Resident of Obstetrics and Gynecology, Tanta University, Tanta, EgyptEgypt
Lecturer of Obstetrics and Gynecology, Tanta University, Tanta, EgyptEgypt
Professor of Obstetrics and Gynecology, Tanta University, Tanta, EgyptEgypt
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Introduction: The incidence of placenta accreta is rising as a consequence of increased rate of cesarean sections and placenta previa which is the strongest risk factor. Intractable postpartum hemorrhage associated with placenta accrete is a leading direct cause of maternal morbidity and mortality. Major surgical modalities were described for management of placenta accreta like hysterectomy, systemic pelvic devascularization, stepwise surgical measures, intervention radiology methods and massive blood transfusions, all were recommended to be used for successful management and saving the maternal life. Patients and Methods: Fifty cases of placenta accrete were included in our study. They were selected from Obstetrics and Gynecology Department at Tanta University Hospital diagnosed by ultrasound (US) and magnetic resonance imaging (MRI). Pre-operative evaluation, laboratory investigations, and cross matched blood were done. Stepwise uterine sparing technique included simply: double ligation of uterine artery at two different levels on both sides before and after placental removal, lower at level of uterine isthmus and higher for utero-ovarian vessels ligation. Hemostatic quadruple sutures with sewing the placental bed were applied for control bleeding at the placental site attachment. Finally insertion of triple way Foley’s catheter through the cervix and inflation to 50 cc saline to compress lower uterine segment and drain bleeding. Results: The stepwise uterine sparing procedure achieved a high success rate 96%. From a total 50 cases with placenta accrete, 41 cases (82%) passed their major surgery and recovery period without any reported complications. There were some common complications between the same cases. There was 14% (7 cases) complicated with bladder injury, 8% (4 cases) with fever, also 8% (4 cases) with UTI, 12% (6 cases) wound infection and 10% (5 cases) needed post operative maternal ICU admission. Neither maternal death, DIC, readmission for any cause nor relaparotomy was reported for any case. Conclusion: The stepwise uterine sparing procedure was successful as a conservative form of surgical management of placenta accrete with preserving the uterus and fertility, saving patient’s life and minimizing major surgical interventions in all patients.
Keywords: Placenta accrete; Uterine sparing technique
All demographic data, pre-operative findings, operative data, complications, and post-operative recording of vital signs, drains, urinary output, bleeding, fever and number of transfused blood units if needed also hemoglobin level checked 6 hours post-operatively.
This study was approved by local ethical committee of Tanta University before start of this study. All patients were informed about procedure, its risks/benefits and all signed a written consent.
The results were analyzed by SPSS, version 18, USA. The tests used were mean, standard deviation, and percentage.
In this study, the enrolled patients (n=50) with placenta accrete were diagnosed prenatally with Ultrasound and MRI. The de-
Table 2. Operative Findings of This Study.
mographic data of the patients were presented in Tables 1 and 2.
The surprising finding in this study was that patients were so younger due to increasing rate of cesarean sections and encouraging preservation of uterus.
Hemoglobin level was significantly dropped after the procedure which was corrected later by cross-matched blood transfusion.
This study showed a high success rate of the stepwise uterine sparing technique in preserving the uterus. The success rate was 96%, included 48 cases from total 50 ones successfully preserved the uterus and only 2 cases who required hysterectomy representing 4%. But there were some related complications in the form of 14% (7 cases) complicated with bladder injury, 8% (4 cases) with post-operative fever, also 8% (4 cases) with urinary tract infection (UTI), 12% (6 cases) wound infection and 10% (5 cases) needed post-operative maternal ICU admission. Postpartum hemorrhage was detected in 6% (3 cases) which was controlled by uterine massage and strong ecbolic. There was no need for vascular surgery during operation, also no need for reoperation or readmission for any case. No visceral or ureteric injuries were reported. Complications are illustrated in Figure 1.
Table 1. Demographic Data of the Patients.
Age 24-39 31.78±3.89 Number of previous CS 0-4 3.12±1.68 Parity 0-6 3.38±1.64 Preterm 34-35.6 35.3±0.8
delivery (weeks) Full-term 36-39 37.10±1.40 Duration since last CS 1-6 years 3.24±1.74
30 (60.00%) 15 (30.00%) 5 (10.00%) 75-140 105.65±27.93 2-5 3.80±1.64 Non complicated 2-3 2.6±0.46 Complicated cases 7-11 9.27±2.34 1000-2500 1750±1060.66 2-5 3.24±1.05 400-1100 745.65±238.96 Pre-operative 8-11.4 9.62±1.21 Post-operative 6.7-10.6 8.22±1.08
Figure 1. Procedure Related Complications.
The results of this study were encouraging to use the stepwise uterine sparing technique in preservation of uterus in morbidly adherent placenta cases. Previous studied conducted to assess the outcome of uterine sparing techniques, were found to be different in the techniques used and results obtained. The results of this study are in agreement with Walker et al in the pre-operative preparations for management of cases with placenta accreta. The main difference was that Walker et al used prophylactic occlusion of the anterior division of the internal iliac artery which is an invasive procedure. Our study achieved a high success rate with uterine artery ligation alone. Comparing the results of both studies, operative time (107 minutes) similar to our study (105 minutes), also the hospital stay was (5 days), our only (3- 11 days) but it had more bladder injury (30%) than our study (14%).6
Shahin et al conducted a similar study depending on bilateral uterine artery ligation for control bleeding. Also the idea of using B-Lynch suturing as compression sutures is similar to the quadruple local hemostatic ones used to control bleeding. The differences were that in Shahin et al, two cases needed internal iliac artery ligation, needed post-operative ICU admission and complicated with disseminated intravascular coagulation (DIC) and maternal death. Shahin et al was associated with the need for (2-5 units) units of fresh blood transfused intra-operatively which were less than our study where (1-4) units of blood transfusion were needed. The total hospital stay in Shahin et al was (17 days) which was longer than hospital stay in our study (11 days).7
El Shazly et al used bilateral uterine artery ligation as primary step with 8-suture compression procedure as a second step for control bleeding associated with placenta accreta when uterine artery ligation failed to stop bleeding. The difference was that the average time of this procedure which was relatively short (142 seconds). The total intra-operative time of our surgical procedure was (75-140 minutes). The mean estimated amount of intra-operative blood loss was (2830 mL) during this procedure and (2375 mL) in women managed with bilateral uterine artery ligation alone in Elshazly et al study while in our study, the total
amount of intraoperative blood loss was (1750 mL).8
Shabana et al reported a modified approach of some surgical steps similar to our study but the only difference was that Shabana et al depended on bilateral ligation of the anterior division of internal iliac artery to control bleeding. The operative time in Shabana et al study was (70-140 minutes), similar to our study (75-140 minutes) and number of blood transfusion units was (2-6 units), similar to our study (2-5 units). The associated complications were (8.5%) rate of cesarean hysterectomy, comparing to our study which was (4%) only. As regard complications 10 patients (14.1%) had urinary tract complications similar to our study, nine (90%) were managed during cesarean section and one case presented later in the form of vesico-uterine fistula. No evidence of later complications as vesico-uterine fistula or later repair in our procedure.9
Kelekci et al achieved a successful technique in management of placenta accrete using the same our surgical steps including suturing the placental bed with squarely shaped sutures for hemostasis, ligation of utero-ovarian anastomosis branches and finally insertion of a balloon of 3-ways 20 F Foley catheter which was inflated by 80 cc saline and placed into the intrauterine cavity. The study of Kelekci et al differed mainly in internal iliac artery ligation for control bleeding and leaving placenta in situ in some cases. Also there were some different results, such as the units of blood transfusion (2-7) units while in our study (2-5) units. The operative time was (110±20) minutes, while in our study was (75-140) minutes and the mean hospital stay was (4.2±0.4) days, while in our study was (3-11) days. Comparing rates of associated complications, one patient had post-operative wound infection while in our study, 6 cases (12%). The post-operative febrile reactions developed in 2 patients in Kelekci et al study while in our study 4 cases (8%) developed post-operative febrile reaction.10
Shehata et al reported a study with 100% success rate. It completely agreed with our surgical technique. Both depended on bilateral ligation of uterine artery, higher incision of uterus and insertion of Foley catheter for compressing lower uterine segment. There were some different results. The operative time was (60-100 minutes), while our study (75-140 minutes) and
blood transfusion (2-4 units) and our study (2-5 units). The complications were presented in 6 cases from the all 15 cases represents (40%), while (82%) of cases in our study passed their surgery without any complications. Two cases (13.3%) had bladder injury, our study (14%), 2 cases (13.3%) had pyrexia, compared to our study (8%), 1 case (6.66%) had pyometria and 1 case (6.66%) of wound disruption. There was readmission for two cases but no need for ICU admission for any case. While in our study, 5 cases needed post-operative ICU admission represented (10%) but there was no need for readmission for any case.11
Palacios-Jaraquemada et al conducted a study with nearly similar surgical procedure which included removal of destructed part of lower uterine segment invaded by the placenta and trimming the uterine edges with repair the defect then insertion of a Foley’s balloon catheter, three-way 22 F, in the lower uterine segment as in our study. The differences were that higher success rates were observed without the need for uterine artery ligation rather than in our study which depended mainly on uterine artery ligation. Also repair of the uterine edges in our study was mediated by healthy uterine tissue with usual sutures without need for using any mesh or other foreign bodies. Comparing rate of CS hysterectomy, 18 of total 68 cases needed cesarean hysterectomy while in our study included 2 from total 50 cases. There were some different surgical complications, 1 case had pelvic hemorrhage, 2 cases had coagulopathies, 3 cases with uterine infection, 2 ureteral ligations, 2 iatrogenic foreign bodies reaction, 3 post-operative collections, rupture of an epigastric artery in 1 case and vesical fistula in another case. In our study, these complications never had been reported in any case.
Successful management of the potentially catastrophic conditions associated with abnormal placental adhesion requires early antenatal diagnosis with well preparation of the selected cases. Early and proper management of cases of placenta accreta can preserve life of both mother and her fetus with preserving her uterus well-functioning for further pregnancy. In this study, we have presented a simple approach as a conservative treatment for placenta accreta cases. Our surgical procedure was effective and safe in the conservative management of patients with placenta accreta.
We are very much thankful to our professors, assistants and residents who helped us to complete this work. We also thankful to statistics analyzers.
The authors declare that they have no conflicts of interest.