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

Postpartum hemorrhage (PPH) is still the most important and potentially avoidable cause of maternal death (1). The uterus in late pregnancy or at term has at any moment a through-flow of blood that corresponds to approximately one-sixth of the pregnant woman’s total blood volume, setting the scene for massive bleeding from up to 200 dilated spiral arteries into the uterine cavity, if the uterus does not retract and contract as expected. Hemorrhage ensues, which in a short time may lead to death of a woman in the prime of her life – death at a time when she is supposed to be healthy and able to tolerate more than at other ages. The rapidity of blood loss often goes unnoticed until the situation starts to deteriorate. If the patient is weak and anemic like many women are in low-resource countries, if she is poorly nourished as may easily be seen in the supposedly richer societies, or if she is in the wrong type of delivery situation where background services and transport are inadequate, the danger of severe morbidity and even death is real. There are good reasons why the overwhelming numbers of maternal deaths from severe PPH have stimulated initiatives from regional and international organizations to try to prevent and limit the serious effects of postpartum hemorrhage. Clinical improvement activities have mainly focused on medical treatment of uterine atony. In 2003 at the FIGO conference in Santiago, Chile, the two professional organizations FIGO (International Federation of Gynecology and Obststerics) and the ICM (International Confederation of Midwives) launched a global initiative to combat maternal death from PPH (2,3). Since there was evidence that active management 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 the third stage should be offered to all women. This involved administration of uterotonic drugs, controlled cord traction and uterine massage following delivery of the placenta. However, the retained placenta and abnormally invasive placenta (AIP) present a different problem where uterine atony may persist along with incomplete separation and thus continued bleeding from a varying and always unknown number of large vessels in the placental bed. The most common form of a retained placenta may not respond effectively to medical treatment and after a while result in atony and bleeding. Which is the best approach to the common retained placenta? For how long should we wait before proceeding to manual evacuation? Giel van Stralen and colleagues in Leiden, Amsterdam and Den Haag, Netherlands (pp. 396–402), Sys Nikolajsen and co-workers in Hillerød, Denmark (pp. 419–423) and Vedran Stefanovic and colleagues in Helsinki, Finland (pp. 424–431) present new data on the clinical management of retained placenta with different results and conclusions. Therefore, and for the paucity of evidence-based literature on this topic, we aim to call for large observational and randomized controlled studies on retained placenta and PPH. One example is the postpartum use of ultrasound when there is a retained placenta. Can ultrasound be used to differ between an entrapped placenta that should be removed manually and AIP, where a quite different management approach is needed? After studying this issue of AOGS, you will agree that this is possible. Furthermore, the prenatal suspicion of AIP is important because that alone will reduce the maternal morbidity, as reported by Fr ed eric Chantraine and a consortium of co-workers in Belgium, Germany and Switzerland (pp. 437–442). Retention of bits and pieces of the placenta or membranes may result in atony, which initially is somewhat responsive to uterotonics, but where hemorrhage will eventually recur in a situation when the mother is lactating, enjoying her first meal and the family is celebrating. Therefore, the management for PPH 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 the medical treatment, Bakri balloon tamponade must also be considered as a rapid and effective option where applicable. The results presented by Maiju Gr€ onvall and co-workers in Helsinki, Finland (pp. 431–436) and Laura Aibar and colleagues in Granada and Motril, Spain (pp. 463–465), are encouraging. All women with retained placenta do potentially need anesthesia. These women need to be prioritized because an unnecessary delay will inevitably result in more blood loss (4). Close collaboration with a view “to make plans” in a team formed by obstetricians, anesthetists and midwives is necessary for these situations. Practical consideration of all eventualities is essential since the quantity of PPH is very time dependent. In