35-year-old mother of one child delivered by cesarean section due to placenta previa 2 years back and admitted to the ward at 36 weeks of POG with mild PV bleeding. This pregnancy also complicated with placenta previa and USS done at 20 weeks didn’t reveal the features of placenta accreta spectrum.

Her fetal growth is satisfactory until up to now but in transverse lie.

1.what are the possible differential diagnosis in this case.

Placenta previa.
Uterine rupture.
Vasa previa.
Placental abruption.
Local causes (cervical polyp, ectropium, cervicitis, cervical CA)
PTL

2.How will you evaluate her History

Symptom analysis

Amount of bleeding (how many pads soaked)
Color is bleeding (fresh red /dark – vasa previa)
Number of episodes.
Association with trauma, sexual intercourse.
Vaginal loss of fluids.
Fetal movements.
Blood group/ last Hb/hx of blood transfusion.
Associated abdominal pain.

(pain less – pp, vasa previa, local painful – abruption, rupture, PTL)

Shoulder tip pain (rupture)
History of high BP, severe pre eclamptic symptoms(abruption)
Cervical smear.
32 USS – persistent PP, features of placenta accreta, CR scan, Cervical length assessment( if CL < 3.5cm – PTL and MOH)
PMH – DM, HT, Anemia, bleeding disorder or anticoagulants.
PSH – complications related to previous LSCS.
(midline/vertical incision, PPH, blood transfusion, ICU care)
Any other pelvic or abdominal surgeries.
Social – DV
Her concerns

EXAMINATION

General examination – pallor. features of severe preeclampsia (oedema, exaggerated reflexes)
CVS – PR, volume, BP.
Obstetric examination – abdomen soft /woody heard /easily palpable fetal parts /FHS /Lye/ presentation.
Speculum examination – rule out local cause / active bleeding .

INVESTIGATIONS

USS ABDOMEN /OBS USS

confirm PP, features of accreta, features of abruption (USS sensitivity 15%, coexisting abruption in PP 10%)

free fluid and fetus in peritoneum

Fetal lye (transverse oblique), presentation, EFW

Placental mapping.

FBC (Hb and PLT), DT 4-6, baseline clotting profile, LFT, RFT.

3.ultimate diagnose was placenta previa. Festus in transverse lye. It has been decided to perform LSCS.

What are the problems you will anticipate during the surgery of this patient

1.Deficult entry – surgical adhesions.

2.Risk of damage to visceral organs – Bladder and bowel.

3.Undiagnosed PAS – need help from GU or GI surgeon.

4.Intraoperative hemorrhage- cut through placenta. 6.Difficult delivery of the baby – transverse lye.

7.PPH.

8.Hysterectomy (last option of surgical management)

9.Anaesthesia related complications.

10.Neonatal complications and resuscitation.

4.What are the information you will divulge when you get the consent?

DR B CAPS

D – Describe procedure.

(midline skin incision, vertical uterine incision)

B – Benefit of the surgery

Safest and only way to deliver the baby

R – Anticipated risks.

Serious Risks

In all woman with placenta previa
Emergency Hysterectomy	11:10 or 11% very common
Need for further laparotomy during recovery	75:1000 or 7.5% common
Thromboembolic disease	3:100 or 3% common
Bladder or ureteric injury	6:100 or 6% common

Massive obstetrical hemorrhage	21:100 or 21% very common

Placenta previa & previous C/S Emergency hysterectomy	27:100 or 27% very common
Abnormally adherent placenta (eg placenta accrete)	Advice that hysterectomy is highly likely

Frequent Risks

Maternal Admission to ICU /Fetal Admission to NICU infections blood Transfusion

Anesthetic method and

complications

Additional procedures
Embolization
Blood transfusion
Hysterectomy

C – consequences of not doing surgery

A – No alternatives.

P – pre operative, intra operative, post operative management.

S – safeguarding. (anticipating complication and measures which can be taken at surgery)

5.How you will prepare the patient for cesarean section other than consent?

Placenta previa care bundle

MDT involvement including
VOG, CA, hematologist, transfusion specialist, neonatologist and relevant specialties if anticipating urinary tract or bowel injury.
Need ICU bed
Keep at least 4 pint blood and blood products, Rapid transfusors.
Trace all investigations and optimize if Hb low.
Pre operative optimization and anesthetist review.
USS – placental mapping / transverse lye (dorso inferior or dorso anterior plan for midline skin and vertical uterine incision )
Plan for day time surgery, inform OT
Two wide bore canula.
Keep fasting
Pre-medications – Antacids
Experienced surgeon and experienced assistant.
Be ready for surgical management of PPH, including instruments for hysterectomy.
Assess the DVT risk and stocking
Perioperative antibiotics

6.what measures you can take to minimize the intraoperative bleeding from pre operative period

Hb optimization
Experienced person with good assistant
Balloon Embolization of uterine arteries (interventional radiologist)
Meticulous surgical techniques
Try not to cut the placenta, intra operative/pre operative mapping
Try not to remove the placenta if not separated.
Medical management of PPH less effective, early surgical management.
Manual aortic compression
Square sutures figure of eight sutures.
Balloon tamponade to lower segment.
Early recourse of hysterectomy

7. After opened up U see the placenta out of the incision. what you will do?

Wait

Assess the extension.

Inform consultant, Anesthetist and scrub nurse.

Arrange the surgical trolly.

Make sure the availability of blood and blood products.

If needed collaborate with vascular or urology team.

Deliver the baby

Go for the total hysterectomy with B/L salpingectomy while placenta insitu.

8. What alternative methods can be considered?

Keep placenta insitu and plan for hysterectomy by three to seven days
Try to remove if placenta can be separated and focal adhesion.
Deliver the baby and partial excision of uterine wall with reconstruction
Expectant management with placenta insitu
Methotrexate not suitable

9.She has undergone hysterectomy as it is PAS. How will you manage her post operatively?

Immediately after the Surgery

Documentation of the event
ICU care
Monitor vital parameters (BP,PR,RR,saturation,UOP)
Check post op Hb and optimize
IV antibiotics
Analgesics

subsequenty

Assess VTE risk and if need VTE prophylaxis (hydration, early mobilization, DVT stockings)
Midline incision – steam inhalation, nebulization, chest physiotherapy)
Breast feeding can be continued
Debrief the mother
Incident reporting
Risk management
(If uterus is preserved – elevated risk of PP and PAS in future ,contraception)