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Precision Surgery for Placenta Previa Complicated with Placenta Percreta

Chen, Juan-Juan1; Yu, Lin1; Su, Chun-Hong1; Zhang, Chun-Fang1; Chen, Yan-Hong1; Zhou, Yan-Mei1; He, Wen-Jun1; He, Fang1; Song, Ting2; Wang, Shou-Ping3; Su, Zhi-Yuan3; Jiang, Qing-Ping4; Zou, Zi-Hao5; Yu, Bin2; Shen, Xiao-Ya1; Guan, Xiao-Ming6; Chen, Dun-Jin1,*

Section Editor(s): Pan, Nan Zhang and Yang

doi: 10.1097/FM9.0000000000000004
Original Article
Open

Objectives: To investigate whether a precise circular resection of the uterine tissue at the placental attachment part is effective in cases with placenta previa complicated with placenta percreta (PPWPP).

Methods: Patients diagnosed with PPWPP were assessed for pregnancy termination at 34–36 weeks of gestation. During the operation, we performed circular resection of the uterine tissue at the placental attachment part. Then the characteristics of the operation and the follow-ups were recorded.

Results: During the operation, the vital signs were stable. The mean intraoperative blood loss, packed red blood cells units transfusion, fresh frozen plasma transfusion, and operation time were 2140 mL, 6 U, 440 mL, and 179.8 minutes, respectively. There was no bowel, ureter, or bladder injury. And there was no patient transferred to the ICU after operation. The mean postoperative blood loss was 458.6 mL. There was no fever, infection, intestinal obstruction, or other complications after operation during the hospitalization. The shape and the blood flow of the uterus were normal. After the patients were discharged, one had developed cesarean scar diverticulum. The mean lochia duration was 30 days. The menstrual cycle and volume were as before. The shape and the blood flow of the uterus and the ovarian were normal.

Conclusions: The circular resection following end-to-end anastomosis is an effective precision surgical approach for PPWPP. It can achieve the purpose of hemostasis while maximizing the protection of organ function and reducing surgical trauma.

1Key Laboratory for Major Obstetric Diseases of Guangdong Province, Department of Gynaecology and Obstetrics, Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, China

2Department of Radiology, Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, China

3Department of Anesthesiology, Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, China

4Department of Pathology, Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, China

5Department of Urology, Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, China

6Department of Obstetrics & Gynecology, Baylor College of Medicine, Houston, USA.

Corresponding author: Dun-Jin Chen, Key Laboratory for Major Obstetric Diseases of Guangdong Province, Department of Gynaecology and Obstetrics, Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, China. E-mail: chendunjin@hotmail.com

Juan-Juan Chen and Lin Yu contributed equally to this study.

Received May 21, 2019

This is an-open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0

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Introduction

The strategy of precision surgery is to seek a balance of maximizing the removal of the target lesion, while maximizing the functional organ remnant and minimizing surgical invasiveness. With the implementation of the second child policy in China, more and more elder women with a history of cesarean section have become pregnant again. Zeng et al. reported that among the pregnant women, 14.9% had a cesarean delivery previously.1 The placenta accreta spectrum rate increased from 0.1% in 2007–2008 to 2.1% in 2015–2016, alongside a rise in elective repeat cesarean delivery from 5.0% to 38.4%. For the United States, it has been estimated that by 2020 the cesarean delivery rate will be over 50% and there will be an additional 4504 annual cases of placenta accreta spectrum disorders and 130 maternal deaths due to its complications.2 Life-threatening hemorrhage is the major concern for these patients,3 especially for the patients diagnosed with placenta previa complicated with placenta percreta (PPWPP). In majority of the cases with abnormal placentation, clinicians prefer to perform cesarean hysterectomy.

In order to achieve precise treatment, we performed ultrasonography and MRI to ensure precise preoperative planning. During the operation, we performed circular resection of the uterine tissue at the placental attachment part to achieve the purpose of hemostasis while maximizing the protection of organ function and reducing surgical trauma. We proposed that the concept of precision surgery should be considered for wider application in PPWPP and other obstetrical surgery.4

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Methods

Treatment Plan and Study Oversight

The treatment described in this article was delivered to patients on the basis of their clinical circumstances, without specific testing of a research hypothesis. All the authors participated in the design of the treatment plan, data collection and analysis, and in the writing of this article. The study received no industry support.

All the patients received a detailed explanation of the risks of treatment from the obstetrician who was responsible for the surgery. All the patients provided written informed consent to treatment. The study protocol was approved by the ethics committee of Guangzhou Medical University [code number: 2016 (0406)], and informed consent was obtained from all participants.

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Study patients

The patients with PPWPP were chosen for circular resection. Eligibility criteria for circular resection are as follows: (1) one or more prior cesarean deliveries; (2) diagnosed with PPWPP by ultrasound or MRI, the placenta percreta position was in the lower part of the anterior and posterior uterine wall; (3) a strong desire to retain the uterus; (4) the placenta was implanted to the myometrium of the uterus, and it cannot be stripped in the operation. Cesarean section hysterectomy was encouraged if the vital signs were not stable.

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Patient management workflow

The procedural workflow for the management of PPWPP is shown in Figure 1. All five patients were diagnosed with PPWPP by ultrasonography and MRI, showing the placenta was extended from the anterior to the posterior wall and embedded within the lower uterine segment. They were assessed for pregnancy termination at 34–36 weeks of gestation. During the operation, we performed circular resection of the uterine tissue at the placental attachment part (the details are provided in the following section).

Figure 1

Figure 1

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Operative Procedures

Guided by ultrasonography and MRI, we precisely located the position of the placenta implanted preoperation. Then we performed circular resection of the lower uterine segment during the operation. The approach mainly included the following four steps (Fig. 2).

Figure 2

Figure 2

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Delivery of the infant avoiding the placenta (Step 1)

The upper uterine segment was incised transversely, being careful not to compromise the placenta. Then the fetus was immediately delivered via this transverse uterine incision above the upper border of the placenta. To enhance uterine contractions and reduce blood loss, oxytocin and carboprost tromethamine were injected into the uterus rapidly.

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Separation of the urinary bladder and compression of blood flow in the lower segment of the uterus by tourniquet (Step 2)

With the infant delivered, gently push the bladder via the back or the side of the uterus, until the bladder is completely detached from the anterior uterine wall. As the anterior wall of the uterus was invaded by the placenta, there was no clear boundary of separation between the bladder and the uterus. During the process, the broad ligaments were divided in order to expose the lower uterine segment. Then a tourniquet was passed through the lower uterine segment and ligated below the placenta, this approach can reduce the blood circulation from the uterine vessels and creates conditions for the further surgical procedures.

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Precise resection of the uterine segments invaded by the placenta (Step 3)

After tying the tourniquet, the part of the placenta was delivered out of the uterine incision by uterine contractions. However, the part in lower uterine segment where the placenta invaded was hypervascularized, placental removal was difficult. Therefore, we performed circular resection of the invaded area of the uterus segments. Ensure that the lower edge of circular resection should be performed beneath the lowest margins of placental invasion, and the upper edge of circular resection should be performed upon the highest margins of placental invasion to minimize bleeding. So the lower uterine segment invaded by the placenta was completely removed. The tourniquet was loosened to evaluate whether the active bleeding comes from the uterine incision. If there was active bleeding, we can ligate the uterine artery, local suture, or uterine packing. If the bleeding was uncontrolled, we should proceed with hysterectomy.

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Closure of the lower uterine segments with end-to-end anastomosis (Step 4)

After placenta and damaged myometrium were removed, closing of the transverse incision of the uterine segment was done with two-layer sutures. Then end-to-end anastomosis following circular resection of lower uterine segments was performed. In the process of anastomosis, we should pay attention to restore the shape of the uterus.

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Observation and follow-up

The patients were discharged 5–7 days after operation. They were observed in the outpatient clinic with obstetricians 42 days, 6 months, 1 year, and 2 years after treatment to determine whether there were long-term complications. The variables of interest included lochia, abdominal incision, menstruation, shape, and blood flow of the uterus.

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Results

Patients

From January 2016 through February 2017, five patients were evaluated for circular resection.

Table 1 outlines the demographic and clinical characteristics of each patient. The mean age of the five patients was 30 years (range: 26–34 years). The mean gravidity was 2.8 (range: 2–4). All patients had history of cesarean delivery, one of them had two times, and the others had only one time. Two of them did not have a history of dilation curettage, and three of them had once. The mean interpregnancy interval was 2.6 years (range: 1–6). The mean gestational age at delivery was 35 + 4 weeks (range: 34 + 2 to 37). Two of them had a history of vaginal bleeding during the pregnancy, the other three had no bleeding. The ultrasound and MRI findings of the five patients were characterized by placenta previa complicated with percreta in the lower part of the anterior and posterior uterine wall (Fig. 3).

Table 1

Table 1

Figure 3

Figure 3

All of the five patients had well-planned surgery. The mean hemoglobin value before operation was 101.8 g/L (range: 89–120 g/L). Then we did the operation as introduced. During the operation, the vital signs were stable. The mean intraoperative blood loss was 2140 mL (range: 1000–3500 mL). The mean crystalloid infused was 4060 mL (range: 2200–5000 mL). The mean packed red blood cell (PRBC) unit transfused was 6 U (range: 0–12 U). The mean FFP transfused was 440 mL (range: 0–1000 mL). The mean operation time was 179.8 minutes (range: 135–199 minutes). There was no bowel, ureter, or bladder injury. And there was no patient transferred to the ICU unit after operation.

For the neonates, the mean birth weight was 2688 g (range: 2180–3450 g), the mean Apgar scores at 1 minute, 5 minutes, and 10 minutes were 7.8, 9.4, and 10 points (range: 6–10, 7–10, and 10 points for each).

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Follow-up

After operation, the patients were transferred to the MICU. The mean postoperative blood loss was 458.6 mL (range: 196–746 mL). Only patient 1 needed to transfuse blood products—PRBC 6 units and PPF 600 mL. There was no fever, infection, intestinal obstruction, or other complications after operation during the hospitalization. Before they were discharged, ultrasound of the uterus was performed. The shape and the blood flow of the uterus were found normal. The mean postoperative length of stay was 6.2 days (range: 4–9 days).

After the patients were discharged, one had developed cesarean scar diverticulum. The mean lochia duration was 30 days (range: 20–40 days). The mean menstrual recovery time was 6.2 months (range: 3–11 months). The menstrual cycle and volume were as before. The shape and the blood flow of the uterus and the ovarian were normal (Fig. 4).

Figure 4

Figure 4

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Discussion

Hysterectomy is a shared endpoint for postpartum hemorrhage after vaginal or cesarean delivery; in majority of the cases with abnormal placentation, clinicians prefer to perform cesarean hysterectomy.4 However, hysterectomy is not only associated with permanent sterility but also potential physiological and psychological disorders. More and more patients hope to get much more precise treatment.

The precision medicine model promises that the fundamentals of health care, including assessments, medical decisions, and treatments, will be customized to the individual. In this study, we performed ultrasonography and MRI to observe the size and location of the placenta.5 Also, we could figure out the relationship between the placenta and the uterine wall or the adjacent organs. During the operation, we performed circular resection of the uterine tissue at the placental attachment part to achieve the purpose of maximizing the removing of the bleeding part to hemostasis while maximizing the protection of organ function and reducing surgical trauma. While retaining the function of fertility, it is more important to avoid serious surgical complications, as well as the occurrence of physiological and psychological disorders.

The patients who underwent hysterectomy may adopt uterine transplantation to generate life. But the procedure is still in the preclinical stages and several ethical, legal, social, and religious concerns are yet to be addressed before it can be integrated into the clinical setting as standard of care for women with absolute uterine factor infertility.6 However, hysterectomy is not only associated with permanent sterility but also potential surgical complications. Six small studies have shown that bladder injuries range from 6% to 12% and ureteral injuries range from 0.4% to 41%.7 Other common risks include hemorrhage, wound complications, and venous thromboembolism, which are increased with peripartum hysterectomies.8 In addition to reproductive function, the uterus and ovary have important metabolic functions. Even when the ovaries are preserved, ovarian failure can occur after a hysterectomy.9 The most commonly held view is that ovarian function may be deteriorated due to damage to the ovarian blood supply during surgery.10 A recent study demonstrated that total abdominal hysterectomy affects ovarian function even if the ovarian blood supply is normal.11 When a hysterectomy is performed, there is disruption of the local nerve and blood supply and the intimate anatomical relationships of the pelvic organs. The nerve supply may be damaged in several ways: The main branches of the nerve plexus that traverse beneath the uterine artery may be cut during division of the cardinal ligaments,12 extensive dissection of the paravaginal tissue may disrupt the pelvic neurons passing from the lateral aspect of the vagina.13 The patients having radical hysterectomy had a high incidence of sexual dysfunction.14 Therefore, hysterectomy may not be a good choice for patients who are very young and wish to remain fertile and preserve their uterus.

To achieve precise treatment, circular resection can be an alternative to total hysterectomy in PPWPP. For the patient with PPWPP, the placenta is mainly attached to the lower part of the uterus; placenta often implant to the previous uterine incision and the surrounding area. After the fetus is delivered, the contraction of the upper uterine is always good. But the lower segment, where the placenta implanted, has abundant blood flow and the muscular layer was damaged by placenta, resulting in no contraction and fatal obstetric hemorrhage. Therefore, we created a novel approach (precise local excision) to solve this problem with fewer complications. The approach described here is to resect the lower uterine segment where the placenta located. Uterus isthmus of nonpregnant women is about 1 cm and that is extended to form the lower uterine segment about 7–10 cm during pregnancy and the thinning of the muscle wall occurs. We choose this place to do circular resection as it has the advantages of simple operation, less bleeding, better healing, and less complications. The lower part of the uterus removed during surgery is minimal, most of the uterine body and cervix was retained. Therefore, circular resection of the lower uterine segment does not affect shape and function of the uterine.

There are several techniques to control hemorrhage in lower uterine segments during cesarean delivery for complete placenta previa,15,16 including Cho's hemostatic suturing technique,17 Hwu's parallel vertical compression sutures,18 and circular isthmic-cervical sutures.19 Other strategies include procedure using Foley catheter20 to compress the lower uterine segment. However, these methods of suture in the lower uterine segments are ineffective in severe cases. Triple-P procedure21 using balloon catheters occludes internal iliac artery blood flow in order to reduce the amount of bleeding. Compared to the balloon catheters, tourniquet is rather easy to access. Anyways, triple-P procedure21 describes placental nonseparation with myometrial excision and reconstruction of the uterine wall. This idea is consistent with our surgical approach, but the difference is that they did not attempt to remove all of the lower uterine segments, Our method can solve the more serious cases that cannot be solved by simple local excision.

All of the five patients were diagnosed with placenta percreta according to the guidelines by the Chinese Medical Association Perinatal Medicine Branch and ACOG. 22,23 The surgical treatment was conducted by the same MDT. Clinically, with inappropriate management, placenta percreta is always followed by massive obstetric hemorrhage, leading to disseminated intravascular coagulopathy, the need for hysterectomy, surgical injury to the ureters, bladder, bowel, or neurovascular structures, acute transfusion reaction, and renal failure. The average amount of bleeding can be as high as 3000–5000 mL,24 and placenta percreta is likely to lead to adverse maternal outcomes.25–27 For the five patients, the mean intraoperative blood loss was 2140 mL, which was less than the average amount of bleeding as reported.24 There was no surgical injury and other adverse maternal outcomes. Of the five cases, the second case was the most bleeding patient, about 3500 mL, and was transfused 12 U PRBC. The reason is closely related to the abdominal adhesion in this case. Because of the adhesion of the anterior wall of the uterus to the peritoneum, the surgical field of vision is not clear and the difficulty of the operation is increased. During the postnatal follow-up, the second patients had longer menstrual duration than before and lasted for 10–14 days. B ultrasound and MRI imaging indicated there was a uterine diverticulum. The other four cases were in good condition. The amount of blood lost during operation was about 2000 mL. The vital signs were stable during the operation and these patients recovered well after operation. All the five patients in this article got good outcomes, MRI showed that their uterine morphology was normal and there was no abnormal echo in the suture of the ring cutting place. Menstruation resumed in normal time. In addition, the healing of the uterus is also safe. Because this method does not affect the uterine blood supply, the upper edge of the ring resection is supplied with blood from the ovarian artery, the lower margin has blood supply from the uterine artery; when anastomosis occurs in the upper and lower ends, the new circulation will be established soon from around the joint, just like an ordinary incision healing.

Overall, the circular resection following end-to-end anastomosis, which we introduced here, is an effective precision surgical approach for PPWPP. It can achieve the purpose of hemostasis while maximizing the protection of organ function and reducing surgical trauma.

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Funding

This study was supported by the National Key R & D Program of China (No. 2016YFC1000405) and Guangdong Natural Science Foundation (No. 2015A030310115).

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Conflicts of Interest

None.

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References

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Keywords:

Placenta previa; Placenta percreta; Precision surgery; Circular resection

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