A.Chohan Continuous Squeezing Suture (ACCSS) for Placenta Previa / Accreta
Condition: Placenta Previa With Hemorrhage - Delivered; Placenta Accreta
MeSH terms: Placenta Accreta; Placenta Previa; Hemorrhage
Study type: Interventional

Summary: 
      Placenta praevia and accreta spectrum disorders are rising in incidence due to increased rate
      of repeat caesarean sections. Peripartum hysterectomy remains the only definitive treatment
      of massive postpartum haemorrhage related to this condition. A multitude of conservative
      treatments is described in literature, which includes pelvic devascularization under
      radiological control, myometrial resection with placenta in situ, and various suturing
      techniques some involving inversion of cervix. Variable success rates are described, but
      search continues for a simple, safe and effective treatment. Such a surgical technique i.e.
      A. Chohan Continuous Squeezing Suture (ACCSS) is described in this study for controlling
      haemorrhage from the lower uterine segment at caesarean section for placenta praevia and
      accrete spectrum disorders.
    

Detailed description: 
      Postpartum haemorrhage (PPH) has always been a prominent cause of maternal morbidity as well
      as mortality worldwide, with uterine atony as the leading cause and peripartum hysterectomy
      as the only definitive treatment option . Researchers are struggling throughout the years to
      find a treatment modality other than hysterectomy, which has least morbidity and potential to
      preserve fertility. In an attempt to find a non-radical treatment for PPH due to uterine
      atony, a novel uterine compression suture was introduced in 1997. The time then witnessed
      emergence of a series of its variants from all over the world which effectively lowered the
      incidence of peripartum hysterectomy from uterine atony.

      Meanwhile the incidence of placenta praevia and placenta accreta spectrum disorder rose
      dramatically across the globe because of rising incidence of repeat caesarean sections.
      Placenta accreta spectrum has opened up a new era in the history of PPH, as forcible
      separation of adherent placenta leads to massive bleeding from placental bed. Peripartum
      hysterectomy has once again emerged as gold standard treatment for this variety of PPH with
      its overall morbidity of 40-50%, and mortality of 7-10% in case of placenta percreta. The
      fear of placental bed bleeding has led to the development of conservative managements like
      "leaving the placenta in situ approach" with its wide range of mild to severe, and serious
      morbidities. The conservative surgical techniques i.e. The triple P procedure, one step
      conservative surgery approach, have also used the concept of non-separation of placenta and
      have instead adopted resection of myometrium with placenta in situ. These surgeries involve
      devascularisation of deep pelvic / major abdominal vessels and ligation of complex arterial
      anastomosis making the procedure technically difficult. Moreover, the devascularisation is
      done under extensive and expensive interventional radiological equipment which places the
      procedures out of reach for the routine setups particularly in the under developed countries.
      Another conservative surgical technique i.e. stepwise surgical approach, which described
      separation of placenta also mainly relied upon devascularisation of pelvic organs by
      bilateral ligation of anterior branch of internal iliac artery rather than elaborating the
      details of technique of controlling haemorrhage at the actual bleeding site.

      Three corners stones of uterine compression sutures have been described in literature i.e.
      simplicity, safety and efficacy and no such suturing technique so far is published. Hence,
      it's the time for innovation in the treatment of placenta praevia and PAS. In this study, we
      report our own experience of a conservative surgical technique i.e. A. Chohan Continuous
      Squeezing Suture (ACCSS) application in the lower uterine segment during caesarean section in
      profusely bleeding patients with placenta praevia and placenta accreta spectrum without
      involvement of urinary bladder and other pelvic organs. This surgical technique takes on the
      separation of placenta and describes a placental bed suturing without involvement of
      interventional radiology as well as ligation of deep pelvic vessels. The objective of this
      study is to assess the simplicity, safety and efficacy of this surgical technique in the
      management of PAS, with the intension to develop a simple, safe and effective alternative to
      hysterectomy.

      Surgical Procedure:

      After opening the abdomen, a transverse incision was given in the lower uterine segment after
      ascertaining the site of easy fetal access avoiding the placenta as far as possible. After
      the delivery of the baby, the uterus was exteriorized and routine uterotonics were given. The
      placenta was left in-situ and incision margins were held with Green-armitage forceps to
      minimize bleeding.

      The urinary bladder was dissected away to allow suturing on the inner side of the lower
      uterine segment. Uterine arteries were ligated on both sides and any blood vessels on the way
      were secured immediately. The placenta was then removed completely.

      Within the puddle of blood, the ring of internal os was identified with the index and middle
      finger of one hand and held with Babcock forceps with the other hand. On the exposed inner
      surface of the LUS, suturing was started from the left corner of uterine incision, taking
      multiple half cm bites through half-thickness of the tissue at half cm intervals to reach the
      outer half of ring of the internal os. The suture was then tied and knot secured causing
      squeezing of uterine tissue. From here onwards similar sutures were placed continuously at 1
      cm distance till the right corner was reached, where the knot was secured. During suturing it
      was ensured that internal os remains patent. The continued pull on the suture caused the
      squeezing of the LUS and arrested bleeding from all sinuses present at the placental site. If
      the bleeding was seen on the posterior uterine wall, a similar suture was applied. It was
      started from the outer half of the posterior lip of the ring of the internal os and going up
      to the highest bleeding point on the posterior wall of the uterus, extending from the left to
      right end of the uterine incision.

      Any left over bleeding points were secured with separate hemostatic sutures, Routine closure
      of the uterus was performed in two layers as in the lower segment cesarean section.

      The hospital stay of the patients was 3-7 days. All patients were reviewed on 7th
      postoperative day and were inquired about the history of fever, abdominal pain and excessive
      vaginal bleeding. The character of vaginal discharge / lochia was noted and any urinary
      complaint recorded. Caesarean section wound was examined and stitches removed. Second follow
      up visit was at 6 weeks postpartum for similar assessment and record of lactation /
      menstruation status. Pelvic ultrasound was done on both visits to detect any pelvic organ
      abnormality and collection of blood or pus.
    

Intervention name(s): ACCSS
Intervention type(s): Procedure
Intervention description(s): A. Chohan Continuous Squeezing Suture (ACCSS)
Intervention model: Single Group Assignment
Intervention model description: Single Group
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Postpartum hemorrhage; Peripartum hysterectomy