Temporary loop ligation of the abdominal aorta during cesarean hysterectomy for reducing blood loss in placenta accrete

Abstract

Placenta accreta is a condition in which the placenta is abnormally attached to the uterus. It is an important cause of massive peripartum hemorrhage and a source of maternal morbidity and mortality in modern obstetrics, accounting for 46% of cesarean hysterectomies (CHs) [1]. The incidence of placenta accreta has increased over the past century from 1/7000 deliveries to 1/2500 deliveries because of the rising rate of caesarean deliveries [2]. Various methods for managing placenta accreta have been described in the literature. These range from conservative methods to hysterectomy. We report here a case in which an innovative procedure, "temporary loop ligation of the abdominal aorta," was performed during CH for placenta accreta, following which there was a dramatic decrease in intraoperative blood loss.A 33-year-old Chinese woman (gravida 3, para 1) was referred to us at 36 weeks' gestation for cesarean delivery with suspected placenta accreta. She had experienced a previous full-term cesarean delivery 4 years before. During a prenatal examination, color Doppler ultrasound scan revealed complete placenta previa and she was referred to our hospital. The color Doppler ultrasound performed at our hospital showed that the placenta had completely covered the cervical ostium. There was a low echogenic area approximately 70 mm  14 mm between the placental edge and the cervical ostium. To clearly identify the relationship between the location of the placenta and the uterine scar, magnetic resonance imaging was performed. It showed features characteristic of complete placenta previa including outward bulging of the lower uterine segment. The demarcation between the placenta and uterine muscle layer was unclear, with heterogeneous signal intensity extending into the uterine muscle layer.After detailed consultation with a professor of general surgery, we decided to perform a temporary loop ligation of the abdominal aorta during CH to minimize operative blood loss. Cesarean delivery was performed under general anesthesia. During the operation, we found the lower uterine segment to be purplish blue and bulging outward with abundant vascular engorgement. A viable female infant weighting 2920 g with 1-minute and 5-minute Apgar scores of 8 and 9, respectively, was delivered through a longitudinal hysterotomy incision. After the fetus was delivered, the abnormally adherent placenta was left in situ. The professor of general surgery performed an abdominal aorta ligation. A retroperitoneal dissection was initially performed to separate the infrarenal abdominal aorta (IAA), approximately 3e4 cm from the inferior vena cava, between the fourth lumbar and aortic bifurcation. A No. 14 gauge catheter was then inserted through the rear end of the abdominal aorta and loop ligation was performed (Figure 1). After meticulously dissecting the uterine ligaments and vessels, a rapid hysterectomy was performed, and the cervical vault was repaired. The surgical procedure was successful, with an estimated blood loss of 400 mL, which is lower tha...

Aortic clamping for limiting blood loss at cesarean hysterectomy for placenta percreta: A case series

“…Dissection proceeds between the aortic wall and the surrounding fascia, so the risk of injury to the adjacent inferior vena cava is minimized. Unlike loop ligation of the aorta, 9 dissection posterior to the aorta is avoided, thereby preventing the possibility of injury to the fourth lumbar vessels that could result in uncontrollable bleeding and later ischemic lesions in the spinal cord 12 . Securing the tubo‐ovarian pedicles before aortic clamping reduced aortic clamping time and stopped anastomotic blood flow from ovarian arteries.…”

“…Recurrent placental adhesive disease has been reported in 30% of subsequent pregnancies 6 . A few case reports have found satisfactory hemostasis with aortic cross clamping during hysterectomy for placenta percreta 7–9 …”

“…6 A few case reports have found satisfactory hemostasis with aortic cross clamping during hysterectomy for placenta percreta. [7][8][9] We report our experience with peri-partum hysterectomy for placenta percreta after clamping the infra-renal aorta to achieve proximal vascular control.…”

Clinical value of serum VEGF and sFlt-1 in pernicious placenta previa

“…It could irreversibly bind to the vascular endothelial growth factor in the placenta such as VEGF and inhibit its biological activity [ 15 ]. Recent studies believe that abnormal blood vessel formation leads to decidua dysplasia and excessive invasion of the trophoblast, resulting in placenta accreta [ 16 ].…”