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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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The Nausicaä suture in the management of the placenta accreta spectrum
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“Different strategies for conservative management of placenta accreta have been described in literature with different success rates [26]: mini invasive surgical treatments including uterine artery embolization [27], pelvic devascularisation [28], haemostatic sutures and balloon tamponed [29] and medical treatments by…”
MethodAlalfy, M., Hussein, E., Saber, W., Elsharkawy, M., Salama, S. H., Lasheen, Y. S., Elshafey, D., Taher, A. M., Farouk, D., Eltaieb, E. M. M., et al. (2019) · The Journal of Maternal-Fetal & Neonatal Medicine · doi:10.1080/14767058.2019.1678140 · Cited by 3
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“Hysterectomy is a definitive surgical treatment but is generally unsuitable for patients who desire to preserve fertility [4].”
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“The increased incidence of placenta accreta spectrum (PAS) in recent years has led to a growing understanding of its pathophysiology, 1–3 management strategies, 4,5 and notable improvements in pregnancy outcomes.”
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Vaidya, A. A., Panchbudhe, S. A., & Satia, M. (2017) · International Journal of Reproduction Contraception Obstetrics and Gynecology · doi:10.18203/2320-1770.ijrcog20172962 · Cited by 2
“Adherent placenta is a leading cause of maternal mortality world over accounting for 7-10%.(1) Adherent placenta are classified according to degree of invasion into the myometrium as placenta accreta, placenta increta”
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Listas de chequeo en obstetricia: ayudas cognitivas que salvan vidas
(FLASOG), A. L. S. I. O. (. C. D. M. M. F. F. L. D. S. D. O. Y. G., Pérez-Wulff, J., Daniel Márquez, C., Veroes, J. A., Muro, J. D., Lugo, C., Cortés, R., Vita, S. D., Araujo, K., Valencia, E., et al. (2020) · Revista de Obstetricia y Ginecología de Venezuela · doi:10.51288/00800406 · Cited by 2
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The Management of Placenta Accreta Spectrum Disorder
Donovan, B. M., & Zuckerwise, L. C. (2025) · Clinical Obstetrics & Gynecology · doi:10.1097/grf.0000000000000942 · Cited by 3
“163 Another technique for uterine preservation with placental resection, named the “ Triple P ” procedure, 145,146 involves perioperative localization of the upper placental edge, uterine devascularization by temporary occlusive balloons in the anterior division of the internal iliac arteries,…”
Madny, E. H., Atwa, K. A., Eid, A., & Farag, M. (2019) · Evidence Based Women s Health Journal · doi:10.21608/ebwhj.2019.28638 · Cited by 2
“Postpartum hemorrhage, a major complication of placenta previa[3] remains the most important cause of maternal mortality that approaches up to 14% in low income countries[4, 5].”
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“From August 2013 we decided to change our support and tested a multidisciplinary approach involving interventional radiologists-anesthesiologists and gynecologist surgeons [12].”
BackgroundIntraoperative Surgical Treatment of Undiagnosed Placenta Percreta
Molnar, A., Surányi, A., Jakó, M., & Németh, G. (2016) · Journal of Clinical Case Reports · doi:10.4172/2165-7920.1000910 · Cited by 2
“Adherent placenta is responsible for 7% to 10% of maternal mortality cases worldwide [1].”
BackgroundIsmail, S., & Azizullah, A. (2019) · Journal of Obstetric Anaesthesia and Critical Care · doi:10.4103/joacc.joacc_60_18 · Cited by 2
“[1,2] Morbidly adherent placenta accounts for 7‐10% of maternal mortality all over the world.[3] There have also been reported antenatal and postpartum complications of multiple gestations.”
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“described their procedure as triple P, and they reported remarkably low blood loss, ranging from 800 to 1500 mL per patient.(16)”
BackgroundEtiology and Management of Hemorrhage (Includes Accreta)
Stafford, I., Fox, K. A., Belfort, M. A., & Dildy, G. A. (2024) · Wiley eBooks · doi:10.1002/9781119820260.ch37 · Cited by 3
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“Other than the psychological impact of losing fertility, the procedure is associated with various complications such as infections, mechanical injuries to the genitourinary tract or bowel, neuropathies, vaginal cuff dehiscence, and maternal mortality [7,8].”
BackgroundAnesthetic Management of Placenta Accreta Spectrum Disorders: A Narrative Review
Alwatban, S., Ibrahim, L. M., Borges, B. C. R., & Miller, S. (2025) · Journal of Obstetric Anaesthesia and Critical Care · doi:10.4103/joacc.joacc_12_24 · Cited by 1
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“42 The procedure involves: 1.”
Stuck on you: The increasing challenge of morbidly adherent placenta in obstetric practice
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“E-mail: waiyoong@nhs.net DOI: 10.3109/01443615.2014.914482 non-separation with myometrial excision of the adherent placental segment has been shown to be a safe and less morbid alternative to elective peripartum hysterectomy (Palacios Jaraquemada et al. 2004; Chandraharan et al. 2012).”
BackgroundInfluentialSoučasný management abnormálně invazivní placenty – placenta accreta/increta/percreta
Koucký, M., Vráblíková, H., Černý, A., & Calda, P. (2016) · Cited by 1
Plazentabedingte Blutungen: Pathophysiologie, Diagnostik, Management
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“В свете вышеуказанных работ, а также принимая во внимание наш собственный опыт, вероятно, следует признать, что такой подход может быть оправдан, когда параллельно осуществляется эндоваскулярный блок на уровне общих подвздошных артерий [16] (так называемая методика Triple-P), а при отсутствии баллонной окклюзии рассчи…”
Case series on placenta accreta spectrum disorder and its management
Kumari, M., Patel, A. D., & Mashruwala, V. M. (2024) · International Journal of Reproduction Contraception Obstetrics and Gynecology · doi:10.18203/2320-1770.ijrcog20241781 · Cited by 1
Placenta percreta - an audacious experience
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“Another technique to preserve the uterus is the Triple P Procedure described by Chandraharan et al., 2012 [11].”
MethodUysal, G., OKÇU, N. T., ESKİMEZ, E., & Yılmaz, E. S. (2018) · The European Research Journal · doi:10.18621/eurj.382390 · Cited by 1
“Conservative managementsinclude; leaving the placenta in situ, hysteroscopic resection of retained adherent placenta, partial en bloc resection with embolization, the Triple P procedure which involves perioperative placental localization, pelvic devascularization, myometrial excision with non-seperated placenta and re…”
BackgroundMethodAlves, Á. L. L., da Silva, L. B., José, C. N. D. S., Ribeiro, B. R., Marques, A. M. D. S., & Filho, A. L. D. S. (2021) · Revista Médica de Minas Gerais · doi:10.5935/2238-3182.20210005 · Cited by 1
“7, 8, 9, 10 Este artigo apresenta um caso de placenta prévia central e increta tratado por meio de excisão miometrial segmentar com reconstrução da parede uterina.”
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Self-citationResektion der Plazentahaftstelle bei pathologischer Plazentainvasion
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Management of Urological Problems During Pregnancy: A Rationale and Strategy
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“The recently described “Triple-P procedure” involves 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—as a safe and…”
MethodPostpartum haemorrhage: what is the role of occlusion balloons?
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Self-citationUterus preserving treatment for abnormally invasive placenta
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“This group runs a regional placenta percreta service and proposed a new operation, The Triple P Procedure in 2012, (Chandraharan et al. 2012) for conservative surgical alternative to peripartum hysterectomy.”
BackgroundPlacenta percreta with iatrogenic megaureter: A maternal near miss case presentation
El-Agwany, A. S. (2017) · Reviews in vascular medicine · doi:10.1016/j.rvm.2017.04.006
Abnormal Invasive Placentation: Management and Complications
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“modified the original Triple-P; blood flow was reduced using tourniquet-placement instead of an internal-iliac-artery-balloon [2].”
MethodManagement of Abnormally Invasive Placenta: One-center Experience
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Plasenta perkretada çevresel rezeksiyon tekniği: bir fertilite koruyucu yaklaşım
Ekin, M., Kaya, C., Akyıldız, G., & Yaşar, L. (2017) · Zeynep Kamil Tıp Bülteni · doi:10.16948/zktipb.270306
Morbid Placental Adhesion –A Nightmare for Obstetricians
Begum, K. (2018) · Journal of Bangladesh College of Physicians and Surgeons · doi:10.3329/jbcps.v37i1.39280
Update on the Management of Morbid Adherent Placenta
Mazumder, A., Kabir, S., & Chowdhury, R. R. (2018) · Journal of Bangladesh College of Physicians and Surgeons · doi:10.3329/jbcps.v37i1.39289
Endovascular Balloon Occlusion in Obstetrical Hemorrhage
Fox, K. A. (2019) · Hot topics in acute care surgery and trauma · doi:10.1007/978-3-030-25341-7_11
Moudgil, S., Karpa, M., Devi, A., Verma, A., & Singh, K. (2020) · Indian Journal of Obstetrics and Gynecology Research · doi:10.18231/j.ijogr.2020.026
CONSERVATIVE TECHNIQUE OF PLACENTA ACCRETA SPECTRUM DISORDER (PASD)
DESYHANDAYANI, A. F. S., & Lubis, M. P. (2020) · International Journal of Current Pharmaceutical Research · doi:10.22159/ijcpr.2020v12i4.39094
“Then the balloon artery catheter was deflated 4 h after surgery [26].”
BackgroundMethodInfluentialChavan, S., Kutemate, P., Jebaraj, S., & Chavan, M. (2019) · Journal of Clinical Research in Anesthesiology · doi:10.33309/2639-8915.020105
Some aspects of the diagnosis and delivery in pregnant women with placenta accreta
Алексеевич, Л. А., & Aksenenko, V. (2020) · Medical news of the North Caucasus · doi:10.14300/mnnc.2020.15105
Techniek van de sectio caesarea
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“The “Triple-P procedure" put forward by British researchers Chandraharan E at al involves perioperative placental localization, pelvic devascularization, placental nonseparation with myometrial excision and reconstruction of the uterine wall, which can effectively preserve the uterus [4].”
MethodOrgan-preserving technologies and their effectiveness in patients with placenta accret
Kasimovna, D. Y., Babazhanova, S. D., & Lyubchich, A. S. (2020) · Obstetrics & Gynecology International Journal · doi:10.15406/ogij.2020.11.00525
Placenta Accreta Spectrum Disorders (Abnormal Invasion of the Placenta)
Carrillo, A. P., Hartopp, R., & Chandraharan, E. (2021) · Cambridge University Press eBooks · doi:10.1017/9781108790932.039
Self-citationPLACENTA ACCRETA IN PRIMIGRAVIDA AT PERIPHERAL SETUP – A RARE CASE REPORT
Chourey, N., RN, H., YADAV, M. S., Ghodke, S., & DOBI, S. (2021) · Asian Journal of Pharmaceutical and Clinical Research · doi:10.22159/ajpcr.2021.v14i6.42115
“of MAP [5], while other two types are less common and more severe form of MAP (placenta percreta and placenta increta).”
BackgroundPostpartum Hemorrhage Management and Role of Interventional Radiology Clinical Review
Naser, M., Naser, M. M., & Shehata, L. H. (2021) · International Journal of Progressive Sciences and Technologies · doi:10.52155/ijpsat.v27.2.3372
Zhao, H., Zhao, X., Chen, C., Tao, Y., & Guo, R. (2021) · Research Square · doi:10.21203/rs.3.rs-448583/v1
Fox, K. A., Belfort, M. A., & Dildy, G. A. (2017)
Management of Postpartum Haemorrhage
Leighton, E., & Chandraharan, E. (2021) · Cambridge University Press eBooks · doi:10.1017/9781108863049.058
Self-citationPlacenta Accreta Spectrum Disorders
Chandraharan, E., Arulkumaran, S., & Bhide, A. (2021) · Cambridge University Press eBooks · doi:10.1017/9781108863049.065
Self-citation10 Blutungen in der Schwangerschaft und während der Geburt
(2013) · De Gruyter eBooks · doi:10.1515/9783111710914.544
Jauniaux, E. R. M., Bhidé, A., & Wright, J. D. (2017) · Elsevier eBooks · doi:10.1016/b978-0-323-32108-2.00021-4
Management of Morbidly Adherent Placenta
Townsend, R., & Chandraharan, E. (2016) · Cambridge University Press eBooks · doi:10.1017/9781316144961.018
Self-citationKasi, A. D., & Chandraharan, E. (2016) · Cambridge University Press eBooks · doi:10.1017/9781316144961.017
Self-citationFrequency of Morbidly Adherent Placenta in Previous Scarred Uterus
Rizwan, N. (2021) · Applied Medical Research · doi:10.47363/amr/2021(8)211
Evidence-Based Management of Placenta Accreta Spectrum
Shazly, S. A., Radwan, A. A., AlMahdy, A. M., Ateya, M. I., Abouzeid, M. H., Sayed, E. G., & Elassall, G. M. (2022) · Springer eBooks · doi:10.1007/978-3-031-10347-6_11
Management des Placenta Accreta Spectrums
Paping, A., & Henrich, W. (2022) · Springer Reference Medizin · doi:10.1007/978-3-662-44369-9_74-2
(2021) · American Registry of PathologyArlington, Virginia eBooks · doi:10.55418/9781933477091-ch09
Management des Placenta Accreta Spectrums
Paping, A., & Henrich, W. (2022) · Springer Reference Medizin · doi:10.1007/978-3-662-44369-9_74-1
Su, S., Gong, Y., Wang, H., & Li, Y. (2022) · Open Journal of Obstetrics and Gynecology · doi:10.4236/ojog.2022.1210084
The Role of Vitamin D and Vitamin D Receptor in Placenta Accreta Spectrum: A Literature Review
Mirani, P., Lestari, P. M., Murti, K., Liberty, I. A., Kesty, C., Andrina, H., & Stevanny, B. (2023) · Indonesian Journal of Obstetrics & Gynecology Science · doi:10.24198/obgynia.v6i1.480
Yang, F., Xiong, M., Zhou, D., Liu, X., Li, S., Wu, Q., & Qin, F. (2023) · Research Square · doi:10.21203/rs.3.rs-2730328/v1
Update on Placenta Accreta Spectrum Diagnosis and Management Challenges
Alalfy, M., Elgazzar, A., Samy, A., & Said, A. (2023) · Current Women s Health Reviews · doi:10.2174/1573404820666230525121727
Placenta Percreta with Bladder Invasion: Case Report
Mahtate, M., Slaoui, A., Cherradi, S., Zeraidi, N., Lakhdar, A., Kharbach, A., & Baydada, A. (2023) · International Journal of Medical Case Reports and Reviews · doi:10.59657/2837-8172.brs.23.003
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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