Role of prophylactic uterine artery balloon catheters in the management of women with suspected placenta accreta

Prophylactic temporary abdominal aortic balloon occlusion for patients with pernicious placenta previa: a retrospective study

BACKGROUND

Pernicious placenta previa (PPP) can increase the risk of perioperative complications. During caesarean section in patients with adherent placenta, intraoperative blood loss, hysterectomy rate and transfusion could be reduced by interventional methods. Our study aimed to investigate the influence of maternal hemodynamics control and neonatal outcomes of prophylactic temporary abdominal aortic balloon (PTAAB) occlusion for patients with pernicious placenta previa.

METHODS

This was a retrospective study using data from the Peking University People's Hospital from January 2014 through January 2020. Clinical records of pregnant women undergoing cesarean section were collected. Patients were divided into two groups: treatment with PTAAB placement (group A) and no balloon placement (group B). Group A was further broken down into two groups: prophylactic placement (Group C) and balloon occlusion (group D).

RESULTS

Clinical records of 33 cases from 5205 pregnant women underwent cesarean section were collected. The number of groups A, B, C, and D were 17, 16, 5 and 12.We found that a significant difference in the post-operative uterine artery embolism rates between group A and group B (0% vs.31.3%, p = 0.018). There was a significant difference in the Apgar scores at first minute between group A and group B (8.94 ± 1.43 vs 9.81 ± 0.75,p = 0.037),and the same significant difference between two groups in the pre-operative central placenta previa (29.4% vs. 0%,p = 0.044), complete placenta previa (58.8% vs 18.8%, p = 0.032),placenta implantation (76.5% vs 31.3%, p = 0.015). We could also observe the significant difference in the amount of blood cell (2.80 ± 2.68vs.10.66 ± 11.97, p = 0.038) and blood plasma transfusion (280.00 ± 268.32 vs. 1033.33 ± 1098.20, p = 0.044) between group C and group D. The significant differences in the preoperative vaginal bleeding conditions (0% vs 75%, p = 0.009), the intraoperative application rates of vasopressors (0% vs. 58.3%, p = 0.044) and the postoperative ICU (intensive care unit) admission rates (0% vs. 58.3%, p = 0.044) were also kept.

CONCLUSIONS

PTAAB occlusion could be useful in reducing the rate of post-operative uterine artery embolism and the amount of transfusion, and be useful in coping with patients with preoperative vaginal bleeding conditions, so as to reduce the rate of intraoperative applications of vasopressors and the postoperative ICU (intensive care unit) admission. In PPP patients with placenta implantation, central placenta previa and complete placenta previa, we advocate the utilization of prophylactic temporary abdominal aortic balloon placement.

The effect prophylactic internal iliac artery balloon occlusion in patients with placenta previa or placental accreta spectrum: a systematic review and meta-analysis

BACKGROUND

Placenta previa describes a placenta that extends partially or completely over the internal cervical oss. Placenta previa is one of the leading causes of widespread postpartum hemorrhage and maternal mortality worldwide. Another cause of bleeding in pregnant women is Placenta accreta spectrum. Therefore, the aim of the present systematic review and meta-analysis is to determine the effect of prophylactic balloon occlusion of the internal iliac arteries in patients with placenta previa or placental accreta spectrum (PAS).

METHODS

In this systematic review and meta-analysis, to identify and select relevant studies, the SID, MagIran, ScienceDirect, Embase, Scopus, PubMed, Web of Science, and Google Scholar databases were searched, using the keywords of internal iliac artery balloon, placenta, previa, balloon, accreta, increta and percreta, without a lower time limit and until 2020. The heterogeneity of the studies was examined using the I² index, and subsequently a random effects model was applied. Data analysis was performed within the Comprehensive Meta-Analysis software (version 2).

RESULTS

In the review of 29 articles with a total sample size of 1140 in the control group, and 1225 in the balloon occlusion group, the mean difference between the two groups was calculated in terms of Intraoperative blood loss index (mL) and it was derived as 3.21 ± 0.38; moreover, in 15 studies with a sample size of 887 in the control group, and 760 in the balloon occlusion group, the mean difference between the two groups in terms of gestation index (weeks) was found as 2.84 ± 0.49; and also with regards to hysterectomy balloon occlusion after prophylactic closure of the iliac artery, hysterectomy (%) balloon occlusion was calculated as 8.9 %, and this, in the hysterectomy control group (%) was obtained as 31.2 %; these differences were statistically significant and showed a positive effect of the intervention (P < 0.05).

CONCLUSION

The results of this study show that the use of prophylactic internal iliac artery balloon occlusion in patients with placenta previa or Placenta accreta spectrum has benefits such as reduced intraoperative blood loss, reduced hysterectomy and increased gestation (weeks), which can be considered by midwives and obstetricians.

A practical FIST maneuver to minimize the bleeding during cesarean hysterectomy for placenta percreta: a retrospective comparative study

BACKGROUND

Placenta percreta (PP) is a life-threatening condition and its surgery poses a very high potential for bleeding. The recommended treatment is a cesarean hysterectomy. There are several techniques reported in the literature to reduce the bleeding during percreta operations.

OBJECTIVE

To show and describe a practical and novel intraoperative maneuver to minimize the hemorrhage during cesarean hysterectomy for PP.

METHODS

The patients who were diagnosed with PP and underwent cesarean hysterectomy (CH) in our unit between 2016 and 2020 were retrospectively evaluated. These patients were divided into two groups. Group A included patients who underwent hysterectomy with intraoperative FIST maneuver. Group B included patients with ordinary cesarean hysterectomy. The groups were compared with regards to the intraoperative bleeding, surgical complications, and perioperative outcomes.

RESULTS

Seventy-two patients who had a cesarean hysterectomy and diagnosed with PP during the study period were included in this retrospective cohort. 22 patients underwent intraoperative FIST maneuver with CH as Group A and 50 patients underwent ordinary CH as Group B. The demographic variables including maternal age, gravida, number of previous cesarean sections, and body-mass index were not statistically different between the two groups. Intraoperative FIST maneuver was significantly associated with reduced operative hemorrhage, the need for transfusion of erythrocyte suspension, admission to intensive care unit, and hospitalization days (p < .005). The operative time was statistically significantly shorter in Group A than Group B, respectively (90 ± 18.6 vs 120 ± 20.5 min) (p < .05).

CONCLUSION

FIST maneuver is a very practical, easy to apply, and effective method that reduces the obstetrical bleeding during cesarean hysterectomy in placenta percreta cases.

High-intensity focused ultrasound in management of placenta accreta spectrum: A systematic review

BACKGROUND

High-intensity focused ultrasound (HIFU) is a non-invasive procedure that has been studied in the management of placenta accreta spectrum (PAS).

OBJECTIVE

To appraise HIFU in the management of PAS and highlight the restrictions on converting uterus-preserving studies into evidence-based practice.

SEARCH STRATEGY

A search on Scopus, Cochrane, PubMed and Web of Science was conducted from date of inception to January 2020.

SELECTION CRITERIA

Studies on using HIFU in the management of PAS were eligible. Review articles, conference papers, and case reports were excluded.

DATA COLLECTION

A standardized sheet was used to abstract data from eligible studies. CON-PAS registry was used to include studies on other conservative modalities.

RESULTS

Four studies were eligible (399 patients). Average residual placental volume was 61.74 cm³ (6.01-339 cm³ ). Treatment was successful in all patients. Normal menstruation recovered after 48.8 days (15-150 days). No major complications were encountered. Sixty-one studies were retrieved from the CON-PAS registry; uterine artery embolization (23 studies), balloon placement (15 studies), compression sutures (10 studies), placenta in situ (7 studies), and uterine resection (6 studies) were successful in 83.7%, 92.9%, 87.9%, 85.2%, and 79.3% of cases, respectively.

CONCLUSIONS

HIFU may fit certain clinical situations in the management of PAS. A global research strategy is recommended to incorporate conservative approaches within a comprehensive management protocol.

Perioperative prophylactic internal iliac artery balloon occlusion in the prevention of postpartum hemorrhage in placenta previa: a randomized controlled trial

BACKGROUND

Placenta previa remains one of the major causes of massive postpartum hemorrhage and maternal mortality worldwide.

OBJECTIVE

To determine whether internal iliac artery balloon occlusion during cesarean delivery for placenta previa could reduce postpartum hemorrhage and other maternal complications.

STUDY DESIGN

This was a prospective randomized controlled trial conducted at a tertiary university obstetric unit in Hong Kong. Pregnant women who were diagnosed to have placenta previa at 34 weeks (defined as lower placenta edge within 2 cm from the internal os) and required cesarean delivery were invited to participate. Eligible pregnant women were randomized into internal iliac artery balloon occlusion (Occlusion) group or standard management (Control) group. Those randomized to the Occlusion group had internal iliac artery balloon catheter placement performed before cesarean delivery and then balloon inflation after delivery of the baby. The primary outcome was the reduction of postpartum hemorrhage in those with internal iliac artery balloon occlusion. Secondary outcome measures included hemoglobin drop after delivery; amount of blood product transfusion; incidence of hysterectomy; maternal complications including renal failure, ischemic liver, disseminated intravascular coagulation, and adult respiratory distress syndrome; length of stay in hospital; admission to intensive care unit; and maternal death.

RESULTS

Between May 2016 and September 2018, 40 women were randomized (20 in each group). Demographic and obstetric characteristics were similar between the 2 groups. In the Occlusion group, 3 women did not receive the scheduled procedure, as it was preceded by antepartum hemorrhage that required emergency cesarean delivery, and 1 woman had repeated scan at 36 weeks showing the placental edge was slightly more than 2 cm from the internal os. Intention-to-treat analysis found no significant differences between the Occlusion and the Control groups regarding to the median intraoperative blood loss (1451 [1024-2388] mL vs 1454 [888-2300] mL; P = .945), the median length of surgery (49 [30-62] min vs 37 [30-51] min; P = .204), or the need for blood transfusion during operation (57.9% vs 50.0%; P = .621). None of the patients had rebleeding after operation, complication related to internal iliac artery procedure, or any other maternal complications. Reanalyzing the data using on-treatment approach showed the same results.

CONCLUSION

The use of prophylactic internal iliac artery balloon occlusion in placenta previa patients undergoing cesarean delivery did not reduce postpartum hemorrhage or have any effect on maternal or neonatal morbidity.

Control of postpartum hemorrhage in women with placenta accreta spectrum using prophylactic balloon occlusion combined with Pituitrin intra-arterial infusion

OBJECTIVES

The aim of this study is to evaluate the efficacy of prophylactic internal iliac artery balloon occlusion combined with Pituitrin intra-arterial infusion in the control of postpartum hemorrhage in women with placenta accreta spectrum (PAS).

METHODS

This is a prospective and non-randomized controlled study. The participants were assigned into three groups: without balloon catheterization (non-BC) group, balloon catheterization (BC) group, and Pituitrin combined with balloon catheterization (PBC) group. The primary outcomes were estimated blood loss (EBL) and the units of transfused packed red blood cells (PRBC). The secondary outcome was the incidence of hysterectomy.

RESULTS

A total of 100 participants were recruited between August 2013 and November 2018 and assigned into the respective groups as follows: 27 in the non-BC group, 22 in the BC group, and 51 in the PBC group. No statistical differences were found in demographic characteristics among the three groups. There was a trend of lower EBL, PRBC, and hysterectomy rate in the BC group than those in the non-BC group, while all values showed no significant differences (all p > 0.05). Patients in the PBC group had significantly lower EBL, PRBC, and hysterectomy rate compared with those in the non-BC group (all p < 0.05). Linear regression analysis revealed that the PBC (vs. others) was negatively correlated with EBL and the non-BC (vs. others) independently predicted more EBL.

CONCLUSIONS

Balloon occlusion combined with Pituitrin infusion is an effective treatment method which significantly reduced EBL, PRBC, and hysterectomy rate in patients with PAS.

KEY POINTS

• Internal iliac artery balloon occlusion combined with Pituitrin intra-arterial infusion can significantly decrease EBL, PRBC, and hysterectomy rate during cesarean section in patients with PAS. • Cesarean section without balloon occlusion and placenta accreta depth are two independent risk factors for EBL in patients with PAS.

Application of ultrasound-guided balloon occlusion in cesarean section in 130 cases of sinister placenta previa

Objective

To investigate the clinical utility of ultrasound-guided balloon occlusion in cesarean section in patients with sinister placenta previa.

Methods

The Interventional and Ultrasound Departments of the authors’ center assisted obstetrics to complete cesarean section in cases of sinister placenta previa. A total of 130 patients with implanted sinister placenta previa were diagnosed using obstetrical ultrasound and magnetic resonance imaging (MRI). Before cesarean section, the balloon was positioned in the bilateral radial or abdominal aorta. Immediately after delivery of the fetus, the balloon was temporarily filled to transiently seal the target vessel. According to the obstetrician’s assessment of hemostasis, the balloon was withdrawn at the appropriate time. Among the 130 patients, there was one case of abdominal aortic occlusion, with 129 cases blocked by the bilateral common iliac artery.

Results

All 130 cases were successfully blocked, with an average blocking time of <15 ​min, while intraoperative blood loss was 800–1500 ​ml.

Conclusion

Ultrasound-guided balloon blocking treatment before cesarean section can mitigate the dangers of placenta previa and significantly reduce blood loss with no exposure to X-ray radiation. Thus, the technique merits serious consideration.

•

The incidence of major bleeding and postpartum hemorrhage in related procedures have increased, seriously threatening the lives of mothers.

•

All 130 cases were successfully blocked, with an average blocking time <15 ​min, with intraoperative blood loss ranging from 800 to 1500 ​ml.

•

Preoperative ultrasound-guided balloon blocking treatment before cesarean section can mitigate the dangers of placenta previa.

•

Significantly reduce blood loss with no exposure to X-ray radiation. As such, the technique merits serious consideration.

Can the combination of internal iliac temporary occlusion and uterine artery embolization reduce bleeding and the need for intraoperative blood transfusion in cases of invasive placentation?

OBJECTIVES

Women with invasive placentation (IP) are at high risk of life-threatening hemorrhage. In the last two decades, less invasive surgical approaches combined with endovascular procedures have proven to be safe. Most case series describe the use of temporary balloon occlusion and embolization, either combined or not. Concerning hemorrhage rates, each separate interventional approach performs better than surgery alone does, yet it is not clear whether the combination of multiple interventional techniques can be beneficial and promote a lower incidence of intrapartum bleeding. We aim to evaluate whether combining temporary balloon occlusion of the internal iliac artery and uterine artery embolization promotes better hemorrhage control than do other individual interventional approaches reported in the scientific literature in the context of cesarean birth followed by hysterectomy in patients with IP.

METHODS

This is a retrospective analysis of patients with confirmed IP who underwent temporary balloon occlusion and embolization of the internal iliac arteries followed by puerperal hysterectomy. We compared patient results to data extracted from a recent systematic review and meta-analysis of the current literature that focused on interventional procedures in patients with IP.

RESULTS

A total of 35 patients underwent the procedure during the study period in our institution. The mean volume of packed red blood cells and the estimated blood loss were 487.9 mL and 1193 mL, respectively. Four patients experienced complications that were attributed to the endovascular procedure.

CONCLUSION

The combination of temporary balloon occlusion and uterine artery embolization does not seem to promote better hemorrhage control than each procedure performed individually does.

Risk factors for abnormally invasive placenta: a systematic review and meta-analysis

Purpose of the article. To explore the strength of association between different maternal and pregnancy characteristics and the occurrence of abnormally invasive placenta (AIP).Materials and methods: Pubmed, Embase, CINAHL databases were searched. The risk factors for AIP explored were: obesity, age >35 years, smoking before or during pregnancy, placenta previa, prior cesarean section (CS), placenta previa and prior CS, prior uterine surgery, abortion and uterine curettage, in vitro fertilization (IVF) pregnancy and interval between a previous CS, and a subsequent pregnancy. Random-effect head-to-head meta-analyses were used to analyze the data.Results: Forty-six were included in the systematic review. Maternal obesity (Odd ratio, OR: 1.4, 95% CI 1.0-1.8), advanced maternal age (OR: 3.1, 95% CI 1.4-7.0) and parity (OR: 2.5, 95% CI 1.7-3.6), but not smoking were associated with a higher risk of AIP. The presence of placenta previa in women with at least a prior CS was associated with a higher risk of AIP compared to controls, with an OR of 12.0, 95% CI 1.6-88.0. Furthermore, the risk of AIP increased with the number of prior CS (OR of 2.6, 95% CI 1.6-4.4 and 5.4, 95% CI 1.7-17.4 for two and three prior CS respectively). Finally, IVF pregnancies were associated with a high risk of AIP, with an OR of 2.8 (95% CI 1.2-6.8).Conclusion: A prior CS and placenta previa are among the strongest risk factors for the occurrence of AIP.

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

PURPOSE

To report on outcomes following the use of prophylactic internal iliac artery occlusion balloons in patients with abnormal placental implantation.

METHODS

A retrospective analysis was undertaken of patients with abnormal placental implantation who underwent prophylactic iliac balloon placement prior to delivery in a University Maternity Hospital. Various clinical and technical factors were analysed, including technical success of balloon placement, blood loss and number of blood units transfused, duration of surgery, length of stay, hysterectomy rates, complications related to the balloon insertion, foetal pH and infant Apgar scores.

RESULTS

Twenty-two patients with placenta accreta or a variant thereof underwent caesarean section after first undergoing prophylactic placement of bilateral internal artery balloons. Average follow-up duration was 2.08 years. The average gestational age was 37 weeks 6 days, and the mean gravidity was 2.8. The mean number of previous caesarean sections was 2.4, while the mean maternal age was 35 years. The mean intraoperative blood loss was 1.4 L, and the mean number of blood units transfused was 2. Mean duration of surgery was 90 min, mean total length of hospital stay 7.5 days, while the mean duration of ICU/HDU stay was 1.2 days. The balloons were inflated in 60% of cases and two patients (2/22-9%) underwent subsequent hysterectomy. There were no major maternal complications due to the procedure.

CONCLUSION

Prophylactic placement of arterial balloons prior to caesarean section in patients with placenta accreta is well tolerated and leads to satisfactory maternal and foetal outcomes with minimal complications.

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.

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.

Prophylactic abdominal aorta balloon occlusion during caesarean section: a retrospective case series

BACKGROUND

The management of patients with morbidly adherent placenta has been described using vascular balloon catheters placed in the iliac arteries, but rarely in the aorta. This case series presents our experience with prophylactic lower abdominal aorta balloon occlusion in 45 women.

METHODS

The records of patients in our centre who underwent caesarean section between May 2013 and June 2014 were retrospectively analysed for the use of prophylactic lower abdominal aorta balloon occlusion.

RESULTS

Forty-five cases were identified. All patients had a morbidly adherent placenta, including placenta accreta (n=22), placenta increta (n=20) and placenta percreta (n=3). A subtotal hysterectomy was performed in four cases. Eleven of the 45 patients received red blood cell transfusion of a mean of 1.7 units. Mean preoperative and postoperative haemoglobin concentrations were 10.1g/dL and 9.4g/dL, respectively. Mean estimated blood loss was 835mL [range 200-6000mL]. The incidence of complications was 4.4% (2/45), including one case of lower extremity arterial thrombosis and one case of ischaemic injury to the femoral nerve. Follow up at one year was completed in 22 patients at which time all babies were well.

CONCLUSIONS

Prophylactic lower abdominal aorta balloon occlusion has the potential to reduce intraoperative blood loss, transfusion and hysterectomy rate in patients with morbidly adherent placenta undergoing caesarean section. Careful patient selection is critical as the technique may be associated with potentially serious complications.

Estimating the Radiation Dose to the Fetus in Prophylactic Internal Iliac Artery Balloon Occlusion: Three Cases

Background. Although radiation exposure is of great concern to expecting patients, little information is available on the fetal radiation dose associated with prophylactic internal iliac artery balloon occlusion (IIABO). Here we estimated the fetal radiation dose associated with prophylactic IIABO in Caesarean section (CS). Cases. We report our experience with the IIABO procedure in three consecutive patients with suspected placenta previa/accreta. Fetal radiation dose measurements were conducted prior to each CS by using an anthropomorphic phantom. Based on the simulated value, we calculated the fetal radiation dose as the absorbed dose. We found that the fetal radiation doses ranged from 12.88 to 31.6 mGy. The fetal radiation dose during the prophylactic IIABOs did not exceed 50 mGy. Conclusion. The IIABO procedure could result in a very small increase in the risk of harmful effects to the fetus.

Anesthetic management of placenta accreta in a low-resource setting: a case series

BACKGROUND

Current recommendations for the anesthetic management of placenta accreta support a conservative approach with neuraxial anesthesia and uterine artery embolization. These are based on case series from experienced centers in developed countries. The aim of this study was to describe the anesthetic management of placenta accreta in a low-resource setting.

METHODS

A retrospective case note review was performed. From 1 August 2006 to 31 July 2011 placentas from cases of suspected placenta accreta were reassessed histologically to confirm the diagnosis. Patient charts were reviewed and information on anesthetic technique, monitoring, blood transfusion, maternal and fetal outcomes was extracted.

RESULTS

Thirty-nine cases were identified. Mean (± SD) maternal age was 33 ± 5.4 years. Hysterectomy was performed at the time of cesarean section in all cases. Thirty-four patients received neuraxial anesthesia, of whom 15 required conversion to general anesthesia. Invasive blood pressure monitoring was used in all patients and a central venous catheter was inserted in 33 cases. Complications associated with monitoring occurred in five patients. Median [IQR] blood loss was 2000 [1100-2700] mL and the median [IQR] number of units of red blood cell transfused was 2 [0-6]. Vasoactive medication was used in 14 patients and 15 patients were transferred to the intensive care unit postoperatively. No maternal or newborn deaths occurred.

CONCLUSION

A multidisciplinary approach can prove valuable when placenta accreta is suspected before delivery. In low-resource settings, lack of interventional radiology services and prenatal diagnostic capability may have an impact on anesthetic management in patients with placenta accreta. However, other than greater blood loss, our study demonstrated that good maternal and neonatal outcomes are possible in spite of limited resources.

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.

[An update of the obstetrics hemorrhage treatment protocol]

Obstetric hemorrhage is still a major cause of maternal and fetal morbimortality in developed countries. This is an underestimated problem, which usually appears unpredictably. A high proportion of the morbidity of obstetric hemorrhage is considered to be preventable if adequately managed. The major international clinical guidelines recommend producing consensus management protocols, adapted to local characteristics and keep them updated in the light of experience and new scientific publications. We present a protocol updated, according to the latest recommendations, and our own experience, in order to be used as a basis for those anesthesiologists who wish to use and adapt it locally to their daily work. This last aspect is very important to be effective, and is a task to be performed at each center, according to the availability of resources, personnel and architectural features.

Challenges in interventional radiology: the pregnant patient

A pregnant patient presenting to interventional radiology (IR) has a different set of needs from any other patient requiring a procedure. Often, the patient's care can be in direct conflict with the growth and development of the fetus, whether it be optimal fluoroscopic imaging, adequate sedation of the mother, or the timing of the needed procedure. Despite the additional risks and complexities associated with pregnancy, IR procedures can be performed safely for the pregnant patient with knowledge of the special and general needs of the pregnant patient, use of acceptable medications and procedures likely to be encountered during pregnancy, in addition to strategies to protect the patient and her fetus from the hazards of radiation.