Abstract：
BACKGROUND: Placenta accreta spectrum (PAS) can lead to major peripartum morbidity. Appropriate management approaches depend on the clinical severity, each individual\'s preference, and the treating team\'s expertise. Peripartum hysterectomy is the most frequently used treatment option. However, it can impact psychological well-being and fertility. We investigated whether conservative treatment with focal resection or leaving the placenta in situ is associated with comparable or lower maternal morbidity than hysterectomy in centers of excellence within the International Society for placenta accreta spectrum (IS-PAS). Furthermore, a survey was conducted to explore potential barriers to conservative management in antenatal counseling and intraoperative decision-making.
METHODS: Confirmed PAS cases in the prospective IS-PAS database from 22 registered centers between January 2020 and June 2022 were included in the analysis. A separate online survey with 21 questions was answered by the IS-PAS center experts about indications, diagnostic criteria, patient counseling, surgical practice, changes from the preoperative treatment plan, and why conservative management may not be offered.
RESULTS: A total of 234 cases were included in the analysis: 186 women received hysterectomy and 38 women were treated by focal resection, and 10 by leaving the placenta in situ. Blood loss was lower in the focal resection group and in the placenta in situ group compared to the hysterectomy group (p = 0.04). 46.4% of the women initially planned for focal resection, and 35.7% of those initially planned for leaving the placenta in situ were ultimately treated by hysterectomy. Our survey showed that the IS-PAS centers preferred hysterectomy according to a woman\'s wishes (64%) and when they expected less blood loss and morbidity (41%). Eighteen percent of centers did not offer focal resection at all due to a lack of experience with this technique. Reasons for not offering to leave the placenta in situ were avoidance of unexpected reoperation (36%), puerperal infection (32%), or skepticism about the method (23%).
CONCLUSIONS: Uterus-preserving treatment strategies such as focal resection appear to be safe alternatives to peripartum hysterectomy. However, less than half of the IS-PAS centers perform them. Acceptance of conservative treatments could be increased by standardized criteria for their implementation and by systematic training for PAS experts.
METHODS: Confirmed PAS cases in the prospective IS-PAS database from 22 registered centers between January 2020 and June 2022 were included in the analysis. A separate online survey with 21 questions was answered by the IS-PAS center experts about indications, diagnostic criteria, patient counseling, surgical practice, changes from the preoperative treatment plan, and why conservative management may not be offered.
RESULTS: A total of 234 cases were included in the analysis: 186 women received hysterectomy and 38 women were treated by focal resection, and 10 by leaving the placenta in situ. Blood loss was lower in the focal resection group and in the placenta in situ group compared to the hysterectomy group (p = 0.04). 46.4% of the women initially planned for focal resection, and 35.7% of those initially planned for leaving the placenta in situ were ultimately treated by hysterectomy. Our survey showed that the IS-PAS centers preferred hysterectomy according to a woman\'s wishes (64%) and when they expected less blood loss and morbidity (41%). Eighteen percent of centers did not offer focal resection at all due to a lack of experience with this technique. Reasons for not offering to leave the placenta in situ were avoidance of unexpected reoperation (36%), puerperal infection (32%), or skepticism about the method (23%).
CONCLUSIONS: Uterus-preserving treatment strategies such as focal resection appear to be safe alternatives to peripartum hysterectomy. However, less than half of the IS-PAS centers perform them. Acceptance of conservative treatments could be increased by standardized criteria for their implementation and by systematic training for PAS experts.
摘要：
背景：胎盘植入谱（PAS）可导致主要的围产期发病率。适当的管理方法取决于临床严重程度，每个人的偏好，和治疗团队的专业知识。围产期子宫切除术是最常用的治疗选择。然而,它会影响心理健康和生育能力。我们调查了在国际胎盘植入谱（IS-PAS）的卓越中心中，采用局部切除术或将胎盘留在原位的保守治疗是否与子宫切除术的产妇发病率相当或更低。此外，本研究进行了一项调查,以探讨在产前咨询和术中决策中保守管理的潜在障碍.
方法：分析包括2020年1月至2022年6月来自22个注册中心的前瞻性IS-PAS数据库中确认的PAS病例。IS-PAS中心专家就适应症回答了另一项包含21个问题的在线调查，诊断标准,病人咨询,外科手术,术前治疗计划的变化，以及为什么不提供保守的管理。
结果：共234例纳入分析：186例妇女接受了子宫切除术，38例妇女接受了局部切除术，10把胎盘留在原位。与子宫切除术组相比，局灶性切除组和胎盘原位组的失血量较低（p=0.04）。46.4%的女性最初计划进行局灶性切除术,最初计划将胎盘留在原位的患者中，有35.7%最终通过子宫切除术治疗。我们的调查显示，IS-PAS中心根据女性的意愿（64％）以及预期失血和发病率较低的情况（41％）首选子宫切除术。由于缺乏这种技术的经验，18％的中心根本没有提供局灶性切除术。不提供离开胎盘原位的原因是避免意外的再次手术（36％），产褥期感染（32%），或对该方法持怀疑态度（23％）。
结论：保留子宫的治疗策略如局灶性切除术似乎是围产期子宫切除术的安全替代方案。然而,不到一半的IS-PAS中心执行这些操作。通过标准化的实施标准和对PAS专家的系统培训，可以增加对保守治疗的接受度。
方法：分析包括2020年1月至2022年6月来自22个注册中心的前瞻性IS-PAS数据库中确认的PAS病例。IS-PAS中心专家就适应症回答了另一项包含21个问题的在线调查，诊断标准,病人咨询,外科手术,术前治疗计划的变化，以及为什么不提供保守的管理。
结果：共234例纳入分析：186例妇女接受了子宫切除术，38例妇女接受了局部切除术，10把胎盘留在原位。与子宫切除术组相比，局灶性切除组和胎盘原位组的失血量较低（p=0.04）。46.4%的女性最初计划进行局灶性切除术,最初计划将胎盘留在原位的患者中，有35.7%最终通过子宫切除术治疗。我们的调查显示，IS-PAS中心根据女性的意愿（64％）以及预期失血和发病率较低的情况（41％）首选子宫切除术。由于缺乏这种技术的经验，18％的中心根本没有提供局灶性切除术。不提供离开胎盘原位的原因是避免意外的再次手术（36％），产褥期感染（32%），或对该方法持怀疑态度（23％）。
结论：保留子宫的治疗策略如局灶性切除术似乎是围产期子宫切除术的安全替代方案。然而,不到一半的IS-PAS中心执行这些操作。通过标准化的实施标准和对PAS专家的系统培训，可以增加对保守治疗的接受度。
