Abstract
Objective: To assess the effect of tourniquet application of intraoperative blood loss in placenta accreta cases undergoing cesarean hysterectomy. Materials and methods: Nine cases and twenty controls with USG and colour Doppler diagnosed placenta accreta with previous cesarean section were chosen to utilize this novel approach. These cases were planned for elective cesarean section followed by hysterectomy. The twenty controls underwent a classical cesarean section followed by total abdominal hysterectomy with the placenta in situ. Among the nine cases, after delivery of the fetus through upper segment cesarean section, a cotton gauze tourniquet was applied all around the lower pole of uterus. Hysterectomy was performed with placenta in situ. Abdomen closed after achieving complete haemostasis. Results: The average operative time taken was 85 ± 11.72 minutes among cases and 98.25 ± 9.9 minutes among controls (p = 0.0039). Average blood loss was 1011.11 ± 99.3 ml among the cases and 1855 ± 222.95 ml among the controls (p ≤ 0.0001). Average requirement of blood transfusion required was two units for the cases and five units for the controls (p = 0.0002). No intra-operative or post-operative surgical complications were observed in any of the cases whereas the controls reportedly had a few. All the mothers and babies were healthy at the time of discharge. Conclusion: The presence of placenta accreta is associated with major fetal and maternal complications. The technique of tourniquet application is efficacious in minimizing the intra-operative blood loss and surgical complications due to obstruction of operative field by bleeding and also by preventing massive blood transfusion related complications.
Highlights
Placenta accreta is a potentially life-threatening obstetric condition that requires a multidisciplinary approach of management [1]
On comparing the cases and controls (Table 1), the results show a striking difference with respect to mean operative time (p = 0.0039), average intraoperative blood loss (p < 0.0001), need for blood transfusion (p = 0.0002), postoperative fall in Hb (p ≤ 0.0001), fall in hct (p ≤ 0.0001) and duration of hospital stay (p ≤ 0.0001)
On comparison amongst the cases with one, two and multiple tourniquet, the results show a longer duration of surgery for those with multiple tourniquet as compared with a single one, the blood loss was relatively less in cases where multiple tourniquet were applied (Table 3)
Summary
Placenta accreta is a potentially life-threatening obstetric condition that requires a multidisciplinary approach of management [1]. The incidence of placenta accreta increases in presence of placenta praevia with prior caesarean sections. Reported incidence of placenta accreta is nearly 10% in cases of placenta praevia and rises upto 40% in women who have an anterior placenta and ≥2 previous caesarean deliveries [3]. In a phenomenal study comprising 39,244 women undergoing caesarean hysterectomy, the incidence of placenta accreta was found to be 38% [4]. Diagnosis of placenta accreta during antenatal period allows skilful planning in an attempt to minimize potential maternal or neonatal morbidity and mortality. Maternal morbidity is reportedly less in cases with antenatal suspicion of placenta accreta who undergo scheduled delivery when compared with emergent delivery [5]
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