Jessica Papillon-Smith

FIGO consensus guidelines on placenta accreta spectrum disorders: Nonconservative surgical management,

For more than half a century after the first case series of placenta accreta was reported in 1937,1 the main and often only approach to management was a cesarean hysterectomy. This approach had the advantage of reducing the immediate risks of major hemorrhage associated with accreta placentation at a time when there was no naccess to blood transfusion. n nOver the last two decades, a variety of conservative options for the management of placenta accreta spectrum (PAS) disorders have evolved, each with varying rates of success, and peripartum and secondary complications.2–4 In a recent systematic review and meta- analysis of the outcome of placenta previa accreta diagnosed prenatally, 208 nout of 232 (89.7%) cases had an elective or emergent cesarean hysterectomy.5 As a result of a lack of randomized clinical trials, the optimal management of PAS disorders remains undefined and is determined by the capacity to diagnose invasive placentation preoperatively, local expertise, depth of villous invasion, and presenting symptoms.4 n nIn cases of high suspicion for PAS disorders during cesarean delivery, the majority of members of the Society for Maternal- Fetal Medicine (SMFM) proceed with hysterectomy and only 15%–32% report conservative management.6,7 n nHowever, there is considerable practice variation reported on aspects of care aroun delivery and hysterectomy by both obstetricians and maternal- fetal medicine nspecialists.6,8 n nThere is also wide variation between high- incomecountries and low- and middle- income countries owing to limited or no access to specialist care and essentia additiona treatment, such as blood products for transfusion. Hysterectomy remains the definitive surgical treatment for PAS disorders, especially for its invasive forms, and a primary elective cesarean hysterectomy is the safest and most practical option for most low- and middle- income countries where diagnostic, follow- up, and additional treatments are not available. In this chapter, we review the evidence- based data onnonconservative surgery (i.e. cesarean hysterectomy) for the management of PAS disorders.

Surgical Management Algorithm for Caesarean Scar Pregnancy

OBJECTIVESnTo report our experience with the management of Caesarean scar pregnancy (CSP) in the first trimester and to develop a unique treatment algorithm allowing physicians to customize their management based on clinical patient characteristics.nnnMETHODSnA retrospective review of 12 patients diagnosed with CSP between December 2012 and June 2016 was conducted in a tertiary care hospital in Toronto. All patients were diagnosed with CSP by transvaginal ultrasound using radiologic criteria. Patients were initially treated with an ultrasound-guided embryocidal injection when fetal heart activity was present. Next, patients underwent medical management with systemic multidose methotrexate (MTX) or surgical management using a laparoscopic or transcervical approach depending on CSP characteristics.nnnRESULTSnThe mean age at diagnosis was 35.6 years. The median number of previous CSs was one. The mean serum human chorionic gonadotropin level was 59 938 IU/L. The mean GA at presentation was 8+1 weeks. Two-thirds of patients received medical management with systemic multidose methotrexate. Of these, 50% required additional surgical treatment for the resolution of their CSP. One-third of patients underwent primary surgical treatment, resulting in complete resolution of CSP with no complications. Given the improved outcomes of surgical management in our series, we suggest a treatment algorithm that tailors the surgical approach, either laparoscopic or transcervical, to the characteristics of the CSP.nnnCONCLUSIONnThis constitutes the largest case series of CSP in Canada. Based on our results, CSP can be safely and effectively managed using the suggested surgical algorithm, which accounts for individual patient characteristics.