Outcome of Stepwise Uterine Sparing Approach as a Conservative Surgical Management of Placenta Accreta

Abstract

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.