Successful management of intraoperative hemorrhage from placenta previa accreta: intrauterine tamponade balloons brought out through the abdominal wall

Expectant Management of Placenta Accreta Spectrum Disorders

Placenta accreta spectrum (PAS) disorder is a potentially life-threatening complication. The incidence of PAS has increased over the past few decades, mainly due to the increased cesarean section rate. While cesarean hysterectomy remains the most standard treatment for the management of PAS, expectant management is becoming increasingly prevalent to avoid serious maternal morbidity and maintain future fertility. Expectant management is defined as leaving the placenta either partially or fully in situ, and waiting for its spontaneous resorption or expulsion. The success rate of expectant management is high, but intraoperative uncontrolled hemorrhage results in hysterectomy. Moreover, some individuals fail expectant management and require delayed hysterectomy due to complications such as secondary postpartum hemorrhage, sepsis, uterine necrosis, and vesicouterine fistula. As a result of the very limited data currently available, there is no consensus on the optimal strategy for the expectant management of PAS. However, it is clear that a multidisciplinary team approach in tertiary centers is essential for women with PAS. In addition, meticulous preparation is the key to successful expectant management. Here, we describe a surgical strategy designed to reduce perioperative blood loss, which is a minimum requirement to ensure maternal safety. This article also addresses practical issues in expectant management of PAS, based on the published literature and our own experience.

Systematic review on near miss cases of placenta accreta spectrum disorders: correlation with invasion topography, prenatal imaging, and surgical outcome

Purpose of the article: Placental accreta spectrum (PAS) is the most dangerous iatrogenic complication of cesarean potentially leading to massive intra-partum haemorrhage and death. Despite this, identification of near miss cases of PAS has not been consistently reported in the published literature. The aim of this systematic review was to explore prenatal and surgical characteristics of near miss cases of PAS disorders.Materials and methods: Medline, Embase, CINAHL, SciELO, and Cochrane databases were searched. Only studies including near miss cases of PAS disorders in which a detailed description of the clinical course, severity of placental invasion, role of prenatal imaging, and surgical management were considered eligible for the inclusion in the present systematic review. Random-effect meta-analyses of proportions were used to pool the data.Results: Thirty-four studies were included in the systematic review. The incidence of placenta accreta, increta, and percreta in near miss cases of PAS disorders was 0% (95% CI 0-24.6), 17.3% (95% CI 8.4-28.6) and 82.7% (95% CI 71.4-91.6). S1 invasion, defined as invasion in the upper posterior bladder wall was present in none of the near miss cases of PAS while all included cases showed S2 invasion. Prenatal imaging, either ultrasound or magnetic resonance imaging, detected invasive placenta in 54.4% (95% CI 41.0-67.5). Clinical symptoms occurred in 65.3% (95% CI 52.1-77.4) of near miss cases of PAS before surgery, while the corresponding figures for symptoms occurring during and after surgery were 65.5% (95% CI 52.2-77.5) and 50.0% (95% CI 36.5-63.5) of cases, respectively. Invasion in the inferior part of the lower uterine segment, posterior bladder and parametria was associated with a high risk of morbidity.Conclusion: Near miss cases of PAS are commonly associated with posterior bladder or parametrial invasion and placenta percreta. Further studies are needed in order to identify women affected by PAS disorders at high risk of surgical complications.

Nationwide survey of severe postpartum hemorrhage in Japan: an exploratory study using the national database of health insurance claims

Aim: The aim of this study was to investigate epidemiological and clinical aspects of severe postpartum hemorrhage (PPH) in Japan. Methods: We used national health insurance claims from 2011 to 2014 provided by the Ministry of Health, Labour and Welfare. The data included randomly selected claims that covered 10% of all inpatients in October, a so-called sampling dataset (covering 1/120 inpatients per year). We extracted claims for transfused blood, and further narrowed down the claims by names of diseases linked to PPH. As most referral obstetric facilities have adopted the diagnosis procedure combination (DPC)-based payment system while small-scale obstetric facilities have not (non-DPC facilities), the claims were also analyzed separately for DPC and non-DPC facilities. We assessed the incidence and causes of PPH, transfusion volume of red blood cells (RBC) and fresh frozen plasma (FFP), and surgical hemostatic management. Results: The number of PPH cases that required blood transfusion in the sampling dataset was 29, 29, 32, and 36 in 2011, 2012, 2013, and 2014, respectively. The leading cause of PPH was uterine atony followed by placental abruption. Although no specific trends were observed for the volume of transfused RBC (1467 ± 234 ml in 2014), there was a steady increase in the rate of FFP utilization in non-DPC facilities from 37% to 79% over the 4-year sampling period. Intrauterine balloon tamponade emerged in 2014. Conclusion: This nationwide survey indicates that the annual incidence of severe PPH is increasing. Furthermore, FFP has become more prevalent in small-scale obstetric facilities.