AIP (abnormally invasive placenta) – from a retained placenta to destruction of the uterine wall

Postpartum hemorrhage (PPH) is still the most importantand potentially avoidable cause of maternal death (1). Theuterus in late pregnancy or at term has at any moment athrough-ow of blood that corresponds to approximatelyone-sixth of the pregnant woman’s total blood volume, set-ting the scene for massive bleeding from up to 200 dilatedspiral arteries into the uterine cavity, if the uterus does notretract and contract as expected. Hemorrhage ensues, whichin a short time may lead to death of a woman in the primeof her life – death at a time when she is supposed to behealthy and able to tolerate more than at other ages. Therapidity of blood loss often goes unnoticed until the situationstarts to deteriorate. If the patient is weak and anemic likemany women are in low-resource countries, if she is poorlynourished as may easily be seen in the supposedly richersocieties, or if she is in the wrong type of delivery situationwhere background services and transport are inadequate, thedanger of severe morbidity and even death is real. There aregood reasons why the overwhelming numbers of maternaldeaths from severe PPH have stimulated initiatives fromregional and international organizations to try to prevent andlimit the serious effects of postpartum hemorrhage.Clinical improvement activities have mainly focused onmedical treatment of uterine atony. In 2003 at the FIGO con-ference in Santiago, Chile, the two professional organizationsFIGO (International Federation of Gynecology andObststerics) and the ICM (International Confederation ofMidwives) launched a global initiative to combat maternaldeath from PPH (2,3). Since there was evidence that activemanagement of the third stage reduced the incidence of PPH,the quantity of blood loss and the use of blood transfusion,the two organizations agreed that active management of thethird stage should be offered to all women. This involvedadministration of uterotonic drugs, controlled cord tractionand uterine massage following delivery of the placenta.However, the retained placenta and abnormally invasiveplacenta (AIP) present a different problem where uterineatony may persist along with incomplete separation and thuscontinued bleeding from a varying and always unknownnumber of large vessels in the placental bed. The most com-mon form of a retained placenta may not respond effectivelyto medical treatment and after a while result in atony andbleeding. Which is the best approach to the common retainedplacenta? For how long should we wait before proceeding tomanual evacuation? Giel van Stralen and colleagues in Leiden,Amsterdam and Den Haag, Netherlands (pp. 396–402), SysNikolajsen and co-workers in Hillerod, Denmark (pp. 419–423)and Vedran Stefanovic and colleagues in Helsinki, Finland(pp. 424–431) present new data on the clinical managementof retained placenta with different results and conclusions.Therefore, and for the paucity of evidence-based literature onthis topic, we aim to call for large observational and random-ized controlled studies on retained placenta and PPH. Oneexample is the postpartum use of ultrasound when there is aretained placenta. Can ultrasound be used to differ betweenan entrapped placenta that should be removed manually andAIP, where a quite different management approach is needed?After studying this issue of AOGS, you will agree that this ispossible. Furthermore, the prenatal suspicion of AIP isimportant because that alone will reduce the maternalmorbidity, as reported by Frederic Chantraine and a consor-tium of co-workers in Belgium, Germany and Switzerland(pp. 437–442).Retention of bits and pieces of the placenta or membranesmay result in atony, which initially is somewhat responsive touterotonics, but where hemorrhage will eventually recur in asituation when the mother is lactating, enjoying her rst mealand the family is celebrating. Therefore, the management forPPH starts with a clinical examination (inspection of vulva,vagina and cervix) and exploration of the uterine cavity,either by manual revision or ultrasound. In addition to themedical treatment, Bakri balloon tamponade must also beconsidered as a rapid and effective option where applicable.The results presented by Maiju Gr€onvall and co-workers inHelsinki, Finland (pp. 431–436) and Laura Aibar and col-leagues in Granada and Motril, Spain (pp. 463–465), areencouraging.All women with retained placenta do potentially need anes-thesia. These women need to be prioritized because an unnec-essary delay will inevitably result in more blood loss (4). Closecollaboration with a view “to make plans” in a team formedby obstetricians, anesthetists and midwives is necessary forthese situations. Practical consideration of all eventualities isessential since the quantity of PPH is very time dependent. In