Abdominopelvic packing in intractable hemorrhage after cesarean hysterectomy for morbidly adherent placenta: a case series

Abstract

Excessive and uncontrolled hemorrhage is the main cause of morbidity and mortality in placenta accreta spectrum (PAS) disorders. We present the role of combined abdominopelvic packing as a lifesaving approach for such morbid situation. This case series describes the retrospectively analyzed outcome of 4 women with placenta accreta spectrum (PAS) who underwent packing in view of intractable oozing from vault and adjacent areas even after cesarean hysterectomy. Three to four roller gauzes were used, and removal was done 48 h later through abdominal exit sites of gauze. The 4 patients underwent cesarean hysterectomy between 32 and 34 weeks of gestation. Prophylactic uterine artery catheterization with inflation of balloon was done in all the patients. Bladder was injured during separation in two cases (50%) with Grade 3b PAS. Massive bleeding was encountered and despite cesarean hysterectomy, bleeding from the vault and surrounding areas continued. Mean blood loss was 2525 ml. Immediate repair of bladder rent was done after cesarean hysterectomy in the two cases with bladder injury. When all attempts to stop bleeding failed, abdominopelvic packing was done using three to four 200-cm roller gauzes. Relaparotomy for pack removal and otherwise, and mortality due to excessive hemorrhage was avoided. None of the patients had any long-term complication related to the procedure. Combined abdominopelvic packing can achieve acceptable results in the patients with severe primary hemorrhage during surgery for PAS. Packing should be used in rare clinical situations where discrete bleeder is not identified, and the patient’s hemodynamic state worsens while on the operating table.