Measures for peripartum hysterectomy for placenta previa accreta: avoiding uterotonic agents and “double distal edge pickup” mass ligation

Abstract

Many studies have been attempting in identifying the risk factors of peripartum hysterectomy. Two recent articles published in the Journal [1, 2] also targeted them; placenta previa accreta was the leading condition requiring peripartum hysterectomy [1, 2]. Identification of risk factors of peripartum hysterectomy is important since it often leads to catastrophic hemorrhage and even maternal death, thus requiring an experienced staff and multidisciplinary approach. However, as even non-experienced obstetricians must handle acute unexpected peripartum hysterectomy, ‘‘everybody manageable’’ measures are needed. In my three-decade obstetrical practice, I have devised some measures for peripartum hysterectomy, which I had described [3–5]. Briefly, the cervix should be held by forceps before surgery, which indicates the vaginal site to be transected [3, 4]. Never-slip-off mass ligation, i.e., ‘‘M cross double ligation’’ should be employed in the transection of the ovarian ligament [5]. I hope to add two more measures, which, to my knowledge, have not been described in textbook or the literature. First, in cesarean section for placenta previa, uterotonic drugs should not be administered after infant delivery. Ultrasound and/or magnetic resonance imaging may predict the presence or absence of placenta previa accreta. Identification of its risk factors [1, 2] may also be useful in predicting it. However, its presence cannot be completely excluded. If uterotonic drugs are administered in case of undiagnosed accreta, the uterus may contract and part of the placenta will separate; a partial placental separation will cause massive hemorrhage. I usually wait until spontaneous placental delivery without administering uterotonics. In many cases without accreta, the placenta is spontaneously delivered. If undelivered, I lightly pull the cord, which will help start placental delivery. If still undelivered, I employ ultrasound and identify the presence/absence of the signs of accreta. Then, the next procedure depends on the presence/absence of accreta signs, and if accreta (?) signs are present, depends on the degree and location of accreta. This measure, even in an unexpected accreta case, affords us some time to prepare hysterectomy. Administration of uterotonics, inducing partial placental separation with hemorrhage, deprives us of this time. A recent meta-analysis [6] indicated that active management of the third stage of labor, including administration of uterotonics before placental delivery, reduced the risk of hemorrhage [1,000 mL in a population of women at mixed risk of excessive bleeding; however, data focusing to patients with possible placenta accreta have been lacking. Second, hemorrhage from the incised uterine side should be prevented, which typically occurs in transection of the parametrium or paracervix. In the non-pregnant uterus, their transection usually does not require medial (uterine) side clamping: hemorrhage does not, or only seldom, even without the clamping. However, in peripartum hysterectomy, the medial (uterine) side has abundant vasculature and thus will bleed from the cutting plane. Two measures may prevent it. One method is that medial forceps should remain clamped until hysterectomy completion (Fig. 1a). However, if the uterine (or cervical) part to be transected is long, many forceps are required and remain there (Fig. 1a). This may block the operation field. Another method is to tightly ligate the medial side. Figure 1b indicates the S. Matsubara (&) Department of Obstetrics and Gynecology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan e-mail: matsushi@jichi.ac.jp