Case Rep. Perinat. Med. 2015; x(x): xxx–xxx
Maya Koyano, Junichi Hasegawa*, Tatsuya Arakaki, Ryu Matsuoka and Akihiko Sekizawa
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Successful treatment of placenta previa totalis using the combination of a two-stage cesarean operation and uterine arteries embolization in a hybrid operating room DOI 10.1515/crpm-2015-0072 Received September 12, 2015. Accepted November 23, 2015.
Abstract: A 37-year-old primigravida female with placenta previa totalis was transferred to our hospital at 29 weeks of gestation. A transvaginal ultrasound examination showed a dropped placenta into the uterine cervix and an effaced lower uterine segment. The boundary between the cervical muscle layer and the placenta was unclear. Consequently, although it was unclear whether complication of the adherence of placenta was present or not, massive hemorrhage with atonic bleeding in the lower uterine segment after placenta removal was strongly suspected. As the patient had uncontrolled vaginal bleeding, an emergency cesarean section was performed in a hybrid operating room. A transverse fundal incision of the uterus was made, and a 1143 g healthy neonate was delivered. As no signs of placental detachment or persistent bleeding were found, the uterus was closed, leaving the placenta. Thereafter bilateral uterine arterial embolization (UAE) with absorbable gelatin sponges was performed. On the third day after the operation, a second operation for placental removal. The placenta detached smoothly, but compression sutures were placed to control the bleeding at the site of placental removal around the uterine isthmus. In this case, we were able to conduct the treatment smoothly because of the antenatal ultrasound assessment and precise preparation of the cesarean section with UAE in the hybrid operation room. Using the hybrid operation room, sharing detailed surgical planning in cooperation with the physicians from other departments is important for obtaining a good outcome. *Corresponding author: Dr. Junichi Hasegawa, Department of Obstetrics and Gynecology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan, Tel.: +81-3-3784-8551, Fax: +81-3-3784-8355, E-mail:
[email protected] Maya Koyano, Tatsuya Arakaki, Ryu Matsuoka and Akihiko Sekizawa: Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
Keywords: Cesarean section; hybrid operating room; placenta accreta; placenta previa totalis; sponge-like findings; UAE.
Case A 37-year-old primigravida female (161 cm, 55 kg) with placenta previa totalis was transferred from another primary hospital to our perinatal center at 29 weeks and 4 days of gestation for perinatal management due to the possibility of massive bleeding from placenta previa because of a shortened cervical length, though the diagnosis of the placenta previa had been made at the primary hospital during a pregnancy checkup at 20 weeks of gestation and it was followed up. On admission, the patient had no uterine contractions or vaginal bleeding. A transvaginal ultrasound examination showed that the placenta had dropped into the uterine cervix and the boundary between the cervical muscle layer and the placenta was unclear because the blood flow was increased. Consequently, although it was difficult to identify whether placenta accreta/increta in the uterine cervix was present, we strongly suspected that massive hemorrhage with atonic bleeding in the lower uterine segment after placental removal even in case without the placental adhesion, because the lower segment of the uterus was widely effaced. The method to be used for cesarean section was discussed among the obstetricians, anesthesiologists, radiologists and other surgical staff members, as well as the midwives. A cesarean section without placental removal after delivering the infant from fundal vertical incision was planned, because the placenta was located widely on the anterior wall from the os to the upper third of the uterus. Then, in order to reduce hemorrhage after placental removal, subsequent UAE in the hybrid operating room, and then re-operation for placental removal 3 days later were planned.
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2 Koyano et al., Placenta previa We performed a simulation assuming that an emergency cesarean section would be performed by these care givers. At 29 weeks and 6 days of gestation, the patient developed uncontrolled vaginal bleeding (140 g). Therefore, we decided to perform the previously simulated emergency cesarean section. The preoperative blood pressure was 137/92 mm Hg, heart rate was 92 beats/min, and hemoglobin was 9.0 g/dL, but the other laboratory findings were within normal limits. After the patient was transferred to the hybrid operating room, combined spinal-epidural analgesia was administered. A transverse fundal incision of the uterus was made, and a 1143 g healthy female neonate was delivered (the Apgar scores were 6 and 8 at 1 and 5 min, respectively). As no signs of placental detachment or persistent bleeding were found, the uterus was closed. Therefore, the initial cesarean operation was successfully finished without placental removal. Then, embolization of the bilateral uterine arteries was attempted with absorbable gelatin sponges. The total amount of blood lost was 1180 mL during the operation. The patient was stable after interventional radiology (IVR) without further bleeding. Six units of RBCs were transfused after the operation. On the third day after the operation, we performed the second operation for placental removal under general anesthesia. The placenta detached smoothly; however, as bleeding from the surface of the uterine myometrium was observed after placental removal, compression sutures were made in uterine isthmus and upper portion of the cervix. The amount of blood lost during the second surgery was 1525 g, so six units of RBCs and eight units of FFP were transfused during and after surgery. She made steady progress toward recovery, and was discharged without complications on postoperative day 10.
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Discussion The sonographic findings suggestive of the adherence of the placenta were previously reported [1]. However, in the present case, a transvaginal ultrasound examination showed the dropped placenta previa in the uterine cervix. In addition, the boundary between the cervical muscle layer and the placenta was unclear because there was an increased blood flow. Therefore, it was difficult to identify whether the abnormal adherence of the placenta existed or not, though its possibility was highly suspected. Otherwise, placenta previa is also likely to increase the risk of massive hemorrhage because of the abundant vascularization to a broad area of the lower segment of the uterus with weak myometrial contractions after removal of the placenta, even if placenta accreta is not present [2]. The effacement of the lower uterine segment may be evaluated by investigating the uterine isthmus and uterine cervix. Cervical shortening with placenta previa was a risk factor for massive bleeding during cesarean section, because a short uterine cervix indicates stronger effacement and involves atonic bleeding [3]. Since the areas with sponge-like echoes are also most likely composed of clusters of richly developed blood vessels in the uterine cervix [4], the present patient was also considered to be a high risk case due to the massive bleeding during cesarean section. In this case, not only was the boundary line between the uterine cervix and the placenta unclear, but the blood flow was increased in the uterine cervix. We considered that the patient would have massive bleeding during the operation regardless of whether there was placenta accreta/increta. Therefore, to perform a safe elective cesarean section, but not an emergency procedure, the patient was hospitalized under supervision while being prepared
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Figure 1: A transvaginal ultrasound picture taken at 29 weeks of gestation: The gray-scale ultrasound image demonstrating that the placenta had dropped into the uterine cervix, and showing the effaced lower uterine segment that resulted in a shortened cervical length (between * and *). The boundary between the cervical muscle layer and the placenta was unclear (arrows) because there was an increased blood flow.
Koyano et al., Placenta previa 3
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Figure 2: Pictures of the uterine arterial embolization: (a,c) Post-embolization anteriogram receals hypervascular uterus. (a: left, b: right) (b,d) An angiogram taken after embolization of the left uterine artery showed complete occlusion. (b: left d: right).
Figure 3: Pictures of the hybrid operating room: The hybrid operating room combines the capabilities of a typical operating room with a fully equipped angiography suite (left: during the cesarean section, right: during UAE in this case).
for an emergency cesarean section. We planned to perform a cesarean section without placental removal after delivering the infant from a fundal vertical incision, which would then be followed by re-operation for placental removal later. Such two-stage operation methods to reduce amount of the hemorrhage after placental removal were previously
demonstrated [5]. Though there are such merits in twostage operation, acute massive bleeding from naturally separated the placenta from uterus, or maternal infection and septic shock should be considerable for waiting to perform second operation. Prolonged period between the first and second operation would be more effective to
4 Koyano et al., Placenta previa reduce blood flows, but would have more risks massive bleeding during waiting period to the placental removal. It is previously reported that vascularity between the bladder and the uterus was reduced over a span of 3 days post-UAE. Therefore, following middle course, we decided second operation for placental removal was performed 3 days later initial cesarean section [6]. Therefore, following middle course, we decided second operation for placental removal was performed 3 days later initial cesarean section. We additionally planned to perform UAE at a hybrid operating room because of the risk of bleeding until reoperation for placental removal. The concept of a hybrid operating room is to combine the capabilities of a typical operating room with a fully equipped angiography suite. Surgery and endovascular procedures can be performed at the same time in the same operating room. The hybrid operating room maintains the same lighting, infection control, and air circulation standards as traditional operating rooms, but has space to accommodate surgical, anesthetic, and neonatology equipment, and superior imaging capabilities compared with portable C-arm fluoroscopy. Moreover, combined radiological and surgical intervention in the same suite avoids the difficulties encountered when transporting an unstable and critically-ill patient between the labor and delivery area and the radiology suite [7]. After the patient developed uncontrolled bleeding, were able to keep the flow of the surgery going smoothly due to the previous simulation with physicians from other departments and the other medical staff members. The amount of blood lost during the second operation was not small, and compression sutures were required due to atonic bleeding around the effaced lower uterine segment attached the placenta. However, the patient recovered fully and was discharged 10 days after the procedure. It should be noted that it is unclear whether the present case was really complicated with placenta accreta or not, because the patient did not undergo a hysterectomy. However, we think that the two-stage cesarean operation with UAE was effective to avoid the critical risks associated with massive bleeding due to the placenta previa. In conclusion, we were able to perform a smooth and successful treatment of this patient because of the antenatal ultrasound assessment and precise preparation for the
cesarean section with UAE in the hybrid operating room. When massive bleeding is suspected, it is thought that the development of a detailed treatment strategy using hybrid operating room and a simulation of the treatment procedures in cooperation with the physicians from other departments and the other medical staff are important for obtaining a good outcome. Ethical Considerations: All of the procedures performed in the present study were carried out in accordance with the ethical standards of the responsible committees on human experimentation (institutional and national) and the 1975 Declaration of Helsinki, as revised in 2008 (5). Informed consent was obtained from the patient described in the study. Funding sources: None.
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