Clinical Analysis On The Effectiveness Of Conservative Suture Technique To Conserve Fertility On Pernicious Placenta Previa

Background: Previa is latin term which means to go before,thus placenta previa basically implies placenta going before fetus in birth canal.Placenta previa is defined as implantation of placenta in the lower uterine segment over the internal os or in proximity to internal os.Placenta previa is divided into four types according to the distance from placental edge to internal os including low lying placenta previa,marginal placenta previa,partial placenta previa,and total placenta previa.This classification is important in management point of view.Invasion of placenta into myometrium is called placenta accreta.Poor development of decidua that lines the lower uterine segment cause firm attachment of placenta which is the most common complication noted in case of placenta previa.Placenta accreta syndrome arises from abnormally implanted placenta.The characteristic feature of placenta previa is sudden onset,painless,and recurrent vaginal bleeding.Painless per vaginal bleeding is most commonly noted at the end of second trimester or later,but may also begin before mid-pregnancy.Incidence of placenta previa is reported to be 1 case per 200 deliveries in average and varies throughout the world.In United States it was reported to be 1 in 300 deliveries in 2003.Canada,England and Israel have similar frequencies.The incidences are influenced by multiple factors like maternal age,parity,numbers of previous cesarean section(CS),maternal behaviors like smoking and previous gynecological surgeries.In those women with a placenta previa,the risk for placenta accreta was 3%,11%,40%,61% and 67% for first,second,third,fourth and fifth repeated CS,respectively.Pernicious placenta previa(PPP)was first described by Chattopadhyay SK.It refers to the occurrence of placenta previa overlying a previous cesarean scar which is often associated with placenta accreta.The placenta invades the superficial layer of the uterus and becomes placenta accrete.The placenta then invades the deep myometrium layer of the uterus making it placenta increta.If the placenta penetrates the wall of the uterus,reaches the uterus’ s serosa,and invades the adjacent organs,it is called placenta percreta.PPP complicated with placenta accreta/increta/percreta is a serious long-term complication of CS and often leads to unmanageable,massive hemorrhage.Treatment of placenta previa is most difficult when placenta previa is complicated with placental invasion and if the invasion is extensive invading uterine serosa and posterior bladder wall.In such condition,the bladder and the uterus are adherent to each other tightly.It is hard to extract placenta and frequently results in massive postpartum hemorrhage.Moreover,bladder and ureter are easily injured during the procedure.This can easily lead to serious complications such as disseminated intravascular coagulation(DIC)and hemorrhagic shock.Its incidence has been as high as 1/533 cases and has become an important cause of postpartum hemorrhage(PPH),intrapartum hysterectomy,and maternal mortality.The treatment of PPP is a serious concern amongst the obstetrician.It is important to have sufficient pre-operative preparations,and multidisciplinary consultation with other departments to accomplish the surgery.Preoperative preparation includes blood products arrangement,a cystoscopy as well as ureter stent by urologist,a central venous catheter by anesthesiologist to monitor and maintain blood pressure(BP).Some surgical procedure to release pelvic adhesions are there which can help to let the bladder free.The most critical skill is focused on stopping the bleeding during operation.Currently,several adjuvant hemostatic techniques including,internal iliac artery ligation,interventional arterial radio embolization,balloon occlusion of the artery is used to minimize intraoperative blood loss and in very severe circumstances hysterectomy is done.Though,all these above techniques have their own limitation and conservation of fertility in consequent pregnancies is an important issue.The maneuvers commonly used in our hospital are uterine contraction medicines,tourniquet around lower uterine segment,Figure-of-8 suture,modified CHO sutures,vertically opening of cervical canal,B-lynch sutures.Pitocin and Hemabate are commonly used uterine contraction medicines in our hospital.Two ampules(10 units /ampule)of Pitocin are injected directly into fundus soon after delivery of fetus.Two ampules of hemabate(250μg /ampule),one is injected into uterine body and the other one into deltoid immediately after injecting Pitocin.Tourniquet which is used commonly in infusion,blood transfusion and blood drawing has also been used to arrest hemorrhage during operation in placenta previa.Tourniquet is easily available in hospital setup,is convenient,efficient and inexpensive.Tourniquet is applied in lower uterine segment without delay soon after delivery of fetus.It transiently compresses bilateral uterine arteries & veins and cut off uterine artery blood supply.However,it should be noticed that sustained use of tourniquet can lead to thrombus formation and uterus ischemic injury.So tourniquet should be loosen in every 10 minutes and should observe a few minutes to identify active bleeding sites.And then tourniquet is fastened again and suturing of the bleeding site is achieved.In cases with placenta previa complicated with placental implantation,placenta is cut off from implantation site along with anterior uterine wall.Figure-of-8 sutures is used for small areas of bleeding.Vertically open cervical canal for continuous cervical canal exsanguination.Bladder is pushed down and cervix is cut vertically approximately 4-5 cm to expand the operation field and to expose the bleeding site.Deep figure-of-8 sutures is put into perimetrium at the heavily bleeding site first and suture other bleeding sites.In placenta previa uterine fundus and body contract well,while lower segment cannot contract well leading to hemorrhage.Modified CHO sutures on bleeding site can stop hemorrhage rapidly.Square sutures had been used to arrest bleeding from placental bed by suturing uterine anterior and posterior walls together to close large sinuses.This suture is hard to perform and is time consuming.Moreover,after suturing it is easy to get lochia retention in the uterine cavity.In order to simplify the procedure and overcome these limitations,we have modified the way of suturing.Instead of suturing anterior and posterior wall together we suture either anterior or posterior wall whichever is bleeding.We alter stitches distance from 2 cm to 3 cm or less,depending on the area of bleeding.With dense stitches compression is stronger.The modified sutures are easier to perform and doesn’t need a long straight needle.Besides,flow of lochia discharge is not disturbed.All kinds of sutures mentioned above may lead to uterine ischemia and anoxia,consequently resulting in uterine atony.CHO sutures is used in lower uterine segment bleeding with good fundus and body contractions.B-lynch suture is widely used in atonic cases where whole uterus remains flabby and unable to contract.After suturing,uterine blood vessels are compressed and hemostasis is achieved. In our study we perform clinical analysis on the effectiveness of conservative suture technique mentioned above to conserve fertility on pernicious placenta previa patients.Objective: To assess the clinical analysis on the effectiveness of conservative suture technique to conserve fertility on pernicious placenta previa.Method: A non-comparative retrospective study was conducted among 217 consecutive women with placenta previa who were admitted to the Department of Obstetrics of the First Affiliated Hospital of Jilin University from January 1,2013,to January 1,2018.This study followed the tenets of the Declaration of Helsinki and was approved by the ethics committee of the First Affiliated Hospital of Jilin University.The first affiliated hospital of Jilin university is referral center and tertiary care center for the pernicious placenta previa cases and other obstetrics emergencies;hence the number of PPP cases is high in our hospital.Informed written consent was acquired from each patient prior to their involvement in the study.Among 217,188 women with placenta previa were included and 29 women were excluded.Women were recruited with positive sonographic(USG)or magnetic resonance imaging(MRI)evidence of placenta previa,all the cases which had crossed a period of viability and with the previous uterine scar or past history of at least one cesarean section.Those with unavailable medical records and lost to follow-up,multiple gestations,women with past history of bleeding disorders expected to affect amount of bleeding,patient with uterine myoma or fibroid,cesarean section due to maternal/fetal indication such as chronic medical condition: psychiatric disorders,fetal distress;likely to interfere the treatment were excluded.Emergency CS was done in the patient with severe uncontrolled vaginal bleeding during the period of observation and was less than 36 weeks as well as refractive to conservative management.Those patients with controlled vaginal bleeding with conservative management were recruited for elective CS.Prenatal diagnosis of PPP was established by USG or MRI findings and a history of previous CS.USG findings comprised the presence of placental lacunae with turbulent flow in placental lacunae,an undistinguishable edge amongst the placenta and the myometrium or cervical tissue,deficiency of decidua area,and increase vascularity in the uterine serosa.Abnormal placental position was established either clinically,or by histopathologically and after delivery.Before the procedure,all the patients were observed as well as counseled by a multidisciplinary team that included an obstetrician,an anesthesiologist,urologist,surgeon,invasive radiologist,and neonatologist.Preoperative preparation included blood and blood products,ureter stent,cystoscopy,central venous catheter.The procedures and the possible complications like intrapartum hemorrhage,postpartum hemorrhage(PPH),pelvic adhesion and unavoidable situations were explained to patient and patient party.All the patients received conservative treatment with combined medical and suture techniques.Our patients were managed with uterine contraction medicines,tourniquet around lower uterine,figure-of-8 suture,modified CHO suture,vertically opening of cervical canal,B-lynch suture.All the maternal medical records were reviewed and the following data were extracted and analyzed: maternal epidemic and clinical data(maternal age,gravidity,gestational age at c/s,number of previous c/s),type of operation(elective or emergency),suture method used to control bleeding and complication after treatment,Operative circumstances and neonatal outcome(amount of bleeding,duration of operation,length of postoperative stay,gestational age at birth,neonatal weight and Apgar score at 1 min and 5 min).Data were analyzed using the statistical software package IBM SPSS Statistics 21.Data were expressed as mean(M)± standard deviation(SD)if normally distributed,and Independent sample t-test was used for statistical comparison.Non normally distributed data were expressed as Median(P25,P75),and analysis was performed using Mann-Whitney-Wilcoxon test.X2 examination was used to count data comparison.A two-sided P value < 0.05 was considered to be statistically significant.Results: Out of 217 patients,188 met inclusion criteria and 29 patients were excluded.In 188 cases,183(97.34%)cases successes with conservative suture technique and 5(2.65%)cases had hysterectomy.Among included group,118 patients(62.76%)had undergone emergency cesarean section and 70 patients(37.23%)underwent elective cesarean section.At the time of cesarean section,the mean maternal age was 32.4±4.3 years,the mean gravidity was 3,the mean of previous cesarean section was 1.1±0.4 and the mean gestational age at the time of cesarean section was 36.1±2.7 weeks.The emergency group had significantly lesser gestation period of gestation at the time of cesarean section(P= 0.021),the mean gestational age was 34.82±4.11 weeks in emergency group and 36.14±3.51 weeks in elective group.Mean neonatal weight was found to be 2955.61±519.75 gm in elective group and 2631.93±709.91 gm in emergency group,showing neonatal weight significantly lower in emergency group than that of the elective group(P= 0.001).The estimated blood loss during surgery was 500-3200 ml(mean: 925 ml).Additionally,the amount of bleeding was found to be significantly more in patient with intraoperative complication(P=0.007)and in patient with implanted placenta(P<0.001).The average bleed loss in patients with intraoperative complication and without intraoperative complications was 1100 ml and 800 ml respectively.While comparing blood loss in patients with placental implantation and without placental implantation it was found 1700 ml in patients with placental implantation and 800 ml in patients without placental implantation.Conclusion: In conclusion,this study demonstrated that suture technique during the cesarean delivery is a feasible,safe and effective alternative conservative surgical technique for the management of bleeding in case of pernicious placenta Previa.Besides good surgical outcome and proper neonatal result this technique also reduces the rate of hysterectomy,thus conserving the fertility for subsequent pregnancies.