- Academic Editor
Backgrounds: To investigate the use of vascular ligation in
the treatment of pernicious placenta previa.
Methods: Clinical data from 199 patients with pernicious
placenta previa were collected and divided into groups according to placenta
location, placenta accretion and vessel ligation, the pregnancy outcome of each
group was compared. Results: The unplanned reoperation rate was
lower for the internal iliac artery ligation group than the group without
internal iliac artery ligation (p
Pernicious placenta previa (PPP) refers to placenta previa in a pregnancy in which the placenta is attached to the scar from a previous uterine surgery, with the possibility of placental accreta and hemorrhage [1]. According to the study, the prevalence of pernicious placenta previa was 11.25% [2]. The incidence of pernicious placenta previa prenatal hemorrhage was 3.9%, postpartum hemorrhage 1.4%, placenta accretion 3.0%, and hysterectomy 5.3% [3]. With the adjustment of fertility policy and the increase in the cesarean section rate in China, the incidence of pernicious placenta previa has increased significantly [4]. PPP can lead to severe postpartum hemorrhage, which is currently one of the main causes of obstetric hysterectomy [5] and is also an important cause of maternal death [6]. With the opening of the three-child policy, an increasing number of women are becoming pregnant, and how to reduce perioperative bleeding and preserve a patient’s uterus has become a major problem in obstetrics.
It has been shown that pelvic artery ligation is an effective surgical procedure for the management of obstetric hemorrhage [7], and pelvic artery ligation includes internal iliac artery ligation and uterine artery ligation. The anterior segment of the internal iliac artery is the main blood supply to the pelvic structures, and ligation of the anterior segment of the internal iliac artery is theoretically effective in controlling hemorrhage caused by pelvic organs. The uterine artery is the anterior branch of the internal iliac artery and provides 90% of the uterine blood supply. Ligation of the uterine artery can rapidly reduce uterine blood flow and control uterine bleeding. It has been shown that uterine artery ligation in patients with pernicious placenta previa can reduce intraoperative bleeding and hysterectomy rates and improve patient prognosis [8, 9], but there are few studies on internal iliac artery ligation in these patients. The purpose of this study was to investigate the application of two vascular ligation methods in patients with pernicious placenta previa by retrospectively analyzing the clinical data of patients with pernicious placenta previa in our obstetrics department and to provide a reference for clinical diagnosis and treatment.
Clinical data were collected for 256 patients with pernicious placenta previa
admitted to the Department of Obstetrics and Gynecology of the Affiliated
Hospital of Southwest Medical University from January 2015 to September 2022.
Fifty-seven patients who did not meet the inclusion criteria were excluded, and
the remaining 199 patients were included in the study for analysis. The inclusion
criteria as follows: ① gestational week
Preoperative assessment of the patients’ condition was moderate, after delivery of the fetal placenta during the operation, there was a lot of uterine bleeding, especially in the middle and upper sections of the uterus, but the bleeding was assessed to be controllable, and bilateral uterine artery ligation was performed at the lower sections of the uterus or below the original uterine scar incision with 2-0 Vichio (AOH0028Y, COVIDIEN, Shanghai, China) line through the uterine muscle wall and broad ligament.
According to the preoperative ultrasonography and magnetic resonance examination report of the patient, the patients’ condition was dangerous, combined with the observation that the blood supply in the lower segment of the uterus was abundant or even open to the naked eye after opening the abdominal cavity during the operation, the patient was assessed to have the risk of massive bleeding. Immediately after the delivery of the fetus, the plasma drainage tube was temporarily lapped in the lower segment of the uterus to block the uterine blood supply, and then the uterus was pulled out of the incision, reach the bifurcation of the common iliac artery and the initial segment of the internal and external iliac arteries, open the posterior peritoneum about 4–5 cm above it, separate the ureter, open the sheath about 2–3 cm below the start of the internal iliac artery, and separate the internal iliac artery, use the gallbladder forceps to carefully separate the posterior wall of the internal iliac artery from the internal iliac vein. After the forceps tip has passed the internal iliac artery, the prepared 2 No. 7 silk threads were taken out and the interval was 0.5 cm for double ligation. Finally, the peritoneum was sutured with No. 4 silk thread to complete the ligation of the internal iliac artery. Therapeutic ligation was suitable for preoperative assessment of the patients’ condition, with a low risk of bleeding. However, due to the turbulent uterine bleeding after delivery of the fetal placenta during the operation, bilateral internal iliac artery ligation was performed immediately same as prophylactic ligation.
Patients with uncontrollable massive bleeding after cesarean section who need to be sent to the operating room again for laparotomy exploration and hemostasis or interventional therapy such as vascular embolization and vascular balloon occlusion are defined as unplanned reoperation.
Placental adhesion and placental accretion with an area less than 3 cm were
defined as shallow placental accretion. The placental accreta area
General information data: location of placental attachment, degree of placental accreta, and mode of vascular ligation; surgery-related indicators: patients’ operation time, intraoperative bleeding, intraoperative blood transfusion, postoperative bleeding, postoperative blood transfusion, the number of hysterectomy patients, the number of intensive care unit (ICU) admissions, and the number of unplanned reoperations.
SPSS 26.0 software (SPSS; Chicago, IL, USA) was used for data analysis, with
skewed continuous variables expressed as the median (range) and categorical
variables expressed as several cases (percentage), using the Mann‒Whitney U test.
The Kruskal‒Wallis H test was used for comparisons between multiple groups, and
Kruskal‒Wallis H one-way ANOVA (k samples) was used for multiple comparisons.
Qualitative data are expressed as several cases (%) and the
Clinical data and different parameters are mentioned in Table 1.
Comparison of uterine artery ligation and internal iliac artery ligation with
and without vascular ligation: the operation time of internal iliac artery
ligation was longer than that of uterine artery ligation and no ligation; the
bleeding was more than that of no ligation, and the difference was significant
(p
Placental position | Implantation status | Vascular ligation | Hysterectomy | |||||
Category | The placenta is mainly attached to the anterior wall and the incision | Mainly attached to the posterior and lateral walls | Shallow implant | Deep implantation | Penetrating implant | Simple uterine artery ligation | Internal iliac artery ligation alone | Hysterectomy |
Number of cases (n) | 92 | 107 | 55 | 39 | 35 | 60 | 56 | 32 |
Proportion (%) | 46.2 | 53.8 | 42.7 | 30.2 | 27.1 | 30.1 | 28.1 | 16 |
Category | Surgery time (min) | Intraoperative bleeding volume (mL) | Intraoperative blood transfusion volume (u) | Postoperative bleeding volume (mL) | Postoperative blood transfusion volume (u) | Implantation area (cm) | Hysterectomy | Penetrating implantation | Bladder implantation |
Uterine artery ligation (I) n = 60 | 80.5 (61–81) | 1000 (500–1700) | 2 (0–3.5) | 0 (0–0) | 0 (0–2) | 4 (3–5) | 0 (0%) | 5 (12.2%) | 0 (0%) |
Internal iliac artery ligation (II) n = 56 | 125 (95–140) | 1200 (700–2000) | 2 (0–4) | 0 (0–20) | 1.5 (0–2.7) | 7 (5–9) | 12 (21.4%) | 17 (42.5%) | 9 (25.7%) |
Untied (III) n = 83 | 80 (65–105) | 800 (500–1500) | 1.5 (0–2) | 0 (0–0) | 0 (0–3) | 2 (2–3) | 20 (24.1%) | 13 (27.1%) | 1 (2.3%) |
H/ |
43.968 | 6.413 | 5.097 | 5.100 | 3.947 | 70.180 | 16.636 | 9.405 | 12.908 |
p value | 0.000 | 0.041 | 0.078 | 0.078 | 0.139 | 0.000 | 0.000 | 0.009 | 0.002 |
I vs. II | 61.935 (0.000) | 19.457 (0.204) | 26.578 (0.003) | 14.341 (0.000) | 9.399 (0.002) | 4.410 (0.045) | |||
I vs. III | 3.247 (1.000) | 5.096 (1.000) | 38.601 (0.000) | 16.809 (0.000) | 3.038 (0.081) | 0.330 (1.000) | |||
II vs. III | 58.688 (0.000) | 24.553 (0.040) | 65.179 (0.000) | 0.134 (0.714) | 2.308 (0.129) | 9.444 (0.004) |
M, Medine.
Comparison of uterine artery ligation and internal iliac artery ligation in
patients with pernicious placenta previa combined with placental accreta: in
patients with pernicious placenta previa combined with superficial implantation,
the operative time of uterine artery ligation was less than that of internal
iliac artery ligation, and the difference was statistically significant
(p
Degree of implantation | Ligation method | Number of patients | Surgery time (min) | Intraoperative bleeding volume (mL) | Intraoperative blood transfusion volume (U) | Postoperative bleeding volume (mL) | Postoperative blood transfusion volume (u) |
Shallow implantation | Simple uterine artery ligation | 22 (53.7%) | 75 (60–91.25) | 600 (500–925) | 0 (0–2.63) | 0 (0–0) | 0 (0–0) |
Internal iliac artery ligation alone | 14 (35%) | 96.5 (80–120) | 750 (575–925) | 0 (0–2) | 0 (0–5) | 0 (0–1.63) | |
z/ |
2.855 | 2.871 | 0.705 | 0.359 | 1.517 | 1.651 | |
p value | 0.091 | 0.004 | 0.490 | 0.761 | 0.413 | 0.296 | |
Deep implantation | Simple uterine artery ligation | 14 (34.1%) | 107.5 (87.3–125) | 1800 (1600–2500) | 4 (3–4.5) | 0 (0–0) | 2 (0–3.25) |
Internal iliac artery ligation alone | 9 (22.5%) | 135 (112.5–140) | 2000 (1850–2250) | 3.5 (2.5–4) | 0 (0–35) | 2 (0–4) | |
z/ |
0.868 | 1.893 | 0.446 | 1.221 | 0.873 | 0.131 | |
p value | 0.352 | 0.062 | 0.688 | 0.250 | 0.557 | 0.926 | |
Penetrating implantation | Simple uterine artery ligation | 5 (12.2%) | 95 (75–125) | 2000 (1500–2750) | 3 (1.75–4) | 0 (0–1400) | 2 (0–5.25) |
Internal iliac artery ligation alone | 17 (42.5%) | 140 (120–178.5) | 2000 (1050–2750) | 4 (2.5–8) | 0 (0–50) | 2 (0.25–4) | |
z/ |
9.399 | 2.359 | 0.079 | 1.425 | 0.957 | 0.24 | |
p value | 0.002 | 0.015 | 0.940 | 0.164 | 0.053 | 0.820 |
M, Medine.
Comparison of different internal iliac artery ligations in pernicious placenta
previa patients: the intraoperative bleeding and transfusion volumes and
postoperative transfusion volume were less in the prophylactic internal iliac
artery ligation group than in the therapeutic ligation group; the ICU admission
rate was lower in the prophylactic internal iliac artery ligation group than in
the therapeutic ligation group, and the difference was statistically significant
(p
Category | Number of patients | Surgery time (min) | Intraoperative bleeding volume (mL) | Intraoperative blood transfusion volume (u) | Postoperative bleeding volume (mL) | Postoperative blood transfusion volume (u) | Hysterectomy rate | ICU admission |
Therapeutic | 29 | 130 (95–145) | 2000 (1200–2100) | 3 (1.75–4) | 0 (0–87.5) | 2 (1.5–4) | 7 (25%) | 7 (46.7%) |
Preventive | 27 | 120 (95–135) | 700 (500–1100) | 1.5 (0–3) | 0 (0–0) | 0 (0–1.5) | 5 (17.9%) | 2 (10%) |
z/ |
1.389 | 4.232 | 2.086 | 1.653 | 3.898 | 1.355 | 6.033 | |
p value | 0.165 | 0.000 | 0.037 | 0.098 | 0.000 | 0.244 | 0.022 |
ICU, Intensive Care Unit; M, Medine.
Category | Number of patients | Surgery time (min) | Intraoperative bleeding volume (mL) | Intraoperative blood transfusion volume (u) | Postoperative bleeding volume (mL) | Postoperative blood transfusion volume (u) |
Therapeutic | 7 | 192 (120–215) | 3000 (2500–4000) | 6 (2–11) | 0 (0–0) | 3 (2–4.5) |
Preventive | 5 | 140 (107.5–156.5) | 2000 (950–2000) | 4 (4–7) | 0 (0–150) | 4 (0.25–7.75) |
z/ |
1.218 | 2.888 | 0.082 | 1.748 | 0.164 | |
p value | 0.268 | 0.003 | 0.934 | 0.268 | 0.876 |
M, Medine.
To prevent severe postpartum hemorrhage in patients with pernicious placenta previa, in addition to cervical lift-off sutures, uterine tamponades, uterine sutures, vascular ligation and balloon blocks, or even hysterectomy, have been used to manage refractory postpartum hemorrhage [10, 11]. Prophylactic balloon blocks have been reported to be effective in controlling postpartum hemorrhage but do not reduce the incidence of hysterectomy in patients with pernicious placenta previa with implantation [12]. Some studies have reported that prophylactic balloon blocks have no significant effect on intraoperative bleeding or the hysterectomy rate in placenta previa patients with implantation and significantly increase the financial burden on patients [13]. The efficacy of balloon blocks has not been unanimously accepted, and there are complications such as coagulation dysfunction [14], fever, lower abdominal pain, thrombosis [10], and lumbosacral pain [15]. In contrast, some studies have shown that arterial ligation can circumvent the complications associated with cannulation and balloon placement while achieving the same efficacy [16, 17]. A randomized controlled study concluded that uterine artery ligation reduced intraoperative bleeding and transfusion volumes during cesarean delivery [18]. It has also been suggested that uterine artery ligation is effective in reducing the rate of hysterectomy for placenta previa patients [19, 20]. Additionally, Camuzcuoglu et al. [21] concluded that internal iliac artery ligation is a safe and effective method for the treatment of severe postpartum hemorrhage.
The statistical results of this study showed that the operative time for the
intraoperative internal iliac artery ligation group was longer than that of the
uterine artery ligation and nonligation groups, and these patients had more
bleeding than nonligation patients; however, the patients in the internal iliac
artery ligation group had extensive placenta implantation and more patients had
bladder implantation, and there was a significant difference (p
A stratified analysis of the degree of placental accreta showed that in
superficial placental accreta patients, internal iliac artery ligation had no
advantage over uterine artery ligation except for a longer operative time; in
deep placental accreta patients, there was no significant difference between
internal iliac artery ligation and uterine artery ligation in terms of operative
time, intraoperative bleeding or blood transfusion volume (p
The statistical results of this study also showed that prophylactic internal
iliac artery ligation was associated with lower intraoperative bleeding,
transfusion and postoperative transfusion volumes and lower ICU admission rates
compared with therapeutic ligation, and prophylactic ligation was also associated
with less intraoperative bleeding than therapeutic ligation in patients who
underwent hysterectomy (p
It is worth noting that a recent study reported that [25] placental accreta is a risk factor for amniotic fluid embolism (AFE), and when stratified by placental accreta spectrum subtypes, more severe forms of placental accreta spectrum had a greater association with AFE. AFE is a rare complication of childbirth, its clinical characteristics are sudden onset, dangerous and unpredictable, which can lead to severe adverse outcomes such as disability and death of maternal and fetal. The incidence of AFE is very low, with clinical reports of (1.7–7.7) per 100,000, but the mortality rate is as high as 19–86% [26, 27, 28]. The study found that failure to rescue after AFE exceeded 30% when AFE occurred in the setting of placental pathology: 42.9% for AFE and placenta accreta spectrum (PAS) [25]. Although none of the 199 patients in this study developed AFE, AFE may be a complication of placenta previa, placenta accreta, postpartum hemorrhage and so on. Once it occurs, it will cause great harm. Therefore, in clinical work, we should pay special attention to and prevent AFE in advance, because appropriate prevention and treatment can avoid the tragedy of maternal death.
In conclusion, vascular ligation is an effective means of managing high-risk obstetric hemorrhage, helping to avoid hysterectomy and unplanned reoperation and improving patient prognosis, although, of course, the surgeon needs to choose a suitable hemostatic modality according to the patients’ condition and his or her skills. This study was a retrospective analysis, and the choice of intraoperative hemostatic modality is biased. Prospective studies on the choice and timing of vascular ligation are needed to identify better treatment options for pernicious placenta previa patients.
The datasets that support the findings of this study are available from the corresponding author upon reasonable written request.
XDF, LJB designed the research study. LJB, JL, QNS collected data. JL, QNS analyzed the data. LJB drafted the manuscript. XDF, LJB revised it. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work to take public responsibility for appropriate portions of the content and agreed to be accountable for all aspects of the work in ensuring that questions related to its accuracy or integrity.
This study has been approved by the Clinical Trial Ethics Committee, Affiliated Hospital of Southwest Medical University, and the ethical approval number is KY2022237. This study was approved by the Ethical Committee of our hospital. Written informed consent was signed from all participants. The study was carried out under senior surgeons following standard techniques and regulations.
Our sincere gratitude goes to the management and staff of the Department of Gynecology and Obstetrics, the Affiliated Hospital of Southwest Medical University during the study period for their support and for assisting with data collection. Thanks to all the peer reviewers for their opinions and suggestions.
This project was supported by the Sichuan Provincial Science and Technology Program (Grant No: 2021JDR0185) and Science and Technology Project of Luzhou City (Grant No: 2020-SYF-27).
The authors declare no conflict of interest.
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