Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure.
OBJECTIVE
To evaluate patient outcomes and need for further interventions in women with a morbidly adherent placenta (MAP), before and after introduction of the Triple-P procedure involving placental non-separation, myometrial excision and reconstruction of the uterine wall.


METHODS
Between December 2007 and February 2014, 30 patients with MAP were treated at our center. In 2007, we instituted a policy of bilateral prophylactic occlusion balloon catheter placement in both internal iliac arteries followed by Cesarean section with non-placental separation and preservation of the uterus. In 2010, the surgical technique was modified and the Triple-P procedure introduced. As a result, 19 women in our study received the Triple-P protocol (study group) and 11 did not (control group). The quantity of blood replacement products, estimated blood loss, and necessity for uterine arterial embolization and/or hysterectomy were recorded retrospectively and compared between the two groups.


RESULTS
Placenta percreta was confirmed in six (54.5%) patients in the control group and 13 (68.4%) in the study group. Estimated mean blood loss during the procedure was lower in the study group than in the control group (1.70 L vs 2.17 L, respectively), but the difference was not statistically significant (P = 0.445). The risks of postpartum hemorrhage (PPH) and hysterectomy were statistically significantly lower in the study group (PPH, 54.5% vs 15.8%; P = 0.035; hysterectomy, 27.3% vs 0.0%; P = 0.045). As a consequence, there was a significant decrease in duration of inpatient stay in the study group (P = 0.044).


CONCLUSIONS
Introduction of the Triple-P procedure conveyed a significantly reduced rate of hysterectomy, PPH and duration of hospital stay in patients with MAP. .
Department of Radiology, St George's Hospital, London, UK.
M
M
Teixidor Viñas
Department of Radiology, St George's Hospital, London, UK.
A M
AM
Belli
Department of Obstetrics and Gynaecology, St George's Hospital, London, UK.
S
S
Arulkumaran
Department of Obstetrics and Gynaecology, St George's Hospital, London, UK.
E
E
Chandraharan
D000328:Adult; D002585:Cesarean Section / Q000379:methods; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000706:statistics & numerical data*; D010921:Placenta Accreta / Q000601:surgery*; D006473:Postpartum Hemorrhage / Q000209:etiology / Q000517:prevention & control*; D011247:Pregnancy; D012189:Retrospective Studies; D016896:Treatment Outcome; D014599:Uterus / Q000601:surgery*
hysterectomy prevention; massive postpartum hemorrhage; prophylactic percutaneous occlusion balloon catheter placement; uterine artery embolization