Fig 10 - uploaded by Satoru Takeda
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Transverse incision in the uterine fundus (Kotsuji technique). A transverse incision is made in the anterior or posterior wall of the uterine fundus, avoiding the uterine horn and keeping a substantial distance from the area of placental attachment. When the incision reaches the uterine cavity, the myometrium is held with two Kelly clamps, and incised between the clamps to extend the incision. These Kelly clamps should be kept in place at this site until the fetus is delivered and the myometrium sutured. (Reproduced with permission from Takeda S. Cesarean section for placenta previa and placenta previa accrete spectrum. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS NOW, No.3. Cesarean section. (Japanese). Tokyo: Medical View; 2010:102-115. Copyright © Medical View).
Source publication
According to the increase in the rate of cesarean section and the increase of high-aged pregnancy, we seem to more often encounter cases with placenta previa and placenta previa accrete spectrum. There are concerns about these cases, such as difficulty in controlling bleeding from the separation surface of placenta previa, the need for hysterectomy...
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Introduction
This study examined national-level trends, characteristics, and perioperative outcomes of women who had intra-arterial balloon occlusion at cesarean hysterectomy for placenta accreta spectrum (PAS).
Material and methods
This was a population-based retrospective observational study that queried the National Inpatient Sample from Octobe...
Objective
To assess whether prophylactic intraoperative abdominal aortic balloon occlusion (IAABO) is indeed beneficial in pregnancies with placenta previa (PP) and placenta accreta spectrum (PAS) during cesarean section.
Methods
A retrospective case–control study included 251 pregnancies with PP and/or PAS. All enrolled patients were divided into...
Background: This study is aimed at evaluating the conservative surgical treatment of patients with placenta accreta spectrum (PAS) disorder and at presenting the experience of a single surgeon.
Materials and Methods: This retrospective study included 245 patients with placenta previa accompanied by PAS disorders operated at a university hospital be...
Placenta accreta spectrum (PAS) is a rare complication of pregnancy associated with a high risk of massive haemorrhage and caesarean hysterectomy. This is a case report of abdominal aortic balloon occlusion, using intravascular ultrasound, to achieve uterine conservation in a case of severe PAS. The patient was a 34-year-old woman, G2P1, with one p...
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Citations
... Авторы также обсуждают возможные осложнения и рекомендации по управлению рисками. Takeda S., Takeda J., Makino S. подчеркивают необходимость индивидуального подхода к каждому случаю и принятие решений на основе множества факторов, включая степень развития рlacenta previa, increta и perсreta, с учетом анамнеза беременности, состояния матери и плода и других клинических параметров [14]. ...
Предлежание плаценты (рlacenta previa) -является одной из серьезных и актуальных проблем современного акушерства. В литературе «рlacenta previa» рассматривается как аномальное расположение плаценты, которое в 34% случаев во время беременности, в 66% случаях во время родов приводит к возникновению массивных аку-шерских кровотечений. Необходимо подчерк- нуть, что возникновение массивных кровотечений требует принятия радикальных мер, вплоть до тотальной гистерэктомии. Нередко «рlacenta previa» является основной причиной материнской и перинатальной смертности [1-3].
... 8 Studies have also demonstrated that pregnancies with placenta previa are associated with an increased risk of surgical complications including hysterectomy, injury to nearby organs, massive transfusions, and disseminated intravascular coagulation. 9 Management of placenta previa includes decreased physical activity to avoid bleeding and re-bleeding, avoidance of intercourse and maintaining folic acid and iron intake during the pregnancy. During the caesarian section, massive bleeding should be anticipated and all necessary arrangements including the availability of an experienced obstetric and anaesthesia team, and blood products. ...
Objective: To find out the frequency of placenta previa and maternal and fetal outcomes in cases of placenta previa in our population. Methods: All women with an age range from 18-40 years diagnosed with placenta previa based on ultrasound were recruited with the study. Data including patient age, parity, previous normal deliveries, previous caesarian sections, grade of the placenta previa and history of previous pregnancies was recorded. Maternal complications including post-partum haemorrhage, hysterectomy and death were also recorded. Fetal complications including low APGAR score at five minutes, low birth weight and death were also recorded. Results: The age group between 26-35 years seems to have the highest incidence of placenta previa (62.58%). Post-partum haemorrhage was seen in 57 (38.77%) patients. Post-partum haemorrhage was strongly associated with the grade of placenta previa. Emergency obstetric hysterectomy was done in 7 (4.76%) patients. Two (1.36%) patients died of complications. Out of 147, 38 (25.85%) had low APGAR scores, 52 (35.37%) had low birth weight and 12 (8.16%) died of various complications. Conclusion: Placenta previa has become a very common condition which may be attributable to higher rates of caesarians. It may lead to increased morbidity and mortality of the mother and the baby if not diagnosed and managed properly. These cases should be managed by experienced multidisciplinary teams in a tertiary care centre to minimize the rate of complications. Keywords: APGAR score, Intrauterine growth retardation,Neonatal, Placenta previa, Postpartum haemorrhage
... Various medical and surgical techniques, like uterotonic agents, ergot alkaloid derivatives, oxytocin, and bimanual uterine compression, control non-traumatic uterine bleeding 5 , the vascular ligation, intrauterine balloon tamponade, and uterine compression suture with B-lynch are carried out to reduce the amount of blood loss during cesarean delivery. 6 Apart from peripartum hysterectomy, there are only a few options for controlling intractable bleeding when massive bleeding occurs. If the usual techniques fail to stop bleeding, conservative surgical procedures like ovarian, uterine, or internal iliac artery ligation are carried out. ...
Objective
The study aimed to demonstrate the efficacy and safety of an innovative hemostatic technique in managing Placenta Previa and Accreta Spectrum by S. Rao Spiral Suturing (SRSS) of a lower uterine segment.
Method
In this retrospective study conducted at Department of Obstetrics & Gynecology Unit-II of Nishtar Medical University, Multan between December 2018 to January 2021, one hundred and thirty consenting patients’ clinical records were reviewed with major degree placenta previa/placenta accrete spectrum, either operated electively or presented in an emergency, with or without a history of previous cesarean section. The enrolled patients underwent SRSS, procedure’s efficacy and safety were measured by the number of obstetrical hysterectomies, the time required for the procedure, estimated blood loss, blood transfusion volume, need for any other hemostatic technique, bladder trauma, pelvic infection, scar site hematoma or abscess, sepsis, duration of hospital stay and maternal mortality.
Results
Out of 130 patients, 17(12.6%) had Placenta Accreta, 86(66.3%) Increta, and 27(21%) Percreta. The Placenta location was anterior dominant in 102(78.4%) cases and posterior in 17(8.4%). Of the patients who underwent surgery, only two required obstetrical hysterectomy due to uncontrolled bleeding. The procedure took three to five minutes in 127 patients and five to seven minutes in three patients. Regarding intraoperative blood transfusion, 54.6% of patients were transfused 1000-2000 ml blood, and 5.38% required > 3000 ml. No blood transfusion was required postoperatively in any patient. Postpartum hemorrhage, infection, fever, and sepsis were not observed in any patient postoperatively. None of the patients suffered bladder injury. All patients were discharged as per routine.
Conclusion
SRSS is an innovative, safe, effective, and simple suturing technique for patients with Placenta Previa and Accreta spectrum.
... However, the rapidly increasing rates of medical interventions in many countries, including the rise in CB, are no longer associated with better perinatal outcomes; at current high levels, they actually increase health risks for women and children. [1][2][3][4] One worldwide study using national data from 159 countries revealed that a CB rate higher than 10% is no longer associated with a decrease in maternal and neonatal mortality. 5 However, as pointed out by other studies, appropriate CB rates are difficult to establish and numerous outcomes should be considered, including perinatal morbidity and mortality, instead of simply relaying on neonatal mortality rates. ...
Background
Poland has one of the highest cesarean birth (CB) rates in Europe. For this study, we used the Robson Ten‐Group Classification System (TGCS) to analyze trends in the induction and CB rates in one hospital in Poland over a period of 11 years. We compare these trends with changes in National Legislative and Medical Guidelines introduced during this time that were aimed at lowering rates of unnecessary medical interventions.
Methods
We conducted a retrospective study including all births after 24 weeks' gestation between 2010 and 2020 from one tertiary hospital (n = 66,716 births). After the deletion of records with missing data, 66,678 births were included in the analysis. All births were classified according to the Robson TGCS. The size, CB rate, and contribution of each group for every year were calculated. Linear regression analyses were used to analyze trends over time.
Results
The total CB rate varied from 29.6% to 33.0% during the study period, with a linear increase of 0.045 percentage points annually (R² = 0.021; F(1) = 0.189; p = 0.674). This study was considerably lower than the total CB rate for Poland, which rose from 33.9% in 2010 to 45.1% in 2020, increasing at a rate of 1.13 percentage points per year (R² = 0.93; F(1) = 61.88; p < 0.001). Induction rates among both nulliparous (R1 + R2) and multiparous (R3 + R4) women at term also increased. Study groups R5 (previous cesarean birth), R2 (nulliparous in induced or prelabor cesarean delivery), and R1 (nulliparous women at term with single cephalic pregnancy in spontaneous labor) were the highest contributors to the overall CB rate. The greatest decrease in the CB rate was detected in group R5b (more than one previous CB). None of the groups showed statistically significant increases in CB rates over the study period.
Conclusions
The CB rate in the hospital where the study was conducted was considerably lower than the total CB rate in Poland. When compared with countries with similar CB rates, group R2b (women with nulliparous, prelabor cesarean birth) in our study was considerably larger. More comparisons across different hospital settings in Poland are needed. However, as hospitals are not encouraged to routinely collect the data needed to construct TGCS, such comparisons are very difficult to conduct.
... It has been found that the existence of placenta previa with a history of Cesarean sections may possess a sixty-one percent increase in the risk of PAS disorders [30]. This parallel relation between the increase of PAS disorders and obstetrics history of previous cesarean sections and placenta previa may be attributed to the hypothesis that a localized uterine injury may result in a locally abnormal decasualization/scarring and aberrant placental adherence in the next pregnancies [31]. ...
Objectives - to provide a view on the frequency, and the risk factors of placenta accreta spectrum disorders (PAS) in Nineveh Province, and to assess the morphological alterations associated with these disorders. A prospective and retrospective cross-sectional study was carried out on paraffinized blocks of 19 females, with gestational age ≥32 weeks, presented with peripartum haemorrhage and subjected to emergency hysterectomy at Maternity Teaching Hospitals, Nineveh Province, North of Iraq. Clinical data, including the mother's age and obstetrics history, were recorded when available. All cases were examined for the presence or absence of histological invasion of placentas supported by immunohistochemistry. The mean age of cases was 34.4±1.6 years by the dominance of the fourth decade. The mean gestational age at the time of diagnosis was 35.6±0.8 weeks. The PAS frequency was increasing and reaching up to 1.18 per 1000 live birth. About 60% of the cases gave a history of previous Cesarean section with or without a concomitant placenta previa. According to light microscopic examination, placenta accreta spectrum disorders were identified in 12(63.1%) cases. The immune expression of cytokeratin was significantly correlated with placental invasion, (p=0.001). The present study reveals an increase in the frequency of abnormal placentation in Nineveh Province. These disorders have well-known predisposing factors. The histo-pathological findings, other than interface decidual loss, may explain the abnormality in placental tissue implantation.
... Although imaging is the best investigation method available for prenatal identification of invasive placentation, its sensitivity and specificity are not 100% (5). Some cases of placenta accreta are difficult to diagnose preoperatively, and the preoperative classification of PAS types remains challenging (6). ...
Purpose
Abnormal placentation is a spectrum disorder that includes creta, increta, and percreta; the term placenta accreta spectrum (PAS) disorders is used as a broad term to describe all of these conditions. PAS can lead to life-threatening hemorrhage. The predictive value of cervical length (CL) in patients with PAS remains controversial. Thus, this study investigated the relationship between CL and the probability of major bleeding in patients with PAS and placenta previa.
Methods
This retrospective cohort study was conducted at a comprehensive tertiary hospital in Chongqing, China, between January 2018 and December 2020. The target independent and dependent variables were CL and intraoperative massive bleeding, respectively. The covariates included demographic, clinical, and ultrasound characteristics. Logistic regression was used to explore the association between CL and massive bleeding.
Results
In total, 317 participants were enrolled, in whom the prevalence of massive bleeding was 41.9% (133/317). The threshold of CL associated with massive bleeding (≥1,000 ml) was 33 mm based on a receiver operating characteristic curve. In the fully adjusted model for each additional unit of CL, the risk of massive bleeding decreased by 7% [95% confidence interval (CI), 0.88–0.98]. The risk of major bleeding was reduced by 44% in patients with a CL greater than 33 mm (95% CI, 0.33–0.97) compared with patients with a CL less than 33 mm.
Conclusions
CL was negatively associated with massive intraoperative bleeding in patients with PAS combined with placenta previa. When the CL was greater than 33 mm, the risk of bleeding decreased by 44%. Thus, CL can be used as a standalone parameter to identify the risk of massive intraoperative bleeding in patients with suspected PAS.
... Placenta previa, a common obstetrical complication whose incidence is increasing day by day, in which placenta is located in the lower uterine segment. 1,2 Patients presenting with placenta previa having scarred uterus are reported to have 16 % risk of underlying emergency peripartum hysterectomy than that of 2 -4 % among patients having un scarred uterus. The combination of different underlying conditions such as increasing parity, number of previous cesarean sections, miscarriages, previous currettings are significantly associated with high burden of placenta previa and high risks of abnormally adherent placenta. ...
Objective: To find the frequency of placenta previa in females undergoing hysterectomy during cesarean delivery at term. Material and methods: This Cross sectional study was conducted at Department of Obstetrics & Gynecology, Lady Willingdon Hospital, Lahore for 6 months. Total 90 females who will fulfill selection criteria were enrolled in the study from operation theatre. Informed consent was obtained. Demographic features was obtained. Then females undergone cesarean section and planned hysterectomy. All surgeries were done by researcher herself. The location of placenta was noted ultrasound before cesarean and placenta previa was labeled if present. Location of placenta previa was also confirmed during cesarean section. Results: There were total 90 patients in our study among them the mean age was 36.61±4.31 years. There were 60(66.7%) women who underwent caesarean section previously. There were 12(13.3%) women with placenta previa. Frequency of placenta previa in different age groups was 41.7% in 30-34 years, 25% in 35-39 and 33.3% in women whose age was >40 years. (p- value=0.71). No statistically significant association was seen between gestational age of women and placenta previa. i.e. (p-value-0.106) Gestational age 37-38: 25% (3/12) & Gestational age 39-40: 75% (9/12). Statistically significant association was seen between parity status of women and placenta previa. i.e. (p-value-0.000) Parity-1: 0(0%), Parity-2: 0(0%), Parity-3:5(41.7%) and Parity-4:7(58.3%). No statistically significant association was seen between previous cesarean section of women and placenta previa. i.e. (p-value-0.366) No previous CS: 25% (3/12), One previous CS: 33.3% (4/12), Two previous CS: 16.7% (2/12) & Three previous CS: 25% (3/12). Conclusion: High frequency of placenta previa was noted in our study among females undergoing postpartum hysterectomy. Keeping in mind the results of this study it can be concluded that the placenta previa being a risk factor for emergency obstetrics hysterectomy should be identified and screened antenatally to improve disease prognosis to achieve desired clinical outcomes. Key words: Placenta previa, Hysterectomy, Cesarean delivery, Term delivery
... In addition, as the frequency of assisted reproductive techniques such as in vitro fertilizationembryo transfer increases in infertile patients, the use of ovulation-promoting drugs may also cause the placenta to develop asynchronously with the endometrium, leading to the development of PP. In recent years, the incidence of PP has increased, so it is significant to explore the risk factors associated with the occurrence of PP to reduce the occurrence of adverse maternal and perinatal outcomes (10). However, most of the current studies are on the risk factors associated with the development of PP in patients with a history of prior pregnancy and delivery (11,12), and there are few reports on the factors influencing the development of PP in first-time pregnant women and the perinatal clinical outcomes. ...
Objective
To analyze the risk factors associated with the development of placenta praevia (PP) in first-time pregnant patients and to observe the perinatal clinical outcomes of patients.Methods
The clinical data of 112 pregnant women with PP (PP group) and 224 pregnant women with normal placental position (general group) who delivered in our hospital from August 2016 to August 2021 were retrospectively analyzed. Baseline demographic data such as age, gestational week, uterine history, assisted reproductive technology use, pregnancy comorbidities, pre-pregnancy body mass index (BMI), smoking, alcohol consumption, placental position, educational level, work were collected from both groups, and logistic regression models were used to analyze the factors influencing the occurrence of PP in patients with first pregnancy. Perinatal outcomes such as implementation of hemostatic treatment (uterine balloon compression, arterial ligation, and B-Lynch suture), maternal postpartum related indicators (amount of postpartum bleeding, incidence of postpartum hemorrhage, blood transfusion rate, blood transfusion volume, and length of hospital stay), and neonatal condition (birth weight, Apgar score at 1 and 5 min after birth) were counted and compared between the two groups.ResultsHistories of endometriosis, use of assisted reproductive technology, and smoking or secondhand smoke inhalation were all high risk factors for PP in patients with first pregnancies, and the proportion of maternal and neonatal adverse outcomes was significantly higher in the PP group than in the general group (P < 0.05).Conclusion
Histories of endometriosis, smoking (secondhand smoke), and use of assisted reproductive technologies are independent risk factors for PP in patients with first pregnancies, which can increase the risk of labor and death of the newborn.
... In such obstetric facts with DIC, particularly in the presence of hypothermia, acidosis, and vasopressor requirement, damage control surgery (DCS) and resuscitation, which represent the performing of the therapeutic concept of life-saving intervention for severe trauma because ordinary hemostatic procedures such as sutures, ligation, and coagulation, etc., are not effective and bleeding persists. 1,2 There are several alternative managements during intraoperative bleeding: autologous transfusion, blood salvage & reinfusion, hemodilution, and donor-directed transfusion. 3 In most cases, the utilization of hemodilution as an option to reduce blood loss and prevent blood transfusion without sacrificing tissue oxygenation. ...
Background: Placenta accreta represents one of the most morbidity conditions in modern obstetrics, with high hemorrhage rates, hysterectomy, and intensive care unit admission. Alternative management during intraoperative bleeding is haemodilution. There are two techniques in hemodilution, including autonomic normovolemic hemodilution and hypervolemic hemodilution. Case: A gravida patient, physical status ASA II with a suspected placenta accreta was planned for a cesarean section. Hypervolemic hemodilution was conducted to anticipate bleeding. Hemodilution was performed with a total fluid of 2000 ml. Total bleeding during surgery is 3500 ml. Close monitoring of hemoglobin (Hb) and hematocrit (Hct) was conducted. The initial Hb and Hct were 9.9 mg/dl and 29.8%. Hb and Hct post-haemodilution 5.7 mg/dl, and 17.1%. Postoperatively, Hb and Hct become 5.4 mg/dl and 16.6%. The patient has been given 450 ml packed red cells (PRC) blood transfusion. The patient was observed in the intensive care unit for 24 hours postoperatively and was subsequently transferred to the ward. The total bleeding was 3500 ml, and there was a reduction of Hb from 5.7 to 5.4 and Hct from 17.7% to 16.6%. Conclusion: In this case, hemodilution was proven effective based on the post-hemodilution and post-hemorrhage Hb and Hct. Hemodilution may be alternative management during intraoperative hemorrhage. However, the anticipation and effect that might arise from hemodilution should be considered.
... The platelet concentration should be kept at or above 100000/cubic millimetres. [18] In our case patient had crossed 36wks and her haemoglobin was 13.4g/dl with pre-eclampsia which could be due to hemoconcentration. Intraoperatively 3 units of packed RBC (PRBC) and 3 units of FFP were transfused as estimated loss in peripartum hysterectomy was2000ml. ...
Background: The placenta is a complicated organ and is partially understood. It is the essential part for physiological changes leading to a successful pregnancy. Placenta percreta is the most severe and least common form of placenta accreta in which villi penetrate the entire myometrial thickness and reach or traverse the serosa to encroach adjacent organs. Patients with placenta percreta are at a greater risk of life-threatening perioperative bleeding as well as massive and deadly thromboembolic events. Case report: Our patient was a 34-year-old gravida 5female who underwent elective cesarean section at 37 weeks of gestation with a diagnosis of placenta accreta or percreta. Intraoperative findings showed placenta percreta with bladder wall involvement. Hence, hysterectomy was done. Anticipated intraoperative haemorrhage and hemodynamic instability were managed properly. Discussion: Placenta percreta is the most serious among abnormal placentation, sometimes leading to catastrophic blood loss and very high maternal mortality and morbidity up to 10%. The most important risk factor in placenta percreta is placenta previa (low lying placenta) after cesarean delivery. Our patient met all these risk factors. Prenatal diagnosis of an invasive placenta is paramount for reducing maternal morbidity and mortality by implementing a multidisciplinary approach. Keywords: haemorrhage, placenta percreta, hysterectomy, high-risk pregnancy.
