DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20194393

Clinical perspective: caesarean hysterectomy for placenta accreta spectrum and role of pelvic packing

Liji David, Anuja Abraham, Annie Regi

Abstract


Caesarean hysterectomy (CH) is considered the gold standard for management of morbidly adherent placenta, now termed as placenta accreta spectrum (PAS). If bleeding is not controlled following removal of uterus, it is sometimes necessary to pack the pelvis and continue monitoring with correction of bleeding and physiological parameters in operating room and intensive care unit. This now comes under the damage control approach, being driven primarily by abnormal physiology rather than anatomical reconstruction. The pelvic packs are removed after about 48 hours. This retrospective study was done in patients with antenatal diagnosis of PAS who required CH, comparing those who required pelvic packing with those who did not. The variables compared were pre-operative (clinical and radiological), intra-operative (duration of surgery, blood loss and transfusion requirements of whole blood and blood products), and the final histopathological diagnosis. Outcome variables in terms of duration of hospital stay, re-admissions, re-laparotomy and complications were also compared. Over two years, three of eight patients with PAS required pelvic packing following CH. There were no differences between the two patient groups with any of the predictor variables or outcomes other than requirement of blood products. This suggests pelvic packing is a safe and efficacious procedure in intractable haemorrhage following CH for PAS. Pelvic packing needs greater awareness amongst obstetricians as the incidence of PAS is likely to increase.


Keywords


Caesarean hysterectomy, Damage control approach, Disseminated intravascular coagulation, Pelvic packing, Placenta accreta spectrum, Postpartum haemorrhage

Full Text:

PDF

References


Jauniaux E, Burton GJ. Pathophysiology of placenta accreta spectrum disorders: a review of current findings. Clin Obstet Gynecol. 2018;61(4):743-54.

Hess JR, Lawson JH. The coagulopathy of trauma versus disseminated intravascular coagulation. J Trauma. 2006;60(6 Suppl):S12-19.

Sagraves SG, Toschlog EA, Rotondo MF. Damage control surgery: the intensivist’s role. J Intensive Care Med. 2006;21(1):5-16.

Fuchs F, Bruyere M, Senat MV, Purenne E, Benhamou D, Fernandez H. Are standard intra-abdominal pressure values different during pregnancy? PloS One. 2013;8(10):e77324.

Chun R, Kirkpatrick AW. Intra-abdominal pressure, intra-abdominal hypertension, and pregnancy: a review. Ann Intensive Care. 2012;2 Suppl 1:S5.

Jauniaux E, Chantraine F, Silver RM, Langhoff-Roos J. FIGO placenta accreta diagnosis and management expert consensus panel. FIGO consensus guidelines on placenta accreta spectrum disorders: epidemiology. Int J Gynaecol Obstet Organ Int Fed Gynaecol Obstet. 2018;140(3):265-73.

Allen L, Jauniaux E, Hobson S, Papillon-Smith J, Belfort MA. FIGO placenta accreta diagnosis and management expert consensus panel. FIGO consensus guidelines on placenta accreta spectrum disorders: Nonconservative surgical management. Int J Gynaecol Obstet Organ Int Fed Gynaecol Obstet. 2018;140(3):281-90.

Sentilhes L, Kayem G, Chandraharan E, Palacios-Jaraquemada J, Jauniaux E. FIGO placenta accreta diagnosis and management expert consensus panel. FIGO consensus guidelines on placenta accreta spectrum disorders: Conservative management. Int J Gynaecol Obstet Organ Int Fed Gynaecol Obstet. 2018;140(3):291-8.

Touhami O, Marzouk SB, Kehila M, Bennasr L, Fezai A, Channoufi MB, et al. Efficacy and safety of pelvic packing after emergency peripartum hysterectomy (EPH) in postpartum hemorrhage (PPH) setting. Eur J Obstet Gynecol Reprod Biol. 2016;202:32-5.

Deffieux X, Vinchant M, Wigniolle I, Goffinet F, Sentilhes L. Maternal outcome after abdominal packing for uncontrolled postpartum hemorrhage despite peripartum hysterectomy. PloS One. 2017;12(6):e0177092.