A NOBLE APPROACH TO PREVENT POST PARTUM HAEMORRHAGE DURING LSCS FOR
MAJOR DEGREE PLACENTA PREVIA- A COMPARATIVE ANALYSIS.
Dr Dilip Kumar Dutta 1, Dr Indranil Dutta2, Dr Tirthankar Deb3
1.Director
GICE clinic, Kalyani, Nadia, West Bengal India.
2Consulting
3
gynaecologist, GICE clinic , kalyani, Nadia, West Bengal , India
Assistant Professor, Department of Pharmacology, College of Medicine & J.N.M Hospital,
WBUHS, Kalyani, Nadia, West Bengal, India
ABSTRACT
OBJECTIVES
Evaluation of a new surgical technique
to prevent postpartum haemorrhage during
cesarean section for major degree placenta previa – A comparative analysis.
METHODS
This study was conducted at tertiary care hospital(JNM, NSGH ,CN) at Kalyani Nadia, West
Bengal, India from the period January 2006 to December 2011.
Sixty (60) cases diagnosed to be having major degree placenta previa, undergoing LSCS
operation, were selected for this study in two group for comparative analysis.
Group A(N-30) - New surgical technique(Dutta ‘s) institute in a stepwise manner = delivery
of baby > bilateral uterine artery ligation by chromic catgut no-1 suture >injection tranexamic
acid (1000mg) IM > injection oxytocin in intravenous infusion (10 units 30 drop /min in 500 ml of
5% dextrose)>delivery of placenta and membranes> checked properly if any tear or laceration in
placental site >
closure of uterine wound
by chromic catgut no 1 in two layers after securing
bleeding from placental bed >closure of abdomen in layers .
Group B (N-30) (traditional method)
= delivery of baby> delivery of placenta and its
membrane > injection oxytocin in intravenous infusion ( 10 units 30 drop /min in 500 ml of 5%
dextrose ) > surgical intervention either by bilateral uterine artery or internal iliac artery ligation
or cesarean hysterectomy or underlying interrupted suture to control post operative haemorrhage
> closure of uterine wound by chromic catgut no 1 suture in two layers > closure of abdomen in
layers.
RESULTS
It was observed from this comparative analysis that in group B intra operative blood loss >
500cc -18(60%) , cesarean hysterectomy- 6(20%) and bilateral internal iliac artery ligation4(13.3%) were found to be increased as compared to group A . Maternal mortality was found to
be high in group B -5(16.6%) as compared to group A- nil . Maternal morbidity was also found to
be
increase in group B- 13(43.3%) cases as compared to group A- 4(13.3%). Subsequent
menstrual cycles were found to be normal in group A – 20(90%) indicating non effect on gonadal
function.
CONCLUSION
This comparative analysis showed that by advocating this noble approach ( Dutta’ s) in
group A, as compared to group B, during LSCS for major degree placenta previa was found to be
simple, safe and quick procedure. It also reduces the perfusion pressure, permits time for the
surgeon to take
further steps in presence of less haemorrhage from operative field, thereby
avoiding unnecessary ligation of bilateral internal iliac arteries and cesarean hysterectomy ( group
B). Maternal mortality and morbidity were also found to be reduced which was statistically
significant. This technique is suitable for rural based hospital in absence of adequate blood
transfusion facility.
Keywords: Major degree placenta previa, new surgical technique vs traditional technique, cesarean
section, PPH.
Address :
Author :
Dr.Dilip Kumar Dutta M.D Ph.D, F.I.C.O.G, M.A.M.S
Director GICE Hospital, A/9/7,kalyani, nadia ,west Bengal, India, pin -741235
Mobile-09433032986, Email: drdilipdutta@yahoo.com
Co-Authors:
Dr. Indranil Dutta,
Resident Gynaecologist, GICE hospital, Kalyani, Nadia, WB ,India ,pin 741235 Mobile:09880148005,
Email:drindranildutta@yahoo.com
Dr. Tirthankar Deb, Assistant Professor, Department of Pharmacology, College of Medicine & JNM
Hospital, Kalyani, Nadia, WB. Mobile: 9088859953, Email: tirthdeb@gmail.com
INTRODUCTION:
Hemorrhage killed more women than any other complications of pregnancy in the
history of mankind. Placenta previa, abruptio-placenta and uterine rupture are three
important causes high rise of maternal mortality and morbidity 1. Till date different
surgical techniques2-17 adopted during LSCS for major degree placenta previa to tackle
excessive bleeding after placental expulsion, have not been found to be effective method
to control intra- operative and post operative hemorrhage. This has led to high incidence of
maternal mortality and morbidity due to lack of blood transfusion facility specially in low
resource setting
Due to above reasons , a noble approach has been developed by author (Dutta ‘s) ,
during LSCS for major degree placenta previa in a stepwise manner to reduce intra and
post partum hemorrhage, unnecessary surgical interventions and maternal mortality and
morbidity.
Materials and Methods
This study was conducted at tertiary level hospital (JNM & NSGH C.N), Kalyani,
Nadia, West Bengal, India from the period of January 2006 to may 2010.
Sixty (60) cases who undergone LSCS operation for major degree placenta previa
were selected for the comparative study in two group.
Group A( Dutta’ s) - (N -30) > delivery of baby from uterine cavity>bilateral uterine
artery ligation by chromic catgut no -1 suture > inj. tranexamic acid (1000 mg) IM> Inj.
oxytocin in intravenous infusion (10 units 30 drops/min in 500ml of 5%
dextrose)>delivery of placenta and membranes and checked properly >
if tear or
laceration in placental site interrupted suture by chromic catgut no 1 > uterine wound
were closed in two layers by chromic catgut no 1 suture after securing bleeding from
placental site or from other site if any> closure of abdominal in layers >inj. tranexamic acid
500 mg IM was given in two doses 6 hourly starting 4 hr. after the operation and inj.
oxytocin (10 units 30 drops/min in
500 ml of ringer lactate and
5% dextrose
alternatively) for 12 hrs .
Group B(traditional technique) (N-30) = delivery of baby > delivery of placenta and
its membrane> injection oxytocin in intravenous trans fusion ( 10 unit 30 drops/min in
500 ml of 5% dextrose )> traditional surgical intervention either bilateral uterine or
internal iliac arteries or cesarean hysterectomy to control intra operative hemorrhage >
closure of uterine wound in two layers by chromic catgut no-1 suture > closure of
abdomen in layers by chromic catgut no-1 suture.
Care of bladder was taken before the LSCS incision was given and before the closure
of uterine wound and abdominal wall.
Through history taking, clinical assessment, blood profile, USG/MRI was advocated.
Intra operative blood loss was estimated from standard mop (50 x 20 inch) weight, blood
from suction apparatus and blood clot. ( cent percent accurate blood loss assessment is
difficult to estimate).
Post operative blood loss per vagina was estimated by collecting blood in kidney tray
and weight of sanitary pad.
All cases were followed up to 7 days to see immediate post operative complications and
upto 2 year to see gonadal function.
Statistical analysis was performed using SPSS 16. Chi square test was applied and P value <
0.05 was considered significant.
Informed consent was obtained from all patients.
RESULTS
Table I
Types Of Placenta Previa
GROUP A
N-30
14(46.6%)
16(53.4%)
TYPE III
TYPE IV
GROUP B
N-30
12 (40%)
18(60%)
Type IV placenta previa was found to more in both group as compared to type III placenta
previa .(Table I)
Table II
Intra Operative Blood Loss
BLOOD LOSS
IN CC
<300
301 TO 500
501 TO 1000
>1000
GROUP A
N-30
21(70%)
8(26.6%)
1(3.4%)
-
GROUPB
N-30
7(23.3%)
5(16.7%)
10(33.4%
8(26.6%).
Chi square statistic: 23.06. df: 3, p value: 0.000
Blood loss during operation was found to less than 300cc-21(70%) in group A as compared
to group B -7(23.3%). Eighteen (60%) cases in group B had lost blood more than 500cc as
compared to group A -1(3.4%). Intra operative blood loss was significantly lower in Group
A as compared to group B (P value< 0.05). (Table II)
Table III
Surgical Interventions
TYPES OF SURGERY
Internal iliac artery
ligation
Interrupted suture in
placental site
GROUP A
N-30
-
GROUP B
N-30
4(13.3%)
P value
0.03844 (Chi Square statistic= 4.286)
2(6.7%)
4(13.3%)
0.3894
(Chi Square statistic=0.7407)
Cesarean subtotal
hysterectomy
-
10(33.4%) 0.0005320 (Chi Square statistic=12)
Degrees of Freedom=1
In group A due to prior ligation of both uterine arteries (30 cases) before placental
expulsion no surgical intervention was instituted except interrupted suture in placental
site- 2(6.7%) whereas in group B both sided uterine artery ligation in 12(40%) (not shown
in table), both sided internal iliac artery ligation in 4(13.3%) cases, interrupted suture in
4(13.3%) cases and cesarean subtotal hysterectomy in 10(33.4%) cases had to be
performed. All surgical interventions, except interrupted suture in placental site, were
found to significantly lower in Group A than Group B (P value< 0.05). (Table III)
Table IV
Post operative blood loss upto 6hrs
Blood loss
<less than 100cc
101 to 300 cc
301 to 500 cc
>500 cc
GROUP A
N-30
9(30%)
18(60%)
3(10%)
-
GROUP B
N-30
3(10%)
12(40%)
10(33.3%)
5(16.7%)
Chi Square statistic=12.97, Degrees of Freedom=3, p-value=0.004704
From table IV it was interesting to note that post operative blood loss in
group A were found to be less than 100cc in 9 (30%) cases, 101 -300 cc in 18 (60%) and
301-500cc in 3(10%) cases, as compared to group B 3(10%) ,12 ( 40%) and 10(33.3%)
cases respectively . In group B, 5(16.7%) cases had blood loss >500cc. Thus post operative
blood loss was found to be significantly lower in group A (P value < 0.05). (Table IV)
Table V
Post Operative follow up for 7 days (n-94)
Good post operative
Recovery
Wound Infection
Puerperal pyrexia
Hemoglobin level in
gm% < 10 gram
GROUP A
N-30
25(83.3%)
GROUP B
N-30
15(50%)
P value
0.006170 (Chi Square statistic=7.5)
1(3.4%)
3(10%)
0.3024 (Chi Square statistic=1.071)
1(3.4%)
4(13.3%)
1 (3.4%)
11(36.6%)
1 (Chi Square statistic=0)
0.0368(Chi Square statistic=4.356)
Degrees of Freedom=1
All the parameters of post operative follow up were found to be better in group A as
compared to group B, except puerperal pyrexia which was equal in both groups at 3.4 %
cases. Good post operative recovery was obtained in 83.3 % cases in group A as compared
to 50% in group B which is statistically significant (P value <0.05) (table V).
TABLE VI
Maternal mortality and morbidity
Maternal mortality
Maternal
morbidity
GROUP A
N-30
Nil
4(13.3%)
GROUP B
N-30
5(16.6%)
15(50%)
P value
0.0388 (Chi Square=4.33)
0.002267(Chi Square=9.32)
Degrees of Freedom=1
Maternal mortality in group A was found to be absent while in group B it was seen in 5
(16.6%) cases. Maternal morbidity was seen in 15 (50%) cases in group B due to anemia
(11) and wound infection (3) and puerperal pyrexia (1) which was found to be significantly
lower in group A (P value <0.05).( table VI)
TABLE VII
Follow up study upto 2 years
Gonadal Function
Gonadal Function
Regular menstrual cycle
Irregular menstrual cycle
Repeated pregnancy
GROUP A
N-22
20(90%)
2(10%)
6(27%)
GROUP B
N-16
10(63.4%)
6(36.6%)
-
Chi Square= 8.708, Degrees of Freedom=2, p-value=0.01285
On follow up study upto 2 yrs, the parameters of gonadal function i.e., regular menstrual
cycle and repeated pregnancy were observed in 20 (90%) and 6(27%) cases respectively in
group A while in 10(63.4%) and 0% cases respectively in group B. This difference was
statistically significant. (table VII)
DISCUSSION
Hemorrhage killed more women than any other complications of pregnancy.
Placenta Previa, Abruption Placenta and Uterine rupture were found to be leading cause
of increase in maternal mortality and morbidity.
It was observed
from this study that type IV placenta previa are found to be
increase in Group A- 16 (53.4%) and in Group B -18(60%), as compared to Type III
placenta previa was seen in Group A- 14(46.6%) and Group B – 12(40%) respectively.
The present technique( Group B) advocated so far , to manage major degree placenta
previa during LSCS, is to deliver the baby from uterine cavity either by cutting through
the placenta or manual separation of placenta in lower uterine segment followed by
hurried removal of placenta which may cause post partum hemorrhage either from
placental bed or lateral extension of the incision (more likely in the friable lower segment)
which necessitates the operating obstetrician either to give interrupted circular suture to
control during LSCS2 or use of haemostatic gel3 ,stepwise uterine devascularization4,pelvic
Arterial Embolisation5 ,Haemostatic Suturing Technique 6 or Supra Cervical Cerclage with
Intra-Cavitary Balloon
7
, Technique by Liyt et al 8, Parallel Vertical Compression Suture
on Lower Uterine segment
9
hydrostatic catheter balloon
during LSCS13 or
segment
15
or Meydanli compression suture
11
10
or use of a large Rusch
or uterine packing during LSCS12 or balloon tamponade
uterine tamponade balloon
14
or compression suture of the lower
or ligation of hypogastric or internal iliac artery16,17 or subtotal or total
cesarean hysterectomy.
If these above mentioned techniques are delayed due to any reason , it may lead to
increased maternal mortality and morbidity due to loss of blood ( 1 to 2 litre) from
placental site.
Hence to prevent post operative hemorrhage during LSCS operation for major
degree placenta previa by adopting this noble new technique (Group A) in a stepwise
manner had showed some promising result as compared to traditional technique(group
B).
Intra operative blood loss was significantly lower in Group A as compared to group B (P
value< 0.05). Due to above reason the extraction of placenta and its membranes was found
to be safer and easier in the new technique(Dutta’s)18 and allow the surgeon to undertake
further step from clear operative field in absent of excessive bleeding.
All surgical interventions namely internal iliac artery ligation and Cesarean subtotal
hysterectomy, except interrupted suture in placental site 2(6.7%), were found to be
significantly absent in Group A than that of Group B (P value< 0.05) thereby avoiding
possible complications arising from additional surgical interventions such as internal iliac
ligation -4(13.3%) and cesarean hysterectomy -10(33.4%)
In Group A idea is to give prophylactic19 Inj Oxytocin (10 units 30 drops /min in
500ml of 5% dextrose) to facilitate upper segment uterine contraction . Inj. Tranexamic
acid (1000 mg) IM was given to reduce the extent of bleeding from vessels placental bed
after placental delivery to 2 hr postpartum and its use was not associated with any side
effects or complications as it was reported that liver, kidney function, prothrombin time
and activity20,21,22 were found to be normal
Postpartum hemorrhage within 2 hours after cesarean section occurs more
frequently seen in major degree placenta previa may be due to poorly contractile lower
segment, presence of large uterine sinuses at lower segment and tear of the friable cervix
. In many places it was reported to be manage by packing the lower segment in order to
procure homeostasis , found to be dangerous as tears of the lower segment may occur23 .
Hence to prevent such complications in group A Inj Tranexamic acid 500 mg IM(
group A) was given 6 hourly for two doses after 4 hrs of operation along with 10 units of
oxytocin 30 drops per minute in 500 ml of 5% dextrose and ringer lactate alternately for 12
hrs were found to be very effective from the finding that post operative blood loss in group
A was found to be less than 300cc - 27(90%) as compared to group B > 300CC 15(50%)
and > 300CC 15(50%) respectively. Thus post operative blood loss was significantly lower
in group A (P value < 0.05).
Good Post operative recovery was obtained in 83.3 % cases in group A as compared
to 50% in group B which is statistically significant (P value <0.05)
In the present study maternal mortality was found to be high in group B 5(16.6%) as compared to group A –nil . Maternal morbidity was also found to be high in
group B -13(43.3%) as compared to group A- 4(13.3%).Both of this observation were
statistically significant (P value <0.05).
Menstrual cycle was found to be regular in 20 (90%) and irregular in 2 ( 10%)
cases in group A. Six (27%) cases had repeated pregnancy indicating that this technique
did not disturb the gonadal function and this beneficial effect in this new technique is
statically significant (p value <0.05)
CONCLUSION
This comparative analysis showed that by advocating this noble approach in Group
A ( Dutta’s), as compared to group B, during LSCS for major degree placenta previa was
found to be simple, safe and quick procedure. It reduces the perfusion pressure, permits
time for further steps in presence less haemorrhage from operative field, thereby avoiding
unnecessary (Group B) ligation of bilateral internal iliac arteries and cesarean
hysterectomy . Maternal mortality and morbidity were also found to be reduced ( Group A)
which was statistically significant. This technique is suitable for rural based hospital in
absence of adequate blood transfusion facility.
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Abbreviation
LSCS - lower segment cesarean section
CS – Cesarean Section