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Yu H, Diao J, Fei J, Wang X, Li D, Yin Z. Conservative management or cesarean hysterectomy for placenta accreta spectrum in middle-income countries: A systematic review and meta-analysis. Int J Gynaecol Obstet 2024. [PMID: 38650462 DOI: 10.1002/ijgo.15558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 03/04/2024] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Cesarean hysterectomy is a dominant and effective approach during delivery in patients with placenta accreta spectrum (PAS). However, as hysterectomy results in a loss of fertility, conservative management is an alternative approach. However, management selection may be affected by a country's overall economic level. Thus the preferred treatment for PAS generates controversy in middle-income countries. OBJECTIVES We aimed to compare conservative management and cesarean hysterectomy for managing PAS in middle-income countries. SEARCH STRATEGY China National Knowledge Infrastructure, Wanfang Med Online Databases, Cochrane Library, Ovid MEDLINE, PubMed, Web of Science, EMBASE, clinicaltrials.gov, and Scopus were searched from inception through to October 1, 2022. SELECTION CRITERIA We included studies that evaluated at least one complication comparing conservative management and hysterectomy. All cases were diagnosed with PAS prenatally and intraoperatively. DATA COLLECTION AND ANALYSIS The primary outcomes were blood loss, adjacent organ damage, and the incidence of hysterectomy. Descriptive analyses were conducted for studies that did not meet the meta-analysis criteria. A fixed-effects model was used for studies without heterogeneity and a random-effects model was used for studies with statistical heterogeneity. MAIN RESULTS In all, 11 observational studies were included, with 975 and 625 patients who underwent conservative management and cesarean hysterectomy, respectively. Conservative management was significantly associated with decreased blood loss and lower risks of adjacent organ injury and hysterectomy. Conservative management significantly reduced blood transfusions, hospitalization duration, operative time, intensive care unit admission rates, and infections. There were no significant differences in the risks of coagulopathy, thromboembolism, or reoperation. CONCLUSION Given short-term complications and future fertility preferences for patients, conservative management appears to effectively manage PAS in middle-income countries. Owing to low levels of evidence, high heterogeneity and insufficient long-term follow-up data, further detailed studies are warranted.
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Affiliation(s)
- Huihui Yu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jingyi Diao
- Department of Medical Administration, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jiajia Fei
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xingxing Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Dan Li
- Department of Scientific Research, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zongzhi Yin
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- NHC Key Laboratory of the Study on abnormal gametes and the reproductive tract, Anhui Medical University, Hefei, China
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Sebastian B, Rajesh U, Scott PM, Sayeed S, Robinson GJ, Ettles DF, Shrivastava V, Lakshminarayan R. Prophylactic Uterine Artery Embolization in Placenta Accreta Spectrum-An Active Intervention to Reduce Morbidity and Promote Uterine Preservation. J Vasc Interv Radiol 2023; 34:1922-1928. [PMID: 37517463 DOI: 10.1016/j.jvir.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/11/2023] [Accepted: 07/21/2023] [Indexed: 08/01/2023] Open
Abstract
PURPOSE To evaluate the feasibility and safety of early and proactive involvement of interventional radiology (IR) in the management of placenta accreta spectrum (PAS) by performing the cesarean operation and prophylactic uterine artery embolization in the IR angiography suite as a combined procedure. MATERIALS AND METHODS This study evaluated the effectiveness and safety of prophylactic uterine artery embolization prior to placental separation in cases of antenatally proven or suspected abnormal placentation. Over a 5-year period, 16 consecutive patients with PAS underwent combined IR and obstetric intervention. In all cases, cesarean delivery was performed in the IR angiography suite. Vascular access was obtained prior to surgery with balloon placement into both internal iliac arteries. These balloons were inflated after delivery, followed by uterine artery embolization (14 of 16) if there was evidence of active postpartum bleeding or inability to deliver the placenta. RESULTS There was no fetal or maternal mortality and no significant IR or surgical adverse events. Mean blood loss was 1900 mL. Seven patients (44%) underwent hysterectomy. CONCLUSIONS In patients with PAS, cesarean section in the angiography suite preceded by prophylactic balloon placement and followed by uterine artery embolization was feasible, safe, and effective in preventing massive blood loss, with a 56% uterine sparing rate.
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Affiliation(s)
- Bibin Sebastian
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Uma Rajesh
- Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Paul M Scott
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Saira Sayeed
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Graham J Robinson
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Duncan F Ettles
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Vivek Shrivastava
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Raghuram Lakshminarayan
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom.
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Ghosh A, Lee S, Lim C, Vogelzang RL, Chrisman HB. Placenta Accreta Spectrum: An Overview. Semin Intervent Radiol 2023; 40:467-471. [PMID: 37927512 PMCID: PMC10622243 DOI: 10.1055/s-0043-1772815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Affiliation(s)
- Abheek Ghosh
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sean Lee
- Touro College of Osteopathic Medicine, New York City, New York
| | - Christina Lim
- Creighton University School of Medicine, Omaha, Nebraska
| | - Robert L. Vogelzang
- Division of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Howard B. Chrisman
- Division of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
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4
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Zhao H, Wang Q, Han M, Xiao X. Current state of interventional procedures to treat pernicious placenta previa accompanied by placenta accreta spectrum: A review. Medicine (Baltimore) 2023; 102:e34770. [PMID: 37713901 PMCID: PMC10508584 DOI: 10.1097/md.0000000000034770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 07/25/2023] [Indexed: 09/17/2023] Open
Abstract
Pernicious placenta previa (PPP) accompanied by placenta accreta spectrum (PAS) is a life-threatening placental implantation that causes a variety of complications, including antepartum hemorrhage, postpartum hemorrhage, hemorrhagic shock, preterm birth, and neonatal asphyxia. Along with continuous improvements in medical technology, interventional procedures have been widely used to prevent intraoperative hemorrhage associated with PPP. The commonly used interventional procedures include abdominal aorta clamping, prophylactic balloon occlusion of the internal or common iliac arteries, and uterine artery embolization. The above-mentioned interventional procedures have their respective advantages and disadvantages. The best procedure for different situations continues to be debated considering the complex pattern of blood supply to the uterus in patients with PPP. The specific choice of interventional procedure depends on the clinical situation of the patient with PPP. For grade III PAS, the need for uterine artery embolization is assessed based on blood loss and preoperative hemostatic effect following abdominal aorta clamping. Repair or hysterectomy may be performed following uterine artery embolization if there is a hybrid operating room for grade III PAS patients with extensive sub-serosal penetration of the uterus and repair difficulty. For grade II PAS (shallow placental implantation), prophylactic balloon occlusion may not be necessary before surgery. Uterine artery embolization can be performed in case of postoperative hemorrhage.
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Affiliation(s)
- Hu Zhao
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Qiong Wang
- Department of Obstetrics and Gynecology, Chengdu Women and Children’s Central Hospital, Chengdu, China
| | - Mou Han
- Department of Intervention, Chengdu Women and Children’s Central Hospital, Chengdu, China
| | - Xue Xiao
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, China
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Shahrrava N, Lerner J, Patel N, Sandman Z, Cuevas J, Moretti M, Bahl S. Prophylactic uterine artery embolization in first-trimester cervical pregnancy termination with placenta accreta: A case report. Case Rep Womens Health 2023; 39:e00554. [PMID: 37868259 PMCID: PMC10585350 DOI: 10.1016/j.crwh.2023.e00554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/24/2023] Open
Abstract
The current standard treatment for placenta accreta is a hysterectomy, which carries a significant risk of hemorrhage. Although prophylactic uterine artery embolization (UAE) is established as an effective means of minimizing perioperative bleeding, there are few reports of its use early in pregnancy with invasive placenta. A 45-year-old woman, gravida 6, para 1, at 11 weeks of gestation presented with heavy, painless uterine bleeding and was diagnosed with a spontaneous abortion complicated by cervical pregnancy and placenta accreta. The patient underwent bilateral UAE followed by gravid hysterectomy. This case report encourages prophylactic UAE prior to abdominal hysterectomy in patients with early gestational cervical pregnancy and placenta accreta to minimize blood loss during surgery.
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Affiliation(s)
- Niki Shahrrava
- St. George's University School of Medicine, St. George's, Grenada, West Indies
| | - Jade Lerner
- Rutgers New Jersey Medical School, 185 S Orange Ave, Newark, NJ 07103, United States
| | - Neil Patel
- The Brooklyn Hospital Center, 121 Dekalb Ave, Brooklyn, NY 11201, United States
| | - Zachary Sandman
- The Brooklyn Hospital Center, 121 Dekalb Ave, Brooklyn, NY 11201, United States
| | - Juana Cuevas
- The Brooklyn Hospital Center, 121 Dekalb Ave, Brooklyn, NY 11201, United States
| | - Michael Moretti
- The Brooklyn Hospital Center, 121 Dekalb Ave, Brooklyn, NY 11201, United States
| | - Sumeet Bahl
- The Brooklyn Hospital Center, 121 Dekalb Ave, Brooklyn, NY 11201, United States
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Gatta LA, Weber JM, Gilner JB, Lee PS, Grotegut CA, Herbert KA, Bashir M, Pieper CF, Ronald J, Pabon-Ramos W, Habib AS, Strickland KC, Secord AA, James AH. Transfusion Requirements with Hybrid Management of Placenta Accreta Spectrum Incorporating Targeted Embolization and a Selective Use of Delayed Hysterectomy. Am J Perinatol 2022; 29:1503-1513. [PMID: 35973741 PMCID: PMC10035416 DOI: 10.1055/s-0042-1754321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study compares the number of units of red blood cells (RBCs) transfused in patients with placenta accreta spectrum (PAS) treated with or without a multidisciplinary algorithm that includes placental uterine arterial embolization (P-UAE) and selective use of either immediate or delayed hysterectomy. STUDY DESIGN This is a retrospective study of deliveries conducted at a tertiary care hospital from 2001 to 2018 with pathology-confirmed PAS. Those with previable pregnancies or microinvasive histology were excluded. To improve the equity of comparison, analyses were made separately among scheduled and unscheduled cases, therefore patients were assigned to one of four cohorts as follows: (1) scheduled/per-algorithm, (2) scheduled/off-algorithm, (3) unscheduled/per-algorithm, or (4) unscheduled/off-algorithm. Primary outcomes included RBCs transfused and estimated blood loss (EBL). Secondary outcomes included perioperative complications and disposition. RESULTS Overall, 95 patients were identified, with 87 patients meeting inclusion criteria: 36 treated per-algorithm (30 scheduled and 6 unscheduled) and 51 off-algorithm patients (24 scheduled and 27 unscheduled). Among scheduled deliveries, 9 (30.0%) patients treated per-algorithm received RBCs compared with 20 (83.3%) patients treated off-algorithm (p < 0.01), with a median (interquartile range [IQR]) of 3.0 (2.0, 4.0) and 6.0 (2.5, 7.5) units transfused (p = 0.13), respectively. Among unscheduled deliveries, 5 (83.3%) per-algorithm patients were transfused RBCs compared with 25 (92.6%) off-algorithm patients (p = 0.47) with a median (IQR) of 4.0 (2.0, 6.0) and 8.0 (3.0, 10.0) units transfused (p = 0.47), respectively. Perioperative complications were similar between cohorts. CONCLUSION A multidisciplinary algorithm including P-UAE and selective use of delayed hysterectomy is associated with a lower rate of blood transfusion in scheduled but not unscheduled cases. KEY POINTS · An algorithm with delayed hysterectomy had less transfusion in scheduled, but not unscheduled, cases.. · Over time, more cases were managed per algorithm; among scheduled cases, the transfusion rate and volume transfused decreased.. · There were similar transfusion outcomes among off-algorithm cases, regardless if delivery was scheduled..
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Affiliation(s)
- Luke A. Gatta
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
| | - Jeremy M. Weber
- Department of Biostatistics and Bioinformatics, Duke University Hospital, Durham, North Carolina
| | - Jennifer B. Gilner
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
| | - Paula S. Lee
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Gynecologic Oncology, Duke University Hospital, Durham, North Carolina
| | - Chad A. Grotegut
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
| | | | - Mustafa Bashir
- Department of Radiology and Medicine, Duke University Hospital, Durham, North Carolina
| | - Carl F. Pieper
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
| | - James Ronald
- Department of Radiology and Medicine, Duke University Hospital, Durham, North Carolina
| | - Waleska Pabon-Ramos
- Department of Radiology and Medicine, Duke University Hospital, Durham, North Carolina
| | - Ashraf S. Habib
- Department of Anesthesiology, Duke University Hospital, Durham, North Carolina
| | - Kyle C. Strickland
- Department of Pathology, Duke University Hospital, Durham, North Carolina
| | - Angeles Alvarez Secord
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Gynecologic Oncology, Duke University Hospital, Durham, North Carolina
| | - Andra H. James
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, North Carolina
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7
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A systematic review and meta-analysis of obstetric and maternal outcomes after prior uterine artery embolization. Sci Rep 2021; 11:16914. [PMID: 34413380 PMCID: PMC8377070 DOI: 10.1038/s41598-021-96273-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 08/09/2021] [Indexed: 12/29/2022] Open
Abstract
This study aimed to review the obstetric complications during subsequent pregnancies after uterine artery embolization (UAE) for postpartum hemorrhage (PPH) by exploring the relationship between prior UAE and obstetric complications through a meta-analysis. We conducted a systematic literature review through March 31, 2021, using PubMed, Scopus, and the Cochrane Central Register of Controlled Trials in compliance with the PRISMA guidelines and determined the effect of prior UAE for PPH on the rate of placenta accreta spectrum (PAS), PPH, placenta previa, hysterectomy, fetal growth restriction (FGR), and preterm birth (PTB). Twenty-three retrospective studies (2003–2021) met the inclusion criteria. They included 483 pregnancies with prior UAE and 320,703 pregnancies without prior UAE. The cumulative results of all women with prior UAE indicated that the rates of obstetric complications PAS, hysterectomy, and PPH were 16.3% (34/208), 6.5% (28/432), and 24.0% (115/480), respectively. According to the patient background-matched analysis based on the presence of prior PPH, women with prior UAE were associated with higher rates of PAS (odds ratio [OR] 20.82; 95% confidence interval [CI] 3.27–132.41) and PPH (OR 5.32, 95% CI 1.40–20.16) but not with higher rates of hysterectomy (OR 8.93, 95% CI 0.43–187.06), placenta previa (OR 2.31, 95% CI 0.35–15.22), FGR (OR 7.22, 95% CI 0.28–188.69), or PTB (OR 3.00, 95% CI 0.74–12.14), compared with those who did not undergo prior UAE. Prior UAE for PPH may be a significant risk factor for PAS and PPH during subsequent pregnancies. Therefore, at the time of delivery, clinicians should be more attentive to PAS and PPH when women have undergone prior UAE. Since the number of women included in the patient background-matched study was limited, further investigations are warranted to confirm the results of this study.
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8
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Gatta LA, Lee PS, Gilner JB, Weber JM, Adkins L, Salinaro JR, Habib AS, Pabon-Ramos W, Strickland KC, Ronald J, Erkanli A, Mehdiratta JE, Grotegut CA, Secord AA. Placental uterine artery embolization followed by delayed hysterectomy for placenta percreta: A case series. Gynecol Oncol Rep 2021; 37:100833. [PMID: 34368412 PMCID: PMC8326725 DOI: 10.1016/j.gore.2021.100833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/07/2021] [Accepted: 07/11/2021] [Indexed: 11/20/2022] Open
Abstract
Approximately 23% of women intending delayed hysterectomy for placenta accreta spectrum will have an unscheduled surgery. Targeted embolization for placenta accreta spectrum appears to be a safe and feasible adjunct to surgical management. Placental regression may contribute to discrepancy between intraoperative and pathology diagnoses in delayed hysterectomy. A multidisciplinary approach to placenta accreta spectrum is associated with a lower blood loss.
We describe outcomes of patients with suspected placenta percreta treated with placental uterine artery embolization (P-UAE) followed by delayed hysterectomy. This is a prospective case series of subjects from 2005 to 2018 with suspected placenta percreta who underwent P-UAE at the time of cesarean delivery followed by delayed hysterectomy. Both scheduled and unscheduled surgical cases were included. Maternal characteristics, surgical approaches, intra- and postoperative outcomes were abstracted from medical records. In total, twenty-two subjects were included. Median (interquartile range, IQR) delivery gestational age was 34.6 (31.9, 35.7) weeks, occurring as scheduled in 17 (77.3%) subjects and unscheduled in 5 (22.7%). Delayed hysterectomy was performed as scheduled in 17 (77.3%) subjects at a median (IQR) 40.5 (38.0, 44.0) days after delivery, and 5 (22.7%) subjects had a hysterectomy prior to scheduled date, median (IQR) 27.0 (17.0, 35.0) days after delivery. Indications for the 5 unscheduled hysterectomies included bleeding (n = 3) and suspected endometritis (n = 2). Three subjects (13.6%) received a blood transfusion (1, 3, 3 units) during delivery, and 7 (31.8%) were transfused during delayed hysterectomy (median [IQR] 2 [1,3] units). Three (13.6%) subjects had bladder resection at the time of hysterectomy; 1 (4.5%) had an unintentional cystotomy and 1 (4.5%) had a ureteral injury. P-UAE followed by delayed hysterectomy appears to be a safe and feasible, although appropriate patient selection and close surveillance are imperative, as 22.7% of patients underwent unscheduled hysterectomy.
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Affiliation(s)
- Luke A. Gatta
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, NC, USA
- Corresponding author at: 2608 Erwin Road, Suite 220, Durham, NC 27705, USA.
| | - Paula S. Lee
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University Hospital, Durham, NC, USA
| | - Jennifer B. Gilner
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, NC, USA
| | - Jeremy M. Weber
- Department of Biostatistics & Bioinformatics, Duke University Hospital, Durham, NC, USA
| | - LaMani Adkins
- Department of Obstetrics & Gynecology, Duke University Hospital, Durham, NC, USA
| | - Julia R. Salinaro
- Department of Obstetrics & Gynecology, Duke University Hospital, Durham, NC, USA
| | - Ashraf S. Habib
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Waleska Pabon-Ramos
- Department of Radiology and Medicine, Duke University Hospital, Durham, NC, USA
| | | | - James Ronald
- Department of Radiology and Medicine, Duke University Hospital, Durham, NC, USA
| | - Alaattin Erkanli
- Department of Biostatistics & Bioinformatics, Duke University Hospital, Durham, NC, USA
| | | | - Chad A. Grotegut
- Division of Maternal-Fetal Medicine, Duke University Hospital, Durham, NC, USA
| | - Angeles Alvarez Secord
- Division of Gynecologic Oncology, Duke Cancer Institute, Duke University Hospital, Durham, NC, USA
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9
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Abstract
Since the introduction of uterine artery embolization as a treatment option for symptomatic leiomyomas, there has been a growing interest in expanding the role of interventional radiology (IR) in the evaluation and treatment of obstetrics and gynecology (OBGYN) patients. This review provides an overview of opportunities for collaboration between IR and OBGYN. This can include medically and/or surgically complex patients, efforts to reduce quantitative blood loss, obstetrical emergencies, and consideration of fertility or uterine preservation. Increased collaborative efforts between IR and OBGYN would allow for patients to be fully informed regarding the complete spectrum of surgical and nonsurgical treatment options available to them. The purpose of this review is to foster opportunities to improve outcomes and respect patient values.
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10
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Radaelli T, Ferrari MM, Duiella SF, Gazzola FG, Campoleoni M, Merlini C, Martinetti L, Ambrosini MT, Ossola MW, Nicolini A. Prophylactic intraoperative uterine artery embolization for the management of major placenta previa. J Matern Fetal Neonatal Med 2020; 35:3359-3364. [PMID: 32928020 DOI: 10.1080/14767058.2020.1818218] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE Placenta previa is a major cause of maternal morbidity and mortality, associated to a high risk of peripartum hemorrhage and hysterectomy. We aimed to verify if prophylactic intraoperative uterine artery embolization in patients with placenta previa and at least one additional risk of bleeding (major placenta previa), can reduce hemorrhage, need for blood transfusions, peripartum hysterectomy and maternal morbidity. MATERIALS AND METHODS We enrolled 76 patients with major placenta previa; a specific multidisciplinary protocol was designed for management, including ultrasound evaluation, hospitalization at 34 weeks, antenatal corticosteroids and scheduled cesarean section at 35-36 weeks. 44 patients (control group or CTR) were treated with elective cesarean section, 32 patients (embolized group or EMB) underwent selective catheterization of bilateral uterine arteries before cesarean section and subsequent uterine embolization. In both cases cesarean section was performed by a senior surgeon. RESULTS Significant differences were found in term of intraoperative blood loss (CTR: 1431 ml; EMB: 693 ml); despite an high percentage of CTR patients had a bleeding greater than 1000 ml (56%), the need for blood transfusion was not significantly different between the two groups. Time of surgery was higher in the EMB group, considering that embolization procedure required approximatively 30 min. Three patients from the CTR group needed hysterectomy and ICU admission, compared to none in the EMB group. Duration of hospitalization and neonatal outcome were similar. Uterine embolization was not related to any short or long-term complications; return to normal menses and preservation of fertility were confirmed at follow up. CONCLUSIONS Our results are promising, although we believe that a major contribution is referable to the multidisciplinary approach rather than the procedure itself. Nevertheless, we demonstrated the feasibility and safety of preventive uterine embolization in patients with placenta previa; in order to establish its prophylactic role in the prevention of peripartum hemorrhage, randomized trial should be carried out, on a larger population.
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Affiliation(s)
- Tatjana Radaelli
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Maria M Ferrari
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Silvia F Duiella
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Federica G Gazzola
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Mauro Campoleoni
- Department of Medical Physics, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Claudia Merlini
- Department of Anesthesiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Laura Martinetti
- Department of Radiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Maria T Ambrosini
- Department of Anesthesiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Manuela W Ossola
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Antonio Nicolini
- Department of Radiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Milan, Italy
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11
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Mori K, Obata-Yasuoka M, Saida T, Nishida K, Takahashi H, Hosokawa Y, Takei Y, Tsumagari A, Yoshida M, Kimura Y, Abe T, Tsukuda Y, Harada S, Kojima T, Minami M. Pelvic arterial embolisation with cyanoacrylate during caesarean hysterectomy for placenta accreta. MINIM INVASIV THER 2020; 31:396-403. [PMID: 32907432 DOI: 10.1080/13645706.2020.1811730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To compare n-butyl cyanoacrylate (NBCA) and gelatine sponge (GS) as embolic materials for prophylactic pelvic arterial embolisation during caesarean hysterectomy for placenta accreta spectrum (PAS). MATERIAL AND METHODS This retrospective study comprised 12 women (age range, 23-42 years; mean, 34.1 years) who underwent caesarean hysterectomy for PAS. Following caesarean delivery, bilateral uterine and non-uterine parasitic arteries were embolized with GS in the first four cases (GS group) and primarily with NBCA mixed with iodized oil in the subsequent eight cases (NBCA group). Procedure time for embolisation and hysterectomy and total blood loss were compared between the two groups using Welch's t-test. RESULTS Although procedure time for embolisation tended to be longer in the NBCA group than in the GS group (111 ± 47 min versus 71 ± 32 min, p=.11), that for hysterectomy was significantly reduced in the NBCA group when compared to the GS group (158 ± 42 min versus 236 ± 39 min, p=.02). Total blood loss was significantly lower in the NBCA group than in the GS group (1375 ± 565 mL versus 2668 ± 587 mL, p=.01). CONCLUSION Procedure time for hysterectomy and total blood loss during caesarean hysterectomy can be reduced by using NBCA instead of GS in prophylactic pelvic arterial embolisation for PAS.
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Affiliation(s)
- Kensaku Mori
- Department of Radiology, University of Tsukuba, Tsukuba, Japan
| | - Mana Obata-Yasuoka
- Department of Obstetrics and Gynecology, University of Tsukuba, Tsukuba, Japan
| | - Tsukasa Saida
- Department of Radiology, University of Tsukuba, Tsukuba, Japan
| | - Keiko Nishida
- Department of Obstetrics and Gynecology, University of Tsukuba, Tsukuba, Japan
| | - Hiroaki Takahashi
- Department of Radiology, Mayo Clinic Rochester, Rochester, United States
| | - Yoshihiko Hosokawa
- Department of Obstetrics and Gynecology, University of Tsukuba, Tsukuba, Japan
| | - Yohei Takei
- Department of Radiology, University of Tsukuba, Tsukuba, Japan
| | - Ayako Tsumagari
- Department of Obstetrics and Gynecology, University of Tsukuba, Tsukuba, Japan
| | - Miki Yoshida
- Department of Radiology, University of Tsukuba, Tsukuba, Japan
| | - Yutaku Kimura
- Department of Obstetrics and Gynecology, University of Tsukuba, Tsukuba, Japan
| | - Tetsuya Abe
- Department of Radiology, University of Tsukuba, Tsukuba, Japan
| | - Yoko Tsukuda
- Department of Obstetrics and Gynecology, University of Tsukuba, Tsukuba, Japan
| | - Shu Harada
- Department of Radiology, University of Tsukuba, Tsukuba, Japan
| | - Takahiro Kojima
- Department of Urology, University of Tsukuba, Tsukuba, Japan
| | - Manabu Minami
- Department of Radiology, University of Tsukuba, Tsukuba, Japan
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12
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High prevalence of intrapelvic parasitic arteries in patients with placenta accreta spectrum: A case-control study using unenhanced magnetic resonance angiography. Clin Imaging 2020; 63:50-56. [DOI: 10.1016/j.clinimag.2020.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/25/2020] [Accepted: 02/25/2020] [Indexed: 11/23/2022]
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13
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Soyer P, Barat M, Loffroy R, Barral M, Dautry R, Vidal V, Pellerin O, Cornelis F, Kohi MP, Dohan A. The role of interventional radiology in the management of abnormally invasive placenta: a systematic review of current evidences. Quant Imaging Med Surg 2020; 10:1370-1391. [PMID: 32550143 DOI: 10.21037/qims-20-548] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Philippe Soyer
- Department of Radiology, Hopital Cochin, Assistance Publique - Hopitaux de Paris, Paris, France.,Université de Paris, Descartes-Paris 5, Paris, France
| | - Maxime Barat
- Department of Radiology, Hopital Cochin, Assistance Publique - Hopitaux de Paris, Paris, France.,Université de Paris, Descartes-Paris 5, Paris, France
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, François-Mitterrand University Hospital, UFR des Sciences de Santé, Université de Bourgogne/Franche-Comté, Dijon, France
| | - Matthias Barral
- Department of Radiology, Hopital Tenon, Assistance Publique - Hopitaux de Paris, Paris, France.,Sorbonne University, Paris, France
| | - Raphael Dautry
- Department of Radiology, Hopital Cochin, Assistance Publique - Hopitaux de Paris, Paris, France
| | - Vincent Vidal
- Interventional Radiology Section, Department of Medical Imaging, University Hospital Timone APHM, LIIE, CERIMED Aix Marseille Univ, Marseille, France
| | - Olivier Pellerin
- Université de Paris, Descartes-Paris 5, Paris, France.,Department of Interventional Radiology, Hopital Européen Georges Pompidou, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Francois Cornelis
- Department of Radiology, Hopital Tenon, Assistance Publique - Hopitaux de Paris, Paris, France
| | - Maureen P Kohi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Anthony Dohan
- Department of Radiology, Hopital Cochin, Assistance Publique - Hopitaux de Paris, Paris, France.,Université de Paris, Descartes-Paris 5, Paris, France
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14
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Mohr-Sasson A, Hochman R, Anteby M, Spira M, Castel E, Hendler I, Mazaki-Tovi S, Sivan E. Cesarean delivery with and without uterine artery embolization for the management of placenta accreta spectrum disorder-A comparative study. Acta Obstet Gynecol Scand 2020; 99:1374-1380. [PMID: 32282925 DOI: 10.1111/aogs.13868] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 04/02/2020] [Accepted: 04/07/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The aim of this study is to compare immediate and long-term obstetrical outcomes of patients who underwent cesarean delivery with and without uterine artery embolization (UAE) for the management of placenta accreta spectrum disorder. MATERIAL AND METHODS A retrospective case control study including all pregnant women admitted to a single tertiary medical center between December 2001 and May 2018 with a diagnosis of placenta accreta spectrum disorder, who underwent cesarean delivery with and without UAE. Groups were compared for maternal characteristics, operative management, postoperative complication rate and long-term outcomes. Follow up on future obstetrical outcomes was conducted via telephone questionnaire. Non-parametric statistics were used. RESULTS During the study period, 272 women met the inclusion criteria: 64 (23.53%) and 208 (76.47%) underwent preservative cesarean section with and without UAE, respectively. UAE procedure was associated with a longer operative time (82.5 [68-110] vs 50.5 [39-77] minutes; P = .001), and higher blood loss (2000 (1500-3000) vs 1000 (600-2000) mL; P = .001). Hysterectomy rate was comparable between the groups (9 [14%] vs 35 [16.82%]; P = .88); however, multivariate logistic regression analysis found UAE to be an independent factor associated with lower hysterectomy rate (P = .02). Postoperative complications were more frequent in the UAE group. Follow up was achieved in 29 (59.18%) and 72 (51.79%) of the women with and without UAE, respectively (P = .36). No differences were found in rate of abortions, pregnancy and deliveries between the groups. CONCLUSIONS Cesarean delivery using UAE in placenta accreta spectrum disorder is associated with a higher rate of operative and postoperative complications. Nevertheless, in cases of severe adherence of the placenta, embolization reduces the need for hysterectomy, allowing future fertility.
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Affiliation(s)
- Aya Mohr-Sasson
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Roni Hochman
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Matan Anteby
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Maya Spira
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Elias Castel
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Israel Hendler
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shali Mazaki-Tovi
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eyal Sivan
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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15
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Weston M, Soyer P, Barral M, Dohan A, Pierre S, Rabei R, Garcia-Reyes K, Kohi MP. Role of Interventional Procedures in Obstetrics and Gynecology. Radiol Clin North Am 2020; 58:445-462. [PMID: 32044017 DOI: 10.1016/j.rcl.2019.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Radiological guided intervention techniques are discussed in obstetric and gynecologic patients. Fallopian tube recanalization, postpartum hemorrhage control, techniques of treating uterine leiomyomas, pelvic congestion treatment, and the use of percutaneous and transvaginal ultrasonography-guided aspirations and biopsy are covered. These techniques use basic radiological interventional skills and show how they are adapted for use in the female pelvis.
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Affiliation(s)
- Michael Weston
- Department of Radiology, St James's University Hospital, Leeds LS9 7TF, UK.
| | - Philippe Soyer
- Department of Radiology, Service de Radiologie A, Hopital Cochin, APHP & Université de Paris-Descartes Paris 5, 27 rue du Faubourg Saint-Jacques, Paris 75014, France
| | - Matthias Barral
- Department of Radiology, Service de Radiologie A, Hopital Cochin, APHP & Université de Paris-Descartes Paris 5, 27 rue du Faubourg Saint-Jacques, Paris 75014, France
| | - Anthony Dohan
- Department of Radiology, Service de Radiologie A, Hopital Cochin, APHP & Université de Paris-Descartes Paris 5, 27 rue du Faubourg Saint-Jacques, Paris 75014, France
| | - Sacha Pierre
- Department of Radiology, St James's University Hospital, Leeds LS9 7TF, UK
| | - Rana Rabei
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, M-361, San Francisco, CA 94143, USA
| | - Kirema Garcia-Reyes
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, M-361, San Francisco, CA 94143, USA
| | - Maureen P Kohi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, M-361, San Francisco, CA 94143, USA
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16
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Yuan Q, Jin Y, Chen L, Ling L, Bai XM. Prophylactic uterine artery embolization during cesarean delivery for placenta previa complicated by placenta accreta. Int J Gynaecol Obstet 2019; 149:43-47. [PMID: 31778209 DOI: 10.1002/ijgo.13072] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 10/02/2019] [Accepted: 11/26/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of prophylactic uterine artery embolization (UAE) during cesarean delivery for women with placenta previa complicated by placenta accreta. METHODS A retrospective analysis of women with placenta previa admitted to The Second Affiliated Hospital of Soochow University, Suzhou, China, for elective cesarean between February 2003 and July 2016. Postpartum estimated blood loss, blood transfusion, hysterectomy, disseminated intravascular coagulation (DIC) incidence, intensive care unit (ICU) duration, and postoperative stay were compared between control women who underwent cesarean delivery only and women who underwent prophylactic intraoperative UAE during cesarean. RESULTS There were 28 and 26 women in the UAE and control group, respectively. There were no differences in hysterectomy incidence (P=0.291), or duration of ICU stay (P=0.085), or postoperative hospitalization (P=0.668) between the groups; however, the incidence of DIC was lower in the UAE group (P=0.035). Mean estimated blood loss (P=0.018) and blood transfusion (P=0.011) were also lower in the UAE group. No serious complications were associated with the endovascular procedures. CONCLUSION Prophylactic intraoperative UAE seemed to effectively reduce blood loss, need for blood transfusion, and incidence of DIC among women with placenta previa complicated by placenta accreta.
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Affiliation(s)
- Qiang Yuan
- Department of Interventional Radiology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Yong Jin
- Department of Interventional Radiology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Li Chen
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Li Ling
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xu-Ming Bai
- Department of Interventional Radiology, The Second Affiliated Hospital of Soochow University, Suzhou, China
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17
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Tong A, Zhao F, Liu P, Zhao X, Qi X. Management of postpartum pulmonary embolism combined with retained placenta accreta: A case report. Medicine (Baltimore) 2019; 98:e17219. [PMID: 31567979 PMCID: PMC6756620 DOI: 10.1097/md.0000000000017219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RATIONALE Retained placenta accreta is an increasing obstetric problem in recent years, and pulmonary embolism (PE) during pregnancy and the postpartum period is a vital condition, but lack of standard therapy guidelines. This report describes a case of postpartum PE combined with retained placenta accreta. PATIENT CONCERNS A 27-year-old woman presenting with fever and dyspnea after delivery was admitted to our hospital with retained placenta accreta. DIAGNOSES The patient was diagnosed with the infection, postpartum PE, and residual placenta. INTERVENTIONS The antibiotics and low molecular weight heparin were initially started to cure the infection and control PE. Mifepristone was then used to promote the necrosis of residual placenta while long-term use of warfarin was served as continuous anticoagulant therapy. Hysteroscopic resection of retained placenta was not performed until thrombi had been almost disappeared after more than 2 months of anticoagulation therapy. OUTCOMES The patient's menstruation returned to normal within several weeks after hysteroscopic resection and she completely recovered from PE after 3 months of anticoagulant therapy. LESSONS Treatment of retained placenta accreta can be postponed when encountering complicated cases, such as postpartum PE. PE in perinatal stage can be managed referring to nonmaternal PE.
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Affiliation(s)
- An Tong
- Department of Gynecology and Obstetrics, Development and Related Diseases of Women and Children Key Laboratory of Sichuan Province, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education
| | - Fumin Zhao
- Department of Radiology, West China Second Hospital, Sichuan University, Chengdu, P.R. China
| | - Ping Liu
- Department of Gynecology and Obstetrics, Development and Related Diseases of Women and Children Key Laboratory of Sichuan Province, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education
| | - Xia Zhao
- Department of Gynecology and Obstetrics, Development and Related Diseases of Women and Children Key Laboratory of Sichuan Province, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education
| | - Xiaorong Qi
- Department of Gynecology and Obstetrics, Development and Related Diseases of Women and Children Key Laboratory of Sichuan Province, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education
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18
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19
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Wang M, Ballah D, Wade A, Taylor AG, Rizzuto G, Li B, Lucero J, Chen LM, Kohi MP. Uterine Artery Embolization following Cesarean Delivery but prior to Hysterectomy in the Management of Patients with Invasive Placenta. J Vasc Interv Radiol 2019; 30:687-691. [PMID: 30922797 PMCID: PMC10468213 DOI: 10.1016/j.jvir.2018.12.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 12/04/2018] [Accepted: 12/06/2018] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To evaluate outcomes of patients with placenta accreta spectrum (PAS) disorders who underwent uterine artery embolization (UAE) following cesarean delivery but before hysterectomy. MATERIALS AND METHODS A retrospective review of patients with PAS treated with cesarean-hysterectomy (C-hyst) was performed. Patients in the UAE group underwent UAE after cesarean delivery but before hysterectomy; patients in the control group underwent C-hyst alone. Estimated blood loss (EBL), transfusion requirements, length of intensive care unit (ICU) stay, and adverse events were evaluated. RESULTS The study included 31 patients, 7 in the UAE group and 24 in the control group. Median EBL, transfusion requirements, and length of ICU stay in the UAE group compared with control group were 1,500 mL (range, 500-2,000 mL) vs 2,000 mL (range, 1,000-4,500 mL) (P = .04), 150 mL (range, 0-650 mL) vs 550 mL (range, 0-3,125 mL) (P = .10), and 0 d (range, 0-1 d) vs 0.5 d (range, 0-2 d) (P = .07). All patients in the UAE group had placenta increta; patients in the control group had placenta accreta (29%), increta (54%), and percreta (17%) (P = .10). Subgroup analysis of patients with placenta increta demonstrated that the UAE group had a significant decrease in median EBL (P = .004), transfusion requirements (P = .009), and length of ICU stay (P = .04). No adverse events following UAE were noted. CONCLUSIONS UAE following cesarean delivery but before hysterectomy in patients with placenta increta appears to be safe and effective in decreasing EBL, transfusion requirements, and length of ICU stay compared with C-hyst alone.
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Affiliation(s)
- Melinda Wang
- Weill Cornell Medical College, New York, New York
| | - Deddeh Ballah
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Alana Wade
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Andrew G Taylor
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Gabrielle Rizzuto
- Department of Pathology and Laboratory Medicine, University of California, San Francisco, San Francisco, California
| | - Benjamin Li
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - Jennifer Lucero
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
| | - Lee-May Chen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - Maureen P Kohi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California.
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20
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Meller CH, Garcia-Monaco RD, Izbizky G, Lamm M, Jaunarena J, Peralta O, Otaño L. Non-conservative Management of Placenta Accreta Spectrum in the Hybrid Operating Room: A Retrospective Cohort Study. Cardiovasc Intervent Radiol 2018; 42:365-370. [DOI: 10.1007/s00270-018-2113-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 11/01/2018] [Indexed: 11/24/2022]
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21
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Kohi MP, Poder L, Thiet MP, Kerlan RK. Uterine Artery Embolization prior to Gravid Hysterectomy in the Setting of Invasive Placenta. J Vasc Interv Radiol 2018; 28:1295-1297. [PMID: 28841941 DOI: 10.1016/j.jvir.2017.03.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/08/2017] [Accepted: 03/20/2017] [Indexed: 11/19/2022] Open
Affiliation(s)
- Maureen P Kohi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Ave., M-361, San Francisco, CA 94143
| | - Liina Poder
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Ave., M-361, San Francisco, CA 94143
| | - Mari-Paule Thiet
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 505 Parnassus Ave., M-361, San Francisco, CA 94143
| | - Robert K Kerlan
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Ave., M-361, San Francisco, CA 94143
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22
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Chen C, Lee SM, Kim JW, Shin JH. Recent Update of Embolization of Postpartum Hemorrhage. Korean J Radiol 2018; 19:585-596. [PMID: 29962865 PMCID: PMC6005941 DOI: 10.3348/kjr.2018.19.4.585] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 12/06/2017] [Indexed: 12/14/2022] Open
Abstract
Postpartum hemorrhage (PPH) is a life-threatening condition and remains a leading cause of maternal mortality. Transcatheter arterial embolization (TAE) is an effective therapeutic strategy for PPH with the advantages of fast speed, repeatability, and the possibility of fertility preservation. We reviewed the vascular anatomy relevant to PPH, the practical details of TAE emphasizing the timing of embolization, and various clinical conditions of PPH according to a recent literature review.
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Affiliation(s)
- Chengshi Chen
- Department of Radiology, Henan Cancer Hospital, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China.,Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Sang Min Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Jong Woo Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
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23
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Outcomes of Planned Compared With Urgent Deliveries Using a Multidisciplinary Team Approach for Morbidly Adherent Placenta. Obstet Gynecol 2018; 131:1164-1165. [DOI: 10.1097/aog.0000000000002666] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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Kaufman C, Tadros A. Endovascular Interventions for the Morbidly Adherent Placenta. J Clin Med 2018; 7:jcm7050092. [PMID: 29723954 PMCID: PMC5977131 DOI: 10.3390/jcm7050092] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 04/20/2018] [Accepted: 04/23/2018] [Indexed: 11/30/2022] Open
Abstract
Morbidly adherent placentas are a spectrum of abnormalities ranging from placental invasion of the myometrium to invasion past the myometrium and muscular layers into adjacent structures. This entity is becoming more prevalent recently with increased number of cesarean deliveries. Given the high risk of morbidity and mortality, this was traditionally treated with pre-term planned cesarean hysterectomy. However, recently, uterine preservation techniques have been implemented for those women wishing to preserve future fertility or their uterus. Early identification is crucial as studies have shown better outcomes for women treated at tertiary care facilities by a dedicated multidisciplinary team. Interventional radiologists are frequently included in the care of these patients as there are several different endovascular techniques which can be implemented to decrease morbidity in these patients both in conjunction with cesarean hysterectomy and in the setting of uterine preservation. This article will review the spectrum of morbidly adherent placentas, imaging, as well as the surgical and endovascular interventions implemented in the care of these complex patients.
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Affiliation(s)
- Claire Kaufman
- Department of Radiology, University of Utah, Salt Lake City, UT 84112, USA.
| | - Anthony Tadros
- Department of Radiology, University of California San Diego, San Diego, CA 92103, USA.
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25
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Endovascular interventional modalities for haemorrhage control in abnormal placental implantation deliveries: a systematic review and meta-analysis. Eur Radiol 2018; 28:2713-2726. [DOI: 10.1007/s00330-017-5222-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/20/2017] [Accepted: 11/28/2017] [Indexed: 11/27/2022]
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26
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Picel AC, Wolford B, Cochran RL, Ramos GA, Roberts AC. Prophylactic Internal Iliac Artery Occlusion Balloon Placement to Reduce Operative Blood Loss in Patients with Invasive Placenta. J Vasc Interv Radiol 2017; 29:219-224. [PMID: 29128157 DOI: 10.1016/j.jvir.2017.08.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/01/2017] [Accepted: 08/15/2017] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To evaluate efficacy and safety of prophylactic internal iliac occlusion balloon placement before cesarean hysterectomy for invasive placenta. MATERIAL AND METHODS A retrospective analysis was performed of patients with invasive placenta treated with and without occlusion balloon placement. Preoperative occlusion balloons were placed in 90 patients; 61 patients were treated without balloon placement (control group). Baseline demographics, including patient age, gestational age at delivery, gravidity, parity, and number of previous cesarean sections, were not significantly different (P > .05). Of the balloon placement group, 56% had placenta percreta compared with 25% in the control group (P < .001), and 83% had placenta previa compared with 66% in the control group (P = .012). RESULTS Median blood loss was 2 L (range, 1.5-2.5 L) in the balloon placement group versus 2.5 L (range, 2-4 L) in the control group (P = .002). Patients with occlusion balloons were transfused a median of 2 U (range, 0-5 U) of packed red blood cells versus 5 U (range, 2-8 U) in patients in the control group (P = .002). In the balloon placement group, 34% had large volume blood loss > 2,500 mL versus 61% in the control group (P = .001), and 21% required blood transfusion > 6 U versus 44% in the control group (P = .002). Eight complications (9%) were attributed to occlusion balloon placement. CONCLUSIONS Prophylactic internal iliac artery occlusion balloon placement reduces operative blood loss and transfusion requirements in patients undergoing hysterectomy for invasive placenta.
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Affiliation(s)
- Andrew C Picel
- Department of Radiology, University of California San Diego, 200 West Arbor Drive, San Diego, CA 92130-8756.
| | - Brent Wolford
- Department of Radiology, University of California San Diego, 200 West Arbor Drive, San Diego, CA 92130-8756
| | - Rory L Cochran
- Department of Radiology, University of California San Diego, 200 West Arbor Drive, San Diego, CA 92130-8756
| | - Gladys A Ramos
- Department of Reproductive Medicine, University of California San Diego, 200 West Arbor Drive, San Diego, CA 92130-8756
| | - Anne C Roberts
- Department of Radiology, University of California San Diego, 200 West Arbor Drive, San Diego, CA 92130-8756
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27
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Juusela AL, Gimovsky ML. Intraoperative Hemorrhage Requiring Emergent Hysterectomy: Failed Conservative Management of a Cervical Placenta Accreta. J Gynecol Surg 2017. [DOI: 10.1089/gyn.2017.0002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Predelivery uterine arteries embolization in patients affected by placental implant anomalies. Radiol Med 2017; 123:71-78. [PMID: 28756581 DOI: 10.1007/s11547-017-0796-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 07/23/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE The aim of this study is to report on a single center experience of managing patients affected by placenta previa major and/or accretism by embolizing uterine arteries immediately before the cesarean delivery to reduce blood loss and secondary the rate of hysterectomies. MATERIALS AND METHODS Sixty-nine patients have been prospectively enrolled. Inclusion criteria were radiological diagnosis of placenta anomalies and risk factors for peri/postpartum hemorrhage. The delivery was electively scheduled between the 35th week and the 36th week of pregnancy. The embolization procedure was performed in the gynecological operating room with a mobile C-arm by injecting calibrated microparticles 500-700 μm. A contrast-enhanced MRI was acquired in a subgroup of 10 patients 6 months after the delivery to evaluate the uterine wall status. RESULTS Hysterectomy had been performed in 43.5%; 52.2% did not require blood transfusions; 1.2 blood units per patient had been meanly transfused. The mean fluoroscopy beam-on time was 195 s per patient. The mean uterine dose was 26.75 mGy. No pH anomalies were measured from the umbilical cord blood; the Apgar score at 5 min was ≥8. The analysis of the neuro-developmental milestones showed normal cognitive development in all children at 6 months. The uterine wall enhancement evaluated with contrast-enhanced MRI 6 months after the embolization procedure showed preserved myometrial perfusion without area of necrosis. CONCLUSIONS In this series of patients, the predelivery uterine arteries' embolization was a safe and effective procedure; this may represent a technical alternative that interventional radiologists can consider when facing this challenging scenario.
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Abstract
Hysterectomy at the time of an obstetric delivery or postpartum is an uncommon time to perform one of the most common gynecologic procedures. Hysterectomy associated with pregnancy is often unplanned and undesired. Postpartum complications associated with the need for hysterectomy carry significant risks, which pose challenges for mother-infant bonding and can signify an unexpected end to fertility. The most common indication for hysterectomy is postpartum hemorrhage. Postpartum hemorrhage is caused by uterine atony, genital tract laceration, uterine rupture, invasive placentation, infection, or coagulopathy. Multidisciplinary teams improve outcomes and are capable of managing complex medical and surgical complications that occur postpartum.
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Affiliation(s)
- Christopher Kevin Huls
- Department of Obstetrics and Gynecology, Banner University Medical Center, 1111 E McDowell, Phoenix, AZ, USA; Department of Obstetrics and Gynecology, University of Arizona, Phoenix, AZ, USA; Phoenix Perinatal Associates of Mednax, Inc., 1840 South Stapley Drive, Suite 131, Mesa, AZ 85204, USA.
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Ko HK, Shin JH, Ko GY, Gwon DI, Kim JH, Han K, Lee SW. Efficacy of Prophylactic Uterine Artery Embolization before Obstetrical Procedures with High Risk for Massive Bleeding. Korean J Radiol 2017; 18:355-360. [PMID: 28246515 PMCID: PMC5313523 DOI: 10.3348/kjr.2017.18.2.355] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 10/20/2016] [Indexed: 11/15/2022] Open
Abstract
Objective To evaluate the safety and efficacy of prophylactic uterine artery embolization (UAE) before obstetrical procedures with high risk for massive bleeding. Materials and Methods A retrospective review of 29 female patients who underwent prophylactic UAE from June 2009 to February 2014 was performed. Indications for prophylactic UAE were as follows: dilatation and curettage (D&C) associated with ectopic pregnancy (cesarean scar pregnancy, n = 9; cervical pregnancy, n = 6), termination of pregnancy with abnormal placentation (placenta previa, n = 8), D&C for retained placenta with vascularity (n = 5), and D&C for suspected gestational trophoblastic disease (n = 1). Their medical records were reviewed to evaluate the safety and efficacy of UAE. Results All women received successful bilateral prophylactic UAE followed by D&C with preservation of the uterus. In all patients, UAE followed by obstetrical procedure prevented significant vaginal bleeding on gynecologic examination. There was no major complication related to UAE. Vaginal spotting continued for 3 months in three cases. Although oligomenorrhea continued for six months in one patient, normal menstruation resumed in all patients afterwards. During follow-up, four had subsequent successful natural pregnancies. Spontaneous abortion occurred in one of them during the first trimester. Conclusion Prophylactic UAE before an obstetrical procedure in patients with high risk of bleeding or symptomatic bleeding may be a safe and effective way to manage or prevent serious bleeding, especially for women who wish to preserve their fertility.
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Affiliation(s)
- Heung Kyu Ko
- Department of Radiology, Asan Medical Center, Ulsan University College of Medicine, Seoul 05505, Korea
| | - Ji Hoon Shin
- Department of Radiology, Asan Medical Center, Ulsan University College of Medicine, Seoul 05505, Korea
| | - Gi Young Ko
- Department of Radiology, Asan Medical Center, Ulsan University College of Medicine, Seoul 05505, Korea
| | - Dong Il Gwon
- Department of Radiology, Asan Medical Center, Ulsan University College of Medicine, Seoul 05505, Korea
| | - Jin Hyung Kim
- Department of Radiology, Asan Medical Center, Ulsan University College of Medicine, Seoul 05505, Korea
| | - Kichang Han
- Department of Radiology, Asan Medical Center, Ulsan University College of Medicine, Seoul 05505, Korea
| | - Shin-Wha Lee
- Department of Obstetrics and Gynecology, Asan Medical Center, Ulsan University College of Medicine, Seoul 05505, Korea
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Niola R, Giurazza F, Nazzaro G, Silvestre M, Nasti G, Di Pasquale MA, Albano G, Valentino L, Sirimarco F, Maglione F. Uterine Artery Embolization before Delivery to Prevent Postpartum Hemorrhage. J Vasc Interv Radiol 2016; 27:376-82. [PMID: 26806693 DOI: 10.1016/j.jvir.2015.12.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 12/01/2015] [Accepted: 12/07/2015] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To assess the safety and outcomes of uterine artery embolization (UAE) performed before delivery in patients with placental implant anomalies at high risk for peripartum or postpartum hemorrhage. MATERIALS AND METHODS From January 2013 to January 2015, 50 consecutive patients with placental implant anomalies at 35-36 weeks of pregnancy were recruited. UAE was performed superselectively by injecting reabsorbable pledgets. We applied 5 dosimeters to patients' backs to measure the uterine radiation dose, considered to be the same radiation dose that the fetus received. Newborns were assessed immediately after birth and at 6-month follow-up. RESULTS All procedures were technically successful. Of patients, 64% did not require transfusions. Mean blood units transfused was 0.7 U (range, 0-4 U). No patient was transferred to the intensive care unit. Hysterectomy was performed in 13 patients (26%). Mean fluoroscopy operative time was 3 minutes 42 seconds (range, 1 min 21 s-6 min 58 s), and mean uterine radiation dose was 15.61 mGy (range, 8.15-38.18 mGy). Mean time between embolization and delivery was 6 minutes 4 seconds (range, 4 min 18 s-8 min 12 s). The 1-minute and 5-minute Apgar scores were 8-9 in all newborns; 8 newborns were lost to follow-up at 6 months. A normal cognitive outcome was evident in all 42 children studied. CONCLUSIONS UAE before delivery appeared to reduce bleeding during cesarean sections in this consecutive series of patients with placental implant anomalies. In the hands of experienced staff, radiation dose to the fetus was minimal.
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Affiliation(s)
- Raffaella Niola
- Interventional Radiology Department, Gynecology Department, Physics Department, and Neonatology Department, A.O.R.N. Antonio Cardarelli, Naples, Italy
| | - Francesco Giurazza
- Interventional Radiology Department, Gynecology Department, Physics Department, and Neonatology Department, A.O.R.N. Antonio Cardarelli, Naples, Italy; Radiology Department, Università Campus Bio-Medico di Roma, Via Alvaro Del Portillo 200, Rome 00198, Italy.
| | - Giuseppe Nazzaro
- Interventional Radiology Department, Gynecology Department, Physics Department, and Neonatology Department, A.O.R.N. Antonio Cardarelli, Naples, Italy
| | - Mattia Silvestre
- Interventional Radiology Department, Gynecology Department, Physics Department, and Neonatology Department, A.O.R.N. Antonio Cardarelli, Naples, Italy; Radiology Department, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Gennaro Nasti
- Interventional Radiology Department, Gynecology Department, Physics Department, and Neonatology Department, A.O.R.N. Antonio Cardarelli, Naples, Italy
| | - Maria Antonella Di Pasquale
- Interventional Radiology Department, Gynecology Department, Physics Department, and Neonatology Department, A.O.R.N. Antonio Cardarelli, Naples, Italy
| | - Giuseppe Albano
- Interventional Radiology Department, Gynecology Department, Physics Department, and Neonatology Department, A.O.R.N. Antonio Cardarelli, Naples, Italy
| | - Liliana Valentino
- Interventional Radiology Department, Gynecology Department, Physics Department, and Neonatology Department, A.O.R.N. Antonio Cardarelli, Naples, Italy
| | - Fabio Sirimarco
- Interventional Radiology Department, Gynecology Department, Physics Department, and Neonatology Department, A.O.R.N. Antonio Cardarelli, Naples, Italy
| | - Franco Maglione
- Interventional Radiology Department, Gynecology Department, Physics Department, and Neonatology Department, A.O.R.N. Antonio Cardarelli, Naples, Italy
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Wang QM, Liu HL, Dang Q. Acute trophoblastic pulmonary embolism during conservative treatment of placenta accreta: case report and review of literature. Eur J Med Res 2015; 20:91. [PMID: 26572917 PMCID: PMC4647333 DOI: 10.1186/s40001-015-0185-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 10/15/2015] [Indexed: 11/10/2022] Open
Abstract
Background Placenta accreta is a rare obstetric condition but can lead to life-threatening complications that was mainly diagnosed in the third trimester. We present a case of acute trophoblastic pulmonary embolism (PE) during conservative treatment of placenta accreta. Case presentation A 24-year-old patient who delivered vaginally at 40+4 weeks gestation. The placenta was retained despite the use of oxytocics and attempts of manual removal. Conservative management including uterine arteria embolism, hysteroscopic resection and mifepristone was used but failed and finally the patient died from acute trophoblastic PE and allergic shock when infusing povidone-iodine into her uterine cavity. Conclusion Although conservative treatment of placenta accreta can retain reproductive potential and trophoblastic PE is rare, clinicians should consider hysterectomy when conservative treatment failed and infusion of povidone-iodine or other liquid into the cavity should be prohibited.
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Affiliation(s)
- Qiu-Ming Wang
- Department of Gynecology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China.
| | - Hui-Li Liu
- Department of Gynecology, Henan Provincial People's Hospital, Zhengzhou, 450000, China.
| | - Qun Dang
- Department of Gynecology, Henan Provincial People's Hospital, Zhengzhou, 450000, China.
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