PPH due to placental accreta

                 Device 7: PPH canula Device 8:   Routine Compression stitches: B-Lynch type / many modifications: Cho sutures?  square sutures/ cervico isthmus opposition suture/ GMC stitch /IAL Square sutures/ cervico isthmus opposition suture/ GMC stitch /IAL cervicoisthmic approximation sutures or if required internal iliac artery location should be tried. Color Doppler prior to lscs will indicate presence of invasion of placenta and upto what extent. Accreta ; increta  or percreta. Surgery can be planned accordingly. But we must remember that  regardless of what the images say -- we need to be prepared to handle surprises and massive hemorrhage and all the emergency stuff --blood ,additional help -anesthesia, ICU ,surgical etc kept ready before hand.

MRI usually not necessary after negative screening ultrasound has ruled out an adherent placenta. ( perhaps in some cases when USG is inconclusive or incomplete or if posterior placenta and USG equivocal ) --per se not necessary in all.

Even in   placenta accreta  nowadays rarely in placenta previa hysterectomy is required. If bleeding is not controlled, cervicoisthmic approximation sutures or if required internal iliac artery location should be tried. As it is her third delivery, tubectomy ca(not this case), Faculty member added . Dangers  in placenta praevia & accretion:--In such conservative surgery-if bladder flap can be dissected down then it will be judicious to place circular stitches on either sides of Cx to occlude Des Cx vessels. I have done couple of occasions but still azygous vessels may trouble U. . As I have repeatedly appealed to all Forum members it will be prudent to put this cases in OT list 1, and to make sure that Urosurgeons friend is available by minutes. In addition to intra operative bleeding, which U are referring to , I am more worried of bladder damage in cases of who had CS twice. I have witnessed infiltration of vesical with pl. tissue-accretion. On the whole, in the days of Consumer as well as a medical practitioner I shall bank more on initial hysterectomy without wasting much time.  This is more applicable when woman concerned and relatives have allowed U -written consent. That will minimize unnecessary transfusion related risks.- If there is suspicion of an accreta, a midline abdominal incision, uterine incisions should be true classical (fundal incision), don't even attempt removal of placenta. Simply deliver the baby (legs first if it's cephalic presentation since incision is in the fundus), tie off the cord, leave cord and placenta in situ and do a quick and clean C/Hysterectomy. The placenta will start to bleed (vaginal bleeding), so we typically place patient in a semi lithotomic position so that someone can check the bottom and the floor for bleeding. Unless someone confirms with certainty that it is not an accreta, I would recommend being prepared for it - blood, blood bank, anesthesia, IVs, surgical help, anesthesia, since the end results can be disastrous in undiagnosed accretes.

 Given  choice : Out of 4  oxytocics (Syntocinon, Methergin, Misoprostol, PGF2  -Which one members prefers in absence of PIH/ Asthma Preferred agent?? . . Among these four three   agents,    rectal misoprostol has emerged in many centers as the preferred agent  due to high efficacy low cost  and low side effects. If   medical   therapy is ineffective, then two   large   bore intravenous   lines should be placed the blood   bank   should be notified and anesthesiologist alerted. Surgical   therapy may  include exploratory    laparotomy with interruption of the   blood    vessels    to the uterus  such as uterine artery   ligation  or internal  iliac artery   ligation . More   recently , suture   methods   that attempt   to compress   the uterus,  such as the B- lynch  stitch, have   been described . If  these fail , then hysterectomy   may be life saving.

Traumatic causes of PPH:-Other   cases of early PPH    include genital   tract   lacerations, which   should be   suspected with a  firm   contracted uterus. The vaginal    side walls   and cervix   should be especially   carefully inspected. Suburetrhral region is notorious for escape notice of the Obstet surgeon, and this procedure of exploration should ideally be done at Operating theater and preferably not at L room which is poorly lighted and seldom an anesthetist agree to administer GA in such cases at L rom. Repair   of the complete   extent of the    laceration is important .

 Uterine    inversion,   whether partial or complete,  must  also  be considered. Placental       causes   include   accreta   or retained   placenta. If the  uterus is firm   and there   are no lacerations, one must also   consider   coagulopathy.

Late  PPH , defined   as occurring  after  the first 24 hours  , may be caused by   sub involution of the placental   site, usually  occurring  at 10  to 14 days   after delivery  . In    this disorder , the Escher over the placental   bed usually  falls off and the lack  of myometrial   contraction   at the site    leads  to bleeding . Classically,   the  patient   will not    have bleeding  until about  2 weeks after delivery  , and is  not  significantly anemic. Oral   ergot  alkaloid   and careful follow  up is the standard    treatment ;  other options   include    intravenous   dilute oxytocin  or intramuscular   prostaglandin F2   alpha compounds.

Another causative   process  is   retained  products  of conception. Women with retained  POC   generally  have uterine    cramping   and bleeding and may  have fever   and / or foul smelling  lochia. Ultrasound   examination  helps  to confirm  the diagnosis . The   treatment   includes  uterine   curettage  and broad spectrum   antibiotics.

 Uterine atony is the most  common cause  of PPH  , even  after cesarean delivery   . With   a prolonged  labor, such     as with    arrest of active phase  , a patient is at risk  for uterine atony. The finding of a boggy   uterus     would be indicative  . Certainly  lacerations or injury  to uterine    vessels  is a potential issue , and should be  visible  on examination. The  treatment   for  uterine atony  during cesarean is  similar  to a patient    who underwent  vaginal   delivery , including   intravenous  dilute pitocin, prostaglandin compounds    . If these measures   are unsuccessful,  then surgical   management   of uterine atony  includes ligation of   blood supply   to the uterus to decrease the pulse pressure  or  the B- lynch    stitch to try to   compress  the uterus   with external  suture netting   . sometimes     hysterectomy  needs  to be performed   due to unresponsive   hemorrhage.

Genital tract  laceration is the   most common  cause of PPH  in a well   contracted uterus. This is   most likely arising   from a cervical   laceration  , commonly laterally  into or adjacent   to the arterial   supply  of  the cervix. Upon   recognition   of PPH   , the physician   should address  the ABCs  assess the patient’s blood pressure  and HR, and have IV   isotonic   crystalloid   infusing   quickly . A second large   bore  IV infusion should be  started . The most common   cause  of PPH  is uterine   atony and so attention   should be    directed   toward  fundal massage  and infusion of   Syntocinon (earlier called—Brand name of Sandoz / may be park Davis PITOCIN) . If the   fundus is firm   and the uterus   well contracted ,  the next step    should be to assess  for a    genital   tract lacerations. Inspection   for whether  the bleeding  is coming supra cervical   bleeding   speaks  for coagulopathy retained POC or atypical   uterine  atony. The cervix   and then   vagina    should be carefully inspected  for lacerations. Often , if the    patient  is in a   regular    labor   and delivery    room,   moving   the patient   to the operating   room with   adequate   lighting and anesthesia   can be  helpful. Blood   products should be    on hand if  bleeding persists. At times  a genital   tract   laceration  may extend  high into the vaginal   fornix ;  careful   assessment   of the full   extent  of the laceration,  and judicious   surgical   repair    is warranted.

Ligation of the ascending  branch of the uterine   arteries  or the internal iliac artery   are methods   for decreasing the  pulse   pressure   to the uterus and can help in PH. Ligation  of the cardinal   ligaments  leads to interruption of the  uterine  arteries, which  usually   means  that a hysterectomy  is necessary. How to diagnose a coagulopathy?? Ans:- Bleeding    from multiple venepunture sites together  with abruption suggests a coagulopathy  . It is a Sytemic diseases as such no type of localized   treatment will solve    the problem. A patient   with disseminated intravascular     coagulation can present with a simultaneously occurring thrombotic  and bleeding problem, which   makes it difficult   to choose  a treatment   option

Unit Head III mentioned that SR should remember the flowing rules :-The  most common cause  of post partum  hemorrhage is uterine atony . This most common  cause   of early PPH  with a firm well contracted   uterus   is a genital  tract laceration . The most  common cause  of secondary  postpartum  hemorrhage  is sub involution  of the  uterus(infective background mostly) . Hypertensive  disease  is a contraindication for ergot  alkaloids , and asthma is a contraindication for prostaglandin F2  alpha

The evaluation and treatment  of PPH  should be  systematic  and efficient  and involves  two aspects ; stabilization of the circulatory status,  and addressing the hemorrhage.

How to stabilize the woman in absence of another doctor in L Room at late night, when U are alone ?? The dictum is   assuring  a second large  bore Iv infusion  of isotonic,  crystalloid , assuring  availability  of blood products if needed, and  constantly monitoring   key  hemodynamic parameters .The systematic   search for the etiology  of PPH  should begin with uterine  atony, then genital  tract lacerations with careful  inspection  to discern  whether  the bleeding  is supra cervical  , cervical   or lower   genital   tract.