An aorta clamp developed by an obstetrician in the State to control torrential bleeding during the surgical management of Placenta Accreta Spectrum (PAS), a serious obstetric complication and a significant cause of maternal mortality, has been found to be quite useful in containing blood loss and saving maternal lives, without any incidence of vascular injury.
The “Paily aorta clamp”, developed by V. P. Paily, a senior obstetric consultant and a master trainer for the Kerala Federation of Obstetrics and Gynaecology, is currently being used in multiple centres across the State and a few centres outside Kerala, with good results.
A retrospective study of 33 women with varying grades of PAS, who underwent Caesarean hysterectomies as elective or emergency procedures utilising the Paily aorta clamp, appears in the March 2022 issue of the International Journal of Gynaecology and Obstetrics.
With the rise in Caesarean sections (C-section) across public as well as private sector hospitals, PAS is emerging as a major concern and is a significant cause of maternal mortality and morbidity. A previous C-section scar is the most typical risk factor for PAS as the placenta deeply adheres to the scar tissue and into the uterine wall, sometimes extending to nearby organs, such as the bladder.
This means that the placenta will not eject itself naturally after delivery and any attempts to remove it results in torrential haemorrhage (especially if encountered unexpectedly during delivery). Even when saved, the woman suffers catastrophic morbidity, including loss of uterus, bladder injuries, and fistula formations.
The condition has to be identified early during antenatal ultrasound scans and the woman has to be referred to a tertiary care centre for a planned Caesarean hysterectomy, to be done at 34-25 weeks.
PAS management is thus a nightmare for obstetricians worldwide because, apart from the risk of catastrophic amounts of blood loss, there is also the the high probability of urological injuries and massive transfusion requirements encountered during non-conservative surgery.
In high-resource settings, PAS disorders are managed by multidisciplinary teams of expert gynecological and vascular surgeons, supported by anaesthesiologists, intensivists, radiologists and urologists.
In major tertiary centres, vascular surgeons attempt to reduce bleeding using intravascular balloon occlusion at the lower end of the abdominal aorta or the common iliac arteries.
But the application of the Paily aorta clamp in low resource settings, where the access to unlimited amounts of blood to transfuse and the services of a vascular surgeon might not be available, says Dr. Paily, who has conducted innumerable demonstrations across the State on PAS management using the aorta clamp.
The Paily aorta clamp is an easy aid that the obstetricians themselves can use to control bleeding. It can be applied rapidly, without retroperitoneal dissection to manage bleeding.
“We started promoting this method in 2011-12 and now, all Government Medical Colleges in the State and many private hospitals too are utilizing the same to prevent torrential bleeding in PAS. Many near-miss cases we analysed in our recent maternal near-miss reviews showed that the clamp had been very handy,” he says.
The clamp, once secured, leaves a bloodless field for the surgeon attempting complex pelvic dissection in high-grade PAS. Dr. Paily says that in emergencies involving PAS, the clamp works well as a “rescue intervention” because it can be applied faster than cross-clamping or aortic balloon occlusion.
Of the 33 PAS cases reviewed in the study, none developed any signs of aortic wall rupture and had positive surgical outcomes with no clamp-related adverse events.
Dr. Paily, however, insists that only obstetrician-gynaecologists with reasonable expertise should attempt to manage PAS using the aorta clamp and that the team must have a urologist to repair any inadvertent injuries.