doi:10.1111/jog.13215 J. Obstet. Gynaecol. Res.

2016

Conservative management of post-partum hemorrhage

secondary to placenta previaaccreta with hypogastric artery
ligation and endo-uterine hemostatic suture

Melekoglu Rauf1, Celik Ebru1, Eraslan Sevil1 and Buyukkurt Selim2

1
Department of Obstetrics and Gynecology, Faculty of Medicine, University of Inonu, Malatya and 2Department of Obstetrics and
Gynecology, Faculty of Medicine, University of Cukurova, Adana, Turkey

Abstract
Aim: The aim of this study was to investigate maternal and neonatal outcomes of conservative management of
post-partum hemorrhage due to placenta previaaccreta using hypogastric artery ligation and endo-uterine he-
mostatic suture to lower uterine segment.
Methods: The records of 38 patients who were managed conservatively with hypogastric artery ligation and
endo-uterine hemostatic suture to control post-partum hemorrhage secondary to placenta previaaccreta between
April 2014 and January 2016, were reviewed retrospectively. Placenta previaaccreta was diagnosed according to
gray-scale, color and 3-D power Doppler ultrasonography in addition to the intraoperative ndings based on
fragmentary or difcult separation of the placenta. In the case of conservative treatment protocol failure, cesarean
hysterectomy was performed.
Results: Of these patients, 55.2% were between 25 and 35 years old; 97.5% were multiparous; 71.2% had two or
more previous cesarean section and 68.5% had preterm delivery. Women with placenta accreta had a median
estimated blood loss of 450 mL; 57.8% of patients had blood transfusion (mean intraoperative transfusion, 2 units
packed red blood cells; range, 09 units). Median duration of operation was 112.5 min (range, 45305 min) and 32
patients (84.3%) with placenta accreta did not undergo cesarean hysterectomy.
Conclusion: Conservative treatment of post-partum hemorrhage secondary to placenta previaaccreta with
hypogastric artery ligation and endo-uterine hemostatic sutures to the lower segment of the uterus is associated
with lower hysterectomy rate compared with the other conservative methods reported in the literature.
Key words: iliac artery, ligation, placenta accreta, placenta previa, post-partum hemorrhage.

Introduction one of the leading causes of peripartum hysterectomy.3

Placenta accreta is dened as a life-threatening condition
characterized by abnormal adhesion of placental villi to
the myometrium due to the absence or defect of
Nitabuch layer and decidua basalis.1 In the last 30 years,
the incidence of placenta accreta has increased dramati-
cally with increased cesarean delivery rates, and is re-
ported at between 1/530 and 1/2500 in developed
countries.2 Placenta accreta has become one of the lead-
ing causes of maternal morbidity and mortality and is
The optimal management of placenta accreta remains
the subject of debate. The extirpative approach involves
manual removal of the placenta and is associated with
massive hemorrhage and emergency hysterectomy.4
The preferred method is cesarean hysterectomy without
placental separation,5,6 but this removes the option of fu-
ture pregnancy, and it is associated with severe morbid-
ity in patients with placenta accreta.2,4 Conservative
management is dened as any approach that spares the
uterus.7 A recent large multicenter study reported a

Received: July 11 2016.

Accepted: September 23 2016.
Correspondence: Assistant Professor Rauf Melekoglu, Department of Obstetrics and Gynecology, Faculty of Medicine, University of Inonu,
44280, Malatya, Turkey. Email: rmelekoglu@gmail.com

2016 Japan Society of Obstetrics and Gynecology 1

M. Rauf et al.
78.4% uterus preservation rate, with 6% severe maternal
morbidity with conservative management.8 The surgical
principles of conservative management involve
avoiding disruption of the hypervascular placenta, step-
wise devascularization, early comprehensive blood
product transfusion and use of interventional radiology
techniques such as vascular embolization.911
In this study, we investigated the maternal and neona-
tal outcomes of conservative management of post-
partum hemorrhage due to placenta previaaccreta
using hypogastric artery ligation and endo-uterine
hemostatic suture to lower uterine segment.
Methods
The study was approved by the Ethics Committee of
Inonu University School of Medicine (Ethics Approval
Number: 2016/156). The records of patients who were
managed conservatively with prophylactic hypogastric
artery ligation and endo-uterine hemostatic suture to
2 2016 Japan Society of Obstetrics and Gynecology
lower uterine segment to control post-partum hemor-
rhage secondary to placenta previaaccreta during April
2014January 2016 at Inonu University School of Medi-
cine Department of Obstetrics and Gynecology, were
reviewed retrospectively. Any patient with diagnosed
placenta previaaccreta in the antenatal period and 24
weeks of gestation, and who had a live fetus on admis-
sion was included in the study. A total of 49 patients
had surgery due to placenta accreta, and eight of these
patients did not accept conservative management after
comprehensive counselling. Of the remaining 41 patients
who underwent conservative treatment, immediate
hysterectomy was required in three patients due to
deep placental invasion to the broad ligaments and
retroperitoneum (Fig. 1). Placenta previaaccreta was di-
agnosed according to gray-scale, color and 3-D power
Doppler ultrasonography, in addition to the intraopera-
tive ndings based on fragmentary or difcult separa-
tion of the placenta. The conservative management
surgical protocol for post-partum hemorrhage due to
placenta previaaccreta consists of the following steps.
Figure 1 Subject selection.

First, comprehensive counseling and obtaining of in-
formed consent, and ensuring the availability of all
blood products in the operation room in the case of intra-
operative bleeding before surgery. Second, insertion of a
central venous catheter prior to surgery, in addition to
the large peripheral vascular access point. Third, use of
Pfannenstiels abdominal incision for the cesarean sec-
tion. After entering the peritoneal cavity, rejection of
the bladder is done with cautious hemostasis of vessels
between the uterine serosa and posterior bladder wall
by electrocautery or suturing. Uterine incision is imple-
mented from the upper segment to avoid placental dis-
ruption. The placenta is left in place after umbilical
cord clamping. Fourth, bilateral hypogastric (internal il-
iac) artery ligation is performed by entering the bilateral
retroperitoneal area via inferolateral incision at the level
of the sacral promontorium from the posterior aspect of
the uterus after palpation of the common iliac artery bi-
furcation and observation of the urether. Once the com-
mon iliac artery is identied, and the right-angled
clamp passed under the internal iliac artery, internal iliac
artery ligation is performed (Fig. 2). Fifth, manual re-
moval of the placenta. Sixth, cross (x-mattress) sutures
Figure 2 (a) Inferolateral incision at
the level of the sacral
promontorium from the posterior
aspect of the uterus; (b) common
iliac artery, external iliac artery,
hypogastric (internal iliac) artery
and urether; (c) right-angled clamp
passed under the internal iliac
artery; and (d) internal iliac artery
ligation.
2016 Japan Society of Obstetrics and Gynecology
Hypogastric artery ligation for previa
are applied to the placental bed with no:1.0 vicryl (70-
mm circular needle; Ethicon, Sommerville, NJ, USA) un-
til bleeding control is achieved. Seventh, single-layer clo-
sure of the hysterectomy incision is carried out with 1.0
Vicryl. Eighth, completion of operation after bleeding
has been controlled and fascia, subcutaneous tissue and
skin closed using a regular technique. In cases of failure
of conservative treatment protocol, cesarean hysterec-
tomy is performed. Failure is dened as ongoing hemor-
rhage or cardiovascular instability or hemorrhagic shock
or disseminated intravascular coagulopathy despite
conservative management. Monitoring of hematologic
parameters is done 24 h before the procedure, intraoper-
atively, and at 2 and 6 h postoperatively. Blood transfu-
sion during operation is carried out based on the
patients vital signs, estimated intraoperative blood loss
and intraoperative hemoglobin; in the postoperative
period, blood transfusion was carried out in the case of
hemoglobin < 7 g/dL.
Statistical Analysis
Descriptive characteristics were calculated for the vari-
ables of interest. Continuous and categorical variables
3
M. Rauf et al.

are given as median and mean SD. IBM SPSS 23.0 Women with placenta accreta had a median estimated
(SPSS, Chicago, Ill., USA) was used for all data blood loss of 450 mL, and 57.8% of patients had blood
analyses. transfusion with mean intraoperative transfusion,
2 units packed red blood cells (RBC; range, 09 units).
Median length of endo-uterine x-mattress sutures at
Results procedure was 14.5 (mean, 14.47; range, 1020). Median
duration of operation was 112.5 min (range, 45305 min),
Data were collected from 38 patients with suspected pla- and 32 patients with placenta accreta did not undergo
centa previaaccreta before delivery and conrmation cesarean hysterectomy. One vascular complication and
during surgery between April 2014 and January 2016, four urinary complications occurred (Table 2).
at Inonu University School of Medicine Turgut Ozal The majority of cesarean sections were planned for
Medical Centre. Of these patients 55.2% were 2535 3437 weeks of gestation, in order to reduce morbidity
years old; 97.5% were multiparous; 71. 2% had two or and mortality due to placenta accreta. Antenatal hemor-
more previous cesarean sections, and 68.5% had preterm rhage was the common indication in patients with pre-
delivery (Table 1). Only two women had a prior medical term delivery before 34 weeks of gestation. Consistent
history of post-partum hemorrhage (5.2%). Body mass with the fact that the majority of deliveries were preterm,
index and preoperative laboratory parameters are listed 26.3% of neonates required neonatal intensive care.
in Table 1. Mean cord blood pH was 7.30 (range, 7.087.49), and
no neonatal deaths occurred. Other neonatal outcomes
are listed in Table 3.
In the postoperative period, the need for blood trans-
Table 1 Placenta accreta: Maternal subject characteristics fusion was lower (median, 0 units postoperative packed
Parameters (n = 38) RBC; range, 03 units), and there was no need for fresh
Age (y) frozen plasma or platelet transfusion. A total of 47.3%
Younger than 25 4 (10.5) of patients required intensive care (Table 4).
25-34,9 21 (55.2)
35 or older 13 (34.3)
Number of prior pregnancies 20
wk of gestation or greater Discussion
0 (nulliparous) 1 (2.5)
1 10 (26.3) In this study, we have demonstrated that conservative
2 16 (42.1) management is associated with a substantial decrease
3 or more 11 (29.1) in cesarean hysterectomy for post-partum hemorrhage
Number of previous cesarean
section due to placenta previaaccreta. Also, bilateral hypogas-
0 (nulliparous) 2 (5.2) tric artery ligation after delivery, and avoidance of dis-
1 9 (23.6) ruption of the placenta are associated with decreased
2 16 (42.1) intraoperative blood loss and, in parallel with this nd-
3 or more 11 (29.1) ing, decreased need for preoperative and postoperative
Previous medical history of 2 (5.2)
postpartum hemorrhage blood products transfusion. Also, we hypothesized that
Gestational age at delivery (week) use of endo-uterine hemostatic x-mattress sutures to
37 12 (31.5) the placental bed after delivery of the placenta is bene-
34- <37 15 (39.4) cial for bleeding control. In contrast, Bailit et al. showed
28-<34 5 (13.1) that women with prenatally suspected morbidly adher-
<28 6 (16)
BMI 30 (19-39) ent placenta had massive blood loss (33%) and need for
Preoperative hemoglobin 12.0 (6.8-13.9) hysterectomy (92%).12 They reviewed a cohort of
value (g/dL) 115 502 women and their neonates born in 25 hospitals
Preoperative platelet 219 (118-577) in the USA over a 3-year period. The difference in the re-
value (103/mL) sults between the studies may be due to the fact that the
Preoperative INR value 0.9 (0.8-1.1)
Preoperative APTT value 27.6 (20.9-33.2) Bailit et al. outcomes were compared according to
therapeutic intervention (i.e. hysterectomy, uterine ar-
Data are given as n (%). Data are presented as median
[interquartile range]. APTT, activated partial thromboplastin time; tery ligation, hypogastric artery ligation, B-Lynch suture,
BMI, body mass index; INR, international normalized ratio. balloon tamponade), and due to variations in

4 2016 Japan Society of Obstetrics and Gynecology

 Hypogastric artery ligation for previa

Table 2 Conservative treatment: Perioperative outcomes

Perioperative Outcomes
Duration of operation (min) 112.5 (45305)
Intraoperative hemoglobin value (g/dL) 9.4 (4.712.6)
Estimated intraoperative blood loss (ml) 450 (1502500)
Intraoperative units of packed RBCs transfused 2 (09)
Intraoperative units of fresh frozen plasma transfused 0.5 (03)
Intraoperative units of platelets transfused 0 (01)
Endouterine suture number 14.5 (1020)
Vascular complication 1 (2.6)
Urinary complication 4 (10.5)
Cesarean hysterectomy 6 (15.7)
Success of conservative treatment (uterine preservation) 32 (84.3)
Data are given as n (%). Data are presented as median [interquartile range].

the present study, Chandraharan et al. described their

Table 3 Placenta accreta: Neonatal outcomes
procedure as triple P in 2006, and they reported remark-
Neonatal outcomes ably low blood loss, ranging from 800 to 1500 mL per pa-
Birth weight (gr) 2637.5 (4204025) tient.13 A follow-up cohort study by the same group
Birth height (cm) 48 (2851) showed a reduction in estimated blood loss, need for de-
1. min APGAR score 6 (28)
layed hysterectomy, and length of inpatient stay com-
5. min APGAR score 8.5 (310)
Cord blood pH 7.30 (7.087.49) pared with leaving the placenta in situ plus arterial
Neonatal intensive care unit 10 (26.3) occlusion.14 In a recent review on the conservative man-
admission agement of morbidly adherent placenta, Fox et al. re-
Data are given as n (%). Data are presented as median ported that conservative methods should be considered
[interquartile range]. only in combination with preparation for immediate
conversion to hysterectomy. They also suggested that
the clinical team must be willing to abandon conserva-
Table 4 Conservative treatment: Postoperative outcomes tive management efforts, and clear endpoints must be
Postoperative outcomes established before surgery. Because a large proportion
Postoperative 2nd hour hemoglobin 9.8 (4.312.9) of conservatively managed patients require delayed
value (g/dL) hysterectomy, they proposed that all cases be considered
Postoperative 6th hour hemoglobin 10.4 (7.213.1) a trial of conservative management and monitored ac-
value (g/dL) cordingly in the postoperative period.7
Postoperative units of packed RBCs 0 (03)
The success rate of bilateral hypogastric artery ligation
transfused
Postoperative units of fresh frozen 0 (0) is reported at between 40% and 100% in various series.15
plasma transfused The procedure requires high skill and experience be-
Postoperative units of platelets 0 (0) cause the operator must be familiar with retroperitoneal
transfused anatomy and potential complications of the procedure.
Transfer to intensive care unit 18 (47.3)
For this reason, in many centers, preoperative placement
Duration of hospitalization 4 (212)
of balloon occlusion catheter into the bilateral hypogas-
Data are given as n (%). Data are presented as mean SD (range)
and median [interquartile range].
tric arteries is commonly planned to avoid hemorrhagic
morbidity. This procedure is available only in a small
number of centers with experienced interventional radi-
preoperative, perioperative and postoperative evalua- ologists, and it has been found that the technique is not
tion as a result of variation in hospitals and surgeon as efcient as expected.16 Greenberg et al. performed a
experience. In the present study, all of the surgical literature review on prophylactic balloon occlusion of
procedures were carried out by the same clinicians in the internal iliac arteries to treat abnormal placentation,
accordance with the aforementioned algorithm. Also, and suggested the careful use of this modality with in-
all of the patients were evaluated preoperatively and tense vascular surveillance for vascular complications.17
postoperatively by the same group experienced in Also, Clausen et al. reported 17 cases of placenta
management of high-risk pregnancies. Consistent with percreata treated with balloon occlusion, and

2016 Japan Society of Obstetrics and Gynecology 5

M. Rauf et al.
hysterectomy was added to the procedure in eight of
these patients. The mean intraoperative blood loss for
the eight women who had a hysterectomy was 5490
mL (range, 45016 000 mL), and the average duration
of hysterectomy was 133 min (range, 65205 min).18 In
the present study, the median estimated blood loss was
450 mL, and the median operation time was 112.5 min
(range, 45305 min). We prefer bilateral hypogastric ar-
tery ligation for the management of morbidly adherent
placenta because it appears to be safe and efcient, and
easy to perform for the treatment of hemorrhage due to
placenta accreta.
Several studies have demonstrated that B-Lynch su-
ture is benecial to control post-partum hemorrhage.19
In this procedure, compression of the uterus via the com-
pression sutures provides self-tamponade for bleeding
control. B-Lynch suture is useful only for uterine atony
rather than post-partum hemorrhage in placenta
previaaccreta. It has no applicability in hemorrhage
control due to uterine rupture or bleeding from vaginal
lacerations.15 Additionally, infection, ischemic necrosis
and synechia have been reported after compression
techniques, negatively affecting subsequent fertility out-
come.20 Bilateral hypogastric artery ligation is useful in
the treatment of post-partum hemorrhage due to several
factors, and it does not seem to affect menstruation or
fertility outcomes adversely.21
Eller et al. analyzed 76 cases of placenta accreta, and
noted that placenta removal signicantly increased ma-
ternal morbidity (67% vs 36%, P = 0.038).4 Also, it was
suggested that avoidance of placenta removal in the
morbidly adherent placenta is essential (especially when
the placenta invades the bladder, cervix, broad liga-
ments, or retroperitoneum), due to difcult hemostatic
control.7 For this reason, we removed the placenta in
fragments, only after performing bilateral hypogastric
artery ligation, due to the benecial effect of the proce-
dure on hemostasis. The mechanism of hemostasis in
bilateral hypogastric artery ligation may be due to the
49% decrease in pelvic blood ow and 85% reduction
in arterial pressure associated with the procedure.22
Although the placenta was removed in fragments, no
clinical or ultrasonographic sign of endometritis or
placenta retention was seen at 1-week follow-up.
Hypogastric artery ligation has been described as part
of a stepwise devascularization technique for post-
partum hemorrhage.23 Although there are several case
series in the literature, the exact complication rates are
not clear. In the present study we encountered one
vascular complication due to hypogastric artery injury
during hypogastric artery ligation. In that case, a
6 2016 Japan Society of Obstetrics and Gynecology
vascular surgeon was involved in the surgical team,
and hypogastric artery repair was performed. There
were also four cases of urinary complication, and all of
them were bladder injury. The total complication rate
of the procedure was 5/38 (13.1%). The potential compli-
cations of hypogastric artery ligation have been dened
as hypogastric vein injury, laceration or ligation of
uretery, external iliac artery ligation and peripheral
nerve injury. Different complication rates have been re-
ported in various series. The exact rate of the procedure
is unclear and depends on operator experience.24
In conclusion, conservative treatment of post-partum
hemorrhage secondary to placenta previaaccreta with
hypogastric artery ligation and endo-uterine hemostatic
suture to the lower segment of the uterus is associated
with lower hysterectomy rate compared with other con-
servative methods reported in the literature. Particularly
in patients with future pregnancy desire, this conserva-
tive surgery technique could be performed with compre-
hensive patient counseling and adequate preoperative
preparation.
Disclosure
The authors declare no conicts of interest.
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