Author response to: Uterus-conserving surgery: tactics to avoid bleeding in placenta percreta

Authors


Author’s Reply

Sir,

We would like to thank Prof. Palacios-Jaraquemada1 for his comments. The aim of our case report was to highlight the ever present danger of significant obstetric haemorrhage in cases of partial placenta percreta where a conservative approach has been employed. Placenta percreta, rather than accreta, remains a rare occurrence in our current practice of obstetrics, although we are beginning to see a rising incidence. We feel that placenta percreta should not be considered in the same light as placenta accreta as the absence of organ invasion in the latter, particularly that of the bladder, renders performing a caesarean hysterectomy technically easier to say nothing of the considerably reduced likelihood of massive haemorrhage. Our local experience is nowhere as extensive as that of Prof. Palacios-Jaraquemada, but we maintain our preference for a conservative multidisciplinary approach in the management of confirmed percretas, which we believe is supported by much of the contemporary literature on this subject.

We agree completely with his comment that collateral vasculature of the gravid uterus is common and that uterine artery embolisation alone would not completely devascularise the organ. How else could the continued viability of the uterus in embolisation cases be explained? The use of magnetic resonance imaging in our protocol is more to determine the extent of placental invasion and the involvement of adjacent organs in confirming the diagnosis and also planning the surgical approach, rather than to study the collateral blood supply per se. Again, our local experience in arterial embolisation of the uterus is limited to the uterine vessels, the aim of which is to reduce the perfusion to the uterus and hence reduce the risk of significant obstetric haemorrhage at the time of caesarean section after delivery of the baby.

We agree with Prof. Palacios-Jaraquemada that the attempt at removal of the prolapsed placenta on third postoperation day was in retrospect misguided and was the likely cause that provoked the haemorrhage. Far from advocating it, the aim of our paper2 was to caution against handling the placenta in placenta percreta, even if a partial percreta, with its extruded portion giving the impression of separation, tempts one to attempt a removal. This case report is a cautionary tale to readers about the partial placenta percreta, which might separate with resultant haemorrhage in the course of pursuing a conservative approach. As Prof. Palacios-Jaraquemada has emphasised, the presence of vascular collaterals may render uterine artery embolisation an insufficient measure to avoid massive obstetric haemorrhage, and indeed, this remains in all cases of conservatively treated placenta percretas.

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