Revista Brasileira de Ginecologia e Obstetrícia

Comments on: Conservative Surgical Treatment of a Case of Placenta Accreta

DOI: 10.1055/s-0038-1675221 - volume 40 - Outubro 2018

Ahmed Reda

Abstract

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Dear Editor,

Placenta accreta describes pathological adherence or invasion of the placenta to the myometrium. It may be a consequence of any procedure affecting the integrity of the uterine lining.1 The incidence is rising due to increase in the rate of cesarean delivery, which is the major risk factor. Published guidelines2 3 4 recommend delivery with planned cesarean hysterectomy and placenta left in situ, while application of conservative management must be individualized according to the patient's desire for future fertility.

In certain cases, the implementation of alternatives to standard or agreed interventions is necessary to preserve the potential for future fertility, but this may carry risk of morbidity and adverse events either from the procedure itself or due to deviation from the agreed management published in the guidelines. Such procedures should be individualized to each case according to history, clinical judgment and the patient's desire for future fertility.

Biyik et al5 reported a case of placenta accreta managed conservatively with segmental uterine resection, with the aim of fertility preservation. From the scenario of the presented case, it is obvious that the patient had completed her family; at the time of the surgery, the patient will be para 4, 39 years old and she requested tubal ligation, which suggests that she is not interested in future fertility. Although the authors stated that blood loss was not measured, significant hemorrhage could be detected from the change in the hemoglobin level from 10.3 g/dL preoperative to 8.5 g/dL postoperative after transfusion of 1 blood unit.

In my opinion, subjecting the patient to hemorrhagic morbidity, with added risks of blood transfusion, to pursue future fertility in a patient requesting permanent contraception—which is already performed during the same operation—is not justified.

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