ABSTRACT
Objective: We previously
described a technique for repair of the myometrial defect at repeat
Caesarean section which increases residual myometrial thickness thereby
potentially reducing future niche-related complications. Here we
describe how this technique can be modified for use for placenta accreta
spectrum disorders.
Design: Comparison of surgical performance of the modified
technique with peripartum hysterectomy in women having repeat Caesarean
delivery for placenta accreta
Setting: A two year retrospective case control study at a
tertiary unit in Singapore.
Population: All women with placenta accreta spectrum disorder
between December 2019 and October 2021.
Methods: After delivery through the isthmocele women either
underwent the modified technique which comprised uterine
exteriorisation, systematic placental removal initiated from the
posterior uterine wall, identification, mobilization and apposition of
the boundaries of myometrial defects and repair or peripartum
hysterectomy.
Main Outcome Measures: Operating time, estimated blood loss and
complication rate.
Results: Ten women had Caesarean hysterectomy and ten had
Caesarean section using the modified approach. Age and gestational age
at delivery were similar for the two groups.
Women
in the modified technique group had had fewer prior Caesarean sections
and had a lower body mass index. Operating time, estimated blood loss
and need for transfusion were lower in the myometrial repair group but
without statistical significance and there were no visceral injuries.
There was one bladder injury in the hysterectomy group.
Conclusion: The modified
approach provides an effective alternative to peripartum hysterectomy
with favourable surgical profile and allows uterine conservation with
restoration of myometrial thickness.
Funding: The study is supported by Singapore Duke-NUS Benjamin
Henry Sheares Professorship in Obstetrics & Gynecology and Integrated
Platform for Research in Advancing Metabolic Health Outcomes of Women &
Children (IPRAMHO) Study Group (NMRC CGAug16C008). The funding was used
to cover the costs of medical illustration and open access submission.
Keywords Caesarean section, isthmocele, residual myometrial
thickness, placenta accreta spectrum disorders