Placenta accreta: comparison of cases managed with and without pelvic artery balloon catheters

Prophylactic Radiologic Interventions for Postpartum Hemorrhage Control in Women With Placenta Accreta Spectrum Disorder: A Systematic Review and Meta-analysis

OBJECTIVE

To quantify the association between prophylactic radiologic interventions and perioperative blood loss during cesarean delivery in women with placenta accreta spectrum disorder through a systematic review and network meta-analysis.

DATA SOURCES

On January 3, 2023, a literature search was conducted in PubMed, EMBASE, Cochrane Library, and Web of Science. We also checked ClinicalTrials.gov retrospectively. Prophylactic radiologic interventions to reduce bleeding during cesarean delivery involved preoperative placement of balloon catheters, distal (internal or common iliac arteries) or proximal (abdominal aorta), or sheaths (uterine arteries). The primary outcome was volume of blood loss; secondary outcomes were the number of red blood cell units transfused and adverse events. Studies including women who received an emergency cesarean delivery were excluded.

METHODS OF STUDY SELECTION

Two authors independently screened citations for relevance, extracted data, and assessed the risk of bias of individual studies with the Cochrane Risk of Bias in Non-randomized Studies of Interventions tool.

TABULTATION, INTEGRATION, AND RESULTS

From a total of 1,332 screened studies, 50 were included in the final analysis, comprising 5,962 women. These studies consisted of two randomized controlled trials and 48 observational studies. Thirty studies compared distal balloon occlusion with a control group, with a mean difference in blood loss of -406 mL (95% CI, -645 to -167). Fourteen studies compared proximal balloon occlusion with a control group, with a mean difference of -1,041 mL (95% CI, -1,371 to -710). Sensitivity analysis excluding studies with serious or critical risk of bias provided similar results. Five studies compared uterine artery embolization with a control group, all with serious or critical risk of bias; the mean difference was -936 mL (95% CI, -1,522 to -350). Reported information on adverse events was limited.

CONCLUSION

Although the predominance of observational studies in the included literature warrants caution in interpreting the findings of this meta-analysis, our findings suggest that prophylactic placement of balloon catheters or sheaths before planned cesarean delivery in women with placenta accreta spectrum disorder may, in some cases, substantially reduce perioperative blood loss. Further study is required to quantify the efficacy according to various severities of placenta accreta spectrum disorder and the associated safety of these radiologic interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022320922.

Association of MRI Features and Adverse Maternal Outcome in Patients With Placenta Accreta Spectrum Disorders After Abdominal Aortic Balloon Occlusion

BACKGROUND

MRI features may be associated with adverse maternal outcome in patients with placenta accreta spectrum (PAS) disorders even with abdominal aortic balloon occlusion (AABO).

PURPOSE

This study aimed to identify risk factors of MRI for association with adverse maternal outcome in patients with PAS disorders after AABO.

STUDY TYPE

Retrospective.

POPULATION

Clinical and MRI features of 80 patients were retrospectively reviewed from October 2016 to August 2021. A total of 40 patients had adverse maternal outcomes including intrapartum/peripartum bleeding >1000 mL and/or emergency hysterectomy after AABO.

SEQUENCE

Half-Fourier acquisition single-shot turbo spin echo and gradient echo imaging True fast imaging with steady-state precession (True-FISP) at 1.5T MR scanner.

ASSESSMENT

MRI features were evaluated by three radiologists and were tested for any association with adverse maternal outcome.

STATISTICAL TESTS

Interobserver agreement was calculated with kappa (k) statistics. Association between MRI features and adverse maternal outcomes were evaluated by univariate and multivariate analyses. A nomogram was constructed based on the logistic regression.

RESULTS

The interobserver agreement ranged from fair to substantial (k = 0.379-0.783). Multivariate analyses revealed that short cervical length (OR: 4.344), abnormal intraplacental vascularity (OR: 6.005), placental bulge (OR: 9.085), and myometrial interruption (OR: 9.550) were independent risk factors for adverse maternal outcomes. The combination of four risk factors together demonstrated the highest AUC of 0.851 (95% CI 0.769-0.933) with a sensitivity and specificity of 77.5% and 72.5%, respectively and then a nomogram composed of the above four risk factors was constructed to represent the probability of adverse maternal outcome.

DATA CONCLUSION

The nomogram demonstrated the association between MRI features and patient's poor outcome after undergoing AABO and C-section delivery for PAS.

EVIDENCE LEVEL

4 TECHNICAL EFFICACY: Stage 3.

Interventional radiology in obstetric patients: A population-based record linkage study of use and outcomes

INTRODUCTION

Interventional radiology (IR) is a technique for controlling hemorrhage and preserving fertility for women with serious obstetric conditions such as placenta accreta spectrum (PAS) or postpartum hemorrhage. This study examined maternal, pregnancy and hospital characteristics and outcomes for women receiving IR in pregnancy and postpartum.

MATERIAL AND METHODS

A population-based record linkage study was conducted, including all women who gave birth in hospital in New South Wales or the major tertiary hospital in the neighboring Australian Capital Territory, Australia, between 2003 and 2019. Data were obtained from birth and hospital records. Characteristics and outcomes of women who underwent IR in pregnancy or postpartum are described. Outcomes following IR were compared in a high-risk cohort of women: those with PAS who had a planned cesarean with hysterectomy. Women were grouped by those who did and those who did did not have IR and were matched using propensity score and other factors.

RESULTS

We identified IR in 236 pregnancies of 1 584 708 (15.0 per 100 000), including 208 in the delivery and 26 in a postpartum admission. Two-thirds of women receiving IR in the birth admission received a transfusion of red cells or blood products, 28% underwent hysterectomy and 12.5% were readmitted within 6 weeks. Other complications included: severe maternal morbidity (29.8%), genitourinary tract trauma/repair (17.3%) and deep vein thrombosis/pulmonary embolism (4.3%). Outcomes for women with PAS who underwent planned cesarean with hysterectomy were similar for those who did and did not receive IR, with a small reduction in transfusion requirement for those who received IR.

CONCLUSIONS

Interventional radiology is infrequently used in pregnant women. In our study it was performed at a limited number of hospitals, largely tertiary centers, with the level of adverse outcomes reflecting use in a high-risk population. For women with PAS undergoing planned cesarean with hysterectomy, most outcomes were similar for those receiving IR and those not receiving IR, but IR may reduce bleeding.

Preoperative Prophylactic Balloon-Assisted Occlusion of the Internal Iliac Arteries in the Management of Placenta Increta/Percreta

Background and Objectives: Preoperative prophylactic balloon-assisted occlusion (PBAO) of the internal iliac arteries minimizes blood loss and facilitates surgery performance, through reductions in the rate of uterine perfusion, which allow for better control in hysterectomy performance, with decreased rates of bleeding and surgical complications. We aimed to investigate the maternal and fetal outcomes associated with PBAO use in women with placenta increta or percreta. Material and Methods: The records of 42 consecutive patients with a diagnosis of placenta increta or percreta were retrospectively reviewed. Of 42 patients, 17 patients (40.5%) with placenta increta or percreta underwent cesarean delivery after prophylactic balloon catheter placement in the bilateral internal iliac artery (balloon group). The blood loss volume, transfusion volume, postoperative hemoglobin changes, rates of hysterectomy and hospitalization, and infant Apgar score in this group were compared to those of 25 similar women who underwent cesarean delivery without balloon placement (surgical group). Results: The mean intraoperative blood loss volume in the balloon group (2319 ± 1191 mL, range 1000–4500 mL) was significantly lower than that in the surgical group (4435 ± 1376 mL, range 1500–10,500 mL) (p = 0.037). The mean blood unit volume transfused in the balloon group (2060 ± 1154 mL, range 1200–8000 mL) was significantly lower than that in the surgical group (3840 ± 1464 mL, range 1800–15,200 mL) (p = 0.043). There was no significant difference in the postoperative hemoglobin change, hysterectomy rates, length of hospitalization, or infant Apgar score between the groups. Conclusion: PBAO of the internal iliac artery prior to cesarean delivery in patients with placenta increta or percreta is a safe and minimally invasive technique that reduces the rate of intraoperative blood loss and transfusion requirements.

Prophylactic internal iliac artery ligation versus balloon occlusion for placenta accreta spectrum disorders: A retrospective cohort study

OBJECTIVE

To compare surgical outcomes between women undergoing prophylactic internal iliac artery ligation or preoperative placement of balloon-occlusive devices at cesarean hysterectomy for placenta accreta spectrum (PAS) disorders.

METHODS

A retrospective cohort study was conducted at a tertiary-care referral center for PAS disorders in Ontario, Canada. Eligible electronic records were reviewed of women undergoing cesarean hysterectomy for PAS disorders between November 2012 and June 2018. Outcomes for the ligation and balloon groups were compared primarily on procedure-related complications and secondarily on total procedure time, bleeding and transfusion metrics, and intraoperative and postoperative complications.

RESULTS

Of the 79 cases of cesarean hysterectomy, 47 underwent balloon placement and 32 underwent ligation. Baseline characteristics between the groups were similar except for more emergency procedures in the ligation group (37.5% vs 12.8%, P=0.014). The balloon-related complication rate was 5/47 (10.6%), with no reported complications in the ligation group (P=0.077). Procedural time was longer in the balloon group (353 ± 14 vs 227 ± 13 minutes, P<0.001). Estimated blood loss was similar (1874 ± 245 mL vs 1713 ± 181 mL, P=0.590).

CONCLUSION

Women undergoing prophylactic placement of endovascular balloons at caesarean hysterectomy for PAS disorders had a 10.6% procedure-related complication rate and increased total procedure time, with no decrease in blood loss compared to those undergoing surgical ligation.

The role of interventional radiology in the management of abnormally invasive placenta: a systematic review of current evidences

Abnormally invasive placenta (AIP) is a potentially severe condition. To date, arterial embolization in women with postpartum hemorrhage due to AIP is the treatment option for which highest degrees of evidence are available. However, other techniques have been tested, including prophylactic catheter placement, balloon occlusion of the iliac arteries and abdominal aorta balloon occlusion. In this systematic review, we provide an overview of the currently reported interventional radiology procedures that are used for the treatment of postpartum hemorrhage due to AIP and suggest recommendations based on current evidences. Owing to a high rate of adverse events, prophylactic occlusion of internal iliac arteries should be used with caution and applied when the endpoint is hysterectomy. On the opposite, when a conservative management is considered to preserve future fertility, uterine artery embolization should be the preferred option as it is associated with a hysterectomy rate of 15.5% compared to 76.5% with prophylactic balloon occlusion of the internal iliac arteries and does not result in fetal irradiation. Limited data are available regarding the application of systematic prophylactic embolization and no comparative studies with arterial embolization are available.

Evaluation of perioperative complications using a newly described staging system for placenta accreta spectrum

INTRODUCTION

The antenatal diagnosis of placenta accreta spectrum (PAS) is in large part subjective and based on expert interpretation. The aim of this study was to externally evaluate a recently developed staging system based on specific and defined prenatal ultrasound (US) features in a cohort of women at risk of PAS undergoing specialist prenatal US, in particular relating to surgical morbidity at delivery.

MATERIALS AND METHODS

Database study of cases with confirmed placenta previa. In all, the placenta was evaluated in a systematic fashion. PAS was subclassified in PAS0-PAS3 according to the loss of clear zone, placental lacunae, bladder wall interruption, uterovesical hypervascularity and increased vascularity in the parametrial region.

RESULTS

43 cases were included, of whom 33 had major placenta previa. 31 cases were categorized as PAS0; 3, 4 and 5 cases as PAS1, PAS2 and PAS3, respectively. All women underwent caesarean section and hysterectomy was required in 10. The comparison of the perinatal outcomes among the PAS categories yielded greater operative time (50 (35-129) minutes for PAS0 vs 70 (48-120) for PAS1 vs 95 (60-150) for PAS2 vs 100 (87-180) for PAS3, p < 0.001) and estimated blood loss (800 (500-2500) mls for PAS0 vs 3500 (800-7500) for PAS1 vs 2850 (500-7500) for PAS2 vs 6000 (2500-11000) for PAS3, p < 0.001) for the highest PAS categories, which were also associated with a higher rate of hysterectomy (p < 0.001), blood transfusion (p = 0.002) and admission to ITU or HDU (p < 0.001) and longer postoperative admission of 3 (1-9) days for PAS0 vs 3 (2-12) for PAS1 vs 4.5 (3-6) for PAS2 vs 5 (3-22) for PAS3, p = 0.02.

CONCLUSION

Perioperative complications are closely associated with PAS stage. This information is useful for counselling women and may be important in allocating staff and infrastructure resources at the time of delivery.

Risk factors for massive bleeding based on angiographic findings in patients with placenta previa and accreta who underwent balloon occlusion of the internal iliac artery during cesarean section

OBJECTIVE

We evaluated the risk factors for massive bleeding based on angiographic findings in patients with placenta previa and accreta who underwent balloon occlusion of the internal iliac artery (BOIA) during cesarean section.

METHODS

We performed a retrospective analysis using the clinical records of 42 patients with placenta previa and accreta who underwent BOIA during cesarean section between 2006 and 2017 in Gunma university hospital. We reviewed incidence of collateral arteries to the uterus on the initial aortography. We evaluated the visualization of the ovarian artery arising directly from the abdominal aorta, round ligament artery arising from the external iliac artery/inferior epigastric artery, and the iliolumbar artery. In addition, the clinical characteristics were reviewed. Patients with an estimated blood loss during delivery of >2500 ml, >4 packed red blood cell transfusions, uterine artery embolization after delivery, or hysterectomy were defined as the massive bleeding group. We compared between the massive and non-massive bleeding groups.

RESULTS

20 patients (48%) had a massive bleeding. No procedure-related severe complications were observed. The massive and non-massive bleeding groups differed in terms of operation time (p < 0.001), hysterectomy (p < 0.001), post-operative hospital stay (p < 0.05), and visualization of round ligament arteries to the uterus [15/20 (75%) patients, p < 0.01].

CONCLUSION

The incidence of collateral blood supply from a round ligament artery to the uterus may be a risk factor for massive bleeding in patients with placenta previa and accreta who have undergone BOIA during cesarean section.

ADVANCES IN KNOWLEDGE

Angiographic visualization of collateral circulation from the round ligament artery to the uterus may be a risk factor for massive bleeding in patients with placenta previa and accreta who have undergone BOIA during cesarean section.

Vascular balloon occlusion and planned caesarean hysterectomy for morbidly adherent placenta: A systematic review

BACKGROUND

Morbidly adherent placenta is potentially life-threatening, often requiring technically difficult surgery and large blood loss. Use of intravascular balloon occlusion with or without hysterectomy to reduce blood loss is increasing despite associated morbidity and lack of evidence of efficacy.

AIMS

To evaluate if prophylactic use of vascular balloon occlusion at the time of planned caesarean hysterectomy for antenatally diagnosed morbidly adherent placenta reduces blood loss and transfusion requirements, and determine rate of associated complications.

MATERIALS AND METHODS

A systematic review of PubMed and Medline covering January 1997 to December 2018 was conducted. Key words included placenta accreta, increta, percreta, and morbidly adherent placenta, balloon, interventional radiology, embolization, and caesarean hysterectomy.

RESULTS

Nineteen studies were included. Only three studies had appropriate controls: two with balloon placement in the internal iliac arteries and one in the common iliac arteries. One showed no difference in blood loss or transfusion requirements, the second showed a reduction in cases of percreta only and the third reported reduction in blood loss. Only few studies reported objective measures of blood loss. Blood loss and transfusion were still high (2.26 L and 3.79 units, respectively) despite use of vascular balloons. Balloon catheter use was associated with a 7.5% rate of complications; 4.5% were minor and 3.0% major.

CONCLUSIONS

There is a large body of poor data evaluating efficacy of prophylactic vascular balloon occlusion in cases of planned caesarean hysterectomy for known morbidly adherent placenta. Limited relevant data provide only scant evidence that these techniques are beneficial in reducing blood loss, despite associated significant complications.

Comparison of infrarenal aortic balloon occlusion with internal iliac artery balloon occlusion for patients with placenta accreta

BACKGROUND

The study was designed to compare the role of infrarenal aortic artery balloon occlusion (IAABC) with internal iliac artery balloon occlusion (IIABOC).

METHODS

One hundred seventy-four cases with placenta accreta were retrospectively analyzed.74 cases who had IAABC were in group A, while the others who had IIABOC were in group B.

RESULTS

Amount of estimated blood loss (EBL), the rate of major blood loss, the rate of blood transfusion and uterine packing, length of hospitalization were not different in both groups. The rate of uterine artery embolization (UAE), balloon occlusion time, operation time and fetus radiation dose in group A were less than those in group B.

CONCLUSIONS

IAABC resulted in better clinical outcomes than IIABOC.

Prophylactic Transcatheter Arterial Embolization Helps Intraoperative Hemorrhagic Control for REMOVING Invasive Placenta

Objectives: The purpose of this article is to investigate the estimated blood loss in pregnant women undergoing cesarean section and placental extirpation to treat abnormal placentation and compare the outcomes of those who underwent prophylactic transcatheter arterial embolization (TAE) with those who did not. Methods: A retrospective study was conducted on 17 pregnant women diagnosed with abnormal placentation in 2001–2018 in a single tertiary center. The patients were diagnosed by surgical finding, ultrasound, or magnetic resonance imaging (MRI). These patients were divided into two groups: a prophylactic TAE group (11 patients) and a control group (6 patients). In the former group, prophylactic TAE of the bilateral uterine artery (UA) and/or internal iliac artery (IIA) was performed immediately after delivery of the infant. The placenta was removed in both groups. The primary outcomes were estimated blood loss (EBL), units of packed red blood cell (pRBC) transfusion, operative time, whether hysterectomy was performed, whether the patient was transferred to the intensive care unit (ICU), and hospitalization days. The secondary outcome was maternal complications. Results: Patients who received prophylactic TAE had significantly reduced intraoperative blood loss (990.9 ± 701.7 mL vs. 3448.3 ± 1767.4 mL, p = 0.018). Units of pRBC transfusion, operative time, hysterectomy, transfer to the ICU, and postoperative hospitalization days were not significantly different between the two groups. Thirteen patients (9 in the TAE group and 4 in the control group) received a blood transfusion during the operation. Three patients underwent a hysterectomy (1 in the TAE group and 2 in the control group). Five patients were transferred to the ICU (3 in the TAE group and 2 in the control group) for maternal complications or monitoring. In the prophylactic TAE group, 3 patients (27%) had a subsequent pregnancy within the next 5 years. Conclusions: Prophylactic TAE was safe and effective for reducing intraoperative hemorrhage from removing an invasive placenta in patients with abnormal placentation.

Prophylactic temporary abdominal aorta balloon occlusion in women with placenta previa accretism during late gestation

BACKGROUND

To evaluate the clinical efficacy of prophylactic temporary balloon occlusion of the abdominal aorta in patients with placenta previa accretism during cesarean section.

METHODS

Twenty-three consecutive patients, prenatally confirmed with placenta previa accretism were retrospectively analyzed in our center from August 2012 to October 2014. All 23 subjects underwent cesarean section with prophylactic balloon occlusion of the abdominal aorta.

RESULTS

All of the 23 subjects experienced singleton pregnancies leading to the birth of live infants. Of these subjects, the following problems were diagnosed: placenta accrete (n = 10), placenta increte (n = 10), and placenta precrete (n = 3). Mean intraoperative hemorrhage was 1170.0 mL. Fifteen patients received red blood cell transfusion with a mean transfusion volume of 2.3 units. The incidence of hysterectomy was 21.74% (5/23) with blood loss ranging from 2000 to 5000 mL (mean 3360.0 mL). One complication encountered in this retrospective study was lower extremity arterial thrombosis. Eighteen patients were followed-up by telephone to 14 months following discharge, all babies were noted to be healthy.

CONCLUSION

Prophylactic abdominal aorta balloon occlusion (ABO) was relatively safe in the treatment of patients with placenta previa accretism. This approach could represent a key aspect in a multidisciplinary algorithm in reducing hemorrhage in abnormal placentation.

Clinical application of prophylactic internal iliac artery balloon occlusion combined with uterine artery embolization in patients with abnormally invasive placenta

BACKGROUND

The purpose of this study is to investigate the role of prophylactic internal iliac artery balloon occlusion combined with uterine artery embolization (UAE) in patients with abnormally invasive placenta.

METHODS

Forty cases with abnormally invasive placenta who visited our hospital were analyzed retrospectively from May 2014 to September 2015. Twenty cases who had prophylactic balloon occlusion of internal iliac artery with/without UAE were in the study group, while the other 20 cases in the control group. Volume of estimated blood loss and blood transfusion, rate of hysterectomy, surgery duration, postoperative complication and length of hospitalization were compared between two groups.

RESULTS

The mean estimated blood loss in the study group (800 ml,500-1800 ml) was less than that in the control group (1875 ml, 500-7600 ml) (p = .01). Only two cases had blood transfusion in the study group, while 12 cases in the control group. No case was performed hysterectomy in the study group, while one case had the operation in the control group. There was no significant difference in surgery duration, postoperative complications and length of hospitalization between two groups.

CONCLUSION

Prophylactic balloon occlusion of internal iliac artery combined with UAE is effective and safe for patients with abnormally invasive placenta.

Prophylactic occlusion balloon placement in internal iliac arteries for the prevention of postpartum haemorrhage due to morbidly adherent placenta: short term outcomes

PURPOSE

To evaluate outcomes of uterine conserving surgery with occlusion balloon technique. A critical review of the complications was performed.

MATERIALS AND METHODS

Between 2010 and 2016, pregnant women, with a prenatal diagnosis of morbidly adherent placenta (MAP), were treated with occlusion balloon catheters in both internal iliac arteries. Parameters such as need for hysterectomy, incidence of PPH, grade of MAP, estimated blood loss during delivery (EBL) and transfusion requirements, mean recovery time and duration of the balloon inflation, were collected and reviewed. Complications requiring further management were analysed.

RESULTS

Thirty-seven women with MAP underwent prophylactic occlusion balloon placement (POBC). Mean recovery was 4.48 days (range 2-10). Catheters were successfully positioned and balloons inflated in obstetric theatre following caesarean delivery in 100% of the cases. The uterus was conserved in every case. The MAP grades were 20 percreta, 3 increta and 14 accreta. The EBL was not statistically different between the different grades of placentation. There was a statistically significant association in the number of patients requiring blood transfusions and the degree of placental invasion (p = 0. 0119). PPH occurred in 5 patients (13.5%) and arterial thrombosis in 4 patients (11%). The EBL during delivery was significantly higher (2811 mL) in patients with complications (p = 0.0102). Furthermore, the group of patients that had complications required statistically significant more blood transfusions compared to those without complications (p = 0.0001). No maternal mortality or foetal morbidity occurred.

CONCLUSION

The utilisation of Prophylactic occlusion balloon catheters allows uterine conserving surgery to be performed safely with few maternal complications.

Outcome of Pregnancies After Balloon Occlusion of the Infrarenal Abdominal Aorta During Caesarean in 230 Patients With Placenta Praevia Accreta

Purpose

To explore the efficacy and safety of prophylactic temporary balloon occlusion of the infrarenal abdominal aorta during caesarean for the management of patients with placenta praevia accreta.

Methods

Two hundred and sixty-eight cases of placenta praevia accreta from January 2012 to June 2015 were retrospectively reviewed. Group A included two hundred and thirty patients who underwent prophylactic temporary balloon occlusion of infrarenal abdominal aorta followed by caesarean section. Group B included thirty-eight patients who underwent caesarean without endovascular intervention. The parameters including operating room time, estimated blood loss, blood transfusion volume, PT (prothrombin time) during operation, days in the intensive care unit, and total hospital days were compared between the two groups.

Results

The operating room time, estimated blood loss, PT, the incidence of hysterectomy, blood transfusion volume, postpartum haemorrhage, and days in intensive care unit were lower in group A than in group B, with statistical significance (P < 0.05). There was no significant difference in the Apgar scores of the neonates and the incidences of thrombosis in lower limbs between the two groups (P > 0.05). No patient in the group with prophylactic temporary balloon occlusion of the infrarenal abdominal aorta was performed hysterectomy, while three patients in group B were performed hysterectomy because of uncontrollable haemorrhage.

Conclusions

The results indicate that prophylactic temporary balloon occlusion of infrarenal abdominal aorta followed by caesarean section is safe and effective to control intraoperative blood loss and greatly decreases the risk of hysterectomy in patients with placenta praevia accreta.

Urological Manifestations of Placenta Percreta

Placenta percreta is a condition of pregnancy associated with abnormal decidua placenta. It is characterized by invasion of chorionic villi past the myometrium and serosa, towards urogenital organs. Complications include massive hemorrhage, bladder dysfunction, and severe infections during delivery. Reports suggest an increasing prevalence of this condition. From a urological perspective, this review suggests how early diagnostic modalities, effective treatment plans, and appropriate surgical methods may aid in decreasing the morbidity and mortality of placenta percreta. The importance of maintaining bladder integrity during hysterectomy is emphasized.

Estimating the Radiation Dose to the Fetus in Prophylactic Internal Iliac Artery Balloon Occlusion: Three Cases

Background. Although radiation exposure is of great concern to expecting patients, little information is available on the fetal radiation dose associated with prophylactic internal iliac artery balloon occlusion (IIABO). Here we estimated the fetal radiation dose associated with prophylactic IIABO in Caesarean section (CS). Cases. We report our experience with the IIABO procedure in three consecutive patients with suspected placenta previa/accreta. Fetal radiation dose measurements were conducted prior to each CS by using an anthropomorphic phantom. Based on the simulated value, we calculated the fetal radiation dose as the absorbed dose. We found that the fetal radiation doses ranged from 12.88 to 31.6 mGy. The fetal radiation dose during the prophylactic IIABOs did not exceed 50 mGy. Conclusion. The IIABO procedure could result in a very small increase in the risk of harmful effects to the fetus.

Prenatal identification of invasive placentation using magnetic resonance imaging: systematic review and meta-analysis

OBJECTIVE

To assess systematically the performance of prenatal magnetic resonance imaging (MRI) in diagnosing the presence, degree and topography of disorders of invasive placentation and to explore the role of the different MRI signs in predicting these disorders. The diagnostic accuracy of ultrasound and MRI in the detection of invasive placentation was also compared.

METHODS

MEDLINE, EMBASE, CINAHL and The Cochrane Library, including The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and The Cochrane Central Register of Controlled Trials, were searched electronically utilizing combinations of the relevant medical subject heading terms, keywords and word variants for 'invasive placentation' and 'magnetic resonance imaging'. Only prospective studies reporting a diagnosis of invasive placentation at the time of MRI and retrospective studies in which the radiologist was blinded to the final results were included in the analysis. The MRI signs explored were: uterine bulging, heterogeneous signal intensity, dark intraplacental bands on T2 weighted sequences, focal interruption of the myometrium and tenting of the bladder. Summary estimates of sensitivity, specificity, positive and negative likelihood ratios (LR+, LR-) and diagnostic odds ratio (DOR) were based, depending on the number of studies, upon DerSimonian-Laird random-effect or hierarchical summary receiver-operating characteristics models.

RESULTS

A total of 18 studies involving 1010 pregnancies at risk for invasive placentation were included. The overall diagnostic accuracy of MRI in detecting the presence of invasive placentation was: sensitivity, 94.4% (95% CI, 86.0-97.9%); specificity, 84.0% (95% CI, 76.0-89.8%); LR+, 5.91 (95% CI, 3.73-9.39); LR-, 0.07 (95% CI, 0.02-0.18); DOR, 89.0 (95% CI, 22.8-348.1). MRI had a high predictive accuracy in assessing both the depth and topography of placental invasion. All five MRI signs showed good predictive accuracy in the diagnosis of disorders of invasive placentation. There was no difference in either the sensitivity (P = 0.24) or the specificity (P = 0.91) between ultrasound and MRI for the detection of invasive placentation.

CONCLUSIONS

Prenatal MRI is highly accurate in diagnosing disorders of invasive placentation. Ultrasound and MRI have comparable predictive accuracy. Large population-based studies are needed in order to assess whether ultrasound can predict the depth and topography of placental invasion as reliably as can MRI.

Prenatal identification of invasive placentation using ultrasound: systematic review and meta-analysis

OBJECTIVE

The accuracy of prospective sonographic prenatal detection of invasive placentation is unclear. The objective of this study was to conduct a systematic review and meta-analysis to assess the performance of ultrasound in at-risk women for prenatal identification of invasive placentation.

METHODS

MEDLINE, EMBASE, The Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE) and The Cochrane Central Register of Controlled Trials (CENTRAL) were searched using the search terms 'placenta accreta', 'placenta increta', 'placenta percreta', 'ultrasound', 'magnetic resonance imaging (MRI)', 'invasive placenta' and 'infiltrative placenta'. Two authors independently abstracted data from the articles. Sensitivity, specificity, positive and negative likelihood ratios (LR+ and LR-), the diagnostic odds ratio (DOR) and their 95% CIs for each study were calculated. Forest plots and summary receiver-operating characteristics curves were produced. Between-study heterogeneity was explored both graphically and statistically. The MOOSE (meta-analysis of observational studies in epidemiology) guidelines were followed.

RESULTS

Twenty-three studies involving 3707 pregnancies at risk for invasive placentation were included. The overall performance of ultrasound for the antenatal detection of invasive placentation was as follows: sensitivity, 90.72 (95% CI, 87.2-93.6)%; specificity, 96.94 (95% CI, 96.3-97.5)%; LR+, 11.01 (95% CI, 6.1-20.0); LR-, 0.16 (95% CI, 0.11-0.23); and DOR, 98.59 (95% CI, 48.8-199.0). Among the different ultrasound signs, color Doppler had the best predictive accuracy (sensitivity, 90.74 (95% CI, 85.2-94.7)%; specificity, 87.68 (95% CI, 84.6-90.4)%; LR+, 7.77 (95% CI, 3.3-18.4); LR-, 0.17 (95% CI, 0.10-0.29); and DOR, 69.02 (95% CI, 22.8-208.9)).

CONCLUSIONS

Ultrasound has a high accuracy for prenatal diagnosis of disorders of invasive placentation in high-risk women. The use of color Doppler improves the test performance.

Exchange of intraoperative balloon occlusion of the internal iliac artery for the common iliac artery during cesarean hysterectomy in a patient with placenta percreta

Patient: Female, 36

Final Diagnosis: Pregnancy – placenta increta

Symptoms: —

Medication: —

Clinical Procedure: Cesarean hysterectomy

Specialty: Obstetrics and Gynecology

Iliac artery rupture related to balloon insertion for placenta accreta causing maternal hemorrhage and neonatal compromise

PURPOSE

The use of internal iliac artery balloons for prevention of hemorrhage in cases of placenta accreta is increasing. Most described complications of this technique are maternal and thromboembolic in nature. Complications related to vascular rupture are rare, their presentation is not well described, and the resultant neonatal consequences are infrequently reported.

CLINICAL FEATURES

A 35-yr-old term parturient with suspected placenta accreta underwent prophylactic endovascular placement of iliac balloons prior to Cesarean delivery. The patient complained of contraction-like pain during balloon placement, and an arterial wall tear was discovered after abdominal incision. This produced significant maternal bleeding and the birth of a neonate with an umbilical venous pH of 6.95 and Apgar scores of 3 and 7.

CONCLUSION

In addition to the known maternal risks, fetal risks must be considered when planning the placement of endovascular iliac balloons during pregnancy. We recommend continuous monitoring of maternal and fetal status when performing the procedure. Contraction-like pain during placement should raise the suspicion of arterial disruption.

Balloon occlusion of the hypogastric arteries in the management of placenta accreta: a case report and review of the literature

Obstetric hemorrhage from placenta accreta is associated with a high rate of maternal morbidity and mortality. Recently, balloon occlusion catheters have been used to control intraoperative bleeding during the surgical management of placenta accreta. In this article, we present a review of the literature reporting the use of balloon occlusion catheters in the management of placenta accrete, and a case presentation outlining the use of a Fogarty balloon occlusion catheter to achieve hemostasis in the preoperative management of placenta percreta.

Emergency peripartum hysterectomy in a tertiary care hospital in saudi arabia

PURPOSE

Post-partum hemorrhage remains an important cause of significant maternal morbidity and mortality throughout the world. The objective of this study was to review the incidence, indications, predisposing factors, and associated complications of emergency peripartum hysterectomy.

METHODS

This is a retrospective observational study done in a Tertiary Care Center, Riyadh, Saudi Arabia, between 1983 and 2006. Women who underwent emergency peripartum hysterectomy after cesarean delivery or following vaginal birth due to severe post-partum hemorrhage who did not respond to conservative treatment were included in the study. Data were abstracted from chart reviews. Descriptive analysis was carried out to summarize relevant variables. Primary outcomes included indications, risk factors, maternal morbidity, and mortality.

RESULTS

There were 66 emergency peripartum hysterectomies among 155,857 deliveries, which yielded an incidence of 0.04 %. Prior cesarean delivery was present in 88 % of the patients; a majority of the patients were grandmultiparous, Para > 6 (65 %). The incidence of hysterectomy after cesarean delivery was much higher than after vaginal delivery (0.3 vs. 0.01 %). Common indications included placenta accreta (65 %), uterine atony (27 %), and uterine rupture (8 %). The majority of the study cohort (64 %) had undergone total hysterectomy. Post-operatively, 25 patients (38 %) developed DIC, 32 (48.5 %) had febrile illnesses, and 22 (33 %) experienced injury to the urinary tract. The maternal mortality in this study was 4.5 %.

CONCLUSIONS

Hysterectomy for the control of obstetric hemorrhage is usually associated with significant mortality and morbidity. Prompt intervention to include peripartum hysterectomy may likely decrease the rate of maternal deaths and significant maternal morbidity.

Intraoperative uterine artery embolization without fetal radiation exposure in patients with placenta previa totalis: Two case reports

Embolization of the uterine arteries is a valuable method for controlling postpartum hemorrhage. There have been recent attempts to apply this tool as a means of controlling bleeding during Cesarean section, especially in patients with placenta previa. However, the benefits are controversial due to lack of randomized controlled studies, no evidence of significant improved outcomes, and potential harm including radiation exposure. This paper includes two case reports of intraoperative uterine artery embolization without fetal radiation exposure in patients with placenta previa totalis.

Role of prophylactic uterine artery balloon catheters in the management of women with suspected placenta accreta

BACKGROUND

Placenta praevia and accreta are leading causes of major obstetric haemorrhage and peripartum hysterectomy. Detection is largely based on a high index of clinical suspicion, though the diagnostic accuracy of radiological imaging is improving. Interventional radiological techniques can reduce blood loss and the incidence of hysterectomy.

METHODS

We have reviewed our experience with bilateral prophylactic uterine artery balloon occlusion in the management of women with suspected placenta accreta. Thirteen women at high risk of major haemorrhage due to placenta praevia or suspected placenta accreta were retrospectively studied. Uterine artery balloons were placed prophylactically under neuraxial anaesthesia in the angiography suite followed by caesarean delivery in the obstetric operating theatre.

RESULTS

Intraoperative blood loss and transfusion requirements were low in our case series. There were no hysterectomies or admissions to the intensive care unit. Fetal bradycardia necessitating immediate caesarean delivery occurred in two women (15.4%).

CONCLUSION

In our case series in women with suspected placenta accreta, prophylactic use of uterine artery balloons was associated with a low requirement for blood transfusion but with possible increased risk of fetal compromise. Performing the interventional procedure at a different site from the operative room complicated management.

Prophylactic endovascular placement of internal iliac occlusion balloon catheters in parturients with placenta accreta: a retrospective case series

BACKGROUND

Endovascular occlusion balloon catheters can be placed preoperatively in internal iliac vessels of patients perceived to be at risk of major obstetric haemorrhage during caesarean section. Their safety and efficacy remains undefined, and we report our experience of 14 patients over four years.

METHODS

We undertook a chart review of all patients who had undergone prophylactic internal iliac balloon catheters before caesarean section in our institution.

RESULTS

Balloon catheters were placed in 14 and inflated in 11 (78.6%) patients. Five of the 14 patients (35.7%) underwent emergency balloon catheter placement before unscheduled caesarean section. Surgeons reported that balloon inflation provided favourable surgical conditions in six of 11 cases (54.5%), no improvement in four and was not required in one due to lack of pathology. Within the balloon-inflated group, nine patients underwent a hysterectomy: two electively, the remaining seven because of perioperative confirmation of placenta accreta or for control of bleeding. One patient suffered massive haemorrhage leading to three perioperative hypovolaemic cardiac arrests. Four patients required intervention to avoid complications related to balloon catheters: three minor and one related to catheter displacement and prolonged resuscitation.

CONCLUSION

Internal iliac balloon catheters can be inserted electively or in an emergency in patients at risk of major obstetric haemorrhage. Although useful in some, they are not universally effective; patients are still at risk of significant blood loss and at high risk of requiring a hysterectomy. In our experience, catheters can be placed electively or in an emergency but have been associated with adverse outcomes. These lessons have been important learning points in perioperative management.

The role of interventional radiology in obstetric hemorrhage

Obstetric hemorrhage remains a major cause of maternal morbidity and mortality worldwide. Traditionally, in cases of obstetric hemorrhage refractory to conservative treatment, obstetricians have resorted to major surgery with the associated risks of general anesthesia, laparotomy, and, in the case of hysterectomy, loss of fertility. Over the past two decades, the role of pelvic arterial embolization has evolved from a novel treatment option to playing a key role in the management of obstetric hemorrhage. To date, interventional radiology offers a minimally invasive, fertility-preserving alternative to conventional surgical treatment. We review current literature regarding the role of interventional radiology in postpartum hemorrhage, abnormal placentation, abortion, and cervical ectopic pregnancy. We discuss techniques, success rates, and complications.

Prophylactic hypogastric artery ballooning in a patient with complete placenta previa and increta

Abnormal attachment of the placenta (Placenta accreta, increta, and percreta) is an uncommon but potentially lethal cause of maternal mortality from massive postpartum hemorrhage. A 33-yr-old woman, who had been diagnosed with a placenta previa, was referred at 30 weeks gestation. On ultrasound, a complete type of placenta previa and multiple intraplacental lacunae, suggestive of placenta accreta, were noted. For further evaluation of the placenta, pelvis MRI was performed and revealed findings suspicious of a placenta increta. An elective cesarean delivery and subsequent hysterectomy were planned for the patient at 38 weeks gestation. On the day of delivery, endovascular catheters for balloon occlusion were placed within the hypogastric arteries, prior to the cesarean section. In the operating room, immediately after the delivery of the baby, bilateral hypogastric arteries were occluded by inflation of the balloons in the catheters previously placed within. With the placenta retained within the uterus, a total hysterectomy was performed in the usual fashion. The occluding balloons were deflated after closure of the vaginal cuff with hemostasis. The patient had stable vital signs and normal laboratory findings during the recovery period; she was discharged six days after delivery without complications. The final pathology confirmed a placenta increta.

Abnormal placentation

Abnormal placentation poses a diagnostic and treatment challenge for all providers caring for pregnant women. As one of the leading causes of postpartum hemorrhage, abnormal placentation involves the attachment of placental villi directly to the myometrium with potentially deeper invasion into the uterine wall or surrounding organs. Surgical procedures that disrupt the integrity of uterus, including cesarean section, dilatation and curettage, and myomectomy, have been implicated as key risk factors for placenta accreta. The diagnosis is typically made by gray-scale ultrasound and confirmed with magnetic resonance imaging, which may better delineate the extent of placental invasion. It is critical to make the diagnosis before delivery because preoperative planning can significantly decrease blood loss and avoid substantial morbidity associated with placenta accreta. Aggressive management of hemorrhage through the use of uterotonics, fluid resuscitation, blood products, planned hysterectomy, and surgical hemostatic agents can be life-saving for these patients. Conservative management, including the use of uterine and placental preservation and subsequent methotrexate therapy or pelvic artery embolization, may be considered when a focal accreta is suspected; however, surgical management remains the current standard of care.

Obstetric and gynecologic emergencies: a review of indications and interventional techniques

There are many interventional techniques that can be used to aid the obstetrician or gynecologist in caring for their patients in the acute setting. Embolization can be life saving in the case of postpartum hemorrhage. Bleeding related to cervical cancer or the threat of bleeding from cervical ectopic pregnancy is amenable to embolization as is hemorrhage related to uterine arteriovenous malformations. Postpartum women are also at a uniquely high risk for deep vein thrombosis and pulmonary emboli and may benefit from consultation and treatment by an interventional radiologist. The goal of this article is to discuss the valuable role that the interventional radiologist plays in the treatment of these obstetric and gynecologic conditions.

Mechanisms of hemostasis at cesarean delivery

Postpartum hemorrhage is an obstetric emergency that represents a major cause of maternal morbidity and mortality. With the recent rise in the cesarean delivery rate, prompt recognition and proper management at the time of cesarean delivery are becoming increasingly important for providers of obstetrics. Preparedness for hemorrhage can be achieved by recognition of prior risk factors and implementation of specific hemorrhage protocols. Medical and surgical therapies are available to treat obstetric hemorrhage after cesarean delivery.

Arterial Embolus During Common Iliac Balloon Catheterization at Cesarean Hysterectomy

BACKGROUND

Placenta accreta is associated with significant maternal morbidity. Prophylactic iliac artery balloon placement has been described as a treatment adjunct to minimize maternal risk of excessive blood loss at hysterectomy.

CASE

A 37-year-old multigravida presented at 37 weeks of gestation with a known placenta previa and suspected placenta accreta. Iliac artery balloon catheters were placed immediately before cesarean delivery. The balloons were inflated after the infant was delivered, and placental-site hemorrhage required a cesarean hysterectomy with a 1,500-mL blood loss. A left popliteal arterial thrombus diagnosed postoperatively required thromboembolectomy. The patient was discharged home on postoperative day 5 with no further sequelae.

CONCLUSION

Prophylactic arterial balloon occlusion may be associated with risks unique to pregnant women.