TY - JOUR
T1 - Uterine conservative–resective surgery for selected placenta accreta spectrum cases
T2 - Surgical–vascular control methods
AU - Aryananda, Rozi Aditya
AU - Aditiawarman, Aditiawarman
AU - Gumilar, Khanisyah Erza
AU - Wardhana, Manggala Pasca
AU - Akbar, M. Ilham Aldika
AU - Cininta, Nareswari
AU - Ernawati, Ernawati
AU - Wicaksono, Budi
AU - Joewono, Hermanto Tri
AU - Dachlan, Erry Gumilar
AU - Bachtiar, Citra Aulia
AU - Kurniawati, Devita
AU - Virdayanti, Dian Puspita
AU - Ariani, Grace
AU - Dekker, Gustaaf Albert
AU - Sulistyono, Agus
N1 - Funding Information:
These new uterine conservative–resective surgery concepts were developed in close collaboration with Prof. José Miguel Palacios-Jaraquemada.
Publisher Copyright:
© 2022 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).
PY - 2022/6
Y1 - 2022/6
N2 - Introduction: The incidence of placenta accreta spectrum (PAS) has increased, but the optimal management and the optimal way to achieve vascular control are still controversial. This study aims to compare maternal outcomes between different methods of vascular control in surgical PAS management. Material and methods: A retrospective cohort study on consecutive cases diagnosed with PAS between 2013 and 2020 in single tertiary hospital. The final diagnosis of PAS was made following preoperative ultrasound and confirmation during surgery. Management of PAS using cesarean hysterectomy with internal iliac artery ligation (IIAL) was compared with two types of vascular control in uterine conservative–resective surgery (IIAL vs identification–ligation of the upper vesical, upper vaginal, and uterine arteries). Results: Over an 8-year period, 234 pregnant women were diagnosed with PAS meeting the inclusion criteria. Uterine conservative–resective surgery (200 cases) was associated with lower mean blood loss compared with cesarean hysterectomy with IIAL (34 cases) in all PAS cases (1379 ± 769 mL vs 3168 ± 1916 mL; p < 0.001). In sub-analysis of the two uterine conservative–resective surgery subgroups, the group with identification–ligation of the upper vesical, upper vaginal, and uterine arteries had a significantly lower blood loss compared with uterine conservative–resective surgery with IIAL (1307 ± 743 mL vs 1701 ± 813 mL; p = 0.005). Women in the hysterectomy with IIAL group had more massive transfusion (35.3% vs 2.5%; p < 0.001; odds ratio [OR] 21.3, 95% confidence interval [CI] 6.9–66), major blood loss (>1500 mL) (70.6% vs 34%, p < 0.001; OR 4.7; 95% CI 2.1–10.3), catastrophic blood loss (>2500 mL) (64.7% vs 12.5%;p < 0.001; OR 12.8, 95% CI 5.7–29.1), other complications (32% vs 12.4%; p = 0.007; OR 3.4, 95% CI 1.5–7.7), and intensive care unit admission (32.4% vs 1.5%; p < 0.001; OR 31.4, 95% CI 8.2–120.7) compared with the uterine conservative–resective surgery groups. The identification–ligation of the upper vesical, upper vaginal and uterine arteries had a significant lower risk for major blood loss (30.5% vs 50%; p = 0.041; OR 0.44, 95% CI = 0.2–0.9) compared with IIAL for vascular control of uterine conservative–resective surgery. Conclusions: Cesarean hysterectomy is not the default treatment for PAS, PAS with invasion above the vesical trigone are suitable for uterine conservative–resective surgery with upper vesical, upper vaginal and uterine artery vascular control.
AB - Introduction: The incidence of placenta accreta spectrum (PAS) has increased, but the optimal management and the optimal way to achieve vascular control are still controversial. This study aims to compare maternal outcomes between different methods of vascular control in surgical PAS management. Material and methods: A retrospective cohort study on consecutive cases diagnosed with PAS between 2013 and 2020 in single tertiary hospital. The final diagnosis of PAS was made following preoperative ultrasound and confirmation during surgery. Management of PAS using cesarean hysterectomy with internal iliac artery ligation (IIAL) was compared with two types of vascular control in uterine conservative–resective surgery (IIAL vs identification–ligation of the upper vesical, upper vaginal, and uterine arteries). Results: Over an 8-year period, 234 pregnant women were diagnosed with PAS meeting the inclusion criteria. Uterine conservative–resective surgery (200 cases) was associated with lower mean blood loss compared with cesarean hysterectomy with IIAL (34 cases) in all PAS cases (1379 ± 769 mL vs 3168 ± 1916 mL; p < 0.001). In sub-analysis of the two uterine conservative–resective surgery subgroups, the group with identification–ligation of the upper vesical, upper vaginal, and uterine arteries had a significantly lower blood loss compared with uterine conservative–resective surgery with IIAL (1307 ± 743 mL vs 1701 ± 813 mL; p = 0.005). Women in the hysterectomy with IIAL group had more massive transfusion (35.3% vs 2.5%; p < 0.001; odds ratio [OR] 21.3, 95% confidence interval [CI] 6.9–66), major blood loss (>1500 mL) (70.6% vs 34%, p < 0.001; OR 4.7; 95% CI 2.1–10.3), catastrophic blood loss (>2500 mL) (64.7% vs 12.5%;p < 0.001; OR 12.8, 95% CI 5.7–29.1), other complications (32% vs 12.4%; p = 0.007; OR 3.4, 95% CI 1.5–7.7), and intensive care unit admission (32.4% vs 1.5%; p < 0.001; OR 31.4, 95% CI 8.2–120.7) compared with the uterine conservative–resective surgery groups. The identification–ligation of the upper vesical, upper vaginal and uterine arteries had a significant lower risk for major blood loss (30.5% vs 50%; p = 0.041; OR 0.44, 95% CI = 0.2–0.9) compared with IIAL for vascular control of uterine conservative–resective surgery. Conclusions: Cesarean hysterectomy is not the default treatment for PAS, PAS with invasion above the vesical trigone are suitable for uterine conservative–resective surgery with upper vesical, upper vaginal and uterine artery vascular control.
KW - placenta accreta spectrum
KW - uterine conservative–resective surgery
KW - vascular control
UR - http://www.scopus.com/inward/record.url?scp=85126442624&partnerID=8YFLogxK
U2 - 10.1111/aogs.14348
DO - 10.1111/aogs.14348
M3 - Article
AN - SCOPUS:85126442624
SN - 0001-6349
VL - 101
SP - 639
EP - 648
JO - Acta Obstetricia et Gynecologica Scandinavica
JF - Acta Obstetricia et Gynecologica Scandinavica
IS - 6
ER -