Selective Manual Removal of Invasive Placentation at Cesarean Section: 13 Consecutive Cases in a Regional Tertiary Center

Abstract

Objective:

Abnormal placentation is an important obstetric disorder and is currently increasing as the cesarean-section rate is also increasing. Manual removal of the placenta is still a controversial issue balancing the risk of massive hemorrhage and the benefit of fertility.

Design:

We performed a retrospective study of 13 pregnancies with invasive placentation in one tertiary perinatal center in Japan.

Materials and Methods:

We had 13 pregnancies with invasive placentation (4 were placenta percreta and 9 was placenta increta). With the aid of antepartum ultrasonography and intraoperative visual evaluation, 5 women were diagnosed or strongly suspicious of having placenta percreta who underwent primary cesarean hysterectomy with placenta left in situ. Selective placental removal was performed in the remaining 8 women. We compared blood loss, blood-transfusion volume, and maternal complications between primary cesarean hysterectomy with placenta left in situ and selective placental removal groups. Fisher's exact test and the Mann-Whitney test were used for statistical significance (p < 0.05).

Results:

Antepartum ultrasonography and intraoperative visual evaluation detected all of the placenta percreta patients, who were then allocated to primary cesarean hysterectomy with the placenta left in situ group. Manual removal was applied to the women with placenta increta, which was not associated with greater blood loss (5795 ± 934 mL in manual removal vs. 6138 ± 2248 mL in placenta in situ) or maternal severe complications (3 disseminated intravascular coagulopathy [DIC] in manual removal and 1 DIC and 2 organ traumas in placenta in situ), but with a 40% chance of preserving fertility.

Conclusions:

We concluded that manual removal should be considered as a choice for women having abnormal placentation who want to preserve their fertility.