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CLINICAL ARTICLE
Pregnancy Health Research Center and Department of Gynecology and Obstetrics, School of Medicine, Zahedan University of Medical Sciences and Health Services, Zahedan, Iran
Genetics of Non-communicable Disease Research Center and Department of Histology, School of Medicine, Zahedan University of Medical Sciences and Health Services, Zahedan, Iran
a r t i c l e
i n f o
Article history:
Received 15 March 2014
Received in revised form 20 August 2014
Accepted 20 October 2014
Keywords:
Cervical inversion
Cesarean delivery
Placenta accreta
Placenta increta
Placenta previa
Postpartum hemorrhage
a b s t r a c t
Objective: To describe the use of cervical inversion for postpartum hemorrhage (PPH) management during
cesarean delivery for placenta previa accreta/increta. Methods: In a retrospective, descriptive study, data were
reviewed for cases in which cervical inversion was used to manage PPH during cesarean delivery at a center in
Zahedan, Iran, between July 2, 2011, and September 25, 2014. Cervical inversion was applied when placental
bleeding was persistent and the sites could not be clearly located. The cervix is inverted using ring forceps or
straight Allis forceps, after which the placental bed is sutured to control bleeding. After bleeding is controlled,
the cervix is returned to its original position. Results: Cervical inversion was successfully applied to 10 cases.
Mean time to completion of cervical inversion was 4.1 0.7 minutes. In all 10 cases, the bleeding was stopped
within 35 minutes from the beginning of the cervical inversion procedure. No apparent complications were
reported, and blood transfusions or obstetric hysterectomies were not necessary. Conclusion: Cervical inversion
is a simple, cost-effective, and time-saving procedure for PPH management in placenta previa accreta/increta.
It could become a routine procedure for preserving the uterus and fertility of affected women.
2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction
Maternal mortality is approximately 14% in low-income countries,
and 4% in high-income countries [1]. Postpartum hemorrhage (PPH)
remains a major leading cause of direct maternal mortality [2,3],
accounting for almost half of all postpartum deaths in low-resource
countries [4].The denitive treatment for severe PPH is hysterectomy,
but this procedure is associated with intraoperative comorbidity and
postpartum depression, and compromises fertility [5]. As a result,
other surgical procedures should be considered initially [6].
Bleeding from the placental bed should be controlled by strong
myometrial contractions and constriction of blood vessels. The absence
of these mechanisms in placenta previapartial or complete coverage
of the internal cervical orice by placental tissue [7]can lead to PPH
[5]. The risk factors for placenta previa include implantation in the
lower segment over a surgical scar, advanced maternal age, smoking,
multiparity, previous placenta previa, alcohol and illicit drug use, spontaneous and induced abortions, multiple pregnancy, maternal anemia
http://dx.doi.org/10.1016/j.ijgo.2014.08.020
0020-7292/ 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
N. Sakhavar et al. / International Journal of Gynecology and Obstetrics 128 (2015) 122125
123
3. Results
Fig. 1. Schematic illustrations of cervical inversion. (A) Horizontal incision of the uterus (Kerr incision). (B) Inversion of the cervix and lower segment into the uterus; the inverted region is
shown as a dotted line. (C) Inversion of the cervix and lower segment into the uterus; a window has been removed for better observation of the inverted region. (D) Repair of the Kerr
incision after the cervix has been returned to its Original position. Figure published with the permission of the artist, Zahra Heidari.
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N. Sakhavar et al. / International Journal of Gynecology and Obstetrics 128 (2015) 122125
can see the bleeding sites directly and thus avoid further tears,
narrowing of the cervical canal, and needle site bleeding.
There are various methods to prevent and manage PPH. Use of
uterotonics is the rst step in controlling bleeding; if the drugs fail,
other techniques such as uterine tamponade and gauze packing, a
Foleys catheter, SengstakenBlakemore tube, or Bakri balloon can be
applied [12]. Treatment of severe PPH by uterine or hypogastric artery
ligation and arterial embolization is effective, but these approaches
can be difcult to perform in practice and complications have been
reported [10]. As described in previous studies [13,14], the reasons for
low use of uterine artery embolization include the small number of
modern angiography units with an experienced skilled team on-call
24 hours per day and the perceived risk of transferring a patient in
unstable condition to the angiography suite.
Johanson et al. [15] described a method of tamponade using a hydrostatic balloon catheter. However, the major disadvantage of packing the
uterus is that the bleeding can continue but remain obscure for a while.
In cases of profuse bleeding, precise identication of the bleeding site
might be difcult. Applying blind compression suturese.g. transverse
annular, parallel vertical, or circular isthmic-cervical suturescan be
associated with further complications, including uterine cavity closure,
infection, and pyometra due to blood entrapment, intrauterine adhesions, and partial uterine wall necrosis. Furthermore, repeated blind
sutures will result in further loss of critical time. By contrast, surgeons
can see the bleeding sites directly and control them with fewer sutures
using cervical inversion.
Another conservative surgical technique is the B-Lynch or brace
suturing technique, in which pressure is applied by the compression
sutures. This method can cause progressive total or partial myometrial
ischemic necrosis and myometrial defects, which might be hazardous
in future pregnancy. In addition, it is only applicable to bleeding in the
upper segment [3]. Moreover, surgeons experienced in this procedure
might not be readily available everywhere.
Matsubara et al. [16] introduced cervix-holding by round forceps
placed simultaneously over the anterior and posterior cervical lips to
N. Sakhavar et al. / International Journal of Gynecology and Obstetrics 128 (2015) 122125
125
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