Management of bleeding from morbidly adherent placenta during elective repeat caesarean section: retrospective -record -based study

Abstract

Background: Controlling massive haemorrhage from morbidly adherent placenta (MAP) at caesarean section is a major surgical challenge to obstetricians. This study compares different intra-operative interventions to control haemorrhage from morbidly adherent placenta and its impact on maternal morbidity.

Methods: Retrospective analysis was done for baseline characteristics, intra-operative and postoperative complications of 125 patients with morbidly adherent placenta who had elective CS at 35-38 weeks gestation in the period from 01/2012 to 01/2017. The included patients were categorized into three groups according to intra-operative interventions they had for controlling bleeding; Group A (n = 42) had only balloon tamponade, Group B (n = 40) had balloon tamponade and bilateral uterine artery ligation, in Group C (n = 43) all cases were managed by bilateral uterine artery ligation and inverting the cervix into the uterine cavity and suturing the anterior and/or the posterior cervical lips into the anterior and/or posterior walls of the lower uterine segment using the cervix as a natural tamponade.

Results: There were no differences of baseline characteristics of patients in all groups. Group C had significantly better outcomes as compared with groups A and B; less total blood loss (Group C 2869.5 ml vs Group B 4580 ml, Group A 4812 ml, P < 0.001), less requirement of blood transfusion more than 4 units (Group C 4/43, Group B 10/40,Group A 12/42, P < 0.02), significant reduction in prolonged hospital stay over 10 days (Group C 2/43, Group B 9/40,Group A 14/42, P < 0.001) and lower risk of coagulopathy (Group C 4/43, B 8/40, A 9/42), visceral injuries (Group C 4/43 vs B 8/40, A 10/42,P < 0.01) and need for hysterectomy (Group C 4/43 vs B 11/40, A 13/42,P < 0.001).

Conclusion: A combination bilateral uterine artery ligation and using the cervix as a natural tamponade are very effective and simple methods in controlling bleeding resulting from separated placenta accreta.

Trial registration: The findings are part of the research project registered in ClinicalTrials.gov NCT02590484 . Registered 28 October 2015.

Keywords: Cervix; Major obstetric haemorrhage; Morbidly adherent placenta; Natural tamponade.

Conflict of interest statement

Ethics approval and consent to participate

This study was approved by the ethical committee of the Department of Obstetrics and Gynaecology, Minia University Hospital on 4/12/2011 (Registration number: MUH14368).

Participants signed a written informed consent about the procedure(s), the risks including occurrence of massive postpartum haemorrhage (PPH), blood transfusion, the use of conservative methods and the possibility of proceeding to emergency hysterectomy with the accompanying risk of injury to adjacent structures as the bladder, ureters and bowel.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Figures

Fig. 1

showed site of closely attached chorionic villi to the myometrium; stained by hematoxylin and eosin × 100