Cesarean hysterectomy in pregnancies complicated with placenta previa accreta: a retrospective hospital-based study.

BACKGROUND: Placenta previa accreta (PPA) is a severe obstetric condition that can cause massive postpartum hemorrhage and transfusion. Cesarean hysterectomy is necessary in some severe cases of PPA to stop the life-threatening bleeding, but cesarean hysterectomy can be associated with significant surgical blood loss and major complications. The current study is conducted to investigate the potential risk factors of excessive blood loss during cesarean hysterectomy in women with PPA. METHODS: This is a retrospective study including singleton pregnancies after 28 weeks of gestation in women with placenta previa and pathologically confirmed placenta accreta spectrum who received hysterectomy during cesarean sections. A total of 199 women from January 2012 to August 2023 were included in this study and were divided into Group 1 (estimated surgical blood loss (EBL) ≤ 3500 mL, n = 103) and Group 2 (EBL > 3500 mL, n = 96). The primary outcome was defined as an EBL over 3500 mL. Baseline characteristics and surgical outcomes were compared between the two groups. A multivariate logistic regression model was applied to find potential risk factors of the primary outcome. RESULTS: Massive surgical blood loss was prevalent in our study group, with a median EBL of 3500 mL. The multivariate logistic analysis showed that emergency surgery (OR 2.18, 95% CI 1.08-4.41, p = 0.029), cervical invasion of the placenta (OR 2.70, 95% CI 1.43-5.10, p = 0.002), and intraoperative bladder injury (OR 5.18, 95% CI 2.02-13.28, p = 0.001) were all associated with the primary outcome. Bilateral internal iliac arteries balloon occlusion (OR 0.57, 95% CI 0.34-0.97) and abdominal aortic balloon occlusion (OR 0.33, 95% CI 0.19-0.56) were negatively associated with the primary outcome. CONCLUSIONS: Emergency surgery, cervical invasion of the placenta, and intraoperative bladder injury were potential risk factors for additional EBL during cesarean hysterectomy in women with PPA. Future prospective studies are needed to confirm the effect of intra-arterial balloon occlusion in cesarean hysterectomy of PPA.

A case with rare complication of chronic puerperal uterine inversion and underwent operation reduction.

OBJECTIVE: Puerperal uterine inversion is a rare and severe complication and is associated with short cord, uncontrolled cord traction, placenta accreta, or uterine atony. CASE REPORT: A primigravida woman gave birth a 2770 gm newborn at term at our hospital, and clinically presented postpartum hemorrhage, hypovolemic shock, postpartum preeclampsia and urinary retention. She discharged 3 days postpartum, but she complained persist vaginal bleeding and lower abdominal pain for more than 1 month. Uterine inversion was diagnosed and laparoscope surgery for reduction was done. CONCLUSION: The non-specific clinical presentation made diagnosis of uterine inversion more difficult. Except pelvic examination, sonographic and hysteroscopic images were record in this article. Surgical intervention was performed. A fundus incision was effective for reduction and had low risk of bladder and bowel injury.

Cephalad-caudad vs transverse blunt expansion of low transverse hysterotomy during caesarean section and risk of severe postpartum haemorrhage: A prospective comparative study.

BACKGROUND: The global prevalence of caesarean section as a delivery method is increasing worldwide. However, there is notable divergence among countries in their national guidelines regarding the optimal technique for blunt expansion hysterotomy of the low transverse uterine incision during caesarean section (cephalad-caudad or transverse). AIM: To compare the risk of severe postpartum haemorrhage (PPH) between cephalad-caudad and transverse blunt expansion hysterotomy during caesarean section. METHODS: This prospective comparative observational study was conducted in a university maternity hospital. All women who gave birth to one infant by caesarean section after 30 weeks of gestation between November 2020 and November 2021 were included in this study. The exclusion criteria were a coagulation disorder, the presence of placenta previa, multiple pregnancies, or enlargement of the hysterotomy with scissors. The choice between cephalad-caudad or transverse blunt expansion of the low transverse hysterotomy was left to the surgeon's discretion. The primary outcome measure was severe PPH, defined as estimated blood loss ≥ 1000 ml. Univariate and multivariate analyses were employed to assess the risk of severe PPH associated with the two methods of enlarging the low transverse hysterotomy. RESULTS: The study included 850 women, of whom 404 underwent transverse blunt expansion and 446 underwent cephalad-caudad blunt expansion. The overall incidence of severe PPH was 13.3 %. Univariate analysis revealed no significant difference in the frequency of severe PPH between the cephalad-caudad and transverse blunt expansion groups (13.9 % vs 12.6 %; p = 0.61). However, the use of additional surgical sutures (mainly additional haemostatic stitches) was less common with cephalad-caudad blunt expansion (26.7 % vs 36.9 %; p < 0.05). Multivariate analysis showed no significant difference in risk between the two techniques (odds ratio 1.17, 95 % confidence interval 0.77-1.78). CONCLUSION: No significant difference in the risk of severe PPH was found between cephalad-caudad and transverse blunt expansion of the low transverse hysterotomy during caesarean section.

Lower Uterine Segment Corrugated Sutures in Hemorrhage during Cesarean Section because Previal and/or Placenta Accreta Spectrum: Case Reports Series and Literature Review.

OBJECTIVES: We present the original technique of compression hemostatic sutures on the lower uterine segment due to early postpartum hemorrhage during cesarean section, with a literature review. METHODS: A retrospective clinical case study was conducted at the tertiary perinatal center. Twelve patients had nine planned and three urgent cesarean sections due to antenatally verified placenta previa and/or placenta accreta spectrum and defined early postpartum hemorrhage > 1000 mL during cesarean section. As the use of uterotonics failed to produce any effect and hemorrhage persisted, compression sutures of the lower uterine segment were made by our own technique, as follows: below the hysterotomy, a horizontal corrugated suture is placed from the right to the left corner and after 2-3 cm vertically and backwards at several sites from the left to the right corner, where it is tightened. RESULTS: Seven patients had one cesarean section, three patients had two cesarean sections, and seven patients had pregnancy from the in vitro fertilization procedure in their history. There were six patients with placenta previa and six patients with anterior invasive placenta accreta or increta. Original hemostatic procedure was applied successfully in ten cases, and after placement of O'Leary suture and persistent bleeding in two cases. In this group, no hysterectomy was performed, and patients received blood transfusion of 440-880 mL. Three patients later had spontaneous pregnancies. CONCLUSION: Our own hemostatic method with a simple technique, fast learning, and minimal logistics contributes to successful management of this currently global problem of morbidly adherent placenta previa.

The impact of internal iliac artery ligation on hormonal and functional ovarian reserve parameters: A case-control study in patients with postpartum hemorrhage in sub-Saharan Africa.

OBJECTIVE: The study aims to evaluate the long-term impact of internal iliac artery ligation (IIAL) on ovarian hormonal and functional changes in women. The procedure is often used for postpartum hemorrhage and is considered uterus-sparing. However, its effects on ovarian reserve and fertility preservation remain controversial. METHODS: This is a retrospective, case-control study involving consecutive female patients aged 17-47 years. These patients underwent successful bilateral IIAL due to severe postpartum hemorrhage between January 2022 and December 2022. The control group included women of matching age, parity, and body mass index (BMI) who did not undergo IIAL. Both groups were followed for 6 months to measure follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels, antral follicle counts, and ovarian volume. RESULTS: The study comprised 62 patients in the IIAL group and 86 in the control group. No significant differences were found in FSH and LH levels between the two groups (P > 0.05). However, the numbers of antral follicles in both the right and left ovaries were significantly lower in the IIAL group than in the control group (P < 0.05). Ovarian volume did not show a significant difference between the groups (P > 0.05). CONCLUSION: The findings suggest that IIAL leads to a significant decrease in the number of ovarian follicles at 6 months post-operation. However, it does not significantly impact FSH and LH levels or ovarian volume.

Perioperative outcomes and causes of postpartum hemorrhage in patients undergoing cesarean delivery in Thailand: A comprehensive retrospective study.

BACKGROUND: This study aimed to identify the characteristics, causes, perioperative anesthetic, and obstetric outcomes of patients experiencing postpartum hemorrhage (PPH) after cesarean delivery. METHODS: We retrospectively analyzed patients who underwent cesarean delivery at the largest university hospital in Bangkok, Thailand, during a 5-year period (January 1, 2016-December 31, 2020). PPH was defined as an estimated blood loss (EBL) of ≥ 1000 ml within 24 hours postpartum. RESULTS: Of 17 187 cesarean deliveries during the study period, 649 patients were included for analysis. The mean EBL was 1774.3 ± 1564.4 ml (range: 1000-26 000 ml). Among the patients, 166 (25.6%) experienced massive PPH (blood loss > 2000 ml). Intraoperative blood transfusions were necessary for 264 patients (40.7%), while 504 individuals (77.7%) needed intraoperative vasopressors. The analysis revealed uterine atony as the leading cause of PPH in 62.7% (n = 407) of the patients, with abnormal placentation following at 29.3% (n = 190). Abnormal placentation was associated with a significantly higher mean EBL of 2345.0 ± 2303.9 ml compared to uterine atony, which had a mean EBL of 1504.0 ± 820.7 ml (P < 0.001). Abnormal placentation also significantly increased the likelihood of blood transfusions and hysterectomies (P < 0.001 for both) and led to more intensive care unit admissions (P = 0.032). The risk of EBL exceeding 2000 ml was markedly higher in patients with abnormal placentation (odds ratio [OR] 5.12, 95% confidence interval [CI] 3.45-7.57, P < 0.001) and in cases involving trauma to the internal organs (OR 2.33, 95% CI 1.16-4.71, P = 0.018) than in patients with uterine atony. The study documented three instances of perioperative cardiac arrest, one of which was fatal. CONCLUSIONS: These findings highlight the importance of comprehensive perioperative management strategies, including the ready availability of adequate blood and blood products, particularly in scenarios predisposed to significant hemorrhage. TRIAL REGISTRATION: Clinical trial registration: Clinicaltrial.gov registration number NCT04833556 (April 6, 2021).

Imaging of Antepartum and Postpartum Hemorrhage.

Severe obstetric hemorrhage is a leading cause of maternal mortality and morbidity worldwide. Major hemorrhage in the antepartum period presents potential risks for both the mother and the fetus. Similarly, postpartum hemorrhage (PPH) accounts for up to a quarter of maternal deaths worldwide. Potential causes of severe antepartum hemorrhage that radiologists should be familiar with include placental abruption, placenta previa, placenta accreta spectrum disorders, and vasa previa. Common causes of PPH that the authors discuss include uterine atony, puerperal genital hematomas, uterine rupture and dehiscence, retained products of conception, and vascular anomalies. Bleeding complications unique to or most frequently encountered after cesarean delivery are also enumerated, including entities such as bladder flap hematomas, rectus sheath and subfascial hemorrhage, and infectious complications of endometritis and uterine dehiscence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Javitt and Madrazo in this issue.

The effect of B-Lynch uterine compression suture performed for uterine atony on future menstrual pattern and reproductive outcome.

OBJECTIVES: The effects of B-Lynch (UCS) compression sutures applied in postpartum hemorrhage cases due to uterine atony on menstrual pattern, fertility, obstetric outcomes, dysmenorrhea and dyspareunia were evaluated. MATERIAL AND METHODS: Between January 2012 and March 2017, 77 patients (study group 37, control group 40) diagnosed postpartum hemorrhage in our clinic were included in the study. The long-term results of the patients were evaluated comparatively. RESULTS: In the B-Lynch UCS group, an increase in the postoperative menstrual cycle length and the intensity of dyspareunia measured by the VAS score, and a statistically significant decrease in the duration of menstrual bleeding were observed. In the control group, a decrease in the self-estimated time of postpartum menstrual bleeding and a statistically significant increase in dyspareunia VAS values ​​were observed. There was a statistically significant difference between the groups in terms of menstrual cycle length only after treatment. CONCLUSIONS: B-Lynch UCS can be used effectively and safely in PPH due to uterine atony without causing any additional pathology in menstrual pattern, fertility, dysmenorrhea and dyspareunia complaints other than the length of the menstrual cycle.

A new step-wise surgical technique of knapsack-like uterine compression sutures for intractable postpartum hemorrhage in cesarean section.

BACKGROUND: Intractable postpartum hemorrhage (PPH) during cesarean section has been a significant concern for obstetricians. We aimed to explore the effectiveness and safety of a new type of uterine compression suture, the step-wise surgical technique of knapsack-like sutures for treating intractable PPH caused by uterine atony and placenta factors in cesarean section. METHODS: The step-wise surgical technique of knapsack-like sutures was established on the basis of the artful combination of vertical strap-like sutures and an annular suture-ligation technique. This novel surgical technique was applied to 34 patients diagnosed with PPH during cesarean section due to severe uterine atony and placental factors in our department. The hemostatic effects, clinical outcomes and follow-up visit results were all reviewed and analyzed. RESULTS: This new uterine compression suture successfully stopped bleeding in 33 patients, and the effective rate was 97.06%. Only 1 patient failed and was changed to use bilateral uterine arterial embolization and internal iliac artery embolization. The follow-up visits indicated that 33 patients restored menstruation except for 1 who was diagnosed with amenorrhea. The gynecological ultrasound tests of all the patients suggested good uterine involutions, and they had no obvious complaints such as hypogastralgia. CONCLUSIONS: This step-wise surgical technique of knapsack-like uterine compression sutures can compress the uterus completely. It is a technique that can conserve the uterus and fertility function without special equipment in caesarean section for PPH, with the characteristics of being safe, simple and stable (3 S) with rapid surgery, reliable hemostasis and resident doctor to operation (3R).

Reflections on peripartum hysterectomy: A 10-year retrospective observational study in Northeast China.

OBJECTIVE: To explore the change trends in incidence and leading factors to peripartum hysterectomy (PH) at a regional tertiary medical center in northeast China. METHODS: This was a retrospective observational study of all PH cases conducted at Shengjing Hospital between January 1, 2012 and December 31, 2021. Information on maternal characteristics of pregnancy and delivery, indications of PH, inventions before hysterectomy, complications, and maternal and neonatal outcomes obtained from the Shengjing Hospital Information System were analyzed. RESULTS: Among a total of 157 553 deliveries, there were 127 cases of PH (overall PH incidence: 0.85/1000 deliveries); 120 patients (94.49%) underwent hysterectomy after cesarean section, and seven (5.51%) underwent vaginal delivery (P < 0.001). Abnormal placentation was the leading indication for PH (101, 79.53%), including placenta previa (PP) with placenta accreta spectrum (PAS) (93, 73.23%), PP alone (5, 3.94%), and PAS alone (3, 2.36%). Among the patients who underwent PH with abnormal placentation, 92.08% had at least one cesarean section (P < 0.001) and 20.19% had bladder injury (P = 0.044). All maternal deaths (n = 2) occurred in referral patients, and the maternal mortality rate was 1.57/100 hysterectomies. CONCLUSION: Abnormal placentation was the primary indication for PH. For such patients, adequate assessment of their condition and complete communication are strongly recommended. The identification of high-risk groups for postpartum hemorrhage, timely and effective rescue, and referral are equally important for avoiding PH.

Peripartum hysterectomy: A 9-year population-based study in Slovakia.

OBJECTIVE: To assess the incidence of peripartum hysterectomy (PH) in Slovakia. Additionally, we wanted to describe reasons for the procedure, associated clinical circumstances, and complications. METHODS: This was a descriptive, population-based study among women who underwent PH in Slovakia between January 2012 and December 2020. Peripartum hysterectomy was defined as surgical removal of the uterus from the peripartum period up to 42 days postpartum. Data were obtained retrospectively from the standardized questionnaires that are completed in Slovakia for any case of PH. The background population consisted of all other women who delivered during the study period. RESULTS: Of the 436 136 births, there were 397 cases of PH, giving an incidence of 0.91 per 1000 births. It was higher with advanced maternal age, multiparity, multiple pregnancies, and cesarean deliveries. The main reasons for the procedure were placental pathologies and uterine atony in 52.9% and 33.0%, respectively. A total of 150 (37.8%) women required admission to an intensive care unit. The mortality rate was 1.5%. CONCLUSION: The incidence of PH is relatively high in Slovakia when compared with other European countries, highlighting the need to improve prenatal diagnosis of morbidly adherent placenta and the management of peripartum hemorrhage.

Large supralevator haematoma: a dilemma in diagnosis and management.

This is a case of postpartum haemorrhage following vaginal delivery of a primigravida in her late 20s resulting from a supralevator haematoma. She delivered in a low-resource hospital setting, with a late diagnosis of severe pre-eclampsia and haemolysis, elevated liver enzymes and low platelet count (HELLP), subsequently developed traumatic postpartum haemorrhage and vaginal haematoma, and was referred to our hospital for further management. She was constantly monitored, and serial ultrasonography revealed an expanding paravaginal haematoma. CT, 4 hours after admission, showed a large ill-defined collection with hyperdense areas of blood attenuation measuring ~8.0×6.2×12.2 cm in toto in the vaginal canal and right paravaginal region with supralevator extension, abutting the rectum posteriorly. The expanding haematoma caused gradual hypovolaemic shock, and hence, she was taken up for vaginal evacuation of supralevator haematoma with drainage tube insertion under ultrasound guidance. She received multiple blood product transfusion. Drain tube was removed on postoperative day 3. Follow-up scan was done and resolving haematoma noted. The patient was discharged on postoperative day 5 in a stable condition. She was followed up in outpatient department, and there was complete resolution of haematoma by 4 weeks.

Indications, risk factors, and outcomes of emergency peripartum hysterectomy: A 7-year retrospective study at a tertiary center in Turkey.

Objective: To determine the incidence, indications, the risk factors, complications, maternal morbidity and mortality of emergency peripartum hysterectomy (EPH), and perinatal outcomes at a tertiary hospital, Turkey. Methods: We analyzed 71 cases of EPH from 2012 to 2019 at a tertiary hospital in a retrospective study. There were 142 control patients. Results: There were 71 EPH out of 69,504 deliveries, for an overall incidence of 1.02 per 1000 births. The main indication for peripartum hysterectomy was abnormal placentation (67.6%), followed by uterine atony (28.1%), and uterine rupture (4.2%). Cesarean section (CS) and previous CS are major risk indicators for EPH. Other risk indicators are advanced maternal age (≥ 35 years) and multiparity. All patients with abnormal placentation had a previous CS. 93% of EPH were performed during and/or after CS, and 7% after vaginal delivery. 69% of EPH were made in total and 31% were subtotal. The three most common maternal morbidity included: wound infection and febrile morbidity (26.7%), bladder injury (16.9%), and disseminated intravascular coagulopathy (11.2%). There were no maternal deaths but perinatal mortality was 4%. Conclusion: The most common indication for EPH was abnormal placentation. Also, CS and previous CS are major risk factors of EPH. Other risk factors for EPH are advanced maternal age (≥ 35 years) and multiparity. Moreover, all unnecessary CS should be avoided.

Peripartum hysterectomy clinical characteristics and outcomes- a hospital based retrospective audit study.

INTRODUCTION: The study aims to evaluate and report on the clinical characteristics, incidence, risk factors and associated complications of emergency and planned peripartum hysterectomy in a single training and research tertiary health care centre in Malaysia. MATERIALS AND METHODS: We conducted a 6-year retrospective cross-sectional study from the 1st January 2016 until 31st December 2021. Clinical, demographic characteristics, perioperative parameters, operative indications, blood loss, maternal/neonatal outcomes and complications were analysed. Patients were subdivided, analysed and studied in two subgroups- emergency hysterectomy (EH) and planned hysterectomy (PH). RESULTS: There were 65 cases of peripartum hysterectomy out of total 100,567 deliveries, with a prevalence rate of 0.06%. Overall, the majority of patients were multiparous (96.9%), having previous caesarean scar (73.8%) or diagnosed with placenta praevia (75.4%). More than half of the total patients (61.5%) have both previous caesarean scar and concomitant placenta praevia. EH was carried out in 39(60%) patients while 26(40%) patients underwent PH. The only indication for surgery in the PH group (100%) was abnormal placentation while the most common indication for surgery in the EH group (53.8%) was postpartum haemorrhage related to abnormal placentation. Patients who underwent EH were more likely to have massive blood loss (p=0.001), require ICU admissions (p=0.001), have DIVC cycles transfused (mean [SD] regime: 1.35 [0.95] vs 0.54 [0.99]; p=0.002), have lower postoperative haemoglobin level (mean [standard deviation, SD] haemoglobin: 9.23g/l [SD1.8] vs. 10.8 g/l [SD1.86]; p=0.001) and have higher difference between pre/post operative haemoglobin level (mean [SD] haemoglobin difference: 1.78g/l [SD6.34] vs 0.32g/l [SD1.7]; p=0.008) compared to patients with PH. Red blood cell transfusion, operating time, length of stay, weight of babies and Apgar score between two groups showed no significant differences. A significant reduction of blood loss between the first and the second half duration of the study (mean [SD] blood loss: 6978 ml [SD 4999.45] vs. 4100ml [SD2569.48]; p=0.004) was also observed. In the emergency group, 'non-placental cause' EH required significantly more red blood cell transfusion than 'placental cause' (p<0.05) while in the PH group, no significant difference was observed between the occlusive internal iliac artery 'balloon' and 'no balloon' subgroup in terms of operating time, total blood loss or blood transfusion. Overall complications showed more cases of post operative fever and relaparotomy in the EH group (18.4% vs. 7.6%) while urinary tract injuries including injuries to bladder and ureter occurred only in the PH group (9.4% vs. 0%). CONCLUSION: The majority of peripartum hysterectomy cases are due to placenta accreta spectrum disorders. Planned peripartum hysterectomies have a lower morbidity rate compared to emergency hysterectomies. Therefore, early identification of placenta accreta spectrum disorders and timely planning for elective procedures are crucial to minimise the need for emergency surgery.

Successful perioperative management with damage control surgery following cardiac arrest due to massive postpartum hemorrhage: A case report.

INTRODUCTION: Although declining, maternal mortality due to postpartum hemorrhage (PPH) remains significant. Here we report the case of a 31-year-old primipara patient admitted with cardiac arrest due to PPH. CASE PRESENTATION: Labor was induced at gestational week 39, and the infant was delivered rapidly. Cardiac arrest due to PPH occurred during the transfer to our hospital, and the patient underwent cardiopulmonary resuscitation upon arrival to the emergency room. On admission, her hemoglobin level was 0.7 g/dL and she was in hypovolemic shock. Resuscitation and hysterectomy were performed immediately, including damage control surgery and gauze packing, to control the diffuse oozing bleeding due to severe disseminated intravascular coagulation. Relaparotomy for hemostasis was subsequently performed because of a decrease in hemoglobin level and blood pressure, and gauze packing was reinserted with temporary abdominal closure. Two days later, the abdominal wall was closed after confirming the absence of bleeding and the patient recovered well without further intervention. CONCLUSION: A prompt and assertive intensive response through collaborative efforts, utilizing feasible damage control surgery, can elegantly salvage uncontrolled bleeding in PPH patients with disseminated intravascular coagulation.

Hysterectomy following severe primary postpartum hemorrhage: A five year review in Abidjan University Hospitals.

Hemostasis hysterectomy is a mutilating technique responsible for definitive side effect on the woman's fertility. The aim was to document to document hemostasis hysterectomies performed in obstetrics units of university hospitals in Côte d'Ivoire. This was a retrospective, cross-sectional, and descriptive study from January 2013 to January 2018 in the three university hospital centers of Abidjan. It involved all parturients of the said university hospital centers who presented a severe postpartum hemorrhage and in whom a hemostasis hysterectomy was performed. The overall frequency of hemostasis hysterectomy in the three university hospitals was 0.32%. The most common etiologies were atony and uterine rupture. Hemostasis hysterectomy was indicated immediately. The deaths recorded were most often intraoperative and in the immediate postoperative period. The reduction of its incidence requires a good surveillance of the third period of delivery.