The incidence of placenta previa complicated with placenta percreta has increased significantly in recent years, which threatens maternal and perinatal safety and health.1,2 The lower uterine segment with its extremely weak myometrium is always over distended in such cases, with excessive placental expansion and accreta. Dilated and tortuous blood vessels on the uterine serous surface are also common. After delivery of the baby, massive bleeding can occur rapidly, and conservative treatments might fail. At this time, hysterectomy is a life-saving method; however, bladder adhesions and abundant posterior bladder neovascularization makes it very difficult. In such a situation, hysterectomy always leads to aggravated bleeding and bladder or ureter damage. These threaten the mother's life and increase the incidence of intraoperative complications. Here we describe a simple, safe and effective MCH to deal with placenta previa complicated with placenta percreta. We carried out a retrospective analysis of the intraoperative conditions, and prognosis for 23 such cases from January 2016 to December 2018. We compared nine cases of MCH and 14 cases of conventional cesarean hysterectomy (CCH).
Material and methods
Twenty-three cases of women with placenta previa complicated with placenta percreta who received a cesarean hysterectomy from January 2016 to December 2018 in the Union Hospital were collected. The patients’ age ranged from 24 to 41 years, and had gestational durations of 32–38 weeks. They had records of 5–7 previous pregnancies, and 1–2 previous cesarean hysterectomies. Antenatal ultrasound or magnetic resonance imaging scans showed complete placenta previa complicated with accreta.3–9 The cases were divided into MCH and CCH groups. All the surgeries were elective cesarean sections. All cases provided signed consent from the patients and families. Data on the following were collected and analyzed: medical history, gravidity, parity, previous cesarean history, gestational weeks, intraoperative bleeding volume, blood transfusion volume, operation time, intensive care unit (ICU) admission duration, postoperative pathology, fetal birth weight, Apgar score, and hospitalization duration.
Indications for cesarean hysterectomy
The indications for cesarean hysterectomy were: a barrel-shaped dilation of the lower uterine segment without or with only weak uterine myometrium; the placenta covering the cervical internal os, migration of the placenta into the uterine myometrium compactly, placental implantation area extending and even penetrating into the serosa; and frequent involvement of parametrial tissue and the bladder hysterectomy was essential in such cases (Fig. 1). Cesarean hysterectomy was implemented if it was still difficult to control bleeding after applying programmed hemostasis measures.
Cesarean hysterectomy procedures
Modified cesarean hysterectomy (MCH)
(1) Delivery and procedural hemostasis measures: a mid-longitudinal incision of the lower abdomen or a longitudinal incision around the umbilicus was used. The placental attachment area and fetal position were reassessed and an appropriate uterine incision was chosen at the place where there was minimal or no placental attachment. An oblique or “J” shaped incision in the lower uterine segment was often applied.10 The myometrium was incised to the interface of amniotic sac or placental surface, not cutting into the placenta. After making a prolonged uterine incision to the appropriate length, the amniotic membrane was pierced directly or the placental lobule was divided to approach the amniotic membrane, then the baby was delivered.
(2) Modified subtotal hysterectomy: when the baby was delivered, the uterus was pulled out from the incision simultaneously. The assistant compressed the lower uterus with hands to control bleeding. Then an elastic bandage tourniquet was placed around the level of the cervical internal os and tightened. The tourniquet was pierced at the nonvascular area inside the circular ligament and fixed at the lowest position of the uterus with forceps. The uterine blood flow was limited to control bleeding (Fig. 2A). After reassessing the situation, if a conventional suture could not stop the bleeding, or the uterus could not be preserved, a cesarean hysterectomy needed to be decided on immediately.
(3) Description of the MCH procedure: routine treatment of bilateral round ligaments and inherent ovarian ligaments (Fig. 2B), close to the uterus, the parametrial tissue was clamped and cut to the upper level of the tourniquet. Because of abnormal placental invasion, the parametrial blood vessels often appeared markedly varicose and thicker. We aimed to avoid mobilizing the bladder or forcing it down to the level of the uterine artery. The edge of the uterine myometrium layer above the tourniquet band was clamped. The inner surface of the lower uterine segment could be exposed, but the tourniquet band was not loosened until most of the placental tissues were removed. The inner cervical os could be seized using tissue forceps and strengthened by suture (Fig. 2C). Then the tourniquet could be tied again after clamping the cervical os. Under direct vision, a continuous braided suture was used to reinforce the residual weak myometrium. After the bleeding sinus had been sutured completely, the tourniquet was relaxed, the incision margin was sutured continuously, and the seromuscular layer was strengthened (Fig. 3). The hemostatic effect could be enhanced further by suturing the ascending branches of both uterine arteries when necessary.
Conventional cesarean hysterectomy
(1) The delivery and hemostasis procedures were the same as described above.
(2) For cesarean hysterectomy, treatments of the bilateral round ligaments and inherent ovarian ligaments were the same as those described above. Because of the close adhesion of the vesicouterine peritoneal fold, it was difficult to dissect and mobilize the bladder away from the lower uterine segment. It often took a lot of time to deal with neovascularization of the bladder, and local injury was prone to occur. In this CCH group, there were three cases of bladder rupture and urological surgeons undertook the repair. After the bladder had been mobilized to the isthmus level, the uterine artery was clamped and cut off. The uterus was lifted and resected through the cervical internal os. The incision margin was sutured continuously.
Observation and contrast indicators
The blood volume, transfusion volume, operation duration, neonatal Apgar score, birth weight, hospital stay after operation, and ICU occupancy rate in the two groups were recorded.
Intraoperative hemorrhage measurement
Intraoperative blood loss was calculated by the volume of autologous blood transfusion, collection in a suction device, and the weights of soaked gauze minus drape gauze.
The blood transfusion volume was calculated (in mL) as the total amount of autologous and allogeneic blood transfused during surgery.
Postoperative monitoring indicators
These included any bleeding on the first day after operation, maternal temperature changes, hospital stay, time to self-urination, and general condition.
Data are shown as the mean ± standard error of the mean. The results were analyzed using SPSS 20.0 (IBM, Armonk, NY, USA) and Prism 8.0 (GraphPad Software, San Diego, California, USA) and compared between groups using Student's t-test, the Wilcoxon signed rank test or the χ2 test. P < 0.05 was assumed to indicate statistical significance.
There were no significant differences in the general condition measures of the patients between the MCH and CCH groups (Table 1). Thus, age, gravidity, parity, and history of cesarean sections had no significant difference between the two groups. The blood loss volume in the MCH group was (2 294 ± 662) mL and transfusion volume was (1 122 ± 499)mL, statistically lower than in the CCH group where the blood loss was (3 807 ± 1768) mL and the blood transfusion volume was (2 015 ± 920) mL (Fig. 4). The operation time in the MCH group was also much shorter than in the CCH group ((132 ± 20) vs. (159 ± 33) min, P < 0.05, Fig. 5). The MCH group had fewer hospitalization days than the CCH group, and the difference was statistically significant ((6.1 ± 0.8) vs. (6.3 ± 0.7) days, P < 0.05). There were no significant differences in neonatal birth weights and Apgar score between the two groups. There was no case of bladder injury in MCH group and three cases in CCH group, which was not significant because of the limited number of cases. The CCH group had slightly more days of admittance into the ICU, but this was not significant (Table 2).
Difficulties in surgical management of placenta previa complicated with placenta percreta
Patients with placenta previa complicated with placenta percreta have histories of previous cesarean sections. In such cases, the placenta adheres closely to the uterine anterior wall, and infiltrates into the previous cesarean section scar which results in placental increta even to the degree of percreta. The rates of massive hemorrhage, hysterectomy, and injury to the urinary system increase dramatically.11 Here we reviewed 23 cases of cesarean hysterectomy required because of placenta previa complicated with placenta percreta with accreta. All cases were treated with elective surgery and were diagnosed by antepartum ultrasound or magnetic resonance imaging scans. All patients had undergone at least once previous cesarean section. The imaging diagnoses were confirmed during the operation.
Severe pelvic adhesions caused difficulties in dissection and increased risk of bleeding during cesarean hysterectomy in such cases. CCH took more time, because of the need to dissect the close adhesions of the vesicouterine peritoneal fold. It was complex to dissect and mobilize the bladder away from the lower uterine segment. Dealing with the bladder's neovascularization also involved more time. Moreover, bladder injury was encountered frequently. If the uterus cannot be removed quickly, excessive bleeding might occur. Low blood volume, loss of coagulation materials, and inadequate fluid transfusion might result in hemorrhagic shock, disseminated intravascular coagulation and even death. The indications for a cesarean hysterectomy include the placenta completely covering the cervical os and adhering to the thin myometrium compactly. The lower uterine segment in these cases showed an over dilated appearance. The implantation area was large and even invaded to the serosal surface. Parametrial tissues and the bladder were often involved. Hysterectomy was decided directly or after implementation of programmed hemostasis; the bleeding was rapid and copious and hysterectomy was the only salvage measure.
Programmed hemostasis measurements and MCH
Having a skilled medical team using programmed hemostasis measures is a necessary preliminary step to deal with such intractable bleeding problems rapidly. Programmed hemostasis based on measurements was used in all placenta previa surgery. After delivery, a tourniquet was used to tighten the lower uterine segment to control bleeding temporarily. It is recommended that such a tourniquet should be placed around the uterine lower segment through the nonvascular area of the broad ligament at the level of the internal cervical os, to control bleeding temporarily and not affect the removal of the placenta thoroughly and enable the application of sutures.12 In more dangerous cases, the lower uterine segment is excessively enlarged, the tourniquet can only be tied at a higher position, but nevertheless, a lot of blood can gush out, or there might be bleeding from the vagina. Gauze pads should be used to press the abdominal aorta in front of the sacral promontory behind the uterus, which might achieve effective hemostasis.
For temporary control of bleeding, the uterus must be removed quickly and the source of bleeding must be controlled to stabilize the patient's hypovolemic state. The major points of MCH include fast resection of the round ligament and the ovarian proper ligament. The parauterine tissue close to the uterus should be clamped and cut off to the level above the tourniquet, without forcibly mobilizing the bladder. After removing the uterine corpus, the remaining placental tissue should be cleared carefully, and the internal cervical os should be explored and seized. The bleeding surface of the placenta should be sutured continuously from the internal os to the edge of the margin, row by row. The ascending branches of uterine artery need to be ligated to strengthen hemostasis. After confirming complete hemostasis, the residual uterine incision margin should be closed.12
The advantages of MCH in cases of placenta previa complicated with placenta percreta
Normally, the placenta cannot deliver spontaneously in cases of incomplete placenta previa with accreta or increta. The extremely enlarged lower segment is incapable of returning to its normal shape by contraction. Simultaneously, severe bleeding often occurs with incomplete placental delivery. Emergency cesarean hysterectomy is necessary to save the mother's life, and prevent pelvic adhesions. Such cases with urinary bladder invasion greatly increase the difficulty of surgery. In recent years, some improved methods of hysterectomy for women with this condition have been reported. Selman13 reported that posterior retrograde abdominal hysterectomy could be used to treat cases of placenta percreta with bladder penetration. The cesarean section is performed by fundal hysterotomy away from the placenta. Cesarean hysterectomy is performed using the posterior retrograde approach. Before hysterectomy, the previous procedure was to ligate the internal iliac artery. For cases with the placenta penetrating the bladder, Selman13 suggested incision of the posterior wall of the bladder and repair. If bleeding is excessive, aortic clamping is suggested to control it temporally. This proposed method used fundal hysterotomy to avoid bleeding followed by placental incision, which provided certain advantages, but there was no significant improvement in avoiding bladder injury. The advantages of the current MCH approach we propose are as follows. In placenta previa complicated with placenta percreta, the bladder often adheres to the anterior wall of the uterus because of previous surgery, and the placenta shows bladder penetration. Many new arteries will be formed in the posterior wall of the bladder. Mobilization of the bladder as usual tends to lead to increased bleeding and repeated hemostasis and arterial suturing increase the operation time. The bladder is fragile, and injury is prone to occur during surgery. We experienced three cases of bladder injury in these 14 cases of CCH. Urological surgeons were required to repair these. No case of bladder injury occurred in the MCH group.
In our MCH approach, the uterine corpus was removed above the tourniquet, equivalent to the top of the bladder. There is no need to mobilize the bladder. After the uterine body has been removed, the lower uterine cavity can be exposed thoroughly under the temporary control of hemorrhage using a tourniquet, and the internal cervical os can be seized quickly using tissue forceps. After the placenta has been removed, continuous suturing row by row from the inner os to the margin of the incision can be applied under clear vision, which helps strengthen the lower uterine segment, and closes the extensive blood sinus. These advantages meant that the operation is timesaving, involves less bleeding, less bladder damage, and shorter hospitalization time. The rate of subsequent infections was not increased, and the patients had a good prognosis. There were no urinary system complications.
In conclusion, this MCH approach can deal effectively with intractable bleeding of a complete placenta previa with bladder penetration. There is no need to mobilize the bladder, avoiding injury and decreasing bleeding. It is emphasized that after the removal of the uterine corpus, the cervical internal os should be found and seized, and the placenta tissue should be removed as far as possible. All residual bleeding in the lower segment of the uterus should be sutured under direct vision. The method is simple and easy to learn, and provides a good choice for grass-roots units to rescue patients.
The authors thank James Cummins, PhD, from LiwenBianji, Edanz Group China (www.edanzediting.com/ac) for editing a draft of this manuscript.
Li Zou participated in research design, Yin Zhao participated in writing the paper, Hui Gao, Jian-Wen Zhu, Di Wu, Xiao-Xia Liu, and Wen Zhang participated in the research. Yin Zhao and Li-Bo Luo participated in data analysis.
Conflicts of Interest
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