Abnormal placentation and selective embolization of the uterine arteries

Uterine artery embolization for postpartum hemorrhage with placenta accreta spectrum

BACKGROUND

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Conventional MRI features for predicting the clinical outcome of patients with invasive placenta

PURPOSE

We aimed to evaluate whether morphologic magnetic resonance imaging (MRI) features could help to predict the maternal outcome after uterine artery embolization (UAE)-assisted cesarean section (CS) in patients with invasive placenta previa.

METHODS

We retrospectively reviewed the MRI data of 40 pregnant women who have undergone UAE-assisted cesarean section due to suspected high risk of massive hemorrhage caused by invasive placenta previa. Patients were divided into two groups based on the maternal outcome (good-outcome group: minor hemorrhage and uterus preserved; poor-outcome group: significant hemorrhage or emergency hysterectomy). Morphologic MRI features were compared between the two groups. Multivariate logistic regression analysis was used to identify the most valuable variables, and predictive value of the identified risk factor was determined.

RESULTS

Low signal intensity bands on T2-weighted imaging (P < 0.001), placenta percreta (P = 0.011), and placental cervical protrusion sign (P = 0.002) were more frequently observed in patients with poor outcome. Low signal intensity bands on T2-weighted imaging was the only significant predictor of poor maternal outcome in multivariate analysis (P = 0.020; odds ratio, 14.79), with 81.3% sensitivity and 84.3% specificity.

CONCLUSION

Low signal intensity bands on T2-weighted imaging might be a predictor of poor maternal outcome after UAE-assisted cesarean section in patients with invasive placenta previa.

Emergency Peripartum Hysterectomies at a District General Hospital in United Kingdom: 10-Year Review of Practice

Peripartum haemorrhage is an obstetric emergency which requires effective and timely management. A retrospective analysis was conducted at a single centre district hospital, over a 10-year period to describe factors that would lead to a peripartum hysterectomy. We sought to establish intraoperative and postoperative risks and review outcomes and complications associated with the procedure. A total of 29 cases (incidence 0.8 per 1000) were reviewed over 2001-2011. The mean parity was 1.8 and the mean maternal age was 33 years. Uterine atony was the most common indication for hysterectomy (12/29) followed by placenta praevia and accreta (4/29 and 5/29 cases, resp.). The commonest postoperative complications were sepsis and paralytic ileus. EPH most commonly occurs due to uterine atony but remains difficult to predict. Hospitals should continue to have robust systems and the necessary resources available to perform EPH where clinically indicated.

Placenta accreta spectrum: accreta, increta, and percreta

Placenta accreta can lead to hemorrhage, resulting in hysterectomy, blood transfusion, multiple organ failure, and death. Accreta has been increasing steadily in incidence owing to an increase in the cesarean delivery rate. Major risk factors are placenta previa in women with prior cesarean deliveries. Obstetric ultrasonography can be used to diagnose placenta accreta antenatally, which allows for scheduled delivery in a multidisciplinary center of excellence for accreta. Controversies exist regarding optimal management, including optimal timing of delivery, surgical approach, use of adjunctive measures, and conservative (uterine-sparing) therapy. We review the definition, risk factors, diagnosis, management, and controversies regarding placenta accreta.

Conservative Management of Invasive Placenta Using Combined Prophylactic Internal Iliac Artery Balloon Occlusion and Immediate Postoperative Uterine Artery Embolization

Purpose

The objective of the study was to evaluate the efficacy and safety of combined prophylactic intraoperative internal iliac artery balloon occlusion and postoperative uterine artery embolization in the conservative management (uterine preservation) of women with invasive placenta undergoing scheduled caesarean delivery.

Methods

Ten women (mean age 35 years) with invasive placenta choosing caesarean delivery without hysterectomy had preoperative insertion of internal iliac artery occlusion balloons, intraoperative inflation of the balloons, and immediate postoperative uterine artery embolization with absorbable gelatin sponge. A retrospective review was performed with institutional review board approval. Outcome measures were intraoperative blood loss, transfusion requirement, hysterectomy rate, endovascular complications, surgical complications, and postoperative morbidity.

Results

All women had placenta increta or percreta, and concomitant complete placenta previa. Mean gestational age at delivery was 36 weeks. In 6 women the placenta was left undisturbed in the uterus, 2 had partial removal of the placenta, and 2 had piecemeal removal of the whole placenta. Mean estimated blood loss during caesarean delivery was 1.2 L. Only 2 patients (20%) required blood transfusion. There were no intraoperative surgical complications, endovascular complications, maternal deaths, or perinatal deaths. Three women developed postpartum complications necessitating postpartum hysterectomy; the hysterectomy rate was therefore 30% and uterine preservation was successful in 70%.

Conclusion

Combined bilateral internal iliac artery balloon occlusion and uterine artery embolization may be an effective strategy to control intraoperative blood loss and preserve the uterus in patients with invasive placenta undergoing caesarean delivery.

Pathological findings in a case of failed uterine artery embolization for placenta previa

The reported success rate of uterine artery embolization (UAE) for obstetrical hemorrhage is more than 90%. We experienced a case of failed UAE for postpartum hemorrhage, although an embolic particle was found pathologically in the uterine vessels without coagulation. A 42-year-old woman (gravida 7, para 2) with placenta previa had genital bleeding at 35 weeks of gestation, and cesarean section was performed. We immediately added UAE aiming to reduce massive bleeding after the cesarean section, successful embolization of the bilateral uterine arteries and internal iliac arteries were confirmed by angiography regardless the vital sign was recovered with an appropriate amount of transfusion; the massive bleeding recurred after 1 hour of UAE. Hysterectomy was performed and pathological findings of the uterus showed that there was no coagulation in the vessels, which was supposed to be observed by the effect of gelatin sponge. In addition, despite the fact that no coagulation was found, only one gelatin sponge was found in 16 slices of the uterine wall specimens. We speculate that thrombotic materials were caught in vasoconstricted vessels triggered by hypovolemic shock due to acute blood loss, and then the gelatin sponge could be washed out after recovering to normalized circulation status leading to recurrent massive hemorrhage.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Planned caesarean in the interventional radiology cath lab to enable immediate uterine artery embolization for the conservative treatment of placenta accreta

AIM

To evaluate the feasibility and efficacy of routine uterine artery embolization (UAE) immediately after planned caesareans performed in the cath lab for conservative treatment of placenta accreta.

MATERIALS AND METHODS

A retrospective study included all patients who had a planned caesarean in the cath lab for conservative treatment of placenta accreta at Angers University Hospital, which is a tertiary care centre, from April 2001 to September 2010. Twelve patients underwent UAE immediately after caesarean with the placenta left partially or totally in situ. The success rate of embolization, blood loss, and complications were reported.

RESULTS

Diagnosis of abnormal placentation was confirmed by caesarean findings in 14 cases. Four patients had a percreta form with bladder invasion. In seven cases blood loss was insignificant and UAE was prophylactic; no secondary haemorrhage was observed in this group. Postpartum haemorrhage occurred in five cases: control of immediate postpartum bleeding by embolization was successful in three and failed in two leading to hysterectomy. In one case uterine necrosis occurred 6 weeks after embolization, requiring a hysterectomy. Delayed complications resulted in hysterectomy and partial bladder resection 3 months after delivery for one of the patients with placenta percreta.

CONCLUSION

UAE immediately after a caesarean performed in the cath lab is a feasible therapeutic option for conservative treatment of placenta accreta. Advantages include reducing stress and risks associated with transferring women with potentially unstable haemodynamics.

Uterine artery embolization for emergent management of postpartum hemorrhage associated with placenta accreta

BACKGROUND

Although uterine artery embolization (UAE) is a well-recognized alternative treatment for postpartum hemorrhage (PPH) with a high clinical efficacy, the reported success rate of UAE for PPH associated with placenta accreta (PA) is lower. Recently, with advances in techniques and expertise, a few studies have reported favorable results of UAE in controlling PPH in the setting of PA.

PURPOSE

To evaluate the efficacy of UAE in the emergent management of intractable PPH associated with PA.

MATERIAL AND METHODS

Seventeen consecutive patients who underwent emergent UAE for the management of PPH associated with PA were included in this retrospective study. Medical records were reviewed regarding the delivery and UAE procedure. Follow-up gynecologic outcomes after UAE were obtained by telephone interview.

RESULTS

UAE successfully controlled PPH in 14 patients (82.4%). Three patients underwent hysterectomy after UAE failed to stop the bleeding. All hysterectomy cases were accompanied by uterine atony or total placenta previa. Relevant gynecologic findings were obtained from 10 patients; three patients were breastfeeding and seven patients resumed normal menstruation, including one pregnancy.

CONCLUSION

UAE appears to be a safe and effective means by which to control PPH associated with PA. PA complicated by uterine atony or placenta previa may be at increased risk of UAE failure.

Air medical transport of a patient with placenta accreta

Air medical transport of high-risk obstetric and postpartum patients accounts for a low number of flights nationwide. Although reflecting a low percentage, they pose potential for increased challenge because of high acuity and increased liability. High-risk obstetrical flight crew education is typically focused on care of the gestational mother and newborn infant, with less time spent on postpartum complications. While uncommon, placenta accreta is one complication that poses a significant mortality risk for postpartum patients.

Obstetric and gynecologic emergencies: a review of indications and interventional techniques

There are many interventional techniques that can be used to aid the obstetrician or gynecologist in caring for their patients in the acute setting. Embolization can be life saving in the case of postpartum hemorrhage. Bleeding related to cervical cancer or the threat of bleeding from cervical ectopic pregnancy is amenable to embolization as is hemorrhage related to uterine arteriovenous malformations. Postpartum women are also at a uniquely high risk for deep vein thrombosis and pulmonary emboli and may benefit from consultation and treatment by an interventional radiologist. The goal of this article is to discuss the valuable role that the interventional radiologist plays in the treatment of these obstetric and gynecologic conditions.

[Current indications for uterine artery embolization to treat postpartum hemorrhage]

Uterine artery embolization is an interventional radiology technique successfully used for more than 30 years in the management of gynecological or obstetrical hemorrhage. Precise indications for uterine artery embolization to treat postpartum hemorrhage have been recently published. Uterine artery embolization is indicated in case of uterine atony despite medical treatment particularly after vaginal delivery, in case of vaginal thrombus or cervical tear after failed surgical repair. Embolization can also be discussed in case of persistent hemorrhage after arterial ligation or hysterectomy. Finally, arterial embolization can be attempted in case of placenta accreta to avoid hysterectomy. In all situations, pluridisciplinary management of patients with involvement of interventional radiologists, anesthesiologists and obstetricians is mandatory. Early transportation of patients for embolization should be discussed taking into consideration time of onset of hemorrhage, expected transfer time and treatment options available on site. For validated indications, success rates of arterial embolization as high as 80% can be expected in experienced hands.

Impact of the new French clinical practice recommendations in embolization in postpartum and post-abortion hemorrhage: study of 48 cases

AIM

To evaluate the use of arterial embolization in postpartum hemorrhage (PPH) by comparing the indications, efficacy, times to diagnosis, treatment, and embolization, and conditions of management of patients before and after publication of the Collège National des Gynécologues et Obstétriciens Français clinical practice recommendations (CPR).

METHODS

Forty-eight patients who underwent embolization between January 2000 and December 2005 were included in a retrospective, descriptive, and comparative study. We compared the management before (n=21) and after (n=27) publication of the CPR. The main outcome measures were time to diagnosis of PPH, time to treatment initiation, time to decision to implement embolization, time to embolization, hemodynamic characteristics.

RESULTS

The number of embolizations has quadrupled since publication of the CPR, and the time taken to decide on embolization has been reduced by 30%. The success rate was 96%, there were no second embolization procedures, and one complication was recorded (hematoma of pubic symphysis). Hemodynamic status was better in patients treated after the CPR (P=0.003).

CONCLUSION

Embolization is an effective and safe technique, with a low complication rate. In our healthcare network, the decision to use embolization was faster since the CPR, embolizations have quadrupled, and patients' hemodynamic status has improved.

Results of endovascular treatment in cases of abnormal placentation with post-partum hemorrhage

AIM

The purpose of this study was to evaluate the clinical success of selective arterial embolization in cases of post-partum hemorrhage due to abnormal placentation.

METHODS

Six patients with persistent hemorrhage and abnormal placental implantation underwent uterine artery embolization over a period of three years.

RESULTS

In four patients, the placenta was left in place after a gentle attempt at removal and post-partum hemorrhage was controlled during or shortly after the procedure. In all cases, embolization was possible even when there was previous arterial ligation (two cases). In one case, a hysterectomy was required at 21 d later due to uterus and bladder necrosis. Arterial embolization in cases of abnormal placental implantation remains an uncommon treatment and is less efficient in these cases than in normal placental implantation.

CONCLUSION

Our results confirmed that even in cases of moderate bleeding, conservation treatment and embolization are possible, but that complications may be more common than in normal placentation.

Conservative management of placenta increta with selective arterial embolization preserves future fertility and results in a favorable outcome in subsequent pregnancies

OBJECTIVE

To present a case of selective arterial embolization for the treatment of placenta increta in a patient with subsequent pregnancy.

DESIGN

Case report and literature review.

SETTING

Community-based hospital.

PATIENT(S)

A 31-year-old G2P1 woman with placenta increta presenting with delayed postpartum hemorrhage.

INTERVENTION(S)

Selective uterine artery embolization.

MAIN OUTCOME MEASURE(S)

Cessation of uterine hemorrhage, future pregnancy.

RESULT(S)

The patient's uterine bleeding immediately resolved. She subsequently delivered a healthy neonate at term without recurrence of abnormal placentation.

CONCLUSION(S)

Arterial embolization is effective for treating placenta increta in women who wish to preserve fertility. A review of the literature demonstrates a 76.9% success rate and an 11% complication rate.

Experience with Conservative Strategy of Uterine Artery Embolization in the Treatment of Placenta Percreta in the first Trimester of Pregnancy

OBJECTIVE

There is little prospective experience in the conservative treatment of placenta percreta during the first trimester in order to preserve uterine fertility. We describe herein our experience with uterine artery embolization (UAE) in the management of placenta percreta at 9 weeks of gestation.

CASE REPORT

A 36-year-old woman, gravida 3, para 1, was referred for ultrasonographic evaluation because of suspected molar pregnancy due to persistent vaginal spotting at 9 weeks of gestation. A Grade 3+ lacunar flow pattern with multiple bizarre and large irregular sonolucent spaces were observed. Color Doppler imaging revealed extensive turbulent lacunar blood flow perfusing throughout the whole surrounding uteroplacental tissues and fetus. The patient was informed of the situation and she had a strong desire to avoid surgery. Conservative management with bilateral UAE was performed using polyvinyl alcohol particles to promote involution and shedding of the abnormally adherent placenta. However, an unsatisfactory vessel-occluding effect caused by extensive collateral supply was still detected after repeated UAE. We, therefore, performed hysterectomy, and the patient had an uneventful postoperative course.

CONCLUSION

The efficacy and complications of UAE as a therapeutic modality for the conservative management of invasive placentation in the first trimester of pregnancy are not clear, as this is the first report of its kind. However, although UAE had failed in this case, it may still be a useful procedure as a prophylactic measure before surgical intervention, and hysterectomy can also be performed for better control of operative hemorrhage.

Prise en charge des hémorragies graves du post-partum: indications et techniques de l’embolisation artérielle

Pluridisciplinary management of women with postpartum hemorrhage is mandatory in order to precisely assess initial seriousness, to maintain hemodynamic parameters and to confirm the cause of bleeding. Embolization should be offered only after exploration of the uterine cavity, inspection of the vagina, cervix and perineum and failure of uterotonic drugs. Embolization should be carried out in an angiography suite under constant monitoring of the patient by the anesthesiologist. Indications to perform arterial embolization include uterine atony particularly following a vaginal delivery, cervico-uterine hemorrhage, cervicovaginal lacerations (previously repaired or if surgical repair has failed) and vaginal thrombus, particularly in case of associated coagulopathy. Arterial embolization is effective in about 85% of cases. Placenta acccreta can also be successfully managed with arterial embolization as an alternative to hysterectomy. Unilateral femoral approach allows selective study of both internal iliac arteries and branches. Selective embolization of both uterine arteries should be ideally performed. In case of spasm or difficult catheterization, embolization of the anterior division of both internal iliac arteries should be considered. In case of bleeding from the cervico-vaginal region, selective evaluation and embolization of cervicovaginal branches should be performed. In case of failure or recurrence of bleeding, ovarian and round ligament arteries should be evaluated. In most cases, resorbable gelatin sponge pledgets should be used to perform embolization. The use of microcatheters and non resorbable embolization agents should be considered by trained interventional radiologists in case of placenta accreta or vascular lesions. After embolization, the patient should be transferred to the intensive care unit for further observation in order to offer emergent surgical procedure or another session of embolization in case of recurrence of bleeding.

Successful Treatment of Post-Cesarean Hemorrhage Related to Placenta Praevia Using an Intrauterine Balloon

The authors report a positive experience in controlling severe postpartum hemorrhage after cesarean section performed for placenta praevia by using an inflated intrauterine balloon and avoiding any further invasive surgery.

Placenta percreta with subsequent uterine rupture at 15 weeks of gestation after two previous cesarean sections

A 25-year-old gravida 3 para 2 woman was referred to our hospital at 15 weeks' gestation with an acute abdomen and free fluid in the peritoneal cavity. On admission she was somnolent. She had a history of two cesarean sections. Fetal cardiac activity was detectable by ultrasound preoperatively. Intraoperatively, a lower uterine-segment rupture was identified in the area of the presumed prior uterine incision. The great blood loss with consecutive coagulopathy required an emergency hysterectomy and multiple blood transfusions. The placenta was located on the lower anterior uterine wall. Intervening decidual cells between placenta and maternal scar tissue were absent in the area of the prior uterine incision. Placental villous tissue deeply invaded and perforated the scar tissue. Histological examination revealed a placenta percreta. Placenta percreta with subsequent uterine rupture is a rare but dramatic complication after previous cesarean section. This should be kept in mind as the rate of elective cesarean sections is rising continuously. Our patient recovered completely.

Surgical uterine devascularization for placenta accreta: immediate and long-term follow-up

BACKGROUND

To report immediate and long-term outcome in patients with surgical uterine devascularization for placenta accreta.

METHODS

Six patients with placenta accreta were treated conservatively during a cesarean section by a bilateral uterine and ovarian surgical devascularization procedure. Menstrual flow, imaging monitoring and further pregnancy were retrospectively reported.

RESULTS

Blood transfusion was necessary in five cases and a hysterectomy was performed in one patient with placenta previa accreta. All patients resumed menstruation without oral contraception but one of them reported temporary clinical symptoms of estrogen insufficiency. A chronic placental retention occurred in three patients with incomplete placenta removal. One patient with both bilateral uterine and ovarian arterial ligations had a subsequent pregnancy complicated by a recurrent placenta accreta that was subsequently treated conservatively.

CONCLUSIONS

Surgical uterine devascularization for placenta accreta may be useful for uterine conservation. However, reproductive capacity may be altered by placental chronic retention and further pregnancies may be complicated by recurrent placenta accreta.

[Intractable postpartum haemorrhages: where is the place of vascular ligations, emergency peripartum hysterectomy or arterial embolization?]

OBJECTIVE

Update of knowledge on the various methods of management of intractable postpartum haemorrhage.

METHOD

PubMed, MEDLINE were the electronic sources, in English and French languages, used for data retrieval. Uterine atony and abnormal placental insertions (placenta praevia or accreta) are the major causes of primary postpartum haemorrhages. To preserve fertility, we dispose of angiographic selective embolization or surgical vascular ligations. Embolization is a non-invasive method practicable by simple catheterization under local anesthesia. Vascular ligations of the uterine vessels or internal iliac arteries require mostly laparotomy. New and easier surgical methods, such as uterine compression or hemostatic suturing techniques have been described for which we lack experience.

RESULTS

For uterine atony, the success rate of arterial embolization and uterine artery ligations is close to 100%. Ligation of internal iliac arteries is a little less effective and technically more difficult to carry out. It remains interesting in obstetrical traumatic hurts, which do not concern the uterus. If bleeding from the lower segment occurs during caesarean section, low uterine artery ligatures are necessary. These methods are all the more effective than they are prematurely implemented before the rise of major coagulopathy. In this case, uterine devascularization has also to be applied to ovarian vessels. With placenta accreta, accreta portion of the placenta can be left in place and arterial embolization or vascular ligations can be done. Nevertheless the main cause of failure with conservative treatments is placenta accreta.

CONCLUSION

The simplest and the least morbid methods must be retained. After vaginal birth, arterial embolization can be done, if there is no maternal haemodynamic disorder nor interventional vascular radiology unit nearby. During caesarean section, progressive uterine artery ligation can be done adapted to the bleeding cause. In case of failure of a conservative treatment, it would be dangerous to multiply techniques. Emergency peripartum then should remain the choice procedure.