Dr.Erica Frecker

Dr. Erica Frecker
DEC Hospital
Fredericton, NB
GA
GP
#
CS
Co-morbidity
US
MRI
Vascular
Urology
Complications
Pathology
35
5/2
2
MSAFP
accreta
percreta
balloon
catheter
after baby
2 units prbc’s
increta?
percreta
34
2/1
1
Type 2 DM
BMI 42
APH
percreta
increta
attempt balloon
after baby
Incisional hernia
percreta
36
7/3
3
APH
accreta
increta
percreta
internal iliac
ligation
planned after
baby
35 units prbc
6 units FFP
5 units plat
Bilateral ureteric
obstruction
Bladder laceration
?vessica vaginal fistula
increta and percreta
36
7/2
2
BMI 34
increta
increta
not done
before baby
6 units
back to OR because
hypotensive
increta
30
9/4
4
BMI 44
APH
Type 2 DM
percreta
not done
internal iliac
ligation
before baby
22 units prbc
8 unit FFP
1 cryo
Bladder laceration
percreta
36
8/3
3
Prior uterine
dehiscence
increta
accreta
balloon
catheters
before baby
none
increta
Increasingly common:
Years
Incidence
1930-50
1/30,739
1950-60
1/19,012
1960-70
1/14,780
1970-80
1/7270
1980 +
1/2500
Now
1/533


Improving Outcomes:
Remains high risk:

Transfusion 90%
 40% >10 U
Years
Mortality
<1934
37.2
1945-55
10
1955-69
9.4
1960-70
3.1
 EBL 3.5-5L




ICU 50%
Reoperation 10%
Cystotomy 20-30%
Ureteral injury 7%
Sentilhes 2013
Physicians have not valued these systemic checks in the
past, in large part because we are judged to be
competent or intelligent based on our apparent capacity
to remember things. This perception makes the use of a
memory aid countercultural and anathema to routine
practice.
Bosk et al Lancet 2009
The complexity of medicine has far exceeded our
ability to understand and process all inputs… we
make errors… with startling regularity.” Weiser and
Barry 2013

OR environment

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




Many of these apply to our cases
involving invasive placentation
Fast paced
Distractions
Multidisciplinary teams
Complex equipment
Fatigue
Stress
Inexperience
Reason. BMJ. 2000



Unrealistic to expect perfect performance from imperfect
people
Can’t prevent all errors, but can mitigate the harm
Checklists create
redundancy to allow
human error to be
captured
 Mortality -48%
 Morbidity -37%
Haynes 2009
Pre delivery diagnosis improves outcomes
Warshack 2010



Experienced surgeon and anesthetist
Massive Transfusion Protocol/ Blood bank
Subspecialty consultation



Gynecologic oncology, MFM, Urology, Interventional
radiology, vascular surgery
ICU
Eller et al. 2011 suggested improved outcomes with
transfer to specialty center
Should be someone with experience with
this condition
Help with setup and vaginal manipulation
Increases local experience
Consider antenatal corticosteroids 48 hrs before delivery


Tan 2013 (Australia): 38 weeks unless bleeding
RCOG 2011

36–37 weeks of gestation for suspected placenta accreta.
 32 weeks would avoid all unexpected deliveries
 90% bleed before 37 weeks
 40% deliver before 38 weeks



AOGS: 35-36 weeks
ACOG: 34 weeks
Robinson 2010: 34(-35) weeks
 RDS 64%, NND 0.379%
 37 weeks: if risk of bleeding is 0-7% or perinatal mortality <0.1%
 39 weeks: if risk of bleeding is <1%
PLACENTA IN SITU
UTERUS PRESERVED
UTERUS REMOVED
Recommended by ASOG
Conservative
Cesearian Hysterectomy
PLACENTA REMOVED
Extirpative
Resection
X
Balloon catheters and Vessel ligation

Internal iliac ligation
“Using
methods
such as ligation of the hypogastric or
 85% reduction
in pulse
pressure arteries are usually unsuccessful and may
uterine
 Only 50% effective
prolong the operation needlessly.”
 Prohibits subsequent
Price et al. 1991
embolization


Technically difficult in gravid
uterus
Risk of vessel injury


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

Embolization first described in 1979 by Brown et al.
to treat postpartum hemorrhage
Alavrez et al. (1992) suggested prophylactic vessel
catheterization for high risk patients
Paull 1995: Balloon occlusion without embolization
RCOG needs study
ACOG insufficient evidence
Inferior mesenteric a.
Ovarian
Aorta: sacral and ileolumbar a.
Posterior division: rectal a.
External iliac: obturator a.,
vaginal arteries via femoral
circumflex, internal pudendal
AORTA: Jaraquemada
COMMON ILIAC: Shih, Matsubara & Angstmann
MAIN TRUNK: Tan & Carnevale
ANTERIOR DIVISION:
Shrivastava

Disadvantages:



Logistics
Surgical delay
Procedural complications 6-16%
 Necrosis ovarian/ failure (embolization)
 Puncture site hematoma
 False aneurysm
 Femoral artery dissection
 Fetal radiation: 3-6 rad
 VTE 5%
 Reperfusion injury (prolonged)
Do you embolize post operatively?
2012 American Survey:
 Only used in 35% of cases
Eller 2009
 68% successful
 Early morbidity 18% vs. 55%
 Ureteral injury 0% vs. 7%
Epidural:
 Less vasodilation
 Less anesthesia exposure for infant
 Allows woman to participate in birth
 Less pain with iliac catheter insertion
 Less post op pain
 ? Fewer transfusions
General anesthetic:
 Less anxiety
 Fewer distractions for anesthesia
 Hemodynamic instability with
emergency GA
Cesarian Hysterectomy


Deliver infant
Decrease blood flow to uterus






Balloon catheters
Ligation
Open paravesical and pararectal spaces if necessary
Devascularize uterus
Dissect bladder flap
Delineate vaginal cuff


Deliver infant
Decrease blood flow to uterus






Balloon catheters
Ligation
Open paravesical and pararectal spaces if necessary
Devascularize uterus
Dissect bladder flap
Delineate vaginal cuff
Pelosi 1999


Deliver infant
Decrease blood flow to uterus






Balloon catheters
Ligation
Open paravesical and pararectal spaces if necessary
Devascularize uterus
Dissect bladder flap
Delineate vaginal cuff

Price 1991. Placenta Percreta + Bladder



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

Divide uterosacral ligaments
Enter vagina posteriorly
Ureter retracted laterally
Ligate uterine vessels and parametria from cephalad to
caudad
Involved portion of urinary bladder is resected with the
uterus
Bladder defect closed in 2 layers

Paravesical tunnel anterior to parametrial vessels
and posterior to bladder pillars


Deliver infant
Decrease blood flow to uterus







Balloon catheters
Ligation
Cervical tourniquet
Open paravesical and pararectal spaces if necessary
Devascularize uterus
Dissect bladder flap
Delineate vaginal cuff


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
Retrofilling bladder deliniates bladder margin
Can go lateral to medial
Use sharp dissection
Hemoclips
Checks for cystotomy


Deliver infant
Decrease blood flow to uterus







Balloon catheters
Ligation
Cervical tourniquet
Open paravesical and pararectal spaces if necessary
Devascularize uterus
Dissect bladder flap
Delineate vaginal cuff



 Lifts lower segment
 Compresses vaginal vessels
Matsubara 2013
 Increases distance between ureter
and vessels
 Delays observation of bleeding
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Apply sponge stick
to cervix
Methylene blue dye
Pack vagina with
gauze roll
Use colpotomizer
3rd assistants fingers
Suggest nothing in vagina until after the infant is delivered
When anticipated blood loss exceeds 1500ml
RCOG guideline
NICE guideline 2005
Use bandage scissors for uterine incision
Use suture not cord clamp in the uterus
Use Hysterectomy clamps not
Kocher clamps on cornuae
‘Back clamp’ all pedicles
High risk of post op bleeding
Compression of cervical branches
Price 1991
Argon beam laser
Hemostatic gel/patch:
Tisseel/ Surgiflo/Evarrest
Can be temporary
PLACENTA IN SITU
UTERUS PRESERVED
Conservative
UTERUS REMOVED
Cesearian Hysterectomy
PLACENTA REMOVED
Extirpative
Ressection
X

Candidates:


Advantages (Amsalem 2011, Kayem 2004):



Fertility sparing, extensive disease, compliant with follow up, minimal
bleeding
Less bleeding (3.6 vs. 0.9ml EBL)
Fewer bladder injuries (25% vs. 10%)
Risks:





50% 2nd surgery
25% (58% percreta) will need delayed hysterectomy
Delayed hemorrhage 10%
Infection 28%
DIC: 38%

Protocol:




Follow up (4-60wks, med. 13.5)


Antibiotics 5-10days
Consider post operative preventative embolization
Likely no role for methotrexate (Intraumbilical vein 50 mg,
Intramuscular 50 mg Q weekly)
Weekly exam, Ultrasound, CBC, INR/ PTT, fibrinogen, +/- CRP
Recurrence in next pregnancy 30%
PLACENTA IN SITU
UTERUS PRESERVED
Conservative
PLACENTA
REMOVED
Clausen
(Copenhagen)
2013
Extirpative
Resection
Jaraquemada (Argentina) 2011
UTERUS REMOVED
Cesarian Hysterectomy
X
Review of Technique

Trim abnormal segment

Traction sutures
Fibrin glue
 Defect covered with vicryl mesh

Successful uterine conservation 45 /50
patients
Pregnancy: 10 /42 in next 3 years
Recurrence: 0 /10 accreta /PPH
Uterine dehiscence: 1 /10



Compression sutures
Suturing cervical lip to lower segment
Balloons

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Abnormally invasive placentation is a condition we will
encounter more often in our practices
The surgeries can be difficult despite good planning
Complication rates are high even in the hands of the world’s
most experienced surgeons
Certain factors increase the risk of surgical error:
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
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Infrequent procedure/ less experience
Multiple disciplines delivering simultaneous care
Fast pace
High stress
Possible ‘middle-of-the-night’ emergency

Centers should have a designated team including
experienced gynecologists and support from:



Anesthesiology, vascular surgery, urology, interventional radiology,
blood bank and MTP
And emergency plan with a surgical checklist
If not patients should be referred to a tertiary center for
delivery
Surgical teams often believe they are performing at their
peak and dismiss checklists as redundant, a waste of time,
or ‘‘touchy-feely’’ instead of as part of the discipline and
protocol of surgical preparation.

Use of a surgical checklist should not be seen as a
sign of weakness but rather as a commitment to a
culture of safety
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Improved efficiency
Improved communication
Unified vision of case
Encourages participation and articulation of concerns
Improves compliance with safety practices
Thank you!

WHO “Safe Surgery saves lives” campaign


Haynes 2009: Published pilot data

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Surgical safety checklist
Mortality -48%
Morbidity -37%
Urbach NEJM 2014:

3 months before and after surgical checklist
implementation in Ontario made no significant difference
in outcomes