Minimizing Surgical Blood Loss at Cesarean Hysterectomy for Placenta Previa With Evidence of Placenta Increta or Placenta Percreta: The State of Play in 2020

Abstract

The evolution of multidisciplinary team-based care for women with placenta accreta spectrum (PAS) disorder has delivered step-wise improvements in clinical outcomes. Central to this overall goal is the ability to limit blood loss at surgery. Placement of inflatable balloons within the pelvic arteries, most commonly in the anterior divisions of the internal iliac arteries, became popular in many centers, at the expense of prolonging surgical care, and with attendant risks of vascular injury. In tandem, the need to expose pelvic sidewall anatomy in order to safely identify the course of the ureters re-popularized the alternative strategy of ligating the same anterior divisions of the internal iliac arteries. With incremental gains in surgical expertise, described in 5 steps in this review, our teams have witnessed a steady safely performing elective cesarean hysterectomy for placenta previa-percreta, the most severe PAS disorder.

A multidisciplinary approach and implementation of a specialized hemorrhage control team improves outcomes for placenta accreta spectrum

“…The REBOA deployment technique has been described elsewhere. 5,8 The position of the balloon in aortic zone III was confirmed using plain radiography (observing the radiopaque markings of the balloon at the level of the third and fourth lumbar vertebra). A maximum time of 25 minutes of AO was recommended.…”

“…Thus, when choosing REBOA, the risk-benefit balance must be considered. 8 Multiple management options are available to prevent or treat massive bleeding in PAS (Table 1), which respond to the specific needs of each particular case and are related to the competencies of each of the medical groups involved. 8 We aimed to examine the frequency of use of different bleeding control techniques (REBOA, endovascular internal iliac artery occlusion balloons [IIAOBs], or none) among women with PAS treated in the same institution, at a low-middle income country, during a 9-year period, as the interdisciplinary group technical skills were improved by organizing a PAS team.…”

Safer outcomes for placenta accreta spectrum disorders: A decade of quality improvement

“…An additional consideration is the use of differing techniques to reduce the IIA blood supply to the uterus, which was adopted in 73.1%–93.8% of individuals across the study period. This remains a controversial subject in the surgical management of PAS disorders and currently there is limited evidence to strongly recommend any method to reduce pelvic blood flow and associated blood loss 25,28 . The change to IIA surgical ligation of the vessels reflect the importance of team audit and feedback.…”

“…This remains a controversial subject in the surgical management of PAS disorders and currently there is limited evidence to strongly recommend any method to reduce pelvic blood flow and associated blood loss. 25,28 The change to IIA surgical ligation of the vessels in other studies. 29 Importantly, the overall rates of complications and adverse events remained statistically similar throughout the study period, with no increase in these balancing measures with the changes implemented.…”

“…• Cesarean delivery, followed by observation for spontaneous placental separation (in cases of mild placenta accreta) with subsequent intraoperative assessment and consensus on the need for peripartum hysterectomy was performed by at least two of the five members of the PAS disorders team at the institution (LMA, AM, gynecologic surgery; JCPK, RCW, SRH, maternal fetal medicine), with the aim of maximizing the use of a standardized surgical technique as previously published. 28 • IOCS was utilized using the XTRA (LivaNova, London, UK) autotransfusion machine. Recovered blood of a sufficient volume underwent washing and concentration with reinfusion back to patients via a Lipiguard SB (Haemonetics, Braintree, MA, USA) leucocyte depletion reinfusion filter.…”