Control of Blood Loss
Blood loss is at its highest immediately following placental delivery. This can be reduced by inflating the internal iliac balloons or applying a paracervical tourniquet, if feasible, while the edges of the myometrial defect are identified (Fig. 6) and secured. Uterine artery ligation can even be considered if necessary. Other measures which can be employed include the standard uterotonic drugs, balloon tamponade, blood transfusion, cell salvage and tranexamic acid.
We examined a consecutive series of twenty cases of PASD managed over a period of twenty-two months between December 2019 and October 2021. The study was conducted in a tertiary obstetric referral hospital in Singapore which has around 12,000 deliveries per year and a Caesarean section rate of 31–32%. The study had institutional review board ethical approval covering surgical management of PASD. The surgical method adopted for each case was mainly governed by patient choice. A low lying placenta was identified for all women on a mid-trimester pelvic ultrasound scan with characteristic ultrasonic features of PASD being identified on subsequent scans. Most of the patients also had an MRI. All deliveries were performed under GA and pre-operative intra iliac balloon catheterization was offered to all women having elective delivery and any being delivered as an emergency, if time permitted. We compared demographic data and peri-operative details as well as outcomes between groups. We looked at surgical time, estimated blood loss, need for transfusion, visceral injury, admission to the Intensive Care Unit and length of stay for our patients.