Non-conservative Management of Placenta Accreta Spectrum in the Hybrid Operating Room: A Retrospective Cohort Study

Implementation and Outcomes of a Model of Care for Placenta Accreta Spectrum in a Community-Based Private Practice

OBJECTIVE

 The aim of the study is to describe a model of care and outcomes for placenta accreta spectrum (PAS) implemented in the context of a community based non-academic health system.

STUDY DESIGN

 The program for management of PAS includes a multidisciplinary team approach with protocols for ultrasound assessment, diagnosis, and surgery. The program was implemented in the two largest private hospitals in the Twin Cities, Minnesota, United States. Maternal and fetal outcomes as well as cost were compared for histopathologic confirmed PAS cases before (2007-2014, n = 41) and after (2015-2017, n = 26) implementation of the PAS program.

RESULTS

 Implementation of the PAS program was associated with ICU admission reductions from 53.7 to 19.2%, p = 0.005; a decrease of 1,682 mL in mean estimated blood loss (EBL) (p = 0.061); a decrease in transfusion from 85.4 to 53.9% (p = 0.005). The PAS program also resulted in a (non-significant) decrease in both surgical complications from 48.8 to 38.5% (p = 0.408) and postoperative complications from 61.0 to 42.3% (p = 0.135). The total cost of care for PAS cases in the 3 years after implementation of the program decreased by 33%.

CONCLUSION

 The implementation of a model of care for PAS led by a perinatology practice at a large regional non-academic referral center resulted in reductions of ICU admissions, operating time, transfusion, selected surgical complications, overall postoperative complications, and cost.

KEY POINTS

· Implementation of a PAS care model resulted in reduced ICU admissions from 53.7% to 19.2%.. · Patient safety increased by reducing blood loss, transfusions and postoperative complications.. · This model decreased operating time, as well as total cost of care by 33%..

Roadmap to safety: a single center study of evidence-informed approach to placenta accreta spectrum

Objective

To assess the impact of an evidence-informed protocol for management of placenta accreta spectrum (PAS).

Methods

This was a retrospective cohort study of patients who underwent cesarean hysterectomy (c-hyst) for suspected PAS from 2012 to 2022 at a single tertiary care center. Perioperative outcomes were compared pre- and post-implementation of a standardized Multidisciplinary Approach to the Placenta Service (MAPS) protocol, which incorporates evidence-informed perioperative interventions including preoperative imaging and group case review. Intraoperatively, the MAPS protocol includes placement of ureteral stents, possible placental mapping with ultrasound, and uterine artery embolization by interventional radiology. Patients suspected to have PAS on prenatal imaging who underwent c-hyst were included in the analysis. Primary outcomes were intraoperative complications and postoperative complications. Secondary outcomes were blood loss, need for ICU, and length of stay. Proportions were compared using Fisher's exact test, and continuous variables were compared used t-tests and Mood's Median test.

Results

There were no differences in baseline demographics between the pre- (n = 38) and post-MAPS (n = 34) groups. The pre-MAPS group had more placenta previa (95% pre- vs. 74% post-MAPS, p = 0.013) and prior cesarean sections (2 prior pre- vs. 1 prior post-MAPS, p = 0.012). The post-MAPS group had more severe pathology (PAS Grade 3 8% pre- vs. 47% post-MAPS, p = 0.001). There were fewer intraoperative complications (39% pre- vs.3% post-MAPS, p < 0.001), postoperative complications (32% pre- vs.12% post-MAPS, p = 0.043), hemorrhages >1l (95% pre- vs.65% post-MAPS, p = 0.001), ICU admissions (59% pre- vs.35% post-MAPS, p = 0.04) and shorter hospital stays (10 days pre- vs.7 days post-MAPS, p = 0.02) in the post-MAPS compared to pre-MAPS patients. Neonatal length of stay was 8 days longer in the post-MAPS group (9 days pre- vs. 17 days post-MAPS, p = 0.03). Subgroup analyses demonstrated that ureteral stent placement and uterine artery embolization (UAE) may be important steps to reduce complications and ICU admissions. When comparing just those who underwent UAE, patients in the post-MAPS group experienced fewer hemorrhages greater five liters (EBL >5l 43% pre- vs.4% post-MAPS, p = 0.007).

Conclusion

An evidence-informed approach to management of PAS was associated with decreased complication rate, EBL >1l, ICU admission and length of hospitalization, particularly for patients with severe pathology.

Placenta accreta spectrum care infrastructure: an evidence-based review of needed resources supporting placenta accreta spectrum care

The incidence of placenta accreta spectrum, the deeply adherent placenta with associated increased risk of maternal morbidity and mortality, has seen a significant rise in recent years. Therefore, there has been a rise in clinical and research focus on this complex diagnosis. There is international consensus that a multidisciplinary coordinated approach optimizes outcomes. The composition of the team will vary from center to center; however, central themes of complex surgical experts, specialists in prenatal diagnosis, critical care specialists, neonatology specialists, obstetrics anesthesiology specialists, blood bank specialists, and dedicated mental health experts are universal throughout. Regionalization of care is a growing trend for complex medical needs, but the location of care alone is just a starting point. The goal of this article is to provide an evidence-based framework for the crucial infrastructure needed to address the unique antepartum, delivery, and postpartum needs of the patient with placenta accreta spectrum. Rather than a clinical checklist, we describe the personnel, clinical unit characteristics, and breadth of contributing clinical roles that make up a team. Screening protocols, diagnostic imaging, surgical and potential need for critical care, and trauma-informed interaction are the basis for comprehensive care. The vision from the author group is that this publication provides a semblance of infrastructure standardization as a means to ensure proper preparation and readiness.

Urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders: systematic review and meta-analysis

OBJECTIVE

To report on the occurrence of urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders (PAS).

METHODS

MEDLINE, EMBASE and the Cochrane databases were searched electronically up to 1 November 2022. Studies reporting on the urological outcome of women undergoing Cesarean section for PAS were included. Two independent reviewers performed data extraction using a predefined protocol and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies, with disagreements resolved by consensus.The primary outcome was the overall occurrence of urological complications. Secondary outcomes were the occurrence of any cystotomy, intentional cystotomy, unintentional cystotomy, ureteral damage, ureteral fistula and vesicovaginal fistula. All outcomes were explored in the overall population of women undergoing surgery for PAS. In addition, we performed subgroup analyses according to the type of surgery (Cesarean hysterectomy, or conservative surgery or management), severity of PAS at histopathology (placenta accreta/increta and placenta percreta), type of intervention (planned vs emergency) and number of cases per year. Random-effects meta-analyses of proportions were used to analyze the data.

RESULTS

There were 62 studies included in the systematic review and 56 were included in the meta-analysis. Urological complications occurred in 15.2% (95% CI, 12.9-17.7%) of cases. Cystotomy complicated 13.5% (95% CI, 9.7-17.9%) of surgical operations. Intentional cystotomy was required in 7.7% (95% CI, 6.5-9.1%) of cases, while unintentional cystotomy occurred in 7.2% (95% CI, 6.0-8.5%) of cases. Urological complications occurred in 19.4% (95% CI, 16.3-22.7%) of cases undergoing hysterectomy and 12.2% (95% CI, 7.5-17.8%) of those undergoing conservative treatment. In the subgroup analyses, urological complications occurred in 9.4% (95% CI, 5.4-14.4%) of women with placenta accreta/increta and 38.5% (95% CI, 21.6-57.0%) of those described as having placenta percreta, and included mainly cystotomy (5.5% (95% CI, 0.6-15.1%) and 22.0% (95% CI, 5.4-45.5%), respectively). Urological complications occurred in 15.4% (95% CI, 8.1-24.6%) of cases undergoing a planned procedure and 24.6% (95% CI, 13.0-38.5%) of those undergoing an emergency intervention. In subanalysis of studies reporting on ≥ 12 cases per year, the incidence of urological complication was similar to that reported in the primary analysis.

CONCLUSIONS

Women undergoing surgery for PAS are at high risk of urological complication, mainly cystotomy. The incidence of these complications was particularly high in women described as having placenta percreta at birth and in those undergoing emergency surgical intervention. The high heterogeneity between the included studies highlights the need for a standardized protocol for the diagnosis of PAS to identify prenatal imaging signs associated with the increased risk of urological morbidity at delivery. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Current state of interventional procedures to treat pernicious placenta previa accompanied by placenta accreta spectrum: A review

Pernicious placenta previa (PPP) accompanied by placenta accreta spectrum (PAS) is a life-threatening placental implantation that causes a variety of complications, including antepartum hemorrhage, postpartum hemorrhage, hemorrhagic shock, preterm birth, and neonatal asphyxia. Along with continuous improvements in medical technology, interventional procedures have been widely used to prevent intraoperative hemorrhage associated with PPP. The commonly used interventional procedures include abdominal aorta clamping, prophylactic balloon occlusion of the internal or common iliac arteries, and uterine artery embolization. The above-mentioned interventional procedures have their respective advantages and disadvantages. The best procedure for different situations continues to be debated considering the complex pattern of blood supply to the uterus in patients with PPP. The specific choice of interventional procedure depends on the clinical situation of the patient with PPP. For grade III PAS, the need for uterine artery embolization is assessed based on blood loss and preoperative hemostatic effect following abdominal aorta clamping. Repair or hysterectomy may be performed following uterine artery embolization if there is a hybrid operating room for grade III PAS patients with extensive sub-serosal penetration of the uterus and repair difficulty. For grade II PAS (shallow placental implantation), prophylactic balloon occlusion may not be necessary before surgery. Uterine artery embolization can be performed in case of postoperative hemorrhage.

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

BACKGROUND

Placenta accreta spectrum disorders are a continuum of placental pathologies with significant maternal morbidity and mortality. Morbidity is related to the overall degree of placental adherence, and thus patients with placenta increta or percreta represent a high-risk category of patients. Hemorrhage and transfusion of blood products represent 90% of placenta accreta spectrum morbidity. Both tranexamic acid and uterine artery embolization independently decrease obstetrical hemorrhage.

OBJECTIVE

This study aimed to provide an evidence-based intraoperative protocol for placenta accreta spectrum management.

STUDY DESIGN

This study was a pre- and postimplementation analysis of concomitant uterine artery embolization and tranexamic acid in cases of patients with antenatally suspected placenta increta and percreta over a 5-year period (2018-2022). For comparison, a 5-year (2013-2017) preimplementation group was used to assess the impact of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum. Patient demographics and clinically relevant outcomes were obtained from electronic medical records.

RESULTS

A total of 126 cases were managed by the placenta accreta spectrum team, of which 66 had suspected placenta increta/percreta over the 10-year time period. Two patients were excluded from the postimplementation cohort because they did not undergo both interventions. Thus, 30 (30/64; 47%) were treated after implementation of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum, and 34 (34/64; 53%) preimplementation patients did not undergo uterine artery embolization or tranexamic acid infusion. With the uterine artery embolization and tranexamic acid protocol, operative times were longer (416 vs 187 minutes; P<.01), and patients were more likely to receive general anesthesia (80% vs 47%; P<.01). However, blood loss was reduced by 33% (2000 vs 3000 cc; P=.03), overall blood transfusion rates decreased by 51% (odds ratio, 0.05 [95% confidence interval, 0.001-0.20]; P<.01), and massive blood transfusion (>10 units transfused) was reduced 5-fold (odds ratio, 0.17 [95% confidence interval, 0.02-0.17]; P=.02). Postoperative complication rates remained unchanged (4 vs 10 events; P=.14). Neonatal outcomes were equivalent.

CONCLUSION

The uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum is an effective approach to the standardization of complex placenta accreta spectrum cases that results in optimal perioperative outcomes and reduced maternal morbidity.

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.

Comparison of One-Stage and Two-Stage Intraoperative Uterine Artery Embolization during Cesarean Delivery for Placenta Accreta: Report of Two Clinical Cases at a Tertiary Referral Medical Center

Placenta accreta spectrum (PAS) described the anchoring placental villi attached or penetrating into/through the myometrium. PAS is clinically important because of the unpredictable bleeding amount when manually removing the defective decidualization at the endometrial-myometrial interface. Therefore, a multidisciplinary strategy for cesarean delivery with PAS is crucial. Postoperative embolization after cesarean hysterectomy in a hybrid suite was studied by many scientists. In this study, we demonstrated two cases of intraoperative embolization without hysterectomy in a hybrid operating room for cesarean delivery with placenta accreta. Our results show that intraoperative uterine artery embolization with a hybrid suite is a time-preserving and safe method for cesarean delivery with PAS owing to avoiding the risk of morbidity and mortality during patient transfer.

The Feasibility and Safety of Temporary Transcatheter Balloon Occlusion of Bilateral Internal Iliac Arteries during Cesarean Section in a Hybrid Operating Room for Placenta Previa with a High Risk of Massive Hemorrhage

This study aimed to evaluate the feasibility and safety of temporary transcatheter balloon occlusion of bilateral internal iliac arteries (TBOIIA) during cesarean section in a hybrid operating room (OR) for placenta previa (PP) with a high risk of massive hemorrhage. This retrospective study analyzed the medical records of 62 patients experiencing PP with a high risk of massive hemorrhage (mean age, 36.2 years; age range 28-45 years) who delivered a baby via planned cesarean section with TBOIIA in a hybrid OR between May 2019 and July 2021. Operation time, estimated blood loss (EBL), amount of intra- and postoperative blood transfusion, perioperative hemoglobin level, hospital stay after operation, balloon time, fluoroscopy time, radiation dose, rate of uterine artery embolization (UAE) and hysterectomy, and complication-related TBOIIA were assessed. The mean operation time was 122 min, and EBL was 1290 mL. Nine out of sixty-two patients (14.5%) received a blood transfusion. The mean hemoglobin levels before surgery, immediately after surgery and within 1 week after surgery were 11.3 g/dL, 10.4 g/dL and 9.2 g/dL, respectively. In terms of radiation dose, the mean dose area product (DAP) and cumulative air kerma were 0.017 Gy/cm² and 0.023 Gy, respectively. Ten out of sixty-two patients (16.1%) underwent UAE postoperatively in the hybrid OR. One out of sixty-two patients had been diagnosed with placenta percreta with bladder invasion based on preoperative ultrasound, and thus underwent cesarean hysterectomy following TBOIIA and UAE. While intra-arterial balloon catheter placement for managing PP with a high risk of hemorrhage remains controversial, a planned cesarean section with TBOIIA in a hybrid OR is effective in eliminating the potential risk of intra-arterial balloon catheter displacement, thus reducing intraoperative blood loss, ensuring safe placental removal and conserving the uterus.

Clinical Analysis of Improved Particle Swarm Algorithm-Based Magnetic Resonance Imaging Diagnosis of Placenta Accreta

The magnetic resonance imaging (MRI) image processing capabilities were investigated based on the improved particle swarm optimization (IPSO) algorithm, and the clinical application analysis of MRI images in the diagnosis of placenta accreta (PA) was evaluated in this study. The MRI uterine images were detected on the basis of IPSO. Besides, the clinical data of 89 patients with PA were selected and collected, who were diagnosed by clinical cesarean section surgery and pathological comprehensive diagnosis in hospital from January 2018 to July 2020. Then, all of them underwent the ultrasound (US) and MRI examinations, and the differences of sensitivity, specificity, and accuracy between MRI and US under IPSO in the diagnosis of PA were compared, as well as the differences in the diagnosis of adhesive, implantable, and penetrated PA. The results showed that the difference in detection between IPSO-based MRI images and US images was not statistically substantial (p > 0.05), but the number of initial detections was higher than the number of US examination. MRI examination had higher sensitivity and specificity in the diagnosis of PA during pregnancy, especially for implantable PA, compared with US examination (p < 0.05). In conclusion, MRI images based on the improved particle swarm optimization algorithm showed a good application effect in the diagnosis of placental implantation diseases, which was worthy of further promotion in clinical practice.

Magnetic Resonance Imaging Artifact Elimination in the Diagnosis of Female Pelvic Abscess under Phase Correction Algorithm

In order to explore the effect of magnetic resonance imaging (MRI) based on phase correction algorithm in diagnosing female pelvic abscess, firstly, the effect of phase correction algorithm on eliminating MRI image motion artifacts was studied, then it was applied to 71 female pelvic cases admitted to our hospital in the diagnosis of abscess patients with magnetic resonance imaging technology, and the results were compared with the results of multislice spiral CT and laparoscopy to explore the accuracy of MRI and CT. It was found that the results of MRI examination were close to those of laparoscopy, and the difference was not statistically significant (P > 0.05); the results of CT examination and laparoscopy were significantly different, and the difference was statistically significant (P < 0.05); in addition, the results of CT examination, the number of bacterial cysts (43 cases) and tuberculous cysts (12 cases), were significantly lower than the results of MRI (50 cases, 18 cases), and the difference was statistically significant (P < 0.05). The size of the mass shown by the MRI examination (4.1  cm × 4.2  cm × 3.9 cm～13.9  cm × 9.5  cm × 8.7 cm) was larger than the size of the mass revealed by the CT examination (5.2  cm × 4.3  cm × 4.1 cm～15.5  cm × 10.1  cm × 9.6 cm), the difference between the two was statistically significant (P < 0.05), and it was closer to the results of laparoscopic pathology (4.1  cm × 4.3  cm × 3.9 cm～14.1  cm × 9.3  cmP < 0.058.7 cm). In short, the phase correction algorithm could eliminate the motion artifacts of MRI images. In the imaging diagnosis of female pelvic abscess, the MRI diagnosis based on the phase correction algorithm is more ideal than the diagnosis of multislice spiral CT. It can be used as a reference basis for clinical disease treatment.

Prophylactic Intraoperative Uterine Artery Embolization During Cesarean Section or Cesarean Hysterectomy in Patients with Abnormal Placentation: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the effectiveness and safety of prophylactic intraoperative uterine artery embolization (UAE) performed immediately after fetal delivery during planned cesarean section or cesarean hysterectomy in patients with placenta accreta spectrum disorder or placenta previa.

METHODS

A systematic search was conducted on Ovid MEDLINE and Embase, PubMed, Web of Science, and Cochrane databases. Studies were selected using the Population/Intervention/Comparison/Outcomes (PICO) strategy. The intraoperative blood loss and the rate of emergent peripartum hysterectomy (EPH) were the primary outcomes, whereas the length of hospital stay and volume of blood transfused were the secondary outcomes. A random-effects model was employed to pool each effect size. The cumulative values of the primary outcomes were calculated using the generic inverse variance method.

RESULTS

Eleven retrospective cohort studies and five case series were included, recruiting 421 women who underwent prophylactic intraoperative UAE (UAE group) and 374 women who did not (control group). Compared with the control group, the UAE group had significantly reduced intraoperative blood loss (p = 0.020) during cesarean section or cesarean hysterectomy. Furthermore, the EPH rate was also significantly decreased (p = 0.020; cumulative rate: 19.65%), but not the length of hospital stay (p = 0.850) and volume of pRBC transfused (p = 0.140), after cesarean section in the UAE group. The incidence of major complications was low (3.33%), despite two patients with uterine necrosis.

CONCLUSION

The currently available data provides encouraging evidence that prophylactic intraoperative UAE may contribute to hemorrhage control and fertility preservation in women with abnormal placentation.

REGISTRATION

PROSPERO registration code: CRD42021230581. https://clinicaltrials.gov/ct2/show/CRD42021230581 LEVEL OF EVIDENCE: Level 2a, systematic review of retrospective cohort studies.

A systematic review on the application of the hybrid operating room in surgery: experiences and challenges

The hybrid operating room has been widely applied in different surgery sub-specialties. We aim to identify the advantages of hybrid operating rooms by focusing on intraoperative imaging and explore what to do for further improving its application. We searched related literature in websites including Pubmed, MEDLINE, Web of science, using the keywords ("hybrid operating room" or "integrated operating room" or "multifunctional operating room") and ("surgery" or "technique" or "intervention" or "radiology"). All the searched papers were screened and underwent quality evaluation. A total of 30 literature was eventually identified after full-text screening. These articles covered 10 countries and presented data for 15,558 individuals. The median sample size was 536 (range 8-12,804). Application of the hybrid operating room in general surgery, neurosurgery, thoracic surgery, urology, gynaecologic and obstetrics surgery, cardiovascular surgery, was summarized. Four different operative indicators were applied (operative duration, mortality rate, operation success rate and complication rate). A hybrid OR could significantly increase the operation success rate and reduce operative duration, mortality rates, and complication rates. Further efforts could be made to reduce radiation exposure in the hybrid operating room and increase its cost-effectiveness ratio.

Placenta accreta spectrum disorder: updates on anesthetic and surgical management strategies

Placenta accreta spectrum (PAS) is a leading contributor to major obstetric hemorrhage and severe maternal morbidity in the developed world. In the United States, PAS has become the most common cause of peripartum hysterectomy. Over the last 40 years, clinicians have also witnessed a dramatic increase in the incidence of PAS. In the 1950s, the incidence of PAS was reported to be 0.03 per 1000 pregnancies. Recent epidemiological studies estimate that the PAS incidence is between 0.79 and 3.11 in 1000 pregnancies. As a consequence, obstetric anesthesiologists are increasingly likely to be called upon to manage women with suspected PAS for delivery. Given the increasing incidence and the morbidity burden associated with PAS, anesthesiologists play a vital role in optimizing maternal outcomes for women with PAS. This review will provide up-to-date information on nomenclature, pathophysiology, risk factors, antenatal detection, systemic preparations (includes timing of delivery, location of surgery, pre-operative evaluation and patient positioning), surgical and anesthetic approach, intra-operative management, invasive radiology and postoperative plans.

Role of interventional radiology in placenta accreta spectrum (PAS) disorders

Placenta accreta spectrum (PAS) disorders are rare but potentially life-threatening obstetric conditions, which can result in severe post-partum haemorrhage (PPH). Traditional management necessitates peripartum hysterectomy, but this carries high rates of morbidity and mortality. More recently, interventional radiology techniques have been developed in order to reduce morbidity and preserve fertility. This article summarises and compares the various reported interventional radiology techniques. Arterial embolisation performed to treat PPH is the therapeutic option which is supported by the highest degree of evidence. The role of preventative procedures, such as temporary balloon occlusion of the internal iliac arteries or distal aorta, continues to be debated due to conflicting outcome data and concerns regarding associated morbidity. The choice of which, if any, interventional radiological technique is utilised is determined by local expertise, available resources and the planned obstetric approach. The most complex patients are likely to benefit from multidisciplinary management in high-volume centres.

Application of the Hybrid Operating Room in Surgery: A Systematic Review

BACKGROUND AND OBJECTIVE

The hybrid operating room has been widely applied in surgery, including neurology, general surgery, gynecology, and obstetrics. By reviewing application of the hybrid operating room in different categories of surgery, we aim to summarize both advantages and disadvantages of the hybrid operating room and discuss what to do for further improving the application of it.

METHODS

We searched related literature in websites including Pubmed, MEDLINE, Web of science, using the keywords "hybrid operating room", "surgery", "technique", "intervention", and "radiology". All the searched papers were screened and underwent quality evaluation. The eventually selected papers were carefully read, with related information extracted and summarized.

RESULTS

After screening and assessment, a total of 29 literature was collected. Application of the hybrid operating room in general surgery, neurosurgery, thoracic surgery, urology, gynecologic and obstetrics surgery, and cardiovascular surgery was summarized. Both advantages and disadvantages of the hybrid operating room were discussed in order to improve application of the hybrid operating room in surgery.

CONCLUSIONS

Surgeries performed in the hybrid operating room take advantages over those conventional operating rooms mainly in terms of higher procedure accuracy, less operative time, and less risk of hemorrhage during the transportation between radiology departments and operating suites. Further efforts should be made to reduce radiation exposure from imaging systems equipped in the hybrid operating room and increase cost-effectiveness ratio of the hybrid operating room.

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.

Minimizing surgical blood loss at cesarean hysterectomy for placenta previa with evidence of placenta increta or placenta percreta: the state of play in 2020

The evolution of multidisciplinary team-based care for women with placenta accreta spectrum disorder has delivered stepwise improvements in clinical outcomes. Central to this overall goal is the ability to limit blood loss at surgery. Placement of inflatable balloons within the pelvic arteries, most commonly in the anterior divisions of the internal iliac arteries, became popular in many centers, at the expense of prolonging surgical care and with attendant risks of vascular injury. In tandem, the need to expose pelvic sidewall anatomy to safely identify the course of the ureters re-popularized the alternative strategy of ligating the same anterior divisions of the internal iliac arteries. With incremental gains in surgical expertise, described in 5 steps in this review, our teams have witnessed a steady decline in surgical blood loss. Nevertheless, a subset of women has the most severe form of placenta accreta spectrum, namely placenta previa-percreta. Such women are at risk of major hemorrhage during surgery from vessels arising outside the territories of the internal iliac arteries. These additional blood supplies, mostly from the external iliac arteries, pose significant risks of major blood loss even in experienced hands. To address this risk, some centers, principally in China, have adopted an approach of routinely placing an infrarenal aortic balloon, with both impressively low rates of blood loss and an ability to conserve the uterus by resecting the placenta with the affected portion of the uterine wall. We review these literature developments in the context of safely performing elective cesarean hysterectomy for placenta previa-percreta, the most severe placenta accreta spectrum disorder.

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.

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.