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).