MATERNAL MORBIDITY

AND MORTALITY
PRESENTER: DR SHAMA SAJJAD
FACILITATOR: DR SHAHNAZ NAWAZ
PATIENT PROFILE

 30years old female

 Married for 3 years
 Consanguineous marriage
 Education: BA
 Profession: Home maker
 Gravida 3 Para 1+1 (previous 1scars), 1alive/healthy babies
 LMP : 5/3/2022
 EDD : 14/12/2022
 Blood group : A +ve
 Regular cycles 5/30
 Non-Booked in Shifa. Presented to A&E department on 29-6-2-22
Past Medical/Surgical
 Previous 1 scars, D&C (1st trimester loss)

Family History
 +ve for Breast CA (grandma), Lung CA (Grandpa)

Past Menstrual history

 Regular cycles with normal flow
COURSE OF PREGNANCY :
 Booked at renowned private hospital of Islamabad.
 Unremarkable initial antenatal course.
 Patient, G3P1+1@17 weeks, was admitted in private set
up due to fever, PV leaking and diaherrea from 2 day.s
Patient was being managed conservatively there and was
referred to SIH when she developed SOB, decreased
saturation and PV bleeding.(from 3 hours) Foetal heart
was initially positive there, but before shifting there was
no heart.
 Patient presented to A&E @0400Hrs, sick looking,
On 28-6-2022 @0430 hrs patient presented in A&E with:

VITALS PER ABDOMEN Per Speculum

Pulse : 130/min Fundal height Os: 1.5cm
BP: 90/40 20weeks Bleeding +++
R/R: 32/min Scar tenderness nil
Temp: 38 C No palpable Patient catheterized:
spO2: 90% with 5L FCA : No foetal Output 20ml/4hours
O2 heart
At room air dropped
to 80%.
BASELINE LABS DONE IN A&E

 Hb: 8.6, TLC: 9K, Platelets: 95K

 Creatinine: 1.1
 CRP: 258
 Covid positive
 INR : 1.6
 Serum electrolytes: normal
 Ultrasound: Dead foetus of 17 weeks with retroplacental 50ml clot. Placenta funoposterior
and not low lying. Placenta accrete spectrum ruled out.
 Procalcitonin, fibrinogen, d-dimer: pending

 Patient got de-saturated and was intubated in ER within 30 mins of

presentation.
 Admitted stat.
 2 wide bore IV lines saved and baseline labs were sent. Intubated.
 6 PRBCs, 8FFPs, 8 Platelets cross match sent / Blood bank was notified of
massive transfusion protocol.
 Consultant was informed immediately and anesthesia/OR staff was taken on
board.
 High risk counselling was done and consent for emergency hysterotomy +/-
hysterectomy+/- need for another surgeon/procedure was obtained. Need of
massive blood transfusion/donor arrangements was also discussed with family.
 2 PRBCs, 4 FFPs, 4 Platelets were transfused in ER prior to shifting.
 Patient was shifted to OR@0530 Hrs.
INITIAL IMPRESSION/ DDS

 SEPTIC SHOCK/ DIC/ IUD WITH RETROPLACENTAL BLEED

 COVID PNEUMONIA
OPERATIVE FINDINGS :

 Low transverse incision through previous scar

 20 weeks size uterus, contracted in fundal region but massively dilated and
purplish with placenta re- crouching up to serosa in the lower part.
 Proceeded straight to hysterectomy.
 Cesarean hysterectomy + Left salpingoophorectomy done with conservation of
right ovary and tube.
 Bladder had thick vascular network. Hemostatic sutures taken on bleeding point.
 Blood loss : 800ml
 5 PRBCS, 6 FFPS, 1 megaunit were transfused.
 Family debriefed.
TIMELINE OF EMERGENCY MANAGEMENT :

 Received in A&E On 29-6-2022 @0430 hrs.

 Patient in OR @0540 Hrs.
 Anesthesia started @0600 Hrs.
 Surgery started @0610 Hrs.
 Surgery ended @0830 Hrs.
ZERO POST OP DAY : (29-6-2021)

VITALS PER ABDOMEN LABS:

Pulse : 100/min Tense abdomen Hb: 14.3
BP: 100/70 Mildly distended PLT: 86k
Temp: Afberile Dressing dy intact TLC: 13K
Chem 7: normal
On low settings of P/V: No bleeding Creat 0.9
vent
Supports: Norepi only
URINE output:
180ml/hr
Drain output : Transfusions:
350ml since surgery 6 ffps, 6 platelets,
NG: 50 ml 6 cryo, 2 PRBCs
 Zero postoperative day 1st postoperative day 2nd postoperative day
(29/6) (30/6) (1/7)
GCS 8/15, SCMV Mode of 9/15, SCMV mode, SCMV mode
vent Norepi 5 Mics GCS10/15
Inotrope: Norepi 35 Norepi 2mics
mics
Vitals Pulse: 135 bpm Pulse: 103 bpm BP: 100/60
BP: 107/60 Pulse: 100/min
BP: 90/60 Temp: afebrile
Temp: Afebrile Temp : 38 C

ABdomen Slightly distended, Soft, gaseous distension Soft , gaseous

dressing dry intact. BS: +, dressings dry/intact BS: distension,
sluggish audible BS : audible

Vaginal No bleeding No bleeding No bleeding

Urine output 130ml/ hr, clear 90ml/ hr, clear Adequate

Drain output 350ml/24 hours serosang 120ml/24H 320ml/24hours, serosang

serosanguinous

MOAR Meronem, vancomycin, Same+ Colistin same

Doxycycline
General condition Sick. Febrile. Blood C/S, Urine Hemodynamically
LABS:
Zero post op day 1st post op day 2nd post op day
CBC: CBC: CBC:
Hb: 8.5 6.8 Hb: 8.2 Hb: 8.9
TLC: 19* TLC: 36 K TLC: 36 K
PLT: 47 K** PLT: 25 K PLT: 33 K
Creat :1.35** Creat: 2.09 ** Creat: 3.1**
CRP: 258*** CRP: 368 *** CRP: 543***
INR: 3.3 *** INR: 1.3 (N) PT/INR: NORMAL
Na: 145 (135-145) CHEM 7: normal CHEM 7 : NORMAL
K: 3.1 (3.5-5) LFTS:
LFTS: AST : 92 LFTS:
AST : 57* (15-45) ALT :32 AST: 63
ALT: 33 (15-45) D dimer: 46.2 ALT: 28
D dimer: 75.2** Fibrinogen: 243
Fibrinogen 152** D dimer: 5.62
TRANSFUSIONS: 1 PRBC, TRANSFUSION: 4FFPs, 4 Fibrinogen: 269
5 PLATELETS, 4 FFPs PLTs TRANSFUSIONS:
2PRBCs, 6Platelets
FURTHER COURSE IN SSD:

 Patient was stable from surgical point of view and needed no further obstetric
intervention.
 Due to rising TLC, CRP and creatinine (Septic Shock/DIC/Non oliguric AKI)
patient was shifted to services of critical care team.
 Drain was removed on day 4 because of minimal output.
 Patient was extubated on day 5.
 Blood cultures remained negative. Urine C/S grew candida. Treated with
antifungal.
 By day 7, patient was stable, afebrile, doing well and was discharged on
Ertapenem.
LABS ON DAY OF DISCHARGE:

 Hb: 10.8
 TLC: 24K
 PLATELTS: 179K
 CRP: 65 (falling trend)
 CREATININE : 2.3 (falling trend)
 INR: 0.9
OPD FOLLOW UP VISIT:

 Vitally stable and doing well.

 Hb: 9.3, TLC: 12K, PLT: 171K, Creat 1.4
 Histopathology: Mature chorionic villi seen extending
myometrium: Placenta increta. Negative for molar
changes.
PLACENTA ACCRETA SPECTRUM (PAS)
1. What is the current acceptable morbidity and mortality
associated with this condition?
 Adherent placentation carries a significant risks of maternal mortality. The
incidence of placenta percreta has increased over the past 50 years from 1 per
30 000 to 1 per 7000 pregnancies, due largely to the rise in the rate of
Caesarean sections.
 Maternal mortality with placenta accrete spectrum has been reported to be as
high as 7%. Maternal death may occur despite optimal planning, transfusion
management, and surgical care.
 With presence of a placenta previa, the risk of placenta accreta spectrum was 3%,
11%, 40%, 61%, and 67% for the first, second, third, fourth, and fifth or greater
repeat cesarean deliveries, respectively.
 Placenta accreta spectrum has been associated with an increased risk of
cystotomy, ureteral injury, pulmonary embolism, need for ventilator use, and an
increased risk of intensive care unit (ICU) admission7 as well as greater blood loss
at delivery, with a mean of 2000-7800mL.
 When placenta percreta involves the bladder, bleeding may be extreme and
surgery is very hazardous. Two deaths among 12 patients have been reported
COMPLICATION

Median estimation of blood loss 2-3 L

Median units of packed red blood cells transfused 3.5-5.4 L
Large-volume blood transfusions (>10 L) 5-40%
Injury to bladder 7-48%
Injury to ureter 0-18%
Admission to intensive care unit 15-66%
Bowel injury/obstruction 2-4%
Venous thromboembolism 4%
Surgical site infection 18-32%
Re-operation 4-18%
Maternal mortality 1-7%
Reference: FIGO
2. CURRENT
What EVIDENCE
are the current BASED
evidence based GUIDELINES
guidelines for the treatment of this condition?
 Midpregnancy routine fetal anomaly scan should include placental localization
 Women with a previous caesarean section require a higher index of suspicion
as there are two problems to exclude: placenta Previa and placenta accreta. If the
placenta lies anteriorly and reaches the cervical os on anomaly scan, a follow-up
scan at 32 weeks can help identify if it is implanted into the caesarean section
scar.
 Antenatal sonographic imaging can be complemented by magnetic
resonance imaging in equivocal cases to distinguish those women at special risk
of placenta accreta. Otherwise the diagnostic value for both MRI/USG is same. MRI
can help in detection of lateral invasion and depth.
 The use of cervical cerclage to reduce bleeding and prolong pregnancy is not
supported.
 Prolonged
inpatient care can be associated with an increased risk of
thromboembolism; therefore, mobility should be encouraged together with the use
TIMINGS OF DELIVERY

 In the absence of risk factors for preterm delivery in women with placenta accreta
spectrum, planned delivery at 35+0 to 36+6 weeks of gestation provides the
best balance between foetal maturity and the risk of unscheduled delivery.
 In case of PAS where risk of blood loss and cesarean hysterectomy is anticipated,
delivery between 34 and 35 weeks is proposed to avoid emergency delivery,
which still occurs in 20% cases despite scheduled.
 Each episode of antenatal PV bleeding is associated with increased risk of
unscheduled delivery. Risk further increases with PPROM.
 Thus the women who may benefit the most from a strategy of planned preterm
delivery are those with a history of episodes of antepartum haemorrhage, PPROM,
or uterine contractions
The six elements considered to be reflective of good care
are:

 Consultant obstetrician planning and directly supervising delivery.

 Consultant anaesthetist planning and directly supervising
anaesthesia at delivery.
 Blood and blood products available.
 Multidisciplinary involvement in preoperative planning.
 Discussion and consent, including possible interventions (such as
hysterectomy, leaving the placenta in situ, interventional
radiology).
 Local availability of a critical care bed.
MANAGEMENT OPTIONS:
 There is limited evidence to support uterus preserving surgery in placenta
percreta and women should be informed of the high risk of peripartum and
secondary complications, including the need for secondary hysterectomy.
 The following four approaches have been described.

1) Primary hysterectomy following delivery of the foetus, without attempting

placental separation.
2) Delivery of the fetus avoiding the placenta, with repair of the incision leaving the
placenta in situ.
3) Delivery of the fetus without disturbing the placenta, followed by partial excision
of the uterine wall (placental implantation site) and repair of the uterus.
4) Delivery of the fetus without disturbing the placenta, and leaving it in situ,
followed by elective secondary hysterectomy 3–7 days following the primary
procedure
 If the placenta is anterior and/or a hysterectomy is planned, a midline skin incision allows
for a high upper-segment transverse uterine incision above the upper margin of the
placenta or more commonly a fundal transverse incision without disturbing the placenta.
 When the urinary bladder is invaded by placental tissue, preoperative cystoscopy and the
placement of ureteric stents have been recommended to avoid urological injury.
 Planned cystotomy can prevent extensive muscularis damage and bleeding from attempts
at dissection.
 Filling the bladder to identify the bladder separation site, opening the bladder to identify
percreta villous tissue and removal of the involved bladder area have also been
recommended by different authors.
 Urologic injuries have been shown to increase when intraoperative blood loss is greater.
Dissection of the bladder first if possible, prior to delivery, has been shown to allow
sufficient time to identify and create the vesicouterine plane before an intraoperative bleed,
which will make the identification of the different tissues difficult. (FIGO)
 Uterus preserving surgery is possible in placenta percreta. A multidisciplinary stepwise
surgical approach, including bilateral ligations of the anterior division of the iliac arteries
before removing the placenta, was shown to be successful in controlling the bleeding and
preserving the woman’s uterus in around 90% of the cases, with 14% of urinary tract
complications, most of which can be identified and repaired during caesarean section.
 Expectant management with the placenta left in situ is associated with severe long-term
complications of haemorrhage and infections, including a 58% risk of secondary
hysterectomy up to 9 months after the birth.
 Conservative management in placenta accreta spectrum is not recommended in women
presenting with major bleeding as it is unlikely to be successful and risks delaying
definitive treatment and increasing morbidity.
 MTX adjuvant therapy should not be used for expectant management as it is of
unproven benefit and has significant adverse effects.
INTERVENTIONAL RADIOLOGY

 Interventional radiology can be life saving for the treatment of massive postpartum
hemorrhage, and therefore having this facility available locally is desirable.
 Various combinations have been proposed, including intraoperative internal iliac artery
and/or postoperative uterine artery embolization and internal iliac artery or abdominal
aorta balloon occlusion.
 Studies evaluating the safety and effectiveness of internal iliac artery ligation in the
context of PAS disorders specifically are few. No differences in mean blood loss or
blood loss greater than 5 L was demonstrated with and without ligation. (FIGO)
 Critic says that occlusion of large vessels cannot prevent catastrophic bleeding since
the blood supply to the pelvis is maintained by the development of rich collaterals
during pregnancy.
 The value of prophylactic placement of balloon catheters in the iliac arteries in
cases of placenta accreta has been more controversial.
 This is mainly because of the higher risks of complications than embolization,
including iliac artery thrombus or rupture, and ischaemic nerve injury. No
difference was observed in studies with pre op balloon insertion in term of blood
loss.
[Link] MAY HAVE CONTRIBUTED TO THE MORBIDITY OF
THIS PATIENT?

 Previous uterine surgeries ( 1 caesareans, 1 D&C)

 Placenta Previa+ increta.
 Covid in pregnancy.
 DIC/ Septic Shock
 Hx. of PPROM and antepartum haemorrhage.
 Non booked
 4. LESSONS LEARNT FOR FUTURE MANAGEMENT:

 The value of making the diagnosis of placenta accrete/Percreta before delivery is

that it allows for multidisciplinary planning in an attempt to minimize potential
maternal or neonatal morbidity and mortality. Surgical expertise in complex pelvic
surgery is a core principle for management of PAS disorder cases
 The value of effective and quick preoperative preparation, with multidisciplinary
team, cross matched blood, relevant investigations, preparation for need of
additional surgical procedures, detailed consent by the patient and husband
regarding the complications associated with this condition
 Pre-op urologist opinion, cystoscopy and stenting in women with suspicion of
bladder invasion can reduce incidence of urological complications.
 In women with episodes of antepartum haemorrhage, especially recurrent, PPROM,
and contractions, scheduled non-emergent deliveries result in a significant
reduction in maternal morbidity
Thank you 