Interpretation
Uterus preserving procedures are considered by many obstetricians worldwide in women with PAS who are highly motivated to preserve their fertility. However, evidence on safety of these procedures is lacking and therefore, their use has not been endorsed by guidelines. An exception is “leaving the placenta in situ”, which is considered by RCOG and FIGO (the International Federation of Gynaecology and Obstetrics) (6, 10). Unfortunately, this approach is not commonly incorporated in practice due to concerns on complexity of postpartum care and possibility of serious complications (11). Uterus preserving procedures lack evidence-based support because data are derived from small studies, which usually present new or modified techniques rather than validation of a previous technique (12, 13). In addition, many of these studies do not define criteria of eligible women for uterus preserving procedures versus caesarean hysterectomy. Instead, they describe a successful technique that was performed on a selected group of patients. Paucity of cases of PAS is another barrier to validation of these studies. Therefore, available data are unlikely to draw a robust conclusion on these procedures. PAS-ID was created to permit studying of a large cohort of women with PAS, that were managed by centres that offer both caesarean hysterectomy and uterus preserving procedures. The study was conducted internationally to convey spectrum of the most widely accepted management options, which were noticeably consistent.
Although current results seem to support uterus preserving procedures as a safe alternative to caesarean hysterectomy in women interested in future fertility, this conclusion should be cautiously interpreted. The study was conducted in PAS referral centres, with long experience in uterus preserving procedures. Since these procedures are not recognized or no longer supported in many countries, experience is limited to some foreign obstetricians and similar results cannot be granted. Accordingly, uterus preserving procedures should only be considered in experienced centres. However, incorporation of uterus preservation training, as a part of a PAS training program, may be encouraged to rebuild and enhance this experience particularly in nationally recognized PAS centres. Interpretation of our results should also encompass patient selection. There were no strict criteria to define which women were considered for uterus preserving procedures in our cohort other than patient preference, and the decision was mainly made intraoperatively. Therefore, our results may be caused by appropriate obstetricians’ judgement in patient selection, which should be recapitulated into criteria to facilitate reproducibility of outcomes. Accordingly, we defined factors which would alter risk of massive blood loss to improve selection process. While relation of these factors to blood loss, such as parametrial invasion, are apparently justifiable, clinical judgement of these factors is necessary. For example, interventional radiology is probably associated with, rather than causative of, massive blood loss since selected women may be those at higher risk of significant intraoperative bleeding. Moreover, a previous study on women who were managed with uterus preserving procedures was conducted using the same database, to create a scoring system that predict success of these procedures. The MOGGE CON-PAS score comprises specific parameters that can be used to calculate probability of success of uterine preservation and can be used to improve selection process (14).