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When we are confronted with a patient experiencing placenta
previa with massive hemorrhage in cesarean delivery, hemostasis
is first attempted using uterotonic drugs, uterine massage,
and intrauterine packing. However, if these maneuvers fail,
then uterine artery ligation, whole myometrial suture, and
subendometrial vasopressin injection should be attempted.
Perhaps these procedures alone or in combination can successfully
control the hemorrhage. Every obstetrician must be familiar
with these simple methods in order to avoid having to perform
a hysterectomy and thus preserving the reproductive capability,
as well as diminishing the operative morbidity. Finally, we
described a full thickness suture for the placental site of
bleeding for the lower uterine segment. (Chang Gung Med J
2002;25: 548-52)
Key words: placenta previa, conservation treatment, vasopressin.
When faced with a patient with an unresponsive and significantly
adherent placenta such as placenta previa, brisk bleeding
from the placental implantation site in the lower uterine
segment sometimes may cause difficulty in achieving hemostasis.
First at all, different traditional methods should be used
to attempt to stop hemorrhaging including sustained uterine
massage, uterine packing, uterotonic agents such as oxytocin,
ergometrine, and prostaglandin, as well as oversewing the
placental bed. Usually, a hysterectomy is promptly considered
when all of the above measures taken to stop hemorrhage fail.
However, hysterectomy can be undesirable particularly in low
parity women. Here, we present a case complicated by placenta
previa with massive hemorrhaging, who was successfully treated
using a combination of multiple methods to preserve the uterus.
We also described a full thickness suture for the bleeding
site of the uterine wall.
CASE REPORTS
Case 1
A 28-year-old woman, gravida 3, para 1, with a history of
previous cesarean delivery and curettage, was seen at 35 weeks'
gestation with complaints of persistent right upper quadrant
abdominal pain and suprapubic cramping. The antepartum history
was unremarkable except for gestational diabetes diagnosed
at 26 weeks of gestation, which was treated with diet control.
During admission, abdominal ultrasonography revealed a normal
viable fetus with placenta previa totalis. In addition, the
retroplacental hypoechoic zone was identified beneath the
entire placenta. The maternal serum a-fetoprotein level in
the second trimester was 0.79 multiple of the median value.
Laboratory test results were all within reference ranges.
With ritodrine infusion, the cardiotocography showed fetal
tachycardia with irregular contractions. Subsequently, she
suddenly developed uterine bleeding; thus, a cesarean delivery
was performed.
A Pfannestiel incision was employed along the previous scar.
A normal 3250 g female infant was delivered via a cut through
of the anterior attachment of the placenta at the lower uterine
segment. The Apgar scores were 8 and 9 at 1 and at 5 min,
respectively. After manual removal of the placenta, heavy
bleeding developed immediately from the lower uterine segment.
At that time, hemostasis was attempted using oxytocin, ergometrine,
direct uterine massage, and uterine packing. However, massive
hemorrhage persisted with no improvement. Subsequently, ligation
of bilateral descending branches of the uterine arteries was
performed inferior to the angles of the uterine incision.
As the bleeding continued and after inferior deflection of
the bladder flap, multiple sutures with 1-0 chromic catgut
were applied at the bleeding sites through the entire thickness
of the anterior uterine wall. Importantly, the knots were
tied outside the serosal surface. These sutures began at the
most superior portion of the lower uterine segment and progressed
inferiorly. The hemorrhage reduced significantly after this
procedure. However, some bleeding continued from the cervical
area although at a much lesser severity. During this stage,
we utilized 1 ml of vasopressin diluted with 19 ml isotonic
sodium chloride solution to infiltrate subendometrially at
the bleeding sites. Thereafter, all bleeding completely stopped.
The remaining procedures were performed in the usual manner.
Total blood loss was estimated to be 1800 ml, and eight units
of packed red blood cells were given. The patient returned
home in stable condition 7 days after admission.
Case 2
A 35-year-old woman presented at 32 weeks' gestation with
painless vaginal bleeding. Her obstetric history was notable
for three uneventful vaginal deliveries. At that time, ultrasonogram
demonstrated a living fetus compatible with gestational age
and a complete placenta previa without retroplacental lucency.
Due to persistent vaginal bleeding, a classical cesarean section
was done via a fundal incision to avoid damage to the placenta.
After the fetus was delivered and the placenta was manually
removed, considerable bleeding ensued from the placental implantation
sites. Subsequently, we attempted to suture the full thickness
of the uterine wall at the bleeding sites, and then the hemorrhage
dramatically subsided. The woman made an uneventful recovery
after a transfusion of four units of packed red cells.
Case 3
The patient is a 32-year-old woman in her second pregnancy
at 37 weeks' gestation with a history of previous cesarean
section. Ultrasonic evaluation revealed a living fetus with
an anterior, low lying-placenta. A cesarean delivery was carried
out. The abdomen was entered through a Pfannestiel incision
along the previous scar. After manual removal of the placenta,
a large area of oozing bleeding continued from the placenta
sites. Oxytocic agents and intrauterine packing were used,
all without effecting hemostasis. Finally, multiple full thickness
suturing of the uterine successfully stopped the bleeding
in these areas. No blood transfusion was given. Her recovery
was uneventful.
DISCUSSION
Previous cesarean delivery is an essential influencing factor
for the subsequent development of placenta previa. In one
report, the risk of placenta previa in patients with previous
cesarean delivery was approximately 5 times greater than in
patients without uterine scars.(1) Furthermore, in most studies
the reported incidence of placenta previa increased proportionately
with the number of prior cesarean deliveries.(2-5) A uterine
scar in the lower segment may effect the location of implantation
of the placenta, or failure of differential growth of a scarred
lower uterine segment may develop into placenta previa.
In a patient complicated by placenta previa, profuse hemorrhage
may occur immediately after separating the placenta from the
uterine wall. Bleeding is thought to be due to poor contraction
of the lower uterine segment and subsequent inability to compress
the torn vessels. The initial steps in securing hemostasis
such as in the presented case include the use of uterotonic
agents, uterine massage, and intrauterine packing. However,
once profound uterine hemorrhage occurs, it may be unlikely
for the uterine vasculature to respond to vasoconstrictor
agents, because of the potential absence of constrictor reactivity
of the uterine vasculature as a result of an unknown mechanism.(6)
Direct ligation of the uterine vessels has been documented
to arrest bleeding at a cesarean section.(7) Bilateral mass
ligation of the descending branch of the uterine arteries
and veins involves placing a suture to include 2 to 3 cm of
the myometrium, at a level 2 to 3 cm beneath the uterine incision.
If bleeding persists, the next step should be occlusion of
the arcuate artery and its branches at the bleeding sites.
This is because the uterine artery penetrates into the uterine
wall, which is ramified into arcuate arteries which pass parallel
to the serosal surface. Subsequently, they branch into radial,
basal, and spiral arteries which extend at right angles toward
the endometrium. Therefore, the suturing technique of the
anterior lower segment in this case started from the serosa
to penetrate into the endometrium. Then the needle was reinserted
from the endometrium to the serosa, 2 cm lateral from the
first suture point (Fig. 1). Thus, the knot was tied outside
the serosal surface. This technique was through the full thickness
of the uterine wall and occluded all arteries. The conventional
sutures performed in the placental bleeding site are generally
superficial and are of less effectiveness in hemostasis (Fig.
2). Similarly, the suturing technique of the posterior uterine
wall is the same except using the surgical straight needle
in instead of the conventional curve needle when required.
This is because the thickness of the posterior uterine wall
is usually greater than that of the anterior lower uterine
segment. Understanding the distribution of these vessels,
one can explain why oversewing the entire thickness of the
uterine wall is more effective than only using endometrial
sutures for hemostasis. However, using this new technique
repeatedly could completely obliterated the arcuate artery
along with the serosal layer of the uterus. Abu-Mesa et al.
first recommended this method to successfully secure bleeding
placental sites in several cases.(8) In addition, we have
used this technique to manage several cases with promising
outcomes during recent months, such as for our cases 2 and
3.
However, vasopressin is known as a potent vasopressor. Recently,
some authors have used vasopressin alone to arrest cesarean
hemorrhage with dramatic effects.(9,10) All of their patients
had excellent outcomes. Simultaneously, this was our first
experience in achieving a promising result in using vasopressin
to stop cervical hemorrhage.
In conclusion, when confronted with a patient experiencing
placenta previa with massive bleeding, preserving childbearing
function and minimizing bleeding should be carefully considered.
In addition to traditional maneuvers, conservative modes including
uterine artery ligation, placental site suturing, and vasopressin
infiltration might produce promising outcomes.
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