Main Findings
All clinical options for PASD after delivery of the fetus carry
potential complications including major hemorrhage. IRP can lead to
sepsis and secondary hemorrhage requiring delayed hysterectomy.
Hysterectomy results in permanent inability to have more children
regardless of family planning wishes although even with uterine
conserving techniques contemporaneous sterilization is often offered to
avoid recurrence. Peripartum hysterectomy carries additional surgical
morbidity related to the need to remove the cervix. It has been
associated with a 7% ureteric injury and 15% rate of bladder injury
(7).
The Triple-P procedure, which involves delivery of the fetus above the
placenta and resection of the myometrium with attached placenta after
pelvic devascularization, was found to have fewer bladder injuries and
no ureteric injury compared with hysterectomy but was complicated by
delayed primary hemorrhage requiring embolization or re-laparotomy for
intra-abdominal bleeding from neovascularization of the bladder serosa
(7). Other conservative surgical techniques are time consuming and also
associated with high operative risk most notably bleeding and visceral
damage.
Our conservative procedure, with favorable surgical outcomes, differs
from the Triple-P and other procedures by focusing on formal recognition
and repair of the pre-existing myometrial defect whose muscle edges are
actively bleeding after delivery to restore tissue integrity. Blood loss
is further controlled using several manoeuvres including expeditious
exteriorization of the uterus, applying manual compression at the level
of the uterine arteries and systematically delivering and detaching the
placenta from posterior wall first and working anteriorly; all of which
can be supported by the use of IIA balloons and other measures to
achieve haemostasis.
The technique, which focuses on conservation and restitution of the
uterus rather than excision, provides an alternative to other
conservative surgical approaches
for placenta accreta spectrum disorder and has a comparable surgical
profile. It has the added advantage of addressing the myometrial niche
with implications for patient’s future symptomatology.