Matsubara-Takahashi cervix-holding technique for massive postpartum hemorrhage in patients with placenta previa with or without placenta accreta spectrum disorders

Retracted: A randomized controlled study comparing two uterine sparing techniques in conservative management of placenta accreta spectrum

OBJECTIVES

To compare the efficacy and safety of two uterine sparing techniques in conservative management of placenta accreta spectrum (PAS).

METHODS

This multicenter randomized controlled study was conducted from January 1, 2017 to December 31, 2020 at two university hospitals. Patients were randomly allocated into two groups; Group 1 was managed by Assar's technique and Group 2 was managed by Shehata's technique. Operative time, blood loss, operative complications (organ or vessel injury), and postoperative complications (early and late) were reported. Success of the technique, units of blood transfusion, and intensive care unit admissions were recorded.

RESULTS

Demographic data in both groups were not significantly different. The mean gestational age at the delivery time was 36 weeks in both groups. Operative time was 120 (100-140) minutes and 75 (60-100) minutes in Assar's and Shehata's techniques, respectively (P < 0.001). Blood loss was higher in Shehata's technique than in Assar's (P < 0.001). Intensive care unit admissions were minimal in both groups. Operative complications were comparable in both groups. The success of Assar's and Shehata's techniques in uterine preservation was 85% and 95%, respectively.

CONCLUSION

Both techniques were safe and successful in uterine sparing. Therefore, we recommend these techniques for conservative management of PAS.

CLINICAL TRIAL REGISTRATION

The trial was registered on UMIN-CTR and had the unique ID: UMIN000025315 on the following link: https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000029120.

Termination of a second-trimester pregnancy with placenta accreta spectrum disorder

Background: The termination of pregnancy in patients with placenta accreta spectrum disorder (PASD) during the second trimester remains uncertain. In addition, interventional radiology techniques, such as arterial embolization and balloon placement, are potential options. We evaluated the outcomes of pregnancy termination in patients with PASD during the second trimester and the effectiveness of preoperative interventional radiology techniques.Methods: This retrospective study analyzed 48 PASD patients who underwent pregnancy termination during the second trimester between January 2016 and May 2021.Results: Of the 48 patients, 20 (41.67%) underwent transvaginal termination, whereas 28 (58.33%) underwent cesarean section. Notably, no significant differences were observed in success rates between the transvaginal termination and cesarean section groups (80.00% vs. 92.86%, P = 0.38). Furthermore, no statistically significant differences were observed in the success rates (94.12% vs 90.32%, P = 1.00) and blood loss (512.35 ± 727.00 ml vs 804.00 ± 838.98 ml, P = 0.23) between the artery embolization and non-embolization groups. In the vaginal termination group, statistically significant differences were observed in gestational weeks (16.70 ± 3.12 vs 22.67 ± 3.63, P < 0.01) and blood loss (165.00 ± 274.43 ml vs 483.64 ± 333.53 ml, P = 0.04) between the (artery embolization and non-embolization) subgroups. Conversely, in the cesarean section group, no significant differences were observed in gestational weeks (23.59 ± 3.14 vs 23.20 ± 4.37, P = 0.79) and blood loss (811.11 ± 879.55 ml vs 989.47 ± 986.52 ml, P = 0.76) between the subgroups.Conclusions: Further studies are needed to evaluate the efficacy of vaginal termination in PASD patients during the second trimester. Regarding cesarean termination, arterial embolization did not demonstrate increased effectiveness.

Transvaginally surgically treatment of early postpartum hemorrhage caused by lower uterine segment atony

OBJECTIVES

Prove the success of transvaginal hemostatic procedures in treatment of the early postpartum hemorrhage caused by lower uterine segment atony.

METHODS

We have conducted a retrospective, clinical study during a 10-year period (2010-2019) in our institution that is tertiary perinatal university center.

RESULTS

This particular study enrolled total number of 29,543 deliveries with 215 cases of early postpartum hemorrhage (0.72%). Lower uterine segment atony was diagnosed in 44 cases (29.93%) in all uterine atony cases of early postpartum hemorrhage. Hemostatic ligation procedures according to authors: Losickaja in two cases, Hebisch-Huch in 13 cases, Habek in seven cases, Hebisch-Huch + Losickaja in 10 cases. According to our results, hemostatic ligation procedures alone (32 cases; 72.72%) or combined with gauze or ballon tamponade (five cases, 11.36%), have shown to be highly effective in 37 cases (84.09%).

CONCLUSIONS

Lower uterine segment atony should definitely be identified and understood as a clinical entity. Transvaginal hemostatic approach for surgical treatment of lower uterine segment atony is accessible, minimally invasive, feasible, successful and lifesaving. All of the above-mentioned methods are of great importance in the prevention and treatment of obstetric shock, multiorgan failure, postpartum hysterectomy and finally vital for fertility preservation.

An intrauterine balloon for puerperal uterine inversion is not only for hemostasis but also for prophylaxis against reinversion: A letter to the editor

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Uterine inversion can recur after uterine repositioning.

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An intrauterine balloon prevents uterine reinversion.

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An intrauterine balloon should be inserted immediately after successful repositioning.

Bleeding-related outcomes of low-risk total placenta previa are equivalent to those of partial/marginal placenta previa

OBJECTIVE

To clarify whether "low-risk total PP" patients bleed more than partial/marginal PP patients.

MATERIALS AND METHODS

The retrospective cohort study was performed involving patients with PP between April 2006 and December 2018. The placental position was determined by ultrasound. From medical charts, the backgrounds as well as obstetric and neonatal outcomes of PP patients were retrieved.

RESULTS

This study included 349 patients with PP, which was classified into three types according to the distance between the placenta and internal ostium: total (n = 174), partial (n = 52), and marginal (n = 123) PP. In total PP patients, three factors (prior CS, anterior placenta, and placental lacunae on ultrasound) significantly increased blood loss at CS, the need for hysterectomy, homologous transfusion (≥10 U), and ICU admission. No significant difference was observed in bleeding-related poor outcomes (rate of blood loss ≥2000 mL, amount of homologous transfusion, need for hysterectomy, and ICU admission) between total PP patients without all three factors: "low-risk total PP patients" and partial/marginal PP patients (19.8 vs. 17.1%; p = 0.604, 3.7 vs. 1.1%; p = 0.330, 1.2 vs. 1.1%; p = 1.000, and 1.2 vs. 1.1%; p = 1.000, respectively).

CONCLUSION

Prior CS, anterior placenta, and placental lacunae on ultrasound were risk factors for a bleeding-related poor outcome in total PP patients. Total PP patients without these three factors showed the same bleeding-related poor outcome as partial/marginal PP patients.

Arresting post-partum hemorrhage using the novel trans-vaginal uterine artery clamp

OBJECTIVES

Post-partum hemorrhage (PPH) continues to be the leading cause of maternal mortality in low-resource settings. The commonest variant - Atonic PPH, is managed by additional pharmacological measures which may fail. Additional surgical interventions for hemostasis take time and are not universally available. Immediate arrest of bleeding was deemed essential and a novel Transvaginal Uterine Artery Clamp (TVUAC) was explored for its effectiveness in achieving immediate hemostasis in atonic and mixed post-partum hemorrhage.

STUDY DESIGN

A retrospective chart review was performed for all patients, who underwent vaginal delivery and developed immediate post-partum atonic PPH, in a tertiary care center in South India, between 1st April 2015 and 31st December 2020. As soon as excess bleeding was observed, two TVUACs were applied trans-vaginally at 3' and 9'o clock position of the cervix to occlude the uterine arteries where it joins the isthmus of the uterus.

RESULTS

Of 3999 vaginal deliveries, there were 251 patients who developed primary atonic PPH during the study period, of which 89 were managed by medical measures alone. Out of the remaining 162 patients, in 153 (94.4%) TVUAC helped to achieve hemostasis; with TVUAC alone in 120 patients (78.43%) and with an additional second line surgical intervention in 33 patients. In nine patients, TVUAC was not readily available and hence second line interventions alone were used. None required any third line surgical interventions (laparotomies) for hemostasis nor were there any incident of maternal mortality or consumptive coagulopathy. TVUAC was applied for a mean duration of 25 ± 10 min. Only 11.6% (29/251, 95% C.I 7.9-16.1%) of the patients required a blood transfusion with a median of 2 (1-4) units of packed RBC. No procedure related complications were reported up to a scheduled 6th week in-person follow-up.

CONCLUSION

The novel TVUAC shows potential in limiting third line interventions, maternal morbidity and mortality. Its effectiveness and safety may be further explored as a first line surgical adjunct to medical measures, in PPH protocols in low-resource settings.

Hemostatic effect of combined procedures for placenta previa: cervix-holding, intrauterine balloon, and uterine compression suture

OBJECTIVES

Various procedures have been introduced to achieve hemostasis for postpartum hemorrhage (PPH) in placenta previa (PP). This study attempted to clarify the effectiveness of the combined use of three hemostatic procedures: Matsubara-Takahashi cervix-holding (MT-holding), intrauterine balloon (IUB), and uterine compression suture (UCS).

STUDY DESIGN

This was a historical cohort study on the hemostatic effect of combined procedures for patients with placenta previa (PP) undergoing cesarean section between April 2006 and December 2018. Until 2011 (2006-2011), we used MT-holding alone, whereas since 2012 we have also been using IUB and UCS: MT-holding alone was used in the former period whereas three procedures (MT-holding, IUB, UCS, and their combinations) have been used in the latter period. Perinatal outcomes were compared between 2006-2011 (before group) and 2012-2018 (after group).

RESULTS

Of 416 patients with PP, excluding 273 patients with cesarean hysterectomy or no hemostatic procedure, the remaining 143 patients were analyzed. In the after group, intraoperative blood loss, the percentage of patients with postoperative blood loss ≥ 500 ml, and incidence of autologous blood transfusion were significantly lower than in the before group. Multivariate analysis showed that postoperative blood loss ≥ 500 ml decreased in the after group (adjusted OR: 0.3, 95%CI: 0.1-0.8, compared with the before group).

CONCLUSION

PPH decreased after introducing the combination of hemostatic procedures in patients with PP. Further studies are needed to determine the best combination and optimal indication for combining hemostatic procedures for PP.

Lower segment folding as novel technique to control bleeding in cases of morbidly adherent placenta

AIM

To evaluate the effectiveness of lower segment folding in controlling lower segment bleeding and conserving uterus in cases with morbidly adherent placenta.

METHODS

This study was conducted on OB/GYN emergency unit of Sohag University hospital. The upper edge of lower segment was sutured to the internal os in continuous purse-string manner using delayed absorbable sutures "N0 2 vicryl (polyglactin 910)." The sutures incude both anterior and lateral aspects of lower uterine segment. Care was taken to maintain patency of endocervix. The folded lower segment was sutured to upper segment as ordinary closure of hysterectomy.

RESULTS

Thirty-two cases were included. The procedure was successful in all studied group to achieve good hemostasis and preservation of uterus. The estimated intraoperative blood loss was (1645 ± 318), there was no need for massive blood transfusion in all cases as number of blood units transfused ranged from 1 to 4 with mean (2.1 ± 0.53). Time required to perform lower segment folding was ranged from 3 to 8 min with mean (4.9 ± 1.1).

CONCLUSION

Lower segment folding is a good option for saving the uterus in cases of morbidly adherent placenta. The technique is rapid, easy to be performed without a need of special expertise nor special equipment's.

Laterally-positioned placenta in placenta previa

Objectives: To clarify perinatal outcomes of patients with placenta previa (PP) with the placenta mainly positioned in the lateral uterine wall (lateral PP), thereby clinically characterizing this condition.Study design: The retrospective cohort study was performed involving patients with lateral PP between January 2006 and December 2016. The placental position was determined and classified by magnetic resonance imaging.Results: This study included 98 patients with PP, which was classified into three types according to the main placental position sites: lateral (n = 30), anterior (n = 32), and posterior (n = 36) PP. Overall, the median blood loss at cesarean section (CS) was 1808 mL and transfusion was performed for 78 patients (80%). Univariate analysis showed that patients with lateral PP bled less at CS than those with non-lateral PP (anterior + posterior PP) [median 1510 (interquartile range 1080-2168) versus 1975 (1570-2860) mL: p=.02]. The other parameters including rates of conception by assisted reproductive technology, prior CS, antepartum bleeding, and placenta accreta spectrum did not show the significances. Among the three groups of PP (lateral versus anterior versus posterior), patients with lateral PP bled less than those with anterior (p=.05) or posterior (p=.13) PP, but this was nonsignificant [lateral 1510 (1080-2168) versus anterior 2145 (1580-3348) versus posterior 1808 (1533-2555) mL]. When dividing into lateral PP to two types: placenta showing anterior dominancy versus posterior dominancy, patients with lateral PP and anterior dominancy bled more those with posterior dominancy [2430 (1410-3400) versus 1170 (1050-1588) mL: p=.002].Conclusion: Patients with lateral PP bled significantly less than those with non-lateral (anterior or posterior) PP. Patients with lateral PP and anterior dominancy bled more than those with posterior dominancy.

Matsubara-Yano suture: a simple uterine compression suture for postpartum hemorrhage during cesarean section

AIMS

The aims of this study were to clarify: (i) the effectiveness of Matsubara-Yano uterine compression suture (MY) to achieve hemostasis in the presence of postpartum hemorrhage (PPH) during cesarean section, (ii) the type of PPH for which MY is effective, (iii) post-operative complications of MY, and (iv) outcomes of pregnancy after MY.

METHODS

This retrospective observational study was performed using medical records of patients for whom MY had been performed between January 1, 2009 and December 31, 2017.

RESULTS

MY was performed for 50 patients, with hemostasis achieved in 46 (92%). The other four (8%: 4/50) patients required transarterial embolization or hysterectomy. Of these four, three patients had placenta accreta spectrum (PAS) disorder-related bleeding. Post-operative complications were observed in three (6%: 3/50) patients, with all showing intrauterine infection. All three patients recovered solely with antibiotics. Eight pregnancies were confirmed (five livebirths, two spontaneous abortions in the first trimester, and one case of ongoing pregnancy). Of the five livebirths, one resulted in cesarean hysterectomy due to placenta previa with PAS disorders.

CONCLUSIONS

MY had a hemostatic effect on PPH. All cases except one with hemostatic failure were associated with PAS disorders, indicating that the hemostatic rate was lower in those with PAS than non-PAS disorders.