Important surgical measures and techniques at cesarean hysterectomy for placenta previa accreta

[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 care infrastructure: an evidence-based review of needed resources supporting placenta accreta spectrum care

The incidence of placenta accreta spectrum, the deeply adherent placenta with associated increased risk of maternal morbidity and mortality, has seen a significant rise in recent years. Therefore, there has been a rise in clinical and research focus on this complex diagnosis. There is international consensus that a multidisciplinary coordinated approach optimizes outcomes. The composition of the team will vary from center to center; however, central themes of complex surgical experts, specialists in prenatal diagnosis, critical care specialists, neonatology specialists, obstetrics anesthesiology specialists, blood bank specialists, and dedicated mental health experts are universal throughout. Regionalization of care is a growing trend for complex medical needs, but the location of care alone is just a starting point. The goal of this article is to provide an evidence-based framework for the crucial infrastructure needed to address the unique antepartum, delivery, and postpartum needs of the patient with placenta accreta spectrum. Rather than a clinical checklist, we describe the personnel, clinical unit characteristics, and breadth of contributing clinical roles that make up a team. Screening protocols, diagnostic imaging, surgical and potential need for critical care, and trauma-informed interaction are the basis for comprehensive care. The vision from the author group is that this publication provides a semblance of infrastructure standardization as a means to ensure proper preparation and readiness.

Placenta previa percreta with surrounding organ involvement: a proposal for management

Placenta accreta spectrum encompasses cases where the placenta is morbidly adherent to the myometrium. Placenta percreta, the most severe form of placenta accreta spectrum (grade 3E), occurs when the placenta invades through the myometrium and possibly into surrounding structures next to the uterine corpus. Maternal morbidity of placenta percreta is high, including severe maternal morbidity in 82.1% and mortality in 1.4% in the recent nationwide U.S. statistics. Although cesarean hysterectomy is commonly performed for patients with placenta accreta spectrum, conservative management is becoming more popular because of reduced morbidity in select cases. Treatment of grade 3E disease involving the urinary bladder, uterine cervix, or parametria is surgically complicated due to the location of the invasive placenta deep in the maternal pelvis. Cesarean hysterectomy in this setting has the potential for catastrophic hemorrhage and significant damage to surrounding organs. We propose a step-by-step schema to evaluate cases of grade 3E disease and determine whether immediate hysterectomy or conservative management, including planned delayed hysterectomy, is the most appropriate treatment option. The approach includes evaluation in the antenatal period with ultrasound and magnetic resonance imaging to determine suspicion for placenta previa percreta with surrounding organ involvement, planned cesarean delivery with a multidisciplinary team including experienced pelvic surgeons such as a gynecologic oncologist, intra-operative assessment including gross surgical field exposure and examination, cystoscopy, and consideration of careful intra-operative transvaginal ultrasound to determine the extent of placental invasion into surrounding organs. This evaluation helps decide the safety of primary cesarean hysterectomy. If safely resectable, additional considerations include intra-operative use of uterine artery embolization combined with tranexamic acid injection in cases at high risk for pelvic hemorrhage and ureteral stent placement. Availability of resuscitative endovascular balloon occlusion of the aorta is ideal. If safe resection is concerned, conservative management including planned delayed hysterectomy at around 4 weeks from cesarean delivery in stable patients is recommended.

General Management Considerations for Placenta Accreta Spectrum

The ideal management of a patient with placenta accreta spectrum (PAS) includes close antepartum management culminating in a planned and coordinated delivery by an experienced multidisciplinary PAS team. Coordinated team management has been shown to optimize outcomes for mother and infant. This section provides a consensus overview from the Pan-American Society for the Placenta Accreta Spectrum regarding general management of PAS.

Surgical Techniques for the Management of Placenta Accreta Spectrum

The surgical management of placenta accreta spectrum (PAS) is often challenging. There are a variety of techniques and management options described in the literature ranging from uterine sparing to cesarean hysterectomy. Following the inaugural meeting of the Pan-American Society for Placenta Accreta Spectrum a multidisciplinary group collaborated to describe collective recommendations for the surgical management of PAS. In this manuscript, we outline individual components of the procedure and provide suggested direction at key points of a cesarean hysterectomy in the setting of PAS. KEY POINTS: · The surgical management of PAS requires careful planning and expertise.. · Multidisciplinary team care for pregnancies complicated by PAS can decrease morbidity and mortality.. · Careful surgical techniques can minimize risk of significant hemorrhage by avoiding pitfalls..

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.

Risk Factors for Urological Complications Associated with Caesarean Section—A Case-Control Study

Background and Objectives: Acute urologic complications, including bladder and/or ureteric injury, are rare but known events occurring at the time of caesarean section (CS). Delayed or inadequate management is associated with increased morbidity and poor long-term outcomes. We conducted this study to identify the risk factors for urologic injuries at CS in order to inform obstetricians and patients of the risks and allow management planning to mitigate these risks. Materials and Methods: We reviewed all cases of urological injuries that occurred at CS surgeries in a tertiary university centre over a period of four years, from January 2016 to December 2019. To assess the risk factors of urologic injuries, a case-control study of women undergoing caesarean delivery was designed, matched 1:3 to randomly selected women who had an uncomplicated CS. Electronic medical records and operative reports were reviewed for socio-demographic and clinical information. Descriptive and univariate analyses were used to characterize the study population and identify the risk factors for urologic complications. Results: There were 36 patients with urologic complications out of 14,340 CS patients, with an incidence of 0.25%. The patients in the case group were older, had a lower gestational age at time of delivery and their newborns had a lower birth weight. Prior CS was more prevalent among the study group (88.2 vs. 66.7%), as was the incidence of placenta accreta and central praevia. In comparison with the control group, the intraoperative blood loss was higher in the case group, although there was no difference among the two groups regarding the type of surgery (emergency vs. elective), uterine rupture, or other obstetrical indications for CS. Prior CS and caesarean hysterectomy were risk factors for urologic injuries at CS. Conclusions: The major risk factor for urological injuries at the time of CS surgery is prior CS. Among patients with previous CS, those who undergo caesarean hysterectomy for placenta previa central and placenta accreta are at higher risk of surgical haemostasis and complex urologic injuries involving the bladder and the ureters.

Hemostatic effect of combined procedures for placenta previa: cervix-holding, intrauterine balloon, and uterine compression suture

OBJECTIVES

Various procedures have been introduced to achieve hemostasis for postpartum hemorrhage (PPH) in placenta previa (PP). This study attempted to clarify the effectiveness of the combined use of three hemostatic procedures: Matsubara-Takahashi cervix-holding (MT-holding), intrauterine balloon (IUB), and uterine compression suture (UCS).

STUDY DESIGN

This was a historical cohort study on the hemostatic effect of combined procedures for patients with placenta previa (PP) undergoing cesarean section between April 2006 and December 2018. Until 2011 (2006-2011), we used MT-holding alone, whereas since 2012 we have also been using IUB and UCS: MT-holding alone was used in the former period whereas three procedures (MT-holding, IUB, UCS, and their combinations) have been used in the latter period. Perinatal outcomes were compared between 2006-2011 (before group) and 2012-2018 (after group).

RESULTS

Of 416 patients with PP, excluding 273 patients with cesarean hysterectomy or no hemostatic procedure, the remaining 143 patients were analyzed. In the after group, intraoperative blood loss, the percentage of patients with postoperative blood loss ≥ 500 ml, and incidence of autologous blood transfusion were significantly lower than in the before group. Multivariate analysis showed that postoperative blood loss ≥ 500 ml decreased in the after group (adjusted OR: 0.3, 95%CI: 0.1-0.8, compared with the before group).

CONCLUSION

PPH decreased after introducing the combination of hemostatic procedures in patients with PP. Further studies are needed to determine the best combination and optimal indication for combining hemostatic procedures for PP.

Telemedicine facilitates surgical training in placenta accreta spectrum

OBJECTIVE

The training of groups responsible for managing patients with placenta accreta spectrum (PAS) is complex because of the lack of hospitals with a high flow of patients and absence of formal educational programs. We report here the results of a virtual training program (VTP) that implemented one-step conservative surgery (OSCS).

METHODS

A prospective observation study of OSCS VTP between three expert groups and PAS reference hospitals without experience in OSCS was performed. Accessible or cost-efficient web meeting platforms were used to implement the VTP components: baseline observation of the participant's prior knowledge; instructions about essential PAS surgery topics; case selection and joint planning of surgery; expert group "telepresence" during surgery and postoperative debriefing.

RESULTS

One-step conservative surgery was performed successfully at six hospitals. All patients had increta/percreta with a median intraoperative bleeding of 1300 ml (IQR 825-2325) and surgical time of 184 min (IQR 113-240). All groups considered the VTP very useful (n = 33, 97%) or useful (n = 1, 3%), they would use it again (definitely: n = 27, 81.8%; or probably: n = 6, 18.2%), and they would recommend it to other colleagues.

CONCLUSION

Tele education and telepresence during PAS surgery facilitates the implementation of OSCS in selected cases.

Cesarean Hysterectomy in Abnormally Invasive Placenta: The Role of Prenatal Diagnosis

An abnormally invasive placenta (AIP) is a placenta that cannot be removed spontaneously or manually without causing severe bleeding. It is a dangerous condition associated with a high rate of maternal and perinatal morbidity and mortality due to the high rate of massive bleeding and visceral injuries. The standardized ultrasound diagnostic criteria have helped improve its early diagnosis, which is essential to plan coordinated actions to reduce associated morbimortality. We present a case report in which ultrasound diagnosis played a decisive role, enabling the coordination of a multidisciplinary team and improving the immediate care of both mother and newborn. Cesarean hysterectomy was performed with minimal blood loss and a good postsurgical recovery.

Pregnancy-Related Hysterectomy for Peripartum Hemorrhage: A Literature Narrative Review of the Diagnosis, Management, and Techniques

Postpartum hemorrhage is a life-threatening situation, in which hysterectomy can be performed to prevent maternal death. However, it is associated with high rates of maternal morbidity and mortality and permanent infertility. The incidence of pregnancy-related hysterectomy varies across countries, but its main indications are the following: uterine atony and placenta spectrum (PAS) disorders. PAS disorder prevalence is rising during the last years, mainly due to the increased number of cesarean sections. As a result, obstetricians should be aware of the difficulties of this emergent condition and improve its accurate antenatal diagnosis rates, as well as its modern management strategies. Of course, special skills are required during a pregnancy-related hysterectomy, so these patients should be referred to centers of excellence in antenatal care, where a multidisciplinary team approach is followed. This study is a narrative review of the literature of the last 5 years (PubMed, Cochrane) regarding postpartum hemorrhage to offer obstetricians up-to-date knowledge on this pregnancy-related life-threatening issue. However, there is a lack of available high-quality data, because most published papers are retrospective case series or observational cohorts.

Complicated placenta accreta spectrum: identifying a high-risk cohort

OBJECTIVE

To assess differences in the perioperative complication rate between patients with placenta accreta spectrum (PAS) with and without complicating factors.

METHODS

This retrospective cohort study included subjects who underwent cesarean hysterectomy with histology-proven PAS between 23 0/7 and 42 0/7 weeks gestational age (GA) from 1 July 2008 to 11 April 2017. Perioperative outcomes were compared between those with uncomplicated PAS and "complicated PAS," defined as PAS subjects who experienced ≥2 bleeding episodes, preterm premature rupture of membranes (PPROM), or premature contractions requiring tocolysis.

RESULTS

Overall, 26 complicated PAS and 27 uncomplicated PAS cases were compared; no difference in the rate of perioperative complications was identified. An increased proportion of complicated PAS cases required blood product transfusion before delivery: 2 (40%), 3 (27.3%), and 2 patients (20%) for those with PPROM, preterm contractions, and ≥2 bleeding episodes respectively, compared to patients with uncomplicated PAS, having no transfusions (p = .001). Time of delivery was earlier for patients with complicated compared to uncomplicated PAS (median GA 30.9 [Q1 = 27.9; Q3 = 31.9] and 34.9 [Q1 = 32.1; Q3 = 35.7], p < .001). Median birthweights were lower (p < .0144) and maternal length of stay longer (p < .0012) for complicated PAS.

CONCLUSION

Patients with complicated PAS were not at higher risk for perioperative complications but were associated with earlier delivery, required more antenatal blood transfusions, and had a longer LOS.

Aortic clamping for limiting blood loss at cesarean hysterectomy for placenta percreta: A case series

OBJECTIVE

In women with placenta percreta, cesarean hysterectomy is associated with massive blood loss during dissection of bladder from lower uterine segment. We studied the safety and effectiveness of temporary aortic clamping as a method of limiting blood loss at cesarean hysterectomy in women with placenta percreta.

METHODS

This was a retrospective case series of 15 women with placenta percreta who underwent cesarean section with total hysterectomy at KEM Hospital, Pune, India, with a technique of temporary clamping of the infra-renal aorta for reducing blood loss during hysterectomy.

RESULTS

Fifteen women with placenta percreta underwent classical cesarean section followed by total hysterectomy with temporary clamping of the aorta. The procedure was associated with median estimated intra-operative blood loss of 650 ml. No woman had ureteric injury or needed post-operative intensive care. Aortic clamping for 28-70 min was not associated with any intra-operative vascular complications or post-operative ischemic lesions in the lower limbs, kidneys, or bowel.

CONCLUSION

Aortic clamping safely and effectively limited blood loss during cesarean hysterectomy for placenta percreta and thereby reduced transfusion requirements. It compares favorably with reported outcomes of other strategies of managing placenta percreta.

Uterine Sandwich Suture: The Concept of "Role Sharing" Is Important

Uterine compression suture and intrauterine hemostatic balloon are important procedures to achieve hemostasis for obstetric hemorrhage. A combined use of these two, with B-Lynch suture + Bakri balloon being the most often employed ones, is referred to as a “uterine sandwich”, which is an effective hemostatic procedure. Fundamentally, the former and latter stop bleeding from the uterine body and lower uterine segment, respectively. This represents the concept of “role sharing” for hemostasis. Recognizing this concept is of practical importance.

Minimizing surgical blood loss at cesarean hysterectomy for placenta previa with evidence of placenta increta or placenta percreta: the state of play in 2020

The evolution of multidisciplinary team-based care for women with placenta accreta spectrum disorder has delivered stepwise improvements in clinical outcomes. Central to this overall goal is the ability to limit blood loss at surgery. Placement of inflatable balloons within the pelvic arteries, most commonly in the anterior divisions of the internal iliac arteries, became popular in many centers, at the expense of prolonging surgical care and with attendant risks of vascular injury. In tandem, the need to expose pelvic sidewall anatomy to safely identify the course of the ureters re-popularized the alternative strategy of ligating the same anterior divisions of the internal iliac arteries. With incremental gains in surgical expertise, described in 5 steps in this review, our teams have witnessed a steady decline in surgical blood loss. Nevertheless, a subset of women has the most severe form of placenta accreta spectrum, namely placenta previa-percreta. Such women are at risk of major hemorrhage during surgery from vessels arising outside the territories of the internal iliac arteries. These additional blood supplies, mostly from the external iliac arteries, pose significant risks of major blood loss even in experienced hands. To address this risk, some centers, principally in China, have adopted an approach of routinely placing an infrarenal aortic balloon, with both impressively low rates of blood loss and an ability to conserve the uterus by resecting the placenta with the affected portion of the uterine wall. We review these literature developments in the context of safely performing elective cesarean hysterectomy for placenta previa-percreta, the most severe placenta accreta spectrum disorder.

Maternal morbidity and mortality due to placenta accreta spectrum disorders

Placenta accreta spectrum (PAS) disorders are an increasing health problem in many parts of the world. They are an important risk factor for adverse maternal outcomes related to delivery, with a reported 18-fold increase in maternal morbidity. Profuse haemorrhage after attempting to remove the placenta is the most frequent complication and can lead to major maternal morbidity and ultimately to maternal death. Morbidity can also arise from the multiple procedures required to treat PAS disorders. Intensive care unit admission, mechanical ventilation, infection, and prolonged hospitalization are common in these patients. Long-term complications related to infertility and psychological disturbances can also occur and may have a strong and long-lasting impact on women's health. Antenatal diagnosis allows for appropriate scheduling of delivery and referral to a specialized centre and has been shown to reduce maternal morbidity and mortality.

A nationwide survey of centers with multidisciplinary teams for placenta accreta patient care in Colombia, observational study

Introduction: MAP is associated with severe morbidity and maternal mortality. Therefore, it requires that patients with this condition to be attended in centers that have trained personnel and specific infrastructure. We aimed to identify the hospitals in Colombia that count on the minimum amount of medical specialties to manage this pathological condition and describe their general care practices.Methodology: Observational study in 87 obstetric tertiary care centers in Colombia. The requested information was collected using a predesigned survey, applied to the reported hospitals, and stored in an electronic database.Results: Eighty-six hospitals were identified as possessing the capacity to care for women with accreta, of which 71 provided information (82.55% compliance). Although 83.09% of hospitals choose to treat patients with accreta, only 36.6% has a fixed group of specialists, 32.21% did not have interventional radiology, 25.36% did not have a blood bank, and 67.79% did not have intraoperative cell recovery devices; 77.46% of the surveyed hospitals had cared for five or fewer patients with accreta per year.Conclusion: Most hospitals manage a low number of MAP cases per year, which are handled by shift specialists and not by a fixed group of professionals, which increases the difficulty of achieving expertise.

The application of prophylactic balloon occlusion of the internal iliac artery for the treatment of placenta accreta spectrum with placenta previa: a retrospective case-control study

Background

Severe obstetric haemorrhage caused by placenta accreta spectrum (PAS) results in significant maternal morbidity and mortality. The effectiveness of prophylactic balloon occlusion of the internal iliac artery in PAS patients remains controversial. Therefore, we conducted a retrospective case-control study to investigate the clinical effectiveness of this treatment.

Methods

The clinical data of 104 patients with PAS complicated with placenta previa who delivered by caesarean section between January 2016 and January 2019 were collected, and the patients were divided into two groups. The study group (48 cases) underwent internal iliac artery preset balloon occlusion before caesarean section and uterine artery embolisation according to the bleeding status after surgery, while the control group (56 cases) did not undergo internal iliac artery preset balloon occlusion before caesarean section.

Results

The operation and hospitalisation times in the study group were longer than those in the control group. Additionally, the hysterectomy rate in the study group was significantly higher than that in the control group. No significant differences in blood loss, blood transfusion volume, urinary system injury, postoperative ICU transfer rate, or neonatal scores were identified between the groups. Among the patients without invasive placenta (placenta increta and percreta), blood loss was lower in the study group, and the caesarean hysterectomy rate did not significantly differ between the groups. Among the patients with invasive placenta, blood loss and the caesarean hysterectomy rate did not significantly differ between the groups. The risk of hysterectomy in the study group was related to invasive placenta penetration, a large area of placental invasion, or abnormal vascular filling. One patient in the study group had a thrombus in the left lower extremity artery.

Conclusions

Balloon occlusion of the internal iliac artery is effective for haemostasis of placenta previa in the absence of invasive placenta. For patients with invasive placenta, especially placenta percreta, a large area of placental invasion or abnormal vascular filling suggests the need for hysterectomy. The risks of the prophylactic use of internal iliac artery balloon occlusion include vascular injury and thrombus formation.

Prediction of cesarean hysterectomy in placenta previa complicated with prior cesarean: a retrospective study

Background

The prevalence of both placenta previa and cesarean are on the rise. Multiple adverse outcomes are critically increased when placenta previa is subsequent to prior cesarean. The purpose of the present study is to develop a pre-surgical method for predicting adverse outcomes in pregnancy complicated with both placenta previa and prior cesarean.

Methods

Clinical data was obtained from the medical history system at the First Affiliated Hospital of Sun Yat-sen University from February 2003 to December 2016. All cases with a final diagnosis of “placenta previa/low lying placenta (ICD:O44.001-105)” and “scarred uterus complicated with pregnancy (ICD: O34.200-202)” were collected and reviewed. Hysterectomy was taken as the primary outcome; and blood loss was taken as the secondary outcome.

Results

Of 219 pregnant women in the final analysis, 25 received a hysterectomy following delivery, and 48 had blood loss exceeding 1000 ml. Pre-surgical risk factors for hysterectomy are ultrasonic signs of vascular lacunae, central placenta previa, and loss of normal hypoechoic retroplacental zone. A pre-surgical predictive equation referred to as “Hysterectomy Index in Placenta Previa with Prior cesarean (HIPs)” was generated and each risk factor was weighted to create an 8-point scale. This index yielded an area under the curve of 0.972 for the prediction of hysterectomy.

Conclusions

Application of the HIPs score may provide an effective pre-surgical prediction of cesarean hysterectomy in pregnant women complicated with both placenta previa and prior cesarean.

Outcomes of balloon occlusion in the University of California Morbidly Adherent Placenta Registry

BACKGROUND

Morbidly adherent placenta, also known as placenta accreta spectrum, is associated with severe maternal morbidity and mortality. Multiple adjunctive procedures have been proposed to improve outcomes, and at many institutions, interventional radiologists will play a role in assisting obstetricians in these cases.

OBJECTIVE

The objective of the study was to evaluate the outcomes of women with morbidly adherent placenta who underwent cesarean hysterectomy with aortic balloon occlusion or internal iliac artery balloon occlusion catheters, compared with cesarean hysterectomy with surgical ligation of the iliac arteries, or cesarean hysterectomy without adjunctive procedures.

STUDY DESIGN

A retrospective review of women with morbidly adherent placenta treated with cesarean hysterectomy was performed at 5 institutions from May 2014 to April 2018. The balloon occlusion group had either prophylactic aortic or iliac balloons placed prior to cesarean hysterectomy. Comparison groups included those who underwent internal iliac artery ligation prior to hysterectomy or a control group if they underwent cesarean hysterectomy without adjuvant procedures. Evaluated outcomes include estimated blood loss, transfusion requirements, intensive care unit admission, and adverse event rates.

RESULTS

There were 171 women with morbidly adherent placenta included in the study. Twenty-eight had balloon placement prior to cesarean hysterectomy, 18 had intraoperative internal iliac artery ligation, and there were 125 control women who underwent cesarean hysterectomy without any adjunctive procedures. Compared with the women who underwent cesarean hysterectomy without adjunctive procedures, women who underwent aortic or iliac artery balloon occlusion prior to hysterectomy had significantly lower estimated blood loss (30.9% decrease, P < .001), transfusion requirements (76.8% decrease, P < .001), intensive care unit admission rates (0% vs 15.2%, P < .001), and intensive care unit stay lengths (0.0 vs 3.1 days, P < .001). Compared with women who underwent surgical ligation of the internal iliac arteries prior to hysterectomy, women who underwent aortic or iliac artery balloon occlusion prior to cesarean hysterectomy had lower estimated blood loss (54.2% decrease, P < .01), transfusion requirements (90.5% decrease, P < .001), operating room times (40.0% decrease, P < .01), intensive care unit admissions rates (0% vs 77.8%, P < .001), intensive care unit stay lengths (0.0 vs 1.4 days, P < .001), and adverse events (3.6% vs 44.4%, P < .01).

CONCLUSION

Aortic and iliac artery balloon occlusion are associated with lower estimated blood loss, transfusion requirements, intensive care unit admission rates, and adverse event rates compared with women who underwent internal iliac artery ligation prior to cesarean hysterectomy or women who had no adjunctive interventions prior to cesarean hysterectomy for morbidly adherent placenta.

Urinary tract injuries during treatment of patients with morbidly adherent placenta

INTRODUCTION

Urinary tract injuries (UTI) are a frequent complication of morbidly adherent placenta (MAP) management. In this study, we aim to characterize the type of UTI that occurs and to define if their incidence varies after establishing a fixed interdisciplinary group for the protocolized management of patients with MAP.

METHODOLOGY

All patients with confirmed MAP attended between 2011 and 2019 in our institution, were included. We analyzed the effect of a change in the surgical protocol including rigid ureteral catheters, vesicouterine dissection before hysterotomy and interdisciplinary planning, in the bladder or ureteral injuries incidence.

RESULTS

The study included 65 women. UTI was identified in 27.7% of patients and was associated with a greater volume of blood loss, transfusion requirement, hospital stay, and the need for additional surgeries. There was a high frequency of UTI in patients without protocolized management. The use of rigid ureteral catheters and retrovesical dissection before hysterotomy were associated with a less ureteral injury.

CONCLUSIONS

Developing expertise among the members of the surgical team is essential to improve results. Using rigid ureteral catheters, performing retrovesical dissection before hysterotomy, and performing less extensive surgeries in selected patients are associated with a low frequency of ureteral injuries.

Bladder filling before accreta surgery is a very effective method for preventing bladder injury: a retrospective cohort study

OBJECTIVES

The aim of this study is to show whether bladder filling with saline before percreta surgery diminish the rate of bladder injuries or not. A secondary aim was to check the operative and postoperative outcomes between the cases of filled and unfilled bladder in placenta accreta surgery.

METHODS

This retrospective multicentric cohort study involved 88 patients who were diagnosed with placenta accreta and underwent cesarean hysterectomy between 1 January 2009 and 1 January 2019. Women who had cesarean hysterectomies due to the indication of placenta accreta and did not have bladder filling were used as the control group.

RESULTS

Eighty-eight women met the inclusion criteria. Forty-nine of the cases, the bladder was filled with saline solution before the operation, whereas in 39 the bladder was not filled. Intraoperative bladder injury occurred less in patients with preoperative filled bladders than in patients with unfilled bladders (p = .015; p < .05). There was a statistically significant difference between the duration of surgery according to bladder inflation (p = .001; p < .01); in the filled bladder group, the operation time was shorter than in the unfilled group.

CONCLUSIONS

Filling the bladder with 200 ml saline solution before starting a cesarean section is an easy and useful technique that can reduce the possibility of bladder injury in placenta accreta surgery.

Management of patients with placenta accreta spectrum disorders who underwent pregnancy terminations in the second trimester: A retrospective study

PURPOSE

To analyse the management of patients with placenta accreta spectrum (PAS) disorders who underwent 2^nd trimester pregnancy terminations.

METHOD

The records of patients with PAS disorders who underwent 2^nd trimester pregnancy terminations were collected and analysed.

RESULTS

Twenty-eight patients were included; 8 (28.6%) patients received prenatal diagnoses and 20 (71.4%) patients received postnatal diagnoses. In the prenatal diagnosis group, scheduling hysterotomy and placenta removal were performed in 5 patients with complete placenta previa and previous caesarean delivery without hysterectomy or postpartum haemorrhage, and medical termination was performed in 3 patients, 2 of whom retained the placenta in situ. In the postnatal diagnosis group, the placenta remained in situ in 11 patients, and in 13 (46.4%) patients overall, adjuvant treatments were applied to the patients, and the abnormally implanted placenta was passed 43.5 (range: 7-102) days after termination. A complication associated with the placenta left in situ included intrauterine infection in one case. Uterus preservation was achieved in all the patients.

CONCLUSIONS

For patients with PAS disorders with complete placenta previa and previous caesarean delivery, hysterotomy is a safe choice for terminating a 2^nd trimester pregnancy. When it is impossible to manually remove the placenta, leaving the placenta in situ with the administration of adjuvant treatment is a good choice for uterus preservation.

Conservative Surgical Management of Placenta Accreta Spectrum: A Pragmatic Approach

In the last 30 years, with increasing cesarean section rates, the incidence of the placenta accreta spectrum has also increased. It is estimated that by the year 2020 there will be nearly 9000 cases annually in the United States. Currently, no consensus exists regarding optimal management. Conventional treatment by cesarean-hysterectomy is challenging, with a high maternal morbidity due to massive hemorrhage, and surgical complications such as urinary tract, bowel and pelvic nerve injury, in addition to loss of fertility and its accompanying psychological trauma. Innovative approaches seek to preserve the uterus with the adherent placenta in situ, thus maintaining fertility and potentially reducing hemorrhage and adjacent organ injury. This review reports strategies for conservative treatment of such conditions, based on the current literature.

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.

Use of routine ureteral stents in cesarean hysterectomy for placenta accreta

Objective: To evaluate benefits of use of ureteral stents in association with cesarean hysterectomy in case of placenta accreta.Methods: This was a single center, cohort study. Clinical records of singleton pregnancies with placenta accreta who underwent cesarean hysterectomy were included in the study. For this study, pregnancies with diagnoses of placenta accreta, increta, or percreta were considered under the umbrella term of placenta accreta. For all women with placenta accreta, delivery was planned via cesarean hysterectomy at 34⁰-35⁶ weeks, without any attempt to remove the placenta. Reasons for earlier delivery included vaginal bleeding and spontaneous onset of labor. The primary outcome was the incidence of unintentional urinary tract injury. Outcomes were compared in a cohort of women who had planned the placement of ureteral stents and in those who did not.Results: Forty-four singleton gestations with confirmed placenta accreta at the time of cesarean hysterectomy were included in the study. Twenty-four (54.5%) of the included women had the placing of ureteral stents prior to cesarean, while 20 (45.5%) did not. At histological confirmation, most of them had placenta accreta (17/44, 38.6%), 14 placenta increta (31.8%), and 13 placenta percreta (29.6%). Urinary tract injuries occurred in eight cases (18.2%), six in the ureteral stents and two in the non-ureteral stents group (25 versus 10%; p = .21). All the injuries were bladder injuries, while no cases of ureteral injury were recorded. All injuries were recognized intraoperatively.Conclusion: In case of placenta accreta, the use of ureteral stents in association with cesarean hysterectomy does not reduce the risk of urinary tract injury.