Prophylactic Placement of Internal Iliac Balloons in Patients with Abnormal Placental Implantation: Maternal and Foetal Outcomes

Tourniquet on the low segment of the uterus reduces blood loss in postpartum hemorrhage during hysterectomy for placenta accreta: Old but gold

Objectives

To investigate the feasibility, safety, and efficiency after application of a cervical tourniquet during caesarian hysterectomy owing to placenta accreta.

Study design

It was a monocentric prospective observational study for 3 years. Patients were allocated into two group: Group Tourniquet: (TG) in which a cervical tourniquet was systematically applied during hysterectomy, control group (CG) when the caesarian hysterectomy was performed without.

Results

20 patients in the TG and 23 patients in the CG. Tourniquet application significantly reduced per operative estimated blood loss volume (TG: 530 ± 135 vs 940 ± 120 ml in the CG, p = 0.0074), ΔHB (0.6 [0.3-1.9] vs 2.5[2.5-3.6] g/dl in the CG, p = 0.006) RBC transfusion requirements' (TG: 2 ± 1.7 vs 4.3 ± 2.1 units in the CG, p = 0.046) procedure duration (TG: 98 ± 21 vs 137 ± 33 min in the CG, p = 0.015), clotting disorders (TG: 1 (5%) vs 6 (26,1%) in the CG, p = 0.013) and the incidence of bladder wounds (TG: 1 (5%) vs 5 (21,7%) in the CG, p = 0.048). There was no significant difference regarding ICU transfer rate (TG: 16 (80%) vs 20 (86.9%) in the CG, p = 0.53) or length of stay (TG: 1.4 [2,3] vs 2.3 [1-4] days in the CG, p = 0.615) and digestive wound (TG: 0 vs 2 (8,7%) in the CG, p = 0.641).

Conclusion

In case of a radical management of placenta accreta. A strategy that involves the application of a cervical Tourniquet should be considered as a feasible, safe and above all efficient alternative to prevent blood spoliation.

Surgical Techniques for the Management of Placenta Accreta Spectrum

The surgical management of placenta accreta spectrum (PAS) is often challenging. There are a variety of techniques and management options described in the literature ranging from uterine sparing to cesarean hysterectomy. Following the inaugural meeting of the Pan-American Society for Placenta Accreta Spectrum a multidisciplinary group collaborated to describe collective recommendations for the surgical management of PAS. In this manuscript, we outline individual components of the procedure and provide suggested direction at key points of a cesarean hysterectomy in the setting of PAS. KEY POINTS: · The surgical management of PAS requires careful planning and expertise.. · Multidisciplinary team care for pregnancies complicated by PAS can decrease morbidity and mortality.. · Careful surgical techniques can minimize risk of significant hemorrhage by avoiding pitfalls..

Placenta accreta spectrum part I: anesthesia considerations based on an extended review of the literature

"Placenta accreta spectrum" (PAS) describes abnormal placental adherence to the uterine wall without spontaneous separation at delivery. Though relatively rare, PAS presents a particular challenge to anesthesiologists, as it is associated with massive peripartum hemorrhage and high maternal morbidity and mortality. Standardized evidence-based PAS management strategies are currently evolving and emphasize: "PAS centers of excellence", multidisciplinary teams, novel diagnostics/pharmaceuticals (especially regarding hemostasis, hemostatic agents, point-of-care diagnostics), and novel operative/interventional approaches (expectant management, balloon occlusion, embolization). Though available data are heterogeneous, these developments affect anesthetic management and must be considered in planed anesthetic approaches. This two-part review provides a critical overview of the current evidence and offers structured evidence-based recommendations to help anesthesiologists improve outcomes for women with PAS. This first part discusses PAS management in centers of excellence, multidisciplinary care team, anesthetic approach and monitoring, surgical approaches, patient safety checklists, temperature management, interventional radiology, postoperative care and pain therapy. The diagnosis and treatment of hemostatic disturbances and preoperative prepartum anemia, blood loss, transfusion management and postpartum venous thromboembolism will be addressed in the second part of this series.

Clinical Utility of the Prenatal Ultrasound Score of the Placenta Combined with Magnetic Resonance Imaging in Diagnosis of Placenta Accreta during the Second and Third Trimester of Pregnancy

Objective. The aim is to explore the clinical utility of the prenatal ultrasound score of the placenta combined with magnetic resonance imaging (MRI) in diagnosis of placenta accreta during the second and third trimester of pregnancy. Materials and Methods. A total of 108 pregnant women with suspected placenta accreta treated in Wuhan Hankou Hospital and Yantaishan Hospital of Yantai from January 2019 to January 2022 were retrospectively analyzed, the enrolled pregnant women received MRI examination because of suspected results of ultrasonic diagnosis, and by taking pathologic findings as the gold standard, the diagnostic efficacy of the ultrasound score, MRI, and their combination to placenta accreta during the second and third trimester of pregnancy was analyzed, and the diagnostic sensitivity, specificity, the positive predictive value, and the negative predictive value of these diagnostic modalities were evaluated. Results. Among 108 patients with suspected placenta accreta, 75 with pathologically confirmed placenta accreta were included in the accreta group, and 33 without placenta accreta were included in the non-accreta group; no statistical between-group differences in the patients’ age, gestational weeks, educational degree, and other general data were observed ( $P>0.05$ ), but the history of cesarean section, history of induced abortion, and incidence rate of placenta praevia were significantly higher in the accreta group than in the non-accreta group ( $P<0.05$ ); the ultrasound score was significantly higher in the accreta group than in the non-accreta group ( $P<0.05$ ); the incidence rates of signs of “placental heterogeneity” and “bulge of lower segment of the uterus and local thickening of the placenta” were obviously higher in the accreta group than in the non-accreta group ( $P<0.05$ ); according to the comparison with pathologic findings, the accuracy rate, sensitivity, specificity, the positive predictive value, and the negative predictive value of combined diagnosis were significantly higher than those of single application of the ultrasound score and MRI diagnosis ( $P<0.05$ ); and ROC analysis found that the area under the curve of combined diagnosis was obviously larger than that of the ultrasound score and MRI diagnosis ( $P<0.05$ ). Conclusion. A combining prenatal ultrasound score of the placenta with MRI plays an important role in the diagnosis of placenta accreta during the second and third trimester of pregnancy, which can further improve the diagnostic accuracy rate of placenta accreta and provide significant guidance in preventing high-risk complications during the perinatal period.

Prophylactic placement of external iliac artery balloon catheter in a patient with intrapelvic prosthesis migration after hemiarthroplasty: A case report

Intrapelvic prosthesis migration is a rare but serious complication of bipolar hemiarthroplasty in femoral neck fractures. The external iliac artery is one of the most frequently damaged arteries during the removal of a migrated implant from the pelvic region. This report describes a case in which prophylactic placement of an external iliac artery balloon catheter was performed to reduce blood loss in the event of vascular injury during implant removal surgery in the pelvic region.

The clinical evaluation of IIA balloon occlusion in caesarean delivery for patients with PAS: a retrospective study

Objective

The aim of this study is the clinical evaluation of IIA balloon occlusion in the caesarean delivery in patients with a diagnosis of placenta accreta spectrum.

Background

High incidence of cesarean section leads to the increasing incidence of placenta accreta spectrum (PAS), which contributes to serious consequences such as severe obstetric postpartum hemorrhage or even maternal mortality.

Methods

Fifty-eight patients with a diagnosis of PAS were retrospectively reviewed. The balloon group consisted of 23 patients, who underwent a caesarean delivery with internal iliac artery occlusion. 35 patients were in the control group, who had a standard caesarean delivery. The primary outcomes were estimated blood loss (EBL). The secondary outcomes were cesarean hysterectomy, blood transferring volume, operating time, intraoperative hemostatic approaches, surgical complications, balloon catheter–related complications, length of maternal stay, cost of hospitalization, and neonatal outcomes.

Results

No difference was observed in estimated blood loss (EBL), blood transferring percentages and volume, additional measures to secure hemostasis, surgical complications, hospital stay postoperatively and newborn outcomes. More than 40% of the balloon group underwent hysterectomy because of uncontrollable postpartum bleeding (10 [43.48%] vs. 11 [31.43%], P=0.350). Complications related to occlusion of IIA did not occur. The duration of the surgery of the balloon group was significantly longer than that of the control group (123.52 min±74.76 versus 89.17±48.68, P=0.038), and the total hospitalization cost was also significantly higher than that of the control group (45116.67±9358.67 yuan versus 30615.41±11587.44 yuan, P=0.000).

Conclusion

It does not permit to draw final conclusions for us on the effectiveness of the balloons IIA given the heterogeneity of selection of cases undergoing the procedures in the retrospective design. However, it is possible that IIA balloon occlusion may contribute to limiting intraoperative blood loss in more severe cases, particularly those undergoing peripartum hysterectomy.

Effect of prophylactic balloon occlusion of internal iliac artery in pregnancies complicated by placenta previa and accreta

Background

Placenta previa and accreta are serious obstetric conditions that are associated with a high risk of intraoperative massive hemorrhage, the prophylactic intravascular balloon occlusion technique is increasingly used in managing uncontrolled hemorrhage in cesarean section (CS). We aim to examine the clinical effectiveness of prophylactic balloon occlusion of the internal iliac artery (PBOIIA) during CS in improving maternal outcomes for patients with placenta previa and accreta.

Methods

A total of 420 women with placenta previa and accreta who underwent CS from January 2014 to December 2018 were included retrospectively. Patients were divided into balloon group in which patients had PBOIIA (n = 248) and the control group in which patients did not have PBOIIA (n = 172). Meanwhile, we performed a subgroup analysis in whether taking parallel transverse uterine incision (PTUI) surgery. Information on conditions of patients and newborns, perioperative blood indicators, surgical outcomes were collected.

Results

Median estimated blood loss (mEBL) was 2200 mL in the balloon group and 2150 mL in the control group respectively, there was no significant difference between two-groups comparison (P > 0.05), and the rate of patients with hysterectomy was also has no difference between the two groups (36.3% verus 35.5%, P > 0.05), while there is a significant difference between two groups in the amount of PRBCs transfused [3 (0–31.5) verus 3 (0–39), P <0.05], moreover, the proportion of PRBCS> 8 units in the balloon group is significantly lower than that in control group (11.29% verus 23.26%, P <0.05).. However, the total hospitalization costs (45,624.4 ± 11,061.9 verus 37,523.1 ± 14,662.2, CYN) and surgery costs (19,910.6 ± 2622.6 verus 11,850.5 ± 3146.1, CYN) in balloon group were significantly higher than those in control group (P < 0.05). Subgroup analysis showed PTUI surgery had no significant differences in EBL (P >0.05), but it could significantly decrease hysterectomy rates (P <0.05).

Conclusions

PBOIIA has no significant effect on reducing intraoperative EBL and hysterectomy rate in patients with placenta previa and accreta. and although it could reduce the intraoperative PRBCs in patients with massive hemorrhage, it significantly increases the financial cost for patients. Therefore, PBOIIA should not be routinely recommended to patients with placenta previa and 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.

Estimating the radiation dose to the fetus during prophylactic internal iliac occlusion in patients with abnormal placentation

AIMS

To evaluate the estimated fetal radiation dose during prophylactic internal iliac arterial occlusion in patients with abnormal placenta and to estimate the risk of radiation induced cancer in child age.

METHODS

Prophylactic occlusion of the internal iliac arteries during Caesarean section was performed in 42 patients with placenta praevia and/or placenta accreta spectrum. Fogarty embolectomy catheters were used for prophylactic occlusion of the internal iliac arteries. All procedures were performed in the hybrid operating room using Philips Allura Xper FD 20 X-ray system. Low dose X-ray fluoroscopy (7.5 frames per second) was used. The CODE (Conceptus dose estimation) Software was used to estimate the fetal dose and the risk of radiation induced carcinoma.

RESULTS

Fluoroscopy times required for insertion of Fogarty catheters were 0.5-4.2 min (mean: 1.7 min, median: 1.5 min). The estimated radiation dose to the fetus was 0.26-3.36 mGy (mean: 1.49 mGy, median: 1.25 mGy). The risk of radiation induced cancer in child age was 0.01-0.04% (mean 0.02%, median 0.01%). One patient developed thrombosis of a common femoral artery.

CONCLUSION

Prophylactic occlusion of the internal iliac arteries is a simple and safe procedure with minimal risk of complications and with a very low estimated radiation dose to the fetus.

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.

Interventional radiology for the obstetric patient

PURPOSE OF REVIEW

To discuss the recent results of the use of interventional radiology modalities treating postpartum hemorrhage (PPH).

RECENT FINDINGS

PPH still is a leading cause of maternal morbidity and mortality. An important risk factor for the development of PPH is the placenta accreta spectrum. In patients with placenta accreta, we can use prophylactic balloon occlusion of the common or internal iliac artery or abdominal aorta to prevent PPH. Balloon occlusion of the abdominal aorta seems to ensure better results than balloon occlusion of the iliac artery in terms of blood loss, transfusion rate and hysterectomy rate reduction with a minimal risk of complications. To treat PPH uterine artery embolization can be effective and potentially fertility-sparing, while having a low complication rate.

SUMMARY

The use of aortic balloon occlusion catheters for the prevention of PPH and uterine artery embolization for the treatment of PPH are well tolerated and feasible options for patients with placenta accreta spectrum.

Risk factors for massive bleeding based on angiographic findings in patients with placenta previa and accreta who underwent balloon occlusion of the internal iliac artery during cesarean section

OBJECTIVE

We evaluated the risk factors for massive bleeding based on angiographic findings in patients with placenta previa and accreta who underwent balloon occlusion of the internal iliac artery (BOIA) during cesarean section.

METHODS

We performed a retrospective analysis using the clinical records of 42 patients with placenta previa and accreta who underwent BOIA during cesarean section between 2006 and 2017 in Gunma university hospital. We reviewed incidence of collateral arteries to the uterus on the initial aortography. We evaluated the visualization of the ovarian artery arising directly from the abdominal aorta, round ligament artery arising from the external iliac artery/inferior epigastric artery, and the iliolumbar artery. In addition, the clinical characteristics were reviewed. Patients with an estimated blood loss during delivery of >2500 ml, >4 packed red blood cell transfusions, uterine artery embolization after delivery, or hysterectomy were defined as the massive bleeding group. We compared between the massive and non-massive bleeding groups.

RESULTS

20 patients (48%) had a massive bleeding. No procedure-related severe complications were observed. The massive and non-massive bleeding groups differed in terms of operation time (p < 0.001), hysterectomy (p < 0.001), post-operative hospital stay (p < 0.05), and visualization of round ligament arteries to the uterus [15/20 (75%) patients, p < 0.01].

CONCLUSION

The incidence of collateral blood supply from a round ligament artery to the uterus may be a risk factor for massive bleeding in patients with placenta previa and accreta who have undergone BOIA during cesarean section.

ADVANCES IN KNOWLEDGE

Angiographic visualization of collateral circulation from the round ligament artery to the uterus may be a risk factor for massive bleeding in patients with placenta previa and accreta who have undergone BOIA during cesarean section.