Conservative Management of Placenta Praevia with a High Risk of Placenta Accreta
Authors: Dunstone Simon J. , Leibowitz Charles B. 
Published: February 2008

EDITORIAL COMMENT: We accepted this case for publication because, together with the 2 following papers concerning interstitial pregnancies, they form an interesting trilogy of case reports where the women were given methotrexate during pregnancy. We do not argue with the management of this patient because of the high risk of a morbidly adherent placenta and the formidable surgery that can be required when such a placenta is dislodged at Caesarean section. Although the authors did not make this comment, it seems to the editor that a normally implanted placenta would be likely to separate at Caesarean section even if it was not handled. The editor can recall a horrendous experience with a patient who had a placenta praevia percreta where the plan of leaving the placenta after classical Caesarean section had to be abandoned because of massive haemorrhage that occurred spontaneously after the baby was removed; this woman died at The Royal Women's Hospital, Melbourne in 1968, some days after delivery, despite heroic resuscitative and surgical management. The case referred to by Jaffe and colleagues (5) and that by Younes and colleagues (6) referred to by the authors in the discussion were cases of placenta percreta (through the uterine wall) as stated in the titles, not increta (in the uterine wall) or accreta (attached to the uterine wall). We have published a number of case reports of morbidly adherent placentas over the years probably because the editor still vividly recalls the case mentioned above. Careful attention to the radiographic and ultrasonographic articles over the years has, in his opinion, never provided convincing evidence that a morbidly adherent placenta can be diagnosed with certainty before delivery, probably with the rare exception of when involvement of the bladder wall results in haematuria (A, B). As stated in a previous editorial comment (C) when a placenta percreta is anticipated, the surgical team assembled should include a surgeon experienced with radical surgery (a gynaecological oncologist). After delivering the baby through the upper segment it is often best to close the wound and get on with the hysterectomy; it may be necessary to electively open the bladder when the lower uterine segment, at the site of previous Caesarean sections, is adherent to it.

Altintas A, Ozgunen FT, Doran S, Doran F. Placenta percreta invading the urinary bladder. Aust NZ J Obstet Gynaecol 1991; 31: 371–372.
Sanders RR. Placenta praevia percreta invading the urinary bladder. Aust NZ J Obstet Gynaecol 1992; 32: 375–376.
Editorial Comment to Souter DJ, Roberts AB, Stables S. Cervicoisthmic pregnancy with placenta percreta ending in a livebirth. Aust NZ J Obstet Gynaecol 1995; 35: 453.

Summary: This case demonstrates that placenta praevia with a risk of placenta accreta can be managed conservatively with removal of the placenta once the serum beta human chorionic gonadotrophin level (beta HCG) is negative and there is absence of sonographically evident vascularity within the placenta.