Management of bleeding from morbidly adherent placenta during elective repeat caesarean section: retrospective -record -based study

摘要

Controlling massive haemorrhage from morbidly adherent placenta (MAP) at caesarean section is a major surgical challenge to obstetricians. This study compares different intra-operative interventions to control haemorrhage from morbidly adherent placenta and its impact on maternal morbidity. Retrospective analysis was done for baseline characteristics, intra-operative and postoperative complications of 125 patients with morbidly adherent placenta who had elective CS at 35-38?weeks gestation in the period from 01/2012 to 01/2017. The included patients were categorized into three groups according to intra-operative interventions they had for controlling bleeding; Group A (n?=?42) had only balloon tamponade, Group B (n?=?40) had balloon tamponade and bilateral uterine artery ligation, in Group C (n?=?43) all cases were managed by bilateral uterine artery ligation and inverting the cervix into the uterine cavity and suturing the anterior and/or the posterior cervical lips into the anterior and/or posterior walls of the lower uterine segment using the cervix as a natural tamponade. There were no differences of baseline characteristics of patients in all groups. Group C had significantly better outcomes as compared with groups A and B; less total blood loss (Group C 2869.5?ml vs Group B 4580?ml, Group A 4812?ml, P???0.001), less requirement of blood transfusion more than 4?units (Group C 4/43, Group B 10/40,Group A 12/42, P???0.02), significant reduction in prolonged hospital stay over 10?days (Group C 2/43, Group B 9/40,Group A 14/42, P??0.001) and lower risk of coagulopathy (Group C 4/43, B 8/40, A 9/42), visceral injuries (Group C 4/43 vs B 8/40, A 10/42,P??0.01) and need for hysterectomy (Group C 4/43 vs B 11/40, A 13/42,P??0.001). A combination bilateral uterine artery ligation and using the cervix as a natural tamponade are very effective and simple methods in controlling bleeding resulting from separated placenta accreta. The findings are part of the research project registered in ClinicalTrials.gov NCT02590484 . Registered 28 October 2015.