Intraoperative aortic balloon occlusion in patients with placenta previa and/or placenta accreta: a retrospective study

Is prophylactic intraoperative abdominal aortic balloon occlusion beneficial in pregnancies with placenta previa and placenta accreta spectrum during cesarean section? A 5-year retrospective study

OBJECTIVE

To assess whether prophylactic intraoperative abdominal aortic balloon occlusion (IAABO) is indeed beneficial in pregnancies with placenta previa (PP) and placenta accreta spectrum (PAS) during cesarean section.

METHODS

A retrospective case-control study included 251 pregnancies with PP and/or PAS. All enrolled patients were divided into a PP/PAS group, a PP + PAS group, and an IAABO group. The demographic characteristics and maternal and neonatal outcomes were compared.

RESULTS

There was no significant difference in blood loss and transfusion between the IAABO group and the PP + PAS group (P > 0.05). However, blood loss and red blood cell and fresh frozen plasma transfusion in the above two groups were significantly higher than in the PP/PAS group (P < 0.05). More pregnancies in the IAABO group had to undergo uterine artery embolization (29.2%) or hysterectomy (20.8%), and this percentage was significantly higher than that in the other two groups (P < 0.001). All neonatal characteristics did not show differences between the IAABO group and PP + PAS group (P > 0.05). IAABO led to femoral artery thrombosis in three cases and minor postoperative renal injury in one case.

CONCLUSION

IAABO only acted as a less important supporting technique during cesarean section. There was no evidence suggesting that IAABO could significantly control the massive hemorrhage in pregnancies with PP and PAS during cesarean delivery.

Association of MRI Features and Adverse Maternal Outcome in Patients With Placenta Accreta Spectrum Disorders After Abdominal Aortic Balloon Occlusion

BACKGROUND

MRI features may be associated with adverse maternal outcome in patients with placenta accreta spectrum (PAS) disorders even with abdominal aortic balloon occlusion (AABO).

PURPOSE

This study aimed to identify risk factors of MRI for association with adverse maternal outcome in patients with PAS disorders after AABO.

STUDY TYPE

Retrospective.

POPULATION

Clinical and MRI features of 80 patients were retrospectively reviewed from October 2016 to August 2021. A total of 40 patients had adverse maternal outcomes including intrapartum/peripartum bleeding >1000 mL and/or emergency hysterectomy after AABO.

SEQUENCE

Half-Fourier acquisition single-shot turbo spin echo and gradient echo imaging True fast imaging with steady-state precession (True-FISP) at 1.5T MR scanner.

ASSESSMENT

MRI features were evaluated by three radiologists and were tested for any association with adverse maternal outcome.

STATISTICAL TESTS

Interobserver agreement was calculated with kappa (k) statistics. Association between MRI features and adverse maternal outcomes were evaluated by univariate and multivariate analyses. A nomogram was constructed based on the logistic regression.

RESULTS

The interobserver agreement ranged from fair to substantial (k = 0.379-0.783). Multivariate analyses revealed that short cervical length (OR: 4.344), abnormal intraplacental vascularity (OR: 6.005), placental bulge (OR: 9.085), and myometrial interruption (OR: 9.550) were independent risk factors for adverse maternal outcomes. The combination of four risk factors together demonstrated the highest AUC of 0.851 (95% CI 0.769-0.933) with a sensitivity and specificity of 77.5% and 72.5%, respectively and then a nomogram composed of the above four risk factors was constructed to represent the probability of adverse maternal outcome.

DATA CONCLUSION

The nomogram demonstrated the association between MRI features and patient's poor outcome after undergoing AABO and C-section delivery for PAS.

EVIDENCE LEVEL

4 TECHNICAL EFFICACY: Stage 3.

Maternal outcomes of abnormally invasive placenta in China and their association with use of abdominal aortic balloon occlusion

OBJECTIVE

To compare maternal outcomes of abnormally invasive placenta in China in 2012, 2015, and 2018, and further examine the association between use of abdominal aortic balloon occlusion (AABO) and the risk of maternal outcomes.

MATERIALS AND METHODS

A retrospective analysis included 830 women diagnosed as abnormally invasive placenta from 5 tertiary care centers in China in 2012, 2015 and 2018. Participants were divided into AABO group and non-AABO group according to whether they were treated with AABO or not. Logistic regression models were used to assess the association of use of AABO with postpartum hemorrhage, blood transfusion, hysterectomy and repeated surgery.

RESULTS

Among 830 participants, 66.0% (548/830) and 34.0% (282/830) of women were diagnosed with placenta increta and percreta, respectively; 33.3% (276/830) of women with abnormally invasive placenta were treated with AABO. In 2012, 2015, and 2018, the rate of blood transfusion was 83.1, 59.8, and 56.2%; the rate of hysterectomy was 50.8, 11.2, and 2.4%; and the rate of repeated surgery was 10.2, 9.4, and 0.9%. Use of AABO was associated with lower risk of postpartum hemorrhage (OR = 0.59, 95% CI: 0.35-0.99), blood transfusion (OR = 0.72, 95% CI: 0.52-0.99), hysterectomy (OR = 0.04, 95% CI: 0.01-0.14) and repeated surgery (OR = 0.14, 95% CI: 0.05-0.41) after adjustment for potential confounders.

CONCLUSION

The rates of blood transfusion, hysterectomy and repeated surgery progressively decreased from 2012 to 2018 in Chinese women with abnormally invasive placenta. Use of AABO was associated with lower risk of postpartum hemorrhage, blood transfusion, hysterectomy and repeated surgery.

Fetal and neonatal outcomes following maternal aortic balloon occlusion for hemorrhage in pregnancy: A review of the literature

BACKGROUND

Hemorrhage is a leading cause of maternal death worldwide, with increased risk in women with abnormal placentation. Aortic balloon occlusion (ABO), including resuscitative endovascular balloon occlusion, has been used for obstetrical hemorrhage for 20 years, and is associated with decreased operative blood loss, fewer transfusions, and lower rates of hysterectomy. However, the effect of aortic occlusion on fetal/neonatal outcomes is not well known.

METHODS

A literature review on ABO for obstetrical or traumatic hemorrhage was performed. Cases were included if fetal/neonatal outcomes were reported. Data were collected on timing of balloon inflation (predelivery or postdelivery), fetal/neonatal mortality, and Apgar scores. Secondary maternal outcomes included blood loss, need for hysterectomy, ABO-related complications, and mortality.

RESULTS

Twenty-one reports of ABO in 825 cases of obstetrical hemorrhage were reviewed (nine case reports/series and twelve comparative studies). 13.5% (111/825) had aortic occlusion prior to delivery of the fetus. Comparative cohorts included 448 patients who underwent iliac artery balloon occlusion (n = 219) or no vascular balloon occlusion (n = 229). The most common neonatal outcome reported was Apgar scores, with no difference in fetal/neonatal outcomes between ABO and non-ABO patients in any study. One neonatal mortality occurred in the sole reported case of ABO use in a pregnant trauma patient at 24 weeks gestation. One maternal mortality occurred because of aortic dissection. Five comparative studies reported significantly decreased blood loss in ABO patients compared to non-ABO patients, and four studies reported significantly lower rates of hysterectomy in ABO patients. ABO-related complications were reported in 1.6% of patients (13/825).

CONCLUSION

Obstetrical hemorrhage is a devastating complication, and ABO may potentially decrease blood loss and reduce the hysterectomy rate without compromising fetal and neonatal outcomes. Further research is needed to determine the safety of predelivery aortic occlusion as this occurred in 14% of the cases.

Intelligent Recognition Algorithm-Based Color Doppler Ultrasound in the Treatment of Dangerous Placenta Previa

The study focused on the clinical diagnostic value of color Doppler ultrasound of dangerous placenta previa patients under the guidance of intelligent recognition algorithms. 58 patients with placenta previa and placenta accreta admitted to the hospital for treatment were selected as research subjects. The color Doppler ultrasound under the guidance of intelligent recognition algorithm was compared with the two-dimensional ultrasound for specificity, sensitivity, and accuracy. The color Doppler ultrasound results showed that, of the 58 patients, there were 32 cases of complete placenta previa and 26 cases of incomplete placenta previa, which were consistent with the surgical pathology results. It was found that patients with malignant placenta previa and placenta accreta had thickened placenta, disappeared posterior placental space, myometrium <2 mm, and increased incidence of cervical enlargement (P < 0.05). In conclusion, the recognition accuracy of color Doppler ultrasound under the guidance of the intelligent recognition algorithm is more than 90%, and it can effectively identify dangerous placenta previa, assisting doctors in diagnosis and treatment of dangerous placenta previa.

A modified suture technique for the treatment of patients with pernicious placenta previa and placenta accreta spectrum: a case series

Background

Pernicious placenta previa complicated by placenta accreta spectrum (PAS) often leads to hysterectomy or even maternal death due to massive bleeding. In recent years, the application of balloons has received increasing attention. It is easier to use and has reasonably good effect. However, for some patients, especially those who still have some placental residue, there might still be active bleeding. To solve this problem, we propose a method of pressure sutures around the balloon to provide a better hemostasis effect.

Methods

An observational study was conducted on patients with pernicious placenta previa and PAS at the Beijing Chaoyang Hospital, Beijing, China, between January 2018 and January 2021. During surgery, an intrauterine balloon was used to compress the hemorrhage site, and two or more absorbable sutures were placed around the uterus to apply strong pressure on the balloon. This method is an updated modification of the Lu-suture which uses a Foley catheter balloon and only one suture. The main improvements include choosing different kinds of balloons depending on various conditions and the addition of a suture below the balloon to provide much stronger pressure and prevent the balloon slipping out through the dilated cervix.

Results

A total of 10 women underwent the procedure. The mean estimated intraoperative blood loss was 1,190±548 mL. Post-surgery, the blood loss was less than 200 mL in all patients. The mean blood transfusion [packed red blood cells (pRBC)] required was 2.2±2.6 units. The mean hemostatic time was 8.1±3.4 minutes.

Conclusions

The modified suture technique provided an easy, cheap, and efficient surgical choice for patients with pernicious placenta previa and PAS.

Efficacy and safety of prophylactic abdominal aortic balloon occlusion versus internal iliac arterial balloon occlusion for placenta accreta spectrum disorder: A systematic review and meta-analysis

PURPOSE

To assess the efficacy and safety of abdominal aortic (AA) balloon occlusion versus internal iliac arteries (IIA) balloon occlusion in patients with placenta accreta spectrum (PAS) disorders.

METHODS

Databases of Embase, PubMed, Web of Science and Cochrane Library were systematically searched from inception to May 2020. The relevant literature was screened and the quality was assessed. RevMan software 5.3 was used to analyze the data.

RESULTS

Six studies involving 239 patients in AA occlusion and 281 patients in IIA occlusion were included. The results demonstrated that the intraoperative hemorrhage volume (MD - 410.61 ml, 95% CI -779.74 to -41.47 ml, p < 0.001), balloon dilatation duration (MD -5.34 min, 95% CI -9.91 to -0.77 min, p = 0.02) and fetus radiation dose (MD-20.81 mGy, 95% CI -31.84 to -9.78 mGy, p < 0.001) were significantly less in AA occlusion compared to IIA occlusion. There was no significant difference in the rate of lower extremity thrombosis between AA occlusion and IIA occlusion (OR 0.21, 95% CI 0.02 to 2.21, p = 0.19); similarly, no significant differences were found in blood transfusion volume (MD -344.50 ml, 95% CI -735.74 to 46.74 ml, p = 0.08), the rate of hysterectomy (OR 0.99, 95% CI 0.22 to 4.44, p = 0.99) and other outcome variables.

CONCLUSION

The available data demonstrated AA occlusion was more effective in reducing intraoperative hemorrhage volume and fetus radiation dose compared with IIA occlusion in patients with PAS disorders. Larger studies or randomized controlled trials are needed to further assert this evidence.

A Participant-assigned Interventional Research of Precesarean Internal Iliac Artery Balloon Catheterization for Managing Intraoperative Hemorrhage of Placenta Previa and Placenta Accreta Spectrum Disorders After Cesarean Section

Placenta accreta spectrum disorder (PASD) and placenta previa (PP) are two of the most hideous obstetric complications which are usually associated with a history of cesarean section (CS). Moreover, women with PASD, PP and/or a cesarean scarred uterus are more likely to have adverse pregnancy outcomes, including blood transfusion, hysterectomy, pelvic organs damage, postpartum hemorrhage, disseminated intravascular coagulation, multi-organ dysfunction syndrome and even maternal or fetal death. This study aimed to investigate the efficacy of precesarean internal iliac artery balloon catheterization (BC) for managing severe hemorrhage caused by PASD and PP with a history of CS. This participant-assigned interventional study was conducted in Tongji Hospital. We recruited 128 women with suspected PASD, PP and a history of CS. Women in the BC group accepted precesarean BC of bilateral internal iliac arteries before the scheduled cesarean delivery. Women in the control group underwent a conventional cesarean delivery. Intraoperative hemorrhage, transfusion volume, radiation dose, exposure time, complications and neonatal outcomes were discussed. There were significant differences in calculated blood loss (CBL) between BC group and control group (1015.0±144.9 vs. 1467.0±171.0 mL, P=0.04). Precesarean BC could reduce intraoperative red blood cell (RBC) transfusion as compared with control group (799.5±136.1 vs. 1286.0±161.6 mL, P=0.02) and lessen the rate of using blood products (57.1% vs. 76.4%, P=0.02). The incidence of hysterectomy was also lower in BC group than in control group. Postpartum outcomes showed no significant differences between the two groups, except that postoperation hospitalization was longer in BC group than in control group (6.7±0.4 vs. 5.8±0.2 days, P=0.03). Precesarean BC of internal iliac artery is an effective method for managing severe hemorrhage caused by PASD and PP with a cesarean scarred uterus, as it could reduce intraoperative blood loss, lessen intraoperative RBC transfusions and potentially decrease hysterectomies.

Common iliac artery dissection as a complication of common iliac artery balloon occlusion for placenta percreta: A case report

A 37-year-old pregnant woman who had undergone three previous cesarean sections was diagnosed as having placenta percreta. We decided to perform cesarean hysterectomy with bilateral common iliac artery balloon occlusion (CIABO). The duration of surgery was 2 h and 2 min and total estimated blood loss was 2600 mL. Surgery was completed without any surgical complications, but the pulse oximeter waveform of the left leg became undetectable during surgery. We immediately performed angiography after closure of laparotomy and found abnormal pooling of contrast media at the left common iliac artery in the region in which the balloon was positioned. We made a diagnosis of left common iliac artery dissection caused by CIABO. We performed emergent revascularization by intravascular stenting. We conclude that CIABO can cause common iliac artery dissection by mechanical stimulation of the inflated balloon. Careful intraoperative evaluation of limb ischemia and preparation of intravascular treatment is needed for a safe procedure.

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

BACKGROUND

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

OBJECTIVE

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION

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

RESULTS

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

CONCLUSIONS

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

Comparison of emergency cesarean hysterectomy with and without prophylactic placement of intravascular balloon catheters in patients with placenta accreta spectrum

OBJECTIVE

The objective of the study was to compare outcomes of women with placenta accreta spectrum(PAS) who underwent emergency cesarean hysterectomy with and without prophylactic intravascular balloon catheters.

Methods Sixty-three cases who had emergency hysterectomy related to PAS disorders were retrospectively analyzed. Subjects with prophylactic intravascular balloon catheter placement plus hysterectomy were compared with those who had hysterectomy alone. The cases were divided into three groups: infrarenal aortic artery balloon occlusion (IAABC) group (who had IAABC plus hysterectomy, n = 31), internal iliac artery balloon occlusion (IIABOC) group (who had IIABOC plus hysterectomy, n = 17), and hysterectomy alone group (control group n = 15).

RESULTS

Outcome measures were not significantly different between the IIABOC group and the control group. IAABC plus hysterectomy resulted in a better outcome than hysterectomy alone, with less amount of estimated blood loss (EBL) during cesarean section (2000 vs 3000 ml, p = .011) and 24 h after cesarean section (2010 vs 4520 ml, p = .004), less operation time(90 vs 106 min, p = .01), and a lower rate of major blood loss(42 vs 93%, p = .029). IAABC plus hysterectomy resulted in better outcomes than IIABOC plus hysterectomy, with less amount of EBL during cesarean section (2000 vs 3000 ml, p = .005) and 24 h after cesarean section (2010 vs 3000 ml, p = .035), a lower rate of major blood loss(42 vs 100%, p < .001), less operation time (90 vs 100 min, p = .038), and less fetus radiation dose（1.9 mGy vs 22.4 mGy, p < .001).

CONCLUSIONS

IAABC was more effective in emergency cesarean hysterectomy related to PAS disorders.

The role of interventional radiology in the management of abnormally invasive placenta: a systematic review of current evidences

Abnormally invasive placenta (AIP) is a potentially severe condition. To date, arterial embolization in women with postpartum hemorrhage due to AIP is the treatment option for which highest degrees of evidence are available. However, other techniques have been tested, including prophylactic catheter placement, balloon occlusion of the iliac arteries and abdominal aorta balloon occlusion. In this systematic review, we provide an overview of the currently reported interventional radiology procedures that are used for the treatment of postpartum hemorrhage due to AIP and suggest recommendations based on current evidences. Owing to a high rate of adverse events, prophylactic occlusion of internal iliac arteries should be used with caution and applied when the endpoint is hysterectomy. On the opposite, when a conservative management is considered to preserve future fertility, uterine artery embolization should be the preferred option as it is associated with a hysterectomy rate of 15.5% compared to 76.5% with prophylactic balloon occlusion of the internal iliac arteries and does not result in fetal irradiation. Limited data are available regarding the application of systematic prophylactic embolization and no comparative studies with arterial embolization are available.

Clinical outcomes and anesthetic management of pregnancies with placenta previa and suspicion for placenta accreta undergoing intraoperative abdominal aortic balloon occlusion during cesarean section

Background

This retrospective study aimed to compare the clinical outcomes of parturients with placenta previa (PP) and placenta accreta (PA) according to their severity, when they were managed with intraoperative abdominal aortic balloon occlusion (IAABO) during cesarean section.

Methods

We retrospectively examined 57 cases of PP and suspicion for PA in which IAABO was performed during cesarean section between April 2014 and June 2016. Based on preoperative examination and clinical risk factors, patients were divided into the low suspicion PA group and the high suspicion PA group. We compared the demographic characteristics, methods of anesthesia, intra- and postoperative parameters, and maternal and neonatal outcomes.

Results

The two groups showed similar demographic characteristics and intraoperative outcomes. Four women underwent cesarean hysterectomy. Eight neonates were admitted to the neonatal intensive care unit and three did not survive. Neonatal Apgar scores were significantly higher in the low suspicion PA group. Eight patients experienced postoperative femoral artery thrombosis and one patient complicated hematoma in the front wall of the common femoral artery. Patients who received neuraxial anesthesia showed significantly lower intraoperative blood loss, lower intraoperative, postoperative and total blood transfusion and shorter surgery than patients who received general anesthesia.

Conclusions

Our data suggested that the severity of aberrant placental position does not affect intraoperative blood loss during a cesarean section while the IAABO is performed. We propose that neuraxial anesthesia is preferred for conducting these surgeries without contraindications.

Long-term follow-up of abdominal aortic balloon occlusion for the treatment of pernicious placenta previa with placenta accreta

OBJECTIVE

To evaluate the efficacy and safety of balloon occlusion of the abdominal aorta for the treatment of pernicious placenta previa with placenta accreta.

METHODS

The clinical data of 623 patients with pernicious placenta previa combined with placenta accrete, who were admitted to our hospital from January 2013 to January 2019 were retrospectively analyzed. All patients underwent abdominal aortic balloon occlusion combined with cesarean section, and 78 patients underwent sequential bilateral uterine artery embolization. We analyzed the operation time, intraoperative blood loss, blood transfusion volume, intraoperative and postoperative complications, fetal radiation exposure time and dose, and the Apgar score of the newborns. We also performed other evaluations to ascertain the efficacy and safety of abdominal aortic balloon occlusion treatment for dangerous placenta previa with placenta accrete.

RESULTS

Of the 623 patients, 545 underwent only abdominal aortic balloon occlusion, and 78 underwent uterine artery embolization due to intraoperative or postoperative bleeding. The uterus was successfully preserved in all patients. Except for five cases of right lower extremity arterial thrombosis, the remaining patients did not have postoperative lower extremity arteriovenous thrombosis, renal insufficiency, late postpartum hemorrhage, ectopic embolism, spinal cord or peripheral nerve damage, pelvic infection, or other serious complications. The mean operative time was 65.3 (±14.5) min. The mean intraoperative blood loss was620 (±570) ml. Ninety-six patients (15.4%, 96/623) were treated with blood transfusion, and the average amount of blood transfused was 750 (±400) ml. The average number of hospitalization days was 6.8 (±3.4) days, the average time of fetal ray exposure was 5.2 (±1.6) s, and the average radiation dose was 4.1 (±2.7) mGy. The neonatal Apgar score, was 8.4 (±0.6) points at 1 ​min, and 9.6 (±0.4) points at 5 ​min. In the follow-up to May 31, 2019, 29 patients were lost to follow-up, 96 were lactating, and 498 were menstruating. Except for the cases lost to follow-up, the remaining 596 surviving newborns (including 2 twins) showed no abnormalities at the 42-day postnatal outpatient follow-up examination.

CONCLUSION

Balloon occlusion of the abdominal aorta is a safe and effective method for the treatment of pernicious placenta previa with placenta accreta.

A retrospective analysis of the treatment on abdominal aortic balloon occlusion-related thrombosis by continuous low-flow diluted heparin

Thrombosis is one of the serious complications related to prophylactic balloon occlusion of the abdominal aorta (PBOAA). This study aims to retrospectively analyze the efficacy and safety of continuous low-flow infusion of diluted heparin saline to prevent this complication related to PBOAA and further to provide the theory and evidences for using PBOAA.A study was carried out at our hospital from March 2016 to December 2018. Women with pernicious placenta previa (PPP) were treated PBOAA to prevent massive bleeding during CS. According to whether continuous low-flow infusion of diluted heparin saline was used to prevent catheter-related thrombosis or not, they were divided into 2 groups, the test group and the control group. The incidence of thrombosis between the 2 groups was compared and the effective treatment of thrombosis was also discussed. The comparison of nonparametric values was accomplished by using Fisher exact test. Statistical significance was set at P < .05.There were 31 women with PPP who received PBOAA during CS who were included in our study. Six of 19 women in control group (31.6%) developed thrombotic complications, while none of 12 women in test group. There were statistically significant differences in the incidence of thrombosis between the 2 groups (P = .037). There was no statistically significant difference in the amount of estimated blood loss and blood transfusion during CS between the 2 groups, nor was there statistically significant difference in the hospital days after CS (P > .05). All 6 women with thrombotic complications had no positive symptoms and thrombotic sequelae. The managements of thrombus included systemic anticoagulation, catheter-directed thrombolysis, and catheter-directed anticoagulation. One of the 6 women was lost to follow-up, and the thrombus of the other 5 women were completely dissolved. No other adverse outcomes or complications related to PBOAA were observed in all women in this study.Continuous low-flow infusion of diluted heparin saline is a safe procedure when PBOAA is performed for patients with PPP. It can effectively reduce or even avoid thrombosis without increasing intraoperative blood loss during CS for PPP patients.

Prophylactic abdominal aortic balloon occlusion in patients with pernicious placenta previa during cesarean section: a systematic review and meta-analysis from randomized controlled trials

PURPOSE

Pernicious placenta previa induces severe hemorrhage during cesarean section. Abdominal aorta balloon occlusion (AABO) is considered as an effective operation for patients with pernicious placenta previa. The aim of this study was to investigate the clinical application of abdominal aortic balloon occlusion in the placenta previa and cesarean section by systematic review and meta-analysis.

METHODS

MEDLINE, EMBASE, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), WAN-FANG DATA and CQVIP were searched from inception to Jan. 15th, 2019. Operative time, intraoperative blood loss volume, postoperative hospitalization duration, intraoperative blood transfusion volume, hysterectomy rate, lower extremity thrombosis rate, ICU admission rate, adverse reaction rate, neonatal birth weight, Apgar 1-min and 5-min scores were regarded as the endpoints. Randomized controlled trials (RCT) were used for meta-analysis.

RESULTS

Fourteen articles were retrieved from total 650 articles, and the results of meta-analysis showed that application of intraoperative AABO had the ability to reduce the operative time (WMD = - 16.581, 95% CI - 26.690 to - 6.472; P = 0.001), the intraoperative blood loss volume (WMD = - 1202.69, 95% CI - 1732.25 to - 673.12; P < 0.001), the intraoperative blood transfusion volume (WMD = - 1202.69, 95% CI - 1732.25 to - 673.12; P < 0.001). The hysterectomy rate (RR = 0.279, 95% CI 0.164-0.474; P < 0.001), postoperative hospitalization duration (WMD = - 1.423, 95% CI - 2.070 to - 0.776; P < 0.001) and the balloon preset time (WMD = - 13.793, 95% CI - 15.341 to - 12.244; P < 0.001; I² = 0.0%) were also reduced in AABO group.

CONCLUSIONS

Application of AABO in patients with pernicious placenta previa is safe and effective, which is worthy of clinical promotion.

Application of abdominal aortic balloon occlusion followed by uterine artery embolization for the treatment of pernicious placenta previa complicated with placenta accreta during cesarean section

OBJECTIVE

This study aimed to investigate the clinical effects of abdominal aortic balloon occlusion followed by uterine artery embolization for the treatment of pernicious placenta previa complicated with placenta accreta during cesarean section.

METHODS

We performed a retrospective analysis of the clinical data for 623 patients who experienced pernicious placenta previa complicated with placenta accreta and received treatment in our hospital from January 2013 to January 2019. All patients underwent abdominal aortic balloon occlusion before their cesarean section. Seventy-eight patients received bilateral uterine artery embolization, and among them, placenta accreta was found at the opening of the cervix in 13 patients. Due to suturing difficulty after the removal of the placenta, gauze packing was used to temporarily compress the hemorrhage. As soon as the uterus was sutured, emergent bilateral uterine artery embolization was performed. Active bleeding was noted in the remaining 65 patients when the lower part of the uterus was pressed after the placenta was removed and the uterus was sutured, therefor, bilateral uterine artery embolization was performed urgently.

RESULTS

Of the 623 patients, 545 patients underwent only abdominal aortic balloon occlusion and 78 patients underwent additional emergent bilateral uterine artery embolization due to hemorrhaging during or after their cesarean section. No hysterectomies were performed. In the 78 patients, the amount of bleeding was 800-3,200 ml with an average of 1,650 ml during the operation; the volume of blood transfused was 360-1,750 ml (average: 960 ml). The fetal fluoroscopy time was 3-8 s (average: 5 s). The dose of radiation exposure was (4.2 ± 2.9) mGy. Fetal appearance, pulse, grimace, activity, and respiration (Apgar) score were normal. No serious complications were observed during or after the operation in the follow-up visits. Conclusion: For patients with pernicious placenta previa complicated with placenta accreta who experience active bleeding after cesarean section and abdominal aortic balloon occlusion, bilateral uterine artery embolization can effectively reduce blood loss and requirement of blood transfusion during the operation, and lowers the risk of hysterectomy.