Prophylactic Perioperative Hypogastric Artery Balloon Occlusion in Abnormal Placentation

General Management Considerations for Placenta Accreta Spectrum

The ideal management of a patient with placenta accreta spectrum (PAS) includes close antepartum management culminating in a planned and coordinated delivery by an experienced multidisciplinary PAS team. Coordinated team management has been shown to optimize outcomes for mother and infant. This section provides a consensus overview from the Pan-American Society for the Placenta Accreta Spectrum regarding general management of PAS.

Effectiveness of Intra-Aortic Ballooning Occlusion for Bleeding Control in Gravida Patients with Placenta Accreta

Introduction: Placenta previa and morbidly adherent placenta cause significant maternal morbidity and mortality from postpartum hemorrhage. Intra-aortic balloon occlusion has been shown to reduce intraoperative hemorrhage effectively. Cases Presentation We reported four cases of women who underwent cesarean section and hysterectomy with IABO. All four were multigravida, gestational age range was 37-39 weeks, MAP score range 6-8. Ultrasound examination showed placenta accreta. After the cesarean section and hysterectomy procedure with IABO, the bleeding was 600-800 cc. Conclusions Intra-Aortic Ballooning Occlusion is an effective method to reduce bleeding complications during and after cesarean section in pregnancies with placenta accreta.  

Postpartum Hemorrhages: Prevention

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

Pelvic arterial embolisation with cyanoacrylate during caesarean hysterectomy for placenta accreta

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.

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

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

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

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

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

BACKGROUND

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

AIMS

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Prophylactic catheterization of uterine arteries with temporary blood flow occlusion in patients at high risk of pospartum hemorrhage: is it a safe technique?

Background

Placenta accreta is an important factor in maternal morbidity and mortality and is responsible for approximately 64% of emergency hysterectomy cases and about 2/3 of cases of puerperal bleeding.

Objectives

To describe a series of cases of prophylactic uterine catheterization performed to prevent significant postpartum bleeding or during caesarean delivery in pregnant women with a previous diagnosis of accretion.

Methods

A retrospective analysis was conducted of medical records of cases of uterine artery catheterization performed during elective or emergency caesarean sections of patients at high risk of postpartum bleeding.

Results

The catheterization of uterine arteries procedure was performed in fourteen patients. Mean duration of surgery and hospital stay were 214.64 minutes (± 42.16) and 7 days, respectively. All patients underwent obstetric hysterectomy. No patient required embolization. There was no bleeding or need to revisit any patient and there were no complications related to puncture. There was one fetal death and no maternal deaths.

Conclusions

In this study, prophylactic uterine artery catheterization with temporary occlusion of blood flow proved to be a safe technique with low fetal mortality, no maternal mortality, and a low rate of blood transfusion and can be considered an important and effective therapeutic strategy for reduction of maternal morbidity and mortality, especially in pregnant women with anomalous placental attachment. Furthermore, the possibility of uterine preservation with the use of this method is an excellent contribution to therapeutic management of this group of patients. However, randomized clinical trials are needed to evaluate the effectiveness of routine use of the technique.

The Utilization of Interventional Radiologic Procedures in the Surgical Management of Placenta Accreta Syndrome

The role of Interventional radiologic procedures for the management of suspected placenta accreta spectrum (PAS) has evolved considerably over last 3 decades. In this article, the authors describe the various techniques of vascular occlusion for the management of PAS and provide a brief review of the literature examining the pros and cons in the use of these devices.

Prophylactic Hypogastric Artery Ligation during Placenta Percreta Surgery: A Retrospective Cohort Study

Objective  To evaluate if prophylactic hypogastric artery ligation (HAL) decreases surgical blood loss and blood products transfused. Study Design  This is a retrospective cohort study comparing patients with placenta percreta undergoing prophylactic HAL at the time of cesarean hysterectomy versus those who did not. Data were presented as means ± standard deviations, proportions, or medians with interquartile ranges. Demographic and clinical data were compared in the groups using Student's t -test for normally distributed data or the Mann-Whitney U test for nonnormally distributed data. Fisher's exact test was used for proportions and categorical variables. Data are reported as significant where p was <0.05. Results  There were 26 patients included in the control group with no HAL and 11 patients included in the study group. Estimated blood loss for the study group was 1,000 mL versus 800 mL in the control. Units of PRCBs transfused were 4.5 units in the study group versus 2 units for the control group. None of these measures were found to be statistically significant. Conclusion  Our data suggest there was no benefit in the use of prophylactic HAL in decreasing surgical blood loss or amount of blood products transfused in patients who had a cesarean hysterectomy performed for placenta percreta. Précis  Prophylactic HAL does not decrease blood loss during surgery for placenta percreta.

Pilot Study of Intra-Aortic Balloon Occlusion to Limit Morbidity in Patients with Adherent Placentation Undergoing Cesarean Hysterectomy

Objective  We study whether using an intra-aortic balloon (IAB) during cesarean hysterectomy decreases delivery morbidity in patients with suspected morbidly adherent placentation. Study Design  This is a retrospective cohort study of deliveries complicated by suspected abnormal placentation between 2009 and 2016 comparing maternal and neonatal outcomes with an IAB placed prior to cesarean hysterectomy versus no IAB. The primary outcome included quantified blood loss (QBL). Results  Thirty-five cases were reviewed, 16 with IAB and 19 without IAB. No difference was seen in median QBL between the two groups (1,351 vs. 1,397 mL; p  = 0.90). There were no significant differences in overall surgical complications (19% IAB, 21% no IAB; p  = 0.86), bladder complications (12 vs. 21%; p  = 0.66), intensive care unit admissions (12 vs. 26%; p  = 0.41), surgical duration (2.9 vs. 2.8 hour; p  = 0.83), or blood transfusions (median 2 vs. 2; p  = 0.27) between the two groups. There was one groin hematoma at the balloon site that was managed conservatively. There were no complications involving thrombosis or limb ischemia in the IAB group. Conclusion  While we did not detect statistically significant differences, larger studies may be warranted given the potential for extreme morbidity in these cases. This study highlights the potential use of an IAB in the management of these cases.

Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure

OBJECTIVES

To evaluate patient outcomes and need for further interventions in women with a morbidly adherent placenta (MAP), before and after introduction of the Triple-P procedure involving placental non-separation, myometrial excision and reconstruction of the uterine wall.

METHODS

Between December 2007 and February 2014, 30 patients with MAP were treated at our center. In 2007, we instituted a policy of bilateral prophylactic occlusion balloon catheter placement in both internal iliac arteries followed by Cesarean section with non-placental separation and preservation of the uterus. In 2010, the surgical technique was modified and the Triple-P procedure introduced. As a result, 19 women in our study received the Triple-P protocol (study group) and 11 did not (control group). The quantity of blood replacement products, estimated blood loss, and necessity for uterine arterial embolization and/or hysterectomy were recorded retrospectively and compared between the two groups.

RESULTS

Placenta percreta was confirmed in six (54.5%) patients in the control group and 13 (68.4%) in the study group. Estimated mean blood loss during the procedure was lower in the study group than in the control group (1.70 L vs 2.17 L, respectively), but the difference was not statistically significant (P = 0.445). The risks of postpartum hemorrhage (PPH) and hysterectomy were statistically significantly lower in the study group (PPH, 54.5% vs 15.8%; P = 0.035; hysterectomy, 27.3% vs 0.0%; P = 0.045). As a consequence, there was a significant decrease in duration of inpatient stay in the study group (P = 0.044).

CONCLUSION

Introduction of the Triple-P procedure conveyed a significantly reduced rate of hysterectomy, PPH and duration of hospital stay in patients with MAP. .

Urological Manifestations of Placenta Percreta

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

Conservative management of placenta percreta: a stepwise approach

PURPOSE

To describe a modified surgical approach in the form of stepwise cesarean section in placenta percreta.

METHODS

We conducted a prospective observational study. A total of 71 patients with placenta percreta were subjected to the new stepwise surgical approach and uterine repair at the time of cesarean delivery.

RESULTS

The procedure was successful in controlling the bleeding and preserving the patient's uterus in 65 (91.5%) women. Ten patients (14.1%) had urinary tract complications, nine (90%) were managed during cesarean section and one presented late in the form of vesicouterine fistula.

CONCLUSIONS

A stepwise cesarean section is safe and effective procedure that can be applied in placenta percreta.

The role of interventional radiology in reducing haemorrhage and hysterectomy following caesarean section for morbidly adherent placenta

AIM

To report experience of prophylactic occlusion balloon catheters (POBCs) in both internal iliac arteries before caesarean section, with or without embolization, to preserve the uterus and reduce haemorrhage.

METHODS AND MATERIALS

Twenty-seven women diagnosed with morbidly adherent placenta (MAP) and with suspected placenta percreta underwent POBC placement before caesarean section. The balloons were inflated immediately after delivery of the baby. The patients' case notes were reviewed retrospectively for histological grading of MAP, blood loss, transfusion, requirement of uterine artery embolization (UAE), or hysterectomy, radiation dose, and infant or maternal morbidity and mortality.

RESULTS

MAP was confirmed histologically as percreta in 17, accreta in eight, and increta in two women. Mean blood loss was 1.92 l (range 0.5-12 l). Postpartum haemorrhage (PPH) occurred in nine patients. Eight were referred for UAE, which was successful in six. Immediate peri-partum hysterectomy was performed in one patient. Three women in total required hysterectomy, two after recurrent haemorrhage after UAE. No foetal morbidity or mortality occurred. No maternal mortality occurred. There was one case of iliac artery thrombosis, which resolved with conservative therapy.

CONCLUSION

POBC, with or without UAE, contributes to reduction of blood loss and preservation of the uterus in women with MAP.

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

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

Emergency peripartum hysterectomy in a tertiary care hospital in saudi arabia

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Preoperative intravascular balloon catheters and surgical outcomes in pregnancies complicated by placenta accreta: a management paradox

OBJECTIVE

The objective of the study was to compare outcomes between patients who did and did not receive preoperative uterine artery balloon catheters in the setting placenta accreta.

STUDY DESIGN

This was a retrospective case-control study of patients with placenta accreta from 1990 to 2011.

RESULTS

Records from 117 patients with pathology-proven accreta were reviewed. Fifty-nine patients (50.4%) had uterine artery balloons (UABs) placed preoperatively. The mean estimated blood loss (EBL) was lower (2165 mL vs 2837 mL; P = .02) for the group that had UABs compared with the group that did not. There were more cases with an EBL greater than 2500 mL and massive transfusions of packed red blood cells (>6 units) in the group that did not have UABs. Percreta was diagnosed more often on final pathology in the group with UABs. Surgical times did not differ between the 2 groups. Two patients (3.3%) had complications related to the UABs.

CONCLUSION

Preoperative placement of UABs is relatively safe and is associated with a reduced EBL and fewer massive transfusions compared with a group without UABs.

Epidemiology, etiology, diagnosis, and management of placenta accreta

Placenta accreta is a severe pregnancy complication and is currently the most common indication for peripartum hysterectomy. It is becoming an increasingly common complication mainly due to the increasing rate of cesarean delivery. Main risk factor for placenta accreta is a previous cesarean delivery particularly when accompanied with a coexisting placenta previa. Antenatal diagnosis seems to be a key factor in optimizing maternal outcome. Diagnosis can be achieved by ultrasound in the majority of cases. Women with placenta accreta are usually delivered by a cesarean section. In order to avoid an emergency cesarean and to minimize complications of prematurity it is acceptable to schedule cesarean at 34 to 35 weeks. A multidisciplinary team approach and delivery at a center with adequate resources, including those for massive transfusion are both essential to reduce neonatal and maternal morbidity and mortality. The optimal management after delivery of the neonate is vague since randomized controlled trials and large cohort studies are lacking. Cesarean hysterectomy is probably the preferable treatment. In carefully selected cases, when fertility is desired, conservative management may be considered with caution. The current review discusses the epidemiology, predisposing factors, pathogenesis, diagnostic methods, clinical implications and management options of this condition.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Morbidity associated with nonemergent hysterectomy for placenta accreta

OBJECTIVE

The purpose of this study was to report the morbidity of nonemergent hysterectomy for suspected placenta accreta.

STUDY DESIGN

This was a retrospective study of all patients who underwent nonemergent hysterectomy for placenta accreta at Tampa General Hospital from June 1, 2003 to May 31, 2009.

RESULTS

Twenty-nine patients were identified. Diagnosis was suspected on ultrasound scanning in 26 women (6 women also underwent magnetic resonance imaging) and on direct vision at repeat cesarean section delivery in 3 women. All of the women were multiparous, and 18 women had undergone > or =2 cesarean section deliveries. Twenty-one women had a placenta previa, and 8 women had a low anterior placenta. Final pathologic findings revealed accreta (20 specimens), increta (6 women), and percreta (3 women). Mean total operative time was 216 minutes; blood loss was 4061 mL. Two women had ureteral transection (1 was bilateral); 3 women had cystotomy, and 3 women had partial cystectomy. Postoperative hemorrhage occurred in 5 women; 1 hemorrhage resolved after catheter embolization, and the other 4 hemorrhage required reoperation.

CONCLUSION

Nonemergent hysterectomy for placenta accreta is associated with significant morbidity in the forms of hemorrhage and urinary tract insult.

The role of interventional radiology in obstetric hemorrhage

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

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

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

Role of three-dimensional power Doppler in the antenatal diagnosis of placenta accreta: comparison with gray-scale and color Doppler techniques

OBJECTIVE

To assess the role of three-dimensional (3D) power Doppler in the antenatal diagnosis of placenta accreta and compare its diagnostic performance with gray-scale and color Doppler ultrasonography.

METHODS

One hundred and seventy pregnant women with persistent placenta previa totalis (after 28 weeks' gestation) were prospectively enrolled into this study. Gray-scale transabdominal ultrasound examination was performed to detect loss of the subendometrial echolucent zone and other abnormalities suggestive of placenta accreta. Color flow mapping was used to scan the whole placenta to detect any newly formed vessels at the serosa-bladder border or the presence of abnormal lacunae. Finally a targeted examination of angioarchitecture in the basal and lateral views of the placenta was carried out using 3D power Doppler. The ultrasound findings were analyzed with reference to the final diagnosis made during Cesarean delivery.

RESULTS

Placenta accreta and its variants (including increta and percreta) were confirmed in 39 patients at the time of Cesarean delivery. Based on receiver-operating characteristics analysis, 'numerous coherent vessels' visualized using 3D power Doppler in the basal view was the best single criterion for the diagnosis of placenta accreta, with a sensitivity of 97% and a specificity of 92%. If we considered the presence of at least one criterion to be diagnostic when using each ultrasound technique, then 3D power Doppler would have the best positive predictive value (76%), followed by gray-scale (51%) and color Doppler (47%). The majority of patients with placenta accreta showed multiple characteristic features on ultrasound imaging. In contrast, those patients with a false-positive diagnosis (i.e. the final diagnosis was placenta previa alone) tended to show isolated ultrasound markers of the condition.

CONCLUSION

3D power Doppler may be useful as a complementary technique for the antenatal diagnosis or exclusion of placenta accreta.