenta
to deliver the baby,8 a manoeuvre that usually produces additional haemorrhage. Then, placental
detachment could produce further bleeding, as a result of the poor contractility of the lower uterine
segment and because of its increased blood supply. If the bleeding is not controlled promptly, the
process may aggravate and end in coagulopathy or other severe complications.23 For this reason,
a rational approach in cases of placenta praevia is to avoid bleeding at first and then provide an easy
and accurate control of haemorrhage.
In cases of placenta praevia, access to the upper part of vagina and lower uterine segment is
required to control bleeding. Although this access is only guaranteed after a wide retrovesical
dissection, this approach allows accurate vascular control and use of haemostatic compression tech-
niques.24 This manoeuvre is not common practice in obstetrics, and some may have concerns about
bladder damage or unwanted bleeding. Safe retrovesical dissection, however, is possible using simple
techniques. After an accurate and complete dissection of vesico-uterine space, bleeding control can be
carried out by manual compression of the lower uterus or by the use of a rubber drainage tube tied
around it.
Although most obstetricians can quickly transect an underlying placenta, use of modified
hysterotomy is a good alternative in cases of placenta praevia. In this procedure, developed by
Ward,25 a hysterotomy is first carried out to avoid any initial damage to the placenta. The operator’s
hand is inserted between the myometrium and the placenta, and partial abruption is created before
membranes are ruptured to deliver the infant through the uterine incision. After the baby is
delivered, most of the placenta is still attached, hence avoidance of additional bleeding. Then, the
placenta is manually detached and an oxytocic drug administered at the same time. In cases of
excessive bleeding, the uterus is exteriorised outside the pelvic cavity and the isthmic portion
tightened with one hand above the cervix immediately to stop the blood loss. A second line
oxytocic drug is then recommended, along with manual compression of the placental bed with
a laparotomy pad. If these measures are not effective after 15 mins, use of lower compression
sutures is proposed. Not all compression sutures, however, have the same effect, because the
effectiveness is dependent on the skill26 and the involved uterine area.24 Compression sutures such
as B-Lynch, Pereira or Hayman that compress the uterine body, and consequently the uterine
branches, are less or ineffective for bleeding produced in the lower segment or cervix (pelvi-
subperitoneal pedicles). In recent years, the B-Lynch procedure has been combined with the
concomitant use of intrauterine balloon to increase the pressure over the lower segment and the
cervix.27 Excessive compression could produce uterine necrosis.28 As multiple vessels provide blood
supply to the lower segment, it is quite difficult to identify specific vessels one by one. Therefore,
compression square suture described by Cho achieves haemostasis of a specific area, regardless of
how many vessels supply this sector.24,29 When the vesicouterine space is open, placement of
square suture in the lower segment is probably the most effective and easiest procedure to stop
bleeding in the lower uterus.
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Emergency situations

When placenta praevia presents as an emergency, it is necessary to deliver the baby quickly, and
control the haemorrhage to avoid shock and coagulopathy. This is not a minor issue, especially when
the response time is short. After carrying out a laparotomy, the baby is delivered quickly to avoid
secondary hypoxaemia from maternal bleeding. Then, an easy and efficient vascular control, such as
the internal aortic compression, must be achieved. During this time, it is recommended to wait until
haemodynamic and haemostatic state is stable after appropriate fluid, blood or blood products are
replaced. Although hysterectomy may be considered as a last chance of achieving haemostasis, I believe
it must be avoided in the presence of evident shock or coagulopathy. This is controversial, but obstetric
hysterectomy itself could produce an estimated blood loss of 2–3 L,30 which could aggravate previous
hypovolaemia and later result in unsafe multiple organ failure. As an alternative, placement of an
Eschmarch’s bandage around the pedicles above the cervix could stop the haemorrhage immediately in
the presence of shock and coagulopathy.23 In addition, this method replaces volume to intravascular
space from the intrauterine lakes (by uterine veins). Placing two rounds of elastic bandage from the
uterine fundus towards the cervix reduces the uterine axial volume by one-half, as the elastic bandage
pressure is high. This procedure provides time to carry out haemodynamic and haemostatic restoration
without the risk of continuous uterine bleeding. When haemodynamic and haemostatic parameters
are stable, the elastic uterine wrap can be removed, and compression sutures can be placed as
definitive haemostatic method.23 Adequate experience and reliable team work with facilities for
replacement of sufficient blood and blood products are needed to undertake such management.

Surgery for placenta accreta

No universal treatment exists for placenta accreta, because its management could be different
according to personal or maternal preferences, experience, skills and resources.16 Although, several
approaches are available, all of them will want to avoid maternal bleeding during delivery. At present,
placenta accrete can be managed in three ways: (1) carry out a hysterectomy; (2) leave the placenta in
situ; and (3) resect the invaded tissues with the entire placenta restoring uterine anatomy. Each one of
them has weaknesses and strengths, and is dependent on the condition itself and the specific pref-
erences taken by the surgeon and the team.16 Placenta accreta and its varieties produce damage of the
invaded tissues (uterus and others) by developing new vascularisation and pelvic anatomic distortion.
These problems can be solved in different ways, and have led to the development of new techniques.

Resective procedures

Hysterectomy

Hysterectomy, is the most common and historical treatment for placenta accrete. Nevertheless, it
is not a simple procedure. Hysterectomy carried out by an unskilled surgeon could end quickly in
severe complications or maternal death. The extreme difficulty of dissecting the tissues, presence of
thick and friable vessels, and increased blood flow at term, make it almost impossible to carry out
a safe hysterectomy without risk of haemodynamic and haemostatic deterioration.16 If resources or
a qualified team are not available, a conservative approach that avoids touching the placenta is
recommended. A multidisciplinary team is required for almost all approaches to placenta accrete,31
as uncontrolled bleeding is practically impossible to solve without an accurate proximal vascular
control and precise tissue management. Because a high percentage of placenta accreta cases are
located in a lower segment, subtotal hysterectomy has been linked with a high rate of re-bleeding.32
For this reason, when hysterectomy for lower invasive placentation is decided, it must be total
instead of subtotal. This decision implies the management of the bladder and the pelvic ureter in
a narrow space populated by plenty of newly formed vessels. Because of the tissue fragility in
placenta accreta, bleeding for invaded tissues is quite impossible to stop by the usual measures
(sutures). For this reason, once hysterectomy is started, if bleeding is present, it would be almost
impossible to stop until it is finished. Posterior bladder dissection is needed to carry out a total
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hysterectomy.4 For this step to be easy, it is recommended that the bladder is pulled up with two Allis
clamps. Then, tissue dissection will start inside the round ligament and a small buttonhole will be
made so that a dissection clamp can be passed through. Ligatures will include the peritoneum and
‘neoformed’ vessels, which must always be ligated between double ligatures.33 In some cases,
dissection may be blocked by dense tissue fibrosis, which makes the dissection difficult. In these
cases, tunnel dissection should be carried out between the cervix and the bladder. Then exert upward
traction to facilitate the cutting of fibrous tissues.34 Retrovesical dissection is finished access is gained
to the upper part of vagina, and total hysterectomy can be carried out. Some publications promote the
use of different types of resection of vesical tissues in cases of anterior abnormal placentation,35 but
resection of vesical tissue in young women may produce secondary morbidity, and consequently,
reduced bladder capacity.

Bladder invasion

When placenta accreta is developed in the lower segment, it takes its blood supply from the uterus,
but also from the surrounding tissues. Because the bladder is the nearest organ to the uterine scar, it is
common that the supplementary blood supply for the placenta is provided by this organ. Microscopic
anastomoses among pelvic organs are enlarged under stimulation from vascular and growth factors
produced by abnormal placentation. As a result of this stimulation, these vessels are thick, with scarce
development of media tunica and able are to carry a great volume of blood.16 Sometimes the placenta,
the caesarean scar, and the posterior vesical wall can be joined by a fibrous process covered by newly
formed vessels. This viewing simulates bladder invasion by the placenta, although, from a histologic
point of view, the placenta never invades the vesical tissues. Abnormal placental invasion with gross
haematuria is not frequent and, if present, requires special attention. In these cases, massive intra-
operative haemorrhage and subclinical disseminated intravascular coagulation are usual; conditions
that could lead to life-threatening emergencies.36,37 Abundant collateral blood supply in a narrow
space, in addition to haemostatic consequences in cases of gross haematuria, is a worse scenario to
practise safe surgery. In cases of bladder involvement, most obstetricians choose a conservative
approach with arterial embolisation. If bleeding cannot stop, packing with laparotomy pads can
promote haemodynamic stabilisation in the patient. Later the original problem can be resolved in
a secondary surgical procedure.38 If gross haematuria cannot be controlled by conservative approaches,
an aortic or bilateral common iliac occlusion is needed to practise safe surgery. Even though my
personal experience is limited (seven cases), gross haematuria was always associated with vascular
invasion of the trigone.
In cases of placental-vascular invasion of the trigone, a colpouterine anastomotic system, which
communicates with vaginal arteries (pudendal internal) with lower uterine branches (uterine and
cervical artery) is significantly engorged between the trigone and the cervix.16 Development of the
newly formed vessels inside this dense conjunctive tissue makes any attempt of safe dissection almost
impossible. Diagnoses of this particular vascular hyperplasia is possible by sagittal placental magnetic
resonance imaging slice; however image diagnosis suggests a placental invasion but it only mimicks
this situation.
Because vaginal arteries and lower vesical arteries arise from the internal pudendal artery, specific
endovascular haemostasis of internal pudendal artery branches is recommended. Although, indirect
haemostasis by crosscurrent arterial embolisation is possible (uterine and internal iliac arteries), the
procedure could need a large amount of particles or high pressure injection to be effective, a fact that
increases the possibility of unwanted organ damage by overembolisation (ischaemia or necrosis). In
these cases, placement of circular compressive sutures around the lower segment is an efficient
method of controlling bleeding.39–41
Cystoscopy is used to identify bladder involvement in cases of abnormal placentation; however, some
particular features make this method of investigation an inaccurate method of evaluating this possibility.
It is known that bladder distention is necessary to carry out cystoscopy, but this also collapses the newly
formed vessels, which are inconspicuous or not visible inside the bladder.16 Because newly formed
vessels from bladder are positioned in the detrusor muscle, not in the mucosa, evidence of new vas-
cularisation inside the bladder is poor or not specific.42 Bladder involvement can be suspected by
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ultrasound or Doppler. Multiplanar studies, such as placental magnetic resonance imaging or three-
dimensional ultrasound provide a better diagnosis.16 Presence of placental tissue inside the bladder is
considered a pathognomonic sign of placenta percreta. This sign, however, can be a consequence of
placental advancement through caesarean scar dehiscence. For this reason, presence of placental tissue
inside the bladder must be evaluated according to medical background.

Conservative treatments

One-step conservative surgery

Although our primary objective in placenta accreta is to prevent bleeding, the ideal treatment of
abnormal placentation should restore the uterine anatomy and ensure a new pregnancy with minimal
risk of complications. According to this idea, a completely new approach for abnormal placentation to
solve all problems of placenta accreta was originally designed.33 This procedure proposes, at first, the
vascular interruption of newly formed vessels and vesical separation of the invaded tissues (like the
steps in a total hysterectomy), then, an upper segmental hysterotomy is carried out. After the baby is
delivered, all invaded tissues and the whole placenta are removed in one piece and compression
sutures stop any additional bleeding. Finally, the anterior myometrium is sutured in two planes, and
bladder is repaired when it is necessary.33
Resection of the invaded tissue, together with the placenta, establishes a radical difference from the
other conservative procedure that leaves the placenta in situ. Although the tissue and vascular
dissection process is extended, this technique rules out the possibility of infection caused by retained
tissues, as the entire placenta is removed.
This procedure is technically complex, so it is not widely used; however, initial step needs the same
dissection as for total hysterectomy; after retrovesical access is guaranteed, the following stages are not
complex at all. To date, 106 women have become pregnant again. Only two women had a partial
recurrence, which, to date, is the lowest recurrence rate worldwide.
Apart from Argentina, some investigators have published experiences with this technique.43,44
Recently, an initial study using a similar technique found good results. This surgical approach was
found to be technically easier and avoids resection of a portion of the urinary bladder, which would be
necessary in cases of caesarean hysterectomy.44 In addition, this approach avoids the potential intra-
operative and postoperative complications associated with peripartum hysterectomy.

Two-step conservative surgery

When surgical conditions are not ideal for carrying out a hysterectomy (i.e. lack of an experienced
team, limited blood or other resources), leaving the placenta in situ can be the best option to avoid
immediate and serious complications. Afterwards, hysterectomy or conservative treatment could be
chosen. Conservative approach to leave the placenta in situ could have some complications in the
postoperative period (i.e. haemorrhage, disseminated intravascular coagulation, retained placental
infection, and sepsis). When the mother is young, is of low parity, desires another pregnancy, refuses
the hysterectomy, or other risks of leaving the placenta in situ are present, an alternative treatment
could be offered.16 This procedure is similar to one-step conservative surgery, but, in this case, the
tissue condition is different. A few days after delivery, the newly formed vessels are collapsed and
some light oedema occurs between the anterior uterine surface and the bladder. Therefore, tissue
dissection is less difficult and, if accidental rupture of the anterior invaded area happens, bleeding is
not severe because the new-born delivery would have released the intrauterine pressure. Although
the experience is limited, conservative management in two steps can eliminate the risk of uncon-
trollable haemorrhage at the first procedure, and then avoid the main complications of retained
placenta (i.e. infection, sepsis, haemorrhage and disseminated intravascular coagulation). Tissue
dissection in cases of two-step surgery is easy and with reduced possibility of bleeding compared
with one-step dissection; the disadvantage is obvious: two surgeries instead of one. This alternative
procedure may have advantages for follow up, secondary morbidity, and the possibility of a safe
future pregnancy.
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Placenta left in situ

Conservative treatment that leaves the placenta in situ avoids dissecting tissues in adverse
conditions, a tactic that prevents expected bleeding. This is not a new approach for abnormal
placentation; the first successful treatment was published almost 80 years ago.45 In this option,
hysterotomy has to avoid placental invasion, the baby is delivered through a safe area, and the
umbilical cord is cut near the placenta. The invaded area and the placenta are left in situ without any
attempt to remove them, and the uterus is closed avoiding any tissue dissection of invaded area.
Uterine artery embolisation is carried out after closing the abdomen to reduce a risk of immediate or
late haemorrhage, although blood loss is not always prevented by this measure. The role of meth-
otrexate or arterial embolisation to improve the safety of conservative management and placental
reabsorption requires further study46; however, there is no rational basis for its use. Use of antibiotics
might be effective in preventing uterine infection, but their efficacy remains to be proven.47 Daily
observations, use of antibiotics, and prolonged hospital stay imply additional expenses without
guarantee of therapeutic efficacy. Nevertheless, as it happens in other clinical situations, antibiotics
in the presence of infected tissue may not be effective at all. For this reason, accurate clinical
examination and laboratory tests are necessary to detect an incipient sepsis or coagulopathy
(subclinical disseminated intravascular coagulation). Septic shock has been reported with conser-
vative treatment when the placenta is left in situ.48 Although myometrial tissue is highly resistant to
infection, when placental infection is not controllable, hysterectomy is usually the best treatment.
One report, however, has described a late infection treated with placental removal and uterine
conservation.49 Obstetricians need to be aware that lack of unnoticed infection or high virulence
organisms can produce unexpected outcomes. The clinical evaluation needs to consider all signs and
symptoms of sepsis, because many of them can be absent or may be masked by antibiotic treatment.
Lethal and other severe complications of conservative management of placenta accreta may be
scarcely reported and are prone to being under-reported, whereas good outcomes may be over-re-
ported.21 To leave the placenta in situ is not a guarantee of immediate bleeding control, even if uterine
arterial embolisation is carried out50; for this reason, the team must be ready to solve this problem
when it happens.
In ideal conditions, the placenta reduces its size, reabsorbs itself or calcifies in weeks or months.
Spontaneous placental expulsion has also been reported, with and without significant haemor-
rhage. When placenta has been expelled or reabsorbed, there is a possibility of future pregnancy.
Even though numerous cases of pregnancies after conservation with placenta in situ have been
reported, the general reproductive outcomes showed high risk of recurrence in the following
pregnancy.15

Proximal vascular control

The pelvic blood supply is one of the most interconnected arterial systems in the body. The internal
iliac system provides the main irrigation for the pelvic organs. This trunk, however, receives anasto-
moses from pedicles that arise from the abdominal aorta, the external iliac artery and the femoral
artery.51 In cases of acute occlusion of the internal iliac artery, this anastomotic system can replace the
blood flow beyond the block immediately. Rational knowledge of these connections allows under-
standing of the efficacy needed for specific vascular control methods.

Common iliac artery occlusion

Initial experiences using bilateral occlusion of common iliac arteries in women with lower
abnormal placentation (i.e. placenta percreta and cervical pregnancy) showed good results.52,53 This
vascular control is efficient because it occludes the pudendal anastomotic component resulting
from the blocking of the posterior branch of iliac internal artery, and also a femoral anastomotic
component to the pelvis. The secure occlusion time after occlusion of both common iliac arteries is
about 90 mins; time in relation to the ischaemic life of the skeletal muscle. A bilateral approach can
increase a risk of local complications, but no large study has confirmed this. Some circumstances
 J.M. Palacios-Jaraquemada / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 221–232 229

may affect the effectiveness of common iliac occlusion, such as presence of enlarged posterior
anastomosis provided by rectal superior artery or by existence of persistent sciatic artery.16 For this
reason, accurate treatment using this method could depend on placental invasion topography and
complete knowledge of possible arterial variations.

Aortic occlusion or compression

As most of the anastomotic vessels from the pelvis arise below the aortic bifurcation, infra-renal
aortic occlusion or clamping is probably the most rational proximal vascular control to the pelvis.
When vascular control takes place below the origin of lumbar arteries (above aortic bifurcation),
spinal cord blood supply is not affected. Aortic vascular control can be achieved by external or
internal occlusion. External compression may be carried out manually or with a specific device.
Experiences in pregnant women have shown that bimanual compression, at the level of umbilicus,
can reduce a femoral flow significantly.54,55 During caesarean, the internal occlusion of infrarenal
aorta is a simple procedure. After delivering the uterus from the pelvis and displacing the sigmoid
colon to the left, the aortic division is easily seen over the promontory. A simple manual pressure over
the aorta (against the spine) allows stopping the aortic blood flow instantaneously.16 Infrarenal cross-
clamping is also efficient, but it needs to be carried out by a vascular surgeon or by a well-trained
surgeon. The infra-renal abdominal aorta can also be occluded by an endovascular balloon.
Obstetric use of aortic compression to control massive obstetrics haemorrhage was described for the
first time in 1995.56 This alternative has some advantages for bilateral occlusion of common iliac
arteries (i.e. shorter procedure time and simplicity). The procedure is conducted by an experienced
interventional radiologist, who places the balloon until the aortic bifurcation. This method is
particularly useful to control bleeding in lower invasions, especially when hazardous dissection is
anticipated.

Internal iliac ligature or occlusion

Ligature of the internal iliac artery is probably the oldest procedure used for proximal vascular
control in the pelvis. Experiences, however, have shown varying results according to different expe-
riences. Physiological studies of internal iliac artery haemodynamics have shown that, after ligature,
the blood flow beyond the ligature of the iliac internal artery is replaced immediately by an extensive
network of arterial collaterals.57 Because a large part of anastomosis of internal iliac artery is ‘vertical’,
a minimal procedure to control pelvic bleeding is bilateral internal iliac ligature or occlusion by
embolisation. Ligature of internal iliac arteries is usually presented as a simple procedure, but serious
complications such as ligature of posterior trunk or external iliac artery (ischaemic complications) or
hypogastric vein injury can occur with non-skilled operators.16 These complications are under-
reported or not reported. Hence, the frequency of such incidents and the consequent hazards are
not well-known. Endovascular occlusion of internal iliac artery provides the same haemodynamic
parameters as internal iliac ligature, although the possibility of embolisation of their branches is
possible and it could enhance its efficiency.

Conclusion

Placenta praevia and accreta are usually located in the lower segment. Differential diagnosis
between these conditions is routinely carried out, but mild or doubtful cases should be explored
by multi-planar methods to avoid unexpected complications or unnecessary hysterectomies.
Access to pelvic subperitoneal spaces and retrovesical dissection are key to achieving vascular
control and haemostatic procedures. Accurate vascular control avoids bleeding and clinical
consequences of haemorrhage, which are closely related to the safety and efficiency of surgical
procedures. Hysterectomy in placenta accreta is a complex surgery, and its risk should never be
underestimated. If resources or team skills are not available, the best option is to deliver the baby
through non-invaded areas and to leave the placenta in situ, until definitive treatment is agreed.
230 J.M. Palacios-Jaraquemada / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 221–232

Practice points

 Transvaginal sonography is the elected method for investigating placental location when the
placenta is thought to be low-lying. Its use is safe at any time in pregnancy and significantly
more accurate than transabdominal ultrasound.
 Abdominal, transvaginal ultrasound, or both, provide an excellent diagnosis in most cases of
placenta accreta or its variance. Placental magnetic resonance imaging and three-
dimensional ultrasound) are accurate methods of delineating the anatomy of placental
invasion.
 Programmed surgery, wide opening of vesicouterine space, planned hysterotomy, manage-
ment of proximal vascular control, and accurate use of compression sutures are essential to
avoid bleeding complications in placenta praevia.
 Carrying out hysterectomy during shock or coagulopathy implies a high risk of immediate
and late complications. Use of effective vascular control, such as internal aortic compression
or Eschmarch’s bandage, may provide time to improve haemodynamic and haemostatic
status, which increases the effectiveness of compression sutures later. Further experience is
needed with such an approach.
 Current treatments for placenta accreta have advantages and disadvantages. Appropriate
approaches and alternatives must be discussed with the patient and decided according to the
expertise and experience of the team and available resources. Hysterectomy or one-step
conservative surgery is complex at first, but offers a relatively known outcome. To leave
placenta in situ provides a bloodless surgery initially, but with risks of unpredictable
complications later.

Research agenda

 Helpfulness of placental magnetic resonance imaging and three-dimensional ultrasound in

procedures that require dissection manoeuvres.
 Effectiveness of the methods for controlling pelvic haemorrhage.
 Teaching and practice of easy, efficient and available methods to control bleeding could
improve initial treatment step.
 Analysis of clinical consequences of puerperal hysterectomy in the presence of shock or
coagulopathy.

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