European Journal of Obstetrics & Gynecology and Reproductive Biology 122 (2005) 122–125 www.elsevier.com/locate/ejogrb
Placenta percreta treated using a new surgical technique Gitte Bennich *, Jens Langhoff-Roos Rigshospitalet, Department of Obstetrics, Blegdamsvej 9, DK-2100 København Ø, Denmark Received 27 August 2003; received in revised form 11 February 2004; accepted 10 November 2004
Abstract Placenta percreta is still a life threatening condition due to the risk of excessive bleeding. Furthermore, it confers a considerable risk of the patient losing her uterus. An improved diagnosis including assessment of the depth of myometrial and serosal invasion is now available by color Doppler imaging, making the planning of elective caesarean section possible. We have designed a new operating technique, by which we successfully have achieved haemostasis of the areas containing the uterine arteries as well as the area between the bladder and the uterine cervix. # 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Placenta percreta; Caesarean section; Ultrasonography; Surgical technique
1. Introduction Placenta accreta is a condition, in which the chorionic villi of the placenta adhere in an abnormal way to the myometrium at the implantation site. It is associated with partial or complete absence of the decidua. The lack of decidua at the implantation site allows the placental villi to become attached to the myometrial segment of the uterine wall. The condition is graded according to depth of invasion: (1) chorionic villi attached directly to the myometrium (placenta accreta), (2) chorionic villi invading the myometrium (placenta increta) and (3) villi penetrating the entire myometrial layer to or through the serosa of the uterus (placenta percreta). In a study of 622 cases of placenta accreta, one-third of the cases were associated with placenta previa and onefourth of the women had previously had a caesarean section (CS). Nearly, one-fourth had previously undergone curettage of the uterus and one-fourth were gravida 6 or more [1]. Other studies have suggested that maternal age is a greater risk factor than parity [2].
* Corresponding author. Present address: Hostrups Have 48, 1. th., DK1954 Frederiksberg C., Denmark. Tel.: +45 51 92 34 91. E-mail address:
[email protected] (G. Bennich).
The clinical diagnosis ‘‘placenta accreta’’ covers a wide spectrum of clinical conditions, from retained placenta or cotyledons with minor blood loss to life threatening haemorrhage, requiring hysterectomy. Reported incidences of placenta accreta vary from 1 in 540 to 1 in 93,000 deliveries [1,2], with an average incidence of approximately 1 in 7000. In this paper, we present a new surgical technique allowing the patient to keep her uterus.
2. Case report A 30-year-old woman, gravida 3, para 0 with no history of previous uterine surgery had placenta previa diagnosed by a transvaginal ultrasonography at weeks 21 + 0. A subsequent color-Doppler imaging clearly indicated not only placenta previa but also placenta percreta with invasive growth of the placenta into the anterior part of the cervix. The patient was admitted to the obstetrical unit and staged until delivery. Until the 26th week of gestation, the patient suffered recurrent minor bleeding episodes and repeated ultrasonography revealed normal foetal growth. In our unit, the following criteria diagnosing placenta percreta were used: placental vessels were seen throughout the myometrium and subplacental vessels were aligning the external surface of the myometrium.
0301-2115/$ – see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejogrb.2004.11.049
G. Bennich, J. Langhoff-Roos / European Journal of Obstetrics & Gynecology and Reproductive Biology 122 (2005) 122–125
Based on the experience of former cases, a surgical technique was designed to reduce bleeding and possibly preserve the uterus. An elective caesarean section was planned at weeks 34 + 0 in an interdisciplinary cooperation with obstetricians, gynaecologists, urologists, anaesthesiologists and neonatologists.
3. Description of the technique: a two-step procedure 3.1. Application of sutures Under epidural anaesthesia, the patient was placed in the lithotomy position. A cystoscopy was performed and bilateral uretheral stents were introduced. A low midline incision was performed. Three straight blunt needles (diameter 2 mm, length 10 cm) were passed from the intraperitoneal cavity into the vagina via fornices at 2, 6 and 10 o’clock (Fig. 1) thus far from the ureters. The three needles were led to the vagina using the right hand, while the left was placed in the vagina to ‘receive’ the needles and hold the ligatures. This procedure was performed after small incisions were made in the broad ligaments in a vessel-free area above the uterine arteries. One suture (A) covered the right uterine artery, another (B) covered the left uterine artery and the third (C) covered the vessels from the bladder region to the anterior cervix and was placed as close to the uterus as possible. The needles were threaded with two sutures each (Ty-cron1 5; non-resorbable polyester fibre), the needle at 6 o’clock carrying the sutures A and B, the needle at 2 o’clock B and C and the needle at 10 o’clock A
Fig. 1. Cervix and the ligatures seen from the vagina. (A) with the right uterine artery, (B) with the left uterine artery and (C) with the vessels from the bladder region to the anterior cervix.
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and C. Afterwards, it was possible to tighten the sutures inside the vagina and thereby achieving haemostasis of (1) and (2) the areas containing the uterine arteries and (3) the area between the bladder and the uterine cervix (Fig. 2). The sutures were not tied immediately but held in position to be tied if necessary after the removal of the placenta. In the meantime they were held in three separately marked clamps. Moderate bleeding in the vagina was observed during this part of the procedure. 3.2. Delivery, removal of placenta and tightening of sutures With the sutures in place, the patient was taken into general anaesthesia. Uterotomy was made and a healthy baby of 2000 g was delivered carefully avoiding the placenta. The placenta was percret especially in the anterior part of the uterine cervix. A major part of the placenta was removed. The ligatures placed in the vagina were tightened and tied. The uterine incision was sutured continuously in one layer. The uterine cervix and isthmus were limp and with 4 l bleeding over 15 min. Forty IU oxytocin i.v. + 10 IU oxytocin in utero were administered followed by intrauterine injection of carboprost 1 mg 2, tranexamic acid 1 g i.v. 2 and methylergometrin 1 ml i.v. After acceptable haemostasis was ensured, the abdominal wall was closed by a normal procedure.
4. Discussion Placenta percreta is still a life threatening condition due to the risk of excessive bleeding [3] and confers a considerable risk of the patient losing her uterus. Owing to the severe consequences of the condition, an operating technique to reduce blood loss and preserve the uterus is desirable. Additionally, there is a need for a method to diagnose the condition before delivery to optimize the clinical management of these patients. The incidences of placenta previa and placenta accreta are higher among women with a previous ‘‘scarred’’ uterus. Furthermore, patients with uterine scars and placenta previa have an increased risk of suffering from placenta accreta [4]. Placenta previa complicates between 0.35% and 0.48% of all pregnancies [5–7] of which about 30% have previously had a CS performed [5–7]. The incidence of placenta previa is 1.9% in those with a previous history of CS [5]. An improved diagnosis is of vital importance in planning an elective CS with a team of obstetricians, gynaecologists, urologists, anaesthesiologists and neonatologists. The sensitivity and specificity of color Doppler imaging for diagnosing placenta accreta are reported to be 82.4–100% and 92–96.8%, respectively [8–10]. The advantages of color Doppler imaging compared with gray-scale ultrasonography are improved specificity and better assessment of the depth of myometrial and serosal invasion [11]. If ultrasonography,
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G. Bennich, J. Langhoff-Roos / European Journal of Obstetrics & Gynecology and Reproductive Biology 122 (2005) 122–125
Fig. 2. The uterus with relevant arteries and the applied ligatures. (A) contains the right uterine artery, (B) the left uterine artery and (C) contains the vessels from the bladder region to the anterior cervix.
color Doppler or power Doppler imaging are not satisfactory and the placenta is located posteriorly and suspected to be at risk of being accret, Levine et al. [9] suggest magnetic resonance imaging (MRI). In patients with findings suggestive of interphase hypervascularity, color Doppler imaging should clearly demonstrate that there are abnormal blood vessels linking the placenta to the bladder and not just bladder varices, possible due to neovascularized vessels from previous CS [10]. Hansch et al. [11] described that uterine artery embolization is a first line alternative to surgery for control of obstetric haemorrhage. In two patients with excessive bleeding caused by placenta percrete they report a 50% rate of success. In one case catheterization and complete embolization of the individual uterine arteries was insufficient, resulting in continued bleeding and subsequent hysterectomy. The procedure has recently been improved to include catheterization of the anterior divisions of the internal iliac artery with occlusion balloon catheters [11]. We do not know if our novel surgical technique will have any impact on subsequent pregnancies. Our technique is comparable but not similar to that of arterial embolization. At least 10 successful subsequent pregnancies have been reported using embolization [12]. In conclusion, ultrasonography, color Doppler imaging and three-dimensional color power Doppler imaging enable us to diagnose placenta percreta as early as 18 weeks of
pregnancy [13]. The correct diagnosis allows delivery to be planned as a multidisciplinary team effort and measures can be taken to reduce excessive bleeding and avoid hysterectomy. We designed an innovative operating technique that is simple and easy to apply. We successfully applied the technique in a case of placenta percreta and the uterus was preserved.
Acknowledgements The National Board of Health, Danish Centre for Evaluation and Health Technology Assessment and ‘‘Danish Hospital Foundation for Medical Research. Region of Copenhagen, The Faeroe Islands and Greenland’’ funded this paper. Thanks to Christel & Kristina Sierra Rosado for helping and producing the graphics.
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