1111aogs12112 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 through64258ow of blood that corresponds to approximately onesixth of ID: 34115
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thisstressfulsituation,ateamcanevenÒforgetÓtoapplytrans-fusionguidelinesasreportedbyMarieBonnetandcolleaguesinParis,Lyon,andBron,France(pp.402-411).Continuoustrain-ingofallthedisciplinesintouchwithPPHandAIPsituationshastobedevelopedbyeachunit.Regularauditingmayhelptokeeptherequiredhighlevelofcompetence.HowdowethendiagnoseandmanagethemostsevereformsofAIP,alsoknownasplacentapercreta,whicharerare,butunavoidablygoingtoincreaseduetotheÒcesareanepi-demicÓ?PredictionofsevereAIPreliesoncompetentscreen-ingbyultrasound,especiallyinwomenwithapreviouscesareansectionandalowanteriorplacenta.ImplantationmayresultinaÒcesareanscarpregnancyÓoraÒplacentaper-cretaÓeithercoveringauterinelowersegmentdehiscenceorinvadingthescartissue(5).Placentaltissueisbynatureinva-siveandstimulatedbyhypoxiatoinvadedeeply(scartissueisworseforbloodconnections)andhereitmaygothroughthescartoseekangio-connectioninaneighboringorgan,usuallythebladder,sinceseverelyinvasiveplacentasaremostoftenlocalizedinapreviousisthmiccesareanscar.Thenwehaveanevenmoreseriousissuewhereitmaybeimpossibletoremovethepathologictissuewithoutexcessivetrauma.Tomanagesuchcaseseffectively,amultidisciplinaryteaminatertiarycarecentertreatingtheseconditionsregularlyisvital.CarolineClausenandhercolleaguesinCopenhagen,Den-mark(pp.384Ð389)demonstrateclearlybytheexampleofballoonocclusionoftheiliacarteriestheneedforexpertiseinthemanagementofsevereAIPcases.ItcanbeforeseenthattertiaryadvicecenterscanalsocomeinwithtelecommunicationmeasurestohelpwiththedifÞcultsurgeryinvariablyinherentinsuchasituation,ordertogiveadviceonwhattodo,howtodoitandwhentostop.ToobtainanoptimalstructureforthemanagementofwomenwithsevereAIP,weneedpreparationintheplaceofdeliveryandexplicitandclearreferralplanstocentersofexcellenceonaregionaloreveninter-countrybasiswithvideo-andtelephonelinksforefÞcientaccesstoexpertknowledge.Theneedforcollaborationbetweenspecialtiescannotbeexaggerated.Thiscallsforeducationbymultidisci-plinarycoursesandfortrainingactivitiesforkeyobstetri-cians,midwivesandspecialistsinanesthesia,fetalmedicine,blood-banking,andinterventionalradiology.JustoverayearagoweputoutacallforarticlesonAIP.Wehadmorethancouldbepublishedinoneissue,whichshowstheinterestandimportanceofthistopicworldwide.Mostarehereandreßectanythingfromoperativemethodol-ogytoaconservativeapproach,eachwiththeirmeritsandlimits,asnoonehastheall-embracinganswer.MorewillappearinthenextissuesofAOGS.WehopethisvolumewillreßectthebroadnessofmedicalinterestandconcernandleadtopracticalproposalsandsolutionslikeatFIGOin2003;onlyhereitisnotjustmidwivesandobstetricianslikewithatonicPPH.Abroadcollaborationwithothermedicalspecialtiesiscalledforaswell.Themaingoalistominimizetheserious,dramaticandevenfatalconsequencesofpostpartumhemorrhage.Uterineatonyisimportant,andtheabnormallyinvasiveplacentaaswell.Whilecontinuingtoforestalluterineatony,thefocusshouldnowshifttosevereAIP.IntheseyearsinternationalnetworksandcollaborativedatacollectionarebeinglaunchedtosolveimportantresearchquestionsinthisÞeld.ExamplesareNOSS(NordicObstetricSurveillanceSystem),UKOSS(UKObstetricSurveillanceSystem)andnowtheEW-AIP(EuropeanWorkingGrouponAIP)initiatives.TheFrenchPACCERTA-project,aprospectivepopulation-basedstudyonAIPpresentedinthisissuebyGillesKayemandco-workersatcentersinFrance(pp.474Ð480),highlightstherightdirectionforclinicalresearchinthisÞeld.Thisthemeissuecoversabroadrangeofstudies,showsnovelsurgicaltechniquesandprovidesdramaticnarratives1.KhanKS,WojdylaD,SayL,GulmezogluAM,VanLookPF.WHOanalysisofcausesofmaternaldeath:asystematicreview.Lancet.2006;367:10662.ICMandFIGO.Jointstatement:managementofthethirdstageoflabourtopreventpost-partumhaemorrhage.JMidwiferyWomensHealth.2004;49:763.MillerS,LesterF,HensleighP.Preventionandtreatmentofpostpartumhemorrhage:newadvancesforlow-resourcesettings.JMidwiferyWomensHealth.2004;49:2834.MarkovaV,SorensenJL,HolmC,NorgaardA,Langhoff-RoosJ.Evaluationofmulti-professionalobstetricskillstrainingforpostpartumhemorrhage.ActaObstetGynecolScand.2012;91:3465.JauniauxE,JurkovicD.Placentaaccreta:Pathogenesisofa20thcenturyiatrogenicuterinedisease.Placenta.2012;33:244Considerattendingat:4thNordicEndometriosisCongress(NCE2013)inTurku,Finlandon23.-25.MayISSHPEuropeanCongressisinTromso,Norway,12.-14.June(InternationalSocietyfortheStudyofHyper-tensioninPregnancy,www.isshp.org).congressoftheEuropeanSocietyofGynecology,BruxellesBelgium18-21September20132013NordicFederationofSocietiesofObstetricsandGynecology,ActaObstetriciaetGynecologicaScandinavica(2013)367368EditorsMessage