Intraoperative uterine artery embolization without fetal radiation exposure in patients with placenta previa totalis: Two case reports
A 40-year-old woman, gravida 0, was admitted to Seoul National University Bundang Hospital in August 2011 for elective Cesarean section and prophylactic intraoperative UAE at 36 weeks and 6 days gestational age. Two thirds of the placenta was located in the posterior wall of the uterus and the remaining placenta was located in the anterior lower segment of the uterus resulting in complete covering of the internal os of cervix. Under spinal anesthesia, a low transverse uterine incision was made and after gently penetrating part of the placenta directly behind the incision site, a live 2,815 g baby was delivered. The upper and lower cut edges and each lateral angle of the uterine incision were clamped using Allis forceps. The torn placental margin was also clamped using Allis forceps. An interventional radiologist, who had been already stood by, stepped into the operation field and then inserted an angiographic catheter into the right femoral artery and approached both uterine arteries using portable fluoroscopy. Insertion of the catheter took five minutes. During that time, the surgeon had observed the uterus carefully for detection of bleeding. Embolization was performed with gelfoam under fluoroscopic guidance for bilateral enlarged tortuous uterine arteries and it took 20 minutes (). After confirming via angiography that there was markedly decreased blood flow, the surgeon removed the placenta. However, bleeding from the implantation site was profuse even though both uterine arteries had been embolized. Bleeding was ultimately controlled by over-sewing the implantation site with 0-monofilament absorbable suture and the rest of the surgery was uneventful. Estimated blood loss for this surgery was 2,500 mL. The patient received five units of packed red blood cells and three units of fresh frozen plasma during the operation. The next day, the patient's hemoglobin was 10.1 g/dL and the sheaths were removed. Routine postoperative care was performed and the patient was discharged from the hospital four days after surgery with no complications.