INTRODUCTION
The prevalence of placenta previa and placenta accreta spectrum disorder (PAS) has risen due to the increase in cesarean deliveries (CDs) and invasive uterine interventions, which are two causes of severe maternal morbidity and mortality due to peripartum hemorrhage [1–5]. During placenta development, Nitabuch’s layer prevents further invasion of the placenta into the endometrium and eventually the myometrium [6]. Therefore, previous CDs or hysteroscopic surgery leading to a damaged endometrium might lessen the preventive effect of the endometrium [1, 7]. In this case, the placenta can implant itself onto the myometrium (placenta accreta), inside the myometrium (placenta increta), or even beyond the myometrium, reaching the uterine serosa, bladder, and adnexal structures (placenta percreta). Placenta increta and percreta are considered as invasive PAS [7]. When invasive PAS occurs, new vessels develop from adjacent tissues toward the uterus to supply blood to the placenta [3, 8–10]. During CD, massive hemorrhage could occur from these vessels that leads increases maternal morbidity and even causes mortality [11, 12]. Sometimes placenta previa and invasive PAS occur together (previa invasive PAS) [7, 13]. Previa invasive PAS has the highest risk of severe hemorrhage following placental delivery. Deeper invasion leads to the development of more vessels from the surrounding tissues toward the placental bed, resulting in severe hemorrhage [7, 12]. In addition, the weak contractile ability of the lower uterine segment leads to increased hemorrhage [13].
The prevalence of PAS in developed countries is approximately 0.13–0.36%, and it continues to rise with increasing CD rates [1, 14–16]. The risk of bladder and ureteral injuries increases during CD in women with previous previa invasive PAS, because the bladder is in the anterior of the uterus and the ureters pass through the lateral side of the lower uterine segment to enter the bladder [3, 5]. The risk is particularly high during cesarean hysterectomy (CH) in women with previa invasive PAS who have had previous CD [3, 5, 17]. Therefore, experienced physicians should perform CDs in these patients. However, there is no consensus on which approach should be preferred for performing CDs. The American College of Obstetrics and Gynecology (ACOG) recommends CD between 34 and 35 weeks of age in women with PAS, where a midline or a transvers abdominal and fundal uterine incision should be made. After fetal delivery, the placenta is left in the uterus and CH is completed [18]. Some experts object to this approach, regarding it as too radical to perform in all women with PAS. They recommend an initial approach that aims to spare the uterus, and CH should be performed if hemorrhage cannot be controlled with other interventions, such as uterotonic agent administration, Bakri balloon insertion, and internal iliac artery ligation [14, 19–24]. In addition, it has not been clarified whether the abdominal entrance should be made with a midline or transverse incision, or whether a uterine incision should be made via a transverse fundal or low-segment transverse incision. Many authors suggest that a transverse abdominal incision is sufficient to perform CD in women with PAS [3, 14, 19, 22, 23]. Moreover, a transverse abdominal incision leads to less pain and dehiscence as well as a lower infection rate, better cosmetic appearance, and shorter recovery time compared with a middle incision [25].
Recent research suggests that CH negatively impacts women’s self-esteem, body integrity, and affect [26–28]. Women who want to be sexually active desire their uterus to be preserved and women who have undergone CH due to PAS have more grief and depression than those who undergo CD [27, 28]. Thus, developing a uterine-sparing surgery has gained significance.
Objectives
a new approach was developed to reduce maternal morbidity, perform uterine-sparing surgery, and prevent morbidity during CD in women with previa invasive PAS. The author has observed that the new approach is effective, feasible, applicable, and has gained sufficient experience in the new approach. Therefore, he aimed to introduce this new approach that would contribute to reduce maternal morbidity during cesarean delivery in women with previa invasive PAS.
MATERIAL AND METHODS
This cohort study was conducted between January 2021 and November 2022, and the data of the participants were collected before discharge, which was conducted in accordance with the Declaration of Helsinki (revised in 2013). Institutional Review Board approval was obtained (date: 2022/09/29, approval number: 18/3). Signed informed consent was obtained from each participant. If necessary, an additional signed form was obtained for consent to use the photos and videos.
A diagnosis of previa invasive PAS was made by ultrasonographic (USG) evaluation, which was performed by a radiologist or perinatologist. The presence of invasive PAS was evaluated when placenta previa was diagnosed. The presence of placental lacunae; the disappearance of the hypoechoic area between the placenta and myometrium; a decrease in myometrial thickness in the retroplacental area (< 1 mm); the presence of placental tissue in the myometrium, serosa, adnexa, or even bladder; the disappearance of the bright whiteness of the bladder wall; and the presence of tortuous, tangled irregular vessels between the uterovesical interface were the diagnostic criteria used for previa invasive PAS, where at least two criterion must have been met (Fig. 1, 2).
All CDs were performed by the authors. The parents were informed of their condition and the operation. The women were placed in a dorsal lithotomy position on the operating table and prepared for surgery. The abdomen was entered by a Pfannenstiel incision, and a low-segment transverse uterine (Kerr) incision was made in the avascular area above the placental implantation site (Fig. 3B, 4A). The fetus was delivered through the opened incision. Then, the shrinking fundus part of the uterus is removed from the abdomen and wrapped with a sterile towel. Removal of the placenta began posteriorly and continued towards the anterior uterine wall, where placental invasion occurred. When the placenta did not separate easily, where it was thought that invasive PAS had developed, the placenta was dissected meticulously by inserting fingers between the myometrium and the placenta (Fig. 3C, D). Excessive force was not applied to the placenta during dissection to prevent rupture of the uterus and bladder walls. Excessive hemorrhage was observed after placental separation, where the placenta firmly adhered to the uterus. It was observed that this hemorrhage resulted from newly developed vessels that supply blood to the placenta (Fig. 4–6). These vessels had two different patterns. The first type was perforating vessels, which originated from the bladder or uterine adnexa and reached the placenta by perforating the uterine wall (Fig. 4 and 6). The second type was superficial vessels, which emerged at the cervical and adnexal regions, ran superficially along the uterine wall, and reached the placental bed (Fig. 5C, D, 6C). If perforating vessels originated from the bladder, firm adhesion usually occurred between the bladder and the uterus. In this case, the visceral peritoneum and bladder tissue were dissected around the adhesions to identify and ligate perforating vessels. Then the newly developed vessels were identified, ligated, and cut. Thereafter, the hemorrhage from the placental bed ceased, and the bladder was removed from the surgical field after cutting the perforating vessels (Fig. 6A–C). If the bladder adhered densely to a prior cesarean incision site without perforating vessels, the adhesions were dissected with sharp dissection. Following bladder dissection from the uterine wall, superficial vessels were identified and ligated (Fig. 5C, D, 6C). In some cases, vessels running from the endometrium to the placenta were observed and were considered to correspond to increased subplacental vascularization upon USG examination. Bleeding from these vessels was stopped using an X-type suture (Fig. 5A, B). Oxytocin, methylergonovine, and tranexamic acid were administered to reduce hemorrhage after placental delivery, if there were no contraindications. After the surgery was completed, all women underwent a vaginal examination to determine whether there was bleeding from the cervix.
RESULTS
The new approach was applied to eight women with previa invasive PAS. Vaginal hemorrhage was observed in a woman without a living child. When the uterine incision was closed, excessive hemorrhage was not observed in the uterine cavity. It was presumed that the hemorrhage originated in the cervical canal. A Cook Cervical Ripening Balloon (CCRB) was placed in the cervix to prevent hemorrhage. The uterine balloon was inflated with 80 cc saline, and the cervical balloon was inflated with 60 cc saline. The CCRB was removed after three hours. Cesarean hysterectomy was performed on three women who did not desire to preserve their fertility to avoid severe morbidity. Bladder and ureteral injuries did not occur, and massive transfusion, internal iliac artery ligation, uterine artery ligation, and invasive radiological intervention were not required. Detailed information regarding the clinical characteristics and outcomes of the new surgical approach is presented in Table 1. Surgery related postoperative complication did not occur in any patient. Massive blood product transfusion, relaparotomy was not required after surgery. All patients discharged with good health. After discharge, readmission to the hospital due to surgery related complication was not occurred.
|
Table 1. Represent about the clinical characteristics and outcomes of the new surgical approach in pregnant women with previa invasive placenta accrete spectrum (PAS) |
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|
Patient (P) |
P1 |
P2 |
P3 |
P4 |
P5 |
P6 |
P7 |
P8 |
|
Age |
35 |
24 |
29 |
39 |
40 |
37 |
40 |
36 |
|
BMI |
28 |
33 |
26 |
31 |
29 |
34 |
28 |
29 |
|
Gravity |
2 |
3 |
4 |
3 |
5 |
14 |
3 |
2 |
|
Parity |
1 |
2 |
3 |
2 |
2 |
8 |
1 |
0 |
|
Abortion |
0 |
0 |
0 |
0 |
2 |
5 |
1 |
1 |
|
Alive |
1 |
2 |
3 |
2 |
2 |
8 |
1 |
0 |
|
Prior vaginal delivery |
0 |
0 |
0 |
0 |
0 |
4 |
0 |
0 |
|
Prior cesarean delivery |
1 |
2 |
3 |
2 |
2 |
4 |
1 |
0 |
|
Pregnancy age [week-day] |
34–5 |
36–0 |
35–0 |
31–2 |
34–1 |
37–1 |
35–6 |
37–4 |
|
Complaint at admission |
No |
Vaginal bleeding |
No |
Vaginal bleeding |
No |
Vaginal bleeding |
No |
No |
|
Hgb at admission [g/mL] |
12.1 |
9.0 |
12.7 |
10.8 |
11.4 |
11.9 |
11.4 |
11.7 |
|
Hgb at discharge [g/mL] |
7.8 |
11.7 |
7.6 |
8.9 |
10.2 |
8.9 |
9.9 |
9.6 |
|
PRBCs transfusion [U] |
3 |
4 |
4 |
1 |
2 |
2 |
2 |
2 |
|
FFP transfusion [U] |
2 |
0 |
3 |
2 |
2 |
1 |
1 |
0 |
|
Peripartum hysterectomy |
Yes |
No |
No |
No |
Yes |
Yes |
No |
0 |
|
Operation time [minutes] |
140 |
90 |
95 |
70 |
90 |
100 |
140 |
95 |
|
Hospital stay [day] |
5 |
2 |
5 |
6 |
3 |
4 |
3 |
3 |
|
BMI — body mass index; FFP — Fresh–frozen plasma; Hbg (g/mL) — hemoglobin; PRBCs — Packed red blood cells; U — Unit |
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DISCUSSION
The results suggest that CD can be performed with Pfannenstiel and a low-segment uterine transverse incision, without causing severe maternal morbidity in women with previa invasive PAS. A CCRB was placed in one woman, and CH was performed in two women who were completed fertility and wanted to have tubal ligation before surgery. Additional interventions, such as ureteral stent insertion, internal iliac artery ligation, uterine artery ligation, and arterial balloon insertion, which increase morbidity, prolong surgery duration, and are accompanied by their own complications, were not required [23].
The diagnosis of PAS should be made by USG evaluation, and a scheduled CD should be performed to prevent emergency surgical complications [18, 19]. Recent expert opinions and research suggest that clinically diagnosed placenta percreta cannot be confirmed via a histologic evaluation [2, 10, 13, 29]. Research indicates that thicker fibrinoid tissue accumulation exists around the anchoring villi of a PAS placenta than around normal placental anchoring villi [2, 10, 13]. Moreover, placental villi always have a fibrinoid shell around them, and they are not anchored to the bladder and adnexal tissues [2, 10, 13]. Unlike an invasive mole, the placental villi of a normal pregnancy are not an invasive characteristic [2, 13]. Loss of the uterine serosa or uterine rupture during surgery causes the outward protrusion of placental villous, causing a percreta appearance [2, 10, 13]. In the present study, the diagnosis of a previa invasive PAS was made with USG and confirmed during CD. During CDs any placental tissue protruding outward to uterine wall and placental implantation on adjacent tissues has not yet been observed during surgery in the presented study. Histological confirmation of clinically diagnosed invasive PAS was not possible because the placenta was removed from the uterus in all cases and two hysterectomies were performed after placental removal. Thus, the author propose that it is not placenta percreta, but neovascularization, which is responsible for severe hemorrhage during CD in women with previa invasive PAS.
In women with PAS during CD, the risk of maternal morbidity and mortality is increased because of severe hemorrhage, bladder, ureter, bowel injury, and complications related to invasive radiological intervention. Neovascularization is the major cause of hemorrhage during cesarean delivery, and the risk increases with increasing vascularity [8, 9, 19, 23, 30]. Neovascularization might be initiated by placental factors released between adjacent tissue and the placental bed [2, 8, 10, 30]. Detecting hypervascularity with USG evaluation and confirmation during CD are essential requirements for a clinical diagnosis of invasive PAS [16, 30–32]. Recent research suggests that new vessels emerge from the uterine artery, superior vesical artery, internal iliac artery, and even external iliac artery [8, 9, 31]. This may explain why hemorrhage continues after CH. During CD identification, ligation or embolization of these vessels is important to prevent hemorrhage [23, 30]. In some case radiologic interventions, such as internal iliac artery balloon and aortic balloon insertion, are performed to prevent massive hemorrhage [21, 30]. In the present study, hemorrhage was ceased following the identification and ligation of the new vessels. So, additional interventions were not required.
Beginning CD with an infraumbilical midline incision is recommended to ensure sufficient visualization and to access the vascular structure [18]. Some authors object to this approach and suggest that CD and CH could be performed with a transverse incision [3, 14, 23]. In addition, radical hysterectomy and pelvic lymph node dissection are possible with a transverse incision [25, 30]. Szlachta-McGinn et al. [14] reported that conducting a hysterectomy with a transverse abdominal incision shortened operation time and decreased the need for ureteral stent insertion. Six CDs and two CHs were performed without complications using the new approach in the presented study. This information suggest that low transvers adnominal incision is provide sufficient visualization of pelvic region to perform CD, CH and bilateral hypogastric arteries ligation. Additionally, sacrocolpopexy operation was performed through low transvers abdominal incision. During sacrocolpopexy the surgeon could visualize common iliac arteries and internal iliac arteries that suggest that pelvic arteries could be identified and ligated through low transvers abdominal incision.
Anteriorly located previa invasive PAS has a higher risk of excessive hemorrhage [18, 19, 22]. In the ACOG recommendations, hysterectomy is performed after the placenta is left in the uterus [18]. In this method, visualization and dissection of the bladder become exceedingly difficult, because the pelvic region is narrow and the presence of the placenta in the uterus results in inadequate visualization. Thus, newly developed vessels are easily ruptured, leading to excessive hemorrhage during hysterectomy. Therefore, the risk of bladder and ureter injuries, as well as excessive hemorrhage, is high with the recommended method. The new surgical approach provides a decrease size of lower uterine segment after placental removal and a clear visualization of the pelvic region. The newly developed vessels ligation ceased the hemorrhage and additional intervention was not required. In some patients, the placenta is implanted into the cervical canal [33, 34]. After placental removal, hemorrhage can occur on the implantation side of the cervical canal [33, 34]. Thus, vaginal examination should be done each woman after surgery. As mentioned in this study CCRB can be placed into the cervix to stop this type of hemorrhage.
Hysterectomy has a negative impact on women’s physiological and psychological health [26–28]. Conceptually, the uterus is an important organ for women in terms of body integrity, self-esteem, a sense of femininity, and sexuality. Therefore, hysterectomy could have a worsening effect on women’s emotions and psychological health, leading to stress, anxiety, and even depression [26]. Grove et al. [28] reported that women who undergo CH due to PAS have more grief/depression, anxiety/worry, long-term health issues, and decreased quality of life for up to three years following surgery than those who undergo CD. If CH is performed due to PAS and the patient desires to preserve fertility, losing the uterus would have a greater effect, potentially leading to depression [28]. In addition, Chang et al. [27] reported that women over the age of 45 years who want to preserve their uterus have a high desire to be sexually active. Cesarean hysterectomies were performed in three women who wanted to have tubal ligation and did not mind fertility preservation. Uterine-sparing surgery was performed with the new approach in six of eight women in this study without severe maternal morbidity. Uterine sparing CD could be provided a positive effect on women’s mental health.
CONCLUSIONS
The study results suggest that CD could be performed with transverse abdominal and a low-segment transverse uterine incision in pregnant women with previa invasive PAS. Severe hemorrhage could be prevented by identifying and ligating newly developed vessels. Understanding neovascularization at the placental bed and its related complications in women with previa invasive PAS could aid in the management of its related complications. The strengths of the study are its reasonability, applicability, and decreased morbidity in women with previa invasive PAS using the proposed method, while its limitations include the use of a single center and a small study population. Multicenter studies with larger sample size are required to evaluate efficacy and applicability of the new surgical approach.
Article information and declarations
Data availability statement
The data supporting the findings of this study are available from the corresponding author upon reasonable request.
Funding
The study received no funding.
Acknowledgement
The author would like to thank Mr. Cemil Gurses for his help in supplying radiological images without any benefit.
Conflict of interest
The author reports no conflicts of interest.
