Placenta percreta with bladder invasion: surgical strategy to avoid massive blood loss

Harika, G; Gabriel, Rene Faustino; Napoléone, C; Quereux, C.; Wahl, P

doi:10.1016/0028-2243(94)90055-8

“…Though the conservative approach is believed to carry a higher risk of maternal death it preserves fertility and provides some psychological support to the woman [6]. It involves either of the following procedures: leaving the placenta in place with packing; a piecemeal blunt dissection with packing; uterine curettage with packing; closing of the uterine defect; localized excision and uterine repair; uterine packing with uterine or even hypogastric artery ligation; bilateral uterine artery embolization; and pelvic artery ligation [6,12,13]. Our patient had the radical approach due to the severe bleeding that she had, and it was a life-saving surgery.…”

Section: Discussionmentioning

confidence: 99%

Placenta Percreta Presenting as an Acute Abdomen in Second Trimester of Pregnancy: Case Report from Middle East

Chamsi¹

2018

WJGWH

1

0

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Abnormal Placentation carries life-threatening consequences to the mother. Placenta percreta is a rare complication of pregnancy. It occurs mostly in the third trimester and presents with severe postpartum hemorrhage and placenta retention. It is rare in the second trimester of pregnancy. Placenta percreta is becoming more common as cesarean section and other uterine surgeries increase. The presence of a uterine scar remains a major risk factor. Clinical presentation is variable with Antepartum hemorrhage is a usual scenario. However, it is usually seen in the third trimester. The presentation here is rare since it occurred in the second trimester rendering clinical suspicion difficult as was evident in the case. We here present a rare presentation of placenta percreta occurring in the second trimester as an acute abdomen secondary to uterine rupture and intraabdominal hemorrhage. She had a life-saving total hysterectomy and good postoperative recovery period. This might be the first case to be presented from Middle east with such scenario. Careful evaluation of a pregnant lady with an acute abdomen must be done with consideration of abnormal placentation as a cause, especially in a patient with risk factors for abnormal placentation.

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“…The other options involve surgical manoeuvres to control blood loss while the placenta is completely removed; this will commonly involve a hysterectomy 2,10 . To this end, ligation of the uterine or hypogastric vessels has been used 11,12 , as has balloon occlusion or embolisation of the internal iliac vessels 13,14 , and, in one report 15 , pre‐operative aortic balloon insertion.…”

Section: Discussionmentioning

confidence: 99%

Emergency use of a transfemoral aortic occlusion catheter to control massive haemorrhage at caesarean hysterectomy

Bell-Thomas

¹

,

Penketh

²

,

Lord

³

et al. 2003

BJOG

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Case reportA 34 year old woman with an ultrasound diagnosis of a major placenta praevia was booked for an elective caesarean section at 38 weeks of gestation. As both of her previous deliveries had been by caesarean section, she was counselled regarding the possibility of an abnormally adherent placenta and the possible need for a hysterectomy at the time of delivery.The caesarean section was carried out on a consultant's elective operating list with a consultant anaesthetist; crossmatched blood was available. Anaesthesia was achieved by a combined spinal and epidural block. Two large bore venous cannulae and an arterial catheter were inserted. Her baby was delivered easily in good condition through a Pfannenstiel incision in the abdomen and a high transverse incision in the lower segment. At this stage, there had been minimal blood loss.Gentle attempts to identify a plane of separation of the placenta provoked torrential bleeding, and at this point, removal of the placenta was abandoned in favour of hysterectomy. The woman was, however, bleeding so heavily that manual aortic compression was necessary as a life-saving measure, and the 'major haemorrhage procedure' of the hospital was implemented. General anaesthesia was induced and assistance was requested. A second obstetric consultant, additional theatre nurses and a renal transplant surgeon gave their services. The haematology department sent a registrar to advise on transfusion and treatment of coagulopathy as the third request for 10 units of blood was received.Aortic compression controlled the bleeding to an extent that a closer inspection of the lower uterine segment was possible and during attempts to further reflect the bladder, placenta percreta involving the cervix and bladder was diagnosed.The incision was extended to the umbilicus in the midline and a subtotal hysterectomy was performed; however, despite this, every time the aorta was released from manual compression, bleeding restarted. At the suggestion of the consultant transplant surgeon (RHL), a cut-down onto the left femoral artery was performed and transluminal aortic occlusion was achieved just below the renal arteries using a 10 French aortic occlusion catheter (BVM Medical, Earl Shilton, Leicestershire). This enabled the remainder of the procedure to be carried out in a relatively bloodless field, with intermittent deflation of the balloon to check haemostasis and reperfuse the lower limbs.Invasion of the cervical stroma necessitated partial removal of the cervix, during which the bladder was opened and part of the bladder wall removed. A left ureteric stent and a suprapubic catheter were placed before closure of the bladder.When adequate haemostasis was achieved, the aortic balloon was deflated and the pelvis was packed with oxidised cellulose gauze ('Oxycel', Becton Dickinson, UK) and gauze soaked in warm saline, and the wound was closed in layers. Finally, the aortic balloon was removed and the femoral artery repaired.Four hours later, the woman was transferred to the intensive care uni...

show abstract

“…The other options involve surgical manoeuvres to control blood loss while the placenta is completely removed; this will commonly involve a hysterectomy 2,10 . To this end, ligation of the uterine or hypogastric vessels has been used 11,12 , as has balloon occlusion or embolisation of the internal iliac vessels 13,14 , and, in one report 15 , preoperative aortic balloon insertion.…”

Section: Discussionmentioning

confidence: 99%

Emergency use of a transfemoral aortic occlusion catheter to control massive haemorrhage at caesarean hysterectomy

Bell-Thomas

¹

2003

BJOG: An International Journal of Obstetrics and Gynaecology

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Case reportA 34 year old woman with an ultrasound diagnosis of a major placenta praevia was booked for an elective caesarean section at 38 weeks of gestation. As both of her previous deliveries had been by caesarean section, she was counselled regarding the possibility of an abnormally adherent placenta and the possible need for a hysterectomy at the time of delivery.The caesarean section was carried out on a consultant's elective operating list with a consultant anaesthetist; crossmatched blood was available. Anaesthesia was achieved by a combined spinal and epidural block. Two large bore venous cannulae and an arterial catheter were inserted. Her baby was delivered easily in good condition through a Pfannenstiel incision in the abdomen and a high transverse incision in the lower segment. At this stage, there had been minimal blood loss.Gentle attempts to identify a plane of separation of the placenta provoked torrential bleeding, and at this point, removal of the placenta was abandoned in favour of hysterectomy. The woman was, however, bleeding so heavily that manual aortic compression was necessary as a life-saving measure, and the 'major haemorrhage procedure' of the hospital was implemented. General anaesthesia was induced and assistance was requested. A second obstetric consultant, additional theatre nurses and a renal transplant surgeon gave their services. The haematology department sent a registrar to advise on transfusion and treatment of coagulopathy as the third request for 10 units of blood was received.Aortic compression controlled the bleeding to an extent that a closer inspection of the lower uterine segment was possible and during attempts to further reflect the bladder, placenta percreta involving the cervix and bladder was diagnosed.The incision was extended to the umbilicus in the midline and a subtotal hysterectomy was performed; however, despite this, every time the aorta was released from manual compression, bleeding restarted. At the suggestion of the consultant transplant surgeon (RHL), a cut-down onto the left femoral artery was performed and transluminal aortic occlusion was achieved just below the renal arteries using a 10 French aortic occlusion catheter (BVM Medical, Earl Shilton, Leicestershire). This enabled the remainder of the procedure to be carried out in a relatively bloodless field, with intermittent deflation of the balloon to check haemostasis and reperfuse the lower limbs.Invasion of the cervical stroma necessitated partial removal of the cervix, during which the bladder was opened and part of the bladder wall removed. A left ureteric stent and a suprapubic catheter were placed before closure of the bladder.When adequate haemostasis was achieved, the aortic balloon was deflated and the pelvis was packed with oxidised cellulose gauze ('Oxycel', Becton Dickinson, UK) and gauze soaked in warm saline, and the wound was closed in layers. Finally, the aortic balloon was removed and the femoral artery repaired.Four hours later, the woman was transferred to the intensive care uni...

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Placenta percreta with bladder invasion: surgical strategy to avoid massive blood loss

Cited by 9 publications

References 12 publications

Placenta Percreta Presenting as an Acute Abdomen in Second Trimester of Pregnancy: Case Report from Middle East

Placenta Percreta Presenting as an Acute Abdomen in Second Trimester of Pregnancy: Case Report from Middle East

Emergency use of a transfemoral aortic occlusion catheter to control massive haemorrhage at caesarean hysterectomy

Emergency use of a transfemoral aortic occlusion catheter to control massive haemorrhage at caesarean hysterectomy

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