An alternate surgical approach to reduce hemorrhage and complications during cesarean hysterectomy for adherent placenta

Publication date: Available online 4 July 2018
Source:European Journal of Obstetrics & Gynecology and Reproductive Biology
Author(s): Pradip Kumar Saha, Rashmi Bagga, Jasvinder Kaur Kalra, Aashima Arora, Rimpi Singla, Vanita Suri, Kajal Jain, Parveen Kumar, Nalini Gupta, Ashish Jain, Tulika Singh, Ravimohan S. Mavuduru
BackgroundCaesarean hysterectomy for adherent placenta is associated with increased maternal morbidity due to massive hemorrhage requiring large volume blood transfusion, bladder or ureteric injury, intensive care unit (ICU) admission and prolonged hospital stay. There is an ongoing effort to improve the outcome of these women and measures to reduce blood loss.ObjectiveThe purpose of the present study was to develop an alternate surgical approach for performing a Caesarean hysterectomy in women with adherent placenta in order to reduce hemorrhage and urinary tract injuries, and thereby improve the maternal outcome.Study designA prospective observational study in a tertiary care hospital in North India. The surgical approach described in the present study was practiced in 12 women who underwent Caesarean hysterectomy for adherent placenta previa. In this approach, dissection of the bladder flap up as close as to the cervix was made prior uterine incision and delivery of the baby. During dissection of the bladder flap, the blood vessels traversing between uterus and bladder were ligated.ResultThese 12 women underwent Caesarean hysterectomy under general anesthesia. The interval from induction of anesthesia to delivery of the baby ranged from 40 to 79 minutes, and none of the babies had birth asphyxia. No woman had bladder or ureteric injury. All women had histopathological proven adherent placenta, 5 had placenta percreta, one had placenta increta and 6 had placenta accreta. The average blood loss was 1.46 litres and the mean number of blood transfusions was 2.1 units. None of the women required post-operative ventilatory support or ICU admission, and all women were discharged from hospital between 4 to 7 days following Caesarean hysterectomyConclusionThe present series describes an alternate surgical approach for Caesarean hysterectomy in adherent placenta. Dissection of the bladder flap prior to delivery of the baby followed by hysterectomy reduced the hemorrhage and there was no bladder or ureteric injury. This surgical approach requires no additional resources and may easily be followed in a low-resource setting.