A new suture technique for cesarean delivery complicated by hemorrhage in cases of placenta previa accreta

Abstract

A 34-year-old woman (gravida 3, para 1) with uterine scarring from previous cesarean was admitted with vaginal bleeding at 36 + 1 weeks. Ultrasonography and magnetic resonance imaging indicated the presence of anterior placenta accreta, which overlapped the internal os, in the uterine scar. Owing to massive vaginal bleeding, an emergency cesarean was performed under general anesthesia at 37 weeks. The upper segment was incised in order to keep away from the placenta; a male infant was delivered rapidly in good condition. Two uterotonics—oxytocin and carboprost tromethamine—were used immediately to enhance uterine contractions. The portion of placenta that was embedded superficially into the myometrium was removed manually. The lower anterior uterine wall (10 × 8 cm) was very thin (approximately 2 mm). Bilateral ascending uterine artery ligation was performed but this did not stop the bleeding. To avoid hysterectomy, we carried out a new superposition suture (Fig. 1). After the thin lower segment of the uterus was folded, fig. 8 suturing was carried out, with the knot tied to the serosal surface. The reinforcement surgery proved to be effective in facilitating hemostasis. Total blood loss of 3000 mL necessitated the use of 7.5 units of red blood cells and 400 mL of fresh frozen plasma. The patient was discharged after 5 days without any complications. Superposition suture. The thin lower segment of the uterus was folded into 3 layers. Fig. 8 suturing was then performed using absorbable polyglycolic sutures, with the knot tied to the serosal surface. In recent decades, the cesarean rate has risen markedly in China. In cases of placenta previa accreta following previous cesarean, patients often have severe obstetric bleeding and a high rate of hysterectomy during the perinatal period. Many conservative treatments have been reported to be successful during or after cesarean, including uterine tamponade [1], pelvic blood vessel ligation [2], and pelvic arterial embolization [3]. In low-resource countries, many hospitals are unable to perform preoperative uterine artery embolization, so it is important for surgeons to ensure timely and effective hemostasis according to the intraoperative situation. Bleeding from placenta accreta is often severe and can be life threatening, so it is essential to administer multiple conservative managements during cesarean delivery in such cases. In the present case, several methods were used. In view of the thinness and poor contractility of the anterior lower uterus, we developed a new superposition suture. The advantages of the technique are that: it greatly reduces the area of placental attachment; it increases myometrial thickness and enhances uterine contraction; and it does not increase the risk of endometriosis because of the lack of endometrium in the folded portion. Consequently, it can stop severe bleeding from the placental attachment site. Furthermore, the technique is very simple and can be performed easily in all labor wards. The present work was supported by the National Natural Science Foundation of China (81200452) and the Science Foundation of Sichuan Province (2011SZ0148). Conflict of interest The authors have no conflicts of interest.