Objective: Failed conservative management placenta accreta spectrum

Methods: Case  series  (3  cases)  failed conservative management of  10 successful from total 63 accreta operative recorded  over  the  last  12  months in dr. Hasan Sadikin Hospital.

Background: Conservative management of placenta accreta spectrum (PAS) is defined as all procedures or strategies aiming to avoid a peripartum hysterectomy and its related mortalitas and consequences. The main goals are to decrease severe maternal morbidity related to PAS, especially the amount of blood loss, and, consequently, the risk of massive transfusion and coagulopathy, as well as operative injury and its potential consequences such as vesicouterine fistula. A second goal may be to attempt to preserve the option of future pregnancies, knowing that fertility is often inextricably linked with societal status and self-esteem.

Case Reports: Patient 1, a 32-year-old woman (para 1) with previous cesarean deliveries, was referred to our department for placenta previa. Ultrasound examination mapping found suspected PAS FIGO 2-type 1- vascular invation S1. Planning one step conservative surgery, and vascular control by internal iliac artery ligation and bilateral uterine artery . Uterine atony is inevitable that performed caesarean hysterectomy. Histopathological examination revealed placenta increta. 

Patient 2, a 33-year-old woman (para 1, abortus 2) with previous caesarean deliveries, was treated at a previous hospital for antepartum bleeding and fetal growth restriction. She received antenatal corticosteroid therapy. Ultrasound examination mapping found total placenta previa with PAS FIGO 2-type 1-vascular invation S1. Performed one step conservative surgery with devascularization by internal iliac artery ligation. Total abdominal hysterectomy was performed because heavy vaginal bleeding 1 hours post operative , and histopathological examination revealed placenta accreta.

Patient 3, a 34-year-old woman (para 1) was referred to our department to confirmation  congenital anomaly.  Diagnostic ultrasound found body stalk anomaly differential with gastroschisis and total placenta previa with suspected PAS FIGO 2-type 1- invasive vascular S2. Planned management conservative uterine, but durante operative massive bleeding, and decided caesarean hysterectomy with control vascular manual compression of aorta. The histopathology result indicated placenta percreta.

Discussion : Prenatal diagnosis of placenta accrete, percreta and increta is essential to avoid potentially life-threatening haemorrhage by optimizing peripartal management. Invasive placentation presents significant challenges at caesarean section , its related conditions, and  even for highly skilled surgeons. In the three cases of PAS presented here we tried to avoid hysterectomy by types of conservative management finally failed. The outcome in each of the three women was different, but no major bleeding or complication occurred in any of the cases. Close follow-up for many weeks is mandatory until post puerperium

Conclusions : The key point in conservative management PAS properly is to evaluate carefully the topography changes based on the structure and vascular using imaging like ultrasound and for deep invasion with MRI imaging. Four types of conservative management is related condition during operation, according the 10 successful conservative surgeries most of us used a combination of one step conservative with modified uterine resection surgical procedure and vascular control upper vesica, upper vagina, bilateral uterine artery and aortic clamping can be considered. On the other hands, the failure of conservative management in our cases are due to massive bleeding intraoperative and postoperative also vascular control inappropriate technique.

 

Keywords : Conservative Management, Placenta Accreta Spectrum,  Caesarean Hysterectomy