Evaluation of Different Surgical Approaches Used for Conservative

Management of Placenta Accreta Spectrum in Sohag University

Hospital

AbdAllah Ahmed Refaat, Magdy AbdelRahman Mohamed, Abdou Saeed Ait-Allah

Department of Obstetrics & Gynecology, Faculty of Medicine, Sohag University, Egypt

Abstract
Background: Placenta accreta spectrum (PAS) disorders have become a major challenge
for obstetricians; due to its increased incidence, morbidity and mortality. The optimal
management strategy is debatable. This study aimed to evaluate various conservative
surgical techniques used in cases of PAS at Sohag university hospital, Egypt.
Methods: A total of 122 cases with PAS disorders were studied in this prospective cohort
study, between August 2022 and June 2023. Patients were divided into 4 groups
according to the used surgical approach. Group (A), (n = 49) in which cervical
tamponade was used, group (B), (n = 37) in which a resective-reconstructive approach
was used, group (C)
(n = 17) in which vertical compression sutures were used, and group (D) (n = 19) in
which a combination of resecting the accreta area and cervical tamponade was used.
Results: The mean age of cases was 30.9 years. The number of previous CS ranged from
1 to 6 times, with an average of 3 times. All cases were associated with placenta previa.
Only 2 cases had undergone cesarean hysterectomy. Group (A) had the least amount of
estimated blood loss (EBL) and the shortest post-operative hospital stay. Group (C) had
the shortest operative duration. The percent of Bladder injuries and ICU admission was
highest in group (D) followed by Group (B).
Conclusion: No conservative procedure seemed to be superior to another, therefore,
management of each case of PAS should be individualized. A combination of multiple
techniques could be used as long as the patient is hemodynamically stable.
Key words: Placenta accreta spectrum, conservative management.
Introduction

The term "placenta accreta spectrum" refers to a group of abnormal conditions in

which all or part of the placenta attaches, invades, or penetrates the myometrium or
surrounding organs, preventing the proper separation of the placenta at delivery,
resulting in massive maternal hemorrhage, and endangering the lives of both the mother
and the unborn baby [1]. It is now a prevalent and dangerous obstetric issue and a major
challenge for medical practitioners.
The prevalence of placenta accreta spectrum (PAS) has risen significantly over
the last few decades, with one in every 533 deliveries now being affected [2]. A shift in
risk variables, most notably the rise in cesarean deliveries, is probably to blame for the
rising rate of PAS disorders during the past four decades [3]. In the presence of placenta
Previa, the incidence of placenta accreta rises from 24% after one caesarean section to
67% after four or more caesarean sections [4].
The optimal strategy for managing PAS disorders remains debatable. The
American College of Obstetricians and Gynecologists (ACOG) recommends elective CS
hysterectomy with the placenta in place. This option may be refused in cases wishing to
preserve their fertility. In such cases, after proper risk counselling, conservative
management should be considered [5].
Conservative management of PAS disorders includes all techniques aimed at
preserving the uterus. It includes the extirpative technique (manual removal of the
placenta); the expectant approach (leaving the placenta in place); one-step conservative
surgery (removal of the accreta area); the Triple-P procedure; and numerous other
conservative surgical techniques. These methods, alone or in combination, have been
used to reduce hemorrhage associated with PAS disorders [6].
For the best possible result, prenatal diagnosis and careful multidisciplinary
preparation during birth are essential [7].
The objective of this study was to evaluate different surgical procedures to
control bleeding in cases of placenta accreta spectrum disorders, aiming to determine the
best procedure regarding maternal morbidity and mortality, and to evaluate the long-term
effects of conservative management of PAS disorders.
Patients and Methods
Setting:
This prospective cohort observational study was carried out at the obstetrics and
gynecology department, in Sohag university hospital (Egyptian tertiary referral hospital)
between August 2022 and June 2023.
Ethical considerations:
The study was approved by the medical research ethics committee of Sohag
Faculty of Medicine. An informed written consent was obtained from each participant in
the study, after explaining the purpose of the study, interventions, outcome and possible
complications.
Inclusion Criteria:
 Women with at least one previous caesarean section and suspected PAS disorders by
imaging studies:
 The ultrasonographic features used to detect PAS disorders were as previously
described in the literature, and included one or more of the following;
Loss or thinning (less than 1 mm) of the normal hypo-echoic retro-placental
myometrial plane, as well as thinning or disruption of the hyper-echoic uterine
serosa-bladder interface or the presence of multiple placental lacunae.
 3-D ultrasound or doppler study were reported if done.
 MRI was not routinely performed at our center, and its role was hampered by
its high cost and difficult interpretation.

Exclusion Criteria:
 Patients with intraoperative spontaneous placental separation.
 Patients with a preoperative diagnosis of placenta percreta who chose to have an
elective hysterectomy.
 Any other associated uterine pathology requiring hysterectomy.
 Coagulation disorders.
 Gestational age < 28 weeks.
 Multiple pregnancy.
Study plan:
A total of 122 cases of pregnant women with placenta accreta spectrum with
previous cesarean section scar were studied. History taking, general and abdominal
examinations, lab investigations, and ultrasound assessment were done for all
participants in this study. Patients with suspected PAS disorders were admitted to the
inpatient department for close monitoring if they had a minor APH, and corticosteroids
were administered if they were less than 34 weeks gestation. At least four cross-matched
blood units were always available. If patients remained asymptomatic, they were
scheduled for an elective repeat CS at 36-38 weeks or earlier in case of any
complications. All patients and their husbands were fully counseled about the risk of
bleeding and surgical options at delivery, including the risk of hysterectomy, the need for
ICU admission and prolonged hospitalization.
All cases were operated by senior experienced obstetricians at the obstetrics and
gynecology department in Sohag university. During CS, patients were in a supine
position, Pfannenstiel incision was done in all cases in this study. After that, the anterior
abdominal wall was opened in layers. The urinary bladder was dissected downwards.
Unless unexpected percreta was noted intraoperatively, a lower segment CS incision was
used in the majority of cases. After the fetus is delivered, a brief attempt at delivering the
placenta was made to confirm the diagnosis.
For patients wishing to preserve their fertility, prompt blood transfusion,
available uterotonic agents were injected, and rapid surgical intervention was made to
control bleeding. The observed intraoperative blood loss was estimated taking into
account the suction volume, surgical pads and swabs.
According to the intraoperative technique used to control bleeding, patients in
this study were divided into different groups as follows:
Group A: in this group, cervical tamponade was done, which was performed by elevating
the cervix into the uterine cavity with Allis forceps, then suturing the anterior and/ or
posterior cervical lip(s) into the anterior and/ or posterior uterine segment(s) depending
on the site of bleeding with two or three simple interrupted or continuous stitches, with
the patency of the cervical canal confirmed, followed by closure of the uterine incision
[8].
Group B: in this group, a resective-reconstructive technique was used, which involved
resecting the invasive accreta area followed by immediate uterine reconstruction and
bladder reinforcement [9].
Group C: in this group, full-thickness vertical compression sutures combined with
inflated intrauterine balloon were used to control bleeding [10].
Group D: in this group, a combination of resection of the invasive accreta area and
cervical tamponade was used to control bleeding.
A multidisciplinary approach involving senior obstetricians, vascular surgeons,
urologists, anesthesiologists, and pediatricians was adopted.
Outcome measures included successful intervention procedure, maternal
mortality and morbidity (ICU admission, need of re-exploration, drop of hemoglobin and
hematocrit values, massive blood transfusion, bladder and/ or ureteric injury,
coagulopathy, infection and hospital re-admission within 6 weeks). Following delivery,
patients were followed-up for return of menstruation at 3 months interval.
Statistical analysis:
Data were collected, revised, coded and entered to the Statistical Package for
Social Science (IBM SPSS) version 20. The qualitative data were presented as number
and percentages while quantitative data were presented as mean, standard deviations and
ranges when their distribution found parametric.
The comparison between two groups with qualitative data was done by using Chi-
square test and/or Fisher exact test which was used instead of Chi-square test when the
expected count in any cell was found less than 5.
The comparison between more than two independent groups with quantitative data
and parametric distribution was done by using One Way ANOVA.
The confidence interval was set to 95% and the margin of error accepted was set to
5%. So, the p-value was considered significant as the following:
P> 0.05 = non-significant (NS).
P < 0.05 = significant (S).
P < 0.001 = highly significant (HS).

Results
This study was conducted on 122 women with an average age of 30.9 years, their
average Parity were 3, The number of cesarean deliveries ranged from one to six times,
with an average of three times. The patients were divided into four groups according to
the used surgical approach as follows:
Group (A) including 49 women, Group (B) including 37 women, Group (C) including 17
women and Group (D) including 19 women.
As shown in table 1, There were no statistically significant differences among the 4
groups regarding Age, Parity, and No. of previous CS.
 As shown in table 2, placenta previa was associated with all the studied cases (76.2%
major degree) and (23.8% minor degree).
Table (1): Comparison among the four groups regarding baseline characteristics.
Group A Group B Group C Group D
P-value
No. = 49 No. = 37 No. = 17 No. = 19
Mean ± SD 31.16 ± 4.74 31.92 ± 5.02 28.35 ± 6.36 30.68 ± 3.97
Age 0.109
Range 22 – 45 23 – 44 18 – 39 25 – 37
Median 3 (3 – 4) 3 (3 – 4) 3 (2 – 4) 3 (2 – 4)
Parity 0.479
Range 1–7 1–7 1–6 1–6
No. of Median 3 (2 – 4) 3 (2 – 4) 2 (1 – 4) 3 (2 – 4)
0.353
previous CS Range 1–6 1–5 1–5 1–4
P-value >0.05: Non significant (NS); P-value <0.05: Significant(S); P-value< 0.01: highly significant
(HS).

Table (2): Association and Degree of placenta previa (PP) in the 4 groups.

Group A Group B Group C Group D

Placenta previa Total No. P-value
No. = 49 No. = 37 No. = 17 No. = 19
Major 93 (76.2%) 38 (77.6%) 30 (81.1%) 6 (35.3%) 19 (100%)
0.001
Minor 29 (23.8%) 11 (22.4%) 7 (18.9%) 11 (64.7%) 0 (0.0%)
P-value >0.05: Non significant (NS); P-value <0.05: Significant(S); P-value< 0.01: highly significant
(HS).

As shown in table (3); The mean gestational age at time of operation was 36.2 weeks.
There were no statistically significant differences among the 4 groups regarding
gestational age (GA) at time of Operation and Medical co-morbidity.

Table (3): Gestational age and medical co-morbidity in different groups.

Total Group A Group B Group C Group D P-
No. = 122 No. = 49 No. = 37 No. = 17 No. = 19 value
GA at time Mean ± SD 36.29 ± 2.67 36.61 ± 2.38 36.16 ± 3.00 35.12 ± 3.69 36.79 ± 1.03
0.193
of Operation Range 28 – 39 28 – 39 28 – 39 29 – 38 34 – 38
Medical Chronic HTN 1 (0.8%) 1 (2.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0.512
co-morbidity DM 1 (0.8%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (5.3%)
Gestational DM 2 (1.6%) 0 (0.0%) 1 (2.7%) 0 (0.0%) 1 (5.3%)
Gestational HTN 2 (1.6%) 1 (2.0%) 0 (0.0%) 1 (5.9%) 0 (0.0%)
 RHD 1 (0.8%) 1 (2.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)
No 115 (94.3%) 46 (93.9%) 36 (97.3%) 16 (94.1%) 17 (89.5%)
P-value >0.05: Non significant (NS); P-value <0.05: Significant(S); P-value< 0.01: highly significant
(HS).

As shown in table (4); Intrauterine catheter was inserted in 75 cases (61.1%).

Bilateral uterine artery (UA) ligation was done in the majority of cases, 120 cases
(98.4%), while bilateral Internal Iliac artery (IIA) ligation was done in only 1 case and it
was done by vascular surgery team.

Table (4): Ancillary hemostatic measures used intraoperative to control hemorrhage.

Total Group A Group B Group C Group D

No. = 122 No. = 49 No. = 37 No. = 17 No. = 19

Intrauterine Yes 75 (61.5%) 28 (57.1%) 18 (48.6%) 16 (94.1%) 13 (68.4%)

catheter insertion No 47 (38.5%) 21 (42.9%) 19 (51.4%) 1 (5.9%) 6 (31.6%)
Yes 120 (98.4%) 48 (98.0%) 36 (97.3%) 17 (100.0%) 19 (100.0%)
UA ligation
No 2 (1.6%) 1 (2.0%) 1 (2.7%) 0 (0.0%) 0 (0.0%)
Yes 1 (0.8%) 1 (2.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)
IIA ligation
No 121 (99.2%) 48 (98.0%) 37 (100.0%) 17 (100.0%) 19 (100.0%)

As shown in table (5), There were no statistically significant differences between pre-
operative HGB levels among the 4 groups, however there was a statistically significant
difference between post-operative HGB levels among the 4 groups. Group A had the
least percent of drop in HGB levels, followed by Group C, then Group B, and finally
group D.

Table (5): Comparison between pre-operative and post-operative HGB levels in different
groups.
Group A Group B Group C Group D
P-value
No. = 49 No. = 37 No. = 17 No. = 19
Pre-Op Mean ± SD 11.60 ± 1.13 11.25 ± 1.04 12.02 ± 0.94 11.33 ± 0.99
0.075
HGB Range 9.4 – 14.7 9.06 – 13 10.6 – 14.1 9.3 – 12.8
Post-Op Mean ± SD 10.73 ± 1.49 9.71 ± 1.29 10.54 ± 1.63 9.60 ± 1.34 0.002
 HGB Range 7.5 – 13.7 7.2 – 12.8 8 – 13.5 7.6 – 12.3
% of Drop
Mean ± SD 9.93 ± 8.82 13.40 ± 10.59 12.22 ± 11.92 15.21 ± 9.43 0.190
in HGB
P-value >0.05: Non significant (NS); P-value <0.05: Significant(S); P-value< 0.01: highly significant
(HS).

As shown in table (6), there were no statistically significant differences among the 4
groups regarding Blood and plasma transfusion intra-operatively and post-operatively.
There was highly statistically significant difference among the 4 groups regarding
duration of surgery (minutes) and Estimated Blood Loss (CC). Group C had the shortest
estimated duration of surgery (mean = 80.88 minutes). The average Estimated Blood
Loss (CC) was the least in Group A (1188.7 cc).

Table (6): Duration of surgery, estimated blood loss (EBL), and blood & plasma
transfusion in different groups.
Group A Group B Group C Group D
P-value
No. = 49 No. = 37 No. = 17 No. = 19
Duration of Mean ± SD 83.37 ± 19.96 103.24 ± 25.80 80.88 ± 17.43 108.42 ± 28.77
0.001
surgery (mins) Range 55 – 140 70 – 180 55 – 115 75 – 180
Mean ± 1188.78 ± 1775.68 ± 1317.65 ± 1863.16 ±
Estimated Blood 521.74 585.19 604.40 820.71
SD 0.001
Loss (CC)
Range 500 – 2800 600 – 3100 600 – 3000 800 – 3400
Blood transfusion Median 2 (1 – 2) 2 (1 – 3) 1 (1 – 2) 2 (2 – 3)
0.116
(Intra-Op) Range 1–4 1–4 1–4 1–4
Blood transfusion Median 0 (0 – 0) 0 (0 – 1) 0 (0 – 0) 0 (0 – 1)
0.679
(Post-Op) Range 0–2 0–4 0–2 0–2
Plasma transfusion Median 1 (0 – 2) 2 (1 – 2) 1 (1 – 2) 2 (1 – 2)
0.076
(Intra-Op) Range 0–3 0–4 0–4 0–4
P-value >0.05: Non significant (NS); P-value <0.05: Significant(S); P-value< 0.01: highly significant
(HS).

As shown in table (7); 33 cases were admitted to the ICU for follow-up post-operatively,
Group D had the largest percentage as regarding ICU admission. Two cases had
undergone cesarean hysterectomy due to failure of conservative techniques.

Table (7): ICU admission and hysterectomy in different groups.

 Total Group A Group B Group C Group D
P-
No No
No. % No. % % No. % % value
. .
Ye
ICU 33 27.0% 13 26.5% 10 27.0% 3 17.6% 7 36.8%
s 0.639
admission
No 89 73.0% 36 73.5% 27 73.0% 14 82.4% 12 36.2%
Ye
2 1.6% 0 0.0% 1 2.7% 0 0.0% 1 5.3%
Hysterectomy s 0.406
No 120 98.4% 49 100.0% 36 97.3% 17 100.0% 18 94.7%
P-value >0.05: Non significant (NS); P-value <0.05: Significant(S); P-value< 0.01: highly significant
(HS).

As shown in table (8); 19 cases had accidental bladder injuries during bladder dissection,
all were repaired by a urology team. Group D had the largest percentage as regarding
bladder injuries and there were no bladder injuries in group C.
Other complications in the form of hospital readmission within 6 weeks, post-partum
hemorrhage (PPH), wound infection, Ileus and abdominal distension were not
statistically significant among the studied groups.

Total Group A Group B Group C Group D

No P-value
No. % No. % No. % % No. %
.
Bladder Yes 19 15.6% 6 12.2% 8 21.6% 0 0.0% 5 26.3%
0.100
Injury No 103 84.4% 43 87.8% 29 78.4% 17 100% 14 73.7%
Hospital
1 0.8% 0 0.0% 0 0.0% 0 0.0% 1 5.3%
readmission
Ileus &
abdominal 2 1.6% 1 2.0% 1 2.7% 0 0.0% 0 0.0%
Other distension 0.469
complications
Wound
1 0.8 0 0.0% 0 0.0% 1 5.8% 0 0.0%
infection
PPH 1 0.8% 0 0.0% 1 2.7% 0 0.0% 0 0.0%
No 118 96.7% 48 98% 35 94.6% 16 94.2% 18 94.7%
Table (8): Bladder Injury and other complications in different groups.

As shown in table (9); The average hospital stay after surgery was the least in group A
followed by group C then group B and finally group D.
At 3 months appointments, 66 patients (54.1%) reported return of menstruation, 21
patients (17.2%) were amenorrhoeic and 35 patients (28.7%) lost follow-up. There were
no statistically significant differences among the 4 groups regarding return of
menstruation after 3 months.
 Table (9) Hospital stay after operation, and return of menstruation in different groups.
Total Group A Group B Group C Group D
P-value
No. = 122 No. = 49 No. = 37 No. = 17 No. = 19
Hospital stay Mean ± SD _ 2.18 ± 1.01 2.97 ± 1.64 2.47 ± 2.03 3.32 ± 1.57
0.016
after Op. (days) Range 1–7 1–7 1–8 2–7
Return of menses
Yes 66 (54.1%) 27 (55.1%) 18 (48.6%) 13 (76.5%) 8 (42.1%)
After 3 months No 21 (17.2%) 9 (18.4%) 7 (18.9%) 0 (0.0%) 5 (26.3%) 0.349
No follow-up 35 (28.7%) 13 (26.5%) 12 (32.4%) 4 (23.5%) 6 (31.6%)

Discussion
The significant increase in caesarean section (CS) delivery rates has been linked
to an increase in both placenta previa and placenta accreta. The risk of placenta accreta
spectrum is significantly increased in the presence of a placenta previa and one or more
prior cesarean births. For women with placenta previa, the risk of placenta accreta is 3%,
11%, 40%, 61%, and 67% for the first, second, third, fourth, and fifth cesarean,
respectively [3].
In our study, the number of previous cesarean deliveries ranged from one to six
times, with an average of three times (32% of studied cases) and all the cases had
associated placenta previa. These results agreed with many authors. Placenta previa,
previous cesarean birth and high maternal age were revealed to be significant risk factors
in a case-control study that was published in 2012 [11].
The high incidence of diagnosed cases of PAS in our study might be attributed to
the fact that it was done in the main tertiary care hospital of our governorate that
received a high proportion of transferred patients (from peripheral health centers).
The optimal strategy for managing PAS disorders remains debatable, it depends
on the available expertise, the depth of placental invasion and its lateral extension, and
the association of placenta previa. In cases wishing to preserve their fertility, after proper
risk counselling, conservative management should be considered [5].
Women included in this study were particularly concerned with preserving their
fertility. Multiple studies have descried the use of various approaches to control bleeding
after partial separation of the adherent placenta. It is possible that no one technique will
be sufficient to stop the extensive bleeding that results from the separation of the
placenta in cases of PAS. All efforts should be made to control intra/ postoperative
hemorrhage.
As shown in our study, multiple surgical techniques, alone or in combination,
were used to control bleeding in cases of PAS including cervical tamponade, resective-
reconstructive approach, vertical compression sutures, IUC insertion and uterine artery
ligation.
 In a case report they published in 2007, Dawlatly and his associates described
how they employed the cervical lip(s) to stop bleeding from the placental bed, preserving
the uterus and the patient's life [12]. In our study, this technique was used alone in 49
cases (Group A) (40.1% of cases) and it proved to be effective in controlling bleeding
and preserving the uterus. In comparison with other techniques in our study, this
technique had the least amount of estimated blood loss (EBL) and the shortest post-
operative hospital stay, bladder injuries occurred in 12.2% of cases.
In a multicenter retrospective case series published in 2022, a resective-
reconstructive approach was employed in cases of invasive placenta and it was
successful in preventing hysterectomy in up to 80% of cases [9]. In our study this
approach was used alone in 37 cases (Group B) (30.3% of cases), however one case in
this group required hysterectomy, and one case suffered from post-partum hemorrhage.
This technique had more EBL and a longer post-operative hospital stay, also bladder
injuries were as high as 21.6% of cases.

Another surgical technique used in this study was the full-thickness vertical
compression sutures [10]. It was employed on 17 cases (Group C) (13.9% of cases) and
it proved to be effective in controlling bleeding in these cases. It should be noted that
only one third of these cases had associated major degree of placenta previa (35.3% of
cases) which is a small percent compared to other groups. This technique was used to a
bigger extent in the simpler cases of placenta accreta with partial separation of placenta
(focal accreta), with the shortest duration of surgery, and a zero% bladder injury.
A combination of more than one surgical technique was done in some cases. In
our study, 19 cases (Group D) (15.5%) had a combination of resecting the invasive
accreta area, and performing cervical tamponade, the combination was successful in
preserving the uterus and controlling bleeding, however one case required hysterectomy.
This group of cases had the longest duration of surgery, post-operative hospital stays,
and the largest amount of EBL. Bladder injuries were highest (26.3% of cases).
Ancillary hemostatic techniques such as intrauterine catheter (IUC) and Bilateral
uterine artery ligation, were used in our experience. UA ligation was almost a routine
practice in our study, and it was done in 98.4% of cases. Bilateral IIA ligation was done
in only one case.
Bladder injury was the commonest intra-operative complication in our study (19
cases) (15.6% of cases). Some cases were kept in the ICU post-operatively for follow-up
(33 cases) (27% of cases).
According to reports, the average mortality rate for PAS disorders was 7.0% [13].
We were fortunate not to record any mortality in the current study.
PAS can cause massive bleeding, which can lead to multiple organ failure,
hysterectomy, blood transfusion, and even death [7]. Massive bleeding should be
anticipated and managed with particular focus paid to the availability of packed RBCs,
platelets concentrate, and fresh frozen plasma.
Some authors identified severe uterine synechiae and amenorrhea in some cases
after conservative management of adherent placenta that may affect future fertility [14].
Patients should be counseled about the high risk of placenta accreta recurring in future
pregnancies [15].
In our study, 54.1% of patients reported return of menstruation after 3 months of
surgery, 28.7% of patients lost follow-up, and the remaining 17.2% were amenorrhoeic
however this could be explained by lactation or contraception. These data were not
sufficient to expect the long-term effect of conservative management on the future
menstrual pattern, future fertility potentials or pregnancies outcomes.

Limitations of the study:

The study's shortcomings included the short study duration and the insufficient
long-term follow-up data. A randomized trial including PAS disorders is challenging,
since we choose the approach that is most appropriate for each individual patient,
however this is considered one of the study’s limitations.

Conclusions
Multidisciplinary team (MDT) is essential in management of PAS disorders.
Previous CS, multiparity and placenta previa are major risk factors for PAS disorders.
In our experience, no conservative procedure seemed to be superior to another, therefore,
management of each case of PAS should be tailored according to the extent of invasion
of placenta into the uterine wall and its partial separation, the association and degree of
placenta previa, and the available expertise. Putting all these factors into consideration,
we could choose the suitable surgical technique or combination of techniques.

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