Letters to the Editor—Brief Communications / European Journal of Obstetrics & Gynecology and Reproductive Biology 181 (2014) 338–346
Snowman sign: a possible predictor of catastrophic abnormal placentation Keywords: Placenta percreta Cesarean hysterectomy Prediction
Dear Editors, While ultrasonographic evaluation is a useful tool to predict the presence of abnormal placentation such as placenta percreta, there are few reliable predictors of massive blood loss and surgical difficulty [1]. Therefore, any sign associated with abnormal placentation leading to catastrophic blood loss will be useful to guide the surgical preparation and approach to peripartum hysterectomy. Here, we report two cases of placenta percreta resulted in large blood loss proposing a possible sign that may predict such complexity of surgery. Case 1 A 31-year-old, gravida 7, para 3-2-1-5, Caucasian at 332/7 weeks gestation, with history of five prior abdominal deliveries, and idiopathic thrombocytopenic purpura (ITP) that was well controlled with medical management, underwent elective cesarean section for complete placenta previa and suspected placenta accreta. The fetus was delivered via classical hysterotomy, with birth weight 2260 g and Apgar scores 7 and 8 at 1 and 5 min, respectively. After the delivery of fetus, the uterus was found to have a significantly enlarged lower uterine segment (LUS) extending to the bilateral pelvic sidewalls. In addition, there were extensive venous plexus covering the surface of the LUS and the bladder. Gynecologic oncology service was intraoperatively consulted to proceed with hysterectomy. The enlarged LUS with venous plexus required modified radical hysterectomy to unroof the ureteral tunnels and to approach paracorpium in order to complete the surgery. The estimated blood loss was 10 l, and the patient received massive transfusion including 12 units of packed
341
red blood cells (PRBC), 10 units of fresh frozen plasma (FFP), 10 units of cryoprecipitate, and 2.5 l of self-salvaged blood. Aortic compression was performed to control bleeding. Histopathologic evaluation confirmed placenta percreta. Case 2 A 39-year-old, gravid 5 para 3-0-1-3 Hispanic at 350/7 weeks gestation with prior three abdominal deliveries underwent elective cesarean section for placenta previa and suspected placenta percreta. The fetus was delivered via classical hysterotomy with birth weight of 2530 g and Apgar scores of 7 and 8 in 1 and 5 min, respectively. Given the enlarged LUS reaching to the bilateral pelvic side walls and extensive venous plexus in the LUS and bladder surface, gynecologic oncologists were intraoperatively consulted to proceed hysterectomy. The LUS was enlarged nearly twice larger than the uterine fundus. The enlarged LUS required modified radical hysterectomy to unroof the ureteral tunnels and to complete the surgery. Due to the placental invasion into the bladder, intentional cystotomy was also performed. Estimated blood loss was 2.5 l and 3 units of PRBC and 1 unit of FFP were intraoperatively administered. Histopathology evaluation confirmed placenta percreta. Peripartum hysterectomy has a significant risk of mortality compared to non-obstetrical hysterectomy (1% versus 0.04%, odds ratio 14.4, p < 0.0001) [2,3]. Amongst indications for peripartum hysterectomy, abnormal placentation such as placenta accreta, increta, or percreta makes hysterectomy substantially difficult, resulting in massive blood loss (mean 3 l) [1]. In our case reports, we described the macroscopic findings of uterus with placenta percreta. Hysterectomy specimens of placenta percreta are shown in Fig. 1A for Case 1 and Fig. 1B for Case 2. In each, due to deep placental invasion into the myometrium of the LUS, the size of the LUS after cesarean delivery can be substantially larger than the uterine fundus as experienced in our two cases, proposing a snowman sign to describe this finding. Practically, the snowman sign is evaluable after the delivery of fetus and closure of hysterotomy scar for cesarean delivery. Thus, this is the moment and step of surgery that the surgeons need to evaluate if there is a sign in the uterus that reflects the retained morbidly adherent
Fig. 1. Macroscopic findings of uterus with placenta percreta. The uteruses for Case 1 (panel A) and Case 2 (panel B) are shown, respectively. Abbreviation: LUS, lower uterine segment.
Letters to the Editor—Brief Communications / European Journal of Obstetrics & Gynecology and Reproductive Biology 181 (2014) 338–346
342
placenta in the LUS. In the event of a snowman sign during cesarean delivery, it is speculated that (i) it could predict large blood loss during cesarean hysterectomy and (ii) radical procedures may be required by experienced pelvic surgeons. Conversely, with absence of snowman sign, cesarean hysterectomy may be performed with less complication even abnormal placentation is suspected. Whether snowman sign reflects placenta accreta or percreta is not known, and further study will be needed. References [1] Wright JD, Pri-Paz S, Herzog TJ, Shah M, Bonanno C, Lewin SN, et al. Predictors of massive blood loss in women with placenta accreta. Am J Obstet Gynecol 2011;205. 38 e1-6. [2] Wright JD, Devine P, Shah M, Gaddipati S, Lewin SN, Simpson LL, et al. Morbidity and mortality of peripartum hysterectomy. Obstet Gynecol 2010;115:1187–93. [3] Wright JD, Bonanno C, Shah M, Gaddipati S, Devine P. Peripartum hysterectomy. Obstet Gynecol 2010;116:429–34.
a
Koji Matsuoa,b,* Division of Gynecologic Oncology, Los Angeles County Medical Center, University of Southern California, 2020 Zonal Avenue, Los Angeles, CA 90033, USA b Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA 90033, USA
Charlotte L. Conturie Department of Obstetrics and Gynecology, Los Angeles County Medical Center, University of Southern California, 2020 Zonal Avenue, Los Angeles, CA 90033, USA Richard H. Lee Division of Maternal-fetal Medicine, Los Angeles County Medical Center, University of Southern California, 2020 Zonal Avenue, Los Angeles, CA 90033, USA *Corresponding author at: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Los Angeles County Medical Center, University of Southern California, 2020 Zonal Avenue, IRD 520, Los Angeles, CA 90033, USA. Tel.: +1 323 226 3416; fax: +1 323 226 3427 E-mail address: [email protected] (K. Matsuo). Received 25 March 2014 http://dx.doi.org/10.1016/j.ejogrb.2014.07.035
Use of haemostatic matrix to arrest a massive obstetric haemorrhage from a posterior vaginal wall haematoma Dear Editors, This case of a massive rectovaginal haematoma demonstrates the safety and usefulness of haemostatic agents to arrest potentially life threatening bleeding. If surgical techniques are unsuccessful, recourse to more novel haemostatic agents-including FLOSEALTM and EVICELTM should be considered. A 35 year old multiple, delivered vaginally at Whipps’ Cross University Hospital. Our unit is one of 3 acute hospitals within an NHS trust with the main embolisation unit 5 miles away. Our patient’s labour was complicated by a massive haemorrhage of 3500 ml from a rectovaginal haematoma, associated with haemodynamic compromise. She was transferred to theatre and resuscitated with intravenous fluids, and blood products (4 units of red cells and 4 units of
fresh frozen plasma). On examination under general anaesthesia, the posterior wall haematoma was vertically incised and over 1000 ml of blood evacuated. Intractable generalised bleeding from the posterior wall could not be controlled with conventional surgical measures and vaginal packing, leading to a rapid haemorrhage of 3500 ml. Embolisation was not immediately available thus temporary haemostasis was achieved through further tight packing with surgical gauze and a haemostatic agent, applied to the base of the cavity. Imaging confirmed no evidence of retro-peritoneal or intraperitoneal extension of the haematoma negating the need for transfer for embolisation. After 24 h stabilisation in ITU, the vaginal pack was removed under anaesthesia, and the vagina wall repaired without further complications. There has been a decline in deaths from haemorrhage (CMACE 2006–2008), due in part to increased vigilance and following use of various haemostatic methods, including B-Lynch sutures, interventional radiology, hysterectomy and the use of haemostatic agents, from 14 in the 2003–2005 triennia (0.66/100,000) to 9 in 2006–2008 (0.39/100,000) [1]. Vulvo-vaginal haematoma is a recognised cause of lifethreatening haemorrhage, occurring in 1:300–1:1500 deliveries, usually in association with other vaginal or perineal trauma but sometimes in isolation [2]. The bleeding source is usually from descending branches of the uterine artery [2]. In our case the bleeding was probably from the submucous plexus rather than the adventitious plexus of the vaginal vein, as the former plexus tends to be thinner and more varicose. Selective arterial embolisation and balloon tamponade have both been used to control haematomas resistant to conventional surgical intervention. Our case is the first reported where a haemostatic agent has been used to arrest bleeding in the presence of vaginal haematoma. Haemostats are a combination of reconstituted human thrombin together with a gelatin, collagen, and cellulose matrix that have been shown to work on actively bleeding tissue. They act on the coagulation cascade from two angles: Firstly, the cellulose matrix acts on the intrinsic pathway, and secondly the reconstituted thrombin acts at the common pathway, leading to the conversion of fibrin from fibrinogen, thereby aiding clot formation. Case reports exist describing use of haemostats in obstetrics to treat complex vaginal lacerations [3] and massive haemorrhages complicated by impaired coagulation [4,5]. One case describes an emergency caesarean and peri-partum hysterectomy resulting in disseminated intra-vascular coagulation [4]. In the other case, haemorrhage resulted from a vacuum delivery in a patient with maternal coagulopathy [5]. Haemostats have also been used effectively in both elective and emergency gynaecological procedures such as myomectomy, ovarian cystectomy, and more recently for an abdominal ectopic pregnancy management. This case demonstrates the importance of prompt treatment of life-threatening haemorrhage using novel haemostatic techniques if meticulous surgical techniques are unsuccessful in stemming the bleeding. Haemostatic agents should be considered in addition to the more traditional techniques of balloon tamponade or embolisation. References [1] Saving Mothers Lives, Reviewing Maternal Deaths to make Motherhood Safer: 2003–2005 The 7th report of the Confidential Enquiry into Maternal and Child Health; December 2007. [2] Ridgway LE. Puerperal emergency. Vaginal and vulvar hematomas. Obstet Gynecol Clin North Am 1995;22(2):275. [3] Whiteside JL, Asif RB, Novello RJ. Fibrin sealant for management of complicated obstetric lacerations. Obstet Gynecol 2010;115(February (2 Pt. 2)):403–4.
Snowman sign: a possible predictor of catastrophic abnormal placentation Keywords: Placenta percreta Cesarean hysterectomy Prediction
Dear Editors, While ultrasonographic evaluation is a useful tool to predict the presence of abnormal placentation such as placenta percreta, there are few reliable predictors of massive blood loss and surgical difficulty [1]. Therefore, any sign associated with abnormal placentation leading to catastrophic blood loss will be useful to guide the surgical preparation and approach to peripartum hysterectomy. Here, we report two cases of placenta percreta resulted in large blood loss proposing a possible sign that may predict such complexity of surgery. Case 1 A 31-year-old, gravida 7, para 3-2-1-5, Caucasian at 332/7 weeks gestation, with history of five prior abdominal deliveries, and idiopathic thrombocytopenic purpura (ITP) that was well controlled with medical management, underwent elective cesarean section for complete placenta previa and suspected placenta accreta. The fetus was delivered via classical hysterotomy, with birth weight 2260 g and Apgar scores 7 and 8 at 1 and 5 min, respectively. After the delivery of fetus, the uterus was found to have a significantly enlarged lower uterine segment (LUS) extending to the bilateral pelvic sidewalls. In addition, there were extensive venous plexus covering the surface of the LUS and the bladder. Gynecologic oncology service was intraoperatively consulted to proceed with hysterectomy. The enlarged LUS with venous plexus required modified radical hysterectomy to unroof the ureteral tunnels and to approach paracorpium in order to complete the surgery. The estimated blood loss was 10 l, and the patient received massive transfusion including 12 units of packed
341
red blood cells (PRBC), 10 units of fresh frozen plasma (FFP), 10 units of cryoprecipitate, and 2.5 l of self-salvaged blood. Aortic compression was performed to control bleeding. Histopathologic evaluation confirmed placenta percreta. Case 2 A 39-year-old, gravid 5 para 3-0-1-3 Hispanic at 350/7 weeks gestation with prior three abdominal deliveries underwent elective cesarean section for placenta previa and suspected placenta percreta. The fetus was delivered via classical hysterotomy with birth weight of 2530 g and Apgar scores of 7 and 8 in 1 and 5 min, respectively. Given the enlarged LUS reaching to the bilateral pelvic side walls and extensive venous plexus in the LUS and bladder surface, gynecologic oncologists were intraoperatively consulted to proceed hysterectomy. The LUS was enlarged nearly twice larger than the uterine fundus. The enlarged LUS required modified radical hysterectomy to unroof the ureteral tunnels and to complete the surgery. Due to the placental invasion into the bladder, intentional cystotomy was also performed. Estimated blood loss was 2.5 l and 3 units of PRBC and 1 unit of FFP were intraoperatively administered. Histopathology evaluation confirmed placenta percreta. Peripartum hysterectomy has a significant risk of mortality compared to non-obstetrical hysterectomy (1% versus 0.04%, odds ratio 14.4, p < 0.0001) [2,3]. Amongst indications for peripartum hysterectomy, abnormal placentation such as placenta accreta, increta, or percreta makes hysterectomy substantially difficult, resulting in massive blood loss (mean 3 l) [1]. In our case reports, we described the macroscopic findings of uterus with placenta percreta. Hysterectomy specimens of placenta percreta are shown in Fig. 1A for Case 1 and Fig. 1B for Case 2. In each, due to deep placental invasion into the myometrium of the LUS, the size of the LUS after cesarean delivery can be substantially larger than the uterine fundus as experienced in our two cases, proposing a snowman sign to describe this finding. Practically, the snowman sign is evaluable after the delivery of fetus and closure of hysterotomy scar for cesarean delivery. Thus, this is the moment and step of surgery that the surgeons need to evaluate if there is a sign in the uterus that reflects the retained morbidly adherent
Fig. 1. Macroscopic findings of uterus with placenta percreta. The uteruses for Case 1 (panel A) and Case 2 (panel B) are shown, respectively. Abbreviation: LUS, lower uterine segment.
Letters to the Editor—Brief Communications / European Journal of Obstetrics & Gynecology and Reproductive Biology 181 (2014) 338–346
342
placenta in the LUS. In the event of a snowman sign during cesarean delivery, it is speculated that (i) it could predict large blood loss during cesarean hysterectomy and (ii) radical procedures may be required by experienced pelvic surgeons. Conversely, with absence of snowman sign, cesarean hysterectomy may be performed with less complication even abnormal placentation is suspected. Whether snowman sign reflects placenta accreta or percreta is not known, and further study will be needed. References [1] Wright JD, Pri-Paz S, Herzog TJ, Shah M, Bonanno C, Lewin SN, et al. Predictors of massive blood loss in women with placenta accreta. Am J Obstet Gynecol 2011;205. 38 e1-6. [2] Wright JD, Devine P, Shah M, Gaddipati S, Lewin SN, Simpson LL, et al. Morbidity and mortality of peripartum hysterectomy. Obstet Gynecol 2010;115:1187–93. [3] Wright JD, Bonanno C, Shah M, Gaddipati S, Devine P. Peripartum hysterectomy. Obstet Gynecol 2010;116:429–34.
a
Koji Matsuoa,b,* Division of Gynecologic Oncology, Los Angeles County Medical Center, University of Southern California, 2020 Zonal Avenue, Los Angeles, CA 90033, USA b Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA 90033, USA
Charlotte L. Conturie Department of Obstetrics and Gynecology, Los Angeles County Medical Center, University of Southern California, 2020 Zonal Avenue, Los Angeles, CA 90033, USA Richard H. Lee Division of Maternal-fetal Medicine, Los Angeles County Medical Center, University of Southern California, 2020 Zonal Avenue, Los Angeles, CA 90033, USA *Corresponding author at: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Los Angeles County Medical Center, University of Southern California, 2020 Zonal Avenue, IRD 520, Los Angeles, CA 90033, USA. Tel.: +1 323 226 3416; fax: +1 323 226 3427 E-mail address: [email protected] (K. Matsuo). Received 25 March 2014 http://dx.doi.org/10.1016/j.ejogrb.2014.07.035
Use of haemostatic matrix to arrest a massive obstetric haemorrhage from a posterior vaginal wall haematoma Dear Editors, This case of a massive rectovaginal haematoma demonstrates the safety and usefulness of haemostatic agents to arrest potentially life threatening bleeding. If surgical techniques are unsuccessful, recourse to more novel haemostatic agents-including FLOSEALTM and EVICELTM should be considered. A 35 year old multiple, delivered vaginally at Whipps’ Cross University Hospital. Our unit is one of 3 acute hospitals within an NHS trust with the main embolisation unit 5 miles away. Our patient’s labour was complicated by a massive haemorrhage of 3500 ml from a rectovaginal haematoma, associated with haemodynamic compromise. She was transferred to theatre and resuscitated with intravenous fluids, and blood products (4 units of red cells and 4 units of
fresh frozen plasma). On examination under general anaesthesia, the posterior wall haematoma was vertically incised and over 1000 ml of blood evacuated. Intractable generalised bleeding from the posterior wall could not be controlled with conventional surgical measures and vaginal packing, leading to a rapid haemorrhage of 3500 ml. Embolisation was not immediately available thus temporary haemostasis was achieved through further tight packing with surgical gauze and a haemostatic agent, applied to the base of the cavity. Imaging confirmed no evidence of retro-peritoneal or intraperitoneal extension of the haematoma negating the need for transfer for embolisation. After 24 h stabilisation in ITU, the vaginal pack was removed under anaesthesia, and the vagina wall repaired without further complications. There has been a decline in deaths from haemorrhage (CMACE 2006–2008), due in part to increased vigilance and following use of various haemostatic methods, including B-Lynch sutures, interventional radiology, hysterectomy and the use of haemostatic agents, from 14 in the 2003–2005 triennia (0.66/100,000) to 9 in 2006–2008 (0.39/100,000) [1]. Vulvo-vaginal haematoma is a recognised cause of lifethreatening haemorrhage, occurring in 1:300–1:1500 deliveries, usually in association with other vaginal or perineal trauma but sometimes in isolation [2]. The bleeding source is usually from descending branches of the uterine artery [2]. In our case the bleeding was probably from the submucous plexus rather than the adventitious plexus of the vaginal vein, as the former plexus tends to be thinner and more varicose. Selective arterial embolisation and balloon tamponade have both been used to control haematomas resistant to conventional surgical intervention. Our case is the first reported where a haemostatic agent has been used to arrest bleeding in the presence of vaginal haematoma. Haemostats are a combination of reconstituted human thrombin together with a gelatin, collagen, and cellulose matrix that have been shown to work on actively bleeding tissue. They act on the coagulation cascade from two angles: Firstly, the cellulose matrix acts on the intrinsic pathway, and secondly the reconstituted thrombin acts at the common pathway, leading to the conversion of fibrin from fibrinogen, thereby aiding clot formation. Case reports exist describing use of haemostats in obstetrics to treat complex vaginal lacerations [3] and massive haemorrhages complicated by impaired coagulation [4,5]. One case describes an emergency caesarean and peri-partum hysterectomy resulting in disseminated intra-vascular coagulation [4]. In the other case, haemorrhage resulted from a vacuum delivery in a patient with maternal coagulopathy [5]. Haemostats have also been used effectively in both elective and emergency gynaecological procedures such as myomectomy, ovarian cystectomy, and more recently for an abdominal ectopic pregnancy management. This case demonstrates the importance of prompt treatment of life-threatening haemorrhage using novel haemostatic techniques if meticulous surgical techniques are unsuccessful in stemming the bleeding. Haemostatic agents should be considered in addition to the more traditional techniques of balloon tamponade or embolisation. References [1] Saving Mothers Lives, Reviewing Maternal Deaths to make Motherhood Safer: 2003–2005 The 7th report of the Confidential Enquiry into Maternal and Child Health; December 2007. [2] Ridgway LE. Puerperal emergency. Vaginal and vulvar hematomas. Obstet Gynecol Clin North Am 1995;22(2):275. [3] Whiteside JL, Asif RB, Novello RJ. Fibrin sealant for management of complicated obstetric lacerations. Obstet Gynecol 2010;115(February (2 Pt. 2)):403–4.
