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EMERGENCY PERIPARTUM HYSTERECTOMY DUE TO PLACENTA PREVIA/ACCRETA: 10 YEARS' EXPERIENCE

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Objective: To identify risk factors for and sonographic findings, complications and outcomes of emergency peripartum hysterectomy due to placenta previa/accreta. Materials and Methods: This was a retrospective review and descriptive study of women who underwent emergency peripartum hysterectomy due to placenta previa/accreta at Chang Gung Memorial Hospital between 1992 and 2001. All emergency peripartum hysterectomies were considered by the responsible physician to be a lifesaving procedure. Each chart was reviewed with emphasis on risk factors, sonographic findings, complications and outcomes. Results: There were 16 cases of emergency peripartum hysterectomy due to placenta previa/accreta (0.6/1,000 births). The mean hospitalization time was 8 days (range, 5–24 days) and the mean operation time was about 150 minutes (range, 85–335 mins). The estimated mean blood loss was 3,800 mL (range, 2,700– 12,000 mL) and the mean amount of whole blood transfused was 15 units (range, 10–38 units). Two cases of bladder injury occurred when dissecting the bladder from the lower uterine segment and cervix. Conclusions: The association of placenta previa and prior cesarean delivery with placenta accreta and emergency peripartum hysterectomy is well documented. Emergency peripartum hysterectomy remains a potentially lifesaving procedure with which every practitioner of obstetrics must be familiar. In facilities that have interventional radiological services and well-trained angiographers available on a 24-hour basis, prophylactic placement of catheters for possible selective embolization may be considered in patients with placenta previa and a prior cesarean section and sonographic findings of placenta accreta. There should be a clear, tried and tested protocol for dealing with massive obstetric hemorrhage to decrease maternal morbidity and mortality. [Taiwanese J Obstet Gynecol 2004;43(4):206–210]
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? ORIGINAL ARTICLE ?
EMERGENCY PERIPARTUM HYSTERECTOMY DUE TO
PLACENTA PREVIA/ACCRETA: 10 YEARS’ EXPERIENCE
Yaw-Ren Hsu*, Fu-Tsai Kung, Cherng-Jau Roan, Chia-Yu Ou, Te-Yao Hsu
Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
SUMMARY
Objective: To identify risk factors for and sonographic findings, complications and outcomes of emergency
peripartum hysterectomy due to placenta previa/accreta.
Materials and Methods: This was a retrospective review and descriptive study of women who underwent
emergency peripartum hysterectomy due to placenta previa/accreta at Chang Gung Memorial Hospital between
1992 and 2001. All emergency peripartum hysterectomies were considered by the responsible physician to be
a lifesaving procedure. Each chart was reviewed with emphasis on risk factors, sonographic findings,
complications and outcomes.
Results: There were 16 cases of emergency peripartum hysterectomy due to placenta previa/accreta
(0.6/1,000 births). The mean hospitalization time was 8 days (range, 5–24 days) and the mean operation time
was about 150 minutes (range, 85–335 mins). The estimated mean blood loss was 3,800 mL (range, 2,700–
12,000 mL) and the mean amount of whole blood transfused was 15 units (range, 10–38 units). Two cases
of bladder injury occurred when dissecting the bladder from the lower uterine segment and cervix.
Conclusions: The association of placenta previa and prior cesarean delivery with placenta accreta and emergency
peripartum hysterectomy is well documented. Emergency peripartum hysterectomy remains a potentially
lifesaving procedure with which every practitioner of obstetrics must be familiar. In facilities that have
interventional radiological services and well-trained angiographers available on a 24-hour basis, prophylactic
placement of catheters for possible selective embolization may be considered in patients with placenta previa
and a prior cesarean section and sonographic findings of placenta accreta. There should be a clear, tried and
tested protocol for dealing with massive obstetric hemorrhage to decrease maternal morbidity and mortality.
[Taiwanese J Obstet Gynecol 2004;43(4):206–210]
Key Words: peripartum hysterectomy, placenta previa, placenta accreta, transarterial embolization
Introduction
in emergency situations [1–7]. This study reviews 10
years of experience with emergency peripartum hyster-
Emergency peripartum hysterectomy in obstetric practice
ectomies due to placenta previa/accreta at our hospital
is generally used in life-threatening situations. Peripartum
to identify the risk factors, sonographic findings, com-
hysterectomy is often associated with relatively high
plications and outcomes. Managing cases of placenta
morbidity and mortality rates, especially when performed
previa totalis with antenatal sonographic diagnosis of
placenta accreta is also discussed.
*Correspondence to: Dr. Yaw-Ren Hsu, Department of Obstetrics
and Gynecology, Chang Gung Memorial Hospital, 123 Ta-Pei
Materials and Methods
Road, NiaoSung, Kaohsiung 833, Taiwan.
E-mail: great318@ms13.hinet.net
This was a retrospective review and descriptive study
Received: April 16, 2004
Revised: July 7, 2004
of women who underwent an emergency peripartum
Accepted: July 7, 2004
hysterectomy due to placenta previa/accreta at our hos-
206
Taiwanese J Obstet Gynecol • December 2004 • Vol 43 • No 4

Emergency Peripartum Hysterectomy due to Placenta Previa/Accreta
pital between 1992 and 2001. The diagnosis of placen-
Results
ta accreta was based on pathologic findings. The ab-
sence of decidua basalis between the placenta villi
During the study period, there were 27,062 deliveries at
and myometrium establishes the diagnosis. All emer-
our hospital, among which 8,930 deliveries (33%) were
gency peripartum hysterectomies were unplanned and
by cesarean section (CS). Sixteen deliveries (0.6/1,000
were considered by the responsible physician to be a
births) were followed by an emergency peripartum hys-
lifesaving procedure. Mothers of fetuses with a gesta-
terectomy to save the life of the mother due to massive
tional age of less than 24 weeks were excluded. Each
hemorrhage at the time of the CS or postpartum.
patient chart was reviewed with an emphasis on risk
All mothers with placenta previa had had at least
factors, sonographic findings, complications and out-
one prior cesarean delivery (Table 1). Four patients un-
comes. The antenatal sonographic diagnosis of placenta
derwent emergency cesarean hysterectomy due to mas-
accreta was based on the presence of prominent large
sive hemorrhage and profound hypotension immedi-
or multiple placental venous lakes (lacunar flow) and
ately after removing the placenta, while in eight cases,
failure to visualize a hypoechoic zone at the placental
emergency postpartum hysterectomy was performed
margin.
for unimproved massive hemorrhage and profound
Table 1. Characteristics of mothers
Case
Age (yr)
GA (wk)
Obstetric history
Pathology
Surgical therapy
1
32
38
Placenta previa totalis,
Placenta accreta,
Postpartum hysterectomy,
2 previous CS, AA1
bladder injury
cystorrhaphy
2
31
39
Placenta previa totalis,
Placenta accreta
2 previous CS, AA1
Postpartum hysterectomy
3
35
37
Placenta previa totalis,
Placenta accreta,
Postpartum hysterectomy,
2 previous CS, AA0
bladder injury
cystorrhaphy
4
29
34
Placenta previa totalis,
Placenta accreta
Postpartum hysterectomy
2 previous CS, AA0
5
36
38
Placenta previa totalis,
Placenta accreta
Postpartum hysterectomy
2 previous CS, AA0
6
32
33
Placenta previa totalis,
Placenta accreta
Cesarean hysterectomy
2 previous CS, AA0
7
30
28
Placenta previa totalis,
Placenta accreta (intrauterine
Postpartum hysterectomy
2 previous CS, AA0
gauze packing failure)
8
44
33
Placenta previa totalis,
Placenta accreta
Postpartum hysterectomy
2 previous CS, AA0
9
32
39
Placenta previa totalis,
Placenta accreta
Cesarean hysterectomy
2 previous CS, AA0
10
29
28
Placenta previa totalis,
Placenta accreta
Postpartum hysterectomy
previous CS, AA0
11
43
30
Placenta previa totalis,
Placenta accreta
Cesarean hysterectomy
previous CS, AA3
12
35
32
Placenta previa totalis,
Placenta accreta
Postpartum hysterectomy
previous CS, AA1
13
32
37
Placenta previa totalis,
Placenta accreta
Cesarean hysterectomy
previous CS, AA1
14
23
39
Placenta previa totalis,
Placenta accreta
Postpartum hysterectomy
previous CS, AA0
(TAE failure)
15
32
35
Placenta previa totalis,
Placenta accreta (intrauterine
Postpartum hysterectomy
previous CS, AA2
gauze packing failure)
16
34
36
Placenta previa totalis,
Placenta accreta (intrauterine
Postpartum hysterectomy
previous CS, AA4
gauze packing failure)
GA = gestational age; CS = cesarean section; AA = artificial abortion; TAE = transarterial embolization.
Taiwanese J Obstet Gynecol • December 2004 • Vol 43 • No 4
207

Y.R. Hsu, et al
hypotension after CS. Of these, three had received in-
of placenta previa was 0.25% with an unscarred uterus
trauterine gauze packing for compression hemostasis
and 1.22% in patients with one or more previous CSs
and one had undergone emergency transarterial embo-
[6]. Clark et al reported that the risk of placenta previa
lization (TAE) before the hysterectomy.
increased from 0.26% with an unscarred uterus to 10%
The mean hospitalization time was 8 days (range,
with four or more previous CSs [8].
5–24 days) (Table 2). The mean operative time for
Patients presenting with placenta previa and an
peripartum hemorrhage was about 150 minutes (range,
unscarred uterus have a 5% risk of clinical placenta
85–335 mins). The estimated mean blood loss was
accreta. With placenta previa and one previous CS, the
3,800 mL (range, 2,700–12,000 mL). The mean amount
risk of placenta accreta is 24%; this risk continues to
of whole blood transfused was 15 units (range, 10–
increase to 67% with placenta previa and four or more
38 units). Two cases of bladder injury occurred when
CSs. With placenta previa and one or more previous
dissecting the bladder from the lower uterine segment
CSs, the overall risk of placenta accreta is 35% [8].
and cervix. The outcomes of bladder injury post-
Nielsen et al reported that patients presenting with pla-
cystorrhaphy were good without sequelae. No mater-
centa previa and a scarred uterus had a 16% risk of
nal deaths or disseminated intravascular coagulation
undergoing a cesarean hysterectomy because of pla-
occurred. All cases experienced either intraoperative
centa accreta and severe hemorrhage, compared to
or postoperative hypotension and needed blood re-
3.6% of patients with placenta previa and an unscarred
placement. Six patients underwent surgery remote from
uterus [6].
term due to massive vaginal bleeding or tocolysis fail-
Transvaginal sonography and color Doppler imaging
ure. Poor chart recordings of sonographic findings con-
improve the diagnostic accuracy of predicting placenta
cerning placenta accreta were noted. Only four cases
accreta in patients with persistent placenta previa. Re-
had chart recordings of sonographic findings of placental
cent reports describe the antenatal sonographic diagno-
turbulent lacunar flow.
sis of placenta accreta based on the presence of promi-
nent large or multiple placental venous lakes (lacunar
flow) and a failure to visualize a hypoechoic zone at the
Discussion
placental margin [9–11].
There are significantly higher risks of hemorrhage,
As the incidence of CS continues to rise, both in Taiwan
disseminated intravascular coagulation, hypotension
and worldwide, the problem of placenta previa/accreta
and a hysterectomy in patients with a previous cesarean
is likely to become more common. The association of
delivery, placenta previa and placenta accreta compared
placenta previa and prior cesarean delivery with placen-
with cases with a previous cesarean delivery and placen-
ta accreta and the risks of a hysterectomy are well
ta previa but no placenta accreta [1–7]. Discovery of pla-
documented [6–8]. Nielsen et al reported that the risk
centa previa and these sonographic features in a pa-
Table 2. Birth characteristics
Case
Birth weight (g)
Apgar score
Blood loss (mL)
Blood transfusion (whole blood)
Complications
1
2,902
9–10
12,700
14 units
Bladder injury
2
2,570
9–10
12,750
10 units
3
3,375
9–10
13,800
14 units
Bladder injury
4
2,250
6–81
13,000
12 units
5
2,670
9–10
13,580
14 units
6
1,788
5–71
12,000
38 units
7
1,114
5–81
14,000
20 units
8
2,410
2–61
13,800
16 units
9
3,790
4–91
12,900
10 units
10
1,060
5–71
12,800
10 units
11
2,010
8–10
14,000
16 units
12
1,800
3–71
16,000
20 units
13
2,790
9–10
12,850
10 units
14
2,710
9–10
13,000
10 units
15
2,400
9–10
14,500
14 units
16
2,760
8–10
13,300
12 units
208
Taiwanese J Obstet Gynecol • December 2004 • Vol 43 • No 4

Emergency Peripartum Hysterectomy due to Placenta Previa/Accreta
tient should alert the physician to the possibility of
significant reduction in total embolization time and,
placenta accreta. It is reasonable to inform the patient
therefore, in radiation exposure in patients undergoing
of the possible need for a peripartum hysterectomy if
prophylactic catheter placement prior to selective embo-
the sonographic features of placenta accreta exist. An
lization. These data support the conclusion that, in pa-
experienced surgical team led by a senior obstetrician
tients determined to be at risk for intrapartum or post-
and anesthetist and experienced assistants are required
partum hemorrhage, the prophylactic placement of
to handle an emergency peripartum hysterectomy.
catheters allows selective embolization in a hemodyna-
Adequate cross-matched blood preparation and intra-
mically intact patient with stable coagulation indices,
venous cannulation prior to the operation may make a
theoretically reducing the risk of maternal morbidity
significant difference in successful resuscitation. Before
and possibly mortality [15].
abdominal delivery, the placental outline should be
In facilities that have interventional radiological
determined by ultrasound and efforts should be made
services and well-trained angiographers available on a
not to cut through it when entering the uterus. If there
24-hour basis, prophylactic placement of catheters for
is an anteriolateral previa, a vertical incision should be
possible selective embolization may be considered for
made in the lower uterine segment on the opposite side.
patients with placenta previa with a prior CS and sono-
The major urologic complications of emergency cesa-
graphic findings of placenta accreta. Angiographers
rean hysterectomy are urinary bladder and ureter inju-
can perform immediate selective embolization if mas-
ries. A previous cesarean delivery requires careful sharp
sive uterine bleeding is encountered after removing the
dissection of the bladder from the lower uterine seg-
placenta. Otherwise, angiographers can be allowed to
ment and cervix. A recognized and properly repaired
perform selective embolization of the uterine artery to
bladder with subsequent drainage is associated with a
decrease the blood supply to the uterus before remov-
low incidence of long-term morbidity. Suspected bladder
ing the placenta. Angiographers can repeat the TAE
injury requires intraoperative evaluation of bladder inte-
procedure to achieve hemostasis if subsequent massive
grity by retrograde administration of indigo carmine
uterine bleeding occurs after removing the placenta. If
or methylene blue. Park and Duff suggest routine eval-
all the TAE procedures fail, Porro’s hysterectomy can
uation of bladder integrity at the conclusion of every
immediately be performed. Prophylactic arterial cathe-
cesarean hysterectomy [12]. To avoid ureteral injury
terization for selective embolization is a promising
during the operation, a urologic surgeon should be
modality for obstetric hemorrhage, especially due to
consulted about placement of the ureteral stent as a
placenta accreta. It deserves greater attention and fur-
marker prior to the operation. An emergency peripartum
ther studies.
hysterectomy remains a potentially lifesaving procedure
It is evident that a history of cesarean delivery has an
with which every practitioner of obstetrics must be
impact on a woman’s future pregnancies. Patients with
familiar.
previous CSs are at increased risk for complications,
Three cases received intrauterine gauze packing for
including lengthy and difficult repeat cesarean deliver-
compression hemostasis, but all failed to achieve hemo-
ies, placenta previa, placenta accreta, uterine rupture,
stasis. Finally, we performed emergency postpartum
hemorrhagic shock, transfusions, hysterectomy and
hysterectomy to save the lives of these women. The
death. To decrease the incidence of emergency peripar-
effectiveness of uterine packing in cases of placenta
tum hysterectomies due to placenta previa/accreta, it
previa/accreta needs to be further evaluated [13].
is vital to decrease the primary CS rate and encourage
Treatment of obstetric hemorrhage by selective em-
vaginal birth after CS with careful supervision [1–8].
bolization of damaged pelvic vessels under fluorosco-
There should be a clear, tried and tested protocol for
py holds promise as an alternative to surgical interven-
dealing with massive obstetric hemorrhage to decrease
tion [14]. Alvarez et al reported five patients who were
maternal morbidity and mortality.
at risk for intrapartum hemorrhage, based on sonogra-
phic findings, for whom catheters were inserted into the
hypogastric vessels prior to elective cesarean deliv-
References
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Taiwanese J Obstet Gynecol • December 2004 • Vol 43 • No 4

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