Placental Pouch Closure (PPC) technique as a uterus sparing technique for management of placenta accreta spectrum, does Bilateral uterine artery ligation as an added step really add?

Placental Pouch Closure (PPC) technique as a uterus sparing technique for management of placenta accreta spectrum, does Bilateral uterine artery ligation as an added step really add? | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Placental Pouch Closure (PPC) technique as a uterus sparing technique for management of placenta accreta spectrum, does Bilateral uterine artery ligation as an added step really add? Kamal M. Zahran, Mohamed A. Shahat, Mostafa H. Abouzeid, Mohamed Zahran. Kamal This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4990486/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Placental pouch closure (Zahran’s) technique looks to be an attractive and effective surgical procedure for conservative management of placenta accreta. The major blood supply of the uterus comes from the uterine artery, so bilateral uterine artery ligation (UAL) before delivering of the placenta greatly decreases the blood loss. this study aimed to evaluate the effect of bilateral uterine artery ligation in decreasing the blood loss in placental pouch closure (PPC) technique and subsequently decreasing the associated maternal morbidity and mortality in women underwent PPC as a conservative surgery. Methods One-hundred thirty women attended women’s health hospital, Assiut University, Egypt with placenta accreta were randomly assigned into 2 groups. Group A included 65 women underwent the original PPC (Zahran’s) technique while group B included women underwent PPC and bilateral uterine artery ligation (modified technique). At 35 weeks, the management plan was discussed and determined by antepartum findings. The intra-operative blood loss was assessed by number of soaked towels and amount of blood at suction device. Results Intraoperative blood loss was significantly higher among women underwent original PPC in comparison to those women who underwent the modified PPC technique (1546.62 ± 212.51 vs. 1149.85 ± 130.54 (cc); p < 0.001). Women who underwent original PPC had significantly higher transfused packed red blood corpuscles (3.23 ± 0.67 vs. 1.77 ± 0.45 (cc); p < 0.001) and fresh frozen plasma (2.50 ± 0.55 vs. 1.50 ± 0.50 (cc); p < 0.001) in comparison to the other group. Conclusions the present study confirm that bilateral uterine artery ligation as an added step for PPC technique resulted in satisfactory decrease in the amount of intra-operative blood loss and subsequently the need for blood transfusion while still allowing for uterine preservation. Trail Registration Number: NCT05314595, submission date: March 11, 2022 placenta previa accreta placental pouch closure (PPC) uterine artery ligation Figures Figure 1 Figure 2 Figure 3 Background Placenta accreta spectrum (PAS) is a term that comprises abnormal placental invasion disorders of the uterine wall. According to the depth of invasion, it ranges from placental invasion in contact with myometrium (placenta accreta), into myometrium (placenta increta), or beyond myometrium (placenta percreta) [ 1 ]. PAS is an obstetric emergency that may be complicated by emergency hysterectomy, intraoperative surgical complications, massive transfusion, hemorrhagic shock, and even maternal death if not managed efficiently [ 2 ]. Previous cesarean deliveries, placenta previa and advanced maternal age are recognized as strong risk factors of PAS, all of which, have become more prevalent among contemporary population [ 3 , 4 ]. PAS is no longer a rare disorder in modern practice; the incidence of PAS has increased from approximately 1 in 30,000 deliveries before 1950 to 3 in 1000 deliveries in the current decade [ 5 ]. Currently, cesarean hysterectomy is the standard management of PAS [ 6 ]. Despite surgical risks, loss of uterine function, and psychological sequences, cesarean hysterectomy permits elective intervention under controlled settings to minimize blood loss. Although several uterus-conserving interventions have been proposed in management of PAS, their contribution to evidence-based practice is limited [ 7 ], and cesarean hysterectomy is endorsed as the standard intervention [ 8 ]. Cesarean hysterectomy, without attempting to remove the placenta, may reduce risk of significant bleeding and associated morbidity [ 9 ]. Leaving the placenta in situ is endorsed as an alternative in patients who refuse hysterectomy being the least invasive uterus-conserving intervention [ 7 , 10 ]. Nevertheless, the need for evidence-based conservative approaches for PAS cannot be underestimated particularly among women who are highly motivated to preserve their fertility. Despite limited evidence, an international survey indicates that 39% of obstetricians consider conservative management as the primary management. Notably, conservative management was inconsistent among respondents [ 1 ]. Placental pouch closure(Zahran’s technique) looks to be an attractive and effective surgical procedure for conservative management of placenta accreta [ 11 ]. In their series of 60 Placenta accreta cases, they reported that by using this technique, 59 out of the 60 enrolled cases, the uterus was successfully conserved and there were no cases of maternal mortality or severe morbidities related to the procedure. One of the important obstacles we faced in placental pouch closure technique is the considerable placental bed bleeding. Therefore, the technique required some modifications and additional steps to decrease blood loss, so bilateral uterine artery ligation was thought to be an essential step to overcome this problem. Major blood supply of the uterus comes from the uterine artery, so bilateral uterine artery ligation (UAL) before delivering of the placenta greatly decreasing the blood loss [ 12 ]. So, the aim of the study was to evaluate the effect of bilateral uterine artery ligation coupled with placental pouch closure (PPC) technique in decreasing the blood loss and subsequently decreasing the associated maternal morbidity and mortality in women who underwent PPC as a conservative technique. Methods This randomized clinical trial was performed at Woman’s Health University Hospital, Assiut, Egypt between August 2020 and August 2022. It was approved by the ethical committee of Assiut Faculty of Medicine on March 8, 2022, (#17101593) and was registered at The Clinicaltrials.gov (ID: NCT05314595). Women who attended women’s health hospital with gestational age (≥ 28 weeks) and diagnosed to be placenta accreta were recruited for the study. Preoperative counselling of all patients followed by written informed consent was taken from those who agreed to participate in the study. Patients coming in emergency condition with bleeding or in labor were excluded from this study. All eligible women underwent ultrasound assessment at 28 weeks and 32 weeks by a sonographer with expertise in diagnosing PAS using 2-D ultrasound and color Doppler. At 35 weeks, the management plan was discussed and determined by antepartum findings. Women who were eligible for conservative management was randomly assigned to be managed by either the original or the modified placental pouch closure technique. Zahran’s technique or the PPC technique includes pivotal steps starting from positioning the patients, applying aesthesia by a spinal intrathecal morphia then performing a Pfannenstiel incision. An incision is made in the uterus above the placental edge after dissection of the bladder. Finally, the fetus is delivered, and the uterus is exteriorized to make a clear surgical view, starting message of the uterus with IV oxytocin drips to minimize the bleeding and enable placental separation [ 11 ]. To minimize the blood loss, the placenta is separated from the top to the bottom considering the most adherent parts to separate at the end. A proper amount of compression is applied at the placental bed where the placenta fragments were separated using surgical towels. After localization of the cervix a catheter is lodged in an upward-downward direction enabling us to recognize the cervical canal and prevent the closure of the cervix while repairing the placental pouch. Spotting the pouch is one of the pivotal steps in the procedure then applying multiple Alli’s forceps to the edges. A cautious continuous running mass suturing is applied to close the pouch and the sutures are adjusted as needed. The regular closure technique of the laparotomy incision is preceded by a double-layer closure of the cesarean incision. While making sure that hemostasis is settled. (Fig. 1 , A and B). Video tape (1) demonstrating the crucial steps of the original placental pouch closure (PPC) technique. A. Dissection of the bladder, B. A transverse incision of the uterus above the placental edge, C. Exteriorization of the uterus after delivery of the fetus, D. Placental separation from the top to the bottom, E. Insertion of Foley’s catheter in the vagina through the cervix, F. Spotting the placental pouch and applying multiple Alli’s forceps to its edges, G. Closure the placental pouch by continuous running sutures, H. Double-layer closure of the cesarean incision, I. Closure of the visceral peritoneum. Blood loss is measured using the number of soaked towels and the amount of blood in suction machine. The Towels size we used were 30*30 cm, and the estimated blood loss was 100 cc. when it was fully saturated ( Fig. 2 ) [ 13 ]. Placental pouch. Figure 1 , A and B: the Placental pouch or bed is seen splitting the anterior uterine wall of the lower uterine segment into two layers, anterior and posterior with clear delineation of its boundaries. The cervix is seen posterior to the pouch with a Foley’s catheter inserted into the cervix from above downward pouch. Figure (2) Visual Guide for Determining Blood Loss for Three Different Sizes of Gauze. There was a 25% increase in total absorptive capacity when the gauze was dripping (supersaturated) and a 25% decrease in each category when the gauze was wet. In modified PPC, Bilateral uterine artery ligation was done after exteriorization of the uterus, and before placental delivery. A Polyglactin 910 number 0 mounted on a curved needle inserted into the cervix from anterior to posterior, medial to the uterine artery, 1.5-2 cm from the broad ligament and 1–2 cm below the CS incision, The same needle is reinserted from posterior to anterior lateral to the uterine artery through the broad ligament on the same side, The knot is then tied and secured. Video tape (2) demonstrating the crucial steps of bilateral uterine artery ligation. A. Exteriorization of the uterus, B. Dissection of the visceral peritoneum and exposure of Vesicouterine space, C. A curved needle inserted into the cervix from anterior to posterior, medial to the uterine artery, and below the CS incision, D. The same needle is reinserted from posterior to anterior lateral to the uterine artery through the broad ligament, E. The knot is tied and secured. Statistical analysis was performed by SPSS version 20 (USA). Categorical variables were expressed as frequency (percentage) and compared by Chi2 test while continuous data were expressed as mean and SD and compared by Student t test. Baseline and follow up hemoglobin level in each group was compared by paired t test. All calculated P values were 2-sided and P values less than 0.05 were considered statistically significant and the level of confidence was kept at 95%. To determine if the Student's t-test was appropriate for each variable, it's essential to check the normality of the data. The t-test assumes that the data are normally distributed. So Shapiro-Wilk Test was performed for each continuous variable. If the p-value is greater than 0.05, the data are considered normally distributed. If the data are normally distributed (p-value > 0.05), the t-test is appropriate. If the data are not normally distributed (p-value < 0.05), consider using a non-parametric test such as the Mann-Whitney U test. Normally Distributed Variables (Student's t-test appropriate) in Age, Gestational age, Blood loss, Packed RBCs, Fresh frozen plasma, Haemoglobin (preoperative and postoperative) and Hospital stay. Non-Normally Distributed Variables (Consider non-parametric test) in Gravidity, Parity, Previous CS and Number of towels. Categorical Variables (Chi-squared or Fisher's exact test) in Bladder injury and admission to ICU Sample size was calculated using Epi- Info7. The previous meta-analysis reported that, percentage of peripartum hysterectomy in placenta accreta spectrum was 27.5% [ 14 ]. Based on this percentage and with a confidence limit of 5% and a confidence level of 80%, the minimum sample needed for the study is estimated to be 130 patients divided into two groups. Group A included 65 cases managed by the original PPC technique and Group B managed by the modified technique. Figure: 3 , Flowchart of the study. Results This study comprised 130 patients divided into two groups according to the intervention either the original PPC (Zahran’s) technique or the modified PPC technique. There was no statistically significant difference between both groups regarding baseline and obstetric data as shown in Table 1 . Two patients of the PPC and another 4 (6.2%) patients of the other group were hypertensive. Only one patient in the study had a history of pelvic surgery for endometriosis. The mean the mean gestational age at delivery was 35.56 ± 2.33 weeks in the original group vs. 34.01 ± 3.03 in the modified group. This difference was statistically insignificant. Table 1 Baseline and obstetric data among the studied groups. PPC group (n = 65) Modified PPC group (n = 65) P value Age (years) Mean ± SD 30.47 ± 6.29 30.97 ± 5.27 0.62 Gravidity Mean (CI) 4 (2–8) 5 (1–14) 0.06 Parity Mean (CI) 3 (1–7) 4 (0–8) 0.21 Previous CS Mean (CI) 3 (1–6) 3 (0–7) 0.17 Gestational age (weeks) Mean ± SD 35.56 ± 2.33 34.01 ± 3.03 0.11 CS: Cesarean Section. SD: Standard Deviation PPC: Placental Pouch Closure. CI: Confidence interval Table 2 . shows Intraoperative blood loss and complications in the studied groups. Intraoperative blood loss was statistically higher among original PPC in comparison to the modified technique (1546.62 ± 212.51 vs. 1149.85 ± 130.54 (cc); p < 0.001), this difference was statistically significant. There was a statistically insignificant difference between both groups as regard frequency of bladder injury in favor of modified technique (18 (27.7%) vs. 10 (15.4%); p = 0.06). Table 2 Intraoperative FIGO clinical grading, blood loss and complications in the studied groups. PPC group (n = 65) Modified PPC group (n = 65) P value FIGO clinical grading Grade 1 Grade 2 Grade 3 44 (67.6%) 16 (24.6%) 5 (7.6%) 41 (63%) 17 (26.15%) 7 (10.7%) 0.2 blood loss (cc) Mean ± SD 1546.62 ± 212.51 1149.85 ± 130.54 < 0.001 * Number of towels (Mean) 900 (13.8) 661 (10.16) Bladder injury n (%) 18 (27.7%) 10 (15.4%) 0.06 Blood transfusion (Units) Packed RBCs Mean ± SD 3.23 ± 0.67 1.77 ± 0.45 < 0.001 * Fresh frozen plasma Mean ± SD 2.50 ± 0.55 1.50 ± 0.50 < 0.001 * CC: Cubic centimeter. * Statistically Significant. SD: Standard Deviation PPC: Placental Pouch Closure. Patients who underwent original PPC had significantly higher transfused packed red blood corpuscles (3.23 ± 0.67 vs. 1.77 ± 0.45 (cc); p < 0.001) and fresh frozen plasma (2.50 ± 0.55 vs. 1.50 ± 0.50 (cc); p < 0.001) in comparison to the other group. Regarding the hemoglobin level, there were no difference in baseline Haemoglobin between both groups, (10.92 ± 0.61 vs. 10.77 ± 0.78 (mg/dl); p = 0.25) but postoperatively, haemoglobin level was significantly higher among patients underwent modified technique (9.85 ± 0.57 vs. 9.09 ± 0.75. (mg/dl); p < 0.001) in comparison to original PPC group. In each separate group, follow up haemoglobin was significantly lower in comparison to baseline level ( p < 0.001). Table 3 . Table 3 Haemoglobin (baseline and follow up), Hospital stay and admission to ICU in the studied groups. PPC group (n = 65) Modified PPC group (n = 65) P value Haemoglobin (mg/dl) Baseline (preoperative) Mean ± SD 10.92 ± 0.61 10.77 ± 0.78 0.25 Follow up (postoperative) Mean ± SD 9.09 ± 0.75 9.85 ± 0.57 < 0.001* Hospital stay (days) Mean ± SD 2.33 ± 0.50 2.10 ± 0.87 0.06 Admission to ICU n (%) 10 (15.4%) 3 (4.6%) 0.03 *Statistically Significant. Ten (15.4%) patients from the original PPC group and 3 (4.6%) patients of the modified PPC technique were admitted to ICU for follow up. There was no difference in the neonatal outcome in both groups. Patients who underwent PPC had statistically insignificantly longer hospital stay in comparison to the other group (2.33 ± 0.50 vs. 2.10 ± 0.87 (day); p = 0.06), Table 3 . Discussion Obstetric haemorrhage was the leading cause of maternal mortality, maternal mortality ratio (MMR) in Women’s Health Hospital of Assiut University in 2012 it was alarmingly high (225/ 100,000) and even after exclusion of referred cases it was 100.5/100,000. Therefore, measures to prevent and manage obstetric hemorrhage in PAS are important to reduce associated mortality and morbidity in Egypt [ 15 ]. In this study, we assessed the uterine artery ligation as an added step for PPC technique aiming for reducing intraoperative blood loss in patients with placenta accreta. PPC whether original or modified was feasible and successful in all cases. The added step showed significant effect on intraoperative blood loss: P value < 0.001 with mean of 1546.62 ± 212.51 vs. 1149.85 ± 130.54 ml in modified group and the mean blood transfused in units with packed RBCs was 3.23 ± 0.67 Vs 1.77 ± 0.45 and with FFP was 2.50 ± 0.55 Vs 1.50 ± 0.50. The main goals of conservative management of PAS are to decrease severe maternal morbidity related to the placental disease, especially the amount of blood loss (in turn, this decreases the risk of massive transfusion and coagulopathy as well as operative injury, mainly bladder and ureteral injury, and its potential consequences such as Vesicouterine fistula) and attempt to preserve the option of future pregnancies [ 10 ]. in the present study, we always waited for spontaneous separation of placenta after administration of ecobolics, Manual removal of the adherent or invasive parts at the end helps decrease bleeding without any bladder or ureteric injuries. This coincides with the logistic of our technique "placental pouch closure" as it begins with a careful, meticulous, and downward dissection of the bladder from the uterus before incising the uterus then bilateral ligation of uterine artery. The main idea of original PPC (Zahran’s) technique was based on our observation that, in many patients with PAS, there was a pouch at the site of placental attachment that represented the dead space left inside the myometrium after removal of the placenta (especially in cases of increta variants of PAS). This pouch represented the chief source of bleeding after the separation of the placenta. First, we had thought that the bottom of the pouch was the cervical canal. However, upon delineating the boundaries of this pouch using Allis’s forceps, we noticed that the cervical canal is placed posterior to this pouch. We looked for the placental pouch and delineated its boundaries by multiple Allis forceps. Therefore, we were able to close this bleeding bed with sutures without having to worry about the risk of closing the cervical canal [ 11 ]. The placental pouch closure (Zahran’s) technique with bilateral uterine artery ligation (the modified technique) is also advantageous compared with other surgical options. For example, ligation of internal iliac artery arteries is technically difficult, and most obstetricians are not well trained to perform it in an emergency situation which may lead to life-threatening complications. Embolization of uterine artery is very rarely to be available in the operating theater especially in developing countries which considered regional challenge. As the main concern of women undergo conservative management is to preserving fertility, bilateral UAL did not have any negative effects on ovarian reserve and subsequently on future fertility [ 15 ]. The risk of abnormal placentation might be increased following a uterine devascularization whatever the procedure used as a long-term complication [ 16 ]. Limitations of the study: One of the important limitations is that our study didn’t include follow-up data about the long-term effects of this modification on the future menstrual pattern, fertility potentials, and pregnancy outcomes. Future longitudinal studies are recommended to address these issues. Another limitation is the present study didn’t include the histological confirmation of PAS in the analysis. However, it is known that the absence of histological features indicative of PAS does not necessarily exclude such diagnosis, especially when high clinical suspicion is present. Another limitation of the study is that we didn’t assess the post-operative pain possibly attributed to bilateral uterine artery ligation. Points of strength: The present study also has some important strengths. The First, we are introducing a novel and effective surgical technique for conservative management of PAS that decreases maternal morbidity and mortality while still allowing for uterine preservation in women who desire future fertility. Another strong point in the study is the large number of patients enrolled in the study (130 patients managed by placental pouch closure (Zahran’s) technique with and without uterine artery ligation). Another strength in the study is that we used well-defined outcomes to measure the effectiveness and safety of our procedure. finally, regarding the generalizability of the technique, since we began this project, many of our obstetricians have mastered the technique, almost most of obstetricians at Women`s Health Hospital, Assiut University working by placental pouch technique and documenting it in the medical records. The learning curve of the technique has been consistently improving, as reflected by a gradual decrease in both the amount of blood lost and the need for blood transfusions over time and decrease the rate of hysterectomy and maternal mortality. In conclusion, the present study confirms that bilateral uterine artery ligation as an added step for Placental Pouch Closure technique result in dramatic decrease in the amount of intra-operative blood loss and subsequently the need for blood transfusion while still allowing for uterine preservation in women who desire future fertility. Another beneficial effect of this technique is decreasing the hospital stay and bladder injury. Long term follow up study is needed. Declarations Ethics approval and consent to participate. The study was approved by the ethical committee of Assiut Faculty of Medicine on March 8, 2022, (#17101593) and a written informed consent was taken from those who agreed to participate in the study. Consent for publication, “Not applicable.” Availability of data and material, the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests, "The authors declare that they have no competing interests." Funding, “Not applicable” Authors' contributions, KMZ. Participated in the design, writing the protocol of the study and helped to revise the data and draft the manuscript. MAS participated in its design and coordination and helped to draft the manuscript. MHA, collected the data and performed the statistical analysis and wrote the manuscript. All authors read and approved the final manuscript. Acknowledgements, not applicable Authors' information: prof. Kamal Zahran is the founder and team leader of placenta accreta task force at Women’s Health Hospital (WHH), Assiut University, Egypt. He created the placental pouch closure surgical technique and taught it to almost all the young generations at WHH. For many years, PPC became the standard surgical technique for conservative management of placenta accreta at WHH and the nearby university hospitals of Upper Egypt. References Cal M, Ayres-de‐Campos D, Jauniaux E. International survey of practices used in the diagnosis and management of placenta accreta spectrum disorders. Int J Gynecol Obstet. 2018;140(3):307–11. Ye M, et al. High-intensity focused ultrasound combined with hysteroscopic resection for the treatment of placenta accreta. BJOG: Int J Obstet Gynecol. 2017;124:71–7. Zeng C, et al. Placenta accreta spectrum disorder trends in the context of the universal two-child policy in China and the risk of hysterectomy. Int J Gynecol Obstet. 2018;140(3):312–8. Silver RM, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006;107(6):1226–32. Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol. 2012;207(1):14–29. Matsubara S, et al. Important surgical measures and techniques at cesarean hysterectomy for placenta previa accreta. Acta Obstet Gynecol Scand. 2013;92(4):372–7. Jauniaux E, et al. Placenta praevia and placenta accreta: diagnosis and management: green-top guideline no. 27a. BJOG. 2018;126(1):e1–48. Practice CoO. ACOG committee opinion. Placenta accreta. Number 266, January 2002. American college of obstetricians and gynecologists. Int J Gynaecol Obstet. 2002;77(1):77–8. Eller A, et al. Optimal management strategies for placenta accreta. BJOG: Int J Obstet Gynecol. 2009;116(5):648–54. Sentilhes L, et al. FIGO consensus guidelines on placenta accreta spectrum disorders: conservative management. Int J Gynecol Obstet. 2018;140(3):291–8. Zahran KM et al. Placental pouch closure: a novel, safe and effective surgical procedure for conservative management of placenta accreta. Proceedings in Obstetrics and Gynecology, 2020. 9(3). Lin J, Lin F, Zhang Y. Uterine artery ligation before placental delivery during caesarean in patients with placenta previa accreta. Medicine, 2019. 98(36). Algadiem EA et al. Blood loss estimation using gauze visual analogue. Trauma monthly, 2016. 21(2). Jauniaux E, et al. Prevalence and main outcomes of placenta accreta spectrum: a systematic review and meta-analysis. Am J Obstet Gynecol. 2019;221(3):208–18. Zahran KM, et al. Maternal mortality in an academic institution in Upper Egypt. J Obstet Gynaecol. 2017;37(3):315–9. Verit FF, et al. Does bilateral uterine artery ligation have negative effects on ovarian reserve markers and ovarian artery blood flow in women with postpartum hemorrhage? Clin Exp Reprod Med. 2019;46(1):30–5. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4990486","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":348836324,"identity":"bc9a8591-9f63-493b-b4f7-77989c3c25e7","order_by":0,"name":"Kamal M. 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Shahat","email":"","orcid":"","institution":"Assiut university","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"A.","lastName":"Shahat","suffix":""},{"id":348836326,"identity":"032b2a8b-b19e-4768-bc90-3e12da79dd07","order_by":2,"name":"Mostafa H. Abouzeid","email":"","orcid":"","institution":"Assiut university","correspondingAuthor":false,"prefix":"","firstName":"Mostafa","middleName":"H.","lastName":"Abouzeid","suffix":""},{"id":348836327,"identity":"6d1db21d-ef9c-4d66-a512-761fa487080c","order_by":3,"name":"Mohamed Zahran. Kamal","email":"","orcid":"","institution":"Assiut university","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Zahran.","lastName":"Kamal","suffix":""}],"badges":[],"createdAt":"2024-08-28 10:53:55","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4990486/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4990486/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":66947261,"identity":"92ab652e-2950-4904-8f62-871c686147cd","added_by":"auto","created_at":"2024-10-18 09:52:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1310991,"visible":true,"origin":"","legend":"\u003cp\u003eA and B: \u0026nbsp;the Placental pouch is seen splitting the uterine wall into two layers, anterior and posterior with clear delineation of its boundaries. the foley’s catheter is seen inserted into the cervix behind the pouch.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4990486/v1/f1075a6cdd18d14b1b82568b.png"},{"id":66947263,"identity":"95718c9d-d468-4c35-943a-2163fe132c77","added_by":"auto","created_at":"2024-10-18 09:52:43","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":185409,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVisual Guide for Determining Blood Loss for Three Different Sizes of Gauze. There was a 25% increase in total absorptive capacity when the gauze was dripping\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4990486/v1/603c09e7969be20843a7f71d.png"},{"id":66947262,"identity":"bcf11e56-57fe-405c-bdcc-a9c6f9e449a2","added_by":"auto","created_at":"2024-10-18 09:52:43","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":70467,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart of the study.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4990486/v1/5a4ffc5addf96e448a37409e.png"},{"id":66950315,"identity":"1fc56585-2f97-4305-a95c-9e8f7bf53974","added_by":"auto","created_at":"2024-10-18 10:08:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2243353,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4990486/v1/9e4844e8-fb33-45c8-baed-faa5997aa507.pdf"},{"id":66947266,"identity":"9c2746ba-c4d6-4ab1-b0cd-f1fcecaff395","added_by":"auto","created_at":"2024-10-18 09:52:47","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":354566327,"visible":true,"origin":"","legend":"","description":"","filename":"video1placentalpouchclosurePPCtechnique.mp4","url":"https://assets-eu.researchsquare.com/files/rs-4990486/v1/816a016eb72dec6774bcbbba.mp4"},{"id":66947265,"identity":"aeca77ed-17ab-42e6-abe7-8ab8184f7ec1","added_by":"auto","created_at":"2024-10-18 09:52:46","extension":"mp4","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":91337982,"visible":true,"origin":"","legend":"","description":"","filename":"video2uteriearteryligationinPAS.mp4","url":"https://assets-eu.researchsquare.com/files/rs-4990486/v1/3ec6cc04bf2271b8260022a1.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"Placental Pouch Closure (PPC) technique as a uterus sparing technique for management of placenta accreta spectrum, does Bilateral uterine artery ligation as an added step really add?","fulltext":[{"header":"Background","content":"\u003cp\u003ePlacenta accreta spectrum (PAS) is a term that comprises abnormal placental invasion disorders of the uterine wall. According to the depth of invasion, it ranges from placental invasion in contact with myometrium (placenta accreta), into myometrium (placenta increta), or beyond myometrium (placenta percreta) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePAS is an obstetric emergency that may be complicated by emergency hysterectomy, intraoperative surgical complications, massive transfusion, hemorrhagic shock, and even maternal death if not managed efficiently [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious cesarean deliveries, placenta previa and advanced maternal age are recognized as strong risk factors of PAS, all of which, have become more prevalent among contemporary population [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePAS is no longer a rare disorder in modern practice; the incidence of PAS has increased from approximately 1 in 30,000 deliveries before 1950 to 3 in 1000 deliveries in the current decade [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrently, cesarean hysterectomy is the standard management of PAS [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Despite surgical risks, loss of uterine function, and psychological sequences, cesarean hysterectomy permits elective intervention under controlled settings to minimize blood loss. Although several uterus-conserving interventions have been proposed in management of PAS, their contribution to evidence-based practice is limited [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and cesarean hysterectomy is endorsed as the standard intervention [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Cesarean hysterectomy, without attempting to remove the placenta, may reduce risk of significant bleeding and associated morbidity [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Leaving the placenta in situ is endorsed as an alternative in patients who refuse hysterectomy being the least invasive uterus-conserving intervention [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNevertheless, the need for evidence-based conservative approaches for PAS cannot be underestimated particularly among women who are highly motivated to preserve their fertility. Despite limited evidence, an international survey indicates that 39% of obstetricians consider conservative management as the primary management. Notably, conservative management was inconsistent among respondents [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePlacental pouch closure(Zahran\u0026rsquo;s technique) looks to be an attractive and effective surgical procedure for conservative management of placenta accreta [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In their series of 60 Placenta accreta cases, they reported that by using this technique, 59 out of the 60 enrolled cases, the uterus was successfully conserved and there were no cases of maternal mortality or severe morbidities related to the procedure.\u003c/p\u003e \u003cp\u003eOne of the important obstacles we faced in placental pouch closure technique is the considerable placental bed bleeding. Therefore, the technique required some modifications and additional steps to decrease blood loss, so bilateral uterine artery ligation was thought to be an essential step to overcome this problem.\u003c/p\u003e \u003cp\u003eMajor blood supply of the uterus comes from the uterine artery, so bilateral uterine artery ligation (UAL) before delivering of the placenta greatly decreasing the blood loss [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. So, the aim of the study was to evaluate the effect of bilateral uterine artery ligation coupled with placental pouch closure (PPC) technique in decreasing the blood loss and subsequently decreasing the associated maternal morbidity and mortality in women who underwent PPC as a conservative technique.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis randomized clinical trial was performed at Woman\u0026rsquo;s Health University Hospital, Assiut, Egypt between August 2020 and August 2022. It was approved by the ethical committee of Assiut Faculty of Medicine on March 8, 2022, (#17101593) and was registered at The Clinicaltrials.gov (ID: NCT05314595). Women who attended women\u0026rsquo;s health hospital with gestational age (\u0026ge;\u0026thinsp;28 weeks) and diagnosed to be placenta accreta were recruited for the study. Preoperative counselling of all patients followed by written informed consent was taken from those who agreed to participate in the study. Patients coming in emergency condition with bleeding or in labor were excluded from this study. All eligible women underwent ultrasound assessment at 28 weeks and 32 weeks by a sonographer with expertise in diagnosing PAS using 2-D ultrasound and color Doppler. At 35 weeks, the management plan was discussed and determined by antepartum findings.\u003c/p\u003e \u003cp\u003eWomen who were eligible for conservative management was randomly assigned to be managed by either the original or the modified placental pouch closure technique.\u003c/p\u003e \u003cp\u003eZahran\u0026rsquo;s technique or the PPC technique includes pivotal steps starting from positioning the patients, applying aesthesia by a spinal intrathecal morphia then performing a Pfannenstiel incision. An incision is made in the uterus above the placental edge after dissection of the bladder. Finally, the fetus is delivered, and the uterus is exteriorized to make a clear surgical view, starting message of the uterus with IV oxytocin drips to minimize the bleeding and enable placental separation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. To minimize the blood loss, the placenta is separated from the top to the bottom considering the most adherent parts to separate at the end. A proper amount of compression is applied at the placental bed where the placenta fragments were separated using surgical towels. After localization of the cervix a catheter is lodged in an upward-downward direction enabling us to recognize the cervical canal and prevent the closure of the cervix while repairing the placental pouch. Spotting the pouch is one of the pivotal steps in the procedure then applying multiple Alli\u0026rsquo;s forceps to the edges. A cautious continuous running mass suturing is applied to close the pouch and the sutures are adjusted as needed. The regular closure technique of the laparotomy incision is preceded by a double-layer closure of the cesarean incision. While making sure that hemostasis is settled. (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003e, A and B).\u003c/p\u003e \u003cp\u003e \u003cb\u003eVideo tape (1) demonstrating the crucial steps of the original placental pouch closure (PPC) technique.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eA. Dissection of the bladder, B. A transverse incision of the uterus above the placental edge, C. Exteriorization of the uterus after delivery of the fetus, D. Placental separation from the top to the bottom, E. Insertion of Foley\u0026rsquo;s catheter in the vagina through the cervix, F. Spotting the placental pouch and applying multiple Alli\u0026rsquo;s forceps to its edges, G. Closure the placental pouch by continuous running sutures, H. Double-layer closure of the cesarean incision, I. Closure of the visceral peritoneum.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eBlood loss is measured using the number of soaked towels and the amount of blood in suction machine. The Towels size we used were 30*30 cm, and the estimated blood loss was 100 cc. when it was fully saturated \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003ePlacental pouch.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003e, A \u003cb\u003eand B: the Placental pouch or bed is seen splitting the anterior uterine wall of the lower uterine segment into two layers, anterior and posterior with clear delineation of its boundaries. The cervix is seen posterior to the pouch with a Foley\u0026rsquo;s catheter inserted into the cervix from above downward pouch.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure (2) Visual Guide for Determining Blood Loss for Three Different Sizes of Gauze. There was a 25% increase in total absorptive capacity when the gauze was dripping (supersaturated) and a 25% decrease in each category when the gauze was wet.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn modified PPC, Bilateral uterine artery ligation was done after exteriorization of the uterus, and before placental delivery. A Polyglactin 910 number 0 mounted on a curved needle inserted into the cervix from anterior to posterior, medial to the uterine artery, 1.5-2 cm from the broad ligament and 1\u0026ndash;2 cm below the CS incision, The same needle is reinserted from posterior to anterior lateral to the uterine artery through the broad ligament on the same side, The knot is then tied and secured.\u003c/p\u003e \u003cp\u003e \u003cb\u003eVideo tape (2) demonstrating the crucial steps of bilateral uterine artery ligation.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eA. Exteriorization of the uterus, B. Dissection of the visceral peritoneum and exposure of Vesicouterine space, C. A curved needle inserted into the cervix from anterior to posterior, medial to the uterine artery, and below the CS incision, D. The same needle is reinserted from posterior to anterior lateral to the uterine artery through the broad ligament, E. The knot is tied and secured.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eStatistical analysis was performed by SPSS version 20 (USA). Categorical variables were expressed as frequency (percentage) and compared by Chi2 test while continuous data were expressed as mean and SD and compared by Student t test. Baseline and follow up hemoglobin level in each group was compared by paired t test. All calculated P values were 2-sided and P values less than 0.05 were considered statistically significant and the level of confidence was kept at 95%.\u003c/p\u003e \u003cp\u003eTo determine if the Student's t-test was appropriate for each variable, it's essential to check the normality of the data. The t-test assumes that the data are normally distributed. So Shapiro-Wilk Test was performed for each continuous variable. If the p-value is greater than 0.05, the data are considered normally distributed. If the data are normally distributed (p-value\u0026thinsp;\u0026gt;\u0026thinsp;0.05), the t-test is appropriate. If the data are not normally distributed (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05), consider using a non-parametric test such as the Mann-Whitney U test.\u003c/p\u003e \u003cp\u003eNormally Distributed Variables (Student's t-test appropriate) in Age, Gestational age, Blood loss, Packed RBCs, Fresh frozen plasma, Haemoglobin (preoperative and postoperative) and Hospital stay.\u003c/p\u003e \u003cp\u003eNon-Normally Distributed Variables (Consider non-parametric test) in Gravidity, Parity, Previous CS and Number of towels.\u003c/p\u003e \u003cp\u003eCategorical Variables (Chi-squared or Fisher's exact test) in Bladder injury and admission to ICU\u003c/p\u003e \u003cp\u003eSample size was calculated using Epi- Info7. The previous meta-analysis reported that, percentage of peripartum hysterectomy in placenta accreta spectrum was 27.5% [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Based on this percentage and with a confidence limit of 5% and a confidence level of 80%, the minimum sample needed for the study is estimated to be 130 patients divided into two groups. Group A included 65 cases managed by the original PPC technique and Group B managed by the modified technique. \u003cb\u003eFigure: 3\u003c/b\u003e, Flowchart of the study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis study comprised 130 patients divided into two groups according to the intervention either the original PPC (Zahran\u0026rsquo;s) technique or the modified PPC technique. There was no statistically significant difference between both groups regarding baseline and obstetric data as shown in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Two patients of the PPC and another 4 (6.2%) patients of the other group were hypertensive. Only one patient in the study had a history of pelvic surgery for endometriosis. The mean the mean gestational age at delivery was 35.56\u0026thinsp;\u0026plusmn;\u0026thinsp;2.33 weeks in the original group vs. 34.01\u0026thinsp;\u0026plusmn;\u0026thinsp;3.03 in the modified group. This difference was statistically insignificant.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline and obstetric data among the studied groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePPC group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModified PPC group (n\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.47\u0026thinsp;\u0026plusmn;\u0026thinsp;6.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.97\u0026thinsp;\u0026plusmn;\u0026thinsp;5.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGravidity\u003c/p\u003e \u003cp\u003eMean (CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (1\u0026ndash;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParity\u003c/p\u003e \u003cp\u003eMean (CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (0\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious CS\u003c/p\u003e \u003cp\u003eMean (CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (0\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational age (weeks)\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.56\u0026thinsp;\u0026plusmn;\u0026thinsp;2.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.01\u0026thinsp;\u0026plusmn;\u0026thinsp;3.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eCS: Cesarean Section. SD: Standard Deviation\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ePPC: Placental Pouch Closure.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eCI: Confidence interval\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. shows Intraoperative blood loss and complications in the studied groups. Intraoperative blood loss was statistically higher among original PPC in comparison to the modified technique (1546.62\u0026thinsp;\u0026plusmn;\u0026thinsp;212.51 vs. 1149.85\u0026thinsp;\u0026plusmn;\u0026thinsp;130.54 (cc); p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), this difference was statistically significant. There was a statistically insignificant difference between both groups as regard frequency of bladder injury in favor of modified technique (18 (27.7%) vs. 10 (15.4%); p\u0026thinsp;=\u0026thinsp;0.06).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraoperative FIGO clinical grading, blood loss and complications in the studied groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePPC group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModified PPC group (n\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFIGO clinical grading\u003c/p\u003e \u003cp\u003eGrade 1\u003c/p\u003e \u003cp\u003eGrade 2\u003c/p\u003e \u003cp\u003eGrade 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (67.6%)\u003c/p\u003e \u003cp\u003e16 (24.6%)\u003c/p\u003e \u003cp\u003e5 (7.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (63%)\u003c/p\u003e \u003cp\u003e17 (26.15%)\u003c/p\u003e \u003cp\u003e7 (10.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eblood loss (cc)\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1546.62\u0026thinsp;\u0026plusmn;\u0026thinsp;212.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1149.85\u0026thinsp;\u0026plusmn;\u0026thinsp;130.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001 *\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of towels\u003c/p\u003e \u003cp\u003e(Mean)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e900 (13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e661 (10.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBladder injury\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (27.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood transfusion (Units)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePacked RBCs\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001 *\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFresh frozen plasma\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001 *\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eCC: Cubic centimeter. * Statistically Significant. SD: Standard Deviation\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003ePPC: Placental Pouch Closure.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePatients who underwent original PPC had significantly higher transfused packed red blood corpuscles (3.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67 vs. 1.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45 (cc); \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and fresh frozen plasma (2.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55 vs. 1.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50 (cc); \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in comparison to the other group.\u003c/p\u003e \u003cp\u003eRegarding the hemoglobin level, there were no difference in baseline Haemoglobin between both groups, (10.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.61 vs. 10.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.78 (mg/dl); p\u0026thinsp;=\u0026thinsp;0.25) but postoperatively, haemoglobin level was significantly higher among patients underwent modified technique (9.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57 vs. 9.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75. (mg/dl); p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in comparison to original PPC group. In each separate group, follow up haemoglobin was significantly lower in comparison to baseline level (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHaemoglobin (baseline and follow up), Hospital stay and admission to ICU in the studied groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePPC group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModified PPC group (n\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaemoglobin (mg/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline (preoperative)\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow up (postoperative)\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital stay (days)\u003c/p\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdmission to ICU\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (4.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Statistically Significant.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTen (15.4%) patients from the original PPC group and 3 (4.6%) patients of the modified PPC technique were admitted to ICU for follow up. There was no difference in the neonatal outcome in both groups. Patients who underwent PPC had statistically insignificantly longer hospital stay in comparison to the other group (2.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50 vs. 2.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.87 (day); p\u0026thinsp;=\u0026thinsp;0.06), Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eObstetric haemorrhage was the leading cause of maternal mortality, maternal mortality ratio (MMR) in Women\u0026rsquo;s Health Hospital of Assiut University in 2012 it was alarmingly high (225/ 100,000) and even after exclusion of referred cases it was 100.5/100,000. Therefore, measures to prevent and manage obstetric hemorrhage in PAS are important to reduce associated mortality and morbidity in Egypt [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, we assessed the uterine artery ligation as an added step for PPC technique aiming for reducing intraoperative blood loss in patients with placenta accreta.\u003c/p\u003e \u003cp\u003ePPC whether original or modified was feasible and successful in all cases. The added step showed significant effect on intraoperative blood loss: P value\u0026thinsp;\u0026lt;\u0026thinsp;0.001 with mean of 1546.62\u0026thinsp;\u0026plusmn;\u0026thinsp;212.51 vs. 1149.85\u0026thinsp;\u0026plusmn;\u0026thinsp;130.54 ml in modified group and the mean blood transfused in units with packed RBCs was 3.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67 Vs 1.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45 and with FFP was 2.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55 Vs 1.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50.\u003c/p\u003e \u003cp\u003eThe main goals of conservative management of PAS are to decrease severe maternal morbidity related to the placental disease, especially the amount of blood loss (in turn, this decreases the risk of massive transfusion and coagulopathy as well as operative injury, mainly bladder and ureteral injury, and its potential consequences such as Vesicouterine fistula) and attempt to preserve the option of future pregnancies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ein the present study, we always waited for spontaneous separation of placenta after administration of ecobolics, Manual removal of the adherent or invasive parts at the end helps decrease bleeding without any bladder or ureteric injuries. This coincides with the logistic of our technique \"placental pouch closure\" as it begins with a careful, meticulous, and downward dissection of the bladder from the uterus before incising the uterus then bilateral ligation of uterine artery.\u003c/p\u003e \u003cp\u003eThe main idea of original PPC (Zahran\u0026rsquo;s) technique was based on our observation that, in many patients with PAS, there was a pouch at the site of placental attachment that represented the dead space left inside the myometrium after removal of the placenta (especially in cases of increta variants of PAS). This pouch represented the chief source of bleeding after the separation of the placenta. First, we had thought that the bottom of the pouch was the cervical canal. However, upon delineating the boundaries of this pouch using Allis\u0026rsquo;s forceps, we noticed that the cervical canal is placed posterior to this pouch. We looked for the placental pouch and delineated its boundaries by multiple Allis forceps. Therefore, we were able to close this bleeding bed with sutures without having to worry about the risk of closing the cervical canal [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe placental pouch closure (Zahran\u0026rsquo;s) technique with bilateral uterine artery ligation (the modified technique) is also advantageous compared with other surgical options. For example, ligation of internal iliac artery arteries is technically difficult, and most obstetricians are not well trained to perform it in an emergency situation which may lead to life-threatening complications. Embolization of uterine artery is very rarely to be available in the operating theater especially in developing countries which considered regional challenge.\u003c/p\u003e \u003cp\u003eAs the main concern of women undergo conservative management is to preserving fertility, bilateral UAL did not have any negative effects on ovarian reserve and subsequently on future fertility [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The risk of abnormal placentation might be increased following a uterine devascularization whatever the procedure used as a long-term complication [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eLimitations of the study:\u003c/h3\u003e\n\u003cp\u003eOne of the important limitations is that our study didn\u0026rsquo;t include follow-up data about the long-term effects of this modification on the future menstrual pattern, fertility potentials, and pregnancy outcomes. Future longitudinal studies are recommended to address these issues.\u003c/p\u003e \u003cp\u003eAnother limitation is the present study didn\u0026rsquo;t include the histological confirmation of PAS in the analysis. However, it is known that the absence of histological features indicative of PAS does not necessarily exclude such diagnosis, especially when high clinical suspicion is present.\u003c/p\u003e \u003cp\u003eAnother limitation of the study is that we didn\u0026rsquo;t assess the post-operative pain possibly attributed to bilateral uterine artery ligation.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePoints of strength:\u003c/h2\u003e \u003cp\u003eThe present study also has some important strengths. The First, we are introducing a novel and effective surgical technique for conservative management of PAS that decreases maternal morbidity and mortality while still allowing for uterine preservation in women who desire future fertility. Another strong point in the study is the large number of patients enrolled in the study (130 patients managed by placental pouch closure (Zahran\u0026rsquo;s) technique with and without uterine artery ligation). Another strength in the study is that we used well-defined outcomes to measure the effectiveness and safety of our procedure. finally, regarding the generalizability of the technique, since we began this project, many of our obstetricians have mastered the technique, almost most of obstetricians at Women`s Health Hospital, Assiut University working by placental pouch technique and documenting it in the medical records. The learning curve of the technique has been consistently improving, as reflected by a gradual decrease in both the amount of blood lost and the need for blood transfusions over time and decrease the rate of hysterectomy and maternal mortality.\u003c/p\u003e \u003cp\u003eIn conclusion, the present study confirms that bilateral uterine artery ligation as an added step for Placental Pouch Closure technique result in dramatic decrease in the amount of intra-operative blood loss and subsequently the need for blood transfusion while still allowing for uterine preservation in women who desire future fertility. Another beneficial effect of this technique is decreasing the hospital stay and bladder injury. Long term follow up study is needed.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was approved by the ethical committee of Assiut Faculty of Medicine on March 8, 2022, (#17101593) and a written informed consent was taken from those who agreed to participate in the study.\u003c/p\u003e\n\u003cp\u003eConsent for publication, \u0026ldquo;Not applicable.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Availability of data and material, the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests, \u0026quot;The authors declare that they have no competing interests.\u0026quot;\u003c/p\u003e\n\u003cp\u003eFunding, \u0026ldquo;Not applicable\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Authors\u0026apos; contributions, KMZ. Participated in the design, writing the protocol of the study and helped to revise the data and draft the manuscript. MAS participated in its design and coordination and helped to draft the manuscript. \u0026nbsp;MHA, collected the data and performed the statistical analysis and wrote the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements, not applicable\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; information: prof. Kamal Zahran is the founder and team leader of placenta accreta task force at Women\u0026rsquo;s Health Hospital (WHH), Assiut University, Egypt. He created the placental pouch closure surgical technique and taught it to almost all the young generations at WHH. \u0026nbsp;For many years, PPC became the standard surgical technique for conservative management of placenta accreta at WHH and the nearby university hospitals of Upper Egypt.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCal M, Ayres-de‐Campos D, Jauniaux E. International survey of practices used in the diagnosis and management of placenta accreta spectrum disorders. Int J Gynecol Obstet. 2018;140(3):307\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYe M, et al. High-intensity focused ultrasound combined with hysteroscopic resection for the treatment of placenta accreta. BJOG: Int J Obstet Gynecol. 2017;124:71\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZeng C, et al. Placenta accreta spectrum disorder trends in the context of the universal two-child policy in China and the risk of hysterectomy. Int J Gynecol Obstet. 2018;140(3):312\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilver RM, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006;107(6):1226\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTimor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol. 2012;207(1):14\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatsubara S, et al. Important surgical measures and techniques at cesarean hysterectomy for placenta previa accreta. Acta Obstet Gynecol Scand. 2013;92(4):372\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJauniaux E, et al. Placenta praevia and placenta accreta: diagnosis and management: green-top guideline no. 27a. BJOG. 2018;126(1):e1\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePractice CoO. ACOG committee opinion. Placenta accreta. Number 266, January 2002. American college of obstetricians and gynecologists. Int J Gynaecol Obstet. 2002;77(1):77\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEller A, et al. Optimal management strategies for placenta accreta. BJOG: Int J Obstet Gynecol. 2009;116(5):648\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSentilhes L, et al. FIGO consensus guidelines on placenta accreta spectrum disorders: conservative management. Int J Gynecol Obstet. 2018;140(3):291\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZahran KM et al. \u003cem\u003ePlacental pouch closure: a novel, safe and effective surgical procedure for conservative management of placenta accreta.\u003c/em\u003e Proceedings in Obstetrics and Gynecology, 2020. 9(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin J, Lin F, Zhang Y. Uterine artery ligation before placental delivery during caesarean in patients with placenta previa accreta. Medicine, 2019. 98(36).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlgadiem EA et al. Blood loss estimation using gauze visual analogue. Trauma monthly, 2016. 21(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJauniaux E, et al. Prevalence and main outcomes of placenta accreta spectrum: a systematic review and meta-analysis. Am J Obstet Gynecol. 2019;221(3):208\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZahran KM, et al. Maternal mortality in an academic institution in Upper Egypt. J Obstet Gynaecol. 2017;37(3):315\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerit FF, et al. Does bilateral uterine artery ligation have negative effects on ovarian reserve markers and ovarian artery blood flow in women with postpartum hemorrhage? Clin Exp Reprod Med. 2019;46(1):30\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"placenta previa, accreta, placental pouch closure (PPC), uterine artery ligation","lastPublishedDoi":"10.21203/rs.3.rs-4990486/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4990486/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePlacental pouch closure (Zahran\u0026rsquo;s) technique looks to be an attractive and effective surgical procedure for conservative management of placenta accreta. The major blood supply of the uterus comes from the uterine artery, so bilateral uterine artery ligation (UAL) before delivering of the placenta greatly decreases the blood loss. this study aimed to evaluate the effect of bilateral uterine artery ligation in decreasing the blood loss in placental pouch closure (PPC) technique and subsequently decreasing the associated maternal morbidity and mortality in women underwent PPC as a conservative surgery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eOne-hundred thirty women attended women\u0026rsquo;s health hospital, Assiut University, Egypt with placenta accreta were randomly assigned into 2 groups. Group A included 65 women underwent the original PPC (Zahran\u0026rsquo;s) technique while group B included women underwent PPC and bilateral uterine artery ligation (modified technique). At 35 weeks, the management plan was discussed and determined by antepartum findings. The intra-operative blood loss was assessed by number of soaked towels and amount of blood at suction device.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIntraoperative blood loss was significantly higher among women underwent original PPC in comparison to those women who underwent the modified PPC technique (1546.62\u0026thinsp;\u0026plusmn;\u0026thinsp;212.51 vs. 1149.85\u0026thinsp;\u0026plusmn;\u0026thinsp;130.54 (cc); p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Women who underwent original PPC had significantly higher transfused packed red blood corpuscles (3.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67 vs. 1.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45 (cc); \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and fresh frozen plasma (2.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55 vs. 1.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50 (cc); \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in comparison to the other group.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ethe present study confirm that bilateral uterine artery ligation as an added step for PPC technique resulted in satisfactory decrease in the amount of intra-operative blood loss and subsequently the need for blood transfusion while still allowing for uterine preservation.\u003c/p\u003e\u003ch2\u003eTrail Registration Number:\u003c/h2\u003e \u003cp\u003eNCT05314595, submission date: March 11, 2022\u003c/p\u003e","manuscriptTitle":"Placental Pouch Closure (PPC) technique as a uterus sparing technique for management of placenta accreta spectrum, does Bilateral uterine artery ligation as an added step really add?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-18 09:52:38","doi":"10.21203/rs.3.rs-4990486/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"efc76d23-7ef4-44d9-bfc9-37ac84941203","owner":[],"postedDate":"October 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-18T09:52:41+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-18 09:52:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4990486","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4990486","identity":"rs-4990486","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}