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I want to keep my uterus!
Abstract Number: FCB-342
Abstract Type: Case Report Case Series
Morbidly adherent placenta is a rare but serious condition defined as a placenta that is abnormally adherent to the uterus. It has a prevalence of about 10/10,000 deliveries but is becoming more common as cesarean delivery rates rise.1 When counseling patients with abnormal placentation, the potential need for hysterectomy must be discussed. We describe a case in which a patient dictated the anesthetic and obstetric course of her cesarean delivery.
A 35-year-old G10P8 at 28 weeks and 4 day was referred to our Maternal-Fetal Medicine (MFM) and high-risk obstetric anesthesiology consult service for supervision and counseling given a diagnosis of placenta accreta. The patient refused standard of care, consisting of scheduled cesarean delivery at 37 weeks and possible cesarean hysterectomy. The patient wanted to be delivered at 39 weeks and refused the possibility of a hysterectomy. She agreed to have in-situ management of the placenta. Use of methotrexate and prophylactic uterine artery embolization was discouraged as the literature did not show improvement in outcomes with their use in this context.
In terms of anesthesia, combined spinal anesthesia was offered as the anesthetic plan with general anesthesia as a back up plan in case of hemodynamic instability. She refused the use of an epidural or general anesthesia (GA), and stated that if she was to become unstable, her husband would decide if GA was a possibility. The patient only agreed to receive a single-shot spinal. The ethics committee was consulted, and it was determined that the patients request be granted as such.
At 37 weeks, the patient asked for her surgery to to be re-scheduled at 39 weeks. At 39 weeks, a cesarean delivery with in-situ management of the placenta was performed under spinal anesthesia. The intraoperative course of the patient was uneventful, and she was discharged on post-operative day 4 in stable condition.
The management of placenta accreta is complicated and it often involves the need to perform a hysterectomy. Even when the plan is to perform an in-situ placenta approach, sepsis and or hemorrhage could lead to the possibility of needing to perform a hysterectomy. In any case, once a patient has been sufficiently informed about the treatment options offered by a physician, the patient has the freedom to decide what a physician or other healthcare professional can or can not do. It is unethical to physically force or coerce a patient into a treatment against her will if she is is mentally capable of making an informed decision. After all, the most important right the patient possess is the right of self-determination; the right to make the final decision of what will or will not be done to their bodies.2
1. Rev Obstet Gynecol. 2009;2(2):127-8.
2. Am J Law Med. 1976 Summer;2(1):41–99.
3. Ausman JI Surg Neurol. 1999 Jan; 51(1):113-4