Keywords cesarean delivery - conservative surgery - complicated pregnancy - postpartum hemorrhage
- placenta accreta spectrum - placenta previa - second trimester - ultrasound - Vietnam
Placenta accreta spectrum (PAS), formerly known as morbidly adherent placenta, is
defined as abnormal adherence of the placental trophoblast to the uterine myometrium.[1 ] PAS has risen dramatically due to the increasing rate of cesarean delivery.[2 ]
[3 ] Seriously, PAS is related to potentially life-threatening conditions for both mother
and neonate, especially, in emergent conditions without adequate preparation.[4 ]
[5 ] Until today, many imaging modalities play an important role in the detection of
PAS.[6 ] The accurate diagnosis could be performed in the first trimester.[7 ]
[8 ] A routine transvaginal ultrasound assessing a lower uterine segment scarred by previous
cesarean section and placenta at 110/7 and 136/7 weeks of gestational age (GA) is a feasible and effective tool to identify significantly
the risk of subsequent development of PAS disorders.[9 ]
Importantly, early management involving planned surgery could reduce the mortality
for pregnant women.[10 ] Currently, many surgical methods have been applied worldwide.[11 ]
[12 ]
[13 ]
[14 ] However, the management of second-trimester PAS is currently center-dependent with
minimal evidence-based practices. Generally, hysterectomy remains a surgical option.[15 ] The surgical performance regarding GA below 22 weeks remains limited. Notably, the
uterine artery embolization and left placenta in situ could not be applied in low-middle-income
countries. Since the low-resource settings and lack of out-patient follow-up, the
one-step surgical method is often chosen. In addition, the PAS should be managed at
the expertise center with a multidisciplinary team.[16 ]
[17 ]
[18 ]
Tu Du Hospital is a tertiary referral hospital in the south of Vietnam where PAS has
been managed by an experienced team. In conservative surgery of PAS in the second
trimester, the team applied the rectangular-shaped hemostatic suture prior to uterine
incision to reduce the blood loss. This technique was developed by an obstetrician
at our hospital (VHB). The team has made a finding on literature databases including
Google Scholar, Medline, PubMed, Scopus, ScieLo, and Web of Science…; however, we
did not find a similar suture in PAS surgical management. Through this study, we aim
to describe the pregnancy outcomes of pregnancies diagnosed with PAS below 22 weeks
undergoing the rectangular-shaped hemostatic suture during PAS surgery.
Materials and Methods
Study Design and Population
A retrospective descriptive study was conducted at Tu Du Hospital, Vietnam, between
January 1, 2018 and December 31, 2022. The study included all pregnancies under 22
weeks GA which was diagnosed with PAS disorder following International Classification
of Diseases 10th Revision (ICD-10) code O43.2. GA was calculated following the first-trimester
ultrasound. In addition, the patient was managed with rectangular-shaped hemostatic
surgery. This study was accepted by the ethical committee of the institution with
approval number CS/TD/23/15.
Inclusion criteria: PAS disorder was diagnosed by ultrasound before surgery and at
intraoperation by the surgeon's macroscopic observation. The histopathological examination
was added to confirm the PAS. The patient underwent elective surgery or emergency
surgery for cesarean delivery, receiving rectangular-shaped hemostatic surgery.
Exclusion criteria: Missing file, disorders of coagulation profile.
Rectangular-Shaped Hemostatic Suture
First, localization of the placental site by intraoperative ultrasound and macroscopic
observation was determined at laparotomy. Second, the procedure of amniotic withdrawal
under ultrasound was performed to reduce the size of the gravid uterus and facilitate
uterine exteriorization. Third, suturing the marginal border of the placenta at the
invasive myometrial layer of the uterus by using Chromic 1/0 absorbable suture. Likely,
the suture line is similar to a rectangular shape ([Fig. 1A ]). This suture was performed carefully before the uterine incision without uterine
artery balloons or other flow-reducing devices ([Video 1 ]). It is noteworthy that all the needling points for our patients were located in
the avascular zone. After the suture is completely tightened, the neovascularization
will be blocked. Therefore, the purpose of this technique was to reduce the bleeding
following uterine incision. Even, the placenta was located at the posterior site or
lateral site. Finally, the uterine incision was made through the placenta ([Fig. 1B ]). The suture was removed with placental delivery and invasive myometrial resection
if required. This suturing needle could touch the fetus during the procedure; thus,
it should be applied in the condition of fetal abortion in PAS surgery.
Fig. 1 The rectangular-shaped hemostatic suture by illumination image (A ) and intraoperative photo (B ).
Video 1 Uterine incision following the rectangular-shaped hemostatic suture.
Surgical Management of Placenta Accreta Spectrum
All the PAS cases under 22 weeks of GA were managed by a multidisciplinary team including
an expert sonographer, anesthetist, and obstetrician. Before surgery, an ultrasound
was performed to assess the PAS. The ultrasound criteria for diagnosis of PAS were
performed according to The International Society of Ultrasound in Obstetrics and Gynecology
(ISUOG) proposal.[19 ]
[20 ] The ultrasound was carried out by an abdominal or transvaginal transducer probe.
Magnetic resonance imaging was indicated depending on the decision of clinicians.
Cesarean delivery was performed under general anesthesia. Upon laparotomy, the PAS
evaluation was observed carefully. Rectangular-shaped hemostatic suture was applied.
After the uterine incision, all placental tissue was delivered completely. Other hemostatic
sutures could be added if necessary. Additionally, oxytocin 10 UI was given after
placental delivery. Uterotonic drugs such as ergometrine, Duratocin, and hemostatic
drug (acid tranexamic) were applied when necessary. The uterine myometrial reconstruction
was performed. The vaginal bleeding was checked before closure of the abdomen. One
surgeon with more than 15 years of experience in the obstetrical field performed this
suture ([Video 2 ]).
Video 2 A presentation of surgery technique relating to the management of placenta accreta
spectrum less than 22 weeks of gestational age.
Data Collection
All the information was collected based on the patient's file.
– Continuous variables: Maternal age (years), GA (weeks), body mass index (kg/m2 ), intraoperative estimated blood loss (mL), operation duration time (minutes), postpartum
course (days).
– Categorical variables: Types of the surgical method, previous cesarean scar, type
of placenta previa on ultrasound ([Fig. 2 ]), bilateral uterine arteries ligation, other hemostatic procedures, left partial
placenta in situ, ureteral injury, operation duration time, postoperative hemorrhage,
and postoperative infection. The grade of PAS disorders according to the International
Federation of Gynecology and Obstetrics (FIGO) 2018 ([Fig. 3 ]).[21 ]
Fig. 2 The classification of placenta previa depends on the distance between the lower edge
of the placenta (white arrow) and the internal cervical os (white star). This classification
on ultrasound includes type I, low-lying placenta (A ), type II, marginal placenta (B ); type III, incomplete/partial central placenta (C ); and type IV, complete/central placenta (D ).
Fig. 3 Ultrasound images show the myometrial thickness, vesicouterine interface (white arrow),
railway sign, lacunae, placental budge, and the degree of hypervascularity on color
Doppler ultrasound. According to imaging characteristics, the types of placenta accreta
spectrum disorders are classified as accreta (A ), increta (B ), and percreta (C ).
Statistical Analysis
Data were statistically analyzed by Statistical Package for the Social Sciences (SPSS)
version 22.0 (SPSS Inc, Chicago, Illinois). Frequency (n ), percentage (%), mean ± standard deviation (SD), median, and interquartile range
were used as measurement data according to the distribution of data.
Results
In our study, thirteen cases were eligible for the study. Among them, the GA from
13 to 17 weeks of GA occupied 11/13 cases. Ten cases were asymptomatic ([Table 1 ]).
Table 1
Baseline characteristics of the study population
Characteristics
Data
Maternal age (y)
33.23 ± 3.35 (27–38)
Body mass index (kg/m2 )
21.87 ± 2.90 (19.53–29.97)
Gravida (times)
2
5 (38.4)
3
4 (30.8)
≥4
4 (30.8)
Prior cesarean scar (times)
1
3 (23.1)
2
8 (51.5)
≥3
2 (15.4)
History
Surgery of uterine corpus
1 (7.7)
Abdominal surgery
13 (100.0)
Uterine malformation[a ]
1 (7.7)
Uterine fibroid
1 (7.7)
Cesarean scar pregnancy
1 (7.7)
PAS
0 (100.0)
Time interval between two pregnancies
>12 mo
12 (92.3)
Clinical symptoms
Asymptomatic
10 (76.9)
Vaginal bleeding/abdominal pain
3 (23.1)
Gestational age (wk)
13–14
6 (46.2)
14–15
1 (7.7)
16–17
4 (30.8)
18–19
1 (7.7)
20–21
1 (7.7)
Alive fetus
13 (100.0)
Note: Data was presented as n (%) and mean ± SD (min–max).
a Bicornuate uterus.
[Table 2 ] shows the ultrasonic features of PAS. More than half of cases are located at the
anterior wall of the uterus and classified as placenta previa type III–IV. Nine cases
were diagnosed with PAS-type percreta. The remained myometrial thickness less than
1 mm was observed in 10 cases. Commonly, the newly vessel proliferation was detected
in 8 cases. In addition, the mean hemoglobin of the pregnant women before surgery
was 11.54 ± 0.86 (g/dL).
Table 2
Paraclinical characteristics of PAS cases under 22 weeks of gestational age
Characteristics
Data
Hemoglobin (g/dL)
Mean ± SD (min–max)
11.54 ± 0.86 (9.9–13.1)
Hematocrit (%)
Mean ± SD (min–max)
34.16 ± 2.65 (28.3–38.8)
Placental site
Anterior
6 (46.1)
Posterior
3 (23.1)
Anterio-posterior
3 (23.1)
Lateral
0 (0.0)
Left latero-posterior
1 (7.7)
Type of placenta previa
I
0 (0.0)
II
0 (0.0)
III
6 (46.2)
IV
7 (53.8)
Grade of PAS
Accreta
0 (0.0)
Increta
3 (23.1)
Percreta
2 (15.3)
Accreta-increta
1 (7.7)
Increta-percreta
3 (23.1)
Percreta invaded other organs
4 (30.8)
Grading of intraplacental lacunae
1
4 (30.8)
2
6 (46.1)
3
0 (0.0)
Not evaluated
3 (23.1)
Loss of “clear zone”
Yes
3 (23.1)
No
7 (53.8)
Not evaluated
3 (23.1)
Myometrial thinning (<1 mm or undetectable)
Yes
10 (77.0)
No
1 (7.7)
Not evaluated
2 (15.3)
Neovascularization signs
Absent/mild
0 (0.0)
Moderate
2 (15.3)
Tortuous
8 (61.6)
Not evaluated
3 (23.1)
Abnormal uterine margin/borderline
Yes
3 (23.1)
No
8 (61.6)
Not evaluated
2 (15.3)
Focal exophytic mass or placental bulging
Yes
5 (38.4)
No
6 (46.2)
Not evaluated
2 (15.4)
Bridge vessels
Yes
2 (15.4)
No
9 (69.2)
Not evaluated
2 (15.4)
PAS invaded to pelvic organs
No
8 (61.5)
Bladder
1 (7.7)
Ureteral
0 (0.0)
Pelvic wall
0 (0.0)
Cervix
0 (0.0)
More than 2 organs
2 (15.3)
Note: Data was presented as n (%) and mean ± SD (min–max).
In this study, almost cases were scheduled for planned surgery, except for 3 cases
receiving emergent surgery due to vaginal bleeding. In surgery, PAS was classified
as accreta (n = 1), increta (n = 1), increta-percreta (n = 2), percreta (n = 4), and percreta invasive to other organs (n = 5). In this study population, bilateral uterine artery ligation of the superior
branch was additionally applied in all cases. Approximately, three-quarters of cases
required placenta bed sutures and ligation of uterine branches originating from the
ovarian artery. The estimated blood loss was 761.54 ± 614.12 (150–2,100 mL). Intraoperatively,
the estimated blood loss from 500 to 1,500 mL occupied 46.15% of cases. Among PAS
types, PAS type percreta relates to severe blood loss (1,210.0 ± 610.7 mL). The surgical
duration time was 180.77 ± 32.07 (130–260 minutes). The postoperative duration time
was 5.85 ± 2.08 (4–12 days; [Table 3 ]).
Table 3
Intraoperative features of PAS management below 22 weeks of gestational age
Characteristics
Data
Grade of PAS
Accreta
1 (7.7)
Increta
1 (7.7)
Percreta
4 (30.8)
Accreta-increta
0 (0.0)
Increta-percreta
2 (15.4)
Percreta invaded other organs
5 (38.5)
Placental site
Bilateral
1 (7.7)
Left lateral
0 (0.0)
Right lateral
1 (7.7)
Anterior and posterior
4 (30.8)
Posterior
1 (7.7)
Anterior
6 (50.0)
Skin incision
Sub-umbilical midline
2 (15.4)
Pfannenstiel
11 (84.6)
Myometrial restoration
Yes
11 (84.6)
No
1 (7.7)
Not recorded
1 (7.7)
Left placenta in situ
Yes
0 (0.0)
No
13 (100.0)
Type of surgery
Planned surgery
10 (76.92)
Emergent surgery
3 (23.08)
Surgical method
Hysterectomy
1 (8.33)
Conservative surgery
12 (91.67)
Hemostatic suture besides rectangular-shaped suture
Bilateral uterine artery ligation (superior branch)
13 (100.0)
Uterine branch of the ovarian artery
10 (77.0)
Placental bed
10 (77.0)
Transverse and vertical B-lynch compression
2 (15.4)
Bilateral cervical uterine artery ligation + bilateral uterine artery ligation (inferior
branches) + intrauterine balloon insertion
1 (7.7)
Intraoperative estimated blood loss (mL)
Mean ± SD (min–max)
761.54 ± 614.12 (150–2,100)
<500
4 (30.77)
500–1,500
6 (46.15)
1,500–2,000
2 (15.39)
>2,000
1 (7.69)
Intraoperative estimated blood loss (mL) following types of PAS
Accreta
337.5 ± 187.5
Increta
625.0 ± 613.1
Percreta
1,210.0 ± 610.7
Ureteral/vesical injuries
Yes
0 (0.0)
No
13 (100.0)
Surgical duration time (min)
Mean ± SD (min–max)
180.77 ± 32.07 (130–260)
Note: Data was presented as n (%) and mean ± SD (min–max).
During the postpartum course, one case was noted with postpartum hemorrhage, one case
was noted with acute renal dysfunction, and one case was noted with postoperative
infection. Out of 13 PAS cases, 12 cases were successfully managed with conservative
surgery. No maternal death was reported ([Table 4 ]).
Table 4
Surgical outcomes in the present study
Characteristics
Data
Postoperative duration time (d)
Mean ± SD (min–max)
5.85 ± 2.08[4 ]
[5 ]
[6 ]
[7 ]
[8 ]
[9 ]
[10 ]
[11 ]
[12 ]
Complications
Postpartum hemorrhage
1 (7.7)
Intraabdominal bleeding
0 (0.0)
Acute renal dysfunction
1 (7.7)
DIC
0 (0.0)
Postpartum infection
1 (7.7)
Antibiotic therapy
1 group
1 (7.7)
≥2 group
12 (92.3)
Maternal death
Yes
0 (0.0)
No
13 (100.0)
Histopathological examination[a ]
Increta
1 (7.7)
Percreta
8 (61.5)
Unidentified PAS
1 (7.7)
Note: Data was presented as n (%) and mean ± SD (min–max).
a Two cases were not sent for histopathological examination and one case was not recorded
in the patient's file.
Discussion
Globally, a lot of practical methods have been applied in second-trimester PAS management
such as vaginal delivery, leaving the placenta in situ by combining methotrexate,
elective artery embolization, one-step surgical approach, and cesarean hysterectomy
by laparotomy and laparoscopy.[22 ]
[23 ]
[24 ] However, embolization is expensive and may not increase the effectiveness of treatment.[25 ] Following Hu et al, terminating a pregnancy by vaginal delivery through medical
induction of labor may be feasible if clinicians have an overall understanding of
GA, the type of placenta previa status, the type of placenta accreta, and patients'
concerns about preserving fertility.[26 ] Conversely, we decided to perform one-step conservative surgery with the removal
of the placenta and restoration of uterine myometrium with an invasive placenta due
to the local condition. Recently, Hessami et al have also demonstrated that conservative
management for pregnancies with PAS is associated with reduced surgical morbidity
and may offer an effective alternative to cesarean hysterectomy.[27 ]
Additionally, the hemostatic suture was used during PAS surgery. Regarding PAS in
the second trimester, we used the rectangular-shaped suture to reduce blood loss before
uterine incision and fetal delivery. Before surgery, the team investigated the placental
characteristics with ultrasound assessment to determine the grade of PAS and the location
of the placenta. According to Panaiotova et al, accurate prediction of PAS can be
achieved by ultrasound examination at 12 to 16 weeks gestation of the pregnancy with
previous uterine surgery and low-lying placenta.[28 ] A finding of the placenta under or within the scar niche should prompt further assessment
at a PAS-specialized center.[29 ]
[30 ] In the present study, almost all cases had at least one cesarean scar and were classified
as placenta previa type III–IV. At our tertiary referral hospital, the sonographic
assessment found four cases of type increta and nine cases of type percreta. Intraoperatively,
the team identified one PAS type accreta, one PAS type increta, and eleven cases type
percreta. Among them, 10 cases had surgical specimens for histopathological examination.
Histology showed one case type increta, eight cases type percreta, and one unidentified
case.
In our study, the estimated blood loss was 761.54 ± 614.12 mL. In a study by Li et
al, cesarean delivery on 28 PAS cases in the second trimester related to increased
blood loss (932.14 ± 940.86 mL).[25 ] In our study, 4/13 cases (30.8%) of PAS underwent emergent cesarean delivery due
to vaginal bleeding and abdominal pain. In line with Luccidi et al, emergency cesarean
delivery complicates approximately 35% of pregnancies affected by PAS disorders and
is associated with a higher risk of adverse maternal and neonatal outcomes.[31 ] Hysterectomy was noted in 21/51 cases in the study of Hu et al. Among 21 cases of
hysterectomy, 17 cases were more than 17 weeks of GA. The blood loss was 752.38 ± 1,310.58 mL.[26 ] To achieve hemostasis, some drugs such as tranexamic acid could be added.[5 ] Ideally, a collaborative team effort in tertiary medical centers with a very experienced
multidisciplinary team and combined application of multiple methods is required to
facilitate patient outcomes.[26 ] Protocol-based interdisciplinary care from diagnosis to surgery will optimize both
intraoperative and postoperative outcomes.[32 ]
Strengths and Limitations
To our knowledge, this study is the first report concerning the rectangular-shaped
hemostatic suture. The technique was performed by the same surgeon. However, this
study included a small sample size. Due to ethical concerns, the study could not carry
out a prospective study with a control group (without rectangular-shaped hemostatic
suture). The retrospective could not avoid the recall bias. The PAS surgery included
other hemostatic procedures; thus, the role of rectangular-shaped hemostatic suture
was difficult to evaluate fully. Furthermore, long-term outcomes on menstrual status
and subsequent pregnancies have not yet been investigated.
Conclusion
In summary, rectangular-shaped hemostatic sutures could be an easy, cheap, and efficient
surgical choice in PAS surgery for pregnancies under 22 weeks of GA. It can greatly
minimize the amount of blood loss and reduce the risk of hysterectomies and maternal
mortality. Further well-designed studies with large samples are warranted to confirm
our findings.
