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

Outcome evaluation of prophylactic internal iliac balloon occlusion in the management of patients with placenta accreta spectrum

PURPOSE

To evaluate outcomes and complications of prophylactic internal iliac balloon occlusion (PIIBO) in the management of patients with placenta accreta spectrum (PAS) at a large regional referral centre.

MATERIALS AND METHODS

A retrospective review of all PIIBO for PAS performed over a 12-year period (2010-2022). Information for analysis was gathered from the local RIS/PACS and clinical documentation. Collected data included patient demographics, indication for procedure, sheath insertion and removal time, total duration of balloon inflation and complications that occurred.

RESULTS

106 patients underwent temporary internal iliac artery balloon occlusion within the 12-year period. All procedures utilised bilateral common femoral artery punctures, 6Fr sheath and 5Fr Le Maitre occlusion balloons. 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. There was no maternal mortality or foetal morbidity. Twenty patients (18.9%) had some form of complication that required further intervention. Of these, 7(6.6%) had post-operative PPH, which was treated with uterine artery embolisation; and 13 (12.3%) had arterial thrombus which required aspiration thrombectomy. All procedures were technically successful with no long-term sequelae.

CONCLUSION

PIIBO plays an important part in reducing morbidity and mortality in patients with PAS. Clear pathways and multidisciplinary team working is critical in the management of these patients to ensure that any complications are dealt with promptly to avoid long-term sequelae.

Placenta Accreta: A Case Report on the Role of Interventional Radiology

Placenta accreta spectrum disorder is a pregnancy-related disorder responsible for important post-partum morbimortality, associated with intractable or massive hemorrhage, leading to uterine loss in up to 64% of women. Despite international recommendations advocating planned preterm cesarean hysterectomy for the management of these patients, uterus preservation management is being continuously reported with the implementation of minimally invasive bleeding reduction strategies, such as prophylactic balloon-assisted occlusion. We present the case of a 40-year-old pregnant woman with a previous cesarean, diagnosed with placenta previa and suspected placenta accreta on magnetic resonance after having second-trimester vaginal bleeding. A peri-operative multidisciplinary panel was involved, in collaboration with the interventional radiologist, and the c-section was scheduled for 36 weeks of gestation. The prophylactic balloon-assisted occlusion was successfully performed, minimizing the blood loss and allowing a uterus-preserving approach.

Prophylactic bilateral internal iliac balloon occlusion to control hemorrhage in placenta accreta spectrum: a boon for obstetricians

BACKGROUND

Placenta accreta spectrum (PAS) is abnormal placental adhesion beyond superficial myometrium, which may lead to severe life-threatening hemorrhage requiring massive blood transfusions in the peripartum period. Prophylactic balloon catheterization of bilateral internal iliac arteries with or without additional embolization with Cesarean hysterectomy in patients with PAS prevent excessive intraoperative hemorrhage and may also obviate the need for hysterectomy.

PURPOSE

To study the efficacy of intervention radiological procedures in controlling intraoperative hemorrhage in patients with PAS.

MATERIAL AND METHODS

This ethically approved prospective study was conducted between November 2017 and October 2019 and written informed consent was obtained from all patients. Consecutive patients diagnosed with PAS during the antepartum period were evaluated. A total of 18 patients with PAS underwent prophylactic balloon catheterization of the bilateral internal iliac arteries followed by delivery of the infant. Interventional and intraoperative data of these patients were collected and compared with retrospectively collected data of patients (control group) who underwent hysterectomy without prophylactic balloon occlusion over the past four years (January 2016-November 2019).

RESULTS

Significantly lower intraoperative blood loss (2.8 L vs. 4.7 L; P = 0.048) and pure red blood cell (PRBC) requirement (P = 0.026) between patients who had hysterectomy with and without interventional radiological management was observed. Significantly higher blood loss (P = 0.006) and fluid requirement (P = 0.007) was observed with a higher degree of placental invasion. Only 1 (6%) major procedure-related complication was observed.

CONCLUSION

Interventional radiological procedures are effective in significantly reducing intraoperative blood loss and blood product requirement in patients with PAS.

Efficacy of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control in patients with abnormally invasive placenta: a historical cohort study

BACKGROUND

Patients with abnormally invasive placenta (AIP) are at high risk of massive postpartum hemorrhage. Resuscitative endovascular balloon occlusion of the aorta (REBOA), as an adjunct therapeutic strategy for hemostasis, offers the obstetrician an alternative for treating patients with AIP. This study aimed to evaluate the role of REBOA in hemorrhage control in patients with AIP.

METHODS

This was a historical cohort study with prospectively collected data between January 2014 to July 2021 at a single tertiary center. According to delivery management, 364 singleton pregnant AIP patients desiring uterus preservation were separated into two groups. The study group (balloon group, n = 278) underwent REBOA during cesarean section, whereas the reference group (n = 86) did not undergo REBOA. Surgical details and maternal outcomes were collected. The primary outcome was estimated blood loss and the rate of uterine preservation.

RESULTS

A total of 278 (76.4%) participants experienced REBOA during cesarean section. The patients in the balloon group had a smaller blood loss during cesarean Sect. (1370.5 [752.0] ml vs. 3536.8 [1383.2] ml; P < .001) and had their uterus salvaged more often (264 [95.0%] vs. 23 [26.7%]; P < .001). These patients were also less likely to be admitted to the intensive care unit after delivery (168 [60.4%] vs. 67 [77.9%]; P = .003) and had a shorter operating time (96.3 [37.6] min vs. 160.6 [45.5] min; P < .001). The rate of neonatal intensive care unit admission (176 [63.3%] vs. 52 [60.4%]; P = .70) and total maternal medical costs ($4925.4 [1740.7] vs. $5083.2 [1705.1]; P = .13) did not differ between the two groups.

CONCLUSIONS

As a robust hemorrhage-control technique, REBOA can reduce intraoperative hemorrhage in patients with AIP. The next step is identifying associated risk factors and defining REBOA inclusion criteria to identify the subgroups of AIP patients who may benefit more.

Prophylactic endovascular internal iliac balloon placement during cesarean hysterectomy for placenta accreta spectrum

BACKGROUND

The utility of prophylactic endovascular internal iliac balloon placement in the surgical management of placenta accreta spectrum is debated.

OBJECTIVE

In this study, we review outcomes of surgical management of placenta accreta spectrum with and without prophylactic endovascular internal iliac balloon catheter use at a single institution.

STUDY DESIGN

This is a retrospective cohort study of consecutive viable singleton pregnancies with a confirmed pathologic diagnosis of placenta accreta spectrum undergoing scheduled delivery from October 2018 through November 2020. In the T1 period (October 2018-August 2019), prophylactic endovascular internal iliac balloon catheters were placed in the operating room before the start of surgery. Balloons were inflated after neonatal delivery and deflated after hysterectomy completion. In the T2 period (September 2019-November 2020), endovascular catheters were not used. In both time periods, all surgeries were performed by a dedicated multidisciplinary team using a standardized surgical approach. The outcomes compared included the estimated blood loss, anesthesia duration, operating room time, surgical duration, and a composite of surgical complications. Comparisons were made using the Wilcoxon rank-sum test and the Fisher exact test.

RESULTS

A total of 30 patients were included in the study (T1=10; T2=20). The proportion of patients with placenta increta or percreta was 80% in both groups, as defined by surgical pathology. The median estimated blood loss was 875 mL in T1 and 1000 mL in T2 (P=.84). The proportion of patients requiring any packed red blood cell transfusion was 60% in T1 and 40% in T2 (P=.44). The proportion of patients requiring >4 units of packed red blood cells was 20% in T1 and 5% in T2 (P=.25). Surgical complications were observed in 1 patient in each group. Median operative anesthesia duration was 497 minutes in T1 and 296 minutes in T2 (P<.001). Median duration of operating room time was 498 minutes in T1 and 205 minutes in T2 (P<.001). Median surgical duration was 227 minutes in T1 and 182 minutes in T2 (P<.05). The median duration of time for prophylactic balloon catheter placement was 74 minutes (range, 46-109 minutes). The median postoperative length of stay was similar in both groups (6 days in T1 and 5.5 days in T2; P=.36).

CONCLUSION

The use of prophylactic endovascular internal iliac balloon catheters was not associated with decreased blood loss, packed red blood cell transfusion, or surgical complications. Catheter use was associated with increased duration of anesthesia, operating room time, and surgical time.

Postpartum Hemorrhages: Prevention

The strict correlation between abnormal invasive placentation and postpartum hemorrhage suggests that a widespread antenatal diagnosis of placental anomalies would improve the management of these challenging patients; acting preventive solutions at the moment of delivery reduces blood loss and avoid hysterectomies. The role of endovascular procedures in this field has been encouraged by multiple studies reporting prophylactic uterine arteries embolization and iliac/aortic balloon catheters positioning. This paper aims to review the main imaging diagnostic findings of placental implant anomalies and summarize the principal preventive endovascular strategies proposed in literature.

High-intensity focused ultrasound in management of placenta accreta spectrum: A systematic review

BACKGROUND

High-intensity focused ultrasound (HIFU) is a non-invasive procedure that has been studied in the management of placenta accreta spectrum (PAS).

OBJECTIVE

To appraise HIFU in the management of PAS and highlight the restrictions on converting uterus-preserving studies into evidence-based practice.

SEARCH STRATEGY

A search on Scopus, Cochrane, PubMed and Web of Science was conducted from date of inception to January 2020.

SELECTION CRITERIA

Studies on using HIFU in the management of PAS were eligible. Review articles, conference papers, and case reports were excluded.

DATA COLLECTION

A standardized sheet was used to abstract data from eligible studies. CON-PAS registry was used to include studies on other conservative modalities.

RESULTS

Four studies were eligible (399 patients). Average residual placental volume was 61.74 cm³ (6.01-339 cm³ ). Treatment was successful in all patients. Normal menstruation recovered after 48.8 days (15-150 days). No major complications were encountered. Sixty-one studies were retrieved from the CON-PAS registry; uterine artery embolization (23 studies), balloon placement (15 studies), compression sutures (10 studies), placenta in situ (7 studies), and uterine resection (6 studies) were successful in 83.7%, 92.9%, 87.9%, 85.2%, and 79.3% of cases, respectively.

CONCLUSIONS

HIFU may fit certain clinical situations in the management of PAS. A global research strategy is recommended to incorporate conservative approaches within a comprehensive management protocol.

Perioperative patient blood management during parallel transverse uterine incision cesarean section in patient with pernicious placenta previa: A retrospective cohort analysis

Pernicious placenta previa (PPP) is the main cause of severe obstetric postpartum hemorrhage and hysterectomy and often requires donor blood transfusion. Prophylactic internal iliac artery (IIA) balloon occlusion (BO) combined with cell salvage is increasingly being deployed in parallel transverse uterine incision (PTUI) cesarean section (CS). The aim of this study was to explore the differences in blood management in PTUI CS with or without prophylactic IIA BO and to evaluate the safety and efficacy of cell salvage to reduce the need for donor blood transfusion during PTUI CS.This retrospective study included all women who were diagnosed with PPP and PA and underwent PTUI CS from October 1, 2016, to October 31, 2018. Sixty-four patients were included: 34 underwent prophylactic IIA BO (IIA group), whereas 30 were treated without prophylactic IIA BO (control group). The primary outcome was a composite measure of perioperative blood management outcomes, including the estimated blood loss (EBL), donor blood transfusion, salvaged blood returned, fresh frozen plasma (FFP), pre- and postoperative serum hemoglobin and hematocrit. In addition, the baseline conditions of mother and neonates were compared.EBL was significantly higher in the IIA group compared to the control group (2883.5 mL in the IIA group vs 1868.7 mL in the control group, P = .001). Overall, the donor blood transfusion rate was 23.5% (8/34), averaging 4.2 U, in the IIA group versus 30% (9/30), averaging 3.4 U, in the control group, which were not significantly different. The FFP transfusion rate was 47%, averaging 765.6 mL, in the IIA group versus 20%, averaging 816.7 mL, in the control group. In the IIA group, 97.1% used cell savage and had salvaged blood returned, averaging 954.9 mL. In the control group, 90% had salvaged blood returned, averaging 617.9 mL. No cases of amniotic fluid embolism were observed with leukocyte depletion filters.Prophylactic IIA BO during PTUI CS in women with PPP and PA does not lead to a statistically significant reduction in EBL. Cell salvage was associated with a reduction in the rate of donor blood transfusion during PTUI CS.

MRI of placenta accreta: diagnostic accuracy and impact of interventional radiology on foetal-maternal delivery outcomes in high-risk women

OBJECTIVE

To assess accuracy and reproducibility of MRI diagnosis of invasive placentation (IP) in high-risk patients and to evaluate reliability of MRI features. Secondary aim was to evaluate impact of interventional radiology (IR) on delivery outcomes in patients with IP at MRI.

METHODS

26 patients (mean age 36.24 y/o,SD 6.16) with clinical risk-factors and echographic suspicion of IP underwent 1.5 T-MRI. Two readers reviewed images. Gold-standard was histology in hysterectomised patients and obstetric evaluation at delivery for patients with preserved uterus. Accuracy and reproducibility of MRI findings were calculated.

RESULTS

Incidence of IP was 50% (13/26) and of PP was 11.54% (3/26). MRI showed 100% sensitivity (95% CI = 75.3-100%) and 92.3% specificity (95% CI = 64.0-100%) in the diagnosis of IP. Gold-standard was histology in 10 cases and obstetric evaluation in 16. MRI findings with higher sensitivity were placental heterogeneity, uterine bulging and black intraplacental bands. Uterine scarring, placental heterogeneity, myometrial interruption and tenting of the bladder showed better specificity. MRI inter-rater agreement with Cohen's K was 1. 11 patients among 14 with MRI diagnosis of IP received IR assistance with positive impact on delivery outcomes in terms of blood loss, red cells count, intense care unit length of stay, days of hospitalisation and risk of being transfused.

CONCLUSION

MRI is an accurate and reproducible technique in prenatal diagnosis of IP. MRI helps planning a safe and appropriate delivery eventually assisted by IR, which positively affects foetal and maternal outcomes.

ADVANCES IN KNOWLEDGE

The adoption of MRI evaluation in patients with high risk of invasive placentation allows a more accurate diagnosis in terms of both presence of the disease and its extension to or through or even beyond the myometrium. This led to a better dedicated delivery management with eventual adoption of interventional radiology with a global positive effect on foetal and maternal outcomes.

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.

Basic embolization techniques: tips and tricks

Good knowledge of the various approaches of embolization of peripheral bleedings and different embolic materials available is of paramount importance for successful and safe embolization. We review and illustrate the main endovascular and percutaneous techniques used for embolization, along with the characteristics of the different embolic materials, and the potential complications.

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.

Self-reported physical, mental, and reproductive sequelae after treatment of abnormally invasive placenta: a single-center observational study

OBJECTIVE

To analyze the types of treatment of abnormally invasive placenta (AIP) and to investigate the self-reported physical and mental short- and long-term sequelae.

METHODS

This single-center observational study was performed between 2003 and 2017. Women with prenatal or intrapartum diagnosis of AIP were identified through the departmental database. Classification was performed according to the time of diagnosis establishment and the type of treatment. Medical complications overall and according to the type of treatment were analyzed. Data about women's perception of diagnosis, treatment, and short- and long-term sequelae were gathered by questionnaire.

RESULTS

Cases were classified into four groups: prenatal diagnosis, cesarean hysterectomy (A, n = 10); prenatal diagnosis, expectant management (B, n = 19); intrapartum diagnosis, cesarean hysterectomy (C, n = 6); intrapartum diagnosis, conservative therapy (D, n = 20). Depth of invasion, total units of transfused red blood cells, and the need for reoperation differed between the treatment groups. Expectant management was successful in 94.7% of cases. Irrespective of the treatment group, 73.3% of women perceived the condition as serious or life-threatening; 30.0% utilized psychological support; and 36.7% reported persistent pain or problems. 37.5% of women after uterine preservation had another live birth, AIP recurred in 44.4% of cases.

CONCLUSION

Conservative management of AIP is feasible in selected cases. The condition is perceived as life-threatening and has a lasting impact on the physical, mental, and reproductive health of those affected. This finding merits further investigation. AIP continues to be a condition with high morbidity.

Prophylactic Occlusion Balloon Placement in the Abdominal Aorta Combined with Uterine or Ovarian Artery Embolization for the Prevention of Cesarean Hysterectomy Due to Placenta Accreta: A Retrospective Study

OBJECTIVE

To evaluate the outcomes of uterine-conserving surgery with the occlusion balloon technique followed by uterine or ovarian artery embolization (OAE) in women with placenta accreta.

METHODS

A total of 31 consecutive patients, who were diagnosed with placenta accreta through grayscale ultrasonography or magnetic resonance imaging prenatally, were retrospectively analyzed in our hospital between October 2015 and September 2017. All of the women underwent a Cesarean section combined with prophylactic placement of a balloon catheter in the abdominal aorta followed by uterine artery embolization (UAE) or OAE when necessary.

RESULTS

Technical success was achieved in 31 cases (100%), including successful catheterization and inflation of balloons. The uterus was conserved in 30 (96.77%) patients. The estimated blood loss, packed RBC transfused, and the operation time were 1906.45 ± 1117.64 ml, 4(0-6) U, and 88.68 ± 28.35 min, respectively. Out of all of the patients, we found nine cases of bleeding after the release of the balloon. Among these patients, six cases originated from the ovarian arteries and three cases originated from uterine arteries. Further embolization was performed through catheterization. The mean fetal radiation exposure was 4.33 ± 0.79 mGy.

CONCLUSIONS

Prophylactic abdominal aorta balloon occlusion followed by UAE or OAE can effectively control postpartum hemorrhaging with reduced blood loss, transfusion requirements, and hysterectomy rates in patients with placenta accreta.

Can the combination of internal iliac temporary occlusion and uterine artery embolization reduce bleeding and the need for intraoperative blood transfusion in cases of invasive placentation?

OBJECTIVES

Women with invasive placentation (IP) are at high risk of life-threatening hemorrhage. In the last two decades, less invasive surgical approaches combined with endovascular procedures have proven to be safe. Most case series describe the use of temporary balloon occlusion and embolization, either combined or not. Concerning hemorrhage rates, each separate interventional approach performs better than surgery alone does, yet it is not clear whether the combination of multiple interventional techniques can be beneficial and promote a lower incidence of intrapartum bleeding. We aim to evaluate whether combining temporary balloon occlusion of the internal iliac artery and uterine artery embolization promotes better hemorrhage control than do other individual interventional approaches reported in the scientific literature in the context of cesarean birth followed by hysterectomy in patients with IP.

METHODS

This is a retrospective analysis of patients with confirmed IP who underwent temporary balloon occlusion and embolization of the internal iliac arteries followed by puerperal hysterectomy. We compared patient results to data extracted from a recent systematic review and meta-analysis of the current literature that focused on interventional procedures in patients with IP.

RESULTS

A total of 35 patients underwent the procedure during the study period in our institution. The mean volume of packed red blood cells and the estimated blood loss were 487.9 mL and 1193 mL, respectively. Four patients experienced complications that were attributed to the endovascular procedure.

CONCLUSION

The combination of temporary balloon occlusion and uterine artery embolization does not seem to promote better hemorrhage control than each procedure performed individually does.

Prophylactic abdominal aortic balloon occlusion: An effective method of controlling hemorrhage in patients with placenta previa or accreta

Postpartum hemorrhage is considered to be a serious complication in patients with pernicious placenta. Approaches employing abdominal aortic balloon occlusion to control hemorrhage are extremely effective for such patients. The present study analyzed 9 patients with pernicious placenta previa in a single hospital from June 2016 to November 2017. Prior to cesarean hysterectomy, an abdominal aortic balloon catheter was placed in all patients. The balloon was inflated and evacuated alternately using saline following delivery of the fetal head. The X-ray dose, bleeding volume and complications during the procedure were observed. Balloon catheterization was successfully performed in all 9 patients. The dose of X-rays ranged from 15.8 to 24.5 mGy, with a mean of 19.3±2.7 mGy; the volume of blood loss ranged from 50 to 4,000 ml, with a mean of ~1,800 ml. Uterine artery embolization was successfully performed in 2 cases due to bleeding following the cesarean hysterectomy, and every uterus was retained. Abdominal aortic balloon occlusion can effectively reduce the amount of bleeding during cesarean hysterectomy in patients with pernicious placenta previa. This may serve as technical support for patients in whom retention of the uterus is expected. However, it is necessary to identify any abnormal uterine tissue above the level of the renal artery in order to avoid ineffective balloon occlusion.