Placenta accreta spectrum with severe morbidity: fibrosis associated with cervical-trigonal invasion

Figures & data

Table 1. PAS patients’ clinical characteristics and surgical management results according to the possibility for complete lower vesical-uterine dissection n = 337.

	Group 1 (PAS type 1, 2U+, 3). n = 305	Group 2 (PAS type 4). n = 32	p Value
Gestational age (weeks)*	35(35–36)	34(31–35)	.06
Number of previous cesarean sections*	1(1–2)	1(1–2)	.4106
Previous dilation and curettage. N (%)	94(30.8)	8(25)	.467
Operative time (minutes)*	80(60–185)	240(102–275)	<.0001
Total hysterectomy. N (%)	104(34.1)	17(53.1)	.03
Modified subtotal hysterectomy. N (%)	1(0.3)	15 (46.9)	<.0001
One step conservative surgery^a. N (%)	201(65.9)	0	<.0001
Percreta. N (%)	90(29.5)	32(100)	<.0001
Increta. N (%)	70(22.9)	0
Acreta. N (%)	145(47.54)	0
Operative bleeding (mL)*	1500(1000–2000)	2500(1800–2975)	<.0001
Cystotomy. N (%)	60(19.7)	15(46.9)	<.0001
Ureteral injury. N (%)	7(2.3)	2(6.2)	.188
Vesicovaginal fistula. N (%)	4(1.3)	1(3.1)	.397
Requirement of proximal arterial control^b. N (%)	59(19.3)	28(87.5)	<.0001
Aortic/common iliac artery occlusion or clamping time (minutes)*	24(19–30)	75(48–130)	<.0001
Pelvic tamponade requirement. N (%)	9(2.9)	3(9.4)	.095
Requirement of relaparotomy. N (%)	19(6.3)	6(18.7)	.022
Transfusion RBCs. N (%)	169(55.4)	30(93.7)	<.0001
RBCs transfused*	2(2–4)	4(3–4.2)	<.0001
Transfusion of more than 4 RBCs. N (%)	19(6.2)	7(21.8)	.011
Any complication in surgery^3. N (%)	72(23.6)	16(50)	<.0001

PAS: placenta accreta spectrum; RBC: red blood cells unit.

*Median (interquartile range).

2U+: Upper parametrial invasion.

^aInvaded uterine segment and placenta “in block” resection + uterine repair.

^bAortic or common iliac artery occlusion.

^cUrinary tract injuries, the requirement of relaparotomy, more than 4 RBCU transfused.

Table 2. Clinical characteristics and surgical management results of patients with PAS type 3 and type 4.

	Group A (GA) PAS ^atype 3.	Group B (GB) PAS ^btype 4
	N = 90	N = 32
Operative time (minutes)*	60(60–120)	240(102–275)	.0349
Operative bleeding (mL)*	1500(1000–2000)	2500(1800–2975)	<.0001
Total hysterectomy. N (%)	44(48.9)	17(53.1)	.001
Modified subtotal hysterectomy. N (%)	1(1.1)	15(46.9)	.002
One step conservative surgery^3. N (%)	45(50)	0	.023
Cystotomy. N (%)	33(36.7)	15(46.9)	.001
Ureteral injury. N (%)	6(6.7)	2(6.2)	.096
Vesicovaginal fistula N (%)	2(2.2)	1(3.1)	.314
Requirement of proximal arterial control^4. N (%)	19(21.1)	28(87.5)	<.0001
Aortic/common iliac artery occlusion or clamping time (minutes)*	29(20–40)	75(48–130)	<.0001
Pelvic tamponade requirement	2(2.2)	3(9.4)	.176
Transfusion RBCs. N (%)	59(65.5)	30(93.7)	.139
RBCs transfused*	3(2–4)	4(3–4.2)	.423
Requirement of relaparotomy. N (%)	7(7.8)	6(18.7)	<.0001
Any complication in surgery^5. N (%)	41(45.5)	16(50)	<.0001

PAS: placenta accreta spectrum. RBC: red blood cells unit.

*Median (IQR).

^aPAS type 3: Placenta accreta spectrum affecting the lower part of the uterine segment and cervix, with a dissectible plane to separate both organs.

^bPAS type 4: Placenta accreta spectrum affecting the lower part of the uterine segment and cervix, with fibrosis between the uterus and the bladder and the impossibility of separating both organs.

^cInvaded uterine segment and placenta “in block” resection + uterine repair.

^dAortic or common iliac artery occlusion.

^eUrinary tract injuries, the requirement of relaparotomy, more than 4 RBCU transfused.

Table 3. Surgical characteristics of patients with PAS type 4^a according to the use of total hysterectomy or modified subtotal hysterectomy.

	Total hysterectomy. N = 17	Modified subtotal hysterectomy. N = 15	p-Value
Operative time (minutes)*	260(210–287)	140(90–240)	.004
Operative bleeding (mL)	2900(2150–5500)	1895(1300–2500)	.0057
Cystotomy N (%)	12(70.6)	3(20)	.004
Ureteral injury N (%)	1(5.9)	0	<.0001
Vesicovaginal fistula N (%)	1(5.9)	0	<.0001
Aortic/common iliac artery occlusion or clamping time (minutes)*	85(52–175)	60(40–115)	.0076
Pelvic tamponade requirement N (%)	3(17.6)	0	.038
Requirement of relaparotomy N (%)	6(35.3)	0	.229
Transfusion RBCs N (%)	17(100)	13(86.7)	.870
RBCs transfused*	4(3–6)	3(2.5–4)	.0125
Transfusion of more than 4 RBCs N (%)	7(41.2)	0	.019
Any complication in surgery^2 N (%)	14(82.3)	3(20)	.045

PAS: placenta accreta spectrum; RBC: red blood cells unit.

*Median (IQR).

^aPAS type 4: Placenta accreta spectrum affecting the lower part of the uterine segment and cervix, with firm adhesion between the uterus and the bladder (Fibrosis).

^bUrinary tract injuries, the requirement of relaparotomy, more than 4 RBCU transfused.