Effectiveness of the Triple P Procedure and its modifications on reducing the blood loss and peripartum hysterectomy rates in women with Placenta Accreta Spectrum (PAS): a review of published literature.

Background: Placenta Accreta Spectrum (PAS) disorders has been reported to be associated with a maternal mortality rate of 7-10%, worldwide, and many women who survive, experience life changing morbidity. Triple P procedure (p- perioperative placental localization and incision on the myometrium above the upper border of the placenta; p- pelvic devascularisation; and p-placental non-separation and myometrial excision) was developed in 2010 as a novel conservative alternative to peripartum hysterectomy to avoid severe maternal morbidity and mortality). There have been several modifications to the original Triple P Procedure to achieve "pelvic devascularisation" based on locally available resources.

Objective: To determine the effectiveness of the Triple P Procedure and its modifications on reducing the blood loss and the rate of peripartum hysterectomy in women who were diagnosed to have placental accreta spectrum (PAS) by reviewing the published literature.

Materials and methods: PubMed, Embase and Google Scholar Search searches were made using "Triple P" and "Modified Triple P." Papers selected were assessed independently for content, data extraction and analysis. The following parameters were included for the analysis: total number of cases, total EBL, need for blood transfusion, injury to adjacent pelvic organs (urinary bladder, ureter, bowel), need for embolization, admission to intensive care unit (ICU), post-operative in-patient hospital stay, peripartum Hysterectomy, for "Modified" Triple P Procedure, the nature of the modification.Study characteristics were extracted using a predesigned data extraction table.

Results: The literature search identified 6 articles on the Triple P Procedure and 8 articles on the modified Triple P Procedure which were deemed eligible for analysis and comparison, based on the inclusion criteria. 75 patients had the Triple P procedure with an estimated mean blood loss of 2.31 L and a blood transfusion rate of 52%. The bladder injury rate was only 1.3%. None of the patients had a peripartum hysterectomy. Overall, 654 patients had the Modified Triple P procedure with an estimated mean blood loss of 1.4 L and a blood transfusion rate of 64.5%. The mean hospital stay was 3.86 days and 6.1% had a peripartum hysterectomy.

Conclusion: The Triple P Procedure and the Modified Triple P procedure are associated with lower estimated blood loss as compared to the reported rates with a peripartum hysterectomy. The Triple P Procedure was associated with lower rates of inadvertent injuries to the bladder and ureters as compared to the Modified Triple P Procedure and reported rates with peripartum hysterectomy. Both the Triple P and the Modified Triple P Procedure are associated with very low rates of peripartum hysterectomy (0% and 6.1%, respectively).