How do you manage a bleeding placenta previa during a cesarean section (c-section)?

Management of Bleeding Placenta Previa During Cesarean Section

The most generally accepted approach to managing bleeding placenta previa during cesarean section is to leave the placenta in situ after delivery of the fetus and proceed with cesarean hysterectomy, as attempts at placental removal often result in profuse hemorrhage and are strongly discouraged. 1

Preoperative Preparation

• Assemble a multidisciplinary team including experienced pelvic surgeons, anesthesiologists, and blood bank personnel
• Position patient in dorsal lithotomy to allow access to vagina and optimal visualization of pelvis
• Ensure adequate IV access with at least two large-bore IV lines
• Notify blood bank and have blood products readily available
• Consider preoperative ureteric stent placement if bladder involvement is suspected (case-by-case basis) 1

Intraoperative Management

Initial Approach

• Inspect the uterus after peritoneal entry to assess placental location and invasion 1
• Make uterine incision that avoids the placenta whenever possible 1
• After fetal delivery, if placenta previa is bleeding:
  • Do NOT attempt forced placental removal as this causes profuse hemorrhage 1
  • Rapidly close the uterine incision if proceeding with hysterectomy 1

Hemorrhage Control Techniques

1. Primary Approach: Cesarean hysterectomy with placenta left in situ 1

   • Total hysterectomy is usually required as lower uterine segment/cervical bleeding often precludes supracervical approach 1
   • Careful retroperitoneal dissection with attention to devascularization of uterine corpus

2. Alternative Techniques (if hysterectomy is not immediately possible or fertility preservation is desired):

   • Uterine packing may be effective for controlling intractable hemorrhage in central placenta previa 2
   • Consider interventional radiology techniques for arterial occlusion in select cases, though evidence is mixed 1

Blood Product Management

• Implement massive transfusion protocol with fixed ratio of packed red blood cells, fresh frozen plasma, and platelets 1
• Do not wait for laboratory results before initiating transfusion in cases of active hemorrhage 1
• Keep patient warm (temperature >36°C) to maintain clotting factor function 1
• Avoid acidosis which impairs coagulation 1
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 1

Special Considerations

Unexpected Placenta Previa/Accreta

If placenta accreta spectrum is unexpectedly recognized during cesarean:

• Temporarily pause the case if possible until optimal surgical expertise arrives
• Alert anesthesia team and consider general anesthesia
• Obtain additional IV access and order blood products 1

Postoperative Management

• Provide intensive hemodynamic monitoring in ICU setting
• Maintain vigilance for ongoing bleeding with low threshold for reoperation
• Monitor for complications: renal failure, liver failure, infection, unrecognized injuries, pulmonary edema, DIC, and Sheehan syndrome 1

Pitfalls to Avoid

• Attempting to remove adherent placenta forcefully
• Delaying hysterectomy when massive hemorrhage is occurring
• Waiting for laboratory results before initiating blood product replacement
• Inadequate surgical expertise for complex cases
• Failure to maintain normothermia during resuscitation

The incidence of placenta previa and placenta accreta spectrum has increased significantly due to rising cesarean section rates, making these high-risk scenarios more common in obstetric practice 1, 3. Delivery at a facility with appropriate resources and expertise significantly improves outcomes 1.