A Novel Conservative Approach to Managing Placenta Accreta Spectrum Disorders

Placenta accreta spectrum (PAS) disorders are a serious condition that can lead to life-threatening bleeding during pregnancy. These disorders include placenta accreta, increta, and percreta, where the placenta attaches too deeply into the uterus, sometimes extending beyond it. This abnormal placental attachment makes it difficult for the placenta to separate after delivery, often leading to severe postpartum hemorrhage.

Traditionally, the recommended treatment for PAS has been a cesarean hysterectomy, which removes the uterus to control bleeding. However, this approach leaves women infertile, impacting their emotional well-being and societal status in some cultures. To address this, many conservative methods have been developed over the past two decades to preserve fertility while managing the risks associated with PAS disorders.

Understanding PAS Disorders

PAS disorders are often diagnosed using ultrasound, which may show signs like:

  • Irregular vascular spaces.
  • Thinning or absent myometrium.
  • Loss of the normal hypoechoic retroplacental zone.
  • Increased vascularity near the uterine serosa-bladder interface.
  • Placental protrusion into the bladder or turbulent blood flow on Doppler.

Patients with PAS face an increased risk of complications such as massive blood transfusion, cystotomy, infection, prolonged hospital stays, and even death. This has made PAS disorders one of the most challenging conditions for obstetricians worldwide.

A Novel Conservative Surgical Technique

A new conservative surgical method has shown promise in reducing maternal morbidity and mortality while preserving the uterus. In a study involving 245 patients with PAS disorders between 2013 and 2023, this technique was performed by an experienced surgeon. Key steps of the procedure include:

  1. Delivery and Hemostasis:
    • After delivering the baby via a transverse uterine incision, the placenta is carefully removed to minimize blood loss.
    • The surgeon applies a “hand tourniquet” to control bleeding and clamps bleeding areas with ovarian forceps.
  2. Repair and Closure:
    • Hemostasis is achieved with targeted sutures, avoiding injury to nearby structures like the bladder or ureter.
    • The uterine incision is closed in two layers using locked and unlocked sutures.

This technique is performed under spinal anesthesia with a Pfannenstiel incision.

Study Outcomes

  • Of the 245 patients, no cesarean hysterectomy was needed, and there were no maternal deaths.
  • The average blood transfusion was 0.52 units per patient.
  • The average surgery time was 54 minutes, with hospital stays averaging 1-2 days.

This approach demonstrated significant benefits, including reduced blood loss, shorter surgery and recovery times, and preserved fertility.

Why This Matters

This simplified conservative surgical technique offers a safer, fertility-preserving alternative to hysterectomy in PAS cases. It reduces the risks of maternal morbidity and mortality while maintaining the quality of life for women. However, the study’s success was attributed to the expertise of a highly experienced surgeon. Obstetricians planning this method should undergo proper training to ensure its safe application.

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