Development and validation of nomograms for predicting blood loss in placenta previa with placenta increta or percreta

Background: We investigated the role of balloon placement in the abdominal aorta (BPAA) in planned conservative management of placenta previa with placenta increta or percreta and the effects of BPAA on perinatal adverse maternal events.Methods: This retrospective case-control study included women with placenta previa (increta or percreta), who underwent pregnancy termination at the Qilu Hospital of Shandong University between January 2016 and June 2019. Patients were categorized into the BPAA and non-BPAA groups based on the BPAA placement before delivery. The Chi-square and non-parametric rank-sum tests were used for the intergroup comparison of patient characteristics. The propensity score matching algorithm was used to minimize the intergroup differences in clinical characteristics. Logistic regression analysis was used to identify the factors associated with a high risk of adverse pregnancy outcomes. The area under the receiver operating characteristic curve [area under the curve (AUC)] was used to evaluate the classification of the selected high-risk factors.Results: The study included 260 patients, and 104 patients were identified after propensity score matching. In the post-matched cohort, intraoperative blood loss was significantly lower in the BPAA than in the non-BPAA group (median 1,000 vs. 2,250 ml, P < 0.001). Intraoperative B-Lynch suture was performed in fewer patients in the BPAA (15.4 vs. 34.6%, P = 0.024) than in the non-BPAA group. The packed red blood cell (PRBC) transfusion rate was lower in the BPAA group (median 4 vs. 8 units, P < 0.001). Overall, 46 (45.1%) patients developed adverse maternal events; however, the rate of adverse maternal events was lower in the BPAA group (19.6 vs. 80.4%, P < 0.001). No ligation of the ascending branch of the uterine artery (P = 0.034), no BPAA (P < 0.001), intraplacental vascular lacunae (P = 0.046), and cervical hypervascularity (P = 0.001) were associated with a high risk of adverse perinatal maternal events. The AUC of the high-risk factors was 0.89 in the post-matched and 0.76 in the pre-matched cohorts.Conclusion: Planned conservative management using BPAA significantly minimized the intraoperative blood loss, the need for a B-Lynch suture, and PRBC transfusion in patients with severe placenta accreta spectrum and placenta previa.

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Maternal and Foetal Outcome in Cases of Placenta Previa, Accreta and Increta

Annals of King Edward Medical University ◽

10.21649/akemu.v22i4.1469 ◽

2016 ◽

Vol 22 (4) ◽

Author(s):

Fauzia Anjum ◽

Rabia Bashir ◽

Arooba Rahim

Keyword(s):

Blood Loss ◽

Placenta Accreta ◽

Placenta Previa ◽

Tertiary Care ◽

Surgical Techniques ◽

Bladder Injury ◽

Placenta Increta ◽

Foetal Outcome ◽

Tertiary Care Hospitals ◽

Placenta Accrete

AbstractObjective: To evaluate the maternal and foetal outcome in cases of placenta previa, placenta accrete and placenta increta.Methods: Medical records of patients from 1 Feb 2014 to 28 Feb 2015 were checked and patients who underwent caesarean section with a diagnosis of placenta previa types III and IV (and placenta accreta, increta and percreta) were identified. Their medical record files were retrieved and data collected regarding patients age, parity, previous LSCS, D&C, blood loss, bladder injury, hysterectomy and use of B-lynch technique were recorded. Neonatal statistics were also recorded regarding birth weight, gender, APGAR score and need for admission in NICU.Results: In total 37 cases of major placenta previa were identified. These included 8 cases with placenta accrete including 2 cases of placenta increta. No maternal death occurred amongst the studied cases. Only one case of IUFD was identified. The incidence of placenta previa (major) was 29.95/1000 births. Average parity of patients with placenta accreta (PA) was signi-ficantly higher than cases of placenta previa (PP) (2.75 vs. 1.55, p = 0.04). Similarly average number of LSCS in cases of PA was significantly higher than cases of PP (2.25 vs. 0.86, p = 0.02). PA cases were delivered at a significantly earlier gestational age as compared to cases with PP (34.5 weeks vs. 37 weeks, p = 0.01). Hysterectomy was done in 6 (75%) cases of PA but in none with PP. Bladder injury occurred in 2(25%) cases of PA but in none with PP. Blood loss was also signi-ficantly higher in PA cases than PP cases (3975 ml vs. 1196 ml, p = 0.006). Conclusion: At tertiary care hospitals, maternal and foetal outcomes for placenta previa and placenta accreta have improved owing to improved surgical techniques and better understanding of these conditions.

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Placenta previa with posterior extrauterine adhesion: clinical features and management practice

BMC Surgery ◽

10.1186/s12893-020-01027-9 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Yoshikazu Nagase ◽

Shinya Matsuzaki ◽

Masayuki Endo ◽

Takeya Hara ◽

Aiko Okada ◽

...

Keyword(s):

Propensity Score ◽

Blood Loss ◽

Cesarean Delivery ◽

Clinical Features ◽

Surgical Outcomes ◽

Multivariate Regression ◽

Placenta Previa ◽

Control Group ◽

Intraoperative Blood Loss ◽

Intraoperative Bleeding

Abstract Background A diagnostic sign on magnetic resonance imaging, suggestive of posterior extrauterine adhesion (PEUA), was identified in patients with placenta previa. However, the clinical features or surgical outcomes of patients with placenta previa and PEUA are unclear. Our study aimed to investigate the clinical characteristics of placenta previa with PEUA and determine whether an altered management strategy improved surgical outcomes. Methods This single institution retrospective study examined patients with placenta previa who underwent cesarean delivery between 2014 and 2019. In June 2017, we recognized that PEUA was associated with increased intraoperative bleeding; thus, we altered the management of patients with placenta previa and PEUA. To assess the relationship between changes in practice and surgical outcomes, a quasi-experimental method was used to examine the difference-in-difference before (pre group) and after (post group) the changes. Surgical management was modified as follows: (i) minimization of uterine exteriorization and adhesion detachment during cesarean delivery and (ii) use of Nelaton catheters for guiding cervical passage during Bakri balloon insertion. To account for patient characteristics, propensity score matching and multivariate regression analyses were performed. Results The study cohort (n = 141) comprised of 24 patients with placenta previa and PEUA (PEUA group) and 117 non-PEUA patients (control group). The PEUA patients were further categorized into the pre (n = 12) and post groups (n = 12) based on the changes in surgical management. Total placenta previa and posterior placentas were more likely in the PEUA group than in the control group (66.7% versus 42.7% [P = 0.04] and 95.8% versus 63.2% [P < 0.01], respectively). After propensity score matching (n = 72), intraoperative blood loss was significantly higher in the PEUA group (n = 24) than in the control group (n = 48) (1515 mL versus 870 mL, P < 0.01). Multivariate regression analysis revealed that PEUA was a significant risk factor for intraoperative bleeding before changes were implemented in practice (t = 2.46, P = 0.02). Intraoperative blood loss in the post group was successfully reduced, as opposed to in the pre group (1180 mL versus 1827 mL, P = 0.04). Conclusions PEUA was associated with total placenta previa, posterior placenta, and increased intraoperative bleeding in patients with placenta previa. Our altered management could reduce the intraoperative blood loss.

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Anesthetic management in cesarean delivery of women with placenta previa: a retrospective cohort study

BMC Anesthesiology ◽

10.1186/s12871-021-01472-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Dazhi Fan ◽

Jiaming Rao ◽

Dongxin Lin ◽

Huishan Zhang ◽

Zixing Zhou ◽

...

Keyword(s):

Cohort Study ◽

Blood Transfusion ◽

Blood Loss ◽

General Anesthesia ◽

Cesarean Delivery ◽

Retrospective Cohort ◽

Placenta Previa ◽

Neuraxial Anesthesia ◽

Estimated Blood Loss ◽

Maternal And Neonatal Outcomes

Abstract Background The incidence of placenta preiva is rising. Cesarean delivery is identified as the only safe and appropriate mode of delivery for pregnancies with placenta previa. Anesthesia is important during the cesarean delivery. The aim of this study is to assess maternal and neonatal outcomes of patients with placenta previa managed with neuraxial anesthesia as compared to those who underwent general anesthesia during cesarean delivery. Methods A retrospective cohort study was performed of all patients with placenta preiva at our large academic institution from January 1, 2014 to June 30, 2019. Patients were managed neuraxial anesthesia and general anesthesia during cesarean delivery. Results We identified 1234 patients with placenta previa who underwent cesarean delivery at our institution. Neuraxial anesthesia was performed in 737 (59.7%), and general anesthesia was completed in 497 (40.3%) patients. The mean estimated blood loss at neuraxial anesthesia of 558.96 ± 42.77 ml were significantly lower than the estimated blood loss at general anesthesia of 1952.51 ± 180 ml (p < 0.001). One hundred and forty-six of 737 (19.8%) patients required blood transfusion at neuraxial anesthesia, whereas 381 out of 497 (76.7%) patients required blood transfusion at general anesthesia. The rate neonatal asphyxia and admission to NICU at neuraxial anesthesia was significantly lower than general anesthesia (2.7% vs. 19.5 and 18.2% vs. 44.1%, respectively). After adjusting confounding factors, blood loss was less, Apgar score at 1- and 5-min were higher, and the rate of blood transfusion, neonatal asphyxia, and admission to NICU were lower in the neuraxial group. Conclusions Our data demonstrated that neuraxial anesthesia is associated with better maternal and neonatal outcomes during cesarean delivery in women with placenta previa.

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Emergency Peripartum Hysterectomy as Postpartum Hemorrhage Treatment: Incidence, Risk factors, and Complications

Journal of Nepal Medical Association ◽

10.31729/jnma.2375 ◽

2014 ◽

Vol 52 (193) ◽

pp. 668-676 ◽

Cited By ~ 3

Author(s):

Meena Pradhan ◽

Yong Shao

Keyword(s):

Risk Factors ◽

Caesarean Section ◽

Blood Loss ◽

Postpartum Hemorrhage ◽

Placenta Previa ◽

Uterine Atony ◽

Previous Caesarean Section ◽

Peripartum Hysterectomy ◽

Incidence Risk ◽

Emergency Peripartum Hysterectomy

Introduction: The aim of the research was to investigate incidence, risk factors, and complications associated with emergency peripartum hysterectomy, the ultimate treatment method for intractable postpartum hemorrhage.Methods: This is a single center case-control study conducted in Chongqing city in central China from 1st January 2007 to 31st December 2012 for emergency peripartum hysterectomy performed as a treatment of postpartum hemorrhage both in caesarean and vaginal delivery cases. While the study group included emergency peripartum hysterectomy (n=61) due to intractable postpartum hemorrhage, the control group included no hysterectomy (n=333) during the same study period.Results: We found 61 cases recorded for emergency peripartum hysterectomy for intractable postpartum hemorrhage. Incidence of peripartum hysterectomy was 2.2 per 1000 deliveries. Emergency peripartum hysterectomy as treatment of intractable postpartum hemorrhage include the followings: (i) blood loss 1000-2000 ml, crude odd ratio (OR) =18.48 (95% CI 5.1-65.7), adjusted odd ratio (AOR) = 9.1 (95% CI 2.2-37.7); (ii) blood loss >2000 ml, OR = 152 (95% CI 43.7-528.4), AOR = 45.3 (95% CI 11.6-176.9); (iii) previous caesarean section, OR = 5.5 (95% CI 2.9-9.7), AOR = 3.7(95% CI 1.4-9.9); (iv) uterine atony, OR = 11.9 (95% CI 5.8-24.6), AOR = 7.5 (95% CI 1.8-30.2); (v) placenta previa, OR = 2.04 (95% CI 1.1-3.5), AOR = none. Conclusions: Emergency peripartum hysterectomy is the last resort as treatment of intractable severe postpartum hemorrhage. Our study depicts that severe post partum hemorrhage, further dreaded complex events for emergency peripartum hysterectomy, has significant association with placental factors, previous caesarean section, and uterine atony. Pathologically, placenta accreta remained the most leading cause of hysterectomy.Keywords: caesarean section; hemorrhage; peripartum hysterectomy; placenta previa.

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The Pattern of Blood Loss in Women With Placenta Previa and Accreta [57]

Obstetrics and Gynecology ◽

10.1097/01.aog.0000462739.27078.03 ◽

2015 ◽

Vol 125 ◽

pp. 26S ◽

Cited By ~ 1

Author(s):

Smitha Sarma ◽

William A. Grobman ◽

Tera Frederick Howard

Keyword(s):

Blood Loss ◽

Placenta Previa

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Fahmy's four quadrant sutures: a new technique for control of blood loss during cesarean delivery for placenta previa

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20183291 ◽

2018 ◽

Vol 7 (8) ◽

pp. 3004

Author(s):

Mohamed S. Fahmy ◽

Laila Ezzat ◽

Maraey M. Khalil ◽

Ahmed H. Elsayed ◽

Sherif S. Fahmy ◽

...

Keyword(s):

Blood Loss ◽

Cesarean Delivery ◽

Simple Procedure ◽

Placenta Previa ◽

Suture Technique ◽

University Hospital ◽

New Technique ◽

Artery Ligation ◽

The Mean ◽

Four Quadrant

Background: The objective of this study is to assess the efficacy and safety of Fahmy's four quadrant suture technique (FFQS) in controlling blood loss during cesarean delivery for placenta previa (PP).Methods: The study was carried out in a tertiary University Hospital between January 2017 to December 2017 involved 12 women with heavy bleeding occurred after removal of the placenta from the lower section during cesarean delivery for PP. The FFQS technique consisted of two sutures to ligate the uterine branches on both sides and two sutures on the anterior and posterior wall of the lower uterine segment. Details regarding the management and maternal outcomes were recorded.Results: The mean age of the study participants was 29.58±5.29 years and the mean parity was 2.25±1.14. The mean gestational age at termination of pregnancy was 36.91±1.38 weeks. The mean duration of the whole surgery was 78.75±43.28 minutes, while the mean duration of FFQS technique was only 10±2.09 minutes. The technique was exclusively effective in 8 out of 12 cases (66.67%) while 2 cases needed bilateral internal iliac artery ligation and 2 cases needed hysterectomy. The mean amount of blood loss in all cases was 2433.33±833.76 ml. the mean amount of transfused packed RBCs was 3.92±1.68 units and fresh frozen plasma (FFP) was 3.42±1.44 units. All cases had uneventful postoperative course and no mortality cases in present series.Conclusions: The new technique; FFQS represents a rapid, effective, and inexpensive opportunity for women with bleeding from the lower segment of uterus due to PP. This simple procedure should be attempted before other complex measures to achieve good hemostasis.

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Peripartum hysterectomy for cesarean section with morbidly adherent placenta: case series of 25 patients

International Journal of Reproduction Contraception Obstetrics and Gynecology ◽

10.18203/2320-1770.ijrcog20184115 ◽

2018 ◽

Vol 7 (10) ◽

pp. 3980

Author(s):

Abdulrahman M. Rageh ◽

Mohamed Khalaf ◽

Ahmed M. Abbas ◽

Hossam T. Salem

Keyword(s):

Blood Loss ◽

Placenta Accreta ◽

Placenta Previa ◽

Case Series ◽

Bladder Injury ◽

Operative Blood Loss ◽

Ureteric Injury ◽

Total Blood ◽

Peripartum Hysterectomy ◽

The Mean

Background: The current paper reports the outcome of case series of patients presented with placenta accreta confirmed histopathologicaly after management by peripartum hysterectomy.Methods: The study was set in Women’s Health Hospital, Assiut University, Egypt. This was a case series of 25 women presented with placenta accreta between May 2017 and April 2018. We included all pregnant women with placenta previa as diagnosed by ultrasound with suspicion of abnormal placentation by Doppler, confirmed intra-operatively undergoing either emergent or elective CS. All cases were performed by an expert team of obstetricians and anesthetists. Cesarean delivery was done under general anesthesia through pfannensteil incision. The primary outcome was the estimated intra-operative blood loss through assessment of amount of blood in the suction by ml, difference between the weight of surgical drapes and towels before and after operation.Results: Pre-operative Hb was 10.64±1.01 gm/dL and there was significant decline in the postoperative Hb reaching 8.36±1.21 gm/dL (p<0.001). The mean drop in Hb was 2.28±1.43gm/dL. Estimated intra-operative blood loss was 974.4±398.05 ml in the towels and 847.6±362.56 ml in the suction apparatus. The total blood loss was 1822±653.73 ml. The mean number of units of whole blood transfused was 2160.0±825.6 ml and fresh frozen plasma was 1010.0±349.7 ml. Regarding intra-operative complications, bladder injury was the most common one in 14 cases (56%), followed by ureteric injury in two cases (8%). Postoperative ICU admission was in 6 cases (24%) and the mean duration of hospital stay 12.44 ± 4.07 days. No cases of maternal mortality.Conclusions: In conclusion, peripartum hysterectomy is considered life-saving surgery in patients with placenta accreta.

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