Elective Cesarean Hysterectomy Research Articles

A Systematic Review of the Indications and Outcomes of Elective Cesarean Hysterectomy

Planned hysterectomy at the time of cesarean section is seldom performed, but may be necessary in certain situations. Our objective was to synthesize the published literature on indications for elective cesarean hysterectomy, beyond that for invasive placentation.

Minimizing Surgical Blood Loss at Cesarean Hysterectomy for Placenta Previa With Evidence of Placenta Increta or Placenta Percreta: The State of Play in 2020

(Am J Obstet Gynecol. 2020;223:322–329) Placenta accreta spectrum (PAS) is associated with notable surgical risks, especially in cases of placenta previa-percreta. Surgical blood loss is the key cause of morbidity or mortality in surgery for PAS. Multidisciplinary management of PAS has developed and improved, leading clinicians to reexamine the use of interventional radiology techniques and ligation of the anterior divisions of the internal iliac arteries. This article reports on developments in the care of patients with PAS, specifically those undergoing elective cesarean hysterectomy for placenta previa-percreta.

The modified radical peripartum cesarean hysterectomy (Soleymani-Alazzam-Collins technique): a systematic, safe procedure for the management of severe placenta accreta spectrum

The prevalence of placenta accreta spectrum is rising worldwide. The severe end of the spectrum where the placenta hasinvaded other organs is fortunately rare, however, few surgical techniques for such a complex hysterectomy have been described in the literature. This study aimed to describe a stepwise, systematic technique for radical cesarean hysterectomy for placenta accreta spectrum to investigate outcomes for women with severe, invasive placenta accreta spectrum who were hysterectomized using this technique. This was a retrospective cohort study undertaken at a large UK tertiary referral center. A total of 24 cases of elective primary cesarean hysterectomy with a confirmed intrapartum diagnosis of severe percreta (Federation of Gynecology and Obstetrics grades 3b and 3c) were identified between 2011 and 2020. Among those cases, 16 had standard care (surgical technique dependent on surgeon's preference), and 8 had a radical peripartum hysterectomy using the Soleymani-Alazzam-Collins technique as described. Nonparametric testing was used because of sample size. The Soleymani-Alazzam-Collins technique resulted in significantly less blood loss (P=.032), more transverse incisions (P=.009), and less intensive care unit admissions (P=.046). Furthermore, there was no significant difference in theater time. The Soleymani-Alazzam-Collins technique demonstrated a significant improvement in outcomes for women with severe placenta accreta spectrum, without increasing surgical time.

The efficacy of LigaSure™ open instruments in cases of cesarean hysterectomy due to placenta percreta: a retrospective, record-based, comparative study

Objective The standard treatment for patients with placenta percreta is cesarean hysterectomy that can cause severe bleeding. New-generation vessel sealing systems like LigaSure can cut and seal vascular structures and tissues. The aim of this study was to retrospectively compare hysterectomies performed with traditional instruments and those performed with LigaSure instruments to determine the possible advantages with the latter. Materials and Methods Patients with placenta percreta who underwent elective cesarean hysterectomy by the same surgeon were divided into two groups based on the type of instruments used. Group 1, the standard conventional hysterectomy group, operated with conventional instruments for cutting and tying; and Group 2, the LigaSure hysterectomy group, operated with the new-generation bipolar sealing and cutting instruments. The groups were retrospectively compared for bleeding, operating time, and complications. Results In Group 2, the operating time, intraoperative and total transfused erythrocyte suspension units, total fluid in the drain, and total hospital stay were lower than in Group 1 (p < .05), as was the need for internal iliac artery ligation (p = .013). The complication rates were similar between the two groups (p > .05). Conclusion The use of LigaSure open instruments in cesarean hysterectomies in patients with placenta percreta may reduce operating times and the amount of bleeding.

Placenta accreta spectrum disorder: a comparison between fertility-sparing techniques and hysterectomy

This study aimed to compare fertility-sparing interventions and hysterectomy among women with placenta accreta spectrum disorder (PAS) who underwent caesarean deliveries. We retrospectively reviewed the data, and classified 148 patients as follows: group B: Bakri balloon without resection (n = 83); group R: segmental uterine resection (n = 23); and group H: hysterectomy (n = 42). The groups differed significantly with respect to operative time, transfused blood products, and post-operative intensive care unit and hospital stays. Morbidity was the highest in group H. The aforementioned parameters did not differ between Groups B and R. Groups R and H differed regarding the operative time, post-operative hospital stay, and transfused blood products. Although the treatment modality and PAS severity differed between the groups of patients with preserved fertility, the surgical outcome parameters did not differ. Hence, the effectiveness of these approaches may be similar without foregoing patient safety. IMPACT STATEMENT What is already known on this subject? As caesarean delivery rates have increased worldwide, the incidence of placenta accreta spectrum disorder (PAS), which has high morbidity and mortality rates, has also risen. Planned caesarean hysterectomy is recommended to reduce mortality and morbidity, but fertility is lost. What do the results of this study add? The severity of PAS can range from mild to severe. A patient-tailored approach, which was based on the intra-operative findings and used either a Bakri balloon tamponade or segmental uterine resection, reduced morbidity and preserved fertility. What are the implications of these findings for clinical practice and/or further research? Instead of adhering to the conventional approach that involves an elective caesarean hysterectomy based on antenatal imaging, more suitable approaches should be considered from the spectrum of haemostatic and fertility-preserving options available, while considering a surgeon’s experience, the intra-operative findings, and patients’ needs.

Cesarean hysterectomy in a hybrid operating room for placenta percreta: a report of three cases

BackgroundPlacenta percreta is the most severe abnormality in invasive placenta and often treated with cesarean hysterectomy. Endovascular embolization for placental abnormality is known to reduce bleeding from the placental bed and from the abnormal neovasculature surrounding the uterus. We describe three cases of placenta percreta treated with uninterrupted cesarean hysterectomy and embolization performed using a hybrid operating room (HOR).Case descriptionCases were two placenta previa percretas and an impending uterine rupture with placenta percreta, treated with elective cesarean hysterectomy in HOR. Planned conversion of spinal to general anesthesia was performed after the fetal delivery. Immediate embolic devascularization of abnormal neovasculature was directly observed and facilitated adhesiolysis. Surgical blood losses were 1850 g, 2500 g, and 1180 g, respectively.ConclusionCesarean hysterectomy combined with endovascular embolization in the HOR for placenta percreta is an advantageous option to enhance patient safety by multidisciplinary approach without patient transfer.

Placenta accreta: Elective versus emergent delivery as a major predictor of blood loss.

To compare blood loss and the use for blood transfusion between elective (planned) and emergent cesarean hysterectomy performed for placenta accreta by a single, multidisciplinary team and to present the team's pre-operative evaluation and the surgical technique. Prospective cohort study at a single tertiary care center. Maternal and neonatal outcomes were compared between elective and emergent delivery of pregnancies complicated by placenta accreta. The primary outcomes were the need for blood transfusion and the number of units transfused. A total of 28 cases of confirmed placenta accreta underwent peripartum hysterectomy, including 22 as elective and 6 as emergent. Eleven out of 22 (50%) subjects in the elective group received blood transfusion, while all subjects in the emergency group required transfusion (p = 0.03). More importantly, the number of units of packed red blood cells transfused was only 1.90 (±2.20) units in the elective cases compared to 7.83 (±4.90) units in cases performed emergently (p = 0.03). Elective cesarean hysterectomy for this indication using a clearly outlined surgical approach is associated with significantly lower blood loss and hence less need for transfusion, compared to its emergent counterpart.

Which type of placenta previa requires blood transfusion more frequently? A new concept of indiscernible edge total previa.

During cesarean section (CS) for placenta previa (PP), the size/area/portion of the lower uterine segment occupied by the placenta may affect the bleeding amount and the subsequent need for a blood transfusion (BT). We propose a new concept, indiscernible edge total PP (IEPP), when vaginal ultrasound does not discern the lower placental edge because the placenta covers the visible lower segment. We characterized IEPP, focusing on its allogeneic BT requirement. We classified PP (n = 307) into four types: marginal, partial, discernible edge total PP (DEPP) and IEPP: internal ostium (os)-placental edge distance measurable or unmeasurable on vaginal ultrasound in DEPP or IEPP, respectively. We determined the clinical characteristics according to the four types; the relationship between the intraoperative blood loss and os-edge distance in DEPP; and risk factors for allogeneic BT. The following were significantly higher/larger in cases of IEPP: previous CS; anterior placentation; lacunae; elective cesarean hysterectomy; intraoperative blood loss; autologous BT; allogeneic BT; intensive care unit admission; and an abnormally invasive placenta (AIP). In DEPP, the os-edge distance was weakly correlated with the bleeding amount (r = 0.214). Multivariate logistic regression analysis showed that previous CS, lacunae, AIP and IEPP were independent risk factors for allogeneic BT (odds ratios 3.8, 3.1, 13.8 and 4.6, respectively). After excluding patients undergoing hemostatic procedures during CS, IEPP remained the only independent risk factor for allogeneic BT (odds ratio 5.2). The new concept of IEPP may be useful for predicting BT in CS for patients with PP.

Nonremoval of an abnormally invasive placenta at cesarean section with postoperative uterine artery embolization

To evaluate the outcome of three different modes of management of abnormally invasive placenta over a 6-year period. Retrospective cohort study. Tertiary hospital in Hong Kong. In 39757 deliveries, 25 cases of abnormally invasive placenta were identified at cesarean section. Identification of cases by hospital database and review of medical records. Blood loss, blood transfusion requirement, operative time, duration of hospital stay, secondary postpartum hemorrhage and endometritis. Six women were managed by leaving the placenta in situ and by postoperative uterine artery embolization. Ten women were managed by an extirpative approach and nine women with direct cesarean hysterectomy. The success rate of nonremoval of the placenta with uterine artery embolization was 4/6 (67%). The intraoperative blood loss, blood transfusion requirements and operation times were lowest in the group with nonremoval of the placenta, although a higher secondary complication rate and a longer hospital stay followed. Nonremoval of an abnormally invasive placenta at cesarean section and prophylactic postoperative uterine artery embolization are an alternative to elective cesarean hysterectomy.

A New Slow Releasing, H2S Generating Compound, GYY4137 Relaxes Spontaneous and Oxytocin-Stimulated Contractions of Human and Rat Pregnant Myometrium

Better tocolytics are required to help prevent preterm labour. The gaseotransmitter Hydrogen sulphide (H2S) has been shown to reduce myometrial contractility and thus is of potential interest. However previous studies used NaHS, which is toxic and releases H2S as a non-physiological bolus and thus alternative H2S donors are sought. GYY4137 has been developed to slowly release H2S and hence better reflect endogenous physiological release. We have examined its effects on spontaneous and oxytocin-stimulated contractility and compared them to NaHS, in human and rat myometrium, throughout gestation. The effects on contractility in response to GYY4137 (1 nM–1 mM) and NaHS (1 mM) were examined on myometrial strips from, biopsies of women undergoing elective caesarean section or hysterectomy, and from non-pregnant, 14, 18, 22 day (term) gestation or labouring rats. In pregnant rat and human myometrium dose-dependent and significant decreases in spontaneous contractions were seen with increasing concentrations of GYY4137, which also reduced underlying Ca transients. GYY4137 and NaHS significantly reduced oxytocin-stimulated and high-K depolarised contractions as well as spontaneous activity. Their inhibitory effects increased as gestation advanced, but were abruptly reversed in labour. Glibenclamide, an inhibitor of ATP-sensitive potassium (KATP) channels, abolished the inhibitory effect of GYY4137. These data suggest (i) H2S contributes to uterine quiescence from mid-gestation until labor, (ii) that H2S affects L-type calcium channels and KATP channels reducing Ca entry and thereby myometrial contractions, (iii) add to the evidence that H2S plays a physiological role in relaxing myometrium, and thus (iv) H2S is an attractive target for therapeutic manipulation of human myometrial contractility.

Continuous spinal anesthesia for Cesarean hysterectomy and massive hemorrhage in a parturient with placenta increta

We present anesthetic management using a continuous spinal anesthesia (CSA) technique in a patient with placenta increta who underwent elective Cesarean hysterectomy with massive postpartum hemorrhage. A 34-yr-old parturient (G3P2) was scheduled for Cesarean delivery and possible hysterectomy at 35(+3) weeks due to suspected placenta accreta. Her body mass index was 21kg·m(-2) and she had a reassuring airway. Inadvertent dural puncture occurred during combined spinal-epidural (CSE) placement, and a decision was made to thread the epidural catheter and utilize a CSA technique. Following delivery of a healthy infant, morbid adherence of the placenta to the myometrium was confirmed, and a supracervical hysterectomy was performed. Eight litres of blood loss occurred postpartum requiring resuscitation with crystalloid 3,800mL, colloid 1,500mL, red blood cells 16 units, fresh frozen plasma 16 units, platelets 4 units, and cryoprecipitate 1 unit. The patient developed pulmonary edema requiring conversion to general anesthesia. The patient's cardiovascular status was stable throughout surgery, and her lungs were mechanically ventilated for 18 hr postoperatively in the intensive care unit. The intrathecal catheter was removed 24 hr after placement. She developed no adverse neurological sequelae and reported no postdural puncture headache. The pathology report confirmed placenta increta. A CSA technique may be a viable option in the event of inadvertent dural puncture during planned CSE or epidural placement in patients with a reassuring airway undergoing Cesarean delivery. Although a catheter-based neuraxial technique is appropriate for Cesarean hysterectomy for abnormal placentation, conversion to general anesthesia may be required in the event of massive perioperative hemorrhage and fluid resuscitation.

Management of morbidly adherent placenta

Morbidly adherent placenta is a rare complication of human placentation that may threaten maternal life due to massive haemorrhage. Its incidence is increasing due to the rising caesarean section rates worldwide. A high degree of clinical suspicion coupled with ultrasonography, magnetic resonance imaging, and cystoscopy helps in antenatal diagnosis. Elective caesarean hysterectomy with a multidisciplinary approach is the conventional treatment for confirmed cases of morbidly adherent placenta. However more conservative fertility saving approaches are also used successfully. DOI: <a href="http://dx.doi.org/10.4038/sljog.v33i2.4004">http://dx.doi.org/10.4038/sljog.v33i2.4004</a> <em>Sri Lanka Journal of Obstetrics and Gynaecology </em>2011; <strong>33</strong>: 39-44

P30.09: Bladder varices: source of confusion for placenta accreta spectrum

performed at 36+3 weeks gestation under general anesthesia with central venous and arterial access in full anticipation of an intraoperative haemorrhage possibly necessitating peripartum hysterectomy. Following delivery of a healthy baby girl, the placenta was allowed to separate spontaneously and minimal blood loss occured. A tubal ligation was performed. She had an uneventful postoperative course and was discharged on day 4 following surgery. A morbidly adherent placenta occurs with an estimated incidence of one in 2500 pregnancies and is traditionally managed by elective caesarean hysterectomy, which carries significant risk for maternal morbidity and mortality, coupled with a loss of reproductive capacity. While many case reports are published on conservative management of this condition, a patient’s reproductive capacity following such management is uncertain and subsequent pregnancy outcomes are rarely reported. This case describes the excellent and encouraging outcome following conservative management of placenta praevia increta and highlights that this method, in selected cases, is a viable option for morbidity reduction and fertility preservation.

Do the CEMACH and RCOG green top recommendations influence the outcome of women with morbidly adherent placenta? A review of 16 antenatally diagnosed cases

Objectiveto assess the effect of CEMACH and Royal College of Obstetricians and Gynaecologists (RCOG) guidelines in the management of women with morbidly adherent placentae (MAP).DesignA prospective observational study of 16...

101: Elective caesarean hysterectomy vs. conservative surgery in patients with invasive placentation

101: Elective caesarean hysterectomy vs. conservative surgery in patients with invasive placentation

Lumbar tattoos, magnetic resonance imaging, and obstetric anesthesia: what do they have in common?

torically, placenta accreta was an incidental fi nding at the time of delivery and was associated with high maternal morbidity and mortality. The development of new imaging techniques such as MRI and transvaginal color Doppler sonography has allowed antenatal diagnosis of this condition [6] and elective preoperative planning of the obstetric and anesthetic management of these patients (e.g., elective Cesarean hysterectomy) [5]. In his practice of obstetric anesthesia, the author of this report encountered an otherwise healthy parturient with a working diagnosis of placenta accreta and colorful lumbar tattoos who was scheduled for MRI studies to determine the extent of placental pathology. At the conclusion of the procedure, the patient reported burning pain in her tattoos, consistent with the absorption of radiofrequency energy in the pigmented skin area. Although (luckily) no burns were diagnosed, this case adds one more piece of evidence that MRI studies should be performed with caution in patients with permanent skin coloring (tattoos).

Pregnancy Outcome After Intra-Abdominal Bleeding Due to Placenta Percreta at 14 Weeks of Gestation

With the rising rate of cesarean deliveries, the rate of placenta previa and placenta percreta will rise concomitantly resulting in a greater incidence of severe complications. This case report describes a pregnancy with a massive intra-abdominal bleeding due to placenta percreta at 14 weeks of gestation. Several management options were discussed, and finally continuation of pregnancy was chosen. No further complications occurred, and in the 35th week, an elective cesarean delivery and hysterectomy were performed. A healthy male newborn of 2,400 g was born. While the outcome of pregnancy was favorable in this case, it does not rule out the possibility of severe complications with this management.

Antenatal diagnosis of non‐previa placenta increta with histological confirmation

Antenatal diagnosis of non‐previa placenta increta with histological confirmation

Autoimmune progesterone dermatitis in a parturient for emergency caesarean section

A parturient with a 14-year history of autoimmune progesterone dermatitis presented in labour at 36 weeks' gestation. She had suffered recurrent episodes of angioedema over a long period and had been scheduled for elective caesarean hysterectomy and bilateral oophorectomy at 37 weeks' gestation. In most cases surgical oophorectomy provides prolonged relief from the recurrent angioedema and dermatological manifestations that are typical of autoimmune progesterone dermatitis. Spinal anaesthesia was chosen in order to avoid airway manipulation, a factor frequently implicated in the development of angioedema. Delivery was uneventful and the obstetricians proceeded to hysterectomy and oophorectomy. Forty minutes after delivery the patient experienced an attack of angioedema, she was markedly hypotensive and was given fluids, ephedrine and phenylephrine with good effect. As she remained normotensive, she was given intramuscular rather than intravenous epinephrine to provide a slower release. She recovered well and stabilised without the need for intubation or ventilation. This case reinforces the rationale for regional anaesthesia in these patients and demonstrates how intramuscular epinephrine contributed towards a positive outcome.

Elective cesarean hysterectomy vs elective cesarean section followed by remote hysterectomy: reassessing the risks

Objective: The purpose of this study was to compare the risks of elective cesarean hysterectomy with the risks of elective cesarean section followed by remote hysterectomy. Methods: A census of elective cesarean hysterectomies ( n = 31) and a random sample of 200 cesarean sections and 200 hysterectomies performed by the authors between 1987 and 1996 were evaluated. Only elective repeat and primary cesarean section patients without labor were selected for study ( n = 86). Total abdominal hysterectomies were drawn from the sample ( n = 60), excluding cancer cases, patients over 50 years old, and those with ancillary procedures other than adnexectomy and lysis of adhesions. General probability theory was used to calculate a predicted complication rate of cesarean section followed by TAH from the complication rates of the component procedures done independently. This predicted combined complication rate was then compared to the observed rate of complications from cesarean hysterectomy to evaluate the risks of the two alternative treatment regimens. Results: Elective cesarean section and total abdominal hysterectomy had complication rates of 12.8% and 13.4%, respectively. The predicted combined complication rate for elective cesarean section followed by TAH was 24.5%. The observed rate of complications for elective cesarean hysterectomy was much lower (16.1%). Although bleeding complications were similar for the two regimens, the rate of transfusion was higher for cesarean hysterectomy (13.0%) than for cesarean section (0%) and TAH (3.4%) alone. Eighty percent of the cesarean hysterectomy patients would have been candidates for autologous blood donation, had it been available. Conclusions: Elective cesarean hysterectomy has a lower risk of complications than elective cesarean section followed by remote abdominal hysterectomy and should be preferred. Transfusion risks are higher for cesarean hysterectomy but can be decreased by the use of autologous blood.