Minimizing surgical blood loss at cesarean hysterectomy for placenta previa with evidence of placenta increta or placenta percreta: the state of play in 2020

Abstract

The evolution of multidisciplinary team-based care for women with placenta accreta spectrum disorder has delivered stepwise improvements in clinical outcomes. Central to this overall goal is the ability to limit blood loss at surgery. Placement of inflatable balloons within the pelvic arteries, most commonly in the anterior divisions of the internal iliac arteries, became popular in many centers, at the expense of prolonging surgical care and with attendant risks of vascular injury. In tandem, the need to expose pelvic sidewall anatomy to safely identify the course of the ureters re-popularized the alternative strategy of ligating the same anterior divisions of the internal iliac arteries. With incremental gains in surgical expertise, described in 5 steps in this review, our teams have witnessed a steady decline in surgical blood loss. Nevertheless, a subset of women has the most severe form of placenta accreta spectrum, namely placenta previa-percreta. Such women are at risk of major hemorrhage during surgery from vessels arising outside the territories of the internal iliac arteries. These additional blood supplies, mostly from the external iliac arteries, pose significant risks of major blood loss even in experienced hands. To address this risk, some centers, principally in China, have adopted an approach of routinely placing an infrarenal aortic balloon, with both impressively low rates of blood loss and an ability to conserve the uterus by resecting the placenta with the affected portion of the uterine wall. We review these literature developments in the context of safely performing elective cesarean hysterectomy for placenta previa-percreta, the most severe placenta accreta spectrum disorder.

Keywords: cesarean hysterectomy; hemorrhage; infrarenal aortic balloon; internal iliac artery ligation; interventional radiology; magnetic resonance imaging; placenta accreta spectrum disorder.

FIGURE 1. Exposing the branches of the left common iliac artery during Cesarean hysterectomy

Illustration by Dr Evelyn Lockhart, University of New Mexico, Albuquerque, New Mexico.

FIGURE 2. Use of the Breisky retractor to identify the upper margin of the anterior fornix, opened using electro-cautery (A). Saggital view of the retractor (B).

Illustration by Dr Evelyn Lockhart, University of New Mexico, Albuquerque, New Mexico.

FIGURE 3. MR angiogram of the abdominal arterial tree at 36 weeks gestation demonstrating the renal arteries (R) and bifurcation of the common iliac arteries (B).

Courtesy of Dr Mike Seed, Department of Medical Imaging, SickKids Hospital, University of Toronto, Canada.