Segmental resection of anterior uterine wall in cases with placenta percreta: a modified technique for fertility preserving approach

Is temporary clamping of the bilateral common iliac artery beneficial in reducing intraoperative blood loss in patients with segmental resected anterior placenta percreta?: A prospective observational study

OBJECTIVE

The aim of our study was to investigate whether temporary clamping of the bilateral common iliac artery (BCIA) has a role in reducing intraoperative blood loss in patients with segmentally resected anterior placenta percreta or not.

METHODS

This prospective observational study included patients with anterior placenta percreta who underwent cesarean segmental resection either with BCIA temporary clamping or without clamping between October 2022 and September 2023.

RESULTS

A comparison of demographic, obstetric, and surgical parameters and the need for transfusion (except for postoperative erythrocyte suspension transfusion) between the two groups revealed no significant difference (P > 0.05). In contrast, the amount of intraoperative blood loss (P = 0.001) (1974 ± 749 mL vs 2702 ± 615 mL) and postoperative erythrocyte suspension transfusion (P = 0.046) in patients who underwent BCIA temporary clamping were significantly lower than in those who did not undergo BCIA temporary clamping.

CONCLUSION

Temporary clamping of BCIA plays a significant favorable role both in reducing blood loss and the need for postoperative transfusion in patients with placenta percreta who underwent segmental uterine resection.

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.

Effectiveness of segmental resection technique in the treatment of placenta accreta spectrum

BACKGROUND

Placental accreta is a serious obstetrical entity and its management is challenging. The aim of this study was to evaluate and define our uterus sparing surgical technique in patients with placenta accreta spectrum.

METHODS

The data of 21 patients who underwent uterine segmental resection during cesarean section with a preliminary diagnosis of placenta accreta spectrum at Ege University between January 2017 and December 2018 were evaluated retrospectively.

RESULTS

Twenty-one patients were successfully treated with the segmental resection technique. In all cases, resected tissues were evaluated by histopathologically and the diagnosis of placenta accreta spectrum was confirmed. Hysterectomy was performed in two cases due to peri-partum hemorrhage that disrupted hemodynamics. None of the patients had complications such as visceral organ injury and wound infection.

CONCLUSION

Our technique of uterine sparing surgery seems to be safe and effective in the management of placenta accreta spectrum without increasing complication rates.

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.

Evaluation of three-step procedure (Shehata's technique) as a conservative management for placenta accreta at a tertiary care hospital in Egypt

OBJECTIVE

To evaluate the benefits and risks of three-step technique as a conservative treatment for women with placenta accreta and desiring future fertility.

STUDY DESIGN

This study is a retrospective study where the files of 91 cases of placenta accreta managed by three-step technique were reviewed. This study was conducted at Tanta University Hospitals in the period from June 1, 2015 to May 31, 2017. All demographic and operative data were extracted and recorded.

RESULTS

The mean age was 32.44±2.72 years; the mean operative time was 81.65±15.68min. The mean gestational age at operation was 35.67±1.19 weeks. The technique succeeded to preserve the uterus in 86 cases and failed in 5 cases. There was no cases required ICU admission with mean hospital stay of 3.065±1.04 days. The postoperative morbidities were mild and in the form of fever (n=9) and wound sepsis (n=4), pyometra (n=1) and secondary hemorrhage (n=1).

CONCLUSION

The three-step procedure is effective as a uterine sparing technique in management of placenta accreta with success rate of 94.5%. The operative and postoperative complications were minimal and expected in such case.

Ultrasound predictors of candidates for segmental resection in pregnants with placenta accreta

Objective: We aimed to assess the predictive values of individual sonographic findings of abnormal placentation to determine the candidates for segmental resectionStudy design: This was a retrospective review of 43 pregnancies with at least one prior cesarean delivery who received an ultrasound diagnosis of placenta previa or low-lying placenta with suspected abnormal placentation in the third trimester at our institution from 2015 through 2017. Sonographic images were reviewed by an investigator blinded to pregnancy outcome. Sonographic parameters were assessed including loss of retroplacental clear zone, irregularity and width of uterine-bladder interface, smallest myometrial thickness, presence of lacunar spaces, and bridging vessels. Diagnosis of placental invasion was based on histologic confirmation. Parameters were analyzed to predict candidates for conservative approach.Results: There were 27 cases with cesarean hysterectomy where as conservative approach was successful in 16 of the cases. Numbers of transfusions of packed red blood cells (2.6 vs. 1.7), fresh frozen plasma (2.3 vs. 0.9) and mean smallest retroplacental myometrial thickness (1.3 vs. 2.1 mm) were significantly different between the two groups (p < .05). Smallest retroplacental myometrial thickness was a significant predictor for the cases appropriate for successful conservative approach (Area Under Curve, AUC =0.911, p < .001), optimal cut off value was obtained at 1.6 mm with 94% sensitivity and 85% specificity.Conclusions: Our data showed that among some sonographic findings of abnormal placentation, smallest myometrial thickness was a significant predictor to determine candidates for conservative approach.