Placenta Accreta Spectrum Disorder Conservative Managment Versus Hysterectomy Prospective Analysis
Condition: Placenta Accreta
MeSH terms: Placenta Accreta
Study type: Observational

Summary: 
      The aim of this study is to identify risk factors associated with performing cesarean
      hysterectomy versus conservative management in patients with placenta accreta spectrum (PAS).

      Research question What are the risk factors associated with cesarean hysterectomy in patients
      with placenta accreta spectrum? Research hypothesis There are certain risk factors associated
      with cesarean hysterectomy in patients with Placenta accreta spectrum (PAS).
    

Detailed description: 
      Placenta accreta spectrum disorder (PAS) is a serious obstetric disorder that is
      characterized by low lying and deep penetration of the villi which are abnormally attached to
      the myometrium of the uterus. This obstructs its complete separation during the third stage
      of labor which induces continued bleeding, and have potentially life- threatening for the
      mother. Most commonly, it is a consequence of a partial or complete absence of the compact
      and spongy layer known as the decidua basalis, and mis-development of the fibrinoid
      Nitabuch's layer which lies between the boundary zone of the thick endometrium and the
      cytotrophoblastic shell in the placenta.

      Traditionally, caesarean hysterectomy at the time of delivery has been the preferred
      management strategy for placenta previa accreta. Not only does this approach preclude future
      fertility, but it is also a procedure synonymous with signiﬁcant perioperative risks. For
      women who wish to conserve their reproductive function, other treatment options have been
      described.

      1.INTRODUCTION/ REVIEW Placenta accreta is defined as "the abnormal localization and
      adherence of the placenta villi to the uterine myometrium. Patients at risk for abnormal
      placentation should be assessed antenally by ultrasonography, with or without adjunct
      magnetic resonance imaging if indicated . Various grading systems of villous invasion during
      placenta implantation are integrated to a spectrum (PAS), including placenta accreta (the
      villi invade superficially into the myometrium), increta (the villi invade deeper into the
      myometrium but do not reach the serosa), and percreta (the villi invade into the uterine
      serosa or adjacent organs) Clinically, severe complications of PA include severe obstetric
      hemorrhage leading to disseminated intravascular coagulopathy (DIC), iatrogenic injury to the
      ureters, bladder, bowel, respiratory distress syndrome (RDS), acute transfusion reactions,
      electrolyte imbalance, and renal failure. In women with PA, the expected blood loss at
      delivery is 3000- 5000 mL, About 90% of patients require a blood transfusion with 40%
      requiring more than ten units of packed cell transfusion .

      The most difficult problem to deal with is controlling hemorrhage during delivery caused by
      PAS disorders. The potential for bleeding correlates with the degree to which the placenta
      invades the myometrium, the area of abnormal adherence involved, and the presence or absence
      of invasion into extrauterine tissues such as the bladder or parametrial tissues .

      Different methods have been employed to manage the PA, ranging from uterine conservation,
      which involves leaving the placenta in situ, to conventional hysterectomy. Classical cesarean
      sections (C- sections) prevent the excessive bleeding by leaving the adherent placenta in
      situ and by adopting strategic planning with a comprehensive analysis that aids the reduction
      in maternal morbidity and mortality rates .

      Perinatal emergency hysterectomy is routinely used to avoid maternal morbidity and mortality
      . Given the fact that cesarean section history and placenta previa are major risk factors,
      the incidence of PAS disorders increases with the increasing rate of cesarean section .

      Other risk factors include spontaneous or induced abortion, repeated miscarriages, in vitro
      fertilization embryo transfer, advanced maternal age, history of endometrial ablation, and
      previous uterine surgery .

      Conservative and non-conservative management for PAS disorders have been compared. Cesarean
      hysterectomy is regarded as the safest and most practical, thereby remaining the management
      option of choice. Nevertheless, hysterectomy is associated with high rates of severe maternal
      morbidity. In cases of placenta percreta, especially with bladder invasion, owing to damage
      to pelvic organs and vasculature during hysterectomy .In recent years, with the application
      of an abdominal artery balloon and the improvement of surgical techniques, efforts are made
      to preserve the uterus for patients PAS. This is not only the improvement for fertility
      preservation, but also for better control of bleeding to reduce maternal morbidity.

      The evidence on conservative management is considered low-quality, less reproducible, and
      operator-dependent. Critics noted the lack of histopathological confirmation or detailed
      differential diagnosis. Confounding factors in these studies needs to be controlled including
      the application of interventional techniques, the severity of placental invasion, and various
      placental positions and suture techniques .

      Therefore, investigators will undertake a prospective study to analyze maternal and neonatal
      outcomes comparing women with PAS disorders treated with cesarean hysterectomy or
      conservatively.
    

Intervention name(s): interventional techniques, the severity of placental invasion, and various placental positions and suture techniques
Intervention type(s): Procedure
Intervention description(s): Clinically, severe complications of PA include severe obstetric hemorrhage leading to disseminated intravascular coagulopathy (DIC), iatrogenic injury to the ureters, bladder, bowel, respiratory distress syndrome (RDS), acute transfusion reactions, electrolyte imbalance, and renal failure. In women with PA, the expected blood loss at delivery is 3000- 5000 mL, About 90% of patients require a blood transfusion with 40% requiring more than ten units of packed cell transfusion
Observational model: Cohort
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        The aim of this study is to identify risk factors associated with performing cesarean
        hysterectomy versus conservative management in patients with placenta accreta spectrum
        (PAS).
      
Keywords: placenta accreta spectrum managment