Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure.

OBJECTIVES: To evaluate patient outcomes and need for further interventions in women with a morbidly adherent placenta (MAP), before and after introduction of the Triple-P procedure involving placental non-separation, myometrial excision and reconstruction of the uterine wall. METHODS: Between December 2007 and February 2014, 30 patients with MAP were treated at our center. In 2007, we instituted a policy of bilateral prophylactic occlusion balloon catheter placement in both internal iliac arteries followed by Cesarean section with non-placental separation and preservation of the uterus. In 2010, the surgical technique was modified and the Triple-P procedure introduced. As a result, 19 women in our study received the Triple-P protocol (study group) and 11 did not (control group). The quantity of blood replacement products, estimated blood loss, and necessity for uterine arterial embolization and/or hysterectomy were recorded retrospectively and compared between the two groups. RESULTS: Placenta percreta was confirmed in six (54.5%) patients in the control group and 13 (68.4%) in the study group. Estimated mean blood loss during the procedure was lower in the study group than in the control group (1.70 L vs 2.17 L, respectively), but the difference was not statistically significant (P = 0.445). The risks of postpartum hemorrhage (PPH) and hysterectomy were statistically significantly lower in the study group (PPH, 54.5% vs 15.8%; P = 0.035; hysterectomy, 27.3% vs 0.0%; P = 0.045). As a consequence, there was a significant decrease in duration of inpatient stay in the study group (P = 0.044). CONCLUSION: Introduction of the Triple-P procedure conveyed a significantly reduced rate of hysterectomy, PPH and duration of hospital stay in patients with MAP. .

The role of interventional radiology in reducing haemorrhage and hysterectomy following caesarean section for morbidly adherent placenta.

AIM: To report experience of prophylactic occlusion balloon catheters (POBCs) in both internal iliac arteries before caesarean section, with or without embolization, to preserve the uterus and reduce haemorrhage. METHODS AND MATERIALS: Twenty-seven women diagnosed with morbidly adherent placenta (MAP) and with suspected placenta percreta underwent POBC placement before caesarean section. The balloons were inflated immediately after delivery of the baby. The patients' case notes were reviewed retrospectively for histological grading of MAP, blood loss, transfusion, requirement of uterine artery embolization (UAE), or hysterectomy, radiation dose, and infant or maternal morbidity and mortality. RESULTS: MAP was confirmed histologically as percreta in 17, accreta in eight, and increta in two women. Mean blood loss was 1.92 l (range 0.5-12 l). Postpartum haemorrhage (PPH) occurred in nine patients. Eight were referred for UAE, which was successful in six. Immediate peri-partum hysterectomy was performed in one patient. Three women in total required hysterectomy, two after recurrent haemorrhage after UAE. No foetal morbidity or mortality occurred. No maternal mortality occurred. There was one case of iliac artery thrombosis, which resolved with conservative therapy. CONCLUSION: POBC, with or without UAE, contributes to reduction of blood loss and preservation of the uterus in women with MAP.