Uterine conservative–resective surgery for selected placenta accreta spectrum cases: Surgical–vascular control methods

Abstract

Introduction:The incidence of placenta accreta spectrum (PAS) has increased, but the optimal management and the optimal way to achieve vascular control are still controversial. This study aims to compare maternal outcomes between different methods of vascular control in surgical PAS management. Material and methods: A retrospective cohort study on consecutive cases diagnosed with PAS between 2013 and 2020 in single tertiary hospital. The final diagnosis of PAS was made following preoperative ultrasound and confirmation during surgery. Management of PAS using cesarean hysterectomy with internal iliac artery ligation (IIAL) was compared with two types of vascular control in uterine conservativeresective surgery (IIAL vs identification-ligation of the upper vesical, upper vaginal, and uterine arteries).Results: Over an 8-year period, 234 pregnant women were diagnosed with PAS meeting the inclusion criteria. Uterine conservative-resective surgery (200 cases) was associated with lower mean blood loss compared with cesarean hysterectomy with IIAL (34 cases) in all PAS cases (1379 ± 769 mL vs 3168 ± 1916 mL; p < 0.001). In subanalysis of the two uterine conservative-resective surgery subgroups, the group with identification-ligation of the upper vesical, upper vaginal, and uterine arteries had a significantly lower blood loss compared with uterine conservative-resective surgery with IIAL (1307 ± 743 mL vs 1701 ± 813 mL; p = 0.005). Women in the hysterectomy with IIAL group had more massive transfusion (35.3% vs 2.5%; p < 0.001; odds ratio[OR] 21.3, 95% confidence interval [CI] 6.9-66), major blood loss (>1500 mL) (70.6% vs 34%, p < 0.001; OR 4.7; 95% CI 2.1-10.3), catastrophic blood loss (>2500 mL)

Management of unexpected placenta accreta spectrum cases in resource-poor settings

“…This retrospective descriptive study included women with histologically confirmed PAS 11 treated from 2016 to 2021 in 2 PAS centers in LMICs: the Dr. Soetomo General Academic Teaching Hospital, Universitas Airlangga, Surabaya, Indonesia (SGATH), and Clínica de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (CAP). 5 , 12 A resource-poor setting was defined as a hospital with a low level of maternal healthcare, in which it is possible to manage uncomplicated pregnancies, and detect, stabilize, and initiate management of unanticipated maternal–fetal problems and high-risk antepartum, intrapartum, or postpartum conditions, but not complex maternal–fetal conditions. 13 We included all women with prenatally undiagnosed PAS who underwent CD in a resource-poor hospital and who, after initial management in that hospital, were transferred to the PAS center.…”

Placenta Accreta Spectrum

“…Single-surgery partial myometrial resection and reconstruction of the uterus is a treatment approach in some areas of the world. [88][89][90] This strategy involves en bloc resection of the placenta and attached myometrium in well-selected cases, followed by repair and reconstruction of the remaining uterus and cervix. 91 This strategy is typically performed during the same surgery as cesarean delivery.…”

A novel approach in the management of placenta accreta spectrum disorders at Tu Du Hospital: a single-center surgical experience from Vietnam

“…Total operation time was ranging from 2 to 3 hours. In this study, blood loss amount in almost cases was reduced to less than 1,500 mL, the level of 1,500 mL can be considered as "cut-off point" in conservative surgery [16]. In this study, intraoperative blood loss was less than 1,500ml in 51 of 65 women, however, the patients needed to blood transfusion in 57 cases due to pre-and postoperative anemia.…”

“…Therefore, besides the development of imaging technology in diagnosing early PASD, the fundamental role of surgery is also extremely important [14]. The advanced trend in PASD management is conservative surgery and preventing catastrophic blood loss [15,16]. In fact, we have many reliable methods to prevent massive postpartum haemorrhage (PPH) and approaching conservative treatment such as internal iliac artery ligation, leaving the placenta completely or partially in situ with or without selective arterial embolization, the stepwise caesarean delivery Nevertheless, some complications have been reported regarding of above-mentioned methods if leaving the placenta in situ, such as severe haemorrhage, septic shock, renal failure, electrolyte imbalance, and pulmonary embolism.…”

“…Moreover, this management needs long-term follow-up, the success rate remains still low and caesarean hysterectomy is often required as the last option for the life-saving procedures. Similarly, internal iliac artery ligation or Triple P procedure is often associated with complications including adjacent organ damage, impact on ovarian reserve, and requires complicated technique [16,21]. In 2015, El Gelany et al described a therapeutic method of cervical inversion as a natural tamponade, which was potentially effective in preventing exceeding blood loss in up to 95% of cases (38 out of 40 cases).…”