Abstract
Aim: To evaluate intraoperative and early postoperative outcomes of a novel placenta delivery technique; extra-abdominal removal vs. intra-abdominal removal of the placenta during cesarean section (CS).
Methods: A total of 210 women delivering by CS at term in a tertiary university hospital between March 2014 and January 2015 were randomized to extra-abdominal removal vs. intra-abdominal removal of the placenta. The women were randomly allocated to the extra- (group 1) or intra-abdominal removal group (group 2) according to random sampling method, where women with even and odd numbers were allocated to intra- and extra-abdominal groups, respectively. The amount of intra-abdominal hemorrhagic fluid accumulation, the duration of operation and estimated blood loss during operation were the primary outcomes. The secondary outcomes included the mean difference between pre- and post-operative hemoglobin and hematocrit levels, the mean postoperative pain score, any additional need of analgesia, postoperative bowel function, postoperative endometritis and wound infections.
Results: The amount of aspirated hemorrhagic fluid was significantly higher in the intra-abdominal group compared to the extra-abdominal group (34.6±22.2 mL vs. 9.4±4.8 mL, P<0.001). Mean duration of the operation, intraoperative blood loss, postoperative requirement of additional analgesia, postoperative pain scores, postoperative endometritis or wound infection, and length of hospital stay were not significantly different between the intra- and extra-abdominal placental removal groups.
Conclusion: By extra-abdominal removal of the placenta, the accumulation of bloody fluid in the abdominal cavity is significantly less compared to the intra-abdominal removal method, which, in turn, provides avoidance of excessive mounted-gauze use, intra-abdominal manipulations, or iatrogenic trauma.
Acknowledgments
The authors thank Ovgu Ozenli and Talha Serin for their support to our study.
Clinical trial registration: Extra-abdominal Removal of Placenta During CS, www.clinicaltrials.gov, and registration number: NCT02101450.
Contribution to authorship: BK and OG equally contributed to the study. BK was the inventor of this novel placenta removal technique and designer of the study. BK wrote the draft of the manuscript, analysed and interpretation of data for the work. OG made statistical analysis of the paper, edited language, revised the manuscript critically for important intellectual content and finalized the article. BK, EY and TA performed the surgical procedures and carried out the follow up of participants. EY, TA AD, AT, KD and AD analysed the data, made substantial contributions to the interpretation of data and critically reviewed the final version. All authors read and approved the final article.
Details of ethics approval: The study was approved by the Ethics Committee of The Near East University (Date: 09.01.2014, Number: YDU/2014/19-100).
Funding: None.
References
[1] Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol. 2011;118:29–38.10.1097/AOG.0b013e31821e5f65Search in Google Scholar
[2] Gün I, Ozdamar O, Ertuğrul S, Oner O, Atay V. The effect of placental removal method on perioperative hemorrhage at cesarean delivery; a randomized clinical trial. Arch Gynecol Obstet. 2013;288:563–7.10.1007/s00404-013-2759-2Search in Google Scholar
[3] Hofmeyr JG, Natalia Novikova N, Mathai M, Shah A. Techniques for cesarean section. Am J Obstet Gynecol. 2009;201:431–44.10.1016/j.ajog.2009.03.018Search in Google Scholar
[4] McCurdy CM Jr, Magann EF, McCurdy CJ, Saltzman AK. The effect of placental management at cesarean delivery on operative blood loss. Am J Obstet Gynecol. 1992;167:1363–7.10.1016/S0002-9378(11)91717-7Search in Google Scholar
[5] Magann EF, Dodson MK, Albert JR, Mc-Curdy CM Jr, Martin RW, Morrison JC. Blood loss at time of cesarean section by method of placental removal and exteriorization versus in situ repair of the uterine incision. Surg Gynecol Obstet. 1993;177:389–92.10.1097/00006254-199405000-00007Search in Google Scholar
[6] Chandra P, Schiavello H, Kluge J, Holloway S. Manual removal of the placenta and postcaesarean endometritis. J Reprod Med. 2002;47:101–6.Search in Google Scholar
[7] Hidar S, Jennane TM, Bouguizane S, Lassoued L, Bibi M, Khaïri H. The effect of placental removal method at cesarean delivery on perioperative hemorrhage: a randomized clinical trial ISRCTN 49779257. Eur J Obstet Gynecol Reprod Biol. 2004;117:179–82.10.1016/j.ejogrb.2004.03.014Search in Google Scholar
[8] Gol M, Baloglu A, Aydin C, Ova L, Yensel U, Karci L. Does manual removal of the placenta affect operative blood loss during cesarean section? Eur J Obstet Gynecol Reprod Biol. 2004;112:57–60.10.1016/S0301-2115(03)00278-1Search in Google Scholar
[9] Merchavy S, Levy A, Holcberg G, Freedman EN, Sheiner E. Method of placental removal during cesarean delivery and postpartum complications. Int J Gynaecol Obstet. 2007;98:232–6.10.1016/j.ijgo.2007.04.002Search in Google Scholar PubMed
[10] Hershey DW, Quilligan EJ. Extraabdominal uterine exteriorization at cesarean section. Obstet Gynecol. 1978;52:189–92.Search in Google Scholar
[11] Wahab MA, Karantzis P, Eccersley PS, Russell IF, Thompson JW, Lindow SW. A randomized, controlled study of uterine exteriorization and repair at cesarean section. Br J Obstet Gynaecol. 1999;106:913–6.10.1111/j.1471-0528.1999.tb08429.xSearch in Google Scholar PubMed
[12] Walsh CA, Walsh SR. Extraabdominal vs intraabdominal uterine repair at cesarean delivery: a metaanalysis. Am J Obstet Gynecol. 2009;200:625.e1–8.10.1016/j.ajog.2009.01.009Search in Google Scholar PubMed
[13] Walfisch A, Beloosesky R, Shrim A, Hallak M. Adhesion prevention after cesarean delivery: evidence, and lack of it. Am J Obstet Gynecol. 2014;211:446–52.10.1016/j.ajog.2014.05.027Search in Google Scholar
[14] Lyell DJ. Adhesions and perioperative complications of repeat cesarean delivery. Am J Obstet Gynecol. 2011;205 (Suppl 6):S11–8.10.1016/j.ajog.2011.09.029Search in Google Scholar
[15] Bates GW Jr, Shomento S. Adhesion prevention in patients with multiple cesarean deliveries. Am J Obstet Gynecol. 2011;205(Suppl 6):S19–24.10.1016/j.ajog.2011.09.030Search in Google Scholar
[16] Andolf E, Thorsell M, Källén K. Cesarean delivery and risk for postoperative adhesions and intestinal obstruction: a nested case-control study of the Swedish Medical Birth Registry. Am J Obstet Gynecol. 2010;203:406.e1–6.10.1016/j.ajog.2010.07.013Search in Google Scholar
[17] El-Mowafi DM, Diamond MP. Are pelvic adhesions preventable? Surg Technol Int. 2003;11:222–35.Search in Google Scholar
[18] Davey A. Maher P. Surgical adhesions: a timely update, a great challenge for the future. J Minim Invasive Gynecol. 2007;14:15–22.10.1016/j.jmig.2006.07.013Search in Google Scholar
[19] The Practice Committee of the American Society for Reproductive Medicine in collaboration with the Society of Reproductive Surgeons. Pathogenesis, consequences, and control of peritoneal adhesions in gynecologic surgery. Fertil Steril. 2008;90(suppl):S144–9.10.1016/j.fertnstert.2008.08.060Search in Google Scholar
[20] Cheung JP, Tsang HH, Cheung JJ, Yu HH, Leung GK, Law WL. Adjuvant therapy for the reduction of postoperative intra-abdominal adhesion formation. Asian J Surg. 2009;32:180–6.10.1016/S1015-9584(09)60392-4Search in Google Scholar
[21] Liakakos T, Thomakos N, Fine PM, Dervenis C, Young RL. Peritoneal adhesions: etiology, pathophysiology, and clinical significance: recent advances in prevention and management. Dig Surg. 2001;18:260–73.10.1159/000050149Search in Google Scholar PubMed
[22] Anorlu RI, Maholwana B, Hofmeyr GJ. Methods of delivering the placenta at cesarean section. Cochrane Database Syst Rev. 2008;16:CD004737.10.1002/14651858.CD004737.pub2Search in Google Scholar PubMed
[23] Dahlke JD, Mendez-Figueroa H, Rouse DJ, Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery: an updated systematic review. Am J Obstet Gynecol. 2013;209:294–306.10.1097/01.aoa.0000452147.34903.17Search in Google Scholar
[24] Xiao CW, Climan AB, Abenhaim HA. The effect on perioperative bleeding of placental extraction from an exteriorized uterus during cesarean section. J Obstet Gynaecol Can. 2014;36: 384–90.10.1016/S1701-2163(15)30583-1Search in Google Scholar
[25] O’Sullivan JF. Cesarean birth. Ulster Med J. 1990;59:1–10.Search in Google Scholar
The authors stated that there are no conflicts of interest regarding the publication of this article.
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