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Chen D, Xu J, Tian Y, Ling Q, Peng B. Clinical evaluation of the effect for prophylactic balloon occlusion in pregnancies complicated with placenta accreta spectrum disorder: A systematic review and meta-analysis. Int J Gynaecol Obstet 2024; 167:109-127. [PMID: 38899567 DOI: 10.1002/ijgo.15704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 04/02/2024] [Accepted: 04/14/2024] [Indexed: 06/21/2024]
Abstract
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.
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Affiliation(s)
- Daijuan Chen
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China
| | - Jinfeng Xu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Yuan Tian
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China
| | - Qiao Ling
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Bing Peng
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, Sichuan, China
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Hung A, Ramos SZ, Wiley R, Sawyer K, Gupta M, Chauhan SP, Deshmukh U, Shainker S, Samshirsaz A, Wagner S. Evidence-based surgery for cesarean hysterectomy secondary to placenta accreta spectrum: A systematic review. Eur J Obstet Gynecol Reprod Biol 2024; 302:155-166. [PMID: 39277964 DOI: 10.1016/j.ejogrb.2024.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 08/08/2024] [Accepted: 09/09/2024] [Indexed: 09/17/2024]
Abstract
OBJECTIVE In this systematic review, we aim to propose evidence-based management for perioperative care to improve outcomes at the time of planned cesarean hysterectomy for placenta accreta spectrum, a procedure associated with significant maternal and neonatal morbidity. DATA SOURCES We conducted a literature search for studies published in MEDLINE (via Ovid), Embase, CINAHL, and Cochrane/CENTRAL up until February 25, 2022. The search included free-text and controlled-vocabulary terms for cesarean section, cesarean delivery, and hysterectomy. STUDY ELIGIBILITY CRITERIA We included randomized controlled trials, prospective cohort, retrospective cohort, and case-control studies published in English that reported on a perioperative intervention in the performance of a planned CH for PAS. Studies must have included a comparator group. Of the 8,907 studies screened in this systematic review, 79 met the inclusion criteria. STUDY APPRAISAL AND SYNTHESIS METHODS Articles examining each step or intervention of the CH were grouped together and reviewed qualitatively as a group. Evidence levels and recommendations were made by consensus of all authors according to the terminology of the United States Preventive Services Task Force (USPSTF). We synthesized the results of 79 articles, and provided 28 recommendations. RESULTS Based on USPSTF criteria, 21.4 % of the recommendations were level B (n = 6), 39.3 % were C (n = 11), 10.7 % were D (n = 3) and 28.6 % were I (n = 8). The interventions with the highest level of recommendation included delivery at a hospital with high cesarean hysterectomy volume, implementation of a standardized hospital protocol, delivery via a planned procedure, neuraxial anesthesia, and transverse skin incision (all level B recommendations by USPSTF criteria). CONCLUSIONS Development of a standardized hospital protocol, delivery at a center with high CH surgical volume, and utilization of neuraxial anesthesia garnered B evidence levels. Recommendations were limited due to the lack of prospective trials. Further research into the technical aspects of this high-risk procedure is warranted.
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Affiliation(s)
- Allan Hung
- Department of Obstetrics and Gynecology, Alpert Medical School, Brown University, Providence, RI, United States
| | - Sebastian Z Ramos
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Tufts University School of Medicine, Boston, MA, United States
| | - Rachel Wiley
- Department of Obstetrics and Gynecology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Kelsey Sawyer
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Tufts University School of Medicine, Boston, MA, United States
| | - Megha Gupta
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA, United States
| | - Suneet P Chauhan
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Christiana Care Medical Center, Christiana, DE, United States
| | - Uma Deshmukh
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA, United States
| | - Scott Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA, United States
| | - Amir Samshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, United States
| | - Stephen Wagner
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA, United States.
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Bonsen LR, Sleijpen K, Hendriks J, Urlings TAJ, Dekkers OM, le Cessie S, van de Velde M, Gurung P, van den Akker T, van der Bom JG, Henriquez DDCA. Prophylactic Radiologic Interventions for Postpartum Hemorrhage Control in Women With Placenta Accreta Spectrum Disorder: A Systematic Review and Meta-analysis. Obstet Gynecol 2024; 144:315-327. [PMID: 38954828 PMCID: PMC11321610 DOI: 10.1097/aog.0000000000005662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/01/2024] [Accepted: 05/23/2024] [Indexed: 07/04/2024]
Abstract
OBJECTIVE To quantify the association between prophylactic radiologic interventions and perioperative blood loss during cesarean delivery in women with placenta accreta spectrum disorder through a systematic review and network meta-analysis. DATA SOURCES On January 3, 2023, a literature search was conducted in PubMed, EMBASE, Cochrane Library, and Web of Science. We also checked ClinicalTrials.gov retrospectively. Prophylactic radiologic interventions to reduce bleeding during cesarean delivery involved preoperative placement of balloon catheters, distal (internal or common iliac arteries) or proximal (abdominal aorta), or sheaths (uterine arteries). The primary outcome was volume of blood loss; secondary outcomes were the number of red blood cell units transfused and adverse events. Studies including women who received an emergency cesarean delivery were excluded. METHODS OF STUDY SELECTION Two authors independently screened citations for relevance, extracted data, and assessed the risk of bias of individual studies with the Cochrane Risk of Bias in Non-randomized Studies of Interventions tool. TABULTATION, INTEGRATION, AND RESULTS From a total of 1,332 screened studies, 50 were included in the final analysis, comprising 5,962 women. These studies consisted of two randomized controlled trials and 48 observational studies. Thirty studies compared distal balloon occlusion with a control group, with a mean difference in blood loss of -406 mL (95% CI, -645 to -167). Fourteen studies compared proximal balloon occlusion with a control group, with a mean difference of -1,041 mL (95% CI, -1,371 to -710). Sensitivity analysis excluding studies with serious or critical risk of bias provided similar results. Five studies compared uterine artery embolization with a control group, all with serious or critical risk of bias; the mean difference was -936 mL (95% CI, -1,522 to -350). Reported information on adverse events was limited. CONCLUSION Although the predominance of observational studies in the included literature warrants caution in interpreting the findings of this meta-analysis, our findings suggest that prophylactic placement of balloon catheters or sheaths before planned cesarean delivery in women with placenta accreta spectrum disorder may, in some cases, substantially reduce perioperative blood loss. Further study is required to quantify the efficacy according to various severities of placenta accreta spectrum disorder and the associated safety of these radiologic interventions. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42022320922.
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Affiliation(s)
- Lisanne R Bonsen
- Departments of Obstetrics and Gynaecology, Clinical Epidemiology, Clinical Endocrinology, and Biomedical Data Sciences, Leiden University Medical Center, and Leiden University Libraries, Leiden University, Leiden, the Department of Radiology, Catharina Hospital, Eindhoven, the Department of Radiology, Haaglanden Medical Center, The Hague, and Athena Institute, VU University, Amsterdam, the Netherlands; and the Department of Cardiovascular Sciences, Section Anesthesiology, KU Leuven and UZ Leuven, Leuven, Belgium
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Osman A, Das R, Pinas A, Hartopp R, Livermore D, Hawthorn B, Chun JY, Mailli L, Morgan R, Ratnam L. Outcome evaluation of prophylactic internal iliac balloon occlusion in the management of patients with placenta accreta spectrum. CVIR Endovasc 2024; 7:57. [PMID: 39039376 PMCID: PMC11263516 DOI: 10.1186/s42155-024-00466-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 06/24/2024] [Indexed: 07/24/2024] Open
Abstract
PURPOSE To evaluate outcomes and complications of prophylactic internal iliac balloon occlusion (PIIBO) in the management of patients with placenta accreta spectrum (PAS) at a large regional referral centre. MATERIALS AND METHODS A retrospective review of all PIIBO for PAS performed over a 12-year period (2010-2022). Information for analysis was gathered from the local RIS/PACS and clinical documentation. Collected data included patient demographics, indication for procedure, sheath insertion and removal time, total duration of balloon inflation and complications that occurred. RESULTS 106 patients underwent temporary internal iliac artery balloon occlusion within the 12-year period. All procedures utilised bilateral common femoral artery punctures, 6Fr sheath and 5Fr Le Maitre occlusion balloons. Catheters were successfully positioned and balloons inflated in obstetric theatre following caesarean delivery in 100% of the cases. The uterus was conserved in every case. There was no maternal mortality or foetal morbidity. Twenty patients (18.9%) had some form of complication that required further intervention. Of these, 7(6.6%) had post-operative PPH, which was treated with uterine artery embolisation; and 13 (12.3%) had arterial thrombus which required aspiration thrombectomy. All procedures were technically successful with no long-term sequelae. CONCLUSION PIIBO plays an important part in reducing morbidity and mortality in patients with PAS. Clear pathways and multidisciplinary team working is critical in the management of these patients to ensure that any complications are dealt with promptly to avoid long-term sequelae.
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Affiliation(s)
- Asaad Osman
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Raj Das
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Ana Pinas
- Department of Obstetrics and Gynaecology, St George's Hospital University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Richard Hartopp
- Department of Anaesthetics, St George's Hospital University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Deborah Livermore
- Department of Obstetrics and Gynaecology, St George's Hospital University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Benjamin Hawthorn
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Joo-Young Chun
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Leto Mailli
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Robert Morgan
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Lakshmi Ratnam
- Department of Radiology, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK.
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Alonso-Burgos A, Díaz-Lorenzo I, Muñoz-Saá L, Gallardo G, Castellanos T, Cardenas R, Chiva de Agustín L. Primary and secondary postpartum haemorrhage: a review for a rationale endovascular approach. CVIR Endovasc 2024; 7:17. [PMID: 38349501 PMCID: PMC10864234 DOI: 10.1186/s42155-024-00429-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/22/2024] [Indexed: 02/16/2024] Open
Abstract
Postpartum haemorrhage (PPH) is a significant cause of maternal mortality globally, necessitating prompt and efficient management. This review provides a comprehensive exploration of endovascular treatment dimensions for both primary and secondary PPH, with a focus on uterine atony, trauma, placenta accreta spectrum (PAS), and retained products of conception (RPOC). Primary PPH, occurring within 24 h, often results from uterine atony in 70% of causes, but also from trauma, or PAS. Uterine atony involves inadequate myometrial contraction, addressed through uterine massage, oxytocin, and, if needed, mechanical modalities like balloon tamponade. Trauma-related PPH may stem from perineal injuries or pseudoaneurysm rupture, while PAS involves abnormal placental adherence. PAS demands early detection due to associated life-threatening bleeding during delivery. Secondary PPH, occurring within 24 h to 6 weeks postpartum, frequently arises from RPOC. Medical management may include uterine contraction drugs and hemostatic agents, but invasive procedures like dilation and curettage (D&C) or hysteroscopic resection may be required.Imaging assessments, particularly through ultrasound (US), play a crucial role in the diagnosis and treatment planning of postpartum haemorrhage (PPH), except for uterine atony, where imaging techniques prove to be of limited utility in its management. Computed tomography play an important role in evaluation of trauma related PPH cases and MRI is essential in diagnosing and treatment planning of PAS and RPOC.Uterine artery embolization (UAE) has become a standard intervention for refractory PPH, offering a rapid, effective, and safe alternative to surgery with a success rate exceeding 85% (Rand T. et al. CVIR Endovasc 3:1-12, 2020). The technical approach involves non-selective uterine artery embolization with resorbable gelatine sponge (GS) in semi-liquid or torpedo presentation as the most extended embolic or calibrated microspheres. Selective embolization is warranted in cases with identifiable bleeding points or RPOC with AVM-like angiographic patterns and liquid embolics could be a good option in this scenario. UAE in PAS requires a tailored approach, considering the degree of placental invasion. A thorough understanding of female pelvis vascular anatomy and collateral pathways is essential for accurate and safe UAE.In conclusion, integrating interventional radiology techniques into clinical guidelines for primary and secondary PPH management and co-working during labour is crucial.
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Affiliation(s)
- Alberto Alonso-Burgos
- Radiology Department, Vascular Surgery and Interventional Radiology Unit, University Clinic of Navarra, Clínica Universidad de Navarra, Marquesado de Santa Marta 1, 28027, Madrid, Spain.
| | - Ignacio Díaz-Lorenzo
- Radiology Department, Interventional Radiology Unit, University Hospital La Princesa, Madrid, Spain
| | - Laura Muñoz-Saá
- Gynaecology and Obstetrics, University Clinic of Navarra, Madrid, Spain
| | | | | | - Regina Cardenas
- Gynaecology and Obstetrics, University Clinic of Navarra, Madrid, Spain
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Berman ZT, Boone CE, Melber DJ, Ballas J, Parikh R, Ramos G, Kelly T, McHale M, Picel AC, Roberts AC. Intraoperative Multivessel Embolization Reduces Blood Loss and Transfusion Requirements Compared to Internal Iliac Artery Balloon Placement during Cesarean Hysterectomy for Placenta Accreta Spectrum. J Vasc Interv Radiol 2023; 34:1915-1921. [PMID: 37527770 DOI: 10.1016/j.jvir.2023.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 07/16/2023] [Accepted: 07/23/2023] [Indexed: 08/03/2023] Open
Abstract
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.
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Affiliation(s)
- Zachary T Berman
- Department of Radiology, Division of Vascular and Interventional Radiology, University of California San Diego, San Diego, California.
| | - Christine E Boone
- Department of Radiology, Division of Vascular and Interventional Radiology, University of California San Diego, San Diego, California
| | - Dora J Melber
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, California
| | - Jerasimos Ballas
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, California
| | - Rupal Parikh
- Department of Radiology, Division of Vascular and Interventional Radiology, University of California San Diego, San Diego, California
| | - Gladys Ramos
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, California
| | - Thomas Kelly
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, California
| | - Michael McHale
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, California
| | - Andrew C Picel
- Department of Radiology, Division of Interventional Radiology, Stanford University, Stanford, California
| | - Anne C Roberts
- Department of Radiology, Division of Vascular and Interventional Radiology, University of California San Diego, San Diego, California
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Sebastian B, Rajesh U, Scott PM, Sayeed S, Robinson GJ, Ettles DF, Shrivastava V, Lakshminarayan R. Prophylactic Uterine Artery Embolization in Placenta Accreta Spectrum-An Active Intervention to Reduce Morbidity and Promote Uterine Preservation. J Vasc Interv Radiol 2023; 34:1922-1928. [PMID: 37517463 DOI: 10.1016/j.jvir.2023.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/11/2023] [Accepted: 07/21/2023] [Indexed: 08/01/2023] Open
Abstract
PURPOSE To evaluate the feasibility and safety of early and proactive involvement of interventional radiology (IR) in the management of placenta accreta spectrum (PAS) by performing the cesarean operation and prophylactic uterine artery embolization in the IR angiography suite as a combined procedure. MATERIALS AND METHODS This study evaluated the effectiveness and safety of prophylactic uterine artery embolization prior to placental separation in cases of antenatally proven or suspected abnormal placentation. Over a 5-year period, 16 consecutive patients with PAS underwent combined IR and obstetric intervention. In all cases, cesarean delivery was performed in the IR angiography suite. Vascular access was obtained prior to surgery with balloon placement into both internal iliac arteries. These balloons were inflated after delivery, followed by uterine artery embolization (14 of 16) if there was evidence of active postpartum bleeding or inability to deliver the placenta. RESULTS There was no fetal or maternal mortality and no significant IR or surgical adverse events. Mean blood loss was 1900 mL. Seven patients (44%) underwent hysterectomy. CONCLUSIONS In patients with PAS, cesarean section in the angiography suite preceded by prophylactic balloon placement and followed by uterine artery embolization was feasible, safe, and effective in preventing massive blood loss, with a 56% uterine sparing rate.
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Affiliation(s)
- Bibin Sebastian
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Uma Rajesh
- Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Paul M Scott
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Saira Sayeed
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Graham J Robinson
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Duncan F Ettles
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Vivek Shrivastava
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom
| | - Raghuram Lakshminarayan
- Division of Vascular Interventional Radiology, Department of Radiology, Hull University Teaching Hospital NHS Trust, Hull, United Kingdom.
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Einerson BD, Gilner JB, Zuckerwise LC. Placenta Accreta Spectrum. Obstet Gynecol 2023; 142:31-50. [PMID: 37290094 PMCID: PMC10491415 DOI: 10.1097/aog.0000000000005229] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/08/2023] [Indexed: 06/10/2023]
Abstract
Placenta accreta spectrum (PAS) is one of the most dangerous conditions in pregnancy and is increasing in frequency. The risk of life-threatening bleeding is present throughout pregnancy but is particularly high at the time of delivery. Although the exact cause is unknown, the result is clear: Severe PAS distorts the uterus and surrounding anatomy and transforms the pelvis into an extremely high-flow vascular state. Screening for risk factors and assessing placental location by antenatal ultrasonography are essential for timely diagnosis. Further evaluation and confirmation of PAS are best performed in referral centers with expertise in antenatal imaging and surgical management of PAS. In the United States, cesarean hysterectomy with the placenta left in situ after delivery of the fetus is the most common treatment for PAS, but even in experienced referral centers, this treatment is often morbid, resulting in prolonged surgery, intraoperative injury to the urinary tract, blood transfusion, and admission to the intensive care unit. Postsurgical complications include high rates of posttraumatic stress disorder, pelvic pain, decreased quality of life, and depression. Team-based, patient-centered, evidence-based care from diagnosis to full recovery is needed to optimally manage this potentially deadly disorder. In a field that has relied mainly on expert opinion, more research is needed to explore alternative treatments and adjunctive surgical approaches to reduce blood loss and postoperative complications.
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Affiliation(s)
- Brett D Einerson
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, Utah; Duke University, Durham, North Carolina; and Vanderbilt University Medical Center, Nashville, Tennessee
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Einerson BD, Sandlin AT, Afshar Y, Sharawi N, Fox KA, Newton JM, Shainker SA, Pezeshkmehr A, Carusi DA, Moroz L. General Management Considerations for Placenta Accreta Spectrum. Am J Perinatol 2023; 40:1026-1032. [PMID: 37336221 DOI: 10.1055/s-0043-1761915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
The ideal management of a patient with placenta accreta spectrum (PAS) includes close antepartum management culminating in a planned and coordinated delivery by an experienced multidisciplinary PAS team. Coordinated team management has been shown to optimize outcomes for mother and infant. This section provides a consensus overview from the Pan-American Society for the Placenta Accreta Spectrum regarding general management of PAS.
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Affiliation(s)
| | - Adam T Sandlin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arizona
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Nadir Sharawi
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arizona
| | - Karin A Fox
- Division of Maternal-Fetal Medicine, Department of Obstetric and Gynecology, Baylor College of Medicine (Texas Children's Hospital Pavilion for Women), Houston, Texas
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center Nashville, Tennessee
| | - Scott A Shainker
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amir Pezeshkmehr
- Department of Radiology Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Daniela A Carusi
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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10
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Khoury-Collado F, Newton JM, Brook OR, Carusi DA, Shrivastava VK, Crosland BA, Fox KA, Khandelwal M, Karam AK, Bennett KA, Sandlin AT, Shainker SA, Einerson BD, Belfort MA. Surgical Techniques for the Management of Placenta Accreta Spectrum. Am J Perinatol 2023; 40:970-979. [PMID: 37336214 DOI: 10.1055/s-0043-1761636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
The surgical management of placenta accreta spectrum (PAS) is often challenging. There are a variety of techniques and management options described in the literature ranging from uterine sparing to cesarean hysterectomy. Following the inaugural meeting of the Pan-American Society for Placenta Accreta Spectrum a multidisciplinary group collaborated to describe collective recommendations for the surgical management of PAS. In this manuscript, we outline individual components of the procedure and provide suggested direction at key points of a cesarean hysterectomy in the setting of PAS. KEY POINTS: · The surgical management of PAS requires careful planning and expertise.. · Multidisciplinary team care for pregnancies complicated by PAS can decrease morbidity and mortality.. · Careful surgical techniques can minimize risk of significant hemorrhage by avoiding pitfalls..
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Affiliation(s)
- Fady Khoury-Collado
- Division of Gynecologic Oncology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Olga R Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Daniela A Carusi
- Department of Obstetrics and Gynecology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vineet K Shrivastava
- Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Memorial Care Miller Children's & Women's Hospital, University of California Irvine, Irvine, California
| | - Brian A Crosland
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Karin A Fox
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Meena Khandelwal
- Department of Obstetrics and Gynecology, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Amer K Karam
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Stanford University, Palo Alto, California
| | - Kelly A Bennett
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adam T Sandlin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Scott A Shainker
- Department of Obstetrics, Gynecology, and Reproductive Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Brett D Einerson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Michael A Belfort
- Departments of Obstetrics and Gynecology, Surgery, Anesthesiology and Neurosurgery, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
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11
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Bae JG, Kim YH, Kim JY, Lee MS. The Feasibility and Safety of Temporary Transcatheter Balloon Occlusion of Bilateral Internal Iliac Arteries during Cesarean Section in a Hybrid Operating Room for Placenta Previa with a High Risk of Massive Hemorrhage. J Clin Med 2022; 11:jcm11082160. [PMID: 35456251 PMCID: PMC9031967 DOI: 10.3390/jcm11082160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/08/2022] [Accepted: 04/10/2022] [Indexed: 11/16/2022] Open
Abstract
This study aimed to evaluate the feasibility and safety of temporary transcatheter balloon occlusion of bilateral internal iliac arteries (TBOIIA) during cesarean section in a hybrid operating room (OR) for placenta previa (PP) with a high risk of massive hemorrhage. This retrospective study analyzed the medical records of 62 patients experiencing PP with a high risk of massive hemorrhage (mean age, 36.2 years; age range 28-45 years) who delivered a baby via planned cesarean section with TBOIIA in a hybrid OR between May 2019 and July 2021. Operation time, estimated blood loss (EBL), amount of intra- and postoperative blood transfusion, perioperative hemoglobin level, hospital stay after operation, balloon time, fluoroscopy time, radiation dose, rate of uterine artery embolization (UAE) and hysterectomy, and complication-related TBOIIA were assessed. The mean operation time was 122 min, and EBL was 1290 mL. Nine out of sixty-two patients (14.5%) received a blood transfusion. The mean hemoglobin levels before surgery, immediately after surgery and within 1 week after surgery were 11.3 g/dL, 10.4 g/dL and 9.2 g/dL, respectively. In terms of radiation dose, the mean dose area product (DAP) and cumulative air kerma were 0.017 Gy/cm2 and 0.023 Gy, respectively. Ten out of sixty-two patients (16.1%) underwent UAE postoperatively in the hybrid OR. One out of sixty-two patients had been diagnosed with placenta percreta with bladder invasion based on preoperative ultrasound, and thus underwent cesarean hysterectomy following TBOIIA and UAE. While intra-arterial balloon catheter placement for managing PP with a high risk of hemorrhage remains controversial, a planned cesarean section with TBOIIA in a hybrid OR is effective in eliminating the potential risk of intra-arterial balloon catheter displacement, thus reducing intraoperative blood loss, ensuring safe placental removal and conserving the uterus.
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Affiliation(s)
- Jin-Gon Bae
- Department of Obstetrics and Gynecology, Keimyung University Dongsan Hospital, School of Medicine, Keimyung University, Daegu 42601, Korea;
| | - Young Hwan Kim
- Department of Radiology, Keimyung University Dongsan Hospital, School of Medicine, Keimyung University, Daegu 42601, Korea; (Y.H.K.); (J.Y.K.)
| | - Jin Young Kim
- Department of Radiology, Keimyung University Dongsan Hospital, School of Medicine, Keimyung University, Daegu 42601, Korea; (Y.H.K.); (J.Y.K.)
| | - Mu Sook Lee
- Department of Radiology, Keimyung University Dongsan Hospital, School of Medicine, Keimyung University, Daegu 42601, Korea; (Y.H.K.); (J.Y.K.)
- Correspondence: ; Tel.: +82-53-258-7862
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12
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The effect of prophylactic balloon occlusion in patients with placenta accreta spectrum: a Bayesian network meta-analysis. Eur Radiol 2021; 32:3297-3308. [PMID: 34846565 DOI: 10.1007/s00330-021-08423-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 10/04/2021] [Accepted: 10/18/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Placenta accreta spectrum (PAS) can induce severe life-threatening obstetric hemorrhage. Herein, we conducted a Bayesian network meta-analysis of previous studies to evaluate the relative benefits of different prophylactic balloon occlusion (PBO) procedures. METHODS PubMed, Embase, Cochrane Library, and Web of Science were searched from inception to July 2021. Blood loss volume, blood transfusion volume, and hysterectomy rate were regarded as the primary endpoints. The data were pooled using a Bayesian network and traditional pairwise meta-analysis. RESULTS Fifty-nine articles with a total sample size of 5150 patients were included. Compared with no PBO (non-PBO) intervention, PBO of the abdominal aorta (PBOAA, mean difference(MD) - 1.02, 95% credible interval (CrI) - 1.4 to - 0.67), common iliac artery (PBOCIA, MD - 0.84; 95%CrI - 1.36 to - 0.06) and internal iliac artery (PBOIIA, MD - 0.42; 95%CrI - 0.72 to - 0.13) significantly lowered blood loss volume, with PBOAA being more effective than PBOIIA (MD - 0.60; 95%CrI - 1.05 to - 0.17). PBOAA and PBOIIA also significantly decreased blood loss volume (MD - 2.33; 95%CrI - 3.74 to - 0.94, MD - 1.57; 95%CrI - 2.77 to - 0.47 respectively) and hysterectomy rate (OR 0.31; 95%CrI 0.16 to 0.54, OR 0.53; 95%CrI 0.29 to 0.92 respectively). PBOAA has the highest probability of being more effective in reducing the blood loss volume, blood transfusion volume, and hysterectomy rate. CONCLUSIONS Performing PBOAA, PBOCIA, or PBOIIA in PAS patients is an effective way to minimize blood loss volume, while PBOAA and PBOIIA also reduce blood transfusion volume and hysterectomy rate. PBOAA is a notably more effective strategy to reduce blood loss volume than PBOIIA. KEY POINTS • PBOAA, PBOCIA, and PBOIIA procedures can significantly reduce the blood loss volume compared to non-PBO intervention in PAS patients, of which PBOAA was more effective than the PBOIIA procedure. • PBOAA and PBOIIA could significantly reduce the blood transfusion volume and hysterectomy rate in contrast to the non-PBO intervention in patients with PAS. • According to our statistical treatment ranking, PBOAA was statistically superior in reducing blood transfusion volume, blood transfusion volume, and hysterectomy rate than other PBO procedures.
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Melber DJ, Berman ZT, Jacobs MB, Picel AC, Conturie CL, Zhang-Rutledge K, Binder PS, Eskander RN, Roberts AC, McHale MT, Ramos GA, Ballas J, Kelly TF. Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization: the PASTIME protocol. Am J Obstet Gynecol 2021; 225:442.e1-442.e10. [PMID: 34245679 DOI: 10.1016/j.ajog.2021.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/27/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Multidisciplinary care of placenta accreta spectrum cases improves pregnancy outcomes, but the specific components of such a multidisciplinary collaboration varies between institutions. As experience with placenta accreta spectrum increases, it is crucial to assess new surgical techniques and protocols to help improve maternal outcomes and to advocate for hospital resources. OBJECTIVE This study aimed to assess a novel multidisciplinary protocol for the treatment of placenta accreta spectrum that comprises cesarean delivery, multivessel uterine embolization, and hysterectomy in a single procedure within a hybrid operative suite. STUDY DESIGN This was a matched prepost study of placenta accreta spectrum cases managed before (2010-2017) and after implementation of the Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization protocol (2018-2021) at a tertiary medical center. Historical cases were managed with internal iliac artery balloon placement in selected cases with the decision to inflate the balloons intraoperatively at the discretion of the primary surgeon. Intraoperative Embolization cases were compared with historical cases in a 1:2 ratio matched on the basis of placenta accreta spectrum severity and surgical urgency. The primary outcome was a requirement for transfusion with packed red blood cells. Secondary outcomes included estimated surgical blood loss, operative and postoperative complications, procedural time, length of stay, and neonatal outcomes. RESULTS A total of 15 Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization cases and 30 matched historical cases were included in the analysis. There were no demographic differences noted between the groups. A median (interquartile range) of 0 units (0-2 units) of packed red blood cells were transfused in the Intraoperative Embolization group compared with 2 units (0-4.5 units) in the historical group (P=.045); 5 of 15 (33.3%) Intraoperative Embolization cases required blood transfusions compared with 19 of 30 (63.3%) cases in the historical group (P=.11). The estimated blood loss was significantly less in the Intraoperative Embolization group with a median (interquartile range) of 750 mL (450-1050 mL) compared with 1750 mL (1050-2500 mL) in the historical group (P=.003). There were no cases requiring massive transfusion (≥10 red blood cell units in 24 hours) in the Intraoperative Embolization group compared with 5 of 30 (16.7%) cases in the historical group (P=.15). There were no intraoperative deaths from hemorrhagic shock using the Intraoperative Embolization protocol, whereas this occurred in 2 of the historical cases. The mean duration of the interventional radiology procedure was longer in the Intraoperative Embolization group (67.8 vs 34.1 minutes; P=.002). Intensive care unit admission and postpartum length of stay were similar, and surgical and postoperative complications were not significantly different between the groups. The gestational age and neonatal birthweights were similar; however, the neonatal length of stay was longer in the Intraoperative Embolization group (median duration, 32 days vs 15 days; P=.02) with a trend toward low Apgar scores. Incidence of arterial umbilical cord blood pH <7.2 and respiratory distress syndrome and intubation rates were not statistically different between the groups. CONCLUSION A multidisciplinary pathway including a single-surgery protocol with multivessel uterine embolization is associated with a decrease in blood transfusion requirements and estimated blood loss with no increase in operative complications. The Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization protocol provides a definitive surgical method that warrants consideration by other centers specializing in placenta accreta spectrum treatment.
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14
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Chen D, Xu J, Tian Y, Ye P, Zhao F, Liu X, Wang X, Peng B. Effect of prophylactic balloon occlusion of internal iliac artery in pregnancies complicated by placenta previa and accreta. BMC Pregnancy Childbirth 2021; 21:640. [PMID: 34548060 PMCID: PMC8456564 DOI: 10.1186/s12884-021-04103-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 08/29/2021] [Indexed: 11/10/2022] Open
Abstract
Background Placenta previa and accreta are serious obstetric conditions that are associated with a high risk of intraoperative massive hemorrhage, the prophylactic intravascular balloon occlusion technique is increasingly used in managing uncontrolled hemorrhage in cesarean section (CS). We aim to examine the clinical effectiveness of prophylactic balloon occlusion of the internal iliac artery (PBOIIA) during CS in improving maternal outcomes for patients with placenta previa and accreta. Methods A total of 420 women with placenta previa and accreta who underwent CS from January 2014 to December 2018 were included retrospectively. Patients were divided into balloon group in which patients had PBOIIA (n = 248) and the control group in which patients did not have PBOIIA (n = 172). Meanwhile, we performed a subgroup analysis in whether taking parallel transverse uterine incision (PTUI) surgery. Information on conditions of patients and newborns, perioperative blood indicators, surgical outcomes were collected. Results Median estimated blood loss (mEBL) was 2200 mL in the balloon group and 2150 mL in the control group respectively, there was no significant difference between two-groups comparison (P > 0.05), and the rate of patients with hysterectomy was also has no difference between the two groups (36.3% verus 35.5%, P > 0.05), while there is a significant difference between two groups in the amount of PRBCs transfused [3 (0–31.5) verus 3 (0–39), P <0.05], moreover, the proportion of PRBCS> 8 units in the balloon group is significantly lower than that in control group (11.29% verus 23.26%, P <0.05).. However, the total hospitalization costs (45,624.4 ± 11,061.9 verus 37,523.1 ± 14,662.2, CYN) and surgery costs (19,910.6 ± 2622.6 verus 11,850.5 ± 3146.1, CYN) in balloon group were significantly higher than those in control group (P < 0.05). Subgroup analysis showed PTUI surgery had no significant differences in EBL (P >0.05), but it could significantly decrease hysterectomy rates (P <0.05). Conclusions PBOIIA has no significant effect on reducing intraoperative EBL and hysterectomy rate in patients with placenta previa and accreta. and although it could reduce the intraoperative PRBCs in patients with massive hemorrhage, it significantly increases the financial cost for patients. Therefore, PBOIIA should not be routinely recommended to patients with placenta previa and accreta.
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Affiliation(s)
- Daijuan Chen
- Department of Obstetrics and Gynecology, Ministry of Education, West China Second University Hospital of Sichuan University/Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
| | - Jinfeng Xu
- Department of Obstetrics and Gynecology, Ministry of Education, West China Second University Hospital of Sichuan University/Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
| | - Yuan Tian
- Department of Obstetrics and Gynecology, Ministry of Education, West China Second University Hospital of Sichuan University/Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
| | - Pengfei Ye
- Department of Radiology, West China Second University Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Fumin Zhao
- Department of Radiology, West China Second University Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Xinghui Liu
- Department of Obstetrics and Gynecology, Ministry of Education, West China Second University Hospital of Sichuan University/Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
| | - Xiaodong Wang
- Department of Obstetrics and Gynecology, Ministry of Education, West China Second University Hospital of Sichuan University/Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
| | - Bing Peng
- Department of Obstetrics and Gynecology, Ministry of Education, West China Second University Hospital of Sichuan University/Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China.
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15
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Yang CC, Chou YC, Kuo TN, Liou JY, Cheng HM, Kuo YT. Prophylactic Intraoperative Uterine Artery Embolization During Cesarean Section or Cesarean Hysterectomy in Patients with Abnormal Placentation: A Systematic Review and Meta-Analysis. Cardiovasc Intervent Radiol 2021; 45:488-501. [PMID: 34282489 DOI: 10.1007/s00270-021-02921-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 07/05/2021] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Cheng-Chun Yang
- Department of Medical Imaging, Chi Mei Medical Center, NO. 901, Zhonghua Rd., Yongkang Dist., Tainan City, 710, Taiwan
| | - Yi-Chen Chou
- Department of Medical Imaging, Chi Mei Medical Center, NO. 901, Zhonghua Rd., Yongkang Dist., Tainan City, 710, Taiwan
| | - Tian-Ni Kuo
- Department of Obstetrics and Gynecology, Chi Mei Medical Center, Tainan, Taiwan
| | - Jyun-Yan Liou
- Department of Medical Imaging, Chi Mei Medical Center, NO. 901, Zhonghua Rd., Yongkang Dist., Tainan City, 710, Taiwan
| | - Hua-Ming Cheng
- Department of Medical Imaging, Chi Mei Medical Center, NO. 901, Zhonghua Rd., Yongkang Dist., Tainan City, 710, Taiwan
| | - Yu-Ting Kuo
- Department of Medical Imaging, Chi Mei Medical Center, NO. 901, Zhonghua Rd., Yongkang Dist., Tainan City, 710, Taiwan.
- Department of Radiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Liang D, Zhao H, Liu D, Lin Y. Internal iliac artery balloon occlusion in the management of placenta accreta: A systematic review and meta-analysis. Eur J Radiol 2021; 139:109711. [PMID: 33910145 DOI: 10.1016/j.ejrad.2021.109711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/05/2021] [Accepted: 04/07/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE To examine the effectiveness and safety of prophylactic internal iliac artery balloon occlusion for hemorrhage control in placenta accreta. METHOD EMBASE, PubMed, and the Cochrane Central Register of Controlled Trials data-bases were searched through November 2020. Clinical trials comparing the management of placenta accreta with and without internal iliac artery balloon occlusion were included. The meta-analysis results were expressed as the risk ratio (RR) or mean difference, with 95 % CIs. RESULTS Fifteen studies including 1098 women were eligible. No statistically significant difference was found between the internal arterial balloon occlusion group and the control group with respect to estimated blood loss volume (-0.525 mL, [95 % CI, -1.112 to -0.061], p = 0.079.), red blood cells (RBCs) transfused in observational studies (-0.682 mL, [95 % CI, -1.540 to 0.176], p = 0.119.) and in randomized controlled trials (0.134 mL, [95 % CI, -0.214 to 0.482], p = 0.451.), intensive care unit admission (p = 0.197), hysterectomy in observational studies (p = 0.969) and in randomized controlled trials (p = 0.323), urinary system injury in observational studies (p = 0.182) and in randomized controlled trials (p = 0.956), Apgar score at 5 min (p = 0.641), and neonatal intensive care unit admission (p = 0.973). CONCLUSIONS The currently available data demonstrate no significant differences between the internal iliac artery balloon occlusion group and the control group in blood loss and packed RBCs transfused for women with placenta accreta. Further large randomized controlled studies are needed to confirm our findings.
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Affiliation(s)
- Deku Liang
- Department of Obstetrics and Gynecology, Chengdu Women and Children's Central Hospital Affiliated to University of Electronic Science and Technology of China, Chengdu, 1617 Riyue Avenue, Qingyang District, Sichuan Province, China
| | - Hu Zhao
- Department of Obstetrics and Gynecology, Chengdu Women and Children's Central Hospital Affiliated to University of Electronic Science and Technology of China, Chengdu, 1617 Riyue Avenue, Qingyang District, Sichuan Province, China
| | - Dandan Liu
- Department of Obstetrics and Gynecology, Chengdu Women and Children's Central Hospital Affiliated to University of Electronic Science and Technology of China, Chengdu, 1617 Riyue Avenue, Qingyang District, Sichuan Province, China
| | - Yonghong Lin
- Department of Obstetrics and Gynecology, Chengdu Women and Children's Central Hospital Affiliated to University of Electronic Science and Technology of China, Chengdu, 1617 Riyue Avenue, Qingyang District, Sichuan Province, China.
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17
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Nankali A, Salari N, Kazeminia M, Mohammadi M, Rasoulinya S, Hosseinian-Far M. The effect prophylactic internal iliac artery balloon occlusion in patients with placenta previa or placental accreta spectrum: a systematic review and meta-analysis. Reprod Biol Endocrinol 2021; 19:40. [PMID: 33663536 PMCID: PMC7931359 DOI: 10.1186/s12958-021-00722-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/23/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Anisodowleh Nankali
- grid.412112.50000 0001 2012 5829Department of Obstetrics and Gynecology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Nader Salari
- grid.412112.50000 0001 2012 5829Department of Biostatistics, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohsen Kazeminia
- grid.412112.50000 0001 2012 5829Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Masoud Mohammadi
- grid.412112.50000 0001 2012 5829Department of Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Samira Rasoulinya
- grid.412112.50000 0001 2012 5829Department of Obstetrics and Gynecology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Melika Hosseinian-Far
- grid.411301.60000 0001 0666 1211Department of Food Science & Technology, Faculty of Agriculture, Ferdowsi University of Mashhad (FUM), Mashhad, Iran
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Giurazza F, Angileri SA, Corvino F, Granata G, Grillo P, Savoldi AP, Albano G, Bracchi L, Carrafiello G, Niola R. Postpartum Hemorrhages: Prevention. Semin Ultrasound CT MR 2021; 42:85-94. [PMID: 33541592 DOI: 10.1053/j.sult.2020.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Francesco Giurazza
- Vascular and Interventional Radiology Department, Cardarelli Hospital, Naples, Italy.
| | | | - Fabio Corvino
- Vascular and Interventional Radiology Department, Cardarelli Hospital, Naples, Italy
| | - Giuseppe Granata
- Postgraduate School in Radiodiagnostic, Facoltà di Medicina e Chirurgia, Università degli Studi di Milano, Milan, Italy
| | - Pasquale Grillo
- Postgraduate School in Radiodiagnostic, Facoltà di Medicina e Chirurgia, Università degli Studi di Milano, Milan, Italy
| | - Anna Paola Savoldi
- Postgraduate School in Radiodiagnostic, Facoltà di Medicina e Chirurgia, Università degli Studi di Milano, Milan, Italy
| | | | - Laura Bracchi
- Diagnostic and Therapeutic Imaging Department, Cerba Healthcare Italia, Milan, Italy
| | | | - Raffaella Niola
- Vascular and Interventional Radiology Department, Cardarelli Hospital, Naples, Italy
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19
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Estimating the radiation dose to the fetus during prophylactic internal iliac occlusion in patients with abnormal placentation. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020; 165:435-440. [PMID: 33252114 DOI: 10.5507/bp.2020.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/02/2020] [Indexed: 11/23/2022] Open
Abstract
AIMS To evaluate the estimated fetal radiation dose during prophylactic internal iliac arterial occlusion in patients with abnormal placenta and to estimate the risk of radiation induced cancer in child age. METHODS Prophylactic occlusion of the internal iliac arteries during Caesarean section was performed in 42 patients with placenta praevia and/or placenta accreta spectrum. Fogarty embolectomy catheters were used for prophylactic occlusion of the internal iliac arteries. All procedures were performed in the hybrid operating room using Philips Allura Xper FD 20 X-ray system. Low dose X-ray fluoroscopy (7.5 frames per second) was used. The CODE (Conceptus dose estimation) Software was used to estimate the fetal dose and the risk of radiation induced carcinoma. RESULTS Fluoroscopy times required for insertion of Fogarty catheters were 0.5-4.2 min (mean: 1.7 min, median: 1.5 min). The estimated radiation dose to the fetus was 0.26-3.36 mGy (mean: 1.49 mGy, median: 1.25 mGy). The risk of radiation induced cancer in child age was 0.01-0.04% (mean 0.02%, median 0.01%). One patient developed thrombosis of a common femoral artery. CONCLUSION Prophylactic occlusion of the internal iliac arteries is a simple and safe procedure with minimal risk of complications and with a very low estimated radiation dose to the fetus.
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20
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Mori K, Obata-Yasuoka M, Saida T, Nishida K, Takahashi H, Hosokawa Y, Takei Y, Tsumagari A, Yoshida M, Kimura Y, Abe T, Tsukuda Y, Harada S, Kojima T, Minami M. Pelvic arterial embolisation with cyanoacrylate during caesarean hysterectomy for placenta accreta. MINIM INVASIV THER 2020; 31:396-403. [PMID: 32907432 DOI: 10.1080/13645706.2020.1811730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To compare n-butyl cyanoacrylate (NBCA) and gelatine sponge (GS) as embolic materials for prophylactic pelvic arterial embolisation during caesarean hysterectomy for placenta accreta spectrum (PAS). MATERIAL AND METHODS This retrospective study comprised 12 women (age range, 23-42 years; mean, 34.1 years) who underwent caesarean hysterectomy for PAS. Following caesarean delivery, bilateral uterine and non-uterine parasitic arteries were embolized with GS in the first four cases (GS group) and primarily with NBCA mixed with iodized oil in the subsequent eight cases (NBCA group). Procedure time for embolisation and hysterectomy and total blood loss were compared between the two groups using Welch's t-test. RESULTS Although procedure time for embolisation tended to be longer in the NBCA group than in the GS group (111 ± 47 min versus 71 ± 32 min, p=.11), that for hysterectomy was significantly reduced in the NBCA group when compared to the GS group (158 ± 42 min versus 236 ± 39 min, p=.02). Total blood loss was significantly lower in the NBCA group than in the GS group (1375 ± 565 mL versus 2668 ± 587 mL, p=.01). CONCLUSION Procedure time for hysterectomy and total blood loss during caesarean hysterectomy can be reduced by using NBCA instead of GS in prophylactic pelvic arterial embolisation for PAS.
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Affiliation(s)
- Kensaku Mori
- Department of Radiology, University of Tsukuba, Tsukuba, Japan
| | - Mana Obata-Yasuoka
- Department of Obstetrics and Gynecology, University of Tsukuba, Tsukuba, Japan
| | - Tsukasa Saida
- Department of Radiology, University of Tsukuba, Tsukuba, Japan
| | - Keiko Nishida
- Department of Obstetrics and Gynecology, University of Tsukuba, Tsukuba, Japan
| | - Hiroaki Takahashi
- Department of Radiology, Mayo Clinic Rochester, Rochester, United States
| | - Yoshihiko Hosokawa
- Department of Obstetrics and Gynecology, University of Tsukuba, Tsukuba, Japan
| | - Yohei Takei
- Department of Radiology, University of Tsukuba, Tsukuba, Japan
| | - Ayako Tsumagari
- Department of Obstetrics and Gynecology, University of Tsukuba, Tsukuba, Japan
| | - Miki Yoshida
- Department of Radiology, University of Tsukuba, Tsukuba, Japan
| | - Yutaku Kimura
- Department of Obstetrics and Gynecology, University of Tsukuba, Tsukuba, Japan
| | - Tetsuya Abe
- Department of Radiology, University of Tsukuba, Tsukuba, Japan
| | - Yoko Tsukuda
- Department of Obstetrics and Gynecology, University of Tsukuba, Tsukuba, Japan
| | - Shu Harada
- Department of Radiology, University of Tsukuba, Tsukuba, Japan
| | - Takahiro Kojima
- Department of Urology, University of Tsukuba, Tsukuba, Japan
| | - Manabu Minami
- Department of Radiology, University of Tsukuba, Tsukuba, Japan
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21
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Ma Y, Luo X, Jiang X, Liu H, Wu L. Perioperative patient blood management during parallel transverse uterine incision cesarean section in patient with pernicious placenta previa: A retrospective cohort analysis. Medicine (Baltimore) 2020; 99:e21916. [PMID: 32871925 PMCID: PMC7458170 DOI: 10.1097/md.0000000000021916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 07/02/2020] [Accepted: 07/25/2020] [Indexed: 12/04/2022] Open
Abstract
Pernicious placenta previa (PPP) is the main cause of severe obstetric postpartum hemorrhage and hysterectomy and often requires donor blood transfusion. Prophylactic internal iliac artery (IIA) balloon occlusion (BO) combined with cell salvage is increasingly being deployed in parallel transverse uterine incision (PTUI) cesarean section (CS). The aim of this study was to explore the differences in blood management in PTUI CS with or without prophylactic IIA BO and to evaluate the safety and efficacy of cell salvage to reduce the need for donor blood transfusion during PTUI CS.This retrospective study included all women who were diagnosed with PPP and PA and underwent PTUI CS from October 1, 2016, to October 31, 2018. Sixty-four patients were included: 34 underwent prophylactic IIA BO (IIA group), whereas 30 were treated without prophylactic IIA BO (control group). The primary outcome was a composite measure of perioperative blood management outcomes, including the estimated blood loss (EBL), donor blood transfusion, salvaged blood returned, fresh frozen plasma (FFP), pre- and postoperative serum hemoglobin and hematocrit. In addition, the baseline conditions of mother and neonates were compared.EBL was significantly higher in the IIA group compared to the control group (2883.5 mL in the IIA group vs 1868.7 mL in the control group, P = .001). Overall, the donor blood transfusion rate was 23.5% (8/34), averaging 4.2 U, in the IIA group versus 30% (9/30), averaging 3.4 U, in the control group, which were not significantly different. The FFP transfusion rate was 47%, averaging 765.6 mL, in the IIA group versus 20%, averaging 816.7 mL, in the control group. In the IIA group, 97.1% used cell savage and had salvaged blood returned, averaging 954.9 mL. In the control group, 90% had salvaged blood returned, averaging 617.9 mL. No cases of amniotic fluid embolism were observed with leukocyte depletion filters.Prophylactic IIA BO during PTUI CS in women with PPP and PA does not lead to a statistically significant reduction in EBL. Cell salvage was associated with a reduction in the rate of donor blood transfusion during PTUI CS.
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Affiliation(s)
- Yushan Ma
- Anesthesiology Department of West China Second University Hospital, Sichuan University, Sichuan Province
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education
| | - Xi Luo
- Intensive Care Unit of Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
| | - Xiaoqin Jiang
- Anesthesiology Department of West China Second University Hospital, Sichuan University, Sichuan Province
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education
| | - Hui Liu
- Anesthesiology Department of West China Second University Hospital, Sichuan University, Sichuan Province
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education
| | - Lan Wu
- Anesthesiology Department of West China Second University Hospital, Sichuan University, Sichuan Province
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education
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22
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Soyer P, Barat M, Loffroy R, Barral M, Dautry R, Vidal V, Pellerin O, Cornelis F, Kohi MP, Dohan A. The role of interventional radiology in the management of abnormally invasive placenta: a systematic review of current evidences. Quant Imaging Med Surg 2020; 10:1370-1391. [PMID: 32550143 DOI: 10.21037/qims-20-548] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Philippe Soyer
- Department of Radiology, Hopital Cochin, Assistance Publique - Hopitaux de Paris, Paris, France.,Université de Paris, Descartes-Paris 5, Paris, France
| | - Maxime Barat
- Department of Radiology, Hopital Cochin, Assistance Publique - Hopitaux de Paris, Paris, France.,Université de Paris, Descartes-Paris 5, Paris, France
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, François-Mitterrand University Hospital, UFR des Sciences de Santé, Université de Bourgogne/Franche-Comté, Dijon, France
| | - Matthias Barral
- Department of Radiology, Hopital Tenon, Assistance Publique - Hopitaux de Paris, Paris, France.,Sorbonne University, Paris, France
| | - Raphael Dautry
- Department of Radiology, Hopital Cochin, Assistance Publique - Hopitaux de Paris, Paris, France
| | - Vincent Vidal
- Interventional Radiology Section, Department of Medical Imaging, University Hospital Timone APHM, LIIE, CERIMED Aix Marseille Univ, Marseille, France
| | - Olivier Pellerin
- Université de Paris, Descartes-Paris 5, Paris, France.,Department of Interventional Radiology, Hopital Européen Georges Pompidou, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Francois Cornelis
- Department of Radiology, Hopital Tenon, Assistance Publique - Hopitaux de Paris, Paris, France
| | - Maureen P Kohi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Anthony Dohan
- Department of Radiology, Hopital Cochin, Assistance Publique - Hopitaux de Paris, Paris, France.,Université de Paris, Descartes-Paris 5, Paris, France
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23
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Control of postpartum hemorrhage in women with placenta accreta spectrum using prophylactic balloon occlusion combined with Pituitrin intra-arterial infusion. Eur Radiol 2020; 30:4524-4533. [PMID: 32222796 DOI: 10.1007/s00330-020-06813-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 02/26/2020] [Accepted: 03/13/2020] [Indexed: 12/16/2022]
Abstract
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.
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24
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Lee AY, Ballah D, Moreno I, Dong PR, Cochran R, Picel A, Lee EW, Moriarty J, Padgett M, Nelson K, Kohi MP. Outcomes of balloon occlusion in the University of California Morbidly Adherent Placenta Registry. Am J Obstet Gynecol MFM 2019; 2:100065. [PMID: 33345981 DOI: 10.1016/j.ajogmf.2019.100065] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/20/2019] [Accepted: 10/24/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Morbidly adherent placenta, also known as placenta accreta spectrum, is associated with severe maternal morbidity and mortality. Multiple adjunctive procedures have been proposed to improve outcomes, and at many institutions, interventional radiologists will play a role in assisting obstetricians in these cases. OBJECTIVE The objective of the study was to evaluate the outcomes of women with morbidly adherent placenta who underwent cesarean hysterectomy with aortic balloon occlusion or internal iliac artery balloon occlusion catheters, compared with cesarean hysterectomy with surgical ligation of the iliac arteries, or cesarean hysterectomy without adjunctive procedures. STUDY DESIGN A retrospective review of women with morbidly adherent placenta treated with cesarean hysterectomy was performed at 5 institutions from May 2014 to April 2018. The balloon occlusion group had either prophylactic aortic or iliac balloons placed prior to cesarean hysterectomy. Comparison groups included those who underwent internal iliac artery ligation prior to hysterectomy or a control group if they underwent cesarean hysterectomy without adjuvant procedures. Evaluated outcomes include estimated blood loss, transfusion requirements, intensive care unit admission, and adverse event rates. RESULTS There were 171 women with morbidly adherent placenta included in the study. Twenty-eight had balloon placement prior to cesarean hysterectomy, 18 had intraoperative internal iliac artery ligation, and there were 125 control women who underwent cesarean hysterectomy without any adjunctive procedures. Compared with the women who underwent cesarean hysterectomy without adjunctive procedures, women who underwent aortic or iliac artery balloon occlusion prior to hysterectomy had significantly lower estimated blood loss (30.9% decrease, P < .001), transfusion requirements (76.8% decrease, P < .001), intensive care unit admission rates (0% vs 15.2%, P < .001), and intensive care unit stay lengths (0.0 vs 3.1 days, P < .001). Compared with women who underwent surgical ligation of the internal iliac arteries prior to hysterectomy, women who underwent aortic or iliac artery balloon occlusion prior to cesarean hysterectomy had lower estimated blood loss (54.2% decrease, P < .01), transfusion requirements (90.5% decrease, P < .001), operating room times (40.0% decrease, P < .01), intensive care unit admissions rates (0% vs 77.8%, P < .001), intensive care unit stay lengths (0.0 vs 1.4 days, P < .001), and adverse events (3.6% vs 44.4%, P < .01). CONCLUSION Aortic and iliac artery balloon occlusion are associated with lower estimated blood loss, transfusion requirements, intensive care unit admission rates, and adverse event rates compared with women who underwent internal iliac artery ligation prior to cesarean hysterectomy or women who had no adjunctive interventions prior to cesarean hysterectomy for morbidly adherent placenta.
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Affiliation(s)
- Andrew Y Lee
- Department of Radiology, University of California, Davis, Sacramento, CA
| | - Deddeh Ballah
- Department of Radiology, University of California, San Francisco, San Francisco, CA
| | - Ismael Moreno
- Department of Radiology, University of California, Davis, Sacramento, CA
| | - Paul R Dong
- Department of Radiology, University of California, Davis, Sacramento, CA; Department of Radiology, Sutter Medical Group, Northern California, Sacramento, CA
| | - Rory Cochran
- Department of Radiology, University of California, San Diego, La Jolla, CA
| | - Andrew Picel
- Department of Radiology, University of California, San Diego, La Jolla, CA
| | - Edward W Lee
- Department of Radiology, University of California, Los Angeles, Los Angeles, CA
| | - John Moriarty
- Department of Radiology, University of California, Los Angeles, Los Angeles, CA
| | - Max Padgett
- Department of Radiology, University of California, Irvine, Orange, CA
| | - Kari Nelson
- Department of Radiology, University of California, Irvine, Orange, CA
| | - Maureen P Kohi
- Department of Radiology, University of California, San Francisco, San Francisco, CA.
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25
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Fratto VM, Conturie CL, Ballas J, Pettit KE, Stephenson ML, Truong YN, Henry D, Afshar Y, Murphy A, Kim L, Field N, Wing DA, Norton ME, Ramos GA. Assessing the multidisciplinary team approaches to placenta accreta spectrum across five institutions within the University of California fetal Consortium (UCfC). J Matern Fetal Neonatal Med 2019; 34:2971-2976. [PMID: 31645153 DOI: 10.1080/14767058.2019.1676411] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To describe the multidisciplinary approaches to placenta accreta spectrum (PAS) across five tertiary care centers that comprise the University of California fetal Consortium (UCfC) and to identify potential best practices. MATERIALS AND METHODS Retrospective review of all cases of pathologically confirmed invasive placenta delivered from 2009 to 2014 at UCfC. Differences in intraoperative management and outcomes based on prenatal suspicion were compared. Interventions assessed included ureteral stent use, intravascular balloon use, anesthetic type, gynecologic oncology (Gyn Onc) involvement, and cell saver use. Intervention variation by institution was also assessed. Analyses were adjusted for final pathologic diagnosis. Chi-square, Fisher's exact, Student's t-test, and Mann-Whitney's U-test were used as appropriate. Binary logistic regression and multivariable linear regression were used to adjust for confounders. RESULTS One hundred and fifty-one cases of pathologically confirmed invasive placenta were identified, of which 82% (123) were suspected prenatally. There was no correlation between the degree of invasion on prenatal imaging and use of each intervention. Ureteral stents were placed in 33% (41) of cases and did not reduce GU injury. Intravascular balloons were placed in 29% (36) of cases and were associated with shorter OR time (161 versus 236 min, p < .01) and lower estimated blood loss (EBL) (1800 versus 2500 ml, p < .01). General endotracheal anesthesia (GETA) was used in 70% (86). EBL did not differ between GETA and regional anesthesia. Gyn Onc was involved in 58% (71) of cases and EBL adjusted for final pathology was reduced with their involvement (2200 versus 2250 ml, p = .02) while OR time and intraoperative complications did not differ. Cell saver was used in 20% (24) and was associated with longer OR time (296 versus 200 min, p < .01). Use of cell saver was not associated with a difference in EBL or number of units of packed red cells transfused. All analyses were adjusted for pathologic severity of invasion. CONCLUSIONS Intravascular interventions such as uterine artery balloons and the inclusion of Gynecologic Oncologists as part of a multidisciplinary approach to treating PAS reduce EBL. Additionally, the placement of intravascular balloons may reduce OR time. No significant differences were seen in outcomes when comparing the use of ureteral stents, general anesthesia, or institutions. A team of experienced operators with a standard approach may be more significant than specific practices.
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Affiliation(s)
- Victoria M Fratto
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, CA, USA
| | - Charlotte L Conturie
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, CA, USA
| | - Jerasimos Ballas
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, CA, USA
| | - Kate E Pettit
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, CA, USA
| | - Megan L Stephenson
- Department of Obstetrics and Gynecology, University of California Irvine, Irvine, CA, USA
| | - Yen N Truong
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Dana Henry
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Yalda Afshar
- Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Aisling Murphy
- Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Lena Kim
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Nancy Field
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Deborah A Wing
- Department of Obstetrics and Gynecology, University of California Irvine, Irvine, CA, USA
| | - Mary E Norton
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Gladys A Ramos
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, CA, USA
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26
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Liu J, Xu J, Jiao D, Duan X, Han X. Comparison of the efficacy of prophylactic balloon occlusion of the abdominal aorta at or below the level of the renal artery in women with placenta accreta undergoing cesarean section. J Matern Fetal Neonatal Med 2019; 34:2427-2434. [PMID: 31510819 DOI: 10.1080/14767058.2019.1667325] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To compare the safety and efficacy of prophylactic balloon occlusion of the abdominal aorta (PBOA) performed at the level of the renal artery (PBOA-ARA) or below this level (PBOA-BRA) for the management of placenta accreta. METHODS We conducted a retrospective investigation of 57 women scheduled for cesarean delivery who underwent PBOA at our hospital between October 2015 and July 2017. The balloon occlusion was performed at (PBOA-ARA group; n = 30) or below (PBOA-BRA group; n = 27) the renal artery origin. The perioperative data of the two groups were compared. RESULTS Estimated blood loss was lower in the PBOA-ARA group than in the PBOA-BRA group (p > .05). There were no intergroup differences in intraoperative blood transfusion volume, hemoglobin reduction, urine output, and serum levels of creatinine and blood urea nitrogen. Postballoon release hemorrhage occurred in eight patients of the PBOA-BRA group, but in none of the PBOA-ARA group, indicating a significant difference (p = .007). Subgroup analysis of placenta types revealed that the estimated blood loss among women with placenta increta in the PBOA-ARA group was less than that in the PBOA-BRA group (p = .015), which was reflected by a significant difference in the reduction of hemoglobin levels (p = .042). CONCLUSIONS PBOA at the level of the renal artery entailed lesser blood loss than that performed below the renal artery origin, particularly in the case of placenta increta; this, in turn, reduces the risk of postpartum hemorrhage from ovarian arteries and subsequent blockade of the ovarian artery origin.
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Affiliation(s)
- Juanfang Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Jianwei Xu
- Department of Ultrasound, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Dechao Jiao
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Xuhua Duan
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Xinwei Han
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People's Republic of China
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27
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Tokue H, Tokue A, Tsushima Y, Kameda T. Risk factors for massive bleeding based on angiographic findings in patients with placenta previa and accreta who underwent balloon occlusion of the internal iliac artery during cesarean section. Br J Radiol 2019; 92:20190127. [PMID: 31317769 DOI: 10.1259/bjr.20190127] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE We evaluated the risk factors for massive bleeding based on angiographic findings in patients with placenta previa and accreta who underwent balloon occlusion of the internal iliac artery (BOIA) during cesarean section. METHODS We performed a retrospective analysis using the clinical records of 42 patients with placenta previa and accreta who underwent BOIA during cesarean section between 2006 and 2017 in Gunma university hospital. We reviewed incidence of collateral arteries to the uterus on the initial aortography. We evaluated the visualization of the ovarian artery arising directly from the abdominal aorta, round ligament artery arising from the external iliac artery/inferior epigastric artery, and the iliolumbar artery. In addition, the clinical characteristics were reviewed. Patients with an estimated blood loss during delivery of >2500 ml, >4 packed red blood cell transfusions, uterine artery embolization after delivery, or hysterectomy were defined as the massive bleeding group. We compared between the massive and non-massive bleeding groups. RESULTS 20 patients (48%) had a massive bleeding. No procedure-related severe complications were observed. The massive and non-massive bleeding groups differed in terms of operation time (p < 0.001), hysterectomy (p < 0.001), post-operative hospital stay (p < 0.05), and visualization of round ligament arteries to the uterus [15/20 (75%) patients, p < 0.01]. CONCLUSION The incidence of collateral blood supply from a round ligament artery to the uterus may be a risk factor for massive bleeding in patients with placenta previa and accreta who have undergone BOIA during cesarean section. ADVANCES IN KNOWLEDGE Angiographic visualization of collateral circulation from the round ligament artery to the uterus may be a risk factor for massive bleeding in patients with placenta previa and accreta who have undergone BOIA during cesarean section.
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Affiliation(s)
- Hiroyuki Tokue
- Department of Diagnostic and Interventional Radiology, Gunma University Hospital, Gunma, Japan
| | - Azusa Tokue
- Department of Diagnostic and Interventional Radiology, Gunma University Hospital, Gunma, Japan
| | - Yoshito Tsushima
- Department of Diagnostic and Interventional Radiology, Gunma University Hospital, Gunma, Japan
| | - Takeshi Kameda
- Department of Obstetrics and Gynecology, Gunma University Hospital, Gunma, Japan
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Makary M, Chowdary P, Westgate JA. Vascular balloon occlusion and planned caesarean hysterectomy for morbidly adherent placenta: A systematic review. Aust N Z J Obstet Gynaecol 2019; 59:608-615. [PMID: 31281966 DOI: 10.1111/ajo.13027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/29/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Morbidly adherent placenta is potentially life-threatening, often requiring technically difficult surgery and large blood loss. Use of intravascular balloon occlusion with or without hysterectomy to reduce blood loss is increasing despite associated morbidity and lack of evidence of efficacy. AIMS To evaluate if prophylactic use of vascular balloon occlusion at the time of planned caesarean hysterectomy for antenatally diagnosed morbidly adherent placenta reduces blood loss and transfusion requirements, and determine rate of associated complications. MATERIALS AND METHODS A systematic review of PubMed and Medline covering January 1997 to December 2018 was conducted. Key words included placenta accreta, increta, percreta, and morbidly adherent placenta, balloon, interventional radiology, embolization, and caesarean hysterectomy. RESULTS Nineteen studies were included. Only three studies had appropriate controls: two with balloon placement in the internal iliac arteries and one in the common iliac arteries. One showed no difference in blood loss or transfusion requirements, the second showed a reduction in cases of percreta only and the third reported reduction in blood loss. Only few studies reported objective measures of blood loss. Blood loss and transfusion were still high (2.26 L and 3.79 units, respectively) despite use of vascular balloons. Balloon catheter use was associated with a 7.5% rate of complications; 4.5% were minor and 3.0% major. CONCLUSIONS There is a large body of poor data evaluating efficacy of prophylactic vascular balloon occlusion in cases of planned caesarean hysterectomy for known morbidly adherent placenta. Limited relevant data provide only scant evidence that these techniques are beneficial in reducing blood loss, despite associated significant complications.
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Affiliation(s)
| | - Prathima Chowdary
- North Shore Hospital WDHB, Auckland, New Zealand.,University of Auckland, Auckland, New Zealand
| | - Jenny Ann Westgate
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
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Wang M, Ballah D, Wade A, Taylor AG, Rizzuto G, Li B, Lucero J, Chen LM, Kohi MP. Uterine Artery Embolization following Cesarean Delivery but prior to Hysterectomy in the Management of Patients with Invasive Placenta. J Vasc Interv Radiol 2019; 30:687-691. [PMID: 30922797 PMCID: PMC10468213 DOI: 10.1016/j.jvir.2018.12.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 12/04/2018] [Accepted: 12/06/2018] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To evaluate outcomes of patients with placenta accreta spectrum (PAS) disorders who underwent uterine artery embolization (UAE) following cesarean delivery but before hysterectomy. MATERIALS AND METHODS A retrospective review of patients with PAS treated with cesarean-hysterectomy (C-hyst) was performed. Patients in the UAE group underwent UAE after cesarean delivery but before hysterectomy; patients in the control group underwent C-hyst alone. Estimated blood loss (EBL), transfusion requirements, length of intensive care unit (ICU) stay, and adverse events were evaluated. RESULTS The study included 31 patients, 7 in the UAE group and 24 in the control group. Median EBL, transfusion requirements, and length of ICU stay in the UAE group compared with control group were 1,500 mL (range, 500-2,000 mL) vs 2,000 mL (range, 1,000-4,500 mL) (P = .04), 150 mL (range, 0-650 mL) vs 550 mL (range, 0-3,125 mL) (P = .10), and 0 d (range, 0-1 d) vs 0.5 d (range, 0-2 d) (P = .07). All patients in the UAE group had placenta increta; patients in the control group had placenta accreta (29%), increta (54%), and percreta (17%) (P = .10). Subgroup analysis of patients with placenta increta demonstrated that the UAE group had a significant decrease in median EBL (P = .004), transfusion requirements (P = .009), and length of ICU stay (P = .04). No adverse events following UAE were noted. CONCLUSIONS UAE following cesarean delivery but before hysterectomy in patients with placenta increta appears to be safe and effective in decreasing EBL, transfusion requirements, and length of ICU stay compared with C-hyst alone.
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Affiliation(s)
- Melinda Wang
- Weill Cornell Medical College, New York, New York
| | - Deddeh Ballah
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Alana Wade
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Andrew G Taylor
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California
| | - Gabrielle Rizzuto
- Department of Pathology and Laboratory Medicine, University of California, San Francisco, San Francisco, California
| | - Benjamin Li
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - Jennifer Lucero
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
| | - Lee-May Chen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - Maureen P Kohi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California.
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Chen M, Lv B, He G, Liu X. Internal iliac artery balloon occlusion during cesarean hysterectomy in women with placenta previa accreta. Int J Gynaecol Obstet 2019; 145:110-115. [PMID: 30667043 DOI: 10.1002/ijgo.12763] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 10/02/2018] [Accepted: 01/21/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Meng Chen
- Department of Obstetrics and GynecologyWest China Second University Hospital of Sichuan University Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University)Ministry of EducationWest China Second University Hospital of Sichuan University Chengdu China
| | - Bin Lv
- Department of Obstetrics and GynecologyWest China Second University Hospital of Sichuan University Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University)Ministry of EducationWest China Second University Hospital of Sichuan University Chengdu China
| | - Guolin He
- Department of Obstetrics and GynecologyWest China Second University Hospital of Sichuan University Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University)Ministry of EducationWest China Second University Hospital of Sichuan University Chengdu China
| | - Xinghui Liu
- Department of Obstetrics and GynecologyWest China Second University Hospital of Sichuan University Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University)Ministry of EducationWest China Second University Hospital of Sichuan University Chengdu China
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Prophylactic Occlusion Balloon Placement in the Abdominal Aorta Combined with Uterine or Ovarian Artery Embolization for the Prevention of Cesarean Hysterectomy Due to Placenta Accreta: A Retrospective Study. Cardiovasc Intervent Radiol 2019; 42:829-834. [PMID: 30701289 DOI: 10.1007/s00270-019-02170-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/23/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the outcomes of uterine-conserving surgery with the occlusion balloon technique followed by uterine or ovarian artery embolization (OAE) in women with placenta accreta. METHODS A total of 31 consecutive patients, who were diagnosed with placenta accreta through grayscale ultrasonography or magnetic resonance imaging prenatally, were retrospectively analyzed in our hospital between October 2015 and September 2017. All of the women underwent a Cesarean section combined with prophylactic placement of a balloon catheter in the abdominal aorta followed by uterine artery embolization (UAE) or OAE when necessary. RESULTS Technical success was achieved in 31 cases (100%), including successful catheterization and inflation of balloons. The uterus was conserved in 30 (96.77%) patients. The estimated blood loss, packed RBC transfused, and the operation time were 1906.45 ± 1117.64 ml, 4(0-6) U, and 88.68 ± 28.35 min, respectively. Out of all of the patients, we found nine cases of bleeding after the release of the balloon. Among these patients, six cases originated from the ovarian arteries and three cases originated from uterine arteries. Further embolization was performed through catheterization. The mean fetal radiation exposure was 4.33 ± 0.79 mGy. CONCLUSIONS Prophylactic abdominal aorta balloon occlusion followed by UAE or OAE can effectively control postpartum hemorrhaging with reduced blood loss, transfusion requirements, and hysterectomy rates in patients with placenta accreta.
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Feldman JB, Kumaraswami S. Cesarean Hysterectomy in a Parturient With Morbidly Adherent Placenta Complicated by Postoperative Ischemic Stroke Secondary to Vertebral Artery Dissection: A Case Report. A A Pract 2019; 12:9-14. [DOI: 10.1213/xaa.0000000000000829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kaufman C, Tadros A. Endovascular Interventions for the Morbidly Adherent Placenta. J Clin Med 2018; 7:jcm7050092. [PMID: 29723954 PMCID: PMC5977131 DOI: 10.3390/jcm7050092] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 04/20/2018] [Accepted: 04/23/2018] [Indexed: 11/30/2022] Open
Abstract
Morbidly adherent placentas are a spectrum of abnormalities ranging from placental invasion of the myometrium to invasion past the myometrium and muscular layers into adjacent structures. This entity is becoming more prevalent recently with increased number of cesarean deliveries. Given the high risk of morbidity and mortality, this was traditionally treated with pre-term planned cesarean hysterectomy. However, recently, uterine preservation techniques have been implemented for those women wishing to preserve future fertility or their uterus. Early identification is crucial as studies have shown better outcomes for women treated at tertiary care facilities by a dedicated multidisciplinary team. Interventional radiologists are frequently included in the care of these patients as there are several different endovascular techniques which can be implemented to decrease morbidity in these patients both in conjunction with cesarean hysterectomy and in the setting of uterine preservation. This article will review the spectrum of morbidly adherent placentas, imaging, as well as the surgical and endovascular interventions implemented in the care of these complex patients.
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Affiliation(s)
- Claire Kaufman
- Department of Radiology, University of Utah, Salt Lake City, UT 84112, USA.
| | - Anthony Tadros
- Department of Radiology, University of California San Diego, San Diego, CA 92103, USA.
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