J Clin Gynecol Obstet

Journal of Clinical Gynecology and Obstetrics, ISSN 1927-1271 print, 1927-128X online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Gynecol Obstet and Elmer Press Inc

Journal website https://www.jcgo.org

Original Article

Volume 11, Number 3, September 2022, pages 75-85

A Novel Approach in Management of Placenta Accreta Spectrum Disorders: A Single-Center Surgical Experience From Vietnam

Figure 1. Myometrial part of uterus (yellow arrow) was removed accompanied with specimen of unseparated placenta (white arrow).

Figure 2. (a) Transverse B-Lynch compressive suture after uterine resection. (b) Transverse B-Lynch procedure followed by uterine closure. Conservative surgery was evaluated successfully by uterine contraction and by reducing active bleeding.

Figure 4. (a) Laparotomy by midline incision. Placenta was invasive deeply through myometrial layer to serosa. Placenta was visible via thin layer of uterus (white arrow). Placenta percreta was located at uterine body, closed to fundus. Newly formed blood vessels were clearly present at uterine serosa’s superficial surface. (b) Laparotomy by midline incision. Placenta was infiltrated robustly through uterine myometrium to serous membrane. Placenta percreta was located at lower segment of uterus, directed to bladder. Vascular angiogenesis developed strongly at anterior position of invasive placenta (yellow arrow).

Figure 5. Frequency of placenta accreta spectrum disorders (PASD) in the present study. Unidentified PAS mentioned on severe invasive placenta confirmed accurately by experienced surgeon, leading to totally disappear of the myometrial layer at invasive placental location. Thus, pathologists could not conclude type of PASD in these cases. PAS: placenta accreta spectrum.

**Table 1.** Protocol of Uterine Conservative Surgery at Tu Du Hospital
Step 1: vascular disconnection of proliferative vessels and the separation of invaded uterine tissues from invaded vesical tissues.
Step 2: incision of the lower uterine segment at upper margin of placenta or cut through placenta, fetal delivery.
Step 3: resection of all invaded myometrial portion, manual removal of the whole placenta, or left partial placenta in situ, hemostasis of local bleeding vessels (Fig. 1).
Step 4: hemostasis by suture of transverse B-Lynch procedure (uterine compression suture), using atraumatic number 1 chromic catgut (Fig. 2a) [14].
Step 5: restore of uterine myometrium by one layer, not using suture of “U” shape (Fig. 2b).
Step 6: bladder repair if necessary.

Table 1. Protocol of Uterine Conservative Surgery at Tu Du Hospital

Step 1: vascular disconnection of proliferative vessels and the separation of invaded uterine tissues from invaded vesical tissues.

Step 2: incision of the lower uterine segment at upper margin of placenta or cut through placenta, fetal delivery.

Step 3: resection of all invaded myometrial portion, manual removal of the whole placenta, or left partial placenta in situ, hemostasis of local bleeding vessels (Fig. 1).

Step 4: hemostasis by suture of transverse B-Lynch procedure (uterine compression suture), using atraumatic number 1 chromic catgut (Fig. 2a) [14].

Step 5: restore of uterine myometrium by one layer, not using suture of “U” shape (Fig. 2b).

Step 6: bladder repair if necessary.

**Table 2.** Characteristic of Demographic Study
Features	Frequency (n)	Percentage (%)
SD: standard deviation.
Maternal age (mean ± SD)	32.78 ± 5.19
< 35	39	60
≥ 35	26	40
Number of previous cesarean scar
0	3	4.6
1	38	58.5
2	23	35.4
3	1	1.5
Gestational age at cesarean delivery (weeks) (mean ± SD)	35.4 ± 2.1
28⁺⁰ - 33⁺⁶	10	15.4
≥ 34⁺⁰ - 36⁺⁶	40	61.5
≥ 37⁺⁰	15	23.1
Insertion of JJ catheter at cesarean delivery
Yes	55	84.6
No	10	15.4
Bilateral uterine artery ligation
Yes	61	93.8
No	4	6.2
Selective ligation of vescical-uterine vessels
Yes	61	93.8
No	4	6.2
Other hemostatic procedures
Yes	14	21.5
No	51	78.5
Intervention of bladder repair
Yes	3	4.6
No	62	95.4
Duration from skin incision to fetal delivery (min) mean ± SD	30 ± 18.8
Left partial placenta in situ	7

Table 2. Characteristic of Demographic Study

Features

Frequency (n)

Percentage (%)

SD: standard deviation.

Maternal age (mean ± SD)

32.78 ± 5.19

< 35

≥ 35

Number of previous cesarean scar

4.6

58.5

35.4

1.5

Gestational age at cesarean delivery (weeks) (mean ± SD)

35.4 ± 2.1

28⁺⁰ - 33⁺⁶

15.4

≥ 34⁺⁰ - 36⁺⁶

61.5

≥ 37⁺⁰

23.1

Insertion of JJ catheter at cesarean delivery

Yes

84.6

15.4

Bilateral uterine artery ligation

Yes

93.8

6.2

Selective ligation of vescical-uterine vessels

Yes

93.8

6.2

Other hemostatic procedures

Yes

21.5

78.5

Intervention of bladder repair

Yes

4.6

95.4

Duration from skin incision to fetal delivery (min) mean ± SD

30 ± 18.8

Left partial placenta in situ

**Table 3.** Characteristics of Neonatal Outcomes in the Study
Newborn outcomes	Frequency (n = 65)	Percentage (%)
SD: standard deviation; NICU: neonatal intensive care unit; CPAP: continuous positive airway pressure; NIPPV: noninvasive positive pressure ventilation; ETT: endotracheal tube.
Weight of newborn infant
Mean ± SD	2,466 ± 515
1,000 - ≤ 1,500 g	3	4.6
>1,500 - ≤ 2,500 g	35	53.9
> 2,500 g	27	41.5
Apgar score at 1 min
Low (0 - 3)	7	10.8
Middle (4 - 6)	55	84.6
Normal (7 - 10)	3	4.6
Apgar score at 5 min
Middle (4 - 6)	23	35.4
Normal (7 - 10)	42	64.6
NICU
Yes	40	61.5
No	24	36.9
Delivery to tertiary neonatal hospital	1	1.6
Postnatal intervention
No need oxygen support	13	20.0
Oxygen via nasal cannula	25	38.5
CPAP	15	23.1
NIPPV	5	7.7
ETT	7	10.8
Infant status during postnatal course
Alive	59	90.7
Transferred to tertiary hospital	6	9.3
Death	0	0

Table 3. Characteristics of Neonatal Outcomes in the Study

Newborn outcomes

Frequency (n = 65)

Percentage (%)

SD: standard deviation; NICU: neonatal intensive care unit; CPAP: continuous positive airway pressure; NIPPV: noninvasive positive pressure ventilation; ETT: endotracheal tube.

Weight of newborn infant

Mean ± SD

2,466 ± 515

1,000 - ≤ 1,500 g

4.6

>1,500 - ≤ 2,500 g

53.9

> 2,500 g

41.5

Apgar score at 1 min

Low (0 - 3)

10.8

Middle (4 - 6)

84.6

Normal (7 - 10)

4.6

Apgar score at 5 min

Middle (4 - 6)

35.4

Normal (7 - 10)

64.6

NICU

Yes

61.5

36.9

Delivery to tertiary neonatal hospital

1.6

Postnatal intervention

No need oxygen support

20.0

Oxygen via nasal cannula

38.5

CPAP

23.1

NIPPV

7.7

ETT

10.8

Infant status during postnatal course

Alive

90.7

Transferred to tertiary hospital

9.3

Death

**Table 4.** Intraoperative and Postoperative Complications
	Frequency (n = 65)	Percentage (%)
aN = 57. SD: standard deviation.
Blood loss amount
Mean ± SD, mL	987 (677 - 1,531)
< 500 mL	8	12.3
Grade I, II (500 - < 1,500) mL	43	66.2
Grade III, IV (1,500 - < 3,000) mL	11	16.9
≥ 3,000 mL	3	4.6
Ureteral injury (at stage of insertion of JJ catheter)	1	1.5
Tubal sterilization	28	43.1
Operation time
Mean ± SD, min	135 ± 31.8
< 120 min	22	33.8
120 - 180 min	39	60.0
> 180 min	4	6.2
Postoperative hemorrhage, relaparotomy with conservative management	1	1.5
Postoperative hemorrhage, relaparotomy with hysterectomy	1	1.5
Postoperative infection, medical therapy, no need of more surgical intervention	2	3.1
Postoperative infection, relaparotomy with hysterectomy	2	3.1
Postpartum course (days)
Mean ± SD	5.79 (4.66 - 7.11)
< 7	53	81.5
7 - ≤ 14	11	16.9
> 14	1	1.5
Blood transfusion volume (mL)a
Red blood cells	831 ± 672
Fresh frozen plasma	446 ± 158
Platelet	250

Table 4. Intraoperative and Postoperative Complications

Frequency (n = 65)

Percentage (%)

aN = 57. SD: standard deviation.

Blood loss amount

Mean ± SD, mL

987 (677 - 1,531)

< 500 mL

12.3

Grade I, II (500 - < 1,500) mL

66.2

Grade III, IV (1,500 - < 3,000) mL

16.9

≥ 3,000 mL

4.6

Ureteral injury (at stage of insertion of JJ catheter)

1.5

Tubal sterilization

43.1

Operation time

Mean ± SD, min

135 ± 31.8

< 120 min

33.8

120 - 180 min

60.0

> 180 min

6.2

Postoperative hemorrhage, relaparotomy with conservative management

1.5

Postoperative hemorrhage, relaparotomy with hysterectomy

1.5

Postoperative infection, medical therapy, no need of more surgical intervention

3.1

Postoperative infection, relaparotomy with hysterectomy

3.1

Postpartum course (days)

Mean ± SD

5.79 (4.66 - 7.11)

< 7

81.5

7 - ≤ 14

16.9

> 14

1.5

Blood transfusion volume (mL)a

Red blood cells

831 ± 672

Fresh frozen plasma

446 ± 158

Platelet

250

**Table 5.** Type of PASD Related to Features of Surgery, Blood Loss Amount
Features	Histopathological result
PAS: placenta accreta spectrum.
Surgery
Elective	10 (16.9)	4 (6.8)	20 (33.9)	25 (33.9)	59 (100.0)
Emergency	0 (0.0)	1 (16.7)	2 (33.3)	3 (50.0)	6 (100.0)
Blood loss amount
< 1,500 mL	9 (20.5)	2 (4.5)	15 (34.1)	18 (40.9)	44 (100.0)
≥ 1,500 mL	1 (4.8)	3 (14.3)	7 (33.30)	10 (47.6)	21 (100.0)

Table 5. Type of PASD Related to Features of Surgery, Blood Loss Amount

Features

Histopathological result

Unidentified PAS n (%)

Placenta accreta n (%)

Placenta increta n (%)

Placenta percreta n (%)

Total n (%)

PAS: placenta accreta spectrum.

Surgery

Elective

10 (16.9)

4 (6.8)

20 (33.9)

25 (33.9)

59 (100.0)

Emergency

0 (0.0)

1 (16.7)

2 (33.3)

3 (50.0)

6 (100.0)

Blood loss amount

< 1,500 mL

9 (20.5)

2 (4.5)

15 (34.1)

18 (40.9)

44 (100.0)

≥ 1,500 mL

1 (4.8)

3 (14.3)

7 (33.30)

10 (47.6)

21 (100.0)