Kulkarni A*, Qureshi S**,
(* First Year Resident, ** Assistant Professor, *** Professor. Department of Obstetrics and Gynecology, Seth GS
College & KEM Hospital, ) Mumbai,
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. 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.
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.
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.
Morbidly adherent placenta is a calamitous state. It has an incidence ranging from 1:540 to 1:70000. 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. 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. 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. 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.
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.
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Kulkarni A, Qureshi S,
Focal Morbid Adherent Placenta on LSCS
Scar. JPGO 2015. Volume 2 No. 2. Available from: http://www.jpgo.org/2015/02/focal-morbid-adherent-placenta-on-lscs.html Gupta AS.