Gupta AS

Tertiary referral medical college centers like ours are seeing an increased number of cases with morbidly adherent placenta. With the rising incidence of cesarean births the incidence of placenta previa and placenta accreta has increased. Any cause that prevents a good decidual reaction like previous cesarean, hysterotomy, myomectomy scars, Asherman syndrome, multiparity can result in a morbidly adherent placenta.  The decidua basalis and the Nitabuch's layer interface between the invading trophoblast and the myometrium is deficient due to the scar tissue. This allows the invading trophoblast to invade the myometrium or the uterine serosa to varying depths. The degree of invasion determines the 3 categories of the adherent placenta, accreta, increta or percreta. The placenta may be totally adherent or only part of the placenta may be focally or partially adherent. Antenatally about 50% cases are diagnosed. Antenatal detection rates can be improved with increased awareness and meticulous effort by the obstetrician, sonologist especially in cases of previous hysterotomies with an anteriorly implanted placenta. USG, Doppler flowmetry and MRI have allowed almost 100% detection rates.
The clinician can encounter either a totally or a focally adherent placenta. Antenatal diagnosis allows the clinician to organize a proper management strategy and team. Proper counseling and consent of the patient, availability of adequate cross matched blood, blood products, team of anesthetists, interventional radiologists, urologists, or surgeons can be arranged prior to delivery. Both the varieties pose management challenges especially in a woman desiring future child bearing. In a totally adherent placenta accreta, increta or percreta a classical cesarean section with ligation of the cord at its placental root, followed by post operative chemotherapy with methotrexate and antibiotics with close monitoring is the mainstay of treatment in a woman desiring future pregnancies. Treatment in cases with involvement of adjacent viscus like the bladder in placenta percreta is very tricky. Any attempts to separate the placenta can lead to torrential life threatening bleeding. Inflation of balloons placed preoperatively in the anterior division of the internal iliac arteries after delivery of the child, intra operative blood replacements, postoperative oxytocics and methotrexate with intensive monitoring may be the best management protocol for patients with placenta percreta. Hysterectomy after the cesarean birth is probably preferred with placenta accreta and increta where the patient does not desire future child birth.  
Focally adherent placenta separates out partially compelling the obstetrician to remove the adherent area of the placenta piecemeal at the time of delivery or proceed with a hysterectomy to control the profuse bleeding from the separated placental bed. In patients desiring future childbearing an attempt to preserve the uterus can be tried by underrunning the placental bed with delayed absorbable sutures. Affronti's, Cho and B Lynch sutures may be used to control bleeding from the placental bed. Balloon tamponade, selective devascularization of the uterine vasculature have been attempted.
In this issue of JPGO we bring two cases of focally adhered placenta with varied presentations which were managed successfully. We hope the readers gainfully benefit from the various interesting cases present in this issue.