title: Suspected placenta accreta and cesarean hysterectomy: observational cohort utilizing an intraoperative decision strategy.
abstract: BACKGROUND
  Planned cesarean hysterectomy (CH) is recommended to minimize morbidity for suspected placenta accreta (PA), yet this ends fertility. We examined CH frequency and post-operative morbidities for suspected PA cases when an intra-operative decision strategy to perform CH was used.
  
  
  METHODS
  Suspected PA cases were pre-operatively identified in one tertiary care center. Women were assessed intra-operatively, prior to uterine incision, for immediate CH or for attempted placental separation. We compared outcomes among women with versus without PA (surgical and/or pathologic diagnosis), and examined outcomes following immediate CH versus attempted placental separation.
  
  
  RESULTS
  Our cohort, from 2002 to 2012, comprised 99 women with suspected PA; 54 (54.5%) had PA diagnosed by surgery/pathology, and 45 (45.5%) did not. Among women diagnoses surgically or pathologically with PA, CH was performed for 46/54 (85%); 8 women with suspected PA had successful placental separation. 27 of the 46 CH were performed immediately following uterine wall examination and 19 were performed following attempted placental separation. We received histological confirmation of the clinical placenta accreta diagnosis for 24/46 (52.2%) cases, and in 22/46 (47.8%) cases the histology did not confirm the clinical diagnosis. Surgery duration, packed cell transfusion requirement and postoperative outcomes were similar among women with PA regardless of immediate CH versus attempted placental separation, except for a higher cystotomy rates following attempted placental separation. Emergency deliveries were performed at significantly earlier gestational ages.
  
  
  CONCLUSIONS
  Among women with suspected PA, an intra-operative CH decision allows some women to avoid CH. Consideration of attempted placental separation did not increase blood transfusion or post-operative complications, but was associated with a higher rate of cystotomy.
authors.affiliation: Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA; Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel. Electronic address: carolynfweiniger@gmail.com.
authors.forename: Carolyn F
authors.initials: CF
authors.lastname: Weiniger
authors.affiliation: Department of Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Ein Kerem, Jerusalem, Israel.
authors.forename: Doron
authors.initials: D
authors.lastname: Kabiri
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Yehuda
authors.initials: Y
authors.lastname: Ginosar
authors.affiliation: Department of Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Ein Kerem, Jerusalem, Israel.
authors.forename: Yossef
authors.initials: Y
authors.lastname: Ezra
authors.affiliation: Department of Pediatrics - Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: BatZion
authors.initials: B
authors.lastname: Shachar
authors.affiliation: Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Deirdre J
authors.initials: DJ
authors.lastname: Lyell
mesh_terms: D000328:Adult; D001803:Blood Transfusion; D002585:Cesarean Section / Q000379:methods*; D000066491:Clinical Decision-Making; D036861:Delivery, Obstetric; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000379:methods*; D010921:Placenta Accreta / Q000601:surgery*; D011184:Postoperative Period; D011247:Pregnancy
keywords: Accreta; Cesarean; Decision; Hysterectomy; Maternal morbidity