Placenta Previa Accreta Research Articles

PLACENTA ACCRETA SPECTRUM: CLINICAL PATHWAY OF A PATIENT IN THE PERINATAL CENTRE OF KYIV

There is no doubt about the danger of obstetric hemorrhage. For many years, the main preventable cause of maternal mortality has been peripartum hemorrhage. Pathology of the placenta – its location and attachment – is one of the main reasons for the development of obstetric hemorrhage, the frequency of which continues to increase, mainly due to the increase in the proportion of abdominal deliveries. For this reason, these conditions receive constant attention from scientists all over the world: there is a constant review of recommendations for the management of pregnant women with these pathologies, as well as the search for the optimal method and timing of delivery to ensure the best health of the mother and the newborn. To date, it has not been possible to reach an unequivocal consensus among diff erent world schools on these issues. Recently, there has been an increase in the number of cases of the placenta growing into the uterine wall – a condition called placenta accreta spectrum, as well as its special form, when the chorionic villi grow into the lower segment of the uterus – placenta previa accreta. These are particularly dangerous conditions that carry a double risk of massive obstetric hemorrhage. The article presents the latest views on the possibilities of organ- preserving surgery for these pathologies and reviews the recommendations of various major world schools of obstetrics and gynecology. We also present our own algorithms for the management and delivery of women withpathologically invasive placenta.

Cesarean hysterectomy in pregnancies complicated with placenta previa accreta: a retrospective hospital-based study

BackgroundPlacenta previa accreta (PPA) is a severe obstetric condition that can cause massive postpartum hemorrhage and transfusion. Cesarean hysterectomy is necessary in some severe cases of PPA to stop the life-threatening bleeding, but cesarean hysterectomy can be associated with significant surgical blood loss and major complications. The current study is conducted to investigate the potential risk factors of excessive blood loss during cesarean hysterectomy in women with PPA.MethodsThis is a retrospective study including singleton pregnancies after 28 weeks of gestation in women with placenta previa and pathologically confirmed placenta accreta spectrum who received hysterectomy during cesarean sections. A total of 199 women from January 2012 to August 2023 were included in this study and were divided into Group 1 (estimated surgical blood loss (EBL) ≤ 3500 mL, n = 103) and Group 2 (EBL > 3500 mL, n = 96). The primary outcome was defined as an EBL over 3500 mL. Baseline characteristics and surgical outcomes were compared between the two groups. A multivariate logistic regression model was applied to find potential risk factors of the primary outcome.ResultsMassive surgical blood loss was prevalent in our study group, with a median EBL of 3500 mL. The multivariate logistic analysis showed that emergency surgery (OR 2.18, 95% CI 1.08–4.41, p = 0.029), cervical invasion of the placenta (OR 2.70, 95% CI 1.43–5.10, p = 0.002), and intraoperative bladder injury (OR 5.18, 95% CI 2.02–13.28, p = 0.001) were all associated with the primary outcome. Bilateral internal iliac arteries balloon occlusion (OR 0.57, 95% CI 0.34–0.97) and abdominal aortic balloon occlusion (OR 0.33, 95% CI 0.19–0.56) were negatively associated with the primary outcome.ConclusionsEmergency surgery, cervical invasion of the placenta, and intraoperative bladder injury were potential risk factors for additional EBL during cesarean hysterectomy in women with PPA. Future prospective studies are needed to confirm the effect of intra-arterial balloon occlusion in cesarean hysterectomy of PPA.

Fluid resuscitation strategy in patients with placenta previa accreta: a retrospective study.

Obstetric hemorrhage is the leading cause of maternal death worldwide. Placenta previa accreta is one of the major direct causes of postpartum hemorrhage, accounting for two-thirds of obstetric hemorrhage cases. Fluid resuscitation is a life-saving procedure for patients suffering from massive hemorrhage. This study aims at evaluating the risk factors of massive hemorrhage and appropriate fluid resuscitation strategy in patients with placenta previa accreta. This study retrospectively analyzed the risk factors for massive hemorrhage, clinical characteristics, and perinatal outcomes of patients with placenta previa accreta. Maternal noninvasively evaluated hemodynamic indicators, including maternal heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and shock index, were collected and analyzed at nine time points, from the administration of anesthesia until the end of procedures, in patients diagnosed with placenta previa accreta and receiving different fluid supply volumes. Complicated with placenta increta/percreta and gestational age of delivery later than 37 weeks are two independent risk factors of massive hemorrhage in patients with placenta previa accreta. A total of 62.27% (170/273) patients diagnosed with placenta increta/percreta had massive hemorrhage, significantly higher than those diagnosed with placenta previa accreta (5.88%, 6/102). Patients delivered after 37 weeks of gestation had significantly higher ratios (86.84%, 99/114) of massive hemorrhage compared with those delivered between 36 and 36+6 weeks of gestation (35.39%, 63/178). Maternal SBP, DBP, and MAP started to decrease immediately after the baby was delivered and reached a relatively stable trough state at 15-30 min after delivery. No statistical differences were found in hemodynamic indicators, the occurrence of hypotension, or in-hospital days after the procedure among the transfusion volumes < 30 ml/kg, 30-80 ml/kg, and ≥ 80 ml/kg groups. Patients with a suspected diagnosis of placenta previa accreta should plan to deliver before 37 weeks of gestation. The ability to identify concurrent placenta increta/percreta should be improved to schedule a reasonably rapid perioperative plan. Restrictive fluid resuscitation could achieve good effects in maintaining hemodynamic stability in patients with placenta previa accreta. A time period of 15-30 min after delivery is the critical stage for fluid resuscitation.

Uterine isthmic tourniquet left insitu as a new approach for placenta previa-accreta surgery: a comparative study.

Placenta previa-accreta spectrum disorders are a cause of obstetric hemorrhage that can lead to maternal fetal mortality and morbidity. We aimed to describe the use of a uterine isthmic tourniquet left in situ as a new uterus-preserving approach for patients with placenta previa-accreta. In this retrospective comparative study, the patients who underwent surgery for placenta previa between 2017 and 2024 at our tertiary hospital were reviewed. Primary outcome of the study is to evaluate feasibility of uterine isthmic tourniquet left in situ for uterine preserving by preventing postpartum hemorrhage for patients with placenta previa-accreta. As a secondary outcome, group 1 (n=28) patients who were managed with uterine isthmic tourniquet left in place were compared with patients in group 2 (n=32) who were managed with only bilateral uterine artery ligation. This new approach uterine isthmic tourniquet technique prevented postpartum hemorrhage with a rate of 100 percent in group 1 patients, while uterine artery ligation prevented postpartum hemorrhage with a rate of 75 % in group 2. Postoperative additional interventions (relaparotomy hysterectomy, balloon tamponade application, uterine or vaginal packing) were performed for eight patients in group 2 (25 %) but not in group 1 (0 %) (p=0.015). The haemoglobin levels before caesarean section were similar in both groups (p=0.235), while the postoperative haemoglobin levels were lower in group 2 (9.69±1.37 vs. 8.15±1.32) (p=0.004). Erythrocyte suspension was given to two patients in group 1 and 12 patients in group 2 (2/28 7 % vs. 12/32 37 %, p=0.018). The uterine isthmic tourniquet left in situ technique is a safe, simple and effective for preventing postpartum hemorrhage and preserving uterus during placenta previa accreta surgery as superior to uterine artery ligation alone.

Updated criteria for the approval of subsequent pregnancy after cesarean section with a transverse uterine fundal incision based on 17 years of experience.

In the case of placenta previa-accreta when the placenta covers the entire anterior uterine wall, it is difficult to avoid transecting the placenta by traditional low-transverse cesarean section (CS), resulting in catastrophic hemorrhage and fetal anemia. To prevent this critical risk, we developed the CS with transverse uterine fundal incision (TUFI) and this technique has been widely used as a beneficial surgical method in clinical practice owing to its safety advantages for the mother and neonate since our first report. However, the risk of uterine rupture during a subsequent pregnancy remains unclear. Based on our 17 years of experience, patients who require TUFI do not need to avoid this beneficial operative method simply because of their desire to conceive again, as long as certain conditions can be met. To approve a post-TUFI pregnancy, an appropriate suture method, delay in conception for at least 12 months with evaluation of the TUFI scar, and cautious postoperative management are at a minimum essential. In this article, we showed our recommendation for operative procedure and discuss the current status of the management of post-TUFI pregnancies based on the evaluation of the TUFI wound scar and experience with postoperative pregnancies.

Evaluation of incision healing status after transverse uterine fundal incision for cesarean delivery and postoperative pregnancy: a ten-year single-center retrospective study

BackgroundTransverse uterine fundal incision (TUFI) is a beneficial procedure for mothers and babies at risk due to placenta previa-accreta, and has been implemented worldwide. However, the risk of uterine rupture during a subsequent pregnancy remains unclear. We therefore evaluated the TUFI wound scar to determine the approval criteria for pregnancy after this surgery.MethodsBetween April 2012 and August 2022, we performed TUFI on 150 women. Among 132 of the 150 women whose uteruses were preserved after TUFI, 84 women wished to conceive again. The wound healing status, scar thickness, and resumption of blood flow were evaluated in these women by magnetic resonance imaging (MRI) and sonohysterogram at 12 months postoperatively. Furthermore, TUFI scars were directly observed during the Cesarean sections in women who subsequently conceived.ResultsTwelve women were lost to follow-up and one conceived before the evaluation, therefore 71 cases were analyzed. MRI scans revealed that the “scar thickness”, the thinnest part of the scar compared with the normal surrounding area, was ≥ 50% in all cases. The TUFI scars were enhanced in dynamic contrast-enhanced MRI except for four women. However, the scar thickness in these four patients was greater than 80%. Twenty-three of the 71 women conceived after TUFI and delivered live babies without notable problems until August 2022. Their MRI scans before pregnancy revealed scar thicknesses of 50–69% in two cases and ≥ 70% in the remaining 21 cases. And resumption of blood flow was confirmed in all patients except two cases whose scar thickness ≥ 90%. No evidence of scar healing failure was detected at subsequent Cesarean sections, but partial thinning was found in two patients whose scar thicknesses were 50–69%. In one woman who conceived seven months after TUFI and before the evaluation, uterine rupture occurred at 26 weeks of gestation.ConclusionsCertain criteria, including an appropriate suture method, delayed conception for at least 12 months, evaluation of the TUFI scar at 12 months postoperatively, and cautious postoperative management, must all be met in order to approve a post-TUFI pregnancy. Possible scar condition criteria for permitting a subsequent pregnancy could include the scar thickness being ≥ 70% of the surrounding area on MRI scans, at least partially resumed blood flow, and no abnormalities on the sonohysterogram.Trial registrationRetrospectively registered.

Outcome of subsequent pregnancies in women with prior uterine rupture

ObjectiveTo report maternal and neonatal outcomes of subsequent pregnancies in a series of women with a prior uterine rupture. MethodsThe records of all 103,542 deliveries (22,286 by cesarean section) performed in a single tertiary medical center from 2009 to 2021 were reviewed. Women with a prior uterine rupture, defined as a separation of the entire thickness of the uterine wall, with extrusion of fetal parts and intra-amniotic contents into the peritoneal cavity documented in the operative report of the previous cesarean delivery or laparotomy, were identified for inclusion in the study. ResultsThe cohort included 38 women with 50 pregnancies (50 neonates). Women had been scheduled for elective cesarean delivery at early term. Mean gestational age at delivery was 36 + 4 weeks (±5 days). In 7 pregnancies (14 %), spontaneous labor occurred before the scheduled cesarean delivery (at 36 + 6, 35 + 4, 35 + 3, 34 + 6, 34 + 3, 32 + 6 and 31 + 0 gestational weeks). A recurrent uterine scar rupture was found in 4 pregnancies (8 %), and uterine scar dehiscence, in 2 pregnancies (4 %), all identified during elective repeat cesarean delivery. In none of these cases was there a clinical suspicion beforehand; all had good maternal and neonatal outcomes. One parturient with placenta previa-accreta had a planned cesarean hysterectomy. ConclusionWomen with prior uterine rupture have good maternal and neonatal outcomes in subsequent pregnancies when managed at a tertiary medical center, with planned elective term cesarean delivery, or even earlier, at the onset of spontaneous preterm labor.

Successful Anesthesia Management of Complicated Case of Placenta Previa Accreta with Massive Intraoperative Bleeding and Incidentally Detected COVID-19

Placenta previa accreta is a serious obstetric condition with high risk of postoperative complications requiring the use of multiple health resource. The risk is higher in patients with previous history of caesarean section. Moreover, presence of COVID-19 infection can deteriorate the disease process. In this case report it was reported that the case of successful anesthetic management of a complicated placenta previa accreta with massive intraoperative bleeding with incidental COVID-19 diagnosis.

Non invasive hemodynamic monitoring for fluids and blood resuscitation during placenta praevia accreta cesarean delivery: a retrospective observational study

BackgroundWe carry out a retrospective observational analysis of clinical records of patients with major placenta praevia who underwent cesarean section surgery over a period of 20 months in our hospital. Out of a total of 40 patients, 20 were subjected to Goal-Directed Therapy (GDT) implemented with non-invasive hemodynamic monitoring using the EV1000 ClearSight system (Group I) and 20 to standard hemodynamic monitoring (Group II). Given the risk of conspicuous blood loss, this study evaluate the impact on maternal and fetal health of GDT relative to standard hemodynamic monitoring.ResultsAverage total infusion of fluids was 1600 +/− 350 ml. Use of blood products occurred in 29 patients (72,5%), of which 11 had a hysterectomy and 8 were treated with Bakri Balloons. For 2 patients > 1000 mL of concentrated red blood cells were used. When stroke volume index SVI dropped below 35 mL/m2/beat, it responded well to the infusion of at least 2 crystalloid boluses (5 ml/kg) in 7 patients. Cardiac index (CI) increased in 8 patients in concomitance with a reduction in medium arterial pressure (MAP), but the use of ephedrine (10 mg iv) re-established acceptable baseline values. Group I means are higher than Group II means for MAP, lower for RBC usage, end-of-surgery maternal lactates and fetal pH, and for LOS. Statistical analysis determines that the null hypotheses of equalities between Groups I and II can be rejected for all measures apart from MAP at baseline and induction. Proportions of serious complications in Groups I and II are respectively 10% and 32% and Boschloo’s test rejects the null of equality of proportions against the alternative hypothesis of lower proportion of occurrence in Group I than in Group II.ConclusionsHypovolemia can lead to vasoconstriction and inadequate perfusion with decreased oxygen delivery to organs and peripheral tissues and ultimately cause organ dysfunction. Despite the small sample size due to the rarity of the pathology, our statistical analysis finds evidence in favor of more favorable clinical outcomes for patients who received GDT implemented with non-invasive hemodynamic monitoring infusion relative to patients who received standard hemodynamic monitoring.

Prospective comparative analysis for application and selection of FIESTA sequence and SSFSE sequence in MRI for prenatal diagnosis of placenta previa accreta

Placenta previa accreta patients were examined using fast-imaging employing steady-state acquisition (FIESTA) and single-shot fast spin echo (SSFSE) sequence. The diagnostic value of the two sequences was compared. FIESTA was better than the SSFSE sequence in displaying outline-boundary (excellent: 82 vs. 26), signal-to-noise ratio (excellent: 75 vs. 54) for placenta and uterus. The direct signs detection rate in FIESTA was higher than SSFSE (implantable: P = .028, adhesive: P = .131, penetrating type: P = .326). The indirect signs detection rate in FIESTA was lower than SSFSE (low-signal density: P = .029, uneven-signal density: P = .328, thicker and more vascular shadow: P = 398). FIESTA combining SSFSE demonstrated higher detecting rates (100% for sensitivity, specificity, and accuracy) for all types than single sequence scanning (FIESTA/SSFSE). In conclusion, FIESTA clearly showed the situation of the placenta and uterus in placenta previa accreta patients, with excellent image quality. A combination of FIESTA and SSFSE can improve the diagnostic value of placenta previa accreta. Important statement What is already known on this subject? Placenta previa is the most common cause of vaginal bleeding in the third trimester of pregnancy. What do the results of this study add? FIESTA was better than the SSFSE sequence in displaying images and demonstrated higher detection rates for direct signs and lower detection rate comparing the SSFSE sequence. FIESTA combining SSFSE sequence demonstrated higher detecting rates for implantable, adhesive and penetrating types than single sequence scanning. What are the implications of these findings for clinical practice and/or further research? FIESTA sequence clearly showed the situation of placenta and uterus in placenta previa accreta patients, with excellent image quality. Combination of FIESTA and SSFSE sequences can effectively improve the diagnostic value of placenta previa accreta.

Outcomes of prophylactic abdominal aortic balloon occlusion in patients with placenta previa accreta: a propensity score matching analysis

BackgroundPlacenta previa accreta is a life-threatening pregnancy complication, and reducing blood loss during operative treatment remains a major challenge. The aim of our study was to investigate the effect of prophylactic abdominal aortic balloon occlusion (AABO) during caesarean section in women with placenta previa accreta.MethodsA retrospective study of women with placenta previa accreta was conducted in a tertiary hospital from January 1, 2015, to December 31, 2020. Women were divided into balloon and control groups by whether AABO was performed. Baseline characteristics and pregnancy outcomes were compared in the two groups. A propensity score analysis was applied to minimise the indication bias. The primary outcome was composite, including estimated blood loss (EBL) ≥ 2.0 L, massive transfusion and hysterectomy.ResultsA total of 156 patients participated in this study, with 68 in the balloon group and 88 in the control group. Propensity score analysis showed that women in the balloon group had less EBL (1590.36 ± 1567.57 vs. 2830.36 ± 2285.58 mL, P = 0.02) as well as a lower proportion of EBL ≥ 1.0 L (50.00% vs. 78.57%, P = 0.03), EBL ≥ 2.0 L (21.43% vs. 50.00%, P = 0.03) and EBL ≥ 3.0 L (14.29% vs. 42.86%, P = 0.04). In addition, women in the control group received more red blood cell transfusions (8.43 U ± 9.96 vs. 3.43 U ± 6.27, P = 0.03), and the proportion of massive transfusions was higher (35.71% vs. 7.14%, P = 0.02). The proportions of disseminated intravascular coagulation (0% vs. 28.57%, P < 0.01), haemorrhagic shock (3.57% vs. 32.14%, P = 0.02) and hysterectomy (10.71% vs. 39.29%, P = 0.03) were significantly lower in the balloon group. Sutures were performed more often in the balloon group (64.29% vs. 17.86%, P < 0.01). Multivariate logistic regression analysis showed that AABO was associated with the primary outcome (adjusted odds ratio 0.46, 95% confidence interval 0.23 ~ 0.96, P = 0.04). No serious balloon catheter-related complications occurred in the balloon group.ConclusionAABO was an effective and safe approach to improve maternal outcomes for patients with placenta previa accreta.

Combined Internal Iliac Artery Ligation, Transverse B-Lynch Suture and Intrauterine Balloon to Control Bleeding from Placenta Accreta during Caesarean Delivery

Introduction and aim: Placenta praevia and accreta are associated with high morbidity and mortality. Bleeding is the sole etiology of both morbidity and mortality. Thus, anti-bleeding measures are mandatory and research continues to search for ideal prophylactic measure. This work was designed to assess the efficacy of bilateral internal iliac artery ligation followed by Transverse B-Lynch compression suturing and intrauterine balloon tamponade as a conservative methods to control placental site bleeding due to placenta praevia accreta.&#x0D; Methodology: The study included 24 pregnant females with placenta praevia accreta who were scheduled for elective cesarean section. All participants were subject to history taking, clinical evaluation and laboratory investigations. Ultrasound examination was carried out for assessment of: Estimated fetal weight, confirmation of gestational age, confirm diagnosis of placenta previa accreta and level of the placental edge in lower uterine segment. Deliveries were scheduled to take place between 36-37 weeks of gestation. The primary outcome was the amount of intra-operative blood loss.&#x0D; Results: Blood loss ranged between 249.29 and 560.43 ml, and there was statistically significant decrease of hematocrit percent and platelets after surgery when compared to corresponding values before surgery. All females need blood transfusion. However, none of them need further surgical intervention or intensive care unit admission.&#x0D; Conclusion: Prophylactic bilateral internal iliac artery ligations before extraction of placenta accreta followed by transverse B Lynch suture and intrauterine balloon tamponade seemed to be an effective and safe technique to reduce intrapartum and postpartum complications, and to avoid emergent peripartum hysterectomy.

Placenta previa and placenta accreta: questions of diagnosing and obstetric management

Placenta previa and placenta accreta: questions of diagnosing and obstetric management

Racial Disparities in the Rates of and Indications for Cesarean Delivery in California: Are They Changing Over Time?

The aim of this study was to assess whether racial disparities in rates of and indications for cesarean delivery (CD) between non-Hispanic Black and non-Hispanic White birthing people in California changed from 2011 to 2017. This was a retrospective cohort study using a database of birth certificates linked to discharge records. Singleton term live births in nulliparous Black and White birthing people in California between 2011 and 2017 were included. Those with noncephalic presentation, placenta previa, and placenta accreta were excluded. CD rate and indication were obtained from birth certificate variables and International Classification of Diseases codes. Differences in CD rate and indication were calculated for Black versus White individuals using univariable and multivariable logistic regression and adjusted for potential confounders. A total of 348,144 birthing people were included, 46,361 Black and 301,783 White. Overall, 30.9% of Black birthing people underwent CD compared with 25.3% of White (adjusted relative risk [aRR]: 1.2, 95% confidence interval [CI]: 1.2-1.3). From 2011 to 2017, the CD rate fell 11% (26.4-23.7%, p < 0.0001) for White birthing people and 1% for Black birthing people (30.4-30.1%, p = 0.037). Over the study period, Black birthing people had a persistent 1.2- to 1.3-fold higher risk of CD and were persistently more likely to undergo CD for fetal intolerance (aRR: 1.1, 95% CI: 1.1-1.2) and less likely for active phase arrest or arrest of descent (aRRs: 0.9 and 0.4; 95% CIs: 0.9-0.9 and 0.3-0.5). The CD rate decreased substantially for White birthing people and minimally for Black birthing people in our cohort over the study period. Meanwhile, disparities in CD rate and indications between the two groups persisted, despite controlling for confounders. Although care bundles for reducing CD may be effective among White birthing people, they are not associated with reduction in CD rates among Black birthing people nor improvements in racial disparities between Black and White birthing people. Despite increasing attention to racial inequities in obstetric outcomes, there were no changes in disparities in CD rates or indications in California from 2011 to 2017. · Black birthing people are more likely to undergo CD than White despite controlling for confounders.. · There are unexplained differences in CD indication among Black and White birthing people.. · These disparities persisted from 2011 to 2017 despite increasing efforts to decrease CD rates in CA..

Cesarean Hysterectomy for Placenta Previa Accreta Using Retrograde Abdominal Hysterectomy Approaching from the Posterior Vaginal Wall.

Hysterectomy for placenta percreta with bladder invasion is a difficult operation because of the high possibility of massive bleeding; therefore, surgery should be performed in a facility equipped with a sufficient number of trained staff. The degree of bladder invasion should be assessed correctly before the operation, and it is necessary to carefully consider how to address intraoperative complications and massive bleeding in the preoperative conference. The following should be prepared preoperatively: autologous blood and stored blood; ureteral catheter and insertion materials; materials to separate and tape the internal iliac artery and ureter; balloon for insertion into the common iliac artery or aorta and aortic clamps; and materials for compression suturing, such as B-Lynch suture. Sufficient informed patient consent is also required. During surgery, which may cause massive and sometimes life-threatening bleeding, the general rule is to begin at a safe site without adhesions and then treat the adhesion site. According to this rule, bladder dissection should be performed last in cases of placenta percreta with bladder invasion. As a surgical technique using this principle, we introduce retrograde hysterectomy approaching from the posterior vaginal wall.

Ureter injury in obstetric hysterectomy with placenta accreta spectrum: Case report.

Introduction and importancePlacenta accreta spectrum (PAS) is a state of abnormal attachment of the placenta, including placenta accreta, placenta increta, and placenta percreta. This condition can be life-threatening due to the placenta cannot spontaneously separated, resulting in continuous bleeding. Cesarean section followed by hysterectomy is one of the treatment options for PAS. There was a great liability for urinary tract injuries during the operation of PAS patient.Case presentationWe present the case of ureter injury during subtotal hysterectomy in patient with PAS. A 30-years-old female patient was diagnosed with recurrent antepartum hemorrhage due to placenta previa accreta spectrum on G2P1 33 weeks of gestational age, singleton live breech presentation, previous c-section 1×. After uterine transverse incision, the baby was delivered. We decided to perform subtotal hysterectomy. There was severe adhesion. On the exploration after subtotal hysterectomy was performed, we found ruptured of the right ureter.Clinical discussionHysterectomy peripartum is one of the treatment of PAS, either to prevent or to control postpartum hemorrhage. In pregnant women with morbid placental adherence, there was a great liability for urinary tract injuries. Distal ureters are the most commonly injured while hysterectomy. Injuries to the ureters in this patient occurred due to severe adhesions and unclear visual organ.ConclusionAlthough it is rare, ureter injury may occur during subtotal hysterectomy in patient with placenta accreta spectrum. To prevent that condition, inserting ureter stent can be perform before the operation. Multidisciplinary approach is carried out so that patient outcomes are good.

CLAP – a new organ-preserving surgery for combined placenta praevia accreta vera into the uterine cicatrix after the previous cesarean section

Objective: to describe a new method of organ-preserving surgery for combined placenta previa and placenta accreta into the uterine scar after a previous cesarean section – the CLAP method. Materials and methods. During 2015–2020, 29 women with placenta praevia and placenta accreta vera into the uterine scar after a previous cesarean section were operated. 15 women (control group) gave birth using the traditional method – cesarean section followed by hysterectomy; in 14 pregnant women (main group) the new method CLAP was used. CLAP consists of the following stages: stage I – C – cesarean section; stage II – L – ligation of internal iliac arteries; stage III – A – adherent placenta's area excision; stage IV – P – pressure, applied to the lower uterine segment, during which the technique of COLUS was performed. Patients were operated at 34–35 weeks of pregnancy after fetal respiratory distress syndrome prophylactics with a course of betamethasone.Results. Statistically significant difference in the age of patients (p = 0.968), status and weight of newborns (p = 0.058) was not found. But significant statistical difference was found in the amount of maternal blood loss during surgical delivery. In the control group, where pregnant women underwent hysterectomy, it was 3652 ± 293 ml, and in the main group, where delivery was performed using the new CLAP technique, blood loss was 2253 ± 153 ml (p &lt;0.001). All patients were discharged in satisfactory condition on the 8th–10th day. Conclusions. CLAP procedure is an effective alternative to previously used organ-preserving operations. It helps to avoid hysterectomy and does not require special equipment during a cesarean section. The CLAP technique has proven to be an effective way to prevent and cease blood loss, as well as to preserve reproductive function of woman.

Conservative stepwise surgical approach for management of placenta previa accreta: A prospective case series study.

To describe a stepwise surgical approach for conservative management of placenta previa accreta to preserve the uterus and to evaluate the efficacy and safety of this approach in controlling postpartum hemorrhage including intrapartum hemorrhage. A prospective case series study conducted on 62 pregnant women with one or more cesarean deliveries diagnosed with placenta previa accreta between January 2018 and June 2019 at Ain Shams University Maternity Hospital. All participants underwent a conservative stepwise surgical approach through Pfannenstiel skin incision with fetal delivery through a uterine incision just above the upper border of the placenta, followed by bilateral uterine artery ligation with myometrial excision of the remaining adherent placenta and cervico-isthmic sutures by MMG (the main surgeon) and MS. Among 62 women, the surgical approach was successful in controlling postpartum hemorrhage and preserving the uterus in 50 (80.64%) participants. Three women (4.83%) had urinary bladder injuries, all were managed intraoperatively during the cesarean section. Five women (8%) had postpartum pyrexia and five women (8%) had postpartum endometritis, all were managed conservatively with broad-spectrum antibiotics. The stepwise surgical approach can be applied to the conservative management of placenta previa accreta to avoid unnecessary cesarean hysterectomy.

Intra-arterial Balloon Occlusion to Reduce Operative Bleeding for Placenta Previa Accreta Spectrum.

Cesarean section for placenta previa accreta spectrum carries a significant risk of massive hemorrhage. Hence, it is necessary to understand the various hemostatic procedures, damage control surgery and resuscitation for massive hemorrhage, and systemic management against hypovolemic shock and coagulopathy. In cases of placenta previa with previous cesarean section, the operation should be performed in a tertiary medical facility with well-trained staff and blood availability for transfusion. Preoperative placement of an intra-arterial balloon occlusion catheter in the common iliac artery or aorta is useful for preventing massive hemorrhage.

Temporary Cross-Clamping of the Infrarenal Abdominal Aorta during Cesarean Hysterectomy to Control Operative Blood Loss.

Temporary cross-clamping of the infrarenal abdominal aorta to reduce bleeding during hysterectomy following cesarean section in patients with placenta previa-accreta is a relatively simple procedure; therefore, it can be an option when intravascular balloon catheter placement is impossible or encountered massive bleeding of the unexpected placenta accreta.