A retrospective study of obstetric hysterectomy cases at tertiary care centre

Background: Postpartum haemorrhage (PPH) is a life-threatening condition. The objective of this study was to determine the incidence, demographic characteristics, indications, and feto-maternal outcomes associated with obstetric hysterectomy in a tertiary care centre.Methods: This is a retrospective analytical study conducted over a period of six years, from March 2014 to April 2020. A total of 68 cases of obstetric hysterectomy were studied at tertiary care centre in Ahmedabad, Gujarat, India.Results: Present study reported 68 obstetric hysterectomies per 44663 total deliveries (incidence - 0.15%), out of them 20 following 26446 vaginal deliveries (0.07%) and 48 following 18217 caesarean section (0.26%). Morbidly adherent placenta (29.41%) was the most common indication followed by atonic postpartum haemorrhage (25.00%) and uterine rupture (17.64%). The most frequent sequelae were disseminated intravascular coagulation (26.47%) and febrile morbidity (10.29%), maternal mortality was 16.17% whereas neonatal mortality was 26.47%.Conclusions: The incidence of obstetric hysterectomy has been found to be more following caesarean sections. There is a change in the indications of obstetric hysterectomy in the past two decades with placenta accreta spectrum being the commonest in present study. This is because of rising number of caesarean sections. Patients who underwent emergency obstetric hysterectomy due to atonic PPH had a higher mortality.

Fetomaternal Outcome with Placenta Previa and Morbidly Adherent Placenta, A Cross Sectional Study

Introduction: Placenta previa occurs when a baby's placentapartially or totally covers the mother's cervix or the outlet forthe uterus. The aim of this descriptive retrospective cohortstudy was to identify maternal complications, placentalposition, mode of delivery, management and fetal outcomes inPlacenta Previa (PP) and Morbidly adherent placentaMaterail and methods: Study was conducted in Departmentof Obstetrics and Gynecology, Pak Red Crescent Medical andDental College (PRCM&DC) Hospital Lahore from June 2017to June 2019. A total of 62 pregnant women were registered.All booked and un-booked mothers with and without historyof previous section with provisional clinical and/or USGdiagnosis of Placenta Previa or MAP.Results: In total, 62 patients with PP were identified 22.58%patients with morbidly adherent placenta were unbooked andother wise are booked. 61.2% patients were the age groupbetween 20-30 years and remaining are more than 30 years. In25.8% type IV placenta previa and same 25.8% are morbidlyadherent placenta and remaining are type I,II &III PP. Placentaprevia, only 6.45% cases were diagnosed in 2nd trimester and93.5% cases were diagnosed in 3rd trimester.Conclusion: Placenta Previa and Morbidly adherent placentaare not a very uncommon condition. Frequency of Incidenceincreases as the rate of cesarean section or abdominal surgerywere increases. Early diagnoses and pre plan mode of deliverywill decrease the risk of low birth weight and low APGARscore infants

Stuck situations in morbidly adherent placenta: how to tackle?

Background: Morbidly adherent placenta is associated with high maternal morbidity and mortality. Its increased prevalence seems to be proportional to the increasing number of caesarean sections. In this study the presentation and management of 32 cases was reviewed with morbidly adherent placenta and maternal and perinatal outcomes from 2014 to 2016, at the hospital.Methods: Study type was retrospective. We reviewed clinical information from patients’ case sheets regarding the risk factors, preparations prior to cesarean section, intraoperative and postoperative complications. Results were interpreted and conclusions were withdrawn.Results: Among the 32 cases, 28 were diagnosed prenatally while 4 were diagnosed intraoperatively. Out of 28 patients, 5 patients were diagnosed early between 14 and 18 weeks of gestational age and other 23 were diagnosed during third trimester by ultrasonography. Caesarean hysterectomy was required in 28 cases.4 were managed conservatively, out of which hysterectomy proved to be necessary in the postpartum period because of severe secondary postpartum hemorrhage in 2 cases. Average no of hospital stay is 10 days ranging from 8-18 days.Conclusions: Prenatal diagnosis of morbidly adherent placenta is essential to plan for the better maternal and perinatal outcome. The decision to perform a cesarean hysterectomy or conservation of uterus (using balloon tamponade or putting haemostatic sutures) is based on the extent of infiltration, the patient’s hemodynamic status, and her desire for future pregnancy. The risk of infection and severe hemorrhage remains high if conservative management is chosen and requires prolonged close monitoring postoperatively. Ideally all the cases should be electively planned and operated by senior surgeon and experienced assistants with senior anesthetist, urosurgeon and physician, with full backup of ICU and blood bank.

Morbidly adherent placenta: management is real challenge

Background: The objective of the present study was to describe management of morbidly adherent placenta with placenta previa and feto-maternal outcome.Methods: All antenatal USG diagnosed cases of morbidly adherent placenta were analyzed. The cases were managed by elective caesarean hysterectomy and non-separation of placenta at delivery. Amount of blood loss, blood transfused, ICU admission, postnatal complications and hospital stay was recorded.Results: From January 2010 to October 2018, 22 cases of morbidly adherent placenta were diagnosed on gray scale and color Doppler during antenatal ultrasound scan. Scheduled caesarean hysterectomy without attempting placental removal was done. Subtotal hysterectomy was performed in 17(77.2%) cases and total hysterectomy in remaining 5(22.8%) cases. All the patients required blood transfusion.  Seven (31.8%) patients had urinary bladder injury. One case developed DIC and One needed ventilatory support. No patient died in this series.Conclusions: Antenatal diagnosed cases of morbidly adherent placenta, avoidance of placental separation and caesarean hysterectomy results in better maternal outcome.

Prenatal diagnosis of morbidly adherent placenta using gray-scale, color doppler, three-dimensional power doppler ultrasound and magnetic resonance imaging – A case report / Philippine Journal of Obstetrics and Gynecology

Background@#Morbidly adherent placenta (MAP) refers to a spectrum of conditions characterized by abnormal adherence of the placenta to the implantation site. It is usually associated with peripartum hysterectomies, excessive blood loss, and bladder and bowel injuries. Reliable antenatal diagnosis of MAP is needed as unexpected encounter with such condition can lead to catastrophic outcomes. It allows the pre-operative assembly of a multidisciplinary team in the surgical management of such cases, an approach which has been shown to improve maternal and fetal outcomes.@*Case summary@#A case of a morbidly adherent placenta diagnosed antenatally using gray-scale, Color Doppler, 3-Dimensional power Doppler ultrasound and Magnetic Resonance Imaging is reported. A multidisciplinary team consisting of OB - GYN ultrasonologist, radiologist, maternal fetal medicine specialist, gynecologic oncologist, anesthesiologist, neonatologist, internist, urologic-oncologist, vascular and general surgeons, was used to manage the case. Favorable maternal and fetal outcomes resulted from the use of this team.@*Conclusion@#Prenatal diagnosis of MAP with gray-scale, Color Doppler, 3-Dimensional power Doppler ultrasound and Magnetic Resonance Imaging and the use of standardized imaging descriptors for AIP allowed the development of a multidisciplinary care team approach during delivery which provided a safe outcome for both mother and baby.

Reliability of ultrasound and colour doppler in the antenatal diagnosis of morbidly adherent placenta in placenta praevia

Background: Morbidly adherent placenta is a life threatening condition that requires multidisciplinary approach for management. Women presenting with placenta praevia have become the highest risk for abnormal placental adherence. Aim: Aim of the present study is to evaluate the efficacy of ultrasound and colour Doppler in the antenatal diagnosis of morbidly adherent placenta in women presenting with placenta praevia. Materials and methods: This was a prospective study conducted on patients with persistent placenta praevia who underwent transabdominal B mode and colour Doppler ultrasound evaluation in the third trimester during the period of May, 2015 to May, 2017. The imaging findings were compared with the final diagnosis at the time of delivery and at pathological examination. Results: In the present study, there were a total of 24 patients of morbidly adherent placenta with an incidence of 1.17 per 1000 pregnancies. Previous caesarean section with placenta praevia was the main risk factor for placental adherence. Conclusion: Ultrasound and colour Doppler have a fairly good sensitivity for prenatal diagnosis of placenta accrete.

Prophylactic bilateral internal iliac artery balloon occlusion in the management of placenta accreta: A 36-month review

Background: The contemporary obstetrician is increasingly put to the test by rising numbers of pregnancies with morbidly adherent placenta. This study illustrates our experience with prophylactic bilateral internal iliac artery occlusion as part of its management. Methods: Between January 2011 to January 2014, 13 consecutive patients received the intervention prior to scheduled caesarean delivery for placenta accreta. All cases were diagnosed by ultrasonography, color Doppler imaging and supplemented with MRI where necessary. The Wanda balloonTM catheter (Boston Scientific, Natick, MA, U.S.A) were placed in the proximal segment of the internal iliac arteries preceding surgery. This was followed by a midline laparotomy and classical caesarean section, avoiding the placenta. Both internal iliac balloons were inflated just before the delivery of fetus and deflated once haemostasis was secured. Primary outcomes measured were perioperative blood loss, blood transfusion requirement and the need for ICU admission. Results: The mean and median intraoperative blood loss were 1076mls±707 and 800mls (300-2500) respectively while mean perioperative blood loss was 1261mls±946. Just over half of the patients in our series required blood and/or blood products transfusion. Two patients (15.4%) required ICU admission. Conclusion: Our study suggests that preoperative prophylactic balloon occlusion of bilateral internal iliac arteries reduces both blood loss and transfusion requirement in patients with placenta accreta, scheduled to undergo elective caesarean hysterectomy. It is an adjunct to be considered in the management of a modern day obstetric problem, although the authors are cautious about generalizing its benefit without larger, randomized trials.

Morbidly Adherent Placenta at Extreme Prematurity: Can Major Haemorrhage and Hysterectomy be Prevented?

Morbidly adherent placenta with spontaneous rupture of membrane at extreme prematurity poses poor pregnancy outcome. Various issues on different management modalities still remain perplexed and individual consideration is vital. Two cases of morbidly adherent placenta with symptomatic per vaginal bleeding and spontaneous rupture of membrane at severe prematurity were reviewed and discussed. We found that, active intervention by termination of pregnancy and methotrexate therapy at early gestation can prevent the need of hysterectomy following major obstetrics haemorrhage.