Natal Management, Non-Conservative Surgical Managament

Dr. Sadun Sucu1
Prof. Dr. Ali Turhan Çağlar2

1Department of Perinatology, Ankara Etlik City Hospital, Ankara, Türkiye
2Department of Perinatology, Ankara Etlik City Hospital, Ankara, Türkiye

ABSTRACT

Placenta accreta spectrum (PAS) patients are confronted with various problems during pregnancy and child- birth. These problems require follow-up care and treatment in experienced centers. These centers can mini- mize blood loss, the most common consequence, with tranexamic acid infusion, intra-arterial balloon applica- tion or ligation of the hypogastric artery. Although none of these methods are routinely used in the guidelines, they have been shown to be beneficial in many studies. There are no large-scale randomized controlled trials of patients diagnosed with placenta accreta using these methods. The risk of urological injury is high due to the deep penetration of the placenta or the patient’s specific medical history. The bladder can be inflated with 200-300 ml diluted methylene blue and bilateral double-J catheters placed in the ureters to prevent urolog- ical damage. Cystoscopy may reveal bladder invasion during this operation. Following standard surgical an- tibiotic prophylaxis in prenatally diagnosed patients who are scheduled for hysterectomy after preoperative complication prophylaxis, a median incision allows visualization of the uterine incision and invasion of the pla- centa. The baby is delivered after a planned uterine incision without damaging the placenta. No postpartum uterotonic drugs are used and the umbilical cord is cut, ligated and placed in the uterus to suture the incision. The severity of placental invasion should determine the necessary caution in separating the bladder and uter- us. Heavy bleeding may occur during the dissection. A tourniquet can be applied to the uterus with a Foley catheter at the level of the isthmus to reduce the uterine bleeding that may occur during this dissection. The arteries and ligaments of the uterus are clamped, cut and ligated after the bladder has been separated from the uterus. The operation is completed with the formation of a vaginal cuff. In general, a total hysterectomy is performed instead of a sub-total hysterectomy.

Keywords: Placenta accreta spectrum; Hysterectomy; Multidisciplinary health teams; Cesarean section, Repeat; Tranexamic acid; Balloon occlusion; Morbidity

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