Successful vaginal packing in placenta previa

Introduction

Placenta previa is present in almost 1 in 200–300 deliveries [2, 5]. Associated factors include maternal age, multiparity, prior cesarean section, cigarette smoking and unexplained elevated maternal serum a-fetoprotein.

Diagnosis is confirmed primarily by ultrasound. Bleeding is the most characteristic event, and it frequently does not occur until the end of the second trimester. Management of placenta previa with a preterm fetus without persistent active bleeding consists of close observation and delivery in appropriate conditions. We present a case of placenta previa in a twin gestation that has been successfully managed by vaginal packing after profuse bleeding while preparing for cervical cerclage. To our knowledge, no similar case has been reported in the literature.

Case report

A 32-year-old G2P0A1 bichorial biamniotic twin pregnancy resulting from IVF, with placenta previa, complained at 21 WA +5 days of persistent lower abdominal pain. Endovaginal ultrasound revealed a 20 mm length cervix with a total placenta previa. After confirming the absence of contractions, she was advised home rest and a control after 1 week. At that time, and despite a complete bed rest, cervical length showed an important shortening to 13 mm but still without evidence of contractions. The patient still complained of pelvic pressure but without any bleeding. Cervical cerclage was suggested, but as this was an unusual indication. We gave a thorough explanation of the benefits, risks and controversies of the clinical situation in discussion with the parents. A decision to perform a cerclage was subsequently taken and the date of the procedure postponed for 5 days because the patient was on aspirin and low dose molecular weight heparin for Factor V Leiden mutation.

The patient had spinal anesthesia, and whilst she was in the gynecologic position, she developed hypotension which in turn elicited a violent vomiting reflex resulting in sudden and heavy bleeding from her vagina, estimated at 1 L in under a minute. A quick vaginal compression with three abdominal pads applied with an upward pressure was performed while preparing for an emergent cesarian section.

Bleeding decreased after 1 min and stopped at 2 min. The patient was adequately perfused, and 2 units of blood were urgently required. We decided to wait for a further 10 min while performing forceful vaginal packing. Ten minutes later we removed the packing, and on speculum examination there was no more bleeding and cervical os was visually open. An ultrasound examination was performed and showed no evidence of placental abruption with two normal fetal heart rates. At that time, the set for a cesarean section was ready, but after explaining the situation to the patient and having her consent, we proceeded with the cervical cerclage. This was acheived with a 5 mm Mersilene tape using the McDonald’s technique without further complications or bleeding and care was taken not to tighten the cervical closure but to leave about a 2 mm opening to see if any bleeding occurred.

The patient received one dose of ketoprofen 100 mg i-v to prevent contractions and another ultrasound was performed showing normal amniotic fluid and no placental abruption. The patient was transferred to her room after a 2-unit transfusion and was closely observed as an in-hospital patient until 33 weeks of gestation without any particular problems except for two episodes of moderate bleeding during a cough reflex. No transfusion or vaginal packing was used during these episodes. Nifedipine (60 mg/day) and episodic use of NSAID were used when contractions were reported at 29 weeks. She was delivered by a cesarean section at 33 WA+1 after a bleeding episode associated with regular contractions and was discharged on the third post-operative day. The babies weighed 1.9 and 1.8 kg and did well in NICU.

Discussion

Placenta previa occurs in about 0.5% of all pregnancies [2], and in about 20–45% of cases there is a complete placenta previa. The major problem encountered is bleeding. Expectant management can be tried in moderate bleeding. However, if the bleeding is profuse, delivery must be performed irrespective of gestational age.

To our knowledge, vaginal packing has never been used in the management of severe bleeding in placenta previa, before delivery, in extremely preterm fetuses and in order to gain time and raise the chances of the fetus viability. However, it was used successfully in the rare cases of cervical varix with profuse bleeding [4].

The most accepted action in cases of severe hemorrhage due to placenta previa is emergent cesarean section. In this case, we took into consideration that this patient had no children, the fetuses were not viable, and the set for rapid intervention was under preparation if the bleeding could not be controlled and that the situation was stable after compression. In addition, the gestational age for neonatal resuscitation in our institution is set by the pediatricians to 25 weeks. Placental abruption cannot be excluded by ultrasound in the case of an acute bleed: acute hemorrhage is known to be hyperechoic to isoechoic when compared with the adjacent placenta. Visualization of abruption however, would influence the patient’s management.

Cervical cerclage in placenta previa is a controversial matter as it was shown to facilitate placental migration and prolong gestational age in one study including 37 patients in India [3]; a prior study including 39 patients did not show any benefit from cerclage in patients with placenta previa [1]. In our case, cerclage was performed solely for evolutive cervical shortening that could eventually lead to bleeding, and not to facilitate placental migration. The indication is, however, debatable, and the procedure was thoroughly discussed with the prospective parents in view of the evolution of the cervix on ultrasound, the absence of infectious etiology and the pelvic discomfort felt by the patient. Additional bleeding would not be concealed because we left cervical os open for a few millimeters.

It is very difficult to provide proof leading to advising this form of intervention, but in view of the change in amount of bleeding in a short time (cataclysmic bleeding before packing and the arrest of bleeding following packing), we found it worthwile to report this case.

Conclusion

In selected cases of placenta previa with profuse bleeding, and in a controlled context, an attempt to stop the bleeding by vaginal packing can be performed while considering immediate delivery. Further investigation is needed before advising such management in placenta previa.