A case report on placenta previa percreta involving urinary bladder

Introduction. We did not find any publications or mentions in the Ukrainian medical segment of the Internet and special medical literature about previously performed similar operations (simultaneous caesarean section and embolization of the uterine arteries directly at the moment of birth), which allows us to consider the two operations performed «Prophylactic selective transcatheter embolization of uterine arteries» in pa­­tients with placenta previa percreta the first in Ukraine. Background. The prevalence of placenta previa and placenta percretaincreases from year to year as a result of an increase in the number of cesarean sections. Because of this, the percentage of women at high risk of massive life-threatening bleeding is also increasing. Predictions around the world show that the incidence of cesarean section will increase, which will lead to an increase in the number of placenta previa and placenta increta and thereafter maternal mortality, since the main cause of maternal mortality is bleeding (about 35 % of cases). The aim study was to asses of the effect of preventi­­ve selective embolization of uterine arteries with placenta previa percreta on the volume of blood loss during delivery, and the possibility of preserving the uterus and the reproductive function of women. Material and methods. In 2018—2019, we per­­formed two prophylactic selective transcatheter em­­bolizations of the uterine arteries in patients with placenta previa percreta. The delivery of these patients took place in the form of simultaneous endovascular embolization of the uterine arteries during cesarean section. The delivery algorithm was as follows: the first stage was the contralateral catheterization of the uterine arteries by transfemoral access. Next, corporal cae­sarean section was performed. After extraction of the fetus and clamping of the umbilical cord, uterine arteries were selectively embolized until the blood flow through them was completely stopped. Then, sepa­­ration/dissection of the placenta, metroplasty and suturing of the wound were performed. At the end of the operation, catheters from the uterine arteries were removed. Results and discussion. The entire embolization procedure (in total: from puncture of the femoral arteries to control angiography after embolization) took 27 minutes in the first case and 38 minutes in the second. The longer embolization time in the second case is partially associated with unilateral access and alternate catheterization of the uterine arteries. This was done to minimize post-procedural complications of the site of puncture of the femoral artery. Unfortunately, the technical conditions for these embolizations did not allow transradial access, which is possible from a practical point of view. The postpartum period was without complications. As the experience of these two operations showed, it was not possible to achieve the fullness of the «dry uterus» by embolization of the uterine arteries, but the volume of blood loss taking into account reinfusion in the form of washed red blood cells turned out to be lower than the median values of most cases and published studies described in foreign literature. Conclusions. Preventive selective transcatheter em­­bo­­lization of the uterine arteries before birth/removal of the placenta can be considered as a good preventi­­on of primary postpartum hemorrhage and thus to provide organ rescue. In pregnant women of high-risk groups, it is better to carry out catheterization of the uterine arteries in a planned manner before delivery, simultaneously with cesarean section, which is technically simpler.

Objectives The objectives of this study were to compare the accuracy of ultrasonography and MRI for prenatal diagnosis of placenta accreta (PA) and to compare the sensitivity and specificity of individual ultrasonographic and MRI markers in predicting placental invasion in cases of PA. Background PA is a significant cause of maternal morbidity and mortality, and at present it is the most common reason for emergent postpartum hysterectomy. Placenta previa and previous cesarean section are the two most important known risk factors for PA. Accurate prenatal identification of affected pregnancies allows optimal obstetric management. Ultrasonography still remains the diagnostic standard. However, in recent years, there has been increased interest in MRI in evaluating PA. Patients and methods A combined prospective and retrospective study was carried out on 20 pregnant women with persistent placenta previa (after 28 weeks gestation). All patients were subjected to history taking, complete medical examination, and ultrasound, Doppler, and MRI. Results The sensitivity and specificity of ultrasonography were 63.6 and 91.6%, whereas the sensitivity and specificity of MRI were 72.70 and 100%, respectively, in their ability to diagnose PA. Conclusion MRI hand-in-hand with ultrasound is important for the accurate diagnosis of placenta previa and the serious coexisting PA. Use of both modalities may provide more diagnostic information.

Although uterine artery embolization (UAE) is a well-recognized alternative treatment for postpartum hemorrhage (PPH) with a high clinical efficacy, the reported success rate of UAE for PPH associated with placenta accreta (PA) is lower. Recently, with advances in techniques and expertise, a few studies have reported favorable results of UAE in controlling PPH in the setting of PA. To evaluate the efficacy of UAE in the emergent management of intractable PPH associated with PA. Seventeen consecutive patients who underwent emergent UAE for the management of PPH associated with PA were included in this retrospective study. Medical records were reviewed regarding the delivery and UAE procedure. Follow-up gynecologic outcomes after UAE were obtained by telephone interview. UAE successfully controlled PPH in 14 patients (82.4%). Three patients underwent hysterectomy after UAE failed to stop the bleeding. All hysterectomy cases were accompanied by uterine atony or total placenta previa. Relevant gynecologic findings were obtained from 10 patients; three patients were breastfeeding and seven patients resumed normal menstruation, including one pregnancy. UAE appears to be a safe and effective means by which to control PPH associated with PA. PA complicated by uterine atony or placenta previa may be at increased risk of UAE failure.

Objective To investigate the diagnosis and the treatment of pernicious placenta previa with cervical accretion to improve the outcome of pregnancy. Methods Retrospectively analyzed 96 cases of pernicious preplacental placenta with placental accretion treated in Jiangxi Provincial Maternal and Child Health Care Hospital from January 2017 to January 2019. Thirty-two cases with cervical implantation were in the cervical implantation group, 64 cases with lower uterine implantation were in the lower uterine implantation group. The bleeding volume, blood transfusion volume, postoperative hemoglobin level, hemostatic method and postoperative complications were compared between the two groups. Results (1) The amount of bleeding in the cervical implantation group was 2000-2975 ml, with an average of 2500 ml, which was significantly higher than that in the lower uterine implantation group (1000-1500 ml, with an average of 1200 ml), (Z=-6.634, P=0.001); The amount of red blood cell suspension, plasma, platelets and cryoprecipitate were also significantly higher than that of the lower uterine implantation group (P<0.05). (2) Fifty-seven cases (89.06%) in the lower uterine segment implantation group were treated with uterine vascular ligation for hemostasis, which was higher than 20 cases (62.5%) in the cervical implantation group ( χ2=9.48, P<0.05). In the cervical implantation group, the rates of cervical circular suture and hysterectomy were 28.13% (9/32) and 34.38% (11/32), respectively, which were higher than those in the lower uterine implantation group, 9.38% (6/64) and 1.56% (1/64), χ2=5.69 and 18.11, P<0.05. (3) The incidence of hemorrhagic shock and bladder injury were 56.25% (18/32) and 15.63% (5/32) in cervical implantation group, respectively, which were higher than that of 14.06% (9/64) and 1.56% (1/64) in the lower uterine implantation group (P<0.05). Conclusions The condition of the patients with pernicious placenta previa complicated with cervical implantation is more dangerous. It is important to accurately evaluate the severity of the pregnant women with placenta previa before the operation, choose appropriate hemostatic measures to control hemorrhage in operation and minimize hysterectomy based on the safety of pregnant women. Key words: Placenta previa; Cervical placental accretion; Postpartum hemorrhage; Hemostasis technigues

Objective The objective of this study was to evaluate maternal and neonatal outcomes of placenta accreta. Background Placenta accreta is the leading cause of maternal and neonatal morbidity and mortality. Patients and methods This descriptive case series study included 40 pregnant women with placenta accreta and was carried out at Department of Obstetrics and Gynecology of Menoufia University Hospitals for 10 months. The study cohort included all admitted pregnant women with the diagnosis of placenta previa accreta whether presenting with or without vaginal bleeding after 28 weeks of gestation confirmed by ultrasound scan. Data were collected and confirmed by positive ultrasonographic criteria of placenta accreta. The study outcomes included maternal mortality, urinary tract injuries, cesarean hysterectomy admission to ICU, preoperative and postoperative hospital stay, perinatal mortality, neonatal birth weight, Apgar score at 1 and 5 min, admission to neonatal ICU, or any other complications. Results Our study included 40 patients, and there was a highly significant statistical difference between patients who underwent hysterectomy (n = 21) and who did not (n = 19) regarding type of cesarean delivery (elective or emergency) (P = 0.005). There was a significant statistical difference in neonatal mortality in cases that were admitted to ICU (P = 0.040). Conclusion Morbidly adherent placenta is becoming an increasingly common complication of pregnancy with increasing rates of cesarean births. Prenatal diagnosis and management is the most important factor in optimizing the treatment and outcome of women with adherent placenta.

Objective To investigate the incidence , risk factors and pregnancy outcomes of placenta previa among uniparas aged over thirty-five.Methods This hospital-based study included 1 065 objects from June 2011 to May 2012 .The chi-square test was used to compare the incidence of placenta plavia among demographic information , obstetric risk factors , and maternal pregnancy outcomes .And the multiple logistic model was used to identify the risk factors independently associated with placenta previa .Results Totals of 160 （15.0%） uniparas had postpartum hemorrhage , while 905 （85.0%） uniparas did not.Within the 160 uniparas, 13（8.13%） uniparas had placenta previa , while within the 950 uniparas, 12（1.33%） uniparas had placenta previa .There were significant differences in the incidence of placenta previa , postpartum hemorrhage and uterine inertia （χ2 =24.53, 12.10, respectively;P〈0.05）.The other complications had no significant difference （P〉0.05）.Identified adverse pregnancy outcomes were being born at a gestational age below 37 weeks （AOR：3.26, 95%CI：1.43-7.44）, postpartum hemorrhage （AOR：5.38, 95%CI：2.37-12.23） and no prenatal risk factors were found .The adverse outcome of placenta previa was premature delivery （ AOR：6.28, 95%CI：1.65-23.82）.Conclusions The uniparas aged over thirty-five are the high-risk groups for placenta previa .So doctors and nurses should identify adverse outcomes of placenta previa among uniparas over thirty-five years old , and take the next step in time . Key words: Maternal health services; Placenta previa; Pregnancy outcomes; Advanced maternal age

The study aimed to demonstrate the efficacy and safety of an innovative hemostatic technique in managing Placenta Previa and Accreta Spectrum by S. Rao Spiral Suturing (SRSS) of a lower uterine segment. In this retrospective study conducted at Department of Obstetrics & Gynecology Unit-II of Nishtar Medical University, Multan between December 2018 to January 2021, one hundred and thirty consenting patients' clinical records were reviewed with major degree placenta previa/placenta accrete spectrum, either operated electively or presented in an emergency, with or without a history of previous cesarean section. The enrolled patients underwent SRSS, procedure's efficacy and safety were measured by the number of obstetrical hysterectomies, the time required for the procedure, estimated blood loss, blood transfusion volume, need for any other hemostatic technique, bladder trauma, pelvic infection, scar site hematoma or abscess, sepsis, duration of hospital stay and maternal mortality. Out of 130 patients, 17(12.6%) had Placenta Accreta, 86(66.3%) Increta, and 27(21%) Percreta. The Placenta location was anterior dominant in 102(78.4%) cases and posterior in 17(8.4%). Of the patients who underwent surgery, only two required obstetrical hysterectomy due to uncontrolled bleeding. The procedure took three to five minutes in 127 patients and five to seven minutes in three patients. Regarding intraoperative blood transfusion, 54.6% of patients were transfused 1000-2000 ml blood, and 5.38% required > 3000 ml. No blood transfusion was required postoperatively in any patient. Postpartum hemorrhage, infection, fever, and sepsis were not observed in any patient postoperatively. None of the patients suffered bladder injury. All patients were discharged as per routine. SRSS is an innovative, safe, effective, and simple suturing technique for patients with Placenta Previa and Accreta spectrum.

In 1985 when a group of experts convened by the World Health Organization in Fortaleza, Brazil, met to discuss the appropriate technology for birth, they echoed what at that moment was considered an unjustified and remarkable increase of caesarean section (CS) rates worldwide.1 Based on the evidence available at that time, the experts in Fortaleza concluded: 'there is no justification for any region to have a caesarean section rate higher than 10–15%'.1 Over the years, this quote has become ubiquitous in scientific literature, being interpreted as the ideal CS rate. Although this reference range was intended for 'populations', which are defined by geopolitical boundaries, in many instances it has been mistakenly used as the measurement for healthcare facilities regardless of their complexity or other characteristics. In addition to the case mix of the obstetric population served, the use of CS at healthcare facilities is also affected by factors such as their capacity to handle cases, availability of resource and the clinical management protocols used locally. Since its publication and for the last 30 years, this reference rate for CS has received intense criticism and has led to controversy, concern, polarised opinions and heated debates, while in parallel, the use of CS as a mode of delivery has continued its worrying rise worldwide. The need to revisit the recommended CS rate has been considered more and more necessary in view of the significant improvements in clinical obstetric care and in the methodology to assess evidence and issue recommendations in the last three decades. The global concern around CS rates is understandable. When medically justified, a CS can prevent maternal and perinatal mortality and morbidity. There is no evidence, however, showing the benefits of the procedure for women or infants where it is not required. CS is associated with short- and long-term risk, which can extend beyond the current delivery and affect future pregnancies. In addition, the increase in CS rates seems uncontrollable, with no signs that it is slowing down. The situation is aggravated by the fact that the causes of the rise are not fully understood but emerge as a complex multifactorial labyrinth involving health systems, health care providers, women, societies, and even fashion and media.2-6 Lastly, non-clinical interventions to reduce unnecessary CS have shown limited effectiveness to date.7 In light of these issues, WHO convened a meeting in Geneva, Switzerland, on 8–9 October 2014 with the objective of (1) establishing the current WHO position on the CS rate or range for optimal maternal and perinatal outcomes at population level, and (2) agreeing on a proposal for a tool to monitor CS rates at facility level. The Statement on Caesarean Section Rates recently released by WHO summarises the results of the systematic reviews and analyses conducted for this purpose and conveys the thinking emerging from the discussions of the meeting.8 A systematic review and an ecological analysis were performed and concluded that at population level, CS rates higher than 10% were not associated with reductions in maternal and newborn mortality rates.9, 10 The Statement notes, however, that the association between CS rates and other relevant outcomes such as stillbirths, maternal and perinatal morbidity, paediatric outcomes and psychological or social well-being could not be determined due to the lack of data on these other outcomes at the population level. This lack of data represents a limitation of these analyses that needs to be borne in mind. Beyond numbers and rates, the Statement emphasises that the critical role played by the quality of care in this equation cannot be overstated. As with any surgery, CS is associated with short- and long-term risks, particularly in settings that lack the facilities or capacity to conduct safe surgery or treat surgical complications properly, or where access to labour care or repeat CS in subsequent pregnancies cannot be taken for granted. On the other hand, inadequate access to timely CS may result in perinatal asphyxia, stillbirth, uterine rupture or obstetric fistula, a marker for exceptionally prolonged, obstructed labour.11 Thus, CS should be undertaken when medically necessary, and rather than striving to achieve a specific rate, efforts should focus on providing caesarean section to all women in need. How to define the woman 'in need' can only be ascertained by the health care providers caring for the woman on a case-by-case basis. Most importantly, at the healthcare facility level, clinicians and administrators struggle to monitor CS rates in a meaningful, reliable and action-oriented manner. Historically, caesarean sections have often been categorised using its indications as the unit being classified. Using indications to classify CS has always been problematic due to the lack of uniform definitions for most common indications and has resulted in poor reproducibility and unsatisfactory comparisons.12 In 2001, Dr Michael Robson proposed a system of 10 groups that classifies all women admitted for delivery (and not indications) according to five obstetric characteristics that are generally routinely collected in most maternities.13 Two systematic reviews conducted at WHO identified this classification as the most appropriate system to fulfil current international and local needs.12, 14 The WHO Statement proposes the use of the Robson classification as the global standard for assessing, monitoring and comparing CS rates within healthcare facilities over time, and between facilities. In the last decade, this classification has witnessed an extraordinary expansion in its use worldwide, particularly in healthcare facilities, due to its intrinsic appealing characteristics: simplicity of design, validity of purpose, ease of implementation and directness of initial interpretation.14 WHO envisions that the information stemming from the classification can be a powerful tool to inform practice. The classification will allow not only for stratification of CS rates in more uniform groups of women but also the assessment of CS rates in relation to other perinatal outcomes and processes (e.g. rates of oxytocin usage, postpartum haemorrhage, newborn outcomes, length of labour). WHO will guide and support countries in the use, implementation and interpretation of the classification so that we can start comparing CS rates in a meaningful, targeted, transparent and useful manner. By endorsing the Robson classification, this Statement should become a catalyst for action. The time has come to put the debate about the preferable rate of CS on hold. Let's start to collect data uniformly so that in the near future we will be able to move our focus from CS rates at population level to monitoring and discussing CS rates and outcomes in each group of the Robson classification. Only then will we have the data and evidence that will lead us more clearly to actions to improve care.15 Ultimately, we hope the debate can recommence with more valuable, solid and informative data to support our discussions. None declared. Completed disclosure of interests form available to view online as supporting information. All authors contributed to the writing of the commentary. This commentary has been written without any external funding. No ethical approval was sought for the writing of this commentary. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of the World Health Organization or other organizations. WHO Working Group on Caesarean Section: HA Aleem (Department of Obstetrics and Gynecology, Women's Health Center, Assiut University Hospital, Assiut, Egypt), F Althabe (Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina), T Bergholt (Department of Obstetrics, University of Copenhagen, Copenhagen, Denmark), L de Bernis (United Nations Population Fund, Geneva, Switzerland), G Carroli (Centro Rosarino de Estudios Perinatales, Rosario, Argentina), C Deneux-Tharaux (INSERM U1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Statistics Sorbonne Paris Cité, Paris Descartes University, Paris, France), R Devlieger (UZLeuven, Campus Gasthuisberg, Department of Obstetrics and Gynecology, Leuven, Belgium), S Debonnet (International Confederation of Midwives, 2517 AN The Hague, the Netherlands), T Duan (Shanghai No.1 Maternal & Infant Health Hospital, Shanghai, China), C Hanson [International Federation of Gynecology & Obstetrics (FIGO), London, UK], J Hofmeyr (Department of Health, Effective Care Research Unit, University of Fort Hare, East London, Eastern Cape, South Africa), R Gonzalez Pérez (Department of Maternal and Gynaecological Health, Pontificia Universidad Catolica de Chile, Santiago de Chile, Chile), A de Jonge (Midwifery Science, AVAG and the EMGO Institute of Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands), K Khan (Women's Health Research Unit, Multi-disciplinary Evidence Synthesis Hub, The Blizard Institute, London, UK), S Lansky (Ministry of Health, Belo Horizonte Minas Gerais, Brazil), G Lazdane (WHO Regional Office for Europe, Copenhagen, Denmark), P Lumbiganon (Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand), D Mackeen (Department of Obstetrics and Gynecology, Division of Maternal–Fetal Medicine, Geisimger Health System, Danville, PA, USA), R Mahaini (WHO Office for the Eastern Mediterranean Region, Cairo, Egypt), S Manyame (Department of Obstetrics & Gynaecology, Harare Hospital & University of Zimbabwe, Harare, Zimbabwe), M Mathai (Department of Maternal and Child Health, World Health Organization, Geneva, Switzerland), R Mikolajczyk (ESME – Epidemiological and Statistical Methods Research Group, Helmholtz Centre for Infection Research, Braunschweig, Germany), R Mori (Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan), B De Mucio (Latin American Center for Perinatology, Women and Reproductive Health (CLAP/WR), WHO Regional Office for the Americas, Montevideo, Uruguay), OT Oladapo (UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzerland), E Ortiz-Panozo (Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico), L Ouedraogo (WHO Regional Office for Africa, Brazzaville, Congo), C Parker (Obstetrics and Gyneacology Department, Baragwanath Maternity Hospital, Johannesburg, South Africa), M Robson (National Maternity Hospital, Dublin, Ireland), S Serruya (Latin American Center for Perinatology, Women and Reproductive Health (CLAP/WR), WHO Regional Office for the Americas, Montevideo, Uruguay), JP Souza [Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto (SP), Brazil], CY Spong (Deputy Director, Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health, Bethesda, MD, USA), C Stanton (Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA), ME Stanton (USAID, Washington DC, USA), EA Sullivan (Faculty of Health, University of Technology, Sydney, Australia), M Temmerman (UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzerland), A Tita (Department of Obstetrics and Gynecology, Division of Maternal–Fetal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA), Ӧ Tunçalp (UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzerland), P Velebil (Perinatal Center of the Institute for the Care of Mother and Child, Prague, Czech Republic), JP Vogel (UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzerland), M Weber (WHO Regional Office for Europe, Copenhagen, Denmark), D Wojdyla (Duke Clinical Research Institute, Durham, NC, USA), J Ye (Ministry of Education–Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China), K Yunis (Department of Pediatrics & Adolescent, Medicine and Department of Pediatrics, American University of Beirut, Beirut, Lebanon), J Zamora (Clinical Biostatistics Unit, Hospital Ramón y Cajal, Madrid, Spain), A Zongo (Research Institute for Development, Université Paris Descartes, Sorbonne Paris Cité, UMR 216, Paris, France and Direction de la santé de la famille, Ministère de la Santé, Ouagadougou, Burkina Faso) Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Caesarean section combined with temporary aortic balloon occlusion followed by uterine artery embolisation for the management of placenta accreta

ABSTRACT;&#x0D; BACKGROUND:Postpartum haemorrhage(PPH) is the most importantr cause of maternal death in Pakistan.Over 125,000 maternal deaths have been reported each year due to PPH. Major causes of PPH include uterine atony and haemorrhage from the placental bed. There is a recent increase in the rate of cesarean section which has increased the incidence of Placenta previa as well as placenta accreta spectrum. Apart from medical management, there are various conservative surgical interventions before imparting to hysterectomy such as uterine compression sutures which effectively secure hemostasis. The Nausicaa compression suture has been a new technique which effectively controls PPH in patients with uterine atony, placenta previa and accrete spectrum.&#x0D; OBJECTIVE: The objective of this study is to determine the efficacy of Nausicaa compression sutures in patientswith PPH undergoing cesarean section.&#x0D; PATIENTS AND METHOD: This study was conducted in the Obstetrics and Gynaecology department of Sir Ganga Ram Hospital,Lahore from 1st September2020 to 30th June,2022. Total of 80 patients who had PPH during cesarean section due to uterine atony or placenta previa spectrum were enrolled after informed consent. Nausicaa compression suture was applied to the anterior, posterior and both uterine walls where required.Successful procedure was those where only Nausicaa compression suture was sufficient to control PPH.&#x0D; RESULTS:The average age of patients was 30.3±4.2 years. There were 24(30%) primigravidas, 28(35%) were G2P1+0 and 28(35%) were multigravidas. The mean gestational age of patients was 37.58 weeks. 46 patients were operated on for indication of placenta previa. 6 patients had placenta accrete. 28 patients had other indications of LSCS. In 9 patients Nausicaa sutures were applied to the anterior uterine wall while in 71 patients to anterior and posterior uterine walls. In 62 patients Nausicaa suture was sufficient to control PPH. 10 patients required other interventions, while 8 patients required emergency hysterectomy due to intractable hemorrhage.&#x0D; CONCLUSION: The Nausicaa compression suture is an effective suture to control postpartum hemorrhage in patients with placenta previa and atonic uterus. It is most effective when applied to anterior and posterior both uterine walls separately.&#x0D; KEY WORDS: Post partum hemorrhage(PPH), Nausicaa Compression suture, Cesarean section.&#x0D;

No. 454 - Nationwide analysis of hospital characteristics, demographics, and cost of uterine fibroid embolization

Framework for safe delivery: A call to action.

To evaluate angiographic findings and outcomes of repeat uterine artery embolization (UAE) for recurrent postpartum hemorrhage (PPH) in patients who previously underwent UAE for PPH after a previous delivery. Among 1805 patients who underwent UAE for PPH from 2007 to 2020 at four participating hospitals, the data of 21 (1.16%) patients who underwent UAE for PPH after subsequent delivery were collected and analyzed retrospectively. The rate of placental abnormalities, causes of PPH, angiographic findings, and clinical success rate were evaluated. The technical success rates were 100% and 95.2%, and clinical success rates were 85.7% and 95.2% in association with first and second UAEs, respectively. The time intervals between first and second UAEs ranged from 15.6 to 103.3months (46.5 ± 25.0months). The rate of placental abnormalities was significantly higher in association with second UAEs than with first UAEs (71.4% vs. 42.8%, p = 0.034). The causes of PPH were different between first and second UAEs with borderline significance (p = 0.049); uterine atony (81.0%) and placenta accreta spectrum (57.1%) were most common in association with first and second UAEs, respectively. During second UAEs, obliterated arteries were observed in 27 uterine arteries (27/42, 64.3%) of 16 patients (16/21, 76.2%), with partial obliteration predominating over total obliteration. Collateral arteries were observed in 15 patients during second UAEs. Repeat UAE is safe and effective for recurrent PPH after subsequent delivery in patients with prior UAE. Obliteration of UAs and formation of collateral arteries are common at the second UAEs. • The rate of placental abnormalities was significantly higher in association with second UAEs than with first UAEs (71.4% vs. 42.8%, p = 0.034). • Obliteration of UAs and formation of collateral arteries are common at the second UAEs. • Repeat UAE is safe and effective for recurrent PPH after subsequent delivery in patients with prior UAE.

Introduction The purpose of this study was to evaluate the efficacy and adverse effects of uterine artery embolization (UAE) to treat postpartum hemorrhage (PPH) and determine the factors associated with clinical outcomes. Material and methods This study included 117 patients who underwent UAE for PPH between January 2010 and November 2018. Their medical records were retrospectively reviewed to assess the mode of delivery, causes of bleeding, detailed laboratory results, clinical outcomes, time from delivery to UAE, and embolizing material used. Results The clinical UAE success rate was 99.1%. Late complications were found in 11 patients. Two total hysterectomies were performed. Most PPH cases treated with UAE had early-onset PPH caused by uterine atony. Late-onset PPH was caused by placenta-related problems (remnant placenta, placenta accreta). Body mass index, cesarean section, the use of mixed embolizing materials, placenta abruption as the cause of PPH, and transferred patients were associated with uterine necrosis. Age, re-embolization, and the use of mixed embolizing materials were associated with adverse complications. Conclusions Although UAE is a safe and effective way to manage PPH, a long-term follow-up is needed to determine the complications of UAE. When uterine necrosis is suspected, prompt and adequate treatment should be performed due to the effects of necrosis on menstrual cycles, fertility, and subsequent pregnancies.

Utilization and Comparative Effectiveness of Uterine Artery Embolization versus Hysterectomy for Severe Postpartum Hemorrhage: A National Inpatient Sample Study