Paper Title
The Cervix As A Natural Tamponade in Postpartum Hemorrhage Associated With Placenta Praevia and Placenta Accrete

Abstract
Background: Patients with placenta praevia may develop severe postpartum hemorrhage after removal of the placenta. Moreover, abnormal adherence of the placenta to the myometrium (placenta accreta) may be associated with life-threatening maternal haemorrhage due to its incomplete separation. Several techniques have been described in the literature for controlling massive bleeding associated with placenta praevia caesarean sections including uterine packing with gauze, balloon tamponade, the B-Lynch suture, the insertion of parallel vertical compression sutures, a square suturing technique and embolization or ligation of the uterine and internal iliac arteries, but there is wide variation in the success rates of these manoeuvres. Dawlatly et al. (2007) in a case report have described a simple technique which involves suturing an inverted lip of the cervix over the bleeding placental bed that was successful in controlling the bleeding and saved the women’s life and her uterus. Here, we present our experience with the use of this Dawlatly stitch in 40 cases with placenta praevia and/ or placenta accreta. Objective: To evaluate the efficacy and safety of the use of the cervix as a natural tamponade in controlling postpartum haemorrhage associated with placenta praevia and placenta accreta. Methods: This study was conducted on 40 pregnant women admitted to our Hospital during the period from June 2012 to November 2014. All these women had previous one caesarean section or more and were diagnosed as having placenta praevia and/ or placenta accreta. Significant bleeding from the placental bed was managed by inverting the cervix into the uterine cavity and suturing the anterior and/or the posterior cervical lips into the anterior and/or posterior walls of the lower uterine segment to compress the bleeding points in the placental bed. Additional manoeuvres like Bakri Ballon insertion were needed in 10 patients. Results: The main technique described above and the additional manoeuvres were successful in stopping the bleeding in 38 patients out of 40 patients giving success rate of 95%. We resorted to hysterectomy in 2 cases only (5%). The mean Intraoperative blood loss was 1272.5 mls and the mean number of blood units transfused was 2.1. The complications encountered were as follow: bladder injury in the 2 patients who underwent hysterectomy, wound infection in 3 patients and postoperative fever which was responsive to antibiotics was 2 patients. The mean duration of postoperative hospital stay was 2.5 days. Conclusion: On the base of this study, we conclude that this technique is a safe, simple, time saving and very effective in controlling the severe postpartum haemorrhage (PPHge) associated with cases of placenta praevia/placenta accreta. It deserves to be one of the weapons in the obstetrician’s hand during facing the life-threatening haemorrhage in cases of placenta accreta. The limitation in our study is the uncertainty of the effect of this technique on the anatomical and functional capacity of the cervix and its impact on future pregnancy and delivery. Key words- placenta praevia, placenta accreta, postpartum haemorrhage, cervix, tamponade.