Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure

Evidence-based surgery for cesarean hysterectomy secondary to placenta accreta spectrum: A systematic review

OBJECTIVE

In this systematic review, we aim to propose evidence-based management for perioperative care to improve outcomes at the time of planned cesarean hysterectomy for placenta accreta spectrum, a procedure associated with significant maternal and neonatal morbidity.

DATA SOURCES

We conducted a literature search for studies published in MEDLINE (via Ovid), Embase, CINAHL, and Cochrane/CENTRAL up until February 25, 2022. The search included free-text and controlled-vocabulary terms for cesarean section, cesarean delivery, and hysterectomy.

STUDY ELIGIBILITY CRITERIA

We included randomized controlled trials, prospective cohort, retrospective cohort, and case-control studies published in English that reported on a perioperative intervention in the performance of a planned CH for PAS. Studies must have included a comparator group. Of the 8,907 studies screened in this systematic review, 79 met the inclusion criteria.

STUDY APPRAISAL AND SYNTHESIS METHODS

Articles examining each step or intervention of the CH were grouped together and reviewed qualitatively as a group. Evidence levels and recommendations were made by consensus of all authors according to the terminology of the United States Preventive Services Task Force (USPSTF). We synthesized the results of 79 articles, and provided 28 recommendations.

RESULTS

Based on USPSTF criteria, 21.4 % of the recommendations were level B (n = 6), 39.3 % were C (n = 11), 10.7 % were D (n = 3) and 28.6 % were I (n = 8). The interventions with the highest level of recommendation included delivery at a hospital with high cesarean hysterectomy volume, implementation of a standardized hospital protocol, delivery via a planned procedure, neuraxial anesthesia, and transverse skin incision (all level B recommendations by USPSTF criteria).

CONCLUSIONS

Development of a standardized hospital protocol, delivery at a center with high CH surgical volume, and utilization of neuraxial anesthesia garnered B evidence levels. Recommendations were limited due to the lack of prospective trials. Further research into the technical aspects of this high-risk procedure is warranted.

Outcome evaluation of prophylactic internal iliac balloon occlusion in the management of patients with placenta accreta spectrum

PURPOSE

To evaluate outcomes and complications of prophylactic internal iliac balloon occlusion (PIIBO) in the management of patients with placenta accreta spectrum (PAS) at a large regional referral centre.

MATERIALS AND METHODS

A retrospective review of all PIIBO for PAS performed over a 12-year period (2010-2022). Information for analysis was gathered from the local RIS/PACS and clinical documentation. Collected data included patient demographics, indication for procedure, sheath insertion and removal time, total duration of balloon inflation and complications that occurred.

RESULTS

106 patients underwent temporary internal iliac artery balloon occlusion within the 12-year period. All procedures utilised bilateral common femoral artery punctures, 6Fr sheath and 5Fr Le Maitre occlusion balloons. Catheters were successfully positioned and balloons inflated in obstetric theatre following caesarean delivery in 100% of the cases. The uterus was conserved in every case. There was no maternal mortality or foetal morbidity. Twenty patients (18.9%) had some form of complication that required further intervention. Of these, 7(6.6%) had post-operative PPH, which was treated with uterine artery embolisation; and 13 (12.3%) had arterial thrombus which required aspiration thrombectomy. All procedures were technically successful with no long-term sequelae.

CONCLUSION

PIIBO plays an important part in reducing morbidity and mortality in patients with PAS. Clear pathways and multidisciplinary team working is critical in the management of these patients to ensure that any complications are dealt with promptly to avoid long-term sequelae.

Urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders: systematic review and meta-analysis

OBJECTIVE

To report on the occurrence of urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders (PAS).

METHODS

MEDLINE, EMBASE and the Cochrane databases were searched electronically up to 1 November 2022. Studies reporting on the urological outcome of women undergoing Cesarean section for PAS were included. Two independent reviewers performed data extraction using a predefined protocol and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies, with disagreements resolved by consensus.The primary outcome was the overall occurrence of urological complications. Secondary outcomes were the occurrence of any cystotomy, intentional cystotomy, unintentional cystotomy, ureteral damage, ureteral fistula and vesicovaginal fistula. All outcomes were explored in the overall population of women undergoing surgery for PAS. In addition, we performed subgroup analyses according to the type of surgery (Cesarean hysterectomy, or conservative surgery or management), severity of PAS at histopathology (placenta accreta/increta and placenta percreta), type of intervention (planned vs emergency) and number of cases per year. Random-effects meta-analyses of proportions were used to analyze the data.

RESULTS

There were 62 studies included in the systematic review and 56 were included in the meta-analysis. Urological complications occurred in 15.2% (95% CI, 12.9-17.7%) of cases. Cystotomy complicated 13.5% (95% CI, 9.7-17.9%) of surgical operations. Intentional cystotomy was required in 7.7% (95% CI, 6.5-9.1%) of cases, while unintentional cystotomy occurred in 7.2% (95% CI, 6.0-8.5%) of cases. Urological complications occurred in 19.4% (95% CI, 16.3-22.7%) of cases undergoing hysterectomy and 12.2% (95% CI, 7.5-17.8%) of those undergoing conservative treatment. In the subgroup analyses, urological complications occurred in 9.4% (95% CI, 5.4-14.4%) of women with placenta accreta/increta and 38.5% (95% CI, 21.6-57.0%) of those described as having placenta percreta, and included mainly cystotomy (5.5% (95% CI, 0.6-15.1%) and 22.0% (95% CI, 5.4-45.5%), respectively). Urological complications occurred in 15.4% (95% CI, 8.1-24.6%) of cases undergoing a planned procedure and 24.6% (95% CI, 13.0-38.5%) of those undergoing an emergency intervention. In subanalysis of studies reporting on ≥ 12 cases per year, the incidence of urological complication was similar to that reported in the primary analysis.

CONCLUSIONS

Women undergoing surgery for PAS are at high risk of urological complication, mainly cystotomy. The incidence of these complications was particularly high in women described as having placenta percreta at birth and in those undergoing emergency surgical intervention. The high heterogeneity between the included studies highlights the need for a standardized protocol for the diagnosis of PAS to identify prenatal imaging signs associated with the increased risk of urological morbidity at delivery. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Kasr Alainy simplified uterine preserving surgery for conservative management of placenta accreta spectrum (PAS): A modified surgical approach

OBJECTIVE

The incidence of placenta accreta spectrum (PAS) is rising rapidly due to the global surge in Caesarean delivery. It is associated with significant maternal morbidity and mortality. It is usually managed with Caesarean hysterectomy. However, uterine preserving surgeries can have advantages over Caesarean hysterectomy and intentional placental retention techniques.

STUDY DESIGN

We present a modified technique of uterine preserving surgery that uses a safe approach for placental bed surgical devascularization. This is followed by resection of the invaded uterine segment and uterine wall reconstruction.

RESULTS

The technique was used in the management of 20 patients with antenatally suspected PAS that were confirmed at laparotomy. It was successful in preserving the uterus in 18/20 (90 %) women. The mean intraoperative blood loss in was 1305 CC (SD: +361.6) with a mean operative time of 123 min (SD: ±38.7). There was only one urinary bladder injury and no other maternal morbidity.

CONCLUSION

Our surgical technique is safe and may be useful for conservative surgical management of PAS, particularly in low- and middle-income countries, where access to complex resources, such as interventional radiology, is limited.

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

OBJECTIVE

Placenta accreta spectrum disorders (PASD) are the leading cause which results in highly maternal mortality during pregnancy. Although hysterectomy has been the gold standard for PASD, the recent study along with our experience has been demonstrated that the association between uterine myometrial resection and transverse B-Lynch suture in conservative management might be effective in the appropriate patients, thus we hereby attempted to determine this issue.

MATERIALS AND METHODS

A retrospective observational study enrolled 65 patients at Tu Du Hospital in Vietnam between January 2017 and December 2018. This study included all pregnant women above 28 weeks of gestational age, who had undergone cesarean delivery due to PASD diagnosed preoperatively by ultrasound or upon laparotomy. Additionally, all patients who desired uterine preservation underwent modified one-step conservative uterine surgery (MOSCUS), avoiding peripartum hysterectomy.

RESULTS

Overall, the rate of successful preservation was 93.8%. Other main outcomes such as average operative blood loss was 987 mL, mean blood transfusion was 831 ± 672 mL; mean operative time was 135 ± 31 min and average postoperative time was 5.79 days. Postoperative complications included six out of 65 cases due to intraoperative bleeding and postoperative infection, requiring hysterectomy in 4 patients.

CONCLUSION

MOSCUS was associated with less operative blood loss and blood transfusion amount. Its success rate of uterine preservation was approximately 94% in our study. Thus, this method can be acceptable in PASD management at our maternity health care center. Further studies might be necessary to evaluate the long-term effects of this method in PASD management.

Procedural techniques to control postpartum hemorrhage

Postpartum hemorrhage can occur unexpectedly and with high dynamics. The mother's life often depends on quick action and good communication within an interdisciplinary team. Knowledge of each other's therapeutic options plays a major role. Treatment procedures include obstetric, surgical, and radiologic techniques. In addition to availability and experience with the techniques, two important aspects must be considered in the selection process: the type of delivery and the cause of the hemorrhage. In particular, the distinction between pregnancies with or without disturbed placentation from the placenta accreta spectrum is crucial. From these two points of view, we discuss here different uterus-preserving and uterus-removing techniques. We describe in detail the advantages and disadvantages of each procedure. Because most therapeutic options are based on small case series and uncontrolled studies, local circumstances and physician experience are critical in setting internal standards.

Placenta accreta spectrum: a non-oncologic challenge for gynecologic oncologists

Placenta accreta spectrum disorders are a major risk factor for severe postpartum hemorrhage and maternal death worldwide, with a rapidly growing incidence in recent decades due to increasing rates of cesarean section. Placenta accreta spectrum disorders represent a complex surgical challenge, with the primary concern of massive obstetrical hemorrhagic sequelae and organ damage, occurring in the context of potentially significant anatomical and physiological changes of pregnancy. Most international obstetrical organizations have published guidelines on placenta accreta spectrum, embracing the creation of regionalized 'Centers of Excellence' in the diagnosis and management of placenta accreta spectrum, which includes a dedicated multidisciplinary surgical team. One mandatory criterion for these Centers of Excellence is the presence of a surgeon experienced in complex pelvic surgeries. Indeed, many institutions in the United States and worldwide rely on gynecologic oncologists in the surgical management of placenta accreta spectrum due to their experience and skills in complex pelvic surgery. Surgical management of placenta accreta spectrum frequently includes challenging pelvic dissection in regions with distortion of anatomy alongside large aberrant neovascularization. With a goal of definitive management through cesarean hysterectomy, surgeons require a systematic and thoughtful approach to promote prevention of urologic injuries, embrace measures to secure challenging hemostasis and, in selected cases, employ conservative management where indicated or desired. In this review recommendations are made for gynecologic oncologists regarding the management and important considerations in the successful care of placenta accreta spectrum disorders. Where required, gynecologic oncologists are encouraged to be proactively involved in the management of placenta accreta spectrum, not only intra-operatively, but also in the development of clinical protocols, guidelines, and pre-operative counseling of patients, as a 'call if needed' approach is suboptimal for this potentially major and life-threatening condition.

Effects and Long-Term Outcomes of a Modified Triple-P Procedure in Patients With Severe PAS: A Retrospective Cohort Study

Background

The distinguished Triple-P procedure has been reported as a conservative surgical alternative to peripartum hysterectomy for placental accreta spectrum (PAS). In this study, we modified the procedure combined with prophylactic abdominal aorta balloon occlusion and/or tourniquet and evaluated the effect and long-term outcomes.

Methods

This was a retrospective study involving pregnant patients with clinically confirmed severe PAS (including placenta increta and percreta) between January 1st, 2017 and June 30th, 2020 in the First Affiliated Hospital of Zhengzhou University. A total of 334 pregnant women were recruited in this study. The 142 women that were subjected to modified Triple P Procedure were regarded as the observation group while 194 pregnant women that were treated with other sutures were regarded as the control group. Demographic characteristics, placental accreta spectrum score (PAS score), estimated blood loss (EBL), operative time, blood transfusion rate and volume, neonatal weight, post-operative hospital stays and costs were evaluated. Short-term complications, including fever, hematoma, thrombus, bladder rupture and intensive care unit (ICU) transfer rate, as well as long-term outcomes including breast feeding, menstruation, intrauterine adhesion, and chronic abdominal pain among others were followed up in the outpatient clinic and by phone calls.

Results

For all cases, EBL was lower in the observation group than in the control group, 1,200 (687–1,812) ml and 1,300 (800–2,500) ml, respectively. The difference was statistically significant (P < 0.05). Operative time were statistically significantly shorter in the observation group [99.5 (84.0–120.0) min and 109.0 (83.8–143.0) min, P < 0.05]. Lengths of postoperative hospital stays were 4 (4–7) and 5 (4–7) days in the observation and control group, which was significantly shorter in the observation group (P < 0.05). There were no significant differences in PAS scores, blood transfusion volume, neonatal weight, fever, hematoma, thrombus, bladder rupture and ICU transfer rates between the two groups. All patients, except one in control group, had preserved uterus. There were no statistically significant differences in short-term and long-term complications between two groups.

Conclusion

In summary, when combined with tourniquet and/or prophylactic abdominal aorta balloon occlusion, modified Triple-P procedure may be effective in reducing intraoperative blood loss and hysterectomy in patients with placenta increta/percreta. It is a safe and effective surgical alternative to peripartum hysterectomy. However, the complications associated with interventional radiology service should be evaluated furthermore.

Prophylactic Intraoperative Uterine Artery Embolization During Cesarean Section or Cesarean Hysterectomy in Patients with Abnormal Placentation: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the effectiveness and safety of prophylactic intraoperative uterine artery embolization (UAE) performed immediately after fetal delivery during planned cesarean section or cesarean hysterectomy in patients with placenta accreta spectrum disorder or placenta previa.

METHODS

A systematic search was conducted on Ovid MEDLINE and Embase, PubMed, Web of Science, and Cochrane databases. Studies were selected using the Population/Intervention/Comparison/Outcomes (PICO) strategy. The intraoperative blood loss and the rate of emergent peripartum hysterectomy (EPH) were the primary outcomes, whereas the length of hospital stay and volume of blood transfused were the secondary outcomes. A random-effects model was employed to pool each effect size. The cumulative values of the primary outcomes were calculated using the generic inverse variance method.

RESULTS

Eleven retrospective cohort studies and five case series were included, recruiting 421 women who underwent prophylactic intraoperative UAE (UAE group) and 374 women who did not (control group). Compared with the control group, the UAE group had significantly reduced intraoperative blood loss (p = 0.020) during cesarean section or cesarean hysterectomy. Furthermore, the EPH rate was also significantly decreased (p = 0.020; cumulative rate: 19.65%), but not the length of hospital stay (p = 0.850) and volume of pRBC transfused (p = 0.140), after cesarean section in the UAE group. The incidence of major complications was low (3.33%), despite two patients with uterine necrosis.

CONCLUSION

The currently available data provides encouraging evidence that prophylactic intraoperative UAE may contribute to hemorrhage control and fertility preservation in women with abnormal placentation.

REGISTRATION

PROSPERO registration code: CRD42021230581. https://clinicaltrials.gov/ct2/show/CRD42021230581 LEVEL OF EVIDENCE: Level 2a, systematic review of retrospective cohort studies.

Placenta accreta spectrum-a catastrophic situation in obstetrics

Placenta accreta is a significant obstetric complication in which the placenta is completely or focally adherent to the myometrium. The worldwide incidence of placenta accreta spectrum (PAS) is increasing day by day, mostly due to the increasing trends in cesarean section rates. The accurate and timely diagnosis of placenta accreta is important to improve the feto-maternal outcome. Although standard ultrasound is a reliable and primary tool for the diagnosis of placenta accreta, the absence of ultrasound findings does not preclude the diagnosis of placenta accreta. Therefore, clinical evaluation of risk factors is equally essential for the prediction of abnormal placental invasion. Pregnant women with a high impression or established diagnosis of placenta accreta should be managed by a multidisciplinary team in a specialist center. Traditionally, PAS has been managed by an emergency obstetric hysterectomy. Previously, few studies suggested a satisfactory success rate of conservative management in well-chosen cases, whereas few studies recommended delayed hysterectomy to reduce the amount of bleeding. The continuously increasing trends of PAS and the challenges for its routine management are the main motives behind this literature review.

What we know about placenta accreta spectrum (PAS)

Placenta accreta spectrum (PAS) is an umbrella term for a variety of pregnancy complications due to abnormal placental implantation, including placenta accreta, placenta increta and placenta percreta. During the past several decades, the prevalence of PAS has been increasing, and the clinical importance of this disease is significant because of the severe complications. In this review, we summarized the available evidence-based data for PAS in various aspects: prevalence, risk factors, pathogenesis, clinical presentation and prenatal screening, and clinical management. Meanwhile, we provided a series of prospects in each section for further studies on PAS. Moreover, we first present a visualized workflow for the management of PAS from three steps: predelivery, during delivery and postdelivery.

Placenta Accreta Spectrum Disorders: Challenges, Risks, and Management Strategies

The worldwide incidence of placenta accreta spectrum (PAS) is rapidly increasing, following the trend of rising cesarean delivery. PAS is an heterogeneous condition associated with a high maternal morbidity and mortality rate, presenting unique challenges in its diagnosis and management. So far, the rarity of this condition, together with the absence of high quality evidence and the lack of a standardized approach in reporting PAS cases for the ultrasound, clinical, and pathologic diagnosis, represented the main challenges for a deep understanding of this condition. The study of the available management strategies of PAS has been hampered by the heterogeneity of the available epidemiological data on this condition. The aim of this review is to provide a critical view of the current available evidence on the screening, the diagnosis, and the management options for PAS disorders, with a special focus on the challenges we foresee for the near future.

A new conservative surgical approach for placenta accreta spectrum in a low-resource setting

OBJECTIVE

To assess the efficacy and safety of a new surgical approach for uterine preservation among patients with placenta accreta spectrum in a low-resource setting.

METHODS

The present prospective cohort included 63 women diagnosed with placenta accreta spectrum undergoing cesarean deliveries who desired future fertility at the obstetrics department of Menoufia University Hospital from January 2018 to November 2019. Surgical management involved direct bilateral uterine arteries clamping below placental bed after broad ligament opening by round ligaments division and ligation and gentle downward dissection of vesical from myometrial tissues from lateral aspect toward trigone of the bladder. Outcomes included intraoperative and postoperative adverse events, hysterectomy rate, and postoperative hospitalization.

RESULTS

Mean operative blood loss was 1860 ± 537 mL (range, 1040-3111 mL) and the incidence of bladder and ureteric injuries were 6.3% (n = 4) and 0%, respectively. The mean length of hospital stay was 4.46 ± 1.39 days. Overall, 7 patients (11.1%) required postoperative blood transfusion, and 2 patients (3.2%) required ICU admission. Five patients required peripartum hysterectomy (7.9%).

CONCLUSION

Our conservative surgical approach is a safe alternative to peripartum hysterectomy with high uterine preservation rate, less intraoperative and postoperative morbidity and less need for blood transfusion in low resource settings.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; NCT04161521.

Management of abnormal invasive placenta in a low- and medium-resource setting

The purpose of this review is to describe the panorama of placenta accreta spectrum (PAS) disorder management in low- and middle-income countries, providing information that allows for the improvement of maternal and perinatal outcomes in the management of this pathology. This spectrum of disorders is associated with implications of high morbidity and mortality, both maternal and perinatal, which is why clinical practice guidelines based on management are produced in settings where there is a wide range of available resources. This situation often contrasts with what the reality is in low-resource countries. Prenatal diagnosis of placental accreta is essential to carry out adequate surgical planning in centres where multidisciplinary teams are in place, which improve results and reduce complications. These ideal scenarios should be developed in countries with more significant difficulties in the availability of human and technological resources, through teamwork in the different hospital centres and the adequate transfer of patients at higher risk to centres with the best interdisciplinary management skills.

Conservative surgical approach: The Triple P procedure

The incidence of abnormally invasive placenta (AIP) or currently called placenta accreta spectrum (PAS) disorders has increased worldwide over the last few decades. Although the exact physiopathology is not yet well established, there is consensus that an increase in the Caesarean section rates, uterine surgery and the advanced maternal age are important contributory factors. Traditionally, the treatment for PAS has been a peripartum hysterectomy. Conservative measures have been reported in the literature include an intentional retention of the placenta (IRP) or partial myometrial excision. We present an alternative conservative approach, the Triple P procedure. It involves three main steps: perioperative localization of the upper placental edge, pelvic devascularization and the placental non-separation with myometrial excision followed by the repair of the myometrial defect. The aim of this approach is to reduce the intra- and post-operative complications associated with a peripartum hysterectomy, to reduce the time of surgery and to minimize common complications of placental retention, such as infection, sepsis secondary postpartum haemorrhage and coagulopathy.

How to set up a regional specialist referral service for Placenta Accreta Spectrum (PAS) disorders?

There has been an approximately fivefold increase in the incidence of placenta accreta spectrum (PAS) disorders during the last 30 years, believed to be secondary to increasing Caesarean section rates. PAS disorder is associated with significantly increased maternal morbidity and mortality worldwide. Antenatal diagnosis by foetal medicine teams that have a special expertise to diagnose PAS disorder by the use of ultrasound scan, and a dedicated, highly specialised multidisciplinary team (MDT) comprising surgeons who are skilled in complex pelvic surgery and obstetric anaesthetists who have an expertise in high-risk obstetric anaesthesia, supported by haematology, operating theatre, interventional radiology, midwifery, neonatology, high-dependency and intensive care teams have been recommended to improve maternal and perinatal outcomes. Setting up a specialist MDT regional referral service, PAS involves collaboration with all stakeholders, ensuring appropriate funding, developing MDT care pathways, continuously auditing patient outcomes and disseminating knowledge through research, innovation, education and publications.

Etiopathogenesis and risk factors for placental accreta spectrum disorders

Placenta accreta spectrum (PAS) disorders, comprising placenta accreta, increta, and percreta, are associated with serious maternal morbidity and mortality in both the developed and the developing world. The incidence of PAS has increased in the recent years, and the rising rates of cesarean section rate, placenta accreta in previous pregnancies, and other uterine surgeries including myomectomies and repeated endometrial curettage are implicated in its etiopathogenesis. The absolute risk of PAS increases with the number of previous cesarean sections. The PAS remains undiagnosed in one-half to two-thirds of cases, thus increasing maternal morbidity and mortality. Understanding etiopathogenesis and risk factors of this condition allows early diagnosis and planning of delivery, and thereby would help improve maternal and fetal outcomes.

Placenta accreta spectrum: Risk factors, diagnosis and management with special reference to the Triple P procedure

Abnormal invasion of placenta or placenta accreta spectrum disorders refer to the penetration of the trophoblastic tissue through the decidua basalis into the underlying uterine myometrium, the uterine serosa or even beyond, extending to pelvic organs. It is classified depending on the degree of invasion into placenta accreta (invasion <50% of the myometrium), increta (invasion >50% of the myometrium) and percreta (invading the serosa and adjacent pelvic organs). Clinical diagnosis is made intra-operatively; however, the confirmative diagnosis can only be made after a histopathological examination. The incidence of abnormal invasion of placenta has increased worldwide, mostly as a consequence of the rise in caesarean section rates, from 1 in 2500 pregnancies to 1 in 500 pregnancies. The importance of the disease is due to the increased maternal and foetal morbidity and mortality. Foetal implications are mainly due to iatrogenic prematurity, while maternal implications are mostly the increased risk of obstetric haemorrhage and surgical complications. The average blood loss is 3000–5000 mL, and up to 90% of the patients require a blood transfusion. An accurate and timely antenatal diagnosis is essential to improve outcomes. The traditional management of abnormal invasion of placenta has been a peripartum hysterectomy; however, the increased incidence and the short- and long-term consequences of a radical approach have led to the development of more conservative techniques, such as the intentional retention of the placenta, partial myometrial excision and the ‘Triple P procedure’. Irrespective of the surgical technique of choice, women with a high suspicion or confirmed abnormally invasive placenta should be managed in a specialist centre with surgical expertise with a multi-disciplinary team who is experienced in managing these complex cases with an immediate availability of blood products, interventional radiology service, an intensive care unit and a neonatal intensive care unit to optimize the outcomes.

Conservative management versus cesarean hysterectomy in patients with placenta increta or percreta

OBJECTIVE

To compare conservative management and cesarean hysterectomy in patients with placenta increta or percreta.

MATERIALS AND METHODS

In this multicenter retrospective study, we recorded data on 2219 patients with placenta increta or percreta from 20 tertiary care centers in China from 1 January 2011 to 31 December 2015. Propensity score analysis was used to control for baseline characteristics. We divided patients into conservative management (C) and hysterectomy (H) groups. The primary outcome was operative/postoperative maternal morbidity; secondary outcomes were maternal-neonatal outcomes.

RESULTS

In total, 17.9% (398/2219) of patients had placenta increta and percreta; 82.1% (1821/2219) of the patients were in group C. After propensity score matching, 140 pairs of patients from the two groups underwent one-to-one matching. Group C showed less average blood loss within 24 h of surgery (1518 ± 1275 vs. 4309 ± 2550 ml in group H, p<.001). There were more patients with blood loss >1000 ml in group H than in group C (93.6% [131/140] vs. 61.4% [86/140], p<.001). More patients received blood transfusions in group H than in group C (p=.014). There was no significant difference between the groups in terms of bladder injury, postoperative anemia, fever, and disseminated intravascular coagulation. Neonatal outcomes in the two groups were similar.

CONCLUSION

Either conservative management or hysterectomy should be considered after thorough evaluation and detailed discussion of risks and benefits. A balance between bleeding control and fertility can be achieved.

A Literature Review of Placenta Accreta Spectrum Disorder: The Place of Expectant Management in Ethiopian Setup

In the last three to four decades, the increasing caesarean delivery rate has contributed to several fold increment in the incidence of placenta accreta spectrum disorders globally. Placenta accreta spectrum with its subtypes (accreta, increta and percreta) is one of the devastating obstetric complications. As a result, it is the commonest indication for peripartum hysterectomy and common cause of severe maternal morbidity. However, in recent years, there is a growing interest in and practice of expectant management either to minimize emergency hysterectomy related maternal complications or to preserve the fertility potential of a woman with an intact uterus. A large body of observational research findings has demonstrated the success rate of expectant management in many of well selected cases. Similarly, the experience on delayed hysterectomy was encouraging in order to have less hemorrhage. For the best success of placenta accreta spectrum management, multidisciplinary team approach, antenatal diagnosis and managing such cases in a hospital with center of excellence has been strongly recommended. This literature review provides a robust synthesis of up-to-date knowledge and practice on the challenges and successes of placenta accreta spectrum disorders management. The currently practiced management options in the high and middle income countries are also summarized under seven categories. Therefore, the purpose of this review was to shed light on the applicability of the PAS disorder management modalities in our setup.

Outcomes following a clinical algorithm allowing for delayed hysterectomy in the management of severe placenta accreta spectrum

BACKGROUND

The incidence of placenta accreta spectrum is rising. Management is most commonly with cesarean hysterectomy. These deliveries often are complicated by massive hemorrhage, urinary tract injury, and admission to the intensive care unit. Up to 60% of patients require transfusion of ≥4 units of packed red blood cells. There is also a significant risk of death of up to 7%.

OBJECTIVE

The purpose of this study was to assess the outcomes of patients with antenatal diagnosis of placenta percreta that was managed with delayed hysterectomy as compared with those patients who underwent immediate cesarean hysterectomy.

STUDY DESIGN

We performed a retrospective study of all patients with an antepartum diagnosis of placenta percreta at our large academic institution from January 1, 2012, to May 30, 2018. Patients were treated according to standard clinical practice that included scheduled cesarean delivery at 34-35 weeks gestation and intraoperative multidisciplinary decision-making regarding immediate vs delayed hysterectomy. In cases of delayed hysterectomy, the hysterotomy for cesarean birth used a fetal surgery technique to minimize blood loss, with a plan for hysterectomy 4-6 weeks after delivery. We collected data regarding demographics, maternal comorbidities, time to interval hysterectomy, blood loss, need for transfusion, occurrence of urinary tract injury and other maternal complications, and maternal and fetal mortality rates. Descriptive statistics were performed, and Wilcoxon rank-sum and chi-square tests were used as appropriate.

RESULTS

We identified 49 patients with an antepartum diagnosis of placenta percreta who were treated at Vanderbilt University Medical Center during the specified period. Of these patients, 34 were confirmed to have severe placenta accreta spectrum, defined as increta or percreta at the time of delivery. Delayed hysterectomy was performed in 14 patients: 9 as scheduled and 5 before the scheduled date. Immediate cesarean hysterectomy was completed in 20 patients: 16 because of intraoperative assessment of resectability and 4 because of preoperative or intraoperative bleeding. The median (interquartile range) estimated blood loss at delayed hysterectomy of 750 mL (650-1450 mL) and the sum total for delivery and delayed hysterectomy of 1300 mL (70 -2150 mL) were significantly lower than the estimated blood loss at immediate hysterectomy of 3000 mL (2375-4250 mL; P<.01 and P=.037, respectively). The median (interquartile range) units of packed red blood cells that were transfused at delayed hysterectomy was 0 (0-2 units), which was significantly lower than units transfused at immediate cesarean hysterectomy (4 units [2-8.25 units]; P<.01). Nine of 20 patients (45%) required transfusion of ≥4 units of red blood cells at immediate cesarean hysterectomy, whereas only 2 of 14 patients (14.2%) required transfusion of ≥4 units of red blood cells at the time of delayed hysterectomy (P=.016). There was 1 maternal death in each group, which were incidences of 7% and 5% in the delayed and immediate hysterectomy patients, respectively.

CONCLUSION

Delayed hysterectomy may represent a strategy for minimizing the degree of hemorrhage and need for massive blood transfusion in patients with an antenatal diagnosis of placenta percreta by allowing time for uterine blood flow to decrease and for the placenta to regress from surrounding structures.

Triple P with T-shaped lower segment suture; an effective novel alternative to hysterectomy in morbidly adherent anterior placenta previa

PURPOSE

To evaluate the efficacy and safety of the Triple-P procedure as a conservative method in women with morbidly adherent placenta (MAP).

MATERIALS AND METHODS

A prospective trial conducted on 20 women performing elective cesarean sections (CS) at 37 weeks for anterior placenta previa accreta or increta. All women were young aged with low parity and previous CS deliveries. Triple-P procedure involved delivery of the fetus through a uterine incision placed above the upper border of the placenta, bilateral uterine arteries ligation immediately after delivery of the fetus followed by placental nonseparation and myometrial excision with reconstruction of the uterine wall in a T-shaped manner. The study outcome measures included duration of surgery, amount of intra and postoperative blood loss, Percentage of hemoglobin (Hb %) reduction, the need to perform hysterectomy and postoperative complications.

RESULTS

Mean duration of surgery was 58 ± 1.8 min, mean intraoperative blood loss was 1.3 ± 0.3 l, mean postoperative blood loss was 180 ± 94 ml and mean Hb % reduction was 1.5 ± 0.1 g/dl. Only one case necessitated hysterectomy for severe bleeding.

CONCLUSION

Triple-P procedure is a novel effective weapon that can replace hysterectomy in suitable women with MAP, especially in young patients with low parity.

Placenta Accreta Spectrum (PAS) disorders: incidence, risk factors and outcomes of different management strategies in a tertiary referral hospital in Minia, Egypt: a prospective study

Background

Placenta accreta spectrum (PAS) disorders have become a significant life-threatening issue due to its increased incidence, morbidity and mortality. Several studies have tried to identify the risk factors for PAS disorders. The ideal management for PAS disorders is a matter of debate. The study objectives were to evaluate the incidence and risk factors of PAS disorders and to compare different management strategies at a tertiary referral hospital, Minia, Egypt.

Methods

This prospective study included 102 women diagnosed with PAS disorders admitted to Minia Maternity university hospital, Egypt between January 2017 to August 2018. These cases were categorized into three groups according to the used approach for management: Group (A), (n = 38) underwent cesarean hysterectomy, group (B), (n = 48) underwent cesarean section (CS) with cervical inversion and ligation of both uterine arteries and group (C), (n = 16): the placenta was left in place.

Results

The incidence of PAS disorders during the study period was 9 / 1000 maternities (0.91%). The mean age of cases was 32.4 ± 4.2 years, 60% of them had a parity ≥3 and 82% of them had ≥2 previous CSs. Also, 1/3 of them had previous history of placenta previa. Estimated blood loss (EBL) and blood transfusion in group A were significantly higher than other groups. Group (C) had higher mean hospital stay duration. Group A was associated with significantly higher complication rate.

Conclusions

The incidence of PAS disorders was 0.91%. Maternal age > 32 years, previous C.S. (≥ 2), multiparity (≥ 3) and previous history of placenta previa were risk factors. The management of PAS disorders should be individualized. Women with PAS disorders who completed their family should be offered cesarean hysterectomy. Using the cervix as a tamponade combined with bilateral uterine artery ligation appears to be a safe alternative to hysterectomy in patients with focal placenta accreta and low parity desiring future fertility. Patients with diffuse placenta accreta keen to preserve the uterus could be offered the option of leaving the placenta aiming at conservative management after proper counseling.

Trial registration

Registered 28th October 2015, ClinicalTrials.gov NCT02590484.

Evidence-based guidelines for the management of abnormally invasive placenta: recommendations from the International Society for Abnormally Invasive Placenta

The worldwide incidence of abnormally invasive placenta is rapidly rising, following the trend of increasing cesarean delivery. It is a heterogeneous condition and has a high maternal morbidity and mortality rate, presenting specific intrapartum challenges. Its rarity makes developing individual expertise difficult for the majority of clinicians. The International Society for Abnormally Invasive Placenta aims to improve clinicians' understanding and skills in managing this difficult condition. By pooling knowledge, experience, and expertise gained within a variety of different healthcare systems, the Society seeks to improve the outcomes for women with abnormally invasive placenta globally. The recommendations presented herewith were reached using a modified Delphi technique and are based on the best available evidence. The evidence base for each is presented using a formal grading system. The topics chosen address the most pertinent questions regarding intrapartum management of abnormally invasive placenta with respect to clinically relevant outcomes, including the following: definition of a center of excellence; requirement for antenatal hospitalization; antenatal optimization of hemoglobin; gestational age for delivery; antenatal corticosteroid administration; use of preoperative cystoscopy, ureteric stents, and prophylactic pelvic arterial balloon catheters; maternal position for surgery; type of skin incision; position of the uterine incision; use of interoperative ultrasound; prophylactic administration of oxytocin; optimal method for intraoperative diagnosis; use of expectant management; adjuvant therapies for expectant management; use of local surgical resection; type of hysterectomy; use of delayed hysterectomy; intraoperative measures to treat life-threatening hemorrhage; and fertility after conservative management.

Role of interventional radiology in pregnancy complicated by placenta accreta spectrum disorder: systematic review and meta-analysis

OBJECTIVE

To evaluate the potential benefit of interventional radiology (IR) in improving the outcome of women undergoing surgery for a placenta accreta spectrum (PAS) disorder.

METHODS

MEDLINE, EMBASE and CINAHL databases were searched for studies comparing outcomes of women with a prenatal diagnosis of PAS who underwent an IR procedure before surgery vs those who did not, using a robust collection of terms relating to PAS. The primary outcome was intraoperative estimated blood loss (EBL). Secondary outcomes were the number of transfused units of packed red blood cells (PRBC), fresh frozen plasma (FFP), platelets and cryoprecipitate, operation time, length of hospital stay, EBL ≥ 2.5 L, PRBC transfused ≥ 5 units, surgical complications, bladder or ureteral injury, relaparotomy, infection, disseminated intravascular coagulation, and complications related to endovascular catheter placement. Only studies reporting on the incidence of, or the mean difference in, the observed outcomes in women affected by a PAS disorder who had vs those who did not have an IR procedure before surgery were considered for inclusion. All outcomes were explored in the overall population of women with a prenatally diagnosed PAS disorder and in those undergoing hysterectomy. Quality assessment of each included study was performed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. The GRADE methodology was used to assess the quality of the body of retrieved evidence.

RESULTS

Fifteen studies (958 women with PAS) were included. In women who underwent IR before surgery, compared with those who did not, mean EBL (mean difference (MD), -1.02 L; 95% CI, -1.60 to -0.43 L; P < 0.001) and the risk of EBL ≥ 2.5 L (odds ratio (OR), 0.18; 95% CI, 0.04-0.78; P = 0.02) were significantly lower. There was no significant difference between the two groups in the other outcomes explored. On subgroup analysis of pregnancies complicated by PAS undergoing hysterectomy, EBL (MD, -0.68 L; 95% CI, -1.24 to -0.12 L; P = 0.02) and the number of transfused FFP units (MD, -1.66; 95% CI, -2.71 to -0.61; P = 0.02) were significantly lower in women who had an endovascular IR procedure compared with controls. Furthermore, women undergoing IR had a significantly lower risk of EBL ≥ 2.5 L (OR, 0.10; 95% CI, 0.02-0.47; P = 0.004). Overall, complications related to the placement of an endovascular catheter occurred in 5.3% (95% CI, 2.6-8.9; I² , 65.3%) of pregnancies undergoing IR. Overall quality of evidence, as assessed by GRADE, was very low.

CONCLUSIONS

The current available data provide encouraging evidence that IR procedures may be associated with lower EBL and need for transfusion in pregnancies undergoing surgery for a PAS disorder. However, given the overall very low quality of the evidence, further large studies are needed in order to confirm the beneficial role of IR in improving the outcome of these women. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Conservative Management of Placenta Accreta Spectrum

The purpose of this review was to assist obstetricians and gynecologists in considering the most appropriate conservative treatment option to manage women with placenta accreta spectrum according to their individual need and local expertise of the heath care team. The issue is challenging, as the quality of evidence with regard to efficacy is poor, and is mainly based on retrospective studies with limited sample size.

Resective-reconstructive treatment of abnormally invasive placenta: Inter Institutional Collaboration by telemedicine (eHealth)

Introduction: Resective-reconstructive treatment of an abnormally invasive placenta, also known as conservative surgical management, allows a comprehensive treatment of the pathology in only one surgery; however, this alternative is not generally included in international consensus, as it requires specific training. Here, we report our experience of this type of treatment and its plausibility after training facilitated by interinstitutional collaboration via telemedicine.Materials and methods: A total of 48 women who were diagnosed with abnormally invasive placenta, before and after changes due to the resection-reconstruction protocol were included in the study.Results: In total, 14 conservative reconstructive procedures were performed with outcomes of a lower rate of bleeding, reduced transfusions and complications, and a shorter duration of hospitalization than women with hysterectomy.Conclusion: Conservative surgical management is a safe alternative when implemented at specialized centers by trained groups of professionals. Interinstitutional collaboration, using appropriate telemedicine is a safe and effective alternative to enable training in resective-conservative management of abnormally invasive placenta.

Management of bleeding from morbidly adherent placenta during elective repeat caesarean section: retrospective -record -based study

Background

Controlling massive haemorrhage from morbidly adherent placenta (MAP) at caesarean section is a major surgical challenge to obstetricians. This study compares different intra-operative interventions to control haemorrhage from morbidly adherent placenta and its impact on maternal morbidity.

Methods

Retrospective analysis was done for baseline characteristics, intra-operative and postoperative complications of 125 patients with morbidly adherent placenta who had elective CS at 35–38 weeks gestation in the period from 01/2012 to 01/2017. The included patients were categorized into three groups according to intra-operative interventions they had for controlling bleeding; Group A (n = 42) had only balloon tamponade, Group B (n = 40) had balloon tamponade and bilateral uterine artery ligation, in Group C (n = 43) all cases were managed by bilateral uterine artery ligation and inverting the cervix into the uterine cavity and suturing the anterior and/or the posterior cervical lips into the anterior and/or posterior walls of the lower uterine segment using the cervix as a natural tamponade.

Results

There were no differences of baseline characteristics of patients in all groups. Group C had significantly better outcomes as compared with groups A and B; less total blood loss (Group C 2869.5 ml vs Group B 4580 ml, Group A 4812 ml, P <  0.001), less requirement of blood transfusion more than 4 units (Group C 4/43, Group B 10/40,Group A 12/42, P <  0.02), significant reduction in prolonged hospital stay over 10 days (Group C 2/43, Group B 9/40,Group A 14/42, P < 0.001) and lower risk of coagulopathy (Group C 4/43, B 8/40, A 9/42), visceral injuries (Group C 4/43 vs B 8/40, A 10/42,P < 0.01) and need for hysterectomy (Group C 4/43 vs B 11/40, A 13/42,P < 0.001).

Conclusion

A combination bilateral uterine artery ligation and using the cervix as a natural tamponade are very effective and simple methods in controlling bleeding resulting from separated placenta accreta.

Trial registration

The findings are part of the research project registered in ClinicalTrials.gov NCT02590484. Registered 28 October 2015.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2244-4) contains supplementary material, which is available to authorized users.

The application of uterine wall local resection and reconstruction to preserve the uterus for the management of morbidly adherent placenta: Case series

OBJECTIVE

We aimed to evaluate our experience with the application of uterine wall local resection and reconstruction to preserve the uterus in patients with morbidly adherent placenta.

MATERIALS AND METHODS

In a retrospective study, data from patients with morbidly adherent placenta who delivered by cesarean section between January 1, 2013 and May 31, 2016 were analyzed. Prophylactic abdominal aorta balloon occlusion and tourniquet were used to prevent massive hemorrhage in all 62 cases, followed by uterine wall local resection and reconstruction to preserve the uterus. The quantity of estimated blood loss (EBL), operation time, and complications were analyzed.

RESULTS

The placenta penetrated to the myometrium in 10 cases, involved the posterior bladder wall in 46 cases, and penetrated the posterior bladder wall in six cases. For all cases, the mean EBL in the surgery was 1377.3 ± 605.2 mL, the mean EBL in the initial postoperative 24 h was 140.6 ± 66.3 mL, the mean operation time was 72.3 ± 24.5 min, and the mean postoperative hospital stay was 5.8 ± 1.6 days. The six cases of placenta penetrating the bladder underwent bladder repair. Sixty-one cases had preserved uterus, and only one case had a hysterectomy due to amniotic fluid embolism (AFE).

CONCLUSION

Combined with prophylactic abdominal aorta balloon occlusion and tourniquet, uterine wall local resection and reconstruction is highly effective to reduce the intraoperative blood loss and hysterectomy in morbidly adherent placenta.

The Rising Triad of Cesarean Scar Pregnancy, Placenta Percreta, and Uterine Rupture: A Case Report and Comprehensive Review of the Literature

As the rate of cesarean sections continues to rapidly rise, knowledge of diagnosis and management of cesarean scar pregnancies (CSPs) is becoming increasingly more relevant. CSPs rest on the continuum of placental abnormalities which include morbidly adherent placenta (accreta, increta, and percreta). A CSP poses a clinical challenge which may have significant fetal and maternal morbidity. At this point, no clear management guidelines and recommendations exist. Herein we describe the case of a second trimester CSP with rapid diagnosis and management in a tertiary care center. The case underscores the need for well-coordinated mobilization of resources and a multidisciplinary approach. A review of the literature is performed and deficits in universal management principles are underscored.

Perinatal and long-term effects of maternal uterine artery adenoviral VEGF-A165 gene therapy in the growth-restricted guinea pig fetus

Uterine artery application of adenoviral vascular endothelial growth factor A₁₆₅ (Ad.VEGF-A₁₆₅) gene therapy increases uterine blood flow and fetal growth in experimental animals with fetal growth restriction (FGR). Whether Ad.VEGF-A₁₆₅ reduces lifelong cardiovascular disease risk imposed by FGR remains unknown. Here, pregnant guinea pigs fed 70% normal food intake to induce FGR received Ad.VEGF-A₁₆₅ (1×10¹⁰ viral particles, n = 15) or vehicle ( n = 10), delivered to the external surface of the uterine arteries, in midpregnancy. Ad libitum-fed controls received vehicle only ( n = 14). Litter size, gestation length, and perinatal mortality were similar in control, untreated FGR, and FGR+Ad.VEGF-A₁₆₅ animals. When compared with controls, birth weight was lower in male but higher in female pups following maternal nutrient restriction, whereas both male and female FGR+Ad.VEGF-A₁₆₅ pups were heavier than untreated FGR pups ( P < 0.05, ANOVA). Postnatal weight gain was 10-20% greater in female FGR+Ad.VEGF-A₁₆₅ than in untreated FGR pups, depending on age, although neither group differed from controls. Maternal nutrient restriction reduced heart weight in adult female offspring irrespective of Ad.VEGF-A₁₆₅ treatment but did not alter ventricular wall thickness. In males, postnatal weight gain and heart morphology were not affected by maternal treatment. Neither systolic, diastolic, mean arterial pressure, adrenal weight, nor basal or challenged plasma cortisol were affected by maternal undernutrition or Ad.VEGF-A₁₆₅ in either sex. Therefore, increased fetal growth conferred by maternal uterine artery Ad.VEGF-A₁₆₅ is sustained postnatally in FGR female guinea pigs. In this study, we did not find evidence for an effect of maternal nutrient restriction or Ad.VEGF-A₁₆₅ therapy on adult offspring blood pressure.

A Case of Placenta Percreta Managed with Sequential Embolisation Procedures

Background

The incidence of morbidly adherent placenta, including placenta percreta, has increased significantly over recent years due to rising caesarean section rates. Historically, abnormally invasive placenta has been managed with caesarean hysterectomy; however nonsurgical interventions such as uterine artery embolisation (UAE) are emerging as safe alternative management techniques. UAE can be utilised to decrease placental perfusion and encourage placental resorption, thereby reducing the risk of haemorrhage and other morbidities.

Case

We describe one of the very few reported cases of placenta percreta which was successfully treated primarily with sequential artery embolisation. Our patient underwent four embolisation procedures over a period of 248 days, with no major morbidity or complications.

Conclusion

Repeat UAE may be a beneficial primary management modality in cases of placenta percreta with bladder involvement.

Peripartum Haemorrhage, Diagnosis and Therapy. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry No. 015/063, March 2016)

Purpose

This is an official interdisciplinary guideline, published and coordinated by the German Society of Gynaecology and Obstetrics (DGGG), the Austrian Society of Gynaecology and Obstetrics (OEGGG) and the Swiss Society of Gynaecology and Obstetrics (SGGG). The guideline was developed for use in German-speaking countries and is backed by the German Society of Anaesthesiology and Intensive Medicine (DGAI), the Society of Thrombosis and Haemostasis Research (GTH) and the German Association of Midwives. The aim is to provide a consensus-based overview of the diagnosis and management of peripartum bleeding obtained from an evaluation of the relevant literature.

Methods

This S2k guideline was developed from the structured consensus of representative members of the various professional associations and professions commissioned by the Guideline Commission of the DGGG.

Recommendations

The guideline encompasses recommendations on definitions, risk stratification, prevention and management.