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.