Implementation and outcomes of a uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum

4-French Aortic Balloon Occlusion in Cesarean Hysterectomy for Placenta Accreta Spectrum Disorder

OBJECTIVE

To evaluate whether using a 4-French balloon aortic occlusion device was associated with lower blood loss and subsequent blood transfusions in placenta accreta spectrum (PAS) cesarean hysterectomy.

METHODS

This was a retrospective cohort study of patients with ultrasound findings consistent with complex PAS (placenta increta or percreta) who were delivered at a single tertiary care center from March 2022 to November 2024 with confirmed placenta increta or percreta on histopathology. We compared patients who had a 4-French aortic balloon inflated with those who had a sheath placed without balloon inflation and those who had no sheath placement for planned cesarean hysterectomy. Our primary outcome was quantitative blood loss. Our secondary outcomes included operative time and blood transfusion.

RESULTS

A total of 81 patients with histopathologic confirmation of placenta increta or percreta were included. Twenty-seven patients (27/81, 33.3%) did not have the 4-French sheath placement at time of surgery. A 4-French balloon sheath was placed in 54 patients; among these, 25 had sheath-only placement with no balloon inflation, and 29 had aortic balloon inflation during cesarean hysterectomy. There were no differences in baseline demographics among the three groups. Pregnancy complications before cesarean hysterectomy were similar. Operative time was longer in surgeries with balloon inflation compared with those with no sheath placement (319±93 minutes vs 244±64 minutes, P <.01). Aortic balloon inflation was associated with lower blood loss compared with no sheath placement (1,526±635 mL vs 2,686±1,420 mL, P <.01). Overall blood transfusion rates were not significantly different between groups, but balloon inflation was associated with a lower overall number of units transfused compared with no sheath (median [25 th percentile, 75 th percentile] 2 [1, 2] units vs 3 [1, 5] units, P <.04) One patient in the aortic balloon group developed a thrombus.

CONCLUSION

In our cohort, inflation of a 4-French aortic occlusion balloon for PAS surgeries was associated with lower blood loss and less blood transfusions but longer operative times compared with no sheath placement. Larger studies are needed to assess for rare outcomes and complications.

Local Resection After Cesarean Delivery for Placenta Accreta Spectrum Disorder: A Systematic Review and Meta-analysis

OBJECTIVE

To compare maternal and surgical outcomes between local resection and immediate hysterectomy after cesarean delivery in patients with placenta accreta spectrum (PAS).

DATA SOURCES

Four public databases (PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials) were systematically searched for relevant publications up to July 31, 2024. Because the Cochrane Library included all the identified clinical trials, it was unnecessary to search ClinicalTrials.gov . The search strategy included the terms "placenta accreta" or "placenta accreta spectrum" and "pregnancy outcomes" and related key words about local resection and cesarean hysterectomy.

METHODS OF STUDY SELECTION

With the use of established inclusion criteria, 4,889 studies were reviewed. The included studies evaluated surgical and maternal outcomes associated with immediate hysterectomy compared with local resection.

TABULATION, INTEGRATION, AND RESULTS

Data extraction was conducted with the Patient/Population, Intervention, Comparison, Outcome, and Study design framework. Both fixed-effects and random-effects models were used to synthesize the findings. A total of 11 studies published between 2018 and 2024 were analyzed (nine retrospective studies, one randomized controlled trial, and one prospective cohort study). The quality of the included studies was globally low, and 7 of 11 studies had severe bias. The immediate hysterectomy group had a significantly higher prevalence of placenta percreta compared with the local resection group (69.4% vs 44.3%, P <.01). In contrast to immediate hysterectomy, local resection yielded improved surgical outcomes, demonstrated by the following metrics: transfusion rate (six studies, 375 vs 205 patients, odds ratio [OR] 0.47, 95% CI, 0.29-0.75), estimated blood loss (seven studies, 416 vs 246 patients, mean difference -396 mL, 95% CI, -534 to -257), urologic complications (seven studies, 408 vs 241 patients, OR 0.18, 95% CI, 0.10-0.33), and intensive care unit admission (three studies, 87 vs 79 patients, OR 0.19, 95% CI, 0.07-0.53). One study recorded three maternal deaths: two in the immediate hysterectomy group and one in the local resection group. The results of subgroup analyses focused on patients with severe forms of PAS (placenta increta and percreta) were similar in the overall analysis.

CONCLUSION

In this systematic review and meta-analysis, eligible studies comparing the local resection with immediate hysterectomy at cesarean hysterectomy for PAS were overall low quality because of the lack of intention-to-treat information. Despite these limitations, local resection for PAS may possibly be an option for appropriately selected patients to reduce surgical morbidity. Because the indication criteria, safety, surgical techniques, and necessity of adjunctive therapies for local resection remain understudied, further prospective studies are warranted.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42024594315.

Evidence-Based Perioperative Management of Placenta Accreta Spectrum Disorder

Placenta accreta spectrum (PAS) disorder, characterized by failure of the abnormally adherent placenta to detach from the uterus after delivery, is a leading cause of severe maternal morbidity. Despite its relatively low incidence, disproportional contributions to perinatal hemorrhage, massive transfusion, and emergency hysterectomy underscore the critical need for development of evidence-based surgical management strategies for PAS. There is clear benefit to preoperative management of anemia, as well as preparation for intraoperative resuscitation with blood products and cell salvage. Several tenets of normal cesarean delivery should be maintained in PAS delivery such as the use of neuraxial anesthesia until delivery, prophylactic antibiotics, mechanical thromboprophylaxis intraoperatively, and administration of tranexamic acid if excessive bleeding occurs. Elements of surgical management distinctive to PAS and accepted as best practice include the following: planning delivery at centers with experienced teams when PAS is suspected antenatally, global intraoperative uterine and pelvic survey on entry into the abdominal cavity to assess for anatomic distortion or abnormal vascularity, selection of hysterotomy site for delivery well away from the placental margin, and direct visual assessment of the placental relationship with the myometrium after neonatal delivery and during the start of uterine involution. Other morbidity-reducing strategies such as routine cystoscopy with or without ureteral stent placement, unconventional transverse abdominal entry, hysterotomy extension with surgical staplers, and endovascular hemorrhage reduction tactics involving aortic or iliac balloon occlusion and multivessel arterial embolization remain experimental and require further research.

Surgical Outcomes and Associated Morbidity of Active and Expectant Management of Second-Trimester Placenta Accreta Spectrum (PAS)

Background and Objectives: Management of second-trimester placenta accreta spectrum (PAS) is currently center-dependent with minimal evidence-based practices. This study aims to analyze outcomes of hysterectomy as second-trimester active management (AM) versus cesarean hysterectomy as expectant management (EM) in cases of PAS with intraoperative and postoperative outcomes. Materials and Methods: This study is a retrospective case-control study of patients with a pathology-confirmed diagnosis of PAS managed at a single center over 16 years (2005-2020). All cases were diagnosed during the first or second trimester by ultrasonography and managed by the same multidisciplinary team with delivery within the second trimester. Results: Thirty-four patients with PAS were diagnosed and delivered by the second trimester. Of these, (41.1%) elected for active management and 20 (58.9%) for expectant management but ultimately required delivery prior to 28 weeks' gestation. Baseline demographics were similar between groups. Intraoperatively, no differences were noted in operative time (191.5 vs. 203 min, p = 0.85), blood loss (2300 vs. 2600 cc, p = 0.85), or incidental cystotomy (1 vs. 7, p = 0.10). Postoperative length of stay was similar (3 vs. 3.5 days, p = 0.28), and ICU admission was not statistically different (6 vs. 12, p = 0.48). Conclusions: This retrospective study suggests that when hysterectomy is planned, there is no difference in maternal outcomes and morbidity with an expectant management with cesarean hysterectomy in the second trimester compared to proactive cesarean hysterectomy.

Looking back to look forward: Has the time arrived for active management of obstetricians in placenta accreta spectrum?

Placenta accreta spectrum (PAS) is a relatively new obstetric condition which, until recently, was poorly understood. The true incidence is unknown because of the poor quality and heterogeneous diagnostic criteria. Classification systems have attempted to provide clarity on how to grade and diagnose PAS, but these are no longer reflective of our current understanding of PAS. This is particularly true for placenta percreta, which referred to extrauterine disease, as recent studies have demonstrated that placental villi associated with PAS have minimal potential to invade beyond the uterine serosa. It is accepted that PAS is a direct consequence of previous iatrogenic uterine injury, most commonly a previous cesarean section. Here, we "look back to look forwards"-starting with the primary predisposing factor for PAS, an iatrogenic uterine injury and subsequent wound healing. We then consider the evolution of definitions and diagnostic criteria of PAS from its first description over a century ago to current classifications. Finally, we discuss why modifications to the current classifications are needed to allow accurate diagnosis of this rare but life-threatening complication, while avoiding overdiagnosis and potential patient harm.

Risk factors for intensive care unit admission after cesarean hysterectomy for placenta accreta spectrum

OBJECTIVE

Placenta accreta spectrum (PAS) is a complex disorder of uterine wall disruption with significant morbidity and mortality, particularly at time of delivery. Both physician and physical hospital resource allocation/utilization remains a challenge in PAS cases including intensive care unit (ICU) beds. The primary objective of the present study was to identify preoperative risk factors for ICU admission and create an ICU admission prediction model for patient counseling and resource utilization decision making in an evidence-based manner.

METHODS

This was a case-control study of 145 patients at our PAS referral center undergoing cesarean hysterectomy for PAS. Final confirmation by histopathology was required for inclusion. Patient disposition after surgery (ICU vs post-anesthesia care unit) was our primary outcome and pre-/intra-/postoperative variables were obtained via electronic medical records with an emphasis on the predictive capabilities of the preoperative variables. Uni- and multivariate analysis was performed to identify independent predictive factors for ICU admission.

RESULTS

In this large cohort of 145 patients who underwent cesarean hysterectomy for PAS, with histopathologic confirmation, 63 (43%) were admitted to the ICU following delivery. These patients were more likely to be delivered at an earlier gestational age (34 vs 35 weeks, P < 0.001), have had >2 episodes of vaginal bleeding and emergent delivery compared to patients admitted to patients with routine recovery care (44% vs 18.3%, P = 0.009). Uni- and multivariate logistic regression showed an area under the curve of 0.73 (95% CI: [0.63, 0.81], P < 0.001) for prediction of ICU admission with these three variables. Patients with all three predictors had 100% ICU admission rate.

CONCLUSION

Resource prediction, utilization and allocation remains a challenge in PAS management. By identifying patients with preoperative risk factors for ICU admission, not only can patients be counseled but this resource can be requested preoperatively for staffing and utilization purposes.

The role of MRI in "estimating" intraoperative bleeding during cesarean section for placenta accreta: A prospective cohort study

Objectives

The prenatal detection of placenta accreta spectrum (PAS) disorder is crucial for treatment strategy formulation. MRI descriptors may offer a more objective method for predicting PAS and clinical outcomes. The aim of this study is to investigate the predictive value of MRI examination for intraoperative blood loss in PAS cesarean section and elucidating the MRI descriptors that are more valuable for predicting intraoperative blood loss.

Methods

A prospective study was carried out on 164 pregnant women diagnosed with PAS. Maternal and neonatal perioperative characteristics were systematically collected. To evaluate the relationship between maternal and perioperative characteristics and intraoperative blood loss, as well as the predictive value of MRI descriptors on intraoperative blood loss, a multivariable linear regression analysis was performed.

Results

Patients were pre-grouped based on a combined ultrasound-MRI evaluation, with 108 cases (65.9 %) classified as placenta accreta, 47 cases (28.7 %) as placenta increta, and 9 cases (5.4 %) as placenta percreta. The results demonstrated that intraoperative blood loss was positively associated with partial MRI descriptors (F = 9.751, df = 15), such as placenta accreta (OR: 243.33, p = 0.006), cross-border blood vessels that pass through the uterine muscle layer (OR: 297.76, p = 0.012), interruption of hyperechoic uterus-bladder interface (bladder line) (OR: 342.59, p = 0.011), and subplacental hypervascularity (OR: 365.96, p = 0.027).

Conclusions

Preoperative MRI demonstrates promising predictive capabilities in estimating intraoperative blood loss for PAS patients. Pregnant women identified as having a high risk of intraoperative bleeding based on MRI findings should undergo closer antenatal monitoring in late pregnancy, along with more comprehensive preoperative blood preparation, to better ensure maternal and fetal safety.

Cesarean hysterectomy for placenta accreta spectrum: Surgeon specialty-specific assessment

OBJECTIVE

To assess (i) clinical and pregnancy characteristics, (ii) patterns of surgical procedures, and (iii) surgical morbidity associated with cesarean hysterectomy for placenta accreta spectrum based on the specialty of the attending surgeon.

METHODS

The Premier Healthcare Database was queried retrospectively to study patients with placenta accreta spectrum who underwent cesarean delivery and concurrent hysterectomy from 2016 to 2020. Surgical morbidity was assessed with propensity score inverse probability of treatment weighting based on surgeon specialty for hysterectomy: general obstetrician-gynecologists, maternal-fetal medicine specialists, and gynecologic oncologists.

RESULTS

A total of 2240 cesarean hysterectomies were studies. The most common surgeon type was general obstetrician-gynecologist (n = 1534, 68.5%), followed by gynecologic oncologist (n = 532, 23.8%) and maternal-fetal medicine specialist (n = 174, 7.8%). Patients in the gynecologic oncologist group had the highest rate of placenta increta or percreta, followed by the maternal-fetal medicine specialist and general obstetrician-gynecologist groups (43.4%, 39.6%, and 30.6%, P < .001). In a propensity score-weighted model, measured surgical morbidity was similar across the three subspecialty groups, including hemorrhage / blood transfusion (59.4-63.7%), bladder injury (18.3-24.0%), ureteral injury (2.2-4.3%), shock (8.6-10.5%), and coagulopathy (3.3-7.4%) (all, P > .05). Among the cesarean hysterectomy performed by gynecologic oncologist, hemorrhage / transfusion rates remained substantial despite additional surgical procedures: tranexamic acid / ureteral stent (60.4%), tranexamic acid / endo-arterial procedure (76.2%), ureteral stent / endo-arterial procedure (51.6%), and all three procedures (55.4%). Tranexamic acid administration with ureteral stent placement was associated with decreased bladder injury (12.8% vs 23.8-32.2%, P < .001).

CONCLUSION

These data suggest that patient characteristics and surgical procedures related to cesarean hysterectomy for placenta accreta spectrum differ based on surgeon specialty. Gynecologic oncologists appear to manage more severe forms of placenta accreta spectrum. Regardless of surgeon's specialty, surgical morbidity of cesarean hysterectomy for placenta accreta spectrum is significant.

Association between Antenatal Vaginal Bleeding and Adverse Perinatal Outcomes in Placenta Accreta Spectrum

Background and Objectives: Placenta accreta spectrum (PAS) disorders are placental conditions associated with significant maternal morbidity and mortality. While antenatal vaginal bleeding in the setting of PAS is common, the implications of this on overall outcomes remain unknown. Our primary objective was to identify the implications of antenatal vaginal bleeding in the setting of suspected PAS on both maternal and fetal outcomes. Materials and Methods: We performed a case-control study of patients referred to our PAS center of excellence delivered by cesarean hysterectomy from 2012 to 2022. Subsequently, antenatal vaginal bleeding episodes were quantified, and components of maternal morbidity were assessed. A maternal composite of surgical morbidity was utilized, comprised of blood loss ≥ 2 L, transfusion ≥ 4 units of blood, intensive care unit (ICU) admission, and post-operative length of stay ≥ 4 days. Results: During the time period, 135 cases of confirmed PAS were managed by cesarean hysterectomy. A total of 61/135 (45.2%) had at least one episode of bleeding antenatally, and 36 (59%) of these had two or more bleeding episodes. Increasing episodes of antenatal vaginal bleeding were associated with emergent delivery (p < 0.01), delivery at an earlier gestational age (35 vs. 34 vs. 33 weeks, p < 0.01), and increased composite maternal morbidity (76, 84, and 94%, p = 0.03). Conclusions: Antenatal vaginal bleeding in the setting of PAS is associated with increased emergent deliveries, earlier gestational ages, and maternal composite morbidity. This important antenatal event may aid in not only counseling patients but also in the coordination of multidisciplinary teams caring for these complex patients.

Management and Outcome of Women with Placenta Accreta Spectrum and Treatment with Uterine Artery Embolization

BACKGROUND

Placenta accreta spectrum (PAS) disorders are a continuum of placental pathologies with increased risk for hemorrhage, blood transfusion and maternal morbidity. Uterine artery embolization (UAE) is a safe approach to the standardization of complex PAS cases. The aim of this study is to analyze anemia and transfusion rate, outcome and anesthesiological management of women who underwent caesarean delivery with subsequent UAE for the management of PAS.

MATERIAL AND METHODS

This retrospective observational study included all pregnant women admitted to the University Hospital Frankfurt between January 2012 and September 2023, with a diagnosis of PAS who underwent a two-step surgical approach for delivery and placenta removal. Primary procedure included cesarean delivery with subsequent UAE, secondary procedure included placenta removal after a minim of five weeks via curettage or HE. Maternal characteristics, anesthesiological management, complications, anemia rate, blood loss and administration of blood products were analyzed.

RESULTS

In total, 17 women with PAS were included in this study. Of these, 5.9% had placenta increta and 94.1% had placenta percreta. Median blood loss was 300 (200-600) mL during primary procedure and 3600 (450-5500) mL during secondary procedure. In total, 11.8% and 62.5% of women received red blood cell transfusion during the primary and secondary procedures, respectively. After primary procedure, postpartum anemia rate was 76.5%. The HE rate was 64.7%. Regional anesthesia was used in 88.2% during primary procedure.

CONCLUSION

The embolization of the uterine artery for women diagnosed with PAS is safe. Anemia management and the implementation of blood conservation strategies are crucial in women undergoing UAE for the management of PAS.

Placenta previa percreta with surrounding organ involvement: a proposal for management

Placenta accreta spectrum encompasses cases where the placenta is morbidly adherent to the myometrium. Placenta percreta, the most severe form of placenta accreta spectrum (grade 3E), occurs when the placenta invades through the myometrium and possibly into surrounding structures next to the uterine corpus. Maternal morbidity of placenta percreta is high, including severe maternal morbidity in 82.1% and mortality in 1.4% in the recent nationwide U.S. statistics. Although cesarean hysterectomy is commonly performed for patients with placenta accreta spectrum, conservative management is becoming more popular because of reduced morbidity in select cases. Treatment of grade 3E disease involving the urinary bladder, uterine cervix, or parametria is surgically complicated due to the location of the invasive placenta deep in the maternal pelvis. Cesarean hysterectomy in this setting has the potential for catastrophic hemorrhage and significant damage to surrounding organs. We propose a step-by-step schema to evaluate cases of grade 3E disease and determine whether immediate hysterectomy or conservative management, including planned delayed hysterectomy, is the most appropriate treatment option. The approach includes evaluation in the antenatal period with ultrasound and magnetic resonance imaging to determine suspicion for placenta previa percreta with surrounding organ involvement, planned cesarean delivery with a multidisciplinary team including experienced pelvic surgeons such as a gynecologic oncologist, intra-operative assessment including gross surgical field exposure and examination, cystoscopy, and consideration of careful intra-operative transvaginal ultrasound to determine the extent of placental invasion into surrounding organs. This evaluation helps decide the safety of primary cesarean hysterectomy. If safely resectable, additional considerations include intra-operative use of uterine artery embolization combined with tranexamic acid injection in cases at high risk for pelvic hemorrhage and ureteral stent placement. Availability of resuscitative endovascular balloon occlusion of the aorta is ideal. If safe resection is concerned, conservative management including planned delayed hysterectomy at around 4 weeks from cesarean delivery in stable patients is recommended.