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).
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).
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.
This study was supported by the National Key R & D Program of China (No. 2016YFC1000405) and Guangdong Natural Science Foundation (No. 2015A030310115).
Conflicts of Interest
. Zeng C, Yang M, Ding Y, et al Placenta accreta spectrum disorder trends in the context of the universal two-child policy in China and the risk of hysterectomy. Int J Gynaecol Obstet 2018;140(3):312–318. doi: 10.1002/ijgo.12418.
. Jauniaux E, Chantraine F, Silver RM, et al FIGO consensus guidelines on placenta accreta spectrum disorders: epidemiology. Int J Gynecol Obstet 2018;140(3):265–273. doi: 10.1002/ijgo.12407.
. Mehrabadi A, Hutcheon JA, Liu S, et al Contribution of placenta accreta to the incidence of postpartum hemorrhage and severe postpartum hemorrhage. Obstet Gynecol 2015;125(4):814–821. doi: 10.1097/AOG.0000000000000722.
. Bateman BT, Mhyre JM, Callaghan WM, et al Peripartum hysterectomy in the United States: nationwide 14 year experience. Am J Obstet Gynecol 2012;206(1):63.1e–63.8e. doi: 10.1016/j.ajog.2011.07.030.
. Jauniaux E, Bhide A, Kennedy A, et al FIGO consensus guidelines on placenta accreta spectrum disorders: prenatal diagnosis and screening. Int J Gynecol Obstet 2018;140(3):274–280. doi: 10.1002/ijgo.12408.
. Taneja A, Das S, Hussain SA, et al Uterine transplant: a risk to life or a chance for life? Sci Eng Ethics 2019;25(2):635–642. doi: 10.1007/s11948-018-0018-4.
. Likis FE, Sathe NA, Morgans AK, et al Management of Postpartum Hemorrhage. 2015;Agency for Healthcare Research and Quality (US), Rockville (MD): Report No. 15-EHC013-EF.
. Wright JD, Devine P, Shah M, et al Morbidity and mortality of peripartum hysterectomy. Obstet Gynecol 2010;15(6):1187–1193. doi: 10.1097/AOG.0b013e3181df94fb.
. Moorman PG, Myers ER, Schildkraut JM, et al Effect of hysterectomy with ovarian preservation on ovarian function. Obstet Gynecol 2011;118(6):1271–1279. doi: 10.1097/AOG.0b013e318236fd12.
. Lee DY, Park HJ, Kim BG, et al Change in the ovarian environment after hysterectomy as assessed by ovarian arterial blood flow indices and serum anti-Mullerian hormone levels. Eur J Obstet Gynecol Reprod Biol 2010;151(1):82–85. doi: 10.1016/j.ejogrb.2010.02.037.
. Singha A, Saha S, Bhattacharjee R, et al Deterioration of ovarian function after total abdominal hysterectomy with preservation of ovaries. Endocr Pract 2016;22(12):1387–1392.
. Smith PH, Ballantyne B. The neuroanatomical basis for denervation of the urinary bladder following major pelvic surgery. Br J Surg 1968;55(12):929–933.
. Parys BT, Haylen BT, Hutton JL, et al The effects of simple hysterectomy on vesicourethral function. Br J Urol 1989;64(6):594–599.
. Wang X, Chen C, Liu P, et al The morbidity of sexual dysfunction of 125 Chinese women following different types of radical hysterectomy for gynaecological malignancies. Arch Gynecol Obstet 2018;297(2):459–466. doi: 10.1007/s00404-017-4625-0.
. Allen L, Jauniaux E, Hobson S, et al FIGO consensus guidelines on placenta accreta spectrum disorders: nonconservative surgical management. Int J Gynecol Obstet 2018;140(3):281–290. doi: 10.1002/ijgo.12409.
. Sentilhes L, Kayem G, Chandraharan E, et al FIGO consensus guidelines on placenta accreta spectrum disorders: conservative management. Int J Gynecol Obstet 2018;140(3):291–298. doi: 10.1002/ijgo.12410.
. Cho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine bleeding during cesarean delivery. Obstet Gynecol 2000;96(1):129–131.
. Hwu YM, Chen CP, Chen HS, et al Parallel vertical compression sutures: a technique to control bleeding from placenta praevia or accreta during caesarean section. BJOG 2005;112(10):1420–1423.
. Dedes I, Ziogas V. Circular isthmic-cervical sutures can be an alternative method to control peripartum haemorrhage during caesarean section for placenta praevia accreta. Arch Gynecol Obstet 2008;278(6):555–557. doi: 10.1007/s00404-008-0646-z.
. Zhu L, Zhang Z, Wang H, et al A modified suture technique for hemorrhage during cesarean delivery complicated by complete placenta previa
. Int J Gynaecol Obstet 2015;129(1):26–29. doi: 10.1016/j.ijgo.2014.11.005.
. Teixidor VM, Belli AM, Arulkumaran S, et al Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure. Ultrasound Obstet Gynecol 2015;46(3):350–355. doi: 10.1002/uog.14728.
. Chinses society of perinatal medicine, Obstetrics group of Chinese society of obstetrics and gynecology. Guidelines for the diagnosis, treatment of placenta accrete. Chin J Perinatal Med 2015;18(7):481–485. doi: 10.3760/cma.j.issn.1007-9408.2015.07.001.
. Committee on Obstetric Practice. Committee opinion No. 529: placenta accreta. Obstet Gynecol 2012;120(1):207–211. doi: 10.1097/AOG.0b013e318262e340.
. Angstmann T, Gard G, Harrington T, et al Surgical management of placenta accreta: a cohort series and suggested approach. Am J Obstet Gynecol 2010;202(1):38.e1–38.e9. doi: 10.1016/j.ajog.2009.08.037.
. Bailit JL, Grobman WA, Rice MM, et al Morbidly adherent placenta treatments and outcomes. Obstet Gynecol 2015;125(3):683–689. doi: 10.1097/AOG.0000000000000680.
. Eshkoli T, Weintraub AY, Sergienko R, et al Placenta accreta: risk factors, perinatal outcomes, and consequences for subsequent births. Am J Obstet Gynecol 2013;208(3):219.e1–219.e7. doi: 10.1016/j.ajog.2012.12.037.
. Chaudhari HK, Shah PK, D'Souza N. Morbidly adherent placenta: its management and maternal and perinatal outcome. J Obstet Gynaecol India 2017;67(1):42–47. doi: 10.1007/s13224-016-0923-x.
Keywords:© 2019 by Lippincott Williams & Wilkins, Inc.
Placenta previa; Placenta percreta; Precision surgery; Circular resection