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320
B. D. Einerson and A. P. Soisson
Obstetric Hemorrhage
Background
Hemorrhage is by far and away the most common complication of cesarean hysterectomy.
Uncomplicated cesarean delivery is associated
with approximately a 1000cc blood loss whereas
blood loss associated with hysterectomy is signicantly higher [7].
Prevention
Uncontrolled obstetric hemorrhage is often the
indication for cesarean hysterectomy, and so
prevention may not be possible. Even so, severe
obstetric hemorrhage can be prevented by prompt
recognition of bleeding during cesarean section
and by thorough evaluation of the cause and possible treatments. In our experience, a delay in
recognizing the need for denitive treatment of
obstetric hemorrhage with hysterectomy is often
the source of preventable morbidity.
Recognition
Estimation of blood loss during surgery by the
surgeon has been shown in multiple studies to be
largely inaccurate. Quantitative methods to measure blood loss are better but do not appear to
alter clinical outcomes and probably are unnecessary [7]. We recommend close monitoring and
communication of blood loss during the case, and
if the procedure is taking longer than 90minutes
we would advise serial hematocrit measurements
every 15 minutes until completion of the
hysterectomy.
Management
Surgeons should anticipate at least a 1500cc blood
loss associated with a simple cesarean hysterectomy and therefore we would recommend that two
units of packed red blood cells be available for the
procedure. We would not anticipate the need for
brinogen or platelets. Furthermore, we would not
anticipate the need for intra-arterial catheters to
temporarily occlude the aorta or the iliac vessels.
Should signicant hemorrhage occur during
the operative procedure we would recommend
consideration of internal iliac or uterine artery
ligation. Should the surgeon elect to perform
internal iliac (hypogastric) ligation, we recommend ligation of the round ligament followed by
retro-peritoneal exploration to identify and locate
the ureter. The internal iliac artery can be either
clipped with a medium-sized Hema-clip or
ligated with a #1 or 0-sized permanent suture
such as silk [8]. The vessel should be ligated
more than 2 cm beyond the bifurcation of the
common and internal iliac artery to avoid disruption of the posterior branch.
Prevention and management of massive hemorrhage related to PAS are discussed further in
the section below.
Surgical Site Infection
Background
The incidence of surgical site infections (SSI),
dened as wound infection or pelvic abscess, is
less than 1% in women undergoing cesarean
delivery [9] but much higher in obese and diabetic women [10]. In women undergoing cesarean hysterectomy, SSI occurs in 6–10%, similar
to the rate in women undergoing abdominal hysterectomy (4–10%) [3, 11].
Prevention
The most signicant clinical factor associated
with a reduction in the risk of SSI after is the
appropriate use of prophylactic antibiotics.
Extrapolating from ACOG committee opinions
and studies, we recommend a single dose of a
second-generation cephalosporin plus metronidazole or clindamycin prior to initiating surgery
[12, 13].
Finally, it is the opinion of the authors that the
use of a prophylactic negative pressure wound
device should be considered in obese women
who undergo cesarean hysterectomy. Studies of
cesarean hysterectomy are lacking, but a
Cochrane literature review of patients undergoing laparotomy [14] and a prospective randomized trial in cesarean section [15] both suggest
30 Cesarean Hysterectomy
321
that these devices will reduce the incidence of
SSI in high-risk individuals.
Recognition
Recognition of an SSI is primarily through physical examination of the wound for the appearance
of erythema, uctuance of the tissues, crepitus,
and the presence of dead and devitalized tissue.
Other signs such as fever and leukocytosis are
often helpful for diagnosis. Pelvic abscess following hysterectomy often presents with fever
and lower abdominal pain, and examination may
reveal a uctuant mass or severe tenderness in the
pelvis or at the vaginal cuff. Imaging with CT is
recommended to evaluate for the presence of a
rim-enhancing, thick-walled uid structure in the
pelvis.
Management
As with all surgical wounds that are infected,
treatment consists of antibiotics, incision and
drainage of the wound if an abscess exits, and
surgical debridement to remove devitalized tissues. Pelvic abscesses should be treated with
broad-spectrum intravenous antibiotics. Larger
abscesses (e.g., those measuring >7 cm) or
smaller abscesses that fail to respond to a
48-hour course of broad-spectrum intravenous
antibiotics may need drainage which can be
accomplished vaginally or by an interventional
radiologist percutaneously, although the indications and criteria for pelvic abscess drainage are
controversial.
Cesarean Hysterectomy
withPlacenta Accreta Spectrum
(PAS)
In addition to the complications listed above,
PAS presents specic challenges to the surgical
team performing cesarean hysterectomy. As a
result of distorted anatomy and pelvic hypervascularity, strategies to prevent and manage complications in patients with PAS differ substantially
from those undergoing cesarean hysterectomy
without PAS.
Massive Obstetric Hemorrhage
Background
The most important and life-threatening complication of cesarean hysterectomy for placenta
accreta spectrum (PAS) is rapid and massive
obstetric hemorrhage. Massive hemorrhage,
which can be described as the need for >8units of
red blood cell transfusion within a 24-hour
period, occurs in 7%-25% depending on disease
severity, the surgical approach, and the surgical
team experience [16].
Patients with PAS are at particularly high risk
for massive bleeding during cesarean hysterectomy for several reasons including [1] signicantly increased blood ow to the pregnant
uterus, [2] distortion of the lower uterine segment
and pelvic anatomy by an abnormally attached
and highly vascular placenta, and [3] recruitment
of sometimes enormous and typically numerous
collateral pelvic blood vessels. Dissection and
ligation of main and collateral arteries during
hysterectomy is therefore potentially hazardous
with even small surgical missteps resulting in
rapid placental bleeding or vascular bleeding.
Prevention
To prevent massive obstetric bleeding in PAS,
there is no substitute for surgical experience and
team-based care. Interdisciplinary team-based
surgical care in high-volume centers is associated
with a marked reduction in the risk of massive
bleeding and other immediate surgical morbidities [17, 18]. Data are lacking to inform the minimum number of cases to ensure adequate volume,
but ideally, the PAS surgical team should perform
several cases per year. Many of the busiest centers in the United States now perform PAS surgery for 20–70 cases per year. When possible,
patients with PAS should be cared for in highvolume centers with PAS experience.
Preventing massive bleeding from PAS is considerably easier than managing it. Experience
enables the surgical team to avoid the surgical
missteps that occur in cesarean hysterectomy for
the placenta accreta spectrum. Common surgical
missteps [19, 20] are:
322
Umbilical
hy
B. D. Einerson and A. P. Soisson
• Disrupting or bisecting the placenta during
delivery of the newborn, resulting in bleeding
from the placenta. If PAS is identied at the
time of laparotomy for cesarean delivery, do
not cut through it or near it. Fundal or even
posterior hysterotomy may be needed to avoid
the placenta. (Fig. 30.1). During delivery of
the newborn, take care to avoid placental disruption that can occur manually with difcult
delivery or with excessive fundal pressure.
• Attempting to forcibly deliver the placenta
when PAS is suspected. Attempted delivery
of the placenta in known cases of PAS most
commonly results in massive and
difcult-to- control bleeding. Make no attempt
to deliver the placenta when PAS is
identied.
• Excessive bleeding from a fundal or classi-
cal hysterotomy during delivery. One
approach to reducing bleeding from the hysterotomy itself is sequential clamping of
engorged sinuses along the length of the incision. Another approach we have adopted is the
use of a linear stapling-cutting device [21] to
create an avascular uterine incision large
enough to deliver the fetus(es). (Fig.30.2a–f).
• Attempting difcult bladder dissection
before securing sources of arterial blood
ow. After securing the utero-ovarian circula-
tion, the team should attempt to ligate the uterine arteries prior to proceeding with bladder
dissection. The intent here is to reduce blood
ow to the placenta as much as possible before
it could potentially be disrupted (and ll the
pelvis with blood).
• Operating too slowly after bleeding has
started. Once brisk placental bleeding has
started, it is incredibly difcult to contain and
may, over the course of a long operation, result
in additional liters of blood loss. The most
experienced surgeons available should move
quickly to complete the hysterectomy to avoid
this misstep. If the cervix is not involved with
PAS, a supracervical hysterectomy can be performed to expedite specimen removal.
Prophylactic use of endovascular interven-
tions to prevent massive bleeding during cesarean
hysterectomy is controversial. Balloon occlusion
can be applied at multiple levels from the distal
aorta to common and internal iliac and uterine
arteries (Fig.30.3). Any time after delivery of the
newborn, balloons can be inated to reduce ow
to the uterus and pelvis. Most prospective studies
show no benet in reducing blood loss [22],
although a meta-analysis of uncontrolled studies
Fig. 30.1 Fundal
hysterotomy may be
needed to avoid the
placenta
Uterine
incision
Fundal
sterotomy
cord
Uterus
Neo
30 Cesarean Hysterectomy
323
cba
fed
Fig. 30.2 (a–f) Use of a linear stapling-cutting device to create an avascular uterine incision large enough to deliver
the fetus
with highly variable approaches suggests possible
Renal artery
benet [23]. More research is needed before
widespread adoption, particularly since serious
complications have been reported, including arterial thrombosis with limb ischemia, balloon rupture or migration, and vessel injury [24].
Alternative approaches to immediate cesar-
Abdominal
aorta
Ovarian artery
Inf. mesenteric
artery
ean hysterectomy for PAS are still considered
investigational. Delaying hysterectomy until
ommon iliac
Internal iliac
terine artery
weeks later may allow for partial involution of
the pregnant uterus and reduction in hypervascularity. Outcomes of delayed hysterectomy suggest that total blood loss is lower with this
approach (750mL vs 2500 mL), although total
vascular
branches
feeding PAS
operating time and hospital length of stay are longer [25, 26]. Another alternative is conservative
in situ management wherein the placenta is left
undisturbed in the uterus, hysterectomy is intentionally avoided, and the patient is monitored
Fig. 30.3 Vascular anatomy related to prophylactic use
of endovascular interventions
closely over time as the placenta slowly is
absorbed or passed out of the body [27].
Conservative in situ management may reduce the
324
Placenta Accreta: Patient in Low Lithotomy
B. D. Einerson and A. P. Soisson
immediate risk of major bleeding and transfusion
by up to 70% [28]. However, patients face prolonged follow-up over the course of months, a
higher rate of hospital readmission and endometritis, and, in the end, 15–20% will require
hysterectomy.
Recognition
Massive placental or vascular bleeding during
cesarean hysterectomy is unmistakable if it
occurs in the surgical eld. But beware: large volumes of blood can be lost vaginally and not recognized if the surgical team is unaware of this
possibility or is not looking. We position the
patient in lithotomy (not supine) and perform
timed surgical check-ins to assess for vaginal
bleeding periodically (Fig.30.4).
Arterial
wrist line
CVP
Management
If brisk placental bleeding is encountered and the
hysterectomy is far from complete, the surgical
team has several options that may help to reduce
blood loss.
A bleeding placenta extruding from the
uterus can be compressed manually by one of
the surgeons or assistants. This is an imperfect
but suitable method in helping the team move
along to the next steps of the hysterectomy
without delay. Spending time suturing, oversewing the placenta, or applying compression
sutures is less effective in our opinion, since
the surrounding uterus is typically thin and distorted and the placenta hemorrhages briskly
once released regardless of these techniques.
(Fig.30.5).
Left and right kidney
Femoral arterial catheter
for endovascular intervention
Bladder
Fig. 30.4 Placenta accreta: Patient in low lithotomy
Ureteral stent in left
and right ureters
Uterus with baby
Placenta accreta
30 Cesarean Hysterectomy
Fig. 30.5 A bleeding
placenta extruding from
the uterus can be
compressed
325
Ut
P
Another option is endovascular balloon
occlusion or embolization. Arterial access (typi-
cally femoral) can be achieved prior to surgery to
allow for more rapid application of arterial catheters (aorta, common iliac, or internal iliac) or
embolization during a hemorrhage. This
approach, applying endovascular interventions in
response to hemorrhage, contrasts with the prophylactic use of these devices as mentioned
above.
When the rate or volume of blood loss is truly
critical and life-threatening, as when there are
several liters lost in a matter of minutes or when
there is cardiovascular collapse due to hypovolemic shock, the surgical team can consider man-
ual aortic compression (pressing down directly
on the aorta) or aortic cross-clamping to reduce
blood ow to the pelvis temporarily while quickly
completing the hysterectomy (Fig.30.6).
Disseminated Intravascular Coagulopathy (DIC)
Background
PAS surgeons often encounter DIC, which is
characterized by systemic activation of the coagulation cascade and hyperbrinolysis [29]. The
true rate of DIC in PAS surgery is unknown but
some degree of coagulopathy or DIC occurs in up
to one-third of patients undergoing hysterectomy
for PAS [17].
Prevention
Rapid or high-volume hemorrhage is usually the
cause—and typically the result—of DIC in PAS
surgery. Consequently, efforts to reduce the volume and rate of blood loss in PAS surgery are the
primary means of prevention of DIC (see section
on Massive Obstetric Hemorrhage). Additionally,
early, aggressive, and balanced transfusion of
blood products is critically important to prevent
DIC in patients with ongoing hemorrhage due to
PAS [30]. Waiting to transfuse until laboratory
testing conrms worsening anemia or
coagulopathy is not prudent, owing to the rapid
changes in coagulation and blood loss that can
occur during cesarean hysterectomy for PAS.
Recognition
Diagnosis is a combination of clinical and laboratory ndings. The surgeon may observe diffuse
bleeding from all cut surfaces despite arterial
control. Coagulopathy may manifest as blood
within the surgical eld that appears thin (like
Kool-Aid) or does not clot as expected. Bleeding
326
B. D. Einerson and A. P. Soisson
Fig. 30.6 Manual aortic compression
from IV and catheter sites or petechiae may be
present. Organ damage occurs as a result of vascular thrombosis and hypoperfusion and may
manifest as kidney failure, liver dysfunction,
acute lung injury, neurologic injury, or adrenal
failure.
When clinical signs of coagulopathy are pres-
ent in the setting of major bleeding, DIC should
Placenta
Placenta
Placenta
Bladder Bladder Bladder
a
30 Cesarean Hysterectomy
327
accreta
spectrum
Fig. 30.7 (a–c) Identifying bladder in relation to PAS
Uterus Uterus Uterus
be presumed. Stat laboratory or point-of-care
broelastic assays should be obtained. Newonset thrombocytopenia, prolonged PT or PTT,
and hypobrinogenemia help to support the presumed clinical diagnosis.
Management
When coagulopathy or DIC is encountered, the
highest priorities should be ongoing aggressive
blood transfusion and immediate control of
hemorrhage.
Whole blood transfusion or the combination
of packed red blood cells (RBC) with fresh frozen plasma (FFP) or cryoprecipitate and platelets
in a balanced ratio is superior to RBC alone. Use
of a specialized rapid blood warmer-infuser
(e.g. The Belmont) should be considered. To
avoid worsening coagulopathy, prevent hypothermia with warming devices and correct hypocalcemia which occurs frequently with multi-unit
transfusion [31].
Clinical coagulopathy or DIC that persists
after completion of the hysterectomy can be managed with abdomino-pelvic packing with or
without a vacuum-assisted device [32]. This
allows the patient to be transferred out of the
operating theater to the intensive care unit for the
many hours it takes to monitor and replace coagulation factors.
accreta
spectrum
accreta
spectrum
cb
Urologic Injury
Background
Bladder injury occurs in 7–9% of cesarean hysterectomies, whereas ureteral injury is much less
common in simple cesarean hysterectomies
(<0.5%) [3, 33]. Patients with PAS are at even
higher risk owing to distortion of the anatomy
when PAS is located in the lower uterine segment. Signicant remodeling of the lower uterine
segment and dense vesicouterine adhesive disease often result in the bladder being surgically
inseparable from the placenta and scar tissue
(Fig.30.7a–c). Bladder dissection away from the
lower uterine segment is often the most difcult
and time-consuming part of cesarean hysterectomy for PAS (Fig. 30.7a–c). As a result, PAS
patients are at high risk of cystotomy and ureteral
injury (9–37%) [34, 35].
Prevention
Identifying the bladder during PAS surgery helps
to avoid injury. This can be done visually and
with the aid of cystoscopy or bladder backlling
(Fig.30.7a–c). Bladder lling has been shown to
decrease bladder injury in prospective [36] and
retrospective [37] studies and should be considered especially in women who have undergone
multiple prior cesarean sections. Finally, sharp
328
B. D. Einerson and A. P. Soisson
meticulous dissection should be performed during hysterectomy to separate the bladder from the
uterus rather than any type of blunt dissection. In
some cases (e.g., percreta with bladder involvement) avoiding bladder injury is not possible
since it can be inseparable from the placenta or
densely encased in pelvic adhesion. In these
cases, intentional cystotomy to dene the area of
placental involvement may aid in the safe removal
of the specimen with a small area of attached
bladder to avoid causing massive bleeding from
placental disruption. When possible, the surgeon
should preserve as much bladder as possible and
avoid excising the bladder near the trigone and
ureteral orices.
Steps to prevent ureteral injury during cesarean hysterectomy include exploration of the retroperitoneum to identify and locate the ureter as
well as the prophylactic use of ureteral stents.
Knowledge of the anatomy of the retroperitoneum and the relationship of the ureter to the
uterine vessels is essential.
Whether routine cystoscopy and ureteral
stenting prevent urinary tract injury is unclear
from the literature [38], but at least one study
suggests that routine use results in a lower chance
of bladder injury as well as ureteral injury [39].
Finally, for PAS, some uncontrolled studies suggest the use of conservative in situ management
may reduce the risk of bladder and other urinary
tract injury [28], although this nding requires a
prospective study to be validated.
Recognition
Bladder defects may be easily identied visually
as the bladder opens to the eld during abdominal entry or more commonly during bladder dissection. Identication of the bladder catheter
bulb or ureteral stents within the bladder conrms the diagnosis. Bladder defects may also be
subtle and only recognized when surgeons perform backlling of the bladder with sterile saline
or dye. Saline or dye leaking into the eld conrms that an occult injury has occurred. Routine
post-hysterectomy evaluation of bladder integrity
with some combination of visual inspection and
bladder backlling or cystoscopy is prudent since
bladder anatomy is often distorted by PAS and
pelvic tissues of pregnant individuals are edematous and hypervascular compared to the nonpregnant state.
Recognition of ureteral injuries is further cov-
ered in Chaps. 6 and 17.
Management
Closure of the cystotomy should be performed in
two layers incorporating a running non-locking
absorbable suture for both layers. Care should be
taken to place the sutures well beyond the lateral
limit of the injury and at least a.5cm in the superior and posterior direction to provide adequate
tissue closure. Primary repair of a simple dome
cystotomy can be performed in two layers incorporating a running non-locking absorbable suture
followed by a second absorbable suture. When a
bladder injury is large (perhaps >8cm), involves
signicant resection or denuding of the bladder,
is associated with ureteral injury, or is in close
proximity to the ureteral orices, it is important
to involve a surgeon experienced in urologic
repair.
Management of complex bladder and ureteral
injury is covered in Chaps. 12 and 17.
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