Vascular Clamps in Perimortem Caesarean Delivery in Parturients with Placenta Accreta Spectrum: Case Report and Literature Review : Journal of Obstetric Anaesthesia and Critical Care

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Case Report

Vascular Clamps in Perimortem Caesarean Delivery in Parturients with Placenta Accreta Spectrum: Case Report and Literature Review

Dogra, Sandipika1; Surampadi, Kameswari2; Madapu, DA Manokanth3; Pandya, Sunil T1,4,5,

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Journal of Obstetric Anaesthesia and Critical Care 13(1):p 94-98, Jan–Jun 2023. | DOI: 10.4103/JOACC.JOACC_33_22
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Abstract

Introduction

India reports an increasing trend in the incidence of caesarean sections (CS). The National Family Health Survey (NFHS)-5 of 2019–21 reports an increase in the incidence of CS in India from 17.2% in 2015–16 to 21.5% in 2019–21.[1] The rates of CS differed by urban (32.3%) and rural (17.6%) and by private (47.4%) and public (14.3%) sector hospitals.[1] Severe PAS can lead to disastrous consequences in childbirth including rupture of the uterus, major surgical morbidity and damage to adjacent structures, coagulation disorders and major haemorrhagic shock, near miss events and maternal mortality.[2–4] Previous studies have reported an average operative blood loss of 3000–5500 mL or even greater, in addition to major urologic morbidities in 7–66.7% of patients and venous thromboembolisms in 4–10.3%.[2,3,5]

Attempts to separate the abnormal invasive placenta after childbirth can cause severe bleeding. Bleeding in placenta accrete spectrum (PAS) disorders may be attributed to the widespread development of intrapelvic vascular anastomosis by arteries to the gravid uterus.[4] Total hysterectomy after foetal delivery is recommended for an invasive placenta but there can be severe blood loss during the surgery. A clear and dry surgical field that makes the surgical procedure easier and reduces blood loss may possibly be achieved by reducing uteroplacental blood flow. Internal iliac artery ligation or balloon occlusion has shown limited success in the management of PAS disorders.[6–8] Balloon occlusion of the infrarenal aorta or common iliac artery has also been attempted to control the bleeding.[9–11] However, balloon occlusion techniques need interventional radiology support that is available only at select institutes. The risk of serious maternal thromboembolic events associated with the use of balloon occlusion was reported to be 5–15.8%.[12–14]

Case Series

Case 1

The first case was a 34-year-old Gravida 4 Para 3 Living 3 with a body mass index of 32, with two prior CSs and placenta percreta in the current pregnancy. The pre-anaesthetic assessment was unremarkable except for Mallampati Grade II. The patient and the family were counselled for regional anaesthesia and the possible need to convert to general anaesthesia if there was a major obstetric haemorrhage. The family was also counselled about the possibility of the need for multiple donors, apheresis platelet concentrate, massive transfusion and associated risks, intensive care unit (ICU) admission, need for post-operative mechanical ventilation and organ supports.

As per the standard protocol at the study institute, 4 units of packed red blood cells (PRBCs), 4 units of fresh frozen plasma (FFPs) were procured and another 6 units of PRBCs, FFPs, 10 units of cryo-precipitates and 6 units of random platelets were reserved. The patient received acid aspiration prophylaxis (Tab. omeprazole 20 mg and Tab. metoclopramide 10 mg) the previous night and 2 h before surgery.

A standard multidisciplinary team approach for PAS was in place (2 anaesthesiologists, 2 anaesthesia technicians, and experienced surgical/nursing teams). The patient was taken up for category IV caesarean section—planned peripartum hysterectomy under combined spinal epidural anaesthesia at 34 weeks of gestational age and received steroids for foetal lung maturity. 14 G and 16 G two peripheral lines were inserted under local anaesthesia followed by the right radial arterial line and right internal jugular, triple lumen central lines under ultrasound guided were also placed under local anaesthesia. The surgery was started after ascertaining an adequate level of block up to D4 dermatomal level. Mechanical compressive stockings were activated as well as the convection warmer with fluid warmer was in use. Bilateral ureteric stents were placed, and the abdomen was opened by a midline skin incision. Placental invasion of the bladder was noted. Major sinuses were doubly ligated. The baby was delivered by classical section, a transverse uterine incision in the upper segment of the uterus. The baby had APGAR scores of 10 at 5 min.

As peripartum hysterectomy was planned, she was not administered any uterotonic agents to minimise retraction and contraction of the uterus so as to avoid the avulsion of major sinuses. However, the patient started bleeding torrentially (quantified blood loss of about 12 L in <15 min) [Figure 1]. Patient was immediately intubated with modified rapid sequence induction—intubation method using ketamine 100 mcg, fentanyl 100 mcg, suxamethonium 100 mg and atracurium bolus 40 m followed by 20 mg per hour infusion. The parallel anaesthesia personnel was focused on volume resuscitation and quantification of blood loss/blood procurement.

F1
Figure 1:
Massive and sudden catastrophic blood loss, each suction jar capacity is 3L, plus the surgical mops (not seen in this pic)

Despite rapid administration and balanced salt solutions (4.5 L) and PRBC transfusions (2 U), patient had acute collapse, arterial trace disappeared and a near arrest situation developed [Figures 1, 2 and 3].

F2
Figure 2:
Parameters immediate post classical Cesarean delivery, good contractile trace and stable parameters
F3
Figure 3:
Tachycardia not much compared to blood loss, Loss of pulsatality on the plethysmographic trace and flat arterial trace (nil artifact), imminent cardiac arrest state

Standard protocols for the prevention of hypotension by pressure infusions of warm fluids and lethal quad (Hypothermia, acidosis, coagulopathy, and hypocalcemia) strategies were continually monitored and proactively corrected. Despite that, the patient’s temperature dropped to 36°C and base deficit to − 16 necessitating the initiation of noradrenaline infusion (0.4 mcg/Kg/min). Additional blood and components were procured and aggressive strategies to maintain MAPs of >65 mm Hg were continuously on. However, the haemodynamic parameters failed to improve despite the aggressive fluid administration and blood tranfusions, as the surgeons were unable to control the haemorrhage. The patient was on FiO2 of 1, ketamine (200 mg), fentanyl (200 mcg) and midazolam (5 mg) in 50 mL NS mixture (KFM Mixture) was initiated at the rate of 5 mL per hour to prevent awareness.

As the patient lost approximately 12 L of blood in <15 min, profound hypotension and oliguria persisted, as a last resort, the vascular clamp was placed on the aorta, infra renally. The surgical field became a little dry and haemodynamic trace also improved [Figure 4]. Vascular injury to the base of the bladder was identified and ligated. Subsequently, the vitals stabilised and the peripartum hysterectomy was uneventful. KFM mixture infusion rate was lowered and sevoflurane with oxygen (50%): air (50%) restarted. The aortic clamp time was about 35 min and prior to clamp release, sodabicard 1 mmol/kg was administered. No haemodynamic perturbations or metabolic acidosis on ABGs were noted. The patient received Inj. Tranexamic acid 1 G was repeated again after 30 min, 12 U PRBCs, 12 U of FFPs, and 6 U of random platelets. A received an additional dose of antibiotic as the total duration of surgery was for 4 h. Fibrinogen levels were 240 mg/dl.

F4
Figure 4:
Improving arterial trace post aortic clamp application

Post-operatively patient was electively ventilated for 6 h. The family was counselled again, and the relatives accepted the condition well as they were already educated and counselled pre-operatively by all the teams. Supportive measures and ERAS protocol were implemented. Subsequent courses in the ICU and hospital were uneventful.

This case highlights the usefulness of the surgical technique using the aortic vascular clamp when standard measures to control catastrophic haemorrhage fail in PAS cases

Case II

A G3, A2, aged 29 years, 30 weeks pregnant patient, hypothyroid on 125 mcg of eltroxin, GDM on metformin, morbidly obese and BMI of 40, was referred with the diagnosis of placenta percreta made elsewhere. The patient was counselled for admission, betamethasone for foetal lung maturity, MRI abdomen to define the extent of placental invasion and blood and component reservation with a tentative plan for termination if the need arose.

The patient suffered maternal cardiac arrest (MCA) (Asystole) in the MRI suite towards the completion of the MRI sequence and code blue was announced. CPR was initiated in the MRI suite and the patient was shifted to the adjacent emergency room (ER) for further ACLS measures. Within 3 min of cardiac arrest, the patient was shifted to ER with CPR and manual left uterine displacement on and was intubated (aided with bougie), ACLS measures were continued.

Diagnosis of percreta with bladder invasion was confirmed on MRI.

Resuscitative hysterotomy was performed at 7th min in the ER. Even post-hysterotomy, the asystole rhythm continued.

While resuscitative hysterotomy was being done, questions were raised on the possibility of haemorrhage in view of placenta percreta invading the bladder, post-ROSC. Hence the vascular clamps were procured; however, ROSC could not be achieved, and the patient was in persistent asystole despite aggressive ACLS measures. CPR was abandoned after 45 min.

Introspection revealed delay at every stage, BLS initiated by the radiology team was suboptimal and manual left uterine displacement was not done till the code blue team arrived. Code blue team took about 2 min to assemble and transit to ER (3 min), again the quality of BLS was suboptimal and once in ER despite the best ACLS measures, the patient could not be revived.

While resuscitative hysterotomy was performed, the team raised a very valid discussion of tackling major haemorrhage post-ROSC, in view of placenta percreta and non-availability of vascular clamps in standard perimortem caesarean delivery (PMCD) sets. Thus, it was hypothesised that the availability of clamps should be a standard norm in all PMCD sets given the current incidence of PAS increasing progressively.

Discussion

The management of PAS disorders in developed countries often involves multidisciplinary teams that include obstetricians, anaesthesiologists, vascular surgeons, haematologists, interventional radiologists and other specialists like urologists. The blood bank and critical care infrastructure are essential components as massive volumes of blood may have to be transfused. However, such resources are available only in advanced tertiary care centres, if at all, in developing countries and setting up a multidisciplinary team may not be pragmatic.

The use of vascular clamps provides a viable alternate in low resource settings. This becomes essential as when there is a catastrophic maternal haemorrhage in PAS patients, however skilful the resuscitative measures by the anaesthesia teams are if surgical control is not achieved, all efforts become futile.

The Paily Aortic Clamp is a simple straight instrument with blunt overlapping tips that guard the vessel from slipping out of the clamp.[15] The blades feature a smooth inner surface and maintain a gap of 2 mm between the blades even on maximum closure to prevent crush injury to the vessel wall and vaso-vasorum of the aorta.[15] Peritoneal dissection or vessel skeletonization is not needed avoiding the risk of injury to the inferior vena cava or the posterior lumbar vessels.[15] The clamping force is stopped when the pulsations cease in the common iliac arteries. The clamp is applied for as short a time as possible and removed after hysterectomy or placental removal.

Although the aorta is clamped, protective mechanisms through anastomotic pathways including the inferior mesenteric artery, left colic artery, superior rectal artery, vaginal artery, posterior anastomosis, the ovarian artery and the vascular channels of the spinal lumbar artery help circulation.[16] The muscle glutathione redox status is not altered after an ischemic duration of 1 h and ischemia of a 2 h duration was found to be associated with changes in muscle energy-rich compounds, but without change in the glutathione redox status.[16,17] The extent of necrosis (mean ± SEM) was found to be 2.0 ± 0.9%, 30.3 ± 6.0% and 90.1 ± 3.5% after 3, 4 and 5 h of ischemia, respectively.[18] Cardiac procedures with safe time limits of aortic cross-clamping (<150 min) were associated with a rather low risk of immediate post-operative adverse events.[19] It is recommended that the maximum duration of aortic cross-clamping should not exceed 60 min and be as short as possible using the minimum occlusive force sufficient to stop blood flow.[5,15]

Paily et al.[15] reported that 33 women of varying grades of PAS had positive surgical outcomes with no clamp-related adverse events in their series that used aortic clamps. They reported that the aortic clamp was applied for a median duration of 55 ± 20 min, the median measured blood loss was 1000 ± 1500 mL and only 51.5% cases needed transfusion including 21.2% that needed a massive transfusion of more than 4 units. The median drop in post-operative haemoglobin was only 0.7 ± 1.7 gm/dL in those that did not need a massive transfusion. They reported a ureteric injury in one patient that was successfully repaired.

Chou et al.[5] reported from their series of 31 patients that the mean estimated blood loss (EBL) was 2295.6 ± 2126.1 mL, average transfusion required was 5.8 ± 4.1 units of PRBCs, 6.7 ± 5.1 units of FFPs and 2.6 ± 4.3 units of single-donor platelets. Two patients (6.5%) suffered inadvertent bladder injuries and 1 patient (3.2%) sustained bladder and ureteral injuries, which were repaired immediately and healed uneventfully. The mean duration of infrarenal aortic cross-clamping was 54.2 ± 8.6 min.

Sucu et al.[20] studied 32 patients that underwent bilateral common iliac artery temporary clamping in cases of caesarean hysterectomy in placenta percreta cases. They reported that the estimated blood loss was lower in the temporary clamping of the common iliac artery group than in the control group (595 ± 172 mL vs. 1450 ± 662 mL, P < 0.001) and the number of intraoperative PRBCs and FFPs transfusions were significantly lower in the temporary clamping group than the control group. The duration of surgery was longer in the temporary clamping group (140 ± 38 min vs. 90 ± 25 min, P = 0.001) and no complications or maternal death was reported in this study.

Jose’ Miguel Palacios-jaraquemada et al.,[21] in their multicentre retrospective case series from tertiary referral hospitals in Argentina, described a technique of conservation of the uterus Using the resective-reconstructive approach (one-step conservative surgery) to the management of invasive placenta, the uterus can be preserved with minimal morbidity and reduced blood loss in almost 80% of cases preventing hysterectomy in 80% of placenta accreta spectrum.

Our experience and the evidence from the literature suggest that there are multiple methods requiring a learning curve for every technique to tackle PAS cases electively.

However, when there is an emergency and or a torrential haemorrhage in PAS cases, the judicious use of vascular clamps in low resource settings (short learning curve) can be a life-saving measure that reduces intraoperative blood loss, minimises massive obstetric haemorrhages and thus the need for massive blood transfusions and provide a clean surgical field for better operative outcomes. These clamps must be made an integral part of the standard resuscitative hysterotomy sets in all settings.

Conclusion

The increasing trend of CS might lead to an increased incidence of PAS disorders in the future. While the resuscitative skills to maintain cardio-respiratory systems are vital to preserve organ functions in settings of catastrophic haemorrhage, surgeons can familiarise themselves with the use of clamps through simulator labs to consolidate the resuscitation goals by controlling surgical haemorrhage. There is a short learning curve associated with the use of vascular clamps.

Resuscitative Hysterotomy (PMCD) following MCA in a parturient with placenta percreta requires a competent anaesthesia and surgical team well versed with medical and surgical management of a major obstetric haemorrhage. MCA is associated with dry surgical fields as pressures are not recordable, however, once ROSC is achieved, parturient is likely to bleed from PAS site. The provision of vascular clamps with the perimortem caesarean delivery kit will be a useful addition as it allows the obstetric team the flexibility to provide rapid control of blood loss without the need for higher end equipment or scarce interventional radiology support and avert a possible double whammy of major haemorrhage following ROSC. This becomes essential when there is a catastrophic maternal haemorrhage in PAS patients as all efforts can become futile, even with appropriate resuscitative measures by the anaesthesia teams, if surgical control is not achieved.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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Keywords:

Major obstetric haemorrhage; massive transfusion; maternal cardiac arrest; perimortem caesarean delivery; placenta accreta spectrum; resuscitative hysterotomy; vascular clamps

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