What is the management approach for a patient with placenta previa undergoing a lower segment cesarean section (LSCS)?

Management of Placenta Previa at Cesarean Section

Immediate Preoperative Preparation

All patients with placenta previa undergoing LSCS require delivery at a tertiary care facility with massive transfusion capabilities, multidisciplinary team coordination, and advance blood bank notification. 1

Critical Risk Assessment

• Screen all patients with placenta previa and prior cesarean deliveries for placenta accreta spectrum disorder, as this dramatically increases surgical morbidity and mortality 1
• The risk of placenta accreta increases 7-fold after one prior cesarean and up to 56-fold after three cesarean deliveries 1
• Additional risk factors include anterior or central placental location, advanced maternal age (≥35 years), high parity, prior uterine surgery, and prior postpartum hemorrhage 1, 2
• Transvaginal ultrasound is the diagnostic modality of choice for placental location assessment; MRI may be helpful for posterior placenta or suspected percreta 1

Multidisciplinary Team Assembly

Coordinate preoperatively with: 1

• Maternal-fetal medicine subspecialists
• Experienced pelvic surgeons (gynecologic oncology or urogynecology)
• Urologic surgeons (for suspected bladder involvement)
• Obstetric anesthesiologists
• Interventional radiologists
• Neonatologists
• Blood bank personnel familiar with massive transfusion protocols

Optimize Maternal Status

• Maximize hemoglobin values before delivery by treating anemia with oral or intravenous iron 1
• Establish large-bore intravenous access for rapid fluid and blood product administration 3
• Notify blood bank in advance due to frequent need for large-volume transfusion 1

Intraoperative Surgical Management

Surgical Approach

• Inspect the uterus after peritoneal entry to determine placental location and optimize uterine incision placement 1
• When possible, make the uterine incision away from the placenta 1
• Consider dorsal lithotomy positioning to allow vaginal access and optimal surgical visualization 1
• For suspected bladder involvement, consider ureteric stent placement preoperatively 1

Management of Placenta Accreta Spectrum

If placenta accreta spectrum is encountered, the most accepted approach is cesarean hysterectomy with the placenta left in situ. 1, 4

• Never attempt forced placental removal, as this causes profuse hemorrhage 1, 4
• After fetal delivery, leave the placenta in place if abnormal attachment is evident 1
• Total hysterectomy is typically required because lower uterine segment bleeding frequently precludes supracervical hysterectomy 4
• If fertility preservation is critically desired in focal accreta cases, conservative management may be considered, but this carries a 6% severe complication rate and 44% failure rate in percreta 4

Hemorrhage Control Strategies

Activate massive transfusion protocol early without waiting for laboratory results if significant bleeding occurs. 3

Blood Product Management

• Transfuse in a fixed 1:1:1 ratio of packed red blood cells:fresh frozen plasma:platelets during massive hemorrhage 1, 3
• Consider tranexamic acid to reduce blood loss 3
• Monitor fibrinogen levels closely, as declining levels indicate consumption 3
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 1

Surgical Hemorrhage Control Techniques (if hysterectomy not immediately performed)

• Intrauterine balloon tamponade with Sengstaken-Blakemore tube or Bakri balloon has shown 84% success in preventing hysterectomy for focal accreta 4, 5
• Application of hemostatic fleece directly onto bleeding lower uterine segment surfaces 6
• Uterine compression sutures 3
• Hypogastric artery ligation 3
• Pelvic packing 3
• Interventional radiology embolization 3

Critical Intraoperative Monitoring

• Maintain maternal temperature above 36°C, as clotting factors function poorly at lower temperatures 1, 3
• Be vigilant for concealed vaginal hemorrhage, especially if hypotension persists despite apparent surgical field control 7
• If binding the lower uterine segment with a tourniquet reduces surgical field bleeding but hypotension persists, immediately check for massive vaginal bleeding 7
• Close monitoring of volume status, urine output, blood loss, and hemodynamics is critical 1, 4

Postoperative Management

Immediate Postoperative Care

• Transfer to intensive care unit for severe cases given risks of ongoing bleeding, fluid overload, renal failure, liver failure, and disseminated intravascular coagulopathy 1, 3
• Maintain intensive hemodynamic monitoring in the early postoperative period 1
• Maintain a low threshold for reoperation if ongoing bleeding is suspected 1, 3

Complications Surveillance

Monitor for: 3

• Ongoing hemorrhage
• Renal failure
• Liver failure
• Infection/sepsis
• Unrecognized ureteral, bladder, or bowel injury
• Pulmonary edema
• Disseminated intravascular coagulation
• Sheehan syndrome (postpartum pituitary necrosis from hypoperfusion)

Follow-up

• Ensure adequate iron supplementation and hemoglobin monitoring if significant blood loss occurred 1

Common Pitfalls to Avoid

• Never perform digital pelvic examination until placenta previa has been excluded, as this can trigger catastrophic hemorrhage 1
• Never attempt manual placental removal in suspected or confirmed placenta accreta spectrum 1, 4
• Do not delay hysterectomy if hemorrhage cannot be quickly controlled; earlier hysterectomy correlates with better outcomes 7
• Do not use methotrexate to hasten placental resorption in conservative management, as it has unproven benefit and possible harm 4
• Do not wait for laboratory results before initiating transfusion protocols in active hemorrhage, as this significantly increases maternal morbidity 3