Triple P Procedure in Placenta Previa (with Accreta Spectrum)

Background

1. Perioperative placental localization and pelvic devascularization
2. Placental non-separation (leaving the placenta in situ after delivery)
3. Placental bed excision and myometrial reconstruction

Step-by-Step Technique

Pre-operative Preparation

• Multidisciplinary team: MFM, urology, IR (interventional radiology), anaesthesia, blood bank
• Preoperative imaging (USS/MRI) to map placental location and invasion depth
• Consider pre-placement of internal iliac / uterine artery balloon catheters for embolization readiness
• General anaesthesia; Foley catheter insertion
• Blood products cross-matched and available; cell salvage set up

Step 1 - Perioperative Placental Localization + Pelvic Devascularization

• Pfannenstiel or midline incision depending on the degree of bladder involvement
• Identify the superior border of the placenta via ultrasound or direct palpation
• High (fundal) uterine incision is made above the upper placental border to avoid cutting through the placenta - this dramatically reduces haemorrhage at hysterotomy
• Baby is delivered through this incision, cord clamped immediately
• Bilateral uterine artery ligation is performed immediately after fetal delivery (before any attempt at placental removal) to reduce perfusion pressure to the lower segment; some centres use internal iliac artery ligation or balloon inflation

Step 2 - Placental Non-separation (Placenta Left In Situ)

• The placenta is deliberately NOT separated from the uterine wall
• Forced manual removal of an adherent placenta causes catastrophic haemorrhage and is strongly contraindicated
• The lower uterine segment is observed while haemostasis is secured

Step 3 - Placental Bed Excision + Myometrial Reconstruction

• Careful bladder dissection from the lower uterine segment (the most technically demanding step) - blunt/lateral window technique preferred over sharp dissection to avoid vascular injury
• The adherent placenta + the underlying myometrium are excised en bloc (myometrial excision)
• The resulting uterine defect is repaired / reconstructed - various suture techniques used:
  • Original: circumferential (purse-string) compression sutures
  • Modification: T-shaped lower segment sutures (Abo-Elroose et al., 2021 - PMID 31615304)
  • Transverse or vertical haemostatic sutures
  • Cervical inversion technique

Modifications to the Original Technique

Outcomes & Evidence

• Mean operative time: 58 ± 1.8 min
• Mean intraoperative blood loss: 1.3 ± 0.3 litres
• Mean postoperative blood loss: 180 ± 94 mL
• Mean Hb reduction: 1.5 g/dL
• Only 1 case (5%) required hysterectomy for severe bleeding
• The procedure was deemed a safe, effective alternative to hysterectomy in young women with low parity

When to Use vs. When to Avoid

• Young patients, low parity, strong desire for fertility preservation
• Antenatal diagnosis at a centre with multidisciplinary expertise
• Placenta accreta or increta (not percreta with bladder/bowel invasion)

• Placenta percreta with bladder/bowel infiltration
• Haemodynamically unstable patient
• No specialist surgical backup or centre of excellence
• Uncontrollable intraoperative haemorrhage during the procedure

Standard Management Context

• Creasy & Resnik's Maternal-Fetal Medicine, p. 1022 - recommends fundal incision + placenta in situ approach, bilateral uterine artery ligation, and highlights the role of multidisciplinary team care

Key Points Summary

1. Triple P = fundal delivery incision + bilateral uterine artery ligation + placental bed excision with myometrial reconstruction
2. The placenta is never forcibly removed - it is either left in situ (for hysterectomy path) or excised en bloc with myometrium (Triple P path)
3. Bladder dissection is the most technically demanding step - cystoinflation is a useful modification
4. Suitable for accreta/increta, less so for percreta
5. Hysterectomy remains the gold standard; Triple P is an expert-centre option for fertility preservation
6. Recent evidence (PMID 31615304) supports its safety with low blood loss and good uterine preservation rates when performed by experienced surgeons

Pressure Suturing (Myometrial Reconstruction Suturing) in the Triple P Procedure

What It Is and Why It Matters

1. Compress the bleeding sinusoids in the excised placental bed
2. Reconstruct the lower uterine wall after myometrial resection
3. Prevent secondary haemorrhage from the denuded lower segment

The Original Chandraharan Technique (2012)

• Sutures placed to bring the anterior and posterior walls of the lower uterine segment together, compressing the vascular bed between them
• This achieves mechanical haemostasis by obliterating the dead space and directly compressing bleeding sinusoids
• No attempt is made to suture bleeding points individually - the compression itself achieves haemostasis

P1 - Perioperative placental localization + fundal uterine incision above the upper border of placenta P2 - Pelvic devascularization (bilateral uterine artery ligation ± internal iliac artery balloon occlusion) P3 - Placental non-separation + myometrial excision + reconstruction of the uterine wall with pressure/compression sutures

Types of Pressure / Haemostatic Sutures Used

1. Circumferential / Purse-String Compression Suture (original)

• A circumferential suture encircles the lower uterine segment
• Compresses the anterior wall against the posterior wall at the level of the excised placental bed
• Stops bleeding from the entire lower segment circumferentially

2. T-Shaped Lower Segment Suture (Abo-Elroose modification, 2021 - PMID 31615304)

• After myometrial excision, the uterine wall is reconstructed in a T-shaped configuration
• A vertical component joins the two lips of the incision, and a horizontal component compresses the lower segment
• Useful for anterior placenta previa accreta/increta

3. Parallel Vertical Compression Sutures (Hwu technique)

• Multiple vertical sutures placed in parallel on the lower uterine segment
• Each suture transfixes both anterior and posterior walls, compressing the vascular bed
• Originally described by Hwu et al. (BJOG 2005) for placenta previa/accreta at caesarean

4. Single Continuous Suture on the Lower Lip (Frontiers modification)

• After excision of the anterior myometrium together with the non-separated placenta, a single continuous suture is run along the lower lip of the uterine incision
• This targets the most common, most severely bled zone: the anterior myometrium just above the cervix, which is full of tortuous vessels
• Any residual bleeding points around the internal cervical os are addressed with figure-of-eight sutures

5. Braided / Spiral Suture

• Continuous suture starting from the cervix, running upward toward the upper uterine segment
• Goes through the full thickness of the myometrium
• Provides fast haemostasis + lower uterine segment reconstruction in a single suture line

6. Funnel Compression Suture (Li et al., BJOG 2016)

• Bladder pushed down first
• Suture starts 1 cm above the upper edge of the cervix, transfixes anterior and posterior uterine walls
• Returns at 2 cm above the upper border of the lower uterine segment
• Creates a "funnel" effect compressing the lower segment vasculature
• Good overall haemostasis but less effective in severe intrauterine bleeding

7. "Nausicaa" Compression Suture (Shih et al., BJOG 2019)

• Simple full-thickness compression suture through anterior and posterior lower uterine walls
• Described as a quick, effective alternative to hysterectomy in PAS

8. Circular Butterfly Suture

• For PAS limited to the anterior wall of the lower uterine segment
• Suture starts from posterior wall, folds once on the anterior wall, returns through posterior wall
• Easy and fast; restricts itself to the invaded region

Technical Points for Successful Suturing

Why the Lower Uterine Segment is Challenging

• The lower segment is thin and poorly contractile (unlike the fundus)
• It is densely adherent to the bladder posteriorly
• It contains large, distended, abnormally invasive vessels that do not respond well to oxytocics
• Standard uterine massage or balloon tamponade alone is insufficient

Outcomes Data

• 75 patients with original Triple P: mean blood loss 2.31 L, hysterectomy rate 0%, bladder injury rate 1.3%
• 654 patients with modified Triple P: mean blood loss 1.4 L, hysterectomy rate 6.1%
• Modified techniques (including improved pressure suturing methods) achieved lower blood loss than the original

Summary

1. Original circumferential compression
2. T-shaped suture (Abo-Elroose)
3. Parallel vertical sutures (Hwu)
4. Single continuous lower-lip suture
5. Braided/spiral continuous suture
6. Funnel compression suture
7. Nausicaa suture
8. Circular butterfly suture