Placenta accreta spectrum: maternal near miss

Abstract

Design: A randomized prospective surgical case series study Setting: antenatal and labor wards and operative theater at AL-Zahra maternity and pediatric teaching hospital at Al-Najaf city, Iraq (tertiary referral center). Participants: patients admitted through the reception room or outpatient clinic, 198 multiparous women in the third trimester ≥30 wk., all patients had a history of prior cesarean section and all cases with a diagnosis of placenta accreta by Doppler ultrasound and at the surgery. Aims and objectives: The present study was to find out maternal near miss inpatient with PAS which is the most dangerous complication of cesarean potentially leading to massive intrapartum hemorrhage and death especially in developing countries and to evaluate the relationship between repeated cesarean deliveries and subsequent development of placenta accrete spectrum and to compare different management strategies, the aim to reduce maternal mortality and morbidity associated with placenta accrete spectrum. Methods: The present prospective research was performed in the Department of Obstetrics and Gynaecology at A l-zahraa maternity and pediatric teaching hospital in Al Najaf, Iraq, from 1 January 2016 to 1 July 2020. This study involved 198 pregnant women with multiple cesarean sections 30 weeks who were prenatally diagnosed by Doppler ultrasound with placenta accrete spectrum and during surgery. The assessment also included if the cesarean section was performed electively or as an emergency, if th e need for hysterectomy was also considered, estimated blood loss during surgery, blood transfusion un its provided and procedures used to reduce bleeding, and reported information on intraoperative and po stoperative events. Maternal morbidity was also reported, including injuries to the urinary tract, ureteric injury, cesarean hysterectomy, and admission to the intensive care unit. Postoperative complications and hospital stay period was noted. Results: In these 4 years and 7 months period, among (104760) deliveries,(76550)Vaginal delivery and (28210) Caesarean Sectiononly198 cases classified as a near miss and met the diagnostic criteria of PAS. In total, 198 patients found Cesarean Hysterectomy performed in 67 cases out of 198 (33.8%). The rate of successful uterine preservation was high (66.2%), in uterine artery ligation 69 cases and internal iliac artery ligation in 8 cases, and 78 cases overseeing of the implantation site, and segmental uterine resection method in 41 cases and B-Lynch or other brace suturing 27cases, The maternal mortality rate was 0.5%(one case), 86 patients were scheduled for cesarean section and 113 patients were emergency cesarean cases owing to active bleeding or labor. The majority of patients presenting with placenta accreta belonged to age group more than 30years (73.2%) and Most of the patients were para 3-5 (59.6%). placenta accreta was the commonest of all(85.4%) and placenta percreta only in 4% but required a maximum number of blood transfusions (>8 units of blood on an average)bladder injury 66 cases, ureteric injury in 3 cases, all cases received intraoperative blood transfusion(198) postoperative blood transfusion in 129 cases, and ICU admission 2 cases, maternal deaths 1 case. In 5 (7.5%) patients total abdominal hysterectomy was performed while 62(92.5%) patients required a subtotal hysterectomy. Conclusion: The most common cause of maternal near miss was hemorrhage, mostly, intrapartum and post-partum hemorrhage incidence of PAS is increasing in recent years due to a higher cesarean section rate. It is increasing maternal morbidity such as excessive blood loss, massive transfusion, and hysterectomy, as well as perinatal morbidity. Antenatal diagnosis of PAS, preoperative counseling, planning, and multidisciplinary approach is necessary to reduce morbidity and mortality associated with PAS.