Treating Morbid Adherent Placenta Previa successfully

A case study of an elderly patient with IVF induced twin pregnancy who survived a concurrent aberrant placenta previa and morbid adherent placenta induced massive bleeding by coordinated team approach at Satguru Partap Singh (SPS) Hospital, Ludhiana

Pregnancy in elderly patients is always associated with more risk because most of them have had artificial methods of conception with a physiology which barely supports the dynamics of child birth. Placenta previa which means placenta at the outlet of uterus and morbid adherent placenta are two other conditions which are considered to be associated with significantly high complication rates independently.

Morbid Adherent Placenta Previa (MAPP) – when both the conditions of placenta occur together is associated with high morbidity and mortality. As the diagnosis is often not certain before delivery, it is highly recommended that all such cases should be managed in properly equipped centres. Calling for extra help early should be encouraged and not seen as ‘losing face’. Uterine artery embolisation (UAE) has been a beneficial alternative procedure for the treatment of postpartum haemorrhage. Prophylactic arterial catheterisation before delivery and, if necessary, selective embolisation are effective ways to stop bleeding.

Report

This is the case of an elderly mother who had a surge of desire to have more babies.

Since in vitro fertilisation is available in many centres now she chose a centre and conceived twins after multiple attempts. But nature did not support her fully. As her pregnancy progressed she was detected with a morbid adherent placenta praevia, which meant that her placenta was lying right at the outlet of her uterus and was tightly embedded and would not separate after the delivery causing fatal bleeding. She was told about the consequences of the complication and was referred to SPS Hospital, Ludhiana for management.

The medical team at the hospital knew about the nature of disease interfering with the childbirth and have had the experience of similar cases which needed skill, speed and superspeciality teamwork.

It was decided to deliver her babies in the peak working hours to avoid emergency situation after discussing the case and deciding the management protocol in the team.

She was delivered with full blood and blood component back up using modified caesarian section technique to avoid injury and handle anticipated bleeding.

Babies were quickly handed over to paediatrician and were resuscitated easily, the mother nevertheless started bleeding torrentially. All surgical manoeuvres like buttressing sutures, packs were applied, but in vain. The uterus could not be removed because whole disease was in lower segment.

This was the time for anesthesia team to apply their skills to allow the patient sufficient time for intervention by other teams. Massive transfusion was started and the interventional radiologist who was kept as a back up informed every progress. The patient was immediately shifted to the cath lab with blood transfusion on and active bleeding happening. Percutaneous access to both sided uterine branches of pelvic vessels were embolised within minutes. The blood pressure which was barely kept pumping with support stabilised, the pulse started beating again.

The urine started pouring, the bleeding stopped and the vital parameters normalised and all this happened within a period of two to three hours.

The anesthesia team had informed a stable situation by now. The patient was awake and was witnessing the whole procedure barring some minutes when her vitals were low and she was half conscious. She was allowed full diet the next morning and was declared ready for discharge along with her babies after four days. The family was anxious and had a question to ask. The doctor nevertheless told them that her reproductive organs were fully functional and her fertility is still maintained and she could conceive if she desires to do so.

Postpartum haemorrhage is the most serious complication encountered by obstetricians during routine patient care and is the leading cause of severe maternal morbidity and death. The incidence of maternal mortality due to postpartum bleeding varies in countries. In developing countries, the incidence of maternal mortality is approximately one in 1,000 deliveries, whereas in developed countries, the incidence is only around one in 10,0000 deliveries. This large difference in maternal mortality is primarily attributed to country-specific differences in management capacity. Recommended procedures for management of postpartum haemorrhage have been well published. The first step in common management of postpartum haemorrhage is the use of uterine stimulants (uterotonics) such as oxytocin, ergot derivatives, prostaglandins and misoprostol, and bimanual compression of the uterus. Recommended operative procedures for the management of postpartum haemorrhage include surgical repair of lower genital tract lacerations, uterine hypogastric artery ligation and hysterectomy.

More recently, the relative benefits of uterine artery embolisation (UAE) versus cesarean hysterectomy (CH) have been debated. Uterine artery embolisation has been practiced over more than 20 years for controlling haemorrhage following delivery/abortion, in ectopic or cervical pregnancy, gestational trophoblastic disease or carcinoma cervix.

The technique was first reported as an effective intervention for fibroids in 1995, when Ravina et al noted that several women with symptomatic leiomyomata who underwent UAE as a pre-hysterectomy treatment had significant clinical improvement to an extent that hysterectomy was no longer required.

UAE is generally accepted to be a safe and reliable procedure. If a patient is generally stable or the bleeding is anticipated and interventional radiologist is present, UAE is a safe first-line treatment for postpartum bleeding.