Management of morbidly adherent placenta

Morbidly adherent placenta refers to an abnormal invasion of the placental tissue (trophoblasts) into inner or outer myometrium or through the serosa of the uterus (termed accreta, increta or percreta, respectively.) Morbidly adherent placenta is associated with significant maternal morbidity and mortality, with a reported worldwide maternal mortality of 7%–10%. It increases the risk of massive obstetric haemorrhage and current management options for this potentially life-threatening condition include radical surgery such as elective peripartum hysterectomy with or without bowel/bladder resection or ureteric re-implantation (for placenta percreta infiltrating these organs) and conservative surgical measures such as myometrial compression sutures with uterine balloon tamponade.Intentional retention of the placenta may be needed in some patients where radical procedures are not appropriate or are refused by the patient in view of desire for future fertility. Unfortunately, both intentional retention of the placenta and peripartum hysterectomy may lead to serious maternal morbidity and mortality.Recently, a conservative surgical technique called the ‘Triple P Procedure’ which involves peri-operative placental localization and delivery of the fetus via transverse uterine incision above the upper border of the placenta; pelvic devascularization; and placental non-separation with myometrial excision and reconstruction of the uterine wall has been described as a safe and effective alternative to intentional retention of the placenta or peripartum hysterectomy.