Study outlines Novel Approach for Conservative Management of Placenta Accreta Spectrum Disorder Cases

A systematic review of near-miss cases of PAS disorders indicated that the invasion in the inferior part of the lower uterine segment, posterior bladder, and parametria was associated with a high risk of maternal morbidity. Patients with PAS disorders are associated with an increased rate of maternal morbidity and mortality, including massive blood transfusion, cystotomy, postpartum infection, peripartum hysterectomy, prolonged hospital stay, intensive care unit (ICU) admission, and even death. PAS disorders are significant life-threatening issues due to the increased incidence, morbidity, and mortality, and it is called “obstetrician’s nightmare” among obstetricians.

The standard surgical treatment recommended for PAS is usually a cesarean hysterectomy, but the loss of the uterus leaves women infertile as well as reduces the woman’s self-esteem and societal status in some countries. Therefore, over the past two decades, many conservative approaches have been reported to preserve fertility in these patients. International Federation of Gynecology and Obstetrics (FIGO) guidelines reported four different primary conservative treatment modalities for PAS disorders: the extirpative technique, leaving the placenta in situ or the expectant approach, one-step conservative surgery, and the Triple-P procedure. In addition to these procedures, interventional radiology procedures are also applied. These methods have been used alone or in combination. Although many modified conservative methods have been tried in the last two decades and these methods have significantly reduced maternal morbidity and mortality, they are still insufficient, and unfortunately, PAS disorders continue to be challenging for obstetricians worldwide. In this study, authors aimed to present a conservative surgical technique in patients with PAS disorders and to contribute to the literature with a new perspective.

Details of Surgical Technique

All cases were delivered by a single surgeon (A.Y.) who was trained and experienced more than 20 years in surgery for PP accompanied with PAS disorders.

Opening of the Abdominal Wall: At least 30 min, but no greater than 60 min before the skin incision, 2 g of a first-generation cephalosporin was administered in all cases. If there is no medical contraindication, after abdominal and vaginal povidone-iodine antisepsis, a cesarean section is performed under spinal anesthesia with a Pfannenstiel incision. Spinal anesthesia allows performing adhesiolysis carefully and gently if there are adhesions between the abdominal wall and subperitoneal internal/pelvic organs. After entering the abdominal cavity, a transverse uterine incision was performed to enter the uterus and deliver the fetus. The uterine incision is created transversely, just above the upper border of the placenta, ensuring that the myometrium’s natural thickness is preserved. When the border of the placenta extends higher, the incision is placed where the myometrial tissue is thicker if possible.

Delivery and Hemostasis: The neonate was grasped and then delivered smoothly through the uterine incision. Following the fetus extraction, the umbilical cord was clamped without separation of the placenta. The uterus is exteriorized together with the placenta. Intravenous oxytocin 10 IU infusion was administered in all patients following the delivery of the fetus. The surgeon grasps and squeezes the lower uterine segment circularly from the back, thereby mechanically preventing blood loss (hand tourniquet), and then tries to separate the whole placenta by squeezing it with the other hand. After the separation of the placenta, all bleeding areas are clamped with several curved ovarian forceps. After the mechanical hemostasis of the lower uterine segment has been achieved, the remaining small amounts of placental fragments are removed by instruments with an aim for complete removal.

Repair and Closure of the Uterine Wall: Following the achievement of the mechanical hemostasis in the lower uterine segment, sutures are placed on both the left and right corners of the uterine incision. The clamps are removed sequentially, and the vesicouterine interface and all spaces are sutured with superficial stitches under the guidance of the surgeon’s fingers. These superficial continuous sutures are not very deep but are placed around the tissue surrounding the vessel to put the squeeze on it and obtain hemostasis. Particular care should be taken to avoid the ureter or bladder injury during this procedure. Then, starting the suturing from the left or right corner of the uterus, the lower edge of the incision is created with continuous locked and unlocked sutures. The surgeon should insert the index finger into the cervical canal for guidance while creating the anterior lower edge of the incision and feel the place where the needle passes with his fingers to avoid passing the suture from the cervical canal. If hemostasis is not achieved in the underlying placental bed and surrounding structures, multiple hemostatic sutures are directly placed to cease the bleeding. After creating the lower edge of the uterine incision, the uterine incision was then closed by double layers and continuously locked and unlocked sutures.

This retrospective study included 245 patients with placenta previa accompanied by PAS disorders operated at a university hospital between June 2013 and December 2023. The diagnosis of PAS was made by a single perinatologist using a combination of transvaginal and transabdominal ultrasonography. All patients were operated with conservative surgical technique by the same surgeon. The demographic and clinical characteristics of the patients, the anesthesia and incision types used, and the details of the surgical technique were evaluated.

Of the patients, 165 were operated on at the scheduled time, 80 were operated on under emergency conditions, and 232 (94.69%) of them were operated on under spinal anesthesia. All patients were operated on with a Pfannenstiel incision followed by a transverse incision to the upper border of the placenta to enter into the uterus. An average of 0.52 units of red blood cells per patient was transfused to all patients. Spontaneous intra-abdominal bleeding developed in five patients, and surgical complications occurred in eight patients. No cesarean hysterectomy was performed, and no maternal mortality was detected in any of the cases. The mean time duration of surgery was 54 44 ± 11 37 (30–90) min, and the mean length of hospital stay was 1 71 ± 1 30 (1–9) days.

In the current study, authors described their simplified conservative surgery approach and presented the outcomes of our conservative surgical technique in PP patients with PAS disorders. They think that this technique will significantly reduce maternal morbidity and mortality while preserving fertility. This technique provides many benefits such as fertility preservation, less blood loss, and shorter operation time, length of hospital stay, and recovery time.

An era of advanced maternal intensive care encourages conservative rather than radical surgical procedures in PAS cases. Authors recommend this procedure as a novel technique and a robust and safe alternative to peripartum hysterectomy and other conservative surgical management procedures for cases with complete PP accompanied with PAS. This technique preserves the uterus as well as reduces blood loss, and transfusion requirement, and thus maternal morbidity and mortality in PAS cases. The surgical method should be reproducible and generalized; thus, many patients could benefit from the conservative surgery, although one surgeon technique could avoid the bias in the study. However, authors recommend that surgeons dealing with this surgery should receive practical training and develop their operative experience and surgical skills before utilizing this procedure.

Source: Ahmet Yalınkaya and Süleyman Cemil Oğlak; Wiley Journal of Pregnancy Volume 2024, Article ID 9910316, 10 pageshttps://doi.org/10.1155/2024/9910316