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Abstract Objective We previously described a technique for repair of the myometrial defect at repeat Caesarean section which increases residual myometrial thickness thereby potentially reducing future niche-related complications. Here we describe how this technique can be modified for use for placenta accreta spectrum disorders, in line with emerging evidence that this is more a disorder of myometrial deficiency than morbid adherence. Design The surgical performance of peripartum hysterectomy was compared with that of the modified technique in all women having repeat Caesarean delivery for placenta accreta spectrum disorder in a tertiary unit in Singapore between December 2019 and October 2021. Methods Modification of the original technique involved the systematic delivery of the placenta starting from its most posterior attachment after uterine exteriorization. This is followed by the identification, mobilization, and apposition of the boundaries of myometrial defects as described previously. Results Ten women had Caesarean hysterectomy and ten had Caesarean section using the modified approach. Age and gestational age at delivery were similar for the two groups. Women in the modified technique group had had fewer prior Caesarean sections and had a lower body mass index. Operating time, estimated blood loss and need for transfusion were all lower in the myometrial repair group but without statistical significance. There were no visceral injuries in the repair group but there was one bladder injury in the hysterectomy group. Conclusion The modified approach provides an effective alternative to peripartum hysterectomy with favourable surgical profile and allows uterine conservation with restoration of myometrial thickness.

Abstract Background To investigate whether the existing surgical technique for uterine closure at repeat lower segment Caesarean section (LSCS) can be modified to achieve adequate residual myometrial thickness (RMT) to ensure scar integrity and reduce complications in future pregnancy. Methods Women with a significant scar defect at repeat LSCS had the anterior uterine wall closed by a single experienced obstetrician with a technique focused on recognition, mobilisation and apposition of the retracted myometrial edges at the boundary of the defect. This was aimed at anatomical restoration of the lower segment. The RMT at the scar area was assessed by postnatal pelvic ultrasound scan at three months. Results Thirty women with a history of at least one previous CS, incidentally found to have a large defect at operation underwent the technique with prior consent. A postnatal scan showed a mean residual myometrial thickness of 8.4 mm (SD ±1.3 mm; range 5.6–11.0 mm). The average operating time was 91 mins and the average blood loss 728 ml. Two women who underwent the repair have gone on to have a further uneventful CS. Conclusion This modified technique resulted in scan evidence of an RMT indicative of uterine wall stability postnatally and offers the potential for reducing the risk of rupture and placenta accreta spectrum (PAS) in future pregnancy.