Placenta previa with posterior extrauterine adhesion: clinical features and management practice

Yoshikazu Nagase, Shinya Matsuzaki, Masayuki Endo, Takeya Hara, Aiko Okada, Kazuya Mimura, Kosuke Hiramatsu, Aiko Kakigano, Erika Nakatsuka, Tatsuya Miyake, Tsuyoshi Takiuchi, Yutaka Ueda, Takuji Tomimatsu, Tadashi Kimura, Yoshikazu Nagase, Shinya Matsuzaki, Masayuki Endo, Takeya Hara, Aiko Okada, Kazuya Mimura, Kosuke Hiramatsu, Aiko Kakigano, Erika Nakatsuka, Tatsuya Miyake, Tsuyoshi Takiuchi, Yutaka Ueda, Takuji Tomimatsu, Tadashi Kimura

Abstract

Background: A diagnostic sign on magnetic resonance imaging, suggestive of posterior extrauterine adhesion (PEUA), was identified in patients with placenta previa. However, the clinical features or surgical outcomes of patients with placenta previa and PEUA are unclear. Our study aimed to investigate the clinical characteristics of placenta previa with PEUA and determine whether an altered management strategy improved surgical outcomes.

Methods: This single institution retrospective study examined patients with placenta previa who underwent cesarean delivery between 2014 and 2019. In June 2017, we recognized that PEUA was associated with increased intraoperative bleeding; thus, we altered the management of patients with placenta previa and PEUA. To assess the relationship between changes in practice and surgical outcomes, a quasi-experimental method was used to examine the difference-in-difference before (pre group) and after (post group) the changes. Surgical management was modified as follows: (i) minimization of uterine exteriorization and adhesion detachment during cesarean delivery and (ii) use of Nelaton catheters for guiding cervical passage during Bakri balloon insertion. To account for patient characteristics, propensity score matching and multivariate regression analyses were performed.

Results: The study cohort (n = 141) comprised of 24 patients with placenta previa and PEUA (PEUA group) and 117 non-PEUA patients (control group). The PEUA patients were further categorized into the pre (n = 12) and post groups (n = 12) based on the changes in surgical management. Total placenta previa and posterior placentas were more likely in the PEUA group than in the control group (66.7% versus 42.7% [P = 0.04] and 95.8% versus 63.2% [P < 0.01], respectively). After propensity score matching (n = 72), intraoperative blood loss was significantly higher in the PEUA group (n = 24) than in the control group (n = 48) (1515 mL versus 870 mL, P < 0.01). Multivariate regression analysis revealed that PEUA was a significant risk factor for intraoperative bleeding before changes were implemented in practice (t = 2.46, P = 0.02). Intraoperative blood loss in the post group was successfully reduced, as opposed to in the pre group (1180 mL versus 1827 mL, P = 0.04).

Conclusions: PEUA was associated with total placenta previa, posterior placenta, and increased intraoperative bleeding in patients with placenta previa. Our altered management could reduce the intraoperative blood loss.

Keywords: Adhesion; Bakri balloon; Endometriosis; Magnetic resonance imaging; Placenta previa.

Conflict of interest statement

Shinya Matsuzaki is an Associate Editor for BMC Pregnancy and Childbirth. The authors declare no conflicts of interest (COI) about this study. All of authors have no competing financial interests regarding this study.

Figures

Fig. 1
Fig. 1
Intrauterine balloon insertion method using a Nelaton catheter as a guide. a A 26-French Nelaton catheter is used and connected to the blood drainage port of a Bakri balloon. The Nelaton catheter is inserted from the uterine incision to the vagina through the cervix. b Insertion of a Bakri balloon using a Nelaton catheter as a guide for cervical passage. Safe and easy placement of an intrauterine balloon, even in a strongly bent uterus, is possible using a Nelaton catheter with appropriate stiffness as a guide
Fig. 2
Fig. 2
Assessment of the relationship between changes in practice and intraoperative blood loss. Abbreviations: Pre pre-change posterior extrauterine adhesion group; Post post-change posterior extrauterine adhesion group
Fig. 3
Fig. 3
Illustration demonstrating the difficulty of Bakri balloon insertion in patients with posterior extrauterine adhesion. Intrauterine balloon tamponade without using a Nelaton catheter as a guide requires additional time for a transvaginal and b transabdominal placement because the balloon catheter is bent by strong retroflexion of the uterus and the longer cervical length

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