Author
Information
Kulkarni A*, Qureshi S**,
(* First Year Resident, ** Assistant Professor, *** Professor. Department
of Obstetrics and Gynecology, Seth GS Medical
College & KEM Hospital , Mumbai ,
India
Abstract
Placenta previa is one
of the two major causes of antepartum hemorrhage. Morbidly adherent placenta is
a major complication of placenta praevia which leads to life threatening
hemorrhage and associated morbidity and mortality.[1] The usual treatment
in such a condition is an obstetric hysterectomy, but newer conservatives
techniques are being performed now. We discuss a case of focal placenta increta
(involving one cotyledon) which was managed conservatively by taking hemostatic
sutures.
Introduction
Placenta increta is
defined as a condition in which there is placental invasion up to the
myometrium due to incomplete development of fibrinoid (Nitabuch’s) layer and
decidua basalis. Its incidence is increasing due to rising cesarean section
rates. It can lead to serious complications like rupture, bleeding and
infections.[2]
Case Report
A 28 year old woman,
married for 5 years G3P1L1A1 with previous lower segment cesarean section
(LSCS) was referred to us at eight months of amenorrhea with complaints of
first episode of vaginal bleeding in an
ultrasound (USG) diagnosed case of complete placenta previa. Bleeding was
minimal (superficial soakage of one pad) and painless. The patient was admitted. She had an LSCS
done four years back for oligohydramnios
and one spontaneous abortion at 3 months of amenorrhea one year back, managed
by check curettage at that time. On examination, her vital parameters were
stable, no pallor was present. On abdominal examination, the uterus was 34
weeks, fetus in vertex presentation, fetal heart rate normal and uterus
relaxed. On speculum examination no local cause of bleeding was found. USG was
repeated. It was suggestive of
single live intrauterine gestation of 35 weeks with placenta left lateral and
completely covering the internal Os. This patient had previously 3 USG scans
done in a private clinic and one in our institute. None of them diagnosed the
adhered placenta. As the USG showed anterior, complete placenta previa, and a
past history of LSCS, we asked for a review USG scan for morbidly adherent
placenta. Review scan showed morbidly adherent placenta. MRI scan was then done
to confirm these findings. It was suggestive of complete placenta previa (grade
4) with placenta increta in the anterior uterine segment. The placenta was seen
infiltrating into the anterio-inferior part of the lower uterine segment with
possible invasion within the previous LSCS scar. The invasion was seen 5 cm
above the internal Os and extending over a linear area of 3 cm towards the left
of the midline. The patient was kept in antenatal ward on strict bed rest. She
was diagnosed with hypothyroidism and started on oral levo thyroxine 75 μg OD.
She had no further episodes of vaginal bleeding. She had an uneventful
pregnancy. She and relatives were counseled about the need for elective LSCS
and possibility of an obstetric hysterectomy. At 38 weeks of gestation age the
patient was scheduled for elective LSCS and possible obstetric
hysterectomy. Four units of cross
matched blood were kept ready. Surgery was performed through a vertical midline
incision. LSCS was performed as per standard procedure. MRI findings were confirmed. The placenta was
pushed to left side and fetus was delivered by vertex presentation. A female child of 2.450 kg, with 9/10 Apgar
scores at 1 and 5 minutes was born. Placenta separated spontaneously and
delivered out. A small part of the placenta of about 2x3 cm was adherent to
lower segment on the left side on the area of the previous scar. Scar was
partly excised and this cotyledon was also removed piecemeal. Four square
haemostatic sutures were taken from the endometrium to the serosa in the area
of the myometrial defect to control the bleeding. Two were tied inside the
uterine cavity and two ere tied on the uterine serosa.
Figure 1. Full thickness
hemostatic suture placement. S is the needle carrying the suture and UC is the
uterine cavity.
Figure 2. Full thickness
hemostatic suture placement. B is the bladder, L is the lower edge of the
uterine incision. Yellow arrows show the square suture placed.
Figure 3. Suture
placement complete. LS is the lower segment. UC is the uterine cavity and arrow
shows the tied suture.
Uterus was closed with
polyglactin continuous sutures. Blood loss was approximately 1500 ml. She was
transfused with one unit of whole blood.
The post operative period was uneventful. The patient was discharged on day 6
after surgery.
Discussion
Morbidly adherent
placenta is a calamitous state. It has an incidence ranging from 1:540 to
1:70000.[3] Common
causes include previous lower segment cesarean section, multiparity, and prior
myomectomy. On USG features suggestive of morbid placenta include thin
myometrium over the placenta, haphazardly spaced vascular lacunae inside the
placenta, clear space behind the placenta, projection of serosa into the
bladder, uterine serosa showing increased blood flow near the bladder vicinity.[4] MRI is not
superior to USG in diagnosis of placenta accreta, increta in an anteriorly
placed placenta but it is a better option in case of posterior placenta.
Morbidly adherent placenta can be complete or focal. In complete variety the
placenta can be left in situ with a closely ligated umbilical cord after
delivering the fetus through an upper segment cesarean section. Further medical
management with Methotrexate, uterotonics, antibiotics, surveillance with USG
and β HCG levels monitoring is required.[5] However, in a focally adherent placenta this
is not possible as the non adherent placenta separates out and the bed keeps
bleeding as the uterus cannot undergo retraction and contraction due to the
presence of the focally adherent placental area. In this case conservative
management is not possible and if the adherent segment of the placenta cannot
be removed and the defect sutured to achieve hemostasis the patient requires an
obstetric hysterectomy as a life saving measure. Intra operatively, focally
adherent placentas have been managed by the hemostatic sutures known as
Affronti’s sutures. Affronti’s sutures are square sutures from the endometrium
to the myometrium without involving the serosa to control bleeding on the
placental bed.[6] Other options during surgery to control bleeding
include uterotonics, external compression by taking B Lynch or Cho sutures,
balloon tamponade and selective devascularization of uterine vasculature.[7,8]
In our case of focal placenta increta, square hemostatic sutures were taken in full thickness including the
serosa as the myometrial defect was very friable and the sutures were cutting
through. The depth of the increta was almost just short of the serosa. By
taking full thickness square sutures the bleeding was controlled and
hysterectomy could be avoided. We recommend that full thickness square sutures
which trap the bleeders between them should be attempted. Sutures can be
tied either in the uterine cavity or on
the serosal surface. Besides when these sutures are placed in the lower segment
this area becomes extra-peritoneal as it gets covered by the vesical
peritoneum. These can also be placed easily, quickly and they do not ‘cut
through’ as the entry and exit points of these sutures are through non
lacerated tissues.
Conclusion
Partially adherent
placenta poses its own management challenges. In the event of failure to
achieve adequate hemostasis the possibility of the patient losing her uterus
surgically is a reality curtailing her obstetric career. In such cases full
thickness hemostatic sutures can help save the uterus.
References
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- Cho JH, Jun HS, and Lee CN. Hemostatic suturing technique for uterine bleeding during cesarean delivery. Obstet Gynecol 2000;96(1):129-131.
Citation
Kulkarni A, Qureshi S, Gupta AS.