Successful Use of the Nausicaa Compression Suture in a Case of Placenta Accreta Spectrum

Abstract

Successful use of the Nausicaa compression suture in a case of placenta accreta spectrumAuthorNaoko Suga, Shintaro Makino, Ayumi Yasuda, Takahumi UjihiraAffiliationDepartment of Obstetrics and Gynecology, Juntendo University Urayasu Hospital, Chiba, JapanCorrespondenceShintaro Makino Email: shintaro@juntendo.ac.jpKeywordsplacenta accreta spectrum, postpartum haemorrhage, Nausicaa compression suture, uterine preservationDear Dr Papageorghiou,We read with great interest the BJOG article by Shih et al. describing the Nausicaa compression suture as a uterine-preserving option for severe postpartum haemorrhage associated with placenta accreta spectrum (PAS). ¹ We would like to share our recent real-world experience that supports the clinical utility of this technique.Our patient was a 38+3-week woman with a history of previous caesarean delivery who underwent an elective caesarean section. Intraoperatively, abnormal placental adherence was identified on the anterior uterine wall, consistent with placenta increta. Following placental removal, massive haemorrhage occurred from the implantation site. Initial management included uterotonic agents and insertion of an intrauterine balloon (Atom Balloon®, ATOM Medical Corporation, Tokyo, Japan); however, adequate haemostasis could not be achieved. We therefore proceeded with re-laparotomy and applied the Nausicaa compression suture as described by Shih et al.¹ Prompt and effective haemostasis was achieved, enabling us to avoid hysterectomy. The postoperative course was uneventful, with no major complications observed. At 3 months postoperatively, hysteroscopy demonstrated a normal uterine cavity with no evidence of intrauterine adhesion.Several aspects of this technique proved particularly valuable in our case. First, the procedure is technically straightforward and easy to recall in an emergency setting. Second, haemostatic efficacy can be directly confirmed immediately after suturing, which is highly reassuring during critical bleeding. Third, because the anterior and posterior uterine walls are not approximated, physiological drainage of lochia is preserved. This may help reduce the risk of postoperative intrauterine infection or abscess formation, a theoretical concern associated with other compression suture techniques.In our clinical situation, a key factor contributing to successful haemostasis was the ability to promptly select this technique, which uses healthy myometrium as an anchoring point for sutures. This allowed secure fixation even in the presence of abnormal placental adherence and active bleeding. This feature was particularly advantageous compared with conventional compression sutures that rely primarily on uterine wall apposition.Matsubara, in his mini commentary on this article, proposed that the Nausicaa suture should be regarded as a systematic haemostatic suture rather than a conventional uterine compression suture, as it does not rely on apposition of the anterior and posterior uterine walls.² We fully agree with his concept that the optimal haemostatic technique should be selected according to the underlying pathology and intraoperative situation. For example, in cases with a thin myometrium, compression sutures may be ineffective, whereas in uterine atony, simple compression may be sufficient. In contrast, in PAS-related bleeding, strategic placement of sutures using healthy myometrium as anchors, as in the Nausicaa technique, may be particularly effective. Our real-world experience strongly supports this tailored approach.Although caesarean hysterectomy remains the standard approach for PAS in many institutions, uterine preservation is an important consideration for carefully selected patients. The Nausicaa compression suture appears to be a valuable option when haemostasis is deemed achievable and fertility preservation is desired. While our observation is limited to a single case, it provides additional support from recent real-world clinical practice for the applicability of this technique.Further accumulation of cases is warranted to better define the indications, limitations, and long-term outcomes, including menstrual function and subsequent fertility. We believe that the Nausicaa compression suture deserves wider recognition as a practical uterine-preserving strategy for managing severe postpartum haemorrhage associated with PAS.