الفهرس 
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Abstract
Placenta accreta spectrum (PAS) is a challenging obstetric problem with significant morbidity and mortality. Cesarean hysterectomy has been the most commonly used approach to PAS. Conservative management of PAS is increasingly considered for women who are clinically stable and wish to preserve fertility. In the present study, we describe a novel surgical technique for conservative management of the uterus in women with PAS. In the first part of the study, We applied this procedure in sixty cases at women`s Health Hospital, tertiary hospital affiliated to Assiut university between September 2017 and January 2019. We included women who had high possibility of PAS based on preoperative ultrasound and Doppler evaluation, and who had the desire for uterine preservation and this part of study (the first sixty cases) was published in Proceeding of obstetrics and gynecology journal under the title of ”Placental pouch closure: a novel, safe and effective surgical procedure for conservative management of placenta accreta” . In the second part of study, we completed the duration of the study till the end of December 2020 and we had 150 cases of PAS operated using placental pouch closure technique and compared them to other conservative surgical techniques practiced at Women`s Health Hospital namely partial myometrial resection and transverse B-Lynch sutures for cases of PAS with the same inclusion criteria. The mean age of study patients was 30.64 years, mean BMI was 29.68 kg\m2, most patients were from rural areas (66%), and 38 % were illiterate. The mean duration of marriage was 9.98 years. Most patients 83.4% had parity two or more times, and 82.7% had two or more times cesarean sections. Moreover, 39.34% had previous setting of D&C and 6.6% had previous myomectomy. The mean gestational age at delivery was 37.01 weeks. Ultrasound and Doppler showed a possibility of high invasion in 53.3% of patients and low invasion in 46.7%. One hundred and forty-nine patients received regional anesthesia as a starting mode of anesthesia and three of them were converted to general anesthesia and only one patient received general anesthesia. Bladder adhesions were marked in 46% of patients. PAS was classified as stage two of FIGO in 60% of patients and stage three in 40%. The mean oxytocin used was 20.78 units. In our surgical technique, we waited for spontaneous separation of placenta before starting manual placental separation. We employed placental pouch closure, a modified type of hemostatic sutures in order to control placental site bleeding (suturing the myometrium invaded and split by the placenta accreta). Our surgical technique included the placement of a catheter in the cervical canal to avoid the risk of closing the cervical canal. The advantages of this procedure are that it is simple, easy, safe, effective, practical, and short (the mean duration of the operation was49.12 ±4.01 minutes). The mean blood loss 1555.37 ml, and the mean of transfused blood was 2.69 units. The mean pre-operative HB was 9.93 gm/dl, which decreased to 9.11 gm/dl postoperatively. Likewise, the mean pre-operative HCT was 30.8%, which decreased to 28.8% postoperatively. Regarding surgical complications, only 3 cases (2%) had bladder injury, and one patient only (0.8%) developed only one case (case No. 53 in our series she was gravida 4 para 3, had three living siblings, previous 3 cesarean sections) developed postoperative hypotension for which immediate laparotomy re-exploration which revealed significant vesico-uterine hematoma and immediate hysterectomy was done. She was admitted in the intensive care unit for two days where she received adequate blood replacement and discharged from the hospital three days later in a good general condition.. Only 2 % of patients needed referral to ICU The first case that was previously mentioned due to postoperative collapse and needed reexplanation and hysterectomy, the second case was cardiac patient (known to have attacks of arrhythmia in the form of supraventricular tacchycardia) and admitted to ICU to ensure smooth postoperative recoveryand the third case had postoperative dyspnea and diagnosed postoperatively to have covid infection based on chest CT scan and oropharyngeal swab. The great majority of patients (27.3%,66%) stayed in hospital post-operative for one to two days only signifies rapid post-operative recovery. Most patients (88%) stayed for one day in the hospital postoperative. When compared with other conservative surgical techniques for PAS currently practiced at our setting (bilateral uterine arteries ligation and wedge resection and transverse B-Lynch), Placental pouch closure technique was associated with statistically significant decrease in the referral to ICU (2% vs. 12%), decrease in post-hospital operative stay, decrease in bladder injury (2 % vs. 25%), blood transfusion in units (2.65 units vs 3.94 units) and better neonatal outcome (9.66 vs. 8.45). However, there was no statistically significant difference in the amount of blood loss between the two groups. In conclusion, our study presents a novel, standardized, effective, and safe 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. This could be a promising, safe, and effective surgical technique for uterine preservation in well-selected cases of PAS with the availability of facilities and expertise. Future studies should be conducted to evaluate the uterine cavity and the effect of the procedure on menstruation, fertility, and pregnancy outcomes. In this study presents a novel, standardized, effective, and safe 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. This could be a promising, safe, and effective surgical technique for uterine preservation in well-selected cases of PAS with the availability of facilities and expertise in grade 2 and 3 PAS. When compared with other conservative surgical techniques for PAS currently practiced at our setting (bilateral uterine arteries ligation and wedge resection and transverse B-Lynch), placental pouch closure technique was associated with statistically significant decrease maternal mortality and morbidity reflected by decrese in the referral to ICU, decrease in post-hospital operative stay, decrease in bladder injury, blood transfusion in units and better neonatal outcome. Placental pouch closure technique is considered to be as a promising, safe, and effective conservative surgical technique in well-selected cases of PAS with the availability of facilities and expertise when women desire fertility. An actively bleeding placenta accreta is a potential obstetric emergency; patients with active bleeding are hospitalized for close maternal and fetal monitoring including monitoring maternal blood loss, hemodynamic status and obtaining a complete blood count and sending blood for type and prepare cross-matched blood. Transfusion of blood products should be guided by the volume of blood loss overtime, changes in hemodynamic parameters, coagulation studies and hemoglobin level. Acute hemorrhage may not be associated with an immediate reduction in either blood pressure or hematocrit value in an otherwise healthy young patient. Thus, a low threshold for ordering a transfusion should be maintained in symptomatic patients. Uterus preserving surgical techniques for PAS cases should be managed by a surgical team who has experience in managing such cases. Prior to delivery, all women with placenta previa and their partners should have a counseling session about delivery. Indications for blood transfusion and hysterectomy should be reviewed, risks of bladder injuries and any additional plans should be clearly discussed and documented. Placenta accreta carry a higher risk of massive obstetric hemorrhage and hysterectomy. Delivery should be arranged in maternity unit with on-sit blood transfusion services and access to critical care. Regional anesthesia is considered safe and is associated with lower risks of hemorrhage than general anesthesia for cesarean delivery in women with placenta accreta. Heightening awareness for morbidly adherent placenta and providing reassurance to a woman who desires future fertility about the feasibility and applicability of placental pouch closure technique. Elective surgery for placenta accrete cases is associated with better maternal and neonatal outcomes.