Transverse uterine fundal incision for placenta praevia with accreta, involving the entire anterior uterine wall: a case series

Abstract

Objective To determine the feasibility and safety of transverse fundal incision with manual placental removal in women with placenta praevia and possible placenta accreta. Design Case series. Setting Four level‐three Japanese obstetric centres. Population Thirty‐four women with prior caesarean section and placenta praevia that widely covers the anterior uterine wall, in whom placenta accreta cannot be ruled out. Methods A transverse fundal incision was performed at the time of caesarean section and manual placental removal was attempted under direct observation. Main outcome measure Operative fluid loss. Results The total volume of fluid lost during our operative procedure compares favourably with the volume lost during our routine transverse lower‐segment caesarean sections performed in patients without placenta praevia or accreta. The average fluid loss was 1370 g. No patients required transfer to intensive care, and there were no cases of fetal anaemia. Conclusions This procedure has the potential to reduce the heavy bleeding that arises from caesarean deliveries in women with placenta praevia and placenta accreta.

Authors' reply: Transverse uterine fundal incision for placenta praevia with accreta

“…Moreover, a large transverse uterine incision allows the precise placement of haemostatic sutures, even in the lowest segment of the uterus. 1 The muscular layer at the uterine fundus is not as thick as we had previously thought: the thickness of the uterine myometrium is gradually reduced towards the uterine fundus. 4 Therefore, our technique involves minimal bleeding from the surgical wound in the uterine fundus, and any bleeding can easily be controlled.…”

“…when other operative procedures are considered too risky in women who desire a future pregnancy. 1 We often perform the technique described by Dr Marasinghe in women with placenta praevia accreta, and understand and agree that a high transverse incision in the upper uterine segment allows a shorter and lower transverse skin incision and precise placement of sutures with direct visualisation of the bleeding point from the detached placental plane. We disagree, however, that the placement of sutures in the lower segment through a fundal incision is more difficult than with the approach through a high transverse incision.…”

Transverse uterine fundal incision for anterior placenta praevia accreta: More harm than good?

“…We read with interest the paper by Kotsuji et al 1 who are proposing a transverse uterine fundal incision for the delivery of pregnancies complicated by placenta praevia with accreta. We agree with the authors that this technique is likely to be associated with a higher rate of uterine rupture before and during labour in subsequent pregnancies, probably similar to that observed after classical caesarean section.…”

Author's reply

“…I read with interest the response to my mini-commentary entitled, 'Clarifying when to recommend progesterone to prevent preterm birth: clear as mud', by Dr Martinez de Tejada et al The issue in question is not why this well-designed, randomised, double-blind, placebo-controlled study was terminated early-this was made clear in both the original article 1 and reiterated again in almost identical terms in the authors' response letter-but whether this decision was reasonable.…”