RU2806515C1 - Method for prevention of massive bleeding during central placenta previa in patients with placenta accreta - Google Patents

Abstract

FIELD: medicine; operative gynaecology; obstetrics.

SUBSTANCE: bottom caesarean section is performed, the foetus is removed through the incision of the uterus, the umbilical cord leading to the placenta is ligated and immersed in the uterus. Then the uterine incision is sutured without removing the placenta by applying two rows of sutures. Two uterine tourniquets are applied, one above the area of the uterine aneurysm with the area of placenta accreta, and the other below the specified area, followed by excision of the uterine aneurysm with the area of placenta accreta. After excision of the uterine aneurysm with the area of placenta accreta, from the side of the uterine cavity, the placental area, located on the posterior wall of the uterus in the area delimited by the upper and lower uterine tourniquets, is inoculated with a terlipressin solution containing 0.2 mg of terlipressin, diluted to 5 ml with a 0.9% chloride solution sodium 4-6 injections are used to a depth of 5-7 mm.

EFFECT: method allows to reduce the volume of blood loss and the incidence of uterine hypotension while ensuring complete haemostasis in the case of central presentation and placenta accreta in the area of the postoperative scar.

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Description

The invention relates to medicine, namely to anesthesiology-reanimatology, obstetrics and gynecology, and can be used during the delivery of patients with placenta accreta with central presentation to reduce the risk of massive intraoperative blood loss and early hypotonic bleeding.

It is known that the frequency of surgical interventions for placenta accreta has increased over the past 20 years on average by 5 times, which is directly related to the increase in the frequency of surgical delivery [Jauniaux, E. Epidemiology of placenta previa accreta: a systematic review and meta-analysis / E. Jauniaux, L. Granbeck, C. Bunce [et al.] // BMJ Open. - 2019. - Vol. 9. - No. 11. - P. 031193]. According to numerous forecasts, the number of cases of abnormal placental attachment will steadily increase [Panigrahi, A.K. A standardized approach for Transfusion Medicine Support in patients with morbidly Adherent Placenta / A.K. Panigrahi, A. Yeaton-Massey, S. Bakhtary [et al.] // Anesthesia and analgesia. - 2017. - Vol. 125. - No. 2. - P. 603-608]. A distinctive feature of operations for placenta accreta is the unpredictability and large volume of simultaneous blood loss at the stage of mobilization and excision of the altered myometrium with the site of the accreta placenta. The cause of massive blood loss during surgical delivery of patients with placenta accreta is the developed vascular network of the placental site. Blood loss during this type of operation is many times higher than blood loss during an uncomplicated caesarean section. According to a multicenter observational study published in 2021, blood loss during surgical treatment of placenta accreta can reach 20,000 ml [Beekhuizen, HJ. A multicenter observational survey of management strategies in 442 pregnancies with suspected placenta accreta spectrum / H.J. Beekhuizen, V. Stefanovic, A. Schwickert [et al.] // Acta Obstet Gynecol Scand. - 2021. - Vol. 100. - No. 1. - P. 12-20]. A complication of simultaneous massive blood loss is the development of hemorrhagic shock with impaired perfusion of organs and tissues, reduced oxygen delivery to them and a high risk of developing multiple organ failure. In addition, as a result of central placenta previa, which often accompanies placenta accreta into the area of the uterine scar, the risk and frequency of uterine hypotension increases, which in turn also contributes to the development of hypotonic bleeding. Accordingly, there is a need to improve methods to prevent the development of massive blood loss during this type of surgery.

It is known to use the drug Terlipressin to reduce the volume of obstetric bleeding in women giving birth at high obstetric risk [Ways to reduce obstetric bleeding in premature abruption and placenta previa / Yu.P. Vdovichenko, N.P. Goncharuk, S.Yu. Vdovichenko // Zhinochy Likar, 2011. No.-4. pp. 28-31; https://z-l.com.ua/upload/ioumals/36/block3 6site4.pdf]. International nonproprietary name - Terlipressin (terlipressin), trade name of the drug - Terlipressin (Remestyp) Registration number: P N013886/01-2002 (https.7/medi.ru/instrukciya/remestip_10395).

Terlipressin was administered intravenously after placenta separation in an amount of 0.2 mg in combination with carbetocin 100 μg, which is a potent uterotonic drug. The results were compared with a group of patients who were administered oxytocin 10 units after separation of the placenta. A limitation of this study is the absence of patients with placenta accreta in the study group; the risk and volume of intraoperative and postoperative blood loss during surgical delivery of patients with placenta accreta is significantly higher. In addition, the intravenous route of administration of terlipressin causes more significant adverse systemic reactions: hemodynamic disturbances, bradycardia, peripheral vasoconstriction and ischemia.

In another publication [Efficacy and safety of terlipressin during cesarean section in pregnant women at high risk of bleeding: the multicenter, omnidirectional cohort study Terli-Bleed. Part II / Yu.S. Raspopin, E.M. Shifman, A.A. Belinina et al. / Issues of gynecology, obstetrics and perinatology, 2021, volume 20, No. 2, p. 26-32] showed that the introduction of terlipressin into the myometrium at a dose of 0.4 mg diluted with saline solution to 10 ml does not affect hemodynamic parameters and does not complicate the course of the intraoperative period.

A method for reducing blood loss during surgical delivery in postpartum women of high risk groups is described [RU 2709819 C1, FSBEI HE VSMU named after. N.N. Burdenko, December 23, 2019]. Intraoperatively, immediately after crossing the umbilical cord before separation of the placenta, the drug Terlipressin is administered at a dose of 0.4 mg with the addition of 0.9% sodium chloride solution and bringing the injected volume to 10 ml into the muscle tissue of the uterus through the incision site on the uterus in equal doses of 0.2 mg into the corners of the incision on the uterus. The method allows to significantly reduce blood loss in postpartum women at high obstetric risk in combination with the normalization of such parameters of the cardiovascular system as cardiac output, systemic vascular resistance, cardiac index, blood pressure in the absence of complications characteristic of the intravenous route of drug administration.

The disadvantage of the described method is the impossibility of its implementation during operations for placenta accreta: technically, this operation is performed using two incisions. In this case, the main source of bleeding is not the incision during cesarean section, which is performed within the healthy myometrium, but the area of the uterine aneurysm with the placental platform, in which there is no unchanged myometrium. Another significant drawback of the described method is the introduction of the drug into the corners of the incision on the uterus in the lower segment, where the main vascular bundles are located, which, on the one hand, can lead to damage to blood vessels and increased bleeding, on the other, increases the risk of intravascular administration and toxic effects of the drug .

A method is described for the prevention of early postpartum hemorrhage in patients with hypertensive disorders during cesarean section by intravenous administration of oxytocin immediately after extraction of the fetus at a dose of 5 units for 1-2 minutes, while additionally using the drug terlipressin, which is administered after extraction of the fetus and intersection of the fetal umbilical cord before separation of the placenta from the placental site into the edges of the uterine wound, into the thickness of the myometrium at a dose of 0.4 mg, diluted with 0.9% sodium chloride solution to 10 ml (RU 2786814 C1, Natalya Yuryevna Pylaeva et al., 12/26/2022). The main disadvantage of this method is the ineffectiveness of its use in patients with placenta accreta, since when the drug is administered in this manner, the area of the uterine aneurysm and placental site does not fall into its zone of action.

The closest to the patented method is the method of surgical delivery of patients with placenta accretion into the uterine scar (RU 2706368 C1, Kulikov I.A., November 18, 2019 - prototype), in which a bottom caesarean section is performed and the fetus is removed through the uterine incision. Next, the umbilical cord leading to the placenta is tied and immersed in the uterus. The uterine incision is sutured without removing the placenta with two rows of sutures. The incompetent uterine wall is excised, including the uterine aneurysm with an area of ingrown placenta within healthy tissue, manual removal of the remaining placental tissue is performed, and the resulting defect is sutured using tourniquet hemostasis. In this case, after suturing the uterine incision without removing the placenta, a balloon is installed in the vagina and inflated, squeezing the vaginal branches of the uterine arteries and pudendal arteries. Tourniquet hemostasis is carried out as follows. The ascending branches of the uterine arteries and ovarian arteries are clamped, for which the first tourniquet is applied at the level of the upper edge of the uterine aneurysm around the body of the uterus, grasping the broad ligaments of the uterus with the fallopian tubes on both sides as a single block. After separation of the uterus from the bladder to the lower edge of the uterine aneurysm, the uterine arteries are clamped, for which a second tourniquet is placed around the uterus at the level of the lower edge of the uterine aneurysm. After excision of the incompetent uterine wall, including a uterine aneurysm with an area of ingrown placenta, and suturing of the resulting uterine wall defect, the tourniquets are removed. The method allows simultaneously increasing the reliability of hemostasis and preserving the organs of the reproductive system. The disadvantages of this method include the impossibility of ensuring complete hemostasis in the case of spread of the placental site along the posterior wall of the uterus and ingrowth of the placenta into nearby organs (placenta percreta).

The present invention is aimed at solving the problem of reducing the volume of blood loss and the incidence of uterine hypotension while ensuring complete hemostasis in the case of central presentation and placenta accreta in the area of the postoperative scar, which is the technical result of the invention.

A patented method for preventing massive bleeding in central placenta previa in a patient with placenta accreta includes performing a bottom cesarean section, removing the fetus through the uterine incision, tying the umbilical cord leading to the placenta and immersing it in the uterus, suturing the uterine incision without removing the placenta by applying two rows of sutures; application of two uterine tourniquets - one above the area of the uterine aneurysm with the area of placenta accreta, and the other below the specified area, followed by excision of the uterine aneurysm with the area of placenta accreta.

The difference is that after excision of the uterine aneurysm with the area of placenta accreta, from the side of the uterine cavity, the placental area located on the posterior wall of the uterus in the area delimited by the upper and lower uterine tourniquets is injected with a terlipressin solution containing 0.2 mg of terlipressin, diluted to 5 ml of 0.9% sodium chloride solution, using 4-6 injections to a depth of 5-7 mm.

Accordingly, terlipressin is administered not into the thickness of the myometrium, as in the mentioned methods, but into the area remaining along the posterior wall of the placental area, delimited by the upper and lower uterine tourniquets, which localize the effect of the drug in the vascular zone. Administration of terlipressin in this way additionally causes vasospasm and bleeding of the site of excision of the area of placenta accreta, which makes it possible to reduce blood loss, the frequency of uterine hypotension, and reduce the dose of the administered drug. The recommended dose of terlipressin avoids such systemic adverse reactions as increased blood pressure, bradycardia, cardiac arrhythmias, bronchospasm, as well as excessive ischemia of the myometrium, which can lead to necrosis of uterine tissue.

To confirm the effectiveness of the proposed method, a study was conducted on the volume of blood loss and the incidence of uterine hypotension in two groups of patients. Group No. 1 “comparison” (prototype) included 38 patients diagnosed with central placenta previa, placenta accreta into the area of the uterine scar, who were not intraoperatively injected with terlipressin into the area of the remaining placental site. Group No. 2 “study” (invention) included 46 patients with the same diagnosis, in whom, after suturing the incision in the fundus of the uterus, applying uterine tourniquets above and below the area of the uterine aneurysm, the area of the uterine aneurysm with the area of placenta accreta was excised. After excision of the uterine aneurysm with the area of placenta accreta, from the side of the uterine cavity, the placental area, located on the posterior wall of the uterus in the area delimited by the upper and lower uterine tourniquets, was injected with a terlipressin solution containing 0.2 mg of terlipressin, diluted to 5 ml with a 0.9% solution sodium chloride, using 4-6 injections to a depth of 5-7 mm.

The groups did not differ significantly in age, birth parity, and the number of cesarean sections in history. It should be noted that in group No. 2 of the “research” (invention), cases of “placenta percreta”, the most severe variant of placenta accreta with damage to nearby organs and tissues, were statistically significantly more common, which always causes a greater volume of blood loss during surgery. The odds ratio was 3.81 95% CI [1.02; 14.26], p=0.046. Thus, in the study group, “placenta percreta” occurred almost 4 times more often, but the frequency of compression sutures on the uterus was 9 times less frequent than in the comparison group. The odds ratio of applying compression sutures to the body of the uterus in the “Comparison” group and the “Study” group was 9.09 95% CI [1.09; 75.58], p=0.041. Administration of the drug Terlipressin using the proposed method clinically significantly reduced the amount of intraoperative blood loss, although this reduction did not reach statistical significance. In the comparison group, intraoperative blood loss was 1266 (851; 1964) ml, while in the study group it was 1186 (700; 1890) ml.

Clinical example 1.

Patient S., 36 years old, height - 164 cm, weight - 82 kg, was admitted to the Vidnovsky Perinatal Center for surgical delivery. After additional examination, the diagnosis was made: V pregnancy, 37 weeks. Insolvent scar on the uterus after 3 cesarean sections with the formation of a uterine aneurysm. Central placenta previa. Placenta accretion into an incompetent scar on the uterus, bladder and cervix (Placenta percreta). The patient was prepared for surgical delivery. Before the operation, a general blood test showed hemoglobin 114 g/l, red blood cells 4.03×10 ¹² /l. Inferomedian laparotomy with bypass of the umbilicus on the left was performed as planned. Bottom caesarean section. After removing the fetus, the umbilical cord leading to the placenta was ligated and immersed in the uterus, the uterine incision was sutured without removing the placenta by applying two rows of sutures, and uterine tourniquets were applied above and below the uterine aneurysm. Then the uterine aneurysm with the area where the placenta has grown into the incompetent scar on the anterior wall of the uterus is excised. After this, 0.2 mg of terlipressin, diluted to 5 ml with a 0.9% sodium chloride solution, was injected into the area of the placental area remaining along the posterior wall of the uterus, delimited by uterine tourniquets, using 4 injections to a depth of 5 mm. Before each administration of the drug, an aspiration test was performed to exclude intravascular administration of terlipressin and the development of undesirable systemic effects. Then the uterus was sutured, the uterine tourniquets were dissolved, hemostasis was monitored and the abdominal cavity was sutured in layers. The total blood loss was 1006 ml (14.4% of blood volume), of which 230 ml was returned intraoperatively to the patient in the form of washed and concentrated autoerythrocytes. In the early postoperative period, the patient was observed in the intensive care unit for 16 hours. There were no signs of early postpartum hemorrhage or uterine hypotension. For further treatment she was transferred to the postpartum department. When translated into a general blood test, hemoglobin was 102 g/l, red blood cells were 3.88×10 ¹² /l. On the fourth day she was discharged from the perinatal center in satisfactory condition.

Clinical example 2.

Patient P., 42 years old, height - 156 cm, weight - 72 kg, was preparing for a planned surgical delivery at the Vidnovsky Perinatal Center with a diagnosis of 4th pregnancy, dichorionic diamniotic twins, 35 weeks, 3rd upcoming birth . Insolvent scar on the uterus after 2 cesarean sections with the formation of a uterine aneurysm. Central placenta previa. Ingrowth of the placenta into an incompetent scar on the uterus, the wall of the bladder (Placenta percreta). During preoperative preparation, the patient received 2 doses of autoplasma. Mild gestational anemia (hemoglobin 104 g/l) was corrected by intravenous administration of a calculated dose of iron (III) sucrose complex. The patient was taken to the operating room for emergency indications - deterioration of the condition of the second fetus. A bottom caesarean section was performed. Two live premature girls with an Apgar score were extracted: 1 child 7-8 points; second child 6-7 points. For further observation and treatment, he was transferred to the neonatal intensive care unit. After the fetuses were delivered, the first placenta separated on its own and was removed. The umbilical cord of the second placenta is tied and immersed in the uterus. The incision on the uterus is closed with two rows of stitches. After this, the first tourniquet is placed above the aneurysm. Then the bladder is separated and a second tourniquet is placed below the aneurysm area. An aneurysm with an area of placenta accreted into an incompetent scar on the anterior wall of the uterus was excised within the uterine tourniquets. After this, 0.2 mg of terlipressin, diluted with a 0.9% sodium chloride solution to 5 ml, was injected into the area of the remaining placental area along the posterior wall of the uterus from the side of the uterine cavity using 6 injections to a depth of 7 mm. An aspiration test was performed before each administration of terlipressin in order to prevent intravascular administration of the drug. After injecting the placental site with terlipressin, the uterus was sutured, uterine tourniquets were removed, hemostasis was controlled, and layer-by-layer suturing of the abdominal cavity was performed. Total blood loss was 1150 ml (19.2% of blood volume). Intraoperatively, washed and concentrated red blood cells were returned in a volume of 310 ml, and one dose of autoplasma was transfused. The early postoperative period proceeded without complications. 6 hours after the operation the patient was activated. After 12 hours she was transferred to the postpartum ward. She was discharged from the perinatal center on the 5th day after delivery in satisfactory condition. Hemoglobin at discharge was 98 g/l, red blood cells were 3.75×10 ¹² /l.

Claims (1)

A method for preventing massive bleeding in central placenta previa in a patient with placenta accreta, including performing a bottom cesarean section, removing the fetus through a uterine incision, tying the umbilical cord leading to the placenta and immersing it in the uterus, suturing the uterine incision without removing the placenta by applying two rows of sutures; the imposition of two uterine tourniquets - one above the area of the uterine aneurysm with the area of placenta accreta, and the other below the specified area, followed by excision of the uterine aneurysm with the area of placenta accreta, characterized in that after excision of the uterine aneurysm with the area of placenta accreta, the placental area is cut off from the side of the uterine cavity , located on the posterior wall of the uterus in the area delimited by the upper and lower uterine tourniquets, with a terlipressin solution containing 0.2 mg of terlipressin, diluted to 5 ml with a 0.9% sodium chloride solution, using 4-6 injections to a depth of 5-7 mm .