Successful surgery on a difficult case: Central placenta previa with accreta in a patient with a history of three cesarean sections.
Central placenta previa is a phenomenon where the placenta attaches incorrectly (attaching at the lower segment of the uterus, completely covering the uterus and the birth canal of the fetus). This is one of the emergency conditions that can cause severe bleeding in obstetrics. Placenta accreta is a condition where the placental villi invade and penetrate the uterine muscle, even extending to other organs in the abdominal cavity such as the bladder, intestines, etc. The combination of central placenta previa and placenta accreta is the most severe clinical form that can lead to many complications during and after surgery, posing a high risk to the lives of both the mother and the fetus. Recently, Hai Phong International Obstetrics and Pediatrics Hospital successfully performed surgery on a case of a mother suffering from both conditions, along with a history of three cesarean sections, ensuring safety and a “healthy mother and baby” outcome for both the mother and the fetus.
The patient T.T.L, 37 years old from Hai An, Hai Phong, had to undergo cesarean sections in all three previous pregnancies. In her fourth pregnancy, patient L managed her pregnancy at Hai Phong International Obstetrics and Pediatrics Hospital, where she was diagnosed with central placenta previa at 5 months of gestation (22 weeks). The doctors at the private hospital closely monitored her pregnancy. At 28 weeks, after an ultrasound, the doctor diagnosed the patient with placenta accreta. By week 34, the patient was hospitalized for monitoring. According to modern obstetric practice trends, central placenta previa with placenta accreta has led to many opinions suggesting that pregnancy should be terminated early to reduce the risk of placental tissue potentially invading the uterine wall into adjacent organs such as the bladder, especially in cases with old cesarean scars, where the uterine wall at the scar site is very thin, allowing the central placenta previa with accreta to penetrate the uterine wall and invade the bladder wall. However, at the Prenatal Department, Dr. Pham Thi Xuan Minh – Head of the Prenatal Department, consulted with experts and unanimously agreed to continue the pregnancy beyond 35 weeks and schedule a cesarean section to reduce the risk of preterm birth for the baby (still adhering to the principle of obstetric management: prioritizing the mother’s safety while considering the baby).
The patient underwent a full range of tests and advanced obstetric examinations, including MRI scans of the blood vessel pathways and the extent of placental invasion, to prepare for the safest surgical team possible, maximizing control over potential complications during surgery and blood loss. The results of the 5D ultrasound and MRI scans both indicated that the placenta had invaded the uterine muscle and infiltrated the bladder wall.
The surgical team is scheduled for the morning of December 5, 2023, with specific assignments for the related teams involved:
- Surgical Team: Assoc. Prof. Dr. Tran Thi Viet Phuong – Director of the Obstetrics Department; Dr. Pham Van Do – Deputy Head of the Delivery-Obstetrics Department; Dr. Nguyen Huu Trung – Delivery Department.
- Anesthesia Team: Dr. Nguyen Do Hung – Head of the Anesthesia and Resuscitation Department; Dr. Pham Dinh Kien – Anesthesia and Resuscitation Department.
- Neonatal Reception Team: Dr. Nguyen Thi Hong Hanh and experienced neonatal resuscitation midwives.
- Blood Supply Support: Dr. Do Manh Toan – Head of the Laboratory Department; Dr. Pham Thi Thuy – Deputy Head of the Laboratory Department.
The surgery took place at 10 o’clock. After the mother was anesthetized using the endotracheal intubation method, the “battle of the white coats” began. With a history of three cesarean sections, the entire anterior surface of the mother’s uterus was adhered to the scar tissue on the abdominal wall. The surgical team skillfully and quickly released the adhesions, exposing the lower segment of the uterus, revealing the entire lower segment up to the body of the uterus, which was densely packed with engorged blood vessels, dark purple (this is the area where the placenta was implanted in a placenta accreta condition). The surgeons found the area with the least blood vessels, which was the body of the uterus directed towards the fundus, to make the incision to retrieve the baby, minimizing the need to cut into areas with abundant blood vessels and reducing bleeding. The baby girl was delivered in a critical condition of the mother, weighing 2100g, cried immediately upon delivery, and exhibited good reflexes despite being premature. After the baby was delivered, due to the central placenta previa with accreta, the placenta was firmly attached to the uterus, not detaching and could not be removed. If attempted to detach, severe bleeding would occur, making it difficult to control and potentially threatening the mother’s life, so the surgical team immediately performed a hysterectomy. Performing a hysterectomy in this case was also extremely challenging due to the history of three previous cesarean sections, as the uterine wall in the scar area was very thin and adhered to the bladder, risking perforation and bladder rupture.The risk was very high… But with the skill and expertise of the surgical team, the aforementioned challenges were overcome, providing the highest safety for the patient.
The surgery was a success beyond expectations. This success was due to thorough and meticulous preparation and the seamless coordination of the related teams (surgery, anesthesia, blood transfusion, neonatal reception, and neonatal resuscitation) along with the modern equipment of the hospital: The surgical process was quick, blood loss was well controlled, and the mother only required two units of blood. After 7 days post-surgery, with the dedicated care of the doctors and nurses in the Postpartum Department, the mother has regained her health, sleeps well, and has enough milk for the baby. The baby’s health is stable.
For the doctors at Hai Phong International Obstetrics and Pediatrics Hospital, success after difficult cases is a gift, an unparalleled happiness. In this case, the obstetrician advises that for pregnant women, during the management of pregnancy, if an ultrasound diagnoses central placenta previa, it must be understood immediately that this is a serious condition due to the very high risk of bleeding for the mother. With many complications that can occur during surgery, this condition needs to be examined and managed at specialized hospitals with modern equipment, good blood supply, and experienced doctors with high surgical skills… like Hai Phong International Obstetrics and Pediatrics Hospital, many cases of pregnant women with central placenta previa – placenta accreta have been detected early by doctors, guiding strict pregnancy management and especially interdisciplinary consultations to prepare an optimal intervention plan, ensuring the best health for both the fetus and the mother. At the same time, to detect this dangerous condition early, for pregnant women, there is no other way than to manage and care for the pregnancy regularly and periodically according to the requirements of obstetricians, so that one can hope for a successful pregnancy.giving birth “mother round, child square” regardless of whether the pregnancy is a high-risk pregnancy or not.
