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The Triple-P procedure as a conservative surgical alternative to peripartum hysterectomy for placenta percreta
Abstract
The reported maternal mortality for morbidly adherent placenta ranges from 7% to 10% worldwide. Current treatment modalities for this potentially life-threatening condition include radical approaches such as elective peripartum hysterectomy with or without bowel/bladder resection or ureteric re-implantation (for placenta percreta infiltrating these organs), and conservative measures such as compression sutures with balloon tamponade and the placenta remaining in situ. However, both conservative and radical measures are associated with significant maternal morbidity and mortality. The present article describes the Triple-P procedure-which involves perioperative placental localization and delivery of the fetus via transverse uterine incision above the upper border of the placenta; pelvic devascularization; and placental non-separation with myometrial excision and reconstruction of the uterine wall-as a safe and effective alternative to conservative management or peripartum hysterectomy.
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“Although the UK and French studies were conducted during a comparable time period, allowing appropriate comparison, the evolution of knowledge, awareness and management of PAS across this time period may be a partial explanation for the differences in outcomes between the countries.”
From Placenta accreta spectrum – variations in clinical practice and maternal morbidity between the UK and France: a population‐based comparative study (2022) · cites this paper as [41]
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“Chanddraharan et al.21 have also described their uterus-sparing ‘Triple P procedure’.”
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“patients with central, anterior placenta percreta.(19) This procedure involves 3 steps: 1) 195 preoperative placental localization using transabdominal ultrasound to identify the 196 superior border of the placenta, with transverse hysterotomy planned 2-fingerbreadths 197 above the uppermost placental edge; 2) preoper…”
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“Women affected by AIP require a tailored surgical management which is commonly accomplished by fundal hysterotomy, followed by delivery of the fetus and subsequent elective hysterectomy, although recent evidences suggest that an appropriate hemostatic control can be achieved by conservative techniques aiming at preser…”
BackgroundNo. 383-Screening, Diagnosis, and Management of Placenta Accreta Spectrum Disorders
Hobson, S. R., Kingdom, J. C., Murji, A., Windrim, R. C., Carvalho, J. C. A., Singh, S. S., Ziegler, C., Birch, C., Frecker, E., Lim, K. I., et al. (2019) · Journal of Obstetrics and Gynaecology Canada · doi:10.1016/j.jogc.2018.12.004 · Cited by 112
“PAS: placenta accreta spectrum. delivery of the placenta or successful wedge resection (triple-P procedure 45 ) of focally invasive PAS disorders, postoperative recovery including extended use of an epidural infusion for 24 hours.”
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Self-citationConservative management of placenta percreta
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“Therapeutic UAE with subsequent manual placenta removal 1/72 (1)”
BackgroundInfluentialSurgical management of placenta accreta: to leave or remove the placenta?
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“This procedure reduces not only the operative time but also the need for ICU admission and overall hospital stay [46,47].”
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Updates on the management of placenta accreta spectrum
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Morbidly Adherent Placenta: Its Management and Maternal and Perinatal Outcome
Chaudhari, H. K., Shah, P. K., & D'Souza, N. (2016) · The Journal of Obstetrics and Gynecology of India · doi:10.1007/s13224-016-0923-x · Cited by 40
“The reported maternal mortality for morbidly adherent placenta ranges from 7 to 10 % worldwide [21].”
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Self-citationPerioperative management of undiagnosed placenta percreta: case report and management strategies
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“Introduction Adherent placenta accounts for 7%–10% of maternal mortality cases worldwide.(1) Placenta percreta is a rare type of adherent placenta that, when not diagnosed early, can lead to severe maternal morbidity.”
Gelany, S. E., Abdelraheim, A. R., Mohammed, M., El-Rab, M. T. G., Yousef, A. M., Ibrahim, E. M., & Khalifa, E. M. (2015) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-015-0731-9 · Cited by 34
“The maternal mortality in women with PA may reach as high as 7–10 % [3, 6–8].”
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“However, the term accreta is frequently preferred and used for the three types [3].”
BackgroundMethodInfluentialPlacenta accreta spectrum disorders clinical practice guidelines: A systematic review
Capannolo, G., D’Amico, A., Alameddine, S., Girolamo, R. D., Khalil, A. A., Calì, G., Trish, I. T., Coutinho, C. M., Herrera, M., Liberati, M., et al. (2023) · Journal of obstetrics and gynaecology research · doi:10.1111/jog.15544 · Cited by 33
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Effectiveness of segmental resection technique in the treatment of placenta accreta spectrum
Çırpan, T., Akdemir, A., Ökmen, F., Hortu, İ., Ekici, H., & İmamoğlu, M. (2019) · The Journal of Maternal-Fetal & Neonatal Medicine · doi:10.1080/14767058.2019.1702019 · Cited by 26
“defined the “Triple P” technique in four cases with anterior placenta percreta [14].”
MethodPaping, A., Bluth, A., Naimi, A. A., Gzirí, M. M., Kolak, M. L., Jaworowski, A. P., Huras, H. K., Morlando, M., Daskalakis, G., Pinto, P. V., et al. (2024) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/aogs.14855 · Cited by 25
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Self-citationConservative surgical approach: The Triple P procedure
Carrillo, A. P., & Chandraharan, E. (2020) · Best Practice & Research Clinical Obstetrics & Gynaecology · doi:10.1016/j.bpobgyn.2020.07.009 · Cited by 25
Self-citationZhao, X., Tao, Y., Du, Y., Zhao, L., Liu, C., Zhou, Y., & Peng, W. (2018) · Taiwanese Journal of Obstetrics and Gynecology · doi:10.1016/j.tjog.2018.02.017 · Cited by 25
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How to set up a regional specialist referral service for Placenta Accreta Spectrum (PAS) disorders?
Chandraharan, E., Hartopp, R., Thilaganathan, B., & Coutinho, C. M. (2020) · Best Practice & Research Clinical Obstetrics & Gynaecology · doi:10.1016/j.bpobgyn.2020.07.007 · Cited by 23
Self-citationRole of interventional radiology in placenta accreta spectrum (PAS) disorders
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“described their procedure as triple P in 2006, and they reported remarkably low blood loss, ranging from 800 to 1500mLper patient.(13) A follow-up cohort study by the same group showed a reduction in estimated blood loss, need for delayed hysterectomy, and length of inpatient stay compared with leaving the placenta in…”
MethodMatsuzaki, S., Yoshino, K., Kumasawa, K., Satou, N., Mimura, K., Kanagawa, T., Ueda, Y., & Kimura, T. (2014) · Clinical Case Reports · doi:10.1002/ccr3.108 · Cited by 21
Uterine conservation in placenta accrete spectrum (PAS) disorders: A retrospective case series
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Conservative management versus cesarean hysterectomy in patients with placenta increta or percreta
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“As demand for uterus-sparing surgery has increased, a number of conservative management options have been introduced (Allahdin et al. 2011; Chandraharan et al. 2012; Karaman et al. 2017; Pala et al. 2018).”
BackgroundPlacenta Accreta Spectrum: Conservative Management and Its Impact on Future Fertility
Abbas, R. A., & Nassar, A. H. (2020) · Maternal-Fetal Medicine · doi:10.1097/fm9.0000000000000077 · Cited by 20
“28,29 It consists of perioperative location of the upper border of the placenta pelvic devascularization by a pre-placed pelvic arterial balloon catheter in the anterior division of the internal iliac artery after delivery of the fetus in attempt to reduce the blood supply to the placenta, and in…”
BackgroundInfluentialPlacenta Accreta Spectrum: A Comprehensive Review of Guidelines
Giouleka, S., Tsakiridis, I. G., Chanioti, E.-R., Ladas, K., Liberis, A., Mamopoulos, A. M., Kalogiannidis, I. A., Athanasiadis, A. P., & Dagklis, T. (2024) · Obstetrical & Gynecological Survey · doi:10.1097/ogx.0000000000001274 · Cited by 20
Management of morbidly adherent placenta
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Self-citationConservative management of placental invasion anomalies with an intracavitary suture technique
Acar, A., Ercan, F., Pekin, A. T., Atılgan, A. E., Sayal, H. B., Balcı, O., & Görkemli, H. (2018) · International Journal of Gynecology & Obstetrics · doi:10.1002/ijgo.12593 · Cited by 18
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Management of abnormal invasive placenta in a low- and medium-resource setting
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Recognition and Management of Postpartum Hemorrhage
Mohamed, T. A. E. H., & Chandraharan, E. (2024) · Maternal-Fetal Medicine · doi:10.1097/fm9.0000000000000256 · Cited by 16
Self-citationSuccessful pregnancy outcome in woman with history of Triple‐P procedure for placenta percreta
Cauldwell, M., Chandraharan, E., Carrillo, A. P., & Pereira, S. (2017) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.17566 · Cited by 16
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““The triple P procedure” includes the following steps: preoperative placental topography to identify the upper edge of the placenta; use of occlusal balloons in the iliac arteries to reduce blood flow to the placental bed and resection of the placenta with the underlying adherent myometrium without separation, followe…”
BackgroundManagement of morbidly adherent placenta
Carrillo, A. P., & Chandraharan, E. (2016) · Obstetrics Gynaecology & Reproductive Medicine · doi:10.1016/j.ogrm.2016.07.006 · Cited by 14
Self-citationThe Use of Modified Triple-P Method with Adherent Placenta Long - Term Results
Цхай, В. Ф. (2017) · MOJ Women s Health · doi:10.15406/mojwh.2017.04.00079 · Cited by 14
Risk of hemorrhage in abnormally invasive placenta according to its management
Pinto, P. V., Machado, A. P., & Montenegro, N. A. M. D. M. (2016) · The Journal of Maternal-Fetal & Neonatal Medicine · doi:10.1080/14767058.2016.1240163 · Cited by 14
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“Their technique involved accurate placental localization, supra placental incision for delivery of the fetus and devascularization followed by lower segment resection [17].”
BackgroundMethodInfluentialPlacenta percreta in primigravida, an unsuspected situation
Rajkumar, B., Kumar, N. S., & Srinivasan, S. (2014) · International Journal of Reproduction Contraception Obstetrics and Gynecology · doi:10.5455/2320-1770.ijrcog20140349 · Cited by 13
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Peng, X., Chen, D., Xu, J., Liu, X., You, Y., & Peng, B. (2019) · Medicine · doi:10.1097/md.0000000000017742 · Cited by 13
“As for surgical technique, it primarily includes 1-step conservative surgery([19]) and the triple-P procedure,([18]) variations such as transverse uterine fundal incision([7]) and the stepwise approach.”
MethodTrends, characteristics, and outcomes of conservative management for placenta percreta
Youssefzadeh, A. C., Matsuzaki, S., Mandelbaum, R. S., Sangara, R. N., Bainvoll, L., Matsushima, K., Ouzounian, J. G., & Matsuo, K. (2022) · Archives of Gynecology and Obstetrics · doi:10.1007/s00404-021-06384-1 · Cited by 13
“A variety of strategies for local resection [11, 12, 17, 26, 35] and adjunctive procedures such as pelvic vasculature arterial balloon occlusion, uterine artery embolization, and use of adjuvant chemotherapeutic agents have been described [14, 36].”
BackgroundChandraharan, E. (2012) · Women s Health · doi:10.2217/whe.12.24 · Cited by 13
“The ‘Triple-P procedure’ for percreta has been developed as a conservative surgical alternative to peripartum hysterectomy [7].”
BackgroundSelf-citationEl Tahan, M., Carrillo, A. P., Moore, J., & Chandraharan, E. (2018) · Journal of Obstetrics and Gynaecology · doi:10.1080/01443615.2017.1334141 · Cited by 12
“The Triple-P Procedure is a new three-step conservative surgery for abnormal invasion of the placenta (Chandraharan et al. 2012).”
BackgroundSelf-citationHigh‐intensity focused ultrasound in management of placenta accreta spectrum: A systematic review
Elazeem, H. A. S. A., Saad, M. M., Ahmed, I., Sayed, E. G., AlMahdy, A. M., Atef, F., Elassall, G. M., Salah, M. A., Ali, A. K., Ragab, E. Y., et al. (2020) · International Journal of Gynecology & Obstetrics · doi:10.1002/ijgo.13391 · Cited by 12
Bertucci, E., Sileo, F. G., Grandi, G., Fenu, V., Cani, C., Mancini, L., Mataca, E., & Facchinetti, F. (2017) · Ultraschall in der Medizin - European Journal of Ultrasound · doi:10.1055/s-0043-119872 · Cited by 11
Patabendige, M., Sanjeewa, J. M. P., Amarasekara, A. M. A. K. G., & Herath, R. P. (2020) · Case Reports in Obstetrics and Gynecology · doi:10.1155/2020/9065342 · Cited by 10
“Other than expectant management with a placenta in situ approach, three further conservative approaches have been described in the literature, namely, extirpative technique (manual removal of the placenta), one-step conservative surgery (removal of the accreta area), and the Triple-P procedure (suturing around the acc…”
Uterine Sparing Techniques in Placenta Accreta
Shehata (2016) · Obstetrics & Gynecology International Journal · doi:10.15406/ogij.2016.05.00143 · Cited by 9
“It is considered a safe and effective alternative to conservative management or peripartum hysterectomy [38].”
BackgroundWildschut, H. I. J., Duvekot, J. J., Cook, J. R., Bacchus, L. J., Bewley, S., Creighton, S., Dear, J., Williams, D., Kilby, M. D., Crouch, N. S., et al. (2017) · Cambridge University Press eBooks · doi:10.1017/9781108349185 · Cited by 11
Postpartum haemorrhage and haematological management
Carrillo, A. P., & Chandraharan, E. (2014) · Obstetrics Gynaecology & Reproductive Medicine · doi:10.1016/j.ogrm.2014.07.004 · Cited by 9
Self-citationMousa, A., Elkhateb, I. T., Gaafar, H. M., Elsherbini, M. M., Mousa, H., Abdalla, M., Abdelbar, A., Shibli, D., majd, H. S., & Collins, S. (2023) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2023.03.026 · Cited by 8
Dawood, A. S., Elgergawy, A. E.-S., & Elhalwagy, A. (2018) · Journal of Gynecology Obstetrics and Human Reproduction · doi:10.1016/j.jogoh.2018.10.007 · Cited by 8
RetractedMazzon, I., Favilli, A., Grasso, M., Horvath, S., & Gerli, S. (2015) · The Journal of Maternal-Fetal & Neonatal Medicine · doi:10.3109/14767058.2015.1056147 · Cited by 8
“In some cases, a multiple approach was described [5].”
Undiagnosed placenta praevia percreta: A rare case report and review of management
Okunowo, A., Ohazurike, E. O., & Habeebu-Adeyemi, F. (2019) · Nigerian Postgraduate Medical Journal · doi:10.4103/npmj.npmj_191_18 · Cited by 10
Drăguşin, R. C., Șorop-Florea, M., Pătru, C. L., Zorilă, G. L., Marinas, C., Sorop, B., Căpitănescu, R., & Iliescu, D. G. (2018) · InTech eBooks · doi:10.5772/intechopen.75985 · Cited by 7
General Management Considerations for Placenta Accreta Spectrum
Einerson, B. D., Sandlin, A. T., Afshar, Y., Sharawi, N., Fox, K. A., Newton, J. M., Shainker, S. A., Pezeshkmehr, A. H., Carusi, D. A., & Moroz, L. A. (2023) · American Journal of Perinatology · doi:10.1055/s-0043-1761915 · Cited by 6
Zhao, H., Zhao, X., Chen, C., Tao, Y., & Guo, R. (2022) · Frontiers in Medicine · doi:10.3389/fmed.2022.839716 · Cited by 6
Abouda, H. S., Aloui, H., Azouz, E., Marzouk, S. B., Frikha, H., Hammami, R., Minjli, S., Hentati, R., Khila, M., Chanoufi, B., et al. (2024) · AJOG Global Reports · doi:10.1016/j.xagr.2024.100430 · Cited by 6
Docheva, N., Slutsky, E. D., Borella, N., Mason, R., Hook, J. W. V., & Seo-Patel, S. (2018) · Case Reports in Obstetrics and Gynecology · doi:10.1155/2018/8797643 · Cited by 6
“Chandraharan describes the surgery as follows: perioperative placental localization and delivery of the fetus via transverse uterine incision above the upper border of the placenta, pelvic devascularization, and placental nonseparation with myometrial excision and reconstruction of the uterine wall [34].”
Conservative Surgical Treatment of a Case of Placenta Accreta
Bıyık, İ., Keskin, F., & Keskin, E. U. (2018) · Revista Brasileira Ginecologia e Obstetrícia · doi:10.1055/s-0038-1668528 · Cited by 6
Maternal outcomes after different surgical techniques in placenta accreta: a prospective study
Kansouh, A., & Eldin, E. S. (2018) · Journal of Medicine in Scientific Research · doi:10.4103/jmisr.jmisr_77_18 · Cited by 6
Placenta Accreta Spectrum 2021: Roundtable Discussion
Fox, K. A., Cassady, C. I., Collins, S., Einerson, B. D., Hobson, S. R., Palacios-Jaraquemada, J. M., Shrivastava, V. K., & Lee, W. (2021) · Journal of Ultrasound in Medicine · doi:10.1002/jum.15685 · Cited by 6
Orsi, M., Ossola, M. W., Iurlaro, E., Perugino, G., Somigliana, E., & Ferrazzi, E. M. (2022) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2022.02.017 · Cited by 6
Bourrellier, L., Bensalem, R., Bersot, Y., Bertrand, A., Duminil, L., Malinovsky, J., Bonneau, S., Graesslin, O., & Raimond, É. (2017) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2017.06.031 · Cited by 6
“To avoid these complications some teams proposed the triple-P procedure ("perioperative placental placement, pelvic devascularization and non-placental separation and myometrial excision") to avoid haemostatic hysterectomy and long latency before placental regression (5).”
MethodPanaitescu, A. M., Peltecu, G. C., Botezatu, R., Iancu, G., & Gică, N. (2022) · Medicina · doi:10.3390/medicina58050678 · Cited by 5
Yalınkaya, A., & Oğlak, S. C. (2024) · Journal of Pregnancy · doi:10.1155/2024/9910316 · Cited by 5
“Also, some other studies employed transverse skin incision and after that a transverse uterine incision in cases with PAS [34, 35].”
ResultNo 383 – Dépistage, diagnostic et prise en charge des troubles du spectre du placenta accreta
Hobson, S. R., Kingdom, J. C., Murji, A., Windrim, R. C., Carvalho, J. C. A., Singh, S. S., Ziegler, C., Birch, C., Frecker, E., Lim, K. I., et al. (2019) · Journal of Obstetrics and Gynaecology Canada · doi:10.1016/j.jogc.2019.04.002 · Cited by 5
Gan, Y., Chen, Z., & Shi, Q. (2020) · Archives of Gynecology and Obstetrics · doi:10.1007/s00404-020-05625-z · Cited by 5
Metadata
- Authors
- Chandraharan, E., Rao, S., Belli, A.-M., & Arulkumaran, S.
- Affiliations
- St George’s University Hospitals NHS Foundation Trust (GB)
- Corresponding author
- Chandraharan, Edwin
- Venue
- International Journal of Gynecology & Obstetrics
- Publisher
- Wiley
- Published
- 2012-02-11
- Volume
- 117
- Issue
- 2
- Pages
- 191-194
- ISSN
- 0020-6695 (ISSN-L)
- 0020-7292
- OpenAlex
- W2006699354
- Cited by
- 221
- References
- 10
- Citations by year
- 2026: 13 · 2025: 11 · 2024: 15 · 2023: 17 · 2022: 16 · 2021: 18 · 2020: 25 · 2019: 24 · 2018: 17 · 2017: 23 · 2016: 15 · 2015: 6 · 2014: 10 · 2013: 6 · 2012: 5
- FWCI
- 7.53
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- International Journal of Gynecology & Obstetrics (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Maternal and fetal healthcare
- Health Sciences › Medicine › Obstetrics and Gynecology › Uterine Myomas and Treatments
- Health Sciences › Medicine › Hematology › Blood transfusion and management
- Keywords
- placenta percreta, placenta accreta spectrum, peripartum hysterectomy, conservative treatment, uterine reconstruction, maternal mortality, maternal morbidity
- MeSH terms
- Female, Postpartum Hemorrhage, Humans, Hysterectomy, Maternal Mortality, Myometrium, Placenta Accreta, Pregnancy, Uterus, Plastic Surgery Procedures, Delivery, Obstetric, Peripartum Period
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