Results
Out of 797 women who were reviewed during data collection, 727 women
were eligible for the study. Five hundred ninety-two (81.43%) women
were managed by uterus preserving procedures, while 135 (18.56%)
underwent caesarean hysterectomy. Their mean ages were 32.99 ± 4.94 and
33.83 ± 4.73 years, respectively. Of women manged by uterus preserving
procedures, PAS type was accreta in 293 (49.49%) and 10 (7.41%) in
women who had caesarean hysterectomy. Placenta percreta was present 86
(63.70%) of women who had caesarean hysterectomy. In women managed by
caesarean hysterectomy, placental site was most commonly central,
covering the internal os in 78 (57.78%) women, while it was equally
localized anterior low, posterior low, or central in women who had
uterus preservation. Among women who were treated with uterus preserving
procedures, compression sutures were applied to 195 (32.94%) patients,
placental bed swing was done in 115 (19.43%) patients, vascular
ligation was performed in 89 (15.03%), and local uterine wall resection
was achieved in 33 (5.57%) patients. Uterus preservation was
unsuccessful in 20.1% of cases. Massive blood loss was reported in 129
(17.74%) of women. Patient characteristics, PAS features and management
approaches are summarized in Table 1.
Incidence of intraoperative complications were significantly higher
among women manged by caesarean hysterectomy. Specifically,
unintentional cystotomy occurred in 33 (24.44%) women in the
“caesarean hysterectomy” group compared to 41 (6.93%) in the “uterus
preservation” group (p < 0.0001). Otherwise, bowel and
ureteric injuries were comparable in both groups. PAS-associated massive
blood loss was more common in “caesarean hysterectomy” group compared
to “uterus preservation” group (43 [31.9%] vs. 86 [14.5%],
respectively; p < 0.0001). There was no significant
difference in the incidence of maternal admission to ICU between the 2
groups. Table 2 shows a summary of clinical outcomes of treatment
groups.
On univariate analysis, uterus preservation was associated with lower
risk of PAS-associated massive blood loss (unadjusted OR 0.36, 95% CI
0.24 - 0.56). After adjustment for significant or close-to-significance
variables, management approach was not associated with higher risk of
massive blood loss (aOR 1.71, 95% CI 0.78 - 3.81). Massive blood loss
was significantly associated with BMI (aOR 1.09, 95% CI 1.02 - 1.15),
gestational age at diagnosis (aOR 1.08, 95% CI 1.02 - 1.14),
preoperative haemoglobin (aOR 0.77, 95% CI 0.65 - 0.92), interventional
radiology (aOR 5.62, 95% CI 2.38 - 13.29), centrally located placenta
(aOR 2.28, 95% CI 1.25 - 4.18), diffuse versus localized invasion (aOR
3.15, 95% 1.61 - 6.16), incision away from the placenta (aOR 0.26, 95%
CI 0.13 - 0.51), bladder invasion (aOR 3.08, 95% CI 1.95 – 8.61),
parametrial invasion (aOR 5.37, 95% CI 1.21 – 23.79), and intrauterine
foetal death (aOR 10.25, 95% CI 1.51 – 69.34) (Table 3).