doi:10.1111/jog.14243 J. Obstet. Gynaecol. Res.

2020

Efficacy of intraoperative wireless ultrasonography for

uterine incision among patients with adherence findings
in placenta previa

Min J. Choi , Chan M. Lim, Dahoe Jeong, Hae-Rin Jeon, Kyung J. Cho and Suk Y. Kim
Department of Obstetrics and Gynecology, Gachon University Gil Medical Center, Incheon, Korea

Abstract
Aim: We evaluated the effectiveness of intraoperative wireless ultrasonography in determining the location
of uterine incision during cesarean delivery in patients with placenta previa who have sonographic adher-
ence findings in order to assess intraoperative blood loss and maternal morbidity.
Methods: A prospective study using wireless sonography, including 15 patients with previa, was conducted
among women with singleton pregnancies who delivered by cesarean section between August 1, 2017, and
August 30, 2019. Retrospective study for the control group included 32 patients with placenta previa who
underwent cesarean section between January 1, 2016, and July 31, 2017, without wireless sonography.
Patients with previa who had adherence findings in prenatal sonography were included in both groups.
Logistic regression was used to identify the association between massive intraoperative bleeding loss and
use of wireless ultrasound sonography.
Results: Intraoperative blood loss was significantly reduced in the study group compared to that in the con-
trol group (P = 0.009). The hospital stay was significantly shorter in the study group compared to the control
group (5 days vs 6 days, P < 0.001). The use of intraoperative wireless sonography (P = 0.01) had a signifi-
cant association with massive intraoperative hemorrhage in multivariable analysis.
Conclusion: Our study is the first study to apply a wireless ultrasound sonography device in women with
placenta previa during cesarean section to examine maternal morbidity. This latest wireless ultrasound
sonography device is advantageous for uterine incision guidance in women with placenta previa and
improves maternal morbidity by reducing intraoperative hemorrhage.
Key words: intraoperative hemorrhage, intraoperative sonography, placenta previa, uterine incision.
wireless ultrasonography.

Introduction lead to an increase in maternal and neonatal morbid-

Placenta previa is defined as the placenta implanted
in the lower uterine segment, either over or near the
internal cervical os.1 The incidence of placenta previa
has risen over the past 30 years, with an average inci-
dence of 0.3%–0.5%.2 Obstetricians should be aware
of the possibility of antepartum, intrapartum and
post-partum hemorrhage, which can subsequently
ity and mortality.2–4 The study by Gibbins et al.
reported that the maternal mortality ratio is increased
approximately threefold for women with placenta
previa.5
For practical reasons, patients with placenta previa
undergo cesarean delivery and have a risk of massive
bleeding during the operation.6 Massive intraoperative
hemorrhage is related to the location of the placenta,

Received: October 17 2019.

Accepted: March 7 2020.
Correspondence: Professor Suk Y. Kim, Department of Obstetrics and Gynecology, Gachon University Gil Medical Center,
21 Namdong-daero 774beon-gil, Namdong-gu, Incheon 21565, Korea. Email: ksyob@gilhospital.com

© 2020 Japan Society of Obstetrics and Gynecology 1

M. J. Choi et al.
as well as surgical procedures, such as uterine incision,
and the placental separation site due to placenta
adherence.3,7
In patients with placenta previa, it is necessary to
check these conditions and perform imaging studies,
such as ultrasound sonography or magnetic resonance
imaging (MRI), before cesarean delivery in order to
precisely determine the best location for uterine inci-
sion. Placental injury by an inappropriate uterine inci-
sion can lead to massive maternal blood loss and fetal
injury during cesarean section.7 Fan et al. conducted
cesarean section with ultrasound sonography to deter-
mine the placental position, and designed the uterine
incision before delivery.8 We believe that it is more
effective to localize the placental position and mark
the location of the uterine incision directly on the
uterus ahead of delivery by recently developed wire-
less mobile ultrasonography (US) in operation field
rather than transecting the placenta.
Therefore, the aim of the present study was to eval-
uate the effectiveness of intraoperative wireless US for
determining the best location for uterine incision dur-
ing cesarean delivery in patients with placenta previa
in order to assess intraoperative blood loss and
reduce maternal morbidity.
Methods
A prospective study using wireless sonography,
including 15 patients with previa, was conducted
among women with singleton pregnancies who deliv-
ered by cesarean section at our institute, a tertiary
university center between August 1, 2017, and August
30, 2019. Patients with previa who had sonographic
adherence findings were included in the study group.
Patients with placenta previa who also had adherence
findings in prenatal sonography and underwent
cesarean section between January 1, 2016, and July
31, 2017, were included in the control group before
we adopted up-to-date wireless mobile US. The study
was approved by the Institutional Review Board, an
ethics committee (assigned number: GDIRB2017-201).
In the present study, we reviewed the types of pla-
centa previa (complete, partial or marginal placenta
previa), the position of placental attachment (anterior
or posterior wall attachment) and sonographic adher-
ence findings, such as placental lacunae, lack of a
clear zone, sponge-like appearance of the cervical wall
and bladder wall disruption. Anterior placentation
with previa was defined by a longer distance from
2 © 2020 Japan Society of Obstetrics and Gynecology
the internal cervical ostium to the placental edge of
the anterior wall than that of the posterior wall.9 We
also included posterior placental previa defined if the
distance from the internal cervical ostium to the pla-
cental edge was longer in the uterine posterior wall
than in the anterior wall. In other words, even though
it is posterior placentation, placenta covers some part
of anterior wall as well. Therefore, we believe that
mobile wireless sonography would be also helpful to
find clear vision of placenta edge to avoid transpla-
cental incision in posterior placenta previa.
Uterine incision was made either low transverse or
body transverse depending on the placentation. The
body transverse incision was 2–3 cm upper apart
from the conventional low transverse incision since it
was inevitable to make a body transverse uterine inci-
sion to avoid a transplacental approach.
Medical records were reviewed in order to collect
data on maternal, neonatal and operative characteris-
tics, including the volume of blood loss, transfusion
rate, operative duration, hospitalization days and neo-
natal Apgar scores. The exclusion criteria were multi-
ple pregnancy, placental abruption, uterine rupture,
intrauterine fetal death, intrauterine infection, pre-
eclampsia, diabetes mellitus (including gestational
diabetes mellitus), intrauterine fetal death and hema-
tologic disorders. All patients in the study group pro-
vided informed consent.
Sonographic assessment with a wireless mobile US
device and a tablet PC (SONON, 300L, Healcerion Inc.,
Seoul, South Korea) was performed in real-time scan-
ning directly on the uterus to check fetal presentation
and placentation during cesarean section (Fig. 1). This
wireless US device uses wireless signals to transfer
images to a display system that shows the images in
real time. The sonography probe was covered with an
aseptic plastic coverage and connected to a portable
tablet via Bluetooth (Fig. 2). Since the sonography
device is connected to a tablet PC, the operator can
check fetal presentation and find the nearest placental
edge for uterine incision directly on the uterus (Fig. 3).
Captured images were saved and collected on the tab-
let. For the control group, the determination of uterine
incision was dependent on the operator’s experience
with prenatal sonographic findings.
Demographic and obstetric characteristics included
maternal age, gestational age at delivery, parity, type of
previa (total or low-lying), position of the placenta
(anterior or posterior), number of previous cesarean sec-
tions and preoperative serum hemoglobin level. Mater-
nal morbidity was assessed by several indicators

Figure 1 (a) Wireless mobile ultrasonography (SONON 300L) and (b) tablet PC.
including total amount of intraoperative bleeding loss,
intraoperative transfusion rate, transfusion unit of
packed red blood cell, post hemoglobin, hemoglobin
changes between preoperation and postoperation,
requirement for additional procedures (uterine artery
embolization or hysterectomy), duration of hospitaliza-
tion, post-partum fever higher than 38 C and serum C-
reactive protein level.
Data were also collected regarding duration of the
operation (min), neonatal injury and neonatal Apgar
scores. The operation time was measured from the
time of skin incision to the time of skin closure. The
intraoperative bleeding loss was also measured dur-
ing the operation; 1 min and 5 min Apgar scores of
less than 7 were assessed for neonatal morbidity. In
the present study, we defined intraoperative hemor-
rhage if the total blood loss during the operation was
more than 1000 mL.
Statistical analysis was performed via IBM SPSS statis-
tics version 22 and presented as the median and inter-
quartile range. Continuous data were analyzed using
Figure 2 Wireless mobile ultrasonography with an aseptic coverage.
© 2020 Japan Society of Obstetrics and Gynecology
Wireless sonography and placenta previa
Mann–Whitney test or Student t-test, as appropriate.
Percentages were compared using Fisher’s exact test or
Pearson’s chi-square test. Gestational age converted to
decimal scale was used. In addition, the association
between clinical characteristics and intraoperative hem-
orrhage was analyzed using univariable and multivari-
able logistic regression analysis, respectively. A P-value
less than 0.05 was considered statistically significant.
Results
The maternal and obstetric characteristics are shown
in Table 1. There were no significant differences
between the two groups in terms of patient character-
istics. Overall, the median maternal age was 35 for
the study group and 33.5 years old for the control
group. In the study group, 11 (73.3%) patients had
complete placenta previa, and in the control group,
25 (78.1%) had complete placenta previa. The median
gestational age at delivery, rate of previous cesarean
3
M. J. Choi et al.

Figure 3 (a) Mapping of uterine incision site and (b) localization of uterine incisional site in edge of placenta.

section and the rate of placental position (anterior
position and posterior position) were also similar
between the two groups.
The maternal outcomes regarding intraoperative
hemorrhage and neonatal morbidity are compared
between the two groups in Table 2. We found that the
intraoperative blood loss in the study group was signifi-
cantly reduced in the study group compared to the con-
trol group (750 mL vs 1000 mL, respectively; P = 0.009).
In addition, the duration of hospital stay was signifi-
cantly shorter in the study group compared to the
patients who underwent cesarean section without wire-
less sonographic study (5 days vs 6 days, P < 0.001).
Although there was no significant difference between
the two groups, it was shown that fewer patients (n = 3,
20%) required intraoperative transfusion in the study
group than in the control group (37.5%). In addition,
only one patient in the control group underwent post-
partum hysterectomy, while no patients in the study
group underwent post-partum hysterectomy. Moreover,
two patients had a postoperative fever (6.3%). The pre-
sent study found no significant differences in fetal
injury rates and neonatal outcomes between groups.
Table 3 shows the results of univariable and multivar-
iable logistic regression analyses performed to assess
the association between massive intraoperative bleeding
loss and potential variables. Only the use of wireless
mobile US was significantly associated with massive
intraoperative hemorrhage in univariate analysis (odds
ratio [OR]: 0.249, 95% confidence interval [CI]:

4 © 2020 Japan Society of Obstetrics and Gynecology

 Wireless sonography and placenta previa

Table 1 Characteristics of patients with sonographic adherence findings in placenta previa (n = 47)†
Characteristic Wireless sonography Wireless sonography P-value
(+) (n = 15) (−) (n = 32)
Maternal age (years), median 35 (31–37) 33.5 (31.50–35.75) 0.395
Parity, n (%)
0 8 (53.3) 18 (56.3)
1 5 (33.3) 9 (28.1) 0.979
2 2 (13.3) 5 (15.6)
Gestational weeks at delivery 37.9 (35.5–38.4) 37.2 (32.07–38.30) 0.417
Types of previa, n (%)
Complete 11 (73.3) 25 (78.1) 0.725
Low-lying 4(26.7) 7 (21.9)
Number of previous cesareans, n (%)
0 11 (73.3) 25 (76.6) 0.725
1 4 (26.7) 7 (21.9)
Position of placenta
Anterior 6 (40) 8 (25) 0.295
Posterior 9 (60) 24 (75)
Preoperative serum hemoglobin level (g/L) 11.7 (11.1–12.4) 12 (11.50–12.60) 0.223
†Values are given as number (percentage) or median (interquartile range).

0.07–0.95, P = 0.043). However, the use of both
intraoperative wireless sonography (OR: 0.065, 95% CI:
0.01–0.52, P = 0.01) and previous cesarean section (OR:
7.527, 95% CI: 1.161–48.80, P = 0.034) were revealed to
have a significant association with massive
intraoperative hemorrhage in multivariable analysis.
Discussion
The present study demonstrated that intraoperative
wireless ultrasound sonography can effectively iden-
tify the location for uterine incision, thereby reducing
intraoperative hemorrhage in women with placenta
previa in whom placenta accrete cannot be ruled out
via prenatal sonography.
It is well known that the following factors are likely
to increase incidence of massive hemorrhage: anterior
placentation, presence of antenatal ultrasonic placen-
tal adherence findings, cesarean section history and a
transplacental approach.3,6,10 In women with one or
more of these conditions, obstetricians should prepare
to encounter profuse bleeding during the cesarean
section.11–13
In order to reduce intraoperative bleeding loss,
Verspyck et al. compared maternal outcomes between
transection of the placenta and avoiding incision of the
anterior placenta by sonographic localization of the pla-
centa among patients with anterior placenta previa.
They found that the loss of intraoperative hemoglobin
count and the frequency of maternal blood transfusion
during or after cesarean section were significantly

Table 2 Clinical outcomes in patients with placenta previa (n = 47)

Characteristic Wireless sonography Wireless sonography P-value
(+) (n = 15) (−) (n = 32)
Operation time (min) 70 (65–100) 80 (66.25–93.75) 0.828
Intraoperative blood loss (mL) 750 (500–1000) 1000 (762.5–1175) 0.009*
Intraoperative transfusion rate (%) 3 (20) 12 (37.5) 0.321
Hospitalization (days) 5 (5–6) 6 (6) <0.001*
Postoperative uterine artery embolization, n (%) 1 (6.7) 1 (3.1) 0.541
Hysterectomy, n (%) 0 (0) 1 (3.1) 0.999
Postoperative serum hemoglobin level (g/L) 9.4 (8.6–10.2) 9.8 (8.73–10.48) 0.833
Changes in hemoglobin (g/dL) 2.2 (1.5–2.6) 2.4 (1.50–2.35) 0.504
Postoperative CRP level (mg/dL) 6.91 (3.50–8.45) 6.1 (3.42–7.03) 0.228
Postoperative fever, n (%) 0 2 (6.3) 0.999
Birth weight (g) 2960 (2614–3040) 2727 (1730.0–3087.5) 0.283
1-min Apgar score (<7) 1 (6.7%) 2 (6.3) 0.999
5-min Apgar score (<7) 0 0
*p < 0.05. and CRP, C-reactive protein.

© 2020 Japan Society of Obstetrics and Gynecology 5

M. J. Choi et al.
Table 3 Logistic regression model to assess association between intraoperative massive hemorrhage and potential
variables
Characteristic Univariable analysis,
odds ratio (95% CI)
Wireless sonography 0.249 (0.065–0.954)
Previous cesarean section 3.733 (0.847–16.452)
Anterior placenta 2.443 (0.670–8.901)
Previa totalis 1.2 (0.310–4.651)
Prehemoglobin 0.906 (0.503–1.631)
Gestational age at delivery 0.944 (0.787–1.133)
*p < 0.05. and CI, confidence interval.
reduced.14 They recommended that determining the
location of the placenta with US before delivery could
be useful technique for precise uterine incision to avoid
transect placenta.
There are several other studies that use ultrasound
sonography or other imaging, such as MRI, to localize
uterine incision in order to avoid rapid transecting pla-
centa and reduce intraoperative hemorrhage. Indeed,
Frank et al. conducted mapping of the placenta location
with real-time sonography to decide the incision site
and type.4 They found that patients with paraplacental
incision had reduced maternal morbidity with
decreased intraoperative blood loss while patients with
conventional transplacental incision required transfu-
sion.4 Furthermore, Cao et al. reported that three-
dimensional (3D) MRI provided accurate guidance for
uterine incision in placenta previa, and avoided placen-
tal injury during cesarean section. They found that
patients with previa who underwent 3D MRI modeling
for uterine incision guide had less intraoperative blood
loss and a shorter operative time compared to the con-
trol group. Moreover, the transfusion frequency was
also significantly reduced in the 3D MRI study.7
Consistent with the abovementioned studies, the pre-
sent study showed that mapping uterine incision by
intraoperative wireless US led to significantly reduced
intraoperative blood loss compared with patients who
underwent cesarean procedures with random uterine
incision (750 mL vs 1000 mL, respectively; P = 0.009). In
addition, the results showed that performing cesarean
section using the new procedure is associated with less
intraoperative hemorrhage based on the data from our
statistical analysis. It would seem that intraoperative
wireless US provides the physician with the exact pla-
centa location and helps to make a precise uterine inci-
sion, leading to reduced incisional site bleeding; thus,
decreasing the intraoperative bleeding loss.
Body or fundal transverse uterine incision in ante-
rior placenta previa was inevitable to avoid incision
6 © 2020 Japan Society of Obstetrics and Gynecology
P-value Multivariable analysis, P-value
odds ratio (95% CI)
0.043* 0.065 (0.008–0.524) 0.01*
0.082 7.527 (1.161–48.799) 0.034*
0.176 4.487 (0.863–23.322) 0.074
0.792 0.845 (0.152–4.692) 0.847
0.742 0.511 (0.234–1.118) 0.093
0.535 1.157 (0.905–1.479) 0.246
at the placenta; this may be considered to lead to
more incisional site bleeding since the uterine body is
thicker than the lower uterine segment.3 However,
using intraoperative sonography, Kotsuji et al. demon-
strated the feasibility and safety of transverse fundal
incision in women with placenta previa, in whom pla-
centa accrete could not be ruled out.11 They stated
that performing transverse fundal incision, compared
to conventional low transverse incision transecting
the placenta, in patients with anterior placenta previa
and possible placenta accrete led to less blood loss
during cesarean section, as well as a clear visualiza-
tion of the operation field.11 The present study
showed that total amount of intraoperative bleeding
loss was significantly reduced even though a study
group had more patients with anterior placentation
about 40% than a control group, 25%. We believe that
it demonstrates the operative usefulness of the wire-
less US in placenta previa, since the result was led by
avoiding transplacental incision with wireless sonog-
raphy although body incision can increase blood loss.
As well as the reduction in intraoperative hemor-
rhage and shorter hospitalization stay, a further sig-
nificant advantage of this procedure is that the
operator is able to identify the placental margin more
accurately, comforting operators to make uterine inci-
sion with less surgical site bleeding in a relaxed con-
dition. Wireless US is a cost-effective, safe and simple
device that can be adapted by obstetricians and
applied successfully when compared to MRI examina-
tion. Furthermore, it only requires a short time for
setup and is easy to manage. Importantly, wireless
US accurately reflects the state of the placenta at the
time of delivery; this included the location of vessels,
placental location and fetal presentation.
The present study is the first study to apply a wire-
less US device in women with placenta previa during
cesarean section. Wireless mobile US has poor image
quality and visual angle compared to conventional

US. However, an important aspect of the mobile US is
the portability and easiness of handling in a more
convenient way. With these reasons, it is applied to
various cases in other fields as well. For examples, it
provides more accurate needle placement in all body
joints, guide a biopsy needle and arterial line inser-
tion, finding vessels prior to injection and other
interventions.
In terms of the study limitations, the sample size
was small (n = 47), and the study was conducted in a
single center. Therefore, a multicenter prospective
randomized clinical study regarding criteria for appli-
cation of the device should be conducted in the
future.
In conclusion, we suggest that the wireless US
mobile device is advantageous for uterine incision
guidance in women with placenta previa and
improves maternal morbidity as a result of reducing
intraoperative hemorrhage.
Acknowledgments
This research was partly supported by the Gachon Uni-
versity Gil Medical Center (Grant number: FRD2015-02)
and the Next-Generation Medical Device Development
Printogram for Newly-Created Market of the National
Research Foundation (NRF) funded by the Korean Gov-
ernment, MSIP (No. 2015M3D5A1065907).
Disclosure
None declared.
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