Keywords
fibrin patch - placenta accrete - morbidly adherent placenta - postpartum hemorrhage
- cesarean
Morbidly adherent placenta represents a profound surgical challenge and source of
maternal morbidity and mortality associated with postpartum hemorrhage. In a cohort
study including 25 hospitals, 158 patients with morbidly adherent placenta were identified
among 115,502 women (1 per 731 births) with a median estimated blood loss (EBL) of
2,000 mL, ICU (intensive care unit) admission rate of 31, and 70% hysterectomy rate.[1] While hysterectomy is the mainstay of morbidly adherent placenta management, a growing
body of literature has described uterine conservation. While leaving the adherent
placenta in situ leads to less immediate blood loss than placental removal, it carries
delayed risks of hemorrhage and infection.[2] Reported techniques to successfully remove the adherent placenta at delivery generally
involve complex surgical techniques.[3] Simpler measures to achieve hemostasis during cesarean delivery after removal of
an adherent placenta are needed.
In 2012, the FDA (Food and Drug Administration) approved the Evarrest Fibrin Sealant
Patch (Ethicon, Inc Somerville, NJ) as an adjunct to hemostasis for soft tissue bleeding.
The patch consists of human fibrinogen and human thrombin embedded on oxidized regenerated
cellulose in a woven polyglactin-910 (Vicryl) patch.[4] While this patch has not been described in obstetric surgery, several reports have
demonstrated successful off-label use of a similar fibrin patch in a variety of obstetric
hemorrhage situations.[5]
[6]
[7] We now report the predelivery plan and use of a fibrin sealant patch to facilitate
hemostasis in a case of confirmed morbidly adherent placenta.
Case Report
A 35-year-old gravida 5, para 2 presented at 36 weeks of gestation for a repeat cesarean
delivery with a complete anterior placenta previa. Antepartum ultrasound suggested
a focal placenta accreta with a hypervascular lower uterine segment ([Fig. 1]). Her one prior cesarean delivery was complicated by an unanticipated morbidly adherent
placenta that was manually removed with an EBL of 1,500 mL. Despite receiving counseling
about the risks of morbidly adherent placenta, hemorrhage, and hysterectomy, the patient
repeatedly expressed a strong desire for repeat uterine conservation. She preferred
placental removal instead of placental retention for management and she consented
to the use of intraoperative uterine artery embolization with the use of a fibrin
sealant patch as a final option to avoid hysterectomy if standard surgical interventions
were unsuccessful. Her preoperative hemoglobin was 11.2 g/dL.
Fig. 1 Anterior placenta with large venous lakes (arrow) in the lower uterine segment.
Following induction of epidural anesthesia and prior to cesarean delivery, bilateral
ureteral stents were placed cystoscopically and a right femoral artery sheath was
placed by the interventional radiologist. Cesarean delivery was performed through
midline vertical skin and vertical uterine incisions. The placenta was noted to be
adherent to the anterior myometrium beneath this incision but could be partially displaced
to allow delivery of a healthy infant. At this point there was no active hemorrhage
and the hysterotomy was closed in a single layer with the placenta left in situ.
The surgical field was covered with sterile drapes and selective bilateral uterine
artery embolization was performed to stasis, as confirmed by fluoroscopy. The obstetric
team then reopened the hysterotomy and forcibly removed the placenta. No separation
plane could be created in the anterior lower uterine segment. As much of the placenta
that could be removed was removed from this area in multiple fragments. Subsequently,
a partial-thickness defect was observed with brisk bleeding from this area of the
uterus. A 2 × 2 inch piece of fibrin sealant patch was placed over the area of bleeding
and held firmly in place with a moist sponge for 3 minutes. Upon reinspection, the
bleeding was well-controlled ([Fig. 2]). The uterus was closed with the fibrin patch left in situ and the remainder of
the case was routine. The EBL was 1,800 mL. The patient was hemodynamically stable,
required no intraoperative transfusion of blood products, and was transferred to the
labor and delivery unit for recovery. She received 1 unit of packed red blood cells
for symptomatic anemia and a hemoglobin of 7.7 g/dL on postoperative day 3. She was
otherwise discharged home routinely on postoperative day 4. On postoperative day 13,
she noted an asthma exacerbation and developed urticaria and pruritis that responded
to oral antihistamine therapy. At her routine visit 6 weeks postpartum, she was doing
well with no further bleeding and a hemoglobin of 13.4 g/dL. An ultrasound showed
a heterogenous thickened anterior myometrium but no evidence of retained products
of conception.
Fig. 2 Hysterotomy with fibrin sealant patch (arrow) on the anterior uterine wall over the
site of bleeding.
Discussion
The introduction of a fibrin-based, manually applied patch to obstetricians' armamentarium
for obstetric surgical bleeding offers a promising potential development, with established
efficacy for soft tissue bleeding and relative ease of use. Here we have demonstrated
a case in which the patch, in addition to uterine artery embolization and pressure,
provided control of focal placental bed bleeding, allowing removal of a focal morbidly
adherent placenta and avoidance of hysterectomy.
A fibrin sealant patch (TachoSil Fibrin Sealant Patch, Baxter Healthcare Corp, Westlake
Village, CA) was first approved in 2010 for use in cardiovascular and hepatic surgery.[8] This patch, which embeds human fibrin and thrombin in an equine collagen bed, has
been described for off-label obstetric use with both external uterine and placental
bed bleeding.[5]
[7] We identified one report of its use during cesarean delivery for morbidly adherent
placenta in which EBL was 4 L but uterine conservation was achieved. Our patient had
a more modest hemorrhage with an 1,800 mL EBL and 1 unit packed red blood cell transfusion
which may reflect the preceding use of uterine artery embolization and preplanned
immediate application of the topical hemostatic patch. Her only postoperative medical
issue was urticaria which was managed uneventfully with oral antihistamines. Hypersensitivity
has been a described side-effect of fibrin sealant patch use and cannot be excluded
in this case.[4]
[8] Given that fibrin sealant patches can cause hypersensitivity reactions, caution
should be used before choosing this therapy for atopic patients at risk for hypersensitivity
reactions. Further, providers should be aware that because the biological components
of the fibrin sealant patch are made from human plasma, it may carry a risk of transmitting
infectious agents, for example, viruses, the variant Creutzfeldt-Jakob disease (vCJD)
agent and theoretically, the Creutzfeldt-Jakob disease (CJD) agent.[4]
Only a minority of patients with morbidly adherent placenta are managed successfully
with uterine conservation, though many may desire retention of the uterus for future
fertility, adherence to cultural norms, and reduction of surgery-related morbidity.
Studies have shown more hemorrhage with attempts to remove the placenta,[2] leading some to recommend that the adherent placenta never be forcibly removed.[3] Alternatively, the risks of delayed hemorrhage and infection with placental retention
may be undesirable for many patients. Surgical techniques for focal placental excision
and uterine reconstruction have been described but are either unfamiliar and/or untenable
to most surgeons.[3] The use of uterine artery embolization prior to attempted adherent placental removal
has not been well studied in a controlled fashion and was insufficient to control
our patient's postpartum hemorrhage. The fibrin sealant patch offers a promising,
simple to use, addition to conservative measures.
While our patient's morbidly adherent placenta was suspected in the antepartum period,
ultrasound often misses focal areas of placental adherence or invasion, and surgical
teams may not be prepared for more sophisticated surgical and interventional radiology
techniques to control bleeding. Thus, the simplicity of this method may bring a conservative
management option to more patients who are diagnosed intraoperatively with this condition
or any other focal bleeding that is encountered at cesarean delivery. We combined
the patch with bilateral uterine artery embolization to offer this patient the standard
conservative management techniques currently used at our center. Since a combination
of methods was used in this case, we cannot be sure that the fibrin patch was singularly
responsible for the cessation of bleeding. However, because placental bleeding is
typically diffuse but low-pressure, fibrin patches may be efficacious without embolization
in some cases.[5] Further research is warranted to demonstrate the success and safety of this technique
for obstetric bleeding and to further establish the long-term effects on the uterus.
