Internal iliac artery balloon occlusion in the management of placenta accreta: A systematic review and meta-analysis

Clinical evaluation of the effect for prophylactic balloon occlusion in pregnancies complicated with placenta accreta spectrum disorder: A systematic review and meta-analysis

BACKGROUND

Placenta accreta spectrum (PAS) disorder is a critical and severe obstetric condition associated with high risk of intraoperative massive hemorrhage and cesarean hysterectomy. Severe obstetric hemorrhage is currently one of the leading causes of maternal death worldwide. Prophylactic balloon occlusions, including prophylactic balloon occlusion of the abdominal aorta (PBOAA) and prophylactic balloon occlusion of the internal iliac arteries (PBOIIA), are the most common means of controlling hemorrhage in patients with PAS disorder, but their effectiveness is still debated.

OBJECTIVE

A systematic review and meta-analysis were conducted to evaluate the clinical effectiveness of prophylactic balloon occlusion during cesarean section (CS) in improving maternal outcomes for PAS patients.

SEARCH STRATEGY

MEDLINE, EMBASE, OVID, PubMed and the Cochrane Library were systematically searched from the inception dates to June 2022, using the keywords "placenta accreta spectrum disorder/morbidly adherent placenta (placenta previa, placenta accreta, placenta increta, placenta percreta), balloon occlusion, internal iliac arteries, abdominal aorta, hemorrhage, hysterectomy, estimated blood loss (EBL), packed red blood cells (PRBCs)" to identify the systematic reviews or meta-analyses.

SELECTION CRITERIA

All articles regarding PAS disorders and including the application of balloon occlusion were included in the screening.

DATA COLLECTION AND ANALYSIS

Two independent researchers performed the data extraction and assessed study quality. EBL volume and PRBC transfusion volume was regarded as the primary endpoints. Random and fixed effects models were used for the meta-analysis (RRs and 95% CIs), and the Newcastle-Ottawa Scale was used for quality assessments.

MAIN RESULTS

Of 429 studies identified, a total of 35 trials involving the application of balloon occlusion for patients with PAS disorder during CS were included. A total of 19 studies involving 935 patients who underwent PBOIIA were included in the PBOIIA group, and 851 patients were included in control 1 group. Ten studies including 428 patients with PAS who underwent PBOAA were allocated to the PBOAA group, and 324 patients without PBOAA were included in control 2 group. Simultaneously, we compared the effect on PBOAA and PBOIIA including seven studies, which referred to 267 cases in the PBOAA group and 313 cases in the PBOIIA group. The results showed that the PBOIIA group had a reduced EBL volume (MD: 342.06 mL, 95% CI: -509.90 to -174.23 mL, I2 = 77%, P < 0.0001) and PRBC volume (MD: -1.57 U, 95% CI: -2.49 to -0.66 U, I2 = 91%, P = 0.0008) than that in control 1 group. With regard to the EBL volume (MD: -926.42 mL, 95% CI: -1437.07 to -415.77 mL, I2 = 96%, P = 0.0004) and PRBC transfusion volume (MD: -2.42 U, 95% CI: -4.25 to -0.59 U, I2 = 99%, P = 0.009) we found significant differences between the PBOAA group and control 2 group. Prophylactic balloon occlusion (PBOAA and PBOIIA) had a significant effect on reducing intraoperative blood loss and blood transfusion volume in patients with PAS. Moreover, PBOAA was more effective than PBOIIA in reducing intraoperative blood loss (MD: -406.63 mL, 95% CI: -754.12 to -59.13 mL, I2 = 92%, P = 0.020), but no significant difference in controlling PRBCs (MD: -3.48 U, 95% CI: -8.90 to 1.95 U, I2 = 99%, P = 0.210) between the PBOIIA group and the PBOAA group. Hierarchical analysis was conducted by differentiating gestational weeks and maternal age to reduce the high heterogeneity of meta-analysis. Hierarchical analysis results demonstrated the heterogeneities of the study were reduced to some extent, and gestational weeks and maternal age might be the cause of increased heterogeneity.

CONCLUSION

Prophylactic balloon occlusion is a safe and effective method to control hemorrhage and reduce PRBC transfusion volume for patients with PAS, and PBOAA could reduce more intraoperative blood loss than PBOIIA. However, we found no statistical difference in lessening packed red blood cell transfusion volume for PAS patients. Hence, preoperative prophylactic balloon occlusion is the recommended application for PAS patients in obstetric CSs. Furthermore, PBOAA is preferred for controlling intraoperative bleeding in patients with corresponding medical conditions.

Prophylactic occlusion balloons of both internal iliac arteries in caesarean hysterectomy for placenta accreta spectrum disorder reduces blood loss: A retrospective comparative study

Background

The placenta accreta spectrum is a complex disorder characterized by abnormal invasion of the placenta into the uterine wall, posing a significant risk of life-threatening haemorrhage for patients. Its incidence is on the rise, largely attributed to the increasing rates of caesarean sections. Management of this spectrum involves a multidisciplinary approach, although standardized protocols are not yet established. While caesarean hysterectomy remains the standard Gold, several adjunctive treatments have emerged in recent years to mitigate bleeding risk and associated morbidity. Among these, prophylactic occlusion balloons placed in the internal iliac arteries have shown promise. The aim of our study is to demonstrate the effect of prophylactic occlusion balloons in both uterine iliac arteries in the management of placental accreta spectrum disorders.

Methods

A retrospective monocentric cohort study was conducted in the Department "C" of Gynaecology and Obstetrics at the Maternity Center of Tunis. The study spanned three years, from January 2nd, 2020, to December 31st, 2022. The study population consisted of two groups: Control Group (CG) comprised patients who underwent caesarean hysterectomy without internal-iliac prophylactic occlusion balloons, and Occlusion balloons of both internal iliac arteries Group (OBIIAG) included patients who underwent caesarean hysterectomy with internal-iliac prophylactic occlusion balloons.

Results

A total of 38 patients were included in the study, all of whom exhibited similar epidemiological characteristics and comparable personal and obstetric histories. The most prevalent risk factor among the patients was a history of caesarean section (92%). On average, patients were diagnosed at 30 weeks of gestation, with third-trimester bleeding being the most common presentation (71% of cases). The median gestational age at delivery was between 36 and 37 weeks. We observed a significant difference in blood loss between the two groups (2888 ml in the control group and 1828 ml in the group with internal-iliac prophylactic occlusion balloons, p < 0.05). Implementation of this technique resulted in a reduced need for massive transfusions (p < 0.01) and shorter operating times (126 min for the control group and 92 min for the group with internal-iliac prophylactic occlusion balloons; p = 0.04). There were no significant differences in morbidity between the two groups.

Conclusion

The intra-iliac prophylactic occlusion balloons can help reduce the risk of hemorrhage and the morbidities that come with the placenta accreta spectrum disorder.

Efficacy and safety of prophylactic balloon occlusion in the management of placenta accreta spectrum disorder: a retrospective cohort study

OBJECTIVE

Placenta accreta spectrum disorder (PAS) is a serious obstetric complication associated with significant maternal morbidity and mortality. Prophylactic balloon occlusion (PBO), as an intravascular interventional therapies, has emerged as a potential management strategy for controlling massive hemorrhage in patients with PAS. However, current evidence about the clinical application of PBO in PAS patients are still controversial. This study aimed to evaluate the effectiveness and safety of PBO in the management of PAS.

METHODS

A retrospective cohort study including PAS patients underwent cesarean delivery was conducted in a tertiary hospital from January 2015 to March 2022. Included PAS patients were further divided into balloon and control groups by whether PBO was performed. Groups were compared for demographic characteristics, intraoperative and postoperative parameters, maternal and neonatal outcomes, PBO-related complication and follow up outcomes. Additionally, multivariate-logistic regression analysis was performed to determine the definitive associations between PBO and risk of massive hemorrhage and hysterectomy.

RESULTS

A total of 285 PAS patients met the inclusion criteria were included, of which 57 PAS patients underwent PBO (PBO group) and 228 women performed cesarean section (CS) without PBO (control group). Irrespective of the differences of baseline characteristics between the two groups, PBO intervention did not reduce the blood loss, hysterectomy rate and postoperative hospital stay, but it prolonged the operation time and increased the cost of hospitalization (All P < 0.05) Additionally, there were no significant differences in postoperative complications, neonatal outcomes, and follow-up outcomes(All P > 0.05). In particular, patients undergoing PBO were more likely to develop the venous thrombosis postoperatively (P = 0.001). However, multivariate logistic regression analysis showed that PBO significantly decreased the risk of massive hemorrhage (OR 0.289, 95%CI:0.109-0.766, P = 0.013). The grade of PAS and MRI with S2 invasion were the significant risk factors affecting massive hemorrhage(OR:6.232 and OR:5.380, P<0.001).

CONCLUSION

PBO has the potential to reduce massive hemorrhage in PAS patients undergoing CS. Obstetricians should, however, be aware of potential complications arising from the PBO. Additionally, MRI with S2 invasion and PAS grade will be useful to identify PAS patients who at high risk and may benefit from PBO. In brief, PBO seem to be a promising alternative for management of PAS, yet well-designed randomized controlled trials are needed to convincingly demonstrate its benefits and triage the necessity of PBO.

Intraoperative Multivessel Embolization Reduces Blood Loss and Transfusion Requirements Compared to Internal Iliac Artery Balloon Placement during Cesarean Hysterectomy for Placenta Accreta Spectrum

PURPOSE

To evaluate the effectiveness and safety of prophylactic multivessel selective embolization (MVSE) compared to those of internal iliac artery occlusion balloon (IIABO) placement in patients undergoing cesarean hysterectomy for placenta accreta spectrum (PAS).

MATERIALS AND METHODS

An institutional review board-approved retrospective series was conducted with consecutive patients with PAS at a single institution between 2010 and 2021. MVSE was performed in a hybrid operating room after cesarean section prior to hysterectomy. IIABO was performed with balloons placed into the bilateral internal iliac arteries, which were inflated during hysterectomy. Median blood loss, transfusion requirements, percentage of cases requiring transfusion, and adverse events were recorded.

RESULTS

A total of 20 patients treated with embolization and 34 patients with balloon placement were included. Placenta percreta and previa were seen in 60% and 90% of patients, respectively. Median blood loss in the MVSE group was 713 mL (interquartile range [IQR], 475-1,000 mL) compared to 2,000 mL (IQR, 1,500-2,425 mL) in the IIABO group (P < .0001). The median total number of units of packed red blood cell transfusions (0 vs 2.5) and percentage of cases requiring a transfusion (20% vs 65%) were less in the MVSE group (P < .01). A median of 4 vessels (IQR, 3-9) were embolized during MVSE. No major adverse events or nontarget embolization consequences were observed.

CONCLUSIONS

Prophylactic MVSE is a safe procedure that reduces operative blood loss and transfusion requirements compared to those of IIABO in patients undergoing cesarean hysterectomy for presumed higher-degree PAS.

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.

Risk factors of MRI findings for predicting patient outcomes of placenta accreta spectrum and placenta previa after prophylactic balloon occlusion of the internal iliac artery

PURPOSE

Our study aimed to identify the risk factors of magnetic resonance imaging (MRI) findings for predicting patient outcomes of placenta accreta spectrum (PAS) and placenta previa after prophylactic balloon occlusion of the internal iliac artery (PBOIIA).

MATERIALS AND METHODS

This retrospective analysis was performed using the clinical records of 46 patients diagnosed with PAS and placenta previa who underwent PBOIIA during caesarean section (CS). The possible clinical risk factors for adverse maternal outcomes were evaluated by consulting patients' clinical records. The inclusion criteria for the massive bleeding group were as follows: estimated blood loss (EBL) > 2500 mL, packed red blood cell (pRBC) transfusion (>4 units), and need for hysterectomy or transcatheter arterial embolization after delivery. The MRI features were compared between the massive and non-massive bleeding groups.

RESULTS

Patients in the massive bleeding group (n = 22) had a significantly longer operation time (p < 0.001), more EBL (p < 0.001), more pRBC transfusions (p < 0.001), and a prolonged postoperative hospital stay (p < 0.05). MRI features showed a T2 dark bands, placenta bulge, and abnormal blood vessels in the placental bed more frequently in the massive bleeding group (p < 0.05). In the multiple logistic regression analysis, T2 dark bands (odds ratio 9.1, p = 0.048) and placental bulge (odds ratio 5.1, p = 0.014) remained statistically significant.

CONCLUSION

T2 dark bands and placental bulges observed on an MRI can predict adverse maternal outcomes in patients with PAS and placenta previa undergoing PBOIIA. If these findings are observed on a preoperative MRI, effective management strategies should be prepared for the possibility of massive hemorrhage during CS.

Placenta accreta risk-antepartum score in predicting clinical outcomes of placenta accreta spectrum: A multicenter validation study

OBJECTIVE

To validate the use of placenta accreta risk-antepartum (PAR-A) score as a predictive tool of clinical outcomes of placenta accreta spectrum (PAS).

METHODS

This is a prospective study, conducted in six PAS specialized centers in six different countries. The study was conducted between October 1, 2020 and March 31, 2021. Women who were provisionally diagnosed with PAS during pregnancy were considered eligible. A machine-learning-based PAR-A score was calculated. Diagnostic performance of the PAR-A score was evaluated using a receiver operating characteristic curve, for perioperative massive blood loss and admission to intensive care unit (ClinicalTrials.gov identifier NCT04525001).

RESULTS

Of 97 eligible women, 86 were included. PAS-associated massive blood loss occurred in 10 patients (11.63%). Median PAR-A scores of massive blood loss in the current cohort were 8.9 (interquartile range 6.9-14.1). In predicting massive blood loss, the area under the curve of PAR-A scores was 0.85 (95% confidence interval [CI] 0.74-0.95), which was not significantly different from the original cohort (P = 0.2). PAR-A score prediction of intensive care unit admission was slightly higher compared with the original cohort (0.88, 95% CI 0.81-0.95; P = 0.06).

CONCLUSION

PAR-A score is a novel scoring system of PAS outcomes, which showed external validity based on current data.

Current Resources for Evidence-Based Practice, September 2021

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes an assessment of safety of birth centers in the United States and commentaries on reviews focused on aspirin prophylaxis in pregnancy and the new gestational weight gain evidence summary from the United States Preventive Services Task Force.