Abnormally adherent placenta: evidence-based guidelines

  • Am J Obstet Gynecol

  • International Clinical Digest
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Takeaway

  • The International Society for Abnormally Invasive Placenta (AIP) lists recommendations for the management of AIP.

Why this matters

  • The incidence of AIP is rising as a result of rising rates of cesarean delivery.

Key results

  • Main recommendations:
    • Outpatient management is acceptable if asymptomatic and patient can rapidly return to hospital.  
    • Optimize hemoglobin levels.
    • Timing of delivery depends upon the situation; planned delivery around 34 weeks should be considered.
    • The use of antenatal steroids should be individualized.
    • Routine preoperative cystoscopy, ureteral stents, or prophylactic arterial balloon catheters not recommended.
    • Dorsal lithotomy position recommended to facilitate manipulation of cervix due to high risk for hysterectomy.
    • Vertical skin incision is not helpful.
    • Avoiding placental transection helpful to reduce blood loss; intraoperative ultrasound scan should be used when possible to locate placenta.
    • Prophylactic uterotonics should not be given immediately after delivery of the infant.
    • Expectant management (leaving placenta untouched) is successful in 60%-93%, but 6% have risk for severe maternal morbidity; methotrexate and prophylactic uterine artery embolization are not recommended.
    • Local resection may be considered.
    • Type of hysterectomy (total vs subtotal) should be individualized.

Study design

  • Systematic review and expert recommendations.
  • Funding: None.

Limitations

  • Expert opinion based on limited research, recommendations may change.

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