Discussion
percreta, pregnancy disorder, increta, blood loss, hemorrhage
POSTPARTUM HEMORRHAGE, PREGNANCY DISORDER, BLOOD LOSS, ABNORMAL MENSTRUAL CYCLE, COMPLICATIONS, HEMORRHAGE, SEPARATION, UTERUS
Since PAS is a life-threatening condition often accompanied with postpartum hemorrhage or hysterectomy, cesarean hysterectomy with the placenta left in situ has been the conventional management approach [In contrast to expectant management of leaving the placenta partially or totally in situ, several approaches of conservative management have been developed [In this study, the prominent hallmark of surgical management was the preservation of the uterus without leaving the placenta in situ, which results in significantly less blood loss. In the past, some surgeons in our center performed prophylactic placement of internal iliac artery balloon catheters in conservative management of two PAS cases, but this unfortunately resulted in significant blood loss (data not shown), and therefore this technique was subsequently abandoned. Bilateral uterine artery ligation was later adopted for hemorrhage control combined with a dedicated suture technique. Therefore, the conservative management approach used by the surgical team was manual separation of the placenta combined with ligation of the ascending branch of uterine artery and clover suturing for hemorrhage control (UAL + CST), which has proved to be effective in preventing postpartum hemorrhage [When China allowed families to have two children instead of limiting to one, there was a 50% increase in annual live births in the study city, peaking in 2017 at 250,857 live births, the highest birth rate growth in China [This study demonstrated that the conservative approach of PAS management was safe and could preserve the uterus. In our follow-up with the most severe form of PAS, the majority of percreta patients (n = 10) resumed normal menstrual cycle within 12 months with normal menstrual fluid volume. As PAS is closely related to previous C-section and parity, most of the patients have had two or more than two children, and they usually would not consider fertility issue. The three patients who later delivered again could be the evidence that the studied surgery technique preserved not only the uterus but also the fertility.Another distinctive finding of this study was the application of MRI in PAS management in a large proportion of cases (~ 44%). After excluding cases with emergency surgeries, which seldom had adequate time for MRI, the rate of MRI in PAS increased to 54%. It is well-known that MRI offers better visualization of maternal pelvic organs, particularly when abnormal invasion (increta and percreta) is suspected, and offers additional detail regarding the utero-placental relationship and the surrounding periuterine environment [It should be acknowledged that part of the reason for the high use of MRI in this study were due to the relatively low cost of MRI at the studied hospital, less than 100 US dollars. We did not find significant impact of use of MRI on blood loss, transfusions, operation durations, hospital stays, and complications. However, in our study, placenta thickness ≥ 50 mm was shown to be closely related to more blood loss and RBC transfusion and longer surgery time and hospital stay. As MRI could obtain a panorama view of placenta and find the thickest part, whereas ultrasound-measured thickness might not be the thickest as it depends on where the probe laid, it is of great value for surgical planning. Moreover, MRI images could be stored permanently and easily accessed by obstetricians and referenced for further training and research, while in contrast, complete ultrasound images were not readily available to the obstetric surgeons for operative planning, and surgeons had to separately request several screenshots of ultrasound images.It should also be noted that total hysterectomy results in detrimental effects in many aspects of pelvic floor function [We understand that our study should have been conducted as a randomized controlled trial study design. However, PAS is a rare life-threatening pregnancy disorder and the Institutional Review Board would not approve randomization when the studied approach is obviously more effective than other approaches. Besides, this study was limited by its retrospective nature, and may not be generalizable to other regions with different cultural norms, and therefore a different cost-benefit ratio with respect to uterus preservation. As no total hysterectomy were performed at this center, we are unable to directly compare patient outcomes and satisfaction between the studied approach and total hysterectomy.