Placenta Accreta Spectrum Outcomes Using Tourniquet and Forceps for Vascular Control

Abstract

Objective: To evaluate the use of tourniquet and forceps to reduce bleeding during surgical treatment of severe placenta accreta spectrum (placenta increta and placenta percreta).Methods: A tourniquet was used in the lower part of the uterus during surgical treatment of severe placenta accreta spectrum. Severe placenta accreta spectrum was classified into two types according to the relative position of the placenta and tourniquet during surgery: upper-tourniquet type, in which the entire placenta was above the tourniquet, and lower-tourniquet type, in which part or all of the placenta was below the tourniquet. The surgical effects of the two types were retrospectively compared. We then added forceps to the lower-tourniquet group to achieve further bleeding reduction. Finally, the surgical effects of the two types were prospectively compared.Results: During the retrospective phase, patients in the lower-tourniquet group experienced more severe symptoms than did patients in the upper-tourniquet group, based on mean intraoperative blood loss (upper-tourniquet group 787.5 ml, lower-tourniquet group 1434.4 ml) intensive care unit admission rate (upper-tourniquet group 1.0%, lower-tourniquet group 33.3%), and length of hospital stay (upper-tourniquet group 10.2d, lower-tourniquet group 12.1d). During the prospective phase, after introduction of the revised surgical method involving forceps (in the lower-tourniquet group), the lower-tourniquet group exhibited improvements in the above indicators (intraoperative average blood loss 722.9 ml, intensive care unit admission rate 4.3%, hospital stays 9.0d). No increase in the rate of complications was observed.Conclusion: The relative positions of the placenta and tourniquet may influence the perioperative risk of severe placenta accreta spectrum. The method using a tourniquet (and forceps if necessary) can improve the surgical effect in cases of severe placenta accreta spectrum.

Tourniquet on the low segment of the uterus reduces blood loss in postpartum hemorrhage during hysterectomy for placenta accreta: Old but gold

“…The expected result is a reduction in blood loss of 750 ml, a hypothesis consistent with the literature [16] , [17] . Thus, to detect a difference of 0.75 l between the means of blood loss for a power of 90% and an alpha risk of 5%, the size of each group must be 22 patients [18] , [19] .…”

The use of the double uterine segment tourniquet in obstetric hysterectomy for bleeding control in patients with placenta accreta spectrum

“…The most important factors that contribute to prolonged length of stay for hysterectomy are trans-operative complications. 14,15 The pre-surgical hemoglobin and degree of invasion are factors that may influence surgical outcomes, but the two groups were uniformly distributed and thus control their influence on the outcomes. As a rule, for better surgical results all patients should be in optimal physiological condition before the surgery, with at least a hemoglobin level of 11 mg/dL as suggested by Agrawal et al 15 Generally, elective surgeries have better outcomes compared with emergency surgeries.…”

“…Even though we found no statistical differences in bladder lesions, we observed an increased length of stay for the group without a tourniquet. The most important factors that contribute to prolonged length of stay for hysterectomy are trans‐operative complications 14,15 . The pre‐surgical hemoglobin and degree of invasion are factors that may influence surgical outcomes, but the two groups were uniformly distributed and thus control their influence on the outcomes.…”

Response: Double tourniquets for cesarean hysterectomy for placenta accreta spectrum—Surgical technique explanation

“…at the top of the vagina; Figure 1b); this blocks the cervicovaginal branch of the uterine artery, the cervical artery, and the ascending branch of the vaginal artery. Studies report that approximately 67% of the blood supply to the cervical artery originates from the uterine artery, 23% originates from the vaginal artery, and 10% originates from the inferior vesical artery 2,3 . Therefore, the blood supply differs between the implantation positions of the placenta.…”