Antepartum Hemorrhage

(APH)
DR (PROF)UPMA SAXENA
VMMC & SAFDARJANG HOSPITAL
 DEFINITION

• Any bleeding from female genital tract after

fetal viability (>28 weeks ) till delivery of
the fetus.

• Incidence: 8.5% in singleton pregnancy

12.6% in twin pregnancy

MacGillivray &Campbell 1988

 OUTCOMES
MATERNAL MORTALITY
• 5% (1945) -------- <0.1% (1988)
Improved medical care & LSCS facilities
• Pre-existing anemia, difficulties with transport &
restricted medical facilities -----responsible for
maternal death
PERINATAL MORTALITY
• More common than maternal death
• 1989-1990 in Scotland: 14% of fetal loss were
associated with APH.
• Neonatal death in placenta praevia were related to
complications of prematurity as it does not cause
intrauterine hypoxia . Incidence fell with expectant
management
 Causes of Maternal Deaths
13.60% PPH
2.70%
0.90% APH
6.80%

Anaesthetic Complications

Puerperal Sepsis
16.40%
10.50%
Obst. Pulmonary Embolism

Ass. Medical Complications

Abortion
5.90%
Ectopic Pregnancy

HDP
13.20%
Obstetric Trauma

Other Unspecified
20.00% Complications
4.00%
Others
4.10% 1.80%
 CAUSES

• Placenta praevia 35%

• Abruptio placenta 35%

• Local causes 5%

• Undetermined 25%
 PLACENTA PREVIA

• Definition
• Risk factors
• Clinical presentation
• Diagnosis
• Management options
 Placenta praevia - Definition

• Placenta that is implanted entirely or in part in the

lower uterine segment .
• Previa in Latin means “in front”
• Incidence 1/200 pregnancies
• Haemorrhage is likely to occur when uterine
contraction dilates the cervix-Bleeding is hence
inevitable.
• With the rising incidence of caesarean section
operations combined with increasing maternal
age, the numbers of cases of placenta praevia
and its complications continue to increase.
 RISK FACTORS

• previous placenta praevia

• previous Cesarean section
• increased maternal age
• increased parity
• large placentas: a. multiple gestations b. erythroblastosis
• maternal history of smoking
• assisted conception
• previous manual removal of placenta a. abnormal
placental villous adherence (~5%): e.g. placenta accreta
 Types of placenta praevia

• Low-lying placenta - placenta implanted in

the lower uterine segment.
• Marginal placenta previa - placental edge
at margin of internal os.
• Partial placenta previa - internal os partly
covered by placenta.
• Total placenta previa - internal os
completely covered by placenta.
Partial placenta praevia
Total placenta praevia
 Screening and diagnosis

• While clinical acumen remains vitally important in

suspecting and managing placenta praevia, the
definitive diagnoses of most low-lying placentas is
now achieved with ultrasound imaging.
• Clinical suspicion should, however, be raised in
any woman with vaginal bleeding and a high
presenting part or an abnormal lie, irrespective of
previous imaging results.
 Imaging for placenta praevia

Imaging investigations are useful

in the detection of placenta
previa and placenta accreta the
most important identifiable risk
factors for massive hemorrhage.
 Use of Ultrasound imaging
• Transabdominal ultrasound is good for ant
placenta previa
• Transvaginal ultrasound is safe and is more
accurate than transabdominal ultrasound in
locating the placenta.
• Distance from the internal os to the placental edge.
• placental edge located two cm or more from the
internal os is not associated with intrapartum
bleeding
 Use of Ultrasound imaging
All low lying placentas seen at routine 18-22 weeks
scanning should be assessed by either transvaginal or
translabial scanning to:Confirm the position of the
placenta in relation to the internal os.
• If the placenta is 2 cm or more from the os -no
follow up is necessary.
• If the placenta is < 2 cm from the internal os
follow up should be obtained at about 32
weeks.
• If the placenta covers the internal os the
distance that it projects beyond the os should be
measured.
 Placenta praevia-diagnosis

• Incidence of low-lying placenta by U/S

• <24 wk - 28%
• >24 wk - 18%
• Term - 3%
Placental Migration-Rpt USG later at 32-34 wks
 Why to repeat scan?
• Placental migration occurs during the second and
third trimesters, owing to the development of the
lower uterine segment, which grows 10 fold from
0.5cm to 5 cm
• Retrospective review of 714 women with placenta
praevia found that, even with a marginal ‘praevia’
at 20–23 weeks , the chance of persistence of the
placenta praevia requiring abdominal delivery was
11% with no uterine scar and 50% with a previous
caesarean section.
 Use of Ultrasound imaging

• Assess the attachment of the umbilical cord

to the placenta as increased incidence of
velamentous insertion with vasa previa.
• To exclude placenta accreta / increta /
percreta especially if placed anteriorly.
USG Types of praevia
USG Types of praevia
TOTAL PLACENTA PREVIA

F
B

P
PARTIAL PLACENTA PREVIA
MARGINAL PLACENTA PREVIA

P
 Abnormal implantation

Placenta Accreta/Increta/Percreta
• Accreta: villi attatched to myometrium
(85%)
• Increta: villi invading the myometrium
(15%)
• Percreta: villi beneath or through the uterine
serosa (5%)
 Abnormal implantation

Risk factors
• Early 30s
• Parity (2 or 3 prior births)
• Prior C/S,hysterotomy,myomectomy
• H/O of D& C
• Prior manual placental removal
• Prior retained placenta
• Infection
 Placenta accreta
In a patient with a previous cesarean
section and a placenta previa:

Previous one has 14% risk of placenta accreta.

Previous two has 24% risk of placenta accreta.
Previous three has 44% risk of placenta accreta.
 RISK OF PPH

• Postpartum Accreta
• 39 – 64%
• 2600 ml (without previa)
• 4700 ml (with previa)
 Placenta Accreta

• Increased risk of accreta if there is anterior

placenta praevia with previous caesarean section,
especially when there has been a short caesarean
to conception interval.
• Antenatal imaging can help to establish a
diagnosis in such cases and techniques used
include ultrasound imaging, power amplitude
ultrasonic angiography, colour flow Doppler and
MRI
 Ultrasound imaging
• Loss of normal hypoechoic retroplacental
myometrial zone
• Lot pf placental lakes –Swiss cheese
appearance
• Abnormal uterine serosa bladder interface
• Exophytic mass adjacent to serosa
 Doppler ultrasonography

• It should be performed in women with

placenta praevia who are at increased risk of
placenta accreta.
• Turbulant lacunar blood flow extending
from placenta into the surrounding tissues
(bridging vessels)is s/o accreta.
• Where this is not possible locally, such
women should be managed as if they have
placenta accreta until proven otherwise.
 Imaging for placenta praevia

Further imaging by MRI is

recommended to assess bladder
involvement in percreta and
assess high-risk cases

Thorp Jr. JM, Councell RB, Sandridge DA, et al. Antepartum

diagnosis of placenta previa percreta by magnetic resonance
imaging. Obstet Gynecol 1992;80:506-8.
 MRI
• MRI has the advantage of being possible without a
full bladder and is an objective test, removing
operator error.
• It is particularly useful in imaging posterior
placentas
• At present for placenta accreta colour flow
Doppler is the investigation of choice until further
experience and/or refinements occur with MRI.
• Imaging antenatally allows for preparation for
surgery but false positives do occur and the
diagnosis should be confirmed intraoperatively to
avoid inappropriate treatment.
 MANAGING ACCRETA

Conservative management
• Leaving the placenta in place
• Localized resection and repair
• Oversewing a defect (esp percreta)
• Blunt disection/curretage
Definite management
-Hysterectomy
Management of placenta previa
 Antenatal management
• Women with major placenta praevia who
have previously bled should be admitted
and managed as inpatients from 34 weeks
of gestation.
• Those with major placenta praevia who
remain asymptomatic, having never bled,
require careful counselling before
contemplating outpatient care.
• Any home-based care requires close
proximity with the hospital, the constant
presence of a companion and full informed
consent from the woman.
 Domicillary management

• Women managed at home should be encouraged to

ensure that they have safety precautions in place,
including having someone available to help them
should the need arise and, particularly, having
ready access to the hospital.
• It should be made clear to any woman being
managed at home that she should attend hospital
immediately if she experiences any bleeding, any
contractions or any pain (including vague
suprapubic period-like aches).
 Role of cerclage and tocolysis

• The use of cervical cerclage to reduce bleeding

and prolong pregnancy is not backed up by
sufficient evidence to recommend this practice
outside of a clinical trial.
• Tocolysis can be useful in selected cases. However
betamimetics were used in the studies to date and,
as these are known to be associated with
significant side effects
 Antenatal counselling

Prior to delivery, all women with placenta

praevia and their partners should have had
antenatal discussions regarding delivery,
haemorrhage, possible blood transfusion
and major surgical interventions, such as
hysterectomy, and any objections or
queries dealt with effectively.
 Clinical presentation
• Painless & causeless bleeding
• Correlation between the maternal bleeding and vitals
• First h’ge usually: not severeso WARNING Hge
• Co-existing abruptio>10%
• ABDOMINAL EXAMINATION:
• Soft
• Non-tender
• Unusually high head
• Fetal malpresentation ie Breech , Transverse, Oblique
• FHR – normal Fetus alive unless severe shock
• VAGINAL EXAMINATION
• No place for routine PV
• Speculum examination-To r/o local cause
 GENERAL MEASURES
MANAGEMENT
• Put two IV line (14 – 16 gauge)
• Blood for FBC, GSH 4 pint packed cell, (coagulation
profile, liver function test - ??abruptio), *Kleihauer test
• Resuscitate with crystalloid and packed cell (Bonnar
2000)
• Give 3 times as much crystalloid as EBL
• Insert CBD for I/O monitoring
• U/S to exclude placenta praevia
• In abruptio ,retroplacental clot & lifting of membrane
seen by usg only when patient is stable
 SUBSEQUENT MANAGEMENT

• Immediate delivery
• Severe bleeding with maternal shock
• Fetal distress
• Fetal death
• Expectant management
• Bleeding has stopped
• Mild bleeding with stable vitals
• No evidence of fetal distress
 Management options

Expectant management
Macafee 1945
• Remains in hospital
• Fully equipped & fully staffed from time of
initial diagnosis to delivery.
• Facilities for immediate caesarean section
and blood transfusion
• Identify & correct anemia (Maintain Hb >10
gm%)
 Expectant management

• Depends on:
• Stage of pregnancy- <37wks
• Extent of haemorrhage-vital stable

Reduce perinatal mortality &

• Preferable, Aim: reduce maternal mortality
• Maximum fetal maturity
• Minimising risk to mother and fetus
 Expectant management

• Outpatient management
• Low lying placenta – repeat U/S at 32-34 wk
• Asymtomatic major praevia – admit at 36wk
Warning
Avoid coitus
Avoid travel & being in crowded places
Communication & transport within 30min
 Immediate delivery
• Indications:
• Severe & continuous bleeding which has
caused or likely to cause haemodynamic
changes
Immediate operative delivery
• Continuing bleeding, neither profuse nor life-
threatening, more than 36wk
• Delivery is preferred
• Mode of delivery will depends on type of
praevia
• EUA in double setting if diagnosis
unconfirmed
 Anaesthesia during cesarean
• The choice of anaesthetic technique for caesarean
section for placenta praevia must be made by the
anaesthetist, in consultation with the obstetrician
and mother, but there is increasing evidence to
support the safety of regional blockade.
• Any woman going to theatre with known placenta
praevia should be delivered by the most
experienced obstetrician and anaesthetist on duty.
As a minimum requirement during a planned
procedure, a consultant obstetrician and
anaesthetist should be present within the delivery
suite.
 Timing of delivery

• The timing of emergency surgery will be

influenced by individual circumstances but, where
possible, elective caesarean section should be
deferred to 37 weeks completed to minimise
neonatal morbidity.
• In the case of placenta accreta, increta and
percreta, the risk of haemorrhage, transfusion and
hysterectomy should be discussed with the patient
as part of the consent procedure and operated at
34 wks.
 Mode of Delivery

• The mode of delivery should be based on clinical

judgement supplemented by USG.
• A placental edge less than 2 cm from the internal
os is likely to need delivery by caesarean section
• Blood should be readily available for the
peripartum period
• There is no evidence to support the use of
autologous blood transfusion for placenta praevia.
 Vasa praevia
• Bleeding from fetus when there is velamentous
insertion of cord and it runs in the membranes at
the level of internal os infront of the presenting
part
• Look for single umblical A, succenturite placenta,
low lying placenta,IVF pregnancy as then the risk
of velamentous insertion increases
• Look at insertion of cord ,whether central or
marginal. If marginal ,increased incidence of
velamentous insertion
• Incidence:0.2%singleton,10% twins, 50% triplet
• Fetal Loss : 50% with membrane intact
75% when membrane ruptured
 Diagnosis of vasa previa

• May palpate a tubular vessel in the membranes .

• Compression of vessel between the examining
finger and presenting part will cause changes in
fetal heart
• On USG: Echogenic parallel or circular line near
the cervix
• Definite diagnosis: TVS with doppler
• Diagnosis of fetal blood: Nucleated RBC seen in
slide stained with Wright stain
• CTG: sinusoid pattern
• Management: Emergency LSCS
 ABRUPTIO PLACENTA

• Definition
• Complications
• Clinical presentation
• Diagnosis
• Management option
 Abruptio placenta - definition

• Bleeding following premature separation of

a normally sited placenta.
• Basic cause unknown.
• Self-extending process
• Three types:
• Concealed 20 – 35%
• Revealed 65 – 80%
• Combined
• Incidence
• All placental abruptions: 1-2%
• Severe placental abruption (Grade 3): 0.2%
• Risk of recurrence in future pregnancy
• One prior placental abruption: 5-16%
• Two or more prior placental abruptions: 25%
Types of abruptio
Concealed abruptio
 RISK FACTORS
• Pregnancy Induced Hypertension
• High parity
• Abdominal Trauma
• Previous placental abruption
• Twin Gestation
• Polyhydramnios
• Maternal Substance Abuse (Cocaine)
• Maternal Tobacco abuse
• PROM
 Classification of Abruptio

• Sher & Statland (1985): 3 grades

• Grade 1: not recognised clinically before
delivery, diagnosed by presence of
retroplacental clot after delivery.
• Grade 2: classical sign of abruptio are present,
fetus still alive.
• Grade 3a: fetus is dead & without coagulopathy
• Grade 3b: fetus is dead & with coagulopathy
 Clinical presentation

• Pain over uterus (may be severe and constant)

• Increase severity
• No periodicity
• Superimposed contraction with continuous
pain
• PV bleeding 70 – 80%
• Quantitate amount of bleeding
• Assess color of blood
• Faintness & collapse
• Absent fetal movement
 Clinical presentation
• On examination
• Tachycardia, weak thready pulse, pallor, cyanosis, cold
& clammy skin
• Uterus extremely hard & tender – ‘woody hard’
• Uterus does not relax
• Fetal part are difficult to palpate
• Head may be engaged
• Blood stained liquor on ARM
• Fetal heart may not be audible
• Clinical diagnosis
Symptoms & signs may be diagnostic
USG: Accurate diagnostic tool. If patient stable
• After delivery – retroplacental clot found
Retroplacental clots
Couvelare uterus
 Abruptio - complications

• Haemorrhagic shock
• Renal damage
• Coagulopathy --- DIVC
• Tetanic uterine contraction
• Fetal compromise
• Fetal death
 Management options
Principle of management
• Immediate delivery
• Adequate blood transfusion
• Adequate analgesia
• Detailed monitoring of maternal condition
• Assessment of fetal condition
Indications for conservative management
• Alive fetus POG < 36 wks
• Maternal condition stable
• Minimal placental sepration with normal coagulation
profile
 Management option

• Prompt treatment & monitoring of mother are vital

• Haemodynamic status
Hematocrit >30%
Urine output >30 cc/hr
• Mark uterine outline and check abdominal
girth hourly
• Blood transfusion
• Correction of coagulation factors
• Oxytocic drug
 Management options
Mode of delivery depends on:
• State of baby
• State of cervix
Alive fetus – vaginal delivery vs LSCS
• Fetal distress /abnormal CTG/cervix not fully
dilated - Em.LSCS
• No fetal distress /normal CTG/cervix almost fully
dilated- vaginal delivery: ARM +/- oxytocin,
continuous CTG,
Dead fetus – Aim for vaginal delivery
Fetal death, irritable uterus, concealed type
 Management option
Fetus alive
Non-irritable uterus, revealed abruption, normal FHR tracing

Vaginal delivery expected

Uterus irritable, concealed type or mixed, abnormal FHR

Emergency LSCS
 Other causes of APH

• Undetermined 47%
• Marginal sinus rupture *common cause of
unknown APH
• Show Include minor
• Cervicitis abruption/praevia
• Trauma
• Vulva varicosities
• Genital tumours, infection
• Vasa praevia
Management of APH
 Place for management

• In hospital management with facilities for:

• Blood transfusion
• Caesarean section
• Neonatal resuscitation
• Intensive care
• If emergency occur at home, arrange for:
• Urgent transport via ambulance
• Any fastest means available
 INITIAL ASSESSMENT

• INITIAL MANAGEMENT IN APH:

• Brief history
• Physical examination (Evaluation’s of patient’s
general condition )
• Initiation of various laboratory test
• Initiation of treatment
 INITIAL ASSESSMENT
• HISTORY
• Gestational age – LMP/US scan
• Initiating factors
• Amount & character of bleeding
• Association of abdominal pain /regular uterine
contraction
• Previous h/o vaginal bleeding
• Information about placental site from previous
scan
• History of ruptured membranes
• H/o Trauma, HT
• Perception of fetal movement
 INITIAL ASSESSMENT
• PHYSICAL EXAMINATION
(AIM: assess maternal & fetal condition)
• PR, BP, RR
• Evidence of shock: restless, pallor, cold clammy
extremities.
• Assess the amount of blood loss
• Abdominal examination:
• FH <=> gestational age, lie ,presentation
• Tenderness, irritability, uterine contraction
• FHR - Dead? Distressed? Alive?
• Vaginal examination
• Inspection to assess the amount of blood loss
• Speculum examination to exclude local lesion, and
look for cervical dilatation
• PV:ONLY AFTER PLACENTA PRAEVIA
EXCLUDED BY DOING USG
 Conclusion

• APH is an important cause of maternal

morbidity & mortality
• Aim of management- Resuscitation and
prolongation of pregnancy if possible with
correction of anemia or immediate delivery
either for fetal or maternal indications.
• Empty the uterus by fastest route possible in
case of massive hemorrhage
THANK YOU
Blood Volume Bl. Pressure Symptoms and Degree of
Loss (systolic) Signs Shock
500-1000 Normal Palpitations , Compensated
(10-15%) tachycardia ,
dizziness
1000-1500 Slight fall Weakness , Mild
mL(15-25%) (80-100 mm tachycardia ,
Hg) sweating
1500-2000 Moderate fall Restlessness , Moderate
(25-35%) (70-80 mm pallor ,
Hg) oliguria
2000- Marked fall Collapse, air Severe
3000mL(35- (50-70 mm hunger, anuria
50%) Hg)
Int Gyaecol Obstet 1997 May;57(2):219-26
 Management of massive
Obstetric hemorrhage(ORDER
• The most recent Confidential Enquiry
into Maternal Deaths in the UK stresses
that all caesarean sections performed in
women with placenta praevia who have
had a previous caesarean section should
be conducted by a consultant
obstetrician, because of the high risk of
major morbidity.
 Management of massive
Obstetric hemorrhage(ORDER)
Follow the Mnemonic “ORDER” Bonner 2000
Organization
1. Call experienced staff
2. Alert the blood bank
3. Designate a nurse to record vitals,urine output and fluids
4. Place operating theatre on standby
Resuscitation
1.Administer oxygen by mask
2.Place 2 large bore (14-gauge)intravenous line
3.Take blood for crossmatch of 6 U PRBC,CBC
count,coagulation sceen,urea,creatinine and electrolyte
4.Start NS or RL
5.Transfuse PRBC
 Management of massive
Obstetric hemorrhage(ORDER)
Defective Blood Coagulation
1.Give FFP if coagulation deranged
2.Cryoprecipitate if bleeding continues with FFP
3.Give platelet if less than 50,000/mm3 and bleeding
continues
4.Use cryoprecipitate and platelet before surgical
intervention
Evaluation of response
1.Monitor pulse,BP,CVP and acid-base status
2.Measure urine output using CBD
3.Order CBC and coagulation test to guide component
therapy
Remedy the cause of bleeding
• Uterotonic agents may help in reducing the blood
loss associated with bleeding from the relatively
atonic lower uterine segment, while bimanual
compression, hydrostatic balloon catheterisation
or uterine packing, or even aortic compression,can
buy time while senior help arrives.
• Additional surgical manoeuvres which may be
considered include the B-Lynch suture, uterine or
internal iliac artery ligation1 or hysterectomy.
• Arterial embolisation has been reported and is
useful in selected cases as long as the iliac vessels
have not been tied off.
Compression of abdominal aorta
and palpation of femoral pulse
• Apply downward pressure with a closed fist over
the abdominal aorta directly through the
abdominal wall:
• - The point of compression is just above the
umbilicus and slightly to the left;
• - Aortic pulsations can be felt easily through the
anterior abdominal wall
• - With the other hand, palpate the femoral pulse to
check the adequacy of compression:
• - If the pulse is palpable during compression, the
pressure exerted by the fist is inadequate;
• - If the femoral pulse is not palpable, the pressure
exerted is adequate;
• - Maintain compression until bleeding is
controlled.
blood supply to the
pelvis
 Ovarian A
Internal iliac (Hypogastric ) A
Are the main vascular supply to the pelvis
connected in a continuous arcade on the lateral
borders of the vagina, uterus, and adnexa.
The ovarian arteries :
Are direct branches of the aorta beneath the
renal arteries. They traverse bilaterally and
retroperitoneally to enter the
infundibulopelvic ligaments
The hypogastric artery:
Are retroperitoneal and posterior to the ureter it
divides into an anterior and posterior
divisions.
 The hypogastric artery

anterior division 5 visceral branches

Uterine
superior vesical
middle hemorrhoidal
 inferior hemorrhoidal
vaginal
3 parietal branches
Obturator
 inferior gluteal
internal pudendal
 The hypogastric artery

posterior division

important collateral to the pelvis.

Iliolumbar
 lateral sacral
superior gluteal
 Uterine Artery Ligation

Uterine artery ligation involves putting sutures

including 2-3 cm of myometrium placed 2-3 cm
below the uterine incision
Stepwise uterine devascularisation. This consists of (1)
unilateral and, if required (2) bilateral uterine vessel
ligation, followed by (3) low bilateral uterine vessel
ligation after mobilisation of the bladder, and (4)
unilateral or bilateral ovarian vessel ligation .
All techniques allow revascularisation of the ligated
vessels with subsequent normal uterine function.
B/L Uterine and ovarian A Ligation Success rate in atony-
95% (O’Leary,1995) 100% (AbdRabbo,1994)
 Hypogastric Artery Ligation

The hypogastric artery is exposed by incising

the pelvic sidewall peritoneum cephalad,
parallel to the infundibulopelvic ligament
between it and the round ligament .The
ureter is visualized and left attached to the
medial peritoneal reflection to prevent
compromising its blood supply. Then common,
internal, and external iliac arteries are identified .
 Hypogastric Artery Ligation

The hypogastric vein lies deep and lateral to the

artery. A blunt-tipped, right-angle clamp is
gently placed around the hypogastric artery,
2.5 to 3.0 cm distal to the bifurcation of the
common iliac artery. Passing the tips of the
clamp from lateral to medial under the artery
is crucial in preventing injury to the
vein.Artery is double ligated with
nonabsorbable 1-0 silk
Internal Iliac A Ligation
Decrease in pulse pressure :
U/L-77% B/L-85% Success rate- 42% (Clark,1985)

Ureter
BIMANUAL COMPRESSION
 Types of surgical
compression
Internal Compression
1.Packing
2.Using distended condom
3.Sengsteken blackmore tube
4.Foleys catheter with 50 cc bulb
External compression
1.B-lynch Brace sutures
2.Hayman uterine compression sutures
3.Cho mutiple square sutures
B Lynch Compression suture B
b
b
b
b
B
_

Lynch et al . Br J Obstet Gynecol 1997; 104 : 372-76

Hayman Uterine Compression Sutures

Hayman et al. Obstet Gynecol 2002 ; 99 : 502-6

 Cesarean Hysterectomy

• Total hysterectomy-controls bleeding from

uterus,lower segment ,cervix and vaginal
fornices
• Subtotal hysterectomy-Control bleeding
from uterus only
• ALWAYS LEAVE OVARIES
 STOP THE BLEEDING
I. Initiate surgical haemostasis
SOONER RATHER THAN LATER
II. At laparotomy, direct
intramyometrial injection of
Carboprost (Haemabate) 0.5mg
III. Bilateral ligation of uterine arteries
IV. Bilateral ligation of internal iliac
(hypogastric arteries)
V. Hysterctomy early rather than late
Resort to hysterectomy
SOONER RATHER THAN
LATER (especially in
cases of placenta accreta
or uterine rupture)
• There have been numerous case reports of
placenta praevia accreta and its management,
which include a number of series where the
placenta has been left in place at the end of the
caesarean section.
• Management in these cases has varied, with some
having prophylactic or therapeutic uterine artery
embolisation, or internal iliac artery ligation at the
same time as initial surgery,and some being
treated following delivery with methotrexate.
• Successful pregnancies have been reported after
this approach but there have been cases of delayed
haemorrhage necessitating hysterectomy.
• In contrast, some cases have had no additional
treatment after leaving the placenta in place and
still had successful outcomes.
• The natural history of five women with retained
adherent placenta and no additional therapy was
followed by Matsumura et al.,who found that
serum human chorionic gonadotrophin levels
decreased spontaneously with a half-life of 5.2
days ± 0.26 days. The uterine artery pulsatility
index remained unchanged (at term pregnancy
levels) until the placenta was successfully
removed surgically, vaginally, within 6 weeks.
• This differed from a smaller series of three cases
where the placental resolution occurred
spontaneously between 10 weeks and 24 weeks
following delivery .In all these cases, the uterine
artery Doppler resistance increased and showed
notching prior to the placental resolution.
• There are two women from France whose cases
were reported, who had also had uterine artery
embolisation, where the placentas were left alone
and disappeared 5–6 months after delivery.
THANK YOU