Cesarean Section For Placenta Previa Research Articles

A simpler alternative to the Sengstaken–Blakemore tube: Cervix‐holding by forceps to control hemorrhage after cesarean section for placenta previa

A simpler alternative to the Sengstaken–Blakemore tube: Cervix‐holding by forceps to control hemorrhage after cesarean section for placenta previa

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

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

Is it true that placenta previa per se is not a risk factor for perinatal mortality?

I read with great interest the article ‘‘Critical analysis of risk factors and outcome of placenta previa’’ by Rosenberg et al. [1], in which two observations were made. First, infertility treatments, prior cesarean section (CS), and advanced maternal age were major risk factors for placenta previa. I agree with these findings. Second, although placenta previa increased the perinatal mortality rate by 5.6 times, placenta previa per se was not the culprit, instead, its associated conditions (preterm birth, growth restriction, and congenital malformation) were the culprits. However, I disagree with the conclusion since it means that placenta previa, in the absence of these conditions, is not a risk factor for perinatal mortality. In other words, placenta previa does not present a risk factor for a term non-malformed normally grown infant. This differs from my clinical impression based on my three decades of experience in obstetrical practice. In my opinion, CS for placenta previa poses three risks to neonates; a view that I believe is shared by many experienced obstetricians. First, CS sometimes induces fetal hemorrhage, leading to neonatal anemia and circulatory collapse. Incision or destruction of the placenta, either accidentally or intentionally, induces hemorrhage, not only maternal but also fetal. Second, ‘‘abdominal dystocia’’ sometimes occurs in CS for placenta previa. The placenta, sometimes being present just adjacent to the incision site and thus bulging, narrows the ‘‘exit’’, preventing a smooth head delivery. Third, resuscitation of the infant, if required, may not be sufficiently provided in a case with unexpectedly severe hemorrhage in an emergent CS setting. General anesthesia may be more frequently employed in CS for placenta previa, especially in an emergent CS. Infant resuscitation may be more frequently required in placenta previa due to the higher possibility of fetal anemia, abdominal dystocia and general anesthesia. CS procedures have been developed to overcome, or at least lessen, the former two problems. First, we perform ultrasound after laparotomy, confirm the placental site and choose the incision site to avoid a transplacental approach as much as possible. If hysterectomy has been decided preoperatively, vertical uterine body incision or transverse uterine fundus incision is employed, which prevents placental incision and thus decreases the amount of hemorrhage [2]. Second, we usually use ‘‘forceps with vacuum’’ to deliver the head, better facilitating delivery than ‘‘manual delivery aided by fundal pressure’’ (Fig. 1). The third problem may be difficult to overcome since it depends on the institutional staffing pattern. Emergent CS at night, when medical staff is limited, may well illustrate the situation. Usually, when an infant is born with asphyxia or circulatory collapse, not only neonatologists but also other staffs on duty, including anesthesiologists or obstetricians, may help resuscitate the infant. However, more medial attention may be required for massive hemorrhage with less attention paid to the infant. Experienced obstetricians may not always be present at emergent CS. Inexperienced and limited staff in emergent CS settings may prevent physicians from performing the procedures described above or cooperating with the infant’s resuscitation. Thus, emergent CS for placenta previa may pose great risks of perinatal mortality. Data from Ananth et al. [3] were in line with this view. Term babies from women with previa, compared with those from women without previa, had a higher neonatal mortality rate, with the mortality rate S. Matsubara (&) Department of Obstetrics and Gynecology and Perinatal Education Center, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan e-mail: matsushi@jichi.ac.jp

Association of first Birth Cesarean Delivery and Placental Abruption or Previa at Second Birth

ABSTRACT Objective To evaluate the strength of association of cesarean delivery for first birth with placenta previa and placental abruption in second pregnancy. Design Retrospective cohort study. Setting Hospital based (Birth register)2004-2008. A total of 1638 pregnancies were available for the final analysis after excluding missing information. Methods Multiple logistic regressions were used to describe the relationship between cesarean section for first birth with placenta previa and placental abruption in second birth singletons. Main outcome measures Placenta previa and placental abruption Results Placenta previa was present in 10 per 1000 second-birth singletons whose first births delivered by cesarean section and 9 per 1000 second-birth singletons whose first births delivered vaginally. The corresponding figures for placental abruption were 5 per 1000 in the previous cesarean delivery group and 5 per 1000 in the previous vaginal delivery group. The adjusted odds ratio (95% confidence intervals) of previous cesarean section for placenta previa in following second pregnancies was 1.10 (0.39 to 3.10) after adjusting for confounders including maternal age and interval between births. The corresponding figure for placental abruption was 1.0 (0.24 to 4.19). Conclusion Cesarean section for first birth is associated with 10% increased risk of placenta previa and no risk of placental abruption in second pregnancy with a singleton.

Ovarian torsion in in vitro fertilization–induced twin pregnancy: Combination of Doppler ultrasound and laparoscopy in diagnosis and treatment can quickly solve the case

To diagnose and treat adnexal torsion in pregnancy. Case report. Obstetrics and Gynecology Department of Perugia Hospital. A 38-year-old woman, gravida 2, para 1 with bichorial twin pregnancy in the 10th week of gestation who was admitted for abdominal pain. She conceived after an IVF attempt. Even if symptoms compared 2 days before the admission, they aggravated just 2 hours before. An ovarian torsion was suspected, and Doppler ultrasound showed a complete absence of vascular flow. The dimension of the right ovary and the absence of ovarian blood flow were strong arguments in favor of the diagnosis of adnexal torsion, and laparoscopic ovarian adnexectomy was performed. The ovarian torsion was confirmed, and right adnexectomy was necessary. The patient had a quick convalescence and was discharged on the third postoperative day. She had no more pain. She underwent a cesarean section for placenta previa. She and her children have remained well. Considering the increased number of IVF pregnancies, an ovarian torsion should be less uncommon than in the past. Doppler ultrasound should be considered as a first-line exam. The complete absence of vascular flow in the ovary may be an indication for adnexectomy. An ovarian torsion in pregnancy should be treated laparoscopically.

Association of caesarean delivery for first birth with placenta praevia and placental abruption in second pregnancy

To quantify the risk of placenta praevia and placental abruption in singleton, second pregnancies after a caesarean delivery of the first pregnancy. Retrospective cohort study. Linked birth and infant mortality database of the USA between 1995 and 2000. A total of 5,146,742 singleton second pregnancies were available for the final analysis after excluding missing information. Multiple logistic regressions were used to describe the relationship between caesarean section at first birth and placenta praevia and placental abruption in second-birth singletons. Placenta praevia and placental abruption. Placenta praevia was recorded in 4.4 per 1000 second-birth singletons whose first births delivered by caesarean section and 2.7 per 1000 second-birth singletons whose first births delivered vaginally. About 6.8 per 1000 births were complicated with placental abruption in second-birth singletons whose first births delivered by caesarean section and 4.8 per 1000 birth in second-birth singletons whose first births delivered vaginally. The adjusted odds ratio (95% CIs) of previous caesarean section for placenta praevia in following second pregnancies was 1.47 (1.41, 1.52) after controlling for maternal age, race, education, marital status, maternal drinking and smoking during pregnancy, adequacy of prenatal care, and fetal gender. The corresponding figure for placental abruption was 1.40 (1.36, 1.45). Caesarean section for first live birth is associated with a 47% increased risk of placenta praevia and 40% increased risk of placental abruption in second pregnancy with a singleton.

Re-Laparotomy And Parallel Vertical-Compression Sutures And Prostaglandins For Massive Intraperitoneal Haemorrhage Following Caesarean Section For Placenta Praevia

Postpartum haemorrhage is a serious, life-threatening obstetric problem. It remains as one of the leading causes of maternal morbidity and mortality both in the developing and the developed world. Traditionally postpartum haemorrhage is treated by either medical or radical surgical procedures. In the last decade conservative surgical procedures have been successfully used in various circumstances and forms. We are reporting for the first time the use of simple parallel through and through vertical compression sutures to the lower segment on re-laparotomy for massive intraperitoneal bleeding following caesarean section for placenta praevia. We discussed the reasons for bleeding from the lower segment and the technique of the procedure undertaken to achieve haemostasis. It is extremely important to closely monitor during post-operative period at risk patients. We also recommend it to be considered as a prophylactic procedure during caesarean section for placenta praevia.

Maternal heterozygosity for a mitochondrial trifunctional protein mutation as a cause for liver disease in pregnancy

Acute fatty liver of pregnancy (AFLP) and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome are serious complications of pregnancy associated with significant maternal and perinatal morbidity and mortality. In previous reports, we have documented an association between AFLP and fetal deficiency of long-chain 3-hydroxyacyl coenzyme A dehydrogenase (LCHAD) [N. Engl. J. Med. 340 (1999) 1723-1731; JAMA 288 (2002) 2163-2166]. LCHAD activity resides in the alpha-subunit of the mitochondrial trifunctional protein (MTP), a complex protein that catalyzes beta-oxidation of long chain fatty acids. In all reported cases, the fetus carried a common alpha-subunit MTP mutation (G1528C, E474Q) on one or both alleles. However, the association between fetal LCHAD deficiency and the maternal HELLP syndrome has been limited. Here, we report a case history of a 27-year-old black female who underwent Cesarean section for placenta previa and fetal distress at 36 weeks gestation. The newborn was a healthy male child. Post-delivery, the mother developed severe HELLP syndrome with complications resulting in death of the patient. We used single strand conformation variance and nucleotide sequence analyses to screen DNA isolated from the mother and the newborn for mutations in the MTP alpha-subunit. The mother was heterozygous for a novel mutation (C1072A, Q322K) in exon 11 of the LCHAD domain of the MTP, while the fetal genotype was completely normal. We hypothesize that, in some cases, maternal heterozygosity for an MTP mutation maybe sufficient to cause the development of maternal liver disease without carrying an affected fetus. Combination of the metabolic stress of pregnancy and other environmental stresses may overwhelm the heterozygous mother's capacity for effective metabolism of long chain fatty acids, leading to an accumulation of potentially toxic fatty acid metabolites in the maternal circulation with subsequent damage to the maternal liver.

Caesarean section for placenta praevia complicated by postpartum haemorrhage managed successfully with recombinant activated human coagulation Factor VIIa

(2004). Caesarean section for placenta praevia complicated by postpartum haemorrhage managed successfully with recombinant activated human coagulation Factor VIIa. Journal of Obstetrics and Gynaecology: Vol. 24, No. 8, pp. 925-926.

Diagnosis of low‐lying placenta: can migration in the third trimester predict outcome?

To investigate the relationship between the rate of migration of a low-lying placenta during the third trimester and the eventual route of delivery. All patients with a placenta lying within 3 cm of the internal cervical os or overlapping it on transvaginal ultrasound at > or = 26 weeks' gestation were included in the study. The exact distance between the center of the internal cervical os and the leading edge of the placenta was measured by transvaginal sonography, repeated at approximately 4-week intervals until delivery. The mean rates of migration in patients who had (n = 7) and who did not have (n = 29) Cesarean section for placenta previa were +0.3 mm/week and +5.4 mm/week, respectively (P < 0.0001). When the placental edge was initially > 20 mm from the internal os, migration occurred in all cases and no Cesarean section for placenta previa was performed. For those between -20 mm and +20 mm, sufficient migration to avoid Cesarean section occurred in 88.5% of cases. Beyond a 20 mm overlap, significant placental migration did not occur and all patients required Cesarean section. Placental migration may occur progressively throughout the third trimester. The initial position of the placental edge and the subsequent rate of migration can be used to predict the eventual route of delivery.

Caesarean Section for Placenta Praevia: A Retrospective Study of Anaesthetic Management

Caesarean Section for Placenta Praevia: A Retrospective Study of Anaesthetic Management

Caesarean section for placenta praevia: a retrospective study of anaesthetic management

A retrospective survey of anaesthesia for Caesarean section (CS) for placenta praevia was performed, covering the period between January 1, 1984 and December 31, 1998. Three hundred and fifty consecutive cases of placenta praevia were identified. Overall a regional technique was used 60% of the time. Five women had a placenta accreta which required Caesarean hysterectomy: one had general anaesthesia (GA) throughout and four initially received a single-shot spinal injection. Of these latter four cases, two were converted to GA during the hysterectomy and two continued with spinal anaesthesia throughout. Two other women (both GA), suffered postoperative thrombotic episodes (one pulmonary embolus and one cerebral thrombosis) but made full recoveries. Control of blood pressure when using regional anaesthesia (RA), even in the presence of considerable haemorrhage, was not a problem. Statistical regression models indicated that RA was associated with a significantly reduced estimated blood loss and reduced need for blood transfusion. This retrospective survey finds no data to support the much quoted aphorism that RA is contraindicated for CS in the presence of placenta praevia.

Low-molecular-weight heparin for immediate management of thromboembolic disease in pregnancy

women had epidural anaesthesia without complication. The fourth woman stayed in hospital and was delivered under spinal anaesthetic by caesarean section for placenta praevia. Intrapartum blood loss for each woman was within normal limits. Median peak (3 h) anti-Xa activity in the four women was 0·67 U/mL (range 0·46–1·00 on 18 observations). In one woman (weight 58 kg), a 24 h anti-Xa activity profile showed that a measurable protective anticoagulant effect (activity >0·2 U/mL) was maintained between drug administration (figure). Furthermore, in each woman, there was no cumulative anticoagulant effect. One woman, treated for 8 weeks, had monthly peak concentrations of anti-Xa of 1·00 U/mL, 1·00 U/mL, and 0·89 U/mL. The activated partial thromboplastin time for each woman remained within normal during enoxaparin treatment and no woman developed thrombocytopenia. Subcutaneous LMWH seems to have advantages over unfractionated heparin for venous thromboembolism in pregnancy. The simplified therapeutic regimen for LMWH enables patients to be treated as outpatients. LMWHs have a higher anti-factor Xa activity/anti-factor IIa activity ratio than unfractionated heparin and a more predictable dose response. LMWH may be a safe and effective treatment for venous thromboembolism in pregnancy with easy administration. Assessment of anti-Xa during treatment should, however, be carried out until greater experience is obtained.

Early low-lying placentae—ultrasonic assessment, progress and outcome

A prospective study was carried out using 100 patients with 64 appropriately matched controls, to follow the course of low-lying placentae, diagnosed before 20 wk gestation. 94% of these placentae had moved out of the lower segment by the 32nd wk, while only 2% of the total required a caesarean section for placenta praevia. No evidence of intrauterine growth retardation or increased incidence of preeclampsia was found. In the light of this and other studies, a routine ultrasound re-check of placental position subsequent to 32 wk is deemed unnecessary unless clinically indicated, saving unnecessary maternal anxiety and over-exposure to ultrasound. Since the posterior low-lying placentae are those more likely to remain praevia, it is they that require follow-up scans.

Placenta accreta found at cesarean section for placenta previa, with preservation of the uterus

Placenta accreta found at cesarean section for placenta previa, with preservation of the uterus

A Case of Caesarean Section for Placenta Previa

A Case of Caesarean Section for Placenta Previa