For women who are near term and who are not bleeding, plns re made for scheduled cesarean delivery. Timing balances fetal immaturity risks against antepartum hemorrhage. One NIH workshop suggested elective delivery at 36 to 37 completed weeks' gestation (Spong, 2011). he Society for Maternal-Fetal Medicine (2017) recommends delivery between 34 and 37 weeks. At Park land Hospital, we usually perform elective cesarean delivery at 38 weeks. With a suspected morbidly adherent placenta, delivery is recommended at 34 to 35 completed weeks by the NIH workshop (p. 781). Our practice is to schedule delivery at 36 completed weeks.
Practically all women with placenta previa undergo cesarean delivery. Many surgeons recommend a vertical laparotomy incision to provide rapid entry in cases with torrential bleeding or operating space if hysterectomy is required. As discussed, cesarean delivery is emergently performed in more than half because of hemorrhage, for which about a fourth require blood transfusion (Boyle, 2009; Sabourin, 2012). Although a low transverse hysterotomy is usually possible, this may cause fetal bleeding if the placenta is implanted anteriorly and the placenta is incised. In such cases, fetal delivery should be expeditious (Silver, 2015a). A vertical uterine incision may be preferable in some instances. In either case, even when the incision extends through the placenta, maternal or fetal outcomes are rarely compromised.
Following placental removal, the placenta site may bleed uncontrollably due to poorly contracted smooth muscle, which is characteristic of the lower uterine segment. If hemostasis at the placental implantation site cannot be obtained by adequate uterotonic administration and pressure, it can be oversewn with O-chromic sutures. Cho and associates (1991) described interrupted O-chromic sutures at I-em intervals to form a circle around the bleeding portion of the lower segment to control hemorrhage. Others have reported success with compression sutures that traversed and compressed the anterior and posterior uterine wall (Kayem, 2011; Penotti, 2012).
Of other methods, Bakri or Foley balloon tamponade used alone or coupled with compression sutures has been described (Albayrak, 2011; Diemert, 2012; Kumru, 2013). Law and coworkers (2010) successfully used a hemostatic gel. Other surgical options are bilateral uterine or internal iliac artery ligation, illustrated later (p. 792). Finally, pelvic artery embolization has also gained acceptance.
If these more conservative methods fail and bleeding is brisk, hysterectomy is necessary. Placenta previa-especially with an abnormally adherent placenta-currently is the most frequent and other institutions Qakobsson, 2015; Wong, 2011). When there is no associated accrete syndrome, the reported incidence of hysterectomy is 2 percent (Gibbins, 2018).
hus, it is not possible to accurately estimate the efect on the hysterectomy rate from previa alone without considering the associated accrete syndromes. Again, or women whose pla centa previa is implanted anteriory at the site of a prior uterine incision, the likelihood of an associated morbidy adherent placenta and need or hysterectomy is increased. In a study of 318 peri partum hysterectomies performed in the United Kingdom, 40 percent were done for abnormal placentation (Knight, 2007).
Similar results were reported for 211 hysterectomies from the
Nordic Obstetric Surveillance Study Qakobsson, 2015). At