Risk Factors Associated With Intraoperative Blood Loss During Cesarean Hysterectomy

INTRODUCTION: Placenta accreta spectrum disorder (PAS) refers to various stages of pathologic placental adherence during pregnancy (PAS FIGO grade 1 accreta, grade 2 increta, and grade 3 percreta). The incidence of PAS is increasing from 1 in 2510 to 1 in 272 in a 2016 study. Cesarean hysterectomy (C-Hys) is indicated in patients with PAS. PAS is associated with hemorrhage, transfusion, maternal ICU admission, extended hospital stay, and high rates of maternal morbidity and mortality. OBJECTIVE: To determine the risk factors (RF) related to surgical techniques influencing increased intraoperative estimated blood loss (EBL) in C-Hys cases. Standard approach involves immediate delivery, then proceeding with C-Hys. We introduce an alternate surgical approach with intraoperative fetal heart rate monitoring directly on the abdomen and then on the uterus, ureteral stent placement, portion of the hysterectomy completed prior to delivery of the fetus, use of electrosurgical vessel sealers, hysterotomy closure with towel clips, triple clamping, and delayed suture ligation of clamped pedicles, which we hypothesize would reduce EBL. METHODS: This is a retrospective case series for women with PAS who underwent C-Hys between 2001 and 2025 at our university hospital. CPT codes utilized included C-Hys (59525), hysterectomy (58510, 58190), cesarean section (59514, 59510, 59515, 59620) plus ICD-10 codes for placenta accreta (O43.2), increta (O43.22X), percreta (O43.23X), accreta affecting pregnancy (O43.219), and previa. We extracted patient demographics, obstetric history, delivery and postoperative details, and details on surgical methods, with 14 patients undergoing the alternative surgical approach. The Mann–Whitney U test was used due to the non-normal distribution. RESULTS: 96 patients with PAS who underwent C-Hys were included. Baseline demographics, BMI, and PAS subtype distribution were similar between groups. Alternate surgical approach listed above was utilized for 14 patients, which resulted in statistically significant lower median EBL of 1.25 L compared to 2.5 L using the standard approach (p=0.012), a statistically significant lower rate of blood transfusion at 2 units (IQR: 0–2) compared to the standard approach, IQR 0–7 (p=0.012). The ICU admission rate for the alternative approach was 7.1% versus 25.9% for the standard (p=0.18). The alternative approach had one postpartum hemorrhage (7.1%), and the standard approach had a 28.2% rate of complications, including hemorrhagic shock, DIC, and bladder injury. The alternative approach had no hospital readmissions; the standard approach had 6 readmissions. There were no cases of maternal mortality for either. There were no fetal deaths in the alternate approach and 1 in the standard approach. The median fetal cord blood arterial pH for the alternate approach was 7.28 and 7.30 for the standard approach (p=0.69). Median APGAR scores are similar for both approaches. CONCLUSIONS: The alternate surgical approach listed above during C-Hys significantly reduces EBL and transfusion rates and decreases ICU admission. There were less postoperative complications. There were no differences in fetal outcomes. These techniques are applicable in emergent and nonemergent settings. Limitations include a small number of subjects (N=14) and difficulty extracting data before the advent of electronic medical records in 2016. Future studies incorporating these techniques are needed to evaluate the impact on and to decrease maternal morbidity.