Placenta Accreta: Management with Uterine Artery Embolization in 17 Cases

Comparison of maternal outcomes and clinical characteristics of prenatally vs nonprenatally diagnosed placenta accreta spectrum: a systematic review and meta-analysis

OBJECTIVE

This study aimed to compare maternal outcomes of prenatally and nonprenatally diagnosed placenta accreta spectrum.

DATA SOURCES

A systematic literature search was performed in PubMed, the Cochrane database, and Web of Science until November 28, 2022.

STUDY ELIGIBILITY CRITERIA

Studies comparing the clinical presentation of prenatally and nonprenatally diagnosed placenta accreta spectrum were included. The primary outcomes were emergent cesarean delivery, hysterectomy, blood loss volume, number of transfused blood product units, urological injury, coagulopathy, reoperation, intensive care unit admission, and maternal death. In addition, the pooled mean values for blood loss volume and the number of transfused blood product units were calculated. The secondary outcomes included maternal age, gestational age at birth, nulliparity, previous cesarean delivery, previous uterine procedure, assisted reproductive technology, placenta increta and percreta, and placenta previa.

METHODS

Study screening was performed after duplicates were identified and removed. The quality of each study and the publication bias were assessed. Forest plots and I2 statistics were calculated for each study outcome for each group. The main analysis was a random-effects analysis.

RESULTS

Overall, 415 abstracts and 157 full-text studies were evaluated. Moreover, 31 studies were analyzed. Prenatally diagnosed placenta accreta spectrum was associated with a significantly lower rate of emergency cesarean delivery (odds ratio, 0.37; 95% confidence interval, 0.21-0.67), higher hysterectomy rate (odds ratio, 1.98; 95% confidence interval, 1.02-3.83), lower blood loss volume (mean difference, -0.65; 95% confidence interval, -1.17 to -0.13), and lower number of transfused red blood cell units (mean difference, -1.96; 95% confidence interval, -3.25 to -0.68) compared with nonprenatally diagnosed placenta accreta spectrum. The pooled mean values for blood loss volume and the number of transfused blood product units tended to be lower in the prenatally diagnosed placenta accreta spectrum groups than in the nonprenatally diagnosed placenta accreta spectrum groups. Nulliparity (odds ratio, 0.14; 95% confidence interval, 0.10-0.20), previous cesarean delivery (odds ratio, 6.81; 95% confidence interval, 4.12-11.25), assisted reproductive technology (odds ratio, 0.19; 95% confidence interval, 0.06-0.61), placenta increta and percreta (odds ratio, 3.97; 95% confidence interval, 2.24-7.03), and placenta previa (odds ratio, 6.81; 95% confidence interval, 4.12-11.25) showed statistical significance. No significant difference was found for the other outcomes.

CONCLUSION

Despite its severity, the positive effect of prenatally diagnosed placenta accreta spectrum on outcomes underscores the necessity of a prenatal diagnosis. In addition, the pooled mean values provide a preoperative preparation guideline.

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.

Placenta Accreta Spectrum: The Role of Interventional Radiology in Multidisciplinary Management

Placenta accreta spectrum is increasing in prevalence and poses significant risks to obstetric patients. This article defines characteristics, diagnosis, management, and outcomes of placenta accreta spectrum, highlighting interventional radiology's role in its management as part of a multidisciplinary approach.

Uterine artery embolization for postpartum hemorrhage with placenta accreta spectrum

BACKGROUND

The reported success rate of uterine artery embolization (UAE) for postpartum hemorrhage (PPH) differs by the cause of bleeding; in some reports, UAE shows less successful results in patients with placenta accreta spectrum (PAS).

PURPOSE

To evaluate the outcome of UAE for treating PPH associated with PAS.

MATERIAL AND METHODS

From September 2011 to September 2021, 227 patients (mean age = 34.67±4.06 years; age range = 19-47 years) underwent UAE for managing intractable PPH. Patients were divided into two groups: those with PAS (n = 46) and those without PAS (n = 181). Delivery details, embolization details, and procedure-related outcomes were compared between the two groups. P values <0.05 were considered statistically significant.

RESULTS

The technical success rate was 96.9% (n = 222) and the clinical success rate was 93.8% (n = 215). There were no significant differences in outcome of UAE between the two patient groups. The technical success rate was 95.7% (n = 44) in patients with PAS and 98.3% (n = 178) in patients without PAS (P = 0.267). The clinical success rate was 91.3% (n = 42) in patients with PAS and 95.6% (n = 173) in patients without PAS (P = 0.269). There were 24 cases of immediate complications, including pelvic pain (n = 20), urticaria (n = 3), and puncture site hematoma (n = 1). No major complication was reported.

CONCLUSION

UAE is a safe and effective method to control intractable PPH for patients with or without PAS.

Transfusion Requirements with Hybrid Management of Placenta Accreta Spectrum Incorporating Targeted Embolization and a Selective Use of Delayed Hysterectomy

OBJECTIVE

This study compares the number of units of red blood cells (RBCs) transfused in patients with placenta accreta spectrum (PAS) treated with or without a multidisciplinary algorithm that includes placental uterine arterial embolization (P-UAE) and selective use of either immediate or delayed hysterectomy.

STUDY DESIGN

This is a retrospective study of deliveries conducted at a tertiary care hospital from 2001 to 2018 with pathology-confirmed PAS. Those with previable pregnancies or microinvasive histology were excluded. To improve the equity of comparison, analyses were made separately among scheduled and unscheduled cases, therefore patients were assigned to one of four cohorts as follows: (1) scheduled/per-algorithm, (2) scheduled/off-algorithm, (3) unscheduled/per-algorithm, or (4) unscheduled/off-algorithm. Primary outcomes included RBCs transfused and estimated blood loss (EBL). Secondary outcomes included perioperative complications and disposition.

RESULTS

Overall, 95 patients were identified, with 87 patients meeting inclusion criteria: 36 treated per-algorithm (30 scheduled and 6 unscheduled) and 51 off-algorithm patients (24 scheduled and 27 unscheduled). Among scheduled deliveries, 9 (30.0%) patients treated per-algorithm received RBCs compared with 20 (83.3%) patients treated off-algorithm (p < 0.01), with a median (interquartile range [IQR]) of 3.0 (2.0, 4.0) and 6.0 (2.5, 7.5) units transfused (p = 0.13), respectively. Among unscheduled deliveries, 5 (83.3%) per-algorithm patients were transfused RBCs compared with 25 (92.6%) off-algorithm patients (p = 0.47) with a median (IQR) of 4.0 (2.0, 6.0) and 8.0 (3.0, 10.0) units transfused (p = 0.47), respectively. Perioperative complications were similar between cohorts.

CONCLUSION

A multidisciplinary algorithm including P-UAE and selective use of delayed hysterectomy is associated with a lower rate of blood transfusion in scheduled but not unscheduled cases.

KEY POINTS

· An algorithm with delayed hysterectomy had less transfusion in scheduled, but not unscheduled, cases.. · Over time, more cases were managed per algorithm; among scheduled cases, the transfusion rate and volume transfused decreased.. · There were similar transfusion outcomes among off-algorithm cases, regardless if delivery was scheduled..

Endovascular uterine artery interventions

Percutaneous vascular embolization plays an important role in the management of various gynecologic and obstetric abnormalities. Transcatheter embolization is a minimally invasive alternative procedure to surgery with reduced morbidity and mortality, and preserves the patient's future fertility potential. The clinical indications for transcatheter embolization are much broader and include many benign gynecologic conditions, such as fibroid, adenomyosis, and arteriovenous malformations (AVMs), as well as intractable bleeding due to inoperable advanced-stage malignancies. The most well-known and well-studied indication is uterine fibroid embolization. Uterine artery embolization (UAE) may be performed to prevent or treat bleeding associated with various obstetric conditions, including postpartum hemorrhage (PPH), placental implantation abnormality, and ectopic pregnancy. Embolization of the uterine artery or the internal iliac artery also may be performed to control pelvic bleeding due to coagulopathy or iatrogenic injury. This article discusses these gynecologic and obstetric indications for transcatheter embolization and reviews procedural techniques and outcomes.

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 comparison of results following the treatment of placenta accreta and placenta increta using high-intensity focused ultrasound followed by hysteroscopic resection

OBJECTIVE

To compare the safety and efficacy of high-intensity focused ultrasound (HIFU) followed by hysteroscopic resection for different placenta accreta spectrum disorders.

MATERIALS AND METHODS

Thirty-four patients with placenta accreta, placenta increta, or placenta percreta were treated with USgHIFU from January 2016 to December 2019 and were retrospectively reviewed. The patients were classified into three categories according to the relationship between the trophoblastic villi and the myometrium, based on magnetic resonance imaging (MRI). Fifteen patients were classified as placenta accreta, 17 patients were classified as placenta increta, and 2 were classified as placenta percreta. All patients completed follow-up. Treatment efficacy and safety were evaluated.

RESULTS

No significant differences in baseline characteristics and results of HIFU ablation were observed between the patients with placenta accreta and those with placenta increta. The return of HCG levels to normal was longer in patients with placenta accreta compared with patients with placenta increta, while no significant difference was observed in the amount of intraoperative blood loss, the return of normal menstruation and the length of hospital stay.

CONCLUSIONS

HIFU treatment followed by hysteroscopic resection is safe and effective in the treatment of patients with placenta accreta and placenta increta.

Postpartum Hemorrhage: Rescue

Severe postpartum hemorrhage (PPH) occurs in around 1%-2% of deliveries and is a leading cause of maternal mortality and morbidity worldwide. Different treatments of PPH are proposed by the scientific society's guidelines; to date, pelvic artery embolization is an effective therapeutic strategy with the advantages of fast speed, repeatability, and the possibility of future fertility preservation. We compared the different PPH treatments, focusing especially on the role of interventional radiology reviewing pelvic vascular anatomy and emphasizing on the timing of embolization and various clinical conditions of PPH.

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.

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.

Clinical applications of digital angiography with the harmonization function in body interventional radiology

Digital subtraction angiography (DSA) is frequently applied in interventional radiology (IR). When DSA is not useful due to misregistration, digital angiography (DA) as an alternative option is used. In DA, the harmonization function (HF) works in real time by harmonizing the distribution of gray steps or reducing the dynamic range; thus, it can compress image gradations, decrease image contrast, and suppress halation artifacts. DA with HF as a good alternative to DSA is clinically advantageous in body IR for generating DSA-like images and simultaneously reducing various motion artifacts and misregistrations caused by patient body motion, poor breath-holding, bowel and ureter peristalsis, and cardiac pulsation as well as halation artifacts often stemming from the lung field. Free-breath DA with HF can improve body IR workflow and decrease the procedure time by reducing the risk of catheter dislocation and using background structures as anatomical landmarks, demonstrating reduced radiation exposure relative to DSA. Thus, HF should be more widely and effectively utilized for appropriate purposes in body IR. This article illustrates the basic facts and principles of HF in DA, and demonstrates clinical advantages and limitations of this function in body IR.

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.

Prophylactic uterine artery embolization during cesarean delivery for placenta previa complicated by placenta accreta

OBJECTIVE

To evaluate the efficacy and safety of prophylactic uterine artery embolization (UAE) during cesarean delivery for women with placenta previa complicated by placenta accreta.

METHODS

A retrospective analysis of women with placenta previa admitted to The Second Affiliated Hospital of Soochow University, Suzhou, China, for elective cesarean between February 2003 and July 2016. Postpartum estimated blood loss, blood transfusion, hysterectomy, disseminated intravascular coagulation (DIC) incidence, intensive care unit (ICU) duration, and postoperative stay were compared between control women who underwent cesarean delivery only and women who underwent prophylactic intraoperative UAE during cesarean.

RESULTS

There were 28 and 26 women in the UAE and control group, respectively. There were no differences in hysterectomy incidence (P=0.291), or duration of ICU stay (P=0.085), or postoperative hospitalization (P=0.668) between the groups; however, the incidence of DIC was lower in the UAE group (P=0.035). Mean estimated blood loss (P=0.018) and blood transfusion (P=0.011) were also lower in the UAE group. No serious complications were associated with the endovascular procedures.

CONCLUSION

Prophylactic intraoperative UAE seemed to effectively reduce blood loss, need for blood transfusion, and incidence of DIC among women with placenta previa complicated by placenta accreta.

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.

Influence of prenatal diagnosis of abnormally invasive placenta on maternal outcome: systematic review and meta-analysis

OBJECTIVE

To ascertain the impact of prenatal diagnosis on surgical outcome of women affected by abnormally invasive placenta (AIP).

METHODS

MEDLINE, EMBASE, CINAHL and Cochrane databases were searched. Observed outcomes included: gestational age at birth (weeks), amount of blood loss (L), units of red blood cells (RBC), platelets (PLT) and fresh frozen plasma (FFP) transfused, length of stay in hospital and the intensive care unit (ICU) (days), urinary tract injury and infection. Only studies reporting the occurrence of any of the explored outcomes in women with a prenatal compared with an intrapartum diagnosis of AIP were considered eligible for inclusion. Random-effect head-to-head meta-analyses were used to analyze the data.

RESULTS

Thirteen studies were included. Women with a prenatal diagnosis of AIP had less blood loss during surgery (mean difference (MD), -0.87; 95% CI, -1.5 to -0.23), had fewer units of RBC (MD, -1.45; 95% CI, -2.9 to -0.04) and FFP (MD, -1.73; 95% CI, -3.3 to -0.2) transfused, and delivered earlier (MD, 1.33 weeks; 95% CI, -2.23 to -0.43) compared with those with an intrapartum diagnosis. The risk of admission to an ICU and length of in-hospital and in-ICU stay were not different between the groups. Prenatal diagnosis of AIP was associated with a higher risk of urinary-tract injury (odds ratio, 2.5; 95% CI, 1.3-4.6), mainly due to the higher prevalence of placenta percreta in the group with AIP diagnosed prenatally.

CONCLUSION

Prenatal diagnosis of AIP is associated with reduced hemorrhagic morbidity compared with cases in which such anomalies are detected at delivery. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Intermittent aortic balloon occlusion combined with cesarean section for the treatment of patients with placenta previa complicated by placenta accreta: A retrospective study

AIM

To compare the efficacy of cesarean section (CS) combined with intermittent aortic balloon occlusion with that of CS alone for treating patients with placenta previa complicated by placenta accreta.

METHODS

Forty-five patients with placenta previa complicated by placenta accreta who underwent CS were retrospectively studied. Twenty-two patients had undergone CS combined with intermittent aortic balloon occlusion (combination group) and 23 patients received conventional hemostatic support only (control group). The postpartum hemorrhage, transfusion requirements, operation time and recovery time, and the ability to preserve the uterus and fertility were analyzed.

RESULTS

Intermittent aortic balloon occlusion significantly decreased the volume of blood loss in the combination group relative to the control group (597 ± 359 mL vs 2687 ± 575 mL; P < 0.001), and transfusion requirements were also reduced (498 ±195 mL vs 2390 ±789 mL; P <0.001). We observed shorter operation time in the combination group relative to the control group (63.8 ± 12.3 min vs 118.8 ± 22.4 min; P < 0.001), and fewer patients required uterine cavity stuffing followed by uterine artery embolization (n = 2 vs n = 10; P <0.05), uterine artery ligation (n = 1 vs n = 9; P < 0.05), and hysterectomy (n = 0 vs n =7; P < 0.05).

CONCLUSION

Intermittent aortic balloon occlusion may control postpartum hemorrhage in pregnancies complicated by placenta accreta, and improve the postoperative conditions.

Recent Update of Embolization of Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is a life-threatening condition and remains a leading cause of maternal mortality. Transcatheter arterial embolization (TAE) is an effective therapeutic strategy for PPH with the advantages of fast speed, repeatability, and the possibility of fertility preservation. We reviewed the vascular anatomy relevant to PPH, the practical details of TAE emphasizing the timing of embolization, and various clinical conditions of PPH according to a recent literature review.

A Case of Placenta Percreta Managed with Sequential Embolisation Procedures

Background

The incidence of morbidly adherent placenta, including placenta percreta, has increased significantly over recent years due to rising caesarean section rates. Historically, abnormally invasive placenta has been managed with caesarean hysterectomy; however nonsurgical interventions such as uterine artery embolisation (UAE) are emerging as safe alternative management techniques. UAE can be utilised to decrease placental perfusion and encourage placental resorption, thereby reducing the risk of haemorrhage and other morbidities.

Case

We describe one of the very few reported cases of placenta percreta which was successfully treated primarily with sequential artery embolisation. Our patient underwent four embolisation procedures over a period of 248 days, with no major morbidity or complications.

Conclusion

Repeat UAE may be a beneficial primary management modality in cases of placenta percreta with bladder involvement.

Pelvic Artery Embolization for Treatment of Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is the leading cause of maternal perinatal morbidity and mortality worldwide. Defined as greater than 500 mL blood loss after vaginal delivery, and greater than 1,000 mL blood loss after cesarean delivery, PPH has many causes, including uterine atony, lower genital tract lacerations, coagulopathy, and placental anomalies. Correction of coagulopathy and identification of the cause of bleeding are mainstays of treatment. Medical therapies such as uterotonics, balloon tamponade, pelvic artery embolization, and uterine-sparing surgical options are available. Hysterectomy is performed when conservative therapies fail. Pelvic artery embolization is safe and effective, and is the first-line therapy for medically refractory PPH. A thorough knowledge of pelvic arterial anatomy is critical. Recognition of variant anatomy can prevent therapeutic failure. Pelvic embolization is minimally invasive, has a low complication rate, spares the uterus, and preserves fertility.

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.

Predelivery uterine arteries embolization in patients affected by placental implant anomalies

PURPOSE

The aim of this study is to report on a single center experience of managing patients affected by placenta previa major and/or accretism by embolizing uterine arteries immediately before the cesarean delivery to reduce blood loss and secondary the rate of hysterectomies.

MATERIALS AND METHODS

Sixty-nine patients have been prospectively enrolled. Inclusion criteria were radiological diagnosis of placenta anomalies and risk factors for peri/postpartum hemorrhage. The delivery was electively scheduled between the 35th week and the 36th week of pregnancy. The embolization procedure was performed in the gynecological operating room with a mobile C-arm by injecting calibrated microparticles 500-700 μm. A contrast-enhanced MRI was acquired in a subgroup of 10 patients 6 months after the delivery to evaluate the uterine wall status.

RESULTS

Hysterectomy had been performed in 43.5%; 52.2% did not require blood transfusions; 1.2 blood units per patient had been meanly transfused. The mean fluoroscopy beam-on time was 195 s per patient. The mean uterine dose was 26.75 mGy. No pH anomalies were measured from the umbilical cord blood; the Apgar score at 5 min was ≥8. The analysis of the neuro-developmental milestones showed normal cognitive development in all children at 6 months. The uterine wall enhancement evaluated with contrast-enhanced MRI 6 months after the embolization procedure showed preserved myometrial perfusion without area of necrosis.

CONCLUSIONS

In this series of patients, the predelivery uterine arteries' embolization was a safe and effective procedure; this may represent a technical alternative that interventional radiologists can consider when facing this challenging scenario.

Uterine Artery Embolization for Management of Primary Postpartum Hemorrhage Associated with Placenta Accreta

Objective To evaluate the efficacy and safety of uterine artery embolization (UAE) in the management of primary postpartum hemorrhage associated with placenta accreta. Methods We retrospectively reviewed the medical records of patients with placenta accreta between January 2010 and August 2014. Totally 18 women (mean age 30.8±4.2 years) of primary massive postpartum hemorrhage with diagnosis of placenta accrete received treatment of UAE after delivery. Images of DSA and medical records were reviewed. Technical success was defined as control of bleeding after embolization. The complications, control of hemorrhage and recurrent bleeding of the placenta left inside the uterus were retrospectively collected for assessment. Results All patients underwent transcatheter embolization of bilateral uterine arteries. The technical success rate of embolization was 100%. Bleeding was controlled in 17 of 18 patients (94%) during follow-up period (median 18 months, 3-31months) without further bleeding recurred. One patient with placenta percreta undertook an emergent hysterectomy along with surgical bladder repair after UAE because of persistent uterine bleeding. Eight patients had postembolization syndrome and no other complications occurred. Conclusion Uterine artery embolization is an effective and safe treatment for the management of primary postpartum massive hemorrhage associated with placenta accreta.

Successful treatment of placenta previa totalis using the combination of a two-stage cesarean operation and uterine arteries embolization in a hybrid operating room

A 37-year-old primigravida female with placenta previa totalis was transferred to our hospital at 29 weeks of gestation. A transvaginal ultrasound examination showed a dropped placenta into the uterine cervix and an effaced lower uterine segment. The boundary between the cervical muscle layer and the placenta was unclear. Consequently, although it was unclear whether complication of the adherence of placenta was present or not, massive hemorrhage with atonic bleeding in the lower uterine segment after placenta removal was strongly suspected. As the patient had uncontrolled vaginal bleeding, an emergency cesarean section was performed in a hybrid operating room. A transverse fundal incision of the uterus was made, and a 1143 g healthy neonate was delivered. As no signs of placental detachment or persistent bleeding were found, the uterus was closed, leaving the placenta. Thereafter bilateral uterine arterial embolization (UAE) with absorbable gelatin sponges was performed. On the third day after the operation, a second operation for placental removal. The placenta detached smoothly, but compression sutures were placed to control the bleeding at the site of placental removal around the uterine isthmus. In this case, we were able to conduct the treatment smoothly because of the antenatal ultrasound assessment and precise preparation of the cesarean section with UAE in the hybrid operation room. Using the hybrid operation room, sharing detailed surgical planning in cooperation with the physicians from other departments is important for obtaining a good outcome.

Uterine Artery Embolization before Delivery to Prevent Postpartum Hemorrhage

PURPOSE

To assess the safety and outcomes of uterine artery embolization (UAE) performed before delivery in patients with placental implant anomalies at high risk for peripartum or postpartum hemorrhage.

MATERIALS AND METHODS

From January 2013 to January 2015, 50 consecutive patients with placental implant anomalies at 35-36 weeks of pregnancy were recruited. UAE was performed superselectively by injecting reabsorbable pledgets. We applied 5 dosimeters to patients' backs to measure the uterine radiation dose, considered to be the same radiation dose that the fetus received. Newborns were assessed immediately after birth and at 6-month follow-up.

RESULTS

All procedures were technically successful. Of patients, 64% did not require transfusions. Mean blood units transfused was 0.7 U (range, 0-4 U). No patient was transferred to the intensive care unit. Hysterectomy was performed in 13 patients (26%). Mean fluoroscopy operative time was 3 minutes 42 seconds (range, 1 min 21 s-6 min 58 s), and mean uterine radiation dose was 15.61 mGy (range, 8.15-38.18 mGy). Mean time between embolization and delivery was 6 minutes 4 seconds (range, 4 min 18 s-8 min 12 s). The 1-minute and 5-minute Apgar scores were 8-9 in all newborns; 8 newborns were lost to follow-up at 6 months. A normal cognitive outcome was evident in all 42 children studied.

CONCLUSIONS

UAE before delivery appeared to reduce bleeding during cesarean sections in this consecutive series of patients with placental implant anomalies. In the hands of experienced staff, radiation dose to the fetus was minimal.

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.

Post-operative hemorrhage after myomectomy: safety and efficacy of transcatheter uterine artery embolization

Objective

To evaluate the safety and clinical efficacy of transcatheter uterine artery embolization (UAE) for post-myomectomy hemorrhage.

Materials and Methods

We identified eight female patients (age ranged from 29 to 51 years and with a median age of 37) in two regional hospitals who suffered from post-myomectomy hemorrhage requiring UAE during the time period from 2004 to 2012. A retrospective review of the patients' clinical data, uterine artery angiographic findings, embolization details, and clinical outcomes was conducted.

Results

The pelvic angiography findings were as follows: hypervascular staining without bleeding focus (n = 5); active contrast extravasation from the uterine artery (n = 2); and pseudoaneurysm in the uterus (n = 1). Gelatin sponge particle was used in bilateral uterine arteries of all eight patients, acting as an empirical or therapeutic embolization agent for the various angiographic findings. N-butyl-2-cyanoacrylate was administered to the target bleeding uterine arteries in the two patients with active contrast extravasation. Technical and clinical success were achieved in all patients (100%) with bleeding cessation and no further related surgical intervention or embolization procedure was required for hemorrhage control. Uterine artery dissection occurred in one patient as a minor complication. Normal menstrual cycles were restored in all patients.

Conclusion

Uterine artery embolization is a safe, minimally invasive, and effective management option for controlling post-myomectomy hemorrhage without the need for hysterectomy.

Prophylactic uterine artery embolization assisted cesarean section for the prevention of intrapartum hemorrhage in high-risk patients

Purpose

To evaluate the safety and efficacy of prophylactic uterine artery embolization (UAE)-assisted cesarean section for the prevention of intrapartum hemorrhage.

Materials and Methods

Twelve consecutive pregnant women (mean age 31 years; range 25–38) with uterine scarring and placenta previa and/or placenta accreta underwent UAE in conjunction with cesarean section to prevent intrapartum hemorrhage. For UAE, the left uterine artery was catheterized prophylactically under fluoroscopic guidance before the cesarean section incision was made. After the infant had been delivered, bilateral UAE was performed with the placenta still in situ. After successful bilateral UAE, the placenta was detached from the uterine wall.

Results

Technical success was achieved in all 12 cases. Ten patients retained their uterus, and the other 2 underwent hysterectomy. The mean operative blood loss was 1,391 mL (range 600–3,600 mL). The total mean fluoroscopy time and mean absorbed dose (air kerma) were 9 min 40 s (range 4 min 35 s–15 min 24 s) and 91.79 mGy (range 30.2–171), respectively. The average fetal fluoroscopy time was 1 min 42 s (range 41 s to 3 min 16 s) with an average X-ray dose of 17.66 mGy (range 6.04–23.90).

Conclusion

UAE-assisted cesarean section is safe and effective in the prevention of intrapartum hemorrhage in patients with uterine scarring and/or placental abnormalities.

Role of interventional radiology in treating obstetric haemorrhages

PURPOSE

The aim of this study was to evaluate the efficacy and the safety of selective uterine artery embolisation in patients with a high risk of haemorrhage due to obstetric issues.

MATERIALS AND METHODS

We retrospectively reviewed the angiographic examinations of 63 patients (average age ± SD, 32.6 years ± 4.8), affected by an obstetric disease with a high risk of haemorrhage (22 cases of ectopic pregnancy, 41 of postpartum haemorrhage) and treated with an interventional approach. In particular, we considered the rate of second treatment with interventional technique or conservative or radical surgery, the incidence of postprocedural complications, and the absorbed radiation dose.

RESULTS

Immediate technical success, defined as the cessation of active bleeding, was achieved in all cases. Uterine artery embolisation was able alone to control the haemorrhage in 95.24 % of cases. Three patients required a second treatment to achieve haemostasis. No peri- or postprocedural complications were observed. At the 12-month follow-up after embolisation, 22/49 conservatively treated patients were found to be pregnant and successfully completed their pregnancy.

CONCLUSIONS

Selective uterine artery embolisation allows for safe and complete control of haemorrhage in patients with obstetric disease, with a very low incidence of complications and preservation of fertility.

Failed pelvic arterial embolization for postpartum hemorrhage: clinical outcomes and predictive factors

PURPOSE

To evaluate clinical outcomes of failed pelvic arterial embolization (PAE) and determine predictive factors associated with this failure in the treatment of postpartum hemorrhage (PPH).

MATERIALS AND METHODS

This retrospective study included all consecutive patients who underwent PAE for life-threatening PPH between March 2004 and January 2011 at a tertiary-care center. Medical records and imaging studies were reviewed to identify cases of failed PAE and their clinical outcomes. Multiple parameters were compared between the failed and successful PAE groups, and multivariate analysis was performed to determine the predictive factors associated with failed PAE.

RESULTS

PAE was performed in 257 patients (mean age, 32 y; range, 20-40 y). A total of 24 cases of PAE involved a failure to achieve hemostasis (9.3%). Patients in the failed PAE group experienced more major complications than those in the successful PAE group (37.5% [nine of 24] vs 9.4% [22 of 233]). Factors more frequently found in failed PAE included hemodynamic instability, hemoglobin level lower than 8g/dL, disseminated intravascular coagulation (DIC), and extravasation detected on angiography. After multivariate analysis, DIC emerged as the only significant predictive factor (odds ratio, 6.569; 95% confidence interval, 1.602-26.932; P = .009).

CONCLUSIONS

PAE is an effective treatment for medically intractable PPH. However, PAE failed in a high percentage of patients and was commonly associated with major complications. DIC was the only significant predictor of failed PAE.

Beyond hemostasis: spectrum of gynecologic and obstetric indications for transcatheter embolization

Percutaneous vascular embolization is a useful therapeutic option for a wide range of gynecologic and obstetric abnormalities. Transcatheter embolization procedures performed with the use of radiologic imaging for guidance are minimally invasive and may obviate surgery, thereby decreasing morbidity and mortality and safeguarding the patient's future fertility potential. To integrate this treatment method optimally into patient care, knowledge is needed about the clinical indications for therapeutic embolization, the relevant vascular anatomy, technical considerations of the procedure, and the potential risks and benefits of embolization. The most well-known and well-studied transcatheter embolization technique for treating a gynecologic-obstetric condition is uterine fibroid embolization. However, the clinical indications for transcatheter embolization are much broader and include many benign gynecologic conditions, such as adenomyosis and arteriovenous malformations, as well as intractable bleeding due to inoperable advanced-stage malignancies. Uterine artery embolization may be performed to prevent or treat bleeding associated with various obstetric conditions, including postpartum hemorrhage, placental implantation abnormality, and ectopic pregnancy. Embolization of the uterine artery or the internal iliac artery also may be performed to control pelvic bleeding due to coagulopathy or iatrogenic injury, and ovarian vein embolization has been shown to be effective for the management of pelvic congestion syndrome. The article discusses these and other gynecologic and obstetric indications for transcatheter embolization, provides detailed descriptions of imaging findings before and after embolization, and reviews procedural techniques and outcomes.

Transcatheter arterial embolisation for the management of obstetric haemorrhage associated with placental abnormality in 40 cases

OBJECTIVE

To evaluate pelvic artery embolisation (PAE) in the emergency management of intractable postpartum haemorrhage (PPH) associated with placenta accreta (PA).

METHODS

Forty such patients (PAE for PPH/PA) were retrospectively reviewed. Medical records were reviewed regarding the delivery and PAE procedure. Follow-up gynaecological outcomes after PAE were obtained by telephone interviews.

RESULTS

Technical success was achieved in all women (100 %). The initial clinical success rate was 82.5 % (33/40). Three patients with PA underwent hysterectomy after PAE failed to stop the bleeding within 24 h after the embolisation. The other three patients underwent re-embolisation (two patients underwent re-embolisation on the next day and one patient had undergone re-embolisation 6 h after the first embolisation), and bleeding had stopped eventually. The clinical success rate was 92.5 %. There were four cases of immediate complications, such as, pelvic pain, nausea and urticaria. There were three late minor complications, temporary menopause, but no late major complications. After the procedure, 35 patients resumed normal menstruation, including two uncomplicated pregnancies. One patient expired owing to disseminated intravascular coagulopathy and intracerebral haemorrhage, despite successful embolisation.

CONCLUSION

PAE can be performed safely and effectively for patients with PPH and PA and can preserve the uterus in many patients.

Laparoscopic-assisted vaginal hysterectomy in a patient with placenta percreta

Placenta percreta is a problem encountered with increasing frequency due to the rising rate of cesarean delivery. Conservative management of this condition is associated with decreased perioperative morbidity. When hysterectomy is necessary, a laparoscopic approach can provide additional benefits. We present the case of a woman with placenta percreta with bladder invasion who was undergoing conservative management and then required delayed hysterectomy. Laparoscopic-assisted vaginal hysterectomy was successfully performed. We review the techniques used to ensure a good outcome and the advantages of a minimally invasive approach to hysterectomy in this patient with placenta percreta.

Primary postpartum hemorrhage: outcome of pelvic arterial embolization in 251 patients at a single institution

PURPOSE

To evaluate the safety and efficacy of pelvic arterial embolization (PAE) for the treatment of primary postpartum hemorrhage (PPH) and to determine the factors associated with clinical outcomes.

MATERIALS AND METHODS

This retrospective single-center study was institutional review board approved, and informed consent was waived. Outcomes were analyzed in 251 patients who underwent PAE for primary PPH between January 2000 and February 2011. Mode of delivery, causes of bleeding, detailed laboratory and treatment records, and clinical outcomes were recorded. Clinical success was defined as cessation of bleeding after initial session of PAE without the need for additional PAE or surgery. Univariate and multivariate analyses were performed to determine the factors related to clinical outcomes.

RESULTS

The clinical success rate was 86.5% (217 of 251). Among the 34 failed cases, 12 underwent repeat PAE, 16 underwent additional surgery, and three recovered with conservative management. Overall bleeding control was achieved in 98.0% (246 of 251) of the patients. Overall mortality was 2% (five of 251) after the first (n = 3) or second (n = 1) session of PAE or additional surgery (n = 1). Among the 113 patients with long-term follow-up, 110 (97.3%) maintained a regular menstrual cycle and 11 had successful pregnancies. Univariate analysis showed that cesarean section delivery, disseminated intravascular coagulation (DIC), and massive transfusion of more than 10 red blood cell units were related to failed PAE. Multivariate analysis showed that DIC (odds ratio, 0.36; P = .04) and massive transfusion (odds ratio, 0.10; P < .001) were significantly related to clinical failure.

CONCLUSION

PAE is safe and effective for managing primary PPH. Patients with DIC and massive transfusion were likely to have poor results after PAE.

Placental vascularity and resorption delay after conservative management of invasive placenta: MR imaging evaluation

OBJECTIVES

To assess the potential of magnetic resonance (MR) imaging in evaluating placental vascularity and predicting placental resorption delay after conservative management of invasive placenta.

METHODS

MR examinations of 23 women with conservative management of invasive placenta were reviewed. Twelve women had pelvic embolisation because of postpartum haemorrhage (Group 1) and 11 had no embolisation (Group 2). Comparisons between the two groups were made with respect to the delay for complete placental resorption at follow-up MR imaging and degree of placental vascularity 24 h after delivery on early (30s) and late (180 s) phase of dynamic gadolinium chelate-enhanced MR imaging.

RESULTS

The median delay for complete placental resorption in the cohort study was 21.1 weeks (range, 1-111 weeks). In Group 1, the median delay for complete placental resorption was shorter than in Group 2 (17 vs 32 weeks) (P = 0.036). Decreased placental vascularity on the early phase was observed in Group 1 by comparison with Group 2 (P = 0.003). Significant correlation was found between the degree of vascularity on early phase of dynamic MR imaging and the delay for complete placental resorption (r = 0.693; P < 0.001).

CONCLUSIONS

MR imaging provides useful information after conservative management of invasive placenta and may help predict delay for complete placental resorption.

Uterine sepsis with uterine artery embolisation in the management of obstetric bleeding

This paper reports three complicated clinical cases of uterine artery embolisation (UAE) in the management of massive obstetric haemorrhage (MPPH), and the consequences of impaired uterine perfusion.

Predictive factors for failure of pelvic arterial embolization for postpartum hemorrhage

OBJECTIVE

To assess the efficacy of pelvic embolization in women with postpartum hemorrhage (PPH) and to determine factors associated with embolization failure.

METHODS

In a retrospective observational study, data were analyzed from 98 consecutive women who underwent pelvic embolization for intractable PPH between January 2007 and November 2009 at Beaujon Hospital, Clichy, France. Women with persistent PPH despite pelvic embolization were compared with women who had cessation of hemorrhage and attained hemodynamic stability.

RESULTS

Among the 98 women, 66 (67.3%) had been transferred from another hospital after delivery. Pelvic arterial embolization failed to control PPH in 8 (8.2%) women. On univariate analysis, factors significantly associated with embolization failure were the presence of placenta accreta (P<0.005), hemoglobin level (P<0.05), prothrombin time (P<0.04), fibrinogen level (P<0.03), red blood transfusion (P<0.02), number of packed red blood cell units transfused (P<0.05), and fresh-frozen plasma transfusion (P<0.02). Hospital-to-hospital transfer with a notable time interval between delivery and embolization was not associated with increased risk of failure.

CONCLUSION

Predictive factors significantly associated with failed pelvic arterial embolization were the presence of placenta accreta, biologic factors, and transfusional factors. Delay due to inter-hospital transfer did not affect the outcome of embolization.