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

Subsequent pregnancy outcomes and risk factors following conservative treatment for placenta accreta spectrum: a retrospective cohort study

BACKGROUND

Placenta accreta spectrum can lead to uncontrollable massive hemorrhage in the perinatal period. Currently, the first-line treatment for placenta accreta spectrum recommended worldwide is hysterectomy. However, adverse outcomes after hysterectomy, including surgical complications, such as difficulty in performing the procedure, and sequelae, such as infertility and psychological issues, cannot be ignored. Several surgical approaches for conservative treatment have been proposed. There are few reports on the effectiveness, safety, and long-term complications of conservative treatments, especially subsequent pregnancy outcomes.

OBJECTIVE

This study aimed to investigate the clinical outcomes and identify risk factors of subsequent pregnancies among patients with placenta accreta spectrum who had undergone conservative surgery.

STUDY DESIGN

This was a retrospective cohort study of subsequent pregnancy cases after cesarean delivery with conservative treatment for placenta accreta spectrum from 2011 to 2019 at The First Affiliated Hospital of Zhengzhou University to identify clinical outcomes of subsequent pregnancies and the risk factors of adverse pregnancy outcomes.

RESULTS

A total of 883 patients undergoing conservative surgery were included in this study, among which 604 (68.4%) were successfully followed up. There were 75 successful pregnancies in 72 patients, including 22 full-term or near-term deliveries, 1 induced labor in the second trimester of pregnancy, 6 cesarean scar pregnancies (8.0%), 2 ectopic pregnancies, and 44 first-trimester pregnancies (3 miscarriages and 41 elective abortions and 12 medical abortions and 32 vacuum aspirations). All newborns survived in the 22 full-term or near-term deliveries. Moreover, 5 placenta accreta spectrum cases (22.7%) and 6 placenta previa cases were observed. Postpartum hemorrhage was observed in 2 cases, with an incidence rate of 9.1%. All parameters, including age at subsequent pregnancy, gravidity, number of cesarean deliveries, type of previous placenta accreta spectrum, gestational week of pregnancy termination, interpregnancy interval, and the use of vascular occlusion techniques, were not found to be associated with recurrent placenta accreta spectrum and cesarean scar pregnancy.

CONCLUSION

Our findings show that treatment for placenta accreta spectrum does not automatically preclude a subsequent pregnancy. However, patients should be fully informed about the risk of recurrent placenta accreta spectrum, scar pregnancy, and postpartum hemorrhage.

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.

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.

Pregnancy outcome in women with prior placenta accreta spectrum disorders treated with conservative-reconstructive surgery: analysis of 202 cases

AIM

To report the outcome of pregnant women with a prior pregnancy complicated by placenta accreta spectrum (PAS) disorders treated with resective-conservative surgery at the time of cesarean section.

MATERIALS AND METHODS

Retrospective analysis of pregnant women treated with conservative surgery in the prior pregnancy complicated by PAS disorders. The primary outcome was spontaneous preterm birth with intact membranes or following a preterm labor rupture of the membranes before 37 weeks of gestation. Secondary outcomes were uterine rupture, need for hysterectomy due to severe ante or intrapartum maternal hemorrhage, myometrial thinning at the time of cesarean section, 5 min Apgar score, birth weight centile, and the occurrence of small for gestational age newborns. All these outcomes were observed in women with prior PAS treated with conservative resective surgery divided according to the topographical surgical classification.

RESULT

Pregnancies included: 89.6% (181/202) related to PAS type 1; 7.9% (16/202) related to PAS type 2, and 2.5% (5/202) related to PAS type 3. 90% of cases (162/179) (95 CI: 90.3-90.6) completed the pregnancy at term (greater than 37 weeks). The average intergenesic period was 15 months for PAS type 1 and 2 (SD 4,76) (Q1:12; Q3:19), and 18 months for PAS 3 (SD 6,56) (Q1:14; Q3:19). A few mothers presented some complications PPROM 1; premature labor 4; hypertension 2; atony 1; overweight 1; and gestational diabetes 2. The mean age was 30 years (T1), 31 years (T2), and 36 years (T3·). The uterine segment was thicker than usual except for one case of partial uterine dehiscence (twins). There were no placenta previa or PAS, a uterine atony case, and there was one case of hysterectomy by patient request.

CONCLUSIONS

Subsequent pregnancies after use of resective-reconstructive for PAS has demonstrated to have similar maternal and neonatal outcomes to typical gestation and cesarean delivery.

Successful conservative treatment of placenta accreta with traditional Chinese medicine: A case report

RATIONALE

Currently, placenta accreta treatment mainly includes nonconservative surgical and conservative treatments such as Traditional Chinese medicine (TCM). This report describes the case of a 37-year-old woman who suffered incomplete placenta accreta after vaginal delivery and was cured by TCM. TCM treatment of placenta accreta has its own unique advantages, including low toxicity and few side effects, unaffected breastfeeding, and retention of the uterus, which can ensure the expulsion of residual placenta and be beneficial to patients' physical and mental health.

PATIENT CONCERNS

Symptoms included a small amount of vaginal bleeding and occasional lesser abdominal pain. The patient showed lesser abdominal tenderness, a red tongue moss with petechial hemorrhage, and a hesitant pulse. The reproductive history was G3P2L2A1. In addition, the patient was afraid of having her uterus removed due to incomplete placental separation.

DIAGNOSES

The case was diagnosed as placental accreta. Ultrasound is the preferred method of diagnosis, and biomarkers, such as beta hCG, assist in screening for placental accreta. Doppler ultrasonography showed that in the bottom of the right uterine cavity, there was an uneven echo group of 7.6 × 4.6 cm, which was not clearly demarcated from the posterior wall; the muscle layer became thinner, with a thinnest part of 0.19 cm, and abundant blood flow signals were observed (Fig. 1JOURNAL/medi/04.03/00005792-202102190-00086/figure1/v/2021-02-16T234818Z/r/image-tiff). The beta hCG was 580.92 mIu/ml.

INTERVENTIONS

The patient initially underwent curettage therapy 9 days after delivery, but it failed due to excessive intraoperative bleeding. The patient then turned to TCM treatment. The doctor prescribed a multi-herbal formula.

OUTCOMES

After 4 months, the residual placenta was expelled, and the patient's symptoms disappeared completely. No adverse and unexpected events occurred during treatment. During 3 months of follow-up, the patient had no abdominal pain, abnormal vaginal bleeding, or other complications.

LESSONS

This study shows that TCM is safe and effective for treating placenta accreta, and it is worth recommending TCM as a conservative treatment along with other treatments. In practice, however, we find that the earlier TCM treatment is applied, the better the effect; therefore, early intervention with TCM is particularly important.

Placenta accreta spectrum disorders-experience of management in a German tertiary perinatal centre

PURPOSE

Placenta accreta spectrum (PAS) disorders can cause major intrapartum haemorrhage. The optimal management approach is not yet defined. We analysed available cases from a tertiary perinatal centre to compare the outcome of different individual management strategies.

METHODS

A monocentric retrospective analysis was performed in patients with clinically confirmed diagnosis of PAS between 07/2012 and 12/2019. Electronic patient and ultrasound databases were examined for perinatal findings, peripartum morbidity including blood loss and management approaches such as (1) vaginal delivery and curettage, (2) caesarean section with placental removal versus left in situ and (3) planned, immediate or delayed hysterectomy.

RESULTS

46 cases were identified with an incidence of 2.49 per 1000 births. Median diagnosis of placenta accreta (56%), increta (39%) or percreta (4%) was made in 35 weeks of gestation. Prenatal detection rate was 33% for all cases and 78% for placenta increta. 33% showed an association with placenta praevia, 41% with previous caesarean section and 52% with previous curettage. Caesarean section rate was 65% and hysterectomy rate 39%. In 9% of the cases, the placenta primarily remained in situ. 54% of patients required blood transfusion. Blood loss did not differ between cases with versus without prenatal diagnosis (p = 0.327). In known cases, an attempt to remove the placenta did not show impact on blood loss (p = 0.417).

CONCLUSION

PAS should be managed in an optimal setting and with a well-coordinated team. Experience with different approaches should be proven in prospective multicentre studies to prepare recommendations for expected and unexpected need for management.

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.

Local uterine resection with Bakri balloon placement in placenta accreta spectrum disorders

OBJECTIVE

Placenta accreta spectrum (PAS) is a potentially life-threatening condition characterized by the abnormal adherence of the placenta to the implantation site. We sought to evaluate the efficacy, surgical feasibility, risks, and advantages of local uterine resection in cases complicated with PAS.

MATERIALS AND METHODS

This study included 97 patients with PAS, which was confirmed during surgery and by histopathological examination between January 2013 and December 2019. The patients were divided into two groups based on operative approach. The study population (local resection group) consisted of 30 cases in whom total resection of adherent placenta and myometrium was performed, whereas the control group (hysterectomy group) of 67 cesarean hysterectomy cases.

RESULTS

Patients who underwent hysterectomy had significantly more bleeding than the local resection group (1180±160 mL vs 877±484 mL; p=0.002). The mean number of transfused packed red blood cells (pRBCs) was greater in the hysterectomy group (4.5±2.3) than in the local resection group (2.6±3.1; p=0.001). Transfusion rate of four and/or more pRBCs was 67.2% in the hysterectomy group and 33.3% in the local resection group, which indicated a statistically significant difference (p=0.002). Of patients, 29.6% required intensive care unit in the hysterectomy group and 6.7% in the local resection group (p=0.023).

CONCLUSION

Local resection can be performed safely in selected PAS cases. In these cases, using a standardized protocol in terms of patient selection and surgical procedure will reduce morbidity and mortality.

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.

Successful conservative treatment of multiorgan infiltrating placenta percreta by uterine embolization and followup with serial magnetic resonance. A case report

•

Morbidly adherent placenta presents sever maternal complications including death.

•

This report presents a case of placenta percreta treated with conservative management without complications.

•

Serial MRI was performed to evaluate the course of conservative management.

Introduction

Conservative management was recently adopted as an option with an aim to reduce surgical complication and improve maternal outcome. We present a case of placenta percreta that invaded the urinary bladder, sigmoid colon, rectum, and vagina of a patient treated with conservative management successfully.

The work has been reported in line with the SCARE criteria (Agha et al., 2018 [1]).

Case presentation

A 32-year-old woman, gravida 4, para 3. She had previously had 3 caesarean sections. At 36 week of gestation patient referred to our centre with a diagnosis of placenta praevia with a high suspicion of placenta percreta. Ultrasound and MRI repeated and confirmed the diagnosis with invasion to the rectum/sigmoid colon, urinary bladder, and upper vagina. Patient treated successfully by uterine embolization and follow up without any complication and we performed serial MRI to evaluate the course of conservative management.

Discussion

Placenta percreta is a serious condition with high maternal morbidity and mortality rate. Cesarean hysterectomy is the standard treatment for now. However, conservative management was recently adopted as an option. Many case reports were published with placenta percreta that invaded the urinary bladder and treated conservatively but this is a placenta percreta that invaded the urinary bladder, sigmoid colon, rectum, and vagina. We opted conservative management and performed serial MRI to evaluate the course of conservative management.

Conclusion

We believe that this case is the first case of placenta percreta that invaded the urinary bladder, sigmoid colon, rectum, and vagina. That treated successfully by conservative management and publishing this case will improve the clinical information about the course of the conservative management of placenta percreta.