Transverse uterine fundal incision for placenta praevia with accreta, involving the entire anterior uterine wall: a case series

Evaluation of incision healing status after transverse uterine fundal incision for cesarean delivery and postoperative pregnancy: a ten-year single-center retrospective study

BACKGROUND

Transverse uterine fundal incision (TUFI) is a beneficial procedure for mothers and babies at risk due to placenta previa-accreta, and has been implemented worldwide. However, the risk of uterine rupture during a subsequent pregnancy remains unclear. We therefore evaluated the TUFI wound scar to determine the approval criteria for pregnancy after this surgery.

METHODS

Between April 2012 and August 2022, we performed TUFI on 150 women. Among 132 of the 150 women whose uteruses were preserved after TUFI, 84 women wished to conceive again. The wound healing status, scar thickness, and resumption of blood flow were evaluated in these women by magnetic resonance imaging (MRI) and sonohysterogram at 12 months postoperatively. Furthermore, TUFI scars were directly observed during the Cesarean sections in women who subsequently conceived.

RESULTS

Twelve women were lost to follow-up and one conceived before the evaluation, therefore 71 cases were analyzed. MRI scans revealed that the "scar thickness", the thinnest part of the scar compared with the normal surrounding area, was ≥ 50% in all cases. The TUFI scars were enhanced in dynamic contrast-enhanced MRI except for four women. However, the scar thickness in these four patients was greater than 80%. Twenty-three of the 71 women conceived after TUFI and delivered live babies without notable problems until August 2022. Their MRI scans before pregnancy revealed scar thicknesses of 50-69% in two cases and ≥ 70% in the remaining 21 cases. And resumption of blood flow was confirmed in all patients except two cases whose scar thickness ≥ 90%. No evidence of scar healing failure was detected at subsequent Cesarean sections, but partial thinning was found in two patients whose scar thicknesses were 50-69%. In one woman who conceived seven months after TUFI and before the evaluation, uterine rupture occurred at 26 weeks of gestation.

CONCLUSIONS

Certain criteria, including an appropriate suture method, delayed conception for at least 12 months, evaluation of the TUFI scar at 12 months postoperatively, and cautious postoperative management, must all be met in order to approve a post-TUFI pregnancy. Possible scar condition criteria for permitting a subsequent pregnancy could include the scar thickness being ≥ 70% of the surrounding area on MRI scans, at least partially resumed blood flow, and no abnormalities on the sonohysterogram.

TRIAL REGISTRATION

Retrospectively registered.

Timing of intra-abdominal aortic balloon occlusion for prevention of hemorrhage in patients with placenta previa and placenta accreta spectrum

OBJECTIVE

Placenta accreta spectrum (PAS) has been linked to severe negative maternal-fetal pregnancy outcomes, including a high risk of maternal death. The goal of this study was to determine whether an abdominal aortic balloon block performed before fetal birth lowered intraoperative bleeding and the risk of severe bleeding, as opposed to a block performed after fetal birth.

METHODS

In this retrospective cohort study, patients who underwent pre-delivery or post-delivery inflation were compared for intraoperative hemorrhage, transfusion rate, hysterectomy rate, intensive care unit (ICU) hospitalization, and newborn indices. To ensure the robustness of our findings, we applied multivariate logistic regression, propensity score analysis, and an inverse probability-weighting model.

RESULTS

This study included 168 patients who underwent balloon occlusion (62 pre-delivery, 106 post-delivery). The overall probability of major bleeding was 56.5% (95/168), and the pre-delivery and post-delivery probabilities for major bleeding were 64.5% (40/62) and 51.9% (55/106) (P = 0.112), respectively. In the multivariable-adjusted model, post-delivery inflation was associated with a 33% numerically higher probability of massive bleeding (odds ratio 1.33, 95% confidence interval 0.54-3.25, P = 0.535). However, the difference was not statistically significant.

CONCLUSION

According to our findings, pre-delivery inflation did not significantly reduce the risk or amount of severe bleeding.

Placenta Percreta Managed by Ultrasound-Guided Vertical Transfundal Uterine Incision with Hysterectomy: Case Report

Placenta accreta spectrum is an obstetrics complication in which the placenta has abnormally adhered to the decidua and uterine wall. Placenta percreta is the rarest and sternest variant of accreta syndrome. In this study, we present a case of placenta percreta where we have done ultrasound-guided trans fundal vertical uterine incision to deliver a healthy fetus and subsequent cesarean hysterectomy. Antepartum diagnosis, involvement of a multidisciplinary team, appropriate counseling of women and their families, ultrasound guidance for placental margin demarcation, and vertical transfundal uterine incision can be considered for patients with placenta percreta.

Difficulty in predicting intra‐abdominal adhesion before cesarean section: A case report

Severe adhesions between the bladder and uterus necessitated an atypical incision in the cesarean section of a woman with endometriosis. This could not be predicted with pre‐surgery MRI. No methods in the literature are able to predict adhesions with true certainty; it is therefore still difficult to diagnose intra‐abdominal adhesions.

Cervical tourniquet during cesarean section to reduce bleeding in morbidly adherent placenta: a pilot study

Objective:

To evaluate a modified surgical technique aiming to reduce bleeding and preserve fertility in morbidly adherent placenta by cervical tourniquet in cesarean sections.

Methods:

The cesarean section operations and the cervical ligation approach were performed by a single expert consultant obstetrician. The general demographics and clinical characteristics for all participants were collected and studied.

Results:

Eleven participants were involved. The uterus was preserved in nine patients, whereas two patients had hysterectomy. The mean blood loss was 1688.8 ml for patients whose uterus was preserved. The mean length of stay was 5.5 days.

Conclusion:

Cervical ligation is a simple method that can be applied by junior and experienced obstetricians to preserve the uterus.

Placenta accreta is the abnormal adhesion of placenta into the uterine wall. It carries a significant risk for hysterectomy, intrapartum and postpartum hemorrhage, and maternal morbidity and mortality. As the preservation of fertility and femininity is desired by many women, numerous methods were adapted to avoid hysterectomy in patients with placenta accreta. In this study, we describe and evaluate a novel technique to preserve the uterus by ligating the cervix with a Foley catheter.

Placental Lesions and Pregnancy Outcome in Anterior as Compared to Posterior Placenta Previa

The uterine location of placenta previa (PP), anterior vs. posterior has an impact on pregnancy outcome. We aimed to study maternal and neonatal outcome and placental histopathology lesions in anterior vs. posterior PP. The medical records and histopathology reports of all singleton cesarean deliveries (CD) performed due to PP, from 24 to 41 weeks, between 12.2008 and 10.2018, were reviewed. Placental lesions were classified into maternal and fetal vascular malperfusion lesions (MVM, FVM), maternal and fetal inflammatory responses (MIR, FIR). Gestational age (GA) at delivery was similar between the anterior PP (n = 67) and posterior PP (n = 105) groups. As compared to the posterior PP group, the anterior PP group had higher rate of previous CD (p < 0.001), placental accreta spectrum (p = 0.04), lower neonatal Hb at birth (p = 0.03), higher rate of neonatal blood transfusion (p = 0.007) and prolonged maternal hospitalization (p = 0.02). Placentas from the anterior PP group had lower weights (p = 0.035), with increased rate of MVM lesions (p = 0.017). The anterior PP location is associated with increased adverse maternal and neonatal outcome, lower placental weights and increased rate of malperfusion lesions. Abnormal placentation in the scarred uterine wall probably has an impact on placental function.

Minimizing abdominal incision for transverse uterine fundal incision by aspiration of amniotic fluid and reduction of uterine size

AIM

Transverse uterine fundal incision (TUFI) was developed to avoid catastrophic hemorrhage associated with cesarean section of the placenta previa-accreta. Abdominal incisions extend as far as the upper abdomen in patients in the third trimester of pregnancy and require general anesthesia. Instead, we tried to aspirate amniotic fluid (AF) to reduce the uterine size.

METHODS

TUFI was performed in 19 of our patients in the third trimester in whom placenta previa accreta could not be ruled out between June 2012 and August 2016. After the lower abdominal vertical incision, we attempted to exteriorize the uterine fundus. If this was impossible, we inserted an 18-gauge spinal needle into the amniotic space. We aspirated AF until the uterine fundus could be exteriorized.

RESULTS

We exteriorized the uterine fundus without extending the incision to the upper abdomen by aspirating 250-670 mL of AF in 12 patients who were between the 33rd and 37th week of pregnancy, and TUFI was performed under spinal anesthesia. AF aspiration was not required in four patients who were in the 30th or 31st week of pregnancy and in two patients with oligohydramnios in the 35th week of pregnancy. In one case, the trial was canceled due to hemorrhagic AF aspiration. No serious complications were observed in mothers or neonates.

CONCLUSION

TUFI could be made by abdominal incision to the left of the umbilicus under spinal anesthesia without anesthesia by reducing the uterine size through AF aspiration, even for patients in the third trimester of pregnancy.

Placenta percreta - a management dilemma: an institutional experience and review of the literature

Objective

Placenta percreta is an extremely high-risk obstetric condition often associated with significant maternal morbidity and mortality. To date, there is no consensus on its management. This article aimed to identify an optimum management option to improve maternal outcomes in patients with placenta percreta.

Material and Methods

This was an observational study conducted at a tertiary care institute from October 2019 to June 2020. A well-defined plan of preoperative, bilateral, uterine artery catheter placement, cesarean delivery (CD) of the baby followed by uterine artery embolization (UAE), and elective delayed hysterectomy after 2-4 weeks, was made by a multidisciplinary team. Demographic variables such as age, parity, period of gestation, presenting complaints, imaging findings, mode of management, intraoperative findings, blood loss, the requirement for blood and blood products, and complications were noted.

Results

We encountered seven cases of placenta percreta over a period of nine months. UAE was performed in 6/7 patients. UAE was not performed in one patient as she presented to the emergency department in shock. Elective delayed hysterectomy was performed after 2-4 weeks in three patients, three patients required emergency hysterectomy (two during CD and one on the seventh postoperative day) and one patient was managed conservatively by leaving the placenta in situ after CD and UAE. Patients who underwent UAE had notably less intraoperative blood loss and requirement of blood and blood products than the patient who could not receive UAE. During cesarean hysterectomy, blood loss was 1,700 mL in embolized (case 4) vs 3,000 mL in unembolized patient (case 7). In embolized patients, the median blood loss during CD (case 1,2,3,5,6) was 200 mL (interquartile range: 165-200 mL) and during delayed elective hysterectomy (case 1,3,5) was 150 mL (range: 125-225 mL). Blood loss in case 2 was 1,000 mL during emergency hysterectomy on the 7^th day of CD and UAE. The blood loss was appreciably higher in patients who underwent immediate cesarean hysterectomy rather than elective delayed hysterectomy.

Conclusion

Placenta percreta, if not managed in a preplanned manner, may lead to disastrous maternal outcomes. Prophylactic devascularization during CD and leaving the placenta in situ followed by elective delayed hysterectomy, might be a reasonable management option in most severe cases of placenta percreta.

Efficacy of intraoperative wireless ultrasonography for uterine incision among patients with adherence findings in placenta previa

AIM

We evaluated the effectiveness of intraoperative wireless ultrasonography in determining the location of uterine incision during cesarean delivery in patients with placenta previa who have sonographic adherence findings in order to assess intraoperative blood loss and maternal morbidity.

METHODS

A prospective study using wireless sonography, including 15 patients with previa, was conducted among women with singleton pregnancies who delivered by cesarean section between August 1, 2017, and August 30, 2019. Retrospective study for the control group included 32 patients with placenta previa who underwent cesarean section between January 1, 2016, and July 31, 2017, without wireless sonography. Patients with previa who had adherence findings in prenatal sonography were included in both groups. Logistic regression was used to identify the association between massive intraoperative bleeding loss and use of wireless ultrasound sonography.

RESULTS

Intraoperative blood loss was significantly reduced in the study group compared to that in the control group (P = 0.009). The hospital stay was significantly shorter in the study group compared to the control group (5 days vs 6 days, P < 0.001). The use of intraoperative wireless sonography (P = 0.01) had a significant association with massive intraoperative hemorrhage in multivariable analysis.

CONCLUSION

Our study is the first study to apply a wireless ultrasound sonography device in women with placenta previa during cesarean section to examine maternal morbidity. This latest wireless ultrasound sonography device is advantageous for uterine incision guidance in women with placenta previa and improves maternal morbidity by reducing intraoperative hemorrhage.

Parallel transverse uterine incisions, a novel approach for managing heavy hemorrhage and preserving the uterus: A retrospective cohort study for patients with anterior placenta previa and accreta

Placenta previa and accreta with prior cesarean section is an extremely serious condition that is associated with maternal morbidity and mortality from obstetric hemorrhage. The aim of our study was to evaluate the efficacy and advantages of a novel surgical technique, parallel transverse uterine incisions (PTUI), during conservative cesarean delivery in patients with placenta previa and accreta.This was a retrospective cohort study including 124 pregnant women, who had at least 1 prior cesarean section and were diagnosed with anterior placenta previa and accreta between January 2014 and October 2017. Using the hospital's information system, patients were retrospectively classified into undergoing either the PTUI surgery (Group A) or the ordinary cesarean section (Group B). Surgical outcomes and maternal complications during hospitalization were collected. The results from 2 groups were compared and analyzed statistically. Multivariable regression analyses were further used to assess the effect of PTUI on severe maternal outcomes.Patients who underwent PTUI were not statistically different from patients who underwent the ordinary cesarean section in terms of maternal and infants' characteristics. However, PTUI was associated with remarkably reduced intraoperative blood loss (P = .005), related vaginal blood loss after surgery (P = .026), and transfusion requirement of packed red cells (P = .000), compared to the ordinary cesarean section. Moreover, cesarean hysterectomy (3.3% vs 21.9%; P = .002) and intensive care unit admission (1.7% vs 29.7%; P = .000) were significantly fewer among patients who underwent PTUI. Multivariable regression analyses further showed that the risk of intraoperative hemorrhage (β = -2343.299, P = .000) and cesarean hysterectomy (odds ratio = 0.027, P = .018) were both significantly decreased by PTUI.PTUI is a novel approach that may significantly reduce maternal complications, while preserving the uterus for patients with anterior placenta previa and accreta.

Evidence-based guidelines for the management of abnormally invasive placenta: recommendations from the International Society for Abnormally Invasive Placenta

The worldwide incidence of abnormally invasive placenta is rapidly rising, following the trend of increasing cesarean delivery. It is a heterogeneous condition and has a high maternal morbidity and mortality rate, presenting specific intrapartum challenges. Its rarity makes developing individual expertise difficult for the majority of clinicians. The International Society for Abnormally Invasive Placenta aims to improve clinicians' understanding and skills in managing this difficult condition. By pooling knowledge, experience, and expertise gained within a variety of different healthcare systems, the Society seeks to improve the outcomes for women with abnormally invasive placenta globally. The recommendations presented herewith were reached using a modified Delphi technique and are based on the best available evidence. The evidence base for each is presented using a formal grading system. The topics chosen address the most pertinent questions regarding intrapartum management of abnormally invasive placenta with respect to clinically relevant outcomes, including the following: definition of a center of excellence; requirement for antenatal hospitalization; antenatal optimization of hemoglobin; gestational age for delivery; antenatal corticosteroid administration; use of preoperative cystoscopy, ureteric stents, and prophylactic pelvic arterial balloon catheters; maternal position for surgery; type of skin incision; position of the uterine incision; use of interoperative ultrasound; prophylactic administration of oxytocin; optimal method for intraoperative diagnosis; use of expectant management; adjuvant therapies for expectant management; use of local surgical resection; type of hysterectomy; use of delayed hysterectomy; intraoperative measures to treat life-threatening hemorrhage; and fertility after conservative management.

Uterine rupture due to placenta percreta in the first trimester of a pregnancy subsequent to a transverse uterine fundal cesarean section: A case report

Transverse uterine fundal cesarean section in cases of total placenta previa reduces blood loss, but its influence on subsequent pregnancies, including the uterine rupture risk, remains unclear. We report a case of uterine rupture due to placenta percreta in the first trimester in a 43-year-old woman who underwent transverse uterine fundal incision in a previous pregnancy (at 40 years old). The patient did not undergo assessment of the uterine scare after the previous operation. Oocyte donation and in vitro fertilization at another institution resulted in the current pregnancy. At 11 weeks 3 days, she was admitted to the emergency department because of sudden severe abdominal pain. Ultrasound showed massive accumulation of free fluid in the peritoneal cavity and the fetus was outside the uterine cavity; uterine rupture was diagnosed. During emergency laparotomy, the uterine rupture was detected at exactly the previous incision site; a total hysterectomy was performed. Pregnancy after a transverse uterine fundal cesarean section is at high risk. As uterine scar dehiscence might have caused the uterine rupture, wounds should be evaluated before allowing subsequent pregnancies.

Successful anticoagulant therapy for disseminated intravascular coagulation during conservative management of placenta percreta: a case report and literature review

Background

Placenta percreta is a rare obstetric condition associated with the risk of massive intraoperative hemorrhage. Recently, conservative management of placenta percreta has been performed to reduce maternal morbidity. However, various complications have been reported during such management. Only a few cases of asymptomatic disseminated intravascular coagulation (DIC) or fever without infection have been reported. Here, we discuss such a case and review the related literature to understand this rare condition better. For this, we performed an electronic literature review.

Case presentation

We present the clinical course, results of blood tests, and serial magnetic resonance images of a 35-year-old female (gravida 5, para 2) with placenta percreta complicated by placenta previa that was managed conservatively. The patient successfully delivered a healthy baby by a cesarean delivery via a transverse uterine fundal incision at 36 weeks of gestation. We did not observe intraoperative complications during cesarean delivery, and the postoperative course remained uncomplicated until 47 days after the delivery. However, asymptomatic DIC developed after 47 days, and her serum fibrinogen level declined to 42 mg/dL, which was successfully treated with anticoagulant therapy by a therapeutic dose of intravenous heparin for 22 days (postoperative days 48–69). Although DIC resolved, subsequent fever persisted for approximately 1 month (postoperative days 67–103). Infection was ruled out, and conservative management was successfully continued.

Literature review revealed that successful conservative management of a patient with asymptomatic DIC and subsequent fever without infection is extremely rare.

Conclusions

Some patients with DIC and fever can continue conservative management of placenta percreta, although careful examination and monitoring are needed.

A pregnant woman with a surgical site infection after mesh repair of an abdominal wall incisional hernia: a case report

Background

Surgical meshes are widely used in incisional hernia repair. However, there are no reports of pregnancies complicated by infection of surgical meshes used for hernia repair. This is the first case report of a pregnant woman who experienced surgical site infection associated with surgical mesh used for repair of an abdominal wall incisional hernia.

Case presentation

We report a case of a 41-year-old pregnant Japanese woman with surgical site infection after mesh repair of an abdominal wall incisional hernia. She was diagnosed with an abdominal wall incisional hernia at 3 months after her third cesarean section, and she underwent an operation of hernia repair with use of monofilament polypropylene mesh 7 months after the third cesarean section. However, a surgical site infection associated with surgical mesh occurred. During antibiotic treatment, she was found to be pregnant. She was referred to our hospital at 13 weeks and 2 days of gestation. The surgeons removed the infected mesh at 16 weeks and 3 days of gestation. Neither the hernia nor infection at the surgical site recurred throughout pregnancy. We planned a cesarean section using a transverse uterine fundal incision method with an upper abdominal incision. The patient delivered a 2478-g healthy female infant.

Conclusions

The present report shows that removal of mesh can safely control surgical site infection during pregnancy.

Safety of cesarean delivery through placental incision in patients with anterior placenta previa

OBJECTIVE

To demonstrate the safety of fetal delivery through placental incision in a placenta previa pregnancy.

METHODS

We examined the medical records of 80 women with singleton pregnancy diagnosed with placenta previa who underwent cesarean section between May 2010 and May 2015 at the Department of Obstetrics and Gynecology, Chungbuk National University Hospital. Among the women with placenta previa, those who did not have the placenta in the uterine incision site gave birth via conventional uterine incision, while those with anterior placenta previa or had placenta attached to the uterine incision site gave birth via uterine incision plus placental incision. We compared the postoperative hemoglobin level and duration of hospital stay for the mother and newborn of the two groups.

RESULTS

There was no difference between the placental incision group and non-incision group in terms of preoperative and postoperative hemoglobin change, the amount of blood transfusions required by the mother, newborns with 1-min or 5-min Apgar scores below 7 points or showing signs of acidosis on umbilical cord blood gas analysis result of pH below 7.20. Moreover, neonatal hemoglobin levels did not differ between the two groups.

CONCLUSION

Fetal delivery through placental incision during cesarean section for placenta previa pregnancy does not negatively influence the prognosis of the mother or the newborn, and therefore, is considered a safe surgical technique.

Placenta percreta with a vaginal fistula after successful management by uterine transverse fundal incision and subsequent cesarean hysterectomy

Placenta previa presents a highest risk to pregnancy, and placenta accreta is the most serious. Placenta accreta requires cesarean delivery and often results in massive obstetric hemorrhage and higher maternal morbidity. Challenges associated with cesarean delivery techniques may contribute to increased maternal blood loss and morbidity rates. Several recent obstetric studies reported the usefulness of transverse uterine fundal incision for managing placenta accreta. We present a case of placenta percreta that was treated by a transverse fundal incision. We successfully avoided cutting through the placenta and helped decrease maternal blood loss. After delivery, the patient underwent a cesarean hysterectomy. Postoperative day 48, she experienced watery discharge and was diagnosed with vaginal fistula. We present our case and review the literature.

Placenta percreta managed by transverse uterine fundal incision with retrograde cesarean hysterectomy: a novel surgical approach

Key Clinical Message

Placenta percreta (with bladder invasion) is a rare obstetric condition with the risk of massive intraoperative hemorrhage. In these cases, the combination of a transverse uterine fundal incision and retrograde cesarean hysterectomy could be useful to minimize maternal hemorrhage and avoid severe bladder injury.