Effectiveness of ligation of uterine vessels prior to uterine incision for major placenta previa on reducing maternal morbidity without increasing neonatal morbidity
Keywords:Blood transfusion, Caesarean hysterectomy, Obstetric haemorrhage, Placenta previa, Uterine artery and vein ligation
Background: Placenta previa causes massive obstetric haemorrhage and severe maternal morbidity. The objective is to analyse the effectiveness of uterine vessels (artery and vein) ligation before uterine incision in reducing blood loss and hysterectomy during caesarean section for major placenta previa without increasing morbidity in the newborn.
Methods: A retrospective analysis of caesarean section for major placenta previa from 2002 to 2017 was done. Uterine vessels ligation before uterine incision was done in 52 patients. In 19 patients unilateral and in 33 patients bilateral uterine vessels ligation was done before uterine incision. In control group, 12 patients with major placenta previa uterine vessels were ligated after the removal of the placenta. The blood loss, blood transfusion, maternal morbidity and NICU admission of the newborns were compared.
Results: The mean blood loss was 1002 ml in unilateral, 793 ml in bilateral uterine vessels ligation group, compared to 2191 ml in the control group. The mean blood transfusion volume 0.89 units in unilateral 0.60 units in bilateral ligation group while 2.33 units in the control group. The difference in blood loss and blood transfusion were statistically significant. Out of 52 babies, only 6 babies were admitted in NICU for mild depression with stay less than 3 days.
Conclusions: Uterine vessels ligation before uterine incision reduces blood loss and hysterectomy during caesarean section for placenta previa without increasing the morbidity in the newborns.
Khan K, Wojdyla D, Say L, Gülmezoglu A, Van Look P. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006;367(9516):1066-74.
Machado L. Emergency peripartum hysterectomy: Incidence, indications, risk factors and outcome. North American J Med Sci. 2011; pp.358-361.
Chou M., Kung H, Hwang J, Chen W, Tseng J. Temporary prophylactic intravascular balloon occlusion of the common iliac arteries before cesarean hysterectomy for controlling operative blood loss in abnormal placentation. Taiwanese J Obstetrics Gynecol. 2015;54(5):493-8.
Sheiner E, Shoham-Vardi I, Hallak M, Hershkowitz R, Katz M, Mazor M. Placenta previa: obstetric risk factors and pregnancy outcome. J Maternal-Fetal Neonatal Med. 2001;10(6):414-9.
Crane J, Van den Hof M, Dodds L, Armson B, Liston R. Maternal complications with placenta previa. American J Perinatol. 2000;17(2):101-6.
Ananth C, Demissie K, Smulian J, Vintzileos A. Relationship Among Placenta Previa, Fetal Growth Restriction, and Preterm Delivery. Obstetrics Gynecology. 2001;98(2):299-306.
Zlatnik M, Cheng Y, Norton M, Thiet M, Caughey A. Placenta previa and the risk of preterm delivery. J Maternal-Fetal Neonatal Med. 2007;20(10):719-23.
Eller A, Silver R. Optimal management strategies for placenta accrete. Int J Obstet Gynaecol. 2009;116(11):1538-9.
Choi S, Song S, Jung K, Oh S, Kim J, Roh, C. Antepartum Risk Factors Associated with Peripartum Cesarean Hysterectomy in Women with Placenta Previa. American J Perinatol. 2008;25(1):37-041.
Leerentveld R, Gilberts E, Arnold M, Wladimiroff J. Accuracy and Safety of Transvaginal Sonographic Placental Localization. Obstetrics Gynecol. 1990;76(5):759-62.
Sherman S, Carlson D, Platt L, Medearis A. Transvaginal ultrasound: does it help in the diagnosis of placenta previa? Ultrasound Obstetrics Gynecol. 1992;2(4):256-60.
Warshak C, Eskander R, Hull A, Scioscia A, Mattrey R, Benirschke K, Resnik R. Accuracy of Ultrasonography and Magnetic Resonance Imaging in the Diagnosis of Placenta Accreta. Obstetrics Gynecol. 2006;108(3):573-81.
Creasy RK, Resnik R, Iams J, Lockwood C, Moore T, Greene M. Placenta previa, placenta accreta, abruptio placentae, and vasa previa. Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice. 7th ed. Philadelphia, PA: Saunders; 2014: 732-742.
Mousa H, Walkinshaw S. Major postpartum haemorrhage. Curr Opinion Obstetrics Gynecol. 2001;13(6):595-603.
Hwu, Chen CP, Chen, Su TH. Parallel vertical compression sutures: a technique to control bleeding from placenta previa or accrete during caesarean section. BJOG. 2005;112:1420-3.
Tjalma WA, Jacquemyn Y. Compression sutures instead of emergency peripartum hysterectomy. Eur J Obstet Gynecol Reprod Biol. 2005;118:258.
Soyama H, Miyamoto M, Sasa H, Ishibashi H, Yoshida M, Nakatsuka M, et al. Effect of routine rapid insertion of Bakri balloon tamponade on reducing hemorrhage from placenta previa during and after cesarean section. Arch Gynecol Obstetrics. 2017;296(3):469-74.
Al Harbi NA, AL- Abra ES, Aiabbad NS.Utero-vaginal packing. Seven years reviewin the management of postpartum haemorrhage due to placenta previa/accrete at a maternity hospital in Central Saudi Arabia. Saudi Med J. 2009;30:243-6.
Fan Y, Gong X, Wang N, Mu K, Feng L, Qiao F et al. A prospective observational study evaluating the efficacy of prophylactic internal iliac artery balloon catheterization in the management of placenta previa–accreta. Medicine. 2017;96(45):e8276.
Vedantham S, Goodwin S, McLucas B, Mohr G. Uterine artery embolization: An underused method of controlling pelvic hemorrhage. Am J Obstetrics Gynecol. 1997;176(4):938-48.
Abduljabbar H, Bahkali N, Al-Basri S, Al Hachim E, Shoudary I, Dause W et al. Placenta previa. A 13 years experience at a tertiary care center in Western Saudi Arabia. Saudi Med J. 2016;37(7):762-6.
Joshi V, Otiv S, Majumder R, Nikam Y, Shrivastava M. Internal iliac artery ligation for arresting postpartum haemorrhage. BJOG. 2007;114(3):356-61.
O Leary JA. Uterine artery ligation in the control of post- caesarean haemorrhage. J Reprod Med. 1995;40:189-93.
Nayak A, Divya S, Nayak R, Mandpe P. Emergency Internal Iliac Artery Ligation in Control of Postpartum Haemorrhage: A Life saving Procedure. Int J Sci Study. 2017;4(12):183-6.
Dutta D, Dutta I. Management of major degree placenta previa during LSCS operation - a new surgical technique (Dutta's). Asian J Med Sci. 2013;4(2).
Kim J, Joung E, Lee S, Kwack J, Kwon Y. Intraoperative bleeding control during cesarean delivery of complete placenta previa with transient occlusion of uterine arteries. Obstetrics Gynecol Sci. 2015;58(6):522.
Luo F, Xie L, Xie P, Liu S, Zhu Y. Intraoperative aortic balloon occlusion in patients with placenta previa and/or placenta accreta: a retrospective study. Taiwanese J Obstetrics Gynecol. 2017;56(2):147-52.
Maged A. Effect of Uterine artery Ligation Prior to Uterine Incision in Women with Placenta Previa. Cairo university, clinicalTrials.gov Identifier: NCT03124472.
Caesarean Section for Placenta Praevia (Consent Advice No. 12) [Internet]. Royal College of Obstetricians & Gynaecologists. Available at: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/consent-advice-12/. Accessed on May 4, 2018.