Placenta accreta is a potentially life threatening condition that continues to challenge the medical field. The prevalence has been on a steady rise over the last few decades, currently between 1 in 533 to 1 in 731 of all deliveries,1 becoming a commonality in obstetrics. Placenta accreta is defined by an abnormal attachment between the placenta and the myometrium of the uterus. The extent of invasiveness is categorized into three different categories: accreta, increta, and percreta. Chorionic villous attachment beyond the normal boundary of Nitabuch layer with superficial attachment of the myometrium is an accreta, villous invasion into the myometrium is increta, and villous invasion up to and beyond the uterine serosa is a percreta. Most morbidities present during the delivery stage and include complications such as uterine atony or postpartum hemorrhage, which can lead to disseminated intravascular coagulopathy, renal failure, or require hysterectomy. Mortality rates increase directly with the degree of invasion and can reach a level as high as 7%.1
A cesarean hysterectomy is an evolved operative procedure that dates back to 1896 when the first human cesarean hysterectomy was performed in the United States. Soon after, Porro of Milan performed the first cesarean hysterectomy in which both mother and fetus survived: coining the alternate name of the “Porro Procedure.”2 Historically, this particular procedure was used as a last resort during life-threatening hemorrhage. With advances in medicine, surgical procedures, and diagnostics, cesarean hysterectomies can now be utilized for a variety of indications. Cesarean hysterectomy is the most common treatment for abnormally invasive placentation. Not surprisingly, the rates of cesarean hysterectomies are increasing. The operation can often times be straightforward to any gynecologic surgeon, if it is carefully planned and meditated upon; the risk of morbidity increases during emergent and time sensitive situations. Morbidities of cesarean hysterectomy include, but are not limited to, hemorrhage, vascular injury, damage to the urinary tract system, and even death.
The intricacies of a cesarean hysterectomy often extend beyond the scope of a general gynecology. Recent research has started to show improved outcomes for patients with abnormally invasive placentation using a multidisciplinary approach and in specialized centers. Commonly observed outcomes with a cesarean hysterectomy include increased blood loss, intraoperative injury, and intensive care unit (ICU) admission. The contributions of specialties such as interventional radiology, trauma, urology, anesthesia, and blood bank services are priceless and can complement the surgical skills of experienced obstetrical or gynecologic surgeons. Every placenta accreta presents a unique challenge; therefore a well-studied and organized team will offer the greatest chance for a successful outcome.
The mechanisms leading to development of a placenta accreta are not well understood and are likely multifactorial. Endometrial damage is a common preceding risk factor, resulting in scar tissue that interferes with normal placentation: previous cesarean, dilation and curettage, endometrial ablation, and myomectomy entering the uterine cavity. Placenta previa ...