Discription of new methods to control pph

2. UniversityofTripoli
FacultyofMedicine
ObstetricsandGynecologyDepartment
TheCervixAsanaturaltamponadein placentapreviaandplacentaprevia accreta

3. Presented by :-
Dr. Wedad Alfithoure
Supervised by :-
Dr . Abdullah Abudaber
Consultant Obstetrician &Gynecologist Libya, Assistant professor, Faculty of Medicine,
University of Tripoli
This dissertation is submitted in partial fulfillment for certification by the master degree
in Obstetrics and Gynecology, Tripoli- Libya, Dec 2018.

4. Subject Page
Study protocol 6
Abstract 11
Introduction 12
Aim of study 17
Materials and methods 19
Result 24
Discussion 27
Conclusion 33
Limitation of the study 34
References 42
Arabic summary 48
Table of content:

5. Introduction

6. Background:-
• A nationwide review of the peripartum hysterectomies by the UK
Obstetric Surveillance System (UKOSS) found that morbidly
adherent placenta was the cause in 38% of cases.

7. • Women undergoing attempts of removal of the placenta before
hysterectomy have an increased incidence of maternal morbidity
(admission to the ICU for >24 hours, transfusion of ≥4 units of
packed red blood cells, coagulopathy, ureteric injury, or early
re‐operation) when compared with those undergoing cesarean
hysterectomy with the placenta left in situ.

8. • Currently, there is dramatic increase in the incidence of placenta
previa and placenta accreta due to the increasing rate of cesarean
delivery combined with increasing maternal age

9. • The maternal mortality in women with PA may reach as high as 7–
10 %.

10. • Manual removal of the placenta would lead to increased risk of
hysterectomy, hemorrhage, and blood transfusion.

11. • Several techniques have been described in the literature for
controlling massive bleeding associated with placenta previa
cesarean sections, including uterine packing with gauze, balloon
tamponades, the B-Lynch suture, insertion of parallel vertical
compression sutures, a square suturing technique, and
embolization or ligation of the uterine and internal iliac arteries ,
but there is a wide variation in the success rate of these
maneuvers.

12. • Internal iliac artery ligation or embolization is associated with
significant risks of failure especially in cases of placenta previa
and accreta as the lower uterine segment has additional arterial
supply by the cervical, inferior vesical and vaginal arteries.

13. • An alternative method to leaving the placenta in situ involves
resection of the invaded myometrium together with the placenta
and suturing the myometrial defect. Reconstruction is possible if
there is non‐invaded segment of the uterus below the placental
invasion, so that the lower uterine segment can be sutured to the
upper segment after resecting the invaded myometrial segment.

14. • In a case report, Dawlatly et al. described a simple technique of
suturing an inverted lip of the cervix over the bleeding placental
bed that was successful in controlling the bleeding, and preserving
fertility.

15. Here
• We present our experience with the use of this Dawlatly stitch in
35 cases of placenta previa and/or placenta previa accreta.

16. Aim of this study

17. Objective
• Evaluate the efficacy and safety of the use of the cervix as a
natural tamponade in controlling intrapartum hemorrhage caused
by placenta previa and accretta .

18. Material and Methods
Study design: prospective study
Study setting : Alkhadra hospital obstetrics and
gynaecology department ,Tripoli ,Libya
Study period : January 2017 and December 2017

19. Study population
• All participating women had one or more previous cesarean
deliveries and were diagnosed with placenta previa and/ or
placenta previa accreta by ultrasound.
All women meeting inclusion criteria were selected which
included 35 patients who had received the decided type of the
modified cervical inversion stitch.

20. • All participating women desired to preserve their fertility. They
were counseled properly and were given clear information about
the diagnosis, the risk of severe postpartum hemorrhage and the
methods that can be used to control this massive hemorrhage,
including conservative methods and radical method (emergency
hysterectomy).

21. • Patients were informed that cesarean hysterectomy is the
first option in case of placenta percreta, diffuse placenta accreta
or increta and in the presence of uncontrollable hemorrhage and
these were considered as exclusion criteria for conservative
management. The conservative methods used were explained to
the patients and included the suture technique described in this
study, uterine and/or internal iliac artery ligation.

22. Primary Outcome measures:-
• The amount of intra-operative blood loss.
• The change in pre and post-partum hemoglobin .
• The need for further surgical intervention to control bleeding.
• The bleeding control with the primary technique
• The need for blood transfusion.
• The operative time.

23. The secondary outcome measures
• Cervical displacement.
• Uterine synechia.
• Infertility.

24. Statistical analysis
• Statistical analysis was performed using the Statistical Package for
Social Science (SPSS Inc., NY) version 21 for Microsoft Windows.
Data was described in terms of mean ± SD (standard deviation) for
continuous variables and frequencies (number of cases) and
percentages for categorical data.

25. • Independent Student’s t-test was used to compare quantitative
variables and Chi square test was used to compare categorical
data. A p value < 0.05% was considered significant.T-test was
performed to compare the mean pre-operative hemoglobin and
the mean post-operative hemoglobin.

26. Results
• Tables one and two ,and figure one, two, and three show the
demographic and the intraoperative clinical data of the studied
group.
The mean age was 29.2 ± 2.7 years. Regarding parity, one patient
(2.85 %) was para 1 , 5 patients (14.28 %) were para 2 , 9 patients
para 3 (25.73 %) , and 20 ( 57.14 % ) patients were para 4 .

27. Table 1: Demographic Data of the patients.
Characteristics Mean _+SD Range Number %
Total 35
Age 29.2 + -2.7 25 -36
Parity :- P1- 4
P1 1 (2.85%)
P2 5 (14.28 %)
P3 9 (25.73 %)
P4 20 (57.14
%)
Number of Living children :- 0 - 4
No alive 3 ( 8.6 % )
1 1 ( 2.8 % )
2 5 ( 14.2 % )
3 10 ( 28.6 % )
4 16 ( 45.8 % )
Previous Cesarean section : -
P1cs 5 ( 14.2 % )
P2cs 7 ( 20 % )
P3cs 7 ( 20 % )
P4cs 16 ( 45.8%
)
Gestational age in weeks 5.9+-1.1 33_ 37
SD – Standard Deviation ,P – Para.

28. Table 2: Intraoperative clinical data of the
participants
Characteristics Number (%)
(Total 35)
Mean + -
SD
P value
Type of placenta previa:
P. previa accreta 27 (77.1 % )
P. previa major anterior 5 ( 14.3 % )
P.previa major posterior 3 (8.6 % )
Cervical Lip Inverted:-
Both cervical lips 8 ( 22.8 % )
Anterior cervical lip 25 ( 71.5 % )
Posterior cervical lip 2 (5.7 % )
Time required to apply the stitch(minutes) 5.4+-0(4.3-
7.1)
Intraoperative blood loss( ml) 1572.2+-
390.2
Hysterectomy 2 (5.7 % )
Haemoglobine :-
Preoperative 10.8 +-0.23 <0.000
1
Postoperative 10.3 +-.22
SD Standard Deviation,

29. Figure1: parity of patients
2.85%
14.28%
25.73%
57.14%
Parity of patients
para 1
Para 2
Para 3
Para 4

30. Figure2: number of previous C/S
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
Previous on C/S Previous two C/S Previous three C/S Previous four C/S
14.20%
20%
20%
45.80%
Number of previous C/S
Number of previous C/S

31. Figure 3: types of placenta previa
77.10%
14.30%
8.60%
Types of palcenta previa
P. previa accreta
P. previa major anterior
P.previa major posterior

32. • . The number of living children, three patients (8.6 %) have no
children and 1 patient (2.8 %) has one child and 5 patients (14.2
%) have two children, 10 patients ( 28.6 %) have three living
children , and 16 ( 45.8 % )patients have four living children
which are considered small family size in our communities.

33. • Intra-operatively, we identified twenty seven cases of placenta
accreta, five cases of placenta previa major anterior and three
cases of placenta previa major posterior.

34. • To control bleeding from the placental bed, both the anterior and
posterior cervical lips were used in eigth cases, the anterior lip
only was used in twenty five cases and the posterior lip in two
cases.

35. • The technique of cervical inversion described above was
successful in stopping the bleeding in 33 out of 35 patients;
yielding a success rate of 95 %.

36. • We resorted to hysterectomy in only two cases (5.7 % ).
Histopathological examination of the uterus in these two cases
showed placenta percreta.

37. • The mean intra-operative blood loss was 1572.5 mL, and the mean
number of blood units transfused was 3.1. The difference between
the mean pre-operative hemoglobin (10.8 ± 0.23 gm/dl) and the
mean post-operative hemoglobin (9.3 ± 0.22 gm/dl) was
statistically significant (p value < .0001).

38. • Table 3 showed that placenta accreta cases were more in those
who had previous 4 cesarean sections .

39. Table 3: Type of previa & Relation to
number of C.S
Type of placenta previa Previous
1 C.S
Previous 2
C.S
Previou
s 3 C.S
Previou
s 4C.S
Total Nu. 35
Placenta previa accreta 3 5 5 14 27
Placenta previa major
anterior
2 1 1 1 5
Placenta previa major
posterior
0 1 1 1 3
Total Nu. 5 7 7 16 35
C.S Cesarean Section

40. • Table 4 showed the postoperative data and the complications
encountered were as follows: bladder injury in the two patients
who underwent hysterectomy and wound infection in one patient.
Postoperative fever that responded to antibiotics occurred in one
patient. The mean duration of the postoperative hospital stay was
3.5 days.

41. Table 4
Postoperative clinical data
Characteristics Number(%)(Total
35)
Mean +-
SD P
value
Postoperative hospital stay ( Days ) 3.5 +-0.6
Blood Transfusion ( units ) 3.1 +-0.6
Urinary bladder injury 2 (5.7 % )
Wound infection 1 (2.8 % )
Postoperative fever 1 (2.8 )
Speculum.examination (at 3 months)
Normal cervix 2931 (93.6%
)
Distorted cervix 231 ( 6.4%
)
SD Standard Deviation

42. • 33 patients were given follow-up appointments 3 and 6 months
following delivery as two patients had hysterectomy done and
were excluded from followup .

43. • At the 3 months follow up appointment, speculum examination
was performed in only 31 cases (93.9 % ), as the other two cases
(6.1 % ) failed to keep their appointment. Speculum examination
revealed normal position and normal morphology of the cervix in
29 cases.

44. • In two patients, the cervix was displaced upwards. Examination of
the cervix in the two patients showed unremarkable findings. In
the same sitting, office hysteroscopy was done and the cavity was
normal with no evidence of intrauterine synechiae in these two
patients.

45. • Twenty five patients ( 80 % ) attended their 6 months follow-up
appointment. Menstruation was resumed in 21 ( 84 % ) patients.
The other four patients (16 %) were amenorrheic and were
lactating .

46. Discussion
• The management options in PPH associated with placenta previa
and placenta accreta include either (1) a radical approach
(Hysterectomy and resection of the involved tissues e.g., partial
cystectomy if the bladder is involved) or (2) a conservative
approach including the adjuvant measures to conserve the uterus.

47. • Although cesarean hysterectomy is still the recommended
treatment for placenta accreta, when placenta percreta involves
adjacent structures, the bleeding might be severe, and surgery is
very risky, with the possibility of damage to these structures due
to the morbidly adherent placenta.

48. • Clearly, this radical approach is unacceptable to women with low
parity who desire uterine preservation.
(3) In some cultures as in our community, many people consider
women who have had a hysterectomy as having lost the most
important aspect of their feminine character. This could have a
major impact on the psychological state of these women, their
quality of life and selfesteem

49. • Conservative management does not mean “no surgery,” because it
often requires emergent delayed hysterectomy (which is
frequently performed without a multidisciplinary team approach).

50. • A very dangerous but unavoidable surgery and the patient’s
insufficient understanding place a great burden on the attending
doctor, pushing him/her into a tight corner, and conservative
management exaggerates this further.

51. • In the presence of hemorrhage, shock, and coagulopathy, it has
been proposed to abandon conservative management and resort to
delayed hysterectomy.

52. • Conservative treatment requires a prolonged period of postpartum
follow-up and patient compliance and adherence to treatment as
well as consideration of the risk for severe morbidity and possibly
mortality for weeks or even months after delivery.

53. • In this study, we present a suture technique which was 1st
described by Dawlatly in a case report in 2007.We used a modified
type of this suturing technique in our department in cases of
cesarean section when the lower uterine flap during the surgery is
extremely thin that can not be salvaged to repaire the uterotomy
incision or in cases of lower segment uterine rupture for the same
reasone

54. • Grasping the cervical lip(s) and suturing it into the paper-thin
lower uterine segment seen in such cases can help to control the
massive bleeding and create a good flap that can be used in
closing the uterine incision even in paper thin lower flaps in none
previa cases. With this technique, the cervix can be used as a
natural tamponade replacing the artificial tamponades that are
frequently used for stopping PPH in cases of placenta previa and
placenta previa accreta.

55. • The cervical canal remains patent, and an absorbable suture
material is used to help return the cervix to its original position.
There is no risk of injury to the ureters or uterine vessels as the
stitches are inserted in the substance of the cervix and the lower
uterine segment.

56. • When compared to artificial tamponades like Bakri balloon,
cervical inversion is a natural method, affordable with no cost and
in the same time appears to be safe, potentially effective and
more useful in controlling bleeding from the placental bed in the
lower uterine segment.

57. • the long term implications of cervical inversion are still unclear
the short term results in our study were satisfactory.

58. • Our patients were of young age and low parity with a small
number of living children. This reflects the importance of using
conservative technique(s) to preserve the uterus and fertility of
women in the studied group. This technique was introduced in our
department and is now widely adopted by our staff. In addition, it
can be used in cases of repeated cesarean deliveries with very
thin lower uterine segment to help close the uterine incision.

59. • Our study is supported by a recent study done by Sakhavar et al.
who reported that cervical inversion exerts pressure on the lower
segment arteries thus reducing the vascular blood flow leading to
relative hemostasis.

60. • Preventive devascularization can be achieved by surgical or
interventional radiology procedures also used in the management
of severe postpartum hemorrhage, such as stepwise uterine
surgical devascularization, bilateral uterine or hypogastric artery
surgical ligation, iliac artery embolization, or balloon occlusion.
Embolization before performing hysterectomy may reduce the risk
of intraoperative blood loss and prophylactic devascularization
may prevent the occurrence of secondary hemorrhage and could
also accelerate placental resorption. Overall, these
uterine‐sparing procedures seem to be less effective in cases of
PAS disorders.

61. • A systematic review including 177 cases of PAS disorders reported
success rates of 90% for arterial embolization, with secondary
hysterectomy necessary in only 11.3%.39 In the remaining 85
women, subsequent menstruation occurred in 87% and three
women had a subsequent pregnancy. The indications for
embolization and the depth of villous invasion are not accurately
reported by the authors, limiting the interpretation of the data.
This technique is also associated with significant maternal
morbidity.

62. • The value of prophylactic placement of balloon catheters in the
iliac arteries in cases of PAS disorders is even more controversial,
mainly owing to the higher risks of complications than with
embolization. In particular, there are two case reports, one of a
popliteal and one of an external iliac arterial thrombus, a case of
iliac artery rupture and a case of ischemic nerve injury
attributable to iliac artery thrombosis complicating common iliac
balloon catheterization at cesarean hysterectomy.

63. • A recent single‐institution observational cohort series of 45 cases
of PAS disorders reported the use of prophylactic lower abdominal
aorta balloon occlusion and found a reduced need for blood
transfusion. One of the cases was complicated by lower extremity
arterial thrombosis and another by ischemic injury to the femoral
nerve.

64. Conclusion
• Based on these preliminary data of this study, we conclude that
this technique of using the cervix as a natural tamponade is
apparently safe, simple, time-saving and potentially effective in
controlling the severe bleeding associated with cases of placenta
previa accreta. This technique deserves to be one of the tools in
the hands of obstetricians who face the life-threatening
hemorrhage of cases of placenta accreta.

65. • Further studies are needed with extended follow-up of the
patients to explore the long-term implications of this
technique.This study is still on going to increase the sample size
and to test the long term results.

66. • Now we are training our junior surgeon with less experience and
skill in emergency conditions so they can apply this technique . It
can be used in hospitals with limited techniques and equipment.

67. Limitation of the Study:-
• The technique is not used in presence of diffuse placenta
accreta, increta and percreta with severe post-partum
hemorrhage diagnosed intraoperatively, as no time for cervical
inversion (these cases excluded from our study) and we proceed to
emergency hysterectomy. The first limitation in interpreting the
results of our study is that it is not a randomized trial.

68. • So this technique might be effective and could gain widespread
acceptance in controlling hemorrhage in placenta previa cases as
we have a good experience with this technique in thin cesarean
section scars .

69. • Another limitation is the difficulty of inversion of the cervix in
some cases as their cervices were not suitable and not partially
dilated and we used a modified technique of partial inversion or
we proceeded to other options of conservative management such
as transverse B Lunch, internal iliac artery ligation, balloon
tamponade and vertical compression sutures.

70. • The last limitation is the uncertainty of the effect of the cervical
inversion technique on the anatomical and functional capacity of
the cervix and its impact on future pregnancy and delivery.
However, these worries could be minimized by the promising
results of the short term follow-up of these patients .

71. • THANKYOU