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Nausicaa suture for placenta accreta spectrum: further studies are needed

2018; Wiley; Volume: 126; Issue: 3 Linguagem: Inglês

10.1111/1471-0528.15422

1471-0528

Shigeki Matsubara,

Maternal and fetal healthcare

A new haemostatic suture for haemorrhage during caesarean section was introduced by Shih et al., ‘Nausicaa compression suture’ (BJOG 2019; 126:412–7). The bleeding point was determined from the hysterotomy window, and several transverse sutures were placed mainly in the uterine anterior wall. The uterus was preserved in all 68 patients. I have some concerns. First, 43 patients (63%) had placenta accreta spectrum (PAS) disorders. Various uterine compression sutures have been devised, many of which mainly target atonic bleeding (Matsubara et al. Acta Obstet Gynecol Scand 2013;92:378–85). Atonic bleeding usually occurs in the uterine body, whereas PAS bleeding occurs in the lower uterine segment. Suturing atonic bleeding is much easier than suturing PAS bleeding. The standard treatment of PAS is caesarean hysterectomy; however, considering its high success rate, the Nausicaa suture may have revived the once-abandoned strategy of an ‘extirpative approach = planned placental removal followed by haemostasis’ (Matsubara & Takahashi Arch Gynecol Obstet 2018;297:1–2). Reliance on the surgeon's skill to select this suture is mandatory, however (Matsubara BJOG 2017;124:1287–88). Indeed, Shih et al. did not use the Nausicaa suture but employed hysterectomy in patients with: (1) apparent parametrial invasion; (2) devastating neovascularisation; or (3) overt bladder invasion. Second, in placenta praevia with PAS (53% of cases), bleeding often occurs from the deep area of the lower segment just after placental removal. It was reported that PAS involving the deeper (more caudal) parts was difficult (Palacios Jaraquemada et al. Acta Obstet Gynecol Scand 2004;83:738–44). Shih et al.'s figure 1b indicates a relatively long distance between the hysterotomy ‘window’ and deep bleeding area. In the midst of marked bleeding from this deep area, identifying and suturing just the appropriate site from this ‘window’ may not be easy. Third, I am concerned about the long-term outcome. Tight ligation is more likely to achieve haemostasis, but is also more likely to cause adverse ischaemic events, with tight ligation versus ischaemic events representing a trade-off relationship. The uterus after Nausicaa suture becomes very thin (figure 1e, f), suggesting that the threads are sometimes tightly tied. Of 68 patients, only three became pregnant, with caesarean section revealing no apparent intraperitoneal adhesion. Experience of this small number may be insufficient to conclude the long-term outcome and safety of this procedure. I wish to learn of follow-up data from Shih et al. in the near future. Finally, the Nausicaa suture may not be classified as a uterine compression suture, which compresses the uterine cavity by apposition of the anterior and posterior uterine walls. The Nausicaa suture should be considered as a systematic haemostatic suture. The Nausicaa-sutured uterus resembles ‘Ohm’, a fictitious worm appearing in the Japanese blockbuster ‘Nausicaa of the Valley of the Wind’. Although ‘Ohm’ can survive in hypoxic conditions, it begins to act violently if treated inadequately. The Nausicaa suture may require adequate thread deployment, tying, and the tying of deeper parts, together with the adequate selection of indicated cases. Without these, this ‘Ohm’ may begin to act badly, i.e. with re-bleeding, necrosis, or a poor outcome of future pregnancy. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.