Comparison between Bladder Dissection at the Beginning of Cesarean Section for Morbidly Adherent Placenta and between Delaying Dissection Until Planning for Cesarean Hysterectomy

Background: Abnormally invasive placentas are a leading cause of maternal morbidity and death. The most common surgical treatment is Cesarean hysterectomy. However, there is little data to suggest the most effective care of this illness. The extant literature consists primarily of case reports and studies conducted utilizing retrospective evaluation of medical data over a period of years in a single or limited number of tertiary-care facilities.
Objective: This study aimed to provide preliminary data to judge between two different approaches during Cesarean section (CS) for morbidly adherent placenta, which are bladder dissection before and after uterine incision as regards operative time, blood loss and incidence of bladder injury.
Materials and methods: This randomized controlled trial (RCT) included 60 cases of morbid placental adherence managed at Ain Shams Maternity hospital, Cairo, Egypt. We divided the cases into 2 groups: Group A included 30 patients had bladder dissection at the start of SC for morbidly adherent placenta and group B that involved 30 patients who had bladder dissection after closing uterine incision and just before clamping uterine artery for Cesarean hysterectomy. Main outcome measures were estimated blood loss, transfusion requirements, operative time and incidence of urological injury.
Results: The study includes 60 cases who were diagnosed by ultrasound and Doppler as abnormally invasive placenta (AIP). The mean blood loss in group A (bladder dissected before uterine incision) was 1791.17 ml, while group B (bladder dissected after uterine incision) was 2368.33 ml, also 33.3% of group A needed blood transfusion while 76.7% in group B. The mean operative time in minutes in group A was 139 while 166 in group B. The incidence of urological injury was 6.7% in group A and 20% in group B.
Conclusion: The study showed that dissection of the bladder before uterine incision during CS of morbidly adherent placenta was associated with less blood loss than delaying dissection after uterine incision. But there was no statistical significance between both groups as regards incidence of urological injury and total operative time despite the noted clinical significant differences.