Endovascular Interventions for the Morbidly Adherent Placenta

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.

Rupture of multiple pseudoaneurysms as a rare complication of common iliac artery balloon occlusion in a patient with placenta accreta: A case report and review of literature

RATIONALE

Placenta accreta is the main cause of severe obstetric postpartum hemorrhage (PPH) and hysterectomy. Several hemostatic techniques have been performed in patients with placenta accreta to prevent PPH and reserve fertility. Abdominal aorta and pelvic arteries balloon occlusion are the only techniques which could be performed before cesarean section (CS) in patients who want to keep the fetus and reserve fertility. However, abdominal aorta and pelvic arteries balloon occlusion might lead to severe complications such as formation and rupture of pseudoaneurysm, angiorrhexis, etc.

PATIENT CONCERNS

We report a case diagnosed with pernicious placenta previa (PPP) combined with Rh(D) negative blood type, who was performed with bilateral common iliac arteries (CIA) balloon occlusion during CS. However, on the first day after CS, the patient caught sudden left-side lumbago and backache accompanied with palpitation and shortness of breath.

DIAGNOSES

Formation and rupture of multiple pseudoaneurysms in left CIA.

INTERVENTIONS

Covered stent was inserted into the proximal part of the left CIA and the ipsilateral internal iliac artery was embolized by coil to prevent endoleak.

OUTCOMES

The patient recovered and discharged from hospital in stable condition without other complications 9 days after CS.

LESSONS

It is of paramount importance that obstetricians and radiologists correctly estimate the appropriate occlusion volume and pressure of pelvic arteries before CS to avoid formation and rupture of a pseudoaneurysm. And if the rupture of a pseudoaneurysm occurred, it should be quickly identified and treated with endovascular intervention.

Prophylactic Internal Iliac Artery Occlusion Balloon Placement to Reduce Operative Blood Loss in Patients with Invasive Placenta

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.

Aortoiliac Thrombosis Following Tranexamic Acid Administration During Urgent Cesarean Hysterectomy: A Case Report

Postpartum hemorrhage (PPH) contributes to 25% of maternal deaths worldwide. Abnormal placentation is a well-known culprit of PPH. Although controversial, iliac artery balloon occlusion has been used in patients to decrease bleeding. The use of antifibrinolytic agents, such as tranexamic acid (TXA), have gained popularity in the management of PPH. We present a 35-year-old parturient with placenta percreta that was managed with internal iliac artery balloon occlusion with concomitant use of TXA during urgent cesarean hysterectomy with subsequent aortoiliac thrombosis formation. The role of both TXA and arterial balloons in PPH, along with their respective limitations, are discussed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The utility and effectiveness of an internal iliac artery balloon occlusion catheter in surgery for large cervical uterine fibroids

OBJECTIVE

Surgery for uterine cervical fibroids is difficult because of restricted surgical access and risks such as intraoperative bleeding or injury to other organs. The internal iliac artery balloon occlusion catheter (IIABOC) provides effective hemostasis for placenta previa and atonic hemorrhage, and is increasingly used in surgery for uterine fibroids for controlling intraoperative hemorrhage. We investigated the efficacy and safety of the IIABOC for controlling intraoperative bleeding in total abdominal hysterectomies (TAH) and abdominal myomectomies (AM) for large cervical fibroids.

MATERIAL AND METHODS

From 2007 to 2014, the IIABOC was used in 22 cases (12 for TAH and 10 for AM) in which cervical fibroids fully occupied the pelvic cavity. Intraoperative blood loss, operating time, sample weight, use of blood transfusion, and injury to other organs were assessed.

RESULT

Mean blood loss, operative time, and sample weight in the IIABOC cases were 510 mL, 178 min, and 2550 g for TAH; and 727.5 mL, 157.5 min, and 1850 g for AM. Blood loss divided by sample weight in IIABOC cases was significantly lower than that in non-IIABOC cases during the same time period, for both TAH and AM. Allogeneic blood transfusion was not necessary, and complications of injury to other organs did not occur in any of the 22 cases.

CONCLUSIONS

For large cervical fibroids with limited operating space, surgery was performed under bleeding control by occlusion of the internal iliac artery with an IIABOC. This technique enables control of hemorrhage and safe operative management in gynecological surgery.

Predelivery uterine arteries embolization in patients affected by placental implant anomalies

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.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Cesarean Hysterectomy and Uterine-Preserving Alternatives

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.

Effect of prophylactic placement of internal iliac artery balloon catheters on outcomes of women with placenta accreta: an impact study

We performed an impact study on the introduction of routine placement of internal iliac artery balloon catheters for the management of haemorrhage during caesarean section in women with placenta accreta. We identified 11 women, with prenatally diagnosed placenta accreta/increta/percreta before this change in practice, who acted as controls, and 30 women who had iliac artery balloons placed. The balloons were inflated in 27 cases. The median (IQR [range]) intra-operative blood loss was 1100 (800-2600 [500-6000]) ml in controls, compared with 1000 (600-2513 [400-15000]) ml in women with iliac artery balloons (p = 0.64). Six (54%) controls received intra-operative blood transfusion compared with 14 (47%) women with iliac artery balloons (p = 0.66). Caesarean hysterectomy was performed in 3 (27.3%) controls and 13 (43.3%) women with iliac artery balloons (p = 0.48). Balloon catheter insertion was associated with a shortened postoperative hospital stay, 6 (5-7 [4-12] days in controls vs. 5 (4-6 [3-10]) in the iliac artery balloon group (p = 0.033). General anaesthesia was used in six (54%) controls, but all women with iliac artery balloons. This study demonstrates that prophylactic balloon occlusion of the internal iliac arteries did not reduce intra-operative haemorrhage or caesarean hysterectomy in women with placenta accreta undergoing caesarean section. In addition, it has a significant impact on the choice of anaesthetic technique.

Retrospective analysis of placenta previa with abnormal placentation with and without prophylactic use of abdominal aorta balloon occlusion

OBJECTIVE

To evaluate the effectiveness of prophylactic abdominal aorta balloon occlusion in cases of placenta previa with abnormal placentation.

METHODS

In a retrospective study, data were analyzed for patients who had placenta previa with placenta accreta and underwent elective cesarean delivery (>34 weeks) with or without temporary aortic balloon occlusion at a center in Zhengzhou, China, between October 2015 and September 2016. The primary clinical outcomes were operative time, estimated blood loss, intraoperative blood transfusion volume, hemoglobin, hysterectomy, and hospitalization.

RESULTS

Among 69 eligible women, 38 had temporary balloon occlusion, and 31 had no balloon occlusion. Operative time, blood transfusion volume, change in hemoglobin, hysterectomy, and length of hospitalization did not differ. Although mean blood loss did not differ, fewer patients in the balloon group than the non-balloon group had an estimated blood loss of more than 1000 mL (24 [63%] vs 28 [90%]; P=0.009). In terms of different placental types, the estimated blood loss among women with placenta accreta and placenta increta was lower in the balloon group than in the non-balloon group (P<0.001 and P=0.01, respectively).

CONCLUSION

Prophylactic balloon occlusion of the abdominal aorta reduced bleeding after cesarean delivery for women with abnormal placentation.

The efficacy of pre-delivery prophylactic trans-catheter arterial balloon occlusion of bilateral internal iliac artery in patients with suspected placental adhesion

Objective

Prophylactic trans-catheter arterial balloon occlusion (PTABO) before cesarean section of placenta previa totalis has been introduced to prevent massive hemorrhage. The purpose of this study is to evaluate the clinical usefulness of PTABO in cases of suspected placental adhesion and to examine antepartal risk factors and perinatal outcomes in women with placental adhesion.

Methods

Between January 2012 and December 2015, 77 patients who had undergone ultrasonography for evaluation of placenta previa were enrolled in this study. Seventeen of these patients with suspected placental adhesion by ultrasonography and Pelvic MRI underwent PTABO before cesarean section and another 59 patients underwent cesarean section without PTABO. Antepartal risk factors and peripartum maternal and neonatal outcomes were compared between patients with PTABO and those without PTABO.

Results

More advanced maternal age, longer in gestational weeks at delivery, and more common previous cesarean section history were observed in the PTABO group. Placenta adhesion, abnormal Doppler findings, and frequency of transfusion were more common in the PTABO group. However there was no significant difference in estimated blood loss, hospital days, and neonatal outcome. It had occurred 3 cases of hysterectomy and 1 case of uterine artery embolization after cesarean section in the PTABO group.

Conclusion

Close surveillance of antepartum risk factors for placental adhesion using ultrasonography and pelvic magnetic resonance imaging is important to prevention of massive hemorrhage during cesarean section. PTABO before cesarean section might result in reduced blood loss and requirement for transfusion during the operation.

Efficacy and Safety of Prophylactic Uterine Artery Embolization in Pregnancy Termination with Placenta Previa

PURPOSE

To appraise the efficacy and safety of prophylactic uterine artery embolization in pregnancy termination with placenta previa.

METHODS

A cohort of 54 consecutive patients with placenta previa underwent prophylactic uterine artery embolization before vaginal delivery from February 2012 to March 2015. Vaginal delivery was attempted in all patients. Cesarean section or hysterectomy was introduced when vaginal delivery failed.

RESULTS

Vaginal delivery succeeded in 50 patients (93.6%) and failed in 4 patients (6.4%), thereupon converted to cesarean delivery. No patients resorted to hysterectomy. Six patients (11.1%) underwent blood transfusion. None of clinical characteristics, including maternal age, gestational age, history of abortion, history of cesarean delivery, and volume of vaginal bleeding, was significantly associated with complete placenta previa (P > 0.05). However, patients with complete placenta previa had a significantly lower successful rate of vaginal delivery than did patients without complete placenta previa (81 vs 100%, P = 0.038). The rate of complications was 3.7%. No major complications were observed.

CONCLUSION

Uterine artery embolization is an effective and safe technique to assist pregnancy termination with placenta previa, which may lower the risk of cesarean section, hysterectomy, and blood transfusion.

Factors Contributing to Massive Blood Loss on Peripartum Hysterectomy for Abnormally Invasive Placenta: Who Bleeds More?

Introduction. To identify factors that determine blood loss during peripartum hysterectomy for abnormally invasive placenta (AIP-hysterectomy). Methods. We reviewed all of the medical charts of 11,919 deliveries in a single tertiary perinatal center. We examined characteristics of AIP-hysterectomy patients, with a single experienced obstetrician attending all AIP-hysterectomies and using the same technique. Results. AIP-hysterectomy was performed in 18 patients (0.15%: 18/11,919). Of the 18, 14 (78%) had a prior cesarean section (CS) history and the other 4 (22%) were primiparous women. Planned AIP-hysterectomy was performed in 12/18 (67%), with the remaining 6 (33%) undergoing emergent AIP-hysterectomy. Of the 6, 4 (4/6: 67%) patients were primiparous women. An intra-arterial balloon was inserted in 9/18 (50%). Women with the following three factors significantly bled less in AIP-hysterectomy than its counterpart: the employment of an intra-arterial balloon (4,448 ± 1,948 versus 8,861 ± 3,988 mL), planned hysterectomy (5,003 ± 2,057 versus 9,957 ± 4,485 mL), and prior CS (5,706 ± 2,727 versus 9,975 ± 5,532 mL). Patients with prior CS (-) bled more: this may be because these patients tended to undergo emergent surgery or attempted placental separation. Conclusion. Patients with intra-arterial balloon catheter insertion bled less on AIP-hysterectomy. Massive bleeding occurred in emergent AIP-hysterectomy without prior CS.

Morbidly Adherent Placenta: Its Management and Maternal and Perinatal Outcome

OBJECTIVES

The aim of the study was to identify the risk factors predisposing to morbidly adherent placenta and to study the different modes of management and the obstetric and neonatal outcome of these patients.

METHODS

This was a retrospective cum prospective observational study conducted in the Department of Obstetrics and Gynaecology in a tertiary care referral hospital in Mumbai from January 2012 to November 2014.

RESULTS

The incidence of morbidly adherent placenta was 1.32 per 1000 pregnancies with patient profile comprising second gravida in the age group 26-28 years; 90 % of the patients in this study had previous Caesarean section and co-existing placenta praevia was diagnosed in 63 %. Fifty-three per cent of the women delivered between 35 and 38 weeks and 40 % had elective deliveries. Caesarean section was the mode of delivery in 90 % of the patients. Prophylactic balloon placement in the internal iliac artery followed by classical Caesarean section, uterine artery embolization and post-operative methotrexate was done in 27 % which preserved the uterus and was associated the blood loss of 1000-2000 mL.

CONCLUSION

Antenatal diagnosis of morbidly adherent placenta allows for multidisciplinary planning in an attempt to minimize potential maternal or neonatal morbidity and mortality.

Data and methods to estimate fetal dose from fluoroscopically guided prophylactic hypogastric artery balloon occlusion

PURPOSE

To provide data for estimation of fetal radiation dose (DF) from prophylactic hypogastric artery balloon occlusion (HABO) procedures.

METHODS

The Monte-Carlo-N-particle (MCNP) transport code and mathematical phantoms representing a pregnant patient at the ninth month of gestation were employed. PA, RAO 20° and LAO 20° fluoroscopy projections of left and right internal iliac arteries were simulated. Projection-specific normalized fetal dose (NFD) data were produced for various beam qualities. The effects of projection angle, x-ray field location relative to the fetus, field size, maternal body size, and fetal size on NFD were investigated. Presented NFD values were compared to corresponding values derived using a physical anthropomorphic phantom simulating pregnancy at the third trimester and thermoluminescence dosimeters.

RESULTS

NFD did not considerably vary when projection angle was altered by ±5°, whereas it was found to markedly depend on tube voltage, filtration, x-ray field location and size, and maternal body size. Differences in NFD < 7.5% were observed for naturally expected variations in fetal size. A difference of less than 13.5% was observed between NFD values estimated by MCNP and direct measurements.

CONCLUSIONS

Data and methods provided allow for reliable estimation of radiation burden to the fetus from HABO.

High-intensity focused ultrasound treatment of placenta accreta after vaginal delivery: a preliminary study

OBJECTIVE

To evaluate the safety and efficiency of high-intensity focused ultrasound (HIFU) in the treatment of placenta accreta after vaginal delivery.

METHODS

Enrolled into this study between September 2011 and September 2013 were 12 patients who had been diagnosed with placenta accreta following vaginal delivery and who had stable vital signs. All patients were treated using an ultrasound-guided HIFU treatment system. As indication of the effectiveness of the treatment we considered decreased vascular index on color Doppler imaging, decrease in size of residual placenta compared with pretreatment size on assessment by three-dimensional ultrasound with Virtual Organ Computer-aided Analysis, reduced signal intensity and degree of enhancement on magnetic resonance imaging and avoidance of hysterectomy following treatment. To assess the safety of HIFU treatment, we recorded side effects, hemorrhage, infection, sex steroid levels, return of menses and subsequent pregnancy. Patients were followed up in this preliminary study until December 2013.

RESULTS

The 12 patients receiving HIFU treatment had an average postpartum hospital stay of 6.8 days and an average period of residual placental involution of 36.9 days. HIFU treatment did not apparently increase the risk of infection or hemorrhage and no patient required hysterectomy. In all patients menstruation recommenced after an average of 80.2 days, and sex steroid levels during the middle luteal phase of the second menstrual cycle were normal. Two patients became pregnant again during the follow-up period.

CONCLUSION

This preliminary study suggests that ultrasound-guided HIFU is a safe and effective non-invasive method to treat placenta accreta patients after vaginal delivery who have stable vital signs and desire to preserve fertility. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Precesarean Prophylactic Balloon Catheters for Suspected Placenta Accreta: A Randomized Controlled Trial

OBJECTIVE

To examine the effect of prophylactic balloon catheters on bleeding morbidity among women with a prenatal diagnosis of placenta accreta.

METHODS

In a randomized trial, women with a prenatal diagnosis of placenta accreta were randomized to either preoperative prophylactic balloon catheters (intervention group) or to a control group. Other than placement of the prophylactic balloon catheters in the anterior division of the internal iliac arteries, the same multidisciplinary approach was used in both groups. The primary study outcome was the number of packed red blood cell (RBC) units transfused. To detect a mean reduction of three packed RBC units with the prophylactic balloon catheters, 12 women in each group were needed.

RESULTS

Between January 2009 and March 2015, 27 women were randomized: 13 in the intervention group and 14 in the control group. Demographic and obstetric characteristics were similar between the groups. Six (46.2%) women in the intervention and seven (50.0%) in the control group underwent cesarean hysterectomy (P=.84). There were no significant differences between the intervention and control groups in the mean number of packed RBC units transfused, 5.2 (±6.2) and 4.1 (±3.8), respectively (P=.90), or in the calculated blood loss, 4,950 (±5,051) and 4,709 (±3,434) mL (P=.72). The number of women with blood loss greater than 2,500 mL, number of plasma products transfused, duration of surgery, peripartum complications, and hospitalization length did not differ significantly between the groups. Reversible adverse effects related probably to prophylactic balloon catheter insertion were noted in 2 of 13 (15.4%) women.

CONCLUSION

In women with preoperative suspicion of placenta accreta, preoperative placement of prophylactic balloon catheters did not affect the number of packed RBC units transfused.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01373255.

LEVEL OF EVIDENCE

I.

Conservative Management of Invasive Placenta Using Combined Prophylactic Internal Iliac Artery Balloon Occlusion and Immediate Postoperative Uterine Artery Embolization

Purpose

The objective of the study was to evaluate the efficacy and safety of combined prophylactic intraoperative internal iliac artery balloon occlusion and postoperative uterine artery embolization in the conservative management (uterine preservation) of women with invasive placenta undergoing scheduled caesarean delivery.

Methods

Ten women (mean age 35 years) with invasive placenta choosing caesarean delivery without hysterectomy had preoperative insertion of internal iliac artery occlusion balloons, intraoperative inflation of the balloons, and immediate postoperative uterine artery embolization with absorbable gelatin sponge. A retrospective review was performed with institutional review board approval. Outcome measures were intraoperative blood loss, transfusion requirement, hysterectomy rate, endovascular complications, surgical complications, and postoperative morbidity.

Results

All women had placenta increta or percreta, and concomitant complete placenta previa. Mean gestational age at delivery was 36 weeks. In 6 women the placenta was left undisturbed in the uterus, 2 had partial removal of the placenta, and 2 had piecemeal removal of the whole placenta. Mean estimated blood loss during caesarean delivery was 1.2 L. Only 2 patients (20%) required blood transfusion. There were no intraoperative surgical complications, endovascular complications, maternal deaths, or perinatal deaths. Three women developed postpartum complications necessitating postpartum hysterectomy; the hysterectomy rate was therefore 30% and uterine preservation was successful in 70%.

Conclusion

Combined bilateral internal iliac artery balloon occlusion and uterine artery embolization may be an effective strategy to control intraoperative blood loss and preserve the uterus in patients with invasive placenta undergoing caesarean delivery.

ACR appropriateness Criteria® second and third trimester bleeding

Vaginal bleeding occurring in the second or third trimesters of pregnancy can variably affect perinatal outcome, depending on whether it is minor (i.e. a single, mild episode) or major (heavy bleeding or multiple episodes.) Ultrasound is used to evaluate these patients. Sonographic findings may range from marginal subchorionic hematoma to placental abruption. Abnormal placentations such as placenta previa, placenta accreta and vasa previa require accurate diagnosis for clinical management. In cases of placenta accreta, magnetic resonance imaging is useful as an adjunct to ultrasound and is often appropriate for evaluation of the extent of placental invasiveness and potential involvement of adjacent structures. MRI is useful for preplanning for cases of complex delivery, which may necessitate a multi-disciplinary approach for optimal care.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every two years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Bloodless surgery by a regional intraarterial tourniquet during primary and revision THA

Primary total hip arthroplasty (THA) and revision THA are associated with blood loss that can be significant. The purpose of this retrospective study was to compare the efficacy of intra-arterial occlusive balloons in reducing blood loss during primary and revision THA. Twelve patients (Jehovah’s Witnesses) scheduled for a primary (n=6) or revision (n=6) THA who refused blood transfusions were compared with 48 control-matched patients (primary THA, n=24; revision THA, n=24). All Jehovah’s Witnesses received an intra-arterial balloon preoperatively, and all control patients underwent conventional surgery. Intraoperatively, balloons were periodically inflated to reduce blood loss and deflated to prevent limb ischemia. Endpoints for the study were estimated blood loss, perioperative hemoglobin, mean hospital stay, mean operative time, amount of intraoperative fluid or blood administered, and complications. None of the patients with an occlusive balloon received blood, whereas the primary THA group received an average of 0.6 units (P=.08) and the revision THA group received an average of 1.9 units (P=.02). Estimated blood loss was significantly decreased in the balloon group compared with the primary THA group (145 vs 402 mL, respectively; P<.01) and the revision THA group (333 vs 767 mL, respectively; P<.01). No complications were associated with the intra-arterial balloons. All patients showed a significant reduction in hemoglobin immediately postoperatively compared with preoperative values. No statistically significant differences existed in the amount of fluids given intraoperatively or the mean hospital stay among all groups. Temporary internal tourniquets used as an adjuvant to surgery significantly reduce intraoperative blood loss during primary and revision THA.

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

Patient: Female, 36

Final Diagnosis: Pregnancy – placenta increta

Symptoms: —

Medication: —

Clinical Procedure: Cesarean hysterectomy

Specialty: Obstetrics and Gynecology

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

PURPOSE

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

CLINICAL FEATURES

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

CONCLUSION

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

Placenta accreta, increta, and percreta

Placenta accreta is an abnormal adherence of the placenta to the uterine wall that can lead to significant maternal morbidity and mortality. The incidence of placenta accreta has increased 13-fold since the early 1900s and directly correlates with the increasing cesarean delivery rate. The prenatal diagnosis of placenta accreta by ultrasound along with risk factors including placenta previa and prior cesarean delivery can aid in delivery planning and improved outcomes. Referral to a tertiary care center and the use of a multidisciplinary care team is recommended.

Sonographic features of placenta accreta after first-trimester abortion

We assessed 5 patients with histologically/clinically confirmed placenta accreta after first-trimester abortion. In 4 patients, sonography showed an unclear endometrium, absence of an endometrium-myometrium interface, a well-vascularized hyperechoic lesion in the uterine body with a low resistive index, and myometrial thinning near the lesion. In 2 patients, contrast-enhanced sonography showed rapid irregular lesion enhancement. Chemotherapy reduced the lesions in 3 patients, and a decreased blood supply increased the resistive index in all lesions. Two patients each underwent hysterectomy and uterine curettage. The fifth patient had a cervical pregnancy; sonography showed a well-vascularized hyperechoic lesion in an enlarged cervix. Methotrexate gradually reduced this lesion. Sonography, especially contrast-enhanced sonography, can detect placenta accreta and guide treatment.

Placenta accreta: risk factors, perinatal outcomes, and consequences for subsequent births

OBJECTIVE

We sought to evaluate risk factors and perinatal outcomes of pregnancies complicated with placenta accreta and to study perinatal outcomes in subsequent pregnancies.

STUDY DESIGN

A retrospective study comparing all singleton cesarean deliveries (CD) of women with and without placenta accreta was conducted. In addition, a retrospective comparison of all subsequent singleton CD of women with a previous placenta accreta, with CD of women with no such history, was performed during the years 1988 through 2011. Stratified analysis using multiple logistic regression models was performed to control for confounders.

RESULTS

During the study period, there were 34,869 CD, of which 0.4% (n = 139) were complicated with placenta accreta. Using a multivariable analysis with backward elimination, year of birth (adjusted odds ratio [aOR], 1.06; 95% confidence interval [CI], 1.03-1.09; P < .001), previous CD (aOR, 5.11; 95% CI, 3.42-7.65; P < .001), and placenta previa (aOR, 50.75; 95% CI, 35.57-72.45; P < .001) were found to be independently associated with placenta accreta. There were 30 subsequent pregnancies of women with placenta accreta. Recurrent accreta occurred in 4 patients (13.3%). Previous placenta accreta was significantly associated with uterine rupture (3.3% vs 0.3%, P < .01) peripartum hysterectomy (3.3% vs 0.2%, P < .001), and the need for blood transfusions (16.7% vs 4%, P < .001). Nevertheless, increased risk for adverse perinatal outcomes such as low Apgar scores at 1 and 5 minutes and perinatal mortality was not found in these patients.

CONCLUSION

Prior CD and placenta previa are independent risk factors for placenta accreta. A pregnancy following a previous placenta accreta is at increased risk for adverse maternal outcomes such as recurrent accreta, uterine rupture, and peripartum hysterectomy. However, adverse perinatal outcomes were not demonstrated.