8
HYSTERECTOMY IN THE 33RD WEEK OF PREGNANCY DUE TO PLACENTA
PRAEVIA – A SEVERE OBSTETRIC COMPLICATION DESPITE CORRECT
DIAGNOSIS
Monika E. Dzwigala1, Agnieszka Dobrowolska-Redo2, Ewa Romejko-Wolniewicz2
1. Students‘ Scientific Group next to 2nd Department of Obstetrics and Gynaecology, Medical University of Warsaw, Poland
2. 2nd Department of Obstetrics and Gynaecology, Medical University of Warsaw, Poland
#Corresponding author: Agnieszka Dobrowolska-Redo, e-mail: [email protected], Warsaw Medical University, Karowa
St 2, p.o. box 00-315 Warsaw, Poland, phone number: +48 22 5966 421, fax +48 22 5966 487
RUNNING TITLE
KEYWORDS
WORD COUNT
CONFLICT OF INTERESTS
Hysterectomy due to placenta praevia
placenta praevia, hysterectomy, postpartum haemorrhage
1350
No conflicts of interest
ABSTRACT
Placenta praevia is one of the leading causes of maternal morbidity and mortality. The incidence of placenta praevia is
from 0.1 to 1.0% of all births. Postpartum haemorrhage (PPH) is the most common cause of maternal death and is
responsible for one-quarter of maternal deaths globally, approximately for 140,000 deaths annually. Obstetric haemorrhage
can occur at any stage of pregnancy. In early pregnancy the major causes of bleeding are ectopic pregnancy, incomplete
abortion and trauma. In the second half of pregnancy and during labour the most common causes of bleeding are placenta
praevia, placental abruption and uterine rupture, including scar dehiscence after previous operations. The causes of
postpartum bleeding are uterine atony, haemorrhage from the space of incorrectly nested placenta, infections, bleeding
disorders, injuries and damage to the birth canal. Haemorrhage in the second half of pregnancy relates to 4% of pregnant
women and they are most often related to abnormalities of the placenta. More than half of the cases are due to placenta
praevia (22%) and improper localization of the placenta (31%). The study presents the case of postpartum haemorrhage
and hysterectomy performed in a 30-year-old woman at 33rd week of pregnancy with placenta praevia.
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BACKGROUND
P
lacenta praevia is an obstetric complication
presented with vaginal bleeding in the
second or third trimester of pregnancy due to
abnormal localization of the placenta in the
internal cervical ostium. Localization on the wall of the
uterus matters. Complete praevia is a complete coverage
of the cervical ostium by the placenta [1, 2]. The women
at greatest risk of placenta praevia are those who have
myometrial damage caused by a previous caesarean
delivery with either anterior or posterior placenta praevia
overlying the uterine scar [1]. Reported risk factors
include: previous placenta praevia, previous caesarean
delivery (CD), multiparty, advanced maternal age,
maternal smoking and others [3]. An anterior placenta
praevia increases the risk of hysterectomy for both
primary and repeated caesareans due to abnormal
placentation [4]. There is an increased risk of preterm
delivery related to antepartum haemorrhage in women
with complete placenta praevia [5].
Placental abruption is the partial or complete separation
of the placenta from the uterine wall. This condition
usually occurs in the third trimester but can occur any
time after the 20 weeks of pregnancy. Risk factors for
abruption include prior abruption, smoking, trauma,
cocaine use, multifetal gestation, hypertension,
preeclampsia, thrombophilia, advanced maternal age,
preterm premature rupture of the membranes,
intrauterine infections and polyhydramnios [6]. Placental
abruption often happens suddenly [7].
In many countries the rate of placental abruption is
increasing and is one of the most important causes of
maternal morbidity and perinatal mortality [8, 9].
Approximately 10% of all preterm births and up to onethird of all perinatal deaths are caused by placental
abruption [6, 10]. Associated peripartum risks for the
mother are caused by bleeding and include need for
blood
transfusion,
emergency
hysterectomy,
disseminated intravascular coagulation (DIC), renal
failure and even maternal death [7, 11].
Placenta accreta is the improper attachment of placenta
to the uterus. Improper attachment of placenta has three
stages. The first is placenta accreta (PA) when placenta
attaches directly to myometrium of the uterus. There is
no decidua separating placenta and myometrium. The
second is placenta increta (PI) when placenta invades
into the myometrium and third is placenta percreta (PP),
when placenta not only destroys the wall of the uterus,
but also can invade local organs such as the bladder.
Each of these conditions can lead to heavy bleeding
during delivery when the placenta does not completely
separate from the uterus [12].
PPH is often defined as the loss of more than 500 ml of
blood following natural delivery and 1000 ml of blood
following caesarean birth. Postpartum bleeding is called
“early” if it occurs within 24 hours after childbirth or “late”
if it occurs after 24 hours to 6 weeks post delivery [13].
CASE DESCRIPTION
A 30-year-old patient in third pregnancy, third delivery, 31
weeks of pregnancy, was admitted electively to the 2nd
MEDtube Science Dec, 2016; Vol. IV (4)
Department of Obstetrics and Gynaecology due to
diagnosis of complete posterior placenta praevia and
history of bleeding. In the past, the patient had
a caesarean section complicated with pulmonary
embolism. The patient was on the continuous low
molecular weight heparin treatment. During the
observation period both the mother and the foetus were
in good condition. Well-being of the child was controlled
by cardiotocography (CTG), monitoring of movements,
ultrasonography (USG) scan.
On the 13th day the patient reported pain in the lower
abdomen and severe vaginal bleeding and due to
suspicion of placental abruption she was admitted to
emergency caesarean section. She delivered a boy
weighing 2420 g who was 47 cm long, and was given
8-8-8 points in Apgar score During the surgery there were
difficulties with placentas removal from the areas close to
cervix of uterus – suspicion of placenta increta. Severe
bleeding from the cervix area of the uterus was stated.
After administration of 5 units of oxytocin, followed by
carbetocin and then suturing, bleeding significantly
reduced. Uterine packing was done. After operation
estimated blood loss was 3000 ml. Due to continuation of
vaginal bleeding during suturing subcutaneous tissues
and post-operation, the intubation of the patient was
continued. She was observed in the operating theatre
after emergency caesarean section. The patient received
4 units of packed red blood cells, 4 units of fresh frozen
plasma and 6 mg of recombinant human coagulation
factor VIIa – Novoseven. Due to decreasing parameters
of general condition, hypotension (blood pressure 85/36
mmHg), tachycardia (heart rate 120/min), the patient was
re-operated and hysterectomy without appendages was
performed. After the operation, the patient was in good
condition and discharged home on 8th day after
emergency caesarean section. The histopathology
examination of uterus confirmed placenta accreta.
DISCUSSION
PPH is the leading cause of maternal mortality in lowincome countries and the primary cause of nearly one
quarter of all maternal deaths globally [14].
According to the World Health Organization (WHO)
recommendations for prevention and treatment of
postpartum haemorrhage, if bleeding persists, despite
treatment with uterotonic drugs and other conservative
interventions, surgical intervention should be performed
without further delay [14].
Peripartum hysterectomy occurs in 1 in 1913 deliveries
[15]. Risk factors associated with significant risk for
hysterectomy include mode of delivery, stillbirth,
placental
abruption,
fibroids,
and
antepartum
haemorrhage [15]. Approximately 0.4-1% of pregnancies
are complicated by placental abruption [7].
Placental abruption is recorded in 10.1 per 1000 and 13.9
per 1000 singleton births [16]. Maternal age over 35
years, smoking and hypertension are risk factors for
abruption [16]. In the analysis of Getahun et al. [17], the
pregnancy after caesarean delivery was associated with
increased risk of placenta praevia compared to vaginal
delivery.
10
Placental abruption is not only life-threating for the
mother, but also impacts outcome of the child. In the
study of Nkwabong et al. [18], placental abruption was
significantly associated with poor perinatal outcome.
Detachment of more than 45% of the placenta was
always associated with stillbirth. Separation of 25-44%
was associated with various degrees of neonatal
asphyxia. Compared to marginal separation of the
placenta, central separation was significantly more often
associated with stillbirth (77.8% versus 10.5%,
p < 0.0002) and perinatal death (88.9% versus 13.1%,
p < 0.0001) [18].
Placenta praevia occurs in 0.1% to 1.0% of pregnancies
[2]. Abnormal placentation is the commonest indication
leading to severe postpartum haemorrhage requiring
peripartum hysterectomy. Previous caesarean section is
strongly associated with abnormal placentation [19].
Palova et al. [20] reported that placenta accreta is the
second most common indication for an emergency
peripartum hysterectomy. There is a high suspicion of
placenta accreta in patients with placenta praevia with
previous caesarean section [19, 20].
Doumouchtsis et al. [21] performed a systematic review
to identify all studies evaluating the success rates of
treatment of major postpartum haemorrhage by uterine
balloon tamponade, uterine compression sutures, pelvic
devascularization and arterial embolization, and
discovered that at present there is no evidence to
suggest that any method is better for the management
of severe postpartum haemorrhage. The cumulative
outcomes showed success rates of 90.7% (95%CI:
85.7%-94.0%) for arterial embolization, 84.0% (95%CI:
77.5%-88.8%) for balloon tamponade, 91.7% (95%CI:
84.9%-95.5%) for uterine compression sutures, and
84.6% (95%CI: 81.2%-87.5%) for iliac artery ligation or
uterine devascularization [21].
Surgical treatment of PPH is used as the last treatment,
when previous procedures (prostaglandins, intrauterine
tamponade, embolization) have failed, or sometimes
from the start when a severe life-threatening PPH
requires stoppage of bleeding in the shortest possible
time. All obstetricians can face these situations during
their practice [22].
The surgical treatment of patients with postpartum
haemorrhage is a significant challenge which requires
detailed analysis and indications, but is a lifesaving
procedure for many patients.
CONCLUSION
We need to remember that even though placenta praevia
occurs in 0.1% to 1.0% of pregnancies, it is still one of the
most actual obstetric problems. It is important to consider
that with the growing number of caesarean sections, the
risk of improper localization of placenta also grows.
Single caesarean section increases the risk of placenta
praevia by 0.65% and four by almost 10% [23]. With an
increasing number of caesarean sections, we can be
threatened by growing frequency of placenta praevia in
the future and its serious complications. This case also
shows that placenta praevia and its complications is
a threat for each obstetrician even if we have modern,
evidence based medicine and proper approach to
individual patients.
CITE THIS AS
MEDTube Science Dec, 2016; Vol. IV (4), 8 – 11
ABBREVIATIONS
PPH – Postpartum haemorrhage
CD – caesarean delivery
DIC – disseminated intravascular coagulation
PA – placenta accrete
PI
– placenta increta
PP – placenta percreta
CTG – cardiotocography
USG – ultrasonography
WHO – World Health Organization
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