No 383 – Dépistage, diagnostic et prise en charge des troubles du spectre du placenta accreta

Prophylactic occlusion balloons of both internal iliac arteries in caesarean hysterectomy for placenta accreta spectrum disorder reduces blood loss: A retrospective comparative study

Background

The placenta accreta spectrum is a complex disorder characterized by abnormal invasion of the placenta into the uterine wall, posing a significant risk of life-threatening haemorrhage for patients. Its incidence is on the rise, largely attributed to the increasing rates of caesarean sections. Management of this spectrum involves a multidisciplinary approach, although standardized protocols are not yet established. While caesarean hysterectomy remains the standard Gold, several adjunctive treatments have emerged in recent years to mitigate bleeding risk and associated morbidity. Among these, prophylactic occlusion balloons placed in the internal iliac arteries have shown promise. The aim of our study is to demonstrate the effect of prophylactic occlusion balloons in both uterine iliac arteries in the management of placental accreta spectrum disorders.

Methods

A retrospective monocentric cohort study was conducted in the Department "C" of Gynaecology and Obstetrics at the Maternity Center of Tunis. The study spanned three years, from January 2nd, 2020, to December 31st, 2022. The study population consisted of two groups: Control Group (CG) comprised patients who underwent caesarean hysterectomy without internal-iliac prophylactic occlusion balloons, and Occlusion balloons of both internal iliac arteries Group (OBIIAG) included patients who underwent caesarean hysterectomy with internal-iliac prophylactic occlusion balloons.

Results

A total of 38 patients were included in the study, all of whom exhibited similar epidemiological characteristics and comparable personal and obstetric histories. The most prevalent risk factor among the patients was a history of caesarean section (92%). On average, patients were diagnosed at 30 weeks of gestation, with third-trimester bleeding being the most common presentation (71% of cases). The median gestational age at delivery was between 36 and 37 weeks. We observed a significant difference in blood loss between the two groups (2888 ml in the control group and 1828 ml in the group with internal-iliac prophylactic occlusion balloons, p < 0.05). Implementation of this technique resulted in a reduced need for massive transfusions (p < 0.01) and shorter operating times (126 min for the control group and 92 min for the group with internal-iliac prophylactic occlusion balloons; p = 0.04). There were no significant differences in morbidity between the two groups.

Conclusion

The intra-iliac prophylactic occlusion balloons can help reduce the risk of hemorrhage and the morbidities that come with the placenta accreta spectrum disorder.

[French survey on the management strategy for placenta accreta spectrum]

OBJECTIVE

Placenta accreta belongs to placenta accreta spectrum and is defined by an adhesion or even invasion of the placental villi in the myometrium. The main risk factor is a history of cesarean section. Its incidence is increasing following an increase in the cesarean section rate in recent years and the cause of severe maternal morbidity (hemorrhage, transfusions, hysterectomy). Treatment can be radical by cesarean section-hysterectomy or conservative with an attempt at uterine preservation. American, English, Canadian and international recommendations have been established but there are no French recommendations to date. The objective of this study was to investigate management strategy for placenta accreta in type III maternity hospitals in France.

MATERIALS AND METHODS

An anonymous questionnaire was sent by email to the obstetrics referents of the university hospital centers in France with type III maternity.

RESULTS

Forty-eight centers were approached, with a participation rate of 77%.

CONCLUSION

The management of placenta accreta spectrum in France is relatively heterogeneous on several points such as multidisciplinary management, evaluation by placental MRI, preoperative urological evaluation, treatment adopted as first-line, cesarean section-hysterectomy or conservative treatment, therapeutic strategy according to the placental invasion. However, the literature is currently poor, which may explain divergent treatment.

[Placenta accreta spectrum disorder: Management and morbidity in a French type-3 maternity]

OBJECTIVES

Placenta accreta spectrum disorder (PASD) is a rare obstetrical pathology, however its incidence is increasing. Morbidity associated with PASD is still high. Even if hysterectomy is considered to be the reference standard treatment, the conservative treatment by leaving the placenta in situ is now an approved option. The objective was to describe management and morbidity of patients with PASD, during the decade, in our French high-level maternity.

METHODS

It was a retrospective study of management and morbidity of PASD in our department between 2007 and 2017.

RESULTS

Forty-six PASD cases were admitted in our center. Thirty-three (71.7%) had a prenatal suspicion of PASD. Conservative treatment was considered for 22 patients (47.8%). It was successful in 12 cases (54.5%). Thirty-four (73.9%) had a primary hysterectomy, eight (17.3%) had a delayed hysterectomy, four (8.6%) had a uterine conservation. Primary Morbidity included 28 blood transfusions, 12 bladder injuries, 1 ureteral injury and 13 transfers to intensive care unit. Secondary morbidity after conservative treatment included two Hemorrhages (16.6%), five endometritis (41.6%) and three disseminated intravacular coagulations (25%).

CONCLUSIONS

Morbidity associated with this pathology is severe. Conservative treatment became an option for PASD. Thanks to a better antenatal diagnosis, it can be proposed to more women. Morbidity seems the same as other centers. Our rate of primary and secondary hysterectomy is higher than other centers. Conservative treatment seems an effective option for women who desire to preserve their fertility to avoid peripartum hysterectomy and its related morbidity and consequences on fertility.