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Application of double-row transfixion suture of the lower uterine segment in cesarean section for pernicious placenta previa complicated by placenta accreta spectrum: a comparative clinical study

BMC Pregnancy and Childbirth volume 25, Article number: 381 (2025) Cite this article

Abstract

Objective

To explore the effectiveness and feasibility of double-row transfixion suture of the lower uterine segment in cesarean section (CS) in patients with pernicious placenta previa complicated by placenta accrete spectrum disorder.

Methods

This retrospective study included 91 women who received CS for pernicious placenta previa complicated by placenta accrete spectrum, which was suggested by preoperative ultrasound and MRI assessment, and confirmed by operation or postoperative pathology. Preoperative ultrasonographic scores were > 6 in all patients. Of them, 47 patients received double-row transfixion suture of the lower uterine segment (study group), and the remaining 44 patients received abdominal aortic balloon placement combined with other uterine suture techniques (control group). The clinical therapeutic efficacy was compared between the two groups. All patients were followed up for two years, during which the duration of bloody lochia, uterine status, menstrual cycle and re-pregnancy were observed.

Results

The study group showed obvious advantages in operative time, length of hospital stay, intraoperative blood loss, and hospitalization cost (P < 0.05). Uterine resection was performed in two cases in the control group vs. none in the study group. During the two-year follow-up period, no significant difference was observed in the duration of lochia in patients with the uterus preserved between the two groups. The uterus was restored to the normal size within 42 days post-operation, and there was no significant difference in menstrual cycle 2 years post-operation. Uterine diverticulum occurred in 3 cases in the control group and 4 in the study group. Except for one patient who underwent artificial abortion because of contraceptive failure, all other patients have had no intention of getting pregnant again.

Conclusion

Double-row transfixion suture of the lower uterine segment in CS for pernicious placenta previa complicated by placenta accrete spectrum deserves wider clinical application, especially in basic-level hospitals, due to reliable hemostasis, shorter operative time, quicker postoperative recovery, fewer complications, lower hospitalization cost, and avoidance of uterine resection.

Peer Review reports

Introduction

Pernicious placenta previa (PPP) is a type of placenta previa attached to the previous uterine scar such as left by cesarean section (CS) [1]. Placental accretra spectrum (PAS) disorder is a group of diseases featured by the abnormal invasion of trophoblast cells into the uterine muscle layer. According to the depth of invasion, PAS can be classified as placenta accreta (PA), placenta increta (PI), and placenta percreta (PP) [2, 3]. About 50% PPP patients are complicated by PAS [4]. During CS, the risk of massive bleeding is generally high due to poor contraction of the lower uterine segment. This often results in hysterectomy or even maternal death [5,6,7,8,9], the American College of Obstetricians and Gynecologists (ACOG) recommends directly performing hysterectomy during CS [10]. However, Direct hysterectomy may lead to over treatment, complications during hysterectomy and loss of fertility. Therefore, there is an urgent need to seek an effective and safe hemostasis method to better preserve the uterus and reduce maternal mortality.

Currently, there is no consensus method for hemostasis, and commonly used methods include uterine cavity packing [11,12,13], uterine artery ligation [14], different methods of uterine sutures [15, 16], and abdominal aortic balloon combined with other uterine suture techniques [17]. These methods have their respective merits and demerits. In recent years, we have applied double-row transfixion suture of the lower uterine segment in CS for patients with PPP complicated by PAS which have obvious advantages such as a better hemostasis effect, fewer complications, and lower hospitalization cost over abdominal aortic balloon combined with other uterine sutures techniques.

It is now reported hereafter.

Materials and methods

General information

A total of 2,835 pregnant women with a history of CS who gave birth at Daping Hospital of the Army Medical University (a public tertiary referral center, Chongqing, China) from January 2017 to December 2020 were reviewed. Among them, 179 pregnant women underwent elective CS because of the diagnosis of placenta previa complicated by PAS as suggested by preoperative ultrasound and MRI, which was later confirmed by intra- and postoperative pathology. Of them, 91 pregnant women with PPP complicated by severe placenta accreta were included as the study subjects. All patients were followed up for two years postpartum. Inclusion criteria were pregnant women (1) at a gestational age ≥ 28 weeks; (2) aged 20–45 years; (3) who underwent uterine lower segment CS in the previous delivery, and had placenta previa and the placenta attached to the previous uterine scar this time; and (4) who were diagnosed with severe PAS as assessed by ultrasound (US) and MRI before delivery, with a US score > 6 (≥ 5 as severe PAS) (Table 1) [18]. Exclusion criteria were patients (1) whose temperature exceeded 38℃ before delivery; (2) who had no hemorrhage after placenta separation without using uterotonics; and (3) who had severe cardiovascular diseases and liver/kidney insufficiency. Of the 91 included patients, 44 patients who received abdominal aortic balloon combined with other uterine suture techniques (such as B-lynch suture and lower uterine segment circular ligation) before 2018-05-31 were used as the control group, and the other 47 patients who received double-row transfixion suture of the lower uterine segment after 2018-06-01 were used as the study group. There was no significant difference in age, gravidity, parity, gestational age at delivery, number of CSs, preoperative hemoglobin (Hb), and US score between the two groups (P > 0.05). This retrospective study was approved by the Ethics Committee of the said hospital (No. 2024 − 111) with a waiver for informed consent and the study was conducted in accordance with the Declaration of Helsinki. All patient data were anonymized to maintain the patients’ privacy prior to the analysis.

Table 1 Placenta accreta scoring system [18]
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Methods

Therapeutic methods

Control group

An arterial balloon was first pre-placed in the lower segment of the abdominal aortic artery via the femoral artery before CS; after the fetus was delivered, 8-15 ml normal saline was injected into the balloon to block blood supply to the uterus, and at the same time uterotonics were administered to enhance uterine contraction. After removing the placenta, bleeding was controlled by selective use of suture techniques according to the state of uterine contraction and the bleeding site, and uterine artery embolization was used when necessary. The balloon was released for 1–5 min at a 20-min interval to restore the normal oxygen saturation of the great toe. After observing for about 10 min and ensuring no significant bleeding in the uterine cavity, the uterine incision was closed routinely.

Study group

Double-row transfixion suture of the lower uterine segment was performed as follows.

  1. 1)

    Preoperative preparations: intravertebral anesthesia was used.

  2. 2)

    Bladder separation: a midline para-longitudinal incision was made to expose the lower uterine segment; the adhesion between the bladder and uterus was dissected; if the adhesion was severe, a lateral approach was employed to open the lateral fossa and find the loose space between the bladder posterior wall and uterine lower segment to fractionally clamp and ligate the blood vessels; the bladder was separated downward until it exceeded the lowest point of the placental attachment or even down to the level of the cervical external orifice. If the ultrasonic knife (Ethicon HARH23) was used, the operation at this site would be easier and less likely to cause hemorrhage.

  3. 3)

    Rubber tube placement. Before delivering the fetus, a rubber tube was placed behind the lower uterine segment and tightened by the assistant during fetal delivery, knowing that it could reduce blood loss significantly. In patients with low placental attachment, cervical invasion, and a thick and short cervix, the tube can be passed through a hole made at the avascular zone of the bilateral broad ligament to completely block the blood flow of the uterus above the lowest point of the placental attachment. After delivery of the placenta, the tube was withdrawn, and at the same time, blood flow of the parametrial blood vessels was clamped with the oval forceps bilaterally, which would not affect the surgical procedure.

  4. 4)

    Double-row transfixion suture of the lower uterine segment. After clearing the residual placenta in the lower uterine segment and cervical canal, the lower uterine segment-cervical anterior and posterior walls were sewed up with 1 − 0 absorbable suture (Ethicon, VCPB341) using the double-row transfixion suture technique, with the superior-inferior interval maintained at 1–2 cm and not exceeding the para-uterine vessels transversely (Fig. 1). The blood sinus was closed by compressing the tissue comprehensively. In cases where the placenta implanted into the muscular layer so deep that only the serosal layer was left or there was a defect, a suture was made after trimming the weak tissue and remodeling the cervix. For the operation performer with right-hand dominance, he/she can place his/her left-hand thumb and the other four fingers at the anteroposterior aspect of the cervix or uterine lower segment respectively for location to achieve precision suture from the inferior to the superior aspect.

  5. 5)

    Release of the oval forceps and observation for 10 min. If there was no bleeding from the uterine cavity, the uterine incision was sutured and the abdominal cavity was closed.

Fig. 1
figure 1

Intraoperative surgical procedure: (A) Place a rubber tube behind the lower uterine segment after separating the bladder; (B), Tighten the tube to decrease bleeding; (C) Clamp the parametrial blood vessels with ovum forceps to decrease bleeding; (D) Lower uterine segment-cervix double-row U-shaped through-and-through suture; (E) Schematic diagram of double-row U-shaped through-and-through suture

Full size image

Observational parameters

Observational parameters included operative time, intraoperative blood loss, transfusion, hysterectomy rate, length of hospital stay, neonatal Apgar at 5 min, hospitalization cost, and postoperative complication rate in both groups. All patients were followed up for 2 years postoperatively, including the time of bloody lochia clearance, US assessment of the uterine status at 42 days and 2 years postpartum, the state and amount of menstruation 2 years after surgery, the presence or absence of dysmenorrhea, and occurrence of re-pregnancy.

Statistical methods

Data statistical analysis was performed using SPSS 16.0. Measurement data of normal distribution were treated by t-test, and the results are expressed as the mean ± standard deviation (χ ± S). Data of abnormal distribution were treated by Rank sum test, and the results are expressed as median (P25, P75). Count data were treated by chi-square test or Fisher exact probability test. P < 0.05 was considered statistically significant.

Results

Comparison of general data between the two groups

There was no significant difference in age, gravidity, parity, gestational age, preoperative Hb, and US score between the two groups (all P>0.05) (Table 2).

Table 2 Comparison of general data between the two groups
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Comparison of the surgical outcomes between the two groups

The study group was significantly superior to the control group in operative time, intraoperative blood loss, length of hospital stay, and hospitalization cost (P < 0.05), and there was no significant difference in intraoperative transfusion and APGAR score at 5 min (P > 0.05) (Table 3).

Table 3 Comparison of surgical outcome between the two groups
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Comparison of postoperative recovery between the two groups

There was no significant difference in the hysterectomy rate and complication rate between the two groups (P > 0.05) (Table 4).

Table 4 Comparison of postoperative recovery between the two groups
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Follow-up status

Except for the two patients in the control group who underwent hysterectomy, the remaining 89 patients underwent uterine US examination at 42 days post-operation, showing that the uterine size was restored to normal size in all these patients. There was no significant difference in the duration of bloody lochia between the two groups. Altogether seven patients lost to follow-up during the 2-year postoperative period. There was no significant difference in the occurrence of uterine diverticulum and menstrual cycles between the two groups (Table 5). Except for one patient in the study group who underwent artificial abortion due to contraceptive failure, all other patients had no intention of getting pregnant again.

Table 5 Comparison of postoperative follow-up outcomes between the two groups
Full size table

Discussion

Postpartum hemorrhage remains the main reason for maternal mortality worldwide [19,20,21]. PPP complicated by PAS is one of the important causes of postpartum hemorrhage [22]. In patients with PPP complicated by PAS, devastating hemorrhage at a rate of 500–1000 ml/min may occur after placental clearance during CS because of difficulty to close the abundant blood sinus at the placenta dissection site due to contraction atony of the uterine lower segment resulting from its weakness and defects [23, 24]. Hysterectomy is the treatment of choice for the prevention of postpartum hemorrhage of PPP complicated by PAS, and it is reported that the hysterectomy rate is as high as 85% in such patients [25]. However, loss of fertility after hysterectomy in young women will cause huge trauma to them both physiologically and psychologically. Therefore, seeking an effective hemostasis method is the key to preserving the uterus and safeguarding the mother and neonate.

Currently, the commonly used conservative hemostasis methods include the following. (1) Guaze packing or balloon compression hemostasis, which achieves hemostasis by compressing the bleeding surface within the uterine cavity. The procedure is simple and minimally invasive, and it does not increase the risk of bladder or ureteral injury. However, in patients with thin implantation of the placenta into the myometrium, uterine cavity packing can lead to increased uterine tension, which may cause uterine rupture or poor healing of the sutured incision. In addition, uterine cavity packing can also lead to endometrial infection and the risk of recurrent postpartum hemorrhage after the removal of gauze or balloon [26, 27]. (2) Uterine compression suture technique, which mainly includes B-Lynch suture [15], Hayman suture [28], and Cho suture [29], each having respective merits and drawbacks. B-Lynch and Hayman suture is used for the whole uterine atony, but may not stop bleeding from the lower uterine segment. Cho et al. reported that square suturing technique could achieve hemostasis, but it may result in uterine cavity synechiae and uterine wall necrosis due to tight compression and insufficient blood supply among the square [30]. (3) Interventional procedures + various uterine suture techniques. Interventional procedures, typically temporary balloon occlusion and vascular embolization, have extensive applications in preventing intraoperative hemorrhage in PPP [16, 31]. Among these methods intra-aortic balloon occlusion is mainly used for PPP complicated by PAS [32]. This method can create a clear surgical field of view, making suture-based hemostasis more convenient, though the operation is technically complex and difficult. In addition, it runs the risk of vascular injury and thrombosis formation. As it requires a high hospital platform, it is difficult to be promoted in basic-level hospitals [31, 33]. In the present study, we used the abdominal artery balloon block + uterine suture technique in 44 patients of the control group, of whom two underwent a hysterectomy, with a uterus conservation rate of 95.45%.

Compared with the control group, double-row transfixion suture of the lower uterine segment exhibited obvious advantages, ensuring reliable hemostasis, greatly minimizing intra- and postoperative complications and avoiding hysterectomy. In the 47 patients of the study group, postoperative vaginal bleeding was minimal, requiring no continuous hemostatic treatment, and the discharge of lochia was not obstructed. None of the patients developed hematometra or pyometra. No uterine external compression suture was performed in any patient, except for six patients who received local sutures due to local hemorrhage at the dissection surface of placental implantation. Probably because PPP complicated by PAS mainly affects the lower uterine segment, the operative time is relatively short, and intraoperative blood loss is reduced, which to some extent reduces the possibility of secondary uterine atony. No hysterectomy was required in any patient of the study group. The sutures should not exceed the para-uterine vessels, which not only ensures the safety of the ureter but also leaves the uterine with efficient blood supply, thus beneficial for the recovery of the uterine. Compared with the control group, the intestinal function of the patients in the study group recovered more quickly, and therefore the length of hospital stay was also shortened, thus significantly reducing the hospitalization cost. The 2-year follow-up observation showed that uterine and menstrual recovery in the study group was similar to that in the control group. Except for one patient who underwent artificial abortion because of contraceptive failure, all other patients have had no intention to get pregnant again.

It is acknowledged that the technique reported herein is not without its limitations. First, the operation performer should have proficient surgical skills and anatomic knowledge. Second, as bladder isolation is performed before fetal delivery, the operative time would be prolonged in patients with severe adhesion, which is inappropriate for both the mother and the fetus with unstable vital signs. Third, rubber tube placement and vascular clamping with the oval forceps to block the blood supply of the uterus are not indicated for patients with severe adhesion between the uterine posterior wall and the intestinal canal. Finally, as this is a case-controlled retrospective study, the result and conclusion reported herein need to be verified by large-scale prospective studies in the future.

In summary, double-row transfixion suture of the lower uterine segment is reliable, safe and cost-effective, which greatly minimizes intra- and postoperative complications and avoids hysterectomy. However, the efficacy and safety of the technique still need to be confirmed in large-scale clinical trials or case series.

Data availability

The datasets used in this study are not publicly available due to patient privacy and institutional policies. However, they may be obtained from the corresponding author upon reasonable request, approval by the relevant institutional ethics committee and the signing of a data usage agreement.

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Acknowledgements

Not applicable.

Funding

This research was supported by Chongqing Medical Scientific Research Project (Joint Project of Chongqing Health Commission and Science and Technology Bureau) (2019ZDXM009);Chongqing Natural Science Foundation(cstc2021jcyj-msxmX1027).

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Author notes

  1. Changxiao Huang and Zhuyun Peng have contributed equally to this work and share first authorship.

Authors and Affiliations

  1. Department of Gynecology and Obstetrics, Daping Hospital, Army Medical University, Third Military Medical University, Chongqing, 400042, P.R. China

    Changxiao Huang, Zhuyun Peng, Lanfang Li, Xiang Gao, Han Xiao, Wan Wang, Li Zhang, Yujiao Yang, Xing Gu & Xiuhui Zheng

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  1. Changxiao Huang
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by CXH, ZYP, LFL, XG, WW, LZ, YJY, XG and XHZ. The first draft of the manuscript was written by CXH and ZYP.All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Xiuhui Zheng.

Ethics declarations

Ethics approval and consent to participate

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study protocol was reviewed and approved by the Daping Hospital of the Army Medical University (No. 2024 − 111). Informed consent was obtained from all individual participants included in the study.

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Not Applicable.

Competing interests

The authors declare no competing interests.

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Huang, C., Peng, Z., Li, L. et al. Application of double-row transfixion suture of the lower uterine segment in cesarean section for pernicious placenta previa complicated by placenta accreta spectrum: a comparative clinical study. BMC Pregnancy Childbirth 25, 381 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12884-025-07469-4

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12884-025-07469-4

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BMC Pregnancy and Childbirth

ISSN: 1471-2393

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