Placenta accreta spectrum: a hysterectomy can be prevented in almost 80% of cases using a resective-reconstructive technique

Objective: To describe the use of surgical repair (One-step resective-conservative surgery) in all cases of placenta accreta spectrum.

Study design: Multicentre retrospective case series from tertiary referral hospitals in Argentina. A total of 452 patients were accepted from 12 hospitals presenting suspicion of invasive placenta by auxiliary methods (ultrasound, Doppler and MRI). At the time of the surgery, placenta accreta spectrum was classified according to invasion topography (specific blood supply) and local features (proximity to other structures, adhesion process, and multiple anastomotic blood vessels). Type 1: upper posterior bladder; type 2: parametrial; type 3: low posterior bladder; and type 4: low posterior bladder and fibrosis. After the ligature of newly formed vessels between the uterus and pelvic organs, the fetus was delivered through an upper segmental hysterotomy. Hemostasis was achieved by selective ligature of vesical-uterine and colpo-uterine vessels. Then, the invaded myometrium and the entire placenta were removed totally in bloc and until detected healthy tissue in both edges, to guarantee the most physiological hysterotomy in the uterine segment. The uterus was closed with a polyglactin suture, double-layer technique. The main outcome measurements were the uterine conservation, the blood loss and other complications classified according to intrasurgical classification.

Results: From 452 accepted patients, 326 patients had a confirmed diagnosis of placenta accreta spectrum by histology analysis and surgical-clinical findings. In 126 cases, placenta accreta spectrum was excluded used the same diagnostic criteria (Type 0 or false positive PAS). They were identified 248 cases as type 1, 44 as type 2, 23 as type 3 and 11 as type 4. Uterine conservation was possible in the 81% of type 1 invasion with 500 mL of blood loss (interquartile range, IQR = Q3 − Q1). The modified Pfannenstiel was the most commonly used incision, while midline incision was chosen in all emergencies or in patients with a previous midline incision. Hysterotomy made in the upper part of the uterine segment presented normally attached placentas and not accreta. Selective vessel ligature, also named custom-made hemostasis method (CMHM) was effective at stopping or preventing bleeding associated with PAS. The entire placenta and the invaded area are removed in block, to guarantee to perform the uterine repair with healthy tissue and to avoid a recurrence in the subsequent cesarean. The uterine-ovary artery axis is never occluded or obliterate to guarantee the uterine-endometrial and ovary blood supply as before surgery. No significant differences existed according to the population; however, the presence of total occlusive placenta previa was more frequent in types 3 and 4, which were also associated with older mothers and age-related collagen changes. Lateral and lower segment invasions (types 2 and 3) were most commonly associated with previous terminations of pregnancy, curettage, and manual removal of the placenta. Blood loss and technical difficulty were clearly associated to the invaded area, while invasion degree was a poor marker to predicting bleeding or complications in all locations Uterine conservation was possible in 202/248 (81.5%) of type 1, 21/44 (47.7%) of type 2, 5/23 (21.8%) of type 3 and 0/11 (0%) of type four cases. Type 0 (false positive) were excluded of statistical analysis, and the uterus was preserved in 100% of cases. In a separate report, we will describe the maternal and fetal outcomes as well as 204 subsequent pregnancies after the use of one-step resective reconstructive technique.

Conclusions: Using the resective-reconstructive approach (one-step conservative surgery) to the management of invasive placenta, the uterus can be preserved with minimal morbidity and reduced blood loss in almost 80% of cases. Précis preventing hysterectomy in 80% of placenta accreta spectrum.