Placenta percreta: Multidisciplinary team may not be enough

Dear Editor, Having been an obstetrician for 35 years, I have devised several methods for caesarean hysterectomy for placenta praevia percreta. However, I still sometimes have a restless night before this surgery. Pather et al. described three women with conservative management for placenta percreta with significant complications. In their review of 57 women with conservative management, 40% received emergent hysterectomy and 42% experienced major morbidity: a pessimistic outcome. Regardless of whether aiming for spontaneous placental resolution or second surgery later at reduced blood flow, this strategy may be a boon if it is proved effective. However, support and criticism continue to be raised on this issue. The situation holds true to caesarean hysterectomy for percreta. There are many surgical techniques, including posterior first method, retrovesical bypass or retroperitoneal opening. Internal iliac/uterine artery ligation or balloon occlusion is controversial. The presence of various techniques/methods indicates that there is ‘no best’ way. Until an optimal strategy, some method universally available for many obstetricians, is forthcoming, I propose that only advanced centres should deal with percreta, irrespective of whether caesarean hysterectomy or conservative management is selected. My reasoning is as follows. For simplicity, let us assume that primary surgery is to be performed. First, the time of surgery can be decided, allowing time for the woman to be transferred. Second, as successful primary surgery does not require long-term follow-up, the woman needs not to continue to visit the centre. Third, the rarity of this condition makes it difficult for not only obstetricians but also multidisciplinary team members to become well accustomed to its treatment/surgery; patient transfer to a centre specialised in this surgery may solve it. Fourth, we must consider some features specific to this surgery. Different from many other surgeries, we usually cannot stop the surgery after starting it. For example, if one encounters life-threatening haemorrhage during radical hysterectomy, one can ‘stop’ the procedures and close the abdomen, expecting to perform irradiation afterwards. In caesarean hysterectomy, there may be no, or at least only a few, chances to ‘stop’ the surgery; thus, a surgeon has ‘passed the point of no return’. Pather et al. stated that attempt of reflecting the bladder and further dissection should be stopped at haemorrhage. I understand the point, but do not completely agree with this view. Hysterectomy is sometimes required for haemostasis; thus, one often cannot stop the surgery. Surgeons experience various surgeries in a stepby-step manner: for gynaecologic oncologists, cystectomy, hysterectomy, radical hysterectomy and ovarian cancer surgery. In contrast, for obstetricians, going from caesarean section to caesarean hysterectomy, step-by-step training is usually difficult. Furthermore, many obstetricians may consider that caesarean hysterectomy can be performed using techniques similar to the nonpregnant hysterectomy. Almost all authors emphasise the importance of a ‘multidisciplinary team’ approach to this disorder, as did Pather et al. To me, not merely a ‘multidisciplinary team’ but a ‘well-experienced and well-trained multidisciplinary team’ is mandatory. The skills and experiences of obstetricians are vital. Centres specialising in this surgery are necessary. Placenta praevia, irrespective of whether primary surgery or conservative management is employed, can cause maternal mortality. I believe that not all university or tertiary centres are adequately experienced to deal with this disorder. Patients with percreta should be directed to the most qualified centre depending on circumstances of the corresponding area to reduce the maternal morbidity and extinguish the maternal mortality.