Development and practical implementation of organ preservation surgery in case of placenta accreta in patients with a scar on the uterus
Comparative analysis of methods for preventing/stopping intraoperative hemorrhage during surgical delivery of patients with placenta accreta (temporary balloon-assisted occlusion of common iliac arteries, internal iliac artery ligation; uterine artery embolization - UAE) has shown that internal iliac artery ligation is not effective. UAE and especially balloon-assisted occlusion of common iliac arteries have demonstrated a significantly greater effect due to the temporary ‘devascularization’ of the uterine corpus. It has been proved that an innovative surgical technique - a lower segment Caesarean section (LSCS) significantly reduces intraoperative blood loss. The main purpose of an alternative uterus cut - anterior placenta previa preserving and bleeding absence before the child removal - has been achieved within all observations. LSCS has caused a significantly smaller (by 1.6 times) amount of intraoperative blood loss than the corporal one. Another innovative surgical technique is metroplasty. It entails removing placenta accreta areas from the uterus with subsequent restoration of the organ integrity.The authors have proved the necessity of autologous advance blood donation and hemodilution strategy, which was first implemented in Moscow Center for Family Planning and Reproduction, and after 2006 was used in all obstetric institutions in Moscow. This allowed reducing the number of blood donations up to 85% and additionally decreased transfusiological risks which is economically valuable as well.Improvement of diagnostic methods, operating techniques, hemostasis, blood volume redistribution and creating an algorithm on its basis has proved the possibility of implementing an organ-, life, health- and fertility preserving approach in cases of placenta accreta in patients with a scar on the uterus after cesarean section.The introduction of the enhanced principles of patient management with placenta accreta has significantly reduced the number of hysterectomies in Moscow (from 48 in 2007 to 8 in 2016), and during the last 2 years no patient with this complication has had a hysterectomy. 12 out of 85 patients who had deliveries in accordance with the developed algorithm, have realized their subsequent fertility.