Emergency hysterectomy after 2nd trimester abortion in a patient with placenta accreta spectrum disorder who had four cesarean deliveries

Overview

Objective: To perform an emergency hysterectomy by ligation of the uterine arteries before bladder dissection in a patient with placenta accreta spectrum disorder who developed excessive hemorrhage after abortion. Case report: A patient with four previous cesarean deliveries presented with pelvic pain and excessive vaginal bleeding following a fetal abortion. The patient’s hemodynamic status worsened. The patient underwent surgery, and the bladder was densely adherent to the previous incision scar. A classic hysterectomy was performed up to the level of the uterine artery bilaterally. The uterine arteries were then skeletonized and ligated before bladder dissection. The anterior visceral peritoneum was dissected at the isthmic level. The bladder below the adhesion was dissected in the lower uterine segment using a lateral approach. The adhesions were dissected, the bladder was removed from the uterus, and a hysterectomy was performed. Conclusion: Obstetricians should be familiar with the dia­gnosis and management of placenta accreta spectrum disorders. In an emergency, the uterine artery could be ligated before bladder dissection. After cessation of bleeding, the bladder could be dissected from the lower uterine segment and a safe hysterectomy could be performed.

Keywords:

Hemorrhage – Hysterectomy – abortion – placenta accreta spectrum

Introduction

Placental implantation occurs in the uterine endometrial layer. A healthy endometrium and the Nitabuch layer of the endometrium restrict further invasion of the placenta into the endometrium, thereby preventing it from reaching the myometrium [1,2]. In an event of basal endometrial loss, placental implantation may occur on the myometrial surface (placenta accreta), into the myometrium (placenta increta), or even beyond the myometrium (placenta percreta) [1–3]. This type of placental implantation is known as placenta accreta spectrum (PAS) disorder. Previous uterine surgery, cesarean delivery, dilatation, curettage, or infection may result in loss of the endometrium, leading to PAS development [3,4].

The main risk associated with PAS is massive obstetric hemorrhage, which can lead to secondary complications, such as coagulopathy, multisystem organ failure, and even death [5,6]. However, there are insufficient data on second-trimester pregnancy termination in patients with PAS. Severe hemorrhage occurs when PAS has not been dia­gnosed prenatally, and manual placental delivery has been attempted [7,8]. If heavy bleeding occurs, emergency hysterectomy is required to stop it [9]. Previous cesarean incisions heal with scar formation. Furthermore, the bladder can adhere to the incision scar in the lower uterine segment [10]. In such cases, bladder injury may occur during hysterectomy, especially during emergency hysterectomy [10,11]. Here, we present a case of emergency hysterectomy performed in the 2^nd trimester of pregnancy due to severe hemorrhage, in which the bladder densely adhered to an incision scar.

Case presentation

A 27-year-old woman presented to the emergency clinic with pelvic pain and vaginal bleeding. She was gravida six with one abortion and four previous cesarean deliveries. On physical examination, minimal vaginal bleeding was observed along with a 2 cm cervical dilatation. Obstetric ultrasonography (USG) revealed the presence of a 17-week-old fetus with cardiac activity. Her amniotic fluid volume decreased, and the placenta was located on a previous cesarean incision scar. The patient was admitted to the clinic with a dia­gnosis of abortus incipiens. The patient’s hemoglobin (Hgb) level was 8.4 g/dL. On the second day of admission, USG examination revealed that fetal cardiac activity had stopped, anhydramnios had developed, and the lower fetal extremity had prolapsed into the vagina. Two hundred micrograms of misoprostol was administered sublingually to induce abortion. Two hours later, the fetus was aborted without the placenta, and excessive bleeding occurred. Subsequently, the placenta was delivered manually under abdominal USG examination, and the bleeding stopped. Approximately 20 min later, the patient’s condition and hemodynamic status worsened. Blood sample was collected to evaluate the patient’s Hgb level (reported as 5.7 g/dL). The patient was then transferred to the operating room.

A decision was made to perform emergency hysterectomy. The patient was placed in the dorsal position, and the abdomen was then accessed through a Pfannenstiel incision. No hemorrhage was observed in the abdomen. A purplish-colored area with a diameter of 5 cm was observed in the upper part of the previous incision (Fig. 1A). The bladder was densely adherent to the previous incision. It was not possible to quickly dissect the adhesions without causing bladder injury. In our experience, bladder adhesions usually occur at the site of a previous incision. We also observed that the bladder did not adhere to the uterine arteries at the isthmic level, or the intact uterine endopelvic fascia below the incision. The bilateral utero-ovarian ligaments, round ligaments, and fallopian tubes were clamped, cut, and ligated to quickly stop the bleeding. Subsequently, the anterior and posterior leaves of the broad ligament were dissected to remove the bladder and ureters from the surgical area and ligate the uterine arteries. The uterine arteries were clamped, cut, and ligated (Fig. 2A). Subsequently, we dissected the visceral peritoneum from the uterus just medial to the uterine arteries at the isthmic level and visualized the endopelvic fascia. We then dissected the bladder from the lower uterine segment immediately below the adhesions using blunt dissection. Blunt dissection continued until only dense bladder adhesions remained (Fig. 2B). While dissecting the bladder, the uterine wall was opened in the purplish-colored area. There was approximately 5 cm of soft tissue in the ruptured area that could not be clearly identified as placental tissue or hematoma (Fig. 1B). Subsequently, the tissues were subjected to histopathological evaluation. The adhesion was dissected using sharp dissection, such that some scar tissues remained on the bladder. Finally, total hysterectomy was performed (Fig. 2B).

Four units of packed red blood cells, two units of fresh frozen plasma, and 1 g of fibrinogen concentrate were transfused. The patient was transferred to the intensive care unit, where the Hgb was 8.6 g/dL and fibrinogen levels were 255 mg/dL. The patient was admitted to the clinic on the first postoperative day, and discharged on the sixth postoperative day with a Hgb level of 7.8 g/dL. Histopathologic evaluation results reported necrotic changes and chronic villus structures in the ruptured area with placental tissue sample in a separate container.

Discussion

Herein, we present a case in which severe maternal morbidity and mortality were prevented by performing rapid hysterectomy without complications. After cesarean section, the uterine endometrial epithelia and visceral peritoneum can heal with regeneration and recolonization at the incision site. However, the myometrium does not heal by regenerating muscle fibers, but by fibrous tissue formation [3]. Scarring may cause abnormal vascularization, resulting in secondary localized hypoxia and lead to defective decasualization and excessive trophoblastic invasion [3,12]. Additionally, neovascularization develops to feed the placenta, and chorionic villi can be found inside the myometrial vascular spaces in PAS [13]. Therefore, any attempt to remove the placenta will result in rupture of these vessels and cause severe bleeding [3]. Obstetricians should consider PAS when the placenta is located on a previous cesarean incision [4]. Additionally, current knowledge is insufficent regarding how pregnant patients with PAS should be managed during second-trimester abortion [2]. However, a few recommendations have been made in the literature, including medical treatment with misoprostol, uterine artery embolization, leaving the placenta in situ, and multiple adjuvant treatments, such as hysterotomy and hysteroscopic excision [1,2,6]. When severe hemorrhage occurs, an emergency hysterectomy is required as definitive treatment, such as in the present case. Moreover, Tocce et al argued that all second-trimester pregnancy terminations should be performed via hysterectomy in pregnant patients with PAS [14].

When the placenta is located at or near a previous cesarean incision, obstetricians should recognize that PAS is highly probable. This possibility increases with repeated cesarean section. Additionally, repeated cesarean delivery increases the risk of bladder adhesion to the incision scar. Bladder adhesions usually occur at the anterior midline of the incision site. Thus, pushing the bladder to remove it from adhesions can cause injury. Bladder adhesion does not occur in the lateral portion of the cervix or the medial side of the uterine artery at the isthmus level. Therefore, dissection should begin in this lateral area to prevent bladder injury [10,15]. It has been reported that women with > 3 prior cesarean deliveries are 20% more likely to experience bladder injury [10]. In Turkey, the general cesarean section rate is > 50%, and the primary cesarean section rate is > 26% [9]. Therefore, we are likely to encounter such cases with a high risk of hemorrhage at any time.

Conclusion

Obstetricians in countries with high rates of cesarean deliveries should be aware of PAS and familiar with the management of spontaneous abortion or medical termination with related complications. In some cases, uterine artery ligation is required before bladder dissection to quickly stop the hemorrhage, as in the present case. This approach stops hemorrhage and provides time for the surgeon to perform hysterectomy quickly, which decreases the complication rate.

This case report was presented as an oral pre­sentation at 19th National Gynecology and Obstetrics Meeting which was held in 18–22 May 2022, in Antalya – Turkey.

ORCID authors

M. Kaba 0000-0002-4368-9712

M. C. Sarica 0000-0002-7032-097X

Y. A. Mayir 0000-0002-9573-1062

Submitted/Doručeno: 2. 12. 2022

Accepted/Přijato: 15. 2. 2023

Metin Kaba, MD

Department of Obstetrics and Gynecology

Antalya Training and Research Hospital

Varlik, Kazim Karabekir Cd.

07100 Muratpasa/Antalya

Turkey

metin13kb@gmail.com