Parallel transverse uterine incisions, a novel approach for managing heavy hemorrhage and preserving the uterus: A retrospective cohort study for patients with anterior placenta previa and accreta

A Multicenter, Retrospective Comparison Study of Pregnancy Outcomes According to Placental Location in Placenta Previa

Background: We investigated the association between placental location and pregnancy outcomes in placenta previa. Methods: This multi-center retrospective study enrolled 781 women who delivered between May 1999 and February 2020. We divided the dataset into anterior (n = 209) and posterior (n = 572) groups and compared the baseline characteristics and obstetric and neonatal outcomes. The adverse obstetric outcomes associated with placenta location were evaluated using a multivariate logistic analysis. Results: Gestational age at delivery in the anterior group (253.0 ± 21.6) was significantly lower than that in the posterior group (257.6 ± 19.1) (p = 0.008). The anterior group showed significantly higher parity, rates of previous cesarean section, non-vertex fetal positions, admissions for bleeding, emergency cesarean sections, transfusions, estimated blood loss, and combined placenta accrete spectrum (p < 0.05). In the multivariate analysis, the anterior group had higher rates of transfusion (OR 2.23; 95% CI 1.50-3.30), placenta accreta spectrum (OR 2.16; 95% CI 1.21-3.97), and non-vertex fetal positions (OR 2.47; 95% CI 1.09-5.88). Conclusions: These findings suggest that more caution is required in the treatment of patients with anterior placenta previa. Therefore, if placenta previa is diagnosed prenatally, it is important to determine the location of the body and prepare for massive bleeding in the anterior group.

Effect of prophylactic balloon occlusion of internal iliac artery in pregnancies complicated by placenta previa and accreta

Background

Placenta previa and accreta are serious obstetric conditions that are associated with a high risk of intraoperative massive hemorrhage, the prophylactic intravascular balloon occlusion technique is increasingly used in managing uncontrolled hemorrhage in cesarean section (CS). We aim to examine the clinical effectiveness of prophylactic balloon occlusion of the internal iliac artery (PBOIIA) during CS in improving maternal outcomes for patients with placenta previa and accreta.

Methods

A total of 420 women with placenta previa and accreta who underwent CS from January 2014 to December 2018 were included retrospectively. Patients were divided into balloon group in which patients had PBOIIA (n = 248) and the control group in which patients did not have PBOIIA (n = 172). Meanwhile, we performed a subgroup analysis in whether taking parallel transverse uterine incision (PTUI) surgery. Information on conditions of patients and newborns, perioperative blood indicators, surgical outcomes were collected.

Results

Median estimated blood loss (mEBL) was 2200 mL in the balloon group and 2150 mL in the control group respectively, there was no significant difference between two-groups comparison (P > 0.05), and the rate of patients with hysterectomy was also has no difference between the two groups (36.3% verus 35.5%, P > 0.05), while there is a significant difference between two groups in the amount of PRBCs transfused [3 (0–31.5) verus 3 (0–39), P <0.05], moreover, the proportion of PRBCS> 8 units in the balloon group is significantly lower than that in control group (11.29% verus 23.26%, P <0.05).. However, the total hospitalization costs (45,624.4 ± 11,061.9 verus 37,523.1 ± 14,662.2, CYN) and surgery costs (19,910.6 ± 2622.6 verus 11,850.5 ± 3146.1, CYN) in balloon group were significantly higher than those in control group (P < 0.05). Subgroup analysis showed PTUI surgery had no significant differences in EBL (P >0.05), but it could significantly decrease hysterectomy rates (P <0.05).

Conclusions

PBOIIA has no significant effect on reducing intraoperative EBL and hysterectomy rate in patients with placenta previa and accreta. and although it could reduce the intraoperative PRBCs in patients with massive hemorrhage, it significantly increases the financial cost for patients. Therefore, PBOIIA should not be routinely recommended to patients with placenta previa and accreta.

A practical FIST maneuver to minimize the bleeding during cesarean hysterectomy for placenta percreta: a retrospective comparative study

BACKGROUND

Placenta percreta (PP) is a life-threatening condition and its surgery poses a very high potential for bleeding. The recommended treatment is a cesarean hysterectomy. There are several techniques reported in the literature to reduce the bleeding during percreta operations.

OBJECTIVE

To show and describe a practical and novel intraoperative maneuver to minimize the hemorrhage during cesarean hysterectomy for PP.

METHODS

The patients who were diagnosed with PP and underwent cesarean hysterectomy (CH) in our unit between 2016 and 2020 were retrospectively evaluated. These patients were divided into two groups. Group A included patients who underwent hysterectomy with intraoperative FIST maneuver. Group B included patients with ordinary cesarean hysterectomy. The groups were compared with regards to the intraoperative bleeding, surgical complications, and perioperative outcomes.

RESULTS

Seventy-two patients who had a cesarean hysterectomy and diagnosed with PP during the study period were included in this retrospective cohort. 22 patients underwent intraoperative FIST maneuver with CH as Group A and 50 patients underwent ordinary CH as Group B. The demographic variables including maternal age, gravida, number of previous cesarean sections, and body-mass index were not statistically different between the two groups. Intraoperative FIST maneuver was significantly associated with reduced operative hemorrhage, the need for transfusion of erythrocyte suspension, admission to intensive care unit, and hospitalization days (p < .005). The operative time was statistically significantly shorter in Group A than Group B, respectively (90 ± 18.6 vs 120 ± 20.5 min) (p < .05).

CONCLUSION

FIST maneuver is a very practical, easy to apply, and effective method that reduces the obstetrical bleeding during cesarean hysterectomy in placenta percreta cases.

Local uterine resection with Bakri balloon placement in placenta accreta spectrum disorders

OBJECTIVE

Placenta accreta spectrum (PAS) is a potentially life-threatening condition characterized by the abnormal adherence of the placenta to the implantation site. We sought to evaluate the efficacy, surgical feasibility, risks, and advantages of local uterine resection in cases complicated with PAS.

MATERIALS AND METHODS

This study included 97 patients with PAS, which was confirmed during surgery and by histopathological examination between January 2013 and December 2019. The patients were divided into two groups based on operative approach. The study population (local resection group) consisted of 30 cases in whom total resection of adherent placenta and myometrium was performed, whereas the control group (hysterectomy group) of 67 cesarean hysterectomy cases.

RESULTS

Patients who underwent hysterectomy had significantly more bleeding than the local resection group (1180±160 mL vs 877±484 mL; p=0.002). The mean number of transfused packed red blood cells (pRBCs) was greater in the hysterectomy group (4.5±2.3) than in the local resection group (2.6±3.1; p=0.001). Transfusion rate of four and/or more pRBCs was 67.2% in the hysterectomy group and 33.3% in the local resection group, which indicated a statistically significant difference (p=0.002). Of patients, 29.6% required intensive care unit in the hysterectomy group and 6.7% in the local resection group (p=0.023).

CONCLUSION

Local resection can be performed safely in selected PAS cases. In these cases, using a standardized protocol in terms of patient selection and surgical procedure will reduce morbidity and mortality.