Balloon occlusion of the hypogastric arteries in the management of placenta accreta: a case report and review of the literature

Outcome evaluation of prophylactic internal iliac balloon occlusion in the management of patients with placenta accreta spectrum

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.

Complete placenta previa and increta after radical trachelectomy: A case report

Background

Placenta accreta spectrum (PAS) disorders are increasing in incidence and represent a significant contributor to severe maternal morbidity in the US. Prior uterine surgeries other than cesarean section are important, yet less common, risk factors for PAS.

Case

This is a case of a 43-year-old woman with a prior history of cervical cancer necessitating radical trachelectomy. She was subsequently diagnosed with a complete placenta previa with a high degree of suspicion for PAS. Multidisciplinary teams convened to plan for delivery. A cesarean hysterectomy was performed at 32 weeks. Final surgical pathology confirmed the presence of morbidly adherent placenta invading the vaginal cuff.

Conclusion

Patients who are diagnosed with early-stage cervical cancers have the option of fertility-preserving surgical management. Serial ultrasound evaluations, specifically looking for PAS, might be warranted in post-trachelectomy pregnancies.

Prophylactic hypogastric arterial ligation before cesarean hysterectomy for controlling complications in pregnant women with placenta adherent abnormality: A randomized controlled clinical trial

BACKGROUND

Placenta adherent abnormality (PAA) is abnormal attachment of the placenta to the myometrium. This abnormal placenta binding has severe clinical consequences for the mother and the fetus. We investigated the outcomes of hypogastric arterial ligation (HAL) before hysterectomy compared to hysterectomy alone in pregnant women with PAA.

MATERIALS AND METHODS

In this randomized controlled clinical trial, 70 patients were randomly allocated to HAL along with hysterectomy and hysterectomy alone groups (35 in each Group). The total amount of intraoperative blood loss, the need for intraoperative blood products transfusion, frequency of deep vein thrombosis, duration of surgery, duration of hospitalization, and visceral trauma were compared between 2 Groups.

RESULTS

Finally, 64 patients completed the study protocol with mean age of 33.84 ± 4.25 years. The study groups were comparable in terms of basic baseline demographic and clinical characteristics. Visceral trauma was less frequently occurred in HAL group compared to hysterectomy alone (0% vs. 15.6%; P = 0.02). Intraoperative blood loss (1525 ± 536.41 cc vs. 2075 ± 889.36 cc; P = 0.001) and were significantly lower in HAL group compared to hysterectomy alone. Duration of operation (179.06 ± 36.28 vs. 197.66 ± 39.47; P = 0.05) and hospitalization (4.97 ± 2.20 vs. 6.10 ± 2.39; P = 0.03) also were significantly lower in HAL group.

CONCLUSION

Our findings suggest that prophylactic HAL has a protective effect on the reduction of blood loss and less visceral trauma in pregnant women with PAA.

Anesthetic considerations for repeat cesarean section

PURPOSE OF REVIEW

The prevalence of cesarean delivery is increasing worldwide despite the advance of Trial of Labor After Cesarean section. In many countries, a history of previous cesarean section is an almost absolute indication for a repeat cesarean section. The purpose of this review was to examine if the perioperative anesthetic management of patients with repeat cesarean section is different from the anesthetic management of patients with primary cesarean section.

RECENT FINDINGS

This review discusses important topics, such as early diagnosis of cases with a potentially high risk for complications; the need for assessment of patients diagnosed with abnormal placentation; the importance of a multidisciplinary approach that includes interaction of the anesthesiologist, gynaecologist, and invasive radiologist; emphasizing the need for reinforcement of new methods of invasive procedures; management of massive bleeding, use of new technologies, and development of an institutional protocol for management of patients with abnormal placentation.

SUMMARY

According to this review, we show that the management of patients with repeat cesarean section without abnormal placentation is almost the same as the management of patients for primary cesarean section. Timely diagnosis of patient with abnormal placentation and multidisciplinary approach is crucial for prevention of morbidity or even mortality.

Prophylactic Internal Iliac Artery Occlusion Balloon Placement to Reduce Operative Blood Loss in Patients with Invasive Placenta

PURPOSE

To evaluate efficacy and safety of prophylactic internal iliac occlusion balloon placement before cesarean hysterectomy for invasive placenta.

MATERIAL AND METHODS

A retrospective analysis was performed of patients with invasive placenta treated with and without occlusion balloon placement. Preoperative occlusion balloons were placed in 90 patients; 61 patients were treated without balloon placement (control group). Baseline demographics, including patient age, gestational age at delivery, gravidity, parity, and number of previous cesarean sections, were not significantly different (P > .05). Of the balloon placement group, 56% had placenta percreta compared with 25% in the control group (P < .001), and 83% had placenta previa compared with 66% in the control group (P = .012).

RESULTS

Median blood loss was 2 L (range, 1.5-2.5 L) in the balloon placement group versus 2.5 L (range, 2-4 L) in the control group (P = .002). Patients with occlusion balloons were transfused a median of 2 U (range, 0-5 U) of packed red blood cells versus 5 U (range, 2-8 U) in patients in the control group (P = .002). In the balloon placement group, 34% had large volume blood loss > 2,500 mL versus 61% in the control group (P = .001), and 21% required blood transfusion > 6 U versus 44% in the control group (P = .002). Eight complications (9%) were attributed to occlusion balloon placement.

CONCLUSIONS

Prophylactic internal iliac artery occlusion balloon placement reduces operative blood loss and transfusion requirements in patients undergoing hysterectomy for invasive placenta.

Precesarean Prophylactic Balloon Catheters for Suspected Placenta Accreta: A Randomized Controlled Trial

OBJECTIVE

To examine the effect of prophylactic balloon catheters on bleeding morbidity among women with a prenatal diagnosis of placenta accreta.

METHODS

In a randomized trial, women with a prenatal diagnosis of placenta accreta were randomized to either preoperative prophylactic balloon catheters (intervention group) or to a control group. Other than placement of the prophylactic balloon catheters in the anterior division of the internal iliac arteries, the same multidisciplinary approach was used in both groups. The primary study outcome was the number of packed red blood cell (RBC) units transfused. To detect a mean reduction of three packed RBC units with the prophylactic balloon catheters, 12 women in each group were needed.

RESULTS

Between January 2009 and March 2015, 27 women were randomized: 13 in the intervention group and 14 in the control group. Demographic and obstetric characteristics were similar between the groups. Six (46.2%) women in the intervention and seven (50.0%) in the control group underwent cesarean hysterectomy (P=.84). There were no significant differences between the intervention and control groups in the mean number of packed RBC units transfused, 5.2 (±6.2) and 4.1 (±3.8), respectively (P=.90), or in the calculated blood loss, 4,950 (±5,051) and 4,709 (±3,434) mL (P=.72). The number of women with blood loss greater than 2,500 mL, number of plasma products transfused, duration of surgery, peripartum complications, and hospitalization length did not differ significantly between the groups. Reversible adverse effects related probably to prophylactic balloon catheter insertion were noted in 2 of 13 (15.4%) women.

CONCLUSION

In women with preoperative suspicion of placenta accreta, preoperative placement of prophylactic balloon catheters did not affect the number of packed RBC units transfused.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01373255.

LEVEL OF EVIDENCE

I.

Urological Manifestations of Placenta Percreta

Placenta percreta is a condition of pregnancy associated with abnormal decidua placenta. It is characterized by invasion of chorionic villi past the myometrium and serosa, towards urogenital organs. Complications include massive hemorrhage, bladder dysfunction, and severe infections during delivery. Reports suggest an increasing prevalence of this condition. From a urological perspective, this review suggests how early diagnostic modalities, effective treatment plans, and appropriate surgical methods may aid in decreasing the morbidity and mortality of placenta percreta. The importance of maintaining bladder integrity during hysterectomy is emphasized.